Clinical and laryngeal characteristics of refractory chronic cough

Refractory chronic cough (RCC) is increasingly recognised within the cough hypersensitivity framework, involving overlapping laryngeal, sensory and behavioural mechanisms. However, its clinical manifestations remain incompletely characterised. We compared clinical and laryngeal features of RCC with non-refractory chronic cough (CC), and examined factors associated with clinically meaningful improvement within RCC. This prospective observational cohort included adults evaluated in a tertiary multidisciplinary cough clinic between May 2022 and April 2026. Following structured assessment and management of relevant treatable traits, patients were classified as CC or RCC according to their diagnostic and treatment course. Baseline demographics, patient-reported outcomes, laryngeal examination and videostroboscopy findings were compared. For secondary analysis, improvement in the RCC cohort was defined by achievement of the minimal clinically important difference (MCID) in Leicester Cough Questionnaire (LCQ) total score at any follow-up visit compared with baseline. Among 149 patients, 38 had CC and 111 had RCC. RCC patients had lower baseline LCQ and Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) irritation scores, higher prevalence of positive superior laryngeal nerve trigger points and abnormal videostroboscopic examinations. Lower LHQ irritation score remained independently associated with RCC (adjusted OR 0.71, 95% CI 0.52–0.97, p=0.03). Eighty (72.1%) RCC patients achieved MCID during follow-up. Lower baseline LCQ total score remained independently associated with MCID achievement (adjusted OR 0.83, 95% CI 0.72–0.96, p=0.02). Patients with RCC demonstrated greater symptom burden and more prominent laryngeal-associated features than patients with CC, providing real-world clinical characterisation of laryngeal involvement in refractory disease.