Chronic Cough in Musculoskeletal disorders: Using high resolution oesophageal manometry in search of an Aetiology

Chronic cough is one of the most commonly reported medical symptom with 12% of the population reporting symptoms daily or weekly [1]. It may be associated with significant morbidity. The differential diagnosis of chronic cough is extensive and rare causes may be overlooked without a perceptive history and examination coupled to appropriate investigations. Reports suggest that up to two thirds of patients with chronic cough have oesophageal dysmotility [2]. Here we describe two patients with chronic cough and musculo-skeletal disease from our tertiary cough clinic in whom the clinical suspicion of oesophageal dysmotility was confirmed by high resolution manometry.A 52-year old woman presented with a 2-year history of cough, often exacerbated by singing. This was associated with a hoarse voice and intermittent wheeziness. She was an ex-smoker, having stopped 18？months previously, with less than 10-pack years of smoking.She had a background medical history of dermatomyositis diagnosed in 2008 managed with methotrexate. Eight months following her initial diagnosis, she had developed heartburn. At her local clinic, her chest x-ray, routine blood tests, and spirometry were within the normal range. For her cough she was initiated on inhaled, budesonide and salbutamol, with no benefit.Physical examination was unremarkable and she had a score of 13 on the Hull Airways Reflux Questionnaire (HARQ) (normal range <13) [3].We arranged for her to have a full oesophageal assessment as well as a cough challenge. High resolution oesophageal studies (Solar GI HRM, Medical Measurement Systems, Enchede, Netherlands) showed partial lower oesophageal sphincter (LOS) relaxation in co-ordination with the upper oesophageal sphincter (UOS), with only 50% of her wet swallows being effective (normal range >90%) (Figure？1). Her mean LOS was 26？mmHg (Normal 15-30？mmHg) while her UOS pressure was 129？mmHg (Normal 34–104？mmHg). A focal area of oesophageal dysmotility was noted at 20？cm from the nos