Presented by Ms Romana Kuchai MRCS DLO MD FRCS (ORL-HNS) Consultant ENT Surgeon

1. is pleased to welcome you to ‘Cough and the larynx’ Presented by Ms Romana KuchaiMRCS DLO MD FRCS (ORL-HNS) Consultant ENT Surgeon

2. A cough is defined- ‘as a forced expiration against a closed glottis, which opens suddenly, with a characteristic sound and expulsion of secretions and foreign materials from the respiratory tract’

3. Can be voluntary or involuntary • Often repetitive

4. 40 % of the population experience chronic cough in their life-time • More common in women

5. Acute cough- lasts upto 3 weeks • Sub-acute cough- lasts 3-8 weeks • Chronic cough- 8 weeks or more

6. Principle function of the larynx is to protect the airway • Involuntary process that happens during the pharyngeal phase of swallowing. • Prevents food penetrating the larynx • In humans the larynx is lower in the neck compared to other mammals- greater risk of aspiration and reflux

8. Multiple aetiologies may explain why many authorities are hypothesizing a- ‘cough hypersensitivity syndrome’ The concept of a hypersensitive larynx serves well when treating patients

9. ‘one airway, one disease’ considers the upper and lower airway as a continuum where inflammation can be secondary to a common pathology

10. common causes: • Post nasal drip (upper airway cough syndrome) or PND • Gastro-oesophageal reflux or GERD • Asthma Yet small percentage of patients with these symptoms suffer with chronic cough

11. Management • History/Examination • FNE • CXR • SPT • Gastroenterology referral if definitive medical therapy failed

12. Poor swallow • Where there are concerns- video fluoroscopic swallow with an experienced radiologist and swallowing therapist

14. Post nasal drip • Allergic rhinitis • Chronic rhinosinusitis- main cause of PND • Nasal polyps • NB only a small number of patients with PND Syndrome complain of cough

15. No objective way of assessing PND • American college of chest physicians suggest ‘Upper airway cough syndrome’

16. Treatment of PND • ARIA Guidelines if allergic rhinitis- topical intranasal steroids with or without anti-histamines • EPOS guidelines if CRS with or without polyps • Treat for 3 to 6 months

17. Gawchik et al (9) in the only randomised control trial showed topical steroids were effective upon chronic cough, associated with post nasal drip syndrome, following a 2-8 week course • Multi-centre RCT double blind trial- mometasone furoate upon SR related cough for 14 days. Daytime cough group improved

18. Infections of the larynx • Chronic cough is associated with infections of the larynx • There must be pre-existing inflammation • Chronic cough may however also traumatise the larynx and cause hyper-reactivity

19. GERD • Gastroesophageal reflux disease (GERD) is considered to be the cause of chronic cough in up to 40% of patients • Based on symptoms scoring and 24 pH monitoring • ? Proteolytic enzymes and bile salts related to laryngeal irritation

20. Symptoms of reflux • Frequent clearing of throat • Hoarseness • Dysphagia • Feeling of mucus in the back of the throat • Heartburn • Sensation of a lump in the throat

21. ENT Surgeons believe posterior erythema of the larynx indicates LPR • Belafsky et al with dual probe monitoring found the most common sign to be posterior laryngeal hypertrophy (85%) Laryngeal ventricle obliteration was found in 80%

22. Standard 24 hour pH studies report reflux events where the pH drops below pH 4 for at least 6 seconds and for greater than 5% off the time of monitoring. • The gold standard for diagnosis of LPR remains multichannel intraluminal impedance manometry (IMM) .

23. Treatment of LPR • PPI- aggressive treatment for upto 3 months • Alginate to deal with non acidic component of refluxate • Lifestyle changes are complementary and crucial • Refractory cases are referred for anti-reflux surgery- Nissen’s Fundoplication

24. Disorders in swallowing • 2% of population suffers with presbyphagia- age related swallowing problems • These are often compounded by poor dentition, increased pharyngeal transit time and neurological issues

25. Disorders leading to swallowing problems

26. Swallowing disorders- Investigations • Video swallow • FEES • Barium swallow- pharyngeal pouch

28. Laryngeal dysfunction • Hypersensitivity associated with hyper-responsiveness • NB- Cough is the only motor reflex of sensory activation • Ryan et al- found PVD- paradoxical vocal fold movement in 56% of patients • PVD can mimic asthma- cough, SOB and wheeze

