What could cause a global sensation in the throat of a healthy adult?

Causes of Global Sensation in Throat (Globus Sensation)

Primary Etiology

Gastroesophageal reflux disease (GERD) is the major causative factor for globus sensation in healthy adults, and high-dose proton pump inhibitor (PPI) therapy should be initiated as first-line treatment after excluding alarm symptoms. 1, 2

Common Etiologies in Healthy Adults

Reflux-Related Causes

• GERD and extraesophageal reflux are the most frequently identified organic causes, with globus commonly associated with extraesophageal reflux manifestations 1, 2
• Esophageal motility dysfunction, particularly ineffective esophageal motility, occurs in approximately 48% of PPI-resistant patients with globus 3

Psychological and Functional Causes

• Anxiety, depression, and stress are frequently associated with globus, with many patients reporting symptom exacerbation during periods of high emotional intensity 1, 4
• Globus may present as a somatoform disorder (ICD-10: F45.8) when no organic cause is identified 5, 6
• Prior trauma (physical, emotional, or psychological) preceding throat symptoms should be explored 1

Inflammatory and Infectious Causes

• Chronic rhinitis and allergic rhinitis may contribute through postnasal drainage 1
• Viral, bacterial, or fungal infection of the throat and/or larynx can present acutely with globus 1
• Pharyngeal inflammation from various sources contributes to the sensation 7

Medication and Substance-Related

• Inhaled steroids (for asthma or COPD) can cause chemical laryngitis and globus 1
• Chronic tobacco use and moderate to heavy alcohol use are associated with laryngeal symptoms including globus 1

Less Common but Important Causes

Structural Abnormalities

• Zenker's diverticulum should be excluded through otolaryngological examination 1, 3
• Foreign body in the larynx, trachea, or esophagus must be considered in acute presentations 1

Neurologic Conditions

• Stroke, Parkinson's disease, and Parkinson-plus syndromes can present with globus as part of pharyngeal symptomatology 1
• Myasthenia gravis, multiple sclerosis, and amyotrophic lateral sclerosis should be considered in appropriate clinical context 1

Endocrine Disorders

• Hypothyroidism and other endocrinopathies can contribute to globus sensation 1
• Testosterone deficiency has been associated with voice and throat symptoms, including globus 1

Systemic Inflammatory Conditions

• Granulomatosis with polyangiitis (GPA) can present with throat symptoms, though typically with additional systemic features 8

Key Distinguishing Features

Globus sensation characteristically improves during eating rather than worsening with swallowing food, which is the critical feature distinguishing it from dysphagia 1, 4, 2

• The sensation is more obvious between meals and typically improves with eating 1, 4
• It presents as a recurrent, non-painful but uncomfortable feeling of a lump in the throat 1, 4
• Associated symptoms include throat clearing, sense of mucus buildup, dry throat, and repeated swallowing 1, 4

Red Flag Symptoms Requiring Urgent Investigation

• Weight loss mandates urgent endoscopy 1
• True dysphagia (difficulty swallowing) or odynophagia (painful swallowing) 1
• Hemoptysis, fever >101.5°F, or night sweats suggest serious underlying pathology 1
• Food bolus obstruction requires urgent gastroenterology referral, as eosinophilic esophagitis is found in up to 46% of these cases 1
• Palpable lymphadenopathy >1.5 cm, firm, or non-tender requires urgent investigation for malignancy 1

Common Pitfalls to Avoid

• Mistaking globus for dysphagia leads to inappropriate treatment approaches; the key distinction is whether symptoms improve with eating 1, 4
• Inadequate PPI trial duration (effects require 8-12 weeks) can lead to premature conclusion of treatment failure 1
• Assuming psychological etiology without excluding organic causes, particularly GERD 2, 7