How do you diagnose and manage upper airway cough syndrome in adults?

Diagnosis and Management of Upper Airway Cough Syndrome in Adults

Diagnostic Approach

Upper airway cough syndrome (UACS) is a clinical diagnosis of exclusion that requires empirical treatment trials rather than extensive testing, with diagnosis confirmed by symptom resolution following targeted therapy. 1, 2

Clinical Presentation

• Look for cobblestoning of the posterior pharyngeal wall, constant throat clearing, and seasonal symptom patterns as pathognomonic findings, though approximately 20% of cases present "silently" without typical nasal discharge or drainage sensation. 1

• Rhinosinusitis symptoms (postnasal dripping, history of sinusitis) have high specificity (80.8%-90.2%) for UACS, making them useful indicators when present. 3

• Poor correlation exists between symptom severity and cough presence, so absence of prominent upper airway symptoms does not exclude UACS. 4

Initial Evaluation

• Perform ear, nose, and throat examination in preference to sinus imaging for suspected rhinosinusitis with persistent cough. 4

• Obtain chest radiograph and spirometry as mandatory baseline investigations to exclude other causes. 5

• Discontinue ACE inhibitors immediately if present, as no patient with troublesome cough should continue these medications. 5, 4

• Assess for concurrent conditions including asthma (using spirometry/methacholine challenge) and GERD, as multiple causes frequently coexist. 1, 5

Management Algorithm

First-Line Therapy

Initiate intranasal corticosteroids (fluticasone propionate 100-200 mcg daily) as first-line therapy for UACS, effective in both allergic and non-allergic rhinitis-related cough. 1, 4

• Trial topical corticosteroid for 1 month minimum when prominent upper airway symptoms are present. 4

• Add ipratropium bromide nasal spray for anticholinergic drying effects, particularly useful in patients with contraindications to oral decongestants. 1

• Implement nasal saline irrigation (not spray) for mechanical removal of mucus and inflammatory mediators, with longer treatment duration (mean 7.5 months) showing better results. 1

Important Medication Considerations

• Avoid newer-generation antihistamines (loratadine, cetirizine) for non-allergic UACS, as they are ineffective despite conflicting evidence about antihistamine efficacy overall. 1, 4

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to rhinitis medicamentosa risk. 1

Concurrent GERD Treatment

If GERD is suspected, initiate intensive acid suppression with proton pump inhibitors (omeprazole 20-40 mg twice daily) plus alginates for minimum 3 months, as reflux-associated cough may occur without gastrointestinal symptoms. 1, 4, 5

• Include dietary modifications: low-fat diet (<45g/24h), avoid coffee, tea, chocolate, citrus, and alcohol. 1

Eosinophilic Inflammation Assessment

Consider a two-week oral corticosteroid trial to exclude eosinophilic airway inflammation if initial treatment fails, as cough is unlikely due to eosinophilic inflammation without response. 5, 4

• Inhaled corticosteroids are mainstay therapy when eosinophilic airway inflammation is confirmed. 6

Monitoring and Follow-up

• Schedule follow-up in 4-6 weeks to assess response using validated cough-specific quality of life questionnaires or visual analog scales. 1, 5

• Monitor blood pressure closely given potential need for decongestants. 1

• Fibreoptic laryngoscopy is recommended for persistent upper airway symptoms despite adequate treatment trial. 4, 5

Refractory Cases

Consider chronic cough idiopathic only after thorough assessment at a specialist cough clinic, as premature diagnosis of idiopathic cough is a critical pitfall. 5, 4

• Referral to specialist cough clinic is strongly encouraged for unexplained chronic cough after complete evaluation and adequate treatment duration. 5, 4

• Recognize that multiple simultaneous causes frequently coexist, requiring additive sequential therapy rather than stopping after first intervention. 5

Critical Pitfalls to Avoid

• Never undertreat GERD: requires full 3-month trial of intensive acid suppression, not shorter durations. 5, 4

• Recognize that cough suppression may be contraindicated when cough clearance is important for secretion management. 5, 4

• Ensure adequate treatment duration before declaring treatment failure: topical corticosteroids require 1 month minimum, GERD treatment requires 3 months minimum. 4

• Use combination of selected diagnostic testing and empirical treatment trials as most cost-effective approach, rather than extensive upfront testing. 4, 5