The upper throat is the shared entry to our windpipe (trachea) and gullet (oesophagus). This area has to be very sensitive to ensure that food and drinks are appropriately pushed towards the back of our throats to be safely swallowed away from your airway. If these sensitive surfaces detect solids or liquids in or on the entry to the windpipe, a cough happens as a reflex action to clear and protect the airway. The sensitivity of the tissues in the throat that can lead patients to have one or more of the chronic throat symptoms listed above.
The most common conditions encountered in patients with 1 or more of these symptoms are:
This is the name of a condition which is primarily associated with a sensation of a lump or something in the throat. Some describe a tightness in the throat. Despite a feeling of difficulty in swallowing, patients with globus typically do not have problems swallowing food or liquids. It is usually experienced centrally and low down in the neck. It is common to have minor voice problems such as huskiness, hoarseness or tiring of the voice with globus pharyngeus.
It is thought to be due to muscle tension or a lack of relaxation of the small circular muscles at the top of the gullet (called the cricopharyngeus). Typically, the sensation may improve on swallowing food as the muscles are prompted to relax by the weight of food passing through into the food pipe (oesophagus).
Globus pharyngeus is very common and affects most people at some point. It may fluctuate in severity, and it may be intermittent. It may be resolved for years before recurring. It should be noted that symptoms with a long stable history are unlikely to be due to any sinister underlying cause. Serious conditions such as cancer tend to get worse over time rather that stopping and starting like globus can.
There are a variety of reasons thought to cause this, sometimes there are multiple factors at play. Sometimes there is no obvious cause. The most common are listed below.
Many patients with globus often have underlying acid reflux (stomach acid flowing the wrong way up into the oesophagus or gullet). This does not always cause heartburn or indigestion. The muscle at the top of the gullet, known as the cricopharyngeus, tightens in response to acid reflux, probably to prevent it coming into the throat.
In smokers, this can be a factor which irritates the throat which causes muscle tension. Smoking also increases the effects of acid reflux.
Symptoms are often worse with stress which increases muscle tension. Anxiety about the cause of these symptoms further increases stress making the globus sensation worse. Stress increases the effects of acid reflux.
Overuse of the voice, or not having the most efficient technique for producing voice can affect the small muscles in the throat which increases muscle tension leading to globus sensation.
Out of 1,000 patients seen in the head and neck clinics at Royal Cornwall Hospital, 126 patients were diagnosed with globus pharyngeus without any other symptoms. None of these people had cancer.
Often it is associated with acid reflux so it is worth referring to the section below on laryngopharyngeal reflux to see if you have any symptoms. If you do, you could ask your GP about treatment for this condition.
Also called silent reflux as many patients do not know they have it. It could be present in the background without causing any symptoms until the throat becomes irritated, often by a throat infection.
These are episodes of the throat feeling like it is closed over, sometimes associated with noisy breathing. This does not happen in all patients with reflux. This can be quite scary as patients describe they feel like they will stop breathing. It typically happens when lying down as acid is more likely to come into the throat without gravity keeping it down as is the case when we are standing or sitting. The episodes pass without patients losing consciousness.
Typically the effects of infection would be expected to resolve over the course of a couple of weeks, but due to the underlying damage to the lining of the throat, and ongoing reflux, the symptoms can persist for much longer following the resolution of the infection itself.
Most people will have acid coming up into the throat occasionally, but only some experience symptoms from it. Various reasons have been proposed for this.
Sometimes this can be so significant that the stomach rides up above the diaphragm (the muscle that sits under the lungs) causing a condition known as hiatus hernia. Some patients with hiatus hernia will not respond fully to anti-reflux medication and may need to see a specialist (gastroenterology or upper GI surgery) to consider whether surgical intervention might be appropriate
It is not uncommon to have laryngopharyngeal reflux symptoms without having symptoms of heartburn or indigestion symptoms. This is because the lining of the oesophagus is better adapted to withstand the effects of acid reflux than the lining of the throat.
Typically, we would recommend Omeprazole 20mg twice a day for 2 months and Gaviscon Advance 10mls four times a day to be taken after meals and before bedtime for 3 months. If symptoms worsen on coming off medication, you may need to take this for longer. Treatment for laryngopharyngeal reflux can be discussed with your GP.
