|Year : 2020 | Volume
| Issue : 2 | Page : 30-34
Laryngeal manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of eastern India
Santosh Kumar Swain1, Tapan Pattnaik2, Satyabrata Acharya1
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Obstetrics and Gynecology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
|Date of Submission||02-Dec-2019|
|Date of Decision||12-Jan-2021|
|Date of Acceptance||14-Jan-2021|
|Date of Web Publication||19-Feb-2021|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Background: There are several physiological changes seen in pregnant women and among them, laryngeal changes are quite important. The laryngeal manifestations in pregnant women are mainly due to changes of the sex hormones levels and these returns to normal in postpartum period. Objective: The objective is to study the laryngeal manifestations in pregnant women. Materials and Methods: This is a prospective observational study where 54 pregnant women participated in this study for laryngeal manifestations. A questionnaire was asked to all participants for assessing the laryngeal manifestations in pregnant women. Eighty-four pregnant women in the age group of 22–35 years participated in this study. They underwent complete laryngeal and obstetric examination. Indirect laryngoscopy and laryngeal endoscopic examinations were done in all cases for the evaluation of hearing loss. Results: The mean age of the pregnant women participated in this study was 26.23 years. The most common otological manifestation was foreign body sensation in throat and it common in first trimester of the pregnancy. Dysphonia was found in 22.22% of the cases. Other manifestations were laryngopharyngeal reflux and hoarseness of voice. Conclusion: The alteration of the hormonal milieu in pregnant women can lead to several laryngeal manifestations such as foreign sensation in throat, change in voice, and irritating cough. Although there are several laryngeal manifestations are seen in pregnant women, yet these manifestations often neglected in clinical practice.
Keywords: Dysphonia, globus, laryngeal manifestations, larynx, pregnancy
|How to cite this article:|
Swain SK, Pattnaik T, Acharya S. Laryngeal manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:30-4
|How to cite this URL:|
Swain SK, Pattnaik T, Acharya S. Laryngeal manifestations in pregnancy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2021 Jul 26];4:30-4. Available from: https://www.aiaohns.in/text.asp?2020/4/2/30/309788
| Introduction|| |
Pregnancy is the period where endocrinal, metabolic, and physiological alterations occur throughout the body including the larynx. The altered hormonal setting is the important factor responsible for physiological or pathological changes during pregnancy. These changes occur due to the production of certain hormones during pregnancy such as estrogen and progesterone as well as placental hormones such as human chorionic gonadotropin (HCG), human placental lactogen (HPL) human chorionic corticotrophin, human chorionic thyrotropin (HCT), and somatomammotropin. These hormones have huge impact on physiology and immunological consequences during the pregnancy. Majority of the alteration in the larynx are temporary and often disappear after delivery of the fetus but few may continue. The surge of estrogen and progesterone during pregnancy cause swelling of the mucosal membrane of the larynx, nasal cavity, oral cavity, and pharynx. Laryngeal manifestations may vary from minor voice changes to life-threatening airway obstruction which requires appropriate and timely management to secure a patent and safe airway. There are no studies to our knowledge about laryngeal manifestations of pregnant women in eastern India. The aim of this study was to find out laryngeal manifestations among pregnant women at a tertiary care teaching hospital of eastern India.
