Why postnasal drip is not always caused by postnasal dripTuesday, July 3rd, 2012, 10:10 am
One of the more frequent complaints that bring patients to the ENT’s office is postnasal drip. Often patients will complain of constant postnasal drip, frequent throat clearing, and phlegm that is stuck in their throat. In addition to these symptoms, patients often complain of a constant cough or need to clear their throat. Often they have hoarseness, which they attribute to the frequent coughing.
In some extreme cases, they will complain of feeling like the mucous is blocking their airway and forcing them to choke or gag.
Often by the time these patients show up they have tried a variety of nasal sprays, decongestants, allergy medications, antibiotics, oral steroids and are often frustrated because nothing has helped. They want to know “Why nothing seems to work?”
While the answer seems simple, it is often missed. If your treating the nose and nothing seems to work, maybe it isn’t a nose problem at all. Or to rephrase, maybe the postnasal drip is not actually the problem.
What these patients are probably suffering from is not related to the nose at all, but is actually related to their stomach. They most likely have Laryngopharyngeal Reflux.
The term LARYNGOPHARYNGEAL REFLUX (LPR) refers to the backflow of stomach contents into the larynx and pharynx (the voice box and throat). LPR can occur during the day or night, and many people who have LPR will not have heartburn; so LPR is sometimes called silent reflux. It is also sometimes called extraesophageal reflux disease (EERD)
These patients are often doubtful of this diagnosis. It is common to hear questions like these:
“It can’t be reflux, I don’t have heartburn”.
“How can reflux affect my nose?”
“How can reflux cause increased drainage?”
I have seen patients that have come to me for second or third opinions because the first ENT told them it was reflux and they didn’t believe it.
So to answer their first question, LPR is different from traditional gastroesophageal reflux (GERD) or heartburn. Typically patients who have LPR do not have traditional heartburn symptoms. That is why some refer to it as silent reflux.
The answers to the second and third questions are a little bit lengthier. The reflux doesn’t affect the nose (at least not usually). What is actually happening is that the acid sits on the voice box and throat and burns/irritates these structures.
The average person produces 1.5 liters of mucous a day from their sinuses and 1-2 liters of saliva from their oral cavity. This totals up to 2.5-3.5 liters of fluid a day. The majority of this fluid is supposed to simply trickle down the back of the throat into the esophagus without the patient even being aware of it. In LPR, the irritated laryngeal mucosa and tissues are overly sensitive and then the patient feels every last drop of mucous. So the answer to the third question is that there is not excessive drainage, but increased sensitivity to normal amounts of drainage.
It is kind of like a guy at work who keeps getting hounded by his boss and then explodes on a coworker when asked a benign, innocent question that normally wouldn’t bother him at all.
What are the Signs of LPR?
• Voice changes or hoarseness
• Difficulty swallowing
• Frequent coughing or choking
• A feeling of “something in my throat” (the medical term for is globus sensation)
• Excessive mucus
• Postnasal drip
• Bad / bitter taste in the mouth
Patients do not typically have all of the above symptoms
What are some of the risk factors for developing LPR?
• Tobacco use
• Alcohol use
• Being overweight
• Eating at bedtime
• Eating large meals
• Lying down or exercising after eating
• Drinking carbonated, caffeinated and/or citrus based beverages
• Eating foods high in fat/grease or spice
• certain foods such tomato based products, citrus fruit, chocolate, licorice and mint
Caffeine, Chocolate, licorice, and mints have all been shown to increase the stomachs acid production.
Carbonated beverages, even if caffeine free can cause LPR because the carbonation can cause acid to rise up the esophagus into the throat.
Alcohol doesn’t actually increase the production of acid, but it relaxes the smooth muscles in the esophagus that usually help keep the acid from rising all the way into the stomach.
How is LPR diagnosed?