If you continue to have symptoms of reflux despite taking medications and implementing lifestyle modifications, you may benefit from further assessment by gastroenterology and/or upper GI surgery. Again if you symptoms persist, you can discuss this with your GP.
Avoid alcohol as it makes reflux worse by relaxing the muscles that try to keep acid down and away from your throat.
Eat a healthy diet and modify your eating habits to reduce foods that cause increased acid reflux. This included foods that are fatty or fried, spicy foods, chocolate, cheese and pastry. Drinks such as coffee, citrus juices and fizzy drink make reflux worse by increasing acid production in the stomach. Drink water instead. Allow several hours after meal time before lying down. If you are overweight, acid reflux is worsened. Try to take measures to address this.
Consider raising the head of your bed about 6 inches with concrete blocks or something similar under the legs or base at the head end of the bed. This makes use of gravity to keep the acid down in your stomach. Do not use lots of pillows under your head as this only makes things worse, increasing abdominal pressure thereby encouraging reflux.
If you smoke, try stopping this as it irritates the throat and makes you more likely to have reflux. Healthy Cornwall can provide smoking cessation services.
Healthy Cornwall can provide support for smoking cessation, diet and weight and alcohol.
Throat clearing is an abrasive action where the voice box is typically pushed and rubbed against the back wall of the throat to relieve irritation. A cough is an explosive closing and opening at the level of the vocal cords to clear the airway.
Minor throat clearing can be normal in managing secretions in the back of your throat for instance with an infection. However, the sensitive tissues in this area are not designed to be abused in this way over a long period of time. Excessive throat clearing itself becomes the cause of swelling and irritation leading to a vicious circle of irritation, sensitivity and abrasive clearing of the throat.
In normal circumstances coughing can be a protective reflex to clear our upper airways or in response to chest secretions. However, coughing (often dry and non-productive) can become a habit if the tissues are overly sensitive.
All irritation to the throat (also known as the pharynx) makes the throat more sensitive. Irritation to the throat may be chemical, most commonly due to acid reflux, which is also known as laryngopharyngeal reflux (see above).
It may be due to exposure to chemicals or dusts in the workplace for example. Irritation may also be mechanical, due to chronic throat clearing and coughing, which bashes the tissues of the throat against themselves causing irritation. Irritation may also be due to infection, and/or inflammation. Often several reasons may co-exist.
The action of throat clearing and coughing is quite aggressive and can traumatise the lining of the throat making it swollen and irritated. The irritation causes the lining of the throat to swell, which makes you want to throat clear and cough more. It is important to understand that the symptoms are made worse, not better, by continuing to throat clear and/or cough.
Avoid throat clearing and coughing wherever possible. Try to replace this behaviour with taking a drink of water from a bottle that you carry with you, then swallowing. This will achieve clearance of throat secretions without causing mechanical trauma which would perpetuate damage to the throat and make you want to throat clear and cough more. This is difficult to implement but is essential, otherwise it will not get better.
Think of the neck as having 2 parts. The back part of the neck contains the spine and all the surrounding muscles. The front part of the neck, contains the throat (the tubes that goes from the back of your nose and mouth down to your windpipe and gullet).
This may be due to strain of the small muscles surrounding the throat. Often there is no obvious cause. Some patients report a preceding history of coughing or throat clearing behaviours which injure these muscles. Typically, patients will have tenderness pressing on the side of the voice box (thyroid cartilage) where small muscles insert, with the pain worsening when swallowing because the muscles pull on the throat as you swallow.
This is typically due to problems with the spine, discs, surrounding muscles or nerves and unrelated to the throat and surrounding structures. Trying to move the neck or pressing on the spine and surrounding structure can make symptoms worse. You should speak to your GP if you feel this applies to you.
It is usually a self-limiting condition for which simple painkillers, especially non-steroidal anti-inflammatories (such as ibuprofen) may help. If there is a history of repetitive coughing or throat clearing, avoidance of such behaviours where possible will allow the muscle injury to heal.