Rhinosinusitis, laryngopharyngeal reflux and cough: an ENT viewpoint

Changes of the airway reactivity in patients with rhinosinusitis

Rhinosinusitis is one of the most common conditions in primary and secondary care all over the world. Rhinosinusitis together with asthma and gastroesophageal reflux disease represent the most common causes of chronic cough. The relationship between rhinosinusitis and cough is still not completely understood, however, direct stimulation of nasal mucosa, upper airway cough syndrome, inflammation of the airways, and cough reflex sensitisation play the crucial role in the pathogenesis of chronic cough.

Irritant-Induced Chronic Cough Triggers: A Scoping Review and Clinical Checklist

Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.

Chronic cough related to the upper airway cough syndrome: one entity but not always the same

Purpose

Upper airway cough syndrome (UACS), described as chronic cough (CC) associated with allergic (AR), non-allergic rhinitis (NAR) or chronic rhinosinusitis (CRS), is one of the major causes of CC. We aimed to characterize a cohort of UACS patients with special attention to differences between patients with AR and NAR.

Methods

A prospective analysis of clinical data of patients, diagnosed with UACS between 2015 and 2018.

Results

There were 143 patients diagnosed with UACS, median age 52 years, women predominance (68.5%), The group comprised of 59 (41%) AR and 84 (59%) NAR subjects, CRS diagnosed in 17 (12%). Median cough duration: 48 months (IQR 24–120), median cough severity (VAS)—60 mm (IQR 42–78), median Leicester Cough Questionnaire (LCQ) score—11.3 (IQR 8.7–13.7), never-smokers: 70%. The most common symptoms: PND (62%), rhinorrhea (59%), nasal congestion (54%), abnormalities of sinus CT: septum deviation (62%), turbinates hypertrophy (53%), mucosal thickening (53%). UACS as the only cause of CC, was presented in 20 patients (14%). We found no differences between patients with AR and NAR in terms of age, gender, duration and severity of cough, BMI, blood eosinophil count, total IgE and FeNO. AR was associated with higher comorbidity of asthma than NAR (54% vs 35%, p = 0.019). Abnormalities in sinus CT scan were more frequently found in patients with NAR than AR (p = 0.018).

Conclusion

NAR is the most common upper airway disease associated with UACS. Clinical characteristics of UACS patients with AR and NAR are similar with only minor differences between these groups. It seems reasonable to plan further studies concerning relationship of NAR and cough sensitivity, also in terms of potential similar neurogenic mechanism.

Correlation between Allergic Rhinitis and Laryngopharyngeal Reflux

Background and Objectives

Laryngopharyngeal reflux (LPR) exhibits nonspecific clinical presentations, and these symptoms may be associated with other conditions such as allergies, including allergic rhinitis and laryngitis. However, there is a gap in the literature regarding the correlation of laryngopharyngeal reflux with allergic rhinitis/laryngitis. Hence, the aim of this study is to explore the correlation between these two conditions.

Patients and Methods

A total of 126 patients with suggestive manifestations of laryngopharyngeal reflux were included in this study. Patients were classified into LPR positive and negative groups based on the results of a 24-hour oropharyngeal pH monitoring system while allergic rhinitis status was assessed with the score for allergic rhinitis (SFAR).

The results of the two groups were compared regarding the SFAR score. Correlation between the pH results and SFAR score was explored. Results

The LPR positive group demonstrated significantly higher SFAR scores compared to the negative LPR group (p < 0.0001). In addition, the Ryan score was significantly correlated with the SFAR total score and its symptomatology-related items (r ranged between 0.35 and 0.5). Conclusion. It seems that laryngopharyngeal reflux increases patients' self-rating of allergic manifestations. It appears that there is an association between laryngopharyngeal reflux and allergic rhinitis/laryngitis.

[A coughing patients makes a visit to the otorhinolaryngologist's office: the practical aspects of diagnostics and treatment]

This article summarizes the modern concepts of the most common causes and mechanism underlying the development of cough. The significance of pathogenetic cough-suppressant therapy is emphasized with special reference to the following aspects: the importance of reducing the thickness or bronchial secretions, its more efficient removal from the lumen of the respiratory passages, creation of the prerequisites for regression of the inflammatory process, lowering the intensity of cough, improvement of subjective feelings and the quality of life of a given patient. The advantages of the application of the compounded preparations containing synergic components responsible for the high therapeutic effectiveness of these medicines is demonstrated as exemplified by the ingredients of the ascoril expectorant. It is concluded that this medication should be recommended for the treatment of patients suffering from cough of the known nature.

