"I started out as an ENT (ear, nose, and throat) surgeon, but since 1981 I have exclusively specialized in laryngology, which deals with voice, swallowing and throat diseases. Many people with chronic cough, however, fall through the cracks between the medical specialties, and often such patients come to see me, because I am an expert in silent (“atypical”) reflux, one of the most common causes of chronic cough. Chronic cough is often disabling and life-disrupting. This interactive blog has an overview article and illustrative cases. Please feel free to contact me."
Background: Chronic cough is the most common symptom for which a patient seeks medical attention; however, many patients with chronic cough fail to obtain an accurate diagnosis and effective treatment. Chronic cough patients are especially enigmatic for the otolaryngologist.
Materials and Methods: Retrospective review of 50 consecutive chronic cough patients. None of the subjects had primary pulmonary disease; although 54% (26/50) had been previously diagnosed with asthma. All subjects underwent laryngeal examination, 92% had reflux testing, 72% had esophagoscopy, and 60% had laryngeal electromyography.
Results: The clinical diagnosis for chronic cough was reflux alone in 40% (20/50), neurogenic (cough) alone in 14% (7/50), and both (reflux-related and neurogenic cough) in 46% (23/50). Eighty-six percent (43/50) had pH-documented reflux; 56% had neuropathic findings on laryngeal EMG; and 46% met criteria for both reflux and vocal fold paresis. The mean number of pH-documented pharyngeal reflux events pH <5 was 146. Of the 43 abnormal pH studies, 93% (43/46) had pharyngeal reflux, but only 37% (16/43) had abnormal esophageal pH data (pH <4). Thus, had those subjects undergone traditional esophageal or impedance reflux testing, 63% (27/43) would have been falsely considered negative. In addition, 36 subjects underwent esophagoscopy and 64% (23/36) had significant pathology. Eighty-eight percent (44/50) responded favorably to treatment.
Conclusions: Although other causes must be excluded, chronic cough in otolaryngologic practice is usually related to airway reflux and/or a neurogenic cause. Airway reflux testing for chronic cough requires specific pharyngeal pH-monitoring technology that is not yet widely available; however, accurate diagnosis is essential to provide effective, patient-specific treatment. In addition, the alarmingly high rate of esophageal pathology in this series of chronic cough patients underscores the need for esophageal screening in patients with airway reflux.