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Foreign Body in External Ear Canal: An Unusual Cause of Chronic Cough
CLINICAL COMMUNICATION TO THE EDITOR
Foreign Body in External Ear Canal: An Unusual Cause of Chronic Cough To the Editor: Many cases of earwax impaction (or foreign body presence) and the relationship to chronic cough may go unrecognized. The routine incorporation of examination of the external auditory canal in patients with chronic cough may reveal a number of patients with impacted earwax.1 The literature suggests that 2% to 6% of the general population have impacted earwax.1 Patients over 65 years of age have much higher prevalence of impacted earwax. Removal of impacted earwax in patients with chronic cough may resolve the symptoms, as demonstrated in the following case: A 63-year-old white man, an avid beach enthusiast, with a history of hyperlipidemia, history of smoking, and with conductive hearing loss of the right ear, presented with a chronic dry cough of 6 months duration. Coughing episodes were often precipitated by eating. Coughing spells often lasted several hours. The cough was refractory to treatment for postnasal drip, cough-variant asthma, and gastroesophageal reflux disease. A chest x-ray study was negative for pathology. In preparation for an audiogram for a hearing aid device, a circumferential foreign body was noted deep and medially in the left external auditory canal abutting the tympanic membrane, and was subsequently removed. The foreign body consisted of a concretion of sand with earwax. Unexpectedly, the chronic cough resolved over several days. The persistent mechanical stimulation of the vagal nerve may be the mechanism associated with a chronic cough through the somatic sensory branch of the vagal nerve, known as Arnold’s nerve.2 Arnold’s nerve innervates the posterior and inferior meatal skin. Fifteen cases have been reported in the literature.2,3 The majority of cases were associated with earwax or a foreign body. A higher incidence of the relationship between chronic cough and earwax impaction is suggested by the following 2 arguments. Firstly, the literature reports that in the US there are 30 million office visits yearly for cough and 12 Funding: None. Conflict of Interest: None for all authors. Authorship: All authors had access to the data and had a role in writing the manuscript. Requests for reprints should be addressed to Kellyanne Rose Gold, JD, Olive VieweUCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
million visits for earwax-related complaints.4,5 Patients presenting for earwax removal may have a chronic cough that is not brought to clinical attention, suggesting that the relationship between chronic cough and earwax impaction may be under-reported. In a study of 500 individuals, the Arnold’s ear-cough reflex was elicited by mechanical stimulation of the external auditory canal in 4.2%.6 Additionally, in adults presenting with chronic cough, over 80% have associated postnasal drip, cough-variant asthma, or gastroesophageal reflux disease. It is possible that the apparent successful empiric treatments for these conditions may be simply coincidental with spontaneous or mechanical removal of impacted earwax during the course of empiric treatments. Interestingly, chronic cough may also arise from the visceral components of the vagal nerve.3 A related condition, postviral vagal neuropathy, is a recently described condition with associated oropharyngeal symptoms, including chronic cough.7 Postviral vagal neuropathy is thought to be the sequela of an antecedent viral infection similar in pathophysiology to Bell’s Palsy and postherpetic neuralgia. The associated symptoms of postviral vagal neuropathy may arise from involvement of either the motor or sensory branches of the vagal nerve. Motor branch involvement may manifest as vocal cord dysfunction. Sensory branch symptoms may include laryngospasm, excessive oropharyngeal mucous and clearing of the throat, and odynophonia. Potential mechanisms that may initiate postviral vagal neuropathy as etiologic in cases of chronic unexplained cough have been described.8 Therapeutic trials with gabapentin have demonstrated favorable results in these refractory patients suggestive of nerve injury.9 A chronic cough may be initiated by stimulation from the somatic sensory portion of the vagal nerve. Thus, patients with chronic cough should have their external auditory canals examined. Kellyanne Rose Gold, JDa,b Jacob L. Wester, MDc Robert Gold, MDa a
Department of Internal Medicine Olive VieweUCLA Medical Center Sylmar, Calif b University of Toledo College of Medicine and Life Sciences Ohio c Department of Head and Neck Surgery UCLA Los Angeles, Calif
http://dx.doi.org/10.1016/j.amjmed.2016.11.026
e2
References 1. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM. 2004;97(8):477-488. 2. Jegoux F, Legent F, Beauvillain de Montreuil C. Chronic cough and ear wax. Lancet. 2002;360(9333):618. 3. Ryan NM, Gibson PG, Birring SS. Arnold’s nerve cough reflex: evidence for chronic cough as a sensory vagal neuropathy. J Thorac Dis. 2014;6(suppl 7):S748-S752. 4. Bellanti JA, Tutuncuoglu SO, Azem M, MacDowell-Carneiro AL, Wallerstedt DB. Persistent cough: differential diagnosis. Allergy Asthma Proc. 2000;21(5):307-308.
The American Journal of Medicine, Vol -, No -,
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2017
5. Coppin R, Wicke D, Little P. Randomized trial of bulb syringes for earwax: impact on health service utilization. Ann Fam Med. 2011;9(2):110-114. 6. Gupta D, Verma S, Vishwakarma SK. Anatomic basis of Arnold’s earcough reflex. Surg Radiol Anat. 1986;8(4):217-220. 7. Greene SM, Simpson CB. Evidence for sensory neuropathy and pharmacologic management. Otolaryngol Clin North Am. 2010;43(1):67-72, viii. 8. Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head Neck Surg. 2006;135(1):17-21. 9. Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet. 2012;380(9853):1583-1589.