30. Laryngospasm • Spasm of vocal folds temporarily interrupts breathing • May last upto 30 secs without LOC • Reflux and allergy are associated • Patients advised to sniff to break the spasm • Intra-laryngeal botox injection

31. Laryngotrachealstenosis • May simulate asthma • Poor exercise tolerance and difficulty in breathing • Congenital or acquired • 50% in adulthood are related to ventilation in ITU

33. Systemic conditions • Sarcoidosis- supraglottis • Wegener’s- subglottis and tracheobronchial tree • MDT • Surgical and complementary medical therapy

34. Other causes • Lesions- benign or malignant • Psychogenic- Attention, cognition, emotion, learning and social factors associated with cortical and psychogical sub-functions they subserve

35. Conclusions • Chronic cough is common but complex • MDT approach • ENT- Direct endoscopic examination identifies signs that can otherwise be missed • Treatment depend upon cause

36. Advice to patient • Carry water – take a sip of cold water to suppress the urge to cough • ‘Humm’ or gently throat clear until you get to the water as this causes less trauma to the larynx than a cough • Steam inhalation – ten minutes two to three times a day will be soothing to the larynx add menthol crystals if preferred

37. sleep with head of bed elevated • -lose weight (if advice is appropriate) • -dietary changes to minimise gastric reflux • -avoid allergens or cough triggers

38. References • 1. Morice A, Kastelik J. Cough 1: chronic cough in adults. Thorax. 2003;58:901-7. • 2. Morice A, McGarvey L, Pavord I. BTS Guidelines: recommendations for thee management of cough in adults. Thorax. 2006;61(suppl 1):1-24. • 3. Morice A, Faruqi S, Wright C, Thompson R, Bland J. Cough hypersensitivity syndrome: a distinct clinical entity. Lung. 2011;189(1):73-9. • 4. Morice A, Fontana G, BelvisiM, Birring S, Chung K, al e. ERS guidelines on the assessment of cough. EurRespir J. 2007;29:1256-76. • 5. Thomas M, Yawn B, Price D, Lund V, Mullol J, Fokkens W, et al. EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007. Prim Care Respir J. 2008;17(2):79-89. • 6. Morice A. Post-nasal drip syndrome - a symptom to be sniffed at? PulmPharmacolTher. 2004;17:343-5. • 7. Pratter M. Chronic upper airway cough syndrome secondary to rhinosinus disease (previously referred to as postnasal drip syndrome). Chest. 2006;129:63S-71S. • 8. Bousquet J, Schunemann H, Samolinski B, al e. Allergic Rhinitis and its impact on Asthma (ARIA): Achievements in 10 years and future needs. J Allergy ClinImmunol. 2012;130(5):1049-62. • 9. Gawchik S, Goldstein S, Prenner B, John A. Relief of cough and nasal symptoms associated with allergic rhinitis by mometasonefuroate nasal spray. Ann Allergy Asthma Immunol. 2003;90:416-21. • Kastelik J, Aziz I, Ojoo J, Thompson R, Redington A, Morice A. Investigation and management of chronic cough using a probability based algorithm. EurRespir J. 2005;25:235-43. 11. Belafsky PC, Postma GN, Koufman J. Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope. 2001;111(6):979-81. 12. Blager F. Paradoxical cvocal cord movement: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2000;8. 13. Ryan N, Vertigan A, Bone S, Gibson P. Cough reflex sensitivity improves with speech language pathology management of refractory chronic persistent cough. Cough. 2010;6:5. 14. Prudon B, Birring S, Vara D, Hall A, Thompson J, Pavord I. Cough and glottic-stop reflex sensitivity in health and disease. Lung. 2012;190(1):55-61. 15. Obholzer R, Nouraei SAR, Ahmed J, Kadhim M, Sandhu GS. An approach to the management of paroxysmal laryngospasm. J Laryngol Otol. 2008;122(1):57-60. 16. Van den Bergh O, Van Diest I, Dupont L, Davenport P. On the psychology of cough. Respir Med. 2009;103(11):1700-5. 17. Polverino M, Polverino F, Fasolino M, Ando F, De Blasio F. Anatomy and neuro-physiology of the cough reflex arc. Multidisciplinary Respiratory Medicine 2012 7;5 18. Chung K F, Widdicombe J G, Boushey H. Cough; Causes, Mechanisms and Therapy. Blackwell Publishing: 2003

39. THANK YOU

40. We look forward to seeing you at one of our future workshops. Ms Romana Kuchai sees Patients here at TMCK on Wednesday and Friday afternoons. Appointments can be made by telephoning Reception on 0207 244 4200