Carotid Sinus Massage, Hypersensitivity, Syndrome

Learn all about carotid sinus massage, hypersensitivity, syndrome.

The Carotid Artery Massage is one of a number of medical procedures called “Vagal maneuvers.” Vagal maneuvers stimulate the vagus nerve (located along the side of the head) and prompt it to release chemicals which slow a patient’s heart rate).

Painful carotid sinus is a common condition which is rarely recognized and often overlooked. The pain is localised in the area of the common carotid artery and at the level of the carotid bulb. The etiology is usually not known and different causes such as inflammation, tumours around the artery or lymphadenitis nearby have been blamed for it.

This is a benign condition, gives rise to no significant lesion of the artery and has a dramatic response to simple analgesics or a combination of simple analgesics and steroids. Fay1 was the first to describe this condition followed by Hilger2 who described it as “Carotid Pain” due to an imbalance of the autonomic nervous system of the carotid tree resulting in Angiospasm and Oedema but no inflammation. Lovshin3 called it “Vascular Neck Pain”, attributed it to an autonomic dysfunction, and treated his patients with a combination therapy of analgesics, psychotherapy, tranquilizers and ergotamine preparations.

Saunders mentioned the possibility of a viral etiology and called it carotid arteritis. He proposed a corticosteroid therapy which was the only effective treatment in his series. Chiossone and Ouiroga4 concluded it to be a viral infection which responded well to steroids with or without analgesics. More recently a Hypersensitive Carotid Sinus. The carotid sinus reflex plays a central role in blood pressure homeostasis.

Carotid Sinus Syndrome Pain

The carotid sinus also known as carotid bulb is an area which is located in the superior portion of the area of bifurcation of the common carotids. This sinus is extremely sensitive to pressure changes in the arterial blood. When this sinus becomes sensitive to even minor stimulation, it may result in many complications like loss of consciousness etc. In this article, we will discuss about the various causes, symptoms, and treatment of Carotid Sinus Hypersensitivity or Carotid Sinus Syndrome. Carotid Sinus Hypersensitivity or Carotid Sinus Syndrome is more found in the elderly population. It generally affects people above the age of 50 and males are usually more prone to Carotid Sinus Hypersensitivity or Carotid Sinus Syndrome.

Carotid Sinus Massage Physiology

Carotid sinus massage can result in one of four possible effects:

temporary decrease in the atrial rate in patients with sinus tachycardia or automatic AT
slowing of AVN conduction and AVN block, which can unmask atrial electrical activity—that is, reveal P waves or flutter waves in patients with AT or AFL by decreasing the number of QRS complexes that obscure the electrical baseline;
some SVTs that require AVN conduction, especially AVNRT and AVRT, the transient slowing of AVN conduction can terminate the arrhythmia by interrupting the reentry circuit; less commonly, carotid sinus massage can cause some ATs to slow and terminate; or
In some cases, no effect is observed.

Carotid Sinus Massage Risks and Contraindications

Carotid sinus massage is indicated in the elderly patient who has a history of unexplained falls, loss of consciousness and presyncope, and in whom results of the cardiac and neurologic work-up have been inconclusive. Because syncopal episodes account for a large number of emergency department visits in the elderly, physicians should know how to perform this maneuver. Risk factors are;

temporary loss of feeling,
weakness, pins and needles in the limbs
Disturbance in vision in about 1 in 1000 patients but this usually recovers within 24 hours.

Absolute contraindications to carotid sinus massage include myocardial infarction, transient ischemic attack or stroke within the preceding three months. If asystole is prolonged, a chest blow should be administered. If neurologic complications occur, the procedure should be stopped; aspirin should be given if not contraindicated. Absolute contraindications are;

Myocardial Infarction
Transient Ischemic Attack (in last 3 months)
Cerebrovascular Accident (in last 3 months)
Carotid Artery Occlusion
Ventricular Fibrillation history
Ventricular Tachycardia history
Previous adverse reaction to Carotid Sinus Massage

Relative Contraindications are:

Carotid Bruit
Evaluate Carotid Bruit prior to massage
Perform carotid Ultrasound
Carotid Stenosis or atheroma suggests risk
Obtain Informed Consent if massage performed

How to do Carotid Sinus Massage?

Carotid sinus massage should be done as;

It’s important that the patient be lying down, in case they experience any lightheadedness or loss of consciousness from the CSM.
Place an electrocardiograph (ECG) on the patient. This medical tool will monitor the electrical activity of the patient’s heart while the CSM is administered.
Monitor the patient’s blood pressure before, during and after the procedure using a continuous blood pressure and heart rate monitor.
The angle of the jaw should be the location at which their jawbone bends about 4 inches (10 centimeters) back from the tip of their chin.
The second carotid sinus will be located in the identical position on the other side of the patient’s neck.
Avoid pressing too hard, or you may risk reducing the flow of oxygen to the patient’s brain. As a rule of thumb, use the amount of pressure that you would need to indent the surface of a tennis ball.
After performing the carotid massage on the right side of a patient’s neck, repeat the massage on the patient’s left carotid sinus. Massage in a circular motion for 5–10 seconds
Following the completion of the CSM, the patient may experience some lightheadedness or may feel mildly dizzy. Ask them to continue lying supine for another 10 minutes
If the patient’s cardiac arrest continues once you’ve stopped administering the CSM, you may need to begin performing live-saving measures, such as a precordial thump
Stop the CSM if the patient faints.
Stop performing the CSM if any neurological complications such as a stroke, occurs.
Ask your patient if a physician has diagnosed them with CSH or if they have ever had a negative reaction to or lost consciousness during a carotid sinus massage.