A rare cause of reflex
syncope is metastatic
cancers involving the head and neck. These can irritate the glossopharyngeal nerve and lead to
glossopharyngeal neuralgia with associated
syncope. This type of
syncope is difficult to treat since it commonly involves both a vasodepressor and cardioinhibitory response, and typically requires removal of the irritative focus. We report a case of a 52-year-old male who presented from home with
syncope. He endorsed a 5-week history of progressively worsened positional
headaches and dramatic 40-pound
weight loss with night sweats over 6 months. In the emergency department, his heart rate was noted to drop into the 20s with associated
hypotension 60/31 mm Hg. Heart rate and blood pressure increased with intravenous
atropine. Physical examination revealed a large ulcerative lesion in the left tonsillar area. After biopsy of the lesion, a diagnosis of stage IV
squamous cell carcinoma of the neck was made; computed tomography angiogram and positron emission tomography/computed tomography confirmed involvement in the posterior tongue extending to the left palatine tonsil in addition to the left jugular chain. The patient was started on
cisplatin and
radiation therapy, but continued to have episodes of
syncope associated with
bradycardia and
hypotension. After a failed trial of
benztropine, the patient was started on
sertraline and
midodrine with resolution of
syncope. This could be a potential treatment option in those with compressive mixed
syncope who are not candidates for surgery or
chemotherapy or are awaiting definitive treatment.