This patient presented with chronic cough, which didn't get better with cough medications for over 2 weeks. Possible causes / Differentials and how you would manage ?
viral pharyngitis There is no specific treatment for. You can relieve symptoms by gargling with warm salt water. anti-inflammatory drugs or medications, such as acetaminophen, Excess of anti-inflammatory sprays may make a sore throat worse.
Chronic cough.... so this patient has it at least 8 weeks. After using general cough medicine 2 weeks, the symptom still can't be relieved, From the picture it looks there is redness of pharynx without exudation or membrane. I would think that it may not be viral pharyngitis (8 weeks viral?? not big chance) Can this be Post Nasal drip and some allergy caused problem? Or GERD?
Pharyngitis: 1-Persistent infection sinus, tonsils, nose and dental sepsis. 2-Mouth breathing because of nasal polyp, rhinitis. 3-over use of voice e.g. singer.
Looks inflamed.... Doesn't look bacterial.... Viral is less likely for chronic cough... Might be inflamed from coughing -> ?reflux, ?ace inhibitors
Answer: this is the classic 'cobblestone appearance' attributed to long standing post-nasal drip, due to mostly allergic rhinitis. The milder form is called 'granular pharyngitis' and can be attributed to a wide varitey of etiologies, ranging from post nasal drip to acute viral infections, GERD, smoking etc. the key to this condition, is a constant source of irritation - which leads to hypertrophy of the lymphoid follicles in the submucosa. The main idea of posting this challenge, was to discuss chronic rhinosinusitis ( allergic included ). The discussion below is in my own words, but I have picked the stuff from Harrison Chp 317, Cummings, 5th ed Chp 40 and Diseases of Ear, nose and throat by P L Dhingra 5th ed. The key is to see if there is a reversible / avoidable cause ...as treatment for chronic rhinsinusitis is usually multipronged with a great degree of overlap ( steroids, antihistamines, nasal decongestants, LT antagonists and antibiotics ) as there is an element of varying etiologies in each case ( for ex - longstanding allergic rhinitis, will kave a superadded bacterial infection )....but, we still have to find out the main cause ( becos otherwise the problem will recur once the treatment is discontinued. ) I will discuss my approach, which is mainly based on history and physical ( since labs are very non specific - nasal smear will show eosinophils, even if not allergic and throat swabs will show the normal commensals and can be very confounding ). History Wheter it is seasonal or perrenial ? Seasonal could mean allergy to pollen or the seasonal flu ( imp. to bear that in mind and possibily consider vaccination ). Allergy is mostly from grass pollen, so avoid the parks with a grass cover ( esp. when blooming ) and the problem is compounded if there is a breeze blowing. Also history of sever itching of nose and eyes in addition to watery congested eyes and nose - supports the diagnosis of allergic rhinitis...but if accompanied by myalgia, arthalgia and a general feeling of malaise, then it goes in favor of viral flu. Please note: When the problem is chronic, then symptoms of itching and sneezing are reduced and the main complaint is difficulty breathing ( due to nasal mucosal congestion and increased secretions ). Viral rhinitis can predispose to bacterial infections which could result due to loss of nasal mucosalciliary activity. This inturn could lead to secretions filling up the paranasal sinuses. If it's perenneial, then it means that the allergen is presen through out the year, ex - dust mite, pet dander. Also ask for occupational exposure Non allergic rhinitis is indistinguishable from allergic and a broad sense of the etiologies will help in the diagnosis. Probable causes of non allergic rhinitisinclude: 1.Irritants ( industrial chemicals, wood dust, tobacco smoke, paint fumes, hair spray, perfumes ). Diagnosis can be confirmed only by performing nasal provocation tests using theoffending irritant. This should be performed under controlled conditions. Gustatory rhinitis which occur following consuming spicy food could be termed as irritant rhinitis. Nasal pretreatment with atropine blocked food induced rhinorrhoea. This explains pathophysiology of this condition i.e. Stimulation of atropine inhibitable muscarinic receptors present in the nose by spicy food. 