Correspondence

Throat Clearing in Asthma

N Engl J Med 2003; 349:194-195July 10, 2003

Article

To the Editor:

Mantzouranis et al. (April 10 issue)1 call attention to a feature of the patchy epithelial inflammatory disease we name according to the area of prime involvement as asthma, allergic rhinitis, or eczema. In adults, the manifestation noted by these authors is termed “postnasal drip.” The assumption is that the secretions seen are formed in the nasal cavity and “drip” down to the trachea, where they induce cough. This complex of symptoms and that described by Mantzouranis et al. as throat clearing are more likely to reflect the same type of inflammation seen in the small airways and nasal mucosa in asthma and allergic rhinitis. In the study by Mantzouranis et al., not all the children with this isolated symptom had abnormal values for the forced expiratory volume in one second (FEV₁), yet all responded to therapy — a finding that supports the idea that the inflammation may be localized to the trachea in those without functional impairment. I think we should recognize this clinical manifestation more widely in adults as well as in children. More useful names would be allergic pharyngitis, tracheitis, or pharyngotracheitis.

Donald M. Scanlon, M.D.
Community Hospital of the Monterey Peninsula, Monterey, CA 93942
dscan@pacbell.net

1 References

1. 1

   Mantzouranis EC, Boikos SA, Chlouverakis G. Throat clearing -- a novel asthma symptom in children. N Engl J Med 2003;348:1502-1503
   Full Text | Web of Science | Medline

To the Editor:

The claim by Mantzouranis et al. that throat clearing may be a symptom of asthma is not substantiated by the evidence they present. They show a significant P value and odds ratio for throat clearing but give no explanation as to their meaning, which seems to relate only to a significant difference between boys and girls. Thirty-nine percent of the throat clearers had a history of asthma or other symptoms of asthma. It is not reported how many of the 28 percent of the total group of throat clearers who were subsequently tested were known to have asthma. The claim that all were found to have clinically unrecognized asthma is based on the fact that, after treatment, the average FEV₁ for the whole group rose from a normal level to a level higher than expected for age. This difference in FEV₁ could easily be accounted for by the proportion who were already known to have asthma or who had other symptoms of asthma. The resolution of throat clearing with asthma medication is meaningless without a control group for comparison.

David S. Ziegler, M.B., B.S.
Sydney Children's Hospital, Randwick 2011, Australia
dziegler@iprimus.com.au

Author/Editor Response

Ziegler asks for an explanation of the precise comparison for which throat clearing had a P value of 0.001; it was a comparison of boys and girls. With respect to the two other issues he raises — namely, the value of throat clearing as a sentinel symptom of asthma and the need for a control group — 61 children were reported to have no current or past asthma or symptoms of asthma other than throat clearing, leading to our suggestion that throat clearing is a sentinel symptom of asthma. Of those children, we asked 30 who were old enough to cooperate to undergo lung-function testing; their mean (±SD) FEV₁ was 93.4±13.2 percent of the predicted value. These children were treated with inhaled corticosteroids. Their throat-clearing symptom resolved, and their mean FEV₁ increased to 119.4±18.0 percent of the predicted value (P<0.001 for the comparison with the FEV₁ before treatment). Thus, if the throat clearing had not been present, asthma would not have been suspected. The children who were not old enough to undergo lung-function tests were not treated and continued to have the throat-clearing symptom and thus acted as the control group.

Scanlon questions the relation between nasal inflammation and throat clearing. We have an alternative explanation based on data not included in our report. We separated children with throat clearing into two groups: those with and those without symptoms of chronic rhinitis. The presence of asthma, current or past, was not significantly associated with the presence of rhinitis (P=0.85) but was significantly associated with the absence of rhinitis (P=0.03). Thus, it seems that throat clearing is not a sign of postnasal secretions but rather one of reactive large airways (e.g., upper trachea or larynx).

Eva C. Mantzouranis, M.D.
Sosipatros A. Boicos, M.D.
George S. Bagourakis, M.D.
University of Crete, Heraklion, Crete 71110, Greece
mantzourani@med.uoc.gr