A Journal of Observational Laryngology

Clinical observations, anecdotes, and insights which other clinicians may want to consider and test with further research.

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When Mucus Seems to Be Causing Your Cough or Throat Clearing – But Isn’t

By Robert W. Bastian, MD

We all have experience trying to manage mucus that is causing us a problem. Sometimes, such as during an upper respiratory infection, our bodies over-produce mucus, in which case we cough it up, blow it out, or “dry it up” with decongestants. Other times, mucus may become thick and crusted, in which case we thin it out by drinking more fluids, using a humidifier and Neti pot, or taking over-the-counter mucolytics. And, if mucus becomes purulent, we treat it with antibiotics.

When Apparent Mucus Is Not the Problem
When it comes to coughing and throat-clearing, however, there are two kinds of circumstances in which mucus might seem to be the cause, but actually is not:

1. When a sensation of mucus is felt, but, while hard to believe, there is not any actual mucus present
2. When mucus is indeed present, but it is the result of coughing rather than its cause

At Bastian Voice Institute we have seen hundreds of cough and throat-clearing patients who at first cannot identify with either circumstance #1 or circumstance #2, but for whom one of the two above circumstances in fact applies. These patients were all diagnosed not with a “mucus” problem, but instead with sensory neuropathic cough or throat clearing. ((Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head and Neck Surg. 2006; 135(1): 17-21.)) ((Bastian ZJ, Bastian RW. The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients. PeerJ. 2015; 3:e816.)) For patients like these, it is crucial to recognize when the cause of their cough or throat clearing seems to be, but is not mucus; rather, the cause is a sensory neuropathic disorder. If a patient does not recognize this, he or she can get sidetracked, continuing to focus on and manage the mucus without ever improving the cough or throat clearing.

Circumstance #1 In More Detail: When Mucus Is Clearly “Felt” but the Mucus Is Not Actually There
This patient may interpret a completely convincing sensation of mucus (dripping or suddenly filling the throat) as being actual mucus, when in fact it isn’t. Consider, for example, the following composite anecdote.

A middle-aged woman had been coughing for more than 10 years. There were so many episodes of coughing each day, and some so violent and protracted, that it was seriously diminishing her quality of life. Co-workers were annoyed; family members were distressed. The several particularly bad episodes of coughing each day were brutal: she would vomit or nearly vomit due to the violence of her attacks. Sometimes she also experienced leaking of urine.

During her visit with me, she explained that the typical initiator of the coughing attacks was a sensation of mucus dripping down the back of her throat. Every conceivable treatment for this “dripping mucus,” applied across the years, had made no difference. Later, during that same initial evaluation, when a videoendoscope had been inserted and was recording a view inside her throat and voicebox, she suddenly began to exclaim, “There! It’s dripping! It’s dripping! It is going to make me cough!”

I asked her where it was dripping. Struggling not to cough, she told me urgently and animatedly that it was in her throat, and pointed to the upper-middle neck. All this time, the videoendoscope was still in position, recording video. She continued to insist that there was mucus actively “dripping” there, and after 20 or 30 seconds of valiantly struggling to resist, she began a severe episode of coughing. At no time was there any mucus visible. There was none within the throat or voicebox or upper windpipe, and none in the back of the nose.

I then reviewed the video-recorded examination with her, second by second, leading up to and including the initial 30 seconds of her attack, to show that
in fact there was no mucus, but instead only the sensation of mucus. I went on to explain the cause for this sensation: a neuropathy. A neuropathy (that is, damaged nerves) usually causes pain, but for individuals with sensory neuropathic cough or throat clearing, the neuropathy instead causes an abrupt false sensation of varying types – the sensation of a “feather,” “sandpaper,” “pinprick,” a “burning sensation,” a “bubble,” or, as with this patient, “dripping mucus.”

For most of the sensations described above, it is easy to grasp that there is not actually a feather, sandpaper, a pin, or a fire inside the person’s throat. However, since mucus is a normal inhabitant of the throat and chest, it escapes most people – doctors as well as patients – to realize that there may be a subset of people with SNC who experience “mucus” without there being any actual, or any sufficiently explanatory, mucus. Thus, the patient gets treated as if he or she did have “problem” mucus, of course with no benefit.

