Understanding Ear, Nose and Throat Manifestations of Celiac Disease

Celiac.com 01/29/2024 - Celiac disease is a multi-systemic autoimmune disorder, with extra-intestinal manifestations that may mark the first presentation of the disease. Doctors now increasingly recognize that celiac disease can present with extra-intestinal manifestations, including affecting the ears, nose, and throat (ENT), which contribute to the difficulty in its diagnosis. 

Improving awareness of celiac disease among otolaryngologists may aid in the process of making the correct diagnosis, and in devising the correct management plan. 

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To highlight that some patients with celiac disease may present initially to the otolaryngologist, researchers Dilhara Karunaratne and Nisal Karunaratne, of the Department of Otolaryngology, Eastbourne District General Hospital, Eastbourne, United Kingdom, recently conducted a scholarly review to examine the extra-intestinal ENT manifestations of celiac disease and its pathophysiology and management.

Their exploration of ENT manifestations reveals a range of symptoms, and underscores the importance of considering celiac disease in patients with unexplained symptoms.

To identify original articles related to celiac disease and ENT manifestations, they conducted a literature review using the PubMed database between the years 2000 and 2020. They used the search string: (“coeliac disease” OR “celiac disease”) AND (“ENT manifestations” OR “hearing loss” OR “epistaxis” OR “nasal septal perforation” OR “obstructive sleep apnea” OR “vertigo” OR “tonsillitis” OR “sinusitis”). They reviewed only articles written in English.

They found a total of 17 papers that met the inclusion criteria. Extra-intestinal ENT manifestations of celiac disease included sensorineural hearing loss, obstructive sleep apnea, nasal septal perforation, epistaxis, and vertigo with nystagmus. 

Hearing Loss and Celiac Disease

One notable ENT manifestation is sensorineural hearing loss (SNHL), a condition that appears to be progressive and permanent in individuals with celiac disease. The mechanism behind this hearing loss is thought to be immunologically mediated, and it emphasizes the need for regular audiological monitoring in affected individuals. The evidence suggests that children with celiac disease may develop subtle SNHL, which could manifest as mild to moderate hearing loss in adulthood. Otolaryngologists are advised to be vigilant in recognizing this potential connection and consider audiological assessment for children with celiac disease.

Sleep Apnea and Sleep Disordered Breathing and Celiac Disease

Obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) are also identified as symptoms that may be associated with celiac disease in children. Importantly, there's evidence indicating that symptoms of SDB and OSA may improve with a gluten-free diet. This finding has significant implications, suggesting that a strict gluten-free diet could be an initial treatment approach for these symptoms, potentially circumventing the need for surgery.

Nasal Septal Perforation, Vertigo and Celiac Disease

Moreover, the impact of celiac disease extends beyond the auditory and respiratory systems. Nasal septal perforation and vertigo have been reported as potential manifestations. These varied symptoms underscore the importance of considering celiac disease in cases where symptoms cannot be easily explained by other diagnoses. The recognition of celiac disease and subsequent adherence to a gluten-free diet have been associated with symptom resolution in these cases.

However, there are limitations to the current understanding. The existing body of literature is relatively small, and studies show variations in sample size, demographics, and measured variables. The diagnosis of sleep-disordered breathing and obstructive sleep apnea in children, in particular, relies on screening questionnaires, rather than more definitive methods like polysomnography, which invites questions about the accuracy of the diagnosis.

This review highlights the need for further research in understanding the ENT manifestations of celiac disease. It emphasizes the diverse range of symptoms associated with celiac disease and the potential for improvement with a gluten-free diet. 

Otolaryngologists and healthcare providers should be aware of these potential connections, and consider celiac disease when diagnosing patients with unexplained ENT symptoms. The ongoing research in this area promises to expand our understanding of celiac disease beyond its traditional gastrointestinal manifestations.

Stay tuned for more on this and related celiac disease news.

Read more in Ear, Nose & Throat Journal