Difficulty breathing and accumulation of mucus in the nasopharynx: how to get rid of the real cause?

Almost every person experiences difficulty breathing through the nose. This is the most commonly diagnosed complaint among patients, because the symptom is associated with a deviated nasal septum. This diagnosis occurs to varying degrees in 80% of the world's population. However, not every patient is bothered by severe discomfort, and therefore not everyone is interested in treatment methods.

In addition to difficulty breathing, patients may experience other symptoms, the intensity of which directly depends on the degree of curvature of the nasal septum.

About mucus in the throat

Mucus in the throat occurs due to the abundant accumulation of phlegm.
Mucus in the throat can accumulate under the influence of various factors associated with both the external environment and diseases of the internal organs. The most common cause of mucus in the throat is diseases of the ENT organs of allergic, non-allergic, as well as bacterial, post-infectious and fungal origin. Abnormalities in the development of the nasopharynx can contribute to the development of mucus in the throat.

Persons who have excessive accumulation of mucus in the throat should be observed by an ENT doctor, since the real cause of this phenomenon is not easy to determine. The main thing is not to self-medicate, so as not to worsen the situation. Mucus in the throat can appear for various reasons. Quite often, mucus in the throat occurs due to abundant accumulation of sputum , which is the first sign of an inflammatory process in the bronchi. To make an accurate diagnosis, you need to consult a medical specialist, that is, an ENT specialist.

A characteristic sign of one of the diseases in which mucus appears in the throat is catarrhal or hypertrophic pharyngitis of a chronic nature. In this case, the inflammation that affects the pharynx area leads to the formation of a lump of mucus, which irritates the mucous membrane, causing the desire to cough.

Laryngopharyngeal reflux in gastroenterological practice

Gastroesophageal reflux disease (GERD) is one of the most common pathologies of the gastrointestinal tract. At the International Congress of Gastroenterology, held in Montreal in 2005, a unified definition of the disease, a description of symptoms and a classification of the disease were developed, which formed the basis of the Montreal Consensus [1]. The Consensus divides the clinical manifestations of GERD into esophageal and extraesophageal syndromes. The presence of reflux-associated symptoms in the absence of damage to the esophageal mucosa is regarded as esophageal syndrome, manifested solely by symptoms, and in the presence of damage to the esophageal mucosa - as esophageal syndromes with damage to the esophagus (complications). Extraesophageal syndromes were divided, in turn, into syndromes whose connection with GERD has been established, and syndromes whose connection with GERD is suspected. Extraesophageal syndromes with an established connection with GERD include reflux cough, reflux laryngitis, reflux asthma and reflux-induced destruction of tooth enamel, and syndromes with a presumptive connection with GERD include pharyngitis, sinusitis, pulmonary idiopathic fibrosis and recurrent otitis media [ 2, 3].

The word “reflux” itself literally means “reverse flow”. GERD is detected in many patients with chronic laryngitis. Otorhinolaryngologists often refer to this condition as laryngopharyngeal reflux (LPR), which represents the retrograde entry of stomach contents - acid and pepsin, as well as bile acids into the laryngopharynx [4, 5]. There are a number of synonyms for LPR, such as extraesophageal reflux, reflux laryngitis and laryngeal reflux. There is currently no gold standard for diagnosing LPR, and therefore data on its epidemiology are limited. In one study of 105 normal healthy volunteers, 86% had laryngopharyngeal reflux during laryngoscopy [6]. In a meta-analysis by AL Merati et al. analyzed data from pH probe readings in 264 patients with LPR; as a result, gastroesophageal reflux was detected in 10–60% of patients [7]. Studies such as these show that LPR is common in the general population, but needs to be diagnosed in some patients before adequate treatment can be given.

