The Ohio State University Wexner Medical Center © 2016

The Ohio State University Wexner Medical Center © 2016

Irineo P. Pantangco Jr. MD/MBA F.A.C.S
Board Certified Otolaryngologist
Columbus, Ohio
Mt. Carmel East Hospital
Nationwide Children’s Hospital

STATE OF ART: 2017
CHRONIC COUGH

No Disclosures

Cough Reflex
1. Afferent Pathway: Sensory nerve fibers branches of the vagus ciliated epithelium of
the upper airways (pulmonary, auricular, pharyngeal, superior laryngeal, gastric),cardiac
and esophageal branches from the diaphragm. Impulses go to the medulla diffusely.
Receptors:
• Rapid Adapting Receptors ( RAR) located pulmonary (on activation inflation and
deflation)‐ bronchospasm.
• Slowly Adapting Stretch receptors ( SAR) present on the alveoli and bronchioles.
Activated during peak inspiration prior to initiation of expiration. Hering Breuer
reflex.
• C‐fibers – unmyelinated sensory in airways and lungs – insensitive to mechanical
stimulation and lung inflation. Directly activated by Bradykinin and Capsaicin.
2. Central Pathway (Cough Center) central coordinating region – upper brain stem and
pons.
3. Efferent Pathway‐ vagus, phrenic and spinal motor
nerves to the diaphragm, abdominal wall and muscles. Nucleus retroambigualis‐ to
inspiratory/expiratory muscles. Nucleus ambiguus to the larynx.

The Efferent Limb
• Deep inspiration
• Glottal closure
• Diaphragm relaxation
• Thoracic contraction
• Tracheal narrowing
• Glottal opening
• Expulsion

The impact of cough
• 30 million visits/year
• Fifth most common office
complaint
• Chronic cough (>8 weeks):
10-38% outpatient
respiratory practice
• Chronic cough is associated
with significant adverse
effects on quality of life
(French CL et al. Impact of chronic cough on
quality of life. Arch Intern Med. 1998; 158: 1657-
1661.)

Chronic Cough:
often multi-factorial
Upper airway Lower airway
• Post-viral vagal neuropathy • Airway disease: asthma, chronic

– Laryngeal sensory neuropathy 5- bronchitis
10% – Asthma represents 10 – 20%
– Chemical Irritation: Industrial asthma
• Allergy and post nasal drip 10%
• Parenchymal disease: interstitial
• Chronic sinusitis 5%
fibrosis, emphysema, sarcoidosis
• GERD/reflux 70%
• Tumors: benign / malignant
Others
• ACE-inhibitor use 12-15% • Chronic infections: bronchiectasis,
• Lisinopril tuberculosis, cystic fibrosis
• Cardiovascular: left HF, aortic • Eosinophilic bronchitis
aneurysm • Recurrent aspiration
• Thyroiditis
• Smoking
• Esophageal cancer

Chronic cough: upper airway
Otolaryngology evaluation
History
• Description of the cough

• Intensity – minor nuisance, chest
wall soreness, associated with
urinary incontinence.
• Frequency – daily or infrequent,
while awake only or on sleeping.
• Duration – cycle of cough leading
to throat irritation can cause more
coughing.
• Association with body position,
while eating.
• Ask about – globus, throat pain
dysphonia, dyspnea, choking,
stridor, heartburn.
• Provoking factor
• Medication changes
• Chemical, reflux esophagitis
• Mechanical, cold/warm, touching
neck, body position
• Sensory – sensation of feeling
abnormal in throat.
16
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History Continued
• Nocturnal cough
• Pulmonary
• Reflux
• Sino-nasal
• Allergy history
• Sinus infections
• Post nasal drainage
• Reflux
• Throat clearing
• Hoarse
• Heartburn
• Dysphagia
• Laryngeal sicca
• OSA – Obstructive Sleep Apnea
• Neurogenic Cough
• Sudden onset after illness or surgery
• Failing all medications
• Seen all specialist, GI/pulmonary
• Present trigger or present for a while
17
Examination
• Rhinoscopy
• Obstruction
• Mucosal dryness or
edema
• Polyps
• Laryngoscopy
Fiberoptic
• Secretions in
nasopharynx and
swollen Torus
tubarius suggestive
of allergy.
Cobblestone
nasopharynx.
Source: 18
Examination Continued
Stroboscopy
• Asymmetric place of glottis, moving from side to
side
• One vocal cord opening, the other closing
• Axis tilt – glottis
• 96% of Laryngoscopy finding leads to an
intervention
• Larnygeal fiindings- supraglottic cyst, posterior
edema, granuloma ,vocal cord edema ,leukoplakia,
thick mucus.
• Flexible bronchoscopy
tracheal narrowing, edema ,mucus, mass.
• Thyroid
• External neck palpation – thyrohyoid
• Test for mobility Larynx- Palpation provokes cough.
• Palpation of larynx
• Provoking cough
Larynx:
- testing for mobility-palpation provokes coughing
- xerostomia
Source: 19
Chronic cough: Upper Airway
Chronic Sinusitis
• Number one illness in all age group in