Usually the doctor can diagnose LPR by examining your throat and voice box in the office. No special preparation is needed for this examination.?The doctor will use a mirror and light, or a special flexible camera (flexible laryngoscope). The tissue in your throat and voice box may look red, irritated and swollen from the acid reflux (backflow) damage. This will eventually go away with lifestyle changes and medication, however, the healing may take a while.
Below is the video from a flexible laryngoscopy that demonstrates some of the findings seen in patients with LPR.
Below is a very well done video that was produced by the Georgia Health Sciences University that discusses how reflux can affect the voice box.
Traditional heartburn can be treated with several medications such as traditional antacids, H2 Blockers (Pepcid, Zantac), or Proton pump inhibitors (PPIs). ?LPR symptoms typically do not respond to antacids or H2 Blockers and require treatment with PPI’s.
Proton pump inhibitors stop stomach acid from forming. The ones currently available are:
• Aciphex (rabeprazole)
• Nexium (esomeprazole)
• Prevacid (lansoprazole) (over the counter Prevacid is 1/2 the prescription strength)
• Prilosec (omeprazole)? (over the counter Prilosec is 1/2 the prescription strength)
• Protonix (pantatoprazole)
• Dexilant (dexlansoprazole)
• Zegerid (omeprazole/sodium bicarbonate)
While treatment of LPR can be successful with once a day dosing, often patients have to take the medications twice a day to eliminate their symptoms. These medications (with the exception of Dexilant) need to be taken 30-60 minutes prior to eating to be maximally effective.
The purpose of these medications is to decrease acid exposure so that the larynx can heal. It isn’t until the larynx has healed that the patients symptoms improve. It can take several weeks to even months of consistent treatment with PPIs before for symptoms begin to improve. Do not expect an overnight, instantaneous improvement.
I tell patients that the irritation caused by the reflux is kind of like a callus that a carpenter gets on his hands from chronic use. Even when the carpenter retires, it takes time for the callus to soften and resolve. Even after starting on a reflux medication, it takes a while for the larynx to heal, which is why it can take weeks to even months before the symptoms resolve.
What else can be done to control LPR?
Some medicines increase the acid levels in your stomach and cause more symptoms of your LPR. Review all of your medicines including over-thecounter and dietary supplements with your doctor. Do not stop any medicines without speaking to the doctor that prescribed them. These medicines include (but are not limited to):
• Non steroidal anti-inflammatory drugs such as aspirin, ibuprofen
• (Advil) and naproxen (Aleve)
• Vitamin C
• Alpha Blockers: Dibenzyline
• Theophylline: Theodur
• Anticholinergics: Scopolamine
• Beta Blockers: Inderal, Metoprolol
• Calcium Channel Blockers: Calan, Cardizam, Procardia
• Progesterone: Provera, oral birth control pills
• Eat small more frequent meals.
• Drink eight, 8-ounce glasses of water.
• Elevate the head of bed 4 to 6 inches.
• Quit smoking.
• Maintain a normal body weight.
• Elevating the head of the bed
This last item can be achieved by sleeping on extra pillows or placing bricks or risers under the feet of the head of the bed. Alternatively several wedge pillows are available that achieve similar results. Several are available on amazon.com, here is a link to one of them. I am not sure which of these pillows are considered the "best".
Limit these foods and drinks:
• Alcohol including wine
• Caffeinated beverages
• Carbonated beverages
• Citrus based beverages
• Citrus fruits
• Fatty foods Spicy foods
• Tomato-based foods Chocolate, licorice and mint
• Wear tight clothing.
• Exercise or sing after a meal.
• Lie down after eating.
• Eat for 3 hours before going to bed.
While LPR is responsible for many complaints of postnasal drainage, cough, throat clearing, globus sensation and hoarseness, many other causes exist. If you have any of these symptoms for a prolonged period of time, you should be evaluated to rule out more serious causes.
Tags: cough, extraesophageal, globus, H2 Blockers, heartburn, hoarseness, laryngopharyngeal, larynx, postnasal drainage, prilosec, Proton pump inhibitors, reflux, rhinitis, silent reflux, singer, throat clearing, vocal, voice