What is the most appropriate next step in management for a 66‑year‑old man with a 12‑day persistent cough that began five days into a 10‑day cruise, no prior lung disease, and who suspects a thermal esophageal injury from hot coffee?

Management of Persistent Cough Following Suspected Thermal Esophageal Injury on Cruise Ship

Direct Answer

This 66-year-old man has subacute post-infectious cough (12 days duration) most likely acquired during his cruise ship exposure, and the suspected thermal esophageal injury from hot coffee is a red herring that does not require specific treatment. 1, 2, 3

Clinical Reasoning and Diagnostic Approach

Why This is Post-Infectious Cough, Not Thermal Injury

The timeline and clinical context strongly favor a respiratory infection acquired on the cruise ship rather than thermal esophageal injury as the cause of his persistent cough:

• The cough started 5 days into a 10-day cruise, which is the classic incubation period for viral upper respiratory infections commonly transmitted in closed environments like cruise ships 1, 2
• Cruise ships are well-documented high-risk environments for respiratory pathogen transmission 1
• The 12-day duration places this in the subacute cough category (lasting beyond 3 days but less than 8 weeks), which is most commonly post-infectious in nature 2, 3
• True thermal esophageal injuries severe enough to cause persistent symptoms typically present with dysphagia, odynophagia, and inability to swallow—not isolated cough 4, 5, 6, 7, 8
• The patient's ability to continue drinking beverages (even if iced) and the absence of reported swallowing difficulty make clinically significant thermal injury extremely unlikely 4, 6, 8

Red Flags Assessment

Before proceeding with empiric treatment, confirm the absence of features requiring urgent evaluation or chest X-ray: 1

• No respiratory distress or abnormal vital signs
• No hemoptysis, weight loss, night sweats, or fever
• No history of immunosuppression, cancer, tuberculosis, or HIV
• Clear lung examination bilaterally
• Normal oxygen saturation

If any of these red flags are present, obtain a chest X-ray immediately. 1, 2 In their absence, proceed with empiric management.

Evidence-Based Treatment Algorithm

First-Line Treatment (Initiate Now)

Start with supportive care and first-generation antihistamine-decongestant combination: 1, 2, 3

• Prescribe a first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) to address upper airway cough syndrome (UACS), which commonly accompanies or follows viral respiratory infections 9, 3
• Expected response time: noticeable improvement within days to 1-2 weeks, with marked improvement potentially taking several weeks 9, 3
• Add guaifenesin 200-400 mg every 4 hours (up to 6 times daily) as an FDA-approved expectorant to help loosen secretions 3
• Recommend honey (1-2 teaspoons as needed) for symptomatic cough suppression through central modulation of the cough reflex 2, 3
• Ensure adequate hydration and consider warm fluids for comfort 2

Second-Line Treatment (If No Improvement After 1-2 Weeks)

If cough persists or significantly affects quality of life after 1-2 weeks of first-line therapy, add inhaled ipratropium bromide: 2, 3

• Ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily has the strongest evidence for attenuating post-infectious cough 2, 3
• Expected response: 1-2 weeks 3
• Continue the antihistamine-decongestant combination as post-infectious cough is frequently multifactorial 9

Third-Line Treatment (If Cough Persists Beyond 3-4 Weeks)

Consider adding inhaled corticosteroids if quality of life remains significantly impaired: 3

• Fluticasone 220 mcg or budesonide 360 mcg twice daily 3
• Allow up to 8 weeks for full response, as this addresses ongoing airway inflammation and bronchial hyperresponsiveness 3
• Reserve oral prednisone (30-40 mg daily for 5-10 days) only for severe paroxysms that significantly impair quality of life, and only after ruling out or adequately treating UACS, asthma, and GERD 2, 3

Critical Management Pitfalls to Avoid

What NOT to Do

Do not prescribe antibiotics. 1, 2, 3 The presentation at 12 days with no fever, clear lung examination, and normal vital signs makes bacterial pneumonia extremely unlikely, and antibiotics have no role in post-infectious cough 2, 3. Inappropriate antibiotic use contributes to antimicrobial resistance and provides no clinical benefit 2.

Do not pursue evaluation or treatment for thermal esophageal injury unless dysphagia or odynophagia develops. 4, 5, 6 Thermal injuries severe enough to cause persistent symptoms present with inability to swallow, not isolated cough 4, 6, 8. The case reports of clinically significant thermal esophageal injury describe patients with severe dysphagia requiring hospitalization, endoscopy showing diffuse ulceration or pseudomembranes, and treatment with proton pump inhibitors and parenteral nutrition 4, 6, 7, 8—none of which apply to this patient.

Do not jump to oral corticosteroids as initial therapy. 3 The evidence-based algorithm prioritizes antihistamine-decongestant combination, then ipratropium, then inhaled corticosteroids, with oral steroids reserved for refractory severe cases 2, 3.

When to Reassess and Escalate

Reassessment Timeline

If cough persists beyond 8 weeks (chronic cough), systematic re-evaluation is required: 9, 3

• At 8 weeks, the diagnosis transitions from subacute post-infectious cough to chronic cough, requiring systematic evaluation for UACS, asthma, and gastroesophageal reflux disease (GERD) 9, 3
• Obtain a chest X-ray at this point if not already done 9, 3
• Consider 24-hour esophageal pH monitoring or empiric high-dose PPI therapy (omeprazole 40 mg twice daily) for GERD, even without typical GI symptoms, as "silent GERD" is common in chronic cough 9, 10
• Response to GERD treatment is more variable than for UACS or asthma, potentially requiring 2 weeks to several months 9

Red Flags Requiring Immediate Re-evaluation

Instruct the patient to return immediately if: 2, 3

• Fever develops
• Hemoptysis occurs
• Dysphagia or odynophagia develops (which would then warrant evaluation for thermal injury)
• Respiratory distress or worsening dyspnea occurs
• Weight loss, night sweats, or other systemic symptoms appear

Special Consideration: Pertussis

Remain vigilant for pertussis if the patient develops paroxysmal cough, post-tussive vomiting, or inspiratory whoop, as cruise ships can be sites of pertussis transmission. 3 Early macrolide therapy is indicated when pertussis is confirmed 3.

Multifactorial Nature of Chronic Cough

Recognize that chronic cough is frequently multifactorial—more than one cause may be present simultaneously. 9 If partial improvement occurs with one treatment, continue that therapy and add the next intervention in the algorithm rather than stopping and switching 3. The cough will not resolve until all contributing causes have been effectively treated 9, 3.