What is the initial approach to managing a patient with globus sensation?

Initial Management of Globus Sensation

Start with high-dose proton pump inhibitor (PPI) therapy as first-line treatment after excluding alarm symptoms, as GERD is a major causative factor in globus sensation. 1

Step 1: Distinguish Globus from Dysphagia

• Globus improves during eating, while dysphagia worsens with swallowing — this is the critical distinguishing feature. 2
• Globus presents as a recurrent, non-painful sensation of a lump in the throat that is more obvious between meals. 2
• True dysphagia (difficulty swallowing) requires a completely different management approach, though approximately 20% of patients may have both conditions. 2, 1
• Mistaking globus for dysphagia leads to inappropriate treatment. 2

Step 2: Screen for Alarm Symptoms Requiring Urgent Investigation

Immediately refer for endoscopy if any of these are present:

• Weight loss — mandates urgent investigation. 1
• Food bolus obstruction — requires urgent gastroenterology referral, as eosinophilic esophagitis is found in up to 46% of these cases. 1
• Odynophagia (painful swallowing) — indicates potential serious pathology. 1
• True dysphagia — requires endoscopic evaluation. 1

Step 3: Perform Focused Otolaryngologic Examination

• Examine the larynx, epiglottis, base of tongue, both pyriform fossae, and hypopharynx to exclude organic causes. 1, 3
• Rule out Zenker's diverticulum, pharyngeal cancer, and thyroid enlargement. 1, 4
• Assess for chronic tonsillitis, pharyngitis, or cervical spondylosis. 5

Step 4: Initiate Empirical High-Dose PPI Therapy

If no alarm symptoms are present, begin high-dose PPI therapy immediately without waiting for diagnostic testing. 1, 4

• This approach is justified because GERD is a major causative factor and globus has a benign natural history. 1
• Globus is commonly associated with extraesophageal reflux manifestations. 1
• Continue PPI therapy for an adequate trial period (typically 8-12 weeks). 4

Adjunctive GERD-targeted therapies:

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

Step 5: Assess Psychological Factors

• Screen for anxiety and depression, as globus is frequently associated with psychological stress and symptom exacerbation during high emotional intensity. 2, 3
• Anxiety is present in approximately 35% of patients with globus, and depression in approximately 13%. 3
• These factors are relevant to the discomfort experienced but are unlikely to be primary etiologic causes. 5
• Reassurance about the benign nature of globus can significantly improve symptoms. 6, 7

Step 6: If PPI-Resistant, Consider Esophageal Motility Evaluation

• In patients who fail PPI therapy, approximately 48% have abnormal esophageal motility, most commonly ineffective esophageal motility. 4
• High-resolution manometry should be performed if symptoms persist despite adequate PPI trial. 4, 7
• Consider adding prokinetics if motility dysfunction is identified. 4

Step 7: Neuromodulator Therapy for Refractory Cases

Tricyclic antidepressants (TCAs) like imipramine should be considered after PPI therapy has been attempted, particularly when GERD-related causes have been addressed but symptoms persist. 8

• TCAs work through neuromodulatory effects on visceral hypersensitivity and central pain processing, independent of antidepressant properties. 8
• Start with low doses (10-25 mg at bedtime) rather than higher doses used for other conditions. 8
• Treatment effects may require several weeks to fully manifest. 8
• Never use muscle relaxants like cyclobenzaprine — globus is a sensory phenomenon related to pharyngolaryngeal hypersensitivity, not true muscle spasm. 8

Critical Pitfalls to Avoid

• Do not confuse globus with dysphagia — this leads to inappropriate invasive testing and treatment. 2
• Do not miss food bolus obstruction — this requires urgent endoscopy due to high prevalence of eosinophilic esophagitis. 1
• Do not prescribe muscle relaxants — they are inappropriate and potentially harmful for this sensory disorder. 8
• Do not perform extensive testing before a PPI trial unless alarm symptoms are present. 1, 4

Expected Prognosis

• Globus has a benign course with no long-term consequences. 7
• Symptoms may decline in magnitude over time. 7
• The symptom has a strong tendency to recur even with treatment. 6