What is the best initial diagnostic test, computed tomography (CT) scan of the neck or ultrasound (US) of the neck, for an adult patient with a sensation of something stuck in their throat, without choking sensation or pain?

Initial Evaluation: Clinical Assessment Over Imaging

For an isolated sensation of something stuck in the throat without pain or choking, neither CT nor ultrasound of the neck is routinely indicated as initial imaging—clinical examination should guide management, and if imaging is pursued, barium esophagram is preferred over CT. 1, 2

Why Imaging is Generally Not Recommended

• Extremely low diagnostic yield: In patients with isolated globus sensation (feeling of something stuck in throat), imaging studies demonstrate clinically significant findings in only 3-4% of cases, and result in a change in clinical management in less than 1% of patients 2
• The combined therapeutic efficacy of neck CT and barium esophagram in uncomplicated globus sensation is only 0.8%, making routine imaging difficult to justify 2

Clinical Evaluation Should Come First

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that providers should systematically assess for red flag features that would elevate concern and potentially warrant imaging 1:

High-Risk Features Requiring Further Workup:

• Duration: Mass or symptoms lasting >2-3 weeks 1
• Voice changes or hoarseness 1
• Trouble or pain with swallowing (your patient has NO pain, which is reassuring) 1
• Unilateral ear pain on the same side 1
• Unexplained weight loss 1
• Fever >101°F 1
• Smoking or alcohol history 1
• History of head and neck cancer or radiation exposure 1

Physical Examination Priorities:

• Direct visualization of the oropharynx with bright light, examining tongue, tonsils, and posterior pharynx 1
• Palpation of neck for masses or lymphadenopathy 1
• Laryngoscopy (mirror or flexible scope) to visualize the larynx and hypopharynx 1

If Imaging is Pursued: Barium Esophagram Over CT

When imaging is deemed necessary for persistent globus sensation, a biphasic barium esophagram is the preferred initial study over CT. 1

Why Barium Esophagram is Superior:

• Functional assessment: Evaluates both structural abnormalities (strictures, rings, masses) AND motility disorders that can cause globus sensation 1
• Mucosal detail: Superior visualization of esophageal mucosa compared to CT 1
• No radiation from CT: Avoids the radiation exposure equivalent to 150 chest x-rays 1
• Cost-effective: Less expensive than CT with higher yield for esophageal pathology 1

When CT Neck Might Be Considered:

CT of the neck is not indicated for isolated globus sensation but may be appropriate if 1, 3:

• A palpable neck mass is present on examination
• There are concerning features suggesting malignancy (see red flags above)
• Suspected deep space infection with fever, severe pain, or systemic symptoms
• Foreign body ingestion is suspected (though plain films should be obtained first) 1

Ultrasound Has No Role Here

• Ultrasound of the neck is not appropriate for evaluating globus sensation 4, 5
• US is useful for thyroid nodules or goiter evaluation, but your patient has no mass or thyroid-related symptoms 4, 5

Common Pitfall to Avoid

The major pitfall is over-imaging patients with benign, self-limited globus sensation. This leads to:

• Unnecessary radiation exposure 1
• Increased healthcare costs 6, 2
• Potential false-positive findings that trigger unnecessary interventions 6
• Patient anxiety from incidental findings 2

Recommended Approach

1. Perform thorough history and physical examination focusing on red flag features listed above 1
2. If examination is normal and no red flags present: Reassure patient, consider trial of proton pump inhibitor for possible reflux-related globus, and arrange follow-up 1
3. If symptoms persist >2-3 weeks despite normal exam: Consider barium esophagram (NOT CT) 1, 2
4. Reserve CT neck for patients with palpable masses, concerning examination findings, or high-risk features suggesting malignancy 1, 3