And I’m back! My wife and I had a wonderful few weeks getting married in Austin and then experiencing the amazing islands of Kauai and the Big Island in Hawaii earlier this month.

Today I’m going to talk about a book I recently read on the topic of chronic cough (defined as a cough which lasts longer than 8 weeks). The author is a famous otolaryngologist, Dr. Jamie Koufman, who has been treating patients with throat, swallowing, and voice problems for the past 30 years or so. She was formerly faculty at the Wake Forest University department of ENT and more recently has set up a practice dedicated to throat disorders in New York City, the Voice Institute of New York. She is well known as a world expert (probably THE expert) on airway reflux and cough.

Link to Amazon page HERE.

The book is fairly compact and well organized. The book is aimed primarily at people with non-pulmonary (i.e. not caused by lung problems or smoking) chronic cough. Most of these people have seen many doctors in several different specialties (ENT, GI, pulmonary typically) without relief. Dr. Koufman makes the point in the book (and I agree) that the problem of non-pulmonary chronic cough overlaps the areas of these 3 specialties and to be treated effectively needs a more comprehensive approach.

In her experience of seeing many thousands of patients with this problem, Dr. Koufman has concluded that the vast majority of non-pulmonary chronic cough patients owe their problem to one or both of the following underlying causes:
1. Airway Reflux (stomach acid/juice which comes backwards into the throat, airway, and lungs)
2. Postviral Vagal Neuropathy a.k.a. Neuropathic cough (chronic inflammation/dysfunction of the vagus nerve following a cold or other viral upper respiratory infection)

The large majority of the book is dedicated to explaining the underlying mechanisms for these problems, how they are diagnosed, and how they are treated.

She provides helpful short surveys to determine with >90% accuracy if you have one or both of these underlying problems.

She also describes her recommendations for treating the problem. For reflux, she believes that reflux can be cured by dietary and lifestyle changes. Her recommendations are summarized in this book and are laid out in more detail in her other book, Dropping Acid: The Reflux Diet Cookbook and Cure. She also discusses medical treatment of reflux with medications like proton pump inhibitors (ex. Prilosec, Nexium, Protonix, others) and H2 blockers (Zantac, Pepcid, Tagamet). She is quite cautious with medications, especially the PPIs and uses them sparingly.

For neurogenic cough, she describes her usual medicines (amitriptyline, gabapentin, tramadol), which are similar to those outlined in my post on chronic cough from a few months ago.

I found the book to be personally useful for several reasons. One is providing a more “big picture” look at chronic cough, reflux, and vagal neuropathy. Another is the idea that reflux can be cured by dietary changes and that the standard treatment with long term proton pump inhibitors is only masking symptoms and can be potentially harmful. I plan to incorporate the information in this book to better treat the many patients I see with chronic cough and/or reflux.

For patients, the writing is overall pretty clear and understandable. There are a lot of medical terms, but there is an extensive glossary at the end of the book to help you understand them. In the Kindle edition which I read, all the medical terms are linked directly to the glossary.

I would encourage anyone with chronic cough, acid reflux, or asthma to read and understand this book. You can purchase it HERE.

Everyone gets a cough every now and then, usually during colds and other minor illnesses.  Some people, however, have chronic cough, which is defined as a cough that lasts over 8 weeks in adults, or 4 weeks in children.  Most people with chronic cough have tried the usual over the counter remedies such as Robitussin and have not gotten any relief.

Chronic cough can be caused by a large list of possible problems.  The majority of chronic cough, however, is caused by one or a combination of these 4 problems:

• Nasal allergies causing postnasal drip into the throat
• Acid reflux from the stomach into the throat
• Asthma
• Smoking

When I evaluate a new patient with chronic cough, I first talk to them and ask about any history of these problems and also ask about common associated symptoms, especially acid reflux symptoms.  On physical exam, I will examine the back of the throat and the voice box using a thin flexible endoscope that I can pass through the patient’s nose.  There are classic signs of acid reflux that can be seen in the throat using the flexible endoscope- typically swelling in the back half of the voice box and “cobblestone” appearance of the back wall of the throat.

