What is the treatment for globus?

Treatment for Globus Sensation

For patients with typical globus sensation (non-painful throat lump that improves with eating), empirical high-dose proton pump inhibitor (PPI) therapy is the recommended first-line treatment after excluding alarm symptoms, as gastroesophageal reflux disease is a major underlying cause. 1, 2

Initial Assessment and Red Flag Exclusion

Before initiating treatment, you must distinguish globus from true dysphagia and screen for alarm symptoms that require immediate investigation 3, 4:

• Weight loss - mandates urgent endoscopy 4
• True dysphagia (worsening with food, not improving) - requires structural evaluation 3
• Odynophagia (painful swallowing) - needs immediate workup 4
• Food bolus obstruction - requires urgent gastroenterology referral for endoscopic intervention, as eosinophilic esophagitis is found in up to 46% of these cases 1, 4

Perform otolaryngological examination to exclude organic causes such as Zenker's diverticulum 4. The key distinguishing feature of true globus is that symptoms improve during eating rather than worsen, unlike dysphagia 3, 4.

First-Line Treatment Algorithm

Step 1: Empirical PPI Therapy

Initiate high-dose PPI therapy as first-line treatment for patients with typical globus and no alarm symptoms 2, 5. This approach is reasonable given:

• The benign nature of globus 2
• GERD is recognized as a major causative factor 1, 2, 6
• Globus is commonly associated with extraesophageal reflux manifestations 1

Important caveat: Globus symptoms in patients with laryngopharyngeal reflux resolve more slowly than classic reflux symptoms, so adequate trial duration is essential 6.

Step 2: If PPI Non-Responsive

For patients who fail empirical PPI therapy, proceed with definitive assessments 2, 5:

• Upper endoscopy - to identify structural abnormalities and evaluate for heterotopic gastric mucosa (inlet patch) in the proximal esophagus 7, 5
• High-resolution manometry - to assess esophageal motility disorders 5
• Ambulatory 24-hour pH-impedance monitoring - to document reflux patterns 2, 5
• Barium radiography - if structural concerns persist 5

Ablation of heterotopic gastric mucosa (inlet patch) in the proximal esophagus has been reported to improve globus symptoms when identified 7, 5.

Adjunctive and Alternative Therapies

For Persistent Idiopathic Globus

When investigations are negative, management options include 2, 7, 5:

• Reassurance and counseling - essential as globus has a benign course with no long-term consequences 5, 8
• Neuromodulators (antidepressants) - helpful for functional disorders and oropharyngeal hypersensitivity 7, 8
• Speech and language therapy - effective in relieving symptoms, particularly when associated with functional voice disorders 2, 6, 8
• Cognitive-behavioral therapy - beneficial for patients with psychological stress exacerbation 2

Personalized Adjunctive Pharmacotherapy

Based on the GERD phenotype, consider 1:

• Alginate antacids - for breakthrough symptoms 1
• Nighttime H2 receptor antagonists - for nocturnal symptoms 1
• Baclofen - for regurgitation or belch-predominant symptoms 1

Common Pitfalls to Avoid

Do not mistake globus for dysphagia, as this leads to inappropriate treatment approaches 3, 4. Remember that approximately 20% of patients with functional dysphagia may experience globus with swallowing, but true globus improves rather than worsens with food intake 3.

Do not over-investigate patients without alarm symptoms, as most investigations yield negative results while incurring patient morbidity and healthcare costs, and malignancy is vanishingly rare in the absence of red flags 8.

Multidisciplinary Considerations

Globus often requires input from multiple specialties 1:

• Otolaryngology - for laryngeal evaluation and exclusion of structural pathology 1
• Gastroenterology - for reflux assessment and endoscopic evaluation 1
• Allergy/Immunology - when laryngeal allergy is suspected 1
• Speech pathology - for functional dysphonia and voice disorders 1
• Behavioral psychology - for stress-related exacerbation 1

Prognosis

The overall prognosis is good, as the magnitude of symptoms may decline over time, and globus has a benign course with no long-term consequences 5.