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October 24, 2019

Intractable Cough After Bilateral Tympanostomy Tube Placement

Author Affiliations
  • 1Baylor Scott & White Health Medical Center, Temple, Texas
  • 2Division of Otolaryngology, Department of Surgery, Texas A&M Health Science Center, Bryan, Texas
JAMA Otolaryngol Head Neck Surg. Published online October 24, 2019. doi:https://doi.org/10.1001/jamaoto.2019.3164

Mechanical stimulation of the auricular branch of the vagus nerve (Arnold nerve) in the posterior medial external auditory canal and tympanic membrane can elicit a cough via the ear-cough reflex (Figure).1-4 We present a unique case of intractable cough after bilateral tympanostomy tube placement, which resolved after tube removal.

Figure.
Course of the Auricular Branch of the Vagus Nerve (Arnold Nerve), Right Ear
Course of the Auricular Branch of the Vagus Nerve (Arnold Nerve), Right Ear

The auricular branch of the vagus nerve (Arnold nerve) originates from the inferior ganglion of the glossopharyngeal nerve and superior ganglion of the vagus nerve. It ascends from the jugular foramen to the mastoid process via the mastoid canaliculus. It has 2 branches: 1 innervates the posterior cranial fossa dura mater (not pictured), whereas the other extends medially to innervate the posterior wall of the external auditory canal and posterolateral surface of the tympanic membrane.3,4

Report of a Case

This case report was reviewed by the Baylor Scott & White Research Institute and determined to be outside the boundaries of institutional review board oversight. An 11-year-old boy underwent bilateral tympanostomy tube placement (beveled Armstrong type) and adenoidectomy at an outside facility for recurrent acute otitis media despite prior placement of tympanostomy tubes. The day after surgery, he was evaluated at an outside emergency department for stridor and increased work of breathing. He responded to racemic epinephrine, intravenous dexamethasone, and nebulized lidocaine and was transferred to the children’s emergency department. When evaluated by a pediatric otolaryngology physician, his only symptom was a persistent cough. He was admitted for observation, and despite a mild persistent cough, his stridor and respiratory distress did not recur. Thus, he was discharged on postoperative day 2.

Later that day, he returned to the children’s emergency department for stridor and respiratory distress, which improved after administration of racemic epinephrine, intravenous methylprednisolone, and heliox. Although findings from a flexible laryngoscopy were normal, he was admitted to the pediatric intensive care unit for airway monitoring. Respiratory virus panel results were negative, but he continued to have a persistent cough, which was occasionally croup-like. He had no fever, congestion, malaise, or any other signs or symptoms suggestive of an upper respiratory illness. On the fourth postoperative day, he had an intermittent low-pitched, biphasic stridor. A diagnostic microlaryngoscopy and bronchoscopy under general anesthesia revealed a normal airway. Postoperatively his cough persisted without stridor, and he was again discharged in stable condition.

On the sixth postoperative day, he returned to the children’s hospital for a third time, with a persistent dry cough refractory to administration of albuterol, intravenous lorazepam, beclometasone dipropionate, and promethazine with codeine. On admission, he was seen by a pediatric pulmonology physician. After failure of conventional therapy, psychogenic cough and Arnold nerve neuropathy were suspected. On the eighth postoperative day, the patient was coughing with every breath, even while sleeping. The following day he underwent bilateral tympanostomy tube removal and myringoplasty using an absorbable gelatin film patch (Gelfilm), and he was discharged the same day. His cough improved immediately after tube removal and completely resolved by the next day. Through 8 months of follow-up, he never had recurrence of cough.

Discussion

To our knowledge, only 2 prior case reports describe tympanostomy tubes as the cause for intractable cough. One case report described an 11-year-old boy who underwent multiple emergency department evaluations and hospital admissions for intractable cough cured only by the removal of a T-type tympanostomy tube from the tympanic membrane.2 Another report described a 43-year-old man with a 4-month history of intractable cough that resolved after a tympanostomy tube spontaneously migrated from the medial to the lateral aspect of the external auditory canal.1

Although intractable cough is a rare complication of tympanostomy tube placement, it should remain a possible differential diagnosis for causes of intractable cough, especially in cases recalcitrant to the usual treatments for cough. This patient’s “barking cough” was not owing to croup, but rather the laryngeal inflammation from constant coughing. Given the low risk of tympanostomy tube removal and myringoplasty, and the potential for considerable benefit, we recommend a low threshold for this procedure in patients with intractable cough and a tympanostomy tube in either the tympanic membrane or the external auditory canal.

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Article Information

Corresponding Author: Collin Juergens, MD, Division of Otolaryngology, Baylor Scott & White Medical Center, 2401 S 31st St, Temple, TX 76508 (collin.juergens@BSWHealth.org).

Published Online: October 24, 2019. doi:10.1001/jamaoto.2019.3164

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s parents for granting permission to publish this information. Editing assistance was provided by Angela D. Rutherford, BA, Medical Writer, Publications Department, Baylor Scott & White Research Institute. We also thank Bryan Moss, AAS, Supervisor/Medical Illustrator, Medical Graphic Services Department, Baylor Scott & White Medical Center, for creating the medical illustration.

References
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Feldman  JI, Woodworth  WF.  Cause for intractable chronic cough: Arnold’s nerve.  Arch Otolaryngol Head Neck Surg. 1993;119(9):1042. doi:10.1001/archotol.1993.01880210136018PubMedGoogle ScholarCrossref
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Hollinshead  W.  Anatomy for Surgeons. Philadelphia: Harper & Row; 1982:164-166.
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Watanabe  K, Tubbs  RS, Satoh  S,  et al.  Isolated deep ear canal pain: possible role of auricular branch of vagus nerve-case illustrations with cadaveric correlation.  World Neurosurg. 2016;96:293-301. doi:10.1016/j.wneu.2016.08.102PubMedGoogle ScholarCrossref
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