Cough is a common symptom encountered by community outpatients, especially by respiratory physicians. Severe, severe, and frequent coughs not only affect the patient’s rest, sleep, and work, but may also cause a variety of serious complications, including a certain percentage of patients with coughs caused by nasal-sinus disease, so it is essential to master its treatment. Cough is very common, and there are many causes of cough.
I. Paying attention to cough caused by rhinosinus disease
Cough is a common symptom encountered by community outpatient physicians, especially those specializing in respiratory medicine. Cough has a wide range of clinical causes, not only related to the respiratory system but also to diseases of the ear, nose and throat, digestive system, cardiovascular and neurological systems, with a significant proportion of cases caused by otorhinolaryngological diseases. From the literature, the presence of otorhinolaryngological disease should be considered first in patients with chronic cough who have no significant abnormalities on chest imaging and no history of smoking or ACEI medications.
In the latest guidelines for the diagnosis and treatment of cough in China, Europe and the United States, it is stated that cough variant asthma (CVA), upper respiratory cough syndrome (UACS), eosinophilic bronchitis (EB) and gastro-oesophageal reflux cough (GERC) account for 70% to 95% of chronic cough in respiratory medicine outpatient clinics, with UACS and some GERC [otorhinolaryngologic term for laryngopharyngeal reflux The UACS and some of the GERC [1aryngopharyngeal reflux disease (LPD)] are apparently associated with otolaryngological diseases.
Nasal-sinus diseases that cause cough: acute viral rhinitis, allergic rhinitis (AR), non-allergic rhinitis, acute and chronic nasal-sinus break criteria.
II. Nasal-sinus diseases causing cough.
1. Acute viral rhinitis
Commonly known as “cold”, it is the main cause of acute cough. Clinical manifestations are nasal-related symptoms, such as runny nose, sneezing, nasal congestion and postnasal drip influenza, throat irritation or discomfort, with or without fever. The cough of the common cold is often associated with postnasal drip.
2.Allergic rhinitis (AR)
It is a chronic inflammatory reactive disease of the nasal mucosa mediated by IgE after exposure to allergens in atopic individuals, beginning with the release of inflammatory mediators (mainly histamine) and involving immunoreactive and pro-inflammatory cells and cytokines. Foreign studies have found that simple lower airway excitation in patients with allergic rhinitis without asthma can cause inflammation of the nasal mucosa and decreased nasal function, and a significant increase in eosinophils in the nasal mucosa and bronchial mucosa was detected. . These studies suggest that there is an interaction between the upper and lower airways, and that upper airway excitation or lower airway excitation can elicit similar inflammatory responses throughout the airways. Due to the consistency of inflammation in the upper and lower airways, AR can affect the lower airways, producing an inflammatory response that results in airway hyperresponsiveness.
The disease is characterized clinically by nasal itching, multiple bouts of sneezing, profuse watery nasal discharge and nasal congestion. Diagnostic criteria: having at least three of the four major symptoms of nasal itching, sneezing, nasal discharge and nasal congestion, with symptoms lasting more than 0.5-1h, more than four days a week; seasonal AR with essentially the same season of onset each year (at least 2 years of onset in the same season), and perennial AR with onset on most days of the year. Inflammatory changes in nasal mucosa morphology. Positive allergen skin test, at least one ++ or +++ or more/ or positive for allergen-specific IgE. Positive eosinophil examination on nasal secretion smear during symptom onset. The diagnosis can be made mainly based on the first three items, of which history and specific tests are the main diagnostic basis.
3.Non-allergic rhinitis
Including vasomotor rhinitis, chronic rhinitis, etc. Vasomotor rhinitis has many causes, mental stress, anxiety, sudden changes in environmental temperature, endocrine disorders can cause excessive release of parasympathetic neurotransmitters, causing non-specific release of histamine, increased glandular secretion, vasodilatation, causing the corresponding clinical symptoms, similar to allergic rhinitis, allergen skin test is negative, nasal secretion smear does not see eosinophils can be distinguished from allergic rhinitis.
4.Acute and chronic rhinosinusitis
EP3OS classifies the symptoms of rhinosinusitis into primary and secondary symptoms; primary symptoms: nasal congestion, mucopurulent secretions. Secondary symptoms: decreased or lost sense of smell, pressure sensation or swelling of the face. Diagnosis of rhinosinusitis requires more than two symptoms, and the primary symptoms must be based on one of them. Physical symptoms: mucopurulent discharge or polyps in the middle nasal tract or olfactory fissure. Imaging: mucosal changes in the sinonasal tract complex or in the sinuses, with signs such as thickening of the sinus mucosa more than 5-6 mm, air-fluid planes or sinus cavity blurring. Chronic rhinosinusitis can be diagnosed with a disease duration greater than 12 weeks, while acute rhinosinusitis remains within 12 weeks.
