Persistent Hiccups After Diaphragmatic Plication Despite Previous Phrenic Nerve Sacrifice
This case report describes a patient with myasthenia gravis who developed persistent postoperative hiccups following diaphragmatic plication despite prior phrenic nerve sacrifice, a condition that was successfully resolved with low-dose gabapentin, suggesting that residual sensory pathways can sustain the hiccup reflex even after motor denervation.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The human body possesses a remarkable, if sometimes irritating, reflex known as the hiccup. It is a sudden, involuntary contraction of the diaphragm, the large muscle that sits beneath the lungs and acts as the primary engine for breathing. When this muscle spasms, the vocal cords snap shut, creating the familiar sound. While most hiccups vanish on their own, a persistent version can become a medical crisis, disrupting sleep, preventing people from eating, and exhausting the body. Scientists understand that this reflex relies on a complex communication loop, a circuit that sends signals from the chest and abdomen to the brainstem and back again. This loop involves several different nerves, including the phrenic nerve, which directly controls the diaphragm's movement. Usually, if the nerve that tells the diaphragm to move is cut or removed, the muscle should stop working entirely, and the reflex should have no way to trigger. This assumption has guided surgical decisions for decades, particularly in cases where the phrenic nerve must be sacrificed to remove a tumor.
A team of surgeons and researchers at the University Regional Hospital of Nancy in France recently challenged this assumption with a single, unusual case. They treated a 53-year-old man who had undergone a major surgery to remove a thymoma, a type of tumor located in the chest. During that initial operation, the surgeons had to intentionally cut the left phrenic nerve to ensure the cancer was fully removed. A year later, the patient developed severe shortness of breath because his left diaphragm had become paralyzed and was no longer helping him breathe. To fix this, the medical team performed a robotic procedure called diaphragmatic plication. This surgery involves folding and stitching the paralyzed muscle tight to stop it from flapping loosely and to improve the patient's breathing capacity. The operation was successful in improving his lung function, but it immediately triggered a new problem: the patient began suffering from relentless, severe hiccups that interfered with his sleep and ability to eat.
The situation presented a medical puzzle. Because the phrenic nerve on that side had been cut a year prior, the diaphragm was supposed to be completely disconnected from the brain's control signals. Theoretically, without that nerve, the muscle should be silent, and the hiccup reflex should be impossible to trigger. Yet, the hiccups were undeniable. The medical team searched for other causes, such as stomach issues or metabolic imbalances, but found none. They suspected that the surgery itself, which involved stretching and stitching the diaphragm, had activated a different set of sensory nerves that were still intact. These alternative pathways, perhaps running through the chest wall or surrounding tissues, seemed to be sending signals to the brain that were interpreted as a need to hiccup, even though the main motor nerve was gone.
Treating the patient was complicated by his underlying condition, myasthenia gravis, a disease that weakens muscles and makes breathing difficult. The standard medication for stubborn hiccups, a drug called baclofen, was ruled out because it relaxes muscles and could have caused the patient's breathing to fail. Instead, the doctors tried a different approach using a low dose of gabapentin, a drug typically used for nerve pain. Within four days, the hiccups stopped completely. The patient returned to normal life without any worsening of his breathing or his underlying muscle disease. At a follow-up six weeks later, the hiccups had not returned.
This case suggests that cutting the phrenic nerve does not necessarily silence the entire hiccup reflex. It indicates that other sensory nerves in the chest can still detect irritation or movement and trigger the reflex, even when the main muscle controller is gone. The researchers propose that the mechanical act of tightening the diaphragm during surgery may have stimulated these alternative pathways. While this is based on a single patient, it serves as a reminder that the body's reflex circuits are more complex and redundant than previously thought. For surgeons, the finding implies that even after removing a phrenic nerve, patients may still experience hiccups if the diaphragm is manipulated later. For the patient, it offered a path to relief through a carefully chosen medication that respected his fragile respiratory system, proving that even in the absence of the primary nerve, the body's reflexes can find a way to speak, and medicine can find a way to listen.
Drowning in papers in your field?
Get daily digests of the most novel papers matching your research keywords — with technical summaries, in your language.