Clinical Diagnosis of Sensory Neuropathic Cough (SNC) via Syndrome-Matching

Background

Bastian Voice Institute (BVI) has long specialized in disorders of voice, swallowing, and airway. Over time, our scope expanded to include patients with chronic, unremitting cough—most often due to Sensory Neuropathic Cough (SNC), a condition first delineated fully for clinical process by Dr. Robert Bastian.

Recognition of SNC

SNC is a syndrome: diagnosis is established via characteristic history above all else, including at least 1 failed prior treatments, and/or exclusion of other conditions. Its recognition has grown through peer-reviewed publications, teaching at the American Academy of Otolaryngology, and educational outreach here on Laryngopedia.com.

Diagnostic Process (Four Steps)

1. Syndromic Criteria

   • Identify the sensory disturbance: stereotyped laryngeal or pharyngeal sensation (tickle, “dry patch,” pinprick, itch, “bubble”).
   • Trigger phenomena: While many episodes are spontaneous, some of the following may make coughing more likely: talking, singing, laughter, temperature shifts, positional change, strong odors, swallowing, light tactile pressure.
   • Episode description: from single cough to prolonged paroxysms; may or may not impact sleep; chronicity (often unremitting for years).
   • Consequences, often but not always: rhinorrhea, retching, emesis, urinary leakage, and occasionally, subconjunctival hemorrhage, rib fracture.
   • Optional: Because of prior workups elsewhere that we would not have done…exclusion of “usual suspects”: history of multiple failed empiric trials (asthma, reflux, allergy), and normal diagnostic studies (CT, PFTs, bronchoscopy, esophagoscopy, CXR).

2. Endoscopic Examination

   • Single office videoendoscopic assessment of the laryngopharynx, documenting normal anatomy, lack of lesions or inflammation. Sometimes subtle neurological signs are seen such as asynchronous vocal cord movements, quivering, etc.

3. Education that Facilitates True “Partnership” with the Patient

   • Structured teaching session (video-based, reinforced verbally). Essential to undergird what can be a multi-step process with different medications, using telemedicine for patient convenience.

4. Therapeutic Trial & Monitoring

   • Stepwise medication trials (amitriptyline, gabapentin, and several others).
   • Symptomatic reduction validates the diagnosis.
   • Follow-up conducted efficiently via Zoom, encrypted email or voicemail, for patient convenience.

Clinical Pearls

• Patients who struggle most: “high fact-finders,” those hesitant about pharmacotherapy, or those discouraged and even jaded by prior medical failures.
• With careful patient education and persistence, most achieve substantial reduction or resolution of symptoms.

👉 Key Message: If you’ve had a chronic cough for years, with each episode starting with a sudden “zing” of some sort, and with no answers despite many tests and treatments, you may have Sensory Neuropathic Cough.