Globus, Latin for globe or ball, is a common and frequently frustrating symptom in primary care. Patients describe it as a sensation of a lump or foreign body in the throat, often worse on dry or empty swallow, despite the absence of a physical obstruction or actual dysphagia.1 Patients may describe it in other ways, such as a frog, hair, phlegm, or catarrh stuck in the throat. Although typically benign, it can be distressing and lead to specialist referrals to reassure patients and clinicians. Given its symptom overlap with serious conditions such as malignancy or neuromuscular disorders, primary care clinicians must be adept at distinguishing benign globus sensation from concerning sinister pathology. This article provides an up-to-date, practical guide to diagnosing and managing globus in primary care.
What causes globus?
Hippocrates, over 2000 years ago, first described the ‘lump in the throat’, believed to be linked to women with hysteria and uterine dysfunction. The term globus hystericus was coined by John Purcell in 1707, who attributed this symptom to contraction of the neck strap muscles during hysterical fits.2 It was not until 1968 that Kenneth Malcomson demonstrated that most patients did not have a hysterical personality, nor were they predominantly female. He also linked gastro-oesophageal reflux using barium swallow testing, leading to a change in terminology to globus pharyngeus.3
Currently, globus is believed to be a multifactorial condition with various contributing factors:
Gastro-oesophageal reflux disease (GORD) and laryngopharyngeal reflux (LPR) — acid reflux into the pharynx is a leading cause, triggering inflammation and heightened sensory perception. It is known that reflux at the gastro-oesophageal junction is associated with an increased tone of the cricopharyngeal sphincter, which might impart a lump sensation in some patients.4
Muscular tension and psychogenic factors — stress, anxiety, and habitual throat clearing can contribute to globus sensation.5
Postnasal drip and chronic throat irritation — upper airway inflammation in conditions such as allergic rhinitis and chronic sinusitis can cause globus sensation by producing increased local sensitivity.6
Cervical spine abnormalities — osteoarthritis with osteophytes and postural issues affecting the neck can lead to referred sensations in the throat.7
Rare causes — neurological disorders, thyroid disease, or malignancies should be considered in persistent or atypical cases.
How common is globus?
Globus is reported to have been experienced by up to 45% of the general population at some point, and accounts for approximately 4% of ear, nose, and throat (ENT) referrals.6 It can occur at any age, but is more prevalent in middle-aged adults, with no significant difference between men and women. Anxiety and psychological stressors often exacerbate symptoms, making it particularly common in individuals with underlying mental health conditions.
When should we be concerned? Red flags
Although globus is usually benign, primary care clinicians should consider urgent ENT referral for further investigation if the following features are present: dysphagia (persistent or progressive); odynophagia (painful swallowing); unexplained weight loss; persistent hoarseness or voice changes; haemoptysis; neck masses or lymphadenopathy; unilateral symptoms (for example, pain and earache); and history of smoking or excessive alcohol use.
A red-flag-driven approach is essential to avoid missing serious pathology, such as head and neck cancer, oesophageal malignancy, or neurological disorders.
How is globus diagnosed?
Globus is primarily a clinical diagnosis, based on history and the absence of red flags.
Key features in history
Sensation of a lump in the throat, often worse when swallowing saliva, and may be relieved by swallowing food.
Fluctuating symptoms, exacerbated by stress, anxiety, or prolonged talking.
Absence of true dysphagia or painful swallowing.
Association with reflux symptoms (heartburn, regurgitation, and throat clearing).
Clinical examination
Oropharyngeal inspection: look for mucosal changes, tonsillar asymmetry, or masses.
Neck palpation: check for lymphadenopathy or thyroid enlargement.
Cranial nerve examination: assess for neurological deficits.
What investigations are necessary?
Most patients with classic globus do not require further investigations. However, targeted tests may be considered in specific cases:
fibre-optic naso-endoscopy (ENT referral) — if symptoms persist, are unilateral, or if there are red flags;
barium swallow is of limited value in investigating patients with globus and should not be requested systematically to rule out malignancy. It may be useful in identifying benign lesions such as hiatus hernia, cervical osteophytes, and cricopharyngeal spasm in up to a third of patients with globus;8 and
24-hour pH monitoring — if LPR or reflux is suspected but empirical treatment fails.
Management in primary care
Reassurance and explanation
Explain the benign nature of globus and the absence of true obstruction.
Discuss the role of stress, muscle tension, and reflux in symptom development.
Encourage patients to avoid habitual throat clearing, as it can worsen irritation.
Lifestyle modifications
Reflux management — avoid trigger foods (for example, caffeine, alcohol, and spicy/fatty foods); encourage weight loss in overweight patients; and recommend elevating the head of the bed and avoiding late meals.
Voice hygiene — reduce excessive voice strain, especially in patients with high vocal demand, and increase hydration to prevent throat dryness.
Stress reduction — cognitive behavioural therapy (CBT) or relaxation techniques may help in anxiety-driven globus.
Medical management
A trial of proton pump inhibitors (PPIs) for 4–6 weeks (for example, omeprazole 20–40 mg daily) is reasonable if LPR or GORD is suspected.
Consider adding an alginate (for example, Gaviscon Advance) to reduce refluxate exposure to the pharynx.
Consider a trial of topical nasal steroids or antihistamines if allergic rhinitis is a contributing factor.
In refractory cases with a strong neuropathic or functional component, low-dose amitriptyline (10–25 mg at night) may help.
Referral to secondary care
Referral to ENT is needed if red flags are present, empirical treatment fails, or symptoms persist despite conservative measures. While some local NHS trusts have established their own protocols, there are no national guidelines for referral to secondary care.
What is the prognosis?
Globus is often a chronic condition with fluctuating symptoms. While most cases are benign and self-limiting, symptoms can persist for months or even years. Addressing underlying reflux, stress, and muscle tension, including speech and behavioural therapy, significantly improves outcomes.
Conclusion
Globus is a common yet often misunderstood condition in general practice (see Box 1 for a list of key points). A structured approach involving careful history, exclusion of red flags, and targeted management can prevent unnecessary investigations and reassure patients. Lifestyle modifications, reflux treatment, and stress management are the mainstays of care, with specialist referrals reserved for persistent or concerning cases. By confidently managing globus in primary care, GPs can reduce patient anxiety and unnecessary secondary care burdens.
Globus is a benign and common condition, often linked to reflux, stress, and muscle tension. Red flags warrant urgent referral (dysphagia, weight loss, hoarseness, neck masses, and unilateral earache). Most cases require reassurance and lifestyle modifications, not extensive investigations. Empirical reflux treatment (PPIs + alginates) can be useful in suspected LPR or GORD. Consider ENT referral if symptoms persist, red flags are present, or further reassurance is required.
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Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2025
