I have a constant feeling of phlegm in my throat. It's always worse just after eating or in the early morning. It affects the way I talk, so I find myself clearing my throat constantly. When I attempt to clear my throat by coughing, something seems to move around, but I never cough anything up. Within a short time (less than 20 minutes), I find I need to clear my throat again. What could cause this?

W.W.

A sensation of phlegm, when no phlegm exists, used to be known by the impolite Latin phrase "globus hystericus." This means "hysterical ball," reflecting the fact that docs used to think this problem was, um, all in your head. Nowadays, we rarely blame the patient's psyche for this symptom, which is known by the more politically correct term "globus."

Globus sensation is due to inflammation. Inflammation of many different anatomic regions can produce this feeling: the nasopharynx (roof of the throat), soft palate (roof of the mouth, including the uvula, that little punching bag in the back of your mouth), base of tongue, posterior pharyngeal wall (back of the throat), larynx (voice box), hypopharynx (lower throat) and esophagus (swallowing tube).

The next obvious question is: What causes this inflammation? Here are a few of the common causes.

1. Gastroesophageal reflux disease. This is arguably the most common explanation. Stomach acid and digestive enzymes "wash up," or reflux, into the lower throat and larynx. Unlike the stomach lining, these tissues are not suited for acid and digestive enzymes, and inflammation results.
2. Rhinosinusitis. Infected mucus from the sinuses and nasal cavities drains down the back of the throat, irritating everything in its path. Globus is usually not the only symptom of sinusitis. Patients with sinusitis also complain of facial pressure or pain, nasal congestion and postnasal drainage. In other words, if you had sinusitis, you WOULD cough something up when you clear your throat. Thus, I doubt that this is your problem.
   

• Chronic throat infection. Commonly infected structures include the tonsils, lingual tonsils and adenoids. (The adenoids are high in the throat, in the nasopharynx. Lingual tonsils are located at the base of the tongue.) Each structure is an example of lymphoid tissue, collections of cells that are supposed to fight infection. As front-line troops, these structures can become chronically inflamed as a result of viral or bacterial infections.
  Your best bet for rapid diagnosis and treatment of globus: Your friendly neighborhood ear, nose and throat specialist (ENT). The diagnosis is often obvious from the patient's description of the symptoms. The physical exam, which may include a examination of the nose and throat using a fiberoptic camera called a scope, often merely confirms what the ENT suspects, based upon the symptoms. Treatment will depend upon the diagnosis. If your ENT thinks you have acid reflux, your treatment will involve diet and lifestyle modifications as well as drugs that reduce stomach acid production. If rhinosinusitis is the problem, several medications may be prescribed, such as antibiotics, nasal steroid sprays and antihistamines. If the diagnosis is a chronic throat infection, antibiotics may be needed.

Assuming you are correctly diagnosed and treated, how rapidly should you expect to recover? As a rule of thumb, chronic problems require chronic solutions. If your symptoms have been present for years, don't expect results within the first week of treatment! Patience is key.