Cough is not only seen in internal medicine (lung, trachea and bronchus), but is also an extremely common clinical symptom in otorhinolaryngology, and how to diagnose and treat it is not only a concern for patients, but also a hot issue studied and discussed by otorhinolaryngologists.
Otorhinolaryngology includes four anatomical parts: ear, nose, throat and pharynx. Cough may occur in response to lesions in the ear, nose, throat and pharynx, and may be a major symptom or a concomitant symptom.
Otorhinolaryngology-related cough, first, is seen in acute inflammation of the upper respiratory tract, and many patients are generally accustomed to seeing internal medicine or pediatrics (pediatric patients), so it is mostly resolved during internal medicine and pediatric visits; second, chronic cough is more common, and it occurs repeatedly or has a prolonged course. If patients have difficulty curing this in internal medicine or pediatric treatment, it is appropriate to consider looking at otolaryngology, which may have better results.
I. Basic knowledge about cough
1. Cough effect
Coughing is one of the most common symptoms of respiratory diseases and is both beneficial and harmful. It is beneficial because it can remove foreign bodies and inflammatory secretions that invade the respiratory tract and eliminate inflammatory factors in the respiratory tract to fight infection; unfavorable because coughing can spread inflammation in the respiratory tract, infecting myself (inflammatory factors spread to other places due to coughing) and others (airborne infection) and causing the spread of disease; increase the burden on the heart (very bad for those with heart failure); violent coughing can cause bleeding (lung, trachea, bronchus, A violent cough can cause bleeding (rupture of capillaries in the lungs, trachea, bronchi, nose and throat due to coughing); rupture of subpleural emphysema bubbles and spontaneous pneumothorax; long-term coughing may form emphysema; excessive coughing can cause vomiting, affect sleep, and consume energy.
2. Mechanism of coughing
Coughing is an expiratory impact action, which can be strong or weak (a strong, persistent cough is more harmful) and is generally divided into four steps: first, a short, deep inspiration, followed by the closure of the vocal cords (vocal cord closure), followed by contraction of the diaphragm and intercoital muscles, making the thoracic cavity smaller and increasing the pressure in the lungs, and finally, further rapid contraction of the diaphragm and the sudden opening of the vocal cords, with sudden high-pressure air in the lungs (forming a single action of coughing). During coughing, if there are foreign bodies or secretions in the lungs or trachea, bronchi, or throat that need to be discharged, they are discharged by impact, and if they are not discharged by impact once, they can be discharged again or even several times (i.e., continuous multiple coughs, also called irritant coughs).
The coughing action is the result of reflex action of nerves. The nerve reflexes of coughing originate mainly from various abnormal stimuli (inflammatory, pulling, temperature, etc.) to the vagus nerve endings, and the peripheral nerves transmit this stimulus information to the cough management center (near the medullary respiratory center), which gives a series of commands to finalize the coughing action. Vagal nerve endings are distributed in many areas (all organs of the thoracic cavity, all organs of the abdominal cavity, and the ear, nose, and throat), but the most common areas prone to the cough reflex are: the external auditory canal, pharynx, larynx, trachea, bronchi, lungs, and pleura. Coughing due to irritation of the heart, stomach, esophagus, intestines, etc. is less common. In addition to this mechanism, cough is also influenced by the cerebral cortex and other factors, and can therefore be altered by medical conditions (inability of tissues and organs associated with the cough reflex to carry out cough commands, such as weakness of the respiratory muscles; inability of the cough center to give cough commands in deep coma, etc.) or by subjective volitional (self-restraint) factors.
3. Differentiation of cough
Coughing should be distinguished from clearing the throat. Coughing is different from coughing, because coughing is a reflex action, which is sometimes difficult to be suppressed by subjective will, while throat clearing is mainly a habitual action, which can often be suppressed by subjective will; when coughing, gas comes out of the lungs in an impacting jet, which lasts for a short time each time, while when clearing the throat, gas generally comes out slowly, which lasts longer than coughing each time, and is “utterly guest-like “. Of course, throat clearing can be accompanied by coughing.
II. Main causes of otorhinolaryngology-related cough
Otorhinolaryngology-related cough is common in specialty clinics as a chronic cough that occurs repeatedly or has a long duration. Acute coughs are generally easy to cure (more patients are used to seeing internal medicine and pediatrics) and are mainly seen in acute inflammation of the upper respiratory tract (which belongs to the category of internal medicine diseases and also to the category of otolaryngology diseases).
