Why do I have to clear my throat so much?

You’re sitting in a quiet place like a library, religious service or lecture hall, when the silence becomes interrupted by the guttural tones of someone who is frequently clearing his or her throat. Mind you, this is no mild “ahem.” This sounds disgusting, like someone about to hock a loogie.

And it continues, without any coughing, sneezing, nose-blowing or other outward signs of a cold or allergies.

Excessive throat-clearing is more of a symptom than a diagnosis, says Dr. Phillip Song, a laryngologist at Massachusetts Eye and Ear Infirmary in Boston. It usually starts with a physical component, such as acid reflux or an upper respiratory tract infection. But then it can become behavioral when it becomes habituated, he explains. “It’s hard to know when it crosses that line.”

So, how can you tell the difference between garden-variety throat clearing from a cold, sore throat, or seasonal allergies and the chronic kind? If it lasts less then two weeks in general, that’s situational, says Song. If it’s greater than three months and it’s there all the time while you’re awake, that’s chronic throat-clearing.

Two of the most common causes of frequent throat clearing are laryngopharyngeal reflux, or LPR, and seasonal allergies, explains Song.

Reflux from the stomach, which may or may not be acidic, comes up through the esophagus and into the back of the throat, where it can irritate the voice box. People with LPR may also have post-nasal drip, an excess of throat mucus, or the feeling like something is stuck in the throat, but nothing is there.

With allergies, an environmental trigger whether it’s pollen, ragweed, or mold is causing itchiness and inflammation in the nose and throat, which forms one continuous airspace. It’s tickling the throat creating a desire to clear it.

People with allergies or reflux are also producing a dry, sticky mucus that’s leading to a phlegm-filled sound when the throat is cleared.

Sometimes asthma can make the throat irritable and hypersensitive. Chronic throat-clearing may also occur in a condition known as vocal hyperfunction, where friction along the length of the vocal cords from straining to speak or explosive coughing, forms small ulcers or masses.

Occasionally, excessive throat clearing is a side effect of people taking blood pressure medications known as ACE inhibitors, so you’d need to switch to a different drug.

Treatment for the problem depends on the cause. There are medications to ease reflux, allergies, and asthma. Voice therapy can help break the throat-clearing cycle of vocal hyperfunction.

If you’re persistently clearing your throat and it doesn’t go away, have your doctor check it out. Most of the time, people are aware they are doing this and it can disrupt their lives, Song says. But sometimes, a spouse brings the person to the doctor’s office because the throat-clearing is driving them crazy, he points out.

Has constant throat clearing ever driven you nuts?

Throat clearing FAQ

An intentional throat clearing – “ahem” – is like a nudge, a discrete way to get someone’s attention, a social cue to back off, a hint to change the subject, or to express doubt. Repetitive, chronic, or excessive throat clearing could be a sign or symptom indicating an underlying condition.

What could be causing my excessive throat clearing?

A common cause of throat clearing is a change to the mucus. If there is too much mucus, if it is too thick, or if it drips back from the nose into the throat, a person will feel a need to clear the mucus. This often happens during a cold, flu, sinusitis, or an allergy flare-up.

Stomach acid due to gastroesophageal reflux (GERD) can flow back up into the throat and cause irritation that triggers throat clearing. Food can sometimes become trapped in a small pouch in the throat (called pharyngeal diverticula) and lead to food regurgitation, bad breath, difficulty swallowing, as well as coughing and repetitive throat clearing. Throat clearing may also be common among those with swallowing problems like dysphagia.

Certain medications may cause cough and repetitive throat clearing, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB), a medication that helps to relax blood vessels and is prescribed for high blood pressure and heart conditions.

In some cases, chronic or excessive throat clearing can be caused by a vocal cord injury or dysfunction, as with benign vocal cord lesions (nodules, polyps, cysts) that develop because of vocal misuse or abuse.

Food allergies or sensitivities to food ingredients can also cause irritation to the lining, causing mucus buildup and throat clearing. You can avoid the problem by avoiding the food that’s causing it.

Anatomical causes, such as very large tonsils or a very long uvula, can also trigger irritation and cause throat clearing. You can treat the problem by surgery (removal of tonsils or uvula).

Throat clearing may also be a sign of asthma or a warning of an approaching asthma attack.

For some people, throat clearing may just be a habit.

Should I be worried about my throat clearing?

Excessive, repetitive throat clearing can cause vocal cord trauma and hoarseness. Your vocal cords are two taut bands of muscle that vibrate in order to make sound. When you clear your throat, you cause the vocal cords to slam together.

Seek medical advice if your throat clearing is disruptive to your life. You may be able to track down the root cause or find help to resolve the habit. In some instances, throat clearing may point your doctor toward a diagnosis of an underlying condition.

How can I break the throat clearing habit?

If throat clearing is in fact a habit, you can take steps to break it. Drink plenty of water to keep your vocal cords lubricated. When you feel the urge to clear your throat, take sips of water. In one observational study, ice cold carbonated water was found to be especially effective. Swallow your saliva to flush out mucus. Try a gentle, breathy cough that may be more protective of your vocal cords than the usual clearing. Or try humming, laughing, or talking your way through the moment.

What Patients Should Know in Decision Making

Management Alternatives

Early Disease:

Early cancer of the glottis (vocal cords) or supraglottis (false vocal cords) can be effectively treated with either surgery alone or radiation therapy. Most surgical procedures can spare major portions of the voice box and with modern techniques, reconstruction of the voice box can be accomplished with preservation of reasonable voice quality and swallowing. The past ten years have seen the introduction of laser resections for many of these cancers thereby avoiding external neck incisions. In general, cancers that are superficial or limited in extent are best treated with laser removal. Similar tumors are also easily cured with 6-7 weeks of radiation treatment. Many physicians feel that voice quality may be better following radiation compared to surgery, but side effects of permanent dry mouth and risks of some long-term swallowing problems are associated with radiation. Decision making as to treatment of choice also depends on availability of skilled surgeons or radiation therapists and the depth of invasion (extent) and the overall size (volume) of cancer.

