W2 Symptom Chronic Cough 8w Normal X-Ray (Review By EOD Friday 28)

Question 1

Symptom: chronic cough>8 weeks with normal X Ray
Possible causes

Answer 1

— Rhinosinusitis
— Upper airway cough syndrome (post nasal drip)
— Smokers cough
— Eosinophilic bronchitis
— ACE- inhibitor
— GERD
— Psychogenic
— Vocal Cord

Chronic cough was defined as cough being sole or predominant symptom lasting more than 8 weeks, without overt identifiable abnormalities on chest X-ray.

Chronic cough is estimated to occur in up to 40% of the population

Cough is a protective reflex serving a normal physiologic function of clearing excessive secretions and debris from the pulmonary tract

Since the etiology of chronic cough can arise from anywhere in the tracheobronchial tree, referrals to the otolaryngologist and pulmonologist are common

Question 2

Chronic Cough> 8 weeks
Most likely causes? 3

Answer 2

Postnasal drip, Asthma, and GERD

These 3 diseases account for the etiologic cause of chronic cough in 92-100% of immunocompetent, non-smoking patients with normal chest radiograph findings.

Additional specialists also important in the workup include the gastroenterologist, allergist and immunologist, neurologist, and speech therapist.

Question 3

What is rhinosinusitis
Occurs usually in the setting of?
Common viruses — 3
Leads to which patho?
Most common bacteria — 3
Chronic sinusitis pathogens? 1 main one

Answer 3

—symptomatic inflammation of the nasal cavity and paranasal sinuses.
—Rhinosinusitis is preferred over sinusitis because sinusitis almost always is accompanied by inflammation of the contiguous nasal mucosa.
—Acute rhinosinusitis most commonly occurs in the setting of a viral upper respiratory tract infection (URI).

Common viruses:
—rhinovirus
—influenza virus
—parainfluenza virus.

Viral infection leads to:
—mucosal edema with sinus ostium obstruction
—mucus stasis
—tissue hypoxia
—ciliary dysfunction
—and epithelial damage, which may enhance bacterial adherence.

Viral Rhinosinusitis is thought to proceed Acute Bacterial Rhinosinusitis
Most common Bacteria:
—Streptococcus pneumoniae
—Haemophilus influenzae
—Moraxella catarrhalis
—Streptococcus pyogenes.

Chronic sinusitis:
—Staphylococcus aureus
—anaerobic bacteria (Prevotella and Porphyromonas, Fusobacterium and Peptostreptococcus spp.)
—Pseudomonas aeruginosa is commonly found patients with nosocomial sinusitis, immunocompromised host, HIV infection, and cystic fibrosis.

Question 4

Rhinosinusitis
Other conditions that may contribute to Acute Bacterial Rhinosinusitis
Which are the most common isolates in neutropenic patients?

Answer 4

ABRS should be investigated, especially in the setting of recurrent Acute Bacterial Rhinosinusitis,ABRS.

These include:
—foreign body
—sinus fungal ball (with bacterial secondary infection),
—and periapical dental disease

Fungi and Pseudomonas aeruginosa are the most common isolates in neutropenic patients.

Question 5

Rhinosinusitis
—Most frequent cause of allergic fungal sinusitis (AFS) and invasive fungal sinusitis (IFS) is?
—The other common organisms responsible for fungal sinusitis are?
—A key feature of mucormycosis is?
—More common in? Age?

Answer 5

—The most frequent cause of allergic fungal sinusitis (AFS) and invasive fungal sinusitis (IFS) is Aspergillus.
—The other common organisms responsible for fungal sinusitis are Mucor and Rhizopus, also known as mucormycosis.jnass
—A key feature of mucormycosis is necrosis of the turbinates.
—Females 45-64 y/o

Question 6

Rhinosinusitis
What is the patho?
Results from which key three factors?

Answer 6

Rhinosinusitis occurs when the sinuses and nasal passages cannot effectively clear out these antigens, leading to an inflammatory state.

