- Filed under: Reflux
Chronic Cough? It Doesn’t Have to Be!
Dr. Simpson is Professor and Director, Division of Laryngology at The University of Alabama at Birmingham. He joined the faculty at UAB in 2020 after a 23-year career in the Department of Otolaryngology at UT Health San Antonio.
Dr. Simpson specializes exclusively in the treatment of patients with voice and upper airway disorders and has published extensively in the area of laryngology and airway disease, co-authoring the definitive textbook on the surgical treatment of laryngotracheal disorders, Operative Techniques in Laryngology, which has subsequently been translated into Spanish and Chinese. Dr. Simpson has developed several innovative techniques that have been adopted widely within the field of Laryngology, including Botox injections into the false vocal cords for Spasmodic Dysphonia/Vocal Tremor, and the Superior Laryngeal Nerve Block, a novel treatment for chronic cough.
He is a founding member of the Laryngeal Education Foundation and is the past president for the American Laryngological Association.
CHRONIC COUGH
Cough is the most common presenting symptom in adults who seek medical treatment in clinic settings and is the primary reason for 3% of all visits to physician clinics in the United States. In addition, $3.6 billion is spent annually on over-the-counter cough medications. Under normal circumstances, cough is an important protective reflex preventing aspiration into the lungs when you are eating, and is essential in removing respiratory mucus due to lung infections such as bronchitis or pneumonia. It is generally self-limiting and resolves within 2 weeks in the vast majority of cases. In some individuals however, it can become prolonged, severe, and debilitating. With increased fear of respiratory illnesses after the COVID pandemic, patients with chronic cough are marginalized due to the perceived threat of spreading infection.
TREATMENT OF CHRONIC COUGH
For those people with “chronic” or long-term cough, a large percentage have a medical condition such as asthma, GERD, or post-nasal drip syndrome causing their condition and this can often be treated successfully. Inhalers, acid suppression/neutralization medications such as Prilosec, Zantac and alginates such as Reflux Gourmet, as well as antihistamines continue to be the mainstay of treatment and generally work to control the cough in the majority of patients.
CHRONIC NEUROGENIC COUGH – THE VOICE BOX IS THE CULPRIT
Unfortunately, in a number of patients with chronic cough, no definitive cause can be identified. These patients typically have a dry non-productive cough that has been present for years and unresponsive to multiple treatments. This condition, commonly referred to as “neurogenic cough” is felt to be related to irritation in the throat as opposed to the chest. This is likely due to the chronic irritation that occurs in the larynx (voice box) – more specifically the vocal cords – during the act of coughing. With each cough the vocal cords forcefully slam shut, and over time, the repetitive compression of the vocal cords leads to inflammation. In turn, this results in a sensitized voice box that is prone to cough with the slightest irritation. Many of these patients have triggers that bring on their cough such as odors, chemical smells, temperature changes, talking, laughing, and even positional changes.
TREATMENT OF NEUROGENIC COUGH
For many years, behavioral cough suppression therapy (BCST) with a speech pathologist and so-called “neuromodulator” medications have been used to treat neurogenic cough. It is thought that reducing nerve impulses to and from the brain’s cough center can act to recalibrate and reduce cough. Cough suppression therapy is a highly specialized treatment protocol, but only a handful of speech pathologists are experienced in this area. Unfortunately, neuromodulator medications have poor side-effect profiles and most have debilitating symptoms associated with their use, which may include drowsiness, mental fog, blurred vision and dizziness. Because of this, many patients cannot tolerate these medications. Coupled with the fact that many patients are unable to access the care of a speech pathologist experienced in BCST, a considerable number of these patients fail to get relief from their condition.
Until recently, these patients did not have another option for the treatment of their chronic cough. In 2015, we developed a new treatment for these patients that involves a numbing shot into the neck to address the overactive voice box nerve network that is often the primary source of these patients’ cough. The treatment, referred to as a superior laryngeal nerve block (SLN block) was first reported in a clinical study we published in 2018 (see reference). Since that time, it has become an extremely popular treatment for chronic cough patients and has been adopted all over the world.
SUPER LARYNGEAL NERVE BLOCK
The SLN block is administered in a clinic setting and almost exclusively performed by ENT doctors (otolaryngologists), particularly subspecialists referred to as laryngologists who specialize in vocal cord and airway disorders. The nerve block is similar to those given for pain management conditions, such as lower back pain, and consists of a local anesthetic and a corticosteroid injected over the superior laryngeal nerve in the neck. The combination of a numbing agent and a steroid can reduce inflammation in the irritated nerve and block the nerve impulses from the voice box that are telling the brain to cough, thereby suppressing of the cough. The results of the shot can be quite dramatic in some patients, resulting in reduction or control of cough in those individuals who have failed to respond to all other treatments in the past. Many of these patients may have been coughing without relief for years, even decades. Overall, it has been shown to be effective in 80% of patients with chronic neurogenic cough and may last for a few weeks to months; additional blocks can be performed if the effects of the treatment wear off.
CHRONIC COUGH-THE BOTTOM LINE
Some patients require multiple treatment modalities to get control of their cough. The important thing to remember is that chronic problems don’t have acute solutions. If cough has been persistent for several years, it may take a year or more of successful treatments to extinguish or control cough. It may take a visit to a local laryngologist (vocal cord expert) to sort out the treatment protocols that are effective. The key is to be consistent with all treatments. It can take a great deal of time and effort – sometimes multiple visits to doctors – to get control of chronic cough, so patience and persistence pays off.
Referenced:
Simpson CB, Tibbetts KM, Loochtan MJ, Dominguez LM. Treatment of chronic neurogenic cough with in-office superior laryngeal nerve block. Laryngoscope. 2018 Aug;128(8):1898-1903. doi: 10.1002/lary.27201. Epub 2018 Apr 18. PMID: 29668037