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ENT complaints in pregnancy: The ear and the throat

OBG Manag. 2010 September;22(9):28-40

Did you know that laryngopharyngeal reflux is distinct from GERD—and becomes worse during pregnancy? That the thyroid enlarges in half of gravidas? That some pregnant women experience changes to their voice?

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IN THIS ARTICLE

Mapping disease in the head and neck
When Bell’s palsy strikes in pregnancy
Could that thyroid nodule be cancer?

References

1. American Gastroenterological Association. The burden of chronic gastrointestinal diseases study. Bethesda, Md: AGA; 2001.

2. Cappell MS, Garcia A. Gastric and duodenal ulcers during pregnancy. Gastroenterol Clin North Am. 1998;27(1):169-195.

3. Gill SK, Maltepe C, Koren G. The effect of heartburn and acid reflux on the severity of nausea and vomiting of pregnancy. Can J Gastroenterol. 2009;23(4):270-272.

4. Wiener GJ, Koufman JA, Wu WC, Cooper JB, Richter JE, Castell DO. Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring. Am J Gastroenterol. 1989;84(12):1503-1508.

5. Gupta R, Sataloff RT. Laryngopharyngeal reflux: current concepts and questions. Curr Opin Otolaryngol Head Neck Surg. 2009;17(3):143-148.

6. Koufman JA, Belafsky PC, Bach KK, Daniel E, Postma GN. Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Laryngoscope. 2002;112(9):1606-1609.

7. Johnston N, Bulmer D, Gill GA, Panetti M, et al. Cell biology of laryngeal epithelial defenses in health and disease: further studies. Ann Otol Rhinol Laryngol. 2003;112(6):481-491.

8. Gill GA, Johnston N, Buda A, et al. Laryngeal epithelial defenses against laryngopharyngeal reflux: investigations of E-cadherin, carbonic anhydrase isoenzyme III, and pepsin. Ann Otol Rhinol Laryngol. 2005;114(12):913-921.

9. Smoak BR, Koufman JA. Effects of gum chewing on pharyngeal and esophageal pH. Ann Otol Rhinol Laryngol. 2001;110(12):1117-1119.

10. Hilsinger RL, Jr, Adour KK, Doty HE. Idiopathic facial paralysis, pregnancy, and the menstrual cycle. Ann Otol Rhinol Laryngol. 1975;84(4 Pt 1):433-442.

11. Vrabec JT, Isaacson B, Van Hook JW. Bell’s palsy and pregnancy. Otolaryngol Head Neck Surg. 2007;137(6):858-861.

12. Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med. 1996;124(1 Pt 1):27-30.

13. Sacks G, Sargent I, Redman C. An innate view of human pregnancy. Immunol Today. 1999;20(3):114-118.

14. Wegmann TG, Lin H, Guilbert L, Mosmann TR. Bidirectional cytokine interactions in the maternal-fetal relationship: is successful pregnancy a TH2 phenomenon? Immunol Today. 1993;14(7):353-356.

15. Stirrat GM. Pregnancy and immunity. BMJ. 1994;308(6941):1385-1386.

16. Gillman GS, Schaitkin BM, May M, Klein SR. Bell’s palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg. 2002;126(1):26-30.

17. Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope. 2000;110(3 Pt 1):335-341.

18. Adour KK, Ruboyianes JM, Von Doersten PG, et al. Bell’s palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol. 1996;105(5):371-378.

19. Hato N, Yamada H, Kohno H, et al. Valacyclovir and prednisolone treatment for Bell’s palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol. 2007;28(3):408-413.

20. Gristwood RE, Venables WN. Pregnancy and otosclerosis. Clin Otolaryngol Allied Sci. 1983;8(3):205-210.

21. Pearson E. The effect of pregnancy on otosclerosis. Ann West Med Surg. 1951;5(5):477-482.

22. Greifenstein. Schwangerschaftsunterbrechung und unfruchtbarmachung aus gesundheitlichen Grunden bei Otosklerose. Zeitschrift fur halsnasen und ohrenheilkunde 1939;46:344-362.

23. Markou K, Goudakos J. An overview of the etiology of otosclerosis. Eur Arch Otorhinolaryngol. 2009;266(1):25-35.

24. Lippy WH, Berenholz LP, Schuring AG, et al. Does pregnancy affect otosclerosis? Laryngoscope. 2005;115(10):1833-1836.

25. Muallem MM, Rubeiz NG. Physiological and biological skin changes in pregnancy. Clin Dermatol. 2006;24(2):80-83.

26. Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I. Nd:YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med. 1994;14(2):178-183.

27. Brodnitz FS. Hormones and the human voice. Bull NY Acad Med. 1971;47(2):183-191.

28. Sataloff RT, Hoover CA. Endocrine dysfunction. In: Sataloff RT, ed. Professional voice: the science and art of clinical care. 2^nd ed. San Diego, CA: Singular Publishing Group, Inc. 1997;293-295.

29. Kung AW, Chau MT, Lao TT, Tam SC, Low LC. The effect of pregnancy on thyroid nodule formation. J Clin Endocrinol Metab. 2002;87(3):1010-1014.

