What could be causing a patient’s one‑year history of itchy throat, paroxysmal cough, and hoarseness, and how should it be evaluated and managed?

Evaluation and Management of Chronic Itchy Throat, Paroxysmal Cough, and Hoarseness

This patient requires systematic evaluation for laryngopharyngeal reflux (LPR), upper airway cough syndrome (UACS), and pertussis, with LPR being the most likely diagnosis given the triad of itchy throat, paroxysmal cough, and hoarseness persisting for one year.

Initial Diagnostic Approach

Obtain a detailed history focusing on:

• Paroxysmal cough characteristics: Ask specifically about post-tussive vomiting, inspiratory whooping sound, and whether cough occurs in sudden bursts followed by a loud inspiratory gasp 1
• Laryngeal symptoms: Assess for throat clearing, globus sensation, voice changes throughout the day, and laryngeal paresthesias (tickle, burning, tightness in throat) 2, 3
• Reflux symptoms: Question about heartburn, regurgitation, worse symptoms when lying down, and dietary triggers, though note that "silent GERD" commonly presents with cough and hoarseness without typical GI symptoms 4, 2
• Upper airway symptoms: Evaluate for nasal congestion, postnasal drip sensation, sneezing, nasal itching, and seasonal variation 1, 5
• Cough triggers: Document allotussia (cough triggered by non-tussive stimuli like talking, laughing, cold air, strong odors) and hypertussia (exaggerated cough response to normal stimuli), as these indicate cough hypersensitivity present in 100% of refractory chronic cough patients 3

Physical Examination Priorities

Perform laryngoscopy or refer to ENT for fiberoptic examination to visualize posterior laryngeal erythema, edema, cobblestoning, and vocal cord abnormalities characteristic of LPR 2. The physical exam between coughing episodes is often surprisingly unremarkable in pertussis, making direct observation of paroxysmal episodes critical 6.

Examine the nasal cavity for turbinate swelling, mucosal erythema, and clear versus purulent discharge to assess for allergic rhinitis or chronic rhinosinusitis 1.

Differential Diagnosis and Diagnostic Testing

Pertussis Evaluation (Must Rule Out First)

When cough lasts ≥2 weeks with paroxysmal episodes, diagnose pertussis unless proven otherwise 1, 7. The one-year duration makes active pertussis unlikely, but if paroxysms, post-tussive vomiting, or inspiratory whoop are present:

• Order nasopharyngeal aspirate or Dacron swab for B. pertussis culture immediately 1, 7
• Do not wait for culture results to initiate treatment if clinical suspicion is high 6, 7
• Consider paired acute and convalescent serology showing fourfold increase in IgG or IgA antibodies to pertussis toxin or filamentous hemagglutinin 1, 7

Laryngopharyngeal Reflux (Most Likely Diagnosis)

LPR is the "great masquerader" that presents with chronic hoarseness, globus pharyngeus, sore throat, chronic cough, and paroxysmal laryngospasm 2. The combination of itchy throat, paroxysmal cough, and hoarseness for one year strongly suggests this diagnosis.

• Initiate empiric high-dose PPI therapy with omeprazole 40 mg twice daily plus dietary modifications (avoid caffeine, alcohol, chocolate, late meals) 4
• Counsel that response may require 2 weeks to several months 4
• Consider 24-hour ambulatory esophageal and pharyngeal pH monitoring if diagnosis remains uncertain after empiric trial 2

Upper Airway Cough Syndrome

UACS accounts for a significant proportion of chronic cough and can present as "silent postnasal drip" with cough as the only symptom 4, 5.

• Start first-generation antihistamine-decongestant combination (brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) 4
• Add intranasal corticosteroid spray (fluticasone or mometasone) 4
• Expect improvement within days to 1-2 weeks if UACS is contributing 4

Allergic Rhinitis

If history suggests seasonal or perennial symptoms with nasal/ocular itching, sneezing, and clear rhinorrhea:

• Perform or refer for specific IgE testing (skin or blood) when diagnosis is uncertain or empiric treatment fails 1
• Key historical features include: itching of nose, palate, or eyes; seasonal pattern; exposure-associated symptoms; and family history of atopy 1

Treatment Algorithm

Step 1: Rule Out Pertussis (If Clinically Suspected)

If paroxysmal cough with post-tussive vomiting or inspiratory whoop:

• Initiate azithromycin immediately (preferred first-line macrolide) without waiting for culture 6, 7
• Isolate patient for 5 days from start of antibiotic treatment 1, 7
• Early treatment within first 2 weeks diminishes paroxysms and prevents transmission; after 3 weeks, benefit is limited 7

Step 2: Initiate Empiric Therapy for Most Likely Causes

Given the one-year duration and symptom triad, start combination therapy:

1. High-dose PPI: Omeprazole 40 mg twice daily for LPR 4
2. First-generation antihistamine-decongestant plus intranasal corticosteroid for UACS 4
3. Inhaled ipratropium bromide 2-3 puffs four times daily if post-infectious component suspected 4

Step 3: Assess Response and Adjust

Chronic cough is frequently multifactorial, and cough will not resolve until all contributing causes are treated 4. If partial improvement occurs:

• Continue current therapy and add next intervention rather than stopping and switching 4
• Allow adequate time for response: UACS responds in days to 1-2 weeks; inhaled corticosteroids require up to 8 weeks; GERD therapy may need 2 weeks to several months 4

Step 4: Consider Laryngeal Hypersensitivity and Speech Pathology

If cough persists despite medical treatment, laryngeal hypersensitivity is likely 3, 8. Laryngeal hyperresponsiveness occurs in 76% of patients with rhinosinusitis/postnasal drip, 77% with GERD, and 66% with unexplained chronic cough 8.

• Refer to speech-language pathology for multidimensional treatment including education, vocal hygiene training, cough suppression strategies, and psychoeducational counseling 9
• Speech pathology intervention produces significant reduction in cough, breathing, voice, and upper airway symptoms in refractory cases 9

Common Pitfalls to Avoid

• Do not prescribe antibiotics for chronic cough unless pertussis or bacterial sinusitis is confirmed 1, 4
• Do not dismiss pertussis in vaccinated adults—illness can be milder with absent whoop in previously vaccinated individuals 6
• Do not fail to recognize "silent GERD" or "silent postnasal drip"—both commonly present with cough as the sole symptom without typical associated complaints 4
• Do not use subtherapeutic doses of antitussives—dextromethorphan requires 60 mg for optimal cough reflex suppression, not typical OTC dosing 4
• Do not treat as simple post-infectious cough—by one year, this is chronic cough requiring systematic evaluation for UACS, asthma, and GERD 4
• Do not overlook laryngeal dysfunction—95% of refractory chronic cough patients report laryngeal paresthesias, and 50% have voice abnormalities 3

Red Flags Requiring Advanced Evaluation

Obtain chest X-ray and consider referral if:

• Hemoptysis, fever, weight loss, or night sweats develop 4
• Unilateral symptoms, severe headache, or anosmia suggest alternative diagnoses 1
• All empiric therapies fail after 8 weeks 4

Consider high-resolution CT chest and bronchoscopy to evaluate for bronchiectasis, interstitial lung disease, occult masses, or endobronchial lesions if complete workup fails 4.