What is the recommended management for upper airway cough syndrome?

Management of Upper Airway Cough Syndrome

Start empiric treatment with a first-generation antihistamine/decongestant combination (such as dexbrompheniramine 6 mg or azatadine 1 mg plus sustained-release pseudoephedrine 120 mg, both twice daily) before pursuing extensive diagnostic workup, as this is the most effective first-line therapy and response to treatment confirms the diagnosis. 1, 2

Initial Diagnostic Approach

The diagnosis of UACS is clinical and based on a combination of criteria rather than any single pathognomonic finding 1:

• Look for: sensation of postnasal drainage, frequent throat clearing, nasal discharge, and cobblestone appearance of the oropharyngeal mucosa 2
• Critical caveat: UACS can be "silent" with no obvious symptoms, yet patients still respond to treatment—do not rule out UACS based on absence of typical symptoms 1, 2
• Confirmation: The pivotal factor in confirming UACS as the cause is improvement or resolution of cough in response to specific treatment 1

Treatment Algorithm Based on Etiology

When Etiology is Unknown (Most Common Scenario)

Empiric first-generation antihistamine/decongestant therapy should be prescribed before extensive workup 1:

• Use older-generation combinations specifically: dexbrompheniramine maleate (6 mg twice daily) or azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) 1, 2
• Do NOT use newer non-sedating antihistamines (terfenadine, loratadine) as they are ineffective for UACS-related cough 1, 2
• Most patients improve within days to 2 weeks of initiating therapy 2

When Allergic Rhinitis is Identified

First-line options include 1, 2:

• Nasal corticosteroids (preferred for allergic rhinitis)
• Antihistamines (nasal or oral)
• Cromolyn sodium
• Oral leukotriene inhibitors as adjunctive therapy 1, 2

For allergic rhinitis specifically, non-sedating antihistamines may be more effective than in non-allergic causes 1, 2

When Non-Allergic Rhinitis or Postviral URI is Present

• First-generation antihistamine/decongestant combinations remain the treatment of choice due to their anticholinergic effects 1, 2
• Alternative: Ipratropium bromide nasal spray for patients who don't respond to A/D combinations or have contraindications (glaucoma, symptomatic benign prostatic hypertrophy) 1, 2

When Chronic Sinusitis is Suspected

If patient fails empiric A/D therapy, obtain sinus imaging (CT or radiographs) 1:

• Treatment regimen for chronic sinusitis: 1
  • Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae
  • Minimum 3 weeks of older-generation A/D twice daily
  • 5 days of nasal decongestant (e.g., oxymetazoline) twice daily
  • After cough resolves: continue intranasal corticosteroids for 3 months 1
• Consider endoscopic sinus surgery only for documented chronic infection refractory to medical therapy with anatomic obstruction 1

When Environmental Irritants are Identified

• Avoidance of exposure is primary 1
• Improve ventilation and use filters 1
• In occupational settings, consider high-efficiency particulate air filter masks 1

When Rhinitis Medicamentosa is Present

• Stop or wean off the offending topical decongestant (can be done one nostril at a time) 1
• Consider A/D or nasal corticosteroids as bridge therapy, though evidence is limited 1

Practical Management Tips

Minimizing Side Effects

• To reduce sedation: Start first-generation antihistamines once daily at bedtime for a few days before advancing to twice-daily dosing 1, 2
• Common side effects: dry mouth and transient dizziness 2
• Monitor for: insomnia, urinary retention (especially older men), jitteriness, tachycardia, worsening hypertension, increased intraocular pressure in glaucoma patients 1, 2

Treatment Duration

• For intranasal corticosteroids in allergic rhinitis: minimum 1-month trial 2
• For chronic conditions: longer treatment courses may be necessary 2

Critical Pitfalls to Avoid

• Never rely on cough character or timing to rule in or rule out UACS—these features are not diagnostically useful 1
• Do not assume absence of postnasal drip symptoms excludes UACS—"silent" UACS is common and responds to treatment 1, 2
• Avoid newer-generation antihistamines for empiric therapy—they lack the anticholinergic properties necessary for non-allergic UACS 1, 2
• Do not diagnose bacterial sinusitis during the first week of symptoms—symptoms and imaging abnormalities are indistinguishable from viral rhinosinusitis 1
• Remember that mucosal thickening <8mm on imaging is often sterile and may not require antibiotics 2