ENT complaints in pregnancy. Part 1: sinonasal disease: pregnancy can cause or aggravate otolaryngologic complaints such as rhinitis, infectious sinusitis, and epistaxis: two ENT specialists offer guidance for your practice on the diagnosis and treatment of these and other sinonasal conditions.
In this two-part series, we review the diagnosis and management of several head and neck conditions encountered during routine obstetric care. In this initial article, we focus on sinonasal disease. In Part 2, which will appear in the September issue of OBG MANAGEMENT, the subjects include gastroesophageal reflux and laryngopharyngeal reflux, laryngopathia gravidarum, eustachian tube dysfunction, melasma, and other conditions.
A careful history draws out vital clues
Among the general public, Sinonasal disease is a common complaint that can profoundly impair quality of life. In the gravid patient, sinonasal symptoms may be magnified. Nasal congestion and rhinorrhea disrupt sleep and affect appetite, and can exacerbate preexisting sinusitis and asthma.
In pregnancy, the differential diagnosis of rhinitis Includes:
* allergic rhinitis
* infectious sinusitis
* pregnancy rhinitis
* rhinitis medicamentosa
* structural nasal obstruction
* vasomotor rhinitis.
A careful history can usually identify the cause of the complaint. For example, has the patient had allergic rhinitis before? If so, is this episode occurring in the same season?
Do congestion and rhinorrhea Increase when she is eating or exercising or during cold weather? Then vasomotor rhinitis is the likely culprit.
Is the patient using a topical nasal decongestant? If she is, consider rhinitis medicamentosa.
And if she experiences purulence, facial pain, headache, or a diminished sense of smell, think sinusitis.
Pregnancy rhinitis usually responds to simple measures
Pregnancy rhinitis is nasal airway obstruction and rhinorrhea that appear during pregnancy, last for at least 2 months, and disappear postpartum. (1) Incidence ranges from 9% to 22%. (2,3)
Although the underlying cause of pregnancy rhinitis has not been fully elucidated, numerous theories have merit. Among the findings that have been linked to the condition are:
* elevated estrogen and progesterone levels
* increased mucosal acetylcholine receptors
* decreased alpha-adrenergic response with subsequent smooth muscle vascular dilatation
* increased blood volume with extravascular engorgement and congestion
* rising values of placental growth hormone (4)
* elevated inflammatory response.
Conservative treatment is the norm
A mainstay of therapy for rhinitis is nasal irrigation using physiologic hypertonic saline solution, which can be purchased commercially or prepared at home. The patient sniffs the solution from her cupped hand or uses a nasal syringe or other commercial product to administer it. Irrigation can be repeated as often as necessary. The saline provides temporary relief, reduces the amount of secretions, and removes dried crusts that may obstruct the nasal airway.
Physical exercise is known to have a decongesting effect on the nasal mucosa. (5) Elevating the head of the patient's bed 6 to 8 inches also may help reduce morning nasal congestion and nocturnal snoring. In addition, simple devices (e.g., Breathe Right nasal strips) that stent open the internal nasal valve may be useful and pose no risk to the fetus.
If conservative measures prove to be ineffective, pharmaceutical products may be an option. Nasal steroids are likely to be safe in pregnancy and may provide relief. However, we lack definitive data establishing their efficacy.
For recalcitrant cases, consider RFA
When nasal congestion is unresponsive to medical therapy and simpler measures, radiofrequency ablation (RFA) may reduce the size of nasal turbinates. In general, we reserve RFA in pregnancy for patients who have a prepregnancy diagnosis of obstructive sleep apnea, who develop pregnancy rhinitis that is unresponsive to conservative measures, and who are unable to tolerate continuous positive airway pressure (CPAP) because of nasal congestion.
RFA can be performed in an office following administration of topical anesthetics. Tissue is ablated by heat desiccation created by frictional energy (<85[degrees]F), leading to coagulative necrosis and tissue shrinkage, with fibrotic scarring and prolonged volume reduction.
One of the advantages of this approach is preservation of the nasal mucosa and normal mucociliary function.
