What is the most appropriate initial evaluation, including imaging, for a patient with chronic globus sensation and dysphagia?

Initial Evaluation of Chronic Globus Sensation with Dysphagia

For a patient presenting with chronic globus sensation and dysphagia, begin with a biphasic barium esophagram that includes videofluoroscopic evaluation of the pharynx plus complete esophageal imaging, followed by upper endoscopy with biopsies to exclude mucosal pathology and gastroesophageal reflux disease. 1

Diagnostic Algorithm

Step 1: Videofluoroscopic Modified Barium Swallow with Complete Esophageal Evaluation

• The American College of Radiology recommends a combined examination of videofluoroscopy with static pharyngeal images plus complete esophageal and gastric cardia evaluation as the preferred initial test, providing higher diagnostic value than either study alone. 1

• This approach is critical because up to 68% of patients with pharyngeal complaints have esophageal abnormalities, and one-third have esophageal pathology as the only finding—distal lesions frequently cause referred dysphagia to the throat. 2

• The videofluoroscopic component identifies causes in 76% of patients and accurately localizes structural findings in 75% of cases. 3

• The biphasic esophagram demonstrates 96% sensitivity for detecting esophageal or gastroesophageal junction cancer and 95% sensitivity for lower esophageal rings and peptic strictures. 1

Step 2: Upper Endoscopy with Biopsies

• Following the barium study, upper endoscopy with biopsies at two levels is mandatory to exclude mucosal lesions, eosinophilic esophagitis, and subtle esophagitis not visible on barium studies. 1

• Endoscopy provides the highest diagnostic yield for esophageal cancer when multiple biopsies and brushings are obtained and is more sensitive than barium studies for detecting mild reflux esophagitis. 1

• Gastroesophageal reflux with esophagitis must always be excluded, especially in patients with globus sensation, as GERD is present in 48% of patients with chronic throat symptoms and laryngeal findings. 4, 5

Why This Sequence Matters

• Barium studies detect 95% of lower esophageal rings versus only 76% by endoscopy because prone single-contrast views provide better distal esophageal distention that endoscopy in the upright position cannot achieve. 1

• Lower esophageal rings are 2-3 times more likely to be missed on endoscopy due to inadequate distention, making initial barium imaging essential to avoid this common pitfall. 1

• The videofluoroscopic component assesses oral cavity, pharynx, cervical esophagus, tongue motion, laryngeal elevation, and aspiration risk—areas not visualized by standard endoscopy. 1

Critical Pitfalls to Avoid

• Never use static barium images alone without videofluoroscopy for throat symptoms, as this misses functional abnormalities such as aspiration, delayed pharyngeal transit, and cricopharyngeal dysfunction. 1

• Do not limit evaluation to the pharynx when symptoms seem localized to the throat—the entire esophagus and gastric cardia must be evaluated because distal lesions produce referred dysphagia in the majority of cases. 3, 2

• Avoid ordering CT neck and chest as initial imaging because it does not assess oropharyngeal and esophageal mucosa or motility; reserve CT for subsequent evaluation if initial studies are unrevealing. 3

• Recognize that barium studies cannot provide tissue for histology and therefore cannot diagnose eosinophilic esophagitis, infectious esophagitis, or confirm malignancy—this is why endoscopy must follow. 1

When to Consider Additional Testing

• If both barium study and endoscopy are normal but dysphagia persists, proceed to high-resolution manometry, which shows 98% sensitivity and 96% specificity for detecting achalasia and other motility disorders. 1

• Occasionally, barium studies reveal dysmotility patterns not captured by manometry, such as beak-like narrowing in achalasia despite normal sphincter relaxation on pressure testing. 1

• For suspected aspiration, note that 55% of patients with aspiration lack a protective cough reflex, making clinical diagnosis difficult—the modified barium swallow is essential for detection. 1

Expected Therapeutic Outcome

• When gastroesophageal reflux disease is identified as the underlying cause, medical antireflux therapy with proton pump inhibitors resolves laryngeal disorders and throat symptoms in 97% of patients (29 out of 30) with sustained results over 8 months of follow-up. 5