Cough is one of the most common symptoms of respiratory system (including nasal, sinus, and throat) diseases. There are many diseases closely related to cough, ranging from the most common upper respiratory tract infections to refractory asthma to COPD, etc. How to quickly, effectively and diagnostically treat cough-related diseases should be a topic of concern and research for clinicians, especially respiratory and otolaryngologists. There are many causes of chronic cough, and diseases in the field of otorhinolaryngology account for a significant portion of them.
The Guidelines for the Diagnosis and Treatment of Cough (draft) published by the Asthma Group of the Chinese Medical Association’s Society of Respiratory Diseases in 2005 defines cough lasting ≥8 weeks as chronic cough, with common causes: coughvariant asthma (coughvariantasthmaCVA), postnasaldripsyndromePNDS, or upperairwaycoughsyndromeUACS, eosinophilicbronchitisEB, gastroesophageal reflux coughGERC, which account for These causes account for 70% – 95% of chronic cough in respiratory medicine clinics. Of these, (PNDS) or (UACS) and partial gastroesophageal reflux cough (GERC) [laryngopharyngeal reflux disease (LPD) in otorhinolaryngology] are clearly closely related to otorhinolaryngological diseases.
I. Etiology and diagnosis of otorhinolaryngologic diseases causing chronic cough
The diagnosis of cough should be based on the search for the cause. Therefore, there should be a reasonable design and selection of diagnostic methods and ideas. Scientifically joint specific examination methods, diagnostic treatments and other means, and master the standardized diagnostic process. This can effectively improve the diagnostic accuracy and make the treatment targeted.
1. Postnasal drip syndrome (PNDS) or upper airway cough syndrome (UACS)
1.1 PNDS is a syndrome in which secretions flow backwards into the postnasal and pharyngeal regions due to nasal and sinus diseases, and even backflow into the vocal cords or trachea, resulting in a longer cough as the main manifestation. It is also known as UACS (upper respiratory cough syndrome).
1.2 Clinical manifestations: In addition to long-term untreated cough and sputum, patients with PNDS usually complain of self-conscious fluid dripping from the throat, adherence of oropharyngeal mucus, frequent throat clearing, throat itching discomfort or nasal itching, nasal congestion, runny nose and sneezing. Sometimes the cough is triggered by recurrent episodes of coughing resulting in hoarseness and talking. Follow up with a history of upper respiratory tract diseases (e.g., colds) often preceding the onset of the illness.
1.3 Diagnostic strategy.
① The underlying diseases that cause PNDS include allergic rhinitis (AR) (both seasonal and perennial), perennial non-allergic rhinitis, vasodilatory rhinitis, infectious rhinitis, rhinosinusitis, common cold, and structural rhinitis. However, it remains controversial whether infectious rhinitis and structural rhinitis can cause chronic cough. The diagnosis is mainly based on a combination of history and relevant examination, and other common causes that may cause chronic cough should be excluded before establishing the diagnosis. In recent years, some scholars have directly adopted rhinitis/sinusitis as the etiologic diagnosis of chronic cough without using the terminology of PNDS.
② The diagnosis can be confirmed by meeting the following criteria: episodic or persistent cough, predominantly daytime cough, with less frequent episodes after sleep; postnasal drip and/or mucus attachment to the posterior pharyngeal wall; history of rhinitis, sinusitis, nasal polyps or chronic pharyngitis, and paranasal sinus imaging signs of sinus cavity mucosal thickening of more than 6 mm, air-fluid planes or sinus cavity blurring; mucus attachment to the posterior pharyngeal wall and cobblestone-like view on specialist examination; and relief of cough with The cough is relieved by targeted treatment. SPT helps in the diagnosis if the cough is seasonal or if the history is related to exposure to specific allergens (pollen, etc.). Skin tests for Aspergillus and other fungi and specific IgE testing are feasible when allergic fungal sinusitis is suspected.
