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Phlegm

The sensation of phlegm or mucus in the throat is a very common physical complaint in the community. The most common cause of phlegm in the throat is postnasal drainage, an abnormal increase in the natural flow of nasal and sinus secretions down into the pharynx and lower throat areas. The paranasal sinuses are air spaces in the facial bones that communicate with the nasal cavities. The lining of the nasal and sinus cavities contains cells that continuously produce mucus. The mucus is transported to the back of the nose, and from there to the throat to be swallowed. This is generally not noticeable to the patient. For noticeable postnasal drainage to be present, there generally has to inflammation from infection or allergies, accompanied by other nasal symptoms such as nasal stuffiness and/or nasal discharge. Treatment of upper respiratory infections can include OTC decongestants, saline nasal mist and oral expectorants. Nasal allergies are usually treated with a non-sedating antihistamine and/or an intranasal steroid spray. If a sinus infection is suspected (duration of upper respiratory infection symptoms greater than 10-11 days), a visit to the doctor may be needed to determine the need for an antibiotic with or without intranasal steroid therapy. The Ear, Nose & Throat specialist can perform a fiber-optic nasal endoscopy in the office to best determine the source of post-nasal drainage.

For patients with isolated phlegm, frequently accompanied by frequent throat clearing or hoarseness, Laryngo-pharyngeal Acid Reflux (LPR) may be the cause. In patients with LPR, the larynx is chronically being exposed to low levels of stomach acid and/or digestive enzymes in the absence of any frequent heartburn. Most of these patients have already been unsuccessfully treated for the above causes of postnasal drainage before presenting to the Ear, Nose & Throat specialist. Fiber-optic examination of the larynx will reveal redness and mild swelling of the back portion of the larynx, adjacent to the opening to the esophagus. LPR is treated initially with anti-acid medication, usually with a proton-pump inhibitor (PPI) such as omeprazole with doses ranging from 20 mg once daily up to 40 mg twice daily until control of the problem is achieved. Dietary habit changes to minimize stomach acid production and intake of acid are initiated as well. In general, symptoms begin to abate after 3 to 6 weeks of therapy.

After a few months of the patient being symptom-free, attempts to reduce or eliminate the PPI medication are made. If medication is needed for long-term maintenance, an H2 blocker (such as ranitidine) or the lowest effective dose of PPI is utilized. Regular follow-up is needed as long as the patient continues to require medical therapy for this disorder.
For patients who are treated presumptively for one or both of the above diagnoses without an ENT evaluation, an ENT consultation would be indicated at this time to rule out less common causes of a phlegm in the throat sensation such as a growth in the throat, and to come up with a new treatment plan.