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MESSAGES TO
Chronic Coughs And Colds

Chronic Coughs And Colds

A DxD Session with Dr Gan Eng Cern


Ended on Thu Nov 15 2018
Ended

Top Answers


The common cold is a viral infection of your upper respiratory tract (includes the nose, sinuses and throat). There are over 200 viruses that can cause a cold and an adult may on average experience a cold two to three times a year. Young children (especially those less than 6 years old) are most at risk of getting a cold.

Common symptoms of a cold include:

  • Sore throat
  • Blocked nose
  • Nasal congestion (mucous stuck in the nose or face)
  • Runny nose (may be clear initially but usually becomes thicker and yellow, brown or green in colour later)
  • Postnasal drip (mucous dripping down the back of the nose to the throat)
  • Fever
  • General feeling of unwell (malaise).

As the common cold is usually caused by a virus, your body will fight it off within 7-10 days. You do not need antibiotics for this. Antibiotics does not work against viruses. You can take medications to relieve the symptoms of your cold, e.g. antihistamines and decontestants, lozenges, cough medications etc. These medications however do not help you fight off the cold. You are much more lightly to get better with adequate rest, sleep and good hydration.

If your symptoms are worsening on day 5 of your cold or the duration of your cold last longer than 10 days, it is likely that you have developed a bacterial sinus infection (known medically as sinusitis). These figures were derived from numerous studies to determine which group of patients will best benefit from a course of oral antibiotics if they suffer from a “prolonged cold”.

A bacterial infection of the sinus is treated with a course of oral antibiotics, nasal douche (wash of the nose with salt solution) and nasal steroid sprays. It is sometimes difficult to differentiate a cold from a sinus infection as the symptoms can be very similar. Having said that, a patient with a sinus infection tend to have less fever, body aches and sore throat and more facial pain.

It is best to consult your general practitioner or an ENT Specialist for an assessment. An ENT Specialist will usually perform a nasoendoscopy (scope through the nose) under local anaesthesia to look for signs of sinusitis in a patient with “prolonged cold”. If you were given a course of oral antibiotics for sinusitis, it is important to complete it to ensure complete eradication of the bacteria (unless you have a side effect or allergic reaction from the antibiotics). Partial treatment of a bacterial infection with antibiotics may potentially lead to bacterial resistance (ie the surviving bacteria can “learn” how to become “immune” to the antibiotics) which can threaten the effectiveness of common antibiotics in the future.

Hope this helps.

25 Jan 2018

 

Thank you for your question. Common causes of postnasal drip (sensation of mucous stuck in the back of the nose or throat) include:

  • Conditions of the nose (e.g sensitive nose or rhinitis, sinusitis)
  • Acid reflux to the throat (called laryngopharyngeal reflux)
  • Dehydration

In patients I’ve seen with similar history to yours, a one sided nasal congestion or postnasal drip may indicate an active sinus infection (sinusitis).

Since it has been ongoing for several months without relief from nasal steroid spray and antihistamine, and you’ve had previous sinus surgery (sphenoidoyomy), I would suggest consulting an ENT Specialist for evaluation.

Your ENT specialist will be able to perform a nasoendoscopy (scope through the nose) to examine the nasal cavity, previously operated sphenoid sinus and your voice box.

If you do have sinusitis, you will need a course of oral antibiotics, nasal douche (nose wash with salt solutions) in addition to the nasal steroid spray.

Hope this helps.

25 Jan 2018

 

Thank you for your question. I’m sorry to hear that your mother is suffering from a prolonged and problematic cough which can be a complex condition.

Coughing is a reflex that protects your upper airway and lungs from irritants such as excessive mucous and foreign bodies. When persistent, it is often a symptom of a condition, ranging from conditions arising from the nose & sinuses (e.g sensitive nose, sinus infections), lungs (e.g asthma and bronchitis), throat and stomach (e.g. acid reflux from the stomach) to side effects from medications or smoking.

If the source of the cough is not found, it is difficult to treat. It would be beyond the scope of this Q&A to address all possible causes of prolonged cough.

