Dysphagia
https://doi.org/10.1007/s00455-019-10044-7
CLINICAL CONUNDRUM
Management of an Unusual Case of Dysphagia
R. S. Shah1 · K. A. Mayuga2 · S. Gabbard3
Received: 22 May 2019 / Accepted: 20 July 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
To the Editors:
The case report has never been published elsewhere, pre-
sented elsewhere, or is being considered elsewhere.
Clinical Conundrum
A 58-year-old male presented to the gastroenterology clinic
with syncope while eating. His medical history was signifi-
cant for hypertension and type 2 diabetes with peripheral
neuropathy. Over the past year, he experienced four syn-
copal episodes while eating. He reported diaphoresis and
lightheadedness before losing consciousness for less than a
minute. In two of these episodes, the patient experienced a
globus sensation at the sternal notch level while swallow-
ing solid foods. He reports solid food dysphagia requiring
self-induced regurgitation with larger swallows. Denies
odynophagia, abdominal pain, nausea, vomiting, heartburn,
voice hoarseness, morning cough, chest pain, palpitations,
and shortness of breath. Physical exam was unremarkable.
Laboratory values were unremarkable. Electroencephalo-
gram, electrocardiogram, and echocardiography were unre-
markable. The patient’s tilt table test was positive, suggest-
ing vasovagal syncope. For evaluation of his dysphagia, he
had an unremarkable esophagogastroduodenoscopy (EGD)
and esophagram. Esophageal manometry indicated normal
liquid swallows, but was remarkable for multiple dry swal-
lows followed by premature contraction (distal latency 2.2 s)
in the distal esophagus suggesting distal esophageal spasm
* R. S. Shah
Shahr4@ccf.org
1
Department of Internal Medicine, Cleveland Clinic,
Cleveland, OH, USA
2
Department of Cardiovascular Medicine, Cleveland Clinic,
Heart and Vascular Institute, Cleveland, OH, USA
3
Department of Digestive Diseases Institute, Cleveland Clinic,
Cleveland, OH, USA
(Fig. 1). While he experienced dysphagia and associated
presyncopal symptoms, Holter monitoring showed sinus
bradycardia followed by three sinus pauses up to four sec-
onds and resumption to normal sinus rhythm. What is the
diagnosis and management of this patient?
Diagnosis and Management
Based on the history and evaluation, a diagnosis of deglu-
tition syncope with combined cardioinhibition and vaso-
depression was made. In addition to avoidance of bulky
food, carbonated beverages, and medications delaying
cardiac conduction, the patient was recommended to have
pacemaker implantation to prevent bradyarrhythmia; how-
ever, the patient refused this intervention. Calcium channel
blockade was contraindicated due to bradycardia [1]. Due to
limited therapeutic options for underlying esophageal and
cardiac disorders, low-dose 10 mg amitriptyline was recom-
mended for its vagolytic activity [2]. At his one-year follow-
up, the patient denied any episodes of deglutition-induced
presyncope or syncope. In this patient with deglutition syn-
cope, it is proposed that cardioinhibition and vasodepression
are induced by the vagovagal reflex secondary to esophageal
spasm. Findings of esophageal spasm on manometry and
bradycardia with sinus pauses on Holter monitoring sup-
port this diagnosis. Exhausted treatment options lead to a
trial of amitriptyline due to its anticholinergic effects on
the vagus nerve to prevent bradycardia and AV dissociation
and its neuromodulator effect for pain in hypercontractile
esophageal dysmotility. Clinically, Oto et al. showed a 91%
prevention rate of vasovagal syncope in 74 patients using
amitriptyline [2]. However, there are no reports of using
amitriptyline specifically for deglutition syncope.
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Fig. 1  Esophageal manometry
Discussion
Deglutition syncope is a rare entity with approximately one-
hundred cases reported[3]. It is a subtype of neurocardio-
genic syncope triggered by deglutition secondary to organic
and/or functional esophageal pathology. Although contro-
versial, one proposed mechanism is the vagovagal reflex
in which the vagal afferent signal of the esophagus relays
an efferent signal to the AV node [3, 4]. Reduction in car-
diac output or sympathetic withdrawal results in decreased
cerebral perfusion and brief loss of consciousness [4]. The
vagovagal mechanism is supported by the prevention of
syncope with pre-administration of atropine [4]. Triggers of
deglutition syncope include hiatal hernia, acid reflux, acha-
lasia, esophageal spasm, stricture, diverticula, and malig-
nancy or in patients with normal esophageal function [4].
Management of this condition has limited options. The
initial management includes treating the underlying trig-
ger and avoiding bulky foods, carbonated beverages, and
medications that delay cardiac conduction. Calcium chan-
nel blockers have been reported to be effective in cases [1].
In this case, we propose the use of 10 mg of amitriptyline
as a preventative treatment for deglutition syncope. Further
studies may be valuable in the treatment of deglutition syn-
cope; however, prospective, randomized controlled trials are
unlikely to be feasible.
13
Management of an Unusual Case of Dysphagia
Compliance with Ethical Standards 
Conflict of interest  No reported conflicts of interest.
Informed Consent  Patient consent was obtained.
References
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Tokgözoğlu L, Kabakçı G, Amasyalı B, Özkutlu H, Nazlı N, Oto
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