1. Acute inflammation of the upper respiratory tract
Acute inflammation of the upper respiratory tract, such as acute pharyngitis, acute tonsillitis, and acute laryngitis, can cause acute cough due to inflammatory stimulation, which improves and disappears as the acute inflammation of the upper respiratory tract subsides.
2. Chronic inflammation of the upper respiratory tract
Chronic inflammation of the upper respiratory tract, such as chronic rhinitis and sinusitis, whose secretions flow back to stimulate the pharynx, as well as a variety of chronic inflammations of the throat, can cause coughing due to inflammatory stimulation. Since chronic inflammation of the upper respiratory tract often has a long duration, it often manifests as a chronic cough that can improve or worsen with the progression of chronic inflammation of the upper respiratory tract.
3. Allergic reactions
Due to type I or type IV allergic factors (allergic rhinitis is the presence of these two pathologies), the main manifestation is the recurrent paroxysmal cough due to itching of the throat, and can be combined with or induced by asthma attacks, which are manifested as acute cough or chronic cough due to the long duration of the disease.
4. Other factors: respiratory foreign body, ear disease, stomach disease
Once a foreign body enters the respiratory tract, especially the vocal cords, trachea and bronchi, the cough will be sudden and severe; a long-standing foreign body in the bronchi may manifest as recurrent cough, fever and chest pain.
Scratching of the external ear canal, or irritation by foreign bodies or cerumen can cause a temporary irritant cough, and in a few cases, a prolonged cough due to the long-term presence of irritating factors.
Gastric disease, or reflux esophagitis, can cause coughing due to reflux of gastric contents (including food, stomach acid; reflux of stomach acid is the main cause) into the throat, often with paroxysmal irritating cough during sleep, or with vomiting, which can be prevented or alleviated by elevating the pillow during sleep, and mostly with other symptoms of gastric disease or esophageal reflux inflammation (see the article on esophageal reflux pharyngitis in Pharyngolaryngology).
III. Common names of otorhinolaryngology-related coughs and their meanings
1. Prolonged cough, chronic cough: symptom name. Cough symptoms that are distinguished from acute cough (new-onset cough) and have a longer duration of more than 8 weeks (two months) of illness can be coughs that include various causes that are known or not known; chronic cough of unknown origin, or chronic cough for short.
2. Chronic cough of unknown origin: name of the symptom. It refers to a cough with a duration of more than 8 weeks (two months), and the cause of which is temporarily unspecified.
3.Laryngogenic cough, pharyngeal cough, pharyngogenic cough, laryngeal cough: disease names. The four disease names are different and have the same connotation, all referring to cough disease caused by pharyngolaryngeal disease and chronic pharyngolaryngeal disease with cough symptoms as an important feature. Among them, laryngeal cough belongs to the disease name specific to Chinese medicine.
4. Irritant cough: the name of the symptom. Cough symptoms characterized by paroxysmal cough with little sputum, often with recurrent episodes, can be seen in the upper respiratory tract or in tracheal and bronchial pathologies (e.g. allergies, foreign bodies, and many other irritating factors).
5. Allergic cough, allergic pharyngitis: disease names. The disease name is different, but the connotation is the same. Mainly due to allergic factors, and also related to non-specific inflammation of the throat. Upper respiratory tract diseases with recurrent paroxysmal cough as the main symptom also belong to the category of laryngogenic cough.
6. Cough variant asthma: name of the disease. It is caused by allergic factors and is also related to non-specific inflammation of the throat. It is characterized by recurrent paroxysmal cough as the main symptom and can lead to the development of asthma. If asthma has already occurred, it belongs to the category of internal medicine; in the absence of asthma, when there are only symptoms of upper respiratory cough, it can be called allergic cough or allergic pharyngitis and is subordinated to the category of otorhinolaryngology.
7. Gastrogenic cough, gastroesophageal reflux cough, dry cough of esophageal origin, and esophageal reflux pharyngitis: disease names. The connotations of the four disease names are basically the same, all referring to cough disease and throat discomfort due to gastric and esophageal reflux lesions, which can belong to both the internal disease category and the otorhinolaryngology disease category.
8. Post-cold cough: It can be the name of a symptom or the name of a disease, and belongs to an unstandardized medical term. It mainly refers to cough disease that remains after the cold (flu, a Chinese medical term similar to acute upper respiratory tract infection) has improved, including those caused by inflammation of the upper respiratory tract, and cough symptoms during the recovery period of tracheobronchitis cannot be excluded.