The majority of prolonged coughs are due to:

  1. Postnasal drip
  2. Acid reflux
  3. Asthma
  4. Bronchitis
  5. Smoking
  6. Side effects from medications.

Since it seems that your mother has been cleared by a Respiratory Physician, we will discuss cough from irritation of the voicebox.

This is usually due to postnasal drip (back drip of mucous from nose allergy or sinus infection) or acid reflux from the stomach.

As the voicebox is a very sensitve organ, once inflamed, it can take months for the inflammation to resolve. It is important to remove the sources of irritation while waiting for inflammation of of the voicebox to resolve.

Since your mum has seen an ENT Specialist and was given an acid suppressant medication (Nexium) and nasal steroid sprays (to treat sensitive nose or nose allergies),  it is important to ensure good compliance with these medications.

The importance of compliance with nasal steroid sprays is often overlooked by many patients. It can take days to weeks for nasal steroid sprays to reduce the mucous in the nose and postnasal drip (which may be a possible source of irritant of your mother’s cough).

Apart from taking Nexium, it is also just as important to ensure that your mother adheres to antireflux measures (e.g no food/drinks 3-4 hours before sleeping, taking small meals and avoiding reflux causing or “heaty” food).

If your mother has done all that I’ve mentioned above, it may also be worthwhile to get her doctor to examine the medications that she is taking (one of the common blood pressure medication can cause cough as a side effect).

Exposure to cigarette smoke can also persistently irritate the voicebox and prevent a full recovery. As your mother’s cough started after a chest infection, she may also have “Postinfectious Cough”, of which the reason is unfortunately unknown.

Some studies attribute this to excessive inflammation of the upper and lower airway after an infection, resulting in a persistent overproduction of mucous. This is difficult to treat and often needs mucous thinners/expectorants and cough medications to keep the symptoms under control or bearable.

If your mother’s cough is accompanied by a whooping inspiratory sound or leads to vomiting, she may need to revisit the Respiratory Physician to rule out  infection that is due to B pertusis bacterial infection.

Hope this helps and all the best.

26 Jan 2018

Thank you for your question. Based on the clinical history provided, I will answer your questions in a few sections as follows:

Sinus vs Sinusitis – What is the difference?

“Sinus” is a common term that many people incorrectly use to describe nose symptoms such as frequent blocked nose, runny nose and sneezing. Sinuses, or the precise term is paranasal sinuses, are hollow spaces that is surrounds the nasal cavity. Everyone has them and it is a normal part of the anatomy in your face. The lining of these spaces (called mucous membranes) produces mucous that drains into the nose.

Sinusitis (infection of the sinuses, aka rhinosinusitis) occurs when the sinuses are blocked and trapped mucous in the sinuses are infected. Patients with sinusitis often present with nasal blockage, nasal congestion (feeling of mucous stuck in the nose or face – ie inability to blow the mucous out), facial pain (most often in the  cheek, forehead and in between the eyes), postnasal drip and coloured phlegm or nose mucous.

What is Rhinitis?

Blocked nose, clear or transparent runny nose, itchy nose and eyes, postnasal drip and sneezing are likely symptoms of Rhinitis. Rhinitis is a medical term for inflammation of the nasal cavity (often called “Sensitive Nose”).

There are broadly 2 types of Rhinitis:

1.     Allergic Rhinitis (commonly called “Hay Fever”)  – Due to exposure to a particular protein (e.g house dust mite, cat or dog fur, grass or fungus)

2.     Non-allergic Rhinitis – Due to unknown causes but common triggers include change in temperature as well as exposure to perfumes and cigarette smoke.

How do I differentiate Allergic Rhinitis (AR) from Non-allergic Rhinitis (NAR)?

AR can be differentiated from NAR with a combination of medical history, nasoendoscopy examination and an allergy test called Skin Prick Test (SPT) or blood tests. The most commonly used allergy test used is a Skin Prick Test. This involves placement of droplets of allergens (protein that causes an allergic reaction – e.g house dust mite, cat and dog furs etc) on to the patient’s forearm. Very small needles are then used to perform a superficial prick on the outer layer of the skin, to allow small amounts of allergens to enter the skin. If a patient is allergic to an allergen, a wheal (small area of swelling like a mosquito bite reaction) will develop over the next 15-20 minutes.

