Chronic Throat Clearing
"Help! I seem to clear my throat all the time!" This is a complaint that is often expressed by patients seeing their ENT doctor. It does not hurt. It does not affect swallowing. There are no other symptoms other than a persistent throat clear that is perhaps more annoying to friends and family than the patient.
The constant throat clearing may occur a few times a day to as often as a few times a minute. Some people find that they consistently throat clear after eating while others do not find this relationship.
If there are other symptoms, they may include:
- Dry Cough
- Globus (lump sensation in throat)
- Tickle in Throat
- Intermittent Mucus Sensation in the Throat
- Voice that sounds "wet" occasionally (if your voice is very raspy, this webpage does NOT apply to you)
So, what may cause this problem?
Reflux (Acidic or Non-acidic)
In the VAST majority of patients complaining of constant throat-clearing, it is due to a disorder called "laryngopharyngeal reflux" or LPR for short. This disorder is due to reflux whether acidic or non-acidic mucus reflux from the stomach that travels up to and briefly irritates the throat region. This transient irritation is just enough to cause a person to clear the throat without causing any other symptoms. Think of this problem like a tiny drop of acid or other irritant that lands in the eye causing a person to briefly itch the eye due to discomfort that may last several days. Watch the video showing active reflux (the frothy white mucus) that re-accumulates immediately after swallowing. Such phlegm can induce a person to constantly throat-clear.
Of note, most patients with LPR do NOT complain of heartburn, nausea, indigestion and other symptoms commonly associated with reflux. That's because the swallowing tube has a protective layer to prevent any damage from acid reflux and is able to withstand several reflux episodes without any problems, but not so in the voicebox and throat region. It takes only a single episode to produce symptoms there.
The treatment for LPR is the same as for the more common and related GERD disorder except that treatment usually takes much longer... sometimes for as long as 6 weeks to 3 months. Some over-the-counter medications used to treat reflux are listed at end of article below.
Alternatively, one can try lifestyle changes prior to medications including:
- Keep head of bed elevated 30 degrees or more (put 2 bricks under the head of bed so the entire bed is tilted)
- Do not eat or drink within 3 hours of laying down (an empty stomach has less chance of reflux than a full one)
- Avoid caffiene and alcohol
- Avoid tomato-based, spicey, and fatty foods
If these conservative interventions do not help and it is confirmed reflux is present reaching the throat level, surgery may need to be pursued.
Typical studies obtained to evaluate for possible reflux triggered throat clearing is a barium swallow, 24 hour multichannel pH and impedance testing with manometry, and upper endoscopy. A rapid spit test can also be performed to determine if reflux is present as well.
To read more about this disorder, click here.
Sometimes, mucus can accumulate in the throat due to nasal drainage triggering throat-clearing. In these patients, they literally feel the drainage traveling from the nose and down into the throat. Often, when one looks in the back of the throat, the drainage can be seen. Treatment for this drainage depends on what it is caused by. If due to sinusitis, antibiotics is the treatment. If due to allergies, allergy treatment is recommended. If due to vasomotor rhinnitis, nasal sprays such as atrovent, patanase, and astelin may be quite helpful. In these patients, turbinate reduction may quite helpful to reduce the amount of drainage.
Avoid all ACE-Inhibitors as well as Angiotensin Receptor Blocker medications. Both of these classes of medications address high blood pressure. However, as a side effect, they also potentially can cause a "tickle" sensation in the throat that makes a person want to clear the throat or cough. If you are taking one of these medications, recommend having your primary care doctor change your medication to a different one (ie, beta-blocker, calcium channel blocker, etc). Would avoid these medications for at least 3 months.
Food Allergies or Sensitivities
Rarely, food allergies/sensitivities can cause throat mucosa irritation and/or excessive throat mucus to develop triggering throat-clearing. The most common culprit is dairy products though reactions to egg, wheat, rice, soy, etc are also possible. Treatment for this problem is mainly avoidance.
Even more rarely, there may be an anatomic abnormality in the throat called a Zenker's Diverticulum. Basically, this abnormality is a pouch that protrudes from the esophagus (swallowing tube) which catches food and mucus preventing it from going down towards the stomach. At random times, the contents in the pouch may suddenly regurgitate causing aspiration as well as mucus collection in the throat.
Treatment is surgical. Click here for more info.
Laryngeal Sensory Neuropathy
Perhaps in the most rare situation, the throat-clearing is due to an abnormally sensitized throat where even the slightest irritation which normally would not trigger a throat-clear does trigger one. Related symptoms include chronic dry cough as well as laryngospasm.
Click here from more info.
Such anatomic triggers include VERY large tonsils or a very long uvula. When the tonsils/uvula are quite large, they may touch the epiglottis causing a person to clear the throat to try and remove the irritation. Treatment is by tonsillectomy and/or uvula removal.
Normal short uvula with rounded end.
Very long uvula.
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)
Only in kids, there is a VERY rare disorder where strep infections can cause tics including throat clearing. If there is concern for this particular disorder, an evaluation with a pediatric neurologist may be warranted. Here is a link to a girl who sneezed constantly due to this disorder. Here is a New York Times article.
Lastly, when all other possible causes have been eliminated, a chronic throat clear could be a tic. Just like a facial tic or eye twitches. In that case, botox injections to the vocal cord may be helpful as well as a neurology evaluation.
Overall, treatment tries to address the underlying cause. As an initial exam, a baseline fiberoptic endoscopy is performed to visualize the area of concern. With reflux, proton pump inhibitors (ie, Prilosec or Prevacid) are often tried for at least 3-4 weeks though in some people, it may take up to 3-6 months for adequate resolution. Should symptoms persist after taking anti-reflux medications for sufficient amount of time, a barium swallow and/or upper esophageal manometry is ordered to assess whether the muscle itself may be abnormal as well as to check for any other physical anatomic abnormalities. Additionally, a 24 hour pH probe and multichannel intraluminal impedance testing may be recommended (watch video on this test). If the barium swallow comes back abnormal, an esophagoscopy may need to be performed. Additional testing may include allergy testing.
Related Blog Articles
- Mucus in Back of Nose/Throat After UPPP or Uvula Removal
- Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults
- What is Considered a Normal Number of Reflux Episodes?
- Suppressing the Gag Reflex
- Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?
- Laying on Right Side Worsens Acid Reflux!
- Mattress Wedges for Reflux Treatment
- New Video of Phlegmy Throat
- Saliva Test for Laryngopharyngeal Reflux (LPR)
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