REVIEW ARTICLE EDITOR'S NOTE: F r o m t i m e t o time, t h e JOURNAL r e c e i v e s manuscripts that a r e well-written a n d scholarly reviews of Important subjects in o t o l a r y n g o l o g y w h i c h c h a l l e n g e us to e x p a n d existing Information. In most cases, t h e reviews d o n o t g o b e y o n d t h e observations of previous authors, so t h e y d o n o t qualify as original articles. A t t h e present time, t h e r e is n o formal r e v i e w article section In OTOLARYNGOLOGY-HEAD AND NECK SURGERY. W e invite your c o m m e n t s o n t h e v a l u e of s u c h a section.
Otolaryngologic manifestations of pregnancy A R T H U R J . T O R S I G L I E R I , JR., MD. L A W R E N C E W . C . T O M , MD, W I L L I A M M . K E A N E , MD. and J O S E P H P. A T K I N S , JR., MD, Philadelphia, Pennsylvania
Over a 9-month period, the pregnant woman under goes physical, physiologic, and hormonal changes that affect nearly every organ system. Many of these man ifestations are referable to the head and neck. There fore, it is important that otolaryngologists be aware of these changes to effectively diagnose and treat these disorders. An understanding of the metabolic changes that occur during pregnancy is essential to understand many of the changes, which exemplify themselves as signs and symptoms. The basal metabolic rate be gins to rise during the second trimester and reaches its peak at term. Physiologically, oxygen consumption follows accordingly, reaching a maximum at term of approximately 20% above the baseline nongravid state. The uterus, placenta, and fetus account for 7 5 % of this added oxygen consumption, and the remainder is needed for the increased work of the maternal heart and lungs. Alveolar ventilation is increased, and func tional residual capacity is lowered, especially in the third trimester. Maternal cardiac output at term is in creased by 50%, with placental blood flow accounting for 15% of the increase. The expansion in blood volume From the Department of Otolaryngology, Hospitaal of the University of Pennsylvania {Dr. Torsiglieri), the Department of Otolaryngol ogy, Children's Hospital of Philadelphia (Dr. Tom), and Pennsyl vania Hospital (Drs. Keane and Atkins). Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Washington, D C . , Sept. 25-29, 1988. Submitted for publication Feb. 16, 1989; accepted Sept. 19, 1989. Reprint requests: Lawrence W.C. Tom, MD, Department of Otolar yngology, Children's Hospital of Philadelphia, Philadelphia, PA 18104. 23/1/16810
results more from an increase in plasma volume than red blood cell volume and this is reflected in a decreased hematocrit. Water retention is an integral part of pregnancy, and total body water usually expands by at least four liters. Early in gestation, the plasma volume increases faster than interstitial fluid. This reverses in the third trimester, when there is a marked rise in extravascular fluid and a predelivery decrease in plasma volume, resulting in boggy mucous membranes and dependent extremity edema. In the postpartum period, plasma volume de clines rapidly, whereas interstitial fluid volume slowly returns to normal. Several hormones increase during pregnancy, espe cially progesterone and estrogen, which peak in the third trimester. These hormones have a direct effect on many tissues in the body, including the nasal mucosa, gin giva, and laryngeal mucosa. There is a steady rise throughout pregnancy of serum C o r t i s o l , thus imparting upon the mother a well-recognized reduction in the in flammatory response, probably best manifested by changes in dermatologie and rheumatoid conditions. Elevated C o r t i s o l levels create a relative gestational immunosuppressed condition and possibly allow for reac tivation of latent viral infections during pregnancy. These physiologic changes have both direct and in direct effects on specific organs in the head and neck, and it is logical to evaluate the otolaryngologic mani festations of pregnancy by reviewing each organ system individually.
OTOLOOIC MANIFESTATIONS Otologic manifestations in pregnancy are not uncom mon. Generalized mucosal edema of the nasopharynx 293
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may lead to eustachian tube obstruction, with subse quent dysfunction and serous otitis media. The diag nostic evaluation is the same in any adult. A thorough examination with emphasis on the ears, nasopharynx, and neck is essential. Both an audiogram and tympanogram should be performed. During pregnancy, patulous eustachian tubes are more common than obstruction. Patulous eustachian tubes are most often described in nonpregnant patients with rapid weight loss and are associated with a loss of fat around the cartilaginous portion of the eustachian tube.' This condition has been noted in pregnant pa tients, and Derkay suggests it may be influenced by insufficient weight gain during pregnancy. Patients most often report autophony or 'roaring' in the affected ear. The audiogram is usually normal, and the otologic examination may reveal tympanic membrane bulging with exhalation. Symptoms worsen when the patient is in an upright position and with decongestants, and im prove with increased humidity, a supine position, and during upper respiratory infections. A forceful inspi ratory nasal sniff (Muller manuever) may suddenly im prove symptoms. Pregnant women must be reassured that the condition is transient and will resolve after delivery. They are encouraged to increase ambient hu midity and perform intermittent Muller manuevers to provide symptomatic relief. An association between pregnancy and otosclerosis has long been recognized, but a causal relationship has not been established. Some have suggested that the observed relationship is merely coincidental, noting that otosclerosis becomes clinically evident most fre quently during childbearing years. It has been hypoth esized that otosclerosis may be exacerbated during preg nancy because elevated estrogen levels indirectly stim ulate otosclerotic foci. The effect of pregnancy is entirely unpredictable in any single case, but it is generally agreed that there is a significant risk of hearing deterioration during preg nancy in women with known otosclerosis. Shambaugh and Glasscock state that the risk of increased hearing loss from any one pregnancy in a woman with oto sclerosis is about one in four. When hearing loss occurs, it is most often noted near term or in the postpartum period. Stapedectomy is not recommended during preg nancy because amplification is an acceptable mode of temporary treatment without the associated morbidity. Sodium fluoride treatment, aside from being contro versial, is contraindicated in pregnancy because it re tards bone absorption by accelerating calcification and thus may harm the fetus. 2
