Treatment of Cough and Cobblestoning of the Pharyngeal Wall
Cobblestoning of the pharyngeal wall is a hallmark finding of Upper Airway Cough Syndrome (UACS), and the most effective first-line treatment is a first-generation antihistamine/decongestant combination, such as dexbrompheniramine plus sustained-release pseudoephedrine or azatadine plus sustained-release pseudoephedrine. 1
Understanding the Clinical Presentation
Cobblestoning of the posterior pharyngeal wall, along with throat clearing and cough, represents the cardinal features of UACS (formerly called postnasal drip syndrome). 1 This condition is the most common cause of chronic cough in adults. 1, 2 Importantly, approximately 20% of patients have "silent" UACS with no obvious postnasal drip symptoms yet still respond to treatment directed at the upper airway. 1, 2
First-Line Treatment Algorithm
Initial Therapy (Days 1-14)
Start with a first-generation antihistamine/decongestant combination as empiric therapy. 1 The American College of Chest Physicians specifically recommends:
- Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, OR 1
- Azatadine maleate plus sustained-release pseudoephedrine sulfate 1
Critical point: First-generation antihistamines are superior to newer non-sedating antihistamines due to their anticholinergic properties, which provide additional drying effects. 1 Second-generation antihistamines (like fexofenadine or loratadine) are ineffective for non-allergic UACS and should not be used. 1, 2
To minimize sedation: Start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy. 1
Expected response: Most patients will see improvement within days to 2 weeks of initiating therapy. 1
If No Response After 1-2 Weeks
Add intranasal corticosteroids for a 1-month trial: 1, 2
Intranasal corticosteroids are effective for both allergic and non-allergic rhinitis-related UACS. 1 A single randomized controlled trial demonstrated that intranasal steroids given for 2 weeks are effective in allergic rhinitis-related cough. 1
Alternative for Patients with Contraindications
If the patient has contraindications to decongestants (hypertension, cardiovascular disease, glaucoma):
- Ipratropium bromide nasal spray (42 mcg per spray, 2 sprays per nostril 4 times daily) provides anticholinergic drying effects without systemic cardiovascular side effects. 1, 2
- This is particularly effective for reducing rhinorrhea. 2
Adjunctive Therapy
Nasal saline irrigation improves symptoms through mechanical removal of mucus, enhanced ciliary activity, and disruption of inflammatory mediators. 2 Irrigation is more effective than saline spray because it better expels secretions. 2
If Symptoms Persist After 2 Weeks of Adequate Upper Airway Treatment
Proceed with sequential evaluation for other common causes of chronic cough: 1
Asthma/Non-asthmatic eosinophilic bronchitis - Consider bronchial provocation testing if spirometry is normal. 3
Gastroesophageal reflux disease (GERD) - Initiate empiric therapy with:
Important: Maintain all partially effective treatments rather than discontinuing them prematurely, as UACS, asthma, and GERD together account for approximately 90% of chronic cough cases. 1
Critical Side Effects to Monitor
Common side effects of first-generation antihistamines: 1
- Dry mouth
- Transient dizziness
Serious side effects requiring monitoring: 1
- Insomnia
- Urinary retention
- Jitteriness
- Tachycardia
- Worsening hypertension
- Increased intraocular pressure in glaucoma patients
Decongestant-specific concerns: 2
- Can cause insomnia, irritability, palpitations, and hypertension
- Monitor blood pressure after initiating therapy 1
Common Pitfalls to Avoid
Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to the risk of rhinitis medicamentosa (rebound congestion). 2, 4
Do not rely on symptoms or physical findings alone for diagnosis. The diagnosis of UACS is confirmed by response to specific therapy, not by symptoms or physical findings. 3, 1 Symptoms and clinical findings are not reliable discriminators for establishing postnasal drip as the cause of cough. 3
Do not overlook "silent" UACS. Failure to consider silent UACS as a causative factor can lead to missed diagnoses. 1, 2
Avoid using second-generation antihistamines as monotherapy for non-allergic UACS, as they lack the anticholinergic properties necessary for effectiveness. 1, 2
Special Considerations for Allergic Rhinitis
If allergic rhinitis is the underlying cause, consider adding: 1