What is the appropriate management for a patient experiencing a globus sensation?

Management of Globus Sensation

Initiate high-dose proton pump inhibitor (PPI) therapy as first-line treatment for patients with typical globus sensation and no alarm symptoms, given that gastroesophageal reflux disease is a major causative factor. 1

Initial Clinical Assessment

Key Distinguishing Features

• Globus improves during eating rather than worsening with swallowing, which is the critical feature separating it from dysphagia 2, 1
• The sensation presents as recurrent, non-painful feeling of a lump in the throat, more obvious between meals 2
• Approximately 20% of patients may experience both globus and functional dysphagia simultaneously, but true globus characteristically improves with food intake 2

Screen for Alarm Symptoms Requiring Urgent Investigation

• Weight loss mandates immediate endoscopy 1
• True dysphagia (difficulty swallowing, not just sensation) 1
• Odynophagia (painful swallowing) 1, 3
• Food bolus obstruction requires urgent gastroenterology referral, as eosinophilic esophagitis is found in up to 46% of these cases 1

Associated Symptoms to Assess

• Psychological stress exacerbation (globus frequently worsens during high emotional intensity) 2
• Throat clearing, sense of mucus buildup, dry throat, repeated swallowing 2
• Co-occurring functional voice disorders 2
• Extraesophageal reflux manifestations 1

Diagnostic Workup

Essential Initial Evaluation

• Perform otolaryngological examination with nasolaryngoscopy to exclude organic causes such as Zenker's diverticulum, pharyngeal cancer, or thyroid enlargement 1, 4, 5
• Carefully distinguish globus from dysphagia, as mistaking one for the other leads to inappropriate treatment approaches 2, 1

When to Pursue Further Testing

If patients are nonresponsive to empirical PPI therapy, consider:

• Upper endoscopy 4, 3
• High-resolution esophageal manometry (47.9% of PPI-resistant patients have abnormal esophageal motility, most commonly ineffective esophageal motility) 5
• Multichannel intraluminal impedance/pH monitoring 4, 3
• Barium radiography 3

Treatment Algorithm

First-Line: High-Dose PPI Therapy

Begin with high-dose proton pump inhibitor therapy for patients with typical globus and no alarm symptoms, recognizing GERD as a major causative factor and the benign nature of globus 1, 4

Adjunctive Acid-Suppression Strategies

Based on GERD phenotype, consider:

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

Second-Line: Prokinetic Therapy

If PPI therapy fails and esophageal motility dysfunction is identified (particularly ineffective esophageal motility), add prokinetics to PPI or use prokinetics alone 5

Third-Line: Neuromodulators

For PPI-resistant patients without esophageal motility dysfunction, tricyclic antidepressants (TCAs) like imipramine should be considered 6

TCA Mechanism and Prescribing

• TCAs work through neuromodulatory effects on visceral hypersensitivity and central pain processing, independent of antidepressant properties 6
• They block muscarinic 1, alpha-1 adrenergic, and histamine 1 receptors, reducing pharyngolaryngeal hypersensitivity 6
• Start with low doses (10-25 mg at bedtime) rather than higher doses used in IBS trials 6
• Beneficial effects may take several weeks to manifest, so ensure adequate trial duration 6
• TCAs address aberrant sensory processing, not muscle spasm—muscle relaxants like cyclobenzaprine are inappropriate and potentially harmful 6

Alternative Neuromodulators

For persistent symptoms despite negative investigations:

• Gabapentin 5
• Other antidepressants 4, 5

Behavioral Interventions

• Speech and language therapy (primary intervention when globus co-occurs with functional voice disorders and laryngeal hypersensitivity) 6, 4
• Cognitive-behavioral therapy 4, 5

Specialized Interventions

Ablation of heterotopic gastric mucosa in the proximal esophagus has been reported to improve globus symptoms when identified 3

Critical Pitfalls to Avoid

• Do not confuse globus with dysphagia—globus improves with eating while dysphagia worsens, and this distinction determines the entire management approach 2, 1
• Do not use muscle relaxants—globus is a sensory phenomenon related to pharyngolaryngeal hypersensitivity, not true muscle spasm 6
• Do not delay urgent endoscopy in patients with weight loss—this is a red flag requiring immediate investigation 1
• Do not miss food bolus obstruction—this requires urgent gastroenterology referral as eosinophilic esophagitis is the most common cause 1

Multidisciplinary Coordination

Globus often requires input from:

• Otolaryngology for laryngeal evaluation and exclusion of structural pathology 1
• Gastroenterology for reflux assessment and endoscopic evaluation 1
• Speech and language therapy for co-occurring functional voice disorders 6

Prognosis and Reassurance

Globus has a benign course with no long-term consequences, and the overall prognosis is good as symptom magnitude may decline over time 3