Hello, my name is Dr. Robert Bastian, and I want to talk to you about coughing that
won't go away. Now we're going to talk in particular about a neurological kind
of coughing that I doubt that you've heard about before. And before we get
on to that particular kind of coughing, I want to review some basic information.
Coughing is an explosion of air from the lungs, whose purpose is to clear
away some kind of material, usually mucus or a foreign body. There is a
usual list of causes of coughing and I want to just review those for you.
Well, now with all of this as background, let's get to the main subject. It's a special kind of
coughing that I discovered about ten years ago. It doesn't respond to treatments for these usual
kinds of coughing. It is a sensory neuropathic cough is what I call it. It's not yet written
about in textbooks, though I think I've treated at least 500 people with this kind of cough.
What is the crucial distinction between a neurogenic former coughing and the usual list of
bronchitis, the pneumonia, the asthma, and so forth? Well, the main distinction is that, that in all of
that original list, pneumonia, asthma, bronchitis and so forth, cough happens for a purpose. It serves a
body purpose. This kind of cough, the neurological kind of cough, doesn't serve any purpose. Instead of
the cough solving a problem for the body, it is the problem. Now let me describe in some detail
an episode of neurogenic or sensory neuropathic coughing and how it differs from the kinds of
coughing with which we're more familiar. What happens to someone with this kind of cough is
that they develop a sudden sensation, usually a tickle. It might be a slight burning sensation,
a very abrupt dry sensation in the throat, some people interpret it as a sudden presence of mucus
in the throat. But whatever the exact description of the sensation, tickle or whatever, it's sort of
a "zing" kind of a sensation, and the person has to cough almost immediately. Most commonly, this kind
of coughing occurs at the sternal notch, which is right here at the base of the neck. Less commonly,
at the level of the larynx, sometimes up a little higher than that and a few times in, in slightly
other locations. But mostly in the low and mid neck. Now that "zing," that sudden tickling
or dryness, may have been going on for anywhere from weeks to decades and in fact, our longest
term coughed patient is a man who started when he was nine and that was 62 years ago.
Now the cough that I'm going to describe a little more can be spontaneous. It can just happen when
one is sitting watching TV, for example, or it may happen after what is called a trigger phenomenon.
Common triggers are talking or singing. We have many patients who say "My friends all know that
when I talked to them on the phone, at a certain point I'm going to start to cough and they just
say, 'Well Martha, hey I'll call you later you need to do your coughing now.'" Some people will say "If
I touch a certain place on my neck it makes me cough." Others say, "Breathing in cold air, I walk
out of the house, breathe–take that first breath of cold air and it triggers a spasm of coughing."
In some it's eating, especially vinegary things or scratchy kinds of foods. Lots of people describe a
trigger phenomenon when they change position. They say, "If I bend over, or if I get in in bed at night
I just know that I have to cough for a minute or so, every night when I get in bed." It's that change
of position. But again, sometimes the cough just occurs spontaneously without a trigger phenomenon.
Now if the person experiences a mild attack of coughing, they may clear their throat a couple of
times and cough a couple of times and that may be it. That might happen a few times a day or it
may happen hundreds of times a day, and in some persons it also occurs at night. If they have a
severe episode, however, instead of it lasting a few seconds it may go on and on. It can become violent,
it can last twenty seconds, a minute, even a few minutes. During that time, people say things like,
"I coughed so hard that I turn red" or, "I feel like I'm turning inside out, it's embarrassing because
people gather around." "I've had bystanders say–run up to me and want to do the Heimlich maneuver in
a restaurant." I've had a number say that kind of thing. They'll say "I'm kind of a mess after it's
over because my eyes are tearing and my nose is running." Not infrequently people will say "I lose
urine." That's called stress incontinence. "I wet myself because of the violence of the coughing."
In severe–even more severe cases people will say "My chest wall actually is sore after a
spasm of coughing." We've had a few actually break ribs from this kind of violent coughing. And then
one last thing that occasionally occurs, is something called laryngospasm, in which the
person suddenly can't catch their breath, and you can look on our website under laryngospasm if
you want to know more about that disorder which sometimes accompanies sensory neuropathic cough.
So let's review the entire scenario of someone with sensory neuropathic cough. We consider this
diagnosis–neurogenic coughing–strongly if you fit that, this description I've given so far. In summary,
you get a sudden sensation a "zing" of tickling, or burning, or dryness, sandpaper in the throat.
An irresistable cuff may or may not be associated with the trigger phenomena that I mentioned. The
cough doesn't respond to the usual treatments and it's non-productive typically, except after
a heavy aggressive attack of coughing. Now if you fit this description quite well, I'd go straight to
this diagnosis if you were in my clinic–straight to this diagnosis, and I wouldn't do any further
tests or treatments for any other kind of coughing if you fit what I've talked about quite well.
While I have no proof, I think of this as being the result of a kind of damage
or dysfunction of the nerve endings in the back of the mouth or in the throat. It might
represent a post viral neuropathy: damage of sensory nerves by a virus.
You, I'm sure, have heard of shingles, an eruption of blisters caused by the chickenpox or herpes
zoster virus. Well if so, you may know that in some cases, even after the blisters have completely
healed, the individual continues to have a burning or jabbing sensation–let's say across the face if
that's where the blisters were–and that's called a post herpetic neuralgia. Now this sort of thing
is what I think has happened in persons with sensory neuropathic cough. Instead of having
pain or burning in the feet or jabbing sensation in the face, the sensation is instead that tickle,
or tingling, or burning, or dryness, all of which provoke that, that irresistible need to cough.
Now because this kind of coughing seems best understood as a neurological disorder, it makes
sense that antibiotics, asthma treatments, cough suppressants and so forth aren't going to work
very well for it and that's in fact the case. Most people with this kind of problem have seen
multiple doctors and have tried those medications and approaches again and again without response...