Constant Itchy Throat with Cough

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.

 

Answers
From the Editors: Allergists around the world are often presented with “constant itchy throat and cough” as a problem. Our two experts provide answers to this common scenario which allow each of us to brush up on an educated and formal approach to resolving it.

From Dr Mandel Sher, Editor: In this case of chronic, unresponsive throat itch and cough, it suggests a non-anatomic etiology (however LPR is still a possiblility) with neurogenic hyper-responsiveness that is commonly seen in chronic idiopathic/refractory/recalcitrant cough.  In this case, trials of amitryptylline or gabapentin should be considered.

 

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

 

By Prof Giovanni Passalacqua

The causes of itchy throat with cough (especially if long-lasting) are multiple. I suppose that asthma has been properly excluded by means of spirometry, nonspecific bronchial challenge (methacholine) or bronchodilation, and angiotensin converting inhibitors are not taken.

The next diagnostic steps should include a fiberoptic rhinoscopy or paranasal sinus CT (chronic rhinosinusitis) and the assessments for gastroesophageal reflux (oesophageal pH measurement and trendelemburg baritate contrast X-raY or fiberoptic gastroscopy). It is essential that, in the case of chronic cough, a standard chest X-ray is performed, to immediately exclude gross pulmonary alterations (1). A further step is the execution of a neck CT, to exclude anatomical alterations (e.g. goitre, abnormal vascularization, malignancies), but this is improbable, also because dysphonia is not reported.

References:

  1. Goldsobel AB, Kelkar PS. The adult with chronic cough. J Allergy Clin Immunol. 2012 Sep; 130(3):825-825
  2. Natt RS, Earis JE, Swift AC. Chronic cough: a multidisciplinary approach. J Laryngol Otol. 2012 May; 126(5):441-4
  3. Giovanni Passalacqua, MD
    Allergy & Respiratory Diseases, Dept of Internal Medicine
    Genova, Italy

 

By Dr. Desiree Larenas-Linnemann and Dr. Gary Stadtmauer  

Reviewing, we have a 62 year-old patient with a chronic complaint of an itchy throat and some cough that does not seem to improve with a change in environment nor with anti-histamines.

There are a few key elements and questions to think about regarding this patient's history. The first is the patient's age which suggests that the problem may not be atopy.

As we know, IgE-mediated allergic diseases decline with age. On the other hand, the prevalence of allergic conditions in elderly people has been augmenting, and recent estimates are that allergic rhinitis affects up to 15% of persons aged 60-70 [1]. Although the above information seems to discard allergy as a cause of her symptoms, we would not rule out allergy from the beginning. Thus, an element of the history is to know whether the patient has any other nasal symptoms suggestive of allergy or sinus disease. Lastly, we would inquire further as to more details about the itch. Is it truly an itch, or does the patient have more of an irritative sensation in the throat? The cough may or may not be relevant, and further questioning is helpful. Is the patient intentionally coughing to relieve the throat symptom?

Several additional details might help us out somewhat further:

  1. Where does she normally live? Is her exposure to environmental factors at home very different from the environment in Australia where she went to?

    1. Where in Australia did she go, as the Northern part (sub-tropical = mostly mites) is very different from center (dry, hot = pollen/mold) and from the Southern part (more temperate =all)?

  2. Also: “for many years” . . . does this mean during the whole year or worse in a certain season?

  3. What anti-histamines, what dose, for how long? Some patients treated with anti-histamines may improve when treated with somewhat higher doses. Other patients do improve while they take anti-histamines, but as they relapse after discontinuing the medication they come to their doctor saying ‘they did not improve at all’, which might be confusing for the treating physician. It is important to explore this in detail to find out if it is really true that while taking a potent anti-histamines at the right dose (or even double dose) the symptoms stay the same.

  4. Post-nasal drip is one of the symptoms of allergy, not so easy recognizable but sometimes quite resistant to systemic anti-histamines. A trial with topical anti-histamine in combination with a topical nasal corticosteroid would be worth a try to rule this out.

  5. SPT negative results: it is important the SPT was done with the right allergens and bought from the right provider (good potency, to reduce as much as possible false negatives). That’s why it is mandatory for the emission of good advice to know where the patient lives. For example, in the (sub) tropical zones of the far East, dust mites are the most important allergens. But, not only of the Dermatophagoides family [2-4]. As there are other mites also of importance over there, a SPT negative for HDM does not rule out the presence of a possible HDM allergy to one of the other mites (Blomia tropicalis, Lepidoglyphus, Acarus siro, etc.) that do cross-react in certain degree, but they do have their own specific allergens as well. [5]

Apart from allergy, itchy throat can be caused by:

  • Infection, but because of the prolonged course of the symptoms, this is not very probable in our patient. Sometimes a sinusitis can give prolonged symptoms, so a sinus CT would be worthwhile checking.