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Meniere's disease may be exacerbated by pregnancy. It is believed that fluid retention results in increased endolymphatic hydrops and exacerbates the symptoms of Meniere's disease. Treatment with diuretics and his tamine may be harmful to the gravid female because they may cause hypovolemia, hypotension, and low ered cardiac output. Surgery is not recommended, and conservative management with antiemetics and vestib ular suppressants are most appropriate in the pregnant patient. Dimenhydranate (Dramamine) and meclizine (Antivert) are relatively safe, especially when admin istered in small doses. Although prochlorperazine (Compazine) had been used in cases of intractable nau sea and vomiting, it is recognized to cause neonatal side effects. Before prescribing these medications, the risk-benefit ratio should be considered and discussed with the patient. Diazepam is contraindicated be cause an increased risk of congenital malformations resulting from its use in the first trimester has been suggested.'" Vertigo in pregnancy may also be related to hormonal factors. High estrogen and progesterone levels in some women tend to cause vertigo. The treatment is similar to that of Meniere's disease. Sudden sensorineural hearing loss rarely occurs dur ing pregnancy and is most often seen in women with associated toxemia. The cause of this hearing loss is believed to be secondary to vascular occlusion in the microcirculation of the inner ear. It has been hypoth esized that elevated estrogens during pregnancy predis pose women to hypercoagulability, especially when toxemia coexists. A complete audiologic and neurootologic evaluation is necessary to eliminate other causes of hearing loss, and treatment is aimed at the underlying toxemia. Anticoagulation is not recom mended. 8
FACIAL NERVE MANIFESTATIONS Idiopathic facial nerve paralysis was first observed in association with pregnancy in 1830 by Bell. Re viewing 446 cases of Bell's palsy, Hilsinger et a l noted that pregnant women have a three times higher incidence than nonpregnant women of the same age group. The majority of cases occurred during the third trimester, and the risk of paralysis was no different in the first than in subsequent pregnancies. The cause of idiopathic facial nerve paralysis in pregnant women remains u n c l e a r . Facial paralysis may be caused by perineural edema and mechanical compression, or p e ' haps a viral inflammatory reaction with subsequent demyelinization. 1 2
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Conservative management of pregnant patients is most appropriate. Medical treatment with steroids may be used judiciously after discussion with the patient's obstetrician. Adrenal corticosteroids cross the placenta, and in animal studies are teratogenic in the first and second trimesters. Steroids are considered safe to use in the third trimester and are commonly given to prevent respiratory distress syndrome. Hilsinger et a l . reported that two thirds of pregnant patients with facial paralysis received steroids, and in no cases were there any fetal side effects. They recommended 40 to 60 mg daily, tapered over 8 to 10 days. 12
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nemia when given later in development. Aminogly cosides may cause renal or neural arch developmental anomalies in the first trimester and nephrotoxicity and ototoxicity in the third trimester. If an aminoglycoside is definitely required, it is probably safest in the second trimester. Levels should be closely monitored. Chlor amphenicol should be used with strict caution because it may cause 'gray baby syndrome'. The side effects of imipenem, vancomycin, rifampin, and isoniazid have not been established, and they should be used with caution. Tetracycline has been shown to inhibit bone growth, as well as cause tooth discoloration, and is strictly contraindicated. Nasal allergy may be initiated, exacerbated, or re lieved by pregnancy. There have been many instances in which patients previously bothered by nasal allergic symptoms experienced relief during pregnancy. This observation supports the notion of a relative gestational immunosuppression resulting from elevated Cortisol levels. The study of allergy associated with pregnancy is difficult and can not depend on in vitro RAST testing. This is because serum IgE levels during pregnancy are quite variable. Patients receiving hyposensitization in jections may be continued on these during pregnancy. Although many obstetricians do not prescribe med ication for treatment of rhinitis during pregnancy, a majority of pregnant women take an over-the-counter medication for relief. Before seeing a physician, many women will have used nose drops or sprays. Hormonal vasodilation of nasal mucosa is resistant to topical va soconstrictors, and most patients will quickly become refractory or experience rebound rhinitis. In one series, almost half of pregnant patients had used topical treat ment to the point of producing rhinitis medicamen tosa. Subsequently, nasal decongestants should be used judiciously or avoided completely. Moreover, na sal sprays are rapidly absorbed and may produce sys temic effects. Topical sympathomimetics and oral de congestants carry a risk of generalized vasoconstriction, and theoretically may cause placental insufficiency. However, no data support this theory, and most decon gestants are safe to use in moderation during preg nancy. Topical intranasal steroids have been shown to improve symptoms of allergic rhinitis in the gravid pa tient. Concern about intranasal steroid use results from absorption and systemic effects, and agents with min imal absorption are believed to be safe. Intraturbinal corticosteroid injection has been shown to relieve nasal congestion during pregnancy. Mabry warns against its use in the first trimester and emphasizes that attention 10
