|Ahead of print publication
Otorhinolaryngological manifestations in pregnant women
Santosh Kumar Swain1, Tapan Pattnaik2
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to Be), Bhubaneswar, Odisha, India
2 Department of Obstetrics and Gynaecology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to Be), Bhubaneswar, Odisha, India
|Date of Submission||17-Dec-2019|
|Date of Decision||23-Dec-2019|
|Date of Acceptance||03-Mar-2020|
Santosh Kumar Swain,
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University(Deemed to be), Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
There are several physiological changes in the body of the pregnant women. Otological, rhinological, and laryngological changes are quite often seen in pregnancy. Most of the otorhinolaryngological manifestations during pregnancy are benign and reverse during the postpartum period and few do not. These changes in pregnancy are mainly due to alteration of the sex hormones in the female body which returns to a normal level once the pregnancy period over. There should be clear understanding between the otolaryngologists and obstetrician for improving the quality of life of the pregnant women by avoiding the drugs for controlling otorhinolaryngological symptoms, especially in the first trimester. It is important to have clinical knowledge in all clinicians regarding the manifestation of otorhinolaryngological manifestations and treatment options with precautions considering effects on the mother and fetus during pregnancy. Here, this review article discusses the alteration in body physiology, clinical manifestations, and current treatment practice of the ear, nose, and throat manifestations during pregnancy. Electronic search of the SCOPUS, Medline, and PubMed databases was done. The search items in the database included pregnancy, otorhinolaryngological manifestations, gravidarum, gestational epistaxis, gestational rhinitis, hearing loss, and vestibular manifestations in pregnancy. All literature was searched for and reviewed by two authors independently. Search results were then cross-examined, and any differences were settled by consensus.
Keywords: Hearing loss, otorhinolaryngological manifestations, pregnancy, rhinitis
| Introduction|| |
There is a considerable change in the body of pregnant women. Majority of the changes cause no harm to the mother and fetus, whereas few can lead to pathological manifestations. Any part of the body affected during pregnancy is due to hormonal and physiological changes in pregnant mother, and hence the ear, nose, and throat are no exception from such changes. There are myriad of otorhinolaryngological manifestations during pregnancy. In the women's body, pregnancy brings several physiological changes. There are certain clinical manifestations that occur in pregnant women in the head-and-neck region. The clinical manifestations include epistaxis, rhinitis, otological disorders, and voice changes. Majority of the otorhinolaryngological manifestations are benign and self-limiting. Although the majority of the symptoms are transient and minor, it is important that otorhinolaryngologists should find the potential to assess the symptoms, manage to this situation, and reassure the pregnant women. Proper understanding of the physiological and pathological manifestations in pregnant mother allows safe and acceptable management of the otorhinolaryngological manifestations in pregnant women. The aim and objective of this clinical review are to highlight the otorhinolaryngological manifestations in pregnancy. Here, the authors discuss the current otological, rhinological, laryngological, and other head-and-neck manifestations during pregnancy along with body physiological and hormonal changes. While it is appreciated that many of these symptoms are transient, their effect on the maternal quality of life can be significant and therefore, medical practitioners should be aware of what to expect to provide reassurance to pregnant women and also to safely manage such symptoms.
| Methodology|| |
For searching the published article, we conducted an electronic search of the SCOPUS, Medline, and PubMed databases. The search terms in the database included pregnancy, otorhinolaryngological manifestations, gravidarum, gestational epistaxis, gestational rhinitis, hearing loss, and vestibular manifestations in pregnancy. The abstracts of the published articles are identified by this methodology, and other articles were identified manually from this citation. All literature was searched for and reviewed by two authors independently. Search results were then cross-examined, and any differences were settled by consensus.
