Constance Gléron1, Domen Vozel2, Jure Urbančič3
self-reported Cough in Chronic rhinosinusitis
Samoocena kašlja pri kroničnem rinosinuzitisu
aBstraCt
KEY WORDS: cough, chronic rhinosinusitis, retro nasal drip, congestion, upper airway cough syndrome
BACKGROUNDS. Cough is an essential protective reflex of the respiratory tract, which
is triggered by various chemical or mechanical stimuli. It can be caused by acute or chro-
nic upper aerodigestive tract conditions, alone or in combination. Cough can be initia-
ted voluntarily from the cortical system or as an involuntary reflex. The upper airway
cough syndrome (i.e., previously post nasal drip syndrome) has been identified as the
most common cause of acute and chronic cough. This syndrome can present in chronic
rhinosinusitis, which is a common disease marked by an inflammation of the sinonasal
mucosa. However, to our best knowledge, the association between chronic rhinosinusi-
tis and cough has not been quantified yet. This paper aims to determine whether there
is difference in self-reported cough between patients with chronic rhinosinusitis and the
control group. METHODS. Cough was self-reported on the Likert scale with values 0–5
derived from the 22-item sino-nasal outcome test (SNOT-22). The analysis included patients
with chronic rhinosinusitis and patients without chronic rhinosinusitis with the latter
being the control group. RESULTS. The study included 477 patients with chronic rhi-
nosinusitis and 73 controls. The median self-reported score for controls was 0 (interquartile
range (IQR) 1) and 3 (IQR 3), p < 0.001 for chronic rhinosinusitis was. Even the ratio of
those who cough is higher in the chronic rhinosinusitis group (23.3% vs. 72.1%), p < 0.001.
This study has shown a difference in self-reported cough depending on whether chronic
rhinosinusitis is present (χ2(1,N=550)=66.9, p<.00001). DISCUSSION. This study under-
lines the intricate relationship between nasal symptoms in chronic rhinosinusitis and
cough. Now that this relationship has been statistically confirmed, one can further que-
stion which specific chronic rhinosinsusitis symptoms (from the sino nasal outcome test
questionnaire) are related to cough. A symptomatic evaluation of cough in the presen-
ce of chronic rhinosinusitis could be developed.
1 Constance Gléron, štud. med, Faculté de biologie et de Médecine, Université de Lausanne, Rue du Bugnon 21,
Lausanne; Medicinska fakulteta, Univerza v Ljubljani, Vrazov trg 2, 1000 Ljubljana; constance.gleron@unil.ch
2 Asist. Domen Vozel, dr. med., Klinika za otorinolaringologijo in cervikofacialno kirurgijo, Univerzitetni klinični center
Ljubljana, Zaloška cesta 2, 1000 Ljubljana; Katedra za otorinolaringologijo, Medicinska fakulteta, Univerza v Ljubljani,
Zaloška cesta 2, 1000 Ljubljana, Univerza v Ljubljani, Vrazov trg 2, 1000 Ljubljana
3 Asist. Jure Urbančič, dr. med., Klinika za otorinolaringologijo in cervikofacialno kirurgijo, Univerzitetni klinični center
Ljubljana, Zaloška cesta 2, 1000 Ljubljana; Katedra za otorinolaringologijo, Medicinska fakulteta, Univerza v Ljubljani,
Zaloška cesta 2, 1000 Ljubljana, Univerza v Ljubljani, Vrazov trg 2, 1000 Ljubljana
399Med Razgl. 2022; 61 Suppl 2: 399–407
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Acute cough (lasting between 1–3
weeks) is a typical symptom of a cold,
which is experienced by the majority of the
population. In this scenario, cough is an
essential symptom for the resolution of the
cold, and in preventing further complica-
tions. This crutial function is illustrated
when looking at patients with neuromus-
cular disease. The latter have a weakened
cough, meaning a decreased airway clea-
rance, predisposing these patients to respi-
ratory infections. Thus, it is recommended
that these patients receive airway clearance
support (3). This highlights the possible
consequences of a dysfunctional cough
mechanism.
