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

Evaluation and Management of Globus Sensation

The evaluation of globus sensation should begin with distinguishing it from dysphagia, followed by targeted investigations to rule out organic causes, and treatment should be directed at underlying conditions when identified or empiric proton pump inhibitor therapy when no cause is found. 1

Clinical Characteristics and Definition

• Globus sensation presents as a recurrent, non-painful but uncomfortable feeling of a lump in the throat that typically improves during eating rather than worsening with swallowing food, which is a key distinguishing feature from dysphagia 1
• The sensation is more obvious between meals and often improves with eating 1
• It can be persistent or intermittent and affects approximately 6% of the population 2

Initial Evaluation

• Carefully distinguish globus from dysphagia (difficulty swallowing), as they require different management approaches, though they can co-occur in approximately 20% of patients with functional dysphagia 1
• Screen for alarm symptoms that require immediate investigation:
  • Pain
  • Weight loss
  • True dysphagia
  • Odynophagia (painful swallowing)
  • Food bolus obstruction 3, 4
• Assess for psychological factors, as globus is frequently associated with:
  • Anxiety (found in up to 53% of patients) 2
  • Depression (found in up to 40% of patients) 2
  • Stress exacerbation 1
  • Somatoform disorders 5

Diagnostic Workup

• Otolaryngological examination should be performed to exclude organic causes such as:
  • Pharyngeal cancer
  • Zenker's diverticulum
  • Thyroid enlargement 6, 4
• If food bolus obstruction is present, urgent referral to gastroenterology for endoscopic intervention is strongly recommended, as eosinophilic esophagitis (EoE) is the most common cause of food bolus obstruction 3
• Upper GI endoscopy should be considered, especially in patients with alarm symptoms or those not responding to empiric treatment 4
• Additional testing based on clinical suspicion may include:
  • Barium swallow study
  • High-resolution esophageal manometry (47.9% of PPI-resistant globus patients have abnormal esophageal motility) 6
  • Ambulatory pH monitoring if GERD is suspected 4
  • Allergic skin testing (some studies show high prevalence of positive skin tests in globus patients) 7

Treatment Approach

• First-line treatment for patients without alarm symptoms:
  • Empiric trial of proton pump inhibitor (PPI) therapy, especially if concurrent reflux symptoms are identified 6, 4
  • Reassurance about the benign nature of the condition 4
• For PPI-resistant patients:
  • Evaluate esophageal motility; if abnormal, consider adding prokinetics to PPI therapy 6
  • For patients with normal esophageal motility who don't respond to PPI therapy, consider:
    • Cognitive-behavioral therapy
    • Anti-depressants
    • Neuromodulators such as gabapentin 6, 4
• For patients with identified allergic components:
  • Anti-allergic treatment has shown improvement in up to 64.3% of patients with positive skin tests 7

Important Considerations

• Globus sensation has a benign course with no long-term consequences, though symptoms may recur 5, 4
• The overall prognosis is good as symptoms often decline over time 4
• Mistaking globus for dysphagia can lead to inappropriate treatment approaches 1
• Evidence for treatment efficacy is limited, with few controlled studies available 5
• Patients with food bolus obstruction require urgent evaluation, as EoE is found in up to 46% of these cases 3