What is the treatment for globus sensation?

Treatment of Globus Sensation

The primary treatment approach for globus sensation should include empirical therapy with a high-dose proton pump inhibitor (PPI), followed by evaluation of esophageal motility if symptoms persist, and consideration of prokinetics, speech therapy, or psychological interventions for refractory cases. 1, 2, 3

Initial Assessment and Diagnosis

• Globus sensation presents as a recurrent, non-painful feeling of a lump in the throat that typically improves during eating rather than worsening with swallowing food, which distinguishes it from true dysphagia 1
• Careful differentiation from dysphagia is essential as they require different management approaches, though they can co-occur in approximately 20% of patients 2
• Screen for alarm symptoms requiring immediate investigation, including weight loss, true dysphagia, and odynophagia (painful swallowing) 2
• Otolaryngological examination should be performed to exclude organic causes such as pharyngeal cancer, Zenker's diverticulum, or thyroid enlargement 3

First-Line Treatment

• Empirical therapy with a high-dose proton pump inhibitor (PPI) is the recommended first-line treatment after excluding organic diseases 3, 4
• This approach is based on the established relationship between gastroesophageal reflux disease (GERD) and globus sensation 3
• Treatment duration should be adequate (typically 8-12 weeks) to properly evaluate response 4

Management of PPI-Resistant Cases

• For patients who don't respond to PPI therapy, evaluation of esophageal motility should be performed 3
• Nearly 48% of PPI-resistant globus patients have abnormal esophageal motility, with ineffective esophageal motility being the most common finding 3
• For patients with identified motility disorders, prokinetics alone or in combination with PPIs should be considered 3
• If esophageal motility is normal, consider the following interventions:

Additional Treatment Options

• Speech and language therapy can be beneficial for patients with persistent symptoms despite negative investigations 4
• Hypnotically-assisted relaxation (HAR) has shown promise in reducing globus symptoms regardless of cause 5
• Cognitive-behavioral therapy may help patients with persistent symptoms, especially when psychological factors are present 3, 4
• Anti-depressants can be helpful for refractory cases, particularly when associated with psychological distress 3, 4
• Gabapentin may be considered for persistent symptoms, though more research is needed 3

Associated Conditions and Management Considerations

• Globus sensation is often linked to psychological stress, with many patients reporting symptom exacerbation during periods of high emotional intensity 1
• It commonly co-occurs with functional voice disorders and is frequently associated with throat clearing, sense of mucus buildup, dry throat, and repeated swallowing 1
• While psychological factors may contribute to symptom perception and severity, they are unlikely to be the primary cause in most cases 6

Treatment Algorithm

1. Exclude organic causes through otolaryngological examination
2. Start empirical high-dose PPI therapy for 8-12 weeks
3. If symptoms persist:
   • Perform esophageal motility testing
   • For abnormal motility: Add or switch to prokinetics
   • For normal motility: Consider speech therapy, HAR, cognitive-behavioral therapy, or anti-depressants

Common Pitfalls to Avoid

• Mistaking globus for dysphagia can lead to inappropriate treatment approaches 1, 2
• Assuming globus is purely psychogenic may lead to missed organic causes 6
• Inadequate duration of PPI therapy before declaring treatment failure 4
• Failing to consider esophageal motility disorders in PPI-resistant cases 3