The degree and duration of volume reduction varies between patients, and data on long-term outcomes are still being collected.
Allergic rhinitis may flare during pregnancy
An allergic response to environmental allergens in the nasal mucosa may begin, worsen, or improve during pregnancy due, in large part, to complex immune alterations. Symptoms of allergic rhinitis typically are nasal congestion, watery rhinorrhea, and sneezing. Additional complaints may include:
* blockage of eustachian tubes
* postnasal drip
* a sensation of pressure in the sinuses resulting from edema and venous engorgement of the nasal mucosa.
Allergic rhinitis occurs when inhaled allergens interact with preformed immunoglobulin E (IgE) antibodies on ceils in the airway. (6) Diagnosis requires a thorough history documenting seasonality, year-to-year persistence, and inciting factors. A physical exam reveal clear rhinorrhea and edematous, engorged turbinates and nasal mucosa.
If conservative measures fail, try a pharmaceutical
Several drug therapies are available that address the underlying pathophysiologic process and relieve symptoms when conservative measures fail:
* Cromolyn sodium nasal spray is a mastcell stabilizer that prevents degranulation of inflammatory mediators through interaction between antigen and preformed IgE antibodies on the surface of mast cells (Pregnancy Category B)
* Antihistamine therapy may be helpful in patients who experience significant rhinorrhea and sneezing. We use 25 to 50 mg of tripelennamine as needed (every 6 hours, to a maximum dosage of 200 mg/d) or 4 to 24 mg/d of chlorpheniramine (in divided doses). These drugs are thought to be safe because of their long history and studies in humans, which show no compromise in fetal outcomes. Newer drugs, such as loratadine (Claritin; Category B) and cetirizine (Zyrtec; Category B), are also considered safe and routinely utilized in our clinic. Human data are limited for fexofenadine (Allegra) and azelastine (Astelin) in pregnancy
* Leukotriene inhibitors include zileuton (Zyflo; Category C), montelukast (Singulair; Category B), and zafirlukast (Accolate; Category B). The approved indications for montelukast include treatment of seasonal allergies and asthma, whereas zafirlukast is indicated only for the treatment of asthma. We do not recommend the use of montelukast for allergic rhinitis in pregnancy because there are alternative treatments that are equally or more effective for which we have much more human data on gestational safety
* Inhaled steroids administered at standard dosages do not impede intrauterine growth, according to published data. Fluticasone propionate (Flonase; Category C) nasal spray does not have a detectable effect on a gravida's morning serum cortisol level or overnight 12-hour urine cortisol level. Nor does it affect fetal growth (as measured by ultrasonography) or pregnancy outcome. (7) When it was inhaled by women in early pregnancy, budesonide (Rhinocort; Category B) did not increase the rate of congenital malformation among 2,014 infants above the rate found in the general population? It likely could also be used safely when inhaled nasally for rhinitis during pregnancy.
Immunotherapy should be avoided during pregnancy due to the small risk of anaphylaxis, although it decreases airway hyper-reactivity and can improve asthma? Skin testing for allergen sensitivity should also be avoided during pregnancy due to the risk of anaphylaxis, and in vitro radioallergosorbent testing (RAST) has limited value in pregnancy owing to variable serum IgE levels. However, most authors agree that immunotherapy can be continued after conception in women who have experienced clinical benefit without systemic reactions. (10)
Vasomotor rhinitis is poorly understood
This condition differs from allergic rhinitis in that symptoms are triggered by changes in temperature or barometric pressure, or both; postural changes; and nasal irritants, such as indoor cleaning solutions, mildew odors, refrigerant (circulating in closed-ventilation systems), perfumes and potpourris, and fresh paint. (11) Patients who have vasomotor rhinitis do not exhibit nasal eosinophilia, and testing for sensitivity to seasonal and perennial allergens is invariably negative. Therefore, diagnosis of vasomotor rhinitis requires the exclusion of allergic rhinitis.