9. Upper airway cough syndrome, postnasal drip syndrome: name of the disease. It mainly refers to cough disease caused by chronic rhinosinusitis. The disease was called postnasal drip syndrome in the early stage, and after 2006 (American College of Chest Physicians) it was renamed upper airway cough syndrome.
10, upper respiratory tract infection: belongs to the Western medical internal medicine disease name, mainly refers to the upper respiratory tract (nose, throat, pharynx) common acute infection of the lesion, early viral infection is dominant, and in the middle and late stages there are mostly combined with bacterial infection, which can be accompanied by cough symptoms. In Chinese internal medicine, it is called cold; in Western otolaryngology, it is called acute rhinitis, acute pharyngitis and acute laryngitis according to their different symptom characteristics, among which acute pharyngitis and acute laryngitis with cough symptoms are common.
IV. Western medical diagnostic points of otorhinolaryngology-related cough
Clinically, otorhinolaryngology-related cough, generally with cough as the main symptom, and mostly manifests as a cough of longer duration or chronic cough. In cases of occasional cough with other obvious throat symptoms (e.g., dryness, obstruction, pain, hoarseness, difficulty in speaking, etc.), such cough is a concomitant condition and is generally recognized from pharyngitis and laryngitis. There are several common otorhinolaryngology-related cough disorders as follows, but different names may be included in each other’s diagnosis by clinicians.
(A) Upper airway cough syndrome
1. Medical history: History of acute or chronic inflammatory disease of the nose or sinuses (cough triggering cause).
2. Clinical symptoms.
(1) Cough: irritating (continuous) or non-irritating (discontinuous) cough, usually more pronounced in the morning (after waking up) and evening (especially just after going to sleep). There is mostly a little mucous sputum.
(2) Postnasal drip and spitting: Mostly with the sensation of nasal mucus flowing backward toward the nasopharynx and causing aspiration back to the nose with aspiration back to spitting.
(3) Nasal symptoms: Most of them have nasal congestion or can blow mucous nasal mucus; there are also some patients with clear nasal breathing, no significant nasal congestion symptoms and no blowing symptoms.
3, examination: nasal examination can be seen in the nasal mucosa with congestion and swelling, or the nasopharynx mucosa with signs such as congestion and adhesion of secretions (commonly found by fiberoptic nasopharyngoscopy). If sinusitis is suspected, X-ray or CT examination can be performed for clarification.
(II) Laryngogenic cough
1. Medical history: History of acute or chronic inflammation of the nose, sinuses, pharynx and larynx.
2. Clinical symptoms.
(1) Cough: cough without or with little sputum, or dry cough mainly, often increasing in the morning and evening, or more pronounced after cold or exercise.
(2) Throat discomfort symptoms: mostly accompanied by dry, slightly painful throat, such as phlegm adhesion and other symptoms, and may be accompanied by throat clearing (uttering and clicking) symptoms.
(3) Other: If it is an acute upper respiratory tract infection, it is a new disease and may have cold triggers or cold symptoms (fever, nasal congestion, runny nose, peripheral discomfort, etc.).
3, examination: acute or chronic congestion and other changes are seen in the pharynx or larynx, or with lymphatic follicular hyperplasia, pharyngeal lateral cord hyperplasia, tonsillar inflammation and other changes in the posterior pharyngeal wall, tongue root and other areas.
(C) Allergic pharyngitis (also belongs to the range of laryngogenic cough)
1. Medical history: There may be a history of allergic disease or chronic pharyngitis.
2. Clinical symptoms
(1) Cough: mostly irritating cough, often aggravated in the morning and evening, or aggravated by stimulation (e.g., irritating gas, cold air inhalation, after exercise), without or with little sputum.
(2) Mostly accompanied by a pronounced throat itch.
3. Examination: Examination of the throat area can be normal, without obvious inflammatory manifestations, or accompanied by signs of chronic inflammation of the throat. Allergen examination can be positive, and the diagnosis cannot be excluded in case of negative reaction.
(D) Esophageal reflux cough
1. Medical history: Mostly with a history of gastric disease.
2. Clinical symptoms
(1) Cough: irritating cough, mostly obvious when falling asleep.
(2) Throat discomfort symptoms: may be accompanied by a sour and spicy feeling in the throat and vomiting when coughing, or dry throat, painful discomfort, hoarseness and other symptoms when the disease is prolonged.
