Can esophageal structural abnormalities cause chronic cough?

Can Esophageal Structural Abnormalities Cause Chronic Cough?

Yes, esophageal structural abnormalities definitively cause chronic cough, and treatment of these structural lesions resolves cough in the vast majority of affected patients.

Evidence for Structural Esophageal Causes

The most compelling evidence comes from a prospective case series demonstrating that structural esophageal abnormalities directly cause chronic cough and their treatment eliminates the symptom. When barium esophagram identified structural abnormalities (hiatal hernia, achalasia, neoplasm, and diverticulum) in 12 patients with chronic cough, appropriate therapy resolved cough in 11 out of 12 patients (92% cure rate) 1. This near-complete resolution after treating the structural abnormality establishes causality, not just association.

Specific Structural Abnormalities That Cause Cough

The following structural lesions have been documented to cause chronic cough 1:

• Hiatal hernia - associated with chronic aspiration and reflux-mediated cough
• Achalasia - causes cough through esophageal stasis and potential aspiration
• Esophageal stricture - impairs normal esophageal clearance
• Esophageal neoplasm - mechanical obstruction and dysmotility
• Esophageal diverticulum - food/fluid retention leading to aspiration risk
• Esophageal webs - anatomic obstruction

Mechanisms Linking Structure to Cough

Structural abnormalities cause cough through three distinct pathways 2, 3:

1. Esophageal-bronchial reflex pathway: Structural lesions that cause stasis or reflux stimulate vagal afferents in the distal esophagus, triggering cough without requiring aspiration 2, 4

2. Microaspiration/macroaspiration: Structural abnormalities (particularly hiatal hernia and diverticula) promote chronic aspiration of gastric contents into airways 1, 2

3. Upper airway irritation: Refluxate reaching the larynx due to structural incompetence causes direct mucosal irritation 2

Esophageal Dysmotility as a Structural-Functional Abnormality

Esophageal dysmotility represents a critical structural-functional abnormality frequently overlooked in chronic cough evaluation. In patients with chronic cough, abnormal esophageal manometry was found in 32% as the only abnormal test, and overall 85% of cough patients with reflux symptoms had either abnormal manometry alone or combined with pH abnormalities 5. Importantly, gastroesophageal scintigraphy has demonstrated esophageal dysmotility causing cough-like symptoms even when reflux is absent 1, suggesting dysmotility itself—independent of acid exposure—can trigger cough.

Diagnostic Approach

Clinical Profile Suggesting Structural Esophageal Disease

Look for these specific features 2, 6:

• Cough associated with meals (occurring during eating or within 2 hours post-meal) - 86.7% positive predictive value for esophageal cause 6
• Positional worsening (nighttime, recumbent position) 2
• Dysphagia or regurgitation (though 75% of patients with esophageal-induced cough have NO gastrointestinal symptoms) 2, 4, 7
• Normal chest radiograph 2, 3

Diagnostic Testing Strategy

Barium esophagram is the appropriate initial imaging study when structural esophageal disease is suspected as a cause of chronic cough 1. The examination evaluates:

• Anatomic pathology (webs, hiatal hernia, stricture, masses, diverticula) 1
• Esophageal dysmotility 1
• Gastroesophageal reflux 1

Critical limitation: Standard 24-hour pH monitoring has significant limitations—it was abnormal in only 4 out of 11 patients with reflux-induced cough confirmed by other methods, meaning it missed 64% of cases 1. Barium esophagram can reveal reflux to the mid-esophagus or higher even when pH monitoring is normal (non-acid reflux) 1.

Esophageal manometry should be considered when barium study and pH monitoring are unrevealing, as it identifies dysmotility in 32% of chronic cough patients as the sole abnormality 1, 5.

Treatment Implications

When structural esophageal abnormalities are identified, definitive treatment of the structural lesion should be pursued rather than empiric medical management alone 1. The 92% resolution rate after treating identified structural abnormalities demonstrates this approach prioritizes morbidity and quality of life outcomes 1.

For patients without identified structural lesions but with reflux-related cough, intensive antireflux therapy is indicated, including proton pump inhibitors, positional therapy (head of bed elevation, avoiding meals within 3 hours of bedtime), and dietary modifications 2. Laparoscopic antireflux surgery achieves 85-86% improvement in chronic cough when medical therapy fails 2.

Common Pitfalls

• Assuming absence of heartburn excludes esophageal disease: Up to 75% of patients with esophageal-induced cough have "silent" GERD with no typical GI symptoms 2, 3, 4, 7
• Relying solely on 24-hour pH monitoring: This test has only ~90% sensitivity and misses non-acid reflux events entirely 1
• Overlooking esophageal dysmotility: Manometry abnormalities occur in the majority of reflux-cough patients and may be the only finding in one-third 1, 5
• Not obtaining barium esophagram: This simple test identifies treatable structural lesions that resolve cough in >90% of cases when treated 1