  • Irritants that dehydrate the pharyngeal mucosa- Chemical irritants (excessive alcohol intake, industrial chemicals, etc.), polluted air, cigarette smoke (active or passive) may cause local irritation and result in itchy throat.

  • Gastro-esophageal Reflux Disease - Heartburns may sometimes result in itchy throat because of reflux of acid up to the throat.

  • Voice mis-use or over-use (Singing Practice, shouting) - Excessive strain on larynx may occur because of shouting or prolonged singing practice. This may result in itchy throat.

  • In a 62 year old patients an itchy throat could be caused by a tumor, however in our case the symptom has been present for years thus indicating that the cause is likely benign.

  • Other Conditions: Then there are the rare causes of an itchy throat:

    • e.g. it has been described as one of the symptoms of Sjögren's syndrome

    • Halzoun: an allergic pharyngitis following the consumption of raw or undercooked ovine liver [6].

    • another very rarely the cause may be parasitic but it's worth considering depending upon the prevalence of these infections in the patients locale [7.]

Concluding, as for the work-up of this patient we would suggest: If correct skin testing with the locally present allergens in right concentrations is negative and there is no response to oral antihistamines then we would try a nasal steroid, nasal antihistamine or combination of the two. If this does not help and a brief burst of prednisone10 days does not relieve symptoms either then it's safe to say that the origin is not at all allergic. As to the workup, our next procedure would then probably be a rhinolaryngoscopy. It is possible that this patient has chronic rhino-sinusitis manifested solely as an itchy throat with occasional coughing. Another possibility would be laryngo-pharyngeal reflux which may be identified endoscopically. Finally, eventually the very rare causes- see above- could be considered.

References:

  1. Wuthrich B, Schmid-Grendelmeier P, Schindler C, Imboden M, Bircher A, Zemp E, et al. Prevalence of Atopy and Respiratory Allergic Diseases in the Elderly SAPALDIA Population. Int Arch Allergy Immunol. 2013;162(2):143-8. Epub 2013/08/08.
  2. Fonseca Fonseca L, Diaz AM. IgE reactivity from serum of Blomia tropicalis allergic patients to the recombinant protein Blo t 1. Puerto Rico health sciences journal. 2003;22(4):353-7. Epub 2004/02/11.
  3. Arlian LG, Morgan MS, Neal JS. Dust mite allergens: ecology and distribution. Curr Allergy Asthma Rep. 2002;2(5):401-11. Epub 2002/08/08.
  4. Vidal C, Boquete O, Gude F, Rey J, Meijide LM, Fernandez-Merino MC, et al. High prevalence of storage mite sensitization in a general adult population. Allergy. 2004;59(4):401-5. Epub 2004/03/10.
  5. Morales-de-Leun G, Lupez-Garcia A, Arana-Muooz O, Carcaoo-Perez Y, Papaqui-Tapia S, Caballero-Lupez CG, et al. [Correlation of cutaneous reactivity between allergenic extracts of Dermatophagoides pteronyssinus and Dermatophagoides farinae with Blomis tropicalis in patients with allergic rinitis and asthma]. Rev Alerg Mex. 2012;59(3):107-12. Epub 2012/07/01. CorrelaciUn de reactividad cut.nea entre extractos alergEnicos de Dermatophagoides pteronyssinus y Dermatophagoides farinae, con Blomia tropicalis en pacientes con rinitis alErgica y asma.
  6. Khalil G, Haddad C, Otrock ZK, Jaber F, Farra A. Halzoun, an allergic pharyngitis syndrome in Lebanon: the trematode Dicrocoelium dendriticum as an additional cause. Acta tropica. 2013;125(1):115-8. Epub 2012/10/02
  7. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. [A case of parasite in throat with laryngeal itching and cough as the first symptom]. [Article in Chinese] 2011 Aug; 46(8):692-3.

Desiree Larenas-Linnemann, MD
Clinic of Allergy, Asthma and Pediatrics Hospital Medica Sur
Mexico City, Mexico

Garry Stadtmauer, MD
City Allergy
New York, New York, USA

 

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