Oto-Tricho-Tussia: An Unexpected Cause Of Cough

Case Rep Otolaryngology
16 Sep, 2020 ,

Rebecca A. Castro et.al. presented a case of three patients with chronic cough. Attempted treatments included a trigger reduction approach, laryngopharyngeal reflux control with a plant-based Mediterranean style diet, and medications for NCC, all of which failed to resolve cough symptoms. Examination revealed one strand of hair within the ear canal with one end on the tympanic membrane and another on the anterior canal floor within the potential distribution of Arnold's nerve reflex sensory afferents.

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Case 1

A 59-year-old male presented with a nonproductive, dry cough for over a year. His cough was preceded by a tickling or itching sensation in his throat. Cough would occur in spasms. His self-reported triggers included talking, laughing, heat, smoke, and certain perfumes. He tried a nasal steroid spray, nasal irrigation, and reflux medication with minimal improvement of symptoms.

His medications included losartan which was discontinued two weeks prior to his visit with no change in his cough. On physical examination, the patient was noted to have a foreign body in his left ear, notably two strands of hair lying on the left tympanic membrane.

The hair was removed under direct vision, and the left ear canal had an otherwise normal appearance. Laryngoscopy revealed mild supraglottic hyperfunction, left vocal fold paresis, asymmetric vibration, slight anterior gap, and bilateral mild decrease in vibration, suggestive of a mild vocal fold neuropathy and neurogenic cough.

At his one month follow-up visit, he reported 30% improvement in cough symptoms. He was instructed on Mediterranean style dietary changes with alkaline water for improvement of laryngopharyngeal reflux. At his follow-up, three months after the initial visit, the patient reported continued improvement in cough. He continued to use nasal saline irrigations and diet adjustments for maintenance of persistent chronic cough symptoms. He was not interested in trying amitriptyline.

Case 2

A 70-year-old woman with history of chronic rhinitis and chronic cough presented with complaint of pressure and feeling of water in her right ear. Coughing fits were triggered by a tickle in her throat and would come on randomly. On physical examination, the patient was noted to have a foreign body in her right ear and 5-6 strands of hair were removed from around and leaning on the tympanic membrane.

The hair stands were removed relieving her feeling of fullness. In further conversation after her visit, she revealed that her chronic coughing symptoms completely resolved after the hair removal. During follow-up with her audiologist a year later, she was noted to have hair in her right ear again, which was removed. Her chronic rhinitis persisted with improvement of cough symptoms.

Case 3

A 51-year-old man presented with voice problems and coughing spasms for over 1.5 months. His cough began before his voice changed. He felt a tickle in his throat that made him cough. Treatment by his primary medical doctor included antibiotics, an inhaled steroid, and reflux medication, which resulted in no change and were discontinued.

During coughing spasms, his eyes teared, his voice became strained, and he became nauseous. He also reported coughing about two minutes after eating. The cough was not triggered by laughing, talking, drinking liquids, or being exposed to cold or certain odors. On physical examination, the patient's left ear canal had a strand of hair lying on the tympanic membrane.

 The foreign body was removed. Laryngoscopy revealed a large hemorrhagic polyp on the left midvocal fold with multiple bilateral ectasias. These findings were likely secondary to the trauma from coughing spasms. The patient noted a cessation of the tickle sensation from the neck to the throat immediately after removal of the foreign body. The patient did not follow up after initial presentation, presumably due to resolution of coughing symptoms.