(3) Gastric and esophageal symptoms: Mostly accompanied by stomach distension and discomfort, or burning sensation behind the sternum (esophagus), often with hiccups, food reflux (obvious after exercise, after meals, bending the chest and head down, lying on the back) and other symptoms of “gastric rebellion”.
3, examination: chronic congestion changes in the mucosa of the throat, or other signs of chronic pharyngitis. Gastroscopy and barium swallow examination of the esophagus may reveal changes such as gastric disease or esophagitis.
Differential diagnosis: In the otolaryngology clinic, cough due to otorhinolaryngological diseases is mainly noted to be differentiated from the following diseases.
1. cough variant asthma: the main pathogenesis is chronic non-specific inflammation (direct and indirect factors including genetic, infectious, physicochemical, and environmental factors), and is related to allergic reactions. irritant cough is predominant and can be accompanied by mild asthma, and its diagnostic criteria are: chronic cough, often accompanied by significant nocturnal irritant cough; positive bronchial excitation test, or peak expiratory flow rate with day-to-day variability >20%. or positive bronchodilator test; positive bronchial excitation test, or day-to-day variability of peak expiratory flow rate >20%; effective bronchodilator treatment.
2, pulmonary tuberculosis: symptomatically mostly chronic cough, characterized by inconspicuous, the main diagnostic basis is lung X-ray or CT examination, positive OT test, positive sputum (tuberculosis bacteria) culture.
4. Chronic tracheobronchitis: it is an inflammatory infection, also related to allergic factors, and is located in the trachea-bronchus; the acute attack is characterized by cough, sputum, shortness of breath (mild wheezing), or fever as the main symptoms; the chronic phase of the disease usually lasts for more than two months, mainly with varying degrees of cough, sputum, shortness of breath, or chest tightness. Lung examination helps to clarify the diagnosis.
V. Outline of Western medical treatment for otorhinolaryngology-related cough
1. Upper airway cough syndrome: treatment of nasal disease is the main treatment, and commonly used treatments include.
(1) Antibacterial and anti-inflammatory drugs: used when necessary, oral administration is the mainstay.
(2) Anti-allergic agents: used when necessary (allergic factors may be involved in chronic rhinopathy), such as loratadine and the like.
(3) Use of nasal drops: decongestants, anti-inflammatory agents, hormonal preparations, anti-allergic agents, etc., 2-3 kinds can be used as appropriate.
2. Laryngogenic cough: Treatment of throat diseases is the mainstay, and if accompanied by nasal diseases, nasal diseases need to be treated at the same time. Common treatments include.
(1) antibacterial anti-inflammatory drugs: generally unnecessary; can be used as appropriate when there are obvious inflammatory factors (such as acute upper respiratory tract infection, etc.).
(2) local treatment of the throat: such as containing agents, ultrasonic nebulization, etc.
(3) Other: longer duration of the disease, immunity is not strong, you can use drugs to enhance the immunity of the upper respiratory tract, such as pidomod and so on, as appropriate; with nasal disease when there is nasal disease treatment methods.
3. Allergic pharyngitis (also belongs to the range of laryngogenic cough): anti-allergic treatment is the main focus, with immunity-enhancing drugs as appropriate. Common treatments include.
(1) Anti-allergic treatment: including hormonal aerosol (bicodone, beclomethasone propionate, etc.) inhalation, oral anti-allergic drugs (such as ketotifen, isoprostanes), often with good results.
(2) anti-inflammatory treatment: when there is obvious inflammation, anti-inflammatory drugs can be taken, commonly used drugs such as penicillin, cephalosporins, roxithromycin, etc.; when there is a viral infection, available antiviral drugs, such as ribavirin.
(3) Enhancement of upper respiratory immunity: commonly used pidomod and the like.
(4) Other: when accompanied by inflammation of the throat, can be combined with local treatment of throat inflammation drugs, such as containing pills and tablets, throat spray (Golden Throat Health, open throat sword) and the like.
4. Esophageal reflux cough: Treatment of gastric disease is the main focus, taking into account the treatment of inflammation of the throat. The main treatment methods include.
(1) Internal treatment: Treatment mainly targets gastric and esophageal reflux, including attention to general dietary contraindications, drugs to promote gastric and esophageal emptying, and drugs to inhibit gastric acid.
(2) Otorhinolaryngology treatment: mainly for the treatment of inflammation of the throat caused by food reflux, generally based on local medication for the throat.
For each of the above diseases, TCM diagnosis and treatment have good advantages and belong to the clinical advantages of TCM.