Normally, the upper esophageal sphincter and, to some extent, the larynx protect the lower respiratory tract from the entry of contents from the esophagus and stomach. The larynx is very well innervated and any esophageal reflux in a normal person will cause a protective cough. In patients with LPR, this “safety mechanism” may fail. For example, JE Aviv et al. The study showed that sensory deficits may play a role in the formation of LPR. The authors found a decrease in the laryngeal reflex in response to endoscopic air insufflation in patients with documented LPR [8]. Most researchers propose two main pathophysiological mechanisms for LPR, which directly or indirectly cause damage to the larynx by the contents of the esophagus and stomach. The direct mechanism is the result of the action of gastric contents (acid, pepsin and/or bile acids) acting directly on the mucous membrane of the hypopharynx. The indirect mechanism manifests itself as a result of the effect of reflux on the reflex structures of the larynx. This irritation is thought to cause bronchospasm, which in turn stimulates the vagal response, usually resulting in a nonproductive cough. The delicate ciliated epithelium of the posterior wall of the larynx, which normally evacuates mucus from the trachea, is significantly damaged by contact with gastroduodenal chemical agents, which can lead to mucous stasis in the larynx and discomfort [9]. Recently, it has been suggested that the enzyme carbonic anhydrase, which stimulates bicarbonate secretion, protects laryngeal tissues from reflux and that this protective mechanism may be impaired in the larynx of patients with LPR [10].

Most patients diagnosed with LPR may not have the classic symptoms of GERD. The main symptoms of LPR are respiratory complaints such as pain or burning in the throat, chronic cough (51%), excessive expectoration of mucus (42%), dysphonia (71%), dysphagia (35%), lump in the throat (47%), vertical (daytime) reflux, laryngospasm [11]. Researchers estimate that up to 50% of patients with laryngeal and voice disorders have reflux [12]. Based on laryngoscopy data, a special scale of “reflux signs” (SRS) was developed in 2001, which included 8 characteristic laryngoscopic symptoms with a general assessment of their severity from 0 to 26 points, which are presented in table. 1 [13]. Conducted by MF Vaezi et al. studies have shown that the presence of more than 7 points on the SRS correlated by 95% with positive data from 24-hour esophageal pH monitoring and suggested the presence of LPR [14]. Many patients with LPR often turn to a phoniatrist because they do not have pathognomonic complaints. If a patient’s dysphonia continues for more than three months, he or she should be screened to detect LPR [15].

Unfortunately, the specificity of laryngoscopic findings and their assessment using the presented SRS is not very high [6]. In 2002, the authors who developed the SRS also proposed the “Reflux Symptoms Index” (RSI) questionnaire, recommended for assessing the effectiveness of LPR treatment with proton pump inhibitors (PPIs), which consists of 9 questions and includes a dynamic assessment of a number of indicators (Table 2). Each IRS symptom is rated over the past month on a scale from 0 (no problems) to 5 (severe problems). A score of more than 13 correlates with a positive result of pH monitoring [13]. It is a self-administered tool that helps clinicians assess the clinical severity of LPR symptoms at diagnosis and then over time after treatment. The IRS is significantly higher in patients with LPR than in healthy controls (21.2 vs. 11.6, p < 0.001). However, this indicator is rarely used by general practitioners and otolaryngologists [16]. In 2004, R. Williams et al. proposed a scale for assessing the severity of chronic laryngitis in otorhinolaryngological manifestations of the extraesophageal form of GERD: degree 0 - no signs of inflammation, degree I (mild) hyperemia and/or swelling in the area of ​​the arytenoid cartilages and interarytenoid space, degree II (moderate) - distribution of hyperemia and/ or edema beyond the area of ​​the arytenoid cartilages and the interarytenoid space to the vocal folds, degree III (severe) - the presence of ulcerations in the area of ​​the arytenoid cartilages and the interarytenoid space or the spread of the inflammatory process to the subvocal part of the larynx [17].

