207 Views

982 - Phrenic Nerve Peripheral Nerve Stimulation Adequately Treats Chronic Intractable Hiccups: A Case Series for a Novel Use

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

HC

Harman Chopra, MD

Senior Resident
Johns Hopkins
Baltimore, Maryland, United States

Co-Author(s)

DJ

David Jevotovsky, MD

Resident
New York University Grossman School of Medicine
New York, New York, United States
MS

Michael Suarez, DO

Resident
Johns Hopkins University School of Medicine
Baltimore, Maryland, United States

Corresponding Author(s)

BM

Bryan Marascalchi, MD

Assistant Professor
Vanderbilt Universty School of Medicine
Nashville, Tennessee, United States

Case Diagnosis: chronic, intractable, and debilitating severe hiccups

Case Description: 73-year-old male with multiple comorbidities presented with six years of intractable hiccups, severely affecting daily activities, speech, singing, eating, and sleep. Conservative treatments failed. Bilateral phrenic and stellate ganglion nerve blocks and external vagal nerve stimulation offered temporary relief. Bilateral PNS placement resulted in a 50% improvement in symptoms, enabling him to speak in full sentences. Post-removal, his HAI score improved to 2/10, with significant enhancements in speech and singing, showing sustained improvement at four months.

52-year-old male with hypertension and a history of COVID-19 tracheostomy had nine months of severe hiccups, leading to weight loss and eating difficulties. Treatments, including medications and acupuncture, were ineffective. Bilateral stellate ganglion blocks and a cervical epidural steroid injection provided short-term relief. Bilateral phrenic PNS implantation under ultrasound guidance significantly reduced hiccup frequency and severity, with a 22% decrease in his HAI score to 7/10 at twelve-week follow-up, showing sustained improvement.

Discussions: Hiccups, though common, have complex pathophysiological mechanisms involving neurotransmitter imbalances (GABA and dopamine) and gastrointestinal disruptions (GERD). Current treatments target these imbalances with medications like chlorpromazine, metoclopramide, and benzodiazepines. However, the lesion's exact location along the hiccup reflex arc remains elusive, making intractable hiccups challenging to treat.
Phrenic PNS offers a promising, minimally invasive alternative with adjustable stimulation parameters based on patient response. It is proposed that peripheral nerve stimulation produces analgesic effects by activating large diameter fibers, leading to cortical “reconditioning.”
Postoperative hiccups, which can risk wound dehiscence, may also benefit from PNS. Further placebo-controlled trials are needed to confirm its efficacy.

Conclusions: It is important to note our conclusions are drawn from observations on a small sample size of two patients lacking a control group, thus a cautious interpretation is advised.