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PRACTICE: Kevin Barraclough Chronic cough in adults BMJ 2009; 338: b1218 [Full text]

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Article misses the point about pertussis

Andrew M Ross   (26 May 2009)

Chronic cough in adults and the pitfall of postnasal drip.

Thiru M Siva, Paul Gurr (Consultant ENT same address)   (13 June 2009)

Article misses the point about pertussis 26 May 2009
Andrew M Ross, general practitioner Northfield Health Centre, 15 St Heliers Road, Northfield, Birmingham B31 1QT Send response to journal: Re: Article misses the point about pertussis	The article about 'test of treatment' in chronic cough in adults mentions that pertussis is a possible cause of chronic cough, but questions the importance of this diagnosis in primary care. Having recently confirmed the diagnosis in a previously vaccinated schoolchild and in a middle aged patient (and in several other cases previously) I can perhaps shed some light on why confirming the diagnosis is actually very important. Firstly the cough classically lasts for 3 months, but in the ensuing years, often the typical tracheal cough returns with subsequent viral respiratory infection. Secondly, treating patients with asthma drugs may give the erroneous impression that any clinical improvement is indicative of asthma... in my experience many patients find that steroid inhalers help their pertussis induced cough, presumably by reducing laryngeal edema and coincidental clinical improvement. The natural history of pertussis with its remitting cough that is worse on exercise means that many patients are mis-diagnosed as being asthmatic. This leads to avoidable patient anxiety and cost to the NHS. Whilst other causes of chronic cough should always be considered whilst waiting for results, confirmatory testing for pertussis of those with a tracheal cough is clinically worthwhile. Competing interests: None declared
Chronic cough in adults and the pitfall of postnasal drip. 13 June 2009
Thiru M Siva, Specialist Registrar ENT Northampton General Hospital, Northampton, NN1 5BD, Paul Gurr (Consultant ENT same address) Send response to journal: Re: Chronic cough in adults and the pitfall of postnasal drip.	Dear Editor, With regard to the article on chronic cough in adults the evidence based approach taken to the diagnostic dilemas is very welcome. The algorithm noted is a useful framework and consistent with most ENT surgeons practice in conjunction with primary care physicians. However with regard to post nasal drip as a symptom of sinusitis, although quoted in the last European Position Paper on Rhinosinusitis and Nasal Polyposis (EP3OS)document, most ENT surgeons see this to be a genuine productive cough than subjective and generally to be a "soft" symptom of sinusitis. The last point is important to note as the next step after antihistamine is secondary care referral. Objective post nasal drip should also be differentiated from a subjective sensation of post nasal drip with may be followed by persistent throat clearing rather than spontaneous cough.This subjective symptom may form part of the Globus Pharyngeus symptom complex which can be successfully treated by Speech therapists.(Khalil HS et al 2003) Ref The use of speech therapy in the treatment of globus pharyngeus patients. A randomised controlled trial. Khalil HS, Bridger MW, Hilton-Pierce M, Vincent J. Rev Laryngol Otol Rhinol (bord). 2003;124(3): 187-90 Competing interests: None declared