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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 159-163

Otological and rhinological manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of East India


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Obstetrics and Gynaecology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
3 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission06-Jan-2020
Date of Decision03-Jan-2020
Date of Acceptance25-Jan-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_87_19

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  Abstract 


BACKGROUND: Hormonal variations during pregnancy can lead to otological and rhinological manifestations. Majority of the manifestations have no harm to the expectant mother or fetus but some of them can become pathological. The objective of this study is to study the audiological and rhinological manifestations occurring during pregnancy.
MATERIALS AND METHODS: This is a prospective study where 82 pregnant women participated. Otological and rhinological manifestations were assessed by asking a questionnaire and detail clinical examinations of the ear, nose, and paranasal sinuses.
RESULTS: The mean age of the pregnant women participated in this study was 24.62 years. The most common otological manifestation was blockage feeling in the ear, whereas the most common rhinological manifestation was rhinitis. Eustachian tube dysfunction was common in the last trimester of the pregnancy.
CONCLUSION: It is important to have clinical knowledge in all clinicians regarding the manifestation of otological and rhinological manifestations and its treatment with precautions considering effects on mother and fetus during pregnancy.

Keywords: Epistaxis, hearing loss, pregnancy, pure-tone audiometry, rhinitis


How to cite this article:
Swain SK, Pattnaik T, Mohanty JN. Otological and rhinological manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of East India. Int J Health Allied Sci 2020;9:159-63

How to cite this URL:
Swain SK, Pattnaik T, Mohanty JN. Otological and rhinological manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of East India. Int J Health Allied Sci [serial online] 2020 [cited 2020 May 30];9:159-63. Available from: http://www.ijhas.in/text.asp?2020/9/2/159/282142




  Introduction Top


The hormones in the body of the women are very characteristic because of its cyclical changes during menstruation, pregnancy, and menopause. There are physiological changes in the body due to the changes in the estrogen and progesterone hormones. These hormones have regulatory influences on the central nervous system.[1] Most of the hormonal changes during pregnancy cause no harm to mother and fetus, whereas few can lead to certain pathological manifestations.[2] During pregnancy, any part of the woman body can affected due to hormonal and physiological changes, and so the ear, nose, and throat are no exception from such changes. There are myriad of otological and rhinological manifestations during pregnancy. These are hearing loss, feeling of blockage in the ear, otitis externa, tinnitus, and vertigo. The rhinological manifestations include epistaxis, rhinitis, and nasal block.[3] Thus, the clinical manifestations caused by otological and rhinological disorders lead to drop in the quality of life during pregnancy which also causes physical and psychological loss.[4] The release of certain neurotransmitters during pregnancy can change the biochemical level in the inner ear which produce neuro-otological manifestations.[5] The variations of estrogen and progesterone levels during pregnancy affect the hearing mechanisms and sinonasal physiology by altering the sensory nervous system.[6],[7] Because of close relation between hormonal alteration in pregnant women and otological and rhinological manifestations, this study aims at the evaluation of otological and rhinological clinical manifestations during pregnancy.