| Materials and Methods|| |
This is a prospective observational study done at the Department of Otorhinolaryngology and Obstetric and Gynecology of a tertiary care teaching hospital of eastern India. This study was conducted between July 2017 and August 2019. This study was approved by Institutional Ethical Committee (IEC) with reference number IEC/IMS/SOAU/32/2017. There were 54 pregnant women presenting with laryngeal manifestations were included in this study. All the participants of this study signed an informed consent agreement. The age range of the participants ranged from 20 to 32 years with mean age of 24.6 years. The inclusion criteria for this study were pregnant women with no previous risk factors for laryngeal and laryngopharyngeal manifestations. The exclusion criteria in this study were pregnant women with no systemic diseases, no toxemia during pregnancy, nondiabetic and nonhypertensive and no previous laryngeal diseases. All underwent complete examinations of the larynx and pharynx. All participants underwent indirect laryngoscopy, direct endoscopic examination of the larynx, examination of the oral cavity, oropharynx, and neck. Direct endoscopic examination of the larynx by 70° rigid Hopkins endoscopy was used in all cases for proper examination of the larynx, hypopharynx, and oropharynx. All the participants of pregnant women examined in each trimester. Each individual examined once in 1–14 weeks (first trimester), second examination in 15–28 weeks of pregnancy (second trimester), and third examination in 29–42 weeks (third trimester). In this study, the diagnosis of the pregnancy dysphonia is diagnosed once a pregnant woman with laryngeal congestion not due to any other conditions makes a consultation for it. Smoking which is itself an irritant and adds several other changes in pregnant women and thus produces congestion of the nasal mucosa. Pregnant women with smoking habits were excluded from this study.
| Results|| |
Out of 378 pregnant women, 54 referred to the outpatient department of otorhinolaryngology for laryngeal manifestations. The age range of the pregnant women those participated in this study ranged from 20 to 32 years with mean age of 24.6 years. Of 54 pregnant women, 19 (35.18%) were presented with foreign body sensation in throat or globus. Twelve pregnant women (22.22%) complained voice changes or dysphonia [Table 1]. Eight pregnant women presented with dry cough during night particularly at sleep time. Throat clearing habit was seen among 11 pregnant women (20.37%). Throat clearing habit was mainly due to laryngopharyngeal reflux (LPR). Breathing difficulty was found in 2 cases (3.70%) whereas dysphagia was seen in 2 cases (3.70%). The most common laryngeal manifestation was LPR seen among 25 cases (46.29%) confirmed from clinical presentations and laryngeal endoscopic examination. The laryngeal endoscopic examinations showed congestions in arytenoids, inter-arytenoid membrane, and posterior part of the vocal folds during pregnant women in this study. All of them advised for anti-reflux measures and voice rest. There were 21 cases showed laryngitis where both vocal folds showed congestion and edematous [Figure 1]. The laryngeal findings were confirmed by fiberoptic nasopharyngolaryngoscopy or rigid laryngeal endoscopy [Table 2]. Four cases presented with vocal nodules where all cases showed early vocal nodules [Figure 2]. All four cases treated with speech therapy. Two cases (3.70%) showed hemorrhagic polyp, one case (1.85%) diagnosed with hemangioma in subglottis [Figure 3] and one case (1.85%) diagnosed as tubercular laryngitis [Figure 4]. In patient of laryngeal tuberculosis, the lesions were found in glottis and epiglottis area without involvement of other parts of the larynx and lungs. The results of this study confirm that the alteration found in the larynx gradually improves and subsequently returns to normal in postpartum period.
