What are the differential diagnoses and treatment options for a patient presenting with a globus sensation?

Differential Diagnoses for Globus Sensation

The differential diagnosis for globus sensation must systematically exclude structural pathology, gastroesophageal reflux disease (GERD), esophageal motility disorders, and psychological factors before arriving at a diagnosis of idiopathic globus. 1, 2

Structural and Organic Causes

Otolaryngologic Pathology

• Pharyngeal or laryngeal malignancy requires exclusion through direct laryngoscopy, particularly in patients with alarm symptoms 1, 2
• Zenker's diverticulum should be evaluated via otolaryngological examination and barium studies 1, 3
• Thyroid enlargement or thyroid pathology can mechanically compress the pharynx and create globus symptoms 3, 4
• Foreign body in the larynx, trachea, or esophagus must be considered in acute presentations 5

Esophageal Structural Abnormalities

• Eosinophilic esophagitis (EoE) is found in up to 46% of patients presenting with food bolus obstruction and requires urgent endoscopic evaluation 1
• Heterotopic gastric mucosa (inlet patch) in the proximal esophagus has been associated with globus, and ablation may improve symptoms 2, 4

Functional and Motility Disorders

GERD and Extraesophageal Reflux

• Gastroesophageal reflux disease is recognized as a major causative factor, with globus commonly associated with extraesophageal reflux manifestations 1, 3
• Laryngopharyngeal reflux (LPR) represents a subset of GERD patients with altered upper esophageal sphincter reflexes that reduce refluxate clearance 6

Esophageal Motility Dysfunction

• Ineffective esophageal motility is the most common abnormality found in PPI-resistant patients, occurring in 47.9% of cases 7
• Upper esophageal sphincter dysfunction can reduce esophageal clearance and increase refluxate penetration 6

Neurologic and Systemic Conditions

Neurologic Disorders

• Stroke, Parkinson's disease, and Parkinson-plus syndromes can present with globus as part of their pharyngeal symptomatology 5
• Myasthenia gravis, multiple sclerosis, and amyotrophic lateral sclerosis should be considered in the appropriate clinical context 5

Endocrine and Metabolic

• Hypothyroidism and other endocrinopathies can contribute to globus sensation 5
• Testosterone deficiency has been associated with voice and throat symptoms 5

Psychological and Functional Disorders

Psychiatric Contributions

• Anxiety, depression, and stress are frequently associated with globus, with many patients reporting symptom exacerbation during periods of high emotional intensity 5, 8
• Prior trauma (physical, emotional, or psychological) preceding voice or throat changes should be explored 5

Pharyngolaryngeal Hypersensitivity

• Oropharyngeal hypersensitivity (chemical or mechanical) represents a functional disorder where sensory processing is aberrant 9, 4
• Functional voice disorders commonly co-occur with globus, along with throat clearing, sense of mucus buildup, dry throat, and repeated swallowing 8

Infectious and Inflammatory Causes

• Viral, bacterial, or fungal infection of the throat and/or larynx can present acutely with globus 5
• Chronic rhinitis and allergic rhinitis may contribute to postnasal drainage and throat symptoms 5

Medication and Substance-Related

• Inhaled steroids (for asthma or COPD) can cause chemical laryngitis and globus 5
• Chronic tobacco use and moderate to heavy alcohol use are associated with laryngeal symptoms 5

Critical Distinguishing Features

Globus vs. Dysphagia

• True globus improves during eating rather than worsening with swallowing food, which is the key distinguishing feature from dysphagia 1, 8
• The sensation is more obvious between meals and typically improves with eating 1, 8
• Approximately 20% of patients with functional dysphagia may experience both conditions simultaneously 1, 8

Red Flag Symptoms Requiring Urgent Investigation

• Weight loss mandates immediate endoscopy 1
• True dysphagia (difficulty swallowing) requires different management than globus 1, 8
• Odynophagia (painful swallowing) necessitates urgent evaluation 1
• Hemoptysis, fever >101.5°F, night sweats suggest serious underlying pathology 5
• Food bolus obstruction requires urgent gastroenterology referral for endoscopic intervention 1

Common Pitfalls

Mistaking globus for dysphagia leads to inappropriate treatment approaches and delays proper management 1, 8. The critical distinction is that globus improves with eating while dysphagia worsens with food intake 1, 8. Additionally, treating globus as a muscle spasm with muscle relaxants like cyclobenzaprine is inappropriate and potentially harmful, as globus is a sensory phenomenon related to pharyngolaryngeal hypersensitivity, not true muscle spasm 9.