Chronic Throat Clearing: Questions and Answers
Chronic cough, Rhinitis and Sinusitis - a Primer for Patients, Physicians Assistants,
Nurse Clinicians AND Physicians |
Table of Drugs used to treat rhinitis & sinusitis |
10 Common Myths, Misconceptions, Errors and Mistakes about Chronic Cough
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Note that, because the problem with throat clearers is mucous in the throat, they will occasionally feel the need to cough it up as well. However, cough is not the predominant symptom, throat clearing is. When taking a medical history from these patients it is important to distinguish between the two symptoms.
1. CAUSE. Chronic cough is a symptom of some problem that is almost always identifiable: for example, sinusitis, postnasal drip, asthma, chronic bronchitis, drug side effect or stomach reflux. By contrast, the cause of chronic throat clearing is seldom identified (although, like chronic cough, chronic throat clearing may start after a cold or viral infection). While there are some specific, identifiable causes of chronic throat clearing, altogether they are in the minority compared to 'unknown cause'. By contrast, identifiable causes of chronic cough are far more common than 'unknown'. Physicians often will presume a cause of chronic throat clearing and give treatment for that presumption, only to find the patient no better months later.
2. TREATMENT. Chronic cough is almost always treatable, or at least suppressable. Depending on the cause, antibiotics, steroids, decongestants, acid-reflex medication, anti-tussives, etc. may eliminate the cough, or at least have a definite suppressant effect. By contrast, there is no simple treatment for most cases of chronic throat clearing; the meds just mentioned usually have little or no effect.
Yes, definitely. The mucous is there, and often the chronic throat clearer expels it into his mouth (where it is swallowed), or if the clearing is especially vigorous, into the air. The mucous is whitish or slightly yellowish, and is not infected nor bloody; it is in fact normal mucous that everyone has in their airways. The chronic throat clearer produces more mucous than is normal and/or feels the mucous more keenly in his throat than is normal, and thus has an uncontrolled urge to clear it.
Acid Reflux: There are two medical terms used to describe the situation
when stomach acid comes up (refluxes) from the stomach and spills over to enter
gastro-esophageal reflux (GERD)
laryngopharyngeal reflux (LPR)
Stomach or GI physicians generally use the term GERD when they attribute airway symptoms (cough, throat clearing) to acid reflux, whereas ENT (ear, nose, throat) physicians use the term LPR. Some ENT physicians and speech therapists like to point out that GERD and LPR are actually different conditions, but the terms are used interchangeably by most professionals; in this context, either term means "your airway problem is from acid reflux." (It's difficult enough for doctors to make either either diagnosis with certainty, let alone differentiate between the two.) Treatment for either condition is usually with a medication called 'proton pump inhibitor', of which there are several (Nexium, Protonix, Aciphex and Prevacid). Typically prescribed for GERD or LPR, for example, would be Nexium at 40 mg (standard dose) or 80 mg (double standard dose) a day, plus elevation of the head of the bed while sleeping, and cessation of coffee or other acid-stimulating foods. If the throat clearing goes away, the diagnosis is presumed acid reflux from the stomach. There are no studies on this treatment for throat clearing, and anecdotally it is rarely effective.
Sinusitis or rhinitis (inflammation of the sinuses and nose, respectively): Standard treatment includes some combination of antibiotics, nasal steroids, prednisone and decongestants. If the throat clearing goes away, this diagnosis is presumed correct. As with acid-reflux, there are no studies on this treatment regimen in chronic throat clearers, and anecdotally at least, it is rarely effective.
Asthma. There is actually a report about asthma causing throat clearing in children (NEJM 2003;348:1502-1503), with the symptom going away after treatment with steroid inhaler. There is no comparable report in adults, and I have personally never seen a case of asthma presenting as undiagnosed throat clearing. Standard treatment for asthma includes some combination of inhaled bronchodilators, inhaled steroids and prednisone. Again, there are no studies about this treatment in adult chronic throat clearers, and anecdotally it is not effective.
Allergies. Here is a patient's comment posted on the web site Wrong Diagnosis:. "I have gone to several doctors for this [chronic throat clearing], including an ENT and none of them can tell me what's wrong. They all just tell me it's allergies and give me a nasal allergy medicine (which makes it worse)." Allergies is not so much a diagnosis as a cause for something else, such as rhinitis (inflammation of nasal passages) or asthma. While allergy can lead to airway problems, there is no evidence for an allergic cause of chronic throat clearing, either directly (acting only on the throat) or indirectly (from rhinitis or asthma).
Most chronic throat clearers seem able to sleep through the night. Some sufferers will occasionally awake with the need to throat clear, but nocturnal symptoms are much less common than when awake. Ability to sleep through the night could be due to two very different reasons: either the upper airway mucous production is much less when we sleep (which it is) or the patient is in effect unconscious and just doesn't feel the acute need to clear as when awake.
For many chronic throat clearers the problem is often worse after eating, not during the meal. Eating generates acid in the stomach and saliva in the mouth -- lots more secretions are present after a meal than before it. Unfortunately, this observation doesn't translate into proving a cause or finding effective treatment. Also, while the symptom is often worse after eating, it is still present throughout the day and when the stomach is empty, including after sleeping thru the night.
