What is the likely cause and appropriate management for a patient who feels a lump-like sensation in the throat when lying down after recent surgery?

Post-FESS Globus Sensation When Lying Down

The sensation of something in the throat when lying down after FESS surgery is most likely gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), and you should initiate proton pump inhibitor (PPI) therapy immediately while ruling out surgical complications.

Understanding the Likely Cause

The positional nature of this symptom (occurring specifically when lying down) strongly suggests reflux-related pathology rather than a surgical complication. 1 LPR is a subset of GERD with specific alterations in upper esophageal sphincter reflexes that reduce esophageal refluxate clearance, and the supine position exacerbates reflux symptoms by removing gravitational assistance in keeping gastric contents in the stomach. 2

Globus pharyngeus—the non-painful sensation of a lump or fullness in the throat—is commonly associated with reflux disease and characteristically may improve during meals but worsen with dry swallows. 2, 3

Immediate Management Algorithm

First-Line Treatment

• Initiate high-dose PPI therapy immediately 4
  • The UK guidelines on esophageal disorders provide high-grade evidence (GRADE: high; strength: strong) that PPI therapy is effective for GORD-related dysphagia and globus symptoms 4
  • PPIs are superior to H2 receptor antagonists for symptom relief 4

Behavioral Modifications

• Elevate the head of the bed to reduce nocturnal reflux
• Avoid eating within 3 hours of lying down
• Assess for post-surgical nasal drainage that may be contributing to throat irritation when supine

When to Suspect Surgical Complications

You must rule out post-operative complications if any of the following are present: 4

• Persistent pain (not just discomfort)
• Fever or tachycardia
• Dysphagia (difficulty swallowing, not just sensation)
• Odynophagia (painful swallowing)
• Progressive worsening of symptoms despite conservative management
• Breathlessness

If any alarm features are present, obtain CT imaging with oral contrast to evaluate for abscess, hematoma, or other structural complications. 4

Diagnostic Workup if Symptoms Persist

If PPI therapy for 8-12 weeks does not resolve symptoms:

1. Laryngoscopy to visualize the pharynx and larynx for post-surgical changes, inflammation, or structural abnormalities 2, 3

2. Upper endoscopy to exclude esophageal pathology, stricture, or heterotopic gastric mucosa (which can be ablated if present and symptomatic) 2, 3

3. Consider high-resolution manometry and ambulatory pH monitoring if diagnosis remains unclear after negative endoscopy 2

Common Pitfalls to Avoid

• Do not dismiss the symptom as purely psychogenic without appropriate evaluation—globus has identifiable organic causes in many cases 2, 3, 5

• Do not perform routine imaging immediately post-operatively unless alarm symptoms are present 4

• Avoid attributing all throat symptoms to anxiety in the post-surgical period—while functional disorders exist, reflux and post-operative inflammation are more common causes 4, 2

Reassurance and Prognosis

Reassure the patient that globus symptoms are benign with no long-term consequences, and the magnitude of symptoms typically declines over time. 2 The positional nature (worse when lying down) further supports a benign, reflux-related etiology rather than a serious surgical complication.

If symptoms persist despite optimal PPI therapy and negative objective testing, consider:

• Neuromodulators (such as low-dose amitriptyline) 3
• Speech and language therapy for functional globus 4
• Cognitive behavioral approaches 3