What is the treatment for upper airway cough syndrome?

Treatment for Upper Airway Cough Syndrome

First-generation antihistamine/decongestant combinations (such as dexbrompheniramine 6 mg or azatadine 1 mg with sustained-release pseudoephedrine 120 mg, both twice daily) are the recommended first-line empiric therapy for upper airway cough syndrome, with treatment response typically seen within days to 2 weeks. 1

Initial Empiric Treatment Approach

When UACS is suspected but the specific etiology is not yet apparent, begin with empiric therapy before extensive diagnostic workup 1:

• Start with a first-generation antihistamine/decongestant (A/D) combination as the primary treatment 1, 2
• The older-generation antihistamines work primarily through their anticholinergic properties, not just antihistamine effects 1, 2
• Newer non-sedating antihistamines (terfenadine, loratadine) are ineffective for non-allergic UACS and should not be used 1, 2

Practical dosing strategy to minimize side effects 1:

• Begin with once-daily dosing at bedtime for several days
• Then advance to twice-daily dosing if tolerated
• This approach reduces sedation complaints

Cause-Specific Treatment Algorithms

For Allergic Rhinitis-Related UACS

When allergic rhinitis is the identified cause 1, 2:

• Nasal corticosteroids are appropriate as first-line therapy 1, 3, 2
• Antihistamines and/or cromolyn can be used concurrently 1, 2
• Oral leukotriene inhibitors are effective alternatives 2
• Non-sedating antihistamines are more effective in allergic rhinitis than in non-allergic conditions 1, 2
• Continue intranasal corticosteroids for 1 month as a trial period 1, 2

For Non-Allergic Rhinitis and Postviral UACS

This represents the most common scenario 1, 2:

• First-generation A/D combinations are superior to newer agents 1, 2
• Specific proven regimens 2:
  • Dexbrompheniramine maleate 6 mg twice daily + pseudoephedrine sulfate 120 mg sustained-release twice daily
  • Azatadine maleate 1 mg twice daily + pseudoephedrine sulfate 120 mg sustained-release twice daily
• If A/D therapy fails or is contraindicated (glaucoma, symptomatic benign prostatic hypertrophy), use ipratropium bromide nasal spray 1, 2

For Chronic Sinusitis-Related UACS

When chronic sinusitis is documented 1, 2:

• Initial combination therapy: antibiotic + first-generation A/D + nasal decongestant for 5 days 3
• Add intranasal corticosteroids to decrease inflammation 3, 2
• After cough resolves, continue intranasal corticosteroids for 3 months as maintenance therapy 3, 2
• If refractory to medical therapy with anatomic obstruction present, consider endoscopic sinus surgery 1

Critical Treatment Timing and Duration

• Most patients show improvement within days to 2 weeks of initiating appropriate therapy 1, 2
• Do not discontinue intranasal corticosteroids prematurely when used for chronic sinusitis—the 3-month continuation after cough resolution prevents recurrence 3, 2
• For topical nasal steroids in upper airway symptoms, a 1-month trial is the minimum recommended duration 1

Important Caveats and Pitfalls

Medication Selection Errors

• Never use intranasal corticosteroids as monotherapy initially for non-allergic UACS—they should follow or accompany A/D combination therapy 3, 2
• Do not confuse intranasal corticosteroids with nasal decongestants (oxymetazoline), which are only used short-term (5 days maximum) 3
• Avoid newer-generation antihistamines for non-allergic causes, as they lack the necessary anticholinergic properties 1, 2

Diagnostic Challenges

• "Silent" UACS exists—patients may have no obvious postnasal drip sensation yet respond to treatment 2, 4
• Symptoms and physical findings are unreliable discriminators; response to specific therapy confirms the diagnosis 1
• If first-line A/D therapy fails, obtain sinus imaging before abandoning the UACS diagnosis 1

Side Effect Management

Common but manageable side effects 1, 2:

• Dry mouth and transient dizziness (most frequent)
• Sedation (mitigated by bedtime-first dosing strategy)

Serious contraindications requiring alternative therapy 1:

• Glaucoma (increased intraocular pressure risk)
• Symptomatic benign prostatic hypertrophy (urinary retention risk)
• Uncontrolled hypertension (decongestant effects)
• Severe insomnia or tachycardia

Environmental and Medication Factors

• Identify and eliminate environmental irritants when present—improved ventilation and filters are effective adjuncts 1
• For rhinitis medicamentosa, the patient must stop or wean off the offending nasal decongestant spray, sometimes one nostril at a time 1

When to Escalate or Refer

If empiric A/D therapy fails 1:

• Proceed to sinus imaging (CT preferred over plain radiographs)
• Consider trial of ipratropium bromide nasal spray
• Evaluate for other causes of chronic cough (asthma, GERD, nonasthmatic eosinophilic bronchitis) 4, 5
• Referral to pulmonologist or otolaryngologist may be warranted for refractory cases 5