Managing Postnasal Drip Cough a Family Physician First & Otorhinolaryngologist Only If Complications Occur

Cough is a protective reflex that helps clear the airways, but it can become pathological and disabling if it's prolonged or troublesome. Glands in our nose and throat continually produce mucus, normally one to two quarts per day. Mucus moistens and cleans the nasal lining, moistens air, traps & clears what is inhaled, and helps fight infection. Normally swallowed unconsciously, but when there is a feeling of the mucus gathering in the throat or dripping from the back of our nose, it is called post-nasal drip. Post-nasal drip often leads to a sore, irritated throat and cough.
The burden of cough globally and in India too is significant. It can be classified into three categories namely acute cough, subacute cough and chronic cough! Despite being the most common ailment, it lacks clear diagnostic and treatment guidelines. Post-nasal drip can cause an acute or sub-acute and chronic cough, usually diagnosed with a physical exam and rarely an endoscope or X-rays. Postnasal drip cough (PNDC) is the commonest health problem in winter. It is caused by allergies, colds, flu, Bacterial infections, hormonal changes, Vasomotor rhinitis, certain foods, & medications that thicken mucus, Gastroesophageal reflux (GERD). Family physicians manage cases of PNDC giving antihistamines & asking to inhale steam.
Materials and Methods
This article is an outcome of managing three types of coughs managed by the author in the last one month following winter and exposure to polluted environment, supported by appropriate literature search.
Outcome: Of the three postnasal drip cough cases, the first acute case was managed with standard treatment with antihistaminic tablets and steam inhalation, the second case of chronic cough despite trying several anti-coughing medications like codeine, cloprednol, dextromethorphan, and levodropropizine, with no improvement. The third case of Syncope from intractable cough caused by postnasal drip was finally managed by Gabapentin 300 mg daily, for 10 days.

Cough is a protective reflex that helps clear the airways, but it can become pathological and disabling if it's prolonged or troublesome. Coughing up phlegm or mucus after an infection with viruses of common cold, Influenza, Corona viruses since 2020 and many other bacterial respiratory infections, is how the lungs and airways keep themselves clear. The annual prevalence of cough in the general population is reported to be 10–33% (2). By far the most common causes of acute cough are infections of the upper respiratory tract (URTI) and acute bronchitis, which together account for more than 60% of diagnosed cases. The global prevalence of chronic cough is highly variable, ranging from 2% to 18% with a median prevalence of 9.6% globally and 5-10% in India [1,4]. 
Nearly every person experiences at least one episode of cough every year in their lifetime, but the majority seek care outside home only after trying known home remedies, and only when cough disturbs their sleep. A cough is divided into four distinct phases- inspiratory, compressive, expiratory, and relaxation, characterized by deep inspiration, closure of the glottis, contraction of expiratory muscles with glottic opening, and relaxation of intercostal and abdominal muscles. Available community surveys data indicates that an average Indian adult has 3 episodes, and an average child has 7-10 such episodes of cough each year [2]. Of those with cough, more than two thirds (CI 60–77) do not seek care from any health care provider. Not seeking care is more frequent in people residing in rural areas (73%) compared with urban areas (53%).  India’s north- eastern (18%) and northern states (26%) states people seek less often outside care compared to districts from the western (46%) and southern (54%) states [3]. The COVID-19 pandemic has increased the magnitude of cough across the world since early 2020 [1]. 
Glands in our nose and throat continually produce mucus, to keep the nasal lining clean, moistens air, and to traps & clear inhaled air, to fight infections. The mucus is normally one to one and half liters per day and is swallowed unconsciously. During any inflammation, infection or allergies there is a feeling of the mucus gathering in the throat or dripping from the back of our nose (post-nasal drip), and we become conscious of its irritation and swallowing. Post-nasal drip leads to a sore in tonsils, adenoids and other tissues in the throat which swell, causing discomfort leading to bouts of Cough [2]. The most annoying part about a cough is “phlegm or mucus.” [1].
