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Lump in Throat

(Globus Sensation)

by Norton J. Greenberger, MD

Lump in the throat (globus sensation, globus hystericus) is the sensation of a lump or mass in the throat, unrelated to swallowing, when no mass is present. (If a mass is present, see Neck Mass.)

Etiology

No specific etiology or physiologic mechanism has been established. Some studies suggest that elevated cricopharyngeal (upper esophageal sphincter) pressure or abnormal hypopharyngeal motility occur during the time of symptoms. The sensation may also result from gastroesophageal reflux disease (GERD) or from frequent swallowing and drying of the throat associated with anxiety or another emotional state. Although not associated with stress factors or a specific psychiatric disorder, globus sensation may be a symptom of certain mood states (eg, grief, pride); some patients may have a predisposition to this response.

Disorders that can be confused with globus sensation include cricopharyngeal (upper esophageal) webs, symptomatic diffuse esophageal spasm, GERD, skeletal muscle disorders (eg, myasthenia gravis, myotonia dystrophica, polymyositis), and mass lesions in the neck or mediastinum that cause esophageal compression.

Evaluation

The main goal is to distinguish globus sensation from true dysphagia (see Dysphagia), which suggests a structural or motor disorder of the pharynx or esophagus.

History

History of present illness should elicit a clear description of the symptom, particularly as to whether there is any pain with swallowing or difficulty swallowing (including sensation of food sticking). Timing of symptoms is important, particularly whether it occurs with eating or drinking or is independent of those activities; association with emotional events should be queried specifically.

Review of systems seeks weight loss (as evidence of a swallowing disorder) and symptoms of muscle weakness.

Past medical history should include known neurologic diagnoses, particularly those causing weakness.


Physical examination

The neck and floor of the mouth are palpated for masses. The oropharynx is inspected (including by direct laryngoscopy). Swallowing (of water and a solid food such as crackers) should be observed. Neurologic examination with particular attention to motor function is important.


Red flags

The following findings are of particular concern:

  • Neck or throat pain

  • Weight loss

  • Abrupt onset after age 50

  • Pain, choking, or difficulty with swallowing

  • Regurgitation of food

  • Muscle weakness

  • Palpable or visible mass

  • Progressive worsening of symptoms


Interpretation of findings

Symptoms unrelated to swallowing, with no pain or difficulty with swallowing, or sensation of food sticking in the throat in a patient with a normal examination imply globus sensation. Any red flag findings or abnormal findings on examination suggest a mechanical or motor disorder of swallowing. Chronic symptoms that occur during unresolved or pathologic grief and that may be relieved by crying suggest globus sensation.


Testing

Patients with findings typical of globus sensation need no testing. If the diagnosis is unclear or the clinician cannot adequately visualize the pharynx, testing as for dysphagia is done. Typical tests include plain or video esophagography, measurement of swallowing time, chest x-ray, and esophageal manometry.


Treatment

Treatment involves reassurance and sympathetic concern. No drug is of proven benefit. Underlying depression, anxiety, or other behavioral disturbances should be managed supportively, with psychiatric referral if necessary. At times, communicating to the patient the association between symptoms and mood state can be beneficial.

Key Points

  • Globus symptoms are unrelated to swallowing.

  • Tests are not needed unless symptoms are related to swallowing, examination is abnormal, or there are red flag findings.

* This is a professional Version *