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.