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An Otolaryngologist on Chronic Cough
Conversations in Chronic Cough: An Otolaryngologist’s Perspective

Released: July 14, 2025

Michael S. Benninger
Michael S. Benninger, MD
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Listen as Michael S. Benninger, MD, describes his approach to the diagnosis and management of chronic cough and refractory chronic cough in the context of a clinically relevant case.

This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.

Patient Case

So let us talk about a patient because this will be more applicable to your practices, I believe. So this is a 51-year-old woman with cough. The cough has been present for four years and started after a respiratory tract infection, and the cough is getting worse with these paroxysmal uncontrollable bouts where she cough, cough, coughs. She was seen by her primary care physician who tried a number of different over-the-counter medications and benzonatate without any help. She had a chest x-ray, which was normal, two years ago, and otherwise, her health has been good and no recent weight loss.

Her cough is non-productive and she notes this little tickle in her throat before she begins coughing. It seems to be worse if she is around certain odors which cause her to cough, and laughing often makes her cough. She occasionally has a little bit of incontinence and bladder leaks when she coughs, and she is now embarrassed to go out to public, even worse since COVID where people are afraid that she might have a serious disease or be contagious.

History

Her past history is pretty unremarkable. She is not using an ACE inhibitor. She has a family history of a father with allergic rhinitis, is a non-smoker, and she works as an accountant, so she is not exposed to a lot of toxic chemicals. Her ENT exam was normal, the ears were normal. She had some mildly swollen turbinates without drainage, a little bit of posterior nasal drip. Her lungs were clear. Her heart did not have any murmurs and was a regular rate and rhythm and no evidence at least in the head and neck and on the arms for a rash.

Treatment

She was diagnosed with asthma and the cough continued despite treatment for underlying asthma, and at times fairly aggressive treatment. Other conditions were ruled out.

Reflux

I think in an ENT practice, one of the things we really should look at is reflux, because often reflux may have been treated but the patient is not on it for a very long period of time or they are not getting an aggressive treatment. I do a combination of acid-suppression diet, weight control, a PPI, and an H2 blocker at night time for about three months.

Chronic Cough

The diagnosis for her is refractory chronic cough. What about chronic cough? It affects between 10% to 12% of the world's population. There is a female predominance and in some surveys, they show that two-thirds of patients were female. Typically presents a little bit later in life, most commonly between age 50 and 69. Smoking and air pollution are of course risk factors. Never-smokers and air pollution show a risk of cough and phlegm production.

Burden

What is the burden? The burden experienced by greater than 50% of patients is it hinders their ability to talk and communicate. They are embarrassed by it, they are frustrated. They worry there may be something more significant and it has not been diagnosed, and there is clearly a reduced quality of life and decrease in activities. What happens is that normal activities may actually precipitate it for them: changes in body position, speaking, singing, exercise, exposure to cold. It may become frequent and severe over time.

About 40% of patients show improvement with medications but that means 60% do not, and about 70% of patients are really frustrated by the persistence of their condition and the lack of effective treatment.

Patient experiences

Here is a couple of quotes from patients. ‘There is no ability to stop coughing or controlling it, it just takes over.’

‘It just takes over your body and you cough until it is all out.’

Then one patient said, ‘I have not slept for many years, the coughing spells start at night,’ although many patients will actually stop coughing once they are asleep.

‘It is to the point where I have to go to the counter or to the sink, and I am also almost holding onto it to prevent me from vomiting or from incontinence.’

‘At times, I will get bad enough where I black out or feel like I am going to black out.’ Most patients do not actively black out. If they do, then you are looking at cough-induced syncope. Most patients just feel like they are going to because they are coughing so aggressively.

Assessment

When we do our initial assessment of chronic cough, the history is really, critically important, and we really have to uncover details that will tell us whether or not this cough is something that we are going to be able to figure out. The length of time of the cough, the length of time between coughs, whether or not there is this paroxysm, a really aggressive cough, cough, cough where they can't seem to stop. Are there triggers in the environment, environmental exposure, or occupational exposures, things that we might be able to rule out? Family history, smoking history, what previous evaluations and treatments have they had?