As is known, the most sensitive test for practical diagnosis of pathological acid gastroesophageal reflux is daily intraesophageal pH monitoring, when intraesophageal pH is continuously recorded at a distance of 5 cm above the lower esophageal sphincter. As a standard test for diagnosing LPR, ambulatory 24-hour intraesophageal hypopharyngeal pH monitoring using two pH sensors is proposed, with the second (proximal) pH sensor for fixing supraesophageal reflux as a cause of ENT disorders installed 5 cm above the upper alimentary sphincter (VPS) [18]. Unfortunately, although hypopharyngeal pH monitoring is a more sensitive test for identifying patients with GERD-induced ENT disorders, negative results cannot exclude LPR due to the intermittent nature of the disease and variability. Currently, a more accurate and patient-friendly method for diagnosing LPR has been developed by measuring naso- and oropharyngeal pH using a special Restech's Dx-pH measurement system, which allows recording pH fluctuations in the oral cavity and nasopharynx every 1/2 s for 48 hours [14 , 19].

Treatment of patients with LPR should include diet, lifestyle modifications, physical therapies, and pharmacotherapy. Modification of diet and lifestyle involves the patient following the following recommendations:

• after eating, you should avoid bending forward, you should go to bed with your head elevated;
• do not wear tight clothes and tight belts;
• avoid large meals;
• do not eat at night;
• limit the consumption of foods that cause a decrease in the pressure of the lower alimentary sphincter (LES) and have an irritating effect (fats, alcohol, coffee, chocolate, citrus fruits);
• stop smoking;
• normalize body weight.

Foods and drinks containing caffeine, alcohol, chocolate and mint relax the lower esophageal sphincter and increase stomach acid production, while carbonated drinks with/or without caffeine increase reflux and belching. In addition, the intake of acidic foods (with a pH below 4.6), such as citrus fruits and other sour fruits, tomatoes, dry wines and some others, should be limited. Lifestyle modifications that can reduce symptoms of LPR, as well as other manifestations of extraesophageal reflux, include smoking cessation and weight loss. A study by DL Steward et al. [20] showed that lifestyle changes for 2 months or more, with or without PPI therapy, significantly reduced the symptoms of chronic laryngitis.

Drug therapy usually includes PPIs, H2 receptor agonists, prokinetics, and cryoprotectants for the laryngeal mucosa. Empirical therapy with PPIs is justified because it can help in the diagnosis ex juvantibus (from the Latin ex - based on, juvanus - helping), i.e. treatment carried out in order to clarify the diagnosis. To date, studies of the effectiveness of PPIs in the treatment of LPR patients have produced a wide range of responses [21].

Studies evaluating the effectiveness of PPIs in LPR show results ranging from very good, with response rates reaching 70%, to no difference with placebo [22]. A controlled trial using lansoprazole 30 mg twice daily for three months in 22 patients with idiopathic chronic laryngitis found that 50% of patients in the treatment group had a complete response compared with 10% in the control group [23]. However, another study using lansoprazole at a similar dosage and regimen found no difference in response rates in patients with laryngopharyngitis [24]. A large multicenter study involving 145 patients with suspected LPR showed no benefit of esomeprazole 40 mg twice daily for four months compared with placebo [25]. One recent study of 85 patients with LPR found that PPI twice daily was more effective than once daily and that extending the course of treatment from two to four months resulted in more positive responses [26]. In general, for LPR, the use of a standard dose of PPI twice daily for two to three months is justified. Current recommendations do not suggest the use of H2-blockers in combination with PPIs in patients with suspected LPR [27, 28]. To achieve the best results, PPIs should be taken on an empty stomach 30 minutes before meals, with a course of treatment of 2–6 months until complete histological remission of laryngitis is achieved [29]. Patients whose quality of life and symptoms do not improve after two to three months of therapy most likely do not have GERD as a cause of LPR, but they should be evaluated for the presence of mixed reflux using manometry and pH monitoring [30]. If there is no effect from taking a PPI, a reassessment of symptoms with the participation of specialists from a pulmonologist and an allergist is necessary [31, 32].

