Otolaryngologic Clinics of North America RSS feed: Current Issue. Otolaryngologic Clinics of North America updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in otolaryngology and is presented under the direction of an experienced guest editor.http://www.oto.theclinics.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. Otolaryngologic Clinics of North America0030-6665431February 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.oto.theclinics.com/article/PIIS003066651000006X/abstract?rss=yesContributors10.1016/S0030-6665(10)00006-XOtolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0iiivhttp://www.oto.theclinics.com/article/PIIS0030666510000071/abstract?rss=yesContents10.1016/S0030-6665(10)00007-1Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0viixiihttp://www.oto.theclinics.com/article/PIIS0030666510000083/abstract?rss=yesForthcoming Issues10.1016/S0030-6665(10)00008-3Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0xiiixiiihttp://www.oto.theclinics.com/article/PIIS0030666509002163/abstract?rss=yesBoth acute and chronic cough are responsible for a significant portion of ambulatory medical visits annually (about 3%), over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. The diagnosis of cough can be simple or profoundly challenging. This ranges from a solitary cause such as allergic rhinitis, to multifactorial and synergistic contributions, to a physiologic mystery that may ultimately impair respiratory function and hinder one's way of life. One unique aspect of this chronic cough is that it is an indicator of underlying disease, rather than being a disease itself.Cough Specialists Collaborate for an Interdisciplinary ProblemKenneth W. Altman, Richard S. Irwin10.1016/j.otc.2009.12.004Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0xvxixhttp://www.oto.theclinics.com/article/PIIS0030666509001820/abstract?rss=yesCough is a common and important respiratory symptom that can produce significant complications for patients and be a diagnostic challenge for physicians. An organized approach to evaluating cough begins with classifying it as acute, subacute, or chronic in duration. Acute cough lasting less than 3 weeks may indicate an acute underlying cardiorespiratory disorder but is most commonly caused by a self-limited viral upper respiratory tract infection (eg, common cold). Subacute cough lasting 3 to 8 weeks commonly has a postinfectious origin; among the causes, Bordetella pertussis infection should be included in the differential diagnosis. Chronic cough lasts longer than 8 weeks. When a patient is a nonsmoker, is not taking an angiotensin-converting enzyme inhibitor, and has a normal or near-normal chest radiograph, chronic cough is most commonly caused by upper airway cough syndrome, asthma, nonasthmatic eosinophilic bronchitis, or gastroesophageal reflux disease alone or in combination.Cough: A Worldwide ProblemJ. Mark Madison, Richard S. Irwin10.1016/j.otc.2009.11.001Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0113http://www.oto.theclinics.com/article/PIIS0030666509002102/abstract?rss=yesBronchopulmonary C fibers and acid-sensitive, capsaicin-insensitive mechanoreceptors innervating the larynx, trachea, and large bronchi regulate the cough reflex. These vagal afferent nerves may interact centrally with sensory input arising from afferent nerves innervating the intrapulmonary airways or even extrapulmonary afferents such as those innervating the nasal mucosa and esophagus to produce chronic cough or enhanced cough responsiveness. The mechanisms of cough initiation in health and in disease are briefly described.Afferent Nerves Regulating the Cough Reflex: Mechanisms and Mediators of Cough in DiseaseBrendan J. Canning10.1016/j.otc.2009.11.012Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-01525http://www.oto.theclinics.com/article/PIIS0030666509001832/abstract?rss=yesA variety of mucoactive medications are used to treat chronic lung disease. When evaluating the role of the cough, it must be considered as an important protective mechanism. Therefore, it may be more important to improve the effectiveness of cough than to suppress or eliminate a chronic cough in patients with chronic lung disease. This article discusses the composition of mucus and phlegm, the process of mucin secretion and mucus clearance, and reviews current therapy and mucolytics in use or being studied for mucus clearance disorders.Mucus and MucinsBruce K. Rubin10.1016/j.otc.2009.11.002Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-02734http://www.oto.theclinics.com/article/PIIS0030666509002138/abstract?rss=yesThe symptom of cough may result from a multitude of etiologies involving different parts of the aerodigestive tract. This article focuses on the association of cough and swallowing dysfunction in the sense that cough may be an indicator of swallow dysfunction and in the importance of cough in preventing aspiration and aspiration-related disorders. Whereas these associations have been known for a long time, research is starting to connect the dots, allowing targeting of strategies aimed at diagnosing and preventing illness in certain dysphagic patients.Cough and Swallowing DysfunctionMilan R. Amin, Peter