Scratchy Throat and Globus Sensation: Differential Diagnosis

A scratchy throat with a "lump in the throat" sensation (globus pharyngeus) has a broad differential. Most causes are benign, but persistent symptoms warrant evaluation.

Common Causes

Infectious / Inflammatory

• Viral pharyngitis: Rhinovirus, adenovirus, EBV, COVID-19. Self-limited.
• Strep throat (GAS): Sudden sore throat, fever, tonsillar exudate, anterior cervical adenopathy, no cough. Centor criteria guide testing.
• Tonsillitis: Tonsillar hypertrophy, exudates, dysphagia.
• Laryngitis: Hoarseness, voice loss, cough; viral or vocal strain.

GERD / LPR (Laryngopharyngeal Reflux)

• Globus is a classic LPR symptom (pepsin/acid irritate laryngopharynx).
• Often without heartburn ("silent reflux").
• Worse morning, post-prandial, supine.

Allergic / Environmental

• Post-nasal drip (allergic rhinitis, vasomotor rhinitis)
• Smoke, pollution, dry air, chemical irritants

Structural / Mechanical

• Thyroid: Goiter, nodules compressing/esophageal displacement.
• Cervical spine: Anterior osteophytes (DISH, spondylosis) → mechanical globus.
• Zenker's diverticulum: Pharyngeal pouch; regurgitation, halitosis.
• Eagle syndrome: Elongated styloid process → throat pain, globus on head turn.

Functional / Neurological

• Globus pharyngeus (primary): Diagnosis of exclusion; stress/anxiety exacerbates; no dysphagia/weight loss.
• Muscle tension dysphonia: Strap muscle overactivity.

Red Flags (Urgent ENT Referral)

• Progressive dysphagia, odynophagia
• Unilateral throat/ear pain (referred)
• Hemoptysis, hematemesis
• Neck mass
• Weight loss, night sweats
• Voice change >2 weeks
• History of head/neck cancer, smoking, alcohol

Initial Workup

• Flexible laryngoscopy (office) — visualizes larynx, hypopharynx, vocal cords
• TSH, thyroid ultrasound if thyroid suspected
• Empiric PPI trial (2–4 weeks) for suspected LPR
• Allergy testing if allergic rhinitis suspected
• Barium swallow / manometry if dysphagia prominent

Most globus resolves with reassurance, hydration, reflux management, and stress reduction. Persistent or red-flag symptoms need ENT evaluation.