The necessary comprehensive diagnosis and treatment of LPR was demonstrated by E. F. Kokorina, who assessed, in addition to endoscopic signs of esophagitis, the severity of chronic laryngitis in otorhinolaryngological manifestations of the extraesophageal form of GERD using the Williams scale, the level of dysphonia was assessed using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE) scoring scale. V), proposed by the American Speech-Language Hearing Association, 2003. All patients underwent correction of GERD using PPI drugs; for the treatment of LPR in the main group of patients, the drug Erespal was added according to the standard regimen for 3 weeks. The duration of standard antireflux therapy was 3 months. Dynamic assessment of LPR was carried out several times up to 6 months after treatment; a statistically significant acceleration in the regression of reflux-induced changes in the larynx in patients of the main group was revealed [33]. I. L. Klyaritskaya, A. P. Balabantseva in their study showed that the use of double doses of PPI (pantoprazole) for 12 weeks leads to a significant reduction in symptoms of LPR compared to the control group. The optimal duration of treatment is 6–12 months, and after stopping the medication after 6 weeks it leads to an increase in scores on the Reflux Symptom Index questionnaire [34].

It is necessary to consider the use of prokinetics in the complex treatment of both GERD and LPR, which is a manifestation of GERD. Drugs such as metoclopramide, domperidone, cisapride and tegaserod have been used in patients with GERD in the past, but regular use of these drugs is not recommended by current standards due to limited indications and a high side effect profile [35]. In the treatment of GERD today, according to indications, the prokinetic agents itopride and mosapride are used; unfortunately, the latter is not registered in Russia. Itopride, registered in Russia since 2007, is used in patients with LPR as an adjuvant together with PPIs, as well as for other extraesophageal syndromes, accelerating the rate of reduction of symptoms [36, 37]. E. P. Oleinik et al. recommend the use of itopride, based on their own experience of using it in almost 1000 patients, in the complex treatment of all types of voice disorders due to GERD and LPR [38]. F.V. Semenov et al. A study involving 200 patients with LPR assessed the effectiveness of a two-week course of itopride in the treatment of otolaryngological manifestations of LPR. Its use led to a decrease in subjective complaints of patients and a weakening of the severity of laryngoscopic signs such as hyperemia and swelling of the mucous membrane of the arytenoid cartilages [39].

There are several scientific publications in the literature regarding rehabilitation speech therapy treatment of LPR with special voice exercises that strengthen the muscles of the larynx, and in some centers such therapy is carried out empirically without medical evidence-based support. A report on laryngeal rehabilitation in the treatment of chronic cough associated with GERD was recently published with significant improvement in symptoms [40].

The role of surgical fundoplication in patients refractory to even high (double) doses of PPI remains controversial. In a study by J. Swoger et al. evaluated symptoms in 10 PPI-resistant patients after fundoplication compared with 12 PPI-resistant patients who continued conservative treatment with double doses of PPI, showing that only 1 patient (10%) benefited from fundoplication, which was no different from the group comparison (7%) [41]. However, the role of surgery in PPI-resistant patients who have abnormal non-acid reflux remains important. They can be successfully treated with laparoscopic Nissen fundoplication [42]. Today, the Society of American Gastrointestinal and Endoscopic Surgeons clinical guidelines recommend antireflux surgery for patients who: have failed or are intolerant to medications; have significant extraesophageal manifestations such as aspiration, asthma, or cough; have ulcerative strictures as a complication of GERD [43].

Thus, there are no specific lesions of the larynx with laryngopharyngeal reflux, so the diagnosis of this pathology should be comprehensive and include both ENT and gastroenterological examination methods. Treatment of laryngopharyngeal reflux should also be comprehensive, from lifestyle modification and the use of local remedies to a long course of proton pump inhibitors and prokinetics in adequate dosage, and if they are ineffective, surgical treatment methods should be used.