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NASAL MANIFESTATIONS Most women note some degree of nasal congestion during pregnancy, and one third may seek professional attention for relief. Most cases of congestion are sec ondary to the effect of estrogen on the nasal mucosa, but the otolaryngologist must thoroughly evaluate the nasal cavity for other conditions." The relationship of estrogen on nasal mucosa was first investigated by Mortimer et a l . It was noted that estrogens caused vascular engorgement in the uterus and nasal mucosa. Toppozada et a l . studied the ultrastructural and histochemical alterations of the nasal mu cosa during pregnancy and concluded that estrogen causes mucosal swelling via a direct cholinergic effect by increasing acetylcholine production. Nasal conges tion worsens throughout pregnancy, with patients being most symptomatic in the third trimester, when estrogen levels peak. This nasal vascular congestion is also ef fected by increased plasma volume and tissue fluid re tention. Derkay demonstrated by rhinomanometry a decrease in nasal patency in pregnant women. Sinusitis, probably secondary to primary nasal congestion and blockage of natural drainage ostia, is not uncommon during pregnancy. Thresholds for ra diographic evaluation by sinus series should be lower in pregnant patients. These studies are safe to both mother and fetus with proper shielding and provide for more discriminant use of antibiotic therapy. The use of antimicrobials during pregnancy is a fre quent cause for concern. Although certain antibiotics are likely to produce fetal abnormalities, any antibiotic may have an adverse effect on the fetus and should be used only when clearly indicated. The teratogenic po tential of many agents remains unknown. Cephalospo rins, clindamycin, erythromycin, and the penicillins seem to be relatively safe." Sulfonamides and tri methoprim appear safe in the first trimester, but they may cause fetal hemolytic anemia and hyperbilirubi 16
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to proper technique is necessary to prevent inadvertent embolization into the retinal circulation, especially in light of the increased nasal mucosa vascularity asso ciated with pregnancy. Epistaxis is common during pregnancy. The in creased vascular congestion and alterations in nasal mucosa may predispose the pregnant woman to nose bleeds. Although these are usually transient and selflimited, epistaxis associated with pregnancy can be se vere and life-threatening. Prophylactic measures, such as humidity and saline nasal sprays, may help. Indi cations for nasal packing and management are the same as in the nongravid patient. Nasal hemangiomas associated with pregnancy are an uncommon but impressive cause of epistaxis. " Characteristically these lesions appear in the nose or upper aerodigestive tract during the early months of pregnancy and involute in the postpartum period. Treat ment is often dependent on symptoms. Excessive bleed ing or significant nasal obstruction may necessitate sur gical excision. 23
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esophagitis is usually self-limited and responds to an tireflux positioning, small frequent meals, and antacids. Hoarseness and sore throat may result from reflux. Other laryngeal disorders include laryngopathica gravidarum, which results from changes in the laryngeal mucosa, consisting of edema, dryness, and crusting. Edema of these mucous membranes can cause partial voice loss or even aphonia. Professional singers main tain that during pregnancy their voice is deeper and their range is diminished. Like nasal hemangiomas, laryngeal hemangiomas may be associated with pregnancy and may cause bleed ing or respiratory problems. Treatment of asymptomatic hemangiomas should be conservative because after de livery most will undergo regression. 31
THYROID MANIFESTATIONS During pregnancy, the thyroid gland becomes en larged in more than 50% of pregnant women. Hyper plasia of the gland and goiter formation associated with pregnancy have long been observed, and it appears to be a physiologic response related to increased renal iodine clearance. During pregnancy, diffuse thyroid enlargement is physiologic and, if it is asymptomatic, is best treated by observation. Clinical features that suggest abnormal thyroid enlargement include rapid or severe growth, compression, voice changes, solitary nodules, and regional adenopathy. Indications for sur gical treatment with nontoxic thyroid enlargement dur ing pregnancy include both proven or suspected car cinoma or tracheal compression caused by goiter. Thyroid testing in the gravid patient should be mod ified. Radioactive iodine scanning is contraindicated in pregnancy. As a general rule, women of child-bearing ages should be questioned about pregnancy before a scan is performed. The results of thyroid function tests are altered during pregnancy. The gravid woman has higher estrogen levels, which cause more thyroxinebinding globulin to be produced by the liver and, thus, the free thyroxine percentage is lower. The test of choice in evaluation of thyroid function during preg nancy is the free thyroxine level ( T 4 ) . Treatment of hyperthyroidism during pregnancy should provide control of hyperthyroidism in the mother and allow normal fetal development. Therapy with I131 is contraindicated. Treatment is limited to either antithyroid drug therapy or surgery, with the specific treatment depending upon the severity of symptoms and the stage of pregnancy. For hyperthyroidism, the pro cedure of choice is a subtotal thyroidectomy, performed in the second trimester when the pregnancy is most stable. Antithyroid drugs are disadvantageous because they are permeable across the placenta and may lead 32