30. Smith LH, Danielsen B, Allen ME, Cress R. Cancer associated with obstetric delivery: results of linkage with the California cancer registry. Am J Obstet Gynecol. 2003;189(4):1128-1135.

31. Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13(4):381-387.

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35. Moosa M, Mazzaferri EL. Outcome of differentiated thyroid cancer diagnosed in pregnant women. J Clin Endocrinol Metab. 1997;82(9):2862-2866.

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Fast Track

Advise the patient not to discontinue a PPI abruptly because of the risk of rebound hypersecretion of gastric acid

It is important to initiate steroid treatment within 14 days after the onset of facial paralysis (Bell’s palsy) to improve recovery

Sudden sensorineural hearing loss has been associated with hypertension and toxemia of pregnancy

When melasma involves extensive pigmentary changes, the patient is likely to have a poor response to topical therapy

Ear, nose, and throat complaints are common even before you superimpose the transformations and demands of pregnancy. Take gastroesophageal reflux disease (GERD), for example. Experts estimate that one third of the US population suffers from this condition.¹ In pregnancy, endocrine and anatomic factors converge to exacerbate acid reflux disorders in 30% to 50% of women.²

Other complaints, too, surface or worsen during gestation. In Part 1 of this series (August 2010), we discussed sinonasal disease in pregnancy: specifically, pregnancy rhinitis, allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, sinusitis, epistaxis, and sleep-disordered breathing. In Part 2, our focus is:

laryngologic complaints

– GERD
– laryngopharyngeal reflux
– laryngopathia gravidarum

otologic disorders

– eustachian tube dysfunction
– facial paralysis (Bell’s palsy)
– otosclerosis
– sudden sensorineural hearing loss

endocrine abnormalities

– thyroid nodules

dermatologic complaints

– melasma
– pyogenic granuloma.

Mapping the head and neck, and the spectrum of disease there in pregnancy

This list includes diseases and problems reviewed in the first part of this article, August 2010.

Why does GERD increase in pregnancy?

The smooth muscle–relaxing effects of progesterone and estrogen are likely responsible for the decreased tone of both the upper esophageal and gastroesophageal sphincters. This reduced tone may lead to increased reflux of stomach contents into the esophagus, larynx, and pharynx. Decreased gastric emptying and increased intestinal transit time may also play a role. Reflux of gastric contents may also be exacerbated by compression from the gravid uterus.

Gastroesophageal reflux is physiologic, occurring in healthy people as often as 50 times a day. It becomes GERD when reflux into the esophagus is excessive, causing tissue damage (esophagitis) and clinical symptoms (heartburn). Recent studies suggest that, in addition to the traditional symptoms, GERD is associated with increased severity of nausea and vomiting in pregnancy.³

Ultimately, refluxed gastric contents cause mucosal injury to the upper aerodigestive tract. The location of injury and subsequent clinical manifestations are believed to correspond to the pattern of reflux.⁴

Some refluxers do it in the daytime

Laryngopharyngeal reflux (LPR), widely viewed as a separate clinical entity from GERD, is backflow of stomach contents into the laryngopharynx (FIGURE).⁵ Fewer than 40% of patients who have LPR experience heartburn, and fewer than 25% have evidence of esophagitis.⁶ LPR patients are predominantly upright, daytime refluxers, whereas GERD patients are predominantly supine or nocturnal refluxers. The threshold for reflux-related injury of the laryngeal epithelium is significantly lower than the threshold for injury to epithelium of the esophagus.⁷ As a result, even brief reflux exposures can injure the laryngeal epithelium.⁸

Injury in LPR manifests clinically as posterior laryngeal edema and erythema, obliteration of the laryngeal ventricles, and interarytenoid hypertrophy.⁵ These changes produce symptoms of chronic throat clearing, hoarseness, cough, and the sensation that something is caught in the throat (globus sensation). History and physical examination are typically sufficient to diagnose LPR.

Lifestyle changes can make a difference in GERD and LPR

Start with simple measures. Advise the patient to elevate the head of her bed 6 to 8 inches. Our patients report that it is usually easier to tolerate books under the legs of the head end of the bed than it is to sleep with extra pillows, especially when a side position is desired.

The patient also should be advised to avoid lying down within 3 hours after eating and to avoid smoking tobacco; drinking beer, wine, coffee, soda, caffeinated tea, and citrus juice; eating foods that are fried, high in fat, or spicy; and using drugs that promote reflux (i.e., calcium channel blockers, sedatives, and nitrates).

An interesting tip: Chewing gum increases salivary bicarbonate production and may neutralize acid.⁹

Pharmacologic options include H2 blockers and PPIs

Antacids, such as sucralfate, neutralize acid already in the stomach and may have a role in the treatment of acute symptoms.

Histamine 2 (H2) blockers such as cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid) block the histamine receptor in the stomach and reduce acid secretion by as much as 50%. These medications are typically taken two to three times daily. They all fall into Pregnancy Category B, except for nizatidine (Axid), which is Category C.