Should chronic catarrh patients seen in primary care be referred for further investigations?

Abstract

Background: Chronic catarrh is commonly encountered in primary care, but often presents a quandary to the clinician because the history of postnasal or pharyngeal mucus build-up is frequently at odds with the absence of physical findings. As with certain other medically mysterious syndromes, the value of often costly investigation remains unclear in both the primary and the secondary care settings. Indeed, investigation may reassure the physician more than the patient (1) and could even prove counter-productive through reinforcement of the patient's belief about the presence of significant pathology (2). Aim: To establish the benefit of referral of chronic catarrh patients for specialist investigation. Design: A cross-sectional survey. Setting: A total of 138 patients referred to secondary care with chronic catarrh, postnasal drip or throat clearing in the north of England. Methods: Subjects completed three disease-specific symptom-scoring questionnaires (RSI, SNOT-20 and GETS). Investigations performed were saccharin clearance time, nasendoscopy, skinprick allergy testing and CT of sinuses. Results were compared with published values. Results: Catarrh patients scored highly on all three symptom questionnaires. Nasendoscopy was normal in 70% of patients, with the remainder demonstrating mostly simple mucus (20%), lymphoid tissue (6%) or mucopus (2%). Only 6 of the 136 patients tested had a prolonged saccharin clearance time greater than 30 min. The mean score of the 63 sinus CT scans obtained was 2.6 (normal range = 0-5). Of patients undergoing skinprick testing (n = 45), 30% reacted to one or more inhaled allergen. No rhinological investigation yielded results above that expected in the general population. Conclusion: Chronic catarrh appears to be related more to pharyngeal symptom awareness than to pathological postnasal drip or mucus over-production. Rhinological investigations have a limited role in the management of chronic catarrh patients. The principal outcome of ENT referral is likely to be reassurance and direction towards patient self-help information. © 2011 Blackwell Publishing Ltd.