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Causes of Chronic Cough in Adults

There are patients who suffer from a mysterious
chronic dry cough (longer than 6 months) that seems to defy all explanation and resist all
the usual standard medications. Some of these patients have coughed for not
only months, but years resulting in frustration not only in terms of treatment, but diagnosis. Chronic cough is difficult to treat mainly
due to the many different possible triggers. As such, in order to properly diagnose and
treat chronic cough, a comprehensive evaluation is mandatory. Numerous tests will be required with the attitude
of leaving no stone unturned. Just trying medications is no longer sufficient. Let’s go thru all the possible causes of
chronic cough and potential testing required. Chronic cough due to the lungs include reactive
airway disease, infections like whooping cough and pneumonia, some type of lung mass including
cancer, as well as inflammatory or autoimmune disorders that may result in lung damage. Workup for pulmonary causes of chronic cough
may include not just a chest x-ray, but also bronchoscopy, CT Chest scans, and breathing
tests like the methacholine challenge test or fractional expired nitric oxide. The esophagus is the swallowing tube that
connects the mouth and throat to the stomach. Reflux and other forms of esophageal dysmotility
can cause chronic cough due to voicebox irritation from mucus that the esophagus may regurgitate
up into the throat. It is important to keep in mind that a patient
with chronic cough may not have any symptoms beyond the cough itself. All these symptoms may be absent: heartburn,
throat burning, choking, lump in throat sensation, or trouble swallowing. However, if such symptoms ARE present, it
does reinforce the possibility of some type of esophageal disorder. Workup for esophageal causes of chronic cough
include upper endoscopy, barium swallow, 24 hour multichannel impedance testing, manometry,
and even spit tests. Sino-nasal conditions such as allergies, chronic
sinusitis, and vasomotor rhinitis can trigger a persistent chronic cough due to a post-nasal
drip that irritates the throat. Workup for sino-nasal causes of chronic cough
include trans-nasal endoscopy, allergy testing, and CT sinus scan. Workup also includes a trial of two different
nasal sprays, an anti-histamine nasal spray as well as ipratropium nasal spray, to address
vasomotor rhinitis for which no good test exists. There are certain drug classes known to commonly
cause a chronic cough as a side effect. The biggest culprits are certain blood pressure
medications known as ACE-inhibitors. Less commonly, another class of blood pressure
medications called angiotensin receptor blockers may also cause chronic cough as a side effect. Some patients with chronic cough ultimately
find that certain foods trigger a persistent cough. The most common foods that have been found
to cause chronic cough are wheat, dairy, and egg. Keep in mind that food sensitivities should
not be confused with food allergies nor should it be confused with foods that may cause reflux. Finally, a patient’s chronic cough may be
due to nerve damage involving the throat nerve responsible for the cough reflex. Normally, the nerve senses a throat irritant
which then triggers a cough reflex. With nerve damage, the nerve may become hyperactive
triggering a constant reflexive cough even in the absence of a significant throat irritant. Normal throat activities like breathing or
allergic post-nasal drip will trigger a cough when normally it would not. Once the cause of chronic cough has been determined,
treatment can then be initiated with successful resolution of the chronic cough. Keep in mind that it is not unusual in patients
with chronic cough going on years that more than one cause may ultimately be found to
be present and as such, multiple different treatments may be required. A full chronic cough workup may require seeing
multiple different specialists including an ENT, gastroenterologist, allergy specialist,
pulmonologist, and neurologist.

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