What are the treatment options for throat drainage?

Treatment for Throat Drainage (Postnasal Drip)

For throat drainage symptoms (postnasal drip/upper airway cough syndrome), start with a first-generation antihistamine/decongestant combination such as dexbrompheniramine 6 mg plus pseudoephedrine 120 mg twice daily, as this is the most effective first-line treatment with proven efficacy in controlled trials. 1, 2

Initial Treatment Algorithm

First-Line Therapy

• Begin with older-generation antihistamine/decongestant combinations rather than newer non-sedating antihistamines, as the anticholinergic properties of first-generation agents are critical for effectiveness 1, 2
• Specific proven regimens include:
  • Dexbrompheniramine maleate 6 mg plus sustained-release pseudoephedrine 120 mg twice daily 1, 2
  • Azatadine maleate 1 mg plus sustained-release pseudoephedrine 120 mg twice daily 1, 2
• Expect improvement within days to 2 weeks of starting therapy 2

Minimizing Side Effects

• To reduce sedation, start with once-daily dosing at bedtime for several days before advancing to twice-daily therapy 2
• Monitor for common side effects: dry mouth and transient dizziness 2
• Watch for serious adverse effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2
• Check blood pressure after initiating decongestants as they can worsen hypertension 2

Treatment Based on Underlying Cause

If Allergic Rhinitis is Suspected

• Add intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial alongside the antihistamine/decongestant combination 2
• Alternative options include nasal cromolyn, oral leukotriene inhibitors, or oral antihistamines 1
• Non-sedating antihistamines are more effective for allergic rhinitis than for non-allergic causes 1, 2

If Non-Allergic Rhinitis is Present

• The older-generation antihistamine plus decongestant remains first-line 1, 2
• For patients who cannot tolerate or have contraindications to decongestants (hypertension, cardiovascular disease), use ipratropium bromide nasal spray as an alternative 1, 2
• Ipratropium provides anticholinergic drying effects without systemic cardiovascular side effects 2

For Postviral Upper Respiratory Infection

• First-generation antihistamine/decongestant combinations have proven efficacy in both acute and chronic cough 1, 2
• Newer generation antihistamines (terfenadine, loratadine) with or without pseudoephedrine are ineffective for this indication 1, 2

Adjunctive Therapies

Nasal Saline Irrigation

• Nasal saline irrigation improves symptoms through mechanical mucus removal, enhanced ciliary activity, and disruption of inflammatory mediators 2, 3
• Irrigation is more effective than saline spray because it better expels secretions 2
• Use isotonic or hypertonic saline solutions 1, 4
• Longer treatment duration (mean 7.5 months) shows better results than shorter courses 2
• One larger pediatric trial showed significant reduction in nasal secretion and breathing obstruction scores 1, 3

Critical Warnings

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 2

When Initial Treatment Fails

After 1-2 Weeks Without Improvement

• If using antihistamine/decongestant alone, add intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial 2
• A single randomized controlled trial showed intranasal steroids given for 2 weeks are effective in allergic rhinitis-related cough 2

After 2 Weeks of Combined Therapy

• Proceed with sequential evaluation for other causes, including asthma/non-asthmatic eosinophilic bronchitis and gastroesophageal reflux disease (GERD) 2
• Postnasal drip symptoms can be confused with GERD 1, 2
• If GERD is suspected, initiate empiric therapy with proton pump inhibitor (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks plus dietary modifications 2

Important Clinical Considerations

Diagnostic Challenges

• Symptoms and clinical findings are not reliable discriminators for establishing postnasal drip as the cause of cough 2
• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet still respond to treatment 1, 2
• A successful response to treatment directed at the upper airway is the recommended diagnostic approach 2
• Cobblestoning of the posterior pharyngeal wall is a hallmark physical finding 2

Common Pitfalls to Avoid

• Newer-generation antihistamines are ineffective for non-allergic causes of postnasal drip cough 2
• First-generation antihistamines alone, without decongestants, have limited efficacy for upper airway cough syndrome 2
• Treatment should be directed at the specific underlying cause when identified rather than empiric therapy 2
• For chronic rhinitis conditions, longer treatment courses may be necessary 2

Alternative Behavioral Therapy

• For persistent throat clearing without clear underlying cause, sipping ice cold carbonated water may help break the vicious cycle of throat clearing, with 63% of patients reporting improvement in symptom severity 5
• This approach is most beneficial for the most severely and frequently affected patients 5