What is the appropriate management for a patient presenting with a throat lump?

Management of Throat Lump (Globus Pharyngeus)

For a patient presenting with a throat lump sensation (globus pharyngeus), begin with nasolaryngoscopy to exclude structural pathology, then initiate empirical high-dose proton pump inhibitor therapy for 8-12 weeks, as gastroesophageal reflux is a major treatable cause. 1

Initial Clinical Assessment

The sensation of a throat lump requires distinguishing between benign globus pharyngeus and serious pathology through specific clinical features:

Red Flag Symptoms Requiring Urgent Evaluation

• Difficulty swallowing (true dysphagia), drooling, neck tenderness, or swelling suggest life-threatening conditions including peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 2, 3
• Persistent fever, rigors, night sweats, tender lymph nodes, tonsillopharyngeal exudates warrant testing for bacterial pharyngitis 2
• Weight loss, hemoptysis, odynophagia (painful swallowing), or hoarseness require endoscopy to exclude malignancy 2, 4

Characteristic Features of Benign Globus

Globus pharyngeus presents as a recurrent, non-painful sensation of a lump in the throat that paradoxically improves with eating and worsens between meals or with dry swallows. 2, 4, 1

• The sensation is described as a foreign body (hair, crumb), tightening, choking feeling, or throat strain 2
• Absence of true dysphagia is essential—patients can swallow normally without food sticking 2
• Symptoms may be associated with throat clearing, sense of mucus buildup, or chronic cough 2
• Inability to swallow in the absence of drooling or excessive oral secretions is a positive diagnostic sign of functional dysphagia 2

Diagnostic Approach

First-Line Investigation

Nasolaryngoscopy is essential as the initial investigation to visualize the oropharynx and supraglottis, as a high proportion of patients have treatable pathology detectable on direct visualization. 5

• Careful examination of the oral cavity, pharynx, and cervical structures should be performed 2
• Look specifically for tonsillar exudates, swollen tonsils, palatal petechiae, or scarlatiniform rash if infectious etiology is suspected 2

When to Pursue Additional Testing

If nasolaryngoscopy is normal and symptoms persist despite empirical PPI therapy, proceed with upper gastrointestinal endoscopy to evaluate the esophagus and gastric cardia, as distal esophageal abnormalities can cause referred pharyngeal symptoms. 2, 1

• Fluoroscopy with biphasic esophagram should include evaluation of the entire esophagus, as 68% of patients with dysphagia complaints have abnormal esophageal transit 2
• One-third of patients with esophageal abnormalities have no pharyngeal findings, making complete esophageal evaluation essential 2
• Multichannel intraluminal impedance/pH monitoring and manometry are reserved for patients nonresponsive to PPI therapy with negative endoscopy 1

Treatment Algorithm

Step 1: Empirical Medical Therapy

Initiate high-dose proton pump inhibitor therapy for 8-12 weeks as first-line treatment, given that gastroesophageal reflux disease is a major cause of globus. 1

• This approach is reasonable for patients with typical globus symptoms and negative nasolaryngoscopy 1
• Reassurance about the benign nature of the condition should be provided early 4, 5

Step 2: Symptomatic Management

Prescribe ibuprofen or acetaminophen for associated throat discomfort, as these are the recommended first-line analgesics for throat symptoms. 2, 6, 7

• Adequate hydration with cool liquids should be encouraged 8
• Salt water gargles and throat lozenges may provide topical relief 2

Step 3: Behavioral and Psychological Interventions

If symptoms persist despite negative investigations and PPI therapy, refer for speech and language therapy, cognitive-behavioral therapy, or consider amitriptyline. 4, 1

• Speech therapy with education, reassurance, and exercises can benefit patients, though the specific mechanism (attention vs. targeted intervention) remains unclear 9
• Psychological factors often play a role, particularly during periods of high emotional stress 2, 1
• Anti-depressants may be helpful in refractory cases 1

Critical Pitfalls to Avoid

Do not dismiss globus as purely psychological ("globus hystericus" is an outdated term)—most patients have a detectable and treatable organic cause. 5

• Approximately 20% of patients with functional dysphagia also experience globus sensation, so these conditions can coexist 2
• Abnormalities of the distal esophagus or gastric cardia commonly cause referred sensation to the pharynx, whereas pharyngeal abnormalities rarely cause referred dysphagia 2
• Patients with pharyngeal carcinomas have significantly increased risk of synchronous esophageal carcinomas, making complete esophageal examination essential when pharyngeal tumors are identified 2
• Videofluoroscopy may show residue in valleculae and pyriform sinuses that contributes to globus symptoms, though this finding does not necessarily change with therapy 9

When Antibiotics Are NOT Indicated

Antibiotics should not be prescribed for globus pharyngeus or throat lump sensation unless group A streptococcal pharyngitis is confirmed by rapid antigen test or culture. 2, 8

• Apply Centor criteria (fever, absence of cough, tonsillar exudates, tender anterior cervical adenopathy) to determine need for testing 2, 8
• Patients with 0-2 Centor criteria do not need testing or antibiotics 2, 8
• Even with 3-4 Centor criteria, testing must confirm bacterial infection before prescribing antibiotics 2