C. Belafsky10.1016/j.otc.2009.12.001Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-03542http://www.oto.theclinics.com/article/PIIS003066650900214X/abstract?rss=yesThis article presents disorders of periodic occurrence of laryngeal obstruction (POLO) resulting in noisy breathing and dyspnea and a variety of secondary symptoms. Included in this classification are glottic disorders, such as paradoxic vocal fold movement and vocal cord dysfunction. The supraglottic disorder, termed, intermittent arytenoid region prolapse or laryngomalacia, is also reviewed. Three categories of POLO are defined as irritant, exertional, and psychological.Vocal Cord Dysfunction, Paradoxic Vocal Fold Motion, or Laryngomalacia? Our Understanding Requires an Interdisciplinary ApproachKent L. Christopher, Michael J. Morris10.1016/j.otc.2009.12.002Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-04366http://www.oto.theclinics.com/article/PIIS0030666509001844/abstract?rss=yesRecent literature points to postviral sensory neuropathy as a possible cause for refractory chronic cough. Vagal neuropathy may affect the sensory branches, inducing chronic cough or laryngospasm. Although the clinical presentation is fairly well described, there is little in the way of diagnostic criteria to establish this diagnosis. This article highlights the clinical picture of this disease and the efficacy, side-effect profiles of the currently used pharmacological interventions.Evidence for Sensory Neuropathy and Pharmacologic ManagementScott M. Greene, C. Blake Simpson10.1016/j.otc.2009.11.003Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-06772http://www.oto.theclinics.com/article/PIIS0030666509001856/abstract?rss=yesThis article describes the assessment and behavioral treatment for paradoxical vocal fold motion disorder (PVFM), chronic cough, and laryngospasm. Behavioral treatment for these disorders is coordinated by the speech–language pathologist. Assessment of PVFM involves a detailed behavioral analysis of the triggers for the conditions and incorporation of the medical findings as they relate to the symptoms. Treatments developed originally by the group at the National Jewish Hospital in Denver, Colorado, and then expanded by others have been shown to reduce or eliminate the symptoms and improve overall quality of life in patients who have these diagnoses.The Role of Voice Therapy in the Management of Paradoxical Vocal Fold Motion, Chronic Cough, and LaryngospasmThomas Murry, Christine Sapienza10.1016/j.otc.2009.11.004Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-07383http://www.oto.theclinics.com/article/PIIS0030666509002114/abstract?rss=yesOccupational and environmental irritants play a role in the pathogenesis of chronic cough. An irritant is a non-corrosive chemical, which causes a reversible inflammatory change on living tissue by chemical action at the site of contact. The clinical and pathologic spectrum of chemically induced respiratory tract irritation ranges from neurogenically mediated alterations in regional blood flow, mucus secretion, and airway caliber to the initiation of cough. In an evolutionary perspective, two types of cough reflexes were created for different protective purposes, but each type used the same anatomic and physiologic neural and muscular structures. The mechanosensory type evolved as human ancestors adapted phonation over olfaction and the larynx moved in close proximity to the esophageal opening. The chemosensory type evolved to protect against an injured lung from a respiratory tract infection or after inhaling high levels of irritant gases and particulates that accumulated in confined quarters of early times. For this latter type of cough reflex, normally quiescent transient receptor potential (TRP) cation channels TRPV1(vanilloid) and TRPA1 (ankyrin) become activated or hyperactivated after lung injury, with lung inflammation, or in response to chemicals. Although animal and laboratory investigations support the possibility of human TRPpathies, further investigations are essential for the further elucidation of the role of TRP cationic channels in instigating chronic cough in humans.Occupational, Environmental, and Irritant-Induced CoughStuart M. Brooks10.1016/j.otc.2009.11.013Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-08596http://www.oto.theclinics.com/article/PIIS0030666509002151/abstract?rss=yesReflux is a significant contributor to cough in otolaryngology practice; cough is just one marker of its many negative effects on the upper aerodigestive tract. Reflux causes cough both by direct irritation/inflammation and by increasing sensitivities to other noxious agents. Detailed and diligent clinical evaluation, including laryngoscopy, is useful in advancing the working diagnosis of reflux-associated cough. Supplemental testing, including impedance monitoring of esophageal refluxate, can be important to evaluate for both acidic and nonacidic reflux exposure. The mainstay of treatment continues to be dietary and other lifestyle interventions and drug therapy. Although proton-pump inhibitor therapy is effective in most patients, especially those with acid reflux disease, prokinetic therapy is probably very important with those with combined acid and nonacid disease and those