Chronic Cough and Throat Clearing
A cough that will not settle, or a constant need to clear the throat, can be exhausting and socially isolating.
When a cough lasts longer than eight weeks and the usual causes have been investigated and treated, it is described as a chronic cough.
In many people the underlying problem is that the nerves supplying the throat and voice box have become oversensitive, so that minor triggers such as talking, laughing, a change in air temperature or a tickle in the throat set off coughing or repeated throat clearing. This is sometimes called chronic cough hypersensitivity or neurogenic cough.
As a laryngologist, I have a particular interest in coughs and throat-clearing that have not responded to standard treatments, and I offer specialised options that are not widely available.
Possible causes of a chronic cough and throat clearing
- Hypersensitivity of the throat and voice-box nerves
- Nasal inflammation / allergy with congestion and thick secretions
- Asthma and other airway conditions
- Side effects of certain blood-pressure medications
- A habit cycle, where throat clearing itself irritates the throat and provokes more clearing
How I assess a chronic cough
At your consultation I take a detailed history and examine your throat and voice box using a thin flexible camera (nasendoscopy) passed gently through the nose. This lets me look directly at the larynx for signs of irritation, lesions or muscle tension, and helps me build a picture of why your throat has become oversensitive.
Where appropriate I will arrange or coordinate further tests and work alongside colleagues in respiratory medicine, gastroenterology and speech therapy.
Treatment Options
Treatment is tailored to the cause and often combines more than one approach.
Speech and language therapy
Specialised cough-control therapy with a speech and language therapist teaches techniques to break the cough cycle and reduce throat clearing. This is often a valuable first step, and I can refer you to a trusted therapist.
Superior laryngeal nerve block
For coughs driven by an oversensitive throat, I offer a superior laryngeal nerve block. This is a targeted injection of local anaesthetic, with a small dose of steroid, placed close to the superior laryngeal nerve in the neck, which carries sensation from the voice box. By calming this oversensitive nerve, the injection can significantly reduce the urge to cough and clear the throat. It is a quick procedure performed in clinic under local anaesthetic, and the effect can build over a series of injections.
Medication (neuromodulators and newer agents)
Several medicines can help to dampen down an oversensitive cough reflex:
- Amitriptyline – a neuromodulator used at low doses to reduce the hypersensitivity of the throat nerves. Although originally developed as an antidepressant, at these low doses it works by settling nerve signalling rather than by treating mood, and it can be very effective for neurogenic cough and throat clearing.
- Gefapixant – a newer, first-in-class medication that blocks the P2X3 receptor involved in the cough reflex. It is specifically designed for refractory or unexplained chronic cough and offers an option for patients whose cough has not responded to other treatments. The most common side effect is a change in taste, which I will discuss with you.
- Other neuromodulators – alternatives such as gabapentin or pregabalin are sometimes used where amitriptyline is not suitable.
- Effective nasal treatments: I find treating nasal congestion is often highly effective in managing certain types of chronic cough. An allergy test is sometimes used to identify the allergen that is driving the nasal irritation and coughing.
I will talk through the benefits, possible side effects and suitability of each medication, and tailor the choice to you. Treating any contributing reflux, nasal or chest conditions at the same time gives the best chance of lasting relief.
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FAQs
What is a superior laryngeal nerve block and does it hurt?
A superior laryngeal nerve block is an injection of local anaesthetic, often with a small amount of steroid, placed near the nerve that carries sensation from the voice box. It calms an oversensitive throat and reduces the urge to cough.
The procedure is quick, carried out in clinic, and most patients tolerate it very well with only brief discomfort. The effect often improves over a course of injections.
How does amitriptyline help a chronic cough?
At the low doses used for cough, amitriptyline acts as a neuromodulator, calming the oversensitive nerves of the throat and voice box rather than treating mood.
This can substantially reduce coughing and throat clearing in people with a neurogenic cough. I will discuss dosing and any side effects with you and review your progress.
What is gefapixant and who is it for?
Gefapixant is a newer medication that blocks the P2X3 receptor, part of the pathway that drives the cough reflex. It is designed for refractory or unexplained chronic cough that has not responded to other treatments. The most common side effect is an altered sense of taste. I will assess whether it is a suitable option for your particular cough.
When should I see a specialist about a cough?
A cough lasting more than eight weeks, or persistent throat clearing that affects your daily life, warrants specialist assessment, especially when the usual treatments have not helped.
Any cough accompanied by coughing up blood, significant weight loss, difficulty swallowing or a persistent change in your voice should be assessed promptly.