Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The pregnant woman occupies a unique position in the sphere of medicine. The metabolic, endocrinologic and physiologic alterations associated with pregnancy affect every organ system to some degree. Many of these changes lead to symptomatology referable to the head and neck, and various disorders managed by the otolaryngologist are more prevalent during pregnancy. Thus, it is important for the otolaryngologist to be familiar with the physiological changes associated with pregnancy and how these changes are manifested in the head and neck. The management of these disorders is also complicated by the gravid state and therefore a thorough understanding of the medical and surgical effects of our therapeutic interventions on both mother and fetus is imperative.

The respiratory system undergoes important changes during pregnancy with regard to the upper airway as well as lung mechanics. These changes are responsible for many of the upper airway symptoms experienced during pregnancy and also have important implications regarding surgery during pregnancy. The increased vascularity found in the respiratory tract mucosa as well as the generalized edema can make evaluation of the upper airway as well as intubation more difficult in that minor trauma to the airway is more likely to result in bleeding.

Lung volumes and capacities begin to change early on in pregnancy. However, the most marked deviations are seen during the second half of gestation. These changes have important implications for the anesthetic management of the pregnant surgical patient. Elevation of the diaphragm and the compensatory increase in the anterior-posterior diameter of the chest serve to keep the total lung capacity and vital capacity virtually unchanged. However these changes lead to an important 15-20% reduction in functional residual capacity. Because of the relationship between FRC and closing volumes, this reduction in FRC may lead to airway closure during normal mechanical ventilation.

Other changes in respiratory function include a 40 - 50 % increase in resting minute ventilation primarily due to an increase in tidal volume as a result of the respiratory stimulant effect of increased progesterone levels.. This, along with a 15% increase in oxygen consumption, places the pregnant surgical patient at an increased risk of hypoxia during periods of apnea or hypoventilation, which may occur during induction of anesthesia or during certain procedures such as direct laryngoscopy or bronchoscopy. To avoid hypoxia, preoxygenation with 100% O2 is recommended.

Important changes occur during pregnancy in terms of the cardiovascular and circulatory system. Increases in blood volume and cardiac output place the pregnant female in a hyperdynamic state. However, due to reduced peripheral resistance as well as a refractory state in regards to the effect of renin and angiotensin, blood pressure is normal or slightly decreased. Any elevation in blood pressure is considered abnormal. An extremely important change is the effect of uterine compression on the vascular system and the syndrome of aortocaval compression. In the supine position the gravid uterus may compress both the aorta as well as the inferior vena cava leading to a reduction in cardiac output. Although blood pressure may be maintained, an occult decrease in blood flow to the fetus may occur. This may be avoided by proper positioning of the surgical patient as well as careful anesthetic management to prevent loss of peripheral vascular tone that may further compromise venous return.

Although elective surgical intervention during pregnancy is obviously contraindicated, surgery may be necessary. Approximately 50,000 or 1.5% of pregnant women undergo surgery each year. Numerous otolaryngologic disorders may require surgical therapy during pregnancy. These include infectious disorders, trauma, airway problems and malignancy. As we have seen, certain precautions may be taken to decrease the risk to mother and fetus alike. Additionally, if surgery can be delayed, the second trimester is the most favorable time for surgical intervention. Surgery in the first trimester may expose the fetus to potentially teratogenic substances during the most crucial period of organogenesis. Surgery during the third trimester increases the risk of premature labor. Even with proper anesthetic and surgical management, surgery during pregnancy is associated with a 5-34 % incidence of perinatal mortality and a 9% incidence of premature labor.

A possible association between pregnancy, and idiopathic facial paralysis or Bell's palsy was first noted by Sir Charles Bell in 1830 and many authors have since reported a higher incidence of Bell's palsy in pregnancy. Hilsinger in 1975 calculated the incidence of Bell's palsy in pregnant women to be 45.1/100,000 compared with an incidence of 17.4/100,00 in nonpregnant women of the same age. This represents a 3.3 times increased risk, which is greatest during the third trimester. Several theories exist as to why pregnancy increases a women's risk of developing Bell's palsy. The edema hypothesis states that as a result of an increase in interstitial fluid volume, edema of the facial nerve and surrounding tissues may lead to compression of the nerve and ischemia in the fallopian canal. This is similar to the mechanism that is believed to account for the increased incidence of carpal tunnel syndrome in pregnancy. The other major hypothesis is the viral hypothesis. During pregnancy, gestational immunosuppression is induced by the rise in cortisol levels. This may lead to a reactivation of a latent herpes simplex virus. It has been demonstrated that the incidence of herpes simplex infection in pregnant women is higher than in nonpregnant women. This reactivation of the herpes virus could cause a facial paralysis analogous to the facial paralysis associated with Ramsay Hunt Syndrome. In terms of prognosis and treatment, the course of Bell's palsy is similar in pregnancy. The usual course of treatment with steroids may be used. However, the use of steroids early in pregnancy has been associated with an increased risk of cleft palates, and infants born to mothers receiving exogenous steroids should be watched for adrenal hypofunction.