Results from three key factors:
1. Obstruction of the sinus ostia (i.e., anatomic causes such as a tumor or septal deviation)
2. Dysfunction of the cilia (i.e., Kartagener syndrome)
3. Thickening of sinus secretions (cystic fibrosis)

sinus, cilia, secretions = rhinosinusitis

Question 7

Rhinosinusitis
Acute
Subacute
Chronic
Recurrent (and in which two diseases would you see this?)

Answer 7

—Acute: symptoms lasting less than 4 weeks
—Subacute symptoms last between 4 and 12 weeks
—Chronic:symptoms lasting more than 12 weeks
—Recurrent:four episodes lasting less than 4 weeks with complete symptom resolution between episodes (cystic fibrosis and asthma)

Question 8

Rhinosinusitis
Symptoms

Answer 8

—Mucopurulent drainage (anterior, posterior, or both)
—Nasal obstruction (congestion)
—Facial pain-pressure-fullness
—Decreased sense of smell
—Pain over cheek and radiating to frontal region or teeth, increasing with straining or bending down

And inflammation as seen by 1 or more of the following:
—Purulent mucus or edema in the middle meatus or ethmoid region
—Polyps in the nasal cavity or the middle meatus
—Radiographic imaging showing inflammation of the paranasal sinuses.

Question 9

Chronic Rhinosinusitis
Characterised by?
Which two symptomatic criteria must be present to diagnose?

Answer 9

Chronic rhinosinusitis (CRS) is characterized by symptomatic inflammation of the nose and paranasal sinuses lasting over 12 weeks.

Two of the following symptomatic criteria must be present to diagnose CRS:
● purulent nasal drainage
● nasal obstruction
● facial pain-pressure-fullness
● decreased sense of smell
● Bad breath
● Cough- laryngeal irritation
● Hoarseness

These patients may also experience acute exacerbation, generally signified by an escalation of symptoms

Question 10

Viral Rhinosinusitis
Which treatment approved?

Answer 10

—Viral is self limiting… watch and wait

Oseltamivir
—is the first neuraminidase inhibitor approved for the treatment and prevention of influenza virus infection.
—must be started within 48 hours for optimal effect.

Buffered hypertonic saline (3–5%) nasal irrigation
—improve symptoms and reduce the need for nonsteroidal anti-inflammatory drugs (NSAIDs).

Supportive measures:
—oral decongestants (pseudoephedrine, 30–60 mg every 4–6 hours or 120 mg twice daily), may provide some relief of rhinorrhea and nasal obstruction.
—Steam inhalation
—NSAIDS

Nasal sprays, such as oxymetazoline or phenylephrine —rapidly effective but should not be used for more than a few days to prevent rebound congestion.

Withdrawal of these nasal sprays after prolonged use leads to rhinitis medicamentosa, an almost addictive need for continuous usage.

Treatment of rhinitis medicamentosa requires mandatory cessation of the sprays, and this is often extremely frustrating for patients.

Topical intranasal corticosteroids eg,
—flunisolide, 2 sprays in each nostril twice daily
—intranasal anticholinergic: ipratropium 0.06% nasal spray, 2–3 sprays every 8 hours as needed)
—or a short tapering course of oral prednisone may help during the withdrawal process

Question 11

Bacterial rhinosinusitis
Treatments 2
Symptoms lasting more than 10d or with i.c patients
(Check this slide)

Answer 11

For suspected bacterial rhinosinusitis:
—intranasal corticosteroids reduce symptoms
—eg, high-dose mometasone furoate 200 mcg each nostril twice daily for 21 days

For symptoms lastings more than 10 days or when symptoms are severe or complicated (such as immunodeficiency).
—first-line therapy is amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125
—severe sinusitis, high dose amoxicillin-clavulanate (2000mg/125mg extended release orally twice daily for 7-10d)

abx therapy should be reserved for complicated or protracted acute bacterial rhinosinusitis. Most patients will improve within 2 weeks without abx

