What is globus sensation?

Globus Sensation: Characteristics and Management

Globus sensation is a recurrent, non-painful but uncomfortable feeling of a lump in the throat that typically improves during eating rather than worsening when swallowing food, which is a key distinguishing feature from dysphagia. 1

Clinical Characteristics

• Globus presents as a persistent or intermittent sensation of a lump or foreign body in the throat that is more obvious between meals and typically improves with eating 1
• The sensation is medially felt in the throat and can be persistent or intermittent in nature 2
• Unlike dysphagia, globus does not interfere with swallowing of food and may actually improve during meals 3
• Approximately 20% of patients with functional dysphagia may experience globus sensation with swallowing, but true globus typically improves rather than worsens with food intake 1

Associated Symptoms and Conditions

• Globus commonly co-occurs with:
  • Throat clearing
  • Sense of mucus buildup
  • Dry throat
  • Repeated swallowing 1
• It is often linked to psychological stress, with many patients reporting symptom exacerbation during periods of high emotional intensity 1
• Psychological factors like anxiety and depression are frequently associated with globus sensation 4
  • Studies show definite anxiety in 34.95% and borderline anxiety in 18.44% of globus patients 4
  • Definite depression was found in 12.5% and borderline depression in 27.9% of patients 4
• Globus sensation affects approximately 6% of the population 4
• It is more common among females, particularly housewives and married individuals 4

Differential Diagnosis

• Important to distinguish globus from dysphagia (difficulty swallowing), although they can co-occur in some patients 1
• Alarm symptoms that require further investigation include:
  • Pain
  • Weight loss
  • Dysphagia
  • Odynophagia 3
• Conditions that may present with similar symptoms include:
  • Pharyngeal cancer
  • Zenker's diverticulum
  • Thyroid enlargement 5
  • Gastroesophageal reflux disease (GERD) 5, 6
  • Esophageal motility disorders 5

Diagnostic Approach

• Careful history taking and nasolaryngoscopy are essential first steps in management 6
• In the absence of alarm symptoms, empirical therapy with proton pump inhibitors (PPIs) may be reasonable, especially if concurrent reflux symptoms are identified 3
• If symptoms persist despite PPI therapy, further investigations should include:
  • Laryngoscopy
  • Upper GI endoscopy
  • High-resolution manometry
  • Barium radiography
  • Ambulatory reflux monitoring 3
• Evaluation of esophageal motility should be considered for PPI-resistant patients, as studies show 47.9% of these patients have abnormal esophageal motility 5

Management Approaches

• For patients with typical globus symptoms without alarm features, empirical therapy with high-dose proton pump inhibitors is reasonable 5, 6
• For PPI-resistant patients with esophageal motility disorders, prokinetics alone or added to PPI therapy should be considered 5
• For patients without esophageal motility dysfunctions who are nonresponsive to PPI therapy, options include:
  • Cognitive-behavioral therapy
  • Anti-depressants
  • Gabapentin 5
  • Speech and language therapy 6
• Reassurance about the benign nature of the condition is important, as globus has a good overall prognosis with symptoms often declining over time 3

Common Pitfalls and Caveats

• Mistaking globus for dysphagia can lead to inappropriate treatment approaches 1
• Organic lesions are rare in patients with globus symptoms, but thorough evaluation is necessary to exclude serious conditions 4
• The etiology of globus is considered multifactorial, making it challenging to establish standard investigation and treatment strategies 4, 6
• The condition has a strong tendency to recur, and evidence-based treatment concepts are limited 2
• Controlled therapy studies are scarce, limiting the development of evidence-based treatment protocols 2