400 Constance Gléron, Domen Vozel, Jure Urbančič self-reported Cough in Chronic rhinosinusitis
iZvleČek
KLJUČNE BESEDE: kašelj, kronični rinosinuzitis, izcedek iz nosu, nosna kongestija, sindrom zgornjih
dihalnih poti
IZHODIŠČA. Kašelj je eden izmed osnovnih zaščitnih refleksov respiratornega trakta. Sproži
ga vrsta kemičnih ali mehanskih sprememb na sluznici dihal. Po trajanju ga delimo na
akutni in kronični kašelj. Redko se kašelj pojavlja samostojno ali v povezavi z drugimi
boleznimi, kašljamo pa lahko tudi hoteno ali nehoteno (refleksno). Klinični sindrom kašlja
v zgornjih dihalnih poteh so včasih enačili z izcedkom iz nosu navzad. Ta sindrom naj
bi bil eden najpogostejših vzrokov akutnega in kroničnega kašlja. Kronični rinosinuzitis
je pogosta bolezen, ki jo zaznamuje vnetje sluznice nosu in obnosnih votlin. Izcedek nav-
zad je eden pogostih simptomov kroničnega rinosinuzitisa. Povezava pojavnosti kašlja
pri bolnikih s kroničnim rinosinuzitisom in kontrolah še ni bila ustrezno raziskana. METO-
DE. Članek opisuje pojavnost in oceno obremenjenosti s kašljem pri bolnikih s kroničnim
rinosinuzitisom in kontrolah. Kašelj je bil ocenjen s pomočjo Likertove lestvice z vred-
nostmi 0–5. Pri tem smo uporabili uveljavljen vprašalnik 22-predmetni test sinusno-nos-
nega izvida (angl. 22-item sino-nasal outcome test, SNOT-22). REZULTATI. V raziskavi je
sodelovalo 550 preiskovancev (447 s kroničnim rinosinuzitisom in 73 kontrol). Mediana
ocen kašlja je bila 0 (kvartilni razmik (angl. interquartile range, IQR) 1) pri kontrolah in
3 (IQR 3) pri bolnikih s kroničnim rinosinuzitisom. Tudi delež tistih, ki kašljajo, je bil pri
kroničnem rinosinuzitisu višji (72,1% proti 23,3%). S tem smo dokazali statistično pomem-
bno razliko v pojavnosti kašlja pri bolnikih s kroničnim rinosinuzitisom. RAZPRAVA.
Raziskava poudarja razmerje med nosnimi simptomi pri kroničnem rinosinuzitisu in
kašljem. Smiselno bi bilo raziskati tudi vpliv ostalih simptomov, ocenjenih z vprašalni-
kom SNOT-22, za razvoj ustreznejših diagnostičnih in terapevtskih načinov za kroničen
kašelj, povezan s kroničnim rinosinuzitisom.
BaCkgroUnDs
Cough is an essential protective reflex of the
respiratory tract. Its prevalence in the ave-
rage population in Europe and the USA has
been recorded to be 9–33%. It is used to clear
the larynx, trachea, and large bronchi of
secretions such as mucus, noxious sub-
stances, foreign particles, or infectious
organisms (1). It is a process triggered by
various inflammatory or mechanical chan-
ges, typically occurring in the upper airways.
Most episodes of cough are a physiological
response to stimuli and tend to be self-limi-
ting. Even so, it can also be a symptom of
an underlying disease such as pneumonia,
lung cancer or laryngeal cancer (2).
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 400
In spite of this symptom’s importance,
a chronic persistant cough can be the mani-
festation of an underlying disease. It can be
associated to vomiting, urinary inconti-
nence, syncope, tiredness, rib fractures and
depression (1, 4, 5). This significant decrea-
se in the health related quality of life of the
affected patients makes it even more impor-
tant to find the underlying cause and treat
the symptom accordingly.
