Brief Answer:
Sneeze syncope

Detailed Answer:
Good evening. My name is Dr. Saghafi and I am an adult neurologist.

As common as the sneeze reflex is, it is not nearly as well studied as other related reflexes such as coughing and vomiting. However, in all the cases of sneezing, coughing, and vomiting the phenomenon of passing out or nearly passing out is believed to be similar. When one passes out it is called SYNCOPE. When one nearly passes out it is called NEAR SYNCOPE. The essential reason as to why we either nearly pass out or pass out in all these situations including sneezing is a lack of blood flow to the brain.

In other words, the act of sneezing violently can stop circulation to the brain long enough to cause a person to lose consciousness and it happens nearly instantly.

The mechanism for this sudden drop in blood pressure comes about through different mechanisms but basically there is a reduced return to the heart of blood due to increased pressure in the chest. This is because when we sneeze we forcibly close the glottis which then, dramatically increases pressure in order to load up the cannon to expel whatever is bothering our nasal passages.

At the same time as the sneeze occurs, pressure in the head itself skyrockets and this also produces a tremendous amount of resistance to blood trying to enter the brainstem and other vital structures. The presence of any small degree of blockage of the arteries leading to the brain therefore, can become a major problem and should be investigated in patients who suffer from this form of syncope.

Another mechanism that can either cause or contribute to sneeze syncope is any type of conduction block in the heart, particularly in the nodal point known as the AV node due to increased firing of the VAGUS NERVE thought to occur with the sudden increase in pressure within the head.

And there is yet one other possible factor or contributing factor that one should be aware of and that is the consumption of certain medications known as BETA BLOCKERS (Inderal, Atenolol, and others) can dampen both heart rates, firing rates at the AV node, and vascular tone all of which can cause either a strong drop of blood pressure or pumping efficiency of the heart.

Even eye drops that are commonly taken for glaucoma and other ocular problems have been discovered to be the culprit behind these types of syncopal episodes.

Therefore, in my practice whenever I hear about someone suffering from either sneeze, cough, or emetic syncope I work the patients up extensively to discover if there are any predisposing factors that the patient may possess such as being on possible contributing medications (beta blockers), the presence of obstructions in the circulation of the carotid or spinal arteries that lead to the brainstem, or if there is an abnormality in the autonomic control centers located in the brainstem or in the periphery which would be responsible for controlling heart rate, rhythm, and blood pressure.

Bottom line- I would ask the primary provider to either refer you to a cardiologist or better yet a neurologist in order to rule out any potential defects you may have that can predispose you to this sort of event.

All the best.

I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments or inquiries to me in the future at:

bit.ly/drdariushsaghafi

I would be honored to answer you quickly and comprehensively.

Please keep me informed as to the outcome of your situation.

The query has required a total of 42 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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Brief Answer:
We don't have solid numbers to answer your question

Detailed Answer:
There is not enough data to be able and predict the odds of a person who nearly passes out or passes out from sneezing as having an actual pathology which significantly contributes to the reason they almost passed out. I can tell you that the vast majority of patients simply don't get worked up to any extent and even when they are worked up it's usually very cursory and they're given a clean XXXXXXX of health.

I believe I mentioned more than 3 contributory PATHOLOGICAL reasons, didn't I?

1. Vascular obstruction to a critical part of the brain from either the carotid or the vertebrobasilar systems

2. Primary Cardiac arrhythmias or conduction defects of some sort which are otherwise silent until exacerbated by increased Vagus Nerve activity from significant increased pressure in the head.

3. Autonomic nervous system dysfunction at a subclinical level which again is unmasked by dramatic changes in intracranial pressure such that increased tone by the Vagus Nerve tips the autonomic system over the edge

4. Medication effects by drugs which themselves cause slowing of the heart or drops in blood pressure (beta blockers most common).

I don't really understand what you mean by saying that you "carry anxiety in your neck" but if it's even close to what I think you're trying to say then, the short answer to your question is 'NO- not related' to your sneeze presyncope.

I won't make any statement about your feeling unbalanced due to the pain in the neck in the shoulders because again, nothing to do in all likelihood with the sneeze presyncope.

I would ask your PMD for a good neurologist who is either AUTONOMIC FUNCTION oriented, STROKE oriented, or BOTH! They may need to tag team with a good cardiologist to complete cover all the bases but that is how I would work up a patient with your symptoms.

