Throat Irritation + Dry Cough: Management

Understanding the Symptom

1. Non-Pharmacological (General Measures)

• Hydration - adequate oral fluid intake keeps mucous membranes moist and thins secretions
• Humidification - a cool-mist humidifier adds moisture to ambient air and reduces mucosal dryness
• Voice rest - minimising talking and whispering reduces laryngeal trauma when the throat is inflamed
• Steam inhalation - warm steam temporarily soothes airway inflammation
• Avoidance of irritants - smoke, dry air, dust, strong scents, and alcohol
• Honey - has well-established evidence as a soothing agent; 1-2 teaspoons in warm water is effective (not for children < 1 year due to botulism risk)
• Saline gargles - warm salt water gargles reduce pharyngeal inflammation
• Elevating the head of the bed - particularly helpful if GERD is a contributing factor

Note on topical anesthetics (e.g. benzocaine lozenges): These are initially soothing but can decrease oropharyngeal/supraglottic sensitivity, allowing overuse of an injured area and potentially worsening mucosal damage. They should generally be avoided. - Cummings Otolaryngology

2. Pharmacological Management by Cause

A. Acute Cough (URTI / Viral)

• Decongestants (e.g. pseudoephedrine, oxymetazoline nasal spray) - provide symptomatic relief in upper respiratory infections; combination antihistamine-decongestant preparations should be avoided due to excessive drying of mucous membranes
• First-generation antihistamines (e.g. chlorpheniramine) - reduce post-nasal drip and have mild antitussive effects, but cause sedation and mucosal drying
• Menthol preparations - initially soothing but paradoxically worsen drying and mucosal irritation with prolonged use; not recommended for ongoing therapy - Cummings Otolaryngology
• Guaifenesin (expectorant/mucolytic) - thins secretions and improves laryngeal lubrication; commonly used as an adjunct, though direct evidence is limited
• Dextromethorphan - centrally-acting cough suppressant for dry, non-productive cough
• Aspirin should be avoided in throat/laryngeal conditions - inhibits platelet function and can cause submucosal laryngeal haemorrhage

B. Allergic Rhinitis / Upper Airway Cough Syndrome (UACS)

• Intranasal corticosteroids (e.g. fluticasone, mometasone) - first-line; effective for allergic rhinitis without the mucosal drying of systemic antihistamines; may take up to 2 weeks for maximal effect
• Non-sedating antihistamines (e.g. cetirizine, loratadine) - useful adjuncts with fewer drying effects than older agents
• Allergen avoidance and, when appropriate, allergen immunotherapy for recurrent/refractory allergic disease - Cummings Otolaryngology

C. Gastroesophageal Reflux Disease (GERD)

• Proton pump inhibitors (PPIs) twice daily - first-line; treatment must be maintained for at least 3 months as GERD cough can take this long to resolve
• Dietary modification - avoid fatty foods, caffeine, alcohol, late meals
• Head-of-bed elevation
• Nissen fundoplication is reserved for confirmed GERD with surgical indications - Cummings Otolaryngology; Murray & Nadel's

D. ACE Inhibitor-Induced Cough

• Stop the ACE inhibitor - cough typically resolves within 1-4 weeks
• Switch to an angiotensin II receptor blocker (ARB), which does not cause cough

E. Asthma / Cough-Variant Asthma

• Inhaled corticosteroids (ICS) - cornerstone of management
• Short-acting beta-2 agonists (SABA) - for relief of bronchospasm
• Avoid beta-blockers (can precipitate or worsen asthma cough)

F. Post-Infectious / Subacute Cough

• Usually self-limiting with supportive care
• Short course of inhaled ipratropium may reduce bronchial hyperresponsiveness
• If pertussis is suspected (cough > 2 weeks + paroxysms), treat with azithromycin or clarithromycin

3. Chronic Cough Algorithm

1. History, examination, chest X-ray
2. Stop ACE inhibitors / smoking
3. Investigate and empirically treat the most likely cause (GERD, asthma, UACS, eosinophilic bronchitis)
4. If partial/no response: consider cough hypersensitivity state, neuromodulators (gabapentin, pregabalin, amitriptyline), or referral to a specialist cough clinic

4. Special Consideration: Paradoxical Vocal Fold Motion Disorder (PVFMD)

5. Red Flags - When to Refer/Investigate Urgently

• Haemoptysis
• Unexplained weight loss
• Dysphagia
• Hoarseness > 3 weeks
• Chest pain
• Smoking history (especially age > 40) - these require chest imaging to exclude malignancy