Chronic rhinosinusitis (CRS) is an upper
airway condition that is often related to the
upper airway cough syndrome (UACS),
which is one of the leading causes of chro-
nic cough (1, 6). UACS includes any rhino-
sinus conditions associated with cough. The
precise association between CRS and cough
has not been quantified to our knowledge.
This article presents the general pathop-
hysiology of cough and its pathogenesis in
CRS to emphasize the significance of cough
in CRS. It aims to determine the influence
of the presence of CRS on self-reported
cough in a retrospective controlled clinical
study. We predict that there will be higher
cough scores in CRS patients rather than in
those from the control group.
Cough Pathogenesis
Cough is characterized by three discinct
phases, which are a deep inspiratory phase,
an intense, forced expiratory phase against
a closed glottis, and a final expiratory phase
with the glottis opening (1). An effective
cough is marked by the capacity to push gas
through the airways, and interactions bet-
ween the flowing gas and the mucus lining.
This process is dependant firstly on the abi-
lity of the respiratory muscles to increase
intrathoracic pressure and compress the air-
ways to push air outside and secondly on
the effective closure of the glottis to main-
tain the pressure gradient in the airways (3).
Cough can be initiated voluntarily from
the cortical system or involuntarily as
a reflex. The latter depends on sensory affe-
rents from cough receptors into the vagus
nerve (1). Both mechanical and chemical
cough receptors converge to initiate a cough
response (3).
The sensory nerves are characterized by
their conduction and their specific triggers.
For instance, some fibers (C fiber receptors)
are activated predominantly by chemical sti-
muli (e.g., hydrogen ions, capsaicin, brady-
kinin), while others have a wider variety of
triggers such as acidity/alkalinity, mecha-
nical stimulation, pulmonary congestion,
or other modifications of pulmonary com-
pliance (rapid-acting receptors) (1). This
array of possible cough triggers and sen-
sory pathways complicate the identification
of the cough’s etiology.
Cough etiology
Cough can be further separated into acute
and chronic according to the duration of the
symptom. Acute cough lasts between 1–3
weeks, typically due to an upper respiratory
tract viral infection, pneumonia or pulmo-
nary emboli (7). Sub-acute cough lasts bet-
ween 3–8 weeks, and chronic cough persists
for more than 8 weeks (1). The diagnosis can
be made by exploring other associated
symptoms.
The most common causes of chronic
cough are referred to as the triad of cough
and include UACS, asthma and gastro-
oesophageal reflux disease (GERD) (1, 5, 8).
One study showed that 94% of chronic
cough cases are caused by one of these
three phenomena, either alone or in com-
bination. Asthma and GERD are specific
disorders that have straightforward dia-
gnostic procedures. At the same time,
UACS encompasses any condition of the
upper airways presenting with cough.
UACS has been named the most common
cause of acute and chronic cough. Indeed,
in 87% of patients consulting American
physicians the cough was attributed to
rhinological causes (5). Several clinical
and epidemiological studies agree that
UACS is the most commonly identified
401Med Razgl. 2022; 61 Suppl 2:
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 401
cause of chronic cough (8, 9). Although this
has been named a specific syndrome since
2006, there is minimal consensus concer-
ning its exact causes, mechanisms, and
management (8, 10, 11).
Upper airway Cough syndrome
UACS encompasses all nasopharyngeal
conditions (allergic rhinitis, rhinosinusitis,
laryngopharyngitis, etc.) that present with
cough (8). It includes disease of the nose or
paranasal sinuses, anatomic abnormali-
ties of the respiratory tract, and pharyngeal
disease (11). There is no single pathogno-
monic finding in this syndrome, which
complicates its identification. The general
clinical presentation of UACS includes
several common complaints reported by the
patients. These are as follows: the sensation
of something draining in the back of the
throat, a need to clear the throat, a tickle
in the throat, nasal congestion or nasal disc-
harge. Hoarsness can also be present aswell
as a history of a previous upper respirato-
ry illness. The diagnosis can be made by
identifying one or more of the following:
drainage in the posterior pharynx, throat
clearing, nasal discharge, cobblestone
appearance of the oropharyngeal mucosa,
or mucus in the oropharynx.
