The auricular cough reflex: lateralization, prevalence, procedural determinants, and the role of examiner handedness

The auricular cough reflex (Arnold's reflex) is a vagally mediated somato-visceral response triggered by stimulation of the external auditory canal (EAC). While classically considered rare, its clinical relevance in otologic procedures remains underexplored.

This study aimed to evaluate the prevalence, lateralization, and potential risk factors of the Arnold reflex during routine otologic examinations, with particular attention to examiner handedness, hearing aid use, and EAC inflammation.

In this prospective observational study, 404 consecutive patients undergoing bilateral ear wax removal in a university otology clinic were assessed for reflex-induced coughing. Reflex occurrence, laterality, instrument type, hearing aid use, signs of local infection, age, and sex were documented. Statistical analyses included chi-square tests, logistic regression, and McNemar's test.

A cough reflex was elicited in 52 patients (12.9%), predominantly right-sided (73.1%, p < 0.001). The reflex was most frequently triggered by curettes (84.6%). No significant association was found between reflex presence and hearing aid use, local infection, age, or sex. The strong right-ear predominance, observed exclusively with a right-handed examiner, suggests that handedness and canal wall anatomy may influence reflex induction.

The Arnold cough reflex occurs more commonly than historically reported, with a notable right-sided predominance potentially linked to examiner handedness and procedural factors. Routine otologic variables such as age, sex, hearing aid use, and local inflammation had no measurable effect. These findings underscore the importance of examiner awareness and gentle technique in the EAC. Future studies should explore anatomical mapping, neurophysiological mechanisms, and the potential role of habituation in chronic ear stimulation.