Okay, if this is not asthma, if this is not related to reflux, can it be something else? Can it be a postnasal drip, can it be related to some kind of sensory neuropathic cough, that has been causing the chronic cough in the patient? In my clinic, what I would do, is that I would not only check for the larynx, but I would also check for the trachea, the upper part of it, at least, under local anaesthesia. And I will say that it's very, very rare, but I have seen a couple of cases in which there was cancer in the trachea that has been growing in there, causing the cough, and it was missed before.
Natalie Watson
Welcome to BLA Connections, A clear voice. Here is another episode of Series five. I'm your host Natalie Watson, and I'm delighted to bring you discussions and insights from experts from across the globe, on all things laryngology.
In today's episode we explore chronic cough with Professor Ahmed Geneid. He is an adjunct professor, laryngologist, and phoniatrician. He is head of department in Helsinki University Hospital of Otolaryngology Head and Neck Surgery. He is currently serving as president of the Finnish Laryngological Society, and President of the Union of the Phoniatricians. Ahmed Geneid leads a multidisciplinary team, dealing with voice and swallowing patients in Helsinki University Hospital, Finland. His main interests are laryngology, phonosurgery and voice therapy. He has a growing number of over 50 publications and lectures regularly on laryngology, phonosurgery, and other voice-related topics. Thank you so much for joining us today.
Professor Ahmed Geneid
Thanks a lot, Natalie. It's a pleasure to be here with you, and I would say that it's a very good idea to discuss this topic. Tackling chronic cough, this is one of the most important issues that we face in laryngology and phoniatrics, and I'm really happy to be talking with you about it.
Natalie Watson
Oh, so am I! I think it's going to be a really popular topic. I think it's really relevant to so many different specialties, as well as laryngology. So let us begin - chronic cough, tell me about it.
Professor Ahmed Geneid
Chronic cough is one of the most important things that or let's say one of the issues that we face, when it comes to our laryngology patients, and in different ENT clinics around the world. And I will say that we as laryngologists, usually get the patient at some point, when the patient has already been examined for a cough that lasted over eight weeks, and asthma has been excluded. And usually the patients are sent to our offices as a way of thinking okay, if this is not asthma, if this is not related to reflux, can it be something else? Can it be a postnasal drip? Can it be related to some kind of sensory neuropathic cough that has been causing the chronic cough in the patient? And this is usually the situation that we face in our ENT clinics around the world.
Natalie Watson
So I mean, chronic cough is really one of the persistent throat symptoms that we see all the time, isn't it? What are the common causes of chronic cough?
Professor Ahmed Geneid
I would say that when I get a patient referred to my clinic with a cough that has been persistent for over eight weeks, then I would try to tackle the possible reasons or the aetiologies, the causes that can be related to chronic cough, or causing it.
Of course the first and most important thing is that we exclude that the patient has a chronic cough from lung disease, is it possibly asthma, is the patient a smoker? Are there any kind of indoor pollutants that are in the patient house or the patient place for work. We usually check if there is some kind of reflux that is behind it, that has a range of pharyngeal reflux in this situation. And sometimes as well we tackle issues like the ACE inhibitors that can add an intragenic side effect, causing a persistent cough in the patients who are taking them.
And of course, one of the most important reasons that we should address, and I will say that this is the reason usually the patient is referred to my clinic, is that the patient has all of the previous things excluded, and right now we are sitting with an idea that it may be a sensory neuropathic cough that is causing the chronic cough of the patient.
Natalie Watson
So sensory neuropathic cough, is another name for that laryngeal hypersensitivity, causing the chronic cough?
Professor Ahmed Geneid
Exactly. And this is one of the terminology problems, because when you check for the medical literature on it, you will find different terminologies that are being used for that. It can be called idiopathic chronic cough, unexplained chronic cough, chronic refractory cough, or chronic neuropathic cough. And all of them are referring to the same issue here, that we have every other thing that is excluded, and we are left with this entity that is usually by exclusion in this situation.
Natalie Watson
Yeah, it's that irritative cough, isn't it? That normally dry cough is what is sent to us. So what's your particular approach for the work up of cough?
