What could be causing a lump sensation in my chest and the back of my throat?

Lump Sensation in Chest and Throat: Evaluation and Management

Most Likely Diagnosis

The sensation of a lump in the throat and chest most commonly represents globus pharyngeus, often associated with laryngopharyngeal reflux disease (LPRD) or gastroesophageal reflux disease (GERD), though structural causes including malignancy must be excluded, particularly in patients with risk factors. 1, 2

Initial Clinical Assessment

Key Historical Features to Elicit

• Relationship to swallowing: Globus characteristically improves with eating rather than worsening, which distinguishes it from true dysphagia 3, 4
• Pain presence: Globus is typically non-painful; odynophagia (painful swallowing) suggests structural pathology 1, 4
• Voice changes or hoarseness: May indicate laryngeal involvement or recurrent laryngeal nerve compression from malignancy 1
• Smoking and alcohol history: These are the greatest risk factors for hypopharyngeal malignancy 5
• Associated symptoms: Chronic cough, throat clearing, heartburn, regurgitation, waterbrash, or chest pain suggest reflux disease 1, 2
• Red flag symptoms: Hemoptysis, weight loss, night sweats, progressive dysphagia, or recurrent pneumonia warrant urgent malignancy evaluation 1

Physical Examination Priorities

• Direct visualization with nasolaryngoscopy is essential as a first-line assessment to exclude structural abnormalities of the oropharynx, hypopharynx, and larynx 4, 6, 7

Diagnostic Algorithm

For Patients WITHOUT Red Flags

Empirical high-dose proton pump inhibitor (PPI) therapy is reasonable as first-line management given that GERD/LPRD is a major cause of globus and the condition is generally benign. 4, 2

• If symptoms resolve with PPI therapy, continue treatment and address underlying reflux triggers 4
• If symptoms persist after 8-12 weeks of PPI therapy, proceed to definitive investigations 4

For Patients WITH Red Flags or PPI-Refractory Symptoms

Proceed directly to imaging and functional studies: 1, 3

1. Modified barium swallow with speech therapy evaluation to assess oropharyngeal swallow function, tongue motion, hyoid elevation, laryngeal penetration, and cricopharyngeus muscle function 1, 3

2. Biphasic esophagram is essential because distal esophageal or gastric cardia abnormalities can cause referred pharyngeal symptoms—abnormalities in the esophagus may be the only finding in one-third of patients with throat complaints 1, 3

3. Upper endoscopy if reflux disease is suspected or to exclude mucosal lesions 4

4. Multichannel intraluminal impedance/pH monitoring and manometry for patients with persistent symptoms despite negative initial investigations 4

Critical Pitfall: Missing Referred Dysphagia

Abnormalities of the mid or distal esophagus or gastric cardia commonly cause referred sensation to the upper chest or pharynx, whereas pharyngeal abnormalities rarely cause referred symptoms. 1 This means a complete esophageal evaluation is mandatory even when symptoms localize to the throat, as 68% of patients with dysphagia complaints have abnormal esophageal transit. 1

When to Suspect Malignancy

• Any patient with risk factors (smoking, alcohol) and persistent throat symptoms requires thorough visualization 5, 6
• Hypopharyngeal tumors are rare but malignant in 97-99% of cases when present 5
• Patients with pharyngeal carcinomas have significantly increased risk of synchronous esophageal carcinomas 1
• 52% of patients with laryngeal cancer thought their hoarseness was harmless and delayed seeking care 1

Management Based on Final Diagnosis

If Globus Pharyngeus (Functional)

• Reassurance and explanation of symptoms 3, 4
• High-dose PPI therapy if GERD symptoms present 3, 4
• Speech and language therapy with behavioral interventions including graduated exposure to feared food textures and relaxation techniques 3, 4
• Cognitive-behavioral therapy or antidepressants for persistent symptoms with anxiety component 4

If LPRD/GERD Confirmed

• Augmentation of upper esophageal sphincter barrier function can reduce reflux penetration 2
• Aggressive acid suppression with high-dose PPI 2, 4
• Lifestyle modifications addressing reflux triggers 2

If Structural Pathology Identified

• Management depends on specific diagnosis (malignancy, thyroid abnormality, cysts, masses in preepiglottic space) and requires appropriate specialist referral 6, 7