|Figure 1: Endoscopic picture of the larynx showing laryngitis in pregnant women|
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|Figure 2: Endoscopic picture of the larynx showing vocal nodules in pregnant women|
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|Figure 3: Endoscopic picture of the larynx showing hemangioma in third trimester of the pregnant women|
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|Figure 4: Endoscopic picture of the larynx showing granulomatous lesion (tubercular laryngitis) in interarytenoid area and epiglottic ulcer in the pregnant women|
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| Discussion|| |
There are number of physiological changes found during the pregnancy and amongst them, laryngeal changes are important one. Pregnancy is an important part of female life where alteration of the body physiology occur, affecting different organs which also not exclude the larynx. This physiological changes in pregnant women is due to secretion of certain hormones such as estrogen and progesterone as well as placental hormones such as HCG, HPL, HCT, somatomammotrophin, and human chorionic and corticotrophin. These hormone produce several effects on physiology and immunological response in body of the pregnant women. The hormonal variations during pregnancy will affect the larynx of the pregnant women. Some of the laryngeal symptoms are pronounced during the first trimester while others are more during second and third trimesters. Although dysphonia or alteration in the quality of the voice is not an uncommon complaint in women, often it is exaggerated in pregnancy. Voice is a very important part of the women in her social and professional life. Hence, women with professional such as teachers, singers, actress, or orators are affected more if voice is affected during pregnancy. Lubrication of vocal folds is associated with good quality of voice during first and second trimesters, with professional singers are able to sing up to 7 months. There are several factors which influence the voice includes nasal obstruction, altered breathing support and LPR. Change in voice or hoarseness of voice signifies alteration of voice which is highly sensitive to the endocrinal changes in the pregnancy leading to alterations in the fluid content of the lamina propria just beneath the laryngeal mucosa. The distension of the abdomen during pregnancy interferes in abdominal muscle functions which alter the mechanics of the phonation and leads overuse injuries. These alteration in voice is called as laryngopathia gravidarum which often associated with preeclampsia. One study demonstrated by acoustic analysis of 25 pregnant women along with comparison of 21 nonpregnant women where vocal fatigue was common during pregnancy with a reduction in maximum phonation time, which usually improved after delivery. The support mechanism altered during last part of the pregnancy due to change in volume of the thoracic cage due to enlarged size of the uterus. In addition to this, pregnancy rhinitis may cause persistent mouth breathing due to nasal block. Marked nasal block due to pregnancy rhinitis bypass the humidifying function of the nasal mucosa, causing both oral and laryngeal dryness. The respiratory tract is lined with secretion in two layers, an aqueous sol layer and a superficial gel layer. Loss of sol layer can occur after around 15 min of mouth breathing, leading to raised phonation threshold along with vocal effort and leading to dysphonia., In this study, 12 pregnant women (22.22%) presented with dysphonia in third trimester of the pregnancy.
Gastroesophageal reflux disease (GERD) is seen in around 30%–50% of the pregnant women which predominantly due to decrease in lower esophageal sphincter pressure by influence of progesterone. Reduced lower esophageal sphincter pressure, raised intra-gastric pressure, delayed intestinal transit time and duodenogastric reflux have been seen in pregnant women with clinical symptom of heart burn, all these lead to increased gastroesophageal reflux. LPR is an important etiological factor for causing dysphonia, dysphagia, clearing of the throat and globus and can be seen even with the absence of symptoms typical of GERD. In this study, 25 pregnant women (46.29%) out of all the laryngeal manifestations presented with LPR . Dysphonia or voice changes was found in 12 pregnant women, throat clearing in 11 cases, globus in 19 cases, and dysphagia in 2 cases in this study. The conservative treatment of LPR includes lifestyle and dietary modifications. These include avoidance of heavy meals in night, elevation of head end of the bed, stop tobacco and alcohol and avoid any known dietary triggers such as chocolate, fatty meals, and caffeine. If the symptoms in LPR are severe, it require pharmacological therapy such as H2-antagonists and/or proton-pump inhibitors (PPIs) and/or a liquid alginate suspension. The use of PPIs (omeprazole, pantoprazole, and lansoprazole), liquid alginates and H2 antagonists (ranitidine and cimetidine) have no teratogenic side effects. However, the H2-antagonists may be associated with premature deliveries., As the GERD or LPR are self-limiting in pregnancy, a conservative treatment is required and does not preclude the use of conventional pharmacological treatment but can be prescribed only in severe cases. In case of laryngopathia gravidarum, there are alterations of the laryngeal functions during pregnancy and these laryngeal changes may be classified into acute or chronic. In acute type, pregnant women presents with hoarseness of voice, dyspnea, sore throat, and odynophagia just before delivery. Examination of the larynx shows edema of the arytenoids, aryepiglottic folds, and false vocal folds with sparing of the true vocal folds. In chronic type, the symptoms are same as in acute but the clinical presentations are persistent and may start earlier in the pregnancy. Although cavernous hemangiomas in the larynx are rare but are not so uncommon in the larynx particularly in pregnant women. This is found in around 5% of all the pregnant women which may be due to presumed stimulus by estrogen during pregnancy. The pre-existing hemangiomas of the larynx can enlarge during pregnancy due to raised estrogen levels and sometimes lead to strider which may require tracheostomy. These symptoms are commonly pronounced in third trimester and regress after delivery although not fully, so need treatment in the postpartum period. There are several other etiological factors associated with laryngeal edema such as raised venous hypertension, fluid overload, weight gain, and pregnancy-induced hypertension.
