Persistent Throat Symptoms, including Reflux, Globus and Cough

‘Persistent throat symptoms’ is a term that covers all sensations that we may be feeling in the throat, but that may not directly affect voice quality. These include:

• Soreness in the throat (may be constant, or may only be noticed when swallowing)
• Globus (a feeling of a ‘lump’ in the throat, this may be constant, or may only be noticed when swallowing)
• Irritation (sensations of tickling, pricking or dryness)
• Persistent cough (when the cough continues after other symptoms of a viral infection have gone)
• Burning

If you have any of these symptoms for longer than 4 weeks, do visit a voice clinic and have your larynx checked by a laryngologist, or ENT doctor.

Often there is no visible cause for these sensations, and you may wonder if it’s ‘all in your head’. Sometimes there is a misrepresentation in the brain of what is really going on. Sensory feedback is perceived by the brain, and the message may appear to be loud and clear, even when there may not be anything evident triggering this. If you are feeling these symptoms, you know that there is something going on, even if it can’t be observed. It is possible that the sensory feedback parts of the brain have become over-sensitised, meaning that your brain is giving you an amplified and disproportional message from the membranes in the throat. A way to reset these messages is to disrupt the habitual pathways, by making an unexpected change to your normal behaviour.

If you have a persistent cough with no visible inflammation or irritation, you can work to override the messages from the throat to the brain.

If you feel a cough coming:

• Breathe out slowly through pursed lips, resisting the outflow of air.
• Suck your tongue up to the roof of your mouth, concentrate on the sensation of suction between the tongue and the hard palate.
• Run the tip of your tongue back and forth against the roof of your mouth.

These are just some examples of activities that can rewire the feedback signals over time.

If you have a sense of a lump in the throat or globus, this may be a combination of muscle imbalance and hypersensitisation of the throat membranes. The muscles in and around the larynx are either over-working or under-working. The ones that are over-working may be tightening into a perceived ‘lump’ which is then amplified by the sensory nerve feedback. As soon as you are reassured that there is no visible lump or growth (with an endoscopic examination in a voice clinic), you will pay less attention to the sensation and this will desensitise the response in the brain.

If you suspect that you may have reflux, this may or may not be the cause of your throat symptoms. There are many ways to manage and understand the symptoms.

• Address levels of stress and anxiety (see below)
• Review of medication - there are some medications that may affect your digestion and result in reflux symptoms – do check this with your doctor if you are on regular medication.
• Diet & dietary habits - there may be certain foods which aggravate your digestion; these could be spicy, or acidic, or another specific irritant for you. You can systematically eliminate certain foods or drink from your diet and see if you notice a difference. It is also advisable to leave 2-3 hours between eating and sleeping.
• Wearing looser clothing and/or weight loss - increased pressure on the abdominal region can exacerbate the symptoms of reflux.
• Monitor snoring – this can contribute to dryness overnight and throat symptoms when you wake.

You may be prescribed PPIs (Proton Pump Inhibitors) and/or Alginates. These may or may not relieve the symptoms and PPIs do have other side effects. Monitor your responses to medication and review it frequently.

Why does stress or anxiety contribute to these physical changes?

When we are anxious, our autonomic nervous system is spending more time in the Sympathetic state. This is our ‘fight or flight’ response, alerting our body to danger and preparing it for action. Our muscles are primed for a response, and are held to some extent. If we are slightly anxious, in a continual state of low-level worry, then our muscles will be slightly held for more of the time. As they are holding, their function is less efficient. This builds over time in systems that are either sensitive to emotional change, or systems that we are using a lot. If you are a professional voice user, it’s your voice that will show the signs of strain.

Another response to the Sympathetic nervous state is for normal digestion to be slowed or halted. This is not a problem if the anxiety is brief and soon dissipated; however, if the situation remains for a longer period at a lower level, your ongoing digestion will be affected, which can result in many different issues – reflux is a common one of these.

What happens next?

If you are troubled by your voice symptoms, book an appointment with your doctor to get a referral to a voice clinic. If you are not diagnosed with a visible pathology, but you are experiencing unpleasant symptoms, you will probably be offered speech therapy. This will help you to relearn the habits and patterns of use that have contributed to the problem. If you are waiting for a doctor’s appointment, therapy is useful in the meantime to help you to manage your vocal habits.

If you are a professional voice user, you may want to work with a Singing Voice Rehabilitation Specialistalongside your speech therapy.

Manual therapy such as gentle vocal massage can be useful to reset your vocal system and relieve some of the symptoms.

If you suspect that anxiety is part of the cause, you may find that counselling or psychotherapy is a helpful path for you.

References

Antonio, J., Newmire, D., Stout, J., Antonio, B., Gibbons, M., Lowery, L., . . . Arent , S. (2024). Common questions and misconceptions about caffeine supplementation: what does the scientific evidence really show? J Int Soc Sports Nutr., 21(1). doi:10.1080/15502783.2024.2323919

Georgalas, V., Kalantzi, N., Harpur, I., & Kenny, C. (2023). The Effects of Caffeine on Voice: A Systematic Review. Journal of Voice, 37(4). doi:https://doi.org/10.1016/j.jvoice.2021.02.025

Watson, G., O’Hara, J., Carding, P., Lecouturier, J., Stocken, D., Fouweather, T., & Wilson, J.
(2016). TOPPITS: Trial Of Proton Pump Inhibitors in Throat Symptoms. Study protocol for a randomised controlled trial. Trials, 17(1), 175. doi:10.1186/s13063-016-1267-7