The burden of cough globally and in India too is significant. Cough is classified into three categories as acute cough (AC- last up to 3 weeks), subacute cough (SAC- 3-8 weeks) and chronic cough (CC-more than 8 weeks) for clinical purpose based on the duration it lasts! Despite being the most common ailment, it lacks clear diagnostic and treatment guidelines. Post-nasal drip can cause an acute or sub-acute and chronic cough, usually diagnosed with a physical exam and rarely using an endoscope or X-rays [1]. This article is based on three cases managed differently and literature review added value to the management at primary care level and cases that need to be referred to a specialist

Pavan Acute PNDC
Pavan, a 37-year-old adult had a common cold from 1 December 2024. The key symptoms were sneezing only for the first 2 days followed cough. During common cold attacks he usually has a running nose that is managed by antihistamines and decongestants. He commonly uses Recofast Plus Tablet (a Prescription drug - a combination of Paracetamol-500 mg + Phenylephrine-10 mg + Triprolidine-2mg 2-3 times a day) for about 5 days. He had to travel to Delhi from 3-6 December and the air pollution coupled with cold climate worsened his cough. He did not have fever but was fatigued & had sleepless nights due to PNDC. Throughout his stay in Delhi, he was on Rico fast Plus. On return to Bengaluru, he was asked to inhale steam 3-4 times, that relieved him of his cough by 10th day.
Veena Chronic PNDC
Veena aged 65 years, a normal resident of Gulbarga with hot climate, went for Kashi Vishwanath and Ayodhya Ram Mandir pilgrimage for 8 days from 3 December with her friends. Three of her friends had a common cold due to pollution and cold temperatures. On her return on 12th December, she had developed a very bad acute cough mainly due to postnasal drip cough. Standard management with steam inhalation and antihistamines had mixed results. The nasal drip was bad on alternate days and needed steam inhalation 2-3 times in the nights too as it was disturbing her sleep. Even after 3 weeks now, she is not relieved of PNDC and may need an Otorhinolaryngologist consultation. Being an elderly patient, she experienced anxiety & depression for the past 2 weeks. Poor sleep quality and loss of work productivity were also observed.
Syncope from intractable cough caused by postnasal drip
A 47-year-old male presented to the emergency department of a government medical college with a complain of episodic loss of consciousness following bouts of cough for two days. The cough had started ten days prior to the presentation. The fainting episodes occurred after a few seconds up to three minutes following the cough. He had no fever or shortness of breath but complained of nasal congestion and discharge. He had a history of diabetes mellitus and hypertension. He was on oral antidiabetic, antidyslipidemic, and anti-hypertensive and aspirin (75mg) but not any medication known to cause the cough. On examination, he was conscious, oriented, and alert. During examination, he had an episode of syncope for seconds following cough.  On examination his vital signs were all within normal limits with no postural drop in blood pressure or resting tachycardia. Investigations to evaluate syncope included brain CT scan and magnetic resonance imaging (MRI), electroencephalogram (EEG), echo-Doppler of the carotid arteries, electrocardiogram (ECG), 24-hour Holter monitoring, 24-hour blood pressure monitor, and Doppler echocardiogram were all normal. A detailed ear, nose, and throat examination with flexible Nas laryngoscopy was unremarkable. Postnasal drip was treated aggressively by the ear, nose, and throat team with antihistamines, steam inhalation every 3 hrs. from a boiling water in a saucepan, using a humidifier to add moisture to the air and rinsing nasal passages with a squeeze bottle. The pulmonary specialists team suspected the most likely cause to be postnasal drip. tried several anti-coughing medications like codeine, dextromethorphan, cloprednol, and levodropropizine, with no improvement. Then the patient was put on Gabapentin 300 mg daily, to which he responded well, and his cough episodes decreased in number until they disappeared completely over a week’s time. 

Normal Nasal Secretion: Human nasal passages are supposed to be moist, for which our nose and sinuses produce about a liter of moisture each day. Mucus is designed to act as lubricant and wash away dust particles, fur, smoke, bacteria and other contaminants, to the back of the nose and into the throat by the cilia.  Once at the throat it is swallowed unconsciously and ends up in the stomach where it is destroyed by gastric acids. 
Annoying Thin Secretions: Constant, overly abundant thin secretions can be a sign of allergic rhinitis or a common cold. They cause us to blow our nose or swallow and upset our stomach. Mucus gathers in the throat or drips from the back of our nose to make us conscious of its irritation & swallowing. Excessive thin secretions for more than seven to 10 days are signs of allergies. Thin postnasal drip may also cause a deviated septum, which an ENT specialist will be able to diagnose. 
Thick Nasal Secretions: The radiant heating systems we use to stay warm during the winter forces dryer than normal, which causes progressive thick nasal secretions. Thicker secretions are harder to swallow and lead to soreness in the throat. If a humidifier is used with the air the moisture keeps nasal secretions thin and will minimize nosebleeds caused by dry air. If our thick nasal secretions are green or yellow, it can be a sign of an infection or even sinusitis. Continued sinusitis leads to pressure headaches and only an antrum wash can help. 
