How to evaluate and manage a patient with a persistent throat symptom in a primary care setting without access to advanced diagnostic tools?

Evaluating Persistent Throat Symptoms in Primary Care

In primary care without advanced diagnostics, start with a chest radiograph and spirometry, then proceed with empirical therapeutic trials targeting the most common causes: gastroesophageal reflux disease (GERD), upper airway cough syndrome (rhinosinusitis), and cough-variant asthma. 1

Initial Assessment

History Taking

Focus your history on these specific elements:

• Medication review: Identify ACE inhibitor use, which is a common and reversible cause of persistent throat symptoms and cough 1
• Smoking status: Essential to document as it significantly alters differential diagnosis 1
• Symptom pattern: Ask specifically about nocturnal symptoms, post-exercise symptoms, or allergen exposure (suggests asthma); heartburn or regurgitation (suggests GERD); nasal discharge or postnasal drip (suggests rhinosinusitis) 1
• Duration: Distinguish acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) symptoms 1
• Red flags: Weight loss, fever, hemoptysis, or dysphagia require urgent investigation for serious pathology 1, 2

Physical Examination

Perform a targeted examination focusing on:

• Upper respiratory tract: Examine ears, nose, and throat for signs of rhinosinusitis or postnasal drip 1
• Chest auscultation: Listen for wheezes (asthma), prolonged expiratory phase (airflow obstruction), or crackles (bronchiectasis, parenchymal disease) 1
• Neck examination: Palpate thyroid for masses that can cause extrinsic compression and throat symptoms 3

Essential Baseline Investigations

Chest Radiograph

Obtain a chest X-ray in all patients with chronic throat symptoms or persistent cough. 1 This identifies approximately 31% of abnormalities that yield a diagnosis and rules out serious pathology like malignancy, infection, or structural abnormalities 1

Spirometry

Perform spirometry in all patients with persistent symptoms. 1

• Measure FEV1 before and after bronchodilator (salbutamol 400 mcg via spacer or 2.5 mg nebulized) 1
• Important caveat: Normal spirometry does NOT exclude asthma as a cause—many patients with cough-variant asthma have normal lung function 1
• Avoid using peak flow measurements for diagnosis as they are less accurate than FEV1 in primary care 1

Empirical Treatment Algorithm

When investigations are normal or unavailable, proceed with sequential therapeutic trials:

First-Line: Trial for Cough-Variant Asthma/Eosinophilic Bronchitis

If spirometry is normal but asthma is suspected, offer a therapeutic trial of prednisolone (typically 30-40 mg daily for 2 weeks) 1

• This addresses both cough-variant asthma and eosinophilic bronchitis, which together account for approximately 30% of chronic cough cases 1
• Response to steroids confirms diagnosis even without demonstrable airway hyperresponsiveness 1

Second-Line: Empirical GERD Treatment

Treat empirically for GERD if typical reflux symptoms are present (heartburn, regurgitation) BEFORE pursuing specialized testing. 1

• GERD is frequently overlooked in primary care but is a major cause of persistent throat symptoms 1
• Initiate high-dose proton pump inhibitor therapy for 8-12 weeks 1
• Critical point: Less than 30% of patients with positive pH studies respond to treatment, so pH monitoring poorly predicts therapeutic response and should not guide initial management 1

Third-Line: Upper Airway Disease Treatment

For suspected rhinosinusitis, treat empirically rather than pursuing imaging. 1

• Prescribe intranasal corticosteroids and consider antihistamines if allergic component suspected 1
• ENT examination is preferred over sinus imaging for persistent cases 1

When to Refer

Refer to a specialist cough clinic when:

• Empirical treatments have failed after adequate trials 1
• Diagnostic uncertainty persists despite systematic approach 1
• Suspicion of uncommon causes (foreign body, drug-induced cough, systemic disease) 1

Common pitfall: Do not diagnose "idiopathic" or "unexplained" cough until specialist evaluation with comprehensive protocols has been completed and uncommon causes ruled out 1

Key Practical Points

• ACE inhibitors: If patient is on an ACE inhibitor, withdraw it as a therapeutic trial—this is a simple, reversible cause 1
• Multiple causes: Recognize that patients often have more than one contributing factor; sequential treatment of each potential cause may be necessary 1
• Treatment duration: Allow adequate time for each therapeutic trial (typically 2-4 weeks minimum for upper airway treatments, 8-12 weeks for GERD) 1
• Avoid bronchoscopy: In primary care referrals, bronchoscopy has very low yield (1-6%) unless foreign body aspiration is suspected 1