The most common oral manifestation of pregnancy is gingival enlargement. Gingival changes during preg nancy are caused by both increased blood volume and local hormonal factors. A spectrum of gingival changes may exist from mild gum bleeding to significant raspberry-colored papular hypertrophy. Poor oral, dental hygiene, and local irritants may exacerbate the condition and cause gingivitis. This may occur in up to 7 5 % of pregnant w o m e n . It is most often painless and commonly noted in the anterior maxillary region. Appropriate treatment begins with good oral hygiene and repair of any irritating dental condition. A discrete interdental granulomatous lesion, granuloma gravida rum, or "pregnancy tumor" will develop in two percent of these patients. These lesions will regress sponta neously after pregnancy and rarely become large or symptomatic enough that local excision is warranted. Other oral manifestations during pregnancy include increased salivation and alterations in taste and smell. Pregnant women commonly experience increases in ap petite, and some crave strange food combinations or occasionally nonfood materials. 29
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AfRODIOfSTIVE MANIFESTATIONS Pregnant women commonly report hoarseness and chest pain. Esophageal reflux commonly occurs during pregnancy, especially in the third trimester. Increased abdominal pressure, decreased gastric emptying, in creased intestinal transit time, and decreased lower esophageal pressure contribute to the condition. Reflux
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to fetal goiter or cretinism. Propylthiouracil (PTU) is preferred over methimazole because PTU crosses the placenta relatively poorly and is thus safer. As with all thyroid disorders, close consultation with an endo crinologist is essential. 33
CONCLUSION There are many otolaryngologic manifestations dur ing pregnancy. While most of these disorders are benign and revert to normal postpartum, it is important that the otolaryngologist be familiar with these conditions and their appropriate treatment so that the best care can be delivered to the pregnant mother, without harm to her unborn child. REFERENCES 1. Miller JB. Patulous eustachian tube. Arch Otolaryngol Head Neck Surg 1961;73:310-21. 2. Derkay CS. Eustachian tube and nasal function during preg nancy: a prospective study. OTOLARYNGOL HEAD NECK SURG
1988;99:558-66. 3. Miller JB. Patulous eustachian tubes in pregnancy. West J Surg Obstet Gynecol 1962;70:156-9. 4. Morrison AW. Diseases of the otic capsule. In: Scott-Brown WB, ed. Diseases of ear, nose, and throat. 4th ed. London: Butterworth, 1965:414. 5. Walsh TE. The effect of pregnancy on the deafness of otoscle rosis. Trans Am Acad Ophthalmol Otolaryngol 1954;58:420-6. 6. Lewis JS. Surgery of the ear, nose, and throat in pregnancy. In: Barber HRK, Graber EA, eds. Surgical diseases in pregnancy. Philadelphia: WB Saunders Co, 1974:248-53. 7. Shambaugh GE, Glasscock ME III. Surgery of the ear. 3rd ed. Philadelphia: WB Saunders Co, 1980:461. 8. Hansen L, Sobol SM, Abeison TI. Otolaryngologic manifesta tions of pregnancy. J Fam Pract 1986;23:151-5. 9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 2nd ed. Baltimore: Williams & Wilkins, 1984:xiixix. 10. Holt GR, Mabry RL. ENT Medications in pregnancy. OTOLAR YNGOL HEAD NECK SURG 1983;91:338-41.
11. The physician's desk reference. 43rd ed. Oradell, NJ: Medical Economics Co, 1989:528, 1773, 2149. 12. Hilsinger RL, Adour KK, Doty HE. Idiopathic facial paralysis, pregnancy, and the menstrual cycle. Ann Otolaryngol 1975;84: 433-42. 13. Robinson JR, Pou JW. Bell's palsy: a predisposition of pregnant women. Arch Otolaryngol 1972;95:125-9. 14. Pope TH, Kenan PD. Bell's palsy in pregnancy. Arch Otolar yngol Head Neck Surg 1969;89:52-6.
15. Mabry RL. The management of nasal obstruction during preg nancy. Ear Nose Throat J 1983;62:16-9. 16. Mortimer H, Wright RP, Collip JB. The effect of the adminis tration of oestrogenic hormones on the nasal mucosa of the mon key. Can Med Assoc J 1936;35:503-12. 17. Toppozada H, Michaels L, Toppozada M, El-Ghazzawi I, Talaat M, Elwany S. The human respiratory mucosa in pregnancy. J Laryngol Otol 1982;96:613-26. 18. Sorri M. Rhinitis during pregnancy. Rhinology 1980;18:83-6. 19. Mabry RL. Rhinitis of pregnancy. South Med J 1986;79:96571. 20. Chow AW, Je wesson PJ. Pharmacokinetics and safety of anti microbial agents during pregnancy. Rev Infect Dis 1985;7:287313. 21. Scharz RH. Consideration of antibiotic therapy during preg nancy. Obstet Gynecol 1981;58:95-9. 22. Safety of antimicrobial drugs in pregnancy. Med Lett 1987; 29:61-3. 23. Amino N, Tanizawa O, Miyai K. Changes of serum immuno globulins IgG, IgA, IgM, and IgE during pregnancy. Obstet Gynecol 1978;52:415-20. 24. Mabry RL. Intranasal steroid injection during pregnancy. South Med J 1980;73:1176-9. 25. Howard DJ. Life-threatening epistaxis in pregnancy. J Laryngol Otol 1985;99:95-6. 26. Kent DL, Fitzwater JE. Nasal hemangioma of pregnancy. Ann Otol Rhinol Laryngol 1979;88:331-3. 27. Fechner RE, Slaughter GFH, Pope TL. Extraordinary growth of giant cell reparative granuloma during pregnancy. Arch Otolar yngol Head Neck Surg 1984;110:116-9. 28. Letter/man G, Schuster M. Cutaneous hemangiomas of the face in pregnancy. Plast Reconstr Surg 1962;29:293-300. 29. McCarty PL. Disorders of the oral cavity. In: Moschella SL, Pillsbury DM, Hurley HO, eds. Dermatology. Philadelphia: WB Saunders, 1975:1594. 30. Downtown D. Diseases of the mouth. In: Scott-Brown WB, ed. Diseases of the ear, nose, and throat. 4th ed. London: Butterworth, 1965:32-3. 31. Mugliston TAH, Sangwan S. Persistent cavernous hemangioma of the larynx—a pregnancy problem. J Laryngol Otol 1985;99: 1309-11. 32. Talbert LM. Hyperthyroidism during pregnancy. Obstet Gynecol 1970;36:779-85. 33. Becker FO, Reeves BD, Economou SG. Endocrine gland surgery in pregnancy. In: Barber HRK, Graber EA, eds. Surgical diseases in pregnancy. Philadelphia: WB Saunders Co, 1974:267-77. 34. Worley RJ, Crosby WM. Hyperthyroidism during pregnancy. Am J Obstet Gynecol 1974;119:150-5. 35. Cooper DS. Medical progress: antithyroid drugs. Ν Engl J Med 1984;311:1353-62.