Foreign Body in External Ear Canal: An Unusual Cause of Chronic Cough To the Editor: Many cases of earwax impaction (or foreign body presence) and the relationship to chronic cough may go unrecognized. The routine incorporation of examination of the external auditory canal in patients with chronic cough may reveal a number of patients with impacted earwax.1 The literature suggests that 2% to 6% of the general population have impacted earwax.1 Patients over 65 years of age have much higher prevalence of impacted earwax. Removal of impacted earwax in patients with chronic cough may resolve the symptoms, as demonstrated in the following case: A 63-year-old white man, an avid beach enthusiast, with a history of hyperlipidemia, history of smoking, and with conductive hearing loss of the right ear, presented with a chronic dry cough of 6 months duration. Coughing episodes were often precipitated by eating. Coughing spells often lasted several hours. The cough was refractory to treatment for postnasal drip, cough-variant asthma, and gastroesophageal reflux disease. A chest x-ray study was negative for pathology. In preparation for an audiogram for a hearing aid device, a circumferential foreign body was noted deep and medially in the left external auditory canal abutting the tympanic membrane, and was subsequently removed. The foreign body consisted of a concretion of sand with earwax. Unexpectedly, the chronic cough resolved over several days. The persistent mechanical stimulation of the vagal nerve may be the mechanism associated with a chronic cough through the somatic sensory branch of the vagal nerve, known as Arnold’s nerve.2 Arnold’s nerve innervates the posterior and inferior meatal skin. Fifteen cases have been reported in the literature.2,3 The majority of cases were associated with earwax or a foreign body. A higher incidence of the relationship between chronic cough and earwax impaction is suggested by the following 2 arguments. Firstly, the literature reports that in the US there are 30 million office visits yearly for cough and 12 Funding: None. Conflict of Interest: None for all authors. Authorship: All authors had access to the data and had a role in writing the manuscript. Requests for reprints should be addressed to Kellyanne Rose Gold, JD, Olive VieweUCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
million visits for earwax-related complaints.4,5 Patients presenting for earwax removal may have a chronic cough that is not brought to clinical attention, suggesting that the relationship between chronic cough and earwax impaction may be under-reported. In a study of 500 individuals, the Arnold’s ear-cough reflex was elicited by mechanical stimulation of the external auditory canal in 4.2%.6 Additionally, in adults presenting with chronic cough, over 80% have associated postnasal drip, cough-variant asthma, or gastroesophageal reflux disease. It is possible that the apparent successful empiric treatments for these conditions may be simply coincidental with spontaneous or mechanical removal of impacted earwax during the course of empiric treatments. Interestingly, chronic cough may also arise from the visceral components of the vagal nerve.3 A related condition, postviral vagal neuropathy, is a recently described condition with associated oropharyngeal symptoms, including chronic cough.7 Postviral vagal neuropathy is thought to be the sequela of an antecedent viral infection similar in pathophysiology to Bell’s Palsy and postherpetic neuralgia. The associated symptoms of postviral vagal neuropathy may arise from involvement of either the motor or sensory branches of the vagal nerve. Motor branch involvement may manifest as vocal cord dysfunction. Sensory branch symptoms may include laryngospasm, excessive oropharyngeal mucous and clearing of the throat, and odynophonia. Potential mechanisms that may initiate postviral vagal neuropathy as etiologic in cases of chronic unexplained cough have been described.8 Therapeutic trials with gabapentin have demonstrated favorable results in these refractory patients suggestive of nerve injury.9 A chronic cough may be initiated by stimulation from the somatic sensory portion of the vagal nerve. Thus, patients with chronic cough should have their external auditory canals examined. Kellyanne Rose Gold, JDa,b Jacob L. Wester, MDc Robert Gold, MDa a
Department of Internal Medicine Olive VieweUCLA Medical Center Sylmar, Calif b University of Toledo College of Medicine and Life Sciences Ohio c Department of Head and Neck Surgery UCLA Los Angeles, Calif
http://dx.doi.org/10.1016/j.amjmed.2016.11.026
e2
References 1. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM. 2004;97(8):477-488. 2. Jegoux F, Legent F, Beauvillain de Montreuil C. Chronic cough and ear wax. Lancet. 2002;360(9333):618. 3. Ryan NM, Gibson PG, Birring SS. Arnold’s nerve cough reflex: evidence for chronic cough as a sensory vagal neuropathy. J Thorac Dis. 2014;6(suppl 7):S748-S752. 4. Bellanti JA, Tutuncuoglu SO, Azem M, MacDowell-Carneiro AL, Wallerstedt DB. Persistent cough: differential diagnosis. Allergy Asthma Proc. 2000;21(5):307-308.
The American Journal of Medicine, Vol -, No -,
-
2017
5. Coppin R, Wicke D, Little P. Randomized trial of bulb syringes for earwax: impact on health service utilization. Ann Fam Med. 2011;9(2):110-114. 6. Gupta D, Verma S, Vishwakarma SK. Anatomic basis of Arnold’s earcough reflex. Surg Radiol Anat. 1986;8(4):217-220. 7. Greene SM, Simpson CB. Evidence for sensory neuropathy and pharmacologic management. Otolaryngol Clin North Am. 2010;43(1):67-72, viii. 8. Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head Neck Surg. 2006;135(1):17-21. 9. Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet. 2012;380(9853):1583-1589.