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Multiple Issues Often Linked to Causes of Cough


Kenneth W. Altman, MD, PhD: ‘It is important to know that two-thirds of cases are multifactoral—the patients have two things going on.’

Cough is the culprit behind more than 31 million visits to physicians annually, and $6.8 billion is spent on over-the-counter cough and cold remedies. Diagnosing the cause of a cough is challenging, and a panel of experts used a series of case presentations Sunday to discuss diagnosis tips.

The most common causes of chronic cough are tobacco use, post-nasal drip syndrome, gastroesophageal reflux/laryngopharyngeal reflux, and bronchitis. Less common causes include bronchiectasis and carcinoma, said Kenneth W. Altman, MD, PhD, Baylor College of Medicine, Houston, who led five other panel members in “Challenging Cough Cases: A Protocolized Approach.”

“It is important to know that two-thirds of cases are multifactoral—the patients have two things going on,” Dr. Altman said. “We should be thinking about testing, diagnosis, and treatment we could be doing.”

That segued into the first case review, of a healthy 52-year-old woman who had a non-productive cough for six months. After more than six weeks of treatment with omeprazole, a CT scan of sinuses, and allergy skin testing, a pulmonary function test was ordered. The patient was diagnosed with mild, persistent asthma, said John H. Krouse, MD, PhD, Temple University, Philadelphia.

“We as otolaryngologists are frequently conditioned to think causes that might awaken someone from sleep are equal to LPR, and it’s not always the case. In fact, cough at night is a frequent symptom of asthma,” he said.

In a second case, a 28-year-old nonsmoker with no allergies, but a persistent cough, was treated with omeprazole and ranitidine for six months with no change, said Thomas L. Carroll, MD, Beth Israel Medical Center, Boston.

A photo of the man’s larynx led panelist Clark A. Rosen, MD, University of Pittsburgh, to say, “You learn nothing from a picture of the larynx. Be extremely careful about that. Millions of dollars are spent to prove that looking at the larynx can’t tell you who has reflux disease.”

Eventually, several scans and probes confirmed the patient had Barrett’s metaplasia.

Amber U. Luong, MD, PhD, University of Texas, Houston, presented a case of a 63-year-old nonsmoker with dry cough and post-nasal drainage. After tests and treatments brought no change, the patient was treated for neurogenic inflammation in which nerves activating mast cells trigger an inflammatory response. Six months of treatment with amitriptyline “broke the cycle” Dr. Luong said.

Dr. Rosen presented a final case of a 47-year-old teacher who had a persistent cough for more than three years and a cough severity index score of 36 out of 40. Treating his larynx helped, and treatment with neurotin and voice therapy for speaking helped.

Dr. Altman concluded by reminding attendees that complex, overlapping physiology is a common theme, so working with physicians in other disciplines is important.