Although the pathophysiology of vasomotor rhinitis is poorly understood, inhaled nasal ipratropium (Atrovent; Category B) is a mainstay of therapy.
Cause of rhinitis medicamentosa? Nasal decongestant sprays
Prolonged use of topical nasal decongestants (oxymetazoline [Afrin; Category C] and phenylephrine [Neo-Synephrine; Category C]) may lead to this condition, which does not resolve spontaneously after delivery. Rebound swelling of the mucosa increases nasal congestion after the decongestive effect of the drug has disappeared. Patients must increase the dosage and frequency of administration of a vasoconstrictor to gain relief. In addition, benzalkonium chloride, a preservative in the nasal preparation, frequently exacerbates congestion. Even small dosages of topical nasal decongestants administered only in the evenings to healthy subjects resulted in rhinitis medicamentosa. (12) We believe abuse of these agents is driven by fears of oral medication, coupled with the belief that nasal sprays are safe.
In general, we strongly discourage use of nasal decongestants to treat chronic rhinitis. Acute sinusitis or severe nasal congestion that is unresponsive to conservative measures may be treated with a short course of one of these agents, provided the patient stops using the drug after 3 to 5 days.
The treatment of rhinitis medicamentosa is cessation of nasal decongestant.
Rate of infectious sinusitis skyrockets in pregnancy
This condition is one of the most common health problems in the general US population-and studies suggest that the incidence increases sixfold in pregnancy. (13) Although data on bacterial sinusitis in pregnancy are extremely limited, the organisms involved appear to be identical to those found in the general population. The majority of cases involve Streptococcus pneumoniae and Haemophilus influenzae. (14)
Pregnant women don't always have classic symptoms and signs
Classic symptoms and signs of sinusitis are absent in almost 50% of women who have documented purulent sinusitis during pregnancy. (13) We recommend that you maintain a high index of suspicion for sinus infection in any gravida who experiences persistent nasal symptoms that are unresponsive to conservative measures. The following symptoms should raise a red flag:
* colored nasal discharge
* maxillary toothache
* facial pain and pressure that is exacerbated by bending forward
Signs of acute bacterial sinusitis include mucous crusting, inability to transilluminate the maxillary sinuses, and visualization of mucopurulence during examination. (15)
Reserve radiographic imaging for patients who experience dramatic symptoms, such as severe, unilateral maxillary pain; facial swelling; and fever; and for patients who have not responded to antibiotic therapy.
Amoxicillin is the drug of choice
According to clinical practice guidelines from the American College of Physicians, most cases of acute sinusitis in the outpatient setting are the result of uncomplicated viral infection, so sinus radiography and antibiotic therapy are usually unnecessary. (16) Instead, the guidelines suggest that symptoms be treated using analgesics, antipyretics, and decongestants as the initial management strategy. (17)
In pregnancy, however, because of the limited pharmaceutical options, we recommend bypassing the usual agents in favor of amoxicillin when the patient has symptoms of sinusitis and purulent discharge. In patients who do not respond to initial treatment, we give amoxicillin/clavulonate (Augmentin; Category B) as second-line therapy.
Although an association between antenatal exposure to Augmentin and neonatal necrotizing enterocolitis in the setting of premature rupture of membranes has been suggested, recent studies do not support these findings. (18,19)
In patients who are allergic to penicillin, we administer the macrolide azithromycin (Category B).
Is snoring cause for concern?