I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments or inquiries to me in the future at:

bit.ly/drdariushsaghafi

I would be honored to answer you quickly and comprehensively.

Please keep me informed as to the outcome of your situation.

The query has required a total of 59 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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Brief Answer:
Not too much more to add to the diagnostic workup I recommended

Detailed Answer:
Thank you much for your very kind comments on the value of my suggestions for your problem.

I don't believe there is much more to add to the information I've already provided as it gets right to the heart of why people who sneeze, cough, strain, or perform any other type of physically spontaneous and exertional activity can sometimes either pass out or nearly pass out. What I mentioned are the things I do for all my patients when trying to determine the cause of the episode you mention.

I don't have a very good feel for what happened to your neck directly and without physically examining I won't be able to see much more in terms of how it is or isn't related to the sneezing episode. Perhaps, the neurologist would've been more impressed with any of the recommendations I forwarded had you physically passed out and I can understand that style of thinking since there is definitely a difference between passing ALL THE WAY OUT vs. feeling lightheaded only and perhaps a little dizzy. One could argue that nearly everyone has had the experience of sneezing very hard and feeling just a twinge of lightheadedness. But that is precisely why this workup makes sense since the mechanism behind feeling lightheaded (even in people who have no obstructions in blood flow, etc.), to my way of thinking demands fuller attention and workup in those who actually go all the way out or NEARLY ALL THE WAY OUT.

Again, perhaps in your case when you said that you "nearly passed out" the neurologist who interviewed did not get the same sense of how the event actually went down compared to my interpretation done from so far away and without being able to examine you, send you for tests, etc.

Of course, North XXXXXXX to XXXXXXX OH I believe is a matter of about 8 hrs! Not that far when you consider how far someone from Australia would have to come to see me! HAHA!

Anyways, the reasons doctors choose not to perform tests on patients for certain problems has already stirred a lot of debate and especially in recent years when there seems to be such a push to NOT TEST people if it doesn't seem to be something that is likely to result in a change of management. I happen NOT TO AGREE with that philosophy of practicing medicine but many physicians ARE BEHOLDEN to that idea BECAUSE they have no choice. They work for hospitals or are in private practice where insurance company reimbursement is their bread and butter and so bucking the insurance company or the patient without proper "permission"....what a joke and a half that is!!....results in loss of remimbursement and eventual loss of referrals from other docters even.

And so I don't know where your neurologist fits into that scheme of things and whether he would love to do more testing but is simply constrained by who he works for or by the insurance companies who reimburse him.

I can tell you that again, in the vast majority of patients who have what we call SNEEZE SYNCOPE...exhaustive workups usually reveal absolutely nothing. And only a small percentage of patients with actual obstructions show up with something significant enough to be picked up and noticed by physicians without the patient actually passing out.

Therefore, imagine the chances of finding something pertinent in someone who didn't ACTUALLY LOSE CONSCIOUSNESS by instead simply felt dizzy or lightheaded? The % yield is insignificant that we will find anything. That doesn't mean we shouldn't play the game exactly by the rules...but in reality that's what happens when private doctors are involved.

I hope that you are able to recruit your doctors into ordering some of the workup I put out there and THAT IT COMES OUT NEGATIVE! Trust me, you don't want any of the 3 possibilities I mentioned....you'd rather be called a person looking for attention or a malingerer before actually having significant and bona fide autonomic function disorder...I'm sure you agree!

Being the FINAL QUESTION/RESPONSE in this thread per network policies may I suggest you consider printing out some of my recommendations so that you may refer to the notes the next time you speak with your doctors and see if they might not agree with doing at least a little bit of the workout for you even though I wouldn't be surprised if everything came out cleanly.

I hope this answer satisfactorily addresses your question. If so, may I ask that you close the thread down so we can archive the transaction. Thank you again for the very kind words which for sure feels very satisfying. I only wish I had more direct control over your care.....I could if you came to XXXXXXX OHIO! LOL.

If you would like to continue talking about this problem or other things you mentioned then, please direct more comments or inquiries to:

bit.ly/drdariushsaghafi

I would be honored to answer you quickly and comprehensively.

I'd love to know the outcome of your situation.

All the very best.

The query has required a total of 91 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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