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Glossopharyngeal neuralgia with cardioinhibitory syncope: is permanent pacemaker required?
Session:
Sessão de Casos Clínicos - I
Speaker:
Ana Marques
Congress:
CPC 2019
Topic:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Ana I. Marques; Daniel Caldeira; Sofia Alegria; Ana Rita F. Pereira; Alexandra Briosa; Sofia Almeida; Rita Miranda; Luis Brandão; Isabel João; Helder Pereira
Abstract
<p>We present a case report of an 80-year-old woman that was admitted to the hospital with a 2 days history of syncopal attacks, preceded with intermittent sharp and severe pain in the right pharynx, during 5 to 25 seconds that radiating to the ipsilateral ear.</p> <p>Pain had started 2 months earlier, with progressive intensity and frequency in the last 2 weeks, with more than 100 episodes daily, without circadian rhythm variability, but so intense that woke up the patient during the sleep. The pain was trigged by swallowing, chewing and talking.</p> <p>At the emergency department, she had syncopal episodes associated with an asystole period lasting more than 6 seconds with low escape beats, associated with arterial hypotension. Between these episodes, she was in sinus rhythm with no abnormalities in electrocardiogram.</p> <p>Her medication history was unremarkable for negative chronotropic drugs.</p> <p>Due to severe sinus bradycardia and asystole, during the pain episodes, a temporary transvenous pacemaker was placed to prevent syncopal episodes.</p> <p>During the first days of hospital stay, the patient had recurrence of cervical pain and, in course of pain attacks, she had transient symptomatic hypotension with bouts of systolic drops pressure over 40 mmHg, but no more syncopal episodes were verified.</p> <p>Both physical and neurological examination, blood tests and echocardiography were normal. Cranial computer tomography (CT) scan and cervical angio-CT did not reveal any signs of glossopharyngeal nerve impingement.</p> <p>In the absence of syncope recurrence with temporary pacemaker (and despite the vasodepressor component) with pain paroxysms, it was decided to implant a permanent dual-chamber pacemaker.</p> <p>After glossopharyngeal neuralgia (GPN) associated with reflex syncope was diagnosed, the patient started on 200mg carbamazepine, twice daily, with clinical improvement.</p> <p>The dose was uptitrated to 600 mg daily and she was asymptomatic at the discharge. At 1-year follow-up, the patient remained asymptomatic, without pain or syncopal episodes. Pacemaker interrogation revealed pacing rates <1%. </p> <p>Glossopharyngeal neuralgia is a rare facial pain syndrome (represents only 0.2–1.3 % of the facial pain syndromes). More rarely, it can be associated with reflex syncope. There are few cases reported in the literature of patients diagnosed with GPN with syncope treated with pacemaker implantation and pharmacological therapy and the importance of implanting a pacemaker to avoid syncopal attacks in follow-up of these patients remains uncertain. This case report supports the current guidelines for pacing in neuro-cardiogenic syncope, the current prevailing expert opinion and the results of the randomized trial VPS-II, by demonstrating a lack of requirement for pacing in a case of neuro-cardiogenic syncope with both cardioinhibitory and vasodepressor responses.</p>
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