Is there a cure for Rhinitis?

This depends on the type of Rhinitis. Majority of symptoms from Allergic and Non-allergic Rhinitis are usually well controlled by:

1.     Allergen or trigger avoidance – e.g getting rid of dust mites by washing your bedsheets and pillow cases once a week with hot water (at least 60 degrees Celsius high to get rid of the dust mites), avoiding cigarette or strong perfume smells etc

2.     Nasal steroid sprays – These are the workhorse in the treatment of Rhinitis. It reduces inflammation in the nasal cavity and usually improves all symptoms of Rhinitis. It however has to be used on a long-term basis.

3.     Oral antihistamines and decongestants – Antihistamines (E.g. Zyrtec, Telfast, Xyzal, Bilaxten etc) work well in reducing itchy nose, runny nose and sneezing. They do not work very well in relieving blocked nose. Blocked nose is best relieved with medications which have decongestants in them (e.g. Telfast D, Zyrtec D, Clarinase, Sudafed etc). These medications however should not be taken on a long-term basis due to potential side effects (e.g hypertension)

If you have Allergic Rhinitis (tested positive for one or more allergens on a skin prick test), there is a potential cure known as Immunotherapy. Immunotherapy involves desensitizing the patient to the known allergen by exposing them to small amounts of the allergen over a period of at least 3 years. The allergens can be given as an injection (called subcutaneous immunotherapy or SCID) or sprayed/placed under the tongue daily (called sublingual immunotherapy or SLIT). Most ENT Clinics in Singapore use SLIT to treat patients with Allergic Rhinitis. This is the only known treatment that modifies the disease process and may offer a potential cure for Allergic Rhinitis.

What if my main problem is blocked nose and I want a long-lasting solution to it?

If your main symptom is nasal blockage and you do not wish to use medications on a long-term basis, there are surgical options to increase the space your nose. Most commonly, blocked nose in patients with Rhinitis is due to enlarged inferior turbinates with or without a deviated nasal septum. The common surgical procedures to correct these include inferior turbinoplasty and septoplasty respectively. Surgical outcome from these procedures are usually good. These procedures are done through the inside of the nose (no cuts or external wounds seen on the face or nose) under general anaesthesia. Unfortunately there is no good surgical options to relieve runny nose or sneezing. Medical treatments are still the best to address these symptoms.

What is the cost of such surgery in Singapore?

You will need an assessment by an ENT Specialist to determine the nature of your condition. The cost depends on the type of surgery/s that is recommended for you.

For example, the total cost could range from SGD 1,000 - 1,500 (coblation of turbinates alone) to over SGD 20,000 (if you need to do septoplasty, inferior turbinoplasty and full sinus sugery ie functional endoscopic sinus surgery). This is partially Medisave claimable.

It is also important for the ENT Specialist to ensure that you are not suffering from concurrent chronic rhinosinusitis.

Hope this helps, and all the best!

13 Mar 2018

Thank you for your question. Cough is a reflex that protects your upper airway from foreign materials and irritants. However, when persistent, it can be a troublesome symptom. The cause of a chronic or prolonged cough can range from conditions arising from the nose (e.g. Rhinitis and Sinusitis), stomach (e.g. acid reflux from the stomach to the throat, medically known as Laryngopharyngeal reflux or LPR) and lungs (e.g. Asthma, Bronchitis etc) to side effects from medications (e.g. Blood pressure medications) and smoking. 

If you have a wheeze associated with the cough and do get shortness of breath, you may have Asthma and should see a GP or Respiratory Physician. Your GP or Respiratory Physician may perform a lung function test to determine how much air moves in and out as you breathe. 

In my practice, the two most common cause of chronic cough are due to a postnasal drip (which can be due to Rhinitis or Sinusitis) and Laryngopharyngeal reflux (LPR).

Postnasal drip refers to a feeling of mucous stuck at the back of the nose and throat. The mucous can cause inflammation of the voice box (larynx). As the voice box is a very sensitive organ, once it is inflamed, it can take weeks to months to recover.