Family Physician’s Approach to Postnasal Drip Syndrome (Cough)
Postnasal drip syndrome (PNDS) is characterized by recurrent secretions from the nose and the paranasal sinuses into the pharynx [1,6]. It is diagnosed clinically relying on patients’ descriptions of i) sensation in their throats, due to constant secretions into the throat and ii) recurrent urge to clear the throat and the nose [6]. Therefore, one can say that the diagnosis of PNDS a subjective diagnosis, as there are no specific nor objective methods to diagnose. The use of nasal endoscopy used by some Otorhinolaryngologists helps in spotting rhinitis and mucopurulent secretions but cannot be diagnostic. It is important to treat this condition even if the primary care physician is unable to find the underlying cause. Empirical therapy is the solution for it not only relieves the symptoms but also confirms the diagnosis. However, family physicians must be alert about red flags and refractory cases to different empirical treatment plans, which are to be referred for a thorough evaluation to an ENT specialist. 
Acute Cough (AC): A cough is considered acute if it lasts less than three weeks. The prevalence of acute cough in India is between 5% and 10%. On average, an adult in India has three episodes of cough per year, while a child has 7–10 episodes. The most common causes of acute cough are upper respiratory tract infections (URTI) and acute bronchitis (AB), both together account for more than 60% of diagnosed cases. In winter months majority of the Indian population experience acute cough, of which two thirds (65%) have a dry cough, 24% a productive cough, and 3% have a bronchospastic cough. Common cold, seasonal allergies, postnasal drip syndrome (PNDS), hay fever, upper respiratory tract infection (URTI), CRDs (cardiorespiratory disorders), exacerbation of asthma or chronic obstructive pulmonary disease (COPD) are responsible for Acute cough in India [3]. Postnasal drip cough (PNDC) is the commonest health problem in winter, due to allergies, Comm cold viruses including rhinovirus, Parainfluenza viruses, Adenoviruses, Enteroviruses, & Human metapneumovirus, flu, Bacterial infections, hormonal changes, Vasomotor rhinitis, certain foods, & medications and Gastroesophageal reflux (GERD). 
Acute cough is the second most common symptom with which patients report, accounting for about 1/3 of total cases seen by primary physicians & hardly 1/3 of them are diagnosed conclusively. Annoying postnasal drip cough or allergic Rhinitis are the common reasons patients complain to their family doctor after trying known family medicines. Family doctors provide experience-based therapy without a confirmed diagnosis in three fourths of cases. 
Vicks VapoRub Steam Inhalation (by putting 1-2 ml in boiling water) is the commonest recommended remedy in India. Alternately 2 drops Vicks Vaporous dissolved slowly in the mouth is also effective in stopping constant coughing. Vicks VapoRub contains 2.6% menthol which interacts with cold receptors in the nose and throat and stops coughing. 
Empiric therapy usually starts with prescribing a first-generation antihistaminic drug and a decongestant. If the cough is improved or resolved completely, the antihistaminic medication must be continued for a few days to weeks [6]. If the antihistamine does not show any improvement, sinus imaging must be done to exclude sinusitis. Sinusitis is treated with appropriate antibiotics, intranasal steroids, and/or decongestants. 
If some cases are refractory to medicinal therapy, referral for sinus evaluation by computed tomography imaging followed by endoscopic sinus surgery which is the treatment of choice in cases of allergic fungal sinusitis to remove the congested mucus with fungal elements [6].
Chronic Cough (CC):  A chronic cough lasts more than eight weeks, and its prevalence in India is less than 5%, as compared to 9.6% globally. CC is mainly attributable to smoking, exposure to dust, use of biomass fuel and chronic diseases like Tuberculosis, Chronic obstructive pulmonary disease (COPD), asthma, and bronchiectasis, rhinosinusitis, gastroesophageal reflux syndrome (GERD), postnasal drip syndrome (PNDS). A chronic cough has a significant impact on quality of life, causing loss of sleep, exhaustion, irritability, etc. Chronic, constant postnasal drip (CCPNDC) cough is not normal, but a symptom of a problem & must be treated by an ear, nose and throat specialist (ENT).
