A 72-year-old man presented to the emergency department with difficulty breathing. He had undergone an open left rotator cuff repair 6 days before presentation and had had singultus since his surgical procedure. The patient had undergone general anesthesia and had a catheter placed on his left side for interscalene brachial plexus block before the operation. The catheter was removed 2 days later. The frequency of the patient's singultus had been increasing since admission to the emergency department, and the patient felt as though he could not catch his breath. He had attempted to abate his singultus by holding his breath and drinking cold water, which had not helped, so his wife brought him in for evaluation. Medical history was notable for Parkinson disease, hypertension, hyperlipidemia, arthritis, benign prostatic hypertrophy, and gastroesophageal reflux disease.
Aside from the singultus-induced shortness of breath and postoperative shoulder pain, the patient denied having fevers, chills, headaches, visual disturbances, coughing, chest pain or tightness, palpitations, dizziness, or leg swelling. He had undergone other surgical procedures, including bilateral inguinal hernia repairs, a hammertoe correction, bilateral blepharoplasty, bilateral cataract removal with lens replacement, and a transurethral resection of the prostate, without experiencing postoperative singultus or other complications. He denied alcohol, tobacco, or other illicit drug use. He was retired and living at home with his wife. Family history included a father with coronary artery disease who died of end-stage renal disease and a mother with diabetes and hypertension who died of coronary artery disease.
The patient's medications included hydrochlorothiazide/triamterene (25-37.5 mg once daily) for hypertension and carbidopa/levodopa (25-100 mg 3 times daily) for Parkinson disease. After his operation, the patient had been prescribed tramadol hydrochloride (50 mg every 6 hours as needed for pain) and naproxen sodium (200 mg every 6 hours as needed for pain). The patient was initially prescribed narcotic pain medications after his operation but stopped taking them after he had visual hallucinations. He also reported an allergy to sulfonamide drugs.
Physical examination revealed a mildly distressed man sitting upright. His vital signs at the time were a temperature of 98.4°F, a pulse rate of 65/min, a respiratory rate of 16/min, and a blood pressure of 135/75 mm Hg. His oxygen saturation level while breathing room air was 98%. Findings from his head, eyes, ears, nose and throat, or HEENT, examination included a normocephalic and atraumatic head and a supple neck with a small bandage on the left side where the interscalene brachial plexus block had been placed. The patient's lung fields were clear to auscultation bilaterally, and cardiac auscultation revealed normal S1 and S2 sounds with no appreciable rubs, gallops, clicks, or murmurs. His abdomen was soft, non-tender, and nondistended, and his left arm was still in the immobilizer from the orthopedic operation. Musculoskeletal examination revealed a bilateral hemidiaphragm restriction with asynchronous respiratory motion; inhibited firing of the left anterior, middle, and posterior scalenes; severe myofascial restriction of the thoracic outlet; C3-C5 spinal levels were flexed, rotated, and sidebent left; and his head was held grossly in left sidebending position secondary to positioning of the shoulder brace strap. Chest radiograph revealed no acute cardiopulmonary process and computed tomographic angiogram of the chest showed no evidence of pulmonary embolism. Blood cultures revealed no growth after 7 days, cardiac enzymes were negative, and electrocardiographic findings were unchanged from preoperative findings.
The patient was nervous about trying pharmaceutical intervention to alleviate singultus because he had a negative experience with narcotic pain medications. Because the results of the imaging studies and laboratory tests had ruled out a cardiopulmonary cause, the patient's singultus was ruled a likely postoperative complication secondary to the intubation and the phrenic nerve block. On the basis of these findings and the patient's preference to avoid medications, OMT appeared to be the best treatment option. After we explained the mechanical connections as well as risks and benefits of OMT to the patient and his wife, the patient agreed to receive OMT to address his somatic dysfunctions.
The patient could not tolerate lying down, so he was treated sitting upright. His surgical sling was left in place as to not disturb the healing surgical site. His respiratory diaphragm, restricted in excursion on the left and mildly on the right, was addressed using gentle direct myofascial release. Myofascial release was also applied to the surrounding ribs to help restore normal rib cage motion. Indirect myofascial release was applied to the thoracic inlet to ease restrictions in the first rib, clavicle, thoracic spine, scalene muscles, and sternocleidomastoid. Dysfunction of the cervical spine was treated using balanced ligamentous tension, with particular attention given to the C3-C5 spinal levels, where the phrenic nerve originates.
6,7 The patient tolerated the procedure well with no apparent complications. During treatment, the patient's singultus rate slowed down tremendously. At his outpatient follow-up with his primary care physician 2 days later, his singultus had completely resolved.