Chronic cough as a complication of treatment with statins: a case report.

Chronic cough as a complication of treatment with Statins see original reportother causes in the differential include

A cough lasting 8 weeks or more (chronic cough)

Some of the most common causes of chronic cough include:

• post-nasal drip syndrome, when mucus drips down your throat from the back of your nose
• allergies
• asthma
• smoking
• COPD (emphysema and chronic bronchitis)
• acid reflux ( gastro-esophageal reflux disease (GERD)or laryngopharyngeal reflux (LPR))
• some high blood pressure medications
• or a combination of these causes

others more serious causes such malignancies ohttp://fauquierent.blogspot.co.nz/2012/07/chronic-cough-due-to-statins.htmlr TB also require investigation

Bilateral vocal cord palsy

I saw a 60 year old patient a week or so ago with a long history of stridor on exercise. She had had a total thyroidectomy 10 years previously and noted the problem since then. Her voice had also changed. She got breathless on exercise and could not walk that far. She had had multiple treatment for asthma over this time. Her astute GP asked us to see her and check her vocal cords, suspicious of recurrent larygeal nerve injury. See endoscopic video(there is probably slight movement of the right vocal cord, but they are lying in a para-median position giving her a poor airway but reasonable voice.)

Bilateral vocal fold (vocal cord) immobility (BVFI) is a broad term that refers to all forms of reduced or absent movement of the vocal folds. Bilateral vocal fold (cord) paralysis (BVFP) refers to the neurologic causes of bilateral vocal fold immobility (BVFI) and specifically refers to the reduced or absent function of the vagus nerve or its distal branch, the recurrent laryngeal nerve (RLN). Vocal fold immobility may also result from mechanical derangement of the laryngeal structures, such as the cricoarytenoid (CA) joint.


According to Benninger's findings in a series of 117 cases BVFI can be attributed to the following causes: surgical trauma (44%), malignancies (17%), endotracheal intubation (15%), neurologic disease (12%), and idiopathic causes (12%).^[1]

History

The importance of a complete history cannot be overstated. The history should include the following:

• Chief symptom, as related to airway, voice, or swallowing
• Onset of symptoms (acute, subacute, chronic)
• Changes in the voice and airway over time
• Related events such as intubation, surgery, or other medical conditions that can affect vocal cord mobility
• Tobacco use

In children, obtaining a history of birth trauma, central nervous system abnormality, intubations, or surgeries is important.

Treatment options

Procedures for bilateral vocal fold (cord) paralysis (BVFP)

• Tracheostomy
• Reinnervation techniques (experimental)^[11]
• Electrical pacing (experimental)
• Permanent procedures

  • Posterior cordotomy (unilateral or bilateral)
  • Arytenoidectomy (endoscopic or external, partial or complete)
  • Cordopexy, lateralization of the vocal cord

 I have asked the specialist Laryngologists in Auckland to review her and suggest treatment options for her.

Laryngopharyngeal reflux (LPR)

Laryngopharyngeal reflux(LPR) is one of the common presentations to our clinic. We probably see a patient with this diagnosis every single clinic.

A patient may have some or all of the following symptoms:

• Hoarseness
• Chronic (ongoing) cough
• Frequent throat clearing
• Constant mucus or phelgm in the throat
• Dry or sandpaper like sensation in the throat
• Pain or burning sensation in the throat
• Feeling of a lump in the throat (globus pharyngeus)
• Problems swallowing
• Bad/bitter taste in the mouth (especially in morning)
• Asthma-like symptoms
• Ear pain and/or persistent ear infections
• Post-nasal drip
• Large lingual tonsils

Note that these symptoms are not the same as GERD, with little heartburn and reflux. 
This condition was not taught to us when I was a student and patients would often be labelled as stressed.(Globus Hystericus). Because we now know that reflux is the trigger it is usually relatively easy to treat with proton pump inhibitors.


