From the Guidelines
For a patient with sore throat, postnasal drip, dry cough, occasional vomiting, and enlarged vocal cords, the most appropriate initial approach is to focus on symptomatic relief with voice rest, adequate hydration, and saline nasal irrigation to address the postnasal drip, as well as considering laryngoscopy to visualize the vocal cords given the symptom of enlarged vocal cords. This approach is based on the understanding that the symptoms could be indicative of several conditions, including viral pharyngitis, allergic rhinitis, or laryngopharyngeal reflux, and that targeted symptomatic treatment addressing inflammation and irritation is the initial step while monitoring for improvement 1.
Initial Testing and Treatment
- A thorough physical examination of the throat is essential, possibly including laryngoscopy to visualize the vocal cords, especially given the symptom of enlarged vocal cords.
- Initial treatment should focus on symptomatic relief:
- Voice rest to reduce strain on the vocal cords.
- Adequate hydration to thin out secretions and keep the throat moist.
- Saline nasal irrigation to address the postnasal drip.
- Over-the-counter medications like acetaminophen (500-1000mg every 6 hours as needed) or ibuprofen (400-600mg every 6-8 hours with food) can help manage pain and inflammation.
- For the postnasal drip, an antihistamine like loratadine (10mg daily) or a nasal steroid spray such as fluticasone (1-2 sprays per nostril daily) may be beneficial.
- A proton pump inhibitor like omeprazole (20mg daily before breakfast) for 4-6 weeks could help if laryngopharyngeal reflux is contributing to the symptoms.
- For the dry cough, a cough suppressant containing dextromethorphan (15-30mg every 6-8 hours) may provide relief.
Further Evaluation
If symptoms persist beyond 2-3 weeks or worsen, further evaluation including:
- Throat culture to rule out bacterial infections.
- Allergy testing to assess for allergic rhinitis.
- Referral to an ENT specialist for more detailed examination and possible diagnosis of conditions like vocal cord dysfunction or laryngomalacia, especially considering the symptom of enlarged vocal cords and the potential for exercise-induced laryngeal abnormalities as discussed in 1.
Given the complexity of symptoms and the potential for multiple underlying conditions, a stepwise approach starting with symptomatic relief and progressing to more specific diagnostic tests based on the patient's response to initial treatment is prudent. The presence of enlarged vocal cords warrants careful consideration of laryngeal conditions, potentially requiring specialized evaluation.
From the Research
Symptoms and Possible Causes
- The patient's symptoms include sore throat, postnasal drip (PND), dry cough, occasional vomiting, and enlarged vocal cords.
- These symptoms could be related to various conditions, including gastro-esophageal reflux disease (GERD), postnasal drip syndrome (PNDS), and pharyngitis 2, 3, 4.
Diagnostic Tests
- For patients with normal chest radiographs, 24-h esophageal pH monitoring can be used to link GERD and cough in a cause and effect relationship 2.
- Rapid antigen detection tests and throat cultures can be used to identify the inciting organism in cases of pharyngitis 4.
- There is no general agreement on how to best interpret the results of 24-h esophageal pH monitoring, and it cannot detect non-acid reflux events 2.
Treatment Options
- Treatment for GERD-related cough may involve minimal medical therapy or intensive regimens, and surgery may be efficacious when intensive medical therapy has failed 2.
- Specific therapy for PNDS depends upon the rhinosinus disease(s) causing the PND, and second-generation H(1)-antagonists may be less effective than first-generation agents in treating cough due to non-histamine-mediated PNDSs 2.
- For pharyngitis, viral causes are often self-limiting, while bacterial and fungal infections typically require antimicrobial therapy, and rapid antigen detection tests should be reserved for concerns about antibiotic initiation 4.