Intermediate Disease:

For those cancers that are of intermediate size (T2, small T3), treatment decisions are more difficult. Deeply invasive cancers are best treated with surgical excision, often combined with modified or selective neck dissection (removal of lymph nodes). Most of these procedures can preserve some vocal function without permanent tracheostomy. More extensive surgical resections are associated with significant problems with voice and swallowing and radiation therapy or combinations of chemotherapy and radiation may be recommended. A recent advancement, pioneered in Europe, includes near total laryngectomy (supracricoid partial laryngectomy) which has achieved excellent results in young, properly selected patients. Superficial cancers or those of smaller volume can be effectively treated with radiation alone, but local recurrence rates are higher than with primary surgery. Overall cure rates are when subsequent surgical salvage of these radiation failures is successful. Unfortunately, many of the patients suffering recurrences after radiation must undergo total laryngectomy in order to be cured.

Advanced Disease:

Standard treatment for patients with advanced laryngeal cancer has historically consisted of total laryngectomy, often combined with modified neck dissection. When metastatic cancer is present in the lymphatics of the neck, surgery is combined with radiation therapy. Five-year cure rates vary from 40-60%. The major sequelae of total laryngectomy include loss of natural voice and problems associated with living with a permanent tracheal stoma (hole in the neck). Modern voice restoration techniques with tracheoesophageal puncture (Blom-Singer prosthesis) has significantly reduced loss of voice as a result of total laryngectomy since the majority of patients are able to speak with a naturally sounding, lung powered voice and fewer patients must rely on the artificial electrolarynx or esophageal speech.

Many patients and physicians will select primary radiation for treatment of advanced laryngeal cancers. When there is no clinical evidence of regional (neck) metastases, cure rates are acceptable even though local tumor control is not as good as with surgery. This is because of the possibility of successful surgical salvage of radiation failures. When clinical metastases have occurred, cure rates with radiation alone are not good and optimal treatment incorporates surgery followed by radiation.

One of the most exciting advances in the treatment of patients with advanced laryngeal cancer has been the introduction of chemotherapy as initial treatment. In pioneering work, the Veterans Affairs Laryngeal Cancer Study Group demonstrated that several cycles of initial chemotherapy combined with radiation can be as successful as total laryngectomy in curing patients with advanced cancer when the tumor responds to initial chemotherapy. For such patients, laryngeal function, voice, swallowing and quality of life are preserved. This approach has now been extended to patients with pharyngeal (throat) cancers that would normally also require total laryngectomy. More recent studies have shown the feasibility of using a single treatment of initial chemotherapy to determine which cancers will respond and then treating these patients with combined, simultaneous chemotherapy and radiation. Unfortunately, patients who have cancer, which is unresponsive to initial chemotherapy, must undergo total laryngectomy with its resultant side effects. Fortunately, cure rates are the same in both groups of treated patients. Typically, nearly 2/3 of patients will be able to avoid surgery with this new approach. Five-year cure rates for patients with advanced disease managed in this fashion are now in the range of 80% at the University of Michigan. There is increasing evidence that combined (concurrent) chemotherapy and radiation may be better treatment than radiation alone. These combined approaches have substantially increased toxicity and make subsequent surgery for cancer recurrences more difficult. Thus, using an initial chemotherapy treatment to select the right patients for combined chemoradiation and selecting the optimal patients for total laryngectomy represents the first real advance in cure rates for this disease and justifies the increased risk of toxicities from combined treatment.

None of the other treatment approaches have demonstrated improvements in survival rates compared to total laryngectomy. Therefore, all patients should be informed about the effects of total laryngectomy and the chances of subsequent total laryngectomy if either radiation or radiation and chemotherapy are offered as initial treatment. The selection of treatment therefore depends on a balance between side effects, experience of the treating physicians, cost and patient desire. Currently, larynx preservation techniques using chemotherapy and radiation can be offered as alternatives to total laryngectomy if the treatment team has experience with these special techniques or is participating in controlled clinical trials of these approaches.

Still have questions about voice box cancer?

Continue learning about head and neck cancer and how to make treatment decisions

    Head and Neck Cancer Clinic at the U-M Rogel Cancer Center

    Trying Treatment: Harry Robins, a head and neck cancer patient, shares his experiences

    Predicting Complications After Larynx Cancer Surgery

    Tips for Selecting an Oncologist and Cancer Treatment Center

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Signs and symptoms of laryngeal (larynx) cancer

Your symptoms will depend on where in the larynx the cancer is. Most cancers begin on, or near, one of the vocal cords.

The most common symptom of laryngeal cancer is changes to your voice, such as hoarseness. Changes to your voice may be an early sign of the cancer affecting your vocal cords (glottis). If you notice any changes to your voice, you should see your GP. If you have hoarseness for 3 to 4 weeks that does not go away, your GP should refer you to a hospital for tests.

Sometimes, the first symptom you notice might be a lump in the throat or neck. You may also have discomfort or pain when chewing or swallowing. These symptoms are more common when the cancer starts above the vocal cords. This is called supraglottic cancer of the larynx.

Other less common symptoms include feeling breathless or having a cough that does not go away. This may happen when the cancer affects the area below the vocal cords (subglottis), near the windpipe. But this is very rare.

If you have any of the symptoms above, you should tell your GP. Other conditions may be causing the symptoms, but it is important to get them checked.

All About Laryngeal Cancer

What is the larynx?

The larynx, or voice box, is an area in the throat that contains both cartilage and muscles. The larynx produces our voice, and also performs other functions such as protecting our airway during swallowing. The larynx is made up of three parts: the supraglottis, the glottis, and the subglottis. The supraglottis is the space above the vocal cords that contains the epiglottis. The epiglottis is a flap of tissue that closes off the larynx when you swallow, which prevents food and fluids from entering your lungs. The supraglottis is protected in the front by the large thyroid cartilage, which can be felt as the “Adam’s apple” in our neck. When you feel for your Adam’s apple, directly under that large piece of firm cartilage is the voice box or the glottis. The glottis is the portion of the larynx where the vocal cords are located. Below the vocal cords is the subglottic larynx or subglottis. This area is the part of the throat and airway below the vocal cords but above the trachea. All three of these areas together are considered the larynx.

What is laryngeal cancer?

