Post-nasal drip

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Post-nasal drip
Other namesUpper airway cough syndrome, postnasal drainage, UACS, or post nasal drip syndrome
Post nasal drip en.png
Post-nasal drip
Specialty Otorhinolaryngology

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing (such as an esophageal motility disorder). Other causes can be allergy, cold, flu, and side effects from medications.

Contents

However, some researchers argue that the flow of mucus down the back of the throat from the nasal cavity is a normal physiologic process that occurs in all healthy individuals. [1] Some researchers challenge post-nasal drip as a syndrome and instead view it as a symptom, also taking into account variation across different societies. Furthermore, this rebuttal is reinforced because of the lack of an accepted definition, pathologic tissue changes, and available biochemical tests. [1]

Signs and symptoms

PND may present itself through the constant presence of discomfort in the upper airways. It is classically described as the sensation of a substance "dripping down the throat" and may also present with rhinorrhea, constant throat clearing, and cough, although its symptoms can be very nonspecific. [2] PND is one of the most common etiologies for chronic cough, defined as a cough persisting beyond 8 weeks. [3]

Post-nasal drip can be a cause of laryngeal inflammation and hyperresponsiveness, leading to symptoms of vocal cord dysfunction. [4] [5] [6]

Causes

There are multiple causes of PND, which can be acute or chronic.

GERD

Gastroesophageal reflux disease (GERD) is often associated with a high prevalence of upper-respiratory symptoms similar to those of PND, such as coughing, throat clearing, hoarseness and change in voice. Reflux causes throat irritation, leading to a sensation of increased mucus in the throat, which is believed to aggravate and, in some cases, cause post-nasal drip. [2]

Allergic rhinitis

Allergic rhinitis (AR) is a common condition where exposure to allergens results in the release of inflammatory mediators, such as histamine, that causes sneezing, rhinorrhea, itchy eyes, and nasal congestion. [7] The increased rhinorrhea and mucus production can result in PND.

Non-allergic rhinitis

Non-allergic rhinitis (NAR) is a condition in which there are symptoms of rhinitis, including rhinorrhea and nasal obstruction, but with negative skin and serum allergy testing results. [7] It can be further categorized into:[ citation needed ]

Rhinosinusitis

Rhinosinusitis is inflammation or infection of the sinus cavities. Acute rhinosinusitis has symptoms lasting less than four weeks, while chronic rhinosinusitis lasts greater than 12 weeks. [8] This persistent irritation can lead to increased mucus production as a result of pro-inflammatory pathways, producing symptoms of PND. [7]

Mechanism

The exact mechanism of PND depends on its etiology, but usually involves increased production of mucus from the nasal mucosa. In addition to providing sense of smell, the nasal cavity serves to filter and regulate the temperature and humidity of inspired air. [7] The nasal mucosa can produce secretions, or mucus, that provides lubrication and protection for the nasal cavity. This mucus production is activated by the autonomic nervous system; specifically, cholinergic neuropeptides are responsible for increasing mucus production. [7] Excess mucus can drain posteriorly into the upper and lower airways, which, along with other physical and chemical irritants, can activate receptors in the respiratory tract that results in a protective physiological cough. [9]

Diagnosis

Diagnosis of PND depends on both a detailed history and clinical examination to help determine its etiology. The history may begin with feelings of obstructed nasal breathing or "stuffy nose" with or without nasal discharge. [10] If allergic rhinitis is suspected, a family history of allergic conditions as well as a personal history of other associated conditions such as food allergy, asthma, and atopic dermatitis can be evaluated. [10] Allergic rhinitis classically has more symptoms of sneezing attacks, itchy eyes, and respiratory problems, although it is difficult to distinguish the different types of rhinitis by symptomology alone. [10] [7] Visual inspection can reveal mouth breathing, which is suggestive of nasal obstruction, or a horizontal crease across the nose (caused by the "allergic salute"). [10]

In the absence of any specific diagnostic tests, it may be difficult to diagnose PND from history of symptoms alone, as the etiology is broad and the symptoms may be very general. As such, suggestive procedures that highlight rhinitis and mucopurulent secretions, such as nasoendoscopy, may instead be utilized because of the vague nature of information available to directly attribute specific symptoms to the syndrome. [11] [2]

