Chronic Hiccups Management
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I would like to present a 53 y/o male patient: 1,78 m 76 kgs, athletic, non smoker, no arterial hypertension, no DM, surgical hx of hyatal hernia 13 months ago presents to the office with chronic hippcups. Thorax Rx has excellent lung expantion (10 intercostal spaces). Again no chronic lung disease
He has been on chlorpromazine, gabapentin, fenoldopam with no response whatsoever. Has had a couple of weeks relief while he took fenoldopam but the he relapsed again.
Have carried out first a right phrenic nerve block with levobupivacaine 0,25% 5cc and 0,2 mgr of dexametasone with 70% relief. (SpO2 95% on room air 1 hr after procedure. No dyspnea. This lasted for 7 days.
I attempted bilateral phrenic nerve blockade (very risky but, kept him under monitorization for 6 hours) with complete relief but hippcup frecuency dropped with did not disappear completely. Went home and after 3 days he has relapsed.
This guy is desperate. He can’t work, cant sleep.
I am planning on RF the right phrenic nerve. Anyone ever had a similar case? Opinions highly appreciated.
Thanks! -
Sounds like the hiccups could be due to nerve irritation or inflammation. I would like some more information about the patient–when exactly did the hiccups start? Any relationship to the hiatal hernia repair? Does the patient drink alcohol–how much? Did you check the patient for neck or throat mass/goiter? What about a CT of the neck? Any possible history of MS or demyelination? MRI of the Brain may be considered. How about an ENT referral—any ear canal or throat pathology that can cause this situation should be evaluated. I would check these avenues before you do RF of the phrenic nerve.
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Maybe first consider stimulation peripheral nerve field stim before RF ?? Never done this but would consider it
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Hi dear. I had similar patients …and very bad cases twice. First among the drugs you used you may try the last one in the list ..pregabalin. It worked with me before and sometimes spared my patients the risky intervention. This is just a notice not supported by any literature however we may do a search on that.
Secondly o read in the literature that if you cannot see which side is cramping try the right side alone. Sometimes it is dominant. I read that in a text book but I could not find it to give you the reference.
Based on that I tried once the phrenic nerve block on the right side in a patient similar to yours and it worked.
Finally if you need to do an RF …I may suggest the pulsed and there was an article supporting the usage of a nerve stimulator for phrenic nerve block ,however theoretically in such a condition stimulation can trigger the hiccough …I don’t know since my patients luckily responded to the previous listed trials. Also try first one side (RT) since it might work if it is a dominant side
I know how fragile an be these patients …I had similar cases be fore
Good luck. -
I think Chlorpromazine is the best treatment. you have to use Chlorpromazine for high doses. Please check it first then, if it does not work you may try to combine.
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Good morning. I’m agree with Mr Myron Nicholas. You should find the cause of the hiccup.
On the other hand, I had good results with oral baclofeno. -
We have done a pulsed radio-frequency over the phrenic nerve recently, it was guided by ultrasound and we confirmed the needle position with motor stimulation, we did this after a previous nerve block. We haven´t seen the patient yet, but I will tell you how it went! We have done the PRF of the phrenic nerve before with very good results, bout it wasn´t because of hiccups but because of pain after cholecystectomy. This last patient does have chronic hiccups.
So… I will tell you! -
Dexamethasone can cause post-procedure hiccups in some patients. Try using other type of steroids.
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Betamethasone has been the biggest offender over the years and is dose related . Uncomplicated ESI, hiccups start within 12 hours and can last days. Atarax seems to help until they diminish. Changing steroids seems to help for repeat visits.
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Thank you everyone for your replies! After blocade he had 60% relief but hippcup returned a few days later! he did well with nefopam (acupam) one injeccion daily for one week. Fortunately, his hiccup did not return after this (or perhaps patient did come back!) He tried chlorpromazine, baclofen and steroids before he was sent to me. None worked. Acupam had the “luck” of being the last drug he tried.
Unfortunately I will never know if it was natural history of if this actually helped him.
Cause is supposed to be post surgical (hiatal hernia repair)
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