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Otolaryngologic manifestations of pregnancy A R T H U R J . T O R S I G L I E R I , JR., MD. L A W R E N C E W . C . T O M , MD, W I L L I A M M . K E A N E , MD. and J O S E P H P. A T K I N S , JR., MD, Philadelphia, Pennsylvania
Over a 9-month period, the pregnant woman under goes physical, physiologic, and hormonal changes that affect nearly every organ system. Many of these man ifestations are referable to the head and neck. There fore, it is important that otolaryngologists be aware of these changes to effectively diagnose and treat these disorders. An understanding of the metabolic changes that occur during pregnancy is essential to understand many of the changes, which exemplify themselves as signs and symptoms. The basal metabolic rate be gins to rise during the second trimester and reaches its peak at term. Physiologically, oxygen consumption follows accordingly, reaching a maximum at term of approximately 20% above the baseline nongravid state. The uterus, placenta, and fetus account for 7 5 % of this added oxygen consumption, and the remainder is needed for the increased work of the maternal heart and lungs. Alveolar ventilation is increased, and func tional residual capacity is lowered, especially in the third trimester. Maternal cardiac output at term is in creased by 50%, with placental blood flow accounting for 15% of the increase. The expansion in blood volume From the Department of Otolaryngology, Hospitaal of the University of Pennsylvania {Dr. Torsiglieri), the Department of Otolaryngol ogy, Children's Hospital of Philadelphia (Dr. Tom), and Pennsyl vania Hospital (Drs. Keane and Atkins). Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Washington, D C . , Sept. 25-29, 1988. Submitted for publication Feb. 16, 1989; accepted Sept. 19, 1989. Reprint requests: Lawrence W.C. Tom, MD, Department of Otolar yngology, Children's Hospital of Philadelphia, Philadelphia, PA 18104. 23/1/16810
results more from an increase in plasma volume than red blood cell volume and this is reflected in a decreased hematocrit. Water retention is an integral part of pregnancy, and total body water usually expands by at least four liters. Early in gestation, the plasma volume increases faster than interstitial fluid. This reverses in the third trimester, when there is a marked rise in extravascular fluid and a predelivery decrease in plasma volume, resulting in boggy mucous membranes and dependent extremity edema. In the postpartum period, plasma volume de clines rapidly, whereas interstitial fluid volume slowly returns to normal. Several hormones increase during pregnancy, espe cially progesterone and estrogen, which peak in the third trimester. These hormones have a direct effect on many tissues in the body, including the nasal mucosa, gin giva, and laryngeal mucosa. There is a steady rise throughout pregnancy of serum C o r t i s o l , thus imparting upon the mother a well-recognized reduction in the in flammatory response, probably best manifested by changes in dermatologie and rheumatoid conditions. Elevated C o r t i s o l levels create a relative gestational immunosuppressed condition and possibly allow for reac tivation of latent viral infections during pregnancy. These physiologic changes have both direct and in direct effects on specific organs in the head and neck, and it is logical to evaluate the otolaryngologic mani festations of pregnancy by reviewing each organ system individually.
OTOLOOIC MANIFESTATIONS Otologic manifestations in pregnancy are not uncom mon. Generalized mucosal edema of the nasopharynx 293
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may lead to eustachian tube obstruction, with subse quent dysfunction and serous otitis media. The diag nostic evaluation is the same in any adult. A thorough examination with emphasis on the ears, nasopharynx, and neck is essential. Both an audiogram and tympanogram should be performed. During pregnancy, patulous eustachian tubes are more common than obstruction. Patulous eustachian tubes are most often described in nonpregnant patients with rapid weight loss and are associated with a loss of fat around the cartilaginous portion of the eustachian tube.' This condition has been noted in pregnant pa tients, and Derkay suggests it may be influenced by insufficient weight gain during pregnancy. Patients most often report autophony or 'roaring' in the affected ear. The audiogram is usually normal, and the otologic examination may reveal tympanic membrane bulging with exhalation. Symptoms worsen when the patient is in an upright position and with decongestants, and im prove with increased humidity, a supine position, and during upper respiratory infections. A forceful inspi ratory nasal sniff (Muller manuever) may suddenly im prove symptoms. Pregnant women must be reassured that the condition is transient and will resolve after delivery. They are encouraged to increase ambient hu midity and perform intermittent Muller manuevers to provide symptomatic relief. An association between pregnancy and otosclerosis has long been recognized, but a causal relationship has not been established. Some have suggested that the observed relationship is merely coincidental, noting that otosclerosis becomes clinically evident most fre quently during childbearing years. It has been hypoth esized that otosclerosis may be exacerbated during preg nancy because elevated estrogen levels indirectly stim ulate otosclerotic foci. The effect of pregnancy is entirely unpredictable in any single case, but it is generally agreed that there is a significant risk of hearing deterioration during preg nancy in women with known otosclerosis. Shambaugh and Glasscock state that the risk of increased hearing loss from any one pregnancy in a woman with oto sclerosis is about one in four. When hearing loss occurs, it is most often noted near term or in the postpartum period. Stapedectomy is not recommended during preg nancy because amplification is an acceptable mode of temporary treatment without the associated morbidity. Sodium fluoride treatment, aside from being contro versial, is contraindicated in pregnancy because it re tards bone absorption by accelerating calcification and thus may harm the fetus. 2