This review article reviews the otorhinolaryngological manifestations and its management. This review article presents a baseline from where further prospective trials can be designed and help as a spur for further research in this commonly encountered clinical entity where not more studies are done.
| Body Physiology and Hormonal Changes|| |
Human chorionic gonadotropin produced in the embryo and stimulates to produce progesterone levels which fall midway through luteal phase following ovulation. Progesterone levels, estrogen, and human placental lactogen increase at the end of first trimester. The effects of these hormones are important for growth of the fetus and these effects beyond the uterus and can alter the physiology of the pregnant women. Basal metabolic rate is increased during pregnancy period due to raised consumption of oxygen, expansion of blood volume, and raised cardiac output. There is 4L increase of total body water during pregnancy period. Plasma volume is increased during the first- and second-trimester, whereas extravascular fluid volume is increased in the third trimester. Increased fluids in the body make boggy mucus membrane and edema in the dependent extremity. In postpartum time, there is rapid decrease in plasma volume and slowly lowering of the interstitial fluid.
| Otological Manifestations|| |
Infection of the external auditory canal or otitis externa is more common during pregnancy because of the alteration of the skin of the external auditory canal due to hormonal influence which makes the environment prone to otitis externa.
Hearing loss and vertigo
Hearing loss and vertigo are two important clinical manifestations found during pregnancy period. Hearing loss occurs often due to otosclerosis, Eustachian dysfunction, and sudden sensorineural hearing loss. Vertigo is usually occurs due to aggravation of preexisting Meniere's disease.
Eustachian tube More Details dysfunction
The dysfunction of the Eustachian tube occurs due to mucosal edema which leads to obstruction and glue ear or otitis media with effusion. The clinical symptoms include feeling of blockage in the ear and reduced hearing of the pregnant female. This is often treated by oral decongestants or topical nasal decongestants. It is less often treated by the insertion of grommet or ventilation tube.
Sudden sensorineural hearing loss
Sudden sensorineural hearing loss is rarely seen during pregnancy period, but sometimes seen due to preeclampsia. Increased estrogen during pregnancy leads to hypercoagulobility and occlusion of the inner ear vessels and microcirculation. Viral etiology must be ruled out for sudden hearing loss. It is important to treat preeclampsia but not with anticoagulant. Corticosteroids can be given in the third trimester.
The clinical manifestations of otosclerosis are aggravated during pregnancy due to effect of the estrogen. The otosclerotic foci stimulated by the estrogen which leads to osteocytic activity and ossifies the otospongiotic lesions. The clinical manifestations are usually seen during near term or postpartum. If the patient face communication problem due to hearing loss, can be fitted with hearing aid during pregnancy. She can be advised for stapedectomy. Sodium fluoride is avoided during pregnancy period because of its known to hamper bone absorption while increasing calcification.
Inner ear pathology
The inner ear or the labyrinth has two important functions of the human being such as hearing and balance. Any injury to the inner ear causes difficulties in hearing and maintaining the body balance. The hormonal changes during pregnancy can result in alteration in the homeostasis of the inner ear fluids and disturb the otological functions. These alterations in the inner ear may present with symptoms such as vertigo, tinnitus, imbalance, fullness in the ear, hyperacusis, and algiacusis.
During pregnancy, the course of the Meniere's disease is poorly documented in the medical literature. Meniere's disease has been shown to be exacerbated in late luteal phase of the menstrual cycle, and hence, it may have some relation with hormonal changes which leads to fluid retention in the inner ear. Meniere's disease or endolymphatic hydrops is a disorder of the inner ear where endolymphatic system is distended by endolymph. It is characterized by vertigo, sensorineural hearing loss, and aural fullness. In acute attack of Meniere's disease, dimenhydrinate and meclizine can be safely given to the pregnant women. Histamines and diuretics are usually avoided in pregnancy for treating Meniere's disease as it cause hypotension, hypovolemia, and decrease the cardiac output. In case of intractable vomiting, metaclopromide can be used.
The inner ear is considered as an end organ and very susceptible to ischemia and immunological injuries. The cochlea depends on a single arterial supply from the posterior cerebral circulation, and hence, vascular occlusion is thought to be an important cause for hearing loss. In pregnancy, if preeclampsia is not detected or not treated in time, it leads to multi-organ failure, coagulopathy, and fetal and maternal death. This is due to endothelial damage of the vessels in preeclampsia which alter vascular reactivity, lack of vascular integrity, and stimulation of coagulation cascade. This pathophysiological changes leads to vasospasm, vasculopathy, inflammatory changes affects different end organs, and also inner ear. Since long, it has been known that inner ear or labyrinth communicates with immunological reaction and rapidly reacts to pathogens and foreign proteins to which it has been sensitized.