Foreign body sensation in throat is often seen among pregnant women. LPR is a common etiology for foreign body sensation in throat along with dysphonia, dysphagia, globus, clearing of throat in the absence of classical symptoms of GERD. In this study, 19 out of the 54 pregnant women with laryngeal symptoms are presented with foreign body sensation in throat. Laryngeal manifestation like acute laryngitis may occur during pregnancy which is often viral. Although the etiology for laryngitis is often multi-factorial but LPR is an important cause. Reduced lower gastroesophageal sphincter pressure, raised intra-gastric pressure, delayed transit time, and duodenogastric reflux have been found in pregnant lady with heart burn., There are some studies which suggests that pregnant women are susceptible for upper respiratory tract infections and laryngitis due to modulations of the immune system in pregnancy., The treatments of acute laryngitis include voice rest, humid environment, steam inhalation with menthol or eucalyptus and plenty of water intakes are much helpful for pregnant women with acute laryngitis. In more severe cases of laryngitis, epinephrine nebulization, and systemic or nebulized steroid may be needed to get a patent airway. Supraglottic infections may need hospitalization, oxygenation, humid environment, intravenous antibiotics, and intravenous fluids to ensure adequate hydration. Early intubation and proper airway management are required for avoiding life-threatening situations. Systemic corticosteroids may be required and should be tapered when laryngeal obstructions resolve.
Laryngeal granulomatous infection such as laryngeal tuberculosis is higher in pregnant women than normal population due to their disturbed cellular immune system where the activity of Th1 cells is decreased, leading to less production of the interferon-gamma. This reduced inflammatory activity of the Th1 cells leads to suppressed cellular immune response and increase chance two times more compared to nonpregnant women, besides the evolution of the disease is more faster and aggressive. In high burden country like India, the prevalence of active tuberculosis in pregnant women is around 0.07%–0.5% among HIV-negative women and 0.7%–11% among HIV-positive women however the epidemiological data regarding laryngeal tuberculosis among pregnant women is scarce. The clinical presentations of laryngeal tuberculosis are dysphonia, dysphagia, weight loss, and odynophagia., In this study, 1.85% cases presented with laryngeal tuberculosis.
We did not find such studies in eastern region of India and this study showed pregnant women have several laryngeal manifestations which can be easily managed by clinicians in day to day clinical practice. Majority of the laryngeal manifestations in pregnant women can be treated conservatively as these disappear after delivery of the baby. Hence, avoidance of unnecessary medications or interventions can decrease the risk to the fetus.
| Conclusion|| |
The laryngeal manifestations are not uncommon among pregnant women. Majority of them are treated conservatively as these disappear after delivery of the baby. Hence, the avoidance of unnecessary medications or interventions may reduce the risk to the fetus. As the pregnancy progress, the laryngeal manifestations disappear with complete resolution in postpartum period which indicates these symptoms are more physiological than pathological. These manifestations often become challenge to otolaryngologist and obstetricians when it compromises the airway. The safety to materno-fetal unit during pregnancy is considered paramount, so treatment with drugs should be based on the safety and efficacy. Otolaryngologists or general practitioners and obstetricians should keep in mind regarding laryngeal manifestations in pregnant women for betterment of mother and fetus.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhagat DR, Chowdhary A, Verma S, Jyotsana. Physiological changes in ENT during pregnancy. Indian J Otolaryngol Head Neck Surg 2006;58:268-70.
Mgbe RB, Umana AN, Adekanye AG, Offiong ME. Ear nose and throat changes observed in pregnancy in Calabar Nigeria. Glob J Pure Appl Sci 2017;23:355-9.