Normally, cells in the body will grow and divide to replace old or damaged cells in the body. This growth is highly regulated, and once enough cells are produced to replace the old ones, normal cells stop dividing. Tumors occur when there is an error in this regulation and cells continue to grow in an uncontrolled way. Tumors can either be benign or malignant. Although benign tumors may grow in an uncontrolled fashion sometimes, they do not spread beyond the part of the body where they started (metastasize) and do not invade into surrounding tissues. Malignant tumors, however, grow in such a way that they invade and damage other tissues around them. They also may spread to other parts of the body, usually through the bloodstream or through the lymphatic system where the lymph nodes are located. Over time, the cells within a malignant tumor become more abnormal and appear less like normal cells. This change in the appearance of cancer cells is called the tumor grade. Cancer cells are described as being well-differentiated, moderately-differentiated, poorly-differentiated, or undifferentiated. Well-differentiated cells are quite normal appearing and resemble the normal cells from which they originated. Undifferentiated cells are cells that have become so abnormal that often we cannot tell what types of cells they started from.

Cancers are described by the types of cells from which they arise. A majority of laryngeal cancers develop from squamous cells, which are found in the epithelium of the larynx, which is the innermost layer lining the larynx. Therefore, they are referred to as squamous cell cancer of the larynx. Most squamous cell cancers start not as cancer, but as a pre-cancerous condition called dysplasia. Usually, dysplasia does not turn into cancer. At times dysplasia can progress into cancer in which cancer cells are limited to the epithelium. This is called carcinoma in situ. There are also other very rare types of laryngeal cancer, including minor salivary gland cancer, sarcoma, and melanoma.

What causes laryngeal cancer and am I at risk?

Approximately 12,410 people are diagnosed with laryngeal cancer each year. Of these cases, about 60% start in the glottis, 35% in the supraglottis and the rest develop in the subglottis or overlap more than one area. It is more common in men than in women. In the United States, it is most common in the African American population. There has been a steady decrease in the number of people diagnosed each year, which is thought to be related to the decrease in smoking rates.

Many risk factors have been associated with the development of laryngeal cancer. These include chronic irritation from laryngitis or voice abuse, chronic gastric reflux, and exposure to certain chemicals (like wood dust, nitrogen mustard, and asbestos), HPV, poor nutrition and some genetic syndromes (Fanconi anemia and Dyskeratosis congenita). However, the largest risk factor for the development of laryngeal cancer is smoking. Pipe smoking, cigar smoking, and cigarette smoking have all been strongly associated with the development of laryngeal cancer. There is also an association between heavy alcohol intake and laryngeal cancer.

How can I prevent laryngeal cancer?

Since it is fairly uncommon for a non-smoker to be diagnosed with laryngeal cancer, smoking cessation is the best way to prevent laryngeal cancer. In fact, not using tobacco of any kind, either smoking or smokeless, is the healthiest thing anyone can do, both in terms of preventing laryngeal cancer, as well as the prevention of other throat cancers, lung cancers, and many other serious health problems.

Reducing alcohol intake may also be helpful in the prevention of laryngeal cancer, especially for people who smoke. You should also eat a healthy and balanced diet. Reducing other risk factors, such as chronic vocal irritation and gastroesophageal reflux (heartburn) may also be beneficial. A healthcare professional should be consulted for chronic health problems such as laryngitis or chronic heartburn.

What are the signs of laryngeal cancer?

Signs or symptoms of cancer of the larynx depend on where the cancer is growing (supraglottis, glottis, or subglottis). Patients with glottic cancer, or cancer that grows on the vocal cords, often present with the early sign of hoarseness. This occurs because even a slight interference with the vibrating function of the vocal cords can produce voice changes. If you have any hoarseness or voice changes you should contact your provider. If hoarseness is ignored or if advanced disease occurs, airway obstruction, pain, or difficulty swallowing can result.

Supraglottic cancers usually do not produce early signs or symptoms, so supraglottic cancers are more often in advanced stage upon diagnosis. Hoarseness can also occur with supraglottic cancer, though usually after the cancer has progressed. Also, in patients with supraglottic cancer, voice changes referred to as “hot potato voice” can occur. This can be described as the type of voice someone would speak in if they had a piece of hot food (potato) in their mouth. In addition to voice changes, patients can also present with pain, problems swallowing, or even ear pain, which can result from the involvement of nerves in the throat by the tumor. Supraglottic cancers often spread to lymph nodes in the neck, and many patients notice a lump in the neck as the first sign of cancer. Any lump or bump in the neck that does not go away within a few days should be evaluated by a medical provider.

Subglottic cancers are fairly rare and often don’t have any early symptoms. Therefore, they also present in more advanced stages and patients can have signs of disease similar to that of supraglottic cancers.

Again, these signs and symptoms are nonspecific and could represent a variety of different conditions-both benign and malignant. However, if you have any of these symptoms, especially if they are longstanding or if you are a smoker, you should see your provider.

How is laryngeal cancer diagnosed?

If your provider thinks you have laryngeal cancer, you will have a physical examination of your neck to check for any lumps or bumps. Your provider may send you to a doctor called an otolaryngologist who specializes in treatment of ear, nose and throat issues.

A provider will also want to look inside your throat. This can be done with a mirror, though it is more commonly done using a fiberoptic scope called a nasopharyngolaryngoscope. This is a camera attached to a long fiberoptic endoscope that is inserted into the patient’s nose or mouth to view the throat. Medicine to numb the inside of a patient’s nose or throat may be used before the procedure to maintain comfort during the exam. This exam is brief and is done in the provider’s office. The entire throat down to the level of the vocal cords is evaluated with special attention to the surfaces of the throat and the movement of the vocal cords. Another, more thorough test that is used is called direct laryngoscopy, which is done in the operating room under anesthesia. Since the patient is sleeping during this examination, a more thorough exam can be done with biopsies being done at that time. A careful examination of the neck is also required to detect spread of tumor to the lymph nodes.

Other procedures are needed to determine the stage of the tumor. CT scans (CAT scans) or sometimes MRIs of the neck are done to further determine the extent of the disease, both in the throat and in the neck. A chest x-ray is also often ordered to rule out spread of tumor to the lungs. Blood tests are often done to ensure that overall blood counts are within normal limits and that a patient’s liver and kidneys are functioning correctly.

How is larynx cancer staged?

