CHRONIC COUGH rhinitis-postnasal drip syndrome Upper airway cough syndrome Sevim Bavbek, M.D. Ankara University, School of Medicine Department of Allergy - PowerPoint PPT Presentation

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CHRONIC COUGH rhinitis-postnasal drip syndrome Upper airway cough syndrome Sevim Bavbek, M.D. Ankara University, School of Medicine Department of Allergy

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Title: CHRONIC COUGH rhinitis-postnasal drip syndrome Upper airway cough syndrome Sevim Bavbek, M.D. Ankara University, School of Medicine Department of Allergy


1
CHRONIC COUGHrhinitis-postnasal
dripsyndromeUpper airway cough
syndromeSevim Bavbek, M.D.Ankara University,
School of MedicineDepartment of Allergy
2
  • Cases
  • Introduction-definition
  • Prevalence
  • Pathogenesis
  • Diagnosis-Diferential diagnosis
  • Treatment

3
Case-1
  • 21 year-old, female, university student
  • She has been suffering sneezing, nasal discharge,
    itching in eyes, nose and ears for 3 years during
    pollen season
  • She has been couging for a month
  • Management?

4
Case-2
  • 28 years-old, dentist
  • She has been suffering dry cough for 2 months
  • Some difficulties in her work and family
    relationship
  • Operation for sinusitis has been suggested a year
    ago
  • On nasal steroid, oral antihistamine/deconjestant
  • Management?

5
Problems
  • Syndrome?
  • Symptom?
  • Lack of objective testing
  • Wastebasket symptom complex?
  • American invention?
  • Upper airway cough syndrome

6
Differential diagnosis for cough in an adult
  • PND
  • Allergic rhinitis
  • Chronic sinusitis
  • GERD/LPR
  • Cough-variant asthma
  • ACE Inhibitor medications
  • Pertussis (whooping cough)
  • Neurogenic
  • Traumatic vagal injury
  • Post-URI neuropathy
  • Psychogenic
  • Chronic aspiration
  • Zenkers diverticulum
  • Foreign body
  • Tracheobronchial tree
  • Laryngopharynx
  • Sinonasal
  • External auditory canal
  • Chronic bronchitis
  • Bronchiectasis
  • Lung carcinoma
  • Subglottic stenosis
  • Tracheomalacia
  • Tracheoesophageal fistula
  • Tuberculosis
  • Sarcoidosis
  • Congestive heart failure

URI, upper-respiratory infection.
Simpson CB. et al. OtolaryngologyHead Neck Surg
2006 134 693-700
7
Percentage of cases presenting one, two, three
and four causative factors
Palombini BC et al. Chest 1999 116 2
8
Comparison of the results of four studies about
the most common single causes of chronic cough.
of patients
Palombini BC et al. Chest 1999 116 2
9
Commonest causes of chronic cough in patients
investigated in specialist clinics
Morice AH. Eur Respir J 2004 24 481492
10
Etiologic factors of chronic cough in the
patients, distributed as the pathogenic triad of
chronic cough
PNDS
ASTHMA
GERD
Palombini BC et al. Chest 1999 116 2
11
Overlap between diagnostic abnormalities in
patients with chronic cough
SCL-90
PNDS
BHR
EOS
Carney IK et al. Am Rev Respir Crit Care Med
1997156211-16
12
Relationship between bronchial and EA
responsiveness during exacerbation of sinusitis
1.8 1.5 1.2 0.9 0.6 0.3 0 -0.3 -0.6
r0.75 plt0.001
PC25 MIF50 log(mg/ml)
-0.6 -0.3 0 0.3 0.6 0.9 1.2 1.5 1.8
PC20 FEV1 log(mg/ml)
Bucca C et al. J Allergy Clin Immunol
199595.'52-9
13
Location of cough receptors and associated
sensory nerve
Greatest concentration of cough receptors.
14
Potential actions of and interactions between the
vagal afferent nerves mediating cough
Canning BJ. et al. Chest 2006 12933S47S
15
Upper airway cough syndrome
  • History
  • Cough
  • Post nasal drip
  • Tickle in the throat
  • Frequent throat cleaning
  • Nasal congestion, discharge
  • Hoarseness
  • Silent
  • Physical exam
  • Mucoid/muco-purulent secretions
  • Cobblesto appearance

16
Upper airway cough syndrome
  • diagnosis

history
physical exam
laboratory
treatment
17
Upper airway cough syndrome
  • Differential diagnosis
  • Allergic rhinitis
  • Nonallergic rhinitis
  • Post-infectious UACS
  • NARES
  • Bacterial sinusitis
  • Allergic fungal sinusitis
  • Rhinitis due to anatomical abnormalities
  • Rhinitis due to physical or chemical irritants
  • Occupational rhinitis
  • Rhinitis medicamentoza
  • Gestational rhinitis