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E. Yu. Plotnikova*, 1, Doctor of Medical Sciences, Professor M. V. Krasnova**, Candidate of Medical Sciences K. A. Krasnov**, Candidate of Medical Sciences E. N. Baranova*

* State Budgetary Educational Institution of Higher Professional Education Kemerovo State Medical Academy of the Ministry of Health of the Russian Federation, Kemerovo ** Municipal Budgetary Healthcare Institution City Clinical Hospital No. 3 named after. M. A. Podgorbunsky, Kemerovo

1 Contact information

Abstract. Ethiopathogenetic mechanisms, clinical indicators and diagnostic methods of laryngopharyngital reflux. Modern treatment methods are described that presumably diet, changing of the mode of life, physical treatment methods and drug therapy as well as indications for surgery.

Causes of mucus in the throat

The causes of mucus in the throat are:

• Pharyngitis (inflammation of the pharyngeal walls);
• Sinunsitis (inflammation of the paranasal sinuses);
• Adenoiditis (inflammation of the pharyngeal tonsil).

All of these diseases cause mucus to accumulate in the throat. Increased mucus production in the throat occurs with nasal polyps and a deviated nasal septum. After nasal injuries, complications such as a forced cough may appear. Mucus in the throat often accumulates after a recent illness , such as the flu or ARVI. The cause of mucus in the throat may be a banal manifestation of bronchial asthma. With a disease such as bronchial asthma, mucus is formed in large volumes as a protective reaction of the body, being a means of evacuating allergens that leave the body in this way.

The accumulation of mucus in the throat can be caused by a carbonated drink, hot, spicy or very cold food. Nicotine and alcohol have such a detrimental effect, which irritates the mucous membrane of the nasopharynx, thereby aggravating the condition. All of these factors can cause congestion, which is manifested by a sensation of mucus accumulation in the throat. Most often, this symptom is observed in the morning after waking up. At night, mucus drains down the back of the throat and accumulates in the throat as a result of prolonged exposure to a horizontal position during sleep. Cough in the morning is not accompanied by changes in the lungs, but is characterized by frequent discharge of mucus clots.

Drug treatment

How to remove mucus from the nasopharynx? The process of evacuation of sputum from the respiratory tract can only be facilitated if its viscosity is reduced. For this purpose, secretolytic and secretomotor agents are used. You also need to take medications that help eliminate inflammation in the mucous membranes.

Mucolytic drugs reduce the amount of mucin in sputum, which has astringent properties. A decrease in the concentration of protein components in the mucus contributes to its liquefaction and detachment from the inner surface of the nasopharynx. With the help of secretolytic agents, not only sputum is removed from the respiratory system, but also purulent exudate, which is often formed during the development of sinusitis, purulent pharyngitis, tracheobronchitis, etc.

Mucolytic drugs can be used to treat adults and children over 3 years of age.

To transform a dry cough into a wet one, it is recommended to use:

• "Fluimucil";
• "ACC";
• "Ambroxol";
• "Mukopront."

Expectorant medications increase the sensitivity of cough receptors, thereby accelerating the process of removing mucus from the nasopharynx. During forced exhalation, pathological secretions containing pathogenic viruses or bacteria are evacuated from the lower and upper parts of the respiratory system. The best drugs with secretomotor action include:

• "Sinupret";
• "Ambrosan";
• "Tavilek";
• "Bromhexine."

Treatment with expectorants is indicated for the development of acute bronchitis, cystic fibrosis, tracheitis, bronchial asthma, etc.

Secretomotor drugs prevent mucus stagnation in the lower parts of the respiratory tract. If you do not start taking medications in time, this will lead to disruption of the drainage function of the bronchi and, as a result, the development of pneumonia.

Local anti-inflammatory drugs can accelerate the regression of pathological processes directly at the sites of inflammation. Restoring the secretory activity of goblet cells will lead to a decrease in the amount of sputum in the respiratory tract. To ease the course of the disease and speed up the recovery process, it is recommended to use the following types of drugs:

• "Orasept";
• "Ingalipt";
• "Pro-Ambassador";
• "Hexoral".

