Chronic cough in Swiss bagpipe player

Introduction

A 34-year-old man presented to our GI clinic with chronic cough. Coughing episodes exacerbated on days of bagpipe playing and the morning after. Methacholine testing revealed airway hyperreactivity. Allergic bronchopulmonary aspergillosis could be excluded; CT scan of the chest was without pathological findings. Also bronchoscopy with bronchoalveolar lavage (BAL) and mucosal biopsy failed to reveal a pulmonary aetiology of the cough. Minor findings in BAL were an elevated number of macrophages and bacteria representative of the oral flora. A trial with inhalative budesonide and formoterol and consecutively 8 weeks of proton pump inhibitor treatment were started, but only led to inadequate reduction of symptoms. The patient was then referred to us, where we performed high-resolution oesophageal manometry (HRM) and 24-hour multichannel intraluminal impedance-pH (24h-MII-pH) testing after unremarkable upper endoscopy.

Questions

What do you expect to see on HRM and 24h-MII-pH? Which additional diagnostic testing could be useful? What is this patient's...

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