The staging of cancer describes the extent of disease. Cancers cause problems because they spread and can disrupt the way the body works normally. One way that larynx cancers can spread is by local extension. Local extension is invasion of the cancer through the normal structures in the throat and into close by parts of the neck. These include the vocal cords, the structures that control voice and swallowing, the epiglottis (which is needed to prevent choking when swallowing), and even the cartilage and muscles surrounding the larynx. All cancers can spread via local extension, though this method of spread is particularly important in larynx cancer and other cancers of the throat. Tumor growth by local extension in the larynx can cause a patient’s airway to be compromised or the swallowing function to be interrupted (which leads to problems eating and possible malnutrition), as well as causing the loss of the protection of the airway during swallowing, leading to choking and infection. Keep in mind that larynx cancers, when spreading via local extension, often spread from one subsite to the other (for example, glottis cancers can spread locally to involve the supraglottis). Sometimes, if cancers are locally advanced, it can be difficult to tell from which part of the larynx they originally grew.

Larynx cancer can also spread through the lymphatic system. The lymphatic system is a complete circulation system in the body (somewhat like the blood circulatory system) that drains into various lymph nodes and organs. When cancer cells get into the lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is called lymphatic spread. Larynx cancers differ in their propensity to spread, again based on the site of the larynx that the tumor involves. Supraglottic cancers have spread to the lymph nodes in over 50% of patients by the time a diagnosis has been made. Glottic cancer (one that has not spread to the supraglottis or other sites within the throat by local extension), has spread to the lymph nodes in less than 5% of patients upon diagnosis. However, keep in mind that once cancer spreads from the glottis (the true vocal cords) to another subsite, it can spread to lymph nodes just as much as a cancer that originated in that other subsite. The first lymph nodes that cancer cells spread to are the “jugular chain” of lymph nodes, which are found along the side of the neck. They can be found in front of the large muscles on either side of the neck that contract when the head is turned from side to side. Tumor cells that spread to the jugular lymph nodes can then spread to the “supraclavicular” lymph nodes (found behind the collar bone) and to other lymph nodes in the neck.

Larynx cancers can also spread through the bloodstream to distant organs. The tumors that arise from this travel to other organs are called metastases. Cancers of the larynx generally spread locally or to lymph nodes before spreading through the bloodstream. This is more common with supraglottic (and subglottic) tumors and distant metastases are found in only a small number of patients with laryngeal cancer. If spread through the bloodstream does occur, the lungs are the most common site of metastasis, followed by the bones.

The staging system used in larynx cancer describes the extent of disease in both the throat itself and the neck (with spread to the lymph nodes). The staging system used to describe laryngeal tumors is the “TNM system.” The TNM system has three parts: T-describing the extent of the “primary” tumor (the tumor in the throat itself); N-describing the spread to the lymph nodes; M-describing the spread to other organs (i.e.-metastases). Since the different subsites of the larynx have different structures, the “T” portion (or local extent of disease) is described separately for each. Your healthcare provider will use the results of the diagnostic workup to assign the TNM result and combine these to get a stage from 0 to IV.

Though complicated, these staging systems help providers determine the extent of the cancer and help create a treatment plan. The stage of cancer, or extent of disease, is based on information gathered through tests done as the diagnosis and work-up of the cancer is being done. The TNM breakdown is quite technical but is provided at the end of this article for your reference.

How is laryngeal cancer treated?

The goal of treatment for laryngeal cancer often is to remove the cancer and to also preserve the patient’s ability to speak and swallow. The options for treating cancer of the larynx are primarily surgery, radiation, and chemotherapy. Your treatment options will depend on where your cancer is and if it has spread. It is important to work with your care team to create a plan that works best for you and your lifestyle.

Surgery

The goal of surgery is to remove all of or as much of the cancer as possible while causing minimal damage to the remaining tissue. In some instances, you will be treated with surgery and chemotherapy or radiation. There are a number of surgical options to treat cancer of the larynx. The type of surgery that your team will suggest depends on where the cancer is and if it has spread or not. Here is a list of possible surgical treatments:

  • Vocal Cord Stripping: The superficial layers of tissue on the vocal cords are stripped away using a long surgical instrument. The purpose of vocal cord stripping is to biopsy or to treat carcinoma in situ (Stage 0). After recovery, the normal speaking voice is usually maintained.
  • Cordectomy: In a cordectomy, either part or all of your vocal cords are removed. The effect on your speech is dependent upon how much of the vocal cord is removed. If only part of the vocal cord is removed, you may experience hoarseness; if both cords are removed you will not have normal speech.
  • Laryngectomy: There are a number of different types of laryngectomies, all with the goal of removing as much cancer as possible while sparing healthy tissue.
    • Partial Laryngectomy: In a partial laryngectomy, only a portion of the larynx is removed. There are two types. In a supraglottic laryngectomy, the portion of the larynx above the vocal cords known as the supraglottis is removed. You will be able to speak normally after surgery. The second is a hemilaryngectomy and in this procedure, only one of the vocal cords is removed. After this procedure, some speech will remain.
    • Total Laryngectomy: The entire larynx is removed because of how advanced the cancer is. Because the entire larynx is removed, the windpipe (trachea) will be brought up through the skin on the front of the neck creating a hole (stoma) that you will now breathe through, rather than through your nose or mouth. This is known as a tracheostomy. You will not be able to speak normally. After recovery from the surgery, you should be able to swallow normally.
  • Laser Surgery: In laser surgery, an endoscope is placed into your mouth and down into your throat to find the tumor and then vaporize or cut out (excise) the tumor using the laser that is on the tip of the endoscope. If this technique is used to remove part of the vocal cord, it can result in a hoarse voice.
  • Lymph Node Dissection: If it is suspected that the cancer has spread to the lymph nodes then your surgeon may choose to do a lymph node dissection or removal. There are several types of dissections, which can range from the removal of one or a few lymph nodes to the removal of nodes, nerves, and muscle. Your surgeon will determine the extent of dissection needed based on the size and location of the original tumor and if the nodes were enlarged on previous imaging tests.

If the cancer has invaded the throat you may have a partial or full pharyngectomy, which is the removal of the throat. If the cancer has affected your thyroid, you may need a thyroidectomy.

