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Postnasal dri p and postnasal dri p-related cough Yu and Becker

cough and clinical suspicion for GERD are to initiate reflux medication [22]. One might consider per forming 24 h pH probe monitoring if there is a fail ure of symptom resolution despite reflux therapy. Barium esophagography can also be performed to assess for normal pH reflux, which may not be detected by pH monitoring [22]. Evaluation by a gastroenterologist may also be warranted. UACS lacks objective diagnostic testing, and its symptoms are variable. ACCP guidelines for UACS state that ‘no pathognomonic findings exist.’ How ever, UACS is often thought to be sinonasal in origin and identification of sinusitis or rhinitis is para mount in management. Diagnosis and treatment of UACS caused by allergic rhinitis should be considered if there is association of symptoms with an offending allergen. Avoidance of allergen is ideal; however, manage ment can include nasal/oral antihistamine, nasal steroid, cromolyn, and leukotriene inhibitors are recommended. Allergy testing and subsequent allergen desensitization can also be performed for long-term results but do not help with immediate symptoms. Nonallergic rhinitis presents with similar symp toms as allergic rhinitis but lacks the allergen irri tant. The mechanism of nonallergic rhinitis remains poorly elucidated and treatment relies on symptom management [23]. Use of first generation antihist amine and decongestant are recommended first-line therapy. Addition of intranasal ipratropium has also been shown to be of benefit in symptom manage ment [10]. UACS associated with acute or chronic sinusitis should be managed with appropriate antibiotics, intranasal steroid, and/or decongestants [10]. In the setting of chronic sinusitis refractory to medi cation, computed tomography imaging should be obtained to evaluate the sinuses for consideration of endoscopic sinus surgery [10]. Such is also the recommendation for allergic fungal sinusitis where endoscopic sinus surgery is performed for removal of the offending inspissated mucus containing fun gal elements [24 & ]. In patients where environmental irritants are a source of rhinitis, avoidance to exposure, use of filters, masks, and improvement in ventilation may help with alleviating symptoms. Also, medi cation-induced rhinitis should also be treated initially with cessation of the medication [10,17]. In the setting of UACS without evidence of other underlying sequelae, including sinonasal disease, GERD, and CVS, the ACCP practice guidelines state first line treatment is first generation antihistamine [5,10]. Further recommendations for continued symptoms are further evaluation and work up,

Suggestions and considerations in evaluation of postnasal drip History and physical • ACE inhibitor • Smoking history • Chest Xray CVA • Trial of antiasthmatic therapy • Methacholine inhalational challenge GERD

• Trial of antireflux therapy • 24hr pH probe monitoring • Barium esophagram

UACS secondary to: Allergic rhinitis • Oral antihistamine

• Inhaled nasal antihistamine • Inhaled nasal steroid • Cromolyn • Leukotriene inhibitor • Allergy testing and desensitization

Nonallergic rhinitis • Oral antihistamine

• Inhaled nasal antihistamine • Decongestant • Ipratropium bromide

Acute/chronic sinusitis • Antibiotics • Intranasal steroids • Decongestant

• Imaging of sinuses • Surgical intervention Chemical irritant/rhinitis medicamentosa • Cessation of medication • Avoidance of chemical irritant • Use of filters, masks, improvement in ventilation

therapy with use of bronchodilator therapy and inhaled corticosteroid has been suggested when managing chronic cough in a patient who presents with history suggestive of asthma [19]. Methacho line inhalation challenge has a very high negative predictive value and such testing if negative will exclude CVA as the source of cough [19,20]. GERD disease has been noted to be a source of cough in 10% of chronic cough patients [2]. When evaluating for chronic cough, review of reflux symp toms is imperative, although up to 75% of patients with chronic cough because of reflux will report no gastrointestinal symptoms [21]. Otolaryngologic assessment for laryngeal symptoms of reflux in combination with nasopharyngolaryngoscopy is important in evaluation for reflux irritation to diag nose GERD-related chronic cough [17]. Recommen dations by the ACCP for patients with chronic FIGURE 1. Key points in evaluation and management of chronic cough. ACE, angiotensin converting enzyme; CVA, cough variant asthma; GERD, gastroesophageal reflux disease; UACS, upper airway cough syndrome.

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