Circumstance #2: When Mucus Is Only the Result of Coughing
The second coughing scenario is one in which mucus is indeed produced and can even be spit out as proof (“foamy white” doesn’t count – that is
saliva), yet this mucus is not produced within the first seconds of coughing, but only near the end of a severe episode of coughing. In such cases, the coughing often ends soon after the mucus is produced. Below is an example of this scenario.

“Doctor,” says the patient, “can you give me something to get the mucus up faster, because once that comes up, my coughing stops.” This patient has already been tried on a long list of “mucus” medications, with no benefit.

“Does the mucus ever come up immediately at the beginning of a coughing attack?” I ask.

“No,” the patient says, “it is after I have been coughing for 20 seconds or a minute.”

“And do you turn red?” I ask. “And do your eyes tear, and does your nose run during this time?”

“Yes,” the patient says. “And I wet myself, and retch, and nearly throw up.”

“Well,” I suggest, “might it be that if your eyes are running and your nose is running, your lungs are ‘running’, too?”

For this group of sensory neuropathic cough patients, mucus production is the result rather than the cause of the coughing. Incidentally, I once sat and made myself cough extremely hard for 30 seconds. I didn’t need to cough, but just forced myself. I produced a surprising amount of phlegm.

Don’t Get Sidetracked
If your diagnosis is sensory neuropathic cough or throat clearing, and if your own experience or other doctors have strongly suggested that mucus is the
culprit behind your coughing or throat clearing, and if numerous “mucus” treatments have failed to provide any benefit, you may be ready to try out the
idea above: that although your sensation of mucus is real (circumstance #1) or the mucus produced by your coughing is real (circumstance #2), it can be the case that in neither case is mucus the actual cause of your coughing. The cause is instead a neuropathic disorder, and it is that neuropathic disorder – not mucus – that we will target with the treatment we prescribe.

22 thoughts on “When Mucus Seems to Be Causing Your Cough or Throat Clearing – But Isn’t

  1. I believe there is a medication under trial now for this condition and laryngospasm that ‘turns off’ or in some way satisfies the receptors on the damaged, up-regulated or hypersensitive nerves. Is there any sign of this medication being near the end of the trial?

    • Did you get an answer for this. I have this condition and am taking desipramine but not getting full results. I would be very interested in finding out about this drug. Thanks.

      • For people with very occasional laryngospasm, we suggest using straw-breathing alone. Most people are not willing to take daily medication to avoid a brief (albeit terrifying) episode just a few times a year. Those with frequent laryngospasm can benefit from the same medications used for sensory neuropathic cough: amitriptyline, gabapentin, desipramine, pregabalin, citalopram, capsaicin, and so forth. If you know of another medication not on this list, please let me know. (I hope you find this information helpful. Please consider Dr. Bastian’s reply to be informational only, and not medical advice; don’t act without your personal physician’s input.)

  2. No reply yet Linda and I don’t expect any until the end of the year. It is apparently still under trial (and therefore secret) in the USA. My UK consultant surgeon told me about it. Good luck, let me know if you hear. Thanks.

    • Unfortunately, Dr. Bastian doesn’t know the doctors in your area well enough to make a recommendation, as to which doctor to see about this. However, he suggests that you do the following to find such a doctor:

      Call the otolaryngology (ENT) department of a nearby university or other large medical center. Ask to speak to the triage nurse. Ask that nurse if there are one or more doctors there who have a special interest in neurological coughing. You may need to make a few different phone calls to find a doctor in your area known to have this particular interest.

      If you can’t find any such doctors, you might also try calling the pulmonary departments of nearby universities or large medical centers. Or, alternatively, you might simply share the information you found about sensory neuropathic cough with your primary care physician and ask, “Could I please try low-dose amitriptyline?”

