What is the initial workup for a patient presenting with globus sensation?

Initial Workup for Globus Sensation

The initial workup for a patient presenting with globus sensation should include a thorough assessment to rule out organic causes, with nasolaryngoscopy and empirical proton pump inhibitor therapy as first-line approaches. 1

Clinical Presentation and Definition

Globus pharyngeus presents as:

• Recurrent, non-painful but uncomfortable sensation of a lump in the throat
• Absence of dysphagia, odynophagia, or GERD
• Sensation of a foreign body (e.g., hair, crumb), tightening/choking feeling
• More obvious between meals and improves with eating
• Often associated with throat clearing, sense of mucus build-up, dry throat, repeated swallowing 1

Initial Evaluation

History Taking

Focus on:

• Onset (abrupt vs. slowly progressive)
• Pattern (persistent vs. intermittent)
• Associated symptoms:
  • Throat clearing, chronic cough, hoarseness
  • Dysphagia (difficulty swallowing)
  • Odynophagia (pain with swallowing)
  • Acid reflux or regurgitation
  • Weight loss
  • Voice changes 1

Key Distinguishing Features

• Globus must be distinguished from true dysphagia, though 20% of patients with functional dysphagia experience globus sensation with swallowing 1
• Assess for psychological factors as globus can be exacerbated during periods of high emotional intensity 1, 2
• Determine impact on quality of life (social withdrawal, anxiety) 1

Physical Examination

• Nasolaryngoscopy (essential first-line examination) 3
• Assessment for:
  • Pharyngolaryngeal tension
  • Signs of reflux laryngitis
  • Structural abnormalities 1

Diagnostic Testing Algorithm

1. First-line investigations:

   • Nasolaryngoscopy to rule out structural abnormalities 3
   • Trial of high-dose proton pump inhibitor (empirical therapy) 3, 4

2. For patients non-responsive to initial PPI therapy:

   • Upper GI endoscopy to exclude organic lesions 2
   • Consider esophageal manometry to evaluate motility disorders (found in 47.9% of PPI-resistant patients) 4
   • Consider 24-hour pH monitoring/impedance testing if GERD is suspected 3, 4

3. Additional testing for persistent symptoms:

   • Barium swallow/esophagram if structural abnormalities are suspected 5
   • Thyroid function tests to rule out thyroid disorders 6
   • Assessment for psychological factors (anxiety and depression screening) 2

Important Clinical Considerations

• Psychological factors are common but may be secondary rather than causal:

  • Anxiety features found in 53.4% of patients (34.95% definite, 18.44% borderline) 2
  • Depression features found in 40.4% of patients (12.5% definite, 27.9% borderline) 2

• Organic causes should not be overlooked:

  • Esophageal motility disorders (particularly ineffective esophageal motility) 4
  • GERD (major contributor in many cases) 3
  • Structural abnormalities (less common but important to exclude) 6

Common Pitfalls to Avoid

1. Assuming psychological origin without adequate investigation

   • Historical view of globus as purely psychogenic is outdated 6
   • Pharyngoesophageal disorders may be sensed only vaguely as globus 6

2. Inadequate empirical treatment

   • PPI therapy should be high-dose and adequate duration 3
   • Consider adding prokinetics for patients with motility disorders 4

3. Overlooking the impact on quality of life

   • Globus can significantly affect psychological well-being and social functioning 1
   • Reassurance after negative investigations can improve symptoms 2

By following this structured approach to the workup of globus sensation, clinicians can effectively rule out serious pathology while providing appropriate management for this often challenging condition.