What imaging is indicated for a patient presenting with globus sensation (persistent lump in the throat) who has no alarm features such as dysphagia, odynophagia, weight loss, hoarseness, neck mass, or neurologic deficits?

Imaging for Globus Sensation Without Alarm Features

No imaging is indicated for patients presenting with isolated globus sensation in the absence of alarm features. 1, 2, 3

Clinical Approach to Globus Without Red Flags

The appropriate initial management is empirical high-dose PPI therapy for 8-12 weeks, not imaging. 1, 4 Globus sensation is a benign functional disorder characterized by a non-painful feeling of a lump in the throat that characteristically improves during eating—a key distinguishing feature from true dysphagia. 1, 2

When Imaging Is NOT Needed

For patients with typical globus presentation:

• No dysphagia (difficulty swallowing that worsens with food) 1, 2
• No odynophagia (painful swallowing) 1, 3
• No weight loss 1, 3
• No hoarseness 5
• No palpable neck mass or lymphadenopathy 5, 1
• No hemoptysis, fever >101.5°F, or night sweats 5, 1

Imaging studies including CT, MRI, and barium studies are not appropriate initial investigations for uncomplicated globus. 5, 3

First-Line Management Algorithm

1. Perform nasolaryngoscopy to exclude structural pharyngeal/laryngeal pathology (Zenker's diverticulum, pharyngeal cancer, thyroid enlargement) 4, 3, 6

2. Initiate empirical high-dose PPI therapy for 8-12 weeks as first-line treatment, given GERD is recognized as a major causative factor 1, 4, 6

3. Reserve endoscopy, manometry, and pH monitoring for patients who fail PPI therapy or have atypical features 4, 3, 6

When Imaging BECOMES Indicated

Imaging should only be pursued if alarm features develop or if initial conservative management fails:

• Barium esophagram with pharyngeal views is appropriate if dysphagia develops or structural abnormality is suspected after failed PPI trial 5
• CT neck may be helpful if a neck mass or lymphadenopathy is detected on physical examination 5
• Contrast studies should not delay endoscopic evaluation if true dysphagia or food bolus obstruction is present 5

Critical Pitfalls to Avoid

Do not mistake globus for dysphagia—the key distinction is that globus improves with eating while dysphagia worsens with swallowing. 1, 2 Misdiagnosis leads to inappropriate invasive testing.

Do not order barium studies as initial investigation for uncomplicated globus—fluoroscopy is designed to evaluate swallowing mechanics and structural abnormalities, neither of which are the primary issue in functional globus. 5

Do not pursue imaging before adequate PPI trial—given the benign nature of globus and its strong association with reflux, empirical acid suppression is more appropriate than immediate objective testing. 1, 4, 3

Adjunctive Therapies After Failed PPI Trial

If symptoms persist despite 8-12 weeks of high-dose PPI:

• Consider speech and language therapy for pharyngolaryngeal tension and functional voice disorders 1, 7
• Evaluate for esophageal motility disorders with high-resolution manometry (47.9% of PPI-resistant patients have abnormal motility) 6
• Consider neuromodulators or cognitive-behavioral therapy for refractory idiopathic globus 4, 3, 6