Facial nerve paralysis/Bell's palsy
The incidence of Bell's palsy or idiopathic facial palsy is higher during pregnancy period. There is 3.3 times chance of developing facial nerve palsy or Bell's palsy in pregnant women particularly during third trimester of pregnancy. There is increased chance of Bell's palsy due to edema of the facial nerve and perifacial area by increased interstitial fluid volume, which lead to compression of the nerve and ischemia inside the Fallopian canal More Details. There is another hypothesis is viral origin of facial nerve paralysis. The gestational immunosuppression is induced by raised cortisol levels in pregnancy leads to reactivation of the latent herpes simplex virus. A course of corticosteroids may be required for treating the Bell's palsy. However, the use of corticosteroids during pregnancy has high chance for cleft palate and adrenal hypofunction in newborn.
| Rhinological Manifestations|| |
The rhinological changes occur in pregnancy by affecting the nasal mucosa and nasal patency. The rhinological manifestations in pregnancy is due to estrogen-mediated cholinergic effect as it block acetylcholinesterase, causing vascular engorgement, and increased activity of the mucous glands.
Rhinitis in pregnancy affects the quality of life and most often creates discomforts along with morning sickness, running nose, and sneezing. Rhinitis in pregnancy causes inflamed nasal mucosa, congested, and irritated nasal cavity. Nasal congestion causes mouth breathing, which leads to dry mouth. Dry mouth is associated with decreased saliva secretion and causes caries teeth by disturbing dental protection system. Prolonged nasal congestion induces sinusitis. Rhinitis can be seen in any time during the pregnancy period and often seen in the first trimester and disappear within 2 weeks after delivery of the baby. It disrupts the sleep, hampers appetite and worsens bronchial asthma and sinusitis.
The symptoms of allergic rhinitis may worsen the situations during pregnancy. This may be due to increased cortisol and gestational immunosuppression. The important part of treatment is to identify the allergens and avoid it. Antihistamines such as chlorpheniramine, cetirizine, and loratadine can be used during pregnancy for the treatment of allergic rhinitis. Systemic corticosteroids are usually contraindicated during pregnancy for treating allergic rhinitis as their association with oral clefts. This association is seen only proven in first trimester of pregnancy, whereas some agree that systemic administration of steroids is also in the second and especially third trimester of pregnancy.
Nose bleed or epistaxis
Nose bleed may be seen during pregnancy and it is up to 20% of the pregnant female in comparison to 6% of the nonpregnant female. This is may be due to high vascularity in the nasal mucosa as result of hormonal changes in the body. There are several case reports regarding gravid granuloma and hemangiomas in the nasal cavity during pregnancy leading to the epistaxis.,
Nasal granuloma gravidarum (synonyms- pregnancy granuloma, pregnancy polyp, and teleangiectatic polyp)
It is a rapidly growing benign tumor which cause nasal block and recurrent nose bleed. Its histology is similar to pyogenic granuloma. This lesion appears as well-vascularized mass and bleeds on touch [Figure 1].
The smell sensation is increased during pregnancy due to raised estradiol level and there occurs swelling of the olfactory membrane.
The ciliary motility in the nasal cavity is decreased, so makes the pregnant women prone for recurrent sinusitis.
| Laryngological Manifestations|| |
It is also called as laryngopathia gravidarum. The voice quality of the human being is highly sensitive to hormonal changes of the pregnancy. Defect in the quality of the voice or dysphonia is a common clinical symptom seen among pregnant women. There is an alteration of the fluid content in the lamina propria of the vocal fold. Distension of the abdomen during pregnancy also affect the abdominal muscle functions and alter the mechanics of the phonation and making overuse vocal injuries. There is good quality of the voice in the first- and second-trimester of pregnancy due to perfect lubrication of the vocal folds, and hence, profession singers can sing up to 7 months. There are several other factors try to alter the voice during pregnancy such as nasal obstruction, altered breathing support, and laryngopharyngeal reflux (LPR). The alteration in the breathing support mechanism is associated with alteration in the volume of the thoracic cavity due to enlarged uterus. In addition, rhinitis occurs during pregnancy which leads to mouth breathing due to marked nasal block. Mouth breathing causes dryness of the larynx, which affect the voice quality. The respiratory tract is lined by secretion of two layers, an aqueous sol layer and superficial gel layer. Loss of sol layer can occur after around 15 min of mouth breathing, which cause raised phonation threshold and vocal effort causing dysphonia. Laryngopathia gravidarum is a clinical entity reported during pregnancy period which relates to the alteration in the laryngeal mucosa and it is thought that a hormonal response of the larynx leading to edema. It may be seen in cases of pregnancy with preeclampsia. There are some other causes for laryngeal edema during pregnancy is fluid over load, increased venous hypertension, weight gain, and pregnancy-related hypertension.