U. S. (14% of population.
• Third most common cause of cough.
• Release of bronchoconstricting agents
and leukotrienes.
• 60% of asthmatics have CRS.
Source: 20
Laryngeal based:
Irritable Larynx Syndrome
• Laryngo-pharyneal reflux
• Laryngeal edema
-Allergic
-Chemical Exposure
-Inhalers
• Paradoxical Vocal Cord Motion Disorder
• Laryngeal Sicca
• Laryngeal Sensory Neuropathy
Source: 21
Laryngeal Based:
Laryngo-Pharyngeal Reflux
Most common inflammatory disorder
Refluxate:
– Acid
– Proteolytic enzymes
Symptoms:
Throat clearing, chronic cough, cervical
dysphagia, hoarseness, globus
sensation, laryngospasm.
– Most common cause of chronic cough
– Alters Laryngeal sensation
– Exacerbates asthma
– RSI- (Reflux Symptom Index)
– >13 indicative of reflux
Source: 22
Laryngeal based
Laryngo-pharyneal reflux
• Findings:
– Edema
– Erythema
– Pachyderma
• Testing
– -ph probe
– Impedance testing
– Esophagogram, TNE, EGD
• Treatment:
– proton pump inhibitor +/- H@ blocker
Source: 23
Laryngeal based:
Causes of edema/inflammation
• Inhaler use
Laryngeal edema
Fungal laryngitis
• Smoking
Polypoid corditis
Laryngeal dryness
Erythema
• Fumes
Cleaning Solutions
Paints
Strong scents or perfumes
• Caustic chemicals
• Occupational asthma
Source: 24
Laryngeal based
Chronic Idiopathic Cough
• Laryngeal Sensory Neuropathy

• Post Viral Vagal Neuropathy
• Women 2:!
• Onset of cough preceded by upper perr
respiratory tract infection in 50%
• Increased excitablility- Inappropriate triggers:
Temperature, laughing, talking , smoke, aerosols,
dry foods.
• Decreased sensory threshold similar to
neuropathic pain
• Evidence of paresis in>90% response rate.
• Neuromodulating medications:
Amitryptyline-12.5-50 mg
Tramadol- 50 mg 1-2 times a day
Gabapentin- 100-900 mg per day
Pregabalin- 75-300 mg twice per day Botox
Source: 25
Chronic Cough
Pulmonary
• Chest xray
• PFT’s
– Spiromtery and peak flow
Fractional Exhaled Nitrous Oxide (FeNO)
– guides treatment
– Methacholine Challenge
– Chest CT
– Brochoscopy
• BAL- Bronchoscopic alveolar lavage
• Eosinophils
Source: 26
Chronic Cough
Management
• Cancel Ace Inhibitor medications
• Chest xray
• TNFL
• Nasal endoscopy
• Laryngeal +/- Tracheoscopy
Symptoms and findings guides therapeutic
approach.
Oral Steroids:
– If responds:
• Reactive airway, eosinophilic bronchitis, irritable
larynx, rhino-sinusitis.
• PFT’s
• Consider inhaled steroid +/-Beta agonist(short and
long acting)
– No response:
• Proton Pump inhibitor
• cough suppressant
• neuromodulators
Source: 27
Chronic Cough Treatment
Cough Related to Allergy:
• Nasal steroids
• Oral steroids
• Atrovent-nasal spray
• Allergy testing and immune therapy
Laryngeal Neuropathy:
1. Occurs following URI or surgery near laryngeal
nerves
2. Non-productive cough
3. Non-responsive to antibiotics, asthma, and
reflux medications
4. Often with sensation of foreign body or ticklish
sensation in throat
Source: 28
Chronic Cough Treatment
Recommendations Borrowed from Control of Neuropathic Pain
• Amytriptyline – 10mg/day 3-7 days increase to 100mg/day treated for

