What is the initial workup for a patient presenting with a globus sensation?

Initial Workup of Globus Sensation

Begin with a focused history to distinguish globus from dysphagia and screen for alarm symptoms, followed by otolaryngological examination to exclude structural pathology, then initiate empiric high-dose PPI therapy for 8-12 weeks if no red flags are present. 1

Key Clinical Distinction

The critical first step is differentiating true globus from dysphagia, as they require entirely different management pathways:

• Globus sensation improves or disappears during eating and is more prominent between meals 1, 2
• Dysphagia worsens with swallowing food and represents true difficulty swallowing 1, 2
• Approximately 20% of patients may have both conditions simultaneously 2

Focused History Elements

Red Flag Symptoms Requiring Urgent Investigation

Screen immediately for alarm features that mandate endoscopy or specialist referral 1:

• Weight loss (requires urgent endoscopy) 1
• True dysphagia or odynophagia (painful swallowing) 1
• Food bolus obstruction (requires urgent gastroenterology referral, as eosinophilic esophagitis is found in up to 46% of these cases) 1
• Hemoptysis, fever >101.5°F, or night sweats 1

Characteristic Globus Features to Elicit

• Recurrent, non-painful sensation of a lump or foreign body in the throat 1, 2
• Symptoms more obvious between meals 1, 2
• Improvement with eating or drinking 1, 2
• Associated throat clearing, sense of mucus buildup, dry throat, or repeated swallowing 1, 2
• Exacerbation during periods of psychological stress 1, 2

Associated Conditions to Assess

• GERD symptoms: heartburn, regurgitation, belching (present in 68-76% of globus patients) 3
• Postural relationship: worsening when bending or lying down suggests reflux 1
• Psychological factors: anxiety, depression, or prior trauma 1, 4
• Medication history: inhaled steroids, which can cause chemical laryngitis 1
• Substance use: chronic tobacco or alcohol use 1

Physical Examination

Otolaryngological Evaluation

Perform laryngoscopy to exclude structural pathology 1:

• Examine larynx, epiglottis, base of tongue, pyriform fossae, and hypopharynx 4
• Look for laryngeal findings suggestive of GERD: pooling of saliva, erythema of posterior one-third of larynx, interarytenoid edema, or granuloma 3
• Exclude Zenker's diverticulum, foreign body, or malignancy 1
• Assess for pharyngolaryngeal tension 1

Neck Examination

• Palpate for lymphadenopathy: nodes >1.5 cm, firm, or non-tender require urgent investigation for malignancy 1
• Assess thyroid for enlargement or nodules 1

Initial Diagnostic Testing

When Imaging or Endoscopy is NOT Needed Initially

If history and physical examination reveal no alarm symptoms and findings are consistent with typical globus:

• No routine endoscopy is indicated 1
• No routine imaging is indicated 1
• Proceed directly to empiric PPI therapy 1

When Further Investigation is Required

Urgent endoscopy indications 1:

• Weight loss
• True dysphagia or odynophagia
• Food bolus obstruction
• Palpable lymphadenopathy >1.5 cm

Consider imaging (CT or MRI) when 1:

• Cervical lymphadenopathy with systemic symptoms
• Suspected structural lesion on examination

First-Line Treatment Algorithm

Empiric PPI Therapy

Initiate high-dose PPI therapy for 8-12 weeks as first-line treatment for patients without alarm symptoms 1:

• GERD is a major causative factor in globus sensation 1
• Globus commonly represents extraesophageal reflux manifestations 1
• Adequate trial duration of 8-12 weeks is essential, as inadequate duration is a common pitfall 1

Adjunctive Therapies Based on GERD Phenotype

If breakthrough symptoms occur during PPI therapy 1:

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

Management After Failed PPI Trial

If Symptoms Persist After 8-12 Weeks of PPI

Consider the following sequential approach:

1. Esophageal motility evaluation: 47.9% of PPI-resistant globus patients have abnormal esophageal motility, most commonly ineffective esophageal motility 5

2. Speech and language therapy: Primary intervention for laryngeal hypersensitivity syndrome, addressing aberrant involuntary learned behaviors 1

3. Neuromodulators (TCAs): Low-dose tricyclic antidepressants (10-25 mg at bedtime) for visceral hypersensitivity, requiring several weeks for effect 6

Multidisciplinary Considerations

Globus often requires input from multiple specialties 1:

• Otolaryngology: laryngeal evaluation and exclusion of structural pathology 1
• Gastroenterology: reflux assessment and endoscopic evaluation when indicated 1
• Psychiatry/psychology: when anxiety or depression is prominent 4

Common Pitfalls to Avoid

• Mistaking globus for dysphagia leads to inappropriate invasive workup 1, 2
• Inadequate PPI trial duration (<8 weeks) results in premature escalation 1
• Prescribing muscle relaxants (e.g., cyclobenzaprine) is inappropriate, as globus is a sensory phenomenon, not true muscle spasm 6
• Missing food bolus obstruction, which requires urgent intervention 1
• Failing to screen for psychological comorbidities, which are present in up to 63% of patients 4