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December 23, 2021

Constant Itchy Throat with Cough

Question

I have a case to present. A woman who is 62 years old complained of constant itchy throat for many years. She tried many kinds of antihistamine drugs without good effect. I can't find any environmental factors influencing her disease. She has been to Australia without a change in symptoms. The SPT showed negative results. I prescribed 1st generation and 2nd generation antihistamines for her without good effect. I can't explain it. She does not have asthma nor allergic rhinitis, etc. She coughs sometimes because of the itching.

Answer

By Dr. Iris E. Hidalgo Nicho

If cough as a result of itchy throat is the only symptom for years, we are facing a case of chronic cough. Cough in adults is defined as chronic when it lasts for more than 8 weeks. Chronic cough is present in 5-10% of the adult population, mainly in women older than 50 years, who present a hyper-reactive response to a trigger causing a strong sensation of throat tickling/irritation that urges them to cough. Sometimes, chronic cough is irregular, with a few weeks of daily cough followed by asymptomatic days or even weeks. In these individuals, cough should be considered chronic if the duration of symptoms over the past 3-6 months is more than 8 weeks.

We have a 62-year-old woman with itchy throat and sporadic cough. It would be important to have more information about the patient’s symptoms such as the age of onset, duration, frequency, and suspected triggers. Are itchy throat and cough the only symptoms? This information will help us to know if the patient has any other symptom suggestive of allergy. Cough as a consequence of rhinitis, especially allergic rhinitis (AR), is often underappreciated; it is often considered to be a comorbidity of AR rather than a direct symptom of AR.

Were local allergic rhinitis (LAR) and non-allergic rhinitis with eosinophilia syndrome (NARES) ruled out? In the first entity, patients have rhinitis symptoms, a negative skin prick test and absence of serum specific IgE antibodies but a positive nasal allergen provocation test to aeroallergens. NARES constitutes a rare nasal condition characterized by chronic, eosinophilic inflammation (>20 % eosinophils in nasal smears) in absence of a demonstrable allergy (negative in vivo and in vitro allergy tests) or other sinonasal disease as chronic rhinosinusitis with or without polyps.

In the reported patient, it would also be important to evaluate non-allergic diseases. Upper airway cough syndrome (previously known as postnasal drip syndrome), asthma and gastroesophageal reflux disease are the three most common conditions underlying chronic cough in adults. Other causes of chronic cough include lung parenchymal diseases, infections, and laryngeal dysfunction. Drugs such as angiotensin-converting enzyme (ACE) inhibitors, topiramate, methotrexate, and mycophenolate mofetil might also be associated with cough. Although rare, heart conditions such as left heart failure, endocarditis, and cardiac arrhythmia are reported to manifest as chronic cough.

Chronic cough is a clinically relevant and difficult syndrome that may require a careful multidisciplinary approach. In the reported patient, several diagnostic tests should be considered such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, serum thyroid hormones, chest X-rays or computed tomography, spirometry, bronchoprovocation testing, upper gastrointestinal endoscopy.

Pharmacologic treatments that modulate neuronal function, such as amitriptyline, pregabalin and gabapentin, have been considered in adults with chronic intractable cough and no confirmed etiology. The rationale for gabapentin is based on the postulation that stimulation of upper airway nerve endings provoke cough.

Finally, non-pharmacologic therapies such as speech and physical exercises can be useful in patients with chronic cough.

 

References:

  1.  Song, Woo-Jung, and Kian Fan Chung. “Exploring the clinical relevance of cough hypersensitivity syndrome.” Expert review of respiratory medicine vol. 14,3 (2020): 275-284. doi:10.1080/17476348.2020.1713102
  2. Vardouniotis, Alexios et al. “Local Allergic Rhinitis Revisited.” Current allergy and asthma reports vol. 20,7 22. 19 May. 2020, doi:10.1007/s11882-020-00925-5
  3. Dykewicz, Mark S et al. “Rhinitis 2020: A practice parameter update.” The Journal of allergy and clinical immunology vol. 146,4 (2020): 721-767. doi:10.1016/j.jaci.2020.07.007
  4. Song, Woo-Jung et al. “Chronic cough in the elderly.” Pulmonary pharmacology & therapeutics vol. 56 (2019): 63-68. doi:10.1016/j.pupt.2019.03.010
  5. Spanevello, Antonio et al. “Chronic cough in adults.” European journal of internal medicine vol. 78 (2020): 8-16. doi:10.1016/j.ejim.2020.03.018
  6. Song, Woo-Jung, and Kian Fan Chung. “Exploring the clinical relevance of cough hypersensitivity syndrome.” Expert review of respiratory medicine vol. 14,3 (2020): 275-284. doi:10.1080/17476348.2020.1713102
  7. Lucanska, M et al. “Upper Airway Cough Syndrome in Pathogenesis of Chronic Cough.” Physiological research vol. 69, Suppl 1 (2020): S35-S42. doi:10.33549/physiolres.934400
  8. Morice, Alyn H et al. “ERS guidelines on the diagnosis and treatment of chronic cough in adults and children.” The European respiratory journal vol. 55,1 1901136. 2 Jan. 2020, doi:10.1183/13993003.01136-2019

Iris E. Hidalgo Nicho, MD

Allergy and Clinical Immunology


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