with pure nonacid disease. It is likely that failure to improve can be due to behavioral and drug compliance issues. Antireflux surgery can yield long-lasting positive outcomes in carefully selected patients despite the lower efficacy of treatment for primary upper aerodigestive tract symptoms (cough, hoarseness, sore throat) compared with heartburn and regurgitation.Reflux and CoughAlbert L. Merati10.1016/j.otc.2009.12.003Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-097110http://www.oto.theclinics.com/article/PIIS0030666509001868/abstract?rss=yesOver the past 10 years, there has been increasing recognition of the interaction between the upper and lower airways in patients with a variety of infectious and inflammatory illnesses, including allergic rhinitis, rhinosinusitis, and asthma. Epidemiologic and mechanistic links have been proposed to demonstrate these relationships and to offer possible etiologic explanations to account for these observations. Among patients with upper respiratory illnesses, cough can be seen as a common symptom, both from the direct influences of upper airway inflammation, which incite reflex changes and bronchospasm, and from the exacerbation of associated pulmonary processes, such as asthma. Despite this increasing awareness of interaction between the upper and lower airways, the influence of both upstream and downstream respiratory inflammatory processes on laryngeal pathophysiology has not been extensively studied. Research suggests, however, that both direct stimulatory effects on the larynx and secondary effects of mucus production and mucus trafficking can create a range of laryngeal symptoms, including cough. This review discusses the interaction of the upper and lower airway in respiratory disease, and focuses on the effect of these respiratory processes on laryngeal inflammation, function, and symptoms.Rhinogenic Laryngitis, Cough, and the Unified AirwayJohn H. Krouse, Kenneth W. Altman10.1016/j.otc.2009.11.005Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0111121http://www.oto.theclinics.com/article/PIIS003066650900187X/abstract?rss=yesAmong the most common causes of chronic cough are asthma (25%) and nonasthmatic eosinophilic bronchitis (10%). In asthma, cough may present as an isolated symptom, in which case it is known as cough variant asthma. Variable airflow obstruction and airway hyper-responsiveness are cardinal features of asthma, which are absent in nonasthmatic eosinophilic bronchitis. The presence of eosinophilic airway inflammation is a common feature of asthma and is a diagnostic criterion for nonasthmatic eosinophilic bronchitis. At a cellular level, mast cell infiltration into the airway smooth muscle bundle, narrowing of the airway wall, and increased interleukin-13 expression are features of asthma and not nonasthmatic eosinophilic bronchitis. In most cases, the trigger that causes the cough is uncertain, but occasionally occupational exposure to a sensitizer is identified, and avoidance is recommended. In both conditions, there is improvement following treatment with inhaled corticosteroids, which is associated with the presence of an airway eosinophilia and increased exhaled nitric oxide. Generally, response to therapy in both conditions is very good, and the limited long-term data available suggest that both usually have a benign course, although in some cases fixed airflow obstruction may occur.Cough Due to Asthma, Cough-Variant Asthma and Non-Asthmatic Eosinophilic BronchitisDhan Desai, Chris Brightling10.1016/j.otc.2009.11.006Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0123130http://www.oto.theclinics.com/article/PIIS0030666509001881/abstract?rss=yesWhen the airways are overwhelmed by noxious particles, gases, or microorganisms, inflammatory and immune responses occur that may cause permanent structural changes. One consequence may be an overproduction of mucus and this may overwhelm mucociliary clearance mechanisms and cause a chronic cough phlegm syndrome. The expectorated mucus is usually clear or white (mucoid) but when it becomes infected, the mucus may become purulent and have a yellow or green color. Diseases associated with chronic productive cough discussed in this article include chronic bronchitis, bronchiectasis, and infectious and noninfectious bronchiolitis and their diagnosis and treatment.The Spectrum of Nonasthmatic Inflammatory Airway Diseases in AdultsSidney S. Braman, Muhanned Abu-Hijleh10.1016/j.otc.2009.11.007Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0131146http://www.oto.theclinics.com/article/PIIS0030666509001893/abstract?rss=yesThis review is an update of recent advances in our understanding of cough suppressants and impairment of cough. Low-dose oral morphine has recently been shown to significantly suppress chronic cough, but the side effect profile of this opioid may limit its widespread utility. Several studies have demonstrated a dissociation between the efficacy of antitussives in some metrics of pathologic cough and their effects on cough sensitivity to inhaled irritants. The relevance of widely used inhaled irritants in understanding pathologic cough and its response to antitussives is questionable. A recent advance in the field is the