A study {the Burden of Obstructive Lung Disease (BOLD)}, to estimate the prevalence of chronic cough across 41 sites of 34 countries, a cross-sectional data from about 34,000 adults aged ≥40 years, two decades ago (between Jan 2, 2003, and Dec 26, 2016 reported prevalence of chronic cough from 3% in India (rural Pune) compared to 24% in the United States of America (Lexington, KY). The most influential risk factors were current smoking and working in a dusty job. Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, or with a history of tuberculosis, those who were obese, hypertensive, or airflow limitation and had low level of education. 
Surgical Treatment (Antral Wash out) for Postnasal Drip
Deviated nasal septum and Sinusitis are the common causes of PNDC, which are managed by an ENT specialist. They do a nasal endoscopy and look inside the nasal cavity and the openings of the sinuses and may order an X-ray.  In cases where a deviated septum causes postnasal drip, septoplasty (surgery to straighten the septum), leads to better airflow and a permanent solution to postnasal drip. Similarly, Antral washout is performed for persistent infection of the maxillary sinus. This is a procedure that flushes out infected mucus, debris, and other obstructions from the sinuses and restores normal ciliary function. It involves making a small puncture on the wall of the maxillary sinus that separates it from the nose, through which a small cannula is pushed into the maxillary sinus and through which the sinus cavity is irrigated with normal Saline. Saline irrigation helps in a variety of sinus conditions, like sinusitis, allergies, colds, and the flu by clearing out mucus, moistening nasal passages, removing allergens, thin out mucus so it can be expelled easily, reduce congestion & relieving pressure pain and headache, also improves breathing [11].
Exclusion of smoking-related pulmonary diseases or chronic ACE inhibitors use is important because they are potential cough causes. Chest radiography must be done to exclude lung disease. Nearly 25% of chronic cough patients have cough variant asthma. Therefore, spirometry must be done though some asthmatic patients may have normal spirometry results. Therefore, initiating an empirical therapy for asthma-like starting the use of inhaled bronchodilators or inhaled corticosteroids. Improvement of the cough and the associated symptoms confirms the diagnosis of cough variant asthma.  
Moreover, 10% of chronic cough patients have been shown to have GERD disease as the precipitating factor. Patients with typical GERD symptoms, such as heartburn and regurgitation, must be treated.  The reflux may directly irritate the laryngopharyngeal mucosa with the possibility of direct exposure of the upper airway to the gastric acid. Naso-pharyngo-laryngoscopy is necessary to evaluate this chronic cough. GERD treatment involves acid-suppressive medications like PPIs for 3 months alongside lifestyle modification [6]
Allergic Rhinitis Care
Allergic rhinitis (AR) is an atopic condition characterized by symptoms such as sneezing, nasal congestion, clear rhinorrhea, and nasal pruritic. It involves an immune response mediated by Ige antibodies, triggered by inhaled antigens, which initiates an immediate phase reaction followed by a leukotriene-mediated late phase response. In India, common allergens that trigger AR include mosquitoes, cockroaches, houseflies, and certain types of pollen, animals, and fungi. Skin prick tests are preferred to identify allergens as they directly assess mast cell reactions and provide more reliable results. Medical management using oral and topical antihistamines, corticosteroids, and leukotriene receptor antagonists is practiced for mild cases.  Allergen identification and immunotherapy are considered for more severe cases, as recognizing each patient's unique immune response and addressing specific needs leads to more effective and long-lasting solutions. A holistic approach involves accurate diagnosis, patient education, allergen avoidance, and personalized treatment plans [6]. 
Skin prick testing involves marking specific areas on the patient's hand or back, applying a drop of allergen, and observing skin reactions. Histamine acts as a positive control, and saline serves as a negative control. Patients must avoid antihistamines or similar medications for 72 hours prior to testing. Intradermal testing, involving allergen injections into the skin, is less commonly used due to higher risks of side effects. 
Blood tests, such as the radioallergosorbent test (RAST), detect serum IgE antibodies to specific allergens are done, but are feared to yield false positives, are more costly and time-consuming compared to skin prick testing. IgE testing is preferred when patients cannot discontinue medications that may interfere with skin testing. 
Occasionally needed diagnostic strategies are serum Ig levels measurement to exclude hypogammaglobulinemia, skin test for allergies, and exclusion of potential allergens that can be present in the patient’s surrounding environment.
First-line therapy for allergic rhinitis: Intranasal corticosteroid sprays are the recommended first-line therapy for rhinitis as per the International Consensus Statement on Allergy and Rhinology (ICSAR). They have a negative impact on short-term growth in children and can cause local adverse effects, but there is no evidence of negative effects on the hypothalamic-pituitary axis. The Joint Task Force Practice Parameters (JTFPP), the 2024 guidelines for the treatment of persistent allergic rhinitis, also recommend intranasal corticosteroids [6].
