The Phlegmy Throat

throatThe Phlegmy Throat (Mucus in Throat)

“Help! There seems to always be phelgm in my throat!” This complaint may be expressed at any age or gender. Though a viral upper respiratory illness can cause this symptom along with feeling sick, often a person may have this complaint without any preceding or concurrent illness. In these healthy patients, the throat mucus sensation is often self-diagnosed with post-nasal drainage, though when specifically asked, many (though not all) people do NOT state they can actually feel the drainage falling from the nose into the throat. Along with this throat mucus sensation, many patients also complain of some or all of these symptoms as well:

  • Chronic throat clearing
  • Cough
  • Globus (lump sensatioin in throat)
  • Tickle in Throat
  • Voice that sounds “wet” intermittently (if your voice is very raspy, this webpage does NOT apply to you)

neckWhen asked where this throat mucus sensation is felt in the throat, they point in the general vicinity indicated in the picture below.

One must first understand a bit of anatomy in this region in order to understand the various causes of this symptom.

The midline external neck landmarks going from superior to inferior is composed of the chin, hyoid bone, Adam’s Apple (laryngeal incisure), thyroid cartilage, cricoid cartilage, rings of the trachea (windpipe), and finally sternum. In the photo, the person is pointing exactly on the cricoid cartilage, which coincidentally, is where individuals with globus pharyngeus complain the lump sensation is located.

neckid

Behind and anchored to the cricoid cartilage, there is a muscle called the cricopharyngeal muscle that makes a sling around the esophagus (or swallowing tube that leads to the stomach from the mouth). This muscle acts like a sphincter to prevent food from coming back into the mouth after swallowing. When this sphincteric muscle becomes too tight for one reason or another, it causes a lump sensation otherwise known as globus.

The throat mucus sensation almost always is localized just above this particular area demarcated by the cricopharyngeal muscle.

So, why does a phlegmy throat occur?

In the VAST majority of patients with this complaint, 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 settles in the throat region. This mucus collection can even be seen on fiberoptic endoscopy as shown in the video. Watch the video showing active reflux (the frothy white mucus) that re-accumulates immediately after swallowing.

Of note, most patients with LPR do NOT complain of heartburn, nausea, indigestion and other symptoms commonly associated with reflux. The cricopharyngeal muscle does tighten up to try and prevent reflux mucus from the stomach from spilling up into the voicebox. However, what this sometimes accomplishes is to PREVENT mucus/saliva from going down resulting in mucus buildup in the throat! Treatment 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. Read more about reflux here.

Alternatively, one can try lifestyle changes prior to medications including:

  • Keep head of bed elevated 30 degrees or more (put a few 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.

Post-Nasal Drainage can sometimes cause a throat mucus sensation. 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, astepro, and astelin may be quite helpful. In these patients, turbinate reduction may quite helpful to reduce the amount of drainage, though rarely cures.

Rarely, food sensitivities (not food allergy per se) can cause excessive throat mucus to develop, much like the way an eye starts to water when exposed to an irritant. The most common culprit is dairy products followed by egg and wheat. Treatment for this problem is mainly avoidance (a rotation diet is usually recommended). Please note that food mucogenic symptoms in this situation may occur anywhere from 1 to 24 hours AFTER the food is eaten! Other food sensitivity symptoms include vague sense of stomach unease, gassy, mental fog, odd skin complaints, feeling fatigued, etc.

Certain rheumatological conditions like Sjogren’s syndrome can decrease saliva production which can lead to thick spit which can hang in the back of the mouth or throat. Dehydration or mouth-breathing can lead to a similar picture.

Rarely, cricopharyngeal muscle or esophageal pathology may cause a phlegmy sensation when the muscle scars, hypertrophies, or becomes chronically spastic or the lining of the esophagus develops a ring, shelf, or stricture. Even more rarely, a Zenker’s Diverticulum or eosinophilic esophagitis may be present. Sometimes, there is esophageal motility problems as well causing phlegm buildup. Lastly, a mass of some kind can cause this mucus sensation. Such masses may include cancer, cysts, granulomas, etc.

Treatment

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) 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 .If the barium swallow comes back abnormal, an esophagoscopy may need to be performed.

A simple spit test can also be performed to determine if LPR is present as well. This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time.