In the nonpregnant population, the incidence of snoring is 4%. During pregnancy, however, it ranges from 14% to 23%. (20,21) Although some clinicians argue that the increased incidence of snoring during pregnancy suggests a positive correlation with sleep-disordered breathing, the scientific evidence does not yet firmly support such a conclusion. (22)
Concern about an association between sleep-disordered breathing and intrauterine growth restriction (IUGR) derives from studies conducted on pregnant subjects who lived in higher altitudes or who experienced hypoxia due to pulmonary parenchymal disorders. These studies demonstrated that maternal hypoxia was associated with retarded fetal development. (23)
Human studies linking sleep-disordered breathing to IUGR have not been definitive, however. One large study found impaired fetal development in 8 (7.1%) of 113 pregnant women who had habitual snoring and 10 (2.6%) of 379 pregnant women who did not have habitual snoring. (21) However, another study found that pregnant women who snored did not deliver infants with compromised outcomes. (20)
If a woman has a prepregnancy diagnosis of obstructive sleep apnea, for which she was advised to use CPAP, it is safe to continue such therapy in pregnancy. (24)
Epistaxis usually abates with local pressure
The incidence of epistaxis during pregnancy is 20%. (25) It is likely caused by endocrine alterations in the nasal mucosa and increased vascular congestion. Treatment typically involves 30 minutes of direct local pressure. Once the bleeding stops, saline nasal sprays and topical petroleum jelly help provide humidity and prevent recurrence. Severe hemorrhage unresponsive to local pressure warrants an otolaryngology consultation that includes investigation for additional pathology.
Hemangiomas sometimes appear in the early months of pregnancy and involute postpartum. Hypertension and toxemia can also produce epistaxis.
See Part 2 of this article in the September issue of OBG MANAGEMENT, for more on ENT complaints in pregnancy.
Reserve radio-frequency ablation for women who have a prepregnancy diagnosis of obstructive sleep apnea and who cannot tolerate CPAP because of refractory nasal congestion
Inhaled nasal ipratropium is a mainstay of therapy for vasomotor rhinitis
In pregnancy, most cases of infectious sinusitis involve Streptococcus pneumoniae and Haemophilus influenzae--just as in the nonpregnant state
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(16.) Physicians CPGotACo. www.annals.org/cgi/ content/full/134/6/495.
(17.) Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. 2004;351(9):902-910.
(18.) Kenyon SL, Taylor DJ, Tarnow-Mordi W, for ORACLE Collaborative Group. Broad-spectrum antibiotics for spontaneous preterm labour: the ORACLE II randomised trial. Lancet. 2001;357(9261):989-994.
(19.) Al-Sabbagh A, Moss S, Subhedar N. Neonatal necrotising enterocolitis and perinatal exposure to co-amoxyclav. Arch Dis Child Fetal Neonatal Ed. 2004;89(2):F187.
(20.) Loube DI, Poceta IS, Morales MC, Peacock MD, Miter MM. Self-reported snoring in pregnancy. Association with fetal outcome. Chest. 1996; 109(4):885-889.
(21.) Franklin KA, Holmgren PA, Jonsson F, Poromaa N, Sterdund H, Svanborg E. Snoring, pregnancy-induced hypertension, and growth retardation of the fetus. Chest. 2000;117(1):137-141.
(22.) Guilleminault C, Querra-Salva M, Chowdhuri S, Poyares D. Normal pregnancy, daytime sleeping, snoring and blood pressure. Sleep Med. 2000;1(4):289-297.
(23.) Bernstein I. Intrauterine growth restriction. In: Gabbe SG, Niebyl JR, Simpson IL, eds. Obstetrics: Normal and Problem Pregnancies. 3rd ed. New York: Churchill Livingstone; 1996:863-886.
(24.) Gullleminault C, Kreutzer M, Chang JL. Pregnancy, sleep disordered breathing and treatment with nasal continuous positive airway pressure. Sleep Med. 2004;5(1):43-51.
(25.) Dugan-Kim M, Connell S, Stika C, Wong CA, Gossett DE Epistaxis of pregnancy and association with postpartum hemorrhage. Obstet Gynecol. 2009; 114(6): 1322-1325.
Dr. Funk is a Facial Plastic Surgeon at the Bressler Center in Houston, Texas.
Dr. Gelbard is a Fifth-Year Resident in the Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery at the Baylor College of Medicine in Houston. Texas.
The authors report no affiliation or financial arrangement relevant to this article.
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|Title Annotation:||FIRST OF 2 PARTS|
|Author:||Funk, Etai; Gelbard, Alexander|
|Article Type:||Clinical report|
|Date:||Aug 1, 2010|
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