Pregnancy is associated with many hormonal and physiological changes, with the ear, nose and throat (ENT) region being no exception. Approximately 30% of gravid women suffer from nasal disorders, including increased incidence of rhinitis and congestion of the sinuses that may lead to a higher rate of sinus infections as well as an increased incidence of epistaxis.^1,2,3 For other ENT problems, the incidence is generally similar to non-pregnancy.⁴ (See Table 1 for a clinical tool covering key principles.)

‘Pharyngitis in pregnancy is often secondary to GERD as a result of progesterone-induced decreased lower esophageal tone. … Treatment should begin conservatively.’

Ears

Otitis externa: Usual treatments, including polymyxin B-neomycin-hydrocortisone otic suspension, are safe in pregnancy if there is no evidence of a tympanic membrane perforation. If tympanic membrane perforation cannot be safely ruled out, then hydrocortisone/ciprofloxacin otic suspension may be used, or the (usually) less expensive option would be using ofloxacin otic suspension plus 0.05% dexamethasone ophthalmic suspension.

Dizziness: Review blood pressure to make sure the symptom is not part of a pregnancy-induced hypertension problem. Also evaluate neurologic status for any other signs of vertebrobasilar CVA. One prospective study found that 52% of a pregnant cohort complained of dizziness. Most cases are secondary to non-vestibular causes.⁵ The nausea and vomiting associated with pregnancy may be precipitated or influenced by the hormonal or fluid-volume changes occurring in the vestibular system. Treatments include anti-emetics (e.g., ondansetron, metoclopramide), meclizine, and canalith or other repositioning maneuvers for the same indications as in non-pregnancy. When used for proper indications, the medicines are generally considered safe throughout pregnancy.

Tinnitus: Tinnitus may be an early warning sign of gestational hypertension and preeclampsia. Evaluate blood pressure accordingly.⁶

‘The only randomized control trial of allergic rhinitis in pregnancy failed to demonstrate a benefit of fluticasone compared to placebo in pregnant women.’

Nose

Pregnancy rhinitis: Pregnancy rhinitis has been reported in nearly one quarter of all pregnancies. It can manifest in any trimester with complete resolution noted within 2 weeks of delivery.4 The only randomized control trial [RCT] of allergic rhinitis in pregnancy failed to demonstrate a benefit of fluticasone compared to placebo in pregnant women.⁷ Nasal lavage is an acceptable therapy for pregnancy-associated rhinitis.⁸ Although it is unknown whether or not pregnancy is associated with an increased sensitivity to allergens, antihistamines can be used for symptom control. First generation antihistamines (e.g., chlorpheniramine, tripelennamine) and second generation antihistamines (e.g., loratadine) are options.⁹

Other treatments include: Anticholinergics: ipratropium nasal spray (Atrovent® 0.03% for allergic rhinitis and 0.06% for colds) can be prescribed as 1-2 sprays each nostril bid to tid. It appears to be safe in pregnancy; External Nasal Dilator: This device (e.g. Breathe Right®), sold over the counter, mechanically widens the external nasal passages. It can improve pregnancy-related nocturnal nasal congestion; Smoking: Discontinuation of smoking is an important part of treatment (in addition to the importance of stopping because of pregnancy itself). This includes avoidance of passive smoke exposure.

Epistaxis: Rates of epistaxis⁴ are increased in pregnancy up to 20% vs. 6% of non-pregnant women, likely secondary to increased vascularity of the nasal mucosa. Pregnant women may also develop gravid granulomas and nasal hemangiomas that lead to severe bleeding. With packing, use antibiotics as in non-pregnancy; beta lactams are safe.

Intranasal thrombin is category C: as pregnant patients are already hypercoagulable, the effect of the drug may be a concern. Discuss with appropriate consultant prior to use.

Sinus

Acute bacterial rhinosinusitis [ABRS]: 2012 guidelines from the Infectious Diseases Society of America¹⁰ are generally applicable to pregnant patients. These include:

• Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low recommendation)
• Either doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) is recommended as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin (strong, moderate).
  • Tetracyclines (including doxycycline, minocycline, etc.) can lead to tooth and bony defects in the fetus. They can also be hepatosis when given IV in excess doses or when given to a mother with compromised renal function. However, under certain circumstances it may be acceptable if recommended by consultant.
  • In high [beta]-lactam– and macrolide-resistance settings, the fluoroquinolones are preferred. The risk of teratogenicity is low, and fluoroquinolones can be given during pregnancy if indicated.¹¹
• Intranasal saline irrigation with either physiologic or hypertonic saline is recommended as an adjunctive treatment (weak, low-moderate).
• Intranasal corticosteroids (INCSs) are recommended as an adjunct to antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis (weak, moderate).
• Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive treatment

Bell’s palsy

Bell’s palsy^12,13,14 is most likely to present in the third trimester of pregnancy and has been associated with a worse prognosis than for non-pregnant patients, likely secondary to reluctance of providers to treat this condition. There is a beneficial effect on recovery if prednisolone is started within 72 hours of facial weakness, with acyclovir providing no additional benefit. Corticosteroids, when indicated, are considered safe in pregnancy.

Throat

Sore throat – Pharyngitis: Pharyngitis in pregnancy is often secondary to GERD as a result of progesterone induced decreased lower esophageal tone.¹⁵ Symptoms tend to dissipate postpartum, and treatment should begin conservatively. However, proton pump inhibitors and H2 antagonists are considered safe treatments by most specialists.⁴

Hoarseness: consider laryngopathia gravidarum – caused by changes in the fluid content of the lamina propria just beneath the laryngeal mucosa.¹⁶ Symptoms include hoarseness, voice loss, deeper voice, and diminished range of pitch.¹⁷ Treatment is supportive with hydration, and singers are encouraged to refrain from singing. Symptoms typically resolve postpartum.

Thyroid Nodules: Diffuse thyroid enlargement during pregnancy occurs in up to 50% of pregnant women. Growth of existing nodules and new nodule formation may also occur during pregnancy.¹⁸ Initial TSH may be helpful, but generally these patients, if stable, are referred for outpatient work-up.

Patient ed

Patient instructions such as this may be distributed: www.babycenter.com/0_stuffy-nose-during-pregnancy_1076.bc

Dr. Roemer is an adjunct associate professor in the Department of Emergency Medicine at the OU School of Community Medicine, Schusterman Center, Tulsa, Okla.; Dr. Martinez is a resident emergency physician in the Department of Emergency Medicine, OU School of Community Medicine, Tulsa, Okla.; Dr. Katz is a clinical professor, Department of OB-GYN, Oregon Health Sciences University, and Medical Director, Women’s Services, Sacred Heart Medical Center, Center for Genetics and Maternal-Fetal Medicine, Eugene, Ore.; and Dr. Riggs is a resident in the Department of Otorhinolaryngology, OU Health Sciences Center, Oklahoma City, Okla.

References

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