When inflamed, the voice box is prone to causing cough, throat itchiness, frequent throat clearing and phlegm. It is important to treat the cause of the postnasal drip (for Rhinitis - with nasal steroid sprays and antihistamines, for Sinusitis - with a nose wash, nasal steroid spray and antibiotics) to allow the swelling on the voice box to resolve.

If the colour of your phlegm is yellow, brown or green, it may be infected (either from sinusitis or bronchitis) and you may need a course of oral antibiotics. 

The voice box can also be inflamed from acid reflux from the stomach (LPR). Common symptoms from LPR include an irritative  dry cough, feeling of something stuck in the throat, frequent throat clearing, sore throat and a hoarse voice.

These can be treated by modifying your lifestyle to prevent the reflux from happening and by taking acid suppressant medications. 

You can visit an ENT Specialist who will likely perform a nasoendoscopy (small scope through the nose and down to the level of the voice box which is done under local anaesthesia) to help you rule out possible ENT causes.

Hope this helps and all the best. 

4 Apr 2018

Thank you for your question. Breathing difficulties during exercise can be dependant on several factors including:

1) Your age

2) Your fitness level

3) Your general health status. If you have a medical condition that may compromise the delivery of blood and oxygen to your vital organs, you can feel breathless on exertion or during exercise. There can be many reasons for these including conditions from the lungs (e.g Asthma, bronchitis) and heart (e.g. congenital defects) to conditions of the blood (e.g. low blood level).

4) Intensity of your exercise regimen 

Blocked nose from a sensitive nose (Rhinitis) should not result in shortness of breath or difficulty in breathing. You may feel "more difficult to breathe" because you have to resort to mouth breathing when your nose is blocked which may be uncomfortable. However, this shouldn't lead to inadequate oxygen flow to your lungs as your mouth and throat which is part of your upper airway should be able to cope with the increased airflow to your lungs during exercise. 

We do know that uncontrolled Allergic Rhinitis can worsen Asthma and their co-existence is often known as United Airway Disease. Inflammatory mucous from the nose and sinuses (from Rhinitis or Sinusitis) can result in exacerbation of common lung conditions such as Asthma and Bronchitis.  Since you mentioned that there is increased mucous in your nose, you may want to see an ENT Specialist to have your nose checked. This will likely involve a nasoendoscopy, a scope through the nose under local anaesthesia. If your ENT Specialist suspect that you may have United Airway Disease, he/she may refer you to a Lung Specialist (Respiratory Physician) who will likely perform a lung function test to assess the ability of your lungs to breathe. Certain types of Asthma can be worse during exercise.

If you have other symptoms such as chest pain, palpitation or light headedness during your run, you may have to see a Cardiologist who can perform stress tests to determine if your difficulty in breathing is due to a heart condition (less likely in a young patient like yourself unless there is an unknown congenital problem). 

If after reading this and you are still unsure, perhaps a visit to a General Practitioner will be a good start.

Hope this helps and all the best!

9 Apr 2018

 Thank you for your question. Cough is a reflex meant to protect your airway from an irritant (e.g. mucous, foreign bodies or virus/bacteria). When persistent, it is usually a symptom of a condition. A cough lasting longer than 8 weeks is called chronic cough.

Common causes of chronic cough in children include problems arising from the nose and sinuses (e.g. allergic rhinitis, sinusitis), lungs (e.g. asthma, bronchitis, foreign bodies) or stomach (acid reflux). 

The treatment of cough depends on the underlying cause. Since you mentioned that your daughter has been diagnosed with sensitive nose (Rhinitis), it is important to ensure that she has been compliant with her nasal steroid sprays for the treatment to be effective. Nasal steroid sprays work by reducing inflammation of the nose and sinuses and this can take up to 2 weeks before you notice significant improvement in nasal symptoms.  

Postnasal drip (mucous flowing from the nose and sinus down the throat) can be a persistent irritant to the voicebox (larynx), causing it to be inflamed and swollen.