Step-wise approach

And I look at it as a step-wise approach. There are certain things that cause cough before we get to recalcitrant or unexplained chronic cough. Most of those are pulmonary, so a pulmonary evaluation is really helpful. Rule out asthma, rule out COPD, rule out airway hypersensitivity. Allergy assessment, and either an allergy assessment with skin testing or blood testing with specific IgE because allergies can cause cough, but usually when allergies cause cough, they are in association with other issues such as pulmonary disease. However, chronic sinusitis and allergies or chronic sinusitis independently can be associated with cough. Reflux, which I already talked about. What medications they are on, prescription and over-the-counter, herbal medications, particularly ACE inhibitors, which many times patients have been on ACE inhibitors for many years but they start coughing later, so a trial of a different blood pressure medication may be indicated.

Red flags

Red flags would be hemoptysis, smoker older than 45 with a new cough, change of voice, or coexisting voice disturbances. Adult patients 55 to 80 who have had a 30-year history of smoking, currently smoke, or have quit within the past 15 years. Prominent dyspnea, especially at rest or at night where they are really short of breath. Hoarseness. We do want to evaluate their larynx, so hoarseness would be important. There are things that can be on the vocal folds that can induce cough, certain lesions can cause cough just from the irritation and tickle sensation. Things like fever, weight loss, peripheral edema, weight gain. Any trouble with swallowing, eating or drinking, vomiting. Recurrent pneumonias where they may be aspirating, so the cough may be in part because of vocal fold bowing or incomplete closure, or abnormal respiratory examination, chest X-ray, CT scan that might show us something that might be significant from a pulmonary standpoint.

Four Main Conditions

The big four conditions account for most of the chronic cough in a immunocompetent, non-smoking patient with normal chest findings and radiographs.

  • Upper airway cough syndrome;
  • asthma;
  • non-asthmatic eosinophilic bronchitis, which is being diagnosed more frequently;
  • and gastroesophageal and particularly gastro-laryngeal or laryngo-pharyngeal reflux disease.

Refractory vs Unexplained Chronic Cough

We have broken this whole thing up into a group of patients with a history for greater than eight weeks of cough, so chronic cough, we break into two major categories.

The first category would be refractory chronic cough. These are patients that have a chronic cough and we know that they have underlying medical conditions such as asthma, but these have been aggressively treated, and even though the asthma might be under good control, the cough persists or they have reflux and the reflux is under good control, they have had a fundoplication and the cough persists.

Then we have unexplained chronic cough. This is associated underlying medical conditions are not identified, so we do not find anything else. We have tried and we have treated for those other things, but they really do not have any particular reason for cough.

I will tell you that this distinction is semantical to some extent and many people are saying that we should probably use the term refractory chronic cough for any patient, although I like to break it down into those two categories: refractory chronic cough if there is underlying pathology, and unexplained chronic cough if there is no underlying pathology.

What Next?

What is next? What if this patient has refractory chronic cough? What do we do? One of the things that we do in our practice is we have them evaluated by a speech and language pathologist, a voice pathologist, where they can really work with them on behavioral ways of reducing the cough. A lot of these patients almost have a habituation. When they feel the cough, rather than trying to prevent the cough, they purposely cough or unconsciously cough. What ends up happening is you cough, you cause laryngeal irritation, so you cough, you get more laryngeal irritation, and it's kind of a self-propelling nightmare for these people. Anything we can do to behaviorally reduce the cough works very well.

Neuromodulators

We can treat neuronal pathways with neuromodulators: gabapentin, pregabalin, amitriptyline, low-dose morphine, tramadol. There is a number of things we could do. I particularly like amitriptyline because I can escalate the dose very slowly. I can have them take 10 milligrams at bedtime, see what the side effects are. If they are no better, they can move to 20. If they are not too sedated, move to 30, and adjust according to the side effects and the success to treatment. Although I will tell you gabapentin tends to work a little bit better, but it also has more side effects.

