In a patient with a three‑week history of persistent globus sensation and no acute infection or airway compromise, what is the preferred initial imaging study—contrast‑enhanced CT of the soft tissues of the neck?

CT Soft Tissue Neck Imaging for Globus Sensation

For a patient with isolated globus sensation persisting 3 weeks without alarm symptoms, imaging with CT neck (with or without contrast) is not indicated and should not be performed. 1

Why Imaging Is Not Appropriate

Globus sensation is a benign, non-painful feeling of a lump or tightness in the throat that characteristically improves during eating or drinking. 2 The condition has no long-term consequences and follows a benign course, with symptoms often declining over time. 2

The ACR Appropriateness Criteria do not include globus sensation as an indication for neck CT imaging. 1 The guidelines specifically address:

• Nonpulsatile neck masses (palpable findings) 1
• Pulsatile neck masses 1
• Parotid region masses 1

None of these scenarios apply to globus sensation, which is a subjective symptom without a palpable mass. 2, 3

When Imaging Would Be Indicated

Imaging should only be considered if alarm symptoms develop, including: 2, 3

• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Unintentional weight loss
• Persistent hoarseness or voice changes
• Hemoptysis
• A palpable neck mass on examination

If a discrete palpable mass is identified on physical examination, then contrast-enhanced CT neck would be the appropriate initial imaging study. 1, 4

Appropriate Initial Management

The recommended first-line approach for uncomplicated globus sensation is:

1. Thorough otolaryngologic examination including nasolaryngoscopy to exclude pharyngeal, laryngeal, or thyroid pathology 5, 2, 3

2. Empirical trial of high-dose proton pump inhibitor (PPI) therapy for 8-12 weeks, given the strong association between gastroesophageal reflux disease and globus symptoms 6, 5, 2

3. If PPI-refractory, consider objective testing with upper endoscopy, high-resolution esophageal manometry, and/or ambulatory pH-impedance monitoring 5, 2

4. For persistent idiopathic globus after negative investigations, treatment options include reassurance, neuromodulators (such as amitriptyline or gabapentin), speech and language therapy, or cognitive-behavioral therapy 6, 5, 2, 3

Common Pitfalls to Avoid

• Do not order CT imaging for isolated globus sensation without alarm symptoms or palpable findings. This exposes the patient to unnecessary radiation (RRL ☢☢☢) without diagnostic benefit. 1

• Do not confuse subjective globus sensation with an objective palpable neck mass. Only the latter warrants cross-sectional imaging. 1

• Do not skip the initial otolaryngologic examination. Nasolaryngoscopy is essential to exclude organic pathology before attributing symptoms to functional globus. 5, 2, 3

• Recognize that 47.9% of PPI-resistant globus patients have esophageal motility disorders, most commonly ineffective esophageal motility, which may respond to prokinetic therapy. 6