Flexible Laryngoscopy in Unexplained Cough: Institutional Outcomes and Community Practice Patterns

BackgroundFlexible laryngoscopy is routinely performed by otolaryngologists for unexplained chronic cough.The objectives were twofold: first, to ascertain institutional outcomes and, second, to understand community provider practice patterns to further inform its role in evaluation. MethodologyThis retrospective case series and cross-sectional survey was conducted at a single tertiary-care academic institution (2018-2024) and a regional otolaryngology continuing medical education conference (February 2025).For the retrospective case series, the study included adult patients seen at the University of Arizona's tertiary laryngology center for unexplained chronic cough from 2018 to 2024.Patients met the inclusion criteria if cough persisted for >8 weeks and they either had not responded to prior proton pump inhibitor (PPI) and asthma therapy or had gastroesophageal reflux disease and asthma ruled out by specialists.The senior author routinely performed flexible laryngoscopy for all patients presenting with unexplained chronic cough.Normal and abnormal laryngeal findings in this retrospective study simply referred to the presence or absence of a mass, ulceration, or paralysis.For the cross-sectional survey, optional anonymous paper surveys were distributed to otolaryngology providers attending a regional otolaryngology continuing medical education conference in Tucson, Arizona, in February 2025. ResultsIn our retrospective case series, 53 of 56 (94.6%) patients had normal laryngoscopic exams in their initial evaluation for unexplained chronic cough.Three (5.4%) patients had abnormalities on laryngoscopy, which included paradoxical vocal fold movement (3.6%, N = 2) and known vocal fold paralysis (1.8%, N = 1).Within our cross-sectional survey of 55 providers, 43 (78.2%) reported frequently performing laryngoscopy.Half of providers (49.1%,N = 27) indicated that findings rarely changed treatment.Common laryngoscopy findings included arytenoid erythema/edema (54.5%, N = 30) or normal exams (41.8%,N = 23).PPIs were the most frequent first-line therapy initiated (69.1%,N = 38). ConclusionsIn this single-institution small case series, laryngoscopy findings in unexplained chronic cough were predominantly normal or benign, with no malignancies identified.These findings suggest that patients with unexplained chronic cough that significant laryngeal pathology may be uncommon, while still supporting the importance of direct visualization before diagnosing unexplained cough.In this limited cross-sectional survey, flexible laryngoscopy was not universally adopted among community providers, highlighting variability in the evaluation for chronic cough.Empiric PPI therapy remains frequently prescribed despite guideline recommendations favoring neuromodulators and cough suppression therapy.