What is the treatment for a patient with a recurrent cough in winter months and a cobblestone appearance on the posterior pharyngeal wall?

Treatment for Recurrent Cough in Winter Months with Cobblestone Posterior Pharyngeal Wall

First-generation antihistamine/decongestant combination therapy is the first-line treatment for recurrent cough in winter months with cobblestone appearance on the posterior pharyngeal wall, which indicates upper airway cough syndrome. 1

Diagnosis: Upper Airway Cough Syndrome (UACS)

The cobblestone appearance of the posterior pharyngeal wall is a classic physical finding associated with upper airway cough syndrome (UACS), previously known as post-nasal drip syndrome (PNDS). The seasonal pattern during winter months further supports this diagnosis, as approximately 20% of patients report cough during winter months 1.

Treatment Algorithm

First-line therapy:

• First-generation antihistamine/decongestant combination for 2-4 weeks 1, 2
  • Example: Brompheniramine with sustained-release pseudoephedrine
  • Note: First-generation (sedating) antihistamines are more effective than non-sedating antihistamines for cough 1

If inadequate response after 2-4 weeks:

• Obtain sinus imaging to evaluate for chronic sinusitis 1
• Add intranasal corticosteroids for 1 month, especially with prominent upper airway symptoms 1, 2

For nighttime cough symptoms:

• First-generation antihistamines are particularly effective due to their sedative properties 1

For symptomatic relief:

• Dextromethorphan (60 mg provides maximum cough reflex suppression) 1, 3
• Menthol inhalation for short-term cough suppression 1

Important Clinical Considerations

1. Avoid codeine or pholcodine - These have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile 1

2. Avoid non-sedating antihistamines - Second-generation antihistamines are ineffective for cough reduction 1

3. Consider overlapping diagnoses - Multiple simultaneous causes of chronic cough are common (59% of cases) 4. The three most common causes are:

   • Upper airway cough syndrome
   • Asthma
   • Gastroesophageal reflux disease (GERD)

4. Monitor response - Improvement with specific therapy confirms the diagnosis of UACS 1

5. Women are more susceptible - Studies show higher prevalence of nocturnal and non-productive cough in women, possibly due to increased cough reflex sensitivity 1

When to Consider Additional Evaluation

If cough persists despite appropriate treatment for 4-8 weeks, consider:

• Evaluation for asthma or cough variant asthma
• Trial of proton pump inhibitors for possible GERD-related cough
• Referral to specialist if cough persists despite appropriate treatment 2

Caution

The character, timing, and complications of chronic cough alone are not reliable for determining the cause 4. A systematic approach to diagnosis and treatment is necessary, with the response to specific therapy being the key to confirming the diagnosis.