What are the management options for upper airway cough syndrome?

Management of Upper Airway Cough Syndrome

For upper airway cough syndrome (UACS), initiate treatment with a first-generation antihistamine plus decongestant combination as first-line therapy, with specific effective regimens including dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate or azatadine maleate plus sustained-release pseudoephedrine sulfate. 1, 2

First-Line Treatment Approach

Initial Empiric Therapy

• Start with a first-generation antihistamine/decongestant (A/D) combination as the primary treatment, as UACS is the most common cause of chronic cough in adults 3, 1, 2
• Begin with once-daily dosing at bedtime to minimize sedation, then increase to twice-daily therapy if tolerated 1, 2
• Continue treatment for a minimum of 3 weeks for chronic cases 1
• Expect noticeable improvement within days to 1-2 weeks, though complete resolution may take several weeks to a few months 3, 1, 2

Critical distinction: Newer-generation (non-sedating) antihistamines are ineffective for non-allergic UACS and should not be used 1, 2, 4. The anticholinergic properties of older-generation antihistamines are essential for efficacy 4.

When Allergic Rhinitis is Present

• Use intranasal corticosteroids as first-line therapy for allergic rhinitis-related UACS 1, 2
• Implement a 1-month trial of topical nasal corticosteroids 3, 1
• Alternative options include oral antihistamines, cromolyn, or leukotriene inhibitors 1, 2

Algorithm for Partial or Non-Response

If Partial Response to A/D Therapy

Assess remaining symptoms:

• No persistent nasal symptoms: Proceed to evaluate for asthma or gastroesophageal reflux 3
• Persistent nasal symptoms: Add topical nasal corticosteroid, nasal anticholinergic agent (ipratropium bromide), or nasal antihistamine 3, 1, 2

If Persistent UACS Symptoms Despite Topical Therapy

• Obtain sinus imaging (radiographs or CT scan) to evaluate for acute or chronic sinusitis 3
• Air-fluid levels present: Treat with antibiotics plus short-term nasal topical vasoconstrictor (α-agonist) for maximum 3-5 days 3, 1
• Mucosal thickening present: Treat presumptively for sinusitis with minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae, plus 3 weeks of oral A/D, plus 5 days of nasal decongestant, followed by 3 months of intranasal corticosteroids 1

Refractory Cases

• Refer to ear, nose, and throat specialist 3
• Measure serum immunoglobulin levels to exclude acquired hypogammaglobulinemia 3
• Consider allergy testing and environmental evaluation of home/workplace 3
• Endoscopic sinus surgery only for documented chronic infection refractory to medical therapy with anatomic obstruction 1

Critical Side Effects to Monitor

Common Side Effects

• Dry mouth and transient dizziness 1, 2

Serious Side Effects Requiring Monitoring

• Insomnia, urinary retention, jitteriness 1, 2
• Tachycardia and worsening hypertension 1, 2
• Increased intraocular pressure in glaucoma patients 1, 2

Important Clinical Pitfalls

"Silent" UACS

• Approximately 20% of UACS patients are unaware of postnasal drip or its connection to their cough 1, 2
• Some patients have no obvious symptoms yet still respond to treatment 1, 2
• Failure to consider "silent" UACS leads to missed diagnoses 1, 2

Diagnostic Challenges

• Symptoms and clinical findings are not reliable discriminators for UACS 3, 2
• Perform ear, nose, and throat examination before sinus imaging in suspected rhinosinusitis 3
• UACS can be confused with gastroesophageal reflux disease 1, 2

Medication Considerations

• Never use topical decongestants for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 1
• Antihistamines may worsen congestion in non-atopic patients by drying nasal mucosa 1
• Chronic cough is often multifactorial—UACS commonly coexists with asthma and/or gastroesophageal reflux, requiring treatment of all identified causes for resolution 3

Diagnostic Confirmation

• Diagnosis is confirmed when therapeutic intervention results in symptom resolution 5
• UACS remains a clinical diagnosis of exclusion with no definitive diagnostic testing or objective findings 5