AIRWAY-ORIENTED TESTS MAY INCLUDE:
GASTROINTESTINAL-ORIENTED TESTS MAY INCLUDE:
It is the belief of many ENT (ear, nose and throat) professionals that chronic throat clearing is a 'learned habit'. The theory is that at some point -- possibly during an upper respiratory infection -- the patient had a lot of mucous that had to cleared, as is common in this situation. However, at that point the patient became highly sensitized to the 'feeling of mucous in the back of the throat', and after the infection went away continued to 'clear' the mucous. Then -- and what follows is essential to this theory -- the very act of throat clearing creates more mucous, placing the patient in a viscious cycle. THROAT CLEARING PERPETUATES THE THROAT CLEARING. In this theory THE PATIENT IS CAUSING THE PROBLEM. Without the constant throat clearing, which ought to be controlled by the patient, the problem would eventually go away. Speech therapists are trained to help people overcome this 'bad habit' of throat clearing, and learn how to control the problem.
At this point (all medical tests negative or inconclusive, and problem is deemed a self-perpetuating bad habit) the goal is to get the patient to decrease his/her urge to throat clear. While there is no scientific basis for these recommendations, speech therapists may attest to success based on selected clinical experience. Many of these methods are in the realm of folk or natural medicine, and include:
There is actually one published study dealing with the last treatment: Ice cold carbonated water: a therapy for persistent hyperawareness of pharyngeal mucus and throat clearing, by Acharya AN, Mirza S, Jones NS. Journal Laryngology and Otolaryngology. 2007 Apr;121(4):354-7. Department of Otorhinolaryngology--Head and Neck Surgery, Queens Medical Centre University Hospital, Nottingham, UK. This is a non-radomized 'observational' study that found ice cold carbonated water was helpful in many patients. The study also discusses the failure of most treatments, and the abstract is worth quoting:
"Chronic throat clearing or a feeling of 'something' at the back of the oropharynx or nasopharynx is a common cause for referral to otorhinolaryngology services. While treatment of an underlying causative condition might be expected to improve these symptoms, in many cases a clear underlying cause is not found. Currently, there is no recognized treatment which is effective against these troublesome symptoms. This observational study investigated the effectiveness of a regime of sipping ice cold carbonated water to try to break the vicious cycle of throat clearing. Seventy-two patients with these symptoms who had previously been advised to use the regime were contacted with a postal questionnaire. Sixty-three per cent of patients documented an improvement in their symptom severity score. The most severely and most frequently affected patients had the greatest benefit. We conclude that the suggested regime can be effective in breaking the vicious cycle of persistent throat-clearing."
There are no similar studies I am aware of that deal with treatment of
chronic throat clearing when the cause is unknown. As the Acharya, et, al, abstract
states, "there is no recognized treatment which is effective..."
It should also be noted that many treatments offered for chronic throat clearing
(including all those by speech therapists) are based on the theory stated
above -- that throat clearing begets more throat
clearing. "Break the vicious cycle" and you solve the problem. However, this approach
is simply inferred and not proven by any means.
It is just as possible that chronic throat clearing is NOT perpetuated by throat clearing. It seems just as plausible that there is true excessive mucous production from certain upper airway structures that cannot be controlled by the patient, no matter how hard the act of clearing is contained. If that is indeed the case then speech-therapy-recommendedations seem foolish, much like blood letting was in the 18th century -- the wrong treatment based on an unproven theory. True, methods to treat chronic throat clearing won't kill the patient, as blood letting often did, but they do indicate that we don't know much about why some people have this annoying affliction.
The answer in part depends on the underlying cause, if one can be found. Asthma, sinusitis, and acid reflux can all be harmful in the long run, but each presents such a giant spectrum of disease (in terms of both symptoms and outcome) that generalities are not helpful. Also, in most cases these conditions are not the cause. Chronic throat clearing is a symptom of something, but in the absence of specific disease that something appears more annoying then serious or life threatening. More studies and long term follow up of patients are needed about this affliction to give any better answer to the question.
There are several web sites dealing with chronic throat clearing, and some of them
contain personal accounts of this malady:
SteadyHealth.com (This is the 1st part of message board with personal accounts of throat-clearing misery)
SteadyHealth.com (Continuation of message board; one of the posters suggests chronic throat clearing is caused by candida [a fungus], and that treatment by a 'kinesiologist' cured her of the problem)
MedHelp (With personal accounts)
Wrong Diagnosis (With personal accounts)
Health Boards (With personal accounts)
Causes of Throat Clearing
GERD vs. LPR
Duke Voice Care Center
I have received several emails, all anecdotal, and have no basis to recommend or refute any of the remedies. A specific treatment that is successful for one individual may not work for another, but at this point there is not much more to offer than personal anecdotes. My observations on all these personal accounts:
Below are two emails that seem particularly interesting.
Chronic cough, Rhinitis and Sinusitis - a Primer for Patients, Physicians Assistants, Nurse Clinicians AND Physicians | Table of Drugs used to treat rhinitis & sinusitis | 10 Common Myths, Misconceptions, Errors and Mistakes about Chronic Cough