Stumped by chronic cough

[MountainReader]

I'm a 39 year old non-smoking female who is about 20 lbs overweight.  I've been stuck in a chronic coughing cycle for years that I can't seem to get to the bottom of.  I coughed for 4 months straight last winter and I'm now 9 weeks into another coughing flare.  Most of the time when the coughing sets in, it is usually in 4 month increments.  I'm not sure where I should be looking for help next.  I've been to one doctor or another every week or two with no real answer. Here is what I know:

*I do have asthma with a cough as my symptom.  Right now, my lungs sound good.  I've been on a couple rounds of Prednisone tapers with no real difference.  I'm on Singular, Advair 250/50 or 500/50 and Albuterol as an inhaler and nebulizer.  I'm also 4 months into Xolair treatment.  My typical asthma triggers are:  cold air, polluted air/mountain valley inversions and chemical/smoke exposures.  While there have been some moderate air quality days this summer, most days have remained in the good air quality range.
*I have allergies.  I'm 3 years into my second go-round of immunotherapy for 28 allergens that appears to be working well.  This summer, I've had little if any congestion and no apparent PND.  I take Allegra and Nasacort currently.  I use Sudafed as needed.
*I have a history of acid reflux.  I had a laproscopic Nissen Fundoplication in 2008 because the acid was irritating my lungs.  The surgery successful and my breathing immediately improved.  I had a Barium Swallow last spring that showed no evidence of any refluxing.  I have also never gone off of the PPI's.  I'm currently on Dexilant 60mg.  I have slept on an incline for years.  I have had no other symptoms of refluxing.  I've also been taking Pepcid at night "just in case".  I'm scheduled for an EGD, but my Gastroenterologist doesn't anticipate finding anything.  I haven't had any pH testing since my fundoplication.
*I had a chest x-ray that showed maybe something was there, but a chest CT came back normal last week.
*I tested negative for TB.
*The constant coughing is really wearing me out.  I'm breathing OK between coughing fits, but the fits last a while.  Sometimes the coughing squeezes my stomach so much that I end up bringing up some food.  I've pulled stomach muscles and tweaked my back coughing.  I've also developed incontinence with the coughs as well.
*I've recently developed Anemia and started on Ferrous Sulfate.  I'm not sure if it is impacting my current coughing jag or not.  I've tested normal on my yearly blood work so I don't think it was a problem with regards to my coughing in the past.
*I've been treated for high blood pressure for about 8 years.  I currently have it under control with Dyazide.  I went off of low-dose Norvasc over a year ago.
*I had 2 pulse-ox overnight tests last year.  One came back normal and the other with 14 incidents during the night.  I haven't been able to afford a Polysomnigram yet.  I do have TMJ and my night orthotic has a post that keeps my lower jaw in a forward position when I sleep similar to some sleep apnea orthotics so I'm already receiving some "treatment" if I do have a sleep problem.
*Pulmonary Function Testing I had last April came back normal.
*I had possible Pertussis about 5 years ago (2 tests came back inconclusive) and this doesn't feel the same.
*I've been on Amoxocillin, Avelox and Doxycycline this summer in case there is an underlying infection and haven't seen any changes afterwards.

I've been to several primary care physicians, a Gastroenterologist, an ENT/Allergist and a Pulmonologist regularly for the last several years.  At this point, I'm not sure where I should be looking for answers anymore.  This chronic cough really is impacting my quality of life and as the weeks go on, it becomes harder and harder to focus all day during work. While I do have health insurance, I work in a social service field so money is an issue for me in terms of the options I have for seeking care as well.  Any suggestions for where I should look for answers or what kinds of questions I should ask would be greatly appreciated.

[MountainReader]

Thanks for the quick and detailed response.  I was treated with PPI's twice per day for about 5 years before switching to the dual delay release Dexilant/Kapidex after my surgery.   I tried all of the PPI's on the market as my symptoms got worse.  I had the Nissen Fundoplication 2 years ago that improved my symptoms immediately.  I've had no other acid symptoms since.  I'll find out in a couple weeks if the EGD shows anything.  My Barium Swallow showed the fundoplication was still intact.  I guess a repeat pH test may be in order.

I had a scope by my ENT a couple months ago and he didn't see any LPR indications remaining.  Said things looked good.

The diet recommendation is good.  Even after the fundoplication, I have continued to follow it fairly strictly.

If it is reflux, I have no idea what other treatment options might be available to me.

[caregiver222]

There is a strong possibility you have Laranghopharangeal reflux disorder, which can be difficult to diagnose. There is no "gold Standard" for diagnosis, however you have textbook symptoms. This disorder involves the retrograde movement of  gastric content into the upper aerodigestive tract. The pathophysiology is poorly understood.

It can be a cause of asthma.

It can co-exist with GERD, but is a distinct disorder.

When the physiological barriers protecting the laryangopharanx from the retrograde flow of gastric contents break down, the gastric contents directly irritate the ciliated columnar epithelial cells of the upper respiratory tract, leading to ciliary dysfunction. This leads to the sensation of post nasal drip.

The laryngopharangeal epitheleum becomes inflamed, and this in turn leads to chronic cough - and often a sense of a "foreign body in the throat".

Your physicians seem to be on the wrong train on the wrong track headed to Alaska.

Curiously melatonin has proved effective in treatment, along with dietary restrictions and medication.

Acid suppression with proton-pump inhibiters  (PPI's) remain the mainstay of treatment, but the length and efficacy of this protocol is controversial.  A recommendation of twice daily for at least two months is common.

Drug therapy is starightforward, but not without controversy. Some physicians prescribe ranitidine 300 mg twice a day.

Avoid caffeine, alcohol, spicey foods, tomatos, chocolate, citrus fruits and acidic fruits, carbonated beverages, jams, jellies,  barbecue sauces, salad dressings,, hot mustard and curry. Wow. That list sort of takes the fun out of life.

The layrnx is extremely susceptable to injury from acid reflux, and LPR typically requires more prolonged and agressive treatment than GERDS.

Fiberoptic larangyoscopy is the most common test by otolaryngologists (the specialist you need for an evaluation) to confirm LPR.

Don't eat too rapidly or drink large quantitites of fluid. Eating within three hours of bedtime should be avoided. Eat small, frequent meals.

Avoid tight clothing, heavy lifting, lying down immediately after meals, heavy exercise, and avoid applying pressure to the abdoman, either by lifting, singing, or screaming at a concert. Weight loss also helps.

When medical management fails a surgical option called a Nissen fundoplication is sometimes considered.