Duration of Oral Corticosteroids: According to the JTFPP, a 5- to 7-day course of oral corticosteroids can be prescribed for very severe or intractable allergic rhinitis. However, oral corticosteroids suppress the hypothalamic-pituitary axis, and prolonged use leads to growth defects in pediatric populations. Parenteral corticosteroids are considered an attractive option because a single administration lasts 3 weeks [6]. 
Allergen immunotherapy lasts three years and is recommended for patients with positive skin prick test results, when allergens cannot be avoided or have significant allergen exposure, uncontrolled symptoms, and a desire for a permanent solution. It offers a disease-modifying treatment by modifying the immune response, shifting from a Th2 to a Th1 pathway, and increasing the production of regulatory IgG antibodies. Immunotherapy, administered sublingually (SLIT) or subcutaneously (SCIT), reduces allergic reactions and new sensitizations. SCIT is more efficient but requires medical supervision due to potential allergic reactions. However, combining immunotherapy with proper avoidance measures yields better treatment outcomes.
Indian Consensus on the Management of Cough at Primary care setting
A panel comprising of 10 experts, including pulmonologists, otolaryngologists, a pediatrician, and a general physician, provided clinical recommendations to diagnose and manage cough in primary healthcare in India. The experts recommended i) empiric use of nonopioid antitussive agents for symptomatic relief of acute dry cough ii) use of oral antihistamines, oral decongestants, or mucoactive agents as a part of fixed-dose combinations in cough associated with rhinitis or upper airway cough syndrome (UACS) iii) maintaining good hydration is important to manage a productive cough iv) Codeine-based preparations are a last resort in patients with an unexplained chronic cough when other treatments have failed. Experts have proposed a management algorithm with an integrated care pathway approach for acute, subacute, & chronic coughs and red flag signs-based referral to higher centers [2].
Recommended initial treatment option for nonallergic rhinitis: Intranasal antihistamines are the recommended initial treatment option for nonallergic rhinitis and first-line monotherapy for seasonal and intermittent allergic rhinitis. Studies have shown that intranasal antihistamines are at least as effective as oral antihistamines, with some even showing they are superior, Azelastine specifically is more effective in nonallergic rhinitis [6].
Intranasal decongestants: JTFPP guidelines recommend intranasal decongestants for allergic rhinitis for up to 5 days only during acute flare phase in cases of severe mucosal edema, which can impair the delivery of other intranasal agents. Oral decongestants use is discouraged or asked with to use with caution for symptomatic management [6].
Combination therapy for rhinitis is most accurate: When monotherapy fails, the ICSAR recommends combining intranasal corticosteroids and antihistamines for patients with allergic rhinitis. For those taking oral antihistamines, oral decongestants can also be added during acute flares. Although first- and second-generation antihistamines can be used together, JTFPP guidelines recommends against first-generation antihistamines [6].

Postnasal drip is a common symptom of many respiratory and cold viruses. With more than 200 cold viruses, it is difficult to prevent catching a cold. Postnasal drip is a common symptom of allergies, nasal irritants, and bacterial and viral infections that causes our nose to increase mucus production. Postnasal drip causes symptoms, like a sore throat, hoarse voice, lingering cough, and bad breath if there are bacterial infections. Preventive strategies like hand and cough hygiene, preventing seasonal and other allergies, including indoor allergens, by reducing our triggers
Consult a doctor if postnasal drip smells bad or have a fever or start wheezing / symptoms are severe or last for 10 days or more.

PNDC: Postnasal Drip Cough; Pachacuti cough; SAC: Sub-acute Cough; CC: Chronic Cough, Phlegm or Mucus; URTI:  Upper Respiratory Tract Infections; COPD: Chronic obstructive pulmonary disease; OLD:  Obstructive Lung Disease; GERD: Gastroesophageal reflux; ENT Specialist (Otorhinolaryngologist): Ear, Nose, Throat Specialists, Family Physician, Primary Care doctor; CT scan, MRI:  magnetic resonance imaging; EEG: electroencephalogram;  ECG: Electrocardiogram, Echo-Doppler of the carotid arteries, Antihistamines, Oral Decongestants containing oxymetazoline, Tab. Reco fast Plus, OTC corticosteroid nasal sprays like beclomethasone and ipratropium (Atrovent), Tab. Gabapentin 300 mg.