Treatment of children with aerosol preparations may provoke undesirable reactions. To prevent negative consequences, doctors recommend treating a sore throat with Lugol's Solution or antiseptic drugs.

Symptoms of mucus in the throat

Typical symptoms of mucus in the throat include:

1. Feeling of burning and rawness in the throat;
2. Sore throat;
3. Unpleasant sensations when swallowing;
4. Constant desire to cough;
5. Lump in throat.

Common symptoms include headaches and enlarged cervical lymph nodes. When a person begins to experience a sore throat or a pleasant sensation while swallowing, these symptoms may indicate mucus in the throat. In other words, a lump in the throat is felt due to a constant desire to cough.

The method of treating mucus in the throat is determined only by an ENT doctor after a comprehensive examination.

Why is the nasal septum deviated?

The cartilage tissue that represents the septum does not have such a dense structure as bone, so it is prone to deformation as a result of injuries, falls, and also against the background of long-term inflammatory processes. The septum consists of quadrangular cartilage and three bones - the perpendicular plate, the vomer and the premaxillary bone from the upper jaw. It is curved due to the fact that there is a discrepancy in the growth of the cartilaginous part and the bone part - something grows faster and, since there is nowhere to grow, goes to the side, or there was an injury, and because of this the septum is bent. Therefore, there are deviated septums without injury.

Until the age of 21, a person’s cartilage tissue still continues to grow, so surgical intervention is considered unacceptable. In many cases, natural self-correction is possible during the growth process. The septum is now operated on at any age, despite the fact that it grows. But if the septum is severely deviated, surgery is performed at any age, including children.

Despite encouraging forecasts, damage not only to the septum itself, but also to internal structures is possible. As a result of such deformation of the internal cavity, serious chronic processes develop, characterized by the accumulation of mucus inside. In this way, indications for surgical intervention are formed.

Treatment of mucus in the throat

Treatment of mucus in the throat at the ENT-Asthma clinic is comprehensive and is aimed at suppressing local symptoms of the disease, affecting the main causes that maintain mucus in the throat. The main task of treating mucus in the throat is to eliminate discomfort. For more effective treatment, painkillers and anti-inflammatory, antiseptic and antibacterial drugs are used.

For local treatment of mucus in the throat, drugs can be used to help moisturize the mucous membrane and relieve sensations that are considered paresthesia - a feeling of soreness and tickling in the throat. In cases where mucus in the throat is a symptom of an infectious disease , atomization of the pharyngeal cavity is used using aerosols of combined action (antiseptic and analgesic). The choice of an antibacterial agent by an ENT doctor largely depends on the identified pathogen in case of moderate and severe course of the disease.

If the mucus in the throat is of an allergic nature, then our specialist doctors use a complex of antihistamines. To treat mucus in the throat, the ENT-Asthma clinic uses immunomodulators , which stimulate the body’s own forces to fight the disease. Simply put, the desired result is achieved by increasing immunity. To effectively treat mucus in the throat, sanitation of foci of infection, the oral cavity and the upper respiratory tract is indicated.

What is sputum

© Hank Grebe/Getty Images

Our body produces mucus that coats certain ducts, such as the respiratory and digestive tracts, to protect and maintain certain functions.

This mucus prevents bacteria and viruses from causing infection.

Moreover, our body produces about a liter of phlegm every day.

Most often we don't notice it, but when the mucus becomes thick and takes on an unusual color, such as yellow, green or brown, it can become a problem.

Accumulations of mucus in infants

Many mothers begin to worry when their baby develops mucus in the nasopharynx. For children of this age, this is a very common phenomenon, since their respiratory system is not yet fully formed. But sometimes such a symptom can actually indicate the presence of a certain disease.

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