      As a last resort, you would of course also be welcome to come to our office in the Chicago area. After that first visit, Dr. Bastian would (if your diagnosis is indeed sensory neuropathic cough) be able to manage your treatment from a distance. But of course, for most people it’s not possible to travel so far.

      We hope you find that information helpful. Please consider it informational only, and not medical advice. Don’t act without your personal physician’s input.

  3. I often find a correlation to Coxsackie Virus Type A16 can cause, amongst other things, selective insult to the recurrent laryngeal nerve, and if the internal laryngeal branch is included/affected, this can change the sensitivity of the receptor thresholds for baroceptors, chemoreceptors, etc, thus causing areas of the laryngeal basin to be altered/heightened in their threshold of sensitivity… more easily reacting to either particle load, humidity, temperature, etc., such as avoidance of “smelly” body lotions/perfumes, etc. Coughing is a natural response to laryngeal irritation mediated via archicortical and brainstem reflexes.
    Unilateral Vocal Cord Paresis.

  4. I have been dealing with this stupid cough every day for the last 7 years. How do I get my doctor to look into SNC as a cause? I have tried many allergy medicines, had lung test for asthma , x-rays and they always say the same thing “nothing is wrong’. That is so annoying cause I cough so hard I gave myself a hernia. I have had pulled muscles, hernia, headaches, fatigue, urinary issues (have to wear a depends), social issues ( embarrassing cough attacks. I went to an ENT he said ‘your sinuses are beautiful’ But I feel the dripping now I just stopped asking and just deal with it. I would love to takes something that will make it go away or even lessen.

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  7. I believe my cough is caused by mucous. I am a targeted Individual and I know that this throat clearing and many other afflictions are caused by directed energy. It makes sense that the people doing this to TI’s testing their techniques for imposing afflictions on people. Afflictions like fibromyalgia, sciatica, MS, IBD, pneumonia and many more. I have college degrees in Electronics Engineering Technology, Biological Science and Computer Science. check out my website jameslico.com TI’s are the canary’s in the coal mine to warn about this slavery. This type of slavery is indicative of the final stages of empire right before collapse.

  8. Ever since I had a bad sinus cold two years ago which had me coughing for 3 months, I also got this severe post nasal drip constantly bothering me and constant clearing of my throat that I look like a turkey, and then the little pinprick of a tickle like I have dust in my throat gets me into a coughing fit, till it all calms down like the kind you get at the end of a cold. If I don’t clear my throat, I will talk like a frog and my whole throat and chest will feel like I am holding my breath. This is a nightmare for me and apparently many people have this. I am sure it is damage done to the sinuses or to the nerves in the throat. I only find relief when I go to bed. The specialist insists it is LPR and that it doesn’t seem to bother them and they even thought at first that it is just a habit – very disappointed with that. I highly doubt it is LPR. Something happened after my cold yet I can’t get a real diagnosis and proper treatment. What are they there for then? Please, if anyone knows anything or any natural procedure let me know.

  9. I forgot one more thing. I have also been sensitive to anything that touches my throat, so food or even some teas can cause the tickle in my throat and then a coughing fit soon follows with a bit of congestion in my nose, maybe from the mucus produced during the coughing. So there you have it, all my symptoms outlined. Never in all my years did I imagine to get this problem.