Professor Ahmed Geneid
That's a very good question. Because when a patient is referred to my clinic, what I would do is that, I would first check that the asthma has been excluded, I would make sure that the thorax X-Ray has been taken. If the patient is a smoker, then the patient stopped smoking ready, and I check the patient's medical list, or let's say what kind of medication the patient is on, and to be sure that ACE inhibitors are not in the repertoire of the patient. And if all of this is being done, then I would go with the plan of treatment of the patient.
Natalie Watson
That's leading me really nicely on to what's your treatment algorithm for these chronic coughs.
Professor Ahmed Geneid
The treatment algorithm, in my opinion goes this way, that we first have to do video endoscopy of the patient. In my clinic, what I would do is that I would not only check for the larynx, but I would also check for the trachea, the upper part of it, at least under local anaesthesia. And I will say that it's very, very rare, but I have seen a couple of cases in which there was cancer in the trachea that has been growing in there, causing the cough, and it was missed before. And I would always advise when you have a patient with chronic cough, that you check that you can see down to the level of the carina, down to the level of the bifurcation, for the bronchi, because in this way, you can do that with local anaesthesia, putting the local anaesthesia on the vocal folds and the subglottal level like below the vocal folds, can make you sure that he will have a very good vision, and you will be able to go with the video endoscopy down and make sure that there is nothing there.
Natalie Watson
I think that's the major thing, isn't it? I think this is the big shift to that in my practice that I've included in my reviews for cough, is actually to explore the trachea as well. And I think now with lots of in office procedures being done, I think we're just so used to applying lots of local anaesthetic to this area to have a really good view. It's not something that routinely people do in ENT clinics. But coming to a complex cough laryngology clinic, you know, in a tertiary centre, it can obviously be done anywhere, it doesn't need to be done in you know, big university hospitals, it can be done in the more district general hospitals or small hospitals in other countries. And I think this is a good important point to labour on just to say how we would actually approach applying the local anaesthetic for someone who needs a tracheoscopy through the vocal cords.
Professor Ahmed Geneid
One of the things is that, let us assume that you have a patient coming to your clinic with let's say six months of chronic cough, every other thing has been excluded. So what I would do, is that I would take a channel video endoscope and go through the nose to the level of their larynx first, check that everything in the larynx looks nice to me, and then through the channel, I would go dripping 4% lidocaine on the vocal folds, while the patient is fornating, for example, saying a long ‘eee’ and while the patient is doing that, I will tell the patient, ‘Okay, now you will feel that there is some kind of water, or some kind of fluid going into the wrong direction. And what I would like you to do is to continue the sound eee, into a gurgling sound’. So the idea here is that to make the lidocaine 4% on the level of the vocal folds, and then I would do by intention, drop a few drops as well in the trachea. And the patient of course will cough during that examination. But the idea is that cough here is a good thing during the examination, because it will help to disseminate the anaesthesia on the tracheal wall, on the vocal folds, and on the larynx. And then I would go and take a dip in the trachea while the patient is breathing and alternating, so while the glottis is open.
I would recommend that we do this for patients who come with chronic coughs, for let us say, for up to three years. But if you have a patient coming that has had a chronic cough for 10 years, then probably there is nothing there in the trachea because it is probably just some kind of tic symptom that has been with a patient for 20 years. But in different situations in which the patient is coming after six months of the beginning of chronic cough, one year, two years, I would go have the anaesthesia being done, go check for the trachea and make sure that there are no surprises down there.
Natalie Watson
Yeah, I think it's worthwhile. The other things that we use in our clinic are using the magic device, the atomizer device with, you know, any type of lidocaine through the syringe and asking them to say ‘eee’ and dribble that down. Also, what we have used is something called the Trachospray for those people who've got a really bad gag reflex, and actually, sometimes, because they've got such an irritable larynx, their gag reflex is heightened. And therefore the Trachospray has been really useful.
So it's a device where you put it into the mouth, and they clench it between their teeth, and every time they breathe in, they raise their hand to say that they're breathing in at that same time, and you push the plunger through as they're breathing in so that they can inhale the Lidocaine that way. So there's a number of different ways of doing it, even if you don't have a channelled endoscope, there are some adjunctive things that you can do to go trans orally. Moving on from there - so we've eliminated tracheal pathology, we think it's an irritable larynx, we think it's laryngeal hypersensitivity. How do you approach actually treating this hypersensitivity?