1.4 Treatment strategy: The principle is based on the underlying disease causing PNDS.
① First-generation antihistamines and decongestants are preferred for PNDS caused by the following etiologies: non-allergic rhinitis; vasodilatory rhinitis; perennial rhinitis; common cold. First-generation antihistamines are represented by drugs such as paracetamol, and the commonly used decongestant is pseudoephedrine hydrochloride. Most patients develop efficacy within a few days to 2 weeks after initial treatment.
Various antihistamines are effective in the treatment of AR. Second and third generation antihistamines without sedative effects are preferred, and commonly used drugs are loratadine or desloratadine. The commonly used drugs are loratadine or desloratadine. The use of “Xyosmin” is no longer advocated because of its cardiotoxicity. However, the first choice of AR treatment is nasal inhalation glucocorticoid, which is represented by beclomethasone propionate or budesonide, etc. The latter has therapeutic and preventive effects on perennial non-allergic rhinitis and nasal polyps. Nasal inhalation glucocorticosteroids pay attention to the correct usage and dosage and the grasp of combined use with antihistamines. For AR prevention and treatment, attention should also be paid to improving the environment and avoiding allergen stimulation. Allergen desensitization therapy is effective but the period is long.
③The problem of antibiotic use: antibacterial drugs are the main drugs for the treatment of acute bacterial sinusitis, and nasal inhalation glucocorticoids and decongestants can be added to reduce inflammation when the effect is poor or the secretion is too much.
④ The recommended regimen for conservative treatment of chronic sinusitis is: application of drugs effective against Gram-positive, Gram-negative and anaerobic bacteria for 3 weeks; oral antihistamines and decongestants for 3 weeks; nasal decongestants for 1 week; and nasal inhaled glucocorticosteroids for 3 months. Surgical procedures such as FESS or nasal structured surgery were used if there was no significant effect after regular conservative treatment.
⑤ Nasal saline rinse and the application of “Genotone”: practice has proved that nasal saline rinse is a proven method to treat acute and chronic diseases of the nasal cavity and sinuses, and antimicrobial agents such as gentamicin can be added to the rinse solution. “It is the only mucus promoter and mucolytic expectorant, which is widely used in acute and chronic sinusitis, bronchitis, COPD and other respiratory system diseases. Our experience is that it is routinely applied to patients with PNDS with definite effect. Application of pharyngeal spray: pharyngeal spray has pharmacological effects such as improving immunity, antibacterial, anti-inflammatory and pain relief, and can moisten the lung and resolve phlegm, produce fluid and stop cough. Its unique rotating arm nozzle can penetrate deep into the throat and directly treat the surgical trauma site, and its main component, eugenolinic acid, has strong antibacterial effects.
2.Partial gastro-oesophageal reflux cough (GERC) or LPD
2.1 Gastric acid or other gastric contents reflux into the esophagus, resulting in cough as the prominent clinical manifestation.GERC is a common cause of chronic cough.LPD is a patient’s clinical manifestation of hoarseness or dysphonia, foreign body sensation in the throat, cough, dyspnea, etc. Examination reveals edema and erythema in the posterior joint area of the vocal cords, diffuse edema of the vocal cords, and in severe cases, granuloma and disappearance of the laryngeal chambers. Dual-probe 24h pH monitoring was performed, and laryngopharyngeal reflux events (pH <4 more than 3 times. Typical reflux symptoms are retrosternal burning, acid reflux, belching and chest tightness. Patients with GERC or LPD with trace aspiration are more likely to have cough, hoarseness or dysphonia, and foreign body sensation in the throat in the early stage, while reflux is not obvious in patients with LPD. The cough mostly occurs during the day and in the self-standing position and presents as a dry cough or a small amount of white mucous sputum.
2.2 Diagnostic strategy.
①Cough with or without reflux-related symptoms or coughing episodes after eating is of some significance in suggesting the diagnosis of GERC or LPD. 24h esophageal pH monitoring is currently the most effective method for diagnosing GERC, and barium meal examination and gastroscopy have limited diagnostic value for GERC and cannot determine the correlation between reflux and cough. ② GERC or LPD can be considered if the following criteria are met: chronic cough, predominantly daytime cough; 24h esophageal pH monitoring Demeester score ≥ 127 (or) SAP ≥ 75%; exclusion of CVA, EB, PNDS and other diseases; significant reduction or disappearance of cough after anti-reflux treatment.
