Lump in Throat

Lump in throat.png


Red Flags requiring urgent ENT review:

·       Acute dysphagia (+ not able to take solids or liquids)

·       History in keeping with foreign body


Assessment

History

  • Duration

  • Constant or Episodic

  • Association with swallowing

  • Ability to swallow (dysphagia)

  • Voice change

  • Throat clearing

  • Neck movement and lumps

  • Reflux history

  • Previous episodes

  • Recent treatment or operations

  • Smoking and alcohol history

  • History of anxiety

  • Nasal symptoms (nasal obstruction, rhinorrhoea)

  • Malignancy red flags (weight loss, referred ear pain, neck lumps, night sweats, haemoptysis, odynophagia-pain on swallowing)

Examination

  • Mouth: Oral hygiene, ulceration or masses

  • Neck: movement (inability to move neck is torticollis), lymphadenopathy or masses

  • Nasal: Anterior rhinoscopy – atopic mucosa or polyps (Chronic rhinosinusitis)

 

Differential Diagnosis

Globus pharyngeus (globus sensation)

It is the sensation of a non-painful lump in the throat. The aetiology is unknown. It is most commonly an intermittent sensation worse on swallowing. It is benign and difficult to manage. The majority of patients receive anti-reflux treatment as it can be difficult to differentiate between the conditions. Other causes include (upper oesophageal sphincter spams, oesophageal dysmotility, lingual tonsils and stress).

Laryngitis

Inflammation of the larynx can be caused by infection (URTI), irritation (laryngopharyngeal reflux or post nasal drip), allergy and overuse/trauma (profession voice use, coughing). Laryngitis can be acute or chronic (symptoms more than 3 weeks). Patients usually have hoarseness and pain in the throat. Acute laryngitis will self resolve with voice rest, avoidance of triggers and hydration. Treatment of the cause of chronic laryngitis is vital. All patients with non-resolving chronic laryngitis should be referred to ENT to rule out laryngeal pathology.

Foreign body

Acute onset where there is associated pain on swallowing (dysphagia) could indicate a foreign body. Following a meal would suggest a swallowed bone or sharp object which may be impacted into the throat or has traumatised the mucosa. These patients need to be referred to ENT on the same day for examination of the upper airway with a flexible nasoendoscope.

Laryngopharyngeal reflux

This is also known as silent reflux and is very common. Gastric contents (mainly activated pepsin enzyme) pass into the larynx or pharynx irritating the mucosal lining. Patients may complain of retrosternal burning or have risk factors for reflux (alcohol intake, weight, diet, eating late at night or spicy food). Patients can be given lifestyle advice (avoid alcohol, improve weight and diet, eat 3 hours before bed and avoid spicy food, exercise and sleep propped up) and a 3 month trial of a PPI and an alginate. These patients can be managed in primary care.

Chronic rhinosinusitis

Symptoms in keeping with chronic rhinosinusitis are nasal obstruction, rhinorrhoea, facial pain and change to smell in adults. Any patient with rhinorrhoea will likely suffer from post nasal drip where mucous passes through the post nasal space into the larynx. This can irritate the mucosal lining causing the need to throat clear and a sensation of a lump in the throat. Patients should be managed as per the EPOS guidelines most commonly with intranasal saline and corticosteroid sprays.

Anxiety

The link between anxiety and globus pharyngeus which is a sensation of a lump in the throat is well established. If physical causes have been excluded management of a patients anxiety with reassurance, medications, counselling or physiological therapy (eg. CBT) can be very helpful.

Laryngeal cancer

It is the second most frequent cause of head and neck cancer and 4 time more common in males. Smoking is the main risk factor. Patients who have chronic hoarseness with or without additional red flag symptoms such as: dysphagia, throat pain, neck lump, referred otalgia, haemoptysis or weight loss should be referred as a 2-week wait for review. NICE recommends all patients over 45 with persistent unexplained hoarseness to be referred as a 2 week wait. An urgent CXR is helpful to rule out chest pathology causing chronic hoarseness. Direct examination of the upper airway plus biopsy or imaging may be required. 

Referral Pathways 

Same day

  • Acute dysphagia (not able to take solids or liquids)

  • History in keeping with foreign body

Cancer-wait referral

  • Persistent symptoms of a lump in the throat with red flag symptoms

Routine referral

  • Patients with globus pharyngeus not responding to conservative management

 

More information

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4582871/

 

Author: Elliot Heward ENT Registrar North West Deanery