Professor Ahmed Geneid
Usually, the patient being referred to a laryngologist, means that the patient already has all of the different other aetiologies excluded, including laryngopharyngeal reflux, and it would say that the patient when he is referred, or when she's referred to my clinic, usually she had a reflux medication for over two months as a trial. So I know that this has been really excluded. And I would say that many of them had a gastroscopy that had been done. So I'm right now in a phase in which I know that I’m addressing a chronic neuropathic cough, and irritable larynx or hypersensitive larynx. And I will think of explaining the reason first to the patient, like I would go with a patient to the time when it started. And usually the patients remember somehow that there was some kind of an upper respiratory tract infection, or even COVID-19 infection, after which it started. And despite that, all of the other symptoms of the upper respiratory tract infection subsided, but still the cough is there.
So I would expect that in this situation, there has been some kind of over sensitivity of the internal branch of the superior laryngeal nerve . In other words, there is some situation in which the nerve is telling the brain all the time, that there is an irritation that is happening inside. And the patient is just reacting, by the way, the reflux, like the evolution, is telling her or him to be coughing. And I would go through a number of different options. So one of the options, for example, is to try amitriptyline for the patient. What I do is that I usually start with about 10 milligrams a day, and I would advise patients to take that during the evening. One of the nice things about it, is that I will say that 100% of the patients would say to me that they sleep much better with it - it's magic when it comes to sleeping, but unfortunately, it's not when it comes to chronic cough. I would say that 50 to 60% would be gaining benefit from it.
And such medications like amitriptyline, gabapentin, they have been tested before in different resources and they have proved to be a good option for a chronic cough, but unfortunately, not for everyone. So you would have patients that you know, feel a little bit, or maybe too much tired, exhausted, with amitriptyline, despite the fact that it is only 10 milligrammes.
One of the things that comes to my mind, which is very important, is that I would always talk with the patient about the fact that amitriptyline was used a long time ago as a depression medication, but no longer anyone is using it. There are much better medications for depression. And I would take that when I'm talking to the patient, because I'm afraid that when the patient is just checking on what is written in the papers inside the medication, and treats that it has been used for depression, then the patient would think that I'm giving him a medication for depression, when in fact, I’m just giving a medication to lower the sensitivity of the nervous system here. Especially tackling the internal branch of the superior laryngeal nerve.
There are other options that I will take into consideration. Usually the two main options that are quite relevant for the patient, one of them is to have speech therapist guidance. That means that I have a couple of Speech and Language Services in my office, who are mainly dealing with cough patients. So they will have about four to five meetings with the patient, in which they give certain manoeuvres that the patient may use to overcome the cough. And of course, there is always the third option, which is to go for a cortisone lidocaine injection like Depo-Medrone, for example. And the insertion of the internal branch of the superior laryngeal nerve on both sides. And I will say that these main three ways, the medical one, amitriptyline, gabapentin, the speech therapist's guidance, and the Depo-Medrone injections, these are the main items for the management of chronic neuropathic cough.
Natalie Watson
Brilliant. Now I think if I was asking my speech language therapy colleagues, they would advise a sniff sniff, blow, blow, sniff sniff, blow blow, a bit like when they do for inducible laryngeal obstruction to just try and overcome that cough, or take a nice sip of water at the time, and just try and do a deep swallow, just to try and overcome the cough urge. Do you know of any other exercises that your speech and language therapists usually use?
Professor Ahmed Geneid
Actually you probably mentioned them all. And I will say that they do work if the patients remember them, and have a way of keeping in mind that ‘Okay, now the coughing is coming on, I'm having this feeling of irritation, I will be going to cough, then I would go for drinking a sip of water, I will go for a deep swallowing while having the chin tuck position’. All of these manoeuvres will help much and one of the most important things is the visual feedback that we give to the patient while we are examining the patient's larynx, that the patient is satisfied with the fact that there is nothing there. And then the patient is accepting the fact that okay, this is a hypersensitive situation, and we should tackle that. And of course, there is no reason to use only one method. You can use the speech therapist guidance in addition to the DepoMedrol injection or in addition to the amitriptyline as well.
