What are the potential diagnoses for my symptoms, including tonsil stones, overactive mucus production, persistent cough, nasal regurgitation, outdoor exercise-induced rhinitis, post-nasal drip, chronic throat clearing, and exercise-induced asthma (already treated with an inhaler)?

Differential Diagnosis for Your Symptom Complex

Most Likely Diagnoses (Ordered by Probability)

1. Upper Airway Cough Syndrome (UACS) with Chronic Rhinosinusitis

This is the most likely diagnosis given your constellation of symptoms. 1

• Your combination of post-nasal drip, chronic throat clearing, persistent cough (>5 years), overactive mucus production, and nasal regurgitation are classic hallmarks of UACS, which accounts for the majority of chronic cough cases in patients with normal chest radiographs 1, 2
• UACS, asthma, and gastroesophageal reflux together account for 93.6% of chronic cough cases, with UACS being present in 57.6% of chronic cough patients 2
• The presence of tonsil stones suggests chronic inflammation and mucus stasis in the upper airway, consistent with chronic rhinosinusitis 1
• Your outdoor exercise-induced rhinitis indicates environmental allergen sensitivity that perpetuates the inflammatory cycle 1
• Critical point: UACS can occur with "silent" post-nasal drip where patients may not always perceive the drainage, but chronic throat clearing is a key indicator 1
• The nasal sensory nerve activation from chronic rhinosinusitis directly sensitizes cough receptors, explaining your persistent cough even with inhaler treatment for asthma 3

2. Mixed Rhinitis (Allergic and Vasomotor Components)

Your symptoms strongly suggest overlapping allergic and non-allergic rhinitis mechanisms. 1

• The outdoor exercise-induced rhinitis points to seasonal or perennial allergic rhinitis triggered by environmental allergens 1
• Overactive mucus production with exercise suggests vasomotor rhinitis, characterized by excessive watery secretions in response to temperature changes, humidity, and physical activity 1
• Mixed rhinitis occurs in 44-87% of patients with allergic rhinitis, making this a highly probable diagnosis 4
• The chronic nature (>5 years) indicates perennial allergen exposure (dust mites, molds, animal dander) combined with vasomotor triggers 1
• Your exercise-induced symptoms could represent both allergic triggers from outdoor allergens and autonomic dysregulation causing vasomotor responses 1

3. Exercise-Induced Laryngeal Dysfunction (EILD) / Vocal Cord Dysfunction

Your exercise-induced symptoms may involve upper airway obstruction rather than purely lower airway disease. 1

• Exercise-induced asthma treated with inhaler may be partially masking concurrent EILD, which presents with throat tightness and breathing difficulties during exercise 1
• EILD can coexist with exercise-induced bronchoconstriction, and beta-agonist inhalers are ineffective for the laryngeal component 1
• Chronic throat clearing and post-nasal drip can contribute to laryngeal irritation and vocal cord dysfunction 1
• The nasal regurgitation you describe could indicate supraglottic dysfunction during swallowing, related to laryngeal abnormalities 1
• Key differentiator: EILD symptoms peak during exercise (not after), with inspiratory stridor and throat tightness that resolves within 5 minutes of stopping exercise 1

4. Gastroesophageal Reflux Disease (GERD) with Laryngopharyngeal Reflux

GERD frequently mimics and coexists with upper airway conditions causing chronic cough. 1, 2

• GERD is present in 41.1% of chronic cough patients and is part of the "pathogenic triad" (asthma, UACS, GERD) responsible for 93.6% of chronic cough cases 2
• Laryngopharyngeal reflux can cause chronic throat clearing, post-nasal drip sensation, and persistent cough without classic heartburn symptoms 1
• The presence of tonsil stones may be exacerbated by acid reflux creating an inflammatory environment in the oropharynx 1
• GERD can sensitize cough receptors and contribute to exercise-induced symptoms through microaspiration 2
• Posterior laryngeal changes from reflux are common in patients with vocal cord dysfunction and chronic upper airway symptoms 1

5. Bronchiectasis with Secondary Upper Airway Involvement

While less likely given your symptom pattern, bronchiectasis should be considered with chronic productive cough. 1

• Chronic productive cough (>5 years) with overactive mucus production can indicate bronchiectasis, though this is present in only 17.9% of chronic cough patients 1, 2
• However, upper airway cough syndrome is far more common (40% vs 4%) as a cause of excessive sputum production than bronchiectasis 1
• Your tonsil stones and post-nasal drip make upper airway pathology much more likely than primary lower airway disease 1
• The fact that your exercise-induced symptoms respond to inhaler treatment argues against significant bronchiectasis, which would show progressive symptoms despite bronchodilator therapy 1
• Bronchiectasis typically presents with daily purulent sputum production, recurrent infections, and crackles on examination—features not emphasized in your symptom description 1

Key Clinical Reasoning

The most important diagnostic consideration is that 61.5% of chronic cough patients have multiple simultaneous causes 2. Your symptom complex likely represents overlapping UACS, mixed rhinitis, and possibly GERD, all contributing to cough reflex sensitization through different mechanisms 3. The exercise-induced component may involve both true bronchospasm (responding to your inhaler) and laryngeal dysfunction (not responding to inhaler) 1.