If your voice or swallowing is affected by the surgery, you had you will be referred to work with a speech therapist. A speech therapist will be able to teach you techniques and give you tools to improve your speech and swallowing. If you are unable to swallow safely and well enough to maintain proper nutrition after surgery, you may have a gastrostomy tube placed. This is a tube that is placed directly through the skin and into the stomach with a port to infuse liquid nutrition into. This will likely be temporary until your swallowing improves enough to maintain proper nutrition. You may also need reconstructive surgery depending upon how much normal tissue was removed. Skin may need to removed from one part of your body to replace skin and tissues removed during surgery.

Radiation Therapy

Radiation therapy can be used as the only treatment or in combination with surgery or chemotherapy to treat laryngeal cancer. Radiation comes in the form of high energy x-rays that are delivered to the patient only in the areas at highest risk for cancer. These x-rays are similar to those used for diagnostic x-rays, but they are of a much higher energy. The higher energy of x-rays in radiation therapy results in damage to the DNA of cells. Cancer cells divide faster than healthy cells, and so their DNA is more likely to be damaged than that of normal cells. Additionally, cancer cells are generally less able to repair damaged DNA than normal cells are, so cancer cells are killed more easily by radiation than normal cells are.

In the early stages of the disease, laryngeal cancer may be treated with radiation alone. This can preserve better voice quality for some patients. When radiation is used with surgery it is called adjuvant therapy. It is used as a treatment after surgery to kill any remaining cancer cells and to lower the chance of recurrence. Radiation may also be the course of treatment for patients who cannot tolerate surgery or whose cancer is so advanced that the goal is to manage symptoms, such as pain and bleeding. It can result in side effects such as skin irritation and it can affect nearby glands and tissues.

Chemotherapy

Chemotherapy is the use of medications that treat cancer. Chemotherapy is known as a “systemic” treatment, which means that it goes throughout the entire body. These medications may be given through a vein (IV, intravenously) or by mouth, as pills. There are two different methods of giving chemotherapy for the treatment of laryngeal cancer, conventional chemotherapy, and chemoradiation.

Conventional chemotherapy is useful in treating the cancer if it has metastasized (spread) or if the cancer was not completely removed during surgery. The chemotherapy medications commonly used to treat laryngeal cancer include cisplatin, carboplatin, fluorouracil, docetaxel, paclitaxel and epirubicin. Which medications you receive and how often will be determined by your provider.

Cetuximab, a targeted therapy, can be used in combination with chemotherapy or radiation to treat laryngeal cancer. Immunotherapy is the use of a person’s own immune system to kill cancer cells. Pembrolizumab and nivolumab are both immunotherapy medications that target and block PD-1. PD-1 is a protein and when it is blocked the body starts an immune response against the cancer cells, which shrinks or slows tumor growth. These medications may be used for the recurrence of the cancer. In some cases, pembrolizumab is the first type of treatment used.

Chemoradiation is chemotherapy that is given at the same time as radiation. Chemoradiation tends to be more effective than using radiation or chemotherapy alone. The medication of choice for chemoradiation is cisplatin and in some cases cetuximab.

Clinical Trials

There are clinical research trials for most types of cancer, and every stage of the disease. Clinical trials are designed to determine the value of specific treatments. Trials are often designed to treat a certain stage of cancer, either as the first form of treatment offered, or as an option for treatment after other treatments have failed to work. They can be used to evaluate medications or treatments to prevent cancer, detect it earlier, or help manage side effects. Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your provider about participating in clinical trials in your area. You can also explore currently open clinical trials using the OncoLink Clinical Trials Matching Service.

Follow-Up Care and Survivorship

After you have completed treatment for laryngeal cancer, your care team will follow you closely to monitor for the recurrence of cancer and to help you manage any side effects you may have from the treatment you received. Visits to your provider will be frequent during the first couple of years after you are done treatment. During the first year you will see your provider about every other month. At these appointments, your provider will examine your neck and may do a laryngoscopy. Your provider may also order chest x-rays and other imaging tests. The longer you are cancer free, the longer the time will be between appointments.

If you were treated with radiation that included your thyroid gland, you will have regular blood tests to check the functioning of your thyroid gland. Radiation may also include the salivary glands in the field, which causes dry mouth, which can affect speech, swallowing and lead to tooth decay. Your provider may suggest more frequent trips to the dentist and preventive oral care to manage these side effects.

Patients who were treated with surgery or surgery and radiation often have issues with swallowing and speech after treatment. You will be referred to work with a speech therapist. A speech therapist will be able to teach you techniques and supply you with tools to improve or regain your speech. A speech therapist can also assist you with swallowing. You may need to adjust your eating habits to better suit your needs after treatment. You may also be referred to a nutritionist to help you manage your nutritional goals and needs. You may temporarily need a feeding tube placed into your stomach until your swallowing improves.

Patients who were treated with a total laryngectomy are left with a tracheostomy, also known as a stoma. A tracheostomy, done through a surgical procedure, is a hole in the front of the throat that is used to breathe, rather than the nose or mouth. The mouth and nose moisten and remove particles from the air that is then introduced into our lungs. Because the air being transferred through a stoma will be drier and cooler, it can cause the buildup of thick mucous, making it difficult to breathe. Patients with stomas will be instructed on how to care for their stoma and how to use a humidifier to moisten the air they are taking in to prevent the buildup of mucous. Your provider and home care nurses will teach you how to care for and protect your stoma.

Difficulty with speech and swallowing, changes in appearance, sexuality, fear of recurrence, financial impact of cancer treatment, employment issues and coping strategies are common emotional and practical issues experienced by laryngeal cancer survivors. Your healthcare team can identify resources for support and management of these practical and emotional challenges faced during and after cancer.

Cancer survivorship is a relatively new focus of oncology care. With nearly 17 million cancer survivors in the US alone, there is a need to help patients transition from active treatment to survivorship. What happens next, how do you get back to normal, what should you know and do to live healthy going forward? A survivorship care plan can be a first step in educating yourself about navigating life after cancer and helping you communicate knowledgeably with your healthcare providers. Create a survivorship care plan today on OncoLink.

Resources for More Information

International Association of Laryngectomees (IAL)
This site offers education, support, and information on suppliers of care products for patients with laryngectomies.

Support for People with Oral and Head and Neck Cancer, INC. (SPOHNC)
Free support for survivors and their families including: resources, referrals, product information and “survivor-to-survivor” network.

