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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Persistent Hiccups Following
Stapedectomy |
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Aidonis I, ENT Surgeon, Euromedica Kyanous Stavros
Hospital, Thessaloniki, Greece,
Skalimis A, Anaesthesiologist,
Euromedica Kyanous Stavros
Hospital, Thessaloniki, Greece,
Kyrodimos E, ENT Surgeon,
ENT Department, Hippokration
General Hospital, University of Athens. |
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Address For Correspondence |
ENT Surgeon,
Euromedica Kyanous Stavros
Hospital,
Thessaloniki, Greece.
E-mail:
johnaidonis@hotmail.com |
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Aidonis
I, Skalimis A, Kyrodimos E. Persistent Hiccups Following
Stapedectomy. Online J Health Allied Scs.
2010;9(3):16 |
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Submitted: Sep 4, 2010;
Accepted:
Sep 5, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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Objective:
We report a case of a 37 year-old man who developed persistent hiccups
after elective stapedectomy. Method and
Results: The diagnostic approach is discussed as well as the non-pharmacologic
and pharmacologic treatments and overall management. The aim is to stress
that there is a variety of potential factors that can induce hiccups
perioperatively and in cases like this a step by step approach must
be taken. Conclusion:
Persistent hiccups are very rare following stapedectomy, control of
them is crucial for the successful outcome. The trigger may be more
than one factors and the good response to treatment may be due to dealing
successfully with more than one thing.
Key Words: Intractable; Singultus; Stapedectomy; Postoperative hiccups
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Hiccups are
an irritating symptom that a patient can present with at any time of
their life. Perioperatively there is a variety of risk factors that
potentially can induce them and set hurdles in the overall management.
In ear surgery with implant insertion, movement restriction is crucial
especially in the immediate postoperative period. Any unnecessary move
is potentially detrimental to the outcome. We present a case in which
a patient presented with this kind of symptoms with them persisting
for a relatively long time and required a lot of attention from the
medical and nursing staff. Management included assessment of the patient’s
condition, evaluation of risk factors and control of them. Conservative
techniques were applied and more invasive ones were considered before
the symptom was controlled and finally resolved. Points of interest
in the following case were: i) the fact that nature of this particular
operation has limited association with this particular symptom, ii)
the delay in the commencement which was remarkable, and iii) a range
of responses to treatments attempted. All of them produced a variety
of possible trigger factors as well as potential treatments of a relatively
benign, but rather worrisome symptom.
A 37 – year
old male was admitted for elective stapedectomy. His past medical history
was of no significance, except for bilateral conductive hearing loss
running within the family. On preoperative assessment all studies were
normal and on systemic examination the only thing that could render
him as ASA II was his increased BMI (34) for which he was on a negative
calorie diet, based mainly on vegetables. He was non smoker and with
no history of excessive alcohol consumption. What was noticed by surgical
and anaesthetic teams was his high apprehension about the operation.
That was the decisive reason for scheduling him to have surgery under
General Anaesthesia.
Anaesthesia
was induced with Propofol 200mg, Fentanyl 100μg, Cis- Atracurium 14mg
and Ondansetron 8mg was administered as anti-emetic. Maintenance was
achieved with Sevoflurane 2.2% in a mixture of Air and Oxygen (FiO2:
0.5). Operation was uneventful and lasted 55 minutes. Operative finding
of note was severe obliteration otosclerosis. Therefore, footplate of
the stapes was opened with the use of a special skeeter 0.8mm diameter
and included successful insertion of a platinum and PTFE piston 4.5X0.6mm.
Recovery was smooth with no symptoms like headache, nausea or vertigo.
During postoperative assessment, there was no nystagmus with positive
Weber test on the side of the operated ear. Instructions regarding mobilisation
of the patient were given, and it was stressed that excessive movement
should be avoided.
His medication
postoperatively included intravenous Methylprednisolone given at a rate
of 500mg/24hours, intravenous Cefuroxime 750mg tds, Ranitidine 150mg
orally bd and Paracetamol 1gram four times a day regularly. He was also
prescribed 3mg nocte oral Bromazepam as a sedative for his excessive
stress and Piracetam 3mg i.v. tds. His diet was mainly fluids and low
salt light food.
Thirty six
hours post surgery, patient noticed the start of bothersome hiccups,
which initially were just observed and control manoeuvres (i.e. breath
holding, sips of cold fluid at certain body position and timing, as
well as trials that could elicit vagal reflexes), were attempted avoiding
Valsalva technique for obvious reasons. As it continued, and it was
thought that operative outcome was at risk, medical treatment was sought.
After Midazolam
2mg was given intravenously for anxiolysis, Lignocaine 1mg/kg was administered
i.v. with no response. Magnesium salts were tried both orally and i.v.
and patient was reassessed a few hours later. All he was asking at the
time was relaxation and Bromazepam 3mg was recommended once again. This
seemed to settle hiccups and the patient didn’t complain for a couple
of hours. Sixteen hours after the presentation of hiccups the symptom
recurred. At that time and due to concerns of causing damage to the
implant, directed management was decided. His prescription chart was
reviewed thoroughly and the steps taken were: i) cessation of
Methylprednisolone as hiccups is a recognised side effect, and ii) discontinuation
of Piracetam to avoid possible unnecessary actions, such as hyperkinesia
and nervousness thought to be trigger factors for hiccups. In addition
to this certain drugs cessation, mobilisation of the patient was initiated
and as he complained of flatulence, Domperidone and Pantoprazole were
added in his medication instead of solo Ranitidine. Chlorpromazine was
considered, but left for later stage. During the course of the next
24 hours there was a gradual decrease in the frequency of the symptoms
with only brief free of symptoms periods. The patient noticed an association
between bowel movements and severity of symptoms. Therefore, a glycerine
enema was arranged and following that, distressing symptoms resolved
50 hours after the initial presentation. He was discharged the next
morning, 72 hours post surgery. In the routine follow up three weeks
after discharge, he confirmed full discontinuation of the bothersome
hiccups and three months later his hearing had improved significantly.
The mechanism
of hiccups mainly involves repetitive involuntary contractions of a
hemi-diaphragm. Most of the times are self limiting and last only a
short period of time. Intractable ones are relatively infrequent and
may last in extreme conditions up to several years. Although simple
hiccups show no preference to sex and age, persistent ones present more
commonly in men.
Phrenic and
vagus nerves along with the sympathetic chain from T6-T12, the respiratory
centre, medullary reticular formation, and the hypothalamus participate
in the development of the hiccup reflex. There is a wide range of trigger
factors for hiccups development and may be associated with literally
any system of the human body and a certain degree of dysfunction in
them, as well as profound underlying disease. Psychological factors
cannot be overlooked. In our case likely causes considered, in order
of probability from least to most, were: i) intraoperative head position
for surgical field optimisation that in this case may stretch the phrenic
nerve roots; the late start of the symptom though is against that assumption,
ii) anaesthetic agents: Benzodiazepines or short-acting barbiturates
that are responsible for similar symptoms were not given during the
operation and first presentation was anyway delayed, iii) patient’s
sex; males are considered to be more prone to intractable hiccups, iv)
drugs like Methylprednisolone known to cause hiccups1 and
Piracetam potentially inducing hyperkinesia and nervousness factors
that can set off hiccups, v) diet based mainly on vegetables, vi) high
apprehension about the operation generating undue stress, vii) limited
mobilisation. The latter three factors above could cause delayed gastric
emptying and potentially causing abdominal bloating2, a combination
that can bring out this bothersome symptoms.
Management
should focus on the most likely causes of hiccups and eliminate the
underlying factors. Laboratory tests seem to be of little value in determining
whether treatment interventions are effective.3 Control of
symptoms can be achieved either with or without drugs. Non – drug
management involves: i) remedies such as stimulation of the nasopharynx
i.e. drinking cold water from the wrong side of a glass, tasting vinegar
or sipping lemon juice, ii) vagal stimulation obtained with Valsalva
manoeuvre, breath holding etc., iii) interventions like phrenic nerve
block with local anaesthetics or surgically, microvascular decompression
of the vagus nerve, transoesophageal diaphragmatic pacing. All of them
should be used in extremely intractable situations4, iv)
for hypnotherapy and acupuncture5 the evidence is limited
and their use has some place in psychogenic cases. Drug management is
attempted only if these remedies have failed and may be beneficial in
the suppression of the symptoms. Drugs that have been involved in the
treatment of hiccups are: i) antipsychotic agents like haloperidol and
chlorpromazine with good results, ii) prokinetics such as Domperidone
or Metoclopramide especially when the suspicious cause is gastrointestinal
track dysfunction6, iii) antiepileptics (phenytoin, carbamazepine, gabapentin, sodium valproate)
have a place since diaphragmatic activity seems to respond well sometimes
in their therapeutic doses7, iv) other agents including Ketamine,
Lignocaine, Midazolam, Bromazepam, Nefopam, Baclofen PPIs or H2-receptor
have been attempted with some success.8,9
In our case
there was no specific factor initially and the first steps involved
the simple non-drug remedies. As it persisted, more concentration was
given in the potential causes. Suspicious drugs were removed from treatment
and conditions thought to precipitate it, were managed medically. Therefore
anxiety was treated with Bromazepam, gastric stasis with Domperidone
and Pantoprazole. Bowel movements were encouraged with mobilisation
and glycerine enema which also may result to vagal stimulation having
the same effect as digital rectal stimulation has in a similar scenario.10
Resolution of hiccups was achieved 50 hours after it started and his
hearing improved with no further morbidity either associated or not
with hiccups.
Singultus can
present as a symptom with or without obvious cause and rarely due to
underlying disease. Due to absence of controlled studies, evidence-based
recommendations for treatment are difficult to produce. This was a relatively
rare case of postoperative intractable hiccups following stapedectomy.
Its control was crucial for the success of the operation and patient’s
wellbeing. Both were eventually obtained. Although uncommon in this
particular operation, persistent hiccups are possible to face and ways
of managing them should be considered.
- Hung
YM, Miller MA, Patel MM.
Persistent hiccups associated with intravenous corticosteroid therapy. Journal of Clinical Rheumatology
2003;9:306-309.
- Launois
S, Bizec JL, Whitelaw WA, et al.
Hiccup in adults: an overview. European Respiratory Journal 1993;6:563-575.
- Cymet
TC. Retrospective analysis
of hiccups in patients at a community hospital from 1995-2000. Journal of the National Medical Association 2002;94:480-483.
- Calvo
E, Fernandez-La Torre F, Brugarolas A.
Cervical phrenic nerve block for intractable hiccups in cancer patients.
Journal of the National Cancer Institute 2002;94:1175-1176.
- Dietzel J, Grundling
M, Pavlovic D, Usichenko TI. Acupuncture for persistent postoperative
hiccup. Anaesthesia 2008;63:1021-1022.
- Hiyama
T, Yoshihara M, Tanaka S, Haruma K, Chayama K.
Effectiveness of prokinetic agents against diseases external to the
gastrointestinal tract. Journal
of Gastroenterology and Hepatology. 2009;24:537-46.
- Moretti
R, Torre P, Antonello RM, et al. Gabapentin as a drug therapy of intractable hiccup because of vascular
lesion: a three-year follow up. The Neurologist 2004;10:102-106.
- Wilcock
A, Twycross R. Midazolam
for intractable hiccup. Journal of Pain and Symptom Management 1996;12:59-61.
- Bilotta F, Pietropaoli
P, Rosa G. Nefopam
for refractory postoperative hiccups.
Anesthesia & Analgesia 2001;93:1358-1360
- Odeh M, Bassan
H, Oliven A.
Termination on of intractable hiccups with digital rectal massage. Journal of Internal Medicine 1990;227:145-146.
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