Treatment

Treatment options depend on the nature of an individual's post-nasal drip and its cause. Antibiotics may be prescribed if the PND is the result of bacterial sinusitis. [8] In cases where PND is caused by allergic rhinitis or irritant rhinitis, avoidance of allergens or irritating factors such as dander, cigarette smoke, and cleaning supplies may be beneficial. [7] Antihistamines are particularly useful for allergic rhinitis and may be beneficial in some cases of non-allergic rhinitis. [7] First-generation antihistamines such as chlorpheniramine and clemastine are more potent but have greater sedatory effects; later-generation antihistamines may be used to reduce these effects. [7] Azelastine, a topical antihistamine, is approved for both allergic and non-allergic rhinitis due to its unique anti-inflammatory effects separate from its histamine receptor antagonism. [7]

Intranasal steroids may also be beneficial in patients who do not respond to antihistamines. In one meta-analysis, intranasal steroids were shown to improve symptoms of non-allergic rhinitis at up to four weeks better than a placebo. [12] Decongestants such as pseudoephedrine can tighten blood vessels of the nasal mucosa and result in a decrease in mucus production. [7] Anticholinergics such as ipratropium bromide can help reduce secretions by blocking parasympathetic effects on the nasal mucosa. [7] [13]

One study has found that symptoms of postnasal drainage improved after 8 to 16 weeks of lansoprazole 30 mg taken twice daily regardless of the presence or absence of typical symptoms of GERD. [14]

Other methods, such as drinking warm fluids and using saline nasal irrigation, may be useful for managing symptoms of PND but their exact efficacy is unclear in medical literature. [15]

Epidemiology

Because PND is often characterized as a "symptom" rather than a separate condition, the exact incidence is unknown and varies by its etiology. Chronic rhinitis, which includes allergic and non-allergic rhinitis, can affect 30-40% of the population. [12] Non-allergic rhinitis is more common in females than in males. [7]

Related Research Articles

<span class="mw-page-title-main">Sinusitis</span> Inflammation of the inner lining of the sinuses

Sinusitis, also known as rhinosinusitis, is an inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include production of thick nasal mucus, nasal congestion, facial congestion, facial pain, facial pressure, loss of smell, or fever.

<span class="mw-page-title-main">Cough</span> Sudden expulsion of air from the lungs as a reflex to clear irritants

A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three phases: an inhalation, a forced exhalation against a closed glottis, and a violent release of air from the lungs following opening of the glottis, usually accompanied by a distinctive sound.

<span class="mw-page-title-main">Allergic rhinitis</span> Nasal inflammation due to allergens in the air

Allergic rhinitis, of which the seasonal type is called hay fever, is a type of inflammation in the nose that occurs when the immune system overreacts to allergens in the air. It is classified as a type I hypersensitivity reaction. Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy, and watery eyes, and swelling around the eyes. The fluid from the nose is usually clear. Symptom onset is often within minutes following allergen exposure, and can affect sleep and the ability to work or study. Some people may develop symptoms only during specific times of the year, often as a result of pollen exposure. Many people with allergic rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis.

A decongestant, or nasal decongestant, is a type of pharmaceutical drug that is used to relieve nasal congestion in the upper respiratory tract. The active ingredient in most decongestants is either pseudoephedrine or phenylephrine. Intranasal corticosteroids can also be used as decongestants and antihistamines can be used to alleviate runny nose, nasal itch, and sneezing.

<span class="mw-page-title-main">Rhinitis</span> Irritation and inflammation of the mucous membrane inside the nose

Rhinitis, also known as coryza, is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip.

<span class="mw-page-title-main">Nasal polyp</span> Noncancerous growths within the nose or sinuses

Nasal polyps are noncancerous growths within the nose or sinuses. Symptoms include trouble breathing through the nose, loss of smell, decreased taste, post nasal drip, and a runny nose. The growths are sac-like, movable, and nontender, though face pain may occasionally occur. They typically occur in both nostrils in those who are affected. Complications may include sinusitis and broadening of the nose.

<span class="mw-page-title-main">Ipratropium bromide</span> Type of anticholinergic

Ipratropium bromide, sold under the brand name Atrovent among others, is a type of anticholinergic medication which is applied by different routes: inhaler, nebulizer, or nasal spray, for different reasons.

Catarrh is an inflammation of mucous membranes in one of the airways or cavities of the body, usually with reference to the throat and paranasal sinuses. It can result in a thick exudate of mucus and white blood cells caused by the swelling of the mucous membranes in the head in response to an infection. It is a symptom usually associated with the common cold, pharyngitis, and chesty coughs, but it can also be found in patients with adenoiditis, otitis media, sinusitis or tonsillitis. The phlegm produced by catarrh may either discharge or cause a blockage that may become chronic.