Referral to a specialist

For the primary care doctor and for us, a referral to a specialist. I routinely see these patients in combination with the pulmonologist, occasionally with the gastroenterologist, and we can refer to a cough center. Most cough centers tend to be virtual centers where each of these specialties are seeing them separately.

Nerve blocks

From my practice, the biggest thing that has changed our treatment of cough has been procedural, and we do superior laryngeal nerve blocks all the time, and we have remarkable success with nerve blocks. I do two sides and I do them once every three months with a combination of 40 milligrams of triamcinolone acetonide and 1cc of lidocaine. We would do it three over three times, and in that group, we have about 80% response with 50% of people experiencing a 90% or better response. The problem with nerve blocks is the problem with everything else, that many of the people become dependent on them or many of the people will eventually get to the point where you have to stop because of local toxicity, et cetera. Botulinum toxin injections can also work, particularly those people with paroxysmal laryngospasm cough. In people with vocal fold bowing, vocal fold augmentation can be used and we can do these things while still keeping them on other medications.

Cough Hypersensitivity

Symptoms of cough hypersensitivity are this urge to cough, irritation, itch, scratch, tickle something there. There is something called allotussia, which is cough triggered by a non-tussive stimulant: talking, laughing, singing, changing positions, humidity, eating. There is hypertussia, an increased sensitivity to stimulant: cold air, dry air, fumes, odor, dust, aerosols, et cetera.

Many of these things are related to both central and peripheral pathways where the neuromodulators tend to work centrally, the nerve blocks tend to work on vagal afferent neural pathways. We can reduce this hypersensitivity. I think there is some real hope on the horizon to have other medications that we can use for cough.

Return to our Patient Case

Let us finish by going back to Joan. Joan was treated for underlying asthma, we did not find anything else. The allergy test was negative. She was treated for reflux. She is not on any medications that would trigger cough, allergy workup was negative. With that, I would say that my next steps would be, and typically, I would use a neuromodulator.

Now I will tell you, if they are older than 70, we are a little cautious starting with neuromodulators, and in fact sometimes, what we will do in those patients is we will do nerve blocks first because we are worried about the side effect and the risk of falling of neuromodulators in the elderly population. But in any case, I would typically start with amitriptyline and do that escalating dose. If they get up to 50 milligrams at night time and either if they are very sedated or they are not getting a response, then I would switch to one of the other neuromodulators. It really would depend on the patient and their age.

If those did not work, I would go to nerve blocks, and really the success of nerve blocks in our practice has been pretty remarkable. They are simple to do. We do a series of three and then we wait three months, and then usually I do a virtual visit with them and see how they are doing. If it got better and then it worsened, then I would do another series of three. If we did two series and they are still getting this dependency where they really need to keep doing it, then I start to do them bilateral nerve blocks once every three months, and oftentimes we can control them.

As I said, with the paroxysmal coughs, the kind of laryngospastic cough, and I think you need to use the diagnostic code laryngospasm or you will have difficulty getting botulinum toxin injections approved for that group, and they really probably are laryngeal spastic. Then we try botulinum toxin injections and we get about the same response. We get about 50% of those people respond. There is no reason they can't continue the neuromodulator, and sometimes we will do nerve blocks with the neuromodulator.

If that does not work, I do not have a lot of potential treatment options. In the elderly patients with bowed vocal folds, with that little aspiration that they get because of that, we can do augmentation. You could try an office augmentation with hyaluronic acid. I prefer fat injections, but sometimes we will do bilateral implants.

It is a step-wise process and you really need to be very conscientious that you have dotted all your i's and crossed all your t's to make sure that we have got the right diagnosis, we have ruled out any other potential causes of cough, and then we have addressed the cough from a symptomatic standpoint.

The last thing is, allergy treatment can often be effective, nasal treatment can be effective. We try a course of intranasal steroids, sometimes we get a CT scan of the sinuses and make sure that that is not involved as there are true postnasal drip chronic sinusitis patients with cough.

From an ENT perspective, we should really, really be a big part of this treatment team, and along with pulmonologists and GI doctors, we can usually get most patients under good control.

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