Rhinitis, sinusitis, and upper airway disease
Chronic cough and irritable larynx

https://doi.org/10.1016/j.jaci.2010.10.038Get rights and content

Background

Perennial rhinitis (PR), chronic rhinosinusitis (CRS), or both, asthma, and gastroesophageal reflux disease (GERD) are the most frequent triggers of chronic cough (CC). Extrathoracic airway receptors might be involved in all 3 conditions because asthma is often associated with PR/CRS and gastroesophageal refluxate might reach the upper airway. We previously found that most patients with rhinosinusitis, postnasal drip, and pharyngolaryngitis show laryngeal hyperresponsiveness (LHR; ie, vocal cord adduction on histamine challenge) that is consistent with an irritable larynx.

Objective

We sought to evaluate the role of LHR in patients with CC.

Methods

LHR and bronchial hyperresponsiveness (BHR) to histamine were assessed in 372 patients with CC and in 52 asthmatic control subjects without cough (asthma/CC−). In 172 patients the challenge was repeated after treatment for the underlying cause of cough.

Results

The primary trigger of CC was PR/CRS in 208 (56%) patients, asthma in 41 (11%) patients (asthma/CC+), GERD in 62 (17%) patients, and unexplained chronic cough (UNEX) in 61 (16%) patients. LHR prevalence was 76% in patients with PR/CRS, 77% in patients with GERD, 66% in patients with UNEX, 93% in asthma/CC+ patients, and 11% in asthma/CC− patients. Upper airway disease was found in most (95%) asthma/CC+ patients and in 6% of asthma/CC− patients. BHR discriminated asthmatic patients and atopy discriminated patients with PR/CRS from patients with GERD and UNEX. Absence of LHR discriminated asthmatic patients without cough. After treatment, LHR resolved in 63% of the patients and improved in 11%, and BHR resolved in 57% and improved in 18%.

Conclusions

An irritable larynx is common in patients with CC and indicates upper airway involvement, whether from rhinitis/sinusitis, gastric reflux, or idiopathic sensory neuropathy.

Section snippets

Methods

All the consecutive patients who presented with CC as their main symptom in the period between January 2002 and June 2008 and had normal spirometric and chest radiographic results were enrolled in the study. The exclusion criteria were as follows: severe systemic illnesses; known bronchopulmonary diseases; acute respiratory tract infections in the last 2 months; treatment with H1- and H2-antihistaminic, antitussive drugs, bronchodilators, oral corticosteroids, or ICSs in the last month, and

Results

According to the diagnostic criteria, the distribution of the 372 patients within each class was as follows: PR/CRS, 208 (56%) patients, 123 with PR and 85 with CRS; GERD, 62 (17%) patients, 51 with laryngeal involvement; UNEX, 61 (16%) patients; and asthma/CC+, 41 (11%) patients, 39 (95%) with persistent rhinitis, sinusitis, or both.

The general characteristics of the patients in the 4 CC classes and of the 52 asthma/CC− control subjects are compared in Table I. The most significant differences

Discussion

The results of this study indicate that an irritable larynx is very common among patients who present with CC as the main symptom. In fact, most of the 372 patients with CC examined showed LHR, consisting of a dose-dependent decrease in inspiratory flows during histamine challenge. In 164 (44%) patients LHR was the only functional abnormality and would have been missed by recording FEV1 as the response variable.

In agreement with the literature,1, 2, 29 the most common triggers of CC were

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    Supported by grants from Regione Piemonte, funds for Applied Scientific Research (2004), and the Italian Ministry of Instruction, University and Research (MIUR, 2002).

    Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest.

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