The 24 hour dual sensor ambulatory pH monitoring, which is considered by some to be the gold standard in detecting gastroesophageal reflux, has been used to investigate any links between globus pharyngeus and acid reflux. Mixed conclusions have been found with some investigators reporting no findings of reflux and others reporting that extraesophageal reflux was proven in up to 32.6% of patients with pure globus pharyngeus [17]. When LPR is found, the dual pH monitor can not predict the severity of the patients symptoms or signs [18]. It is important to note that most of these trials contain low numbers and often utilise a pH 4.0 threshold for positive findings of reflux. Problems arise because the larynx lacks the protective layers of the lower oesophagus and it is believed that lower amounts of acid exposure at higher pH can cause irritation and that the exposure time required to produce this effect is much less than in the oesophagus. In addition to this, the presence of activated pepsin within gastric contents may coat the larynx and result in laryngeal inflammation and irritation for a longer period than the original exposure [19].

Barium swallows are often requested to evaluate patients with globus pharyngeus and to exclude pharyngeal and upper oesophageal neoplastic lesions [20]. In two recent studies, with patient numbers totalling 3286, there was no serious pathology detected and no malignancies found [14,21]. The commonest finding during these studies was cervical osteophyte indentation.

The sensitivity of barium swallow to pick up small upper aero-digestive tumours, particularly in the hypopharynx, is low and has been reported to miss approximately 50% of these [22]. Given this low sensitivity and lack of findings in patients with pure globus pharyngeus, along with the costs involved and the attendant radiation effects, it was suggested that barium swallows should be reserved for patients with atypical symptoms or risk factors for upper aero-digestive tumours [14,21].

The value of rigid endoscopy in the investigation of globus symptoms remains questionable. A recent retrospective study of 250 rigid endoscopies for globus pharyngeus demonstrated 217 (86.8%) were entirely normal [23]. Given that abnormal findings in this study were not neoplastic and included cricopharyngeal spasm, reflux, pharyngitis, webs and retention cysts; the argument raised is that rigid endoscopy may be inappropriate in the management of globus patients.

Rigid endoscopy is, overall, the best way of ruling out malignancy however the risks, costs and discomfort associated with this can be avoided in patients who do not have atypical features or findings on history and examination.

There has been some investigation into thyroid pathology as a potential cause of globus sensation. In one paper, consisting of 43 patients with globus pharyngeus and 33 controls, it was found that ultrasound-detectable abnormalities were significantly more common in patients with globus pharyngeus than in controls [24].

The leading current theory is that laryngopharyngeal reflux causes globus symptoms [25-27]. A survey of general practitioners in 2005 showed the vast majority were unaware of laryngopharyngeal reflux (LPR) and its association with globus pharyngeus [28]. Conversely, in a recent survey of ENT consultants in the UK, 90% believed in laryngopharyngeal reflux and greater than 50% prescribed proton pump inhibitors (PPI’s) for the treatment of this [29]. The regimen used varied within this survey, with most prescribing once daily PPI. Interestingly, a more recent double blind, randomised, placebocontrolled trial has suggested that the globus pharyngeus patient who presents with a normal head and neck examination and without sinister otolaryngologic complaints does not benefit from once-daily PPI therapy [30]. To strengthen this argument, further research has shown that laryngopharyngeal symptoms improve significantly more slowly than esophageal symptoms following acid-suppression therapy [31]. This has led to the treatment of laryngopharyngeal reflux (LPR) with higher doses of PPI for a longer period to decrease laryngeal oedema [32]. This consists of twice daily PPI for a period of 3 to 6 months. Timing of administration of the PPI is essential. They should be administered 30 mins before food. This is to allow maximal therapeutic blood levels, prior to activation of the proton pumps within the stomach by eating [19]. Unfortunately, long term randomised controlled trials are lacking for the efficacy of this treatment.

Other therapies have been attempted, a double-blind controlled study showed no significant difference in treatment of patients with globus symptoms using either a histamine H₂ receptor antagonist or placebo [33]. Conversely, in a recent pilot non-placebo-controlled study, the use of liquid alginate suspension has shown promising results for treating laryngopharyngeal reflux symptoms [34].

Some lifestyle modifications have been suggested to help with gastroesophageal reflux and LPR.

Firstly, avoidance of certain foods can help. Citrus fruits, jams, jellies, tomatoes and some sauces such as barbeque sauce and salad dressings have pH below 4.6 and worsen reflux symptoms. Along with these, other foods such as curry, mustard and peppers can cause direct irritation and inflammation to the larynx [19]. Caffeine, alcohol, chocolate and peppermint all relax the oesophageal sphincters and increase reflux symptoms.

Behavioral advice, such as not eating large meals prior to exercise or going to bed can aid in symptom control. Physically raising the head of the bed with blocks to let gravity prevent reflux is often a good tool to help night time reflux.

There has been some investigation into the effectiveness of SLT in treating globus pharyngeus [35-37]. A recent paper reported good improvement in symptom scores following a treatment programme that included education, reassurance and the use of exercises. Numbers within the trial were, however, limited and the authors were unable to detect which part of their program specifically helped with symptoms. There were also no objective videofluoroscopic changes following therapy [35].

Certainly, further research into the effectiveness of SLT in treating globus symptoms is desirable.

The presence of a goitre or thyroid mass is significant in the management of globus pharyngeus. Within a 2 year prospective trial investigating the relationship between thyroid pathology and globus symptoms; as many as one third of patients with a thyroid mass had globus symptoms. Following surgery, 80% saw resolution of their symptoms [38]. It has been questioned previously if thyroidectomy can actually cause globus symptoms. A recent survey of patients following thyroidectomy did not show any worsening of globus symptoms at 3 and 12 months but, in fact, showed improvement in these symptoms [39].

There have been two validated severity scoring tools available for use over the last 15 years. These are the Glasgow and Edinburgh Throat Scale [40] (GETS) and the Reflux Symptom Index (RSI) [41]. Both scales ask the patient to score specific symptoms in terms of severity and, overall, seem to detect similar symptom clusters [42]. Both scales can be used to monitor symptom progression or resolution. Another scoring system used is the Reflux Finding Score (RFS) which is a an eight-item validated clinical severity scale used during endoscopic evaluation of the larynx that was introduced as a means of offering some standardization to the process of laryngopharyngeal reflux diagnosis [43].

Interestingly, in the recent survey of ENT consultant in the UK, 94% did not use popular scoring scales such as the reflux symptom index or the reflux finding score [29]. This finding raises questions regarding the application of these scoring scales in clinical practice.