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Chronic cough and ear wax
CASE REPORT
Case report
Chronic cough and ear wax
F Jegoux, F Legent, C Beauvillain de Montreuil A 7-year-old boy had a right-sided tympanoplasty for attical cholesteatoma in 1998. He had no postoperative complications or recurrence. A year later, he complained of a persistent dry cough that was present both day and night. Over the next 7 years, he had many investigations of the upper and lower respiratory tracts, including serial chest radiographs, computed tomography of the sinuses, bronchoscopy, nasofibroscopy, and allergy screening. He also had cerebral computed tomography and a psychological evaluation to exclude a psychogenic origin for his cough. None of these tests were sufficient to determine a cause. In November, 1995, at the age of 14 years, the boy was referred to us, with the isolated complaint of a chronic dry cough of 7 years duration. He had no other symptoms. On examination we found only an accumulation of epidermal cerumen surrounding a skin ulceration in a narrowed external auditory meatus on the right side. We stimulated the anterior wall of the ear canal with a cotton bud and triggered a marked cough reflex. We removed the accumulated cerumen, and the cough disappeared for several weeks. However, the patient returned on a regular basis with recurrent complaints of a dry cough. Each time, we found newly formed cerumen, and removed it, resulting in temporary remission of his cough. After months of this pattern, in October, 1996, we surgically excised the skin ulceration and enlarged the bony stenosis of the ear canal. The cough disappeared, and when last seen in September, 1999, at the age of 18, the patient had no further complaints. However, gentle stimulation of the external auditory meatus still provoked a strong cough reflex. The ear-cough reflex was first described by Arnold in 1832 and reported by Itard in 1842. Its incidence ranges from 1·7 to 4·2%.1,3 Arnold’s nerve arises from the jugular ganglion of the vagus, emerges through the tympanomastoid fissure and usually supplies the posterior and inferior meatal skin (figure). However, an ear-cough reflex can be elicited by stimulation of the anterior wall in one third of cases, and is bilateral in two-thirds.3
1
3
6 7
9
8
Posterior view of temporal bone 1 vagus nerve, 2 glossopharyngeal nerve, 3 facial nerve, 4 chorda tympani, 5 auricular branch of the vagus (Arnold's nerve), 6 anastomosis with auricular branch of the facial 7, 8 jugular vein, 9 internal carotid artery (reproduced from Tiedemans Z Schr Physiol, 1832)
Stimulation of Arnold’s nerve can also induce extrarespiratory symptoms such as vomiting and syncope.5 About 15 cases of pathologic cough due to ear disease have been reported since 1842. Foreign bodies and impacted earwax were the most frequent causes. In the absence of auricular symptoms, the diagnosis is often made by chance, since an otoscope is not consistently used in the examination of a patient with chronic cough. In most of the reported cases, the patient was aware of a foreign body or complained of auricular symptoms. Feldman treated a cough-variant asthma by removing a T-tube and Sheehy treated unexplained chronic cough by cholesteatoma removal.2,4 Otoscopy is an easy and safe way to find an auricular origin of an unproductive cough, and clinicians should not forget to examine the ear canals of their patients. References 1 2
Service d’Otorhinolaryngologie et Chirurgie Cervico-faciale (F Jegoux MD, F Legent MD, C Beauvillain de Montreuil MD), CHU Hotel-Dieu, Place Alexis Ricordeau, 44000 Nantes, France
3
618
4 5
Lancet 2002; 360: 618
Correspondence to: Dr Frank Jegoux (e-mail: [email protected])
2
4 5
Bloustine S, Langston L, Miller T. Ear-cough (Arnold’s) reflex. Ann Otol Rhinol Laryngol 1976; 85: 406–07. Feldman JI, Woodworth WF. Cause for intractable chronic cough: Arnold’s nerve. Arch Otolaryngol Head Neck Surg 1993; 119: 1042. Gupta D, Verma S, Vishwakarma SK. Anatomic basis of ear-cough reflex. Surg Radiol Anat 1986; 8: 217–20. Sheehy JL, Lee S. Chronic cough due to cholesteatoma. A case report. Am J Otol 1988; 9: 392. Todisco T. The oto-respiratory reflex. Respiration 1982; 43: 354–58.