These clinical findigs are linked to
high specificity but low sensitivity, making
their presence difficult to interpret. (8).
Some researchers even stipulate that the
presence of clinical manifestations is not
compulsory. There is still a lot of debate
regarding it's validity (11). As a conse-
quence, the diagnosis of this syndrome is
made by considering a combination of cri-
teria including symptoms, physical exa-
mination, radiographic findings and the
response to specific therapy (9).
The exact pathogenesis of UACS is not
yet elucidated. The current theories are the
following (14):
• post nasal drip stimulates cough recep-
tors in the hypopharynx or larynx,
• direct irritation and sensitization of the
cough receptors in the nasal mucosa,
• inflammation and irritation of both the
upper and lower airways and
• cough reflex sensitization.
Although UACS is described in many artic-
les, the pathogenesis and diagnosis are
still inconsistent. As previously cited, many
studies report a high prevalence of UACS.
The Japanese respiratory society does not
report such a high frequency. They instead
propose the categorization of the sino-
bronchial syndrome (SBS), which they find
to be the most common cause of cough
together with atopic cough (12). SBS is cha-
racterized by a cough related to CRS and
chronic lower airway inflammation. In light
of this controversy, it seems paramount to
investigate the link between cough and
CRS more specifically.
Chronic rhinosinusitis and Cough
CRS is a common condition with a preva-
lence of 5.5–28% of the population world-
wide and 10.9% of Europeans (14, 15). Its
prominent marker is the inflammation of
the mucosa in the nose and paranasal sinu-
ses (14). The physiological function of the
mucosa is to provide a barrier to regulate
interactions with the immune system. This
will provide tolerance, symbiosis, while also
limiting inflammation. Hence, in patients
with CRS, there is a dysfunction of this bar-
rier. The hypothesis for the aetiology of this
syndrome has signficiantly evolved in the
past 15 years. There is a clear role of both
environmental and predisposing factors
in the host. However, several other com-
ponents are frequently associated to a wor-
stening of this syndrome such as bacteria,
fungus and smoking (14). The pathogene-
sis of CRS is thus attributed to a combina-
tion of environmental triggers and genetic
predispositions working together to pene-
trate this protective barrier. This will indu-
ce an immune response through cellular
402 Constance Gléron, Domen Vozel, Jure Urbančič self-reported Cough in Chronic rhinosinusitis
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 402
interactions and various cytokine releases,
eventually leading to the diverse phenotype
of CRS.
This syndrome can present itself in
many ways, and in different severities.
Hence, a standard assessment tool is
a patient-completed survey to quantify the
patient-specific presentations of the disor-
der and analyze the treatment options. The
Sino-Nasal Outcome test (SNOT-22) is
commonly used as a validated Quality of
Life (QoL) tool in patients with CRS (16, 17).
It is a 22 domain score exploring the self-
reported severity of different symptoms,
both physical and psychological (17, 18).
Rhinosinusitis-associated cough is one
of the items reported on the SNOT-22 que-
stionnaire. This symptom is typically cate-
gorized as UACS. Nevertheless, there is no
consensus regarding upper airway cough
syndrome and its link to CRS. The propo-
sed theories of cough in CRS are (6):
• cough reflex hypersensitivity,
• post nasal drip,
• aspirated secretions from the lower
airways and
• enhanced sensitivity to environmental
factors.
