What is the best approach to diagnose and manage an adult patient with no significant past medical history presenting with globus sensation or a feeling of throat tightening?

Distinguishing Globus Sensation from Throat Tightening

Globus sensation is a non-painful feeling of a lump in the throat that characteristically improves during eating, while throat tightening that worsens with swallowing suggests true dysphagia or laryngeal hypersensitivity syndrome and requires different diagnostic and management pathways. 1, 2

Key Distinguishing Features

Globus Sensation Characteristics

• Improves with eating rather than worsening—this is the single most important distinguishing feature 2, 3
• More prominent between meals and often resolves during food intake 1, 2
• Non-painful, recurrent sensation described as a lump, foreign body (hair/crumb), or tightening 1
• Associated with throat clearing, sense of mucus buildup, dry throat, and repeated swallowing 1
• May include sensation of food sticking after swallowing, but actual swallowing is not impaired 1

Throat Tightening (Laryngeal Hypersensitivity Syndrome)

• Presents as intermittent episodes triggered by specific stimuli (change in air temperature, scents, sprays, aerosols, exercise) 1
• May occur with phonation (talking, laughing) 1
• Can manifest as vocal cord dysfunction or chronic cough 1
• Does not improve with eating 1
• May be associated with perceived panic or autonomic arousal 1

Diagnostic Approach

Initial Assessment—Red Flags Requiring Urgent Investigation

• Weight loss mandates urgent endoscopy 4
• True dysphagia (difficulty swallowing, not just sensation) 4, 3
• Odynophagia (painful swallowing) 4, 3
• Food bolus obstruction requires urgent gastroenterology referral (eosinophilic esophagitis found in up to 46% of cases) 4
• Hemoptysis, fever >101.5°F, night sweats 4

History Taking—Critical Details

• Relationship to eating: Does the sensation improve, worsen, or remain unchanged with food intake? 2, 3
• Timing: More prominent between meals versus during/after meals 2
• Triggers: Specific stimuli like temperature changes, scents, talking, exercise 1
• Associated symptoms: Throat clearing, chronic cough, hoarseness, voice changes 1
• Psychological stress patterns: Many patients report exacerbation during high emotional intensity 1, 2
• Postural relationship: Symptoms with bending or lying down suggest reflux 1

Physical Examination

• Nasolaryngoscopy to exclude structural pathology (Zenker's diverticulum, masses, laryngeal abnormalities) 4, 5
• Assess for pharyngolaryngeal tension and functional voice disorders 1

Diagnostic Testing Strategy

For Typical Globus (improves with eating, no alarm symptoms):

• Empirical high-dose PPI therapy is reasonable as first-line approach given GERD as a major causative factor 4, 5
• If non-responsive to PPI trial, proceed to definitive assessment 5

For Atypical Presentations or PPI Failure:

• Upper endoscopy to exclude organic lesions 5, 3
• High-resolution esophageal manometry 3
• Ambulatory pH-impedance monitoring 5, 3
• Barium esophagram if structural abnormality suspected 3

For Throat Tightening/Laryngeal Hypersensitivity:

• Respiratory assessment by physician including spirometry 1
• Respiratory exposure chamber testing in persistent cases 1
• Diagnosis should be clearly established prior to speech therapy referral 1

Management Algorithm

For Globus Sensation

First-Line Treatment:

• High-dose PPI therapy (e.g., esomeprazole 40 mg twice daily or equivalent) for patients with typical globus and no alarm symptoms 4, 5
• Trial duration of 8-12 weeks 1

Adjunctive Therapies Based on GERD Phenotype:

• Alginate antacids for breakthrough symptoms 4
• Nighttime H2 receptor antagonists for nocturnal symptoms 4
• Baclofen for regurgitation or belch-predominant symptoms 4

Second-Line Treatment (if PPI fails):

• Low-dose tricyclic antidepressants (imipramine 10-25 mg at bedtime) for neuromodulation of visceral hypersensitivity 6
• Effects may require several weeks to manifest 6
• Critical caveat: Muscle relaxants like cyclobenzaprine are inappropriate—globus is a sensory phenomenon, not true muscle spasm 6

Behavioral Interventions:

• Speech and language therapy for coexistent functional voice disorders 1, 5
• Cognitive-behavioral therapy, particularly when psychological factors are prominent 5
• Reassurance based on negative investigations can improve symptoms 7, 3

For Throat Tightening/Laryngeal Hypersensitivity Syndrome

Primary Treatment:

• Speech and language therapy is the primary recommended intervention 1, 6
• Focus on addressing aberrant involuntary learned behaviors 1
• Patient education about the functional nature of the disorder 1

Adjunctive Neuromodulators:

• Consider after behavioral interventions if symptoms persist 6
• Low-dose TCAs (10-25 mg at bedtime) address aberrant sensory processing 6

Common Pitfalls to Avoid

• Mistaking globus for dysphagia leads to inappropriate treatment approaches 2
• Approximately 20% of functional dysphagia patients experience globus with swallowing, but the key distinction remains whether symptoms improve with eating 1, 2
• Prescribing muscle relaxants for globus is inappropriate and potentially harmful—the condition involves pharyngolaryngeal hypersensitivity, not true muscle spasm 6
• Failing to screen for psychological comorbidity (anxiety in 35%, depression in 13% of patients), though these are often secondary rather than causal 7
• Inadequate PPI trial duration—effects require 8-12 weeks 1
• Missing red flag symptoms that require urgent investigation rather than empirical therapy 4, 3

Prognosis

• Globus has a benign course with no long-term consequences 3
• Symptom magnitude may decline over time 3
• Symptoms are often persistent, difficult to treat, and have a tendency to recur 5, 8
• Adequate investigations with negative results can reassure patients and improve symptoms 7