The phenomenon of hearing loss associated with otosclerosis in pregnancy was first noted by Erhard in 1858. Before the era of stapes surgery, young women with otosclerosis were often advised to avoid pregnancy. In 1953 a questionnaire sent by Howard House to women with otosclerosis regarding the effects of pregnancy on their otosclerosis revealed a possible association. Out of 194 replies to his questionnaire, 55% had noticed no effect of the pregnancy on their otosclerosis, while 45 % noticed the deafness was made worse by pregnancy. Shambaugh, in 1967, reported the risk of increased hearing loss in pregnant women with otosclerosis to be about 25%. Some authors have attempted to show, without much success, that the risk of pregnancy adversely affecting hearing is greater in bilateral cases of otosclerosis and increases with subsequent pregnancies. Studies by House and Shea have shown that the effects of pregnancy on the progression of otosclerosis are more pronounced on a nonoperated ear as opposed to an operated ear.

While studies have suggested a possible association between pregnancy and hearing deterioration in patients with otosclerosis, no research exists that shows this association to be as strong as to recommend women with otosclerosis refrain from becoming pregnant. The best approach seems to be operating on women with suspected otosclerosis, if clinically indicated, before they get pregnant and possibly evaluating their hearing post partum.

Sudden sensorineural hearing loss, uncommonly seen during pregnancy, has been associated with toxemia of pregnancy and hypertension, presumably due to vascular occlusion of the microcirculation of the cochlea and auditory nerve by microemboli. Complete otologic and audiologic evaluation, as well as treatment of the toxemia, is recommended. Sudden sensorineural hearing loss may also rarely be seen during an uncomplicated pregnancy, possibly secondary to the hypercoagulable state seen during pregnancy. However, anticoagulation is to be discouraged.

Nasal obstruction during pregnancy, or rhinitis of pregnancy, has been accepted as a distinct and very common pathological and clinical entity for many years. It is believed to occur in anywhere from 5-32% of pregnant women and most commonly is first noted during the end of the first trimester, and may persist up to the time of delivery or a few weeks afterward. The nasal obstruction is associated with clear rhinorrhea and physical exam shows edematous nasal mucosa. This condition is caused by a number of related factors. The generalized increase in interstitial fluid volumes seen during pregnancy also affects the nasal mucosa, and is made worse by the direct effect of estrogen on the nasal mucosa, which causes increased vascularity and mucosal edema. Electronmicrographic and histochemical studies performed by Toppozada on the respiratory epithelium of pregnant women have suggested that an overactivity of the parasympathetic system leading to increased glandular secretion and vascular congestion is responsible for the state of nasal congestion. This overactivity of the parasympathetic system may be an allergic response to placental proteins, fetal proteins or a women's own sex hormones.

The treatment of this condition is complicated by the fact that many patients seek relief from over the counter topical decongestants, leading to a superimposed rhinitis medicamentosa, and the fact that the physicians are limited in terms of the medications that are safe to use during pregnancy. While the use of antihistamines has not been linked to any increases in the rate of fetal malformations, certain antihistamines carry a warning in the PDR that they should not be used during pregnancy. Systemic decongestants, while not teratogenic, carry the theoretical risk of causing placental insufficiency due to vascular constriction, and of aggravating hypertension of pregnancy. In light of this, the physician must carefully consider the risk benefit ratio before prescribing either of these two classes of medications Antibiotics should only be administered for specific infections, such as purulent sinusitis that may develop as a result of the generalized mucosal edema. Corticosteroid nasal aerosols may be very useful in refractory rhinitis of pregnancy as well as in treating superimposed rhinitis medicamentosa. Because of the very low systemic absorption seen at therapeutic dosages, the use of nasal steroids is safe during pregnancy. Lastly, intraturbinal corticosteroid injection, while not very popular, can be very effective in severe rhinitis, and has no risks other than those inherent to the procedure, namely inadvertent embolization to the retinal artery. The rate of systemic absorption is extremely low and thus its use during pregnancy is considered safe.

