A lump in the throat feeling: why it happens, and when is it dangerous?

Globus is the feeling of a lump, a mouthful of food or tightness in the throat when there is in fact no mass there. Cleveland Clinic defines it as feeling like there is a lump in your throat when there is nothing there, and in medical definitions this feeling is painless. Its old name, globus hystericus, belongs to a time when the feeling was put down purely to a psychological problem. The name used today is globus pharyngeus, and the cause is thought to lie not in one place but in the interplay between the throat muscles, the lining of the throat and the way the nervous system perceives the signals coming from this area.

The definition itself gives you a distinction you can use at home. The criteria used for globus in the medical literature are these: a persistent or intermittent feeling of a lump or foreign body in the throat lasting at least 12 weeks; the feeling occurring between meals; no difficulty swallowing (dysphagia) and no pain on swallowing (odynophagia); and no reflux disease or disorder of the oesophageal muscles that would explain it. In short, globus is a feeling you notice when you swallow with nothing in your mouth, not food genuinely getting stuck.

You can test this on yourself as follows. First swallow your saliva with nothing in your mouth and note where the feeling is. Then take a sip of water, followed by a soft mouthful of food you have chewed well. With globus, the feeling usually stands out on an empty swallow, and nothing sticks as the food or water goes down. If food genuinely stops in your throat or chest, comes back up after eating, or you cough when you swallow, the picture is no longer globus but difficulty swallowing. This test does not make a diagnosis; it helps you choose which route to take.

Cleveland Clinic lists the common accompanying causes as follows: stomach acid escaping into the oesophagus or the voice box (reflux), tension in the throat muscles, allergies and infections, postnasal drip running from the nose into the throat, tonsillitis and sinusitis, changes in the neck vertebrae, smoking and vaping, straining the voice, stress and anxiety, and thyroid disease or thyroid nodules. None of the items on this list is the cause on its own; in most people, several play a part at the same time.

The stress and anxiety side should not be underestimated, but it should not be taken as the only explanation either. In the Rome Foundation's worldwide internet survey of 54,127 people, the prevalence of globus meeting strict criteria came out at 0.75%. Of these people, 60.5% had symptoms of anxiety or depression; by contrast, the proportion with heartburn several days a week was only 17.4%. The same study showed that globus is slightly more common in women and that the largest group of those affected is aged between 40 and 64. So globus that does not go away with reflux medicine alone is not surprising.

Do not let that 0.75% mislead you: the strict criteria only count a picture that has lasted three months and has no other explanation. Far more people experience this feeling at some point in their lives. A review in the Australian journal of general practice reports that globus is seen at lifetime rates of up to 45% in the general population and accounts for around 4% of referrals from GPs to ear, nose and throat specialists. The same review notes that most causes are harmless but that doctors should keep the possibility of cancer in mind, because that is usually the patient's real worry.

So could this feeling be cancer? The largest follow-up study comes from two university hospitals in the United States. 377 patients newly diagnosed with globus in 2015, with no previous head and neck cancer, were followed for at least 4 years; during that time 4 patients developed head and neck cancer, which is 1% over 4 years. The authors consider this rate low and say that a patient whose examination, flexible camera view of the throat and targeted tests are normal can be reassured. The condition here is clear: the reassurance comes from the examination having been done.

Globus runs a slow course. In Ireland, 55 of 79 globus patients who had undergone a barium swallow and an endoscopy of the oesophagus were contacted an average of 5 years and 3 months later. In 31 of them (56%) the complaint had resolved, and resolution had taken an average of 13 months; 24 of the 55 patients contacted (44%) still had symptoms. No patient developed a malignant disease during follow-up. Cleveland Clinic likewise writes that globus often goes away on its own or comes and goes, but in some people it can last for months or even years.

The first list is the typical behaviour of globus; in this picture your GP or an ENT specialist sees you by appointment. If even one item from the second list applies, do not wait on the assumption that it is globus.