2.Medication induced ( mainly OC pills and Aspirin ) 3.Hormonal ( ex - hypothroidism - by neurogenic mechanisms and pregnancy rhinits - seen in1 in 5 pregnancies, ususally during the last 6 weeks of pregnancy) 4.Atrophic 5.Non allergic rhinitis with eosinophilia syndrome (NARES) Drug exposure - OCpills and aspirin ( due to leukotriene overproduction and forms the basis of treatment with LT antagonist - Montelukast esp.in patients in whom discontinuing aspirin is not an option ) Aspirin exacerbated upper airway disorder goes under the name “Samter's triad” Features of this triad include: Aspirin sensitivity, Nasal polyposis and Bronchial asthma. Synonyms:Acetylsalicylic acid triad, Widal's triad, Francis's triad Chronologically the first symptom to occur after ingestion of aspirin is rhinitis (withsymptoms of sneezing, running nose and congestion). Typically this disorder gradually progresses to asthma, nasal polyposis and aspirin hypersensitivity(whichcomes rather at the fag end of the disease spectrum). Typically these patients are alsoanosmic because inflammation does not spare the olfactory mucosa also. Rhinitis medicamentosa is a condition characterised by nasal congestion withoutrhinorrohea or sneezing. This condition is caused by the use of topical nasaldecongestants for a prolonged period of time. Use of these topical decongestants for more than a week is sufficient to cause this problem. Physical exam Allergic shiners, allergic salutes, facies of chronic mouth breathing, pain over the sinuses in case of rhinosinusitis ( even without having to press ) nasal exam - will show congested pale mucosa ( but according to cummin's 5th ed - there is no pathognomoc appearance for allergic rhinits ). Subsequently use a decongestant, to view the middle meatus better and look for any pus ozzing out of the meatal openings. Look for DNS oropharynx - in additon to looking for congestion, look for a shiny posterior pharyngeal wall and the enlargement of the submucous lymphoid tissue, indicating post nasl drip. investigations X ray - PNS Ig E levels CBC ( although the eosinophilia and basophilia is non-specific, it can sometimes help in the folow up) Nasal and throat swabs in persistent cases Treatment Avoid the exacerbating allergen if identified. Nasal Irrigation with warm saline ( approx 40 degree celcius ), salt water gargle, steam inhalation. Dietary restrictions: A diet low in omega ”“ 6 oils which are precursors of arachidonic acid could be of help in these susceptible patients. Diet rich in omega ”“ 3 oils could be of some help. Low salicylate diet (Feingold diet) could really help these patients. Organic food are supposed to contain more salicylates because plants are known to produce moresalicylates when attacked by pests. This is actually a protective mechanism. ref - Baxter GJ, Graham AB, Lawrence JR, Wiles D, Paterson JR (December 2001)."Salicylic acid in soups prepared from organically and non-organically grown vegetables15. Also strongly consider " milk allergy " in case of chronic pharyngitis. Viral rhinitis can be managed symptomatically, but if the same condition persists for more than a week then super added bacterial infection should be suspected andanitbiotics should be prescribed. As already mentiones above, a trial of steroids, antihistamines. Decongestants ( oxymtazoline / xylometazoline ) should be given for a couple of days only. If no improvement and allergy is strongly suspected, then allergy skin testing and possibly desentisation + LT antagonist ( to tackle the late phase of inflammation, since most cases are well established by the time they present) +/- Ipratropium bromide Credit to 'Karel from Olomouc' for being spot on and this was his opening post on the forum...what a start !!! (Y)
A self Assessment question on the topic A 52-year-old woman comes to the physician because of an 8-month history of an intermittent nonproductive cough. She takes no medications. She has smoked one pack of cigarettes daily for 25 years. She has had three episodes of sinusitis over the past 18 months. Examination shows pale nasal mucosa and cobblestoning of the posterior pharynx. The lungs are clear to auscultation. There is no clubbing or cyanosis. Which of the following is the most likely cause of this patient's cough? A) Allergic rhinitis B) Bronchiectasis C) Chronic bronchitis D) Hypersensitivity pneumonitis E) Rhinitis medicamentosa Ans: Allergic Rhinitis
