The response of the abdominal viscera and the contraction of the intercostal muscles during the respiratory phase of sneezing increases intrathoracic pressure, which may lead to several complications. However, there are no reports in the literature concerning aortic dissection after sneezing. We report a patient in whom the development of dissection was secondary to sneezing, although hypertension was present as a risk factor, and we discuss the relationship between sneezing and aortic dissection. To our knowledge, this is the first report of aortic dissection provoked by sneezing in the literature.
- Valsalva manoeuvre
- acute aortic dissection
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Aortic dissection occurs from a rupture of the intima, which allows blood to enter the media and dissect between the intimal and the adventitial layers.1 The estimated incidence of aortic dissection is 5 to 30 cases per million population per year. Chronic systemic hypertension is the most common factor predisposing to aortic dissection and is present in 62–78% of patients with aortic dissection.2
The increase in intrathoracic pressure during sneezing may lead to serious complications. We present a case in which the development of aortic dissection was considered secondary to sneezing, although hypertension was present as a risk factor, and we discuss the relationship between sneezing and aortic dissection. To our knowledge, this is the first reported case of aortic dissection provoked by sneezing.
A 51 year old man was admitted to the emergency department (ED) with severe, sudden onset chest pain and dyspnoea following sneezing. The patient reported that the pain was very severe and by the time he arrived at the ED (a period of about 20 minutes), had spread towards his back. He had a history of hypertension diagnosed 5 years previously, which was regulated with nifedipine (Adalat) and lisinopril 20 mg plus hydrochlorothiazide 12.5 mg (Sinoretik).
On physical examination, blood pressure was 190/110 mmHg, pulse rate 90 beats/min, respiration rate 24 breaths/min and temperature 36 °C. He was conscious, cooperative, and in moderate health. All other physical findings were normal. Laboratory findings showed glucose of 1.14 g/l (normal 0.7–1.1 g/l) and albumin 33 g/l, while other findings were within normal limits. There was no abnormal finding on 12 lead electrocardiography.
Chest x ray revealed a widening in the aortic knob and the lateral margin of the descending aorta (fig 1A). Spiral computed tomography (CT) was performed to rule out aortic dissection, but showed an intimal flap that seperated the aortic lumen into two parts, extending from the proximal descending aorta to the left common iliac artery. The ascending aorta and supraaortic branches were normal (fig 1B). Using transoesophageal echocardiography, a dissection was detected starting just after the subclavian artery orifice and extending downwards distally.
After clinical and radiological evaluation, a Stanford type B aortic dissection was diagnosed and medical treatment commenced in the ED, after which the patient was admitted to a hospital ward. During follow up, the chest pain had not subsided and the patient’s blood pressure could not be controlled despite appropriate treatment. A control CT scan taken 1 week later showed some abnormalities in the descending aortic contour at the level of right pulmonary artery orifice and a small effusion in the left pleural space (fig 1C). The patient underwent surgery for possible aortic aneurysm rupture.
During the sneeze reflex, the intrathoracic pressure is raised, which may lead to several complications. Brock et al reported a case of chest pain following sneezing, which occurred from fractures of ribs 8, 9, 10, and11. There are some reports of lung herniation triggered by sneezing, as demonstrated on chest x ray.3
The increase in intrathoracic and intra-abdominal pressure raises the venous pressure in these spaces, leading to a further increase in the epidural veins and a corresponding increase in intracranial pressure.4 A case has been reported with a temporary hemiparesis caused by a sneezing induced intracranial aneurysm.5 Sharir et al reported a patient who had an attack of acute angle closure glaucoma precipitated by sneezing, which may have been the result of an increase in the ocular venous return precipitated by the increase in the intrathoracic pressure.6 Whitehead et al7 and Azem and Calderelli8 have reported patients who developed hearing loss in association with stapes fracture due to increased intracranial pressure following sneezing.
Coughing, sneezing, and the other Valsalva manoeuvres not only increase intrathoracic pressure but also alter the haemodynamics. Initially, the arterial pressure increases with a rise in respiratory tract pressure, but then decreases following a decline in venous return.4 It has also been reported in another study that systolic and diastolic arterial pressure increase during the Valsalva manoeuvre.9 Systemic hypertension, one of the most common predisposing factors of acute aortic dissection, increases the tension on the aortic wall. We believe that in our hypertensive patient, the increase in arterial pressure caused by the rise in intrathoracic pressure during sneezing, enhanced the aortic wall tension, and that this sudden increase of pressure on the aortic wall triggered the intimal tear.
Aortic dissection is an important disease because, although rare, it may be life threatening. In over 38% of patients the diagnosis is missed at the first evaluation.2 In untreated patients, the mortality rate is 25% iwithin 24 hours, 70% by 2 weeks and 90% after 2 weeks.10
Chest pain is the most common symptom in aortic dissection cases presenting to the ED. Typically, the pain starts suddenly and is unbearable. Pain is the most intense when the symptoms begin. The localisation of the pain is related to the region in which the intimal rupture occurs; if the tear is above the aortic valve the pain is felt anteriorly, but if it is distal to the left subclavian vein it is felt in the back. Spreading of the pain may be a sign of progressive dissection.11 It has been reported that >90% of the patients with acute aortic dissection undergo intense chest pain.11,12 In our patient, the chest pain spread to the back, and the dissection was detected in the descending aorta.
It has been reported that >90% of the patients with aortic dissection have widening of the mediastinum and aortic knob detected by chest radiography.11 In a study by Kodolitsch et al, it was found that that mediastinal and/or aortic widening was related to dissection in 39% of cases. In addition, it has been found that the existence of chest pain and changes in pulsation and blood pressure are related to the dissection in 83–100% of cases.12 In our case, there was a typical spontaneous and spreading type of chest pain. A widening of the aortic knob and the descending aortic lateral wall was revealed by chest radiography. However, the blood pressure was high but the pulse was normal.
Aortic dissection should be considered a possible diagnosis in patients who present to the ED with complaints of atypical chest pain after sneezing. If the patient’s history implies intrathoracic pressure increase and other suggestive findings are present, as in our case, noninvasive diagnostic methods such as CT, transoesophageal echocardiography and magnetic resonance imaging should be performed promptly to rule out aortic dissection, which is a very severe life threatening condition. Aortic dissection may be added to the complications seen after sneezing.
Competing interests: none declared
Presented at the First National Emergency Medicine Congress, 22–25 October 2003, Konya, Turkey.