Sensation of a Lump in the Throat

A 30-year old small business owner consults her primary care physician (PCP) because of a feeling of a lump in the throat (Box 1, Fig 4). She has had this symptom intermittently for about one year, but the intensity has increased during the last few weeks. There was no obvious precipitating event. Her swallowing is normal, and not painful. There is no dysphagia (Box 4) or odynophagia, and no hoarseness or other change in her voice (Box 6). Eating improves the symptom. Yet, the patient has the impression that something is stuck in her throat. She rarely experiences heartburn, and has had no weight loss. The patient is otherwise healthy. She is a non-smoker and takes alcohol in moderation (Box 6). Apart from an oral contraceptive she does not use any drugs.

The PCP examines the patient’s neck, throat, and oral cavity, but finds nothing abnormal (Box 2). There are no palpable masses, no enlarged lymph nodes and the thyroid is not enlarged. The PCP has the impression that the patient is experiencing some anxiety and explores whether the lump sensation is temporally related to stress, but the patient denies this association. The PCP, convinced that he is dealing with a functional disorder, explains to the patient that nothing is seriously wrong and attempts to reassure her.

However, two weeks later the patient consults her PCP again because of a continuing lump sensation. She is then referred to an ear-nose-throat physician because, in reviewing her history, she did have substantial exposure to second hand smoking and was quite concerned about this (Box 7). The latter does not find any abnormalities at examination which includes nasolaryngoscopy (Box 8). , Because of an association between globus and the endoscopic finding of ectopic gastric mucosa in the proximal esophagus and esophageal cancer, the patient is referred for endoscopy (Box 10). No abnormalities were found (Box 11). Because of the presence of some heartburn, 6-week trial of PPI therapy is initiated (Box 14). This does not lead to improvement of the lump sensation (Box 15). The patient is again reassured of the benign nature of her condition and a diagnosis of globus is made (Box 17).