The voicebox is a very sensitive organ. Once infamed, it is prone to causing symptoms such as feeling of something stuck in the throat (globus sensation), itchy throat with frequent throat clearing, cough, hoarse voice, sore throat and clear phlegm.

Inflammation of the voicebox can take time to settle down. Apart from mucous from the nose and sinuses, acid reflux from the stomach can also be a source of irritant to the voicebox.

Your daughter can visit an ENT Specialist who can help optimize the treatment of her sensitive nose and exclude other problems in her upper airway that is causing a persistent cough (including sinusitis although this is less common in children).

If your daughter has other symptoms from her lungs such as shortness of breath or wheezing, she may need to visit a Respiratory Physician (Lung Specialist).

Although over the counter (OTC) cough medications  (e.g. dextrometharphan, guaifenescin, antihistamines,codeine etc) may help ease cough in some children, a Cochrane meta-analysis (a summarized analysis of high level studies) has concluded that they are no more effective than placebo (medications with no cough suppresant properties) and may have potential side effects (e.g. drowsiness and insomnia).

In fact, 1-2 teaspoons of honey a day has been shown to be as or more effective than some OTC cough medications and with excellent safety profile (in children older than 2 years old).

Having said that, it is still more important to find out the reason for the cough and treat the underlying cause accordingly.

Hope this helps and all the best. 

22 Apr 2018

I am sorry to hear that you are experiencing sinus infection (medically known as sinusitis) every 1-2 months. It is important to determine if the "sinus infections" are indeed sinusitis. Common symptoms of a sinus infection includes:

  • Blocked nose
  • Facial congestion or pain
  • Coloured nasal discharge/mucous (yellow, brown, green or even blood stained)
  • Postnasal drip
  • Reduced sense of smell

A sinus infection usually last longer than 10 days or continues to worsen on day 5 of your illness. If your symptoms are less than these, you may be experiencing a cold/flu (described medically as a viral upper respiratory tract infection or URTI). It is important to differentiate between a cold/flu and sinus infection because one needs a course or oral antibiotics while the other don't. Sinus infections are caused by bacteria and a course of antibiotics will be required, while a cold/flu is caused by viruses and do not need to be treated with antibiotics.

There are certain risk factors that predisposes a person to getting more frequent sinus infections. These include nasal allergies (Allergic Rhinitis), deviated nasal septum, narrow sinus drainage pathways, smoking and genetic predisposition. Many of my patients with frequent sinus infections do have uncontrolled or poorly controlled nasal allergies. Keeping your nasal allergies under control may prevent frequent sinus infections. 

I also have a number of patients who think that they have a sinus infection but in actual fact, they are suffering from Rhinitis (sensitive nose), which can be allergic or non-allergic. Common symptoms of Rhinitis include:

  • Blocked nose
  • Clear runny nose
  • Itchy nose
  • Sneezing
  • Postnasal drip

As you can see, some of the symptoms between sinusitis, rhinitis and the common cold do overlap and it can be confusing for patients. Sometimes it is also difficult for doctors to differentiate between the 3 conditions. You should see an ENT Specialist to get an assessment as often, with a detailed clinical history and a nasoendoscopy (scope through the nose in the clinic), a correct diagnosis can be achieved.

Prevention of frequent sinus infections depends on the underlying cause and sometimes a CT scan (special series of X-rays) of the sinuses may be required to assess any anatomical abnormalities that resulted in a blocked sinus or narrow sinus drainage pathway. If these are present, endoscopic sinus surgery to widen the drainage pathway of the sinuses while preserving its physiological function may be required. 

Hope this helps and all the best!

23 May 2018

If you have a sinus infection and bronchitis that has not gone away with antibiotics, you can see an ENT Specialist for an assessment and likely a nasoendoscopy (scope through the nose done in the clinic under local anaesthesia). If there is still infected mucous (mucopus) seen in your nose, a sample of the mucopus has to be taken and sent to the lab for analysis (bacterial culture). This is to determine the type of bacteria responsible for your sinus infection and the antibiotics that will be effective against that bacteria. 