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Appendix: Complete Laryngeal Cancer Staging

American Joint Committee on Cancer (8th ed.)

Supraglottis – T

T

Description

TX

Primary tumor cannot be assessed.

Tis

Carcinoma in situ

T1

Tumor limited to one subsite of supraglottis with normal vocal cord mobility

T2

Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx.

T3

Tumor limited to the larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglo, and/or inner cortex of thyroid cartilage.

T4

Moderately advanced or very advanced

T4a

Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx.

T4b

Very advanced local disease. Tumor invades pre-vertebral space, encases carotid artery, or invades mediastinal structures.

Glottis – T

T

Description

TX

Primary tumor cannot be assessed.

Tis

Carcinoma in situ.

T1

Tumor limited to the vocal cord(s) with normal mobility.

T1a

Tumor limited to one vocal cord.

T1b

Tumor involves both vocal cords.

T2

Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.

T3

Tumor limited to the larynx with vocal cord fixation and/or invasion of the paraglottic space, and/or inner cortex of the thyroid cartilage

T4

Moderately advanced or very advanced.

T4a

Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx.

T4b

Very advanced local disease. Tumor invades pre-vertebral space, encases carotid artery, or invades mediastinal structures.

Subglottis – T

T

Description

TX

Primary tumor cannot be assessed.

Tis

Carcinoma in situ.

T1

Tumor limited to the subglottis.

T2

Tumor extends to vocal cord(s) with normal or impaired mobility.

T3

Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.

T4

Moderately advanced or very advanced.

T4a

Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx.

T4b

Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

Supraglottis, Glottis, and Subglottis – N

Regional Lymph Nodes (N)

Description

NX

Regional lymph nodes cannot be assessed.

N0

No regional lymph node metastasis.

N1

Metastasis in a single ipsilateral lymph node, 3cm or less in greatest dimension and ENE(-).

N2

Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension and ENE(-); or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension and ENE(-); or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension and ENE(-).

N2a

Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension and ENE(-).

N2b

Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension and ENE(-).

N2c

Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension and ENE(-).

N3

Metastasis in a lymph node, more than 6 cm in greatest dimension and ENE(-) or metastasis in any lymph nodes with clinically overt ENE(+).

N3a

Metastasis in a lymph node, larger than 6 cm in greatest dimension and ENE(-).

N3b

Metastasis in any lymph node(s) with clinically overt ENE(+).

Supraglottis, Glottis, and Subglottis – M

Distant Metastasis (M)

Description

cM0

No distant metastasis

cM1

Distant metastasis

pM1

Distant metastasis, microscopically confirmed.

Anatomic Stage

T

N

M

Stage 0

Tis

N0

M0

Stage I

T1

N0

M0

Stage II

T2

N0

M0

Stage III

T3

T1

T2

T3

N0

N1

N1

N1

M0

M0

M0

M0

Stage IVA

T4a

T4a

T1

T2

T3

T4a

N0

N1

N2

N2

N2

N2

M0

M0

M0

M0

M0

M0

Stage IVB

T4b

Any T

Any N

N3

M0

M0

Stage IVC

Any T

Any N

M1

Histologic Grade (G)

Description

GX

Grade cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

Apr 17, 2013 4:00 PM

Author: Katherine Kendall, MD, FACS

Talking is something we humans do without putting much thought into it. We do it automatically and don’t have to think consciously about how to do it. That is, until something goes wrong with our ability to talk. Hoarseness, or a deterioration of vocal quality, typically is the sign of some kind of injury to the vocal folds. Interestingly, when the margins of the vocal folds are injured, there is usually very little pain associated with the injury. Individuals with injury to the vocal folds will experience a change in vocal quality and may have an increased sense of effort when they speak. Especially when chronic hoarseness is a problem, patients need to recognize any change in vocal quality or change in the effort required to speak as a sign of further injury signaling the need for voice rest.

The most common situation leading to hoarseness is a bout of laryngitis that comes along with a cold or flu. The voice change in that situation is due to swelling and inflammation of the vocal folds from the viral infection. Even though viral laryngitis typically goes away on its own in a few days, it is important to recognize that the vocal folds are suffering from injury during that time and it is important to rest them by minimizing voice use until the voice change goes away.

There is no need to wait for a vocal fold injury to employ good vocal habits and to optimize vocal health, however. In order to keep vocal folds healthy, it is important to minimize excessive vocal demands such as talking over background noise or talking for long periods of time. Try not to talk on the phone in the car (traffic background noise) and don’t call to family members in another room. A good rule of thumb is to try to get close to the person you wish to speak to. Professional voice users, such as teachers, should use amplification systems in the classroom in order to avoid voice fatigue. And again, it is important to rest the voice if vocal deterioration is noted.

Certain non-verbal vocal behaviors such as chronic throat clearing or coughing are also very hard on the vocal folds and can lead to irritation and injury. Most people with this problem report that they feel a sensation of mucus or a tickle leading them to clear their throat. The throat clear improves the feeling for a short while and then the feeling comes back. In reality, what is happening is a vicious cycle. The throat clear or cough causes as much irritation as it relieves and, in the end, the more one clears their throat, the more one is likely to feel like the need to again. Strategies to help avoid chronic throat clearing include sipping water, using lozenges (avoid menthol or eucalyptus), chewing gum, a rapid exhalation, or a dry swallow. None of these strategies feel as good as a throat clear but they help, and the more one is able to resist that next throat clear, the closer one is to no longer feeling the need to.

Good hydration is very important for optimal vocal health. Movement of mucus out of the trachea and over the vocal folds clears irritants that are resting on the surface. The mucus moves faster with better hydration so irritants don’t sit on the vocal folds for a long period of time. A good estimate of individual water intake needs is about half one’s body weight in ounces per day. So, for example, a man who weighs 170 lbs. should drink 85 ounces of water per day. Keep in mind that other beverages that have caffeine or alcohol in them act as diuretics and will cause more fluid loss that needs to be made up by drinking more water.

Lastly, it is very important not to ignore a change in vocal quality that persists beyond a couple of weeks. Although chronic hoarseness is most likely due to a benign process, it is also the most common sign of an early laryngeal cancer. An examination by an otolaryngologist (ENT doc) is warranted to determine the cause in any individual suffering from chronic hoarseness.