Once I’ve made a full evaluation, I will plan to treat any of the underlying problems (allergies, asthma, and/or reflux) with medication and will instruct any smokers to quit.  If people continue smoking, they cannot expect that their cough will ever get better.

I will usually see patients back a few weeks later, and a lot of them get better.  However, some do not.  These patients may need adjustment of their medication doses, but I will usually at this point consider the possibility of more unusual diagnoses such as neurogenic cough or lung disorders.

Neurogenic cough is a chronic cough caused by abnormal nerve activity to the voice box.  Patients will usually complain of a constant tickle in the throat with recurrent spells of dry coughing.  There are medications that can successfully suppress this type of cough.  These include tramadol (a type of pain medication), gabapentin (also used for nerve pain and seizure prevention), and nortriptyline (also used for migraine prevention and as an antidepressant).

If I have suspicion for any lung problem, I will order a chest X-ray and possibly refer the patient to a pulmonary specialist at this point.

Chronic cough can be a very difficult problem to deal with, but fortunately most patients can be treated successfully once their underlying issue is diagnosed and dealt with.

Laryngopharyngeal reflux (LPR) is a very common problem which affects the throat. It occurs when stomach acid travels backwards up the esophagus into the throat. LPR is essentially the same problem as the more commonly known gastroesophageal reflux disease (GERD), or “acid reflux.”

Acid reflux occurs when stomach acid backs up into the esophagus and throat rather than moving forward into the intestines as it should.

Classic symptoms of acid reflux are heartburn, bloating, stomach pain, burping, and bad acid taste in the mouth. Patients with LPR may have these classic symptoms of GERD but many times they do not.

If the stomach acid backs up into the esophagus and stops there, patients typically experience heartburn. If the acid backs all the way into the throat, many patients will not have heartburn but rather common throat symptoms associated with LPR.

The most common symptom associated with LPR is a sensation of something caught in the throat, or a lump in the throat. The medical name for this complaint is “globus sensation.”

Other very common symptoms of LPR are hoarse voice, difficulty swallowing (usually worst with pills or large bites of food), frequent throat clearing, cough, lots of phlegm in the throat, and post-nasal drip sensation. These symptoms are frequently worst in the early mornings after patients have been lying flat all night. When lying flat, it is easier for stomach liquid to reflux back up the esophagus into the throat.

Smokers and people with nasal allergies can also have similar throat symptoms and may also have LPR at the same time.

LPR is diagnosed by a patient history consistent with the above symptoms (though not all patients have all symptoms). In addition, I will perform an endoscopic exam where I pass a small camera through the patient’s nose to see the back of the throat and the voice box (larynx). There are several classic abnormalities I can see during the endoscopic exam which are associated with reflux.

There is good news and bad news about LPR.

The good news is that while LPR is annoying and unpleasant, it is not a serious or life-threatening issue. Many patients have a sensation of a lump in their throat because of the acid reflux, and they are worried about the possibility of a tumor.

The bad news is that LPR can sometimes be a difficult problem to treat. Medicines and diet/lifestyle changes usually help the symptoms and make them happen less often, but it is a challenge to completely get rid of the throat symptoms forever.

The first recommendation I make for patients with LPR is to adjust their diet to foods that are less likely to cause acid reflux (click here for more details). The most important thing is to not eat or drink within 2 hours of going to bed. Lying flat with a full stomach is very likely to cause reflux.

Overweight or obese patients should lose weight because excess weight around the stomach makes reflux more likely.

Anyone with LPR who smokes should quit smoking for this and many other reasons. If patients with LPR also have nasal allergies, I will treat those as well.

Finally, I will prescribe a anti-reflux medication such as prilosec, nexium, protonix, dexilant, or other similar drugs. This medication should be taken in the morning before breakfast every day. Give it 3-4 weeks to have a full effect. If there is not enough improvement after 3-4 weeks, the medication can be increased to twice daily.

For certain patients with reflux that does not improve with the above treatments, I will refer them to a gastroenterologist for further evaluation.