xRead - Globus and Chronic Cough (April 2024)

Review Clinical Review & Education

Otolaryngologic Management of Chronic Cough in School-aged Children

patients presenting to an otolaryngology office, the diagnosis of GERD is often made based on symptoms reported by the care giver. In the presence of these specific symptoms, it is reasonable to perform a trial of antireflux medication; however, in their ab sence, it is not recommended to start antireflux medication be cause of the potential for harm. 23 Other potential therapies for GERD that can be effective include behavioral modifications, such as re duced volume and increased frequency of feeds and thickened feeds, although these modifications are more commonly used in infants rather than school-aged children. Treatment for asthma and airway hyperresponsiveness is of ten initiated by a pulmonologist and may include use of short acting or long-acting bronchodilators, inhaled corticosteroids, or leukotriene inhibitors. Treatment is typically initiated in a stepwise approach as advocated in the 2007 National Heart, Lung, and Blood Institute guidelines 46 and 2008 Global Initiative for Asthma guidelines. 47 All patients with asthma will be prescribed a short acting β-agonist, such as albuterol or levalbuterol—both of which have similar adverse effect profiles but mixed data on which is more effective at improving asthma scores and forced expiratory volume. 48,49 For children with persistent asthma, inhaled cortico steroids are first-line treatment as the preferred second step of therapy. 50 Although inhaled steroids improve overall asthma con trol and symptoms, they will not alter the progression of asthma. 51 In patients who are started on inhaled steroid therapy, the treat ment is generally well tolerated with fewer adverse effects than systemic steroid therapy; however, it is important to recognize that adverse events can occur, and patients should be continuously monitored for development of adverse effects. 52 Although adverse effects are rare with inhaled steroid therapy, they can be significant and include suppression of the hypothalamic–pituitary–adrenal axis, slowing of linear growth, decreased bone mineral density, and development of type 2 diabetes. 52 Inhaled steroids have been effective in increasing cough-free periods and improving disease specific quality of life in children. 53,54 For patients with persistent symptoms despite inhaled steroid use, the next step of therapy includes either higher doses of inhaled steroid, addition of a long acting β-agonist, or addition an antileukotriene agent. Long acting β-agonists should not be used alone, 55 but when added to an inhaled steroid, they can improve lung function in certain asthma phenotypes. 56,57 Addition of leukotriene receptor antagonists, such as montelukast, to inhaled steroids may improve cough more than just steroids alone, 58 particularly in children with higher eosinophil blood counts. 59 However, a Coch rane review did not find any significant changes in other aspects of asthma control, particularly in the need for rescue oral steroids or hospital admissions, when an antileukotriene was added to an inhaled steroid. 60 Of the pediatric patients with asthma, approximately half of the cases are due to an underlying allergic cause. 61,62 Similar to the treat ment of allergic rhinitis, treatment of atopic asthma centers on al lergen avoidance, pharmacotherapy, immunotherapy, and newer biologic agents, such as the anti-IgE monoclonal antibody omalizumab. 63 Both subcutaneous and sublingual immuno therapy can reduce the risk of asthma symptoms in patients with al lergic rhinitis 64,65 and, in patients with asthma, can reduce medica tion use, improve lung function, and improve disease-specific quality of life, including cough. 66,67

habit cough is that it does not occur while the child is sleeping. It is a diagnosis of exclusion. Habit cough can cause significant distur bance to the patient and affects functioning at school and in the child’s personal life.

Treatment for Pediatric Chronic Cough In children with chronic cough that has an identified cause, treat ment of underlying pathology often leads to resolution. For upper respiratory tract infections resulting from viral illness, supportive treatment is usually all that is needed, and most cases will resolve within 4 to 6 weeks. Over-the-counter antitussives, mucolytics, and antihistamines have not consistently shown significant benefit in pe diatric cough 33,34 ; however, a 2012 randomized clinical trial found improvement in upper respiratory tract infection–related cough with nocturnal honey administration. 35 For nonspecific productive coughs that persist longer than 4 weeks, a 2018 Cochrane review supports an antibiotic course (amoxicillin/clavulanate acid or erythromycin) of 7 to 14 days as beneficial in curing cough and preventing disease progression. 36 Medical therapies for chronic rhinosinusitis, including nasal saline irrigations, nasal steroids, and prolonged antibiotic trials, will improve cough and other symptoms of chronic rhinosinusitis in more than half of patients. 13,37 For those in whom conservative therapies fail, surgical intervention can be considered. In children younger than 12 years, adenoidectomy is the most common first line procedure for chronic rhinosinusitis, 38 as the adenoids can cause a physical obstruction within the nasopharynx and serve as a repository of biofilm, which can seed the nasal cavity and sinuses. In a meta-analysis of studies examining adenoidectomy for treat ment of pediatric chronic rhinosinusitis, up to 70% of patients had improvement in symptoms, with even further improvement when maxillary sinus irrigation was performed at the time of adenoidectomy. 39 For children older than 12 years, those with ana tomic sinus obstruction, or those with persistent disease despite adenoidectomy, functional endoscopic sinus surgery can lead to disease and symptom improvement in up to 88% to 96% of patients. 40,41 While functional endoscopic sinus surgery is a more complex surgical procedure compared with adenoidectomy, the overall complication rate remains low (<3%), and it is considered a generally safe procedure when performed by experienced surgeons. 42 Given the uncertain association between pediatric cough and reflux, CHEST recommendations advise against treatment for re flux in children younger than 14 years in the absence of clinical fea tures of GERD. 43 In a study examining the effect of proton pump in hibitor (PPI) therapy on chronic cough in children, there was no difference found between PPI and placebo use with regard to cough improvement. 44 This study did find a significantly higher incidence of adverse events, particularly lower respiratory tract infections, in the PPI-treated group. In children treated with PPIs and histamine type 2 receptor antagonists, adverse effects have been reported in up to 34% and 23%, respectively. 45 These adverse events can in clude vitamin deficiency, respiratory tract infections, and bone frac tures, among others. Therefore, pharmacotherapy should only be instituted for patients with known or suspected GERD and not started empirically when cough is the only symptom. 43 In pediatric

(Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2020 Volume 146, Number 11 1061

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