Many patients experience the feeling of fullness in the throat or a sensation of a lump in the throat. Others have a chronic cough or throat clearing. These common conditions are quite bothersome but rarely are associated with conditions that might threaten one’s health. Patients often confuse phlegm or mucous in the throat with true post nasal drainage or a sensation of the “drainage coming from behind the nose.”
Conditions that commonly cause the above problems and some treatment options are listed below:
- Allergic Rhinitis: these patients should have significant nasal symptoms: This of course is treated with antihistamines, decongestants, nasal steroids, avoiding the offending material or taking allergy shots. If the patient does not have significant sinonasal symptoms this is probably not the cause.
- Chronic Sinusitis: This is usually, but not always, associated with sinonasal symptoms. Sometimes sinus X-rays are needed to check for this. X-rays should be grossly abnormal and not just some “minimal” or “trace” mucoperiosteal thickening. Radiology reports rendering an impression of “chronic sinusitis” are often misleading in this regard and unless the report clearly outlines marked abnormalities the X-rays should be reviewed before concluding sinusitis is the cause of the patient’s symptoms. Should sinusitis be present obviously a course of antibiotics perhaps with topical and/or systemic decongestants should be used.
- Gastroesophageal Reflux is commonly associated with the feeling of heartburn or of frank reflux although it often occurs while sleeping so the symptom goes unnoticed. Caffeine, alcohol and nicotine all cause lower esophageal sphincter relaxation so a history of significant use of these items should be explored. It usually takes more than two cups of coffee a day to cause reflux symptoms. Colas usually contain about half the caffeine a serving of coffee does. In addition to H2 blockers or PPI’s, reflux is treated by avoiding alcohol and tobacco while limiting caffeine to one or two cups per day. Elevating the head of bed by placing a pillow between the box spring or mattress and/or bricks under the headboard posts and avoiding eating within two hours of bedtime are often helpful interventions.
- Other esophageal lesions: Although uncommon, other esophageal problems such as a Zenker’s diverticulum, swallowing disorders, or neoplasia can possibly cause these symptoms. Usually there is significant dysphagia associated with these entities. A history of dysphagia, weight loss or smoking should lead to consideration of an esophogram, dysphagia evaluation or an EGD. These studies should also be considered if the patient’s symptoms persist despite an otherwise negative exam and trial of conservative management or other measures.
- Laryngeal Lesions are not a common cause of these symptoms but certainly can be especially if hoarseness is present or if there is a history of smoking, intubation or anterior neck surgery. Vocal strain can also cause these symptoms.
- Asthma, COPD or other lung conditions can cause coughing directly as “tussive asthma” (seen more commonly in children) or as an indirect result of laryngeal irritation from a pulmonary cough or pulmonary inhalers. A lung exam and chest X-ray can be an important part of evaluation of these patients. A trial of asthma inhalers may be helpful. Occasionally PFT’s or a bronchoscopy is indicated.
- Medication induced cough: ACE inhibitors such as Zestril are well known to cause a foreign body sensation in the throat or a cough. This can onset even years after beginning such medications. About 15% of patients on ACE I inhibitors will experience such symptoms and about 5% will need to discontinue therapy. ACE II inhibitors have a much lower incidence of such problems. Diuretic induced dehydration can make mucous to be thicker and can lead to a feeling of mucous getting caught in the throat. Antidepressants cause similar drying which can also be a normal age related phenomenon. As mentioned earlier, pulmonary inhalers can cause laryngeal irritation. Fosmax can cause gastroesophageal reflux.
- Recurrent irritation caused by the cough or throat clearing: The act of coughing or throat clearing irritates the vocal cords causing one to cough or clear the throat again, which then irritates the vocal cords all over again producing yet another cough or urge throat clear. The original cause of a cough such as a cold or bronchitis or even the other entities discussed herein may be gone or resolved but the cough or throat clearing itself persists. Such coughing or throat clearing is often associated with a feeling of phlegm in the throat. This is rarely due to an over production of phlegm, but rather an over awareness of it. Actually we each make a quart of mucous in our throats daily and swallow it without noticing it. Because the larynx must elevate during swallowing, one notices the swallowing of this mucous much more when the vocal cords are irritated. In addition, when the vocal cords are irritated the mucous also tends to stick to them, and so the patient’s cough or throat clearing may seem “productive” as this adherent mucous is coughed up. The patient notices some relief for a few minutes only to have the feeling recur as the mucous re-adheres to the vocal cord. It is a often helpful to explain the above to the patient indicating that “the mucous is more a symptom than a cause of the problem.”
- Anxiety over the symptom itself or other problems can cause tension in the throat muscles leading to fullness in the throat. A thorough examination can allow the patient to relax and be less conscious of, and bothered by, the symptom. Sometimes anti-anxiety medicines are needed.
Treatments for a “self perpetuating” cough include:
- Mentally suppressing the urge to cough or clear the throat, sip some water instead (keep a water bottle handy).
- Taking plenty of liquids to keep the mucous thin. Note: Caffeine tends to thicken the mucous.
- Taking cough medicine such as Robitussin DM regularly (2 tsp. 3 to 4 X/day) for two weeks
- Taking steroid medicine to decrease the irritation. It is important to warn the patient that thesemedications can cause mood swings or elevate blood sugar. The patient is usually placed on an H2 blocker and asked to avoid NSAIDS or COX inhibitors to prevent gastritis.
Usual Rx: prednisone 10mg: 3 tabs qAM X 14 days, 2 qAM X 3 days, 1 qAM X 3 days.
Evaluation:
Evaluation of the chronic cough patient includes a thorough history focusing on sinonasal, laryngeal, pulmonary and gastroesophageal symptoms as well as tobacco, caffeine and alcohol use history. This is followed by a head, neck and pulmonary exam. Consideration to obtaining sinus and chest X-rays as well as an esophogram, dysphagia evaluation or EGD should be given especially if symptoms persist after conservative management, a trial of medication or a change of medication as outlined above. If symptoms persist, one should consider referral, as directed by the patient’s history, exam and other studies to otolaryngology, pulmonology, gastroenterology, or perhaps to an allergist.