Management of Chronic Cough with Swollen Tonsils and Purulent Phlegm
This presentation suggests an acute exacerbation of chronic bronchitis requiring antibiotic therapy, given the presence of purulent phlegm and 2-month duration, particularly if accompanied by increased dyspnea or worsening symptoms. 1, 2
Initial Assessment and Diagnosis
The combination of chronic cough (>8 weeks), swollen tonsils, and purulent sputum requires distinguishing between stable chronic bronchitis versus an acute exacerbation:
- Acute exacerbation is likely if there has been a sudden deterioration with increased cough, sputum production, sputum purulence, and/or shortness of breath, often preceded by upper respiratory tract infection symptoms 1
- The presence of purulent phlegm is a key indicator favoring antibiotic treatment 1, 2
- Chest radiography and spirometry are mandatory to exclude other causes and assess airflow obstruction 1
Treatment Algorithm
For Acute Exacerbation (Most Likely Given Purulent Phlegm)
Antibiotics are recommended, especially with purulent sputum and severe symptoms (increased cough, sputum volume, and dyspnea) 1, 2, 3:
- Most effective in patients with all three cardinal symptoms and more severe baseline airflow obstruction 1
- Standard course duration for acute exacerbations 2
Bronchodilator therapy during exacerbation 2, 3:
- Short-acting β-agonists (albuterol) or anticholinergic bronchodilators (ipratropium bromide) should be administered 2, 3
- Ipratropium bromide 36 μg (2 inhalations) four times daily 3
Systemic corticosteroids 2, 3:
- A short course (10-15 days) is effective for acute exacerbations 2, 3
- Oral therapy for ambulatory patients 3
For Stable Chronic Bronchitis Component
Environmental modification is paramount 1, 2:
- Smoking cessation is the most effective intervention, with 90% of patients experiencing cough resolution 1, 2
- Avoidance of respiratory irritants, passive smoke, and workplace hazards 1
Long-term bronchodilator therapy 2, 3:
- Ipratropium bromide as first-line therapy to improve cough (Grade A recommendation) 2, 3
- Short-acting β-agonists to control bronchospasm and may reduce chronic cough 2, 3
- Long-acting β-agonists combined with inhaled corticosteroids for patients with severe airflow obstruction or frequent exacerbations 2
Symptomatic Cough Relief
For troublesome cough requiring temporary suppression 3, 4:
- Dextromethorphan or codeine reduce cough counts by 40-60% 3, 4
- These are recommended for short-term symptomatic relief 2
- Dextromethorphan should not be used if cough occurs with too much phlegm (mucus) per FDA labeling 5
Critical Pitfalls to Avoid
Do NOT use long-term prophylactic antibiotics in stable chronic bronchitis patients (Grade I recommendation) 1, 2, 3:
- No role for prevention despite small historical benefits 1
- Concerns about antibiotic resistance and side effects 1
Expectorants are not recommended for either stable chronic bronchitis or acute bronchitis 2, 3:
Insufficient evidence for routine pharmacologic treatments in stable chronic bronchitis to relieve cough per se until proven safe and effective 1
When to Reassess
- If cough persists beyond 8 weeks despite treatment, consider other diagnoses including upper airway cough syndrome, gastroesophageal reflux disease, asthma, or nonasthmatic eosinophilic bronchitis 6
- When character of cough changes for prolonged periods, consider bronchogenic carcinoma or other complications 1
- Demonstration of sputum eosinophilia has important treatment implications and should be assessed if initial treatments fail 1