Efficacy and safety of Qing-Feng-Gan-Ke Granules in patients with postinfectious cough: study protocol of a novel-design phase III placebo-controlled, double-blind randomized trial

BACKGROUND

Postinfectious cough (PIC) is a common condition that affects millions of people worldwide every year. There is Western medicine for this condition but the treatment effect is often incomplete. Traditional Chinese medicine (TCM) has been increasingly prescribed for patients with PIC. Preliminary trials on Qing-Feng-Gan-Ke-Granules (QFGKG) conveyed promising results in treating PIC. This protocol describes an ongoing phase III randomized controlled clinical trial, designed according to a novel methodology of "one study, one primary outcome", with the objective of evaluating the efficacy and safety of QFGKG in patients suffering from PIC.

METHODS/DESIGN

This is a multicenter, phase III, randomized, double-blind, parallel-group, placebo-controlled clinical trial, comprising two simultaneously conducted study parts, part A and part B, intending to investigate two primary outcomes, i.e. time to cough resolution and cough symptom score, respectively. A total of 480 patients, aged 18 to 65 years, who complain of an ongoing persistent cough that has been lasting ≥ 3 weeks, will be recruited from six participating sites and then randomized to receive QFGKG 12.0 g twice daily or placebo 12.0 g twice daily. Each part will enroll 240 patients, with 180 patients being allocated to the QFGKG group and 60 to the placebo group.

DISCUSSION

Although traditional Chinese medicine is a structured intervention that has shown some promise in treating persistent cough, existing unconvincing evidence has noted limitations. This is a rare well-designed and rigorously-controlled, randomized, double-blind trial to evaluate the effects and safety of a Chinese herbal medicine in patients with postinfectious cough, providing tangible benefits for clinical research. Results of this trial are inclined to be conjectured as more truthful by implementing separate study parts that specifically estimate exclusive primary outcome. It will not only provide robust clinical evidence on the efficacy and safety of QFGKG for postinfectious cough, but will also provide a critical piece of information on the availability and superiority of a novel methodology for future clinical trials. The current trial is ongoing with recruitment of the predetermined number of patients being in progress.

TRIAL REGISTRATION

The two parts of this trial were separately registered with the Chinese Clinical Trial Registry: ChiCTR-TRC-13003278 (part A); and ChiCTR-TRC-13003337 (part B).

Advances in upper airway cough syndrome

Upper airway cough syndrome (UACS), previously referred to as postnasal drip syndrome, is one of the most common causes of chronic cough. However, the pathogenesis of UACS/postnasal drip syndrome remains unclear, and physicians in countries throughout the world have different definitions and ways of treating this disease. The various proposed pathogeneses of UACS include the early postnasal drip theory, subsequent chronic airway inflammation theory, and a recent sensory neural hypersensitivity theory. Additionally, some researchers suggest that UACS is a clinical phenotype of cough hypersensitivity syndrome. While the general principles involved in treating UACS are similar throughout the world, the specific details of treatment differ. This review summarizes the various definitions, pathogenic mechanisms, treatments, and other aspects of UACS, to aid clinicians in expanding their knowledge of how to diagnose and treat this syndrome.

Honey plus coffee versus systemic steroid in the treatment of persistent post-infectious cough: a randomised controlled trial

BACKGROUND

Persistent post-infectious cough (PPC) is a cough that remains after a common cold or an upper respiratory tract infection for more than three weeks or perhaps for many months. Two of the suggested treatments for PPC are systemic steroid and honey plus coffee.

AIMS

The aim of this study was to evaluate and compare scientifically the therapeutic effects of these two regimens.

METHODS

A double-blind randomised controlled trial was conducted from 2008 to 2011 at the Baqiyatallah University Hospital, Tehran, Iran. Included in the study were 97 adults who had experienced PPC for more than three weeks. Patients with other causes of chronic cough, systemic disease, or abnormal routine laboratory tests were excluded. The participants were distributed into three groups. A jam like paste was prepared which consisted of honey plus coffee for the first group ('HC'), prednisolone for the second group (steroid, 'S'), and guaifenesin for the third group (control, 'C'). The participants were told to dissolve a specified amount of their product in warm water and to drink the solution every eight hours for one week. All the participants were evaluated before treatment and one week after completion of treatment to measure the severity of their cough. The main outcome measure was the mean cough frequency before and after one week's treatment calculated by a validated visual analogue cough questionnaire score.

RESULTS

There were 97 adult patients (55 men) enrolled in this study with the mean of age of 40.1 years. The mean (+/- SD) cough scores pre- and post-treatment were: HC group 2.9 (0.3) pre-treatment and 0.2 (0.5) post-treatment (p < 0.001); steroid ('S') group 3.0 (0.0) pre-treatment and 2.4 (0.6) post-treatment (p < 0.05); control ('C') group 2.8 (0.4) pre-treatment and 2.7 (0.5) post-treatment (p > 0.05). Analysis of variance showed a significant difference between the mean cough frequency before and after treatment in the HC group versus the S group (p< 0.001). Honey plus coffee was found to be the most effective treatment modality for PPC.

CONCLUSIONS

A combination of honey and coffee can be used as an alternative medicine in the treatment of PPC.