You should also be washing your nose with a nasal douche (salt water solution e.g. Neilmed or Flosinus) and apply nasal steroid sprays to your nasal cavities (e.g. Nasonex, Avamys or Nasacort). Most sinus infections do clear with a culture-directed antibiotics. If this fails, you may need a CT scan (speial series of X rays) of the sinuses to assess the severity of your blocked sinuses and the structural abnormalities that caused it.

If you have been refractory to medical treatments and have persistent sinus infection or structural abnormalities on the CT scan, you may need to undergo sinus surgery (functional endoscopic sinus surgery or FESS) to unblock the sinuses. This is a minimally invasive surgery done through the nose under general anaesthesia.

If you do not have a fever or shortness of breath, it is likely that your "bronchitis" is due to postnasal drip from the sinus infection causing accumulation of mucous in your throat region, resuling in phelgm and cough. If your ENT Specialist is concerned about a concurrent lung infection that failed to clear despite treatment of your sinusitis, he or she can refer you to a lung specialist.

For other causes of excessive phelgm, do refer to my answer on a similar DxD question at this link.

Hope this helps and all the best!

28 May 2018

Nosebleeds in children are most often due to prominent blood vessels on the front part of the nasal septum (wall that separates the nose into right and left sides) that have burst. This can be spontaneous or triggered by certain activities such as frequent nose digging or violent sneezing. He may alsonbe suffering from Rhinitis (sensitive nose).

If the nosebleeds happen twice a week and he has troublesome sensitive nose, you should consider bringing him to see an ENT Specialist. If the cause of the nosebleed is due to enlarged blood vessels on the front part of the nasal septum, it can be easily sealed off using Silver nitrate sticks.

His sensitive nose can  be treated with nasal steroid sprays and antihistamines. For more information on nosebleeds and sensitive nose, do check out my previous articles and answers on DxD (below are the links):

Hope this helps and all the best!

29 Jun 2018

Croup is a viral infectious respiratory illness affecting mainly the voicebox, windpipe and sometimes the lungs. Many viruses can cause croup, including those responsible for the common cold and flu. Hence, the measure to prevent a croup are similar to that for a common cold.

These include practising good hand hygiene (by washing your hands regularly), coughing and sneezing into a tissue or into the elbow, cleaning surfaces regularly, avoiding food/drink sharing and keeping your children's immunization up to date.

In terms of medications, cough or cold medications have not been shown to be effective in the treatment of croup. Although the symptoms of a croup can be alarming, it is important to stay calm, sit your child upright and keep him/her well hydrated and well rested. Most of the time, croup resolves on its own within 48 hours. Having said that, if your child has the following warning symptoms, he/she should visit the A&E:

- Struggling to breathe (heavy breathing sounds or you see his/her tummy sucked in during breathing)

- Skin looks blue

- Unusually quiet and still

Hope this helps and all the best!

29 Jun 2018

Thank you for your question. Both Allergic Rhinitis and Laryngopharyngeal Reflux can cause a feeling of something stuck in the throat aka globus sensation. However, they are very different conditions. 

Allergic Rhinitis refers to inflammation of the nasal cavity due to exposure to a known allergen (protein that triggers an allergic reaction in the nose - most common culprit is house dust mites). Typical symptoms include blocked nose, runny nose, sneezing, postnasal drip itchy nose and itchy eyes.

To find out more please read my article that was published in DxD ("Hate your sensitive nose? This is your cure!")

Laryngopharyngeal reflux (LPR) refers to acid reflux from the stomach to the voice box in the throat. Common symptoms include feeling of something stuck in the throat, sore throat, cough, frequent throat clearing and hoarse voice.

To find out more about laryngopharyngeal reflux, do read my article on DxD ("This is what really causes your sore throat when you eat too much "heaty" food")

As both postnasal drip from Allergic Rhinitis and LPR can cause a feeling of something stuck in the throat (sometimes mucous or just a swollen feeling in the throat), you could be suffering from one of the two condition or both conditions.

Your ENT Specialist will need to take a thorough history and perform a complete physical examination, including a nasoendoscopy (a relatively simple and painless scope through the nose and down to the level of the voice box) to determine the likely cause of your symptoms.

Hope this helps and all the best. 

27 Oct 2018