  Materials and Methods Top


This is a prospective study done at the department of otorhinolaryngology and obstetrics and gynecology of a tertiary care teaching hospital of East India. This study was conducted between July 2017 and August 2019. This study was approved by the Institutional Ethical Committee (IEC) with reference number IEC/IMS/SOAU/32/2017. Eighty-two pregnant women presenting with audiological and rhinological manifestations were included in this study. All the participants of this study signed informed consent agreement. The age range of the participants ranged from 20 to 32 years, with a mean age of 24.6 years. The inclusion criteria for this study were pregnant women, with no previous risk factors for audiological and rhinological manifestations. The exclusion criteria in this study were pregnant women with no systemic diseases, no toxemia during pregnancy, nondiabetic and nonhypertensive, and no previous otorhinolaryngological diseases. All participants underwent complete examinations of the ear and nose and paranasal sinuses. All participants underwent otoscopic examinations, tuning fork tests, and pure-tone audiometry for the assessment of the ear. Tuning fork tests such as Rinne's test, Weber test, and absolute bone conduction tests were performed by using 128, 256, 512, and 1024 Hz tuning fork. The hearing acuity was calculated by pure-tone audiometry, and hearing threshold was measured in all participants between 250 and 8000 Hz frequencies for air conduction and bone conduction. The hearing thresholds were measured using Elkon Model EPA3N3 plus audiometer in the participants of the study. The hearing threshold measurement by pure-tone audiometry was done in a soundproof room. The nose and paranasal sinuses were examined by anterior rhinoscopy, posterior rhinoscopy, cold spatula tests, and diagnostic nasal endoscopy. Nasal patency and changes in the nasal mucosa were examined in all the participants of this study. All the participants of pregnant women examined in each trimester. Each individual examined once in 1–14 weeks ( first trimester), second examination in 15–28 weeks of pregnancy (second trimester), and third examination in 29–42 weeks (third trimester). In this study, the diagnosis of the pregnancy rhinitis is diagnosed once a pregnant woman with nasal congestion not due to any other conditions makes a consultation for it. Smoking which is itself an irritant and adds several other changes in pregnant women and thus produces congestion of the nasal mucosa. Pregnant women with smoking habits were excluded from this study.


  Results Top


Out of 379 pregnant women, 82 attended the outpatient department of otorhinolaryngology with presentations of otological and rhinological manifestations. The age range of the pregnant women who participated in this study ranged from 20 to 32 years, with a mean age of 24.6 years. Out of 82 patients, 51 patients presented with otological manifestations [Table 1]. The most common otological manifestation was Eustachian tube dysfunctions seen among 19 cases (37.25%) confirmed from impedance audiometry with type-C tympanometry curve. All of the cases with Eustachian dysfunctions presented with blockage feeling in the ear during the third trimester of pregnancy. All of them advised for Valsalva maneuver and topical nasal decongestants for relieve of mucosal edema at the nasopharyngeal opening of the Eustachian tube. There were 11 cases showed hearing loss where 5 cases showed conductive hearing loss affecting low frequencies (250, 500, and 100 Hz) in pure-tone audiometry and Rinne negative, 4 cases showed sensorineural hearing loss in pure-tone audiometry and Rinne positive, and 2 cases showed mixed hearing loss [Table 2]. Pure-tone audiometry, impedance, and tuning fork tests confirmed two cases of otosclerosis. In this study, notch was seen in the bone conduction curve of the pure-tone audiometry along with as type tympanometry curve in two cases. In this study, four cases showed mild-to-moderate sensorineural hearing loss detected during the first trimester of pregnancy. Out of these 4 cases, one was diagnosed with Meniere's disease before pregnancy. Three cases showed true vertigo with spinning sensations. Out of three cases of true vertigo, one was with Meniere's disease, and the rest two diagnosed with benign paroxysmal vertigo which confirmed by Dix-Hallpike test. Rhinological manifestations were seen in 31 cases of the 82 cases of otorhinolaryngological presentations [Table 3]. Pregnancy rhinitis was found in 11 cases (35.48%) which affected the quality of life during the pregnancy period. Pregnancy rhinitis was the most common discomfort associated with pregnancy in this study. Pregnant women presented with rhinitis showed inflamed and congested nasal mucosa in anterior rhinoscopy examination, and they presented with sneezing, nasal block, and running nose. All of the pregnancy rhinitis presented during the first trimester. Nine pregnant women (29.03%) presented with epistaxis, and on examinations showed increased vascularity in the nasal mucosa which may be due to raised estrogen during pregnancy. All of these cases of epistaxis treated with normal saline nasal drops throughout the pregnancy. An olfactory disturbance such as an increased sense of smell or hyperosmia was presented in 7 (22.58%) cases of pregnant women during the first trimester. Pyogenic granuloma [Figure 1] was observed in four (12.90%) cases of pregnant women. All of this pyogenic granuloma was presented during the third trimester of pregnancy.
Table 1: Otological manifestations in pregnant women (n=51)

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Table 2: Hearing loss in pregnant women (n=11)

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Table 3: Rhinological manifestations in pregnant women (n=31)

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Figure 1: Pregnant women presented with pyogenic granuloma at the nostril

