title: Ultrasound-Guided Phrenic Nerve Block for Intractable Hiccups following Placement of Esophageal Stent for Esophageal Squamous Cell Carcinoma.
abstract: Hiccups are actions consisting of sudden contractions of the diaphragm and intercostals followed by a sudden inspiration and transient closure of the vocal cords. They are generally short lived and benign; however, in extreme and rare cases, such as esophageal carcinoma, they can become persistent or intractable, up to and involving significant pain, dramatically impacting the patient's quality of life. This case involves a 60-year-old man with a known history of squamous cell carcinoma of the esophagus. He was considered to have high surgical risk, and therefore he received palliative care through the use of fully covered metallic esophageal self-expandable stents due to a spontaneous perforated esophagus, after which he developed intractable hiccups and associated mediastinal pain. Conservative treatment, including baclofen, chlorpromazine, metoclopramide, and omeprazole, provided no relief for his symptoms. The patient was referred to pain management from gastroenterology for consultation on pain control. He ultimately received an ultrasound-guided left phrenic nerve block with bupivacaine and depomedrol, and 3 days later underwent the identical procedure on the right phrenic nerve. This led to complete resolution of his hiccups and associated mediastinal pain. At follow-up, 2 and 4 weeks after the left phrenic nerve block, the patient was found to maintain complete alleviation of the hiccups. Esophageal dilatation and/or phrenic or vagal afferent fiber irritation can be suspected in cases of intractable hiccups secondary to esophageal stenting. Regional anesthesia of the phrenic nerve through ultrasound guidance offers a long-term therapeutic option for intractable hiccups and associated mediastinal pain in selected patients with esophageal carcinoma after stent placement.
  
  
  
  Esophageal stent, esophageal stenting, intractable hiccups, intractable singultus, phrenic nerve block, phrenic nerve, ultrasound, palliative care, esophageal carcinoma.
authors.affiliation: University of Vermont College of Medicine, Burlington, VT.
authors.forename: David
authors.initials: D
authors.lastname: Arsanious
authors.affiliation: Division of Pain Management, University of Toledo, Toledo, OH.
authors.forename: Spiro
authors.initials: S
authors.lastname: Khoury
authors.affiliation: Department of Internal Medicine, University of Toledo, Toledo, OH.
authors.forename: Edgar
authors.initials: E
authors.lastname: Martinez
authors.affiliation: Division of Gastroenterology and Endoscopy, University of Toledo, Toledo, OH.
authors.forename: Ali
authors.initials: A
authors.lastname: Nawras
authors.affiliation: Department of Anesthesiology, University of Toledo, Toledo, OH.
authors.forename: Gregory
authors.initials: G
authors.lastname: Filatoff
authors.affiliation: Division of Pain Management, University of Toledo, Toledo, OH.
authors.forename: Hossam
authors.initials: H
authors.lastname: Ajabnoor
authors.affiliation: Department of Internal Medicine, University of Toledo, Toledo, OH.
authors.forename: Umar
authors.initials: U
authors.lastname: Darr
authors.forename: Joseph
authors.initials: J
authors.lastname: Atallah
mesh_terms: D001340:Autonomic Nerve Block / Q000379:methods*; D002294:Carcinoma, Squamous Cell / Q000150:complications* / Q000628:therapy; D004938:Esophageal Neoplasms / Q000150:complications* / Q000628:therapy; D000077277:Esophageal Squamous Cell Carcinoma; D006606:Hiccup / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010791:Phrenic Nerve / Q000000981:diagnostic imaging / Q000187:drug effects*; D015607:Stents / Q000009:adverse effects*; D014463:Ultrasonography