Natalie Watson
It's one thing that I think laryngologists have in their armamentarium, is that biofeedback mechanism, because we are so privileged to be able to show patients their larynxes and to show them how good they look. You know, it gives them some reassurance that with the hypersensitive larynx, actually, there's nothing physically that you can see easily, wrong. There's no lumps or bumps. There's no big lump that's causing them to cough. And actually that in itself can be very reassuring, I’ve found.
Professor Ahmed Geneid
Exactly. And one last way to do that or to tackle this issue in our armamentarium here, is that if we have tried these three options, you have tried the amitriptyline, the Depo-Medrol, the speech and language therapist guidance, in this situation. Then one additional way, which in my opinion is the last way, is to have Botox injections in the vocal folds, for the patients who have chronic cough that is not reacting at all, to all of the previous ways. And for these patients, of course, we have to address the fact that Botox, botulinum toxin, will have a side effect on the voice of the patient for about two to three weeks after the injection. However, I would recommend that we start with the three other options, and if the patient is not reacting, then we can go forward to have a botulinum injection in the vocal folds.
Natalie Watson
Now I want to just focus, just very briefly, like we did with the local anaesthetic about the techniques of giving that Depo-Medrol injection. We're getting more and more familiar within office procedures. So presumably you do these in office?
Professor Ahmed Geneid
Exactly, and without anaesthesia. So it's a very quick procedure to be done for the patient.
Natalie Watson
So we'd prepare the larynx just as we would doing a tracheostomy, dribbling some lidocaine around the area because it folds this time and the vocal cords just so that the whole area of the larynx is presumably numb.
Professor Ahmed Geneid
Actually what I do is a little bit different. So if I have a patient coming for Depo-Medrol injection in the internal branch of the superior laryngeal nerve, the patient will just lie flat on the bed with their head tilted to the back a little bit in the extension position. And then I would go from the outside, without applying anaesthesia in the inside of the larynx, I would go from the outside palpating for two main landmarks. The first one is the back end of the hyoid bone. And the second landmark is the superior Cornu of the thyroid cartilage. And between them, and a little bit to the front, is the exact place of the internal branch of the superior laryngeal nerve. And then I would go with the Depo-Medrol, let us say that we have 25g needle or 24g needle, go there, have the Depo-Medrol injected, and that's all.
The one trick that is important to apply here is not to go too deep, and not to go to too superficial, because if you go too deep, you'd actually go inside and that will provoke an intense bout of coughing, if you go to the superficial, then you may end up with very early side effects on the skin of the patient, on the skin of the neck of the patient in this situation.
Natalie Watson
Right, now how much do you inject (and this is in the UK), this is methylprednisolone injection.
Professor Ahmed Geneid
It's exactly like this, and per site, I would inject 80 milligrams of methylprednisolone acetate, and 20 milligrams of lidocaine hydrochloride. So this is a total of two millilitres, which sounds a little bit like a huge volume, but in fact, I'd say that, it makes me sure that what I'm injecting is going to end around the nerve.
Natalie Watson
And how long does it take for you to find an effect from that injection?
Professor Ahmed Geneid
What the patients say, is that immediately, like, just within one minute after the injection, the patient will report to you that there is some kind of a feeling of a lump in the throat. And some patients have this feeling that swallowing is a little bit difficult. And that would be there for about two hours, sometimes more. And usually what I do, is that I would call the patient back in about three weeks and ask how it is going?
Some patients will say, yeah, they noticed an effect. And then if that effect is like 100%, that I'm really happy. And I would say that I do see some wonderful, even surprising effects in certain patients, who didn't have a chronic cough for too long. Let us say that patients who had a chronic cough for only six months after COVID-19, or patients who had chronic cough for six months after an upper respiratory tract infection, they are the ones that react in a marvellous way. And of course, though, those that react in a less positive way are those who had the chronic cough for like three years, four years.
Natalie Watson
What I want to know now, is have you ever done an endoscopic injection of the sensory innovation of the larynx, injecting on the aryepiglottic fold for the superior laryngeal nerve?