In hospitals without esophageal pH monitoring or in patients with chronic cough with limited economic conditions, diagnostic treatment can be considered for those with the following indications: the patient has significant feeding-related cough, such as postprandial cough, feeding cough, etc.; the patient has GER symptoms, such as acid reflux belching retrosternal burning sensation or hoarse cough only; exclude diseases such as CVA, EB, PNDS, etc., or treat as above diseases The effect is not satisfactory, and the cough disappears or is significantly relieved by anti-reflux treatment, which can be clinically diagnosed as GERC or LPD.
2.3 Treatment strategies.
① Scientific lifestyle: lose weight, eat less and more often, avoid oversaturated bedtime meals, avoid acidic and oily foods and beverages, avoid coffee and smoking. High pillow position.
②Acid control and promotion of gastric motility: proton pump inhibitors (such as omeprazine or similar drugs) or H2 receptor antagonists (ranitidine, etc.) are often used, and domperidone is used to promote gastric motility, but must be taken before meals.
③Patients with underlying gastroduodenal disease (chronic gastritis gastric ulcer duodenal inflammation or ulcer) with H. pylori infection should all be treated accordingly.
④Regular medical treatment requires more than 3 months, usually 2-4 weeks to show efficacy, and anti-reflux surgery is only for a small number of patients with severe reflux who have failed medical treatment.
3. Obstructive sleep apnea-hypopnea syndrome (OSAHS)
3.1 OSAHS refers to apnea and hypoventilation caused by collapsed obstruction of the upper airway during sleep with frequent snoring sleep structure disorders, decreased oxygen saturation, daytime sleepiness and other symptoms. This disease can cause a variety of throat discomfort, such as clearing the throat chronic cough hoarseness, etc. Recent studies have found that OSAHS may be one of the causes of LPD.(or GERD) and asthma.Teramoto et al. 2000 showed that reflux is the main cause of chronic cough symptoms in patients with OSAHS. The following points support the association of OSAHS with reflux.
(1) The prevalence of GERD is significantly higher in patients with OSAHS than in the normal population, and GERD is very common in Western countries. The results of epidemiological surveys in Beijing and Shanghai in China showed that the prevalence of GERD was 5.77%, while the prevalence of GERD in OSAHS population was over 70%.
(ii) Obesity and alcohol consumption are common causative factors for both.
③OSAHS can cause and aggravate reflux symptoms. Teramoto et al. (1999) found that hypercapnia and hypoxemia caused by OSAHS can lead to a decrease in swallowing function and with it, the ability to clear acid from the esophagus, which can aggravate the effects of reflux.
(iv) Reflux disease can aggravate OSAHS symptoms, and reflux can cause tracheal edema and even stenosis, which can aggravate OSAHS symptoms. Several scholars have found that performing antacid therapy can significantly reduce OSAHS symptoms.
3.2 OSAHS diagnostic strategy: OSAHS patients are diagnosed in accordance with OSAHS diagnostic basis and efficacy assessment criteria cum UPPP indications (Hangzhou), PSG is the gold standard for diagnosing OSAHS, while hospitals without PSG are judged by history, symptoms, signs, and nasal endoscopic laryngeal endoscopy in a comprehensive manner.
3.3 OSAHS treatment strategy: Patients with OSAHS can be intervened by modified UPPP surgery (H-UPPP) and/or structured nasal surgery, or by CPAP method, etc. Regardless of that method of treatment changing poor lifestyle habits weight loss, smoking cessation, and cessation of smoking are particularly important to improve and consolidate the outcome. Of course, regular antacid therapy is also included.
