Dorsal Preservation Rhinoplasty

Keith R. Conti, MD Ronak Modi, MD Aaron Jaworek, MD

Introduction

Despite adherence to guidelines and initiating appropriate treatment algorithms, 46% of patients with chronic cough evaluated in secondary care settings continued to have an “unexplained” cough,1 suggesting the need for a more thorough understanding of underlying mechanisms and treatment options.

Case Report

The patient is a 72-year-old woman who presented to the tertiary referral laryngology office with a past medical history of exercise induced asthma, environmental allergies, and traumatic brain injury (TBI) 4 years prior. She had a persistent cough that started with upper respiratory tract infection nine months after her TBI. She completed antibiotics with resolution of all symptoms except for the cough. Social history was significant for a remote history of cigarette smoking until quitting 45 years ago. The cough was described as mostly dry, occurring daily, and worse with talking, when sitting in her car, and when getting out of bed in the morning. It was not worse after meals, with exertion, with cold air, or strong odors. She denied dyspnea and dysphagia except for occasional effortful swallows. She denied heartburn, chest pain, and regurgitation. She reported occasional sensations of mucous and post-nasal drip without throat clearing, globus, or sore throat. She had been evaluated previously by two pulmonologists, an allergist, and another laryngologist. Prior therapeutic trials with minimal or no benefit included over-the-counter cough suppressants, gabapentin 600mg twice daily, lansoprazole 60mg before breakfast, oral antihistamines (first and second generation), intranasal antihistamine, intranasal corticosteroid, ipratropium nasal spray, and corticosteroid/albuterol inhalers. Prednisone was helpful, however, the cough would return once discontinued. Pantoprazole 40mg before breakfast with ranitidine 300mg at bedtime and a low acid diet had resulted in decreased reflux symptom index from 27 to 18, but the cough did not improve. Comprehensive head and neck examination with strobovideolaryngoscopy and laryngeal sensory testing revealed a reflux finding score of 11 (positive score > 11), mild right vocal fold paresis, and slightly diminished laryngeal adductor reflex responses bilaterally. Additional diagnostic workup was normal including chest x-ray, labs (thyroid stimulating hormone, free T4, anti-nuclear antibody, rheumatoid factor, mycoplasma titer, gluten sensitivity panel, and lyme titer), fractional exhaled nitric oxide, and esophagogastroduodenoscopy (EGD) with biopsies. Cough and breathing retraining therapy by a speech-language pathologist fellowship trained in voice was pursued which provided some relief with cough. Twenty-four hour multichannel intraluminal impedance with dual pH sensors and esophageal high-resolution manometry (HRM) were performed while taking pantoprazole 40 mg before breakfast and ranitidine 300 mg at bedtime. The impedance test showed 42 reflux events with 12 acid (pH< 4) events, and three events of laryngopharyngeal reflux. Ten out of the 33 reported coughs were preceded by reflux with a symptom index of 30% (positive if >50%), and a symptom association probability of 100% (positive if >95%). Hypercontractile esophagus (HE) was noted on HRM with an elevated distal contractile integral (DCI) in five of 10 swallows. A DCI >8000 mmHg·sec·cm is considered elevated with HE defined as two or more swallows having elevated DCI. The average integrated relaxation pressure (IRP) was within normal range, making achalasia unlikely. She was started on diltiazem 60 mg three times daily by gastroenterology to treat HE. At follow up, she reported >50% improvement in her cough since starting diltiazem. She stated that she was no longer coughing during the day or from triggers like sitting in her car. Her satisfaction with improvement in cough severity and normal EGD resulted in a decrease in acid suppression therapy to ranitidine 150mg at bedtime with sustained benefit.

On the left is high resolution esophageal manometry (HRM) for one out of ten swallows prior to diltiazem pharmacotherapy. The color corresponds to amount of pressure, in mmHg, in each of the four contractile segments: upper esophageal sphincter (UES) (1st segment), esophageal body (2nd and 3rd segments), and lower esophageal sphincter (LES) (4th segment). On the right a corresponding line plot depicting pressure, in mmHg, versus time, in seconds.