Etiology of cough caused by acute and chronic rhinosinusitis: bacterial infections, mostly a mixture of two and more, mainly gram-positive bacteria. Fungal infections. Infections of adjacent organs, such as odontogenic or tonsillar proliferators. Metamorphic reactions and immunological factors. Abnormalities in the anatomy of the nasal cavity and sinuses. Abnormal function of the ciliary system.
Clinical manifestations of cough caused by UACS, cough mechanism, and diagnostic criteria.
Third, UACS is also an important cause of cough
ACCP renamed postnasal drip syndrome (PNDs) as UACS, which refers to the syndrome of backflow of secretions into the posterior nostril, nasopharynx and pharynx, or even backflow into the voice box or trachea due to nasal diseases, resulting in a cough as the main manifestation, which may be accompanied by a foreign body sensation in the pharynx. Some European scholars directly adopt rhinitis/sinusitis as the etiological diagnosis of chronic cough without using the terminology of UACS or PNDs. According to foreign scholars, 97% of patients with cough accompanied by throat drops, frequent throat clearing, or nasal itching, nasal congestion, or runny nose have normal chest radiographs.
Clinical manifestations: In addition to cough and sputum, there are usually complaints of throat drip, oropharyngeal mucus adherence, frequent throat clearing, throat itching discomfort or nasal itching, nasal congestion, runny nose, and sneezing. Sometimes the patient may complain of hoarseness and speech induced cough, but other causes of cough can also have such complaints. The onset is usually preceded by a history of upper respiratory tract disease (e.g., cold).
Cough mechanism: The underlying diseases that cause UACS include seasonal allergic rhinitis, perennial allergic rhinitis, perennial non-allergic rhinitis, vasodilatory rhinitis, infectious rhinitis, fungal rhinitis, the common cold, and chronic sinusitis. The ciliary system of the nasal mucosa performs an important defensive function, transporting the surface mucus blanket to the nasopharynx through the regular oscillation of the cilia to remove foreign pathogenic microorganisms. In patients with cough with nasal-sinus disease, the nasal and sinus mucosa has an inflammatory response similar to that of the lower respiratory tract, and its sensory nerve endings have airway stimulation sensory nerves that increase cough reflex sensitivity and produce cough neuropeptides and neurotransmitters. The backflow of nasal-sinus secretions into the pharynx stimulates the cough receptors here, generating impulses that put the cough reflex in a hypersensitive state through the neural reflex.
Diagnostic criteria: episodic or persistent cough, mainly during the day and less after sleep; postnasal drip and/or mucus adhesion to the posterior pharyngeal wall; history of rhinitis, sinusitis, nasal polyps or chronic pharyngitis; examination reveals mucus adhesion to the posterior pharyngeal wall and cobblestone-like appearance; cough relieved after targeted treatment. Therefore, other common causes of chronic cough should be excluded before establishing a diagnosis.
The pharmacological treatment of cough due to various rhinosinus diseases is described below. It is important to master them.
Drug therapy for cough caused by nasal and sinus diseases
1. The treatment of acute cough caused by the common cold (i.e. acute viral rhinitis) is based on symptomatic treatment and generally does not require antibacterial drugs.
(1) Anti-allergic drugs: first-generation antihistamines, such as chlorpheniramine maleate and dextrobromopheniramine, are preferred; second-generation antihistamines are not effective.
(2) Decongestants: pseudoephedrine, etc.
(3) antipyretic drugs: antipyretic and analgesic drugs.
(4) Anti-cough drugs: central cough suppressants, proprietary Chinese medicines, etc. Clinically, a combination of the above drugs is usually used. ACCP recommends that first-generation antihistamines + pseudoephedrine are preferred for treatment, which can effectively relieve coughing and sneezing, nasal congestion and other symptoms. A central cough suppressant is chosen for intense cough.
Unless the patient has significant allergic rhinitis, second-generation antihistamines are not used because first-generation antihistamines have the ability to cross the blood-brain barrier, penetrate into central nerve cells, bind to histamine receptors, and have anticholinergic effects, thus exerting a cough suppressant effect, which is not due to their central sedative effect. Second-generation antihistamines, despite their excellent characteristics of non-drowsiness and non-sedation, do not have anticholinergic characteristics, so it is difficult to exert cough suppressant effects.
2. Principles of AR treatment.
Try to avoid contact with allergens and use antihistamines, decongestants and nasal glucocorticoids correctly. Allergen immunotherapy is also effective, but it takes longer to take effect.