identification and measurement of an index of sensation related to cough: the urge to cough. This measure highlights the potential involvement of suprapontine regions of the brain in the genesis and potential suppression of cough in the awake human. There are no new studies showing that mucolytic agents are of value as monotherapies for chronic cough. However, some of these drugs, presumably because of their antioxidant activity, may be of use as adjunct therapies or in selected patient populations. The term dystussia (impairment of cough) has been coined recently and represents a common and life-threatening problem in patients with neurologic disease. Dystussia is strongly associated with severe dysphagia and the occurrence of both indicates that the patient has a high risk for aspiration. No pharmacologic treatments ae available for dystussia, but scientists and clinicians with experience in studying chronic cough are well qualified to develop methodologies to address the problem of impaired cough.Pharmacologic Management of CoughDonald C. Bolser10.1016/j.otc.2009.11.008Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0147155http://www.oto.theclinics.com/article/PIIS0030666509002126/abstract?rss=yesAn antitussive agent should reduce the amount of coughing experienced by the patient sufficiently for the patient to appreciate an improvement in cough severity and regard the improvement as sufficient to outweigh any adverse effects or risks associated with the treatment. In recent years the development of objective cough counting devices and cough-specific quality of life tools have vastly improved our ability to appropriately assess the effectiveness of anti-tussive agents and hopefully will lead to the development of safe and effective treatments in the future. This article summarizes current knowledge of methodologies available for assessing cough therapies, the patient groups to study, and the design of clinical trials.Assessing Efficacy of Therapy for CoughJaclyn A. Smith10.1016/j.otc.2009.11.014Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0157166http://www.oto.theclinics.com/article/PIIS003066650900190X/abstract?rss=yesUnexplained cough is a diagnosis of exclusion that should not be made until a thorough validated diagnostic evaluation is performed, specific and appropriate validated treatments have been tried and failed, and uncommon causes have been ruled out. When chronic cough remains troublesome after the initial work up, determine that a protocol has been used that has been shown to lead to successful results. If such a protocol has been used, next consider whether or not pitfalls in management have been avoided. If they have been, the frequency of truly unexplained chronic cough usually should not exceed 10%. While patients with truly unexplained coughs have an overly sensitive cough reflex, the mere presence of an overly sensitive cough reflex does not by itself explain why they do not get better, because most patients with chronic cough, even those who respond to treatment and get better, have demonstrable heightened cough sensitivity. Management options include referral to a cough clinic with interdisciplinary expertise, speech therapy, and self-limited trials of drugs, preferentially with those shown to be effective in randomized, double-blind placebo-controlled trials in patients with unexplained chronic cough.Unexplained Cough in the AdultRichard S. Irwin10.1016/j.otc.2009.11.009Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0167180http://www.oto.theclinics.com/article/PIIS0030666509001911/abstract?rss=yesChildren with cough, in particular chronic cough, are sometimes referred to otolaryngologists for assessment, diagnosis, and management. Although the likely diagnoses encountered by otolaryngologists are rhinosinusitis, foreign body aspiration, and tracheomalacia, otolaryngologists should be cognizant of the many other possible diagnoses and the evidence for and against their association. This article highlights and focuses the discussion on the cough issues relevant to otolaryngologists.Cough in the Pediatric PopulationAnne B. Chang, Robert G. Berkowitz10.1016/j.otc.2009.11.010Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0181198http://www.oto.theclinics.com/article/PIIS0030666509001923/abstract?rss=yesCough is a common and troublesome symptom that can be difficult to treat. New therapeutic options that are safe and more effective than those currently available are needed. In this article, the authors offer opinion on future directions in the treatment of cough, with a particular emphasis on the clinical syndrome associated with cough reflex hypersensitivity. In addition, the article provides an overview of some of the diagnostic technologies and promising drug targets likely to emerge from current clinical and scientific endeavor.Future Directions in Treating CoughLorcan P.A. McGarvey, Jennifer Elder10.1016/j.otc.2009.11.011Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0199211http://www.oto.theclinics.com/article/PIIS0030666510000095/abstract?rss=yesIndex10.1016/S0030-6665(10)00009-5Otolaryngologic Clinics of North America 43, 1 (2010)2010-02-01Otolaryngologic Clinics of North America2010-02-01431S0030-6665(10)X0002-0213219