What is the diagnosis and treatment for a female adult patient with a sensation of something stuck in her throat for over 1 month, which began after a scratchy throat illness, occurs when swallowing fluids, and is without pain?

Diagnosis: Globus Sensation (Globus Pharyngeus)

This patient has globus sensation, a benign condition characterized by the persistent feeling of something stuck in the throat that paradoxically improves with eating rather than worsening—a key distinguishing feature from true dysphagia. 1

Key Diagnostic Features Supporting Globus

• The sensation improves during eating rather than worsening with food intake, which is the hallmark feature distinguishing globus from true dysphagia 1
• Absence of pain (odynophagia) makes structural lesions, malignancy, or acute inflammation unlikely 2
• Intermittent, non-progressive nature over 1 month argues strongly against mechanical obstruction or malignancy 1
• Onset after upper respiratory illness with scratchy throat suggests post-viral laryngopharyngeal irritation or heightened sensory awareness 3

The sensation occurring specifically with fluid swallowing is consistent with globus, as patients often report the feeling is more noticeable with dry swallows or thin liquids rather than solid food 4.

Critical Distinction: Globus vs. True Dysphagia

True dysphagia presents with consistent difficulty swallowing, whereas globus is a recurrent, non-painful sensation that is typically more obvious between meals. 1 This patient lacks the cardinal features of oropharyngeal dysphagia (coughing, choking, aspiration, difficulty initiating swallow) 2 and esophageal dysphagia (progressive difficulty with solids then liquids, weight loss) 1.

Recommended Evaluation Approach

Initial Clinical Assessment

• Thorough examination of the neck, mouth, oropharynx, and larynx to identify masses, inflammation, or anatomical abnormalities 1
• Flexible fiberoptic nasolaryngoscopy to visualize the hypopharynx and larynx, looking for erythema, edema, or structural abnormalities 3, 5
• Assess for psychological stressors that may exacerbate globus sensation, as anxiety and stress commonly contribute 1, 4
• Review medication history, particularly ACE inhibitors which can cause chronic cough and throat irritation 2

Red Flags Requiring Urgent Evaluation

If any of the following develop, immediate further workup is mandatory:

• Progressive dysphagia (worsening difficulty swallowing solids then liquids suggests mechanical obstruction like cancer) 1
• Unintentional weight loss or anemia (suggests esophageal malignancy) 1
• Persistent symptoms lasting weeks with worsening pattern rather than intermittent episodes 1
• Dysphagia to both solids and liquids simultaneously from onset (suggests motility disorder like achalasia) 1
• Odynophagia (painful swallowing) which this patient does NOT have 2

When to Pursue Imaging

If true dysphagia develops (consistent difficulty swallowing), biphasic esophagram (barium swallow) is the appropriate next imaging study, with 96% sensitivity for esophageal cancer and 80-89% sensitivity for motility disorders. 1 However, for isolated globus sensation without red flags, imaging is typically not indicated initially 4.

Do not delay endoscopy with empiric acid suppression if alarm symptoms develop (progressive dysphagia, weight loss, anemia), as this can mask underlying malignancy. 1

Management Algorithm

First-Line Conservative Management (No Red Flags Present)

For presumed globus sensation without red flags, reassurance and stress management are first-line approaches. 1

• Reassurance that this is a benign condition and not cancer is therapeutic in itself 4
• Empiric trial of proton pump inhibitor (PPI) therapy for 8-12 weeks, as gastroesophageal reflux disease is a common contributor to globus even without typical heartburn symptoms 3, 6, 4
• Lifestyle modifications including avoiding late meals, elevating head of bed, reducing caffeine and alcohol 3
• Stress reduction and behavioral therapy if psychological factors are prominent 1, 4

Second-Line Options if Conservative Management Fails

• Speech therapy for swallowing exercises and behavioral modification 4
• Cognitive behavioral therapy to address anxiety and hypervigilance to throat sensations 4
• Low-dose amitriptyline (10-25 mg at bedtime) for neuromodulation of sensory hypersensitivity 4

When to Refer to Gastroenterology

• Failure to improve after 3 months of conservative management 4
• Development of any red flag symptoms 1
• Patient anxiety requiring definitive exclusion of structural pathology via upper endoscopy 4

Common Pitfalls to Avoid

Mistaking globus for dysphagia can lead to inappropriate treatment approaches and unnecessary invasive testing. 1 The key is recognizing that globus improves with eating, while true dysphagia worsens with eating.

Approximately 20% of patients with functional dysphagia may experience globus with swallowing, but true globus typically improves rather than worsens with food. 1

Do not dismiss persistent symptoms as purely psychogenic without proper evaluation, as rare structural causes (medially displaced thyroid cartilage, pharyngeal masses) can present similarly 5.

Gastroesophageal reflux disease can cause globus even in the absence of heartburn, with 20-60% of GERD patients having head and neck symptoms without appreciable heartburn 3, 6. Therefore, a PPI trial is reasonable even without typical reflux symptoms.

Expected Clinical Course

With reassurance and conservative management, most patients with globus sensation improve over weeks to months 4. The benign nature and favorable prognosis should be emphasized to reduce patient anxiety, which itself can perpetuate symptoms 4.