Chronic Post Nasal Drip

If long-lasting post-nasal drip is the best description of your problem, a few possibilities come to mind. 

From the nose 

Sometimes one or more of the back sinuses (the sphenoid sinus, or the back of the ethmoid sinus, both of which sit deep behind the nose) can be quietly infected without causing other nose symptoms. An infection can also build up on the surfaces at the back of the nose where the adenoid sits. The drainage from this kind of problem is irritating and usually leaves a clear redness at the back of the throat that a doctor can see on exam. People who fit this pattern should see a specialist. 

If a long-lasting infection is suspected, the first step is usually to treat for long-lasting sinusitis with a long course of broad antibiotics plus steroid sprays or pills. If allergies are suspected, allergy pills (antihistamines) or steroid nose sprays are tried. 

If a nose-based cause is strongly suspected and the diagnosis is still unclear, a CT scan of the sinuses is often the next step.  

Not from the nose 

Most people assume long-lasting infection or allergy is the cause of post-nasal drip. When post-nasal drip is long-lasting and there aren't many other nose symptoms, in my experience the cause is much more often LPR (laryngo-pharyngeal reflux). This is a form of acid reflux that mainly affects the voice box area. 

People often have a hard time believing this at first, usually because they have never considered it and may not have any heartburn or indigestion. 

LPR symptoms vary from person to person and may include one or more of the following. Heartburn and indigestion are surprisingly often missing. 


Common LPR symptoms 

A feeling of thick mucus in the throat 
A lump-in-the-throat feeling when you swallow, especially with a "dry" swallow 
Hoarseness or a voice that gets tired easily 
Long-lasting cough or constant throat-clearing 
Long-lasting sore throat, low in the throat near the voice box 
Waking up choking or with a burning feeling 
More likely in people who are overweight, snore loudly, or have sleep apnea 


What to do if this sounds like your problem? 

If the problem is severe or getting worse, see a specialist. An in-office camera exam of the voice box (laryngeal endoscopy) can help rule out the rare possibility of throat cancer, and can give information that supports an LPR diagnosis or points to something else. If LPR seems likely, the next "test" is to treat with high-dose acid reducers and see whether symptoms get better. If the doctor thinks a long-lasting infection is more likely, a course of carefully chosen antibiotics may be tried, or a sample (culture) from the back of the nose can be taken to identify the bacteria. If things still don't improve, a CT scan may help. 


If you want to try treating this yourself for a while, start with saltwater nose rinses and high-dose acid reducers. Not just any acid reducer. LPR can be hard to treat, and results often come slowly. Get Prilosec OTC® and take 2 in the morning and 2 in the evening. I'd suggest using it at this dose for at least 2 weeks, and probably 4 weeks, before drawing any conclusions. This kind of medicine is expensive, even the over-the-counter form. 

Proton pump inhibitors (PPIs) like Prilosec have a good safety record overall, but some recent studies raise questions about long-term use. The usual prescription dose is the same as 2 of the OTC pills, taken once a day. Taking it twice a day is "off label," but is often needed to get LPR symptoms under control, especially at the start of treatment.   Prilosec and similar medicines should be taken about 30 minutes before a meal.  They don't work as well if taken at other times.

The first month on these medicines should be thought of as a test. Treatment is usually started on an educated guess. One of the best ways to confirm an LPR diagnosis is to see a good response to acid-reducer medicines. It is best to start with the strongest medicines at higher doses. Once symptoms are gone, a lower dose is usually enough to keep them from coming back.