THE LANCET • Vol 360 • August 24, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Case report
Chronic cough and ear wax
F Jegoux, F Legent, C Beauvillain de Montreuil A 7-year-old boy had a right-sided tympanoplasty for attical cholesteatoma in 1998. He had no postoperative complications or recurrence. A year later, he complained of a persistent dry cough that was present both day and night. Over the next 7 years, he had many investigations of the upper and lower respiratory tracts, including serial chest radiographs, computed tomography of the sinuses, bronchoscopy, nasofibroscopy, and allergy screening. He also had cerebral computed tomography and a psychological evaluation to exclude a psychogenic origin for his cough. None of these tests were sufficient to determine a cause. In November, 1995, at the age of 14 years, the boy was referred to us, with the isolated complaint of a chronic dry cough of 7 years duration. He had no other symptoms. On examination we found only an accumulation of epidermal cerumen surrounding a skin ulceration in a narrowed external auditory meatus on the right side. We stimulated the anterior wall of the ear canal with a cotton bud and triggered a marked cough reflex. We removed the accumulated cerumen, and the cough disappeared for several weeks. However, the patient returned on a regular basis with recurrent complaints of a dry cough. Each time, we found newly formed cerumen, and removed it, resulting in temporary remission of his cough. After months of this pattern, in October, 1996, we surgically excised the skin ulceration and enlarged the bony stenosis of the ear canal. The cough disappeared, and when last seen in September, 1999, at the age of 18, the patient had no further complaints. However, gentle stimulation of the external auditory meatus still provoked a strong cough reflex. The ear-cough reflex was first described by Arnold in 1832 and reported by Itard in 1842. Its incidence ranges from 1·7 to 4·2%.1,3 Arnold’s nerve arises from the jugular ganglion of the vagus, emerges through the tympanomastoid fissure and usually supplies the posterior and inferior meatal skin (figure). However, an ear-cough reflex can be elicited by stimulation of the anterior wall in one third of cases, and is bilateral in two-thirds.3
1
3
6 7
9
8
Posterior view of temporal bone 1 vagus nerve, 2 glossopharyngeal nerve, 3 facial nerve, 4 chorda tympani, 5 auricular branch of the vagus (Arnold's nerve), 6 anastomosis with auricular branch of the facial 7, 8 jugular vein, 9 internal carotid artery (reproduced from Tiedemans Z Schr Physiol, 1832)
Stimulation of Arnold’s nerve can also induce extrarespiratory symptoms such as vomiting and syncope.5 About 15 cases of pathologic cough due to ear disease have been reported since 1842. Foreign bodies and impacted earwax were the most frequent causes. In the absence of auricular symptoms, the diagnosis is often made by chance, since an otoscope is not consistently used in the examination of a patient with chronic cough. In most of the reported cases, the patient was aware of a foreign body or complained of auricular symptoms. Feldman treated a cough-variant asthma by removing a T-tube and Sheehy treated unexplained chronic cough by cholesteatoma removal.2,4 Otoscopy is an easy and safe way to find an auricular origin of an unproductive cough, and clinicians should not forget to examine the ear canals of their patients. References 1 2
Service d’Otorhinolaryngologie et Chirurgie Cervico-faciale (F Jegoux MD, F Legent MD, C Beauvillain de Montreuil MD), CHU Hotel-Dieu, Place Alexis Ricordeau, 44000 Nantes, France
3
618
4 5
Lancet 2002; 360: 618
Correspondence to: Dr Frank Jegoux (e-mail: [email protected])
2
4 5
Bloustine S, Langston L, Miller T. Ear-cough (Arnold’s) reflex. Ann Otol Rhinol Laryngol 1976; 85: 406–07. Feldman JI, Woodworth WF. Cause for intractable chronic cough: Arnold’s nerve. Arch Otolaryngol Head Neck Surg 1993; 119: 1042. Gupta D, Verma S, Vishwakarma SK. Anatomic basis of ear-cough reflex. Surg Radiol Anat 1986; 8: 217–20. Sheehy JL, Lee S. Chronic cough due to cholesteatoma. A case report. Am J Otol 1988; 9: 392. Todisco T. The oto-respiratory reflex. Respiration 1982; 43: 354–58.
THE LANCET • Vol 360 • August 24, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.