<span class="mw-page-title-main">Nasal irrigation</span> Personal hygiene practice for rinsing out nasal passages

Nasal irrigation is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses, in order to enhance nasal breathing. Nasal irrigation can also refer to the use of saline nasal spray or nebulizers to moisten the mucous membranes.

<span class="mw-page-title-main">Nasal congestion</span> Partial or complete blockage of nasal passages

Nasal congestion is the partial or complete blockage of nasal passages, leading to impaired nasal breathing, usually due to membranes lining the nose becoming swollen from inflammation of blood vessels.

<span class="mw-page-title-main">Rhinorrhea</span> Filling of the nasal cavity with fluid mucus

Rhinorrhea, also spelled rhinorrhoea or rhinorrhœa, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies or certain viral infections, such as the common cold or COVID-19. It can be a side effect of crying, exposure to cold temperatures, cocaine abuse, or drug withdrawal, such as from methadone or other opioids. Treatment for rhinorrhea may be aimed at reducing symptoms or treating underlying causes. Rhinorrhea usually resolves without intervention, but may require treatment by a doctor if symptoms last more than 10 days or if symptoms are the result of foreign bodies in the nose.

<span class="mw-page-title-main">Rhinitis medicamentosa</span> Medical condition

Rhinitis medicamentosa is a condition of rebound nasal congestion suspected to be brought on by extended use of topical decongestants and certain oral medications that constrict blood vessels in the lining of the nose, although evidence has been contradictory.

<span class="mw-page-title-main">Azelastine</span> Chemical compound

Azelastine, sold under the brand name Astelin among others, is a H1 receptor-blocking medication primarily used as a nasal spray to treat allergic rhinitis (hay fever) and as eye drops for allergic conjunctivitis. Other uses may include asthma and skin rashes for which it is taken by mouth. Onset of effects is within minutes when used in the eyes and within an hour when used in the nose. Effects last for up to 12 hours.

<span class="mw-page-title-main">Mometasone</span> Steroid medication

Mometasone, also known as mometasone furoate, is a steroid medication used to treat certain skin conditions, hay fever, and asthma. Specifically it is used to prevent rather than treat asthma attacks. It can be applied to the skin, inhaled, or used in the nose. Mometasone furoate, not mometasone, is used in medical products.

Chronic atrophic rhinitis, or simply atrophic rhinitis, is a chronic inflammation of the nose characterised by atrophy of nasal mucosa, including the glands, turbinate bones and the nerve elements supplying the nose. Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic rhinitis are rhinitis sicca anterior and ozaena. It can also be described as the empty nose syndrome.

Vocal cord dysfunction (VCD) is a condition affecting the vocal cords. It is characterized by abnormal closure of the vocal folds, which can result in significant difficulties and distress during breathing, particularly during inhalation.

Nonallergic rhinitis is rhinitis—inflammation of the inner part of the nose—not caused by an allergy. Nonallergic rhinitis displays symptoms including chronic sneezing or having a congested, drippy nose, without an identified allergic reaction with allergy testing being normal. Other common terms for nonallergic rhinitis are vasomotor rhinitis and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis rather than allergic rhinitis. Other symptoms that are more specific to non-allergic rhinitis include ear plugging or discomfort with eustachian tube dysfunction, headaches, sinus pressure, and muffled hearing. Common triggers for non-allergic rhinitis include irritants such as tobacco smoke, cleaning agents, or abrupt changes in ambient temperature.

In clinical guidelines chronic cough is defined as a cough lasting more than 8 weeks in adults and more than 4 weeks in children. there are studies suggest that a chronic cough must persist upwards of three months. The prevalence of chronic cough is about 10% although the prevalence may differ depending on definition and geographic area. Chronic cough is a common symptom in several different respiratory diseases like COPD or pulmonary fibrosis but in non-smokers with a normal chest x-ray chronic cough are often associated with asthma, rhinosinusitis, and gastroesophageal reflux disease or could be idiopathic. Generally, a cough, for example after an upper respiratory tract infection, lasts around one to two weeks; however, chronic cough can persist for an extended period of time, several years in some cases. The current theory about the cause of chronic cough, independent of associated condition, is that it is caused by a hypersensitivity in the cough sensory nerves, called cough hypersensitivity syndrome. There are a number of treatments available, depending on the associated disease but the clinical management of the patients remains a challenge. Risk factors include exposure to cigarette smoke, and exposure to pollution, especially particulates.

