Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited. An uncommon case of right-sided throat pain and swallow syncope Enrico Favaretto, Nella Schenal, Nicola Russo, Gianfranco Buja, Sabino Iliceto and Claudio Bilato A 63-year-old man presented with recurrent syncopal attacks associated with swallowing and right-sided throat pain. Immediately after admission, he presented a 16-s asystolia. The patient’s clinical history was unremarkable except for previous postimplant periodontitis. Several episodes of severe bradycardia and sinus pauses, always associated with painful deglutition, were recorded subsequently. X-ray orthopanthomography and magnetic resonance imaging of the neck confirmed several areas of periodontitis around the previous dental implants and right mastoid inflammation. A barium swallow and fibre-optic endoscopy also revealed a small sliding hiatus hernia and distal chronic oesophageal inflammation. Despite complete dental curettage, antibiotics and antigastro-oesophageal reflux therapy, only partial relief of the pain and incomplete resolution of the arrhythmic disorder were obtained after 3 weeks, and the patient underwent pacemaker implantation. At 1-month follow-up, however, he reported the complete relief of the throat pain; subsequent Holter monitoring showed normal sinus rhythm, without pacemaker-induced electrical activity. J Cardiovasc Med 9:1152–1155 Q 2008 Italian Federation of Cardiology. Journal of Cardiovascular Medicine 2008, 9:1152–1155 Keywords: autonomic disorders, bradyarrhythmia, neurally mediated syncope, swallow syncope Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy Correspondence to Dr Claudio Bilato, MD, PhD, Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy Tel: +39 49 8211844; fax: +39 49 8761764; e-mail: claudio.bilato@sanita.padova.it Received 17 April 2008 Revised 20 June 2008 Accepted 4 July 2008 Introduction Swallow syncope is a rare disorder characterized by sudden transient loss of consciousness during or soon after swallowing [1]. It is nowadays considered as a form of neurally mediated syncope, characterized by a reflex- mediated withdrawal of sympathetic tone and increase in vagal tone, resulting in sinus bradyarrhythmias [2]. We report an unusual case of syncope associated with prolonged sinus pauses secondary to painful swallowing during throat inflammation and lasting more than 1 month. Case report A 63-year-old man was referred to our department because of multiple, recurrent near and syncopal epi- sodes. Clinical history did not reveal previous relevant cardiac events or preexisting cardiovascular diseases. The patient was a mild smoker and was not taking any medications. He reported dental implant procedures 5 years before, complicated by several episodes of period- ontitis in the following years. A few days before admis- sion, he began to experience severe throat pain and painful deglutition, followed by profound weakness and dizziness, lasting a few seconds. Because of the severity of the symptoms, he was admitted to the emer- gency room of another hospital. During electrocardio- gram (ECG) monitoring, tracts of severe bradycardia and sinus arrest (up to 6 s) were recorded, always simul- taneously with swallowing. An otolaryngology examin- ation showed inflammation of the pharynx and signs of gastro-oesophageal reflux. A computed tomography scan of the neck did not reveal significant alterations. The patient was then referred to our department. On admis- sion, the patient’s heart rate was 55 beats per minute (bpm); systemic blood pressure was 110/70 mmHg (with- out postural fall). The patient was haemodynamically stable. Physical examination confirmed hyperaemia of the pharynx; cardiac findings and other physiological examinations were unremarkable. Haematological and biochemical tests revealed mild anaemia (haemoglobin 13.5 g/dl), moderate increase of plasma uric acid, sub- clinical hyperthyroidism and mild elevation of plasma C-reactive protein. Liver and renal function, lipid and other metabolic parameters and electrolyte concentrations were normal. Microbiology tests were negative. Twelve- lead ECG showed sinus rhythm without any relevant alterations. Chest X-ray did not reveal any significant Case report 1558-2027 ß 2008 Italian Federation of Cardiology DOI:10.2459/JCM.0b013e32830f42b1