A feeling of a lump in the throat

Ask about

• How long the feeling of a lump has been present. Ask the patient to describe this feeling. Try to distinguish from a pain (which may be a more significant pathology). Globus is often described as a feeling that is central and suprasternal.

• Is it getting worse, and do the symptoms come and go? Persisting symptoms would raise more concern.

• Difficulties swallowing (dysphagia). If so, then ask specifically about dysphagia to liquids or solids, or both. Ask about symptoms of regurgitation, which may indicate the possibility of a pharyngeal pouch.

• Pain on swallowing (odynophagia). Is the pain central or does it lateralise? Pain would not be expected with globus pharyngeus.

• Does the feeling improve on swallowing solids or liquids? Globus pharyngeus is typically worse when swallowing saliva (dry swallow) and is often less noticeable on swallowing food and drink.

• Change in voice or hoarseness. If so, is this intermittent or progressive (with the latter possibly being of more concern, especially if no history of voice overuse)?

• Dyspepsia. If so, ask about relevant risk factors such as eating late at night, spicy foods, etc.

• Symptoms of otalgia. This may represent a referred pain, especially if the symptoms are unilateral. There may be an underlying pathology in the oral cavity (trigeminal nerve); the oropharynx or tonsils (glossopharyngeal nerve); or from the laryngopharynx (vagus nerve).

• Any cough. This can irritate the larynx.

• Presence of systemic symptoms (also known as B symptoms). These include fever, weight loss, and night sweats that may be associated with lymphoma. These may be relevant in the presence of neck lumps or asymmetrical tonsils that could indicate disease.

• Any lumps on the neck

• Previous head and neck surgery (particularly for malignancy)

• History of radiotherapy (this may increase the risk of further malignancy in the head and neck).

• Alcohol consumption and smoking history. Both significantly increase the risk of head and neck malignancies.

• Any symptoms of nasal blockage or nasal discharge (anterior and posterior). Postnasal discharge is an irritant and may contribute to symptoms.

• Try to gauge any other stresses in patient’s life. Stress and anxiety can have an adverse effect on laryngeal muscle tension, with a resultant worsening of symptoms. There may also be an underlying fear of malignancy.

Examination

A full examination of the head and neck is essential. Listen to the patient’s voice. Is there any evidence of hoarseness?

• Neck examination—The neck needs to be examined systematically, taking in all anatomical areas. The regions are classically divided into an anterior triangle (bordered by the midline anteriorly, the mandible superiorly, and the anterior border of sternocleidomastoid posteriorly) and the posterior triangle (bordered by sternocleidomastoid anteriorly, the clavicle inferiorly, and the anterior border of trapezius posteriorly). Feel for any tenderness or masses. Assess the thyroid in the midline, asking the patient to swallow during palpation.

• Oropharynx—Evaluate all of the mucosa, taking care to view the floor of the mouth and the rest of the oral cavity. Assess for abnormalities such as leucoplakia, which presents as white patches of keratosis that are premalignant. Note the tonsils and assess for any asymmetry as his may indicate a malignancy (lymphoma or squamous cell carcinoma) and should always be referred to otolaryngology for further assessment. Palpation of the tonsils, tongue base, and floor of mouth with a finger may be helpful (if the patient permits) to feel for hardness or mucosal changes, which may raise suspicions of a malignancy.

• Nose—Look for any obvious evidence of a rhinitic nasal mucosa via anterior rhinoscopy (manually elevate nasal tip and examine with torch). There may be hypertrophied nasal turbinates, evidence of pus or polyps. Postnasal drip may be a contributing factor to symptoms of an irritable throat.

• Ear—Perform otoscopy. Look for evidence of otitis externa or a middle ear effusion if the patient also complains of otalgia to rule out an obvious infection. If it is not possible to rule out an aural cause for otalgia prompt referral is required.