“For chronic cough, two-thirds of these patients have multi-factorial contributions, whether it’s sinusitis and allergy or sinusitis and bronchitis—there’s more than one combination of more than one factor,” Dr. Altman said. “And that means you have to be comprehensive about how you work it up and how you treat it in order to get a good resolution of their problem.”
Explore this issue:October 2012
In discussing cases of chronic cough, panel members emphasized the importance of going deep into a patient’s history to try to get at medical clues that might be linked to the present problem. They also noted that when the otolaryngologist is sometimes the third physician called upon by the patient, there are challenges in relying on previous work-ups when necessary tools—such as a simple chest X-ray or a pulmonary function test—may not have been employed in a timely manner by other physicians. Consideration of international cases highlighted the fact that there is “no standardization of how to systematically approach the cough patient,” said Dr. Altman.
Jack Krouse, MD, PhD, chair of the department of otolaryngology head and neck surgery at Temple University in Philadelphia, talked about the importance of recognizing that everything is related. “We are really coming to the understanding and the realization that the respiratory tract works as a unified unit,” he said. “And anything you do to disturb one part of the respiratory system is going to have effects distal to that.” He urged the audience to “look at all the relative contributors: Look at the sinus, look at the nose, look at the lungs, look at the larynx, because of this shared inflammatory process that occurs across this entire tract.”
He also said it was important to remember the physiological function of the nose in conditioning air—and if there’s a significant nasal obstruction, patients will be more likely to breathe through their mouths, leading to harsher, colder air irritating the lower lung. Another thing to note, he said, is that “over time, patients with allergic rhinitis are at a greater risk of developing asthma.”
Mucus production, he said, also leads to behavioral changes, like throat clearing, that can worsen cough. “This is an interactive process between what’s going on in mucus production and inflammation and the patient behaviors that they use in order to try to improve their voice or improve their feeling of mucus in the throat,” Dr. Krouse said.
The Role of Laryngopharyngeal Reflux
Tom Carroll, MD, director of the Center for Voice and Swallowing at Tufts Medical Center in Boston, turned to laryngopharyngeal reflux. He said that only a small subset of patients actually need testing for this condition, because many improve through empiric acid suppression medication trials. But when testing for LPR is needed, it can be tricky. Neither proton-pump inhibitor (PPI) trials alone nor standard pH-only testing are enough to rule out LPR as the cause of chronic cough. It’s important, he said, to further the workup and look for non-acid reflux or breakthrough acid reflux in patients who are already on a high dose of a PPI.