© 2003 American Thoracic Society
Persistent troublesome coughTo the Editor:Over the years, Dr. Irwin and his colleagues have systematically investigated and published algorithms to manage troublesome cough (1). Their recent publication in AJRCCM (2) summarizes the recommendations for a physician and a patient frustrated with a cough that will not just go away. A major omission seems to be the investigation for an auricular origin of the cough, particularly in children (3). In the era of high-tech medicine, it is worthwhile emphasizing the use of a rhinoscope and an otoscope in the investigation of a chronic cough.
St. Joseph's Healthcare & McMaster University Hamilton, Ontario, Canada REFERENCES
From the Authors:We thank Dr. Parameswaran for providing us with the opportunity to explain more fully the focuses of two of our recent publications (1, 2) to which he refers and provide our perspective on cough due to ear conditions. Because of specific and limited focuses, it was not our intention to specifically mention most of the uncommon or rare causes of chronic cough. Nevertheless, in our clinical commentary on "The Persistently Troublesome Cough" published in this journal (2), we provided the readers with a reference source (3) that was "a more comprehensive listing of causes" of chronic cough. That listing, which includes a variety of ear problems, is categorized anatomically because it has been known for years that cough can be caused by a multiplicity of diseases located in a variety of anatomic locations (4). It was this knowledge that led to the anatomic diagnostic protocol that was first proposed in 1977 (4).Because involuntary coughing is a purely vagal phenomenon, the core of the anatomic diagnostic protocol is the systematic evaluation by history, physical examination, and laboratory testing of the anatomic sites of the vagal afferent nerves that subserve the cough reflex. Because of knowledge of an ear-cough reflex via the auricular branch of the vagus nerve first described by Arnold in 1832 (5), evaluation of the ears has always been a part of the anatomic diagnostic protocol (4). Because we recently reviewed this protocol in a separate publication (6) and we assumed that all cough specialists were aware of the importance of evaluating all the sites of the vagus nerve, a restatement of the protocol was not included in our clinical commentary (2). Although it has been reported that an ear-cough reflex can exist in up to 4.2% of subjects (5), cough due to ear conditions (e.g., foreign bodies, cerumen, cholesteatoma, implanted hair [3, 5]) is very rare. Apparently, only 15 cases have been reported since 1842 (5). And, one of us (R.S.I.) has never seen a case despite routinely looking for it in all patients (greater than 2,700) referred with chronic cough of unknown etiology since 1975. Nevertheless, we will continue to screen for it and other rare conditions of the head and neck region (3) as part of the anatomic diagnostic protocol and the physical examination of cough.
University of Massachusetts Medical School Worcester, Massachusetts REFERENCES
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