Nasal carcinoma – a rare indication for a permanent pacemaker

Abstract

-Cardiac sinus syncope is a recognised but rare complication of head and neck cancers. Although electrical pacing remains an important treatment to prevent further syncopal episodes related to bradycardia, vasopressorrelated syncope remains a more difficult management problem. The article describes the case of a 66-year-old patient with metastatic squamous cell carcinoma of the nose, who presented with syncope and exhibited carotid sinus syncope related to both carotid body invasion and vasopressor mechanisms. Successful management by the insertion of a permanent pacemaker is described, and a review of the literature on this rare complication is given. KEY WORDS: carotid sinus syncope, pacemaker, squamous cell carcinoma, vasopressor related syncopeMetastatic malignant disease of the head and neck is a recognised but rare cause of carotid sinus syncope. The mechanisms underlying carotid sinus syncope are complex. Recognising the symptoms and signs of the different types of carotid sinus syncope are essential if it is to be managed successfully. Patient historyA 66-year-old man presented in November 1998 with a large 2-cm ulcerating lesion arising from his right nasal vestibule. He had first noticed it one month before and it had rapidly grown since then. The lesion extended from the right nasal vestibule to the floor of the nostril. We found no enlarged lymph glands in the neck. A biopsy of the lesion showed a well differentiated squamous cell carcinoma. A magnetic resonance imaging (MRI) scan of the head and neck was otherwise normal, staging the disease as T3 N0.In view of the difficult location, the patient underwent radiotherapy with a three-field arrangement with a wax block to bolus up the nose and nasal cavity. A dose of 55 Gy in 20 fractions was given over four weeks. After two months, there was no visible tumour at the nostril, and clinical examination at that stage was normal.In May 2001, a right submandibular lymph node was noted. Aspiration of this site revealed metastatic disease, and a 3 cm by 2 cm necrotic lesion was confirmed on repeat MRI scan. The patient underwent a right modified neck dissection; of 17 nodes that were removed only one was positive (20 mm node with extracapsular spread). Adjunct radiotherapy was given to the area: 60 Gy to the right neck and 50 Gy to the left neck. He made a good postoperative recovery.The patient presented in December 2001 to casualty after a syncopal episode. There were no preceding symptoms. Localised cutaneous radiotherapy changes affecting the right neck, a right palatal palsy and right vocal cord palsy suggested a right vagal nerve palsy. There was no palpable lymphadenopathy. Routine X-ray and laboratory investigations were also normal. While being monitored in hospital, he had another witnessed syncopal episode associated with profound sinus bradycardia (pulse 38 b/min, blood pressure 60/40) (see Fig 1a). This rapidly responded to a bolus of 1 mg intravenous atropine. A temporary pacing wire was inserted (Fig 1b). Over the next five days, the p...