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  Discussion Top


There are considerable alterations seen in the body of pregnant women. Majority of the changes in the pregnancy are harmless to the expectant mother and fetus, whereas some may cause pathological effects. Any organ of the body is affected during pregnancy by hormonal changes of a pregnant mother so as in otological and rhinological system. Ringing sound in the ear or tinnitus is the common auditory complaint presented by pregnant women. Tinnitus in pregnant may be due raised perilymphatic fluid pressure, hyperdynamic circulation, and hormonal changes.[8] One study showed 33% of the pregnant women complained with tinnitus in comparison to 11% of nonpregnant women in the control group with relieve of symptoms after delivery.[4],[9] Severe tinnitus in pregnant women even leads to early cesarean delivery at 34 weeks with the resolution of tinnitus after delivery.[10] Tinnitus may be an early warning sign for gestational hypertension or preeclampsia and should be prudent for such type of cases to be monitored carefully, although there is no definitive scientific study has been identified except with few case reports.[11] In this study, out of the 82 cases those attended otorhinolaryngology outpatient department, only four cases presented with tinnitus in the ear. Infection of the external auditory canal or otitis externa is common in 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.[12] In this study, only four cases presented with otitis externa. Hearing loss and vertigo are two important clinical manifestations found during the pregnancy period. Hearing loss occurs often due to otosclerosis, Eustachian dysfunction, and sudden sensorineural hearing loss. In this study, out of 82 patients with otological and rhinological manifestations, only 11 cases presented with hearing loss which confirmed by tuning-fork tests and pure-tone audiometry. In cases of otosclerosis with pregnancy, the clinical manifestations are aggravated due to the 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 the near term or postpartum. If the patient faces communication problem due to hearing loss, he/she can be fitted with hearing aid during pregnancy. She can be advised for stapedotomy. Sodium fluoride is avoided during the pregnancy period because of its known to hamper bone absorption while increasing the calcification.[13] Sudden sensorineural hearing loss is less commonly seen during pregnancy but sometimes seen due to toxemia. Increased estrogen during pregnancy leads to hypercoagulability and occlusion of the inner ear vessels and microcirculation. Viral etiology must be ruled out for the cause of sudden hearing loss. It is important to treat toxemia but not with anticoagulant. Corticosteroids can be given to pregnant women in the third trimester.[14] 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 such as feeling of blockage in the ear and reduced hearing of the pregnant lady. This is often treated by oral decongestants or topical nasal decongestants. It is less often treated by the insertion of grommet or ventilation tube. In this study, 19 cases presented with fullness in the ear which confirmed as Eustachian tube dysfunction from impedance audiometry. The labyrinth or inner ear has two important functions of human beings such as hearing and balance. Any injury or pathology 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 inner ear functions. These alterations in the inner ear may present with symptoms such as vertigo, tinnitus, imbalance, fullness in the ear, hyperacusis, and algiacusis.[15] In this study, only three cases presented with vertigo. Vertigo is usually occurs due to aggravation of preexisting Meniere's disease. During pregnancy, the course of Meniere's disease is poorly documented in the medical literature. Meniere's disease has been shown to be exacerbated in the late luteal phase of the menstrual cycle, so it may have some relation with hormonal changes which leads to fluid retention in the inner ear.[16] 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, aural fullness, and aural fullness. Probably, estrogen and progesterone worsen the clinical scenario of the Meniere's disease. In acute attack of Meniere's disease, dimenhydrinate and meclizine can be safely given to pregnant women. Histamines and diuretics are usually avoided in pregnancy for treating Meniere's disease as it causes hypotension, hypovolemia, and decreases the cardiac output. In case of intractable vomiting, metoclopramide can be used.[17] One case was confirmed as Meniere's disease in this study.

