A young female patient presented with lightheadedness, dizziness, and near-syncope during exercises of varying extensional activity. These symptoms have been presents for years and she has previously exhausted many forms of medical investigation; internists, cardiologists, stress-testing, cortisol levels, and even neurotransmitter blood testing. Even after these interventions a blood pressure related issue was resulting in transient decreases in cerebral blood prefusion.
During history and examination, it was learned that her symptoms could be brought about with cervical, shoulder, and upper limp positioning and manipulation. In previous case studies it has been noted that carotid baroreceptor stimulation (e.g., mechanical forces such as may occur with turning of the neck or looking upward) results in vagal activation and/or sympathetic inhibition. (1) Historically, this phenomenon is seen in older males with sclerotic carotid arteries and accompanied by a diagnosis of carotid sinus syndrome (CSS). (1) In this patient’s case, it may indicate Carotid Sinus Hypersensitivity (CSH). (1) Whereas the muscle activation, head and neck positioning, and physical compression is enough of an adequate stimulus to trigger an unwanted carotid reflex.
Carotid massage has been a classic diagnostic tool for the differentiation of ventricular tachycardias. To a lesser degree it has been used in cases such as this one to recreate patient symptoms. This is an uncommon situation; however, it should be noted that an unintended carotid massage could take place during many manipulative and soft tissue procedures. Caution should be taken during spinal manipulative therapies (SMT) and instrument assisted soft tissue mobilization (IASTM) of structures in and around the carotid triangle (SCM, upper traps, and scalene musculature).
In moving forward with this patient… some guidelines for CSH have been established. They are, however, difficult to test and do not imperially yield a diagnosis. Most importantly a carotid massage (intentional of otherwise) has the ability to create an embolism and should only be performed buy trained medical professionals.
- Benditt, David, and Brian C Downey. “Carotid Sinus Hypersensitivity and Carotid Sinus Syndrome.” Edited by Peter Kowey, UpToDate, 16 Jan. 2019, www.uptodate.com/contents/carotid-sinus-hypersensitivity-and-carotid-sinus-syndrome.