What causes a feeling of having a lump in the throat?

What Could Cause a Lump-in-Throat Sensation?

The sensation of a lump in the throat—called globus sensation—is most commonly caused by gastroesophageal reflux disease (GERD), psychological stress, or laryngeal hypersensitivity, and characteristically improves during eating rather than worsening with food intake. 1, 2

Key Distinguishing Feature: Does Eating Help or Hurt?

The single most important diagnostic clue is whether the sensation improves or worsens with eating:

• Globus sensation improves during eating and is more prominent between meals—this is the hallmark feature that distinguishes it from true dysphagia 1, 2, 3
• True dysphagia (difficulty swallowing) worsens with eating, particularly with solid foods, and suggests mechanical obstruction or motility disorders 1
• Approximately 20% of patients may experience both globus and functional dysphagia simultaneously 2

Primary Causes of Globus Sensation

Gastroesophageal Reflux Disease (GERD)

• GERD is recognized as a major causative factor for globus sensation, with 20-60% of GERD patients experiencing head and neck symptoms without appreciable heartburn 2, 4
• Laryngopharyngeal reflux causes erythema of the posterior larynx and edema of the true vocal cords 4
• Distal esophageal abnormalities can cause referred sensation to the throat, so the entire esophagus must be evaluated even when symptoms seem pharyngeal 1, 5

Psychological and Stress-Related Factors

• Anxiety, depression, and stress are frequently associated with globus, with many patients reporting symptom exacerbation during periods of high emotional intensity 6, 2
• Globus may present as a somatoform disorder when no organic cause is identified 7
• Prior trauma (physical, emotional, or psychological) should be explored as a contributing factor 2

Laryngeal Hypersensitivity and Chronic Cough

• Patients often describe abnormal sensations such as a persisting itch, tickle, or "lump" in the back of the throat 6
• This is part of cough hypersensitivity syndrome, where troublesome coughing is triggered by low levels of thermal, mechanical, or chemical exposure 6
• Associated symptoms include chronic throat clearing, chronic cough, and voice changes 6, 2

Other Important Causes to Consider

Structural and Anatomic Abnormalities

• Zenker's diverticulum should be excluded through otolaryngological examination 2, 3
• Nasal septal deviation, turbinate hypertrophy, or adenoidal hypertrophy can cause postnasal drip leading to throat symptoms 6
• Foreign body in the larynx, trachea, or esophagus must be considered in acute presentations 2
• Tumors (benign or malignant) may cause unilateral nasal obstruction and throat symptoms 6

Infectious and Inflammatory Causes

• Viral, bacterial, or fungal infection of the throat and/or larynx can present acutely with globus 6, 2
• Chronic rhinitis and allergic rhinitis may contribute through postnasal drainage 2
• Laryngopharyngeal reflux in infants causes inflammation and narrowing of the posterior choanae 6

Neurologic and Systemic Conditions

• Stroke, Parkinson's disease, and Parkinson-plus syndromes can present with globus as part of their pharyngeal symptomatology 2
• Myasthenia gravis, multiple sclerosis, and amyotrophic lateral sclerosis should be considered in appropriate clinical contexts 6, 2
• Hypothyroidism and testosterone deficiency have been associated with throat symptoms 2

Medication and Substance-Related

• Inhaled steroids for asthma or COPD can cause chemical laryngitis and globus 2
• Chronic tobacco use and moderate to heavy alcohol use are associated with laryngeal symptoms 2

Red Flags Requiring Urgent Evaluation

You must immediately investigate for serious pathology if any of these are present:

• Progressive dysphagia (worsening difficulty swallowing solids then 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
• Hemoptysis, fever >101.5°F, or night sweats suggest serious underlying pathology 2
• Palpable lymphadenopathy >1.5 cm, firm, or non-tender requires urgent investigation for malignancy 2
• Food bolus obstruction requires urgent gastroenterology referral, as eosinophilic esophagitis is found in up to 46% of these cases 1, 2

Diagnostic Approach

Initial Evaluation

• Perform thorough examination of the neck, mouth, oropharynx, and larynx to identify masses, inflammation, or tonsilloliths 1
• Assess psychological stressors that may exacerbate globus sensation 1
• Distinguish globus from dysphagia carefully—mistaking one for the other leads to inappropriate treatment approaches 1, 2

When to Order Imaging

• If true dysphagia develops (consistent difficulty swallowing), biphasic esophagram (barium swallow) is the appropriate next imaging study, with 96% sensitivity for esophageal cancer and 80-89% sensitivity for motility disorders 1
• Do not delay endoscopy with empiric acid suppression if alarm symptoms develop (progressive dysphagia, weight loss, anemia), as this can mask underlying malignancy 1
• Plain radiographs have a false-negative rate of up to 47% for foreign bodies and 85% for food bolus 5

Treatment Algorithm for Globus Without Red Flags

First-Line Treatment

Initiate high-dose proton pump inhibitor (PPI) therapy as first-line treatment for patients with typical globus and no alarm symptoms, given the benign nature of globus and the recognition of GERD as a major causative factor 2, 3

• Trial duration must be 8-12 weeks—inadequate PPI trial duration is a common pitfall 2
• Consider alginate antacids for breakthrough symptoms 2
• Consider nighttime H2 receptor antagonists for nocturnal symptoms 2

If PPI-Resistant After 8-12 Weeks

• Evaluate esophageal motility, as 47.9% of PPI-resistant patients have abnormal esophageal motility, with ineffective esophageal motility being most common 8
• Consider adding prokinetics to PPI therapy 8

If Negative Investigations Persist

• Speech and language therapy is the primary recommended intervention for laryngeal hypersensitivity syndrome, focusing on addressing aberrant involuntary learned behaviors 2
• Anti-depressants and cognitive-behavioral therapy can be helpful 3, 8
• Gabapentin may be considered for persistent symptoms 8

Reassurance and Conservative Management

• For presumed globus sensation without red flags, reassurance and stress management are first-line approaches 1
• Approximately 20% of patients with functional dysphagia may experience globus with swallowing 1

Critical Pitfalls to Avoid

• Do not mistake globus for dysphagia—the key distinction is whether symptoms improve with eating (globus) or worsen with eating (dysphagia) 1, 2
• Do not use inadequate PPI trial duration—effects require 8-12 weeks 2
• Do not order oral contrast studies in acute obstruction—they increase aspiration risk and delay definitive intervention 5
• Do not assume pharyngeal symptoms mean pharyngeal pathology—up to 68% of patients with pharyngeal complaints have esophageal abnormalities 5
• Do not delay endoscopy if alarm symptoms develop—empiric acid suppression can mask underlying malignancy 1