18
Cough counts/hour in healthy controls and
patients with chronic cough
150 125 100 75 50 25 0
Coughs/hour
plt0.001
Normal
Chronic cough
Birring SS et al., Respir Med 20059(23)
19
Complications of Cough-1
Irwin RS. Chest 2006 12954S58S
20
Complications of Cough-2
Irwin RS. Chest 2006 12954S58S
21
Complications of Cough-3
Irwin RS. Chest 2006 12954S58S
22
Spectrum and frequency of reasons why patients
with chronic cough sough medical care
N 39. The relative frequencies for the 28
patients used in the major analyses of this study
were similar. AIDS indicates acquired
immunodeficieny syndrome TB tuberculosis.
French CL. Arch Intern Med 158(10) 1657-1661,
1998
23
Sickness Impact Profile (SIP) scores at baseline
in patient with chronic cough
French CL. Arch Intern Med 158(10) 1657-1661,
1998
24
Sickness Impact Profile (SIP) scores before and
after successful treatment of chronic cough at
baseline in patient with chronic cough
p.003
plt.02
6 4 2 0
6 4 2 0
6 4 2 0
p.05
Physical Score,
Total SIP Score,
Physicososyal Score,
Before
After
Before
After
Before
After
Treatment
Treatment
Treatment
French CL. Arch Intern Med 158(10) 1657-1661,
1998
25
Symptoms of allergic rhinitis
C.van Drunen et al. Allergy 2005605-19
26
Treatment of allergic rhiitis
27
Treatment
  • Antihistamins
  • Steroids
  • Mast cell stabilizators
  • Decongestans
  • Antihistaminik ve dekonjestan kombinasyonu
  • Anticholinerjics
  • Leucotriene antagonists

28
Nonallergic rhinitis NARES
  • Nasal symptoms similar to those of vasomotor
    rhinitis
  • Additionally, pruritus of nasal and ocular
    mucosae and lacrimation are common
  • Clinical findings
  • Eosinophils in nasal secretions

DIAGNOSIS
  • Nasal cs.

TREATMENT
Pratter MR. Chest 2006 12963S-71S
29
Nonallergic rhinitis Vasomotor rhinitis
  • Excessive,thin watery secretions often in reponse
    to odors, changes in temperature or humidity,
    eating, or alcohol ingestion
  • DIAGNOSIS History and exclusion of other
    diseases
  • TREATMENT Ipratropium bromide

30
Postinfectious UACS
  • Persistent cough lasting gt3 weeks after
    experiencing the acute symptoms of an upper
    respiratory tract infection
  • DIAGNOSIS A history of a upper respiratory tract
    infection
  • TREATMENT Antihistamine/decongestant
    combination
  • Systemic cs? Ipratropium bromide?

31
(No Transcript)
32
Symptoms of rhinosinusitis
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33
Symptoms suggestive of chronic sinusitis
  • Initial evaluation
  • History
  • Physical examination
  • Consider sinus CT and/or nasal endoscopy
  • Evaluate underlying risk factors
  • Consider consultation with a specialist for
    evaluation underlying risk factors
  • Treatment
  • Antibiotics
  • Antiinflammatory and/or decongestant therapy

Refractory Chronic Sinusitis
  • Consider non-infectious hyperplastic eosinophilic
    sinusitis
  • Consider consultation with a surgeon
  • Continued individualized medical therapy

Sinusitis Update Workgroup. JACI 2005116S13-47
34
Allergic Aspergillus sinusitis
35
Diagnosis
  • Radiological evaluation
  • Histopathological evaluation
  • Nasal lavage evaluation
  • Serolojik testings

Shah a. ACII 200517(5)172-180
36
Therapeutic suggestions for allergic fungal
sinusitis
  • Prednisone and topical intranasal corticosteroid
  • Sinus irrigation if necessary
  • Follow-up CT scans of sinuses
  • After 8 weeks, discontinue prednisone and
    continue topical corticosteroids

Greenburger PA. Allergic bronchopulmoner
aspergillosis 1995 p53-55
37
Case-1
  • Skin prick test Highly pozitif for grass pollen
  • Pulmonary function testing Normal
  • Treatment Nasal steroid and antihistamine

38
Case-2
  • Skin prick test Negatif
  • Pulmonary function testing Normal
  • Bronchial provocation test
  • Methacholine Pc20 2.3 mg/ml
  • Treatment inhaled steroidsinus surgery

39
Conclusions
  • Upper airway cough syndrome seems to be more
    accurate (UACS)
  • The diagnosis should be determined by a
    combination of symptoms, physical examination
    findings, radiographic findings, and response to
    specific therapy
  • Specific treatment should be directed at the
    cause of cough
  • Empiric therapy for UACS with 1st generation
    antihistamine/decongestan should be prescribed
    before extensive diagnostic workup.

Pratter MR. Chest 2006 12963S-71S
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