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Globus sensation and laryngopharyngeal reflux.


A 61-year-old man was evaluated for a 2-month history of globus sensation and throat irritation. He also complained of daily reflux and heartburn that had not responded to ranitidine therapy; to that point, he had not tried a proton-pump inhibitor (PPI). He described a feeling of food sticking in his chest while eating, which he often cleared with swallows of liquid. He denied weight loss or throat pain. His history also included anxiety, for which he was being treated with clonazepam.

Findings on the physical examination were unremarkable. Transnasal laryngoscopy revealed mild vocal fold atrophy without masses or lesions, normal fold movement, minimal pooling of secretions in the postcricoid area, and vocal fold and postcricoid edema suggesting laryngopharyngeal reflux (LPR).

Esophagography revealed a normal mucosal profile, mild esophageal dysmotility, and distal esophageal spasms. There was transient intraesophageal stasis at the aortic notch that was elicited by a marshmallow fragment, which reproduced the dysphagia symptoms and cleared with a swallow of thin barium. A small hiatal hernia was noted (figure, A), along with spontaneously elicited reflux to the thoracic inlet (figure, B).

The patient was prescribed twice-daily omeprazole (20 mg) and counseled about lifestyle changes. At the 3-month follow-up, he reported a near-total resolution of his symptoms. He was continued on omeprazole once daily in addition to the clonazepam as needed.

Globus sensation is a multifactorial condition of often-uncertain etiology. It is responsible for approximately 4% of all new referrals to ENT clinics, and it has been reported by as many as 46% of otherwise healthy patients; its incidence peaks during middle age. (1)

Despite its prevalence, no true standard for investigative diagnosis or treatment has been developed for globus. (2) LPR is linked to globus by two main mechanisms: (1) vagal reflux stimulation in the esophagus by acidic reflux and (2) mucosal injury in the larynx from direct contact with refluxate that contains gastric acid and pepsin. (3) A favorable response to empiric treatment with a twice-daily PPI for 2 or 3 months is diagnostic. (4)

Some study results have suggested that psychological factors such as depression and anxiety can influence the etiology of globus. Such patients might improve after being reassured that an investigation has found no serious pathology. (5)

Esophagography can assess esophageal motility and mucosal integrity, and it sometimes demonstrates spontaneous reflux to the thoracic inlet, as occurred in this case. Patients who do not improve with PPI therapy should be evaluated with esophageal manometry and/or impedance testing, with consideration for motility disorders or ongoing non-acid reflux contributing to their pathophysiology.

Michael J. Knabel, BS; Jonathan M. Bock, MD, FACS

From the Division of Laryngology and the Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee.


(1.) Lee BE, Kim GH. Globus pharyngeus: A review of its etiology, diagnosis and treatment. World J Gastroenterol 2012;18(20):2462-71.

(2.) Bums P, O'Neill JP. the diagnosis and management of globus: A perspective from Ireland. Curr Opin Otolaryngol Head Neck Surg 2008;16(6):503-6.

(3.) Tsutsui H, Manabe N, Uno M, et al. Esophageal motor dysfunction plays a key role in GERD with globus sensation--analysis of factors promoting resistance to PPI therapy. Scand J Gastroenterol 2012;47(8-9):893-9.

(4.) Campagnolo AM, Priston J, Thoen RH, et al. Laryngopharyngeal reflux: Diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol 2014;18(2):184-91.

(5.) Oishi N, Saito K, Isogai Y, et al. Endoscopic investigation and evaluation of anxiety for the management of globus sensation. Auris Nasus Larynx 2013;40(20):199-203.
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Author:Knabel, Michael J.; Bock, Jonathan M.
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Date:Oct 1, 2015
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