These theories strongly overlap those for
cough in UACS, underlining the similari-
ties between the two. The understanding
of the lack of objective critera for these syn-
dromes and their relative ambiguity sup-
403Med Razgl. 2022; 61 Suppl 2:
ports the lack of consensus between aut-
hors (19).
MetHoDs
study Design
The study was designed as a retrospecti-
ve single-center controlled trial conducted
at the Department of Otorhinolaryngology
and Cervicofacial Surgery of the University
Medical Centre Ljubljana from 2011 to 2021.
The National Medical Ethics Committee
Slovenia approved the study. Written infor-
med consent was obtained from all indi-
vidual participants included in the study.
There were two study groups: CRS patients
and patients without CRS (control group).
inclusion and exclusion
Criteria
See Table 1.
Diagnosis of Chronic
rhinosinusitis
The European Position Paper on Rhino-
sinusitis and Nasal Polyps (EPOS) guide-
lines for the diagnosis of CRS are the
following: the obligated presence of at least
one of these symptoms: nasal blockage/
obstruction/nasal discharge (anterior or
posterior) and the optional presence of
facial pain/pressure or the loss of smell, for
more than 14 days, with positive endosco-
py or CT signs of the disease in the para-
nasal sinuses (14).
table 1. Inclusion and exclusion criteria for the patients and the control groups. CRS – chronic rhinosinu-
sitis, EPOS – European Position Paper on Rhinosinusitis and Nasal Polyposis.
Crs patients Controls
Inclusion criteria patients above 18 years old patients above 18 years old
consulting for rhinological complaints consulting for rhinological complaints
diagnosed CRS (according to the EPOS
criteria)
Exclusion criteria diagnosed tumor (benign or malignant)
any non-related pathology (identified neoplasia and autoimmune disease of non-CRS
related immunodeficiencies such as cystic fibrosis or primary ciliary dyskinesia)
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 403
Quality of life related to
Chronic rhinosinusitis
(sino-nasal outcome
test Questionnaire)
All patients fitting the inclusion criteria for
this study were asked to complete the
SNOT-22 questionnaire. The questionnaire
had previously been translated, adapted, and
validated in the Slovenian language (20).
Patients score the severity of 22 items
(nasal symptoms and their health-related
quality of life) on a Likert scale of 0–5. In
addition to the SNOT-22 questionnaire, the
age and gender were systematically recor-
ded. Finally, the diagnosis of CRS and its
subtypes was documented following EPOS
guidelines (14). All patients with CRS were
regarded as a uniform group (disregar-
ding the diagnostic categories with/without
nasal polyps).
statistical analysis 
The Kolmogorov-Smirnov and the Shapiro-
Wilk test were used to determine the distri-
bution of our data. We found a non-normal
distribution of the results. Therefore, we
represented our data using medians and
interquartile ranges and further analyzed
it using non-parametric tests (21).
The next step was to use the Kruskal-
Wallis test to compare the distribution of
gender in our data. The same was perfor-
med for the age distribution analysis.
Cough was graded on a Likert scale of
0–5 according to the SNOT-22 question-
naire. In addition to this, we decided to bina-
rize the cough symptom. A score of 0–1 was
graded as »no cough,« and 2–5 signified the
presence of a cough. This cut-off point
was chosen because, when looking at all our
patients, the median of the cough scoring
was 2. A binomial test was performed to
determine the distribution of patients with
and without cough within the two groups.
The Mann-Whitney U test was used to
determine the statistical difference bet-
ween the medians of cough score between
our two groups. Then, we used the χ2 test
to determine the difference in binarized
cough between the groups. A p-value
of < 0.05 was considered statistically signi-
ficant. All statistical analyses were done
using the SPSS statistics program version
27 (IBM, Armonk, USA).
resUlts
The patient characteristics for our study are
shown in table 2. A total of 550 patients par-
ticipated in our study. 477 had CRS and 73
were controls. There was no statistically
significant difference between the gen-
ders or across age disctibution (p > 0.05) in
either of the groups.