3, non-allergic rhinitis treatment is mainly drug therapy, antihistamines, decongestants, nasal steroids and so on.
Chronic rhinitis includes chronic simple rhinitis and chronic hypertrophic rhinitis, which is a chronic inflammation of the nasal mucosa and submucosa, the main clinical manifestations are nasal congestion and runny nose, which can be treated with decongestants, nasal steroid hormones and proprietary Chinese medicines.
4. For rhinosinusitis-like diseases causing chronic cough, ACCP recommends that first-generation antihistamines and decongestants are preferred for empirical treatment.
The first generation antihistamines are mainly used for their anticholinergic effects rather than their antiallergic effects, so unless the cough is accompanied by significant allergic rhinitis, the use of second-generation antihistamines is not recommended. The more classic first-generation antihistamines are mainly chlorpheniramine maleate and dextrobromopheniramine. Most patients develop efficacy within a few days to 2 weeks after initial treatment. Decongestants can improve nasal symptoms more quickly, and the commonly used decongestant is pseudoephedrine hydrochloride.
5. Treatment of cough due to UACS depends on the underlying disease causing the UACS.
First-generation antihistamines and decongestants are preferred for UACS due to the following etiologies.
(1) non-allergic rhinitis.
(2) vasodilatory rhinitis.
(3) year-round rhinitis.
(4) Common cold. The representative 1st generation antihistamine is chlorpheniramine maleate and the commonly used decongestant is pseudoephedrine hydrochloride. Most patients develop efficacy within a few days to 2 weeks after initial treatment.
Nasal inhaled glucocorticoids and oral antihistamines are the preferred treatment for patients with allergic rhinitis. Various antihistamines are effective in the treatment of allergic rhinitis. Second-generation antihistamines without sedative effects are preferred, and avoiding or reducing exposure to allergens helps to reduce the symptoms of allergic rhinitis. Leukotriene receptor antagonists, short-term nasal or oral decongestants can be added when necessary. Specific allergen immunotherapy may be effective in those with more severe symptoms and poor results with conventional medications, but the onset of action is longer.
Bacterial sinusitis is mostly a mixed infection and anti-infection is an important therapeutic measure. The antimicrobial spectrum should cover Gram-positive, negative and anaerobic bacteria for not less than 2 weeks for acute and longer for chronic recommended as appropriate, with commonly used drugs being amoxicillin/clavulanic acid, cephalosporins or quinolones. There is evidence that long-term low-dose macrolide antibiotics have a therapeutic effect in chronic sinusitis. Combined with nasal inhalation glucocorticoids, recommended for 3 months, decongestants reduce nasal mucosal congestion and edema and facilitate drainage of secretions, with a course of treatment typically <1 week. Those with allergic symptoms such as sneezing and nasal itching can take additional or nasal antihistamines. If medical treatment is not effective, it is recommended to consult a specialist and, if necessary, to undergo nasal endoscopic surgery.
What further measures should we take if medication fails to treat cough caused by nasal-sinus disease? Surgical treatment.
V. Surgical treatment of cough caused by nasal-sinus disease
So far, although surgical treatment has been largely minimally invasive, the treatment of acute rhinosinusitis is still on the conservative side, and surgical treatment is more often chosen for those whose conservative treatment is ineffective and whose sinusitis already has complications. It was introduced worldwide in the 1980s and has been evaluated in numerous retrospective and prospective case-control studies or non-randomized clinical trials. The aim of functional nasal endoscopic surgery is to restore the function of the diseased nasal mucosa, improve nasal ventilation and drainage, and re-establish clear function of the nasal mucosal cilia through minimally invasive surgery.
Chronic rhinosinusitis can be treated surgically if one of the following conditions is present: obvious anatomical abnormalities affecting the sinonasal complex or the drainage of each sinus; nasal polyps affecting the sinonasal complex or the drainage of each sinus; unsatisfactory improvement of symptoms with drug treatment; and cranial and orbital complications.
VI. Summary
Currently, there are no truly effective nonspecific cough suppressants for cough, and etiologically specific treatment should be the best treatment. In patients without specific etiologic manifestations of chronic cough, empiric treatment against UACS should be performed with first-generation antihistamines/decongestants until more extensive diagnostic workup is performed. Otolaryngologic disorders are common causes of cough, and it is important to apply therapeutic agents in adequate doses to avoid compromising efficacy. If there is more than one cause, treatment should be administered accordingly to the order of abnormal findings, not discontinuing some of the effective treatments, but adding them in sequence. Along with the treatment of the cause, symptomatic treatment is required, usually with various central or peripheral cough suppressants.