Rhinological disorders are commonly seen in the general population and also frequently found during pregnancy. Approximately 30% of pregnant women suffer from nasal disorders during pregnancy.[18] There is specific nasal manifestation such as “pregnancy rhinitis occurs in around 20% of the pregnant women, fortunately found in last 6 or more weeks of pregnancy.”[19] Pregnancy rhinitis is not associated with respiratory tract infection or nasal allergy which disappears within 2 weeks after delivery of the baby. In this study, 11 cases showed rhinitis. Normal saline instillation into the nose, antihistamines, and topical nasal corticosteroids are often recommended.[19] Topical nasal decongestants can also be used for controlling the nasal congestion which facilitates the other topical treatments such as nasal corticosteroids; however, their administration should be restricted to 7 days as prolonged use may lead to rhinitis medicamentosa. There is no statistically significant association between any congenital abnormalities of the fetus and maternal exposure to nasal oxymetazoline or phenylephrine.[20] Nasal obstruction and rhinitis during pregnancy have been considered as distinct and common manifestations. It is seen in 5%–32% of the pregnant women and most often noted during the end of the first trimester and even persists up to the time of delivery of the baby or few weeks afterward. Pregnant women usually present with clear rhinorrhea and edematous nasal mucosa.[21] Pregnancy rhinitis has an impact on the quality of life and provides discomforts associated with morning sickness, running nose, and sneezing due to congested and irritated nasal mucosa. In this study, nasal patency was assessed by a cold spatula test. Congestion and edema of the nasal mucosa were confirmed by anterior rhinoscopy and diagnostic nasal endoscopy. Congestion of the nasal mucosa due to airborne allergy is often associated with running nose and sneezing, which is not seen in pregnancy rhinitis. In this study, 11 pregnant women (35.48%) presented with rhinitis. Rhinitis due to house dust mites usually produces nasal congestion only, and if it is seen during pregnancy for the first time, it is often difficult for clinician to differentiate from pregnancy rhinitis as they may coexist. Allergy can be excluded by certain allergy tests specific to immunoglobulin E. One study showed the mucociliary movement of the nasal cavity during pregnancy and concluded that pregnancy rhinitis affects around 20% of pregnant women.[22] The mucociliary transport in the nasal cavity is higher in pregnancy rhinitis and was lower in women without this condition. This study found a significant correlation between mucociliary transport and pregnancy rhinitis.[22] The severity of directly nasal obstruction is directly related to the extent of nasal resistance present in the nasal cavity which is regulated by the nasal valve, dilator naris muscle, and most importantly by the erectile tissue present in the inferior, middle, and superior turbinates. The nasal mucosa is usually controlled by the sympathetic and parasympathetic nervous system. The sympathetic nervous system usually controls blood flow in the nasal mucosa, with norepinephrine as a primary neurotransmitter at the end-organ level. The parasympathetic nervous system usually stimulates glandular secretions and cause vasodilation of the nasal vessels, leading to mucosal engorgement where primary neurotransmitter is acetylcholine at the end-organ level. All these parasympathetic and sympathetic nervous systems are affected by the hormonal changes in pregnant women. Pregnancy granuloma or nasal granuloma gravidarum is a rapidly growing benign tumor which causes the nasal block. The histopathological picture is often similar to pyogenic granuloma. In contrast to pyogenic granuloma, nasal granuloma gravidarum is usually unilateral and leads to recurrent epistaxis.[23] This nasal mass appears as reddish vascularized and bleeds on touch.[24] It sometimes protrudes anteriorly outside of the nose or adjacent to the nasal vestibule. It can be excised under local anesthesia if there is recurrent epistaxis or nasal obstruction, but there is a chance of spontaneous regression of this tumor after delivery.[25] The edematous nasal mucosa over the turbinates responds well to the topical nasal decongestants, which helps for better inspections of the nasal cavities. We did not find such studies in the eastern region of India, and this study showed that pregnant women have several otological and rhinological manifestations which can be easily managed by the clinicians in a day-to-day clinical practice.


  Conclusion Top


Otological and rhinological symptoms are often seen in pregnant women, and majority of them are treated conservatively as these disappear after delivery of the baby. Hence, avoidance of unnecessary medications or interventions can decrease the risk to the fetus. As the pregnancy progresses, the otological and rhinological manifestations disappear with complete resolution in the postpartum period, which indicates that these symptoms are more physiological than pathological. General practitioners and obstetricians should keep in mind regarding the otological and rhinological manifestations in pregnant women for betterment of mother and fetus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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