In the 73 patients from the control
group, the median self reported sino-nasal
outcome test (SNOT) score was 9 (inter-
quartile range (IQR) of 24). In the 477 CRS
patients it was 53 (IQR of 30). These results
indeed showed a significant statistical dif-
ference (p > 0.05). The exact difference bet-
ween the two medians is 44, this represents
a 40% increase in the total SNOT score
(the range is from 0–110 points). The IQR
of the total SNOT score was 24 for the con-
trol group and 30 for the CRS patients.
Concerning the specific cough SNOT sco-
res, the median was 0 (IQR 1) for the con-
trol group and 3 (IQR 3) for the CRS
patient groups. Again, showing a statisti-
cally significant difference (p < 0.05). The
number of people in the control group who
had a cough score higher than 1 was 17
(23.3%) versus 56 who reported a score of
0 or 1 (76.7%). In the CRS patients, 344
reported a cough score higher than 1
(72.1%) and 133 equal to or less than 1
(27.9%). A statistically significant diffe-
rence (p < 0.05) was found between the
two diagnostic groups, and in the cough
versus no cough categories, with a result
of χ2(1,N=550)= 66.9, p<.00001. The IQR
was 1 for the control group and 3 for the
CRS patients, reflecting a larger range of
cough scores in the latter group.
404 Constance Gléron, Domen Vozel, Jure Urbančič self-reported Cough in Chronic rhinosinusitis
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 404
DisCUssion
A significant difference between SNOT
scores of both groups was observed. This
reflects a higher severity and frequency of
symptoms in CRS patients, which transla-
tes to a lower health related QoL. The
same is seen concerning the specific cough
scores. The higher IQR for cough in CRS
patients (3 points) mirrors the heteroge-
neity of the severity of these symptoms,
contrasting the IQR of 1 point in control
groups. Both the general SNOT score and
the specific cough score show that there are
more symptoms present in patients with
CRS and are reported to be more severe. By
performing a χ2 test, we can confidently say
that our data supports our hypothesis that
CRS patients report more severe cough
than other patients.
CRS was historically connected to
cough, but according to the EPOS 2020, the
diagnosis is not associated with cough
unless pediatric CRS is diagnosed (6, 14).
Yet, it is one of the domains of a widely used
QoL questionnaire for CRS, SNOT-22 (18).
To our best knowledge, no published stu-
dies examine the exact relationship between
CRS and cough or compare the symptom
of cough in patients with or without CRS.
We set up a study to compare the self-repor-
ted cough score in controls and CRS patients.
We had previously established a valid dia-
gnosis of CRS using the EPOS 2020 crite-
ria. Our control group consisted of patients
who did not have CRS. We have opted for
a self-reported cough score due to the lack
of a simple objective cough evaluation
scheme. Morevorer, it has been previously
established that cough significantly dete-
riorates the QoL (22). Consequently, the use
of the SNOT-22 questionnaire seems ade-
quate. The use of the Likert scale allowed
us to compare quantifiable results. We
confirmed that self-reported cough is pre-
sent in a higher proportion of patients
with CRS compared to patients without
CRS, and that cough has a more conside-
rable negative impact on the QoL. This
405Med Razgl. 2022; 61 Suppl 2:
table 2. Baseline characteristics of the patients. CRS – chronic rhinosinusitis, N – number of patients,
SNOT-22 – 22-item Sino-nasal Outcome Test, Mdn – median value, IQR – inter quartile range.
Controls (n=73) Crs patients (n=477) p-valuea
Gender
Male (n, %) 35 (47.9%) 274 (57.4%) 0.128b
Female (n, %) 38 (52.1%) 203 (42.6%)
Age
Mdn years; IQR 42; 27 51; 23 0.384b
SNOT-22
Mdn score; IQR 9; 24 53; 30 <0.001b
Cough scorec
Mdn score; IQR 0; 1 3; 3 <0.001b
Yes (n, %) 17 (23.3%) 344 (72.1%) <0.001b
No (n, %) 56 (76.7%) 133 (27.9%)
p-valuea <0.001d <0.001d
a p-value < 0.05 denotes a statistically significant difference
b Mann-Whitney U test
c the specific score given to the symptom of cough on the SNOT-22 questionnaire
d Binominal test
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 405
study also implies a relationship between
CRS and cough. Especially since the ratio
of subjects with cough is higher in the CRS
group.