Kumar R, Hayhurst KL, Robson AK. Ear, nose, and throat manifestations during pregnancy. Otolaryngol Head Neck Surg 2011;145:188-98.
Hamdan AL, Mahfoud L, Sibai A, Seoud M. Effect of pregnancy on the speaking voice. J Voice 2009;23:490-3.
Ajiya A, Ayyuba R, Hamisu A, Daneji SM. Otorhinolaryngological health of women attending antenatal care clinic in a tertiary hospital: The Aminu Kano Teaching Hospital experience. Niger J Basic Clin Sci 2016;13:119-24. [Full text]
Sivasankar M, Fisher KV. Oral breathing increases Pth and vocal effort by superficial drying of vocal fold mucosa. J Voice 2002;16:172-81.
Longman RE, Johnson TR. Viral respiratory disease in pregnancy. Curr Opin Obstet Gynecol 2007;19:120-5.
Richter JE. Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin North Am 2003;32:235-61.
Gill SK, Maltepe C, Koren G. The effect of heartburn and acid reflux on the severity of nausea and vomiting of pregnancy. Can J Gastroenterol 2009;23:270-2.
Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002;127:32-5.
Ali RA, Egan LJ. Gastroesophageal reflux disease in pregnancy. Best Pract Res Clin Gastroenterol 2007;21:793-806.
Diav-Citrin O, Arnon J, Shechtman S, Schaefer C, van Tonningen MR, Clementi M, et al
. The safety of proton pump inhibitors in pregnancy: A multicentre prospective controlled study. Aliment Pharmacol Ther 2005;21:269-75.
McGlashan JA, Johnstone LM, Sykes J, Strugala V, Dettmar PW. The value of a liquid alginate suspension (Gaviscon advance) in the management of laryngopharyngeal reflux. Eur Arch Oto Rhino Laryngol 2009;266:243-51.
Mugliston TA, Sangwan S. Persistent cavernous haemangioma of the larynx – A pregnancy problem. J Laryngol Otol 1985;99:1309-11.
Brimacombe J. Acute pharyngolaryngeal oedema and pre-eclamptic toxaemia. Anaesth Intensive Care 1992;20:97-8.
Koufman J, Sataloff RT, Toohill R. Laryngopharyngeal reflux: Consensus conference report. J Voice 1996;10:215-6.
Israeli I, Cohen R, Berkovitch M, Koren G. Determinants of medication adherence in nausea and vomiting of pregnancy. J Gynecol Res 2018;4:201.
Harris J, Sheiner E. Does an upper respiratory tract infection during pregnancy affect perinatal outcome? A literature review. Curr Inf Dis Rep 2013;15:143-7.
Shiny Sherlie V, Varghese A. ENT changes of pregnancy and its management. Indian J Otolaryngol Head Neck Surg 2014;66:6-9.
Schatz M. The efficacy and safety of asthma medications during pregnancy. Semin Perinatol 2001;25:145-52.
Sulis G, Pai M. Tuberculosis in pregnancy: A treacherous yet neglected issue. J Obstet Gynaecol Can 2018;40:1003-5.
Geier J, Orlando B. Pulmonary and laryngeal tuberculosis in a 25-weeks' gestation parturient, diagnosed after failed tracheal intubation. Int J Obstet Anesth 2018;33:75-7.
Bates M, Ahmed Y, Kapata N, Maeurer M, Mwaba P, Zumla A. Perspectives on tuberculosis in pregnancy. Int J Infect Dis 2015;32:124-7.
Swain SK, Sahu MC, Kar SS. Primary laryngeal tuberculosis – A frequently misdiagnosed disease. J Laryngol Voice 2018;8:1-5. [Full text]
Swain SK, Behera IC, Sahu MC. Primary laryngeal tuberculosis: Our experiences at a tertiary care teaching hospital in Eastern India. J Voice 2019;33:812-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]