  10. I am a non smoker, non drinker 69 year old male. I inhaled dust in my garage 4 weeks ago when moving an old welcome carpet. I started to cough immediately, and for the next week and a half had many intense coughing fits. I couldn’t sleep most of the night. Then I started to develop sinus congestion. Codeine and opioid cough medicines gave almost no relief. Benzoate helped a little. I was given a 4 day course of prednisone 40 mg which reduced the cough but did not eliminate it. The coughing caused laryngitis. I ha e a constant lump or globes feeling in my throat. After a couple of weeks I would go into a spasm while coughing, similar to the feeling one has just before a sneeze. I I then went to an ENT who performed a scope and noted that I had hemorrhages one of my vocal cords but it was healing. He wants to see me in 4 weeks. I went on 2 weeks course of omeprazole in the am and Zantac in the pm, stopped late night eating, and ate smaller portions. I then started to feel irritated when I would swallow. My primary care internist Examiner me 2weeks after the ENT. He said my lymph glands were swollen and that I now had sinusitis and pharyngitis, put me on augmentin and mucinex. The augmentin has helped with the pharyngitis and swallowing, but I am still experiencing the spasmodic coughing although less frequently. He sent me for a chest X-ray which showed a mild atelectasis caused by the heavy coughing. He prescribed an inhaler to be used in order to mitigate the atelectasis. The spasmodic coughing has frightened me, not because of the 20 seconds when I have troubke catching my breath ( I got used to that) but because I am worried about damage to my esophagus and new damage to my vocal cords. The situation is at its worst when I first wake up, which means hav been told is common. The sandpaper feeling in my throat seems to increase over a 15 minute period, and then I start coughing for about 20 to 30 seconds with he spasm. Then there is a sense of relief, followed by another slow build of the sandpaper feeling followed by another coughing episode. The other day out of desperation i took a half of a zanax and it calmed my whole body down, giving me an hour and a half relief from coughing.

    My questions are:
    1) Could one exposure with inhalation of dust from an old dirty carpet set off such a chain reaction?
    2) Can the hemorrhage of the vocal cord result in a permanent spasm when coughing?
    3) Will the coughing keep irritating the vocal cord and force this vicious cycle to continue?
    4) Could I have both LPR and laryngeal neurosensitivity?
    5) is there any way to break the chain of coughing, irritation, and then as a result of he irritation more coughing?
    6) can this issue resolve itself since I do not have an underlying respiratory or ENT condition or disease?

  11. Hello everyone!
    Yesterday afternoon, I put a chocolate in my mouth and as it touched my tongue, I felt a tingle on my tonsil (right side) and needed to cough. I thought nothing of it.
    Since then, when I put any food in my mouth, the same thing happens. Very weird!

    Do I need to worry??

  12. I am a 61 year old female. I feel like the first example above sounds like my symptoms. I had a terrible cough for at least 20 years. A lot of things triggered it. If I get too hot, smells like perfume or aerosol sprays, certain foods, excess mucus, etc. About 10 years ago my doctor tested me and gave drugs for asthma, acid reflux, GERD and nothing helped. I would have massive coughing attacks that came on suddenly all day long. I think that I even lost a temp job because the boss couldn’t handle my coughing. I went thru a handful of Halls a day and always had water near by. I just learned to live with it. But, I know it was annoying for people around me. My cousin started using CBD oil for her back pains. She invited me to a facebook page for people using the oil and testimonies about what it helped for them. I decided to give it a try. I would try anything to quit coughing. It has helped tremendously. I still have coughs now and then but more like normal people. No more coughing attacks. I never wake up coughing any more. I may use 1 or 2 cough drops a day. It may be worth a try.

  13. Reading your pages explaining about the symptoms of coughing spells. I to feel like I j
    Have a small amount of phelm in my throat. It is very irritating. I had the flu but had gotten the flu shot. But this got better and then developed this hacking cough. It is very annoying. I went to the Dr and got a z pack and cough meds with codeine But I finishes the z pack and still have the cough. I have tried everything. mucinex I take everyday. Also my throat has a burning feeling. I sleep with no problem. But when I wake up after awhile the irritation is back and I start coughing again. I would please like a recommendation of something that would help to clear this up. If you have any suggestions please let me know. This has been going on for 4 weeks. I am so tired of trying things that do not work

  14. Marion Fortner, I also have exactly same problem. I sleep well during the night on my left. Airways seem to be clear. I can breath from my nose or mouth. It’s just like something stuck to my throat and it’s not going away since a month just like you. I suck candies, eat honey, ginger, gargle with salt water and I will like something has stuck to my throat. It’s like phlegm but when I put my finger (after washing) to my throat , no mucus. It doesn’t hurt me but it’s like constantly there. I wonder if I am getting enough rest for it to go away as I have to work during the day from home.

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