American Journal of Emergency Medicine 32 (2014) 487.e5–487.e6
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute coronary syndrome presenting with earache and sore throat Abstract Chest pain and discomfort are regarded as the hallmark symptoms of acute coronary syndrome, and the absence of these symptoms are described as “atypical” presentation. In this case, we aimed to report an acute coronary syndrome–diagnosed patient who was admitted to our emergency service with unilateral earache. Chest pain is a typical symptom of acute coronary syndrome (ACS). However, this symptom may not be present in all cases of ACS. Dyspnea, nausea, sweating, and neck or jaw and arm pain may occur in cases of ACS [1]. Ear pain and sore throat are unusual symptoms of ACS [2]. These unusual symptoms make diagnosis and treatment difficult and challenging. A misdiagnosis of ACS may cause unfavorable outcomes. A 55-year-old woman presented to the emergency department (ED) complaining of severe earache and sore throat. She was agitated showing her throat with both hands. She described sore throat as a “choking” sensation and earache as an “intense fullness or congestion in the ear.” She reported that she had the feeling of “stop of breathing.” She had first presented to the ED about 6 hours ago with complaints of mild pain while swallowing and earache of 2-day duration. She lost her father due to coronary artery disease (CAD). In her first visit, she appeared restless. Her vital signs were blood pressure of 135/70 mm Hg, pulse of 70 beats per minute, respiratory rate of 22 breaths per minute, temperature of 36.5°C. Cardiovascular, pulmonary, abdominal, ear, nose, and throat examinations were unremarkable. Because of a possible atypical presentation related to a referred cardiac abnormalities, an electrocardiogram (ECG) and cardiac biomarkers were obtained. Neither ECG nor cardiac biomarkers showed any cardiac abnormalities. Other blood tests were normal. The patient was discharged 6 hours later. On her second arrival at the ED, her complaints were much more severe. Her skin was pale and cold. She was markedly agitated. Her vital signs on arrival at the ED were blood pressure of 143/75 mm Hg, pulse of 75 beats per minute, respiratory rate of 24 breaths per minute, temperature of 36.5°C. Because of a possible atypical presentation related to a referred cardiac pathology, an ECG was ordered immediately. The ECG displayed ST elevations in the inferior leads with reciprocal changes. The patient was then admitted to the intensive coronary care unit. An emergent coronary angiogram revealed 90% occlusion at the proximal part of the right coronary artery (RCA), 40% occlusion at the midpart of the left coronary artery, and 80% occlusion at the distal part of the circumflex artery. Subsequent angioplasty and stent placement for RCA resulted in complete recanalization. Patients presenting with ACSs are classically described as having chest pressure with radiation to the left arm. Pain may be referred to multiple sites including the neck, abdomen, face, and the contralateral arm.
Symptoms of ACS in the absence of chest pain are dyspnea, nausea, sweating, and neck or jaw and arm pain. Symptoms of ear pain for CAD and acute arterial occlusion in a patient have rarely been discussed in the literature [3]. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region, and teeth [4]. The referred earache and sore throat can be explained by autonomic dysfunction of the auricular branch of the vagus nerve. This branch of the vagus innervates the inner portion of the outer ear and also controls the skeletal muscles including the superior, middle, and inferior pharyngeal constrictors. It can be suggested that partial occlusion of the RCA promoted damage of the parasympathetic fibers of the right vagus and was the cause of referred earache and throat pain in our patient [5,6]. At this point, atypical presentations of ACS have been reported in the literature. Sheikh et al [7] reported an 85-year-old case with sudden bilateral ear pain as the sole presentation of ACS. In their case, the patient had CAD history, and the patient died 24 hours after treatment. In our case, there was no CAD history. Similarly, Yolcu and Beceren reported a patient who was admitted to ED because of fever but was diagnosed with ACS [8]. Emergency physicians should be aware and recognize that ear and throat pain may represent symptoms of ACS.
Umut Ocak, MD Department of Emergency Medicine Yuksekova Government Hospital Yuksekova-Hakkari Turkey E-mail address: [email protected] Levent Avşaroğulları Department of Emergency Medicine Erciyes University, Medical School Kayseri Turkey Mehmet Güngör Kaya Department of Cardiology Erciyes University, Medical School Kayseri Turkey Yavuz Özmen, MD Bahadır Taşlıdere, MD Erkan Abdullah Güldeste, MD Şule Yakar, MD Department of Emergency Medicine Erciyes University, Medical School Kayseri Turkey http://dx.doi.org/10.1016/j.ajem.2013.10.059
0735-6757/$ – see front matter. Crown Copyright © 2014 Published by Elsevier Inc. All rights reserved.
487.e6
U. Ocak et al. / American Journal of Emergency Medicine 32 (2014) 487.e5–487.e6
References [1] Ambrose JA, Dango G. Unstable angina: current concepts of pathogenesis and treatment. Arch Intern Med 2000;160:25–37. [2] Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9. [3] Amirhaeri S, Spencer D. Myocardial infarction with unusual presentation of otalgia: a case report. Int J Emerg Med 2010;3:459–60.
[4] Sone M, Koizumi A, Tamiya E, et al. Angina pectoris with pharyngeal pain alone: a case report. Angiology 2009;60:259–61. [5] Trichon BH, Roe MT. Acute coronary syndromes and diabetes mellitus. Diab Vasc Dis Res 2004;1:23–32. [6] Hammoud T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol 2000;36:355–65. [7] Sheikh M, Adlakha S, Chahal M, et al. “Cardiac otalgia”: acute coronary syndrome masquerading as bilateral ear pain. Cardiol J 2010;17(6):623–4. [8] Yolcu S, Beceren NG. Fever; as an atypical presentation of acute coronary syndrome. Bozok Med J 2013;1:76–8.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute coronary syndrome presenting with earache and sore throat Abstract Chest pain and discomfort are regarded as the hallmark symptoms of acute coronary syndrome, and the absence of these symptoms are described as “atypical” presentation. In this case, we aimed to report an acute coronary syndrome–diagnosed patient who was admitted to our emergency service with unilateral earache. Chest pain is a typical symptom of acute coronary syndrome (ACS). However, this symptom may not be present in all cases of ACS. Dyspnea, nausea, sweating, and neck or jaw and arm pain may occur in cases of ACS [1]. Ear pain and sore throat are unusual symptoms of ACS [2]. These unusual symptoms make diagnosis and treatment difficult and challenging. A misdiagnosis of ACS may cause unfavorable outcomes. A 55-year-old woman presented to the emergency department (ED) complaining of severe earache and sore throat. She was agitated showing her throat with both hands. She described sore throat as a “choking” sensation and earache as an “intense fullness or congestion in the ear.” She reported that she had the feeling of “stop of breathing.” She had first presented to the ED about 6 hours ago with complaints of mild pain while swallowing and earache of 2-day duration. She lost her father due to coronary artery disease (CAD). In her first visit, she appeared restless. Her vital signs were blood pressure of 135/70 mm Hg, pulse of 70 beats per minute, respiratory rate of 22 breaths per minute, temperature of 36.5°C. Cardiovascular, pulmonary, abdominal, ear, nose, and throat examinations were unremarkable. Because of a possible atypical presentation related to a referred cardiac abnormