Swallow Syncope, a Case Report and Review of the Literature

Pathophysiology of syncope: current concepts and their development

Syncope is a symptom in which transient loss of consciousness occurs as a consequence of a self-limited, spontaneously terminating period of cerebral hypoperfusion. Many circulatory disturbances (e.g. brady- or tachyarrhythmias, reflex cardioinhibition-vasodepression-hypotension) may trigger a syncope or near-syncope episode, and identifying the cause(s) is often challenging. Some syncope may involve multiple etiologies operating in concert, whereas in other cases multiple syncope events may be due to various differing causes at different times. In this communication, we address the current understanding of the principal contributors to syncope pathophysiology including examination of the manner in which concepts evolved, an overview of factors that constitute consciousness and loss of consciousness, and aspects of neurovascular control and communication that are impacted by cerebral hypoperfusion leading to syncope. Emphasis focuses on 1) current understanding of the way transient systemic hypotension impacts brain blood flow and brain function; 2) the complexity and temporal sequence of vascular, humoral, and cardiac factors that may accompany the most common causes of syncope; 3) the range of circumstances and disease states that may lead to syncope; and 4) clinical features associated with syncope and in particular the reflex syncope syndromes.

Aortic Aneurysm Presenting As Deglutition Syncope

Deglutitive syncope is defined as a neurally mediated syncope in which loss of consciousness occurs during or immediately after swallowing. The causes of deglutitive syncope vary widely and range from intraluminal causes, as well as extra-esophageal compression. In this case report, we present a rare case of deglutitive syncope caused by a thoracic aortic aneurysm compressing the proximal esophagus, a clinical entity described in the literature as dysphagia aortica.

Post Total Thyroidectomy Deglutition Syncope

Deglutition syncope is a form of situational syncope where patients develop presyncope or syncope during swallowing. This condition has been observed to occur most commonly in patients with prior gastroesophageal conditions. Our patient developed deglutition syncope that started to occur a few weeks after undergoing a total thyroidectomy. The patient was found to have paroxysmal atrioventricular (AV) block, with up to 5.1 seconds of asystole during swallowing, manifested with episodes of dizziness and lightheadedness. A barium swallow test revealed normal peristalsis and no evidence of dysmotility. The patient underwent placement of a dual chamber pacemaker, and the syncopal episodes resolved. Interrogation of the pacemaker showed no recorded abnormal events.

Deglutition Syncope Due to Exaggerated Vagal Reflex

Swallow or deglutition syncope is an uncommon cause of syncope associated with bradyarrhythmia and hypotension during food swallowing. Early recognition of this condition is imperative but challenging. We report a case of a 60-year-old female who presented with a complaint of intermittent lightheadedness after swallowing food. An episode of presyncope was observed and a reduced pulse rate from baseline was noted when she was instructed to eat a candy bar in the clinic. Further workup revealed normal in-office electrocardiogram, bilateral carotid ultrasound, transthoracic echocardiogram, and videofluoroscopic swallow study. Our goal in presenting this case is to raise awareness of the condition in medical literature and provide a good understanding of its clinical manifestation to prevent life-threatening events.

Swallow-induced syncope after magnetic sphincter augmentation: a case report and physiologic explanation

Swallow-induced syncope is a rare cause of syncope that occurs during or immediately after swallowing. This phenomenon has been reported in association with few esophageal pathologies and the likely explanation is a vagal reflex during deglutition that results in inhibition of the cardiac conduction system. This report describes a case of swallow-induced syncope related to the implantation of a magnetic sphincter augmenting (MSA) device. Two episodes of syncope after food bolus occurred with the device in place and upon removal of the device, the patient had no further episodes of syncope. Vagal stimulation from distention of the esophagus or vagus nerve contact irritation by the implant are the potential explanation for syncope in this patient. Although this is an extremely rare complication of magnetic sphincter device augmentation, it is one that physicians should be cognizant of given the dangers of syncope events.

The clinical characteristics of situational syncope in children and adults undergoing head-up tilt testing

OBJECTIVE

Situational syncope is a subtype of neurally mediated syncope and associated with specific circumstances. This paper is to assess the clinical characteristics and underlying causes of situational syncope.

METHODS

This is a retrospective study of patients who underwent head-up tilt testing (HUTT). Medical records including age at HUTT, gender, number of syncopal episodes, family history of syncope, triggers before the syncopal episode, position during the syncopal episode and the responses to HUTT were reviewed.

RESULTS

Among 3140 patients, 354 patients (mean age 28.3 ± 16.6 years old, with 184 males and 170 females) were diagnosed with situational syncope. The causes of situational syncope included micturition (50.85%), defecation (15.82%), bathing (10.45%), swallowing (6.50%), cough (4.80%), post-dinner (3.95%), singing (3.11%), teeth brushing (2.26%), and hair grooming (2.26%). Patients with syncope triggered by micturition, cough, post-dinner were more likely to be men, while those caused by bathing, swallowing, singing, teeth brushing and hair grooming were more likely to be women. 34.75% of patients with situational syncope were between the ages of 10-19 years old, and 20.34% were between the ages of 40-49 years old. 74.01% of situational syncopal events occurred in an upright position. 47.74% of patients had positive responses to HUTT.

CONCLUSIONS

These findings show that micturition was the most common cause of situational syncope in both children and adults. There were significant gender and age differences among situational syncope triggered by different causes. Most of situational syncope occurred in the upright position and nearly half of the patients had positive responses to HUTT.

Swallow syncope: a case report and review of literature

Background

Swallow or deglutition syncope is an unusual type of neurally-mediated syncope associated with life-threatening bradyarrhythmia and hypotension. It is a difficult condition to diagnose with commonly delayed diagnosis and management. There is lack of review articles that elucidate the basic demographics, clinical characteristics and management of this rare condition. This publication systematically reviews the 101 case reports published since 1793 on swallow syncope.

Case presentation

A 59-year-old man presented with the complaint of recurrent dizziness associated with meals. A 24-h ambulatory ECG recording confirmed an episode of p-wave asystole at the time of food intake. Oesophagogastroduodenoscopy with balloon inflation in the mid to lower oesophagus resulted in a 5.6 s sinus pause. The patient’s symptoms resolved completely following insertion of a permanent dual chamber pacemaker.

Conclusions

Swallow syncope is extremely rare, but still needs to be considered during diagnostic workup. It is commonly associated with gastro-intestinal disease. Permanent pacemaker implantation is the first line treatment.

Cardiogenic anorexia and underweighting in a child: case report

Introduction

In this case, we present a child with a diagnosis of anorexia and no known cardiac disease, who was referred to our clinic for a routine cardiac monitoring. ‘Asymptomatic’ high degree of atrioventricular block (AVB) was revealed. She underwent successful pacemaker (PM) implantation and losing of the weight stopped.

Case presentation

In this case, the abrupt AVB with more than 6 s ventricular pauses without escape rhythm during the day-time most possible is a type of neurally mediated AVB which was presented by anorexia, underweighting, and refusing to eat in a 12-year-old girl. All symptoms disappeared after PM implantation, and weight gain was recorded during 6 months of follow-up.

Discussion

The causal link between AVB and anorexia is discussed. In this case, patient’s eating disorder was related to her AV conduction abnormality. The main reason of this case report is to emphasize, that in children with unexplained anorexia and underweighting cardiogenic origin must be excluded.

[A case of swallow syncope associated with Parkinson disease]

A 73-year-old woman with Parkinson disease (PD) was admitted to our hospital because of aspiration pneumonia. She presented with recurrent episodes of loss of consciousness with bradycardia while swallowing solid foods or fluids. Upper endoscopy revealed a normal esophagus without hiatus hernia, cancer, diverticulum, stenosis, or achalasia. Balloon inflation at the cervical esophagus induced sinus arrest and bradycardia followed by a loss of consciousness. The diagnosis of swallow syncope (SS) was confirmed. Esophageal dilatation and an increase in the esophageal pressure induced by esophageal peristaltic disturbance associated with PD can cause SS by stimulating the vagal reflex. In addition, the head-up tilt test showed that she had orthostatic hypotension, and the coefficients of variations of the R-R intervals on electrocardiograms and the total number of beat-to-beat differences greater than 50 mseconds in the RR interval during a 24 hour ambulatory electrocardiogram were normal. The cardiovascular autonomic dysfunction characterized by the presence of sympathetic inhibition and a preserved parasympathetic function might be involved in the onset of SS. Permanent pacemaker implantation improved her clinical symptoms. The recognition of SS on the examination of a PD patient with loss of consciousness while eating is important, as PD patients might develop SS due to peristaltic disturbance and autonomic dysfunction caused by PD.

Dangerous noodle: A case of swallowing syncope and a review of 122 cases from the literature

Swallowing syncope is a rare medical condition. Even though it has been known as a neurally mediated syncope, the definitive mechanism of this condition remains unclear. We show in this study an additional case of swallowing syncope and review the 122 reported cases from the literature. A 47-year-old Japanese man had been suffering from recurrent syncopal attacks, when he fainted immediately after swallowing. Holter electrocardiogram monitoring demonstrated a sinus pause (maximum R-R interval of 3.8 seconds) after he swallowed a noodle quickly. A permanent pacemaker was implanted because the frequency of syncope increased.

Swallow (deglutition) syncope: An evaluation of swallowing-induced heart rate and hemodynamic changes in affected patients and control subjects

BACKGROUND

Syncope triggered by swallowing is a well-known but uncommon condition that has been the focus of case reports but is otherwise largely unstudied. To better understand swallow syncope we examined heart rate (HR) and blood pressure (BP) changes during swallowing in clinically suspected swallow syncope patients and asymptomatic control subjects.

METHODS

The study population comprised four individuals with a history suggesting swallow syncope (three men, 53 ± 14.9 years) and 15 (nine men, 46 ± 17.1 years, P = NS vs patients) asymptomatic volunteer control subjects. Studies in all individuals comprised noninvasive beat-to-beat HR and BP measurement during swallowing 150 mL of cold liquid while standing. Additional tests in swallow syncope patients included: active standing, Valsalva maneuver, carotid sinus massage (CSM), and head-up tilt (HUT).

RESULTS

Swallowing resulted in a greater decrease of both HR (-22 ± 22.1 vs -3 ± 11.7 beats/minute [bpm]; P = 0.045) and BP (-22 ± 17.4 vs - 2 ± 11.8; P = 0.036) in swallow syncope patients than in controls. Further, in swallow syncope patients the time to lowest HR and BP differed (9 ± 5.5 vs 19 ± 7.2 seconds; P = 0.02), suggesting that both cardioinhibitory (CI) and vasodepressor (VD) mechanisms are present but operate independently. Other autonomic studies were normal in swallow syncope patients except for CSM pause more than 3 seconds in two patients.

CONCLUSION

Swallow syncope is associated with transient and temporally independent CI and VD features, consistent with reflex syncope. Potentially, a swallowing test during autonomic evaluation may be useful to unmask relative magnitudes of CI and VD responses, thereby facilitating treatment strategy decisions.

Dysphagia, Hyperglycemia, and Presyncope

There have been over 80 documented cases of swallow syncope-a rare form of reflex or neurally mediated syncope-with most cases associated with an underlying esophageal disorder. Here, we describe the first reported case of swallow syncope or presyncope caused by an infectious esophagitis. Our 65-year-old patient initially developed dysphagia, odynophagia, and presyncope with swallowing. This lead to nutrition and medication avoidance behavior, which was followed by the development of diabetic ketoacidosis. The diagnosis of swallow presyncope was confirmed with a provocative swallow study demonstrating 8 s sinus arrest, and an underlying cause of Candida esophagitis was found by upper endoscopy. Symptoms completely resolved after treatment with micafungin.

Citrus fruits induced swallow syncope with atrioventricular block or sinus arrest

Swallow syncope is a relatively rare syndrome and caused by various foods and drinks. A 76-year-old man was admitted with frequent syncope while eating. Holter electrocardiogram revealed frequent occurrence of atrioventricular block during meals. Both atrioventricular block and sinus arrest were induced by only eating citrus fruits, citrus jelly, and acidic foods but not by other drinks and foods. These arrhythmias were suppressed after administration of atropine. No further episodes of syncope recurred after the implantation of a DDD pacemaker. This case indicated that acidic stimulation of citrus induced a vasovagal reflex via esophageal nociceptors leading to syncope.

Swallow-induced syncope in 5 patients: Electrophysiologic evaluation during swallowing

Background

We sought to characterize a cohort of participants with swallow-induced syncope (SIS) with clinical and electrophysiologic evaluations.

Methods

Using electrocardiographic monitoring and neurophysiologic methods of swallowing, we evaluated a cohort of 5 patients with SIS, 4 of whom had longitudinal follow-up.

Results

We determined electrophysiologically that the duration between the onset of swallow and a bradyarrhythmia or asystole is extremely short (2-3 seconds) in SIS. Most participants with SIS do not have a neurologic or esophageal disorder. SIS can occur with different food types, in sitting or standing position, and has varying frequency in different participants. Permanent pacemaker placement is a curative measure in SIS.

Conclusions

Our findings suggest that SIS is elicited by reflex afferent pathways originating in the oropharynx, rather than an esophageal origin, as previously proposed. Our longitudinally followed cohort with detailed clinical and electrophysiologic characterization should aid the clinician in the diagnosis and treatment of this potentially life-threatening condition.

Deglutition Syncope: Two Case Reports Attributed to Vagal Hyperactivity

Deglutition syncope is a relatively rare cause of syncope that belongs to the category of neurally mediated reflex syncopal syndromes. The phenomenon is related to vagal reflex in context to deglutition causing atrioventricular block and acute reduction in cardiac output leading to dizziness or syncope. We present case series of two cases of deglutition syncope, of which first was managed medically and second with pacemaker implantation.

Asystole From Direct Laryngoscopy: A Case Report and Literature Review

The rare and potentially fatal complication of asystole during direct laryngoscopy is linked to direct vagal stimulation. This case describes asystole in an 85-year-old female who underwent suspension microlaryngoscopy with tracheal dilation for subglottic stenosis. Quick recognition of this rare event with immediate cessation of laryngoscopy resulted in the return of normal sinus rhythm. This incident emphasizes the implications of continued vigilance during laryngoscopy and the importance of communication between the anesthesia and surgical staff to identify and treat this rare complication. The case was successfully concluded by premedication with an anticholinergic and by increasing the depth of anesthesia.

Syncope with Swallowing

Swallowing can be a trigger for syncope and can cause significant morbidity and mortality if not recognized. A 13-year-old presented with clusters of transient complete atrioventricular block after repair of a sinus venosus atrial septal defect. Pacemaker implantation was successful in treating these symptoms.

Swallow syncope caused by third-degree atrioventricular block

We report a case of a patient with more than 30 years of repeated syncopes, always following food intake. The patient was diagnosed with a swallow-related third-degree atrioventricular block and successfully treated with an artificial pacemaker.

Deglutition Syncope: A Case Report and Review of the Literature

Deglutition syncope (DS) is a rare, neurally-mediated syncopal syndrome arising from an aberrant vagotonic reflex during swallow-associated esophageal dilation. Its association with gastroesophageal disorders often prompts gastroenterology consultation. An 89-year-old man with recent dysphagia and otalgia was admitted after a syncopal episode occurred while eating. Esophageal imaging and endoscopy demonstrated no causative abnormalities. Maxillofacial imaging revealed chronic sinusitis and mastoiditis. Telemetry monitoring demonstrated high-grade atrioventricular block and pause associated with swallowing. His symptoms and swallow-associated arrhythmia resolved after dual chamber pacemaker implantation. DS is highly treatable once identified and multidisciplinary coordination is helpful in optimizing outcomes and avoiding superfluous testing.

Blackout during meals: A case report of swallow syncope due to sinus arrest

A 79-year-old male, with a history of percutaneous coronary intervention (PCI), was referred to our cardiovascular department for a detailed examination of blackout caused by sinus arrest only during meals. Ultrasound echocardiography showed normal cardiac contraction with no asynergy, irrespective of the remaining stenotic coronary lesion. An electrophysiological study revealed deteriorated atrioventricular nodal conduction at a Wenckebach point of 70 beats per minute. However, sinus node function was normal as demonstrated by a sinus node recovery time of 1369 ms. Coronary angiography showed triple-vessel disease including the remaining stenotic coronary lesion, and a PCI was performed on the right coronary artery. Nevertheless, sinus arrest during meals was unchanged. Swallow syncope was partially improved by dietary modification; however, pacemaker implantation (PMI) was performed eventually, and the patient became asymptomatic after PMI. <Learning objective: Swallow syncope is a rare cause of syncope that belongs to the neurally mediated reflex syncopal syndromes, which can induce a variety of bradyarrhythmias: sinus bradycardia, sinus arrest, sinoatrial block, atrioventricular block, or atrial and ventricular asystole. In this case, we demonstrated that dietary modification or pacemaker implantation improved swallow syncope due to sinus arrest.>.

Swallow syncope: clinical presentation, diagnostic criteria, and therapeutic options

We recently encountered three patients with episodes of syncope associated with food ingestion. A 31-year-old woman had an episode of syncope in the hospital while drinking soda. Transient asystole was noted on the telemonitor, confirming the diagnosis of swallow syncope. The other two patients were 78- and 80 year old gentlemen, respectively, who presented with recurrent and transient episodes of dizziness during deglutition. Extensive work-up of syncope was negative in both cases and a diagnosis of swallow syncope was made by clinical criteria. These cases illustrate the challenging problem of swallow syncope. The diagnosis can be suspected on the basis of clinical presentation and confirmed with the demonstration of transient brady-arrhythmia during deglutition. Medical management includes avoiding trigger foods, use of anticholinergics, and/or placement of a permanent cardiac pacemaker.

A case of swallow syncope associated with cold beverage ingestion

Swallow syncope (also known as deglutition syncope) is a relatively rare type of syncope that is treatable if diagnosed correctly. We report a case of a 39-year-old man with recurrent swallow syncope. The patient did not have structural heart disease. He developed a complete atrioventricular block upon drinking a cold beverage (Chilsung cider) while undergoing a repeated head-up tilt test. The patient was advised to avoid cold beverages and has been symptom free for 5 months.

Swallow syncope: a case report and review of the literature

Swallow or deglutition syncope is a relatively rare syndrome. It is a vagally mediated syncope induced by swallowing. Swallow syncope may occur in all age groups and, when diagnosed, is treatable. A woman, aged 60 years, presented with an episode of a syncopal attack associated with swallowing a sandwich. She had a 6-month history of recurrent episodes of lightheadedness while eating solid foods. Telemetry monitoring demonstrated several episodes of severe bradycardia and complete atrioventricular block with up to a 7.0 second pause associated with meals. Computed tomography of the head and neck revealed no significant findings, and barium esophagram was normal. Echocardiogram was within normal limits. Her symptoms resolved after permanent pacemaker placement. Herein, we review the diagnosis, mechanism, and management of swallow syncope.

Deglutition syncope: a manifestation of vagal hyperactivity following carotid endarterectomy

A 61-year-old man with left amaurosis fugax and bilateral >80% internal carotid artery stenoses underwent a left carotid endarterectomy. On the first postoperative day, he developed hypotension, bradycardia, and chest pain with food ingestion. He was diagnosed as having deglutition syncope and was treated with oral anticholinergics. Similar symptoms occurred when he underwent a right carotid endarterectomy. Deglutition syncope is a neurally mediated situational syncope resulting from vagus nerve over-activity. This is the first report of deglutition syncope associated with carotid endarterectomy. It is important to recognize and differentiate these symptoms from other causes of postendarterectomy hemodynamic instability.

Deglutition syncope associated with ventricular asystole in a patient with permanent atrial fibrillation

Deglutition syncope is a situational syncope that is diagnosed only by a detailed history. We report deglutition syncope in a 62-year-old man, who had permanent atrial fibrillation. The patient had no structural or functional abnormalities of the esophagus. During syncopal attacks, his electrocardiography showed ventricular asystole that was sustained for 12 seconds. The patient was successfully treated by implantation of a permanent pacemaker.

An uncommon case of right-sided throat pain and swallow syncope

A 63-year-old man presented with recurrent syncopal attacks associated with swallowing and right-sided throat pain. Immediately after admission, he presented a 16-s asystolia. The patient's clinical history was unremarkable except for previous postimplant periodontitis. Several episodes of severe bradycardia and sinus pauses, always associated with painful deglutition, were recorded subsequently. X-ray orthopanthomography and magnetic resonance imaging of the neck confirmed several areas of periodontitis around the previous dental implants and right mastoid inflammation. A barium swallow and fibre-optic endoscopy also revealed a small sliding hiatus hernia and distal chronic oesophageal inflammation. Despite complete dental curettage, antibiotics and antigastro-oesophageal reflux therapy, only partial relief of the pain and incomplete resolution of the arrhythmic disorder were obtained after 3 weeks, and the patient underwent pacemaker implantation. At 1-month follow-up, however, he reported the complete relief of the throat pain; subsequent Holter monitoring showed normal sinus rhythm, without pacemaker-induced electrical activity.

Swallow syncope associated with complete atrioventricular block in an adolescent

We describe a 16-year-old female with a history of swallowing-induced syncope. The physical examination, ECG, echocardiography, barium swallow test, and thyroid function tests were within normal limits. The ambulatory ECG revealed intermittent complete atrioventricular block only associated with swallowing. There was also intermittent first-degree atrioventricular block not related to eating. An electrophysiologic study was performed during the implantation of a single-chamber transvenous ventricular pacemaker. There was mild atrioventricular nodal conduction disturbance with a His-ventricular interval of 70 msec and Wenckebach cycle length of 420 msec. During 1 year follow-up, the patient remained asymptomatic.

Radiofrequency ablation of swallowing-induced atrial tachycardia: case report and review of literature

We report the case of a 47-year-old white man who presented with 1-year history of palpitations while swallowing. Event monitor confirmed the episodes were atrial tachycardia. Medical management with a calcium channel blocker did not alleviate the patient's symptoms. Gastrointestinal endoscopy did not reveal any abnormality. Electrophysiologic study was performed to identify and map the tachycardia. Swallowing during the procedure was used to repeatedly induce the tachycardia. A focal right atrial tachycardia that was mapped to the lower posterior right atrium was successfully ablated. Follow-up at 6 months and 1 year showed complete resolution of symptoms. An in-depth review of the literature and all published case reports of swallowing-induced atrial tachycardia is presented, and possible mechanisms of this rare form of tachycardia are discussed.