Hiccups are actions consisting of sudden contractions of the diaphragm and intercostals
followed by a sudden inspiration and transient closure of the vocal cords. They are generally
short lived and benign; however, in extreme and rare cases, such as esophageal carcinoma,
they can become persistent or intractable, up to and involving significant pain, dramatically
impacting the patient’s quality of life.
This case involves a 60-year-old man with a known history of squamous cell carcinoma of the
esophagus. He was considered to have high surgical risk, and therefore he received palliative
care through the use of fully covered metallic esophageal self-expandable stents due to
a spontaneous perforated esophagus, after which he developed intractable hiccups and
associated mediastinal pain. Conservative treatment, including baclofen, chlorpromazine,
metoclopramide, and omeprazole, provided no relief for his symptoms. The patient was
referred to pain management from gastroenterology for consultation on pain control. He
ultimately received an ultrasound-guided left phrenic nerve block with bupivacaine and
depomedrol, and 3 days later underwent the identical procedure on the right phrenic nerve.
This led to complete resolution of his hiccups and associated mediastinal pain. At followup, 2 and 4 weeks after the left phrenic nerve block, the patient was found to maintain
complete alleviation of the hiccups.
Esophageal dilatation and/or phrenic or vagal afferent fiber irritation can be suspected
in cases of intractable hiccups secondary to esophageal stenting. Regional anesthesia of
the phrenic nerve through ultrasound guidance offers a long-term therapeutic option for
intractable hiccups and associated mediastinal pain in selected patients with esophageal
carcinoma after stent placement.
Key words: Esophageal stent, esophageal stenting, intractable hiccups, intractable
singultus, phrenic nerve block, phrenic nerve, ultrasound, palliative care, esophageal
carcinoma
Cervical Phrenic Nerve Block for Intractable Hiccups in Cancer Patients