Chronic Throat Clearing and Silent Reflux

Chronic throat clearing is a symptom of many different conditions ranging from post-nasal drip to chronic sinusitis to acid reflux. Gastric reflux is the back flow of stomach contents and gastric acid up from the stomach into the esophagus, the tube that connects the throat to the stomach. Gastric acid can damage the esophagus and cause irritation. With chronic exposure to stomach acid, sufferers feel symptoms of indigestion and heartburn. These symptoms are from a common disorder known as GERD, or gastroesophageal reflux disease.

Beyond GERD and Up to the Throat

Sometimes, the back flow of stomach acids goes beyond the esophagus, reaching up into the voice box and throat and sometimes even go into the nose and sinuses. As the reflux progresses, there are many associated symptoms, including hoarseness, post-nasal drip, a lump in the throat, pain, shortness of breath, difficulty swallowing, a chronic cough and, the most common, excessive throat clearing.

This syndrome is called laryngopharyngeal reflux or LPR. People who suffer from LPR may not experience heartburn and indigestion because the stomach acid is going higher than the esophagus. Sufferers of LPR may experience a range of symptoms, only a few or many. Because these symptoms can be masked, LPR is often called “silent reflux.”

Diagnosing Silent Reflux/LPR

Since there are many causes of throat clearing, silent reflux may sometimes go undiagnosed. If you experience any of the symptoms, especially throat clearing, see an ear, nose, throat (ENT) doctor. Making a diagnosis of LPR is not painful. Usually, a flexible endoscope is inserted through the nose into the throat, which allows the ENT to see the lining of the throat. The stomach acid causes the irritated lining to become red and sometimes there is evidence of damage. The throat is much more sensitive to stomach acid than the esophagus, so even a small amount of acid may cause irritation and chronic throat clearing.

Relieving Symptoms

The most effective way to lessen symptoms and help treat LPR is a modifying the diet. Many foods cause reflux, including citrus, tomatoes, onions, fatty foods and caffeinated foods. Alcohol, particularly red wine, and nicotine also increase symptoms.

Losing weight and easing stress can be helpful, too. The timing of meals is also important. Patients are recommended to avoid eating two to three hours before bedtime to reduce nighttime symptoms.

Some patients may need to take a proton pump inhibitor (PPI), like Nexium, Aciphex, Protonix, a half hour before breakfast every morning. Other patients may be required to take an additional medication like an H2 blocker (Zantac). In some cases, treatment is required for several weeks, and in others, long-term therapy is needed to control symptoms.

As time progresses, with the right, tailored treatment, symptoms may lessen. It is always important to keep your physician up to date on all of your symptoms, so that treatments can be tweaked as necessary. Be especially careful to alert your doctor to all your symptoms and their severity, even if you feel it may not be related. For instance, some LPR cases cause ear pain and nasal congestion.

Chronic Throat Clearing

by Dr. Christopher Chang, last modified on 12/3/19.
Read and comment below!

“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.

Your browser does not support the video tag.

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.

Also, reflux can be non-acidic in nature which would not cause any burning type symptoms. Click here for more information about non-acidic reflux.

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

Recent research suggests specifically that a modified Mediterranean diet helps as much as medications in resolving LPR .

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.

Post-Nasal Drainage

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.

Medication Side-Effect

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.

Zenker’s Diverticulum

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.

Anatomic Triggers

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 to a girl who sneezed constantly due to this disorder. Here is a New York Times article.

Non-Organic Tic

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.

Treatment

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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Cough That Lasts May Be Sign of Underlying Problem

April 6, 2012

Dear Mayo Clinic:

What could cause a cough that lasts for months? I take antihistamine tablets and use nasal saline spray but still cough throughout the day and at night.

Answer:

Coughing is a normal reaction to irritants in your respiratory system. Coughing forcefully expels foreign bodies, mucus and other irritants, such as pollution, from your throat and clears them from your airway.

However, when a cough lasts too long, it may be a sign of an underlying problem or disease. Moreover, coughing itself becomes a problem. The forces exerted on your body by persistent coughing can result in direct physical problems — such as damage to your vocal cords, rupture of small blood vessels in your airway, fainting spells, hernias or even broken ribs. It can also harm the quality of your life, sleep and social life.

When a cough lasts longer than six to eight weeks, it’s considered a chronic cough. Diagnosing the cause can be time-consuming, but is usually a critical first step which involves systematically eliminating probable causes through history taking, testing and trying different treatments. Common causes of chronic cough include:

  • Postnasal drip — This is a sensation of mucus trickling from the back of your nose down into your throat. It may be due to hay fever, allergies or irritants. How postnasal drip causes a cough is still not clearly understood. In some cases, this sensation may not even be noticed. In chronic cough, postnasal drip may be due to inflammation of your nasal passages including your sinuses.
  • Asthma — While unusual, asthma can present with only a cough. This is known as cough variant asthma. It doesn’t necessarily mean that you will develop chronic asthma with wheezing.
  • Gastroesophageal reflux disease (GERD) — With GERD, stomachacid, digestive enzymes andbile back up (reflux) into youresophagus. It may reach up to thevoice box. In severe cases, refluxmaterial may get into the lungs.These substances are irritating to your respiratory tract and can trigger a cough.Coughing itself may cause acid reflux, turning it into a vicious cycle. While heartburn is common in reflux, not everyone with reflux experiences it. Hoarseness, throat clearing, the sensation of a tickle in the throat and cough — usually when in an upright position — may be associated with GERD affecting the throat. This is called laryngopharyngeal reflux (LPR).
  • Pertussis — Chronic cough may be due to an unrecognized case of whooping cough (pertussis).
  • Angiotensin-converting enzyme (ACE) inhibitors — Takento lower blood pressure, drugs inthis class include enalapril (Vasotec),lisinopril (Zestril) and others.Chronic cough can occur long after these drugs have been started. And, it may take two to three weeks for a cough to improve after stopping these medications.
  • Lung disorders — Chronic cough can be caused by airway damage called bronchiectasis, and by a condition that causes asthma-like symptoms, but with normal lung function (eosinophilic bronchitis).

In smokers, persistent cough and phlegm production (chronic bronchitis) is common. Throat or lung cancer may be suspected in a smoker or former smoker who has a chronic cough that changes abruptly or lasts for more than one month following smoking cessation, or if they cough up blood or note a change in their voice.