3
4
5
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Meniere's disease may be exacerbated by pregnancy. It is believed that fluid retention results in increased endolymphatic hydrops and exacerbates the symptoms of Meniere's disease. Treatment with diuretics and his tamine may be harmful to the gravid female because they may cause hypovolemia, hypotension, and low ered cardiac output. Surgery is not recommended, and conservative management with antiemetics and vestib ular suppressants are most appropriate in the pregnant patient. Dimenhydranate (Dramamine) and meclizine (Antivert) are relatively safe, especially when admin istered in small doses. Although prochlorperazine (Compazine) had been used in cases of intractable nau sea and vomiting, it is recognized to cause neonatal side effects. Before prescribing these medications, the risk-benefit ratio should be considered and discussed with the patient. Diazepam is contraindicated be cause an increased risk of congenital malformations resulting from its use in the first trimester has been suggested.'" Vertigo in pregnancy may also be related to hormonal factors. High estrogen and progesterone levels in some women tend to cause vertigo. The treatment is similar to that of Meniere's disease. Sudden sensorineural hearing loss rarely occurs dur ing pregnancy and is most often seen in women with associated toxemia. The cause of this hearing loss is believed to be secondary to vascular occlusion in the microcirculation of the inner ear. It has been hypoth esized that elevated estrogens during pregnancy predis pose women to hypercoagulability, especially when toxemia coexists. A complete audiologic and neurootologic evaluation is necessary to eliminate other causes of hearing loss, and treatment is aimed at the underlying toxemia. Anticoagulation is not recom mended. 8
FACIAL NERVE MANIFESTATIONS Idiopathic facial nerve paralysis was first observed in association with pregnancy in 1830 by Bell. Re viewing 446 cases of Bell's palsy, Hilsinger et a l noted that pregnant women have a three times higher incidence than nonpregnant women of the same age group. The majority of cases occurred during the third trimester, and the risk of paralysis was no different in the first than in subsequent pregnancies. The cause of idiopathic facial nerve paralysis in pregnant women remains u n c l e a r . Facial paralysis may be caused by perineural edema and mechanical compression, or p e ' haps a viral inflammatory reaction with subsequent demyelinization. 1 2
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Conservative management of pregnant patients is most appropriate. Medical treatment with steroids may be used judiciously after discussion with the patient's obstetrician. Adrenal corticosteroids cross the placenta, and in animal studies are teratogenic in the first and second trimesters. Steroids are considered safe to use in the third trimester and are commonly given to prevent respiratory distress syndrome. Hilsinger et a l . reported that two thirds of pregnant patients with facial paralysis received steroids, and in no cases were there any fetal side effects. They recommended 40 to 60 mg daily, tapered over 8 to 10 days. 12
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nemia when given later in development. Aminogly cosides may cause renal or neural arch developmental anomalies in the first trimester and nephrotoxicity and ototoxicity in the third trimester. If an aminoglycoside is definitely required, it is probably safest in the second trimester. Levels should be closely monitored. Chlor amphenicol should be used with strict caution because it may cause 'gray baby syndrome'. The side effects of imipenem, vancomycin, rifampin, and isoniazid have not been established, and they should be used with caution. Tetracycline has been shown to inhibit bone growth, as well as cause tooth discoloration, and is strictly contraindicated. Nasal allergy may be initiated, exacerbated, or re lieved by pregnancy. There have been many instances in which patients previously bothered by nasal allergic symptoms experienced relief during pregnancy. This observation supports the notion of a relative gestational immunosuppression resulting from elevated Cortisol levels. The study of allergy associated with pregnancy is difficult and can not depend on in vitro RAST testing. This is because serum IgE levels during pregnancy are quite variable. Patients receiving hyposensitization in jections may be continued on these during pregnancy. Although many obstetricians do not prescribe med ication for treatment of rhinitis during pregnancy, a majority of pregnant women take an over-the-counter medication for relief. Before seeing a physician, many women will have used nose drops or sprays. Hormonal vasodilation of nasal mucosa is resistant to topical va soconstrictors, and most patients will quickly become refractory or experience rebound rhinitis. In one series, almost half of pregnant patients had used topical treat ment to the point of producing rhinitis medicamen tosa. Subsequently, nasal decongestants should be used judiciously or avoided completely. Moreover, na sal sprays are rapidly absorbed and may produce sys temic effects. Topical sympathomimetics and oral de congestants carry a risk of generalized vasoconstriction, and theoretically may cause placental insufficiency. However, no data support this theory, and most decon gestants are safe to use in moderation during preg nancy. Topical intranasal steroids have been shown to improve symptoms of allergic rhinitis in the gravid pa tient. Concern about intranasal steroid use results from absorption and systemic effects, and agents with min imal absorption are believed to be safe. Intraturbinal corticosteroid injection has been shown to relieve nasal congestion during pregnancy. Mabry warns against its use in the first trimester and emphasizes that attention 10