The order deliberately starts with danger. Globus is a diagnosis made once other causes have been ruled out.

1. 1

   Breathing first: A&E if you are struggling or hear a whistling sound

   If you are struggling to breathe, hear a whistling sound when you breathe in, are choking or cannot speak, the assessment happens in A&E, not in an outpatient clinic. The NHS goitre page says to call 999 or go to A&E if you are struggling to breathe or hear a whistling sound when you breathe in; in Turkey, call 112. Do not drive yourself to A&E, and take the medicines you use with you.

2. 2

   The history: a feeling, or food sticking?

   The clinician asks how long the feeling has lasted, whether it is between meals or during them, whether food sticks, and about pain on swallowing, changes in your voice, weight loss, smoking and alcohol. The answers to these questions separate globus from difficulty swallowing.

3. 3

   Examining the neck and mouth

   The lymph nodes in the neck and the thyroid gland are examined by hand, and the inside of the mouth, the base of the tongue and the tonsils are looked at. The NHS writes that when laryngeal or thyroid cancer is suspected, the doctor looks inside your mouth and feels your neck.

4. 4

   Looking at the throat with a flexible camera

   The ENT specialist passes a thin, flexible camera (nasopharyngolaryngoscope) through the nose to see the base of the tongue, the voice box and the vocal cords. The procedure is done in the clinic. The authors of the long-term follow-up study say that it is when this examination in particular is normal that the patient can be reassured.

5. 5

   Targeted tests if needed

   If there is a swelling in the neck, an ultrasound scan and thyroid blood tests are requested; if there is difficulty swallowing or weight loss, an endoscopy of the oesophagus or a barium swallow. The tests are chosen according to the complaint; not every globus patient has all of them as a routine.

6. 6

   The globus diagnosis and a treatment plan

   If the examination and any necessary tests are normal, the diagnosis is globus. The plan is built around the accompanying cause: reflux treatment if reflux symptoms stand out, nasal treatment for postnasal drip, voice and swallowing therapy for muscle tension, and psychological support if anxiety is to the fore.

There is no single treatment for globus. What is done depends on what stands out behind the feeling.

The points below are wrong decisions often made with this complaint. We set them out so that you can ask the right questions whichever doctor you see.

Globus usually clears slowly rather than quickly. The course below applies to globus where the examination has come back normal; the plan of the doctor following you takes priority.

1. The first weeks after the examination

   For many people, learning that there is no serious cause makes the feeling less noticeable. Stopping throat clearing, sipping water often and cutting down on irritants such as smoking are the work of this period.

2. If reflux treatment has been started

   The NHS writes that medicine to reduce stomach acid is usually given for 4 to 8 weeks. At the end of this period, you and your doctor assess whether the feeling has eased or not.

3. Over months

   In the long-term follow-up study, patients whose symptoms resolved reported that they eased after an average of 13 months. The feeling can come back at times; Cleveland Clinic writes that in some people it can last for months or years.

4. Years later

   At an average follow-up of 5 years, the complaint had resolved in more than half of patients, but a notable proportion still had symptoms. As long as no new symptom is added to the picture, this does not mean the diagnosis was wrong.

We do not give a single figure here, because behind a lump in the throat feeling there may be globus needing only an examination and reassurance, or a swallowing problem or thyroid finding that calls for detailed tests. These are the items that determine the scope:

Accompanying symptoms

The feeling on its own and a feeling with hoarseness, difficulty swallowing or a swelling in the neck mean completely different lists of tests.

The need for imaging and endoscopy

With most globus, an examination and a look with a flexible camera are enough; an ultrasound scan, an endoscopy of the oesophagus or a barium swallow is added according to the complaint.

The type of treatment

Reflux medicine, nasal treatment, voice and swallowing therapy or psychological support each need a different length of time and number of sessions.

The length of follow-up

Because globus clears slowly over months, the number of follow-up examinations varies from person to person.