4. Diagnostic and treatment strategies for post-cold cough (laryngogenic cough)
4.1 When the cough persists after the symptoms of the acute phase of the cold itself have disappeared, it is clinically called post-cold cough (or laryngogenic cough). In addition to respiratory viruses, other respiratory infections may also cause this type of cough, which is collectively referred to in the literature as post-infectious cough. The patient presents with an irritating dry cough or a small amount of white mucus sputum that can last 3-8 weeks or longer.
4.2 Post-cold cough (laryngogenic cough) is self-limiting and usually resolves on its own. However, antibiotic treatment is not effective. Antihistamine H1 receptor antagonists and central cough suppressants (Huifenesin, etc.) can be applied for a short time for some chronic prolonged coughs. In cases where general treatment is ineffective (in a few cases of cough after a persistent severe cold), inhaled or oral glucocorticoid therapy can be tried for a short period of 3-7 days. Wylde et al. used a combination of Chinese and Western medicine to treat laryngogenic cough with definite efficacy and an efficiency of 95%, which is economical and easy.
5. Diagnosis and treatment of cough caused by external auditory canal diseases
The ear branch of the vagus nerve is located in the posterior and inferior walls of the external auditory canal, and about 23% of policy people can cause a cough reflex when stimulating this area When there is a hard cerumen foreign body shedding hairs on the surface of the eardrum in these patients, coughing symptoms can occur at night when the affected ear is pressurized, and the symptoms can be relieved immediately when the foreign body is removed.
II. Diagnostic process of chronic cough etiology
1. The etiological diagnosis of chronic cough is based on the following principles.
① Pay attention to the medical history, especially the history of otorhinolaryngology and digestive system diseases;
②Select relevant tests according to the medical history, from simple to complex;
③Check common diseases first, then rare diseases.
④Diagnosis and treatment should be carried out simultaneously or sequentially.
If conditions are not available in terms of diagnosis, diagnostic treatment should be carried out according to clinical features and the cause of the cough should be determined according to the response to treatment, and relevant tests should be selected when treatment is ineffective.
2. Specific diagnostic steps and procedures.
① Detailed medical history and physical examination;
②X-ray chest examination, which is recommended as a routine examination for chronic cough, and further examination according to the morphological nature of the lesion in case of obvious lesions on X-ray chest film.
③Test lung ventilation function + bronchial excitation test to diagnose and differentiate asthma. For negative excitation test with normal ventilation function, induction sputum examination is performed to diagnose EB.
(④When postnasal drip or frequent throat clearing is present in the history, treatment can be started according to PNDS, using a combination of several methods for PNDS as described above. Add nasal inhaled glucocorticoids for AR. If the symptoms do not improve in 1-2 weeks of treatment, sinus CT or nasal endoscopy is feasible.
⑤ If the above tests are not abnormal, or if the patient has reflux-related symptoms with or without reflux, 24h esophageal pH monitoring can be considered. If pH monitoring is not available, empirical treatment can be performed for those with high suspicion.
(6) SPT, serum IgE and cough sensitivity testing are feasible for those with suspected allergic cough.
(⑦If the diagnosis cannot be confirmed by the above tests or if the cough continues after experimental treatment, high-resolution CT, fibrinoscopy, and cardiac examination should be selected to exclude diseases such as bronchiectasis, endobronchial tuberculosis, and left heart insufficiency.
(8) The diagnosis of the etiology can only be established after the cough is relieved by the appropriate treatment. In addition, some patients may have multiple etiologies at the same time. If a patient has partial relief of cough symptoms after treatment, consideration should be given to whether other diseases are also combined.
From clinical practice and literature reports, the presence of otorhinolaryngological disease should be considered first in patients with chronic cough without a history of smoking or ACEI medications and without significant abnormalities on repeated chest imaging. Otolaryngological diseases are a common cause of chronic cough and are also closely associated with respiratory and gastroenterology departments. It has been proven that only through multidisciplinary cooperation and comprehensive thinking in all aspects can more patients with chronic cough receive timely and correct diagnosis and treatment, and minimize and/or avoid misdiagnosis and mistreatment for the benefit of the majority of patients with chronic cough.