Still Coughing After COVID? | Sensory Neuropathic Cough (SNC)

8 min read
In this video, Dr. Robert W. Bastian explains three explanations for coughing in the context of Covid-19 infection, with emphasis on the potential for sensory neuropathic cough (Phase 3). The possible phases are: 1) During the “hurricaine” of the infection…

In this video, Dr. Robert W. Bastian explains three explanations for coughing in the context of Covid-19 infection, with emphasis on the potential for sensory neuropathic cough (Phase 3). The possible phases are:

1) During the “hurricaine” of the infection itself, when your lungs may be fighting active and as-yet undefeated virus.

2) During the “cleanup phase,” when the virus has been vanquished, but the lung debris (think: “downed branches and detached roof shingles”) is being cleaned up, even though “the sun is shining.”

3) For weeks to months after phases 1 and 2 are long past, coughing caused by damaged nerve endings that go “ZING!” with a tickling, burning, dry, or dripping sensation that initiates coughing, throat clearing, or laryngospasm.

This often-overlooked sensory neuropathic type of cough is explained in detail, including how to treat it.

PeerJ Article on SNC:

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#coughing #covid #snc #voice #vocalcords #sensoryneuropathiccough

Hello, I'm Dr. Robert Bastian of Laryngopedia 
and Bastian Voice Institute (BVI). Our subject   Is coughing in the context of Covid-19. Covid-19 
has intruded into our lives in innumerable ways.   We've lost a lot of our fellow citizens. Others 
contracted the virus and were very ill from it,   Including with pneumonia or bronchitis, and 
hard coughing was a part of the fight to recover   Completely, and they are now fully recovered. A 
second group has recovered in general, and they're   Weeks or months passed the acute infection, but 
they are experiencing a lingering and somewhat   Productive cough. For this second group, it is as 
though a viral hurricane hit weeks or months ago,   And now for some, the high winds have been- are 
gone—the acute infection is gone—but there's a   Lot of damage and debris. It's like the limbs and 
the roof shingles that have been blown off by the   Hurricane, even though the sun is 
out—those things have to be cleared away.   So for some of these people, there is coughing 
that continues for a time even after they're   Relatively well, as inflammation resolves. 
So it still has a purpose; (the cough) it's   Cleaning up after the storm. A third group—the 
illness is gone and the lungs are tidied up.   They're healed and clean, there's nothing being 
produced, but the person continues to cough.   It isn't a cough like during the hurricane or 
immediately after clearing out debris. It's just   A cough that serves no purpose. It no longer 
is solving a problem of clearing things away   But the cough is the problem—it's 
interfering with quality of life.   So what's the explanation if there's no active 
infection and there's no debris to clean up?   This third group may have damaged or sensitized 
sensory nerve endings in the larynx. Here's the   Vocal cords in the trachea. So the trachea here, 
the larynx here, and in the pharynx. Those areas   May have damaged sensory nerve endings. So these 
traumatized, damaged nerve endings are irritable   And twitchy. They go zing for no apparent reason 
and demand that you cough. Such persons with   Covid-19 nerve ending damage may have a specific 
cough diagnosis called Sensory Neuropathic Cough   That not a lot of people still know about. Now 
I have described sensory neuropathic cough in   Detail in prior videos and on my teaching website 
Laryngopedia. I've also published on the subject,   And I've worked with general post-viral sensory 
neuropathic cough for 25 years, and I believe the   Covid-19 infection has simply taken its place 
along some of those earlier viruses as a cause   Of sensory neuropathic cough. Well to review 
what I've described previously, key features of   Sensory neuropathic cough are that each episode of 
coughing is initiated by a stereotype sensation;   A zing. People say it's a tickle, a dry patch, 
an itch, a pinprick, a dripping sensation. It's   Like it happens again and again. The commonest 
location is at the sternal notch. The sternal   Notch is right here. It's right at the base of 
the neck. The sternal notch, right there. That's   The most common. A second would be at the level 
of the larynx itself, and then there's some where   It's higher up here in the throat. And there are a 
few where it's kind of central chest down in here.