 It is important though to exclude other more serious pathologies by performing a flexible endoscopic examination. Many patients have the fear of cancer and are reassured by examination. 

Public Health services question the Indications for adenotonsillectomy in Children

At a recent Medical Executive meeting the following topic was presented.

4.1             Atlas of Healthcare Variation 

·        Originally scheduled for publication by 30 June, now delayed till later in July.

·        Atlas will highlight variation in health service provision and outcomes between different geographic areas of New Zealand.

·        Information to be displayed in maps, graphs and tables, and displayed on the HQSC (Health Quality and Safety Commission) website.

·        Atlas to be organised into ‘domains’ with 10 domains to be published each year.

·        First 3 domains will be :

-         Maternity, ie vaginal deliveries, c-section rates

-         Surgical Procedures of Potentially Questionable Usefulness, ie tonsillectomies/grommets

-         Life Expectancy, and other demographic variables

Now I wasn't at this meeting and although have requested more detail, non is forthcoming. Having researched what the Atlas of Healthcare Variation is, it appears to have been directly "borrowed" from the NHS in UK.
For those GP's and Specialists who like me are concerned by the statement that "Tonsillectomies/grommets may be of questionable usefulness", I direct you to a Joint Position paper of the Paediatrics and Child Health Division of the Royal Australian College of Physicians and The Society of Otolaryngology, Head and Neck Surgery(July 2008).


It states
Conclusion 2
Current Suboptimal rates of adenotonsillectomy for OSA in Australia and New Zealand
     The incidence of adenotonsillectomy in Australia and New Zealand for OSA is significantly below that expected. The analysis suggests that only 1 in 7-10 children who could benefit from adenotonsillectomy is being treated.


I wont go onto discuss the indications for grommets but there is plenty of similar research to confirm its usefulness. Unfortunately there are going to plenty of more pushes to save money in our health service and worryingly many may be directed towards children. (editor)

Fauquier ENT Blog: Stem Cells Restore Toddler's Congenital Hearing Loss

Fauquier ENT Blog: Stem Cells Restore Toddler's Congenital Hearing Loss

Medical Management of Chronic sinusitis

We see a lot of patients with  chronic sinusitis who have often not had a full course of medical management before being referred to our department.  Many patients will come right with adequate treatment and will avoid a surgical option.

SymptomsCommon symptoms include facial pain / pressure / fullness; nasal obstruction / blockage; purulent nasal or post nasal discharge; hyposmia or anosmia; fever (acute sinusitis only); dental pain.

Physical SignsOften minimal. Mucosal swelling/inflammation; postnasal drip; facial tenderness and
swelling. Post nasal mucous alone is not typical of sinusitis.
Look for nasal polyps, deviated nasal septum or enlarged turbinates.
Examination ideally done after decongestion (Otrivine spray or Co-phenylcaine Forte
Spray in multidose container).

Differential DiagnosisAllergic rhinitis: atypical facial pain; headaches (migraine or tension).
Gastro-oesophageal reflux: TMJ pain; dental pain.

 Chronic sinusitis (continuous symptoms > 3 months)
Management

•  Supportive treatment 
•  - increase fluids, analgesia (paracetamol, NSAIDS) steam inhalations, decongestants i.e. otrivine / drixine nasal sprays or oral pseudoephedrine (maximum 5 days only), and most importantly nasal saline irrigation (Sinus Rinse or Narium commercial preparations are OTC products or use saline irrigation using syringe or straw inhalation). see video here
•  First line antibiotic 4 weeks
• First line antibiotics – amoxycillin, cotrimoxazole, doxycyline.
•  Topical nasal steroid 3 months.

 If no improvement second line antibiotic for further 1 month plus oral steroid minimum 2 weeks – Prednisone 20mg/day for 1 week then Prednisone 10mg/day for further week.

RadiologyPlain x-rays not indicated.
CT Scan indicated for recurrent or chronic sinusitis if no response to medical management as above.

See Healthpoint for full management options and referral criteria