Post-Nasal Drip

mucus drainingGlands in the nose and throat normally produce one to two quarts of mucus every day. This mucus moistens the lining of the nose and sinuses, humidifies the air, traps inhaled particles, and helps to fight infections. Normally this mucus is swallowed unconsciously many times throughout the day. When the mucus becomes thick or excessive in volume, it can cause the sensation of post-nasal drip. Post-nasal drainage can often lead to cough, sore throat, frequent throat clearing, and the feeling of a lump in the throat.

An excess in thin, clear secretions can be from viral infections, allergies, spicy foods, temperature changes, pregnancy, and some medications (birth control pills, blood pressure medications). Increased thick secretions can occur from low humidity in the winter, a decrease in fluid intake (dehydration), bacterial sinus infections, or from some medications (antihistamines). Swallowing problems or acid reflux can give patients similar symptoms of nasal/throat drainage or phlegm.

A correct diagnosis of the underlying problem is essential to properly treat a patient with post-nasal drip. Treatments for viral infections, allergies, and sinusitis are discussed in other sections. Acid reflux is treated with over-the-counter or prescription medications, depending upon the severity of the symptoms. Other causes are less common and should be thoroughly evaluated by an ENT specialist.

Laryngopharyngeal Reflux (LPR)

What is LPR?

LPR is similar to Gastroesophageal Reflux Disease, or GERD. It occurs when the lower esophageal sphincter (LED) does not close properly and the stomach contents are allowed to leak back or reflux into the esophagus and then up to the voice box and possibly the back of the nose and sinus cavity. When the refluxed stomach acid comes into contact with the lining of the esophagus, it causes a burning sensation in the chest or the throat that we call heartburn or acid indigestion. When stomach contents irritate the voice box and back of the throat/nose, symptoms are less often heartburn, and more often consist of post-nasal drip, throat clearing, cough, and a lump in the throat.

What causes LPR?

Eating habits, diet, and obesity all contribute to the development of GERD. Eating large meals and lying down after eating may induce reflux symptoms. Many foods are acidic or contain irritating substances that increase the stomach’s production of acid. Obesity and pregnancy also contribute to LPR/GERD symptoms because the additional weight places increased pressure on the sphincter muscles in attempt to keep food in the stomach. Tight-fitting clothing may place pressure inside the abdominal cavity much like excessive body weight does and therefore may cause reflux symptoms.

What are the symptoms of LPR/GERD?

The classic symptom of GERD is heartburn. Many people have LPR without any associated heartburn and instead, they experience chest pain, hoarseness, difficulty swallowing, excessive mucous, throat clearing, a sensation of a lump in the throat, sore throat, choking spells, wheezing, post-nasal drip, dry cough, or bad breath.

How do you diagnose LPR/GERD?

LPR/GERD may be diagnosed by carefully listening to the symptoms the patient reports along with a thorough examination of the head and neck. There are also several diagnostic tests available to help establish and monitor a diagnosis of LPR/GERD: 

  • pH monitoring: A small tube is put into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid refluxes into your esophagus. Manometry can also be performed using the same probe. This detects pressure changes and is a more sensitive technique than measuring pH alone.
  • Barium swallow: You drink a solution and then several X-rays are taken to help spot abnormalities such as a hiatal hernia or narrowing of the esophagus.
  • Upper endoscopy: The doctor will spray your throat to numb it and then slide down a thin, flexible tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the esophagus and to look for abnormalities.
  • Nasal endoscopy: Many ENT doctors will apply a topical nasal decongestant and numbing medicine to the lining of the nose by a nasal spray prior to endoscopy. Often, the examination can be completed without any special medicines at all. A rigid or flexible scope may be used to see around corners - much like a child's toy periscope. Nasal endoscopy provides a detailed examination of the nasal cavity, sinuses, and voice box.

What is the treatment for LPR/GERD?

Medication:

  • Your doctor may recommend medications that you can buy over the counter or may give you a prescription for a medication.  These medications can help to neutralize the acid in your stomach, stop acid production, or help the muscles that empty your stomach.  Medications work in different ways and a combination of medications may help to best control your symptoms. Reflux is typically present for years, so it usually takes 2-3 months of medication to see benefits. Unfortunately, there is no “quick fix”.
  • Proton pump inhibitors (PPI): Examples are Prilosec (omeprazole). If you are taking one PPI per day, take it in the morning on an empty stomach 30-60 minutes before breakfast. Then eat some protein with breakfast. If you are taking two PPIs per day, take them on an empty stomach. One in the morning 30-60 minutes before breakfast and the other 30-60 minutes before dinner.
  • H2 Blocker: Examples are Pepcid (famotidine), these should be taken at bedtime.

 

Reflux Diet and Lifestyle Changes

  • Avoid foods that are acidic or contain irritating substances that increase the production of acid.  Foods that are known to promote reflux include: fatty foods, spicy foods, coffee, tea, soda and other caffeinated beverages, alcohol, chocolates, nuts, citrus fruits and juices, mints, cough drops, breath fresheners, gum, hard candies, and some mouthwashes.
  • Multiple small meals spread throughout the day is preferable to fewer larger meals.  Less food in the stomach at a time will lead to less reflux.
  • Try not to eat anything for 3 hours before bedtime because reflux is often worse when we lie down.
  • Weight loss often results in a significant reduction of reflux symptoms.
  • Raising the head of your bed may also help to counteract the loss of gravity that occurs from lying down.

 Food Group

 Foods Allowed

 Foods to Avoid
 Dairy Skim or low-fat milk and cheese  Whole milk, cream
 Meats and proteins Baked, broiled, stewed, or roasted meats or beans Fried or fatty foods, peanut butter, lunch meats
 Eggs Prepared without fat Fried eggs
 Vegetables Prepared without fat Tomato sauce, fried veggies
 Fruit Any that cause GI discomfort Citrus
 Breads Most  
 Cereal All None
 Potatoes Potatoes, rice, pasta  Fried potatoes/rice, avoid white sauces
 Fats Butter, margarine, vegetable oils, reduced calorie salad dressings Regular gravies or salad dressings
 Beverages Water, decaf coffee, herbal tea Caffeinated coffee/tea, citrus juice, alcohol, carbonated beverages
 Soups   Those made with cream or fat
 Sweets Fruit, sherbet, honey, jelly, jam Ice cream, commercial pies/cakes/cookies with whole milk. Desserts with chocolate, nuts, cream, coconut.
 Seasonings  Mild Hot or spicy, menthol/mint