Postoperative singultus: an osteopathic approach

Participants

• Number: 1

• Description: a 72-year-old man with a breathing difficulty which brought him to the emergency room. He had undergone an open left rotator cuff repair 6 days earlier. The hiccups  had started at this time together with shoulder pain. During the surgery, the patient had undergone general anesthesia while a catheter had been placed on his left hand side for interscalene brachial plexus block before the surgery.
  The frequency of hiccups had increased after admission to the emergency room, inducing a sense of inability to catch his breath.
  The patient’s medical history showed Parkinson’s disease, hypertension, hyperlipidemia, arthritis, benign prostatic hypertrophy, and gastroesophageal reflux, as well as other surgeries such as bilateral inguinal hernia repair, hammertoe correction, bilateral blepharoplasty, bilateral cataract removal with lens replacement, and prostate resection. His father had suffered from coronary artery disease and died of kidney disease, while the mother had diabetes and hypertension and died of coronary artery disease.

There were no fevers, chills, headaches, coughs, chest pain or stiffness, visual dysturias, dizziness, palpitations or leg swelling.
He did not smoke, drink alcohol, or use drugs. He was retired. In addition to medications for hypertension and Parkinson’s, the patient was taking tramadol and naproxen for pain (he initially took narcotics but had stopped because of hallucinations).The thoracic physical examination, as well as radiographic examination, revealed no particular signs in the skull, lungs, heart, and abdomen. Bacterial culture tests and blood tests were also negative.

A respiratory rate of 16 breaths per minute and a variety of musculoskeletal dysfunctions emerged: bilateral hemidiaphragm restriction, major myofascial restriction of the thoracic outlet, alterations at the level of C3-C5, and inhibition of the anterior, middle, and posterior scalenes. Most likely, according to these data, the onset of hiccups did not depend on cardiopulmonary causes, but was considered to be a consequence of intubation and phrenic nerve blockade.
Given the patient’s fear of taking new medications, a decision was made to try OMT.

Interventions and evaluations

• Evaluation of the symptoms
• 1 session of OMT
• OMT:
  • patient in a seated position
  • Techniques used: direct myofascial release for diaphragm and ribs; indirect myofascial release for thoracic outlet; balanced ligamentous tension for C3-C5 and phrenic nerve.

Results

OMT was well tolerated by the patient and hiccups decreased significantly during the treatment. The patient no longer showed any sign of hiccups when he saw his general practitioner two days later.

Discussion

In cases where the hiccups are not resolved by the Valsalva maneuver or by cold water intake, medications are usually used, but these can have significant adverse effects, like phrenic nerve blockage.

OMT, on the other hand, is a noninvasive treatment that can resolve the underlying mechanical dysfunction by improving blood and lymphatic flow, respiration, and musculoskeletal recovery.

However, studies on a large sample of people are needed to verify the actual effectiveness of OMT in managing hiccups. Further studies are also needed to check for recurrent somatic dysfunction that could help improve the effectiveness of treatment.