What could be causing a feeling of swallowing around something in the throat?

Feeling of Swallowing Around Something in the Throat

The sensation of a lump or foreign body in the throat is most likely globus sensation, which characteristically improves or disappears completely during eating or drinking—distinguishing it from true dysphagia—and should prompt evaluation for gastroesophageal reflux disease as the primary underlying cause, followed by assessment for esophageal motility disorders if acid suppression fails. 1, 2, 3

Key Diagnostic Distinction

The critical first step is determining whether this represents globus sensation versus true dysphagia:

• Globus sensation presents as a recurrent, non-painful feeling of a lump in the throat that improves or disappears with eating and drinking, is more noticeable between meals, and does not cause actual difficulty swallowing 1, 2
• True dysphagia causes consistent difficulty with swallowing that worsens during eating, with food actually getting stuck 1, 4
• The intermittent, non-progressive nature strongly argues against mechanical obstruction or malignancy 1

Most Common Causes

Primary Etiology: Gastroesophageal Reflux Disease

• GERD is the most common identifiable cause of globus sensation and must always be excluded 2, 3
• Esophageal acid reflux has a close relationship with globus sensation, even without typical heartburn symptoms 3
• Empirical therapy with high-dose proton pump inhibitor (PPI) is indicated as first-line treatment after excluding organic disease 3

Secondary Etiology: Esophageal Motility Disorders

• In PPI-resistant patients, 47.9% have abnormal esophageal motility, with ineffective esophageal motility being the most common abnormality 3
• Dyskinetic upper esophageal sphincter commonly represents extrapharyngeal disease associated with gastroesophageal reflux 2
• Prokinetics alone or added to PPI should be considered for motility dysfunction 3

Less Common Structural Causes

• Medially displaced superior cornu of the thyroid cartilage can cause foreign body sensation at the hyoid level, diagnosed by careful neck examination and flexible laryngoscopy 5
• Pharyngeal cancer, Zenker's diverticulum, or thyroid enlargement must be excluded 3

Red Flags Requiring Urgent Evaluation

Immediate endoscopy is warranted if any of the following develop:

• Progressive dysphagia (worsening difficulty with solids progressing to liquids suggests mechanical obstruction like cancer) 1
• Weight loss or anemia (suggests esophageal malignancy) 1
• Persistent symptoms lasting weeks rather than intermittent episodes 1
• Dysphagia to both solids and liquids simultaneously from onset (suggests motility disorder like achalasia) 1
• Complete inability to swallow saliva (requires emergent endoscopy within 2-6 hours) 6

Diagnostic Approach Algorithm

Step 1: Clinical Evaluation

• Perform thorough examination of neck, mouth, oropharynx, and larynx to identify masses, inflammation, or thyroid abnormalities 1, 5
• Evaluate psychological stressors that may exacerbate globus sensation 1
• Assess for symptoms of GERD (heartburn, regurgitation) 2, 3

Step 2: Initial Management (No Red Flags Present)

• Trial of high-dose PPI therapy for 4 weeks as empirical treatment 3, 6
• Reassurance and stress management for presumed globus sensation 1
• Approximately 20% of patients with functional dysphagia experience globus with swallowing 1

Step 3: If PPI-Resistant

• Evaluate esophageal motility with high-resolution manometry (98% sensitivity, 96% specificity for achalasia) 6, 3
• Consider adding prokinetics if motility dysfunction identified 3
• Biphasic barium esophagram if true dysphagia develops (96% sensitivity for structural abnormalities, 80-89% sensitivity for motility disorders) 6, 1

Step 4: If Motility Normal and Still Symptomatic

• Consider cognitive-behavioral therapy, antidepressants, or gabapentin 3
• Re-evaluate for structural causes with flexible laryngoscopy 5

Critical Pitfalls to Avoid

• Do not mistake globus for dysphagia, as this leads to inappropriate treatment approaches 1
• Do not delay endoscopy with empiric acid suppression if alarm symptoms develop, as this can mask underlying malignancy 1
• Do not use oral contrast studies in complete esophageal obstruction due to increased aspiration risk 6
• Remember that distal esophageal abnormalities can cause referred sensation to the throat, so the entire esophagus must be evaluated even when symptoms seem pharyngeal 7, 6, 4
• Silent aspiration occurs in 55% of patients with aspiration who lack a protective cough reflex, making clinical diagnosis difficult 6, 7