6-8 weeks with 2 weeks at the maximum dose.
• Gabapentine – 100-300mg/day or 100-300mg t.i.d for 1-7 days max.
Dose of 3600. Duration 3-8 weeks with 2 weeks of maximum dose.
• Progabalin – 50mg t.i.d inc. to 300mg/day after 3-7 days then by
150mg/day 3-7 days max dose 600mg/day duration of treatment 4
weeks.
Laryngeal Botox injection in rare instance.
Source: 29
CXR

+ ‐
Treat specific Oral
problem steroids
 CHF
 Pneumonia +
 Tumor ‐
Trial of
PFT’s PPI
‐ + ‐
+
Sinus CT
Methacholine Treat for 3‐6 months
Challenge then taper
Trial of inhaled steroids +
+/‐Esophogram or
 LABA and steroid EGD

‐
+
‐
Chest CT Treat sinusitis

Sputum or BAL
(eosinophils)
+ Allergy testing
‐
Treat for neurogenic cough
 Amitriptyline
 Tramadol
Treat positives  Gabapentin
 Pregabalin
 Botox 30
Chronic Cough:
Pediatrics
31
Classification
Acute < 2 weeks
Protracted – 2‐4 weeks
Chronic > 4 weeks
Differential Diagnosis:
1. Congenital:
Laryngoltracheo‐ bronchomalacia – i.e. Laryngeal anomalies with
aspiration.
2. Infectious:
• Chronic Bronchitis
• Rhinitis/Sinusitis – 2nd most common
• Layrngotracheitis – “croup” with barky cough, prolonged suspect
subglottic stenosis
3. Inflammatory:
• Cough variant of asthma – worse at night and worse on exertion.
• Allergic rhinitis – sneezing, rhinorrhea noted for nocturnal cough.
• Asthma
32
Differential Diagnosis Continued
3. Inflammatory Continued:
• GERD – cough with esophagitis – regurgitation, irritability, crying
and arching back. PPI‐ not effective in young children. Insufficient
data for older children.
• No studies done for diet management.
4. Traumatic: Foreign body: cough common symptom
• Suspicious with prolonged cough unresponsive to medical
treatment
• Diagnosis: x‐ray, findings: unilateral atelectasis, Hyperinflation,
mediastinal shift.
• 30‐60% normal chest x‐ray
5. Systemic: Habit Cough (Psychological Cough)
• Diagnosis by exclusion – explosive and barky – coughing while
awake
• Rx – identify psychological stress, make patient aware,
psychological family involvement, biofeedback, and cognitive
copying.
33
Management of Chronic Cough
Metaanalysis:
• Antibiotics reduces the episodes but not

cure. Amoxicillin with clavulonic acid
responds 48% with 16% persistence.
• OTC medications are not recommended
except for honey. Use antibiotics only for wet
coughs.
American College of Chest

Physicians- recommends- chest x-ray and
spirometry.
Watch, wait and review tests: Dry cough- inhaled
steroids. Wet cough- antibiotics.
34
Summary
• Cough reflex – new findings with neuroreceptors,
myelinated fibers.
• Chronic cough on 2/3 of cases is multifactorial.
• Flow chart provided in the approach for
evaluation of chronic cough.
• Recommended therapy for neurogenic and
idiopathic cough.
• Chronic cough; pediatrics – difference compared
to adults – evaluation, causes, and current
recommendations.
35

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