What are the next steps for a patient with a globus sensation in the throat, normal laryngoscopy results, and symptoms consistent with Laryngopharyngeal Reflux (LPR), who has been treated for LPR?

Management of Persistent Globus Sensation After Failed LPR Treatment

For a patient with persistent globus sensation, normal laryngoscopy, and failed LPR treatment, you should discontinue PPI therapy and consider this a functional laryngeal disorder requiring neuromodulator therapy (such as low-dose amitriptyline or SSRIs) combined with speech-language pathology behavioral interventions. 1, 2

Why PPIs Should Be Stopped

• Laryngoscopic findings are unreliable for LPR diagnosis and should not be used to guide treatment decisions, with sensitivity and specificity both less than 50% and substantial inter-observer variability. 1

• PPIs demonstrate no benefit over placebo for isolated LPR symptoms without heartburn or regurgitation, with meta-analyses of 8 randomized controlled trials showing no advantage (relative risk 1.28; 95% CI 0.94-1.74). 1, 3, 4

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against prescribing antireflux medications for isolated dysphonia or LPR symptoms without documented GERD. 3, 4

• Continuing PPIs beyond 3 months without response exposes patients to unnecessary risks including impaired cognition, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease. 3

The Functional Laryngeal Disorder Paradigm

Globus sensation with normal laryngoscopy after failed PPI therapy represents functional laryngeal disorder or laryngeal hypersensitivity, not reflux disease. 1, 2

Medical Management Options:

• Low-dose amitriptyline or SSRIs are recommended for globus sensation, as these neuromodulators address the underlying sensory hypersensitivity mechanism. 1, 2

• Consider starting amitriptyline 10-25 mg at bedtime, titrating upward based on response and tolerability. 1

• SSRIs represent an alternative for patients who cannot tolerate tricyclic antidepressants. 1

Behavioral Interventions:

• Refer to speech-language pathology for specific behavioral therapy targeting functional throat symptoms. 1

• Cognitive Behavioral Therapy strategies should identify and challenge maladaptive beliefs (e.g., "food will stick in my throat"), self-reported sensations (e.g., "my throat feels tight"), and avoidance behaviors. 1

• Recommend positive self-statements such as "my throat feels easy" to redirect attention away from throat sensations. 1

• Address hypervigilance to bodily functions and abnormal illness beliefs through counseling. 1

Diagnostic Workup Before Neuromodulator Therapy

If you have not already performed objective reflux testing, consider pH-impedance monitoring off PPI therapy to definitively exclude pathologic reflux before committing to neuromodulator therapy. 1

• Reflux monitoring has limited diagnostic utility for extra-esophageal GERD, with poor sensitivity, specificity, and predictive value for PPI response. 1

• However, documenting absence of pathologic reflux provides reassurance to both clinician and patient that the functional diagnosis is correct. 1

• After one failed 3-month trial of appropriate therapy, performing esophageal manometry and pH-metry is recommended before trying additional medications. 3, 4

Critical Pitfalls to Avoid

• Do not add H2-receptor antagonists to PPI therapy - there is no evidence of improved efficacy, and H2RAs develop tachyphylaxis with frequent use. 3

• Do not increase PPI dosing or switch to different PPIs - if twice-daily dosing for 3 months failed, additional acid suppression will not help. 3, 4

• Do not perform anti-reflux surgery - lack of response to PPI therapy predicts lack of response to fundoplication. 5, 6

• Do not continue empiric therapy beyond 3 months without objective improvement - this delays appropriate diagnosis and treatment of the functional disorder. 3, 4

Treatment Timeline and Expectations

• Neuromodulator therapy typically requires 4-8 weeks to demonstrate benefit for functional laryngeal symptoms. 1, 2

• Behavioral interventions through speech-language pathology should be initiated concurrently with pharmacotherapy for optimal outcomes. 1

• If no improvement after 8-12 weeks of combined neuromodulator and behavioral therapy, reassess for alternative diagnoses including post-nasal drip, allergic rhinitis, or chronic sinusitis. 5