Anti-allergic agents are medications used to treat allergic reactions. Anti-allergic agents have existed since 3000 B.C in countries such as China and Egypt. It was not until 1933 when antihistamines, the first type of anti-allergic agents, were developed. Common allergic diseases include allergic rhinitis, allergic asthma and atopic dermatitis with varying symptoms, including runny nose, watery eyes, itchiness, coughing, and shortness of breath. More than one-third of the world's population is currently being affected by one or more allergic conditions.

References

  1. 1 2 Morice AH (2004). "Post-nasal drip syndrome--a symptom to be sniffed at?". Pulmonary Pharmacology & Therapeutics. 17 (6): 343–5. doi:10.1016/j.pupt.2004.09.005. PMID   15564073.
  2. 1 2 3 Sylvester DC, Karkos PD, Vaughan C, Johnston J, Dwivedi RC, Atkinson H, Kortequee S (2012). "Chronic cough, reflux, postnasal drip syndrome, and the otolaryngologist". International Journal of Otolaryngology. 2012: 564852. doi: 10.1155/2012/564852 . PMC   3332192 . PMID   22577385.
  3. ↑ Gibson P, Wang G, McGarvey L, Vertigan AE, Altman KW, Birring SS (January 2016). "Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report". Chest. 149 (1): 27–44. doi:10.1378/chest.15-1496. PMC   5831652 . PMID   26426314.
  4. ↑ Ibrahim WH, Gheriani HA, Almohamed AA, Raza T (March 2007). "Paradoxical vocal cord motion disorder: past, present and future". Postgraduate Medical Journal. 83 (977): 164–72. doi:10.1136/pgmj.2006.052522. PMC   2599980 . PMID   17344570.
  5. ↑ Gimenez LM, Zafra H (April 2011). "Vocal cord dysfunction: an update". Annals of Allergy, Asthma & Immunology. 106 (4): 267–74, quiz 275. doi:10.1016/j.anai.2010.09.004. PMID   21457874.
  6. ↑ Kenn K, Balkissoon R (January 2011). "Vocal cord dysfunction: what do we know?". The European Respiratory Journal. 37 (1): 194–200. doi: 10.1183/09031936.00192809 . PMID   21205712. S2CID   12436689.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 13 Flint PW, Haughey BH, Robbins KT, Thomas JR, Niparko JK, Lund VJ, Lesperance MM (2014). Cummings Otolaryngology: Head & Neck Surgery (Sixth ed.). Philadelphia, PA. ISBN   978-0-323-27820-1. OCLC   894112159.{{cite book}}: CS1 maint: location missing publisher (link)
  8. 1 2 Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. (April 2015). "Clinical practice guideline (update): adult sinusitis". Otolaryngology–Head and Neck Surgery. 152 (2 Suppl): S1–S39. doi: 10.1177/0194599815572097 . PMID   25832968. S2CID   30043393.
  9. ↑ McCallion P, De Soyza A (December 2017). "Cough and bronchiectasis". Pulmonary Pharmacology & Therapeutics. 47: 77–83. doi:10.1016/j.pupt.2017.04.010. PMID   28602999.
  10. 1 2 3 4 Probst R, Grevers G, Iro H (2017). Basic Otorhinolaryngology. Georg Thieme Verlag. doi:10.1055/b-005-148915. ISBN   978-3-13-203472-3.
  11. ↑ Pratter MR (January 2006). "Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 63S–71S. doi: 10.1378/chest.129.1_suppl.63s . PMID   16428694.
  12. 1 2 Segboer C, Gevorgyan A, Avdeeva K, Chusakul S, Kanjanaumporn J, Aeumjaturapat S, et al. (Cochrane ENT Group) (November 2019). "Intranasal corticosteroids for non-allergic rhinitis". The Cochrane Database of Systematic Reviews. 2019 (11). doi:10.1002/14651858.CD010592.pub2. PMC   6824914 . PMID   31677153.
  13. ↑ Naclerio R (August 2009). "Anticholinergic drugs in nonallergic rhinitis". The World Allergy Organization Journal. 2 (8): 162–5. doi:10.1097/WOX.0b013e3181b35336. PMC   3650956 . PMID   24228813.
  14. ↑ Fossmark, Reidar; Ness-Jensen, Eivind; Sørdal, Øystein (2023-09-06). "Is empiric proton pump inhibition in patients with symptoms of extraesophageal gastroesophageal reflux justified?". BMC Gastroenterology. 23 (1). Springer Science and Business Media LLC: 303. doi: 10.1186/s12876-023-02945-7 . ISSN   1471-230X. PMC   10483799 . PMID   37674110.
  15. ↑ "Banishing Sinus Infection Misery? - Andrew Weil, M.D."
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