Globus Presents Diagnostic Challenge for Otolaryngologists

“I tend to think radiologic imaging is unnecessary in most cases unless the patient is at a higher risk for malignancy—for example, [if] they smoke or have other ominous symptoms, or if there’s no improvement with empiric treatment,” said Dr. Rubin. “However, the level of concern is marginally higher if the globus is a feeling of a lump rather than a ‘mucous’ sensation, and it can be argued that gabapentin could mask a malignancy, so clinical acumen and follow-up is warranted. But, of course, in-office endoscopy and head and neck examination allow us to evaluate the patient fairly thoroughly.”

Resolving the Issue

Newer cases of globus sensation often resolve themselves, but this is less likely to happen in longer-standing cases. There are key treatments that can help resolve the problem. Because reflux is the most common cause of globus, medications that treat reflux, including proton pump inhibitors, H2 receptor blockers, and

antacids, can help eliminate the mucous sensation that patients often feel. A very strict diet to keep reflux under control, in combination with medication, can also help.

If neuralgia is suspected, protein pump inhibitors and gabapentin, commonly used to treat seizures and nerve pain, can improve the condition. Because gabapentin generally works in a few weeks rather than the few months required for reflux medications, using it for treatment can provide diagnostic insight as well. “We have a new understanding of vagal motor and sensory neuropathies that occur; they are often treated with medications like amitriptyline HCl,” said Dr. Pitman. “At the moment, it’s unclear if such treatment is viable for “idiopathic” globus, but it’s being investigated.”

Additional empirical remedies must be assessed based on the suspected cause. Voice therapy can often be useful in cases involving muscle strain, for instance, while antidepressants may help resolve the sensation in patients who have globus that is connected to a form of anxiety disorder.

Finding a resolution of symptoms can require a tremendous effort, however, and this may not be important to all patients. “If none of the treatments you try are successful, you may find that some patients decide that, so long as they know they’re healthy overall, it’s all right with them to not treat the globus,” added Dr. Pitman.

Reassuring Patients

The bottom line, according to both Drs. Pitman and Rubin, is to reassure patients who are concerned about what the sensation might mean in terms of their health. “Patients will often come in very worried,” said Dr. Rubin. “Reassure them that it is unlikely the sign of anything terribly serious, and that as a physician, your goals are to rule out anything bad and to try to help improve the system.”