Dysphagia

Aetiology

3 conditions account for ~95% of chronic cough:

1. Postnasal drip syndrome/upper airway cough syndrome (UACS)
2. Asthma
3. GORD

Be aware that a number of other conditions make up the remainder e.g. ACE inhibitor therapy, smoking, CHF, non-asthmatic eosinophilic bronchitis etc.

UACS - secretions containing inflammatory mediators stimulate pharyngeal and laryngeal sites -> cough 

GORD - either via:
1. Distal oesophageal acid exposure that stimulates an oesophageal-tracheobronchial cough reflex via CN X
2. Microaspiration of acid to the larynx/trachea (laryngopharyngeal reflux) this is most often silent i.e. patients do not get heartburn

Investigation and Management

For this presentation history has very little yield for diagnosis 

UACS
Treat any underlying sinusitis, avoid allergens
Hallmark of this syndrome is the lack of pathognomonic findings - diagnosis made by response to:
Chronic Rhinosinusitis treatment (see Rhinology section)
NB: response may take weeks to months

Non-asthmatic eosinophilic bronchitis
Diagnosis made by induced sputum showing increased eosinophils
Highly responsive to inhaled corticosteroids

GORD
Treated with PPI e.g. omeprazole

Therefore investigation should proceed with:

1. Stop smoking and other factors e.g. ACE inhibitor therapy (response may take one month)
2. Chest XR - to rule out pulmonary lesions
3. Trial GORD treatment
4. CT sinuses
5. Induced sputum
6. If the above show no yield then more extensive investigation required: sputum for TB, HRCT, bronchoscopy

Aetiology

1. GORD - accounts for ~25 to 50% of patients
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2. Non-specific oesophageal motility disorder
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3. Malignancy
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4. Psychological/stress
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5. Others: retroverted epiglottis, thyroid disease, TMJ dysfunction etc.

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Investigation and Management

Like with chronic cough, the history is low yield but should be used to evaluate for malignancy, reflux & psychological factors  

1. Full ENT exam including laryngoscopy - to exclude malignancy + other causes
2. 3 month trial of PPI therapy (e.g. omeprazole)
3. If unresponsive to PPI then further Ix: 24 hour pH monitoring, endoscopy and barium swallow
4. If above negative consider: psychiatry input

If suspicious findings on history, exam or laryngoscopy then more aggressive investigation is needed

Investigation

Barium swallow
Fibreoptic endoscopic evaluation of swallow 
+/- pH monitoring to assess for associated GORD

Management

Transoral endoscopic treatment with CO2 laser or electrocautery is becoming standard
Open neck approaches are also still performed