Now when that zing happens, it can initiate 
a single cough so a person could go   <cough> and they're just doing that 
dozens or hundreds of times a day.   Or it could be a few seconds of coughing, they 
get that zing and they kind of go <cough> <cough>   And then they're done. Or, unfortunately, 
sometimes it will trigger a violent and protracted   Episode of talk- coughing that could go on 
for 30 seconds, a minute, and even longer.   So stereotype sensory disturbance, that's kind 
of this tickle, or itch, or something. Number   Two is that the cough is out of proportion to 
anything produced by that cough. The cough is dry   Or it produces mucus only after hard coughing, 
and I'm not sick at all I haven't been sick,   But if I sit here and force myself to cough really 
hard I will produce a surprising amount of mucus.   So the person asks in exhaustion, "Who coughs 
this much to produce that little amount of mucus,   Or coughs that long before the mucus comes up?" 
The person may even cough hundreds of times a day,   Mostly briefly, but they also can have 
those agonizing protracted and exhausting   Episodes several times a day, to the point of 
embarrassment in public or even humiliation.   And that's not overlooked that some have it 
also interrupting their sleep a time or two, and   Sometimes many times people are awakened at night, 
fortunately not all. So sensory disturbance,   Cough out of proportion to anything you produce, 
and trigger phenomena. While coughing spells   Can occur spontaneously, certain actions make that 
"zing!" more likely to happen. So people say things   Like, "You know, I have a big laugh and I don't 
dare laugh in my usual way because every time I   Do that it makes me cough." Or "If I talk a while 
on the phone," or "If I go outside in the cold   And I breathe in that first breath of cold air," 
or "I smell something really strong, a cleaning   Solution," or "I swallow." Change your position. 
"I get in bed at night," or "When I get up at   Night to use the bathroom I- it makes me cough." 
Or they'll say "If I touch right there it makes   Me cough." Those are trigger phenomena. Fourth is 
the seeming futility of usual treatments. Taking   An expression from the film Casablanca, remember 
the french chief of police says to his underlings   At one point, "Go round up the usual suspects." 
Well those are allergy, acid reflux and asthma,   When people have this kind of chronic cough, 
and the treatment for those things does nothing.   Steroids may help but only while you're on them, 
and narcotic cough suppressants may provide some   Relief, but that's not a good long-term treatment 
if the cough is going to go on and on and on for   Months and months. Well what is the best approach? 
It's to target the irritable nerve endings.   Medications like Amitriptyline or Desipramine, 
Gabapentin, Citalopram, Mirtazapine, Venlafaxine,   Capsaicin spray, all of these have been 
described, I think most of them are on my   Website, Laryngopedia. Usually one of the 
first two, if you're under 65, it would be   Amitriptyline or Gabapentin, usually one of those 
is effective. May not abolish the cough totally   But it's usually much much better. Persons with 
resistant cases may need to work their way down  

A longer list beyond the first two, and so, 
you have to be patient to just work your way   Through this series of medications. Occasionally 
injection of a long-acting local anesthetic—I   Use Mepivacaine or Bupivacaine—combined 
with a locally acting steroid—the same   Kind of thing you would have in a sore 
shoulder, or injected into your knee,   Or that kind of thing—that is injected into a 
sensitized area and sometimes that can help.   Well what are the practicalities of finding help 
for sensory neuropathic cough after Covid-19?   Well first, if you're still very early after the 
infection and you're congested and bringing up   Mucus and material, stay the course 
with the normal treatments of hydration,   Cough suppressants and so forth. If the infection 
was weeks ago and you're feeling reasonably well,   But the main impediment to recovery and 
return of quality of life is your cough,   It seems like it's a cough that's the problem; not 
solving anything. Then educate yourself more fully   About sensory neuropathic cough. Laryngopedia has 
many articles, videos, patient interviews that   You can find by typing "COUGH" into the search 
window. Or, you can read an article—I'll link here   Below—on the subject. It's a peer-reviewed article 
found in an open source medical journal—that is,   It's not behind a paywall because 
I wanted people to be able to   To get it anywhere around the world. And then 
raise the question with your personal physician,   "Is it possible I have sensory 
neuropathic cough?" and hand the article.   Consider that article because your doctor may 
not have encountered this diagnosis before.   And in that article, the treatment 
protocol is clearly outlined.   Think about doing advanced work before you go see 
a doctor. Call the group ENT or pulmonary and ask   To speak to the triage nurse. Say "I need that 
conversation before I decide whether or not I'm   Going to come." And then ask him or her, "So any 
of your doctors treat sensory neuropathic cough?"   If the answer is no, or you get this kind of 
awkward response that lets you know they don't,   Then call the next group with the same question. 
If you exhaust all local sources of help,   Consider a teleconversation with an expert who 
lives far away from you. There are a number of   Physicians across the country who are now 
aware of this diagnosis, but you may have   To do a little work to find them. Do your internet 
search and find people like us at Laryngopedia or   You are welcome to work with any of our doctors at 
Bastian Voice Institute in the suburbs of Chicago.   Now doctors at BVI would also be glad to 
help you in person if you live near Chicago.   Well here is wishing you a speedy resolution 
of your cough and hoping, along with you,   That it is only a brief aftermath of Covid-19. 
If, on the other hand, you are struggling with   Coughing that won't go away, and after many 
weeks and despite many tests and treatments,   Then I hope this discussion has helped give 
you a direction. Thank you for listening!

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