Cough is one of the most common
symptoms worldwide, often associated with
acute, self-resolving conditions. Yet, it can
be chronic and represent a health burden for
the affected subjects. Contrary to asthma and
GERD, the two other most common causes
of chronic cough, UACS does not have some
specific, objective diagnostic criteria (5, 14).
Previous research observes that this dia-
gnosis is broad and is made with any upper
airway symptoms. These are associated
with a multitude of diseases affecting the
upper airway. Our study provided an insight
on the association between CRS and cough.
This is important as CRS is a heterogeneous
syndrome and should perhaps be conside-
red individually when associated with cough
rather than be associated with an equally
heterogeneous syndrome such as UACS.
Perhaps we should rethink the classification
of UACS into smaller, more specific dia-
gnoses.
The shortcomings of our study begin
with the possible overestimation of patient-
reported cough scores (SNOT-22). This
starts with the problem of exact cough mea-
surement. The SNOT-22 questionnaire is
a subjective estimation of the severity of
symptoms, meaning that it depends on an
individual’s personal evaluation of the symp-
tom. Moreover, both the control groups and
the CRS patients were consulting the ear,
nose, and throat (ENT) clinic for rhinolo-
gical complaints. We therefore cannot
generalize our data to the general popula-
tion since we do not represent CRS patients
with mild symptoms who do not necessa-
rily seek medical care (12). Similarly, we pla-
ced all CRS subtypes in one single category.
Perhaps there are notable differences in the
incidence of cough between those groups
that cannot be observed with our present
methods. Although uncommon, it is impor-
tant to consider that a psychological aspect
may play a role in the representation of
cough (4). It is especially prevalent in CRS
patients, where psychological comorbidities
are common, and can be associated with
pain catastrophization, leading to worsened
health-related QoL for those specific patients
(23). It could be interesting to record pos-
sible psychiatric comorbidities in those
patients. Finally, our study does not diffe-
rentiate cough in terms of duration. We
assumed that patients had a chronic cough.
However, the SNOT-22 questionnaire expli-
citly asks subjects about the last 14 days.
It is also vital to mention cultural diffe-
rences when evaluating symptoms (24).
Hence, these results are not generalizable
to any population as most of the patients
were Slovenian. To lessen score exaggera-
tion and acquire a more generalizable set
of data, it would be essential to apply a popu-
lation-based method with a more hetero-
geneous group of people. Nonetheless, our
methods provided sufficient data and sho-
wed significant differences in cough bet-
ween both the controls and the CRS patients.
This study has shown a difference in
self-reported cough depending on whether
CRS is present or not. This confirms the
broad relationship between the symptom
of cough and CRS and draws attention to
the ambiguity of the UACS as an endpoint
diagnosis.
Comparing self-reported cough in the
control group and in patients with CRS has
shown a higher cough score and a higher
ratio of cough in the CRS group. Our study
underlines the intricate relationship bet-
ween nasal symptoms in CRS and cough.
One can now wonder which symptoms gra-
ded on the SNOT-22 questionnaire are rela-
ted to cough and whether there is a decrease
in self-reported cough and well-controlled
CRS. In the long term, a specific sympto-
matic evaluation and treatment for chronic
cough associated to CRS could be develo-
ped.
406 Constance Gléron, Domen Vozel, Jure Urbančič self-reported Cough in Chronic rhinosinusitis
ORL 2022_Mr10_2.qxd  2.9.2022  13:00  Page 406
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