Epistaxis during pregnancy may be more common due to several factors. First and foremost, the increased vascularity of the nasal mucosa due to the effects of estrogen makes bleeding secondary to minor trauma much more likely. This generalized increase in vascular tissue has also been associated with the development of specific lesions such as giant cell reparative granulomas of the maxilla and mandible, or granuloma gravidarum, lobular capillary hemangiomas or pregnancy tumor and nasal hemangiomas. This last lesion has been associated with epistaxis during pregnancy. These hypervascular lesions typically appear in the oral or nasal cavities during the early months of pregnancy and involute following delivery or termination of pregnancy.

Eustachian tube dysfunction has been estimated to affect between 5% and 30% of pregnant women and can be variable in terms of its symptomatology. Dysfunction can consist of either tubal obstruction or patulous Eustachian tubes. The signs and symptoms, which usually begin after the first trimester, depend on which form of dysfunction exists. Women with tubal obstruction report a clogged or popping sensation in their ears with muffling of sounds. In severe cases, a serous effusion may develop. Women with patulous tubes usually manifest intermittent symptoms consisting of autophony and a roaring sensation in their ears that is synchronous with respiration and is worse in the upright position or with exercise. The pathophysiology of tubal obstruction is again related to edema of the respiratory mucosa. The cause of patulous Eustachian tubes is less clear. It has been noted that women with less weight gain during pregnancy are more likely to develop this condition and, ironically, any condition that leads to mucosal congestion will provide relief of symptoms.

Diagnosis is based primarily on history but tests of Eustachian tube dysfunction such as the patulous Eustachian tube test, in which impedance variations are seen with respiration, and sonotubometry, which measures sound transmission from the nasopharynx through the Eustachian tube to the middle ear during swallowing, may help make the diagnosis. Because symptoms are usually minimal, no treatment may be necessary. In cases in which symptoms are more distressing to the patient, increased humidity, frequent valsalva or Mueller maneuvers, and the injection of irritating substances into the peritubal space have had variable success in relieving symptoms.

Laryngopathia gravidarum is a term that has been used to describe the changes in laryngeal function seen during pregnancy. Two forms have been described, an acute form and a chronic recurrent form. In the acute presentation, women are affected just prior to delivery and present with dyspnea, hoarseness, sore throat and odynophagia. Laryngeal exam reveals edema of the aryepiglottic folds, arytenoids and false cords with sparing of the true vocal cords. Pathologically, one sees submucosal inflammation with an increase in the number of lymphocytes and plasma cells as well as dilated capillaries. In the chronic form, the symptoms are similar but persistent, and may begin earlier in pregnancy.

Gastroesophageal reflux is estimated to occur in 30% - 50 % of all pregnancies, with symptoms being most common during the last trimester. The pathophysiology of GE reflux involves primarily two factors, namely a decrease in lower esophageal sphincter tone and an increase in intra-abdominal pressure. The decrease in sphincter tone has been attributed to increased circulating levels of estrogen and progesterone, which cause a reversible inhibition of LES function. The increase in intra-abdominal pressure is secondary to the effects of the gravid uterus. Studies have also shown a delay in gastric emptying during pregnancy that may contribute to gastroesophageal reflux. The symptoms of GE reflux during pregnancy are similar to the nongravid state, with heartburn predominating. However, atypical presentations with chest pain, cough, wheezing, sore throat and hoarseness are seen. The treatment of reflux during pregnancy primarily involves lifestyle modifications, due to concerns regarding the possible teratogenicity of certain systemic drug therapy. However, the use of certain medications such as carafate and antacids, which are not systemically absorbed to any great extent, is believed to be safe as well as effective in decreasing the symptoms of GE reflux. Oral metoclopromide, which increases lower esophageal sphincter pressure and increases gastric emptying, has also been found to be effective in decreasing reflux and is considered safe. In regards to the H2 blockers, less information is available in terms of the possible teratogenic effects, yet they are generally felt to be safe. Omeprazole has been found in animal studies to produce dose related increases in fetal deaths and pregnancy disruptions, and thus, its use during pregnancy is not recommended.

