Sara kurtevski, MD
Resident Physician
University of Miami/ Jackson Health System
Miami, Florida, United States
William Ventura, MD
Research assistant
University of Miami(UM)
Miami, Florida, United States
Diana M. Molinares Mejia, MD
Attending Physician
Jackson Memorial Hospital/University of Miami
Miami, FL, Florida, United States
64-year-old man with squamous cell carcinoma of the base of the tongue and recent diagnosis of osteoradionecrosis of right mandible underwent reconstructive surgery complicated by multiple intraoral wound dehiscence requiring further surgery. The patient was admitted to our inpatient rehabilitation facility (IRF) for functional impairments. His therapy participation was limited by symptomatic orthostatic hypotension prompting further medical investigation. Infectious workup including head and neck CT was negative. In addition, isolated episodes of bradycardia were noted despite discontinuation of beta-blockers and unremarkable cardiac workup. Trial of fluids was given for intravascular volume depletion and orthostatic-provoking medication was discontinued without improvement. Given the known oncological treatment history, clinical presentation, and inconclusive workup, radiation-induced baroreceptor dysfunction was diagnosed. Symptomatic-based treatment approach was implemented with non-pharmacological interventions with abdominal binder, and thromboembolic deterrent (TED) stockings. Additional pharmacological treatment with midodrine and fludrocortisone improved his symptoms.
Discussions:
Differential diagnosis for orthostatic hypotension can be extensive ranging from serious to benign conditions; thus, clinicians should approach this thoughtfully. Radiation-induced baroreceptor dysfunction is likely under-diagnosed despite being a known complication of radiation. Baroreceptors contribute to hemodynamic regulation and will un-inhibit sympathetic activity when positional decrease in blood pressure is sensed. Dysfunction in this system leads to hypotensive episodes and inability to appropriately increase heart rate. Here, we bring to attention the expertise of a cancer physiatrists to approach orthostatic hypotension of a head and neck patient allowing for final diagnosis of radiation-induced baroreceptor dysfunction and appropriate treatment.
Conclusions:
Orthostatic hypotension is a common problem encountered by physiatrists which can increase risk of falls and limit functional improvement. With growing recognition of functional impairments in cancer survivors, physiatrists should consider radiation-induced baroreceptor dysfunction as a possible diagnosis in patients with orthostatic hypotension and history of radiation to the neck.