LPR is seen in approximately 50%–75% of the pregnant women. The clinical symptoms are heartburn, throat pain, foreign-body sensation in throat, and hoarseness of voice. These symptoms are more during the third trimester of the pregnancy due to raised intra-abdominal pressure, less gastric emptying, and reduced lower esophageal pressure. The treatment of this condition includes primarily lifestyle modifications. The treatment of LPR during pregnancy include changing to food habit such as small frequent meals and proton-pump inhibitors such as lansprazole, rabeprazole, and pantoprazole. The use of antacids and sucralfate which are not systemically absorbed to great extent is thought to be safe and effective. Sucralfate is a gastric mucosal protectant with no or little systemic absorption. Treatment with H2-receptor antagonists or proton-pump inhibitors can be prescribed in case of refractory symptoms. Oral H2 blockers and metoclopramide is also considered to be safer drug during pregnancy. Omeprazole may cause dose-related increase in death of fetus and disruption of pregnancy and so it is unsafe in pregnancy.
| Other Head-and-Neck Manifestations|| |
Obstructive sleep apnea
It may be seen during pregnancy but is less common as progesterone is a good ventilator stimulant. The pregnant women are advised to sleep on one side for preventing sleep apnea. Obstructive sleep apnea can cause hypoxia which can affect poor fetal growth, cardiac arrhythmias in fetus, daytime somnolence, and personality's disorders. In pregnancy, sleep apnea is usually treated by continuous positive airway pressure which splits the oropharyngeal airway and relieves upper airway obstruction and apnea.
It is excessive secretion saliva during pregnancy and of unknown etiology. These patients usually face difficulty to swallow her saliva in all the trimesters of pregnancy. Excess secretion of saliva may be diminished during sleep time; however, they may complain more saliva secretion as one of the important cause for nocturnal wakening. These patients may avoid social encounters during pregnancy. They may use gum or ice as temporary coping strategies; however, pregnant woman may complain bad taste and maintain swallowing of thickened or excessive saliva which perpetuates the felling of the nausea.
This pathological lesion is seen during pregnancy and often called as pregnancy tumor. It is a pyogenic granuloma which arises on the gingival in pregnancy period. It is a benign hyperplastic lesion of the mucosal lining of the oral cavity and is seen in around 5% of the pregnancies. It is a painless, sessile, or pedunculated and rapidly growing lesion seen in the gingival of varied sizes. These lesions are more common in the upper jaw than lower jaw. Although rare, this may be found on the dorsum of the tongue. The histopathological picture of the granuloma gravidarum shows loose granulation tissue with capillary vessels and proliferation of endothelial cells, accompanied by the mixture of inflammatory cells. The treatment of the granuloma gravidarum depends on the severity of clinical presentations. If the lesions are in early stage, only clinical follow-up is needed. Oral hygiene is recommended in case of pregnant women. If the lesions are large presenting with bleeding and pain require surgery. If the lesions are not resolved after delivery, the lesions can be excised. Laser (neodymium-doped yttrium aluminum garnet) may be used to excise for preventing bleeding during surgery.
Limitations and future directions
High-quality evidence for the management of pregnancy-related otorhinolaryngological manifestations is still limited, and it requires further research in future. It is highly important for family physicians, obstetricians, and otolaryngologists to become knowledgeable concerning these disorders so that they may manage the pregnant women with otorhinolaryngological manifestations.
| Conclusion|| |
Pregnant women often face a challenging situation from the ear, nose, and throat problems during pregnancy period. It make more stressful from otorhinolaryngological symptoms such as nasal block, epistaxis, hearing loss, and laryngological manifestations. Although these symptoms are transient and minor, it is important that clinician should recognize the problem, treat these symptoms, and reassure the women. Most of the symptoms found during pregnancy should be treated conservatively as they usually disappear postpartum. Hence, the unnecessary treatment may be avoided to reduce the risk to the fetus.
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Conflicts of interest
There are no conflicts of interest.
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