Patients with high risk for penicillin-resistant S pneumoniae (age over 65 years, hospitalization in the prior 5 days, antibiotic use in the prior month, i.c, cormorbs etc. Recommended high dose **amoxicillin-clavulanate 2000mg/125mg extended release PO BID 7-10d)

Question 12

Rhinosinusitis
Complications

Answer 12

Complications:
Untreated, inadequately treated, or partially treated rhinosinusitis may lead to…
—Chronic rhinosinusitis
—Meningitis
—Brain abscess
—Osteomyelitis
—Cellulitis; preseptal cellulitis, orbital cellulitis, subperiosteal abscess
—Orbital abscess
—Cavernous sinus thrombosis

Osteomyelitis of the frontal bone
—called a Pott puffy tumor and represents a subperiosteal abscess with local edema anterior to the frontal sinus.
—can advance to form a fistula to the upper lid with sequestration of necrotic bone
—medical Emergency

Question 13

[SKILLS OSCE]
What is this

Answer 13

Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins

Question 14

Upper airway cough syndrome — aka?
Presentation
Diagnosis based on
2 treatments
Avoidance
Further work up to include

Answer 14

Upper airway cough syndrome (UACS), previously referred to as postnasal drip syndrome (PNDS)
most common cause of chronic cough (87% of patients).
nasal secretions flow down airway and induce a cough

—secretions from the nose or sinuses that drain into the pharynx in addition to nasal discharge and frequent throat clearing.
—secretions containing inflammatory mediators are thought to stimulate pharyngeal and laryngeal sites, inducing cough.
—diagnosis is made based on response to specific therapy, which includes antihistamines and decongestants.
—avoiding environmental irritants and offending antigens, treating sinusitis with antibiotics, and weaning patients off nasal decongestants for rhinitis medicamentosa.
—further workup may include allergy testing for allergic rhinitis or sinus CT scan for sinusitis, as indicated

Question 15

Smoker’s cough
When does it resolve after patient stops smoking

Answer 15

Chronic cough in smokers—smoking is a leading cause!

—Sooner or later, most cigarette smokers develop a chronic “smoker’s cough.”
—Chemical irritation is responsible — but the same noxious chemicals that cause the simple smoker’s cough can lead to far more serious conditions, such as bronchitis, emphysema, pneumonia, and lung cancer.
—The chronic cough is always a cause of concern for smokers and warrants further work-up
—Most patients have a resolution of their cough within 4 weeks of smoking cessation

Question 16

Eosinophilic bronchitis
Diagnosed by?
What do you see? 2
Responds well to which therapy?
Resolution seen in how many weeks?

Answer 16

—Nonasthmatic eosinophilic bronchitis can be diagnosed with induced sputum analysis
—raised induced sputum eosinophil counts and increased exhaled nitric oxide levels
—Etiology of chronic cough in 13-33% of patients.
—characterized by eosinophilic infiltration of the bronchial tree as well as the absence of variable airflow obstruction and airway hyperresponsiveness.
—Treatment includes ICS, with oral corticosteroids reserved for refractory cases.
—Response is usually seen within 4 weeks

Question 17

ACE inhibitor cough
When does it develop?
Resolution?
Which treatment should you switch to?
What is a more series ADR of ACEI?

Answer 17

—A dry, tickly and often bothersome cough
—Develop in ~ 10% of the patients treated with ACE inhibitors
—ACE inhibition increases the cough reflex
—Onset can be months or even a year later
—Discontinuing ACE inhibitor is the treatment.
—Cough will usually resolve in a few days
—Replacement by another ACE inhibitor should not be tried, since the cough will almost always recur on rechallenge with the same or another ACE inhibitor.
serious adverse reaction with ACE-I is Angioedema

Question 18

GERD
What is it?
Patho
Complications
Risk factors

Answer 18

Gastroesophageal reflux disease (GERD) is the excessive retrograde movement of acid-containing gastric secretions or bile and acid-containing secretions from the duodenum and stomach into the esophagus

—Distal esophageal acid exposure that stimulates an esophageal-tracheobronchial cough reflex via the vagus nerve
—Microaspiration of esophageal contents into the laryngopharynx and tracheobronchial tree.

