What is the initial evaluation and treatment for a patient presenting with a globus sensation?

Initial Evaluation and Treatment for Globus Sensation

The initial evaluation of globus sensation should include a thorough history to rule out concerning symptoms, nasolaryngoscopy to exclude structural abnormalities, and an empirical trial of high-dose proton pump inhibitors (PPIs) as first-line treatment, as gastroesophageal reflux disease (GERD) is a major cause of globus pharyngeus. 1, 2

Definition and Clinical Presentation

Globus pharyngeus is characterized by:

• A recurrent, non-painful but uncomfortable sensation of a lump in the throat
• Absence of dysphagia, odynophagia, or histopathology-based esophageal motility disorder
• Symptoms that may be persistent or intermittent
• Sensation of a foreign body, tightening, choking feeling, or lump in the throat
• Improvement during eating (distinguishing feature)
• Often associated with throat clearing, sense of mucus build-up, dry throat, repeated swallowing, chronic cough or hoarseness 1

Initial Evaluation Algorithm

1. History taking - Focus on:

   • Duration and pattern of symptoms
   • Relationship to meals (improves with eating in true globus)
   • Presence of alarm symptoms (weight loss, dysphagia, odynophagia, pain)
   • Psychological stress factors (may exacerbate symptoms)
   • Associated symptoms (throat clearing, cough, voice changes)

2. Physical examination:

   • Nasolaryngoscopy - Essential first-line examination to exclude structural pathology 1, 2
   • Examination of the neck for thyroid enlargement

3. Initial diagnostic workup:

   • If alarm symptoms present (dysphagia, odynophagia, weight loss, pain):
     • Proceed directly to endoscopy to rule out malignancy 1, 3
   • If typical globus symptoms without alarm features:
     • Consider empirical PPI therapy before extensive testing 2, 4

Treatment Approach

First-line Treatment:

• High-dose proton pump inhibitor (PPI) therapy for 8-12 weeks
  • Based on evidence that GERD is a major cause of globus sensation, even in patients without typical reflux symptoms 2, 5
  • Up to 65% of patients with globus may have pathological reflux on pH monitoring 5

For Patients Not Responding to PPI Therapy:

1. Additional diagnostic testing:

   • Upper endoscopy to exclude structural abnormalities
   • Consider esophageal manometry to evaluate for motility disorders (present in up to 47.9% of PPI-resistant globus patients) 4
   • Consider 24-hour pH monitoring or impedance testing in selected cases 3

2. Second-line treatments:

   • Prokinetic agents - Particularly if ineffective esophageal motility is identified 4
   • Speech and language therapy - For pharyngolaryngeal tension 1
   • Antidepressants - For persistent symptoms despite negative investigations 1, 2
   • Cognitive-behavioral therapy - May help patients with persistent symptoms 2, 4

Important Clinical Considerations

• Globus must be distinguished from dysphagia, though empirical data suggests 20% of patients with functional dysphagia experience globus sensation with swallowing 1
• Psychological and psychiatric disorders may be an outcome rather than a predisposing factor of globus 1, 6
• Globus has a benign course with no long-term consequences, though symptoms may persist or recur 2, 3
• Reassurance about the benign nature of the condition is an important component of management 3

Common Pitfalls to Avoid

1. Failing to exclude serious pathology - Always perform nasolaryngoscopy to rule out structural causes
2. Attributing symptoms solely to psychological factors - Organic disorders are frequently identified in patients with globus 6
3. Inadequate PPI dosing or duration - Use high-dose PPI for adequate trial period
4. Missing esophageal motility disorders - Consider manometry in PPI-resistant cases 4
5. Overlooking that reflux limited to the distal esophagus can still cause globus - Acid does not need to reach the pharynx to produce globus sensation 5

By following this structured approach to evaluation and treatment, most patients with globus sensation can be effectively managed with reassurance of the benign nature of their condition and appropriate targeted therapy.