Pregnancy commonly affects the thyroid gland and its function in important ways Ancient Egyptians viewed goiter as a positive sign of pregnancy assessed by snapping a reed tied around a women's neck. During a normal pregnancy, thyroid function and thyroid function test undergo physiological changes that are important to recognize when trying to identify the presence of disease. Total T4 and reverse T3 are elevated due to the influence of estrogen induced increases in thyroxine binding globulin or TBG. Free T4 and free T3 are slightly elevated early in pregnancy due to the thyrotropic effect of human chorionic gonadotropin. T3 uptake is normally reduced secondary to increased TBG concentrations. TSH levels are normal or suppressed early and rise to normal levels in the third trimester.

The main causes of hypothyroidism in developed countries are Hashimoto's thyroiditis, idiopathic myxedema, postablative hypothyroidism in Graves disease and surgical hypothyroidism. In underdeveloped countries, the main cause by far is iodine deficiency. Hypothyroidism during pregnancy is important to recognize because of its strong association with perinatal mortality and congenital malformations affecting both mental and somatic development. The diagnosis can be difficult in that normal pregnancy may be associated with hypothyroid-type symptoms. The most sensitive indicator of primary hypothyroidism is an elevated TSH. Treatment consists of thyroid replacement using L-thyroxine.

Hyperthyroidism occurs in about 2 of every 1000 pregnancies and untreated has been associated with a 6% incidence of neonatal mortality and low birth weight infants. The most common cause is autoimmune thyrotoxicosis or Graves disease even though Graves disease tends to remit in late pregnancy. Thyrotoxicosis may also be associated with the severe vomiting seen with hyperemesis gravidarum, believed to be caused by increased levels of beta hCG. The diagnosis of hyperthyroidism may be suspected by the usual clinical findings and confirmed by thyroid function test showing high levels of total and free T4 and T3 with suppressed TSH levels. The treatment of choice for hyperthyroidism during pregnancy are the antithyroid drugs, specifically propylthiouracil because it is more highly protein- bound than the other agents and thus crosses the placenta to a lesser extent. Betablockers may be used for short periods of time to treat severe and symptomatic thyrotoxicosis. Radioactive iodine is absolutely contraindicated during pregnancy. The main indication for surgery in the treatment of hyperthyroidism is major or intolerable side effects of medical therapy.

There is little evidence that pregnancy has any effect on the development of thyroid nodules or malignancy. However, asymptomatic nodules may be found on physical exam. The workup of a thyroid nodule is slightly different during pregnancy in that thyroid scans are contraindicated. Fine needle aspirations may be helpful in determining the nature of the nodule and thus the best course of treatment. If FNA reveals a malignancy, then surgery, preferably during the second trimester, is indicated. If discovered late in the pregnancy, then one may wait until the postpartum period to operate. Radioactive iodine is contraindicated during pregnancy. Benign nodules may be followed clinically or suppression with thyroxine may be attempted. The dilemma arises when FNA cannot distinguish benign from malignant as is commonly the case. In this situation, the decision as to whether to treat conservatively or perform surgery must be made in close conjunction with the patient after explaining carefully the potential risks and benefits.

The list of otolaryngologic disorders and manifestations experienced by the gravid female is quite extensive. The management of these disorders can be both challenging and frustrating for the otolaryngologist. The usual armamentarium, both medical and surgical, used to treat these disorders is reduced by the restrictions emposed secondary to considerations regarding the welfare of the fetus.

Thus, it is important for the otolaryngologist treating these patients to have a basic understanding of the changes experienced by the pregnant patient both mentally and physically, as well as a thorough understanding of the head and neck manifestations of pregnancy. Lastly, one must keep in mind that our therapeutic interventions affect more than just one human life, and what is good for the patient may not necessarily be good for the unborn fetus.

A 26-year-old, G4 P2 Ab1 Latin American woman presented during her 16th week of pregnancy. She complained of nasal obstruction which began during the first trimester of her previous pregnancy and resolved shortly after delivery. She has again begun to experience constant nasal obstruction for which she has been taking Afrin on a regular basis. Her symptoms are worse at night and are associated with clear nasal discharge and occasional facial pain and pressure. She denies any history of fever or purulent rhinorrhea. Physical exam was significant for erythematous and boggy nasal mucosa with clear discharge. There was no facial tenderness noted. The rest of her physical exam was normal. She was strongly encouraged to discontinue her Afrin use and was started on Beconase nasal steroid preparation. On her follow-up visit she reports that she has stopped using Afrin and her symptoms have improved.

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