Usually, chronic cough can be stopped by treating an underlying cause. In about 90 percent of cases, the underlying cause is postnasal drip, asthma or GERD. If sinus disease or reflux is suspected, response to treatment may help determine the cause. Sometimes, there can be more than one cause that needs to be addressed.

Depending on your diagnosis, treatment may include:

  • Antihistamine allergy medications and decongestants — Theseare standard treatments for postnasaldrip. If you can identify a triggerthat causes symptoms, avoiding that triggermay be helpful. Nasal corticosteroidsprays also may be of value.
  • Inhaled asthma medications — These reduce inflammation and spasms and open your airways.
  • Drugs to suppress stomach acid — These help manage acidreflux. Additional measures for reducingacid reflux include losingweight if you’re overweight, eatingmeals three to four hours before lyingdown for bed or elevating thehead of your bed a few inches.
  • Antibiotics — If your coughing is suspected of being caused by a bacterial infection, such as a persistent sinus infection or a lung infection, antibiotics may help.
  • Not smoking and avoiding secondhand smoke — In additionto causing chronic bronchitis,smoking irritates your lungs and canworsen coughs from other causes.

If no cause for your cough is found, or if the cause can’t be effectively treated, drugs may be prescribed to suppress the cough, loosen mucus or relax airways.

— Kaiser Lim, M.D., Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minn.

9 Causes for Throat Clearing and How to Make It Stop

Chronic throat clearing isn’t a diagnosis alone, but rather a symptom of another underlying condition. Some common causes of chronic throat clearing include:

1. Reflux

Most people who complain of chronic throat clearing have a disorder called laryngopharyngeal reflux (LPR). It’s caused when matter from the stomach — both acidic and nonacidic — travels up to the throat region, causing an uncomfortable sensation that makes you clear your throat. Most people with LPR don’t experience other symptoms that typically go along with reflux, such as heartburn and indigestion.

Treatment for LPR may include medication and surgery in some severe cases. Lifestyle changes and home remedies may be effective in many cases, too. Here are some things you can try at home:

  • Elevate the head of your bed 30 degree or more.
  • Avoid eating or drinking within three hours of lying down.
  • Avoid caffeine and alcohol.
  • Avoid spicy, fatty, and acidic foods.
  • Follow a Mediterranean diet, which may be as effective as medication to resolve LPR symptoms.
  • Lose weight.
  • Reduce stress.

2. Postnasal drainage

Another common cause of throat clearing is postnasal drip. Postnasal drip happens when your body starts producing extra mucus. You may feel it dripping down your throat from the back of your nose. Other symptoms may include:

  • a cough that’s worse at night
  • nausea, which can be caused from excess mucus moving into your stomach
  • a sore, scratchy throat
  • bad breath

Allergies are a common cause of postnasal drip. Other causes include:

  • a deviated septum
  • cold temperatures
  • viral infections, which can lead to cold or flu
  • sinus infections
  • pregnancy
  • changes in the weather
  • dry air
  • eating spicy food
  • certain medications

Treatment for post nasal drip varies depending on the cause. For example, if it’s related to allergies, avoiding the allergen or taking medications may stop the drip. Other treatments for postnasal drip may include:

  • over-the-counter decongestants, such as pseudoephedrine (Sudafed)
  • antihistamines, such as loratadine (Claritin)
  • saline nasal sprays
  • sleeping with your head elevated
  • staying hydrated
  • drinking warm liquids

3. Zenker’s diverticulum

Though rare, sometimes the esophagus has an abnormal pouch that prevents food from traveling to the stomach. This is known as Zenker’s diverticulum. The condition occasionally causes the contents of the pouch and mucus to get stuck in the throat.

Treatment for Zenker’s diverticulum typically involves surgery.

4. Chronic motor tic disorder

Chronic motor tic disorder involves brief, uncontrollable, spasmlike movements or phonic tics. It typically begins before age 18 and lasts four to six years.

Other symptoms of chronic motor tic disorder may include:

  • facial grimacing
  • blinking, twitching, jerking or shrugging
  • sudden uncontrollable movements of the legs, arms, or body
  • grunts and groans

Treatment varies depending on the severity of symptoms, but may include behavior therapy and medications.

5. Tourette syndrome

Tourette syndrome is a neurological disorder that causes both a physical tic and a vocal outburst. Other symptoms of Tourette syndrome may include:

  • eye blinking and darting
  • nose twitching
  • mouth movements
  • head jerking
  • grunting
  • coughing
  • repeating your own words or phrases, or those of others

Treatment for Tourette syndrome may include neurological treatment, medications, and therapy.

6. Pediatric autoimmune neuropsychiatric disorder with streptococcus (PANDAS)

PANDAS disorders typically appear suddenly after strep throat or scarlet fever in children. In addition to throat clearing and other vocal tics, symptoms of PANDAS may include:

  • motor tics
  • obsessions and compulsions
  • moodiness or irritability
  • panic attacks

Treatment for PANDAS may include therapy, counseling, and the use of medications.

7. Food allergies

In some cases, a food allergy or sensitivity may cause a tickling in your throat that makes you clear it. Dairy is a frequent culprit, but foods such as eggs, rice, and soy may also cause the sensation. The treatment in such cases is avoiding the food that leads to symptoms.

8. A side effect of medication

Some blood pressure medications can cause a tickle in your throat that contributes to chronic throat clearing. If you’re taking blood pressure medication and are frequently clearing your throat, talk to your doctor about a potential substitute.

9. Habit

In some cases, there may be no underlying condition causing the throat clearing. Instead, it may be a habit or something you subconsciously do when you’re anxious or stressed.

The following techniques may help you stop the habit:

  • Drink more fluids.
  • Monitor your throat clearing or ask someone else to help you monitor it.
  • Find an alternative activity, such as swallowing or tapping your fingers.

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:

  1. Mentally suppressing the urge to cough or clear the throat, sip some water instead (keep a water bottle handy).
  2. Taking plenty of liquids to keep the mucous thin. Note: Caffeine tends to thicken the mucous.
  3. Taking cough medicine such as Robitussin DM regularly (2 tsp. 3 to 4 X/day) for two weeks
  4. 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.

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