Is Acid Reflux with Throat Globus Worrisome in a Patient with Known GERD?
This presentation is generally not worrisome and represents a common extraesophageal manifestation of GERD, but requires a structured approach to rule out alarm features and optimize treatment. 1
Initial Assessment: Rule Out Alarm Features
Before attributing symptoms to GERD, you must actively exclude concerning features:
- Dysphagia pattern matters critically: New-onset dysphagia, progressive dysphagia, or dysphagia persisting despite therapy demands endoscopic investigation to exclude malignancy or stricture 1
- Weight loss, odynophagia, or family history of esophageal cancer require immediate endoscopy 1
- Duration assessment: Dysphagia that is intermittent and responsive to treatment is less concerning than persistent symptoms 1
Understanding Globus as an Extraesophageal Manifestation
The sensation of something stuck in the throat (globus) is a recognized extraesophageal manifestation of GERD:
- Up to 75% of patients with extraesophageal symptoms may not experience heartburn or regurgitation, placing the diagnostic burden on you to recognize GERD as the contributor 2
- Globus occurs through two mechanisms: direct reflux pathway (acid/pepsin reaching the pharynx) or reflex pathway (vagal reflexes triggered by esophageal acid exposure) 2, 1
- The pharynx and larynx lack the intrinsic protective mechanisms of the esophagus (bicarbonate production, tissue resistance), making them vulnerable to even small amounts of reflux 3
Treatment Approach
Start with optimized PPI therapy before pursuing extensive testing:
- Twice-daily PPI taken 30-60 minutes before meals for 8-12 weeks (extraesophageal symptoms require longer treatment than typical GERD) 1, 2, 3
- Implement dietary modifications: limit fat to <45g/24h, avoid coffee, tea, soda, chocolate, mints, citrus, tomatoes, and alcohol 1
- A 75% reduction in symptom frequency defines a positive therapeutic response 1
When to Pursue Objective Testing
If symptoms persist despite twice-daily PPI for 8-12 weeks, obtain pH/impedance monitoring:
- Testing should be performed while on PPI therapy since you have established GERD history, to assess whether current dosing provides adequate acid suppression 1, 4
- pH/impedance monitoring is superior to pH monitoring alone because it detects both acid and non-acid reflux episodes that may contribute to throat symptoms 1
- This testing helps distinguish between refractory GERD, hypersensitive esophagus, and functional disorders 1, 4
Common Pitfalls to Avoid
- Don't dismiss persistent or progressive dysphagia: While dysphagia is common (14% community prevalence), its pattern determines whether investigation is needed 1
- Don't assume all throat symptoms are GERD-related: 50-60% of patients with extraesophageal manifestations lacking typical GERD symptoms will not have GERD as the underlying cause 2
- Don't try multiple different PPIs empirically: If one optimized PPI trial fails, pursue objective testing rather than medication trials, as further empiric therapy is low yield 2, 4
Multidisciplinary Consideration
Consider otolaryngology referral if symptoms persist despite optimized therapy, as throat symptoms are often multifactorial and may require input from ENT specialists for comprehensive evaluation of laryngeal findings 1