Complications associated with GERD
—esophagitis, stricture, and Barrett esophagus.
—approximately 50% of patients with gastric reflux develop esophagitis

Risk Factors
● Overweight or obese.
● Pregnant.
● Smoking or are regularly exposed to secondhand smoke.
● Medications

Motor abnormalities:
● esophageal dysmotility causing impaired esophageal acid clearance
● impairment in the tone of the lower esophageal sphincter (LES)
● transient LES relaxation
● delayed gastric emptying are included in the causation of GERD

Anatomical factors like the presence of hiatal hernia or an increase in intra-abdominal pressure, as seen in obesity are associated with an increased risk of developing GERD

Question 19

GERD
Symptoms
Diagnosis

Answer 19

Symptoms
Heartburn
Regurgitation
Dysphagia
Gas
Bloating
Excess salivation

Outside GI tract
Coughing and/or wheezing
Hoarseness/ sore throat
Otitis media
Bad Breath
Non-cardiac chest pain
Enamel erosion or other dental manifestations

Diagnosis
—upper GI endoscopy
—esophageal manometry
—ambulatory pH monitoring: criterion standard in establishing a diagnosis of Gastroesophageal reflux disease

⭐️The criterion standard for diagnosis of GERD is dual-channel 24-hour pH probe monitoring ⭐️.

Alternatively, flexible nasopharyngoscopy can reveal glottic changes associated with reflux. These include laryngeal edema and erythema, laryngeal pseudosulcus, and posterior commissure hypertrophy or pachydermia.

Question 20

GERD
Lifestyle modifications
Pharm therapy
Surgical therapy

Answer 20

Lifestyle modifications:
● Losing weight (if overweight)
● Avoiding alcohol, chocolate, citrus juice, and tomato-based products
● Avoiding peppermint, coffee, and possibly the onion family ● Eating small, frequent meals rather than large meals
● Waiting 3 hours after a meal to lie down
● Refraining from ingesting food (except liquids) within 3 hours of bedtime
● Elevating the head of the bed by 8 inches
● Avoiding bending or stooping positions

Pharmacotherapy
● H2 receptor antagonists (eg, cimetidine, famotidine, nizatidine)
● Proton pump inhibitors (eg, omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole)
● Prokinetic agents (eg, metoclopramide)
● Antacids (eg, aluminum hydroxide, magnesium hydroxide)

Surgical
● Nissen Fundoplication- Surgical- proximal stomach wrapped around distal esophagus =creates an antireflux barrier

Question 21

Psychogenic Cough

Answer 21

—chronic cough of no obvious organic basis that has failed therapy directed at postnasal drip, asthma, and gastroesophageal reflux.
—AKA “habit cough,”
—described in children, adolescents, and rarely adults
—may be associated with psychosocial stressors.
—is croupy and explosive, never occurs during sleep, and is not affected by antitussive drugs.
—rads = normal
—behavioral therapy has been demonstrated to be effective for most children with habit cough;

Question 22

Vocal chord dysfunction
What is the treatment?

Answer 22

Cough is an important symptom in Vocal Cord Dysfunction.

Patients presenting with chronic cough may have underlying VCD as a cause of their cough. Since cough and VCD symptoms co-occur clinicians need to consider cough when are treating VCD and VCD when treating chronic cough.

Treatment for vocal cord dysfunction is often nonmedicinal and involves respiratory retraining therapy with a qualified speech-language pathologist.
Therapy generally requires two to six 60-minute sessions.

These sessions aim to:
● Identify and eliminate sources of chronic throat irritation.
● Identify and control triggers for PVFM episodes.
● Provide an exercise program to give patients better control over breathing, reduce the discomfort and fear
that comes with being short of breath, and lessen PVFM episode frequency and duration.
● Include feedback to help the individual learn to relax the throat and keep the vocal cords apart when breathing.