Professor Ahmed Geneid
No, I didn't do that. It's technically quite possible. And I would say that, I guess some colleagues have been doing it, but I didn't do that. Assuming that it's easier to do that from the outside, around the nerve from the part from which it leaves from the larynx upwards.
Natalie Watson
So I mean, I haven't done it at my practice, but having just been to the ELS, there were some colleagues that were talking about the endoscopic approach, so that is also a possibility. From listening to them, it sounded as if they looked around the aryepiglottic fold, they would use the same injections, but they would prepare the larynx as you would with any laryngoscopy, and, have an intra oral/trans oral or channelled endoscopic injection, kind of just lateral to the area of aryepiglottic fold while in the area of fold to hit the superior laryngeal nerve that way. So just an alternative if the external did not appeal to you.
So we have our treatment algorithm. We have some speech and language therapy, we have some medications that we can use for this irritable larynx. And we've also got some surgical intervention, where we are injecting, and treating some inflammation, and resetting the superior laryngeal nerve, to try and give the brain some feedback. To say that it's not under threat. And so are there any other remedies on the horizon?
Professor Ahmed Geneid
There was one that was being planned to be available. And unfortunately, the company that was actually planning on it, and developing it, decided to stop the pipeline in terms of this medication. So I really would say that, as far as I know, right now, there are no new medications that are becoming available on our site for the treatment and management of chronic cough.
Natalie Watson
Right, well, we will just have to wait and see! I'm sure there are other medications out there that may be being trialled. And maybe it'd be quite nice to get some respiratory doctor to come and have a chat as well, and see about their perspective of chronic cough from their point of view, and what they have to do to kind of eliminate everything else before they send it over to us.
Professor Ahmed Geneid
That will be fantastic.
Natalie Watson
Any final words from you, Ahmed?
Professor Ahmed Geneid
One final word when it comes to the patients with a chronic cough. And this is actually something that is very interesting. We do see chronic cough more among women than men. And I would attribute that to the evolution. And actually it was examined that women do have a lower threshold for cough, in comparison to men. And I would say in this situation, that probably women are more ahead in terms of the evolution than men. So probably it has developed with the ability to be pregnant and protecting against aspiration while pregnant. And that's why women do have more, let's say hypersensitive cough problems, in comparison to men. And that's a very interesting thing to explain, why do we have such presentation.
And one thing is well, for the listeners. It is quite normal during upper respiratory tract infection to have a cough, and this is unfortunately part of the deal, because this is a way in which we can make sure that our lungs and our larynx, that they are clearing all of the mucus there, and with time it will go down. And if it doesn't go down, then at this time, we just have to wait. If it goes for over eight weeks, then this is a situation of a chronic cough for the patient and should be tackled upon as we discussed it.
Natalie Watson
Brilliant. Well thank you so much for joining us today, and sharing your experience of managing chronic cough from the laryngology perspective.
Professor Ahmed Geneid
Thanks a lot Natalie, that was a really fantastic discussion, thanks to you.
Natalie Watson
Well, thank you, and I want to leave, by just reminding everyone that we have our next BLA joint with UEP meeting, on the 14th of September in London, England. If anybody wants to join for the fantastic programme we have in store, focusing on all the major aspects of laryngology - airway, swallow, neurolaryngology, and voice. It will be fantastic to see you there. Ahmed, you'll be joining us?
Professor Ahmed Geneid
Yes for sure. And I will be very happy to be there in the first inaugural joint meeting between the BLA and the UAP. It will be a fantastic one, with different topics addressing the most important ones in laryngology and phoniatrics, and of course, it's open to laryngologists, phoniatricians, speech and language therapists, voice coaches and acousticians. Everyone is invited.
Natalie Watson
Absolutely, it's going to be relevant to all. So thank you so much.
We hope you have enjoyed listening to BLA Connections, A Clear Voice. I have been your host Natalie Watson. Please do tune in this series, for more laryngology topics. We would also love to hear from you. Please feel free to email with any topics you would like us to explore, any questions you have, along with any suggested experts you would like to hear from. Also, if you'd like to contribute to these podcasts, please email inquiries@britishlaryngological.org
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