14 January 2013
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Article series on “Cough and its Management” #1

Dr Himanshu Gul Mirani

Dr Himanshu Gul Mirani
Emergency Physician,
Urgent Care Centre

Cough is one of the most common presentations to any general practitioner or an emergency setting. It affects the quality of life to a great extent and also maybe a pointer to some very significant underlying medical ailments like Pulmonary Embolism, Gastro-esophageal reflux or heart failure.
Depending on the onset of symptoms, cough can be defined as acute if it’s for less than 3 weeks and chronic if it is for greater than 3 weeks.
Going ahead with this series of articles on cough and its management, I would share some thoughts on the common underlying pathologies manifesting as cough.
Post Nasal Drip Syndrome (PNDS):-
Common cold is one of the most common diseases encountered and thus the associated problems become equally prevalent. Post Nasal Drip Syndrome is one such associate problem with common cold and other upper respiratory tract diseases which can lead to both acute and chronic presentations.
Causes:- Common cold is usually caused from a viral pathology; the symptom of running nose can have other incrementing factors too like allergies – both seasonal and perennial, sinusitis – acute or chronic, drug abuse or indiscriminate use of nasal decongestants, fungal allergies or environmental irritants. Sometimes Autonomic Nervous System malfunction can cause a condition called vasomotor rhinitis which can again lead to PNDS.
The acuteness of the complain helps narrowing the list of differential causes.
All these conditions primarily cause increased secretions from nasal mucosa which flows down the throat and irritates it, trickling lower down to cause the cough.
Common Symptoms :-  Patients usually have symptoms of the primary complaint. For example those with common cold complain of running stuffy nose with increased watery secretions from the eyes and sensation of some fluid trickling down their throat and causing “scratchy” feeling. The symptoms are worst when the lie as the secretions gravitate down their throat from the nose. Repeated need to clear the throat (called hawking) is another common complaint.
Hoarseness of voice and excessive sputum production can also be present. In acute cases, history of nasal complaint followed by a throat involvement is usually there.
Still again there can be patients with “silent PNDS” who lack classical findings of upper airway involvement but once given a trial of medications used for PNDS, do respond favorably.
Diagnosis: - History of recent cold-like features usually point to post-infectious PNDS. Since it’s usually viral, no active tests are needed.
Sinusitis, especially chronic in nature would show up as mucosal thickening on CT scan or X-rays. Associated complaints like Deviated Nasal Septum, predisposing to sinusitis may also be detected with radiological tests.
Skin Allergy testing would be helpful to detect sensitivity against common allergens like house dust/ mite/ common plants and foods. Fungal infections and allergies are also a common cause.
Treatment options: - Treatment should be directed to treating the cause precipitating PNDS.
If its post viral, treatment with antihistaminic and nasal decongestants would suffice.
Sinusitis, if diagnosed, needs to be treated. Antibiotics have a role in acute presentations.
If an allergen is identified, then avoiding it is the best measure. Mast cell stabilizers and local steroids (as nasal sprays) are very helpful.
Vasomotor rhinitis responds well to ipratropium.
One must remember that all these medications have potential side effects like drowsiness/dizziness, causing dry mouth, difficulty in urination, increased eye pressure etc and thus need supervision prior to initiating treatment, especially if for chronic use.
Summary: - PNDS is a common cause of cough. Diagnosis is made by taking into consideration the history, clinical feature, adjunctive tests and also the response to treatment as there may be cases who are having Silent PNDS with no classical features but who show a positive response to treatment.