Swallow syncope: a case report and review of literature

Abstract

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.

Cracking the Case of Achalasia-induced Syncopal Episode

“…This is believed to be due to afferent impulses from the esophageal plexus which travel via the vagus nerve to the brain stem and then trigger efferent fibers to signal back through the vagus nerve to the heart. This type of syncope has been reported since 1793 by Spens, but literature review has not shown syncope to occur in achalasia without swallowing [2]. We present the case of a patient with achalasia and a nonswallowing syncopal episode.…”

“…This is all thought to be due to reflex arcs in the parasympathetic system between afferent and efferent fibers [3]. Dilatational treatment of the achalasia typically results in complete resolution of the deglutition syncope [2,4,5].…”

Deglutition Syncope Due to Exaggerated Vagal Reflex

“…DS is often found in older adults, with a mean reported age of 57.5 years at the time of initial presentation [13]. The exact mechanism of DS remains unknown.…”

“…When it comes to diagnosing DS, it is essential to rule out any esophageal disorders and cardiac diseases beforehand [9]. The diagnosis of DS involves careful history taking and recognition of presyncopal events or syncope triggered by the process of swallowing (provocative test) [13].…”

Timing of Circulatory and Neurological Events in Syncope

“…The nature and severity of CI differs between types of reflex syncope. In swallow syncope asystole due to an AV-block has been frequently described (8), although a selection bias cannot be ruled out. This "reflex AV-block" differs in some respects from an intrinsic AV-block, and is probably due to stronger inhibition of the AV-than the SA-node.…”