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NASAL MANIFESTATIONS Most women note some degree of nasal congestion during pregnancy, and one third may seek professional attention for relief. Most cases of congestion are sec ondary to the effect of estrogen on the nasal mucosa, but the otolaryngologist must thoroughly evaluate the nasal cavity for other conditions." The relationship of estrogen on nasal mucosa was first investigated by Mortimer et a l . It was noted that estrogens caused vascular engorgement in the uterus and nasal mucosa. Toppozada et a l . studied the ultrastructural and histochemical alterations of the nasal mu cosa during pregnancy and concluded that estrogen causes mucosal swelling via a direct cholinergic effect by increasing acetylcholine production. Nasal conges tion worsens throughout pregnancy, with patients being most symptomatic in the third trimester, when estrogen levels peak. This nasal vascular congestion is also ef fected by increased plasma volume and tissue fluid re tention. Derkay demonstrated by rhinomanometry a decrease in nasal patency in pregnant women. Sinusitis, probably secondary to primary nasal congestion and blockage of natural drainage ostia, is not uncommon during pregnancy. Thresholds for ra diographic evaluation by sinus series should be lower in pregnant patients. These studies are safe to both mother and fetus with proper shielding and provide for more discriminant use of antibiotic therapy. The use of antimicrobials during pregnancy is a fre quent cause for concern. Although certain antibiotics are likely to produce fetal abnormalities, any antibiotic may have an adverse effect on the fetus and should be used only when clearly indicated. The teratogenic po tential of many agents remains unknown. Cephalospo rins, clindamycin, erythromycin, and the penicillins seem to be relatively safe." Sulfonamides and tri methoprim appear safe in the first trimester, but they may cause fetal hemolytic anemia and hyperbilirubi 16
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to proper technique is necessary to prevent inadvertent embolization into the retinal circulation, especially in light of the increased nasal mucosa vascularity asso ciated with pregnancy. Epistaxis is common during pregnancy. The in creased vascular congestion and alterations in nasal mucosa may predispose the pregnant woman to nose bleeds. Although these are usually transient and selflimited, epistaxis associated with pregnancy can be se vere and life-threatening. Prophylactic measures, such as humidity and saline nasal sprays, may help. Indi cations for nasal packing and management are the same as in the nongravid patient. Nasal hemangiomas associated with pregnancy are an uncommon but impressive cause of epistaxis. " Characteristically these lesions appear in the nose or upper aerodigestive tract during the early months of pregnancy and involute in the postpartum period. Treat ment is often dependent on symptoms. Excessive bleed ing or significant nasal obstruction may necessitate sur gical excision. 23
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esophagitis is usually self-limited and responds to an tireflux positioning, small frequent meals, and antacids. Hoarseness and sore throat may result from reflux. Other laryngeal disorders include laryngopathica gravidarum, which results from changes in the laryngeal mucosa, consisting of edema, dryness, and crusting. Edema of these mucous membranes can cause partial voice loss or even aphonia. Professional singers main tain that during pregnancy their voice is deeper and their range is diminished. Like nasal hemangiomas, laryngeal hemangiomas may be associated with pregnancy and may cause bleed ing or respiratory problems. Treatment of asymptomatic hemangiomas should be conservative because after de livery most will undergo regression. 31
THYROID MANIFESTATIONS During pregnancy, the thyroid gland becomes en larged in more than 50% of pregnant women. Hyper plasia of the gland and goiter formation associated with pregnancy have long been observed, and it appears to be a physiologic response related to increased renal iodine clearance. During pregnancy, diffuse thyroid enlargement is physiologic and, if it is asymptomatic, is best treated by observation. Clinical features that suggest abnormal thyroid enlargement include rapid or severe growth, compression, voice changes, solitary nodules, and regional adenopathy. Indications for sur gical treatment with nontoxic thyroid enlargement dur ing pregnancy include both proven or suspected car cinoma or tracheal compression caused by goiter. Thyroid testing in the gravid patient should be mod ified. Radioactive iodine scanning is contraindicated in pregnancy. As a general rule, women of child-bearing ages should be questioned about pregnancy before a scan is performed. The results of thyroid function tests are altered during pregnancy. The gravid woman has higher estrogen levels, which cause more thyroxinebinding globulin to be produced by the liver and, thus, the free thyroxine percentage is lower. The test of choice in evaluation of thyroid function during preg nancy is the free thyroxine level ( T 4 ) . Treatment of hyperthyroidism during pregnancy should provide control of hyperthyroidism in the mother and allow normal fetal development. Therapy with I131 is contraindicated. Treatment is limited to either antithyroid drug therapy or surgery, with the specific treatment depending upon the severity of symptoms and the stage of pregnancy. For hyperthyroidism, the pro cedure of choice is a subtotal thyroidectomy, performed in the second trimester when the pregnancy is most stable. Antithyroid drugs are disadvantageous because they are permeable across the placenta and may lead 32
The most common oral manifestation of pregnancy is gingival enlargement. Gingival changes during preg nancy are caused by both increased blood volume and local hormonal factors. A spectrum of gingival changes may exist from mild gum bleeding to significant raspberry-colored papular hypertrophy. Poor oral, dental hygiene, and local irritants may exacerbate the condition and cause gingivitis. This may occur in up to 7 5 % of pregnant w o m e n . It is most often painless and commonly noted in the anterior maxillary region. Appropriate treatment begins with good oral hygiene and repair of any irritating dental condition. A discrete interdental granulomatous lesion, granuloma gravida rum, or "pregnancy tumor" will develop in two percent of these patients. These lesions will regress sponta neously after pregnancy and rarely become large or symptomatic enough that local excision is warranted. Other oral manifestations during pregnancy include increased salivation and alterations in taste and smell. Pregnant women commonly experience increases in ap petite, and some crave strange food combinations or occasionally nonfood materials. 29
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AfRODIOfSTIVE MANIFESTATIONS Pregnant women commonly report hoarseness and chest pain. Esophageal reflux commonly occurs during pregnancy, especially in the third trimester. Increased abdominal pressure, decreased gastric emptying, in creased intestinal transit time, and decreased lower esophageal pressure contribute to the condition. Reflux
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to fetal goiter or cretinism. Propylthiouracil (PTU) is preferred over methimazole because PTU crosses the placenta relatively poorly and is thus safer. As with all thyroid disorders, close consultation with an endo crinologist is essential. 33
CONCLUSION There are many otolaryngologic manifestations dur ing pregnancy. While most of these disorders are benign and revert to normal postpartum, it is important that the otolaryngologist be familiar with these conditions and their appropriate treatment so that the best care can be delivered to the pregnant mother, without harm to her unborn child. REFERENCES 1. Miller JB. Patulous eustachian tube. Arch Otolaryngol Head Neck Surg 1961;73:310-21. 2. Derkay CS. Eustachian tube and nasal function during preg nancy: a prospective study. OTOLARYNGOL HEAD NECK SURG
1988;99:558-66. 3. Miller JB. Patulous eustachian tubes in pregnancy. West J Surg Obstet Gynecol 1962;70:156-9. 4. Morrison AW. Diseases of the otic capsule. In: Scott-Brown WB, ed. Diseases of ear, nose, and throat. 4th ed. London: Butterworth, 1965:414. 5. Walsh TE. The effect of pregnancy on the deafness of otoscle rosis. Trans Am Acad Ophthalmol Otolaryngol 1954;58:420-6. 6. Lewis JS. Surgery of the ear, nose, and throat in pregnancy. In: Barber HRK, Graber EA, eds. Surgical diseases in pregnancy. Philadelphia: WB Saunders Co, 1974:248-53. 7. Shambaugh GE, Glasscock ME III. Surgery of the ear. 3rd ed. Philadelphia: WB Saunders Co, 1980:461. 8. Hansen L, Sobol SM, Abeison TI. Otolaryngologic manifesta tions of pregnancy. J Fam Pract 1986;23:151-5. 9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 2nd ed. Baltimore: Williams & Wilkins, 1984:xiixix. 10. Holt GR, Mabry RL. ENT Medications in pregnancy. OTOLAR YNGOL HEAD NECK SURG 1983;91:338-41.
11. The physician's desk reference. 43rd ed. Oradell, NJ: Medical Economics Co, 1989:528, 1773, 2149. 12. Hilsinger RL, Adour KK, Doty HE. Idiopathic facial paralysis, pregnancy, and the menstrual cycle. Ann Otolaryngol 1975;84: 433-42. 13. Robinson JR, Pou JW. Bell's palsy: a predisposition of pregnant women. Arch Otolaryngol 1972;95:125-9. 14. Pope TH, Kenan PD. Bell's palsy in pregnancy. Arch Otolar yngol Head Neck Surg 1969;89:52-6.
15. Mabry RL. The management of nasal obstruction during preg nancy. Ear Nose Throat J 1983;62:16-9. 16. Mortimer H, Wright RP, Collip JB. The effect of the adminis tration of oestrogenic hormones on the nasal mucosa of the mon key. Can Med Assoc J 1936;35:503-12. 17. Toppozada H, Michaels L, Toppozada M, El-Ghazzawi I, Talaat M, Elwany S. The human respiratory mucosa in pregnancy. J Laryngol Otol 1982;96:613-26. 18. Sorri M. Rhinitis during pregnancy. Rhinology 1980;18:83-6. 19. Mabry RL. Rhinitis of pregnancy. South Med J 1986;79:96571. 20. Chow AW, Je wesson PJ. Pharmacokinetics and safety of anti microbial agents during pregnancy. Rev Infect Dis 1985;7:287313. 21. Scharz RH. Consideration of antibiotic therapy during preg nancy. Obstet Gynecol 1981;58:95-9. 22. Safety of antimicrobial drugs in pregnancy. Med Lett 1987; 29:61-3. 23. Amino N, Tanizawa O, Miyai K. Changes of serum immuno globulins IgG, IgA, IgM, and IgE during pregnancy. Obstet Gynecol 1978;52:415-20. 24. Mabry RL. Intranasal steroid injection during pregnancy. South Med J 1980;73:1176-9. 25. Howard DJ. Life-threatening epistaxis in pregnancy. J Laryngol Otol 1985;99:95-6. 26. Kent DL, Fitzwater JE. Nasal hemangioma of pregnancy. Ann Otol Rhinol Laryngol 1979;88:331-3. 27. Fechner RE, Slaughter GFH, Pope TL. Extraordinary growth of giant cell reparative granuloma during pregnancy. Arch Otolar yngol Head Neck Surg 1984;110:116-9. 28. Letter/man G, Schuster M. Cutaneous hemangiomas of the face in pregnancy. Plast Reconstr Surg 1962;29:293-300. 29. McCarty PL. Disorders of the oral cavity. In: Moschella SL, Pillsbury DM, Hurley HO, eds. Dermatology. Philadelphia: WB Saunders, 1975:1594. 30. Downtown D. Diseases of the mouth. In: Scott-Brown WB, ed. Diseases of the ear, nose, and throat. 4th ed. London: Butterworth, 1965:32-3. 31. Mugliston TAH, Sangwan S. Persistent cavernous hemangioma of the larynx—a pregnancy problem. J Laryngol Otol 1985;99: 1309-11. 32. Talbert LM. Hyperthyroidism during pregnancy. Obstet Gynecol 1970;36:779-85. 33. Becker FO, Reeves BD, Economou SG. Endocrine gland surgery in pregnancy. In: Barber HRK, Graber EA, eds. Surgical diseases in pregnancy. Philadelphia: WB Saunders Co, 1974:267-77. 34. Worley RJ, Crosby WM. Hyperthyroidism during pregnancy. Am J Obstet Gynecol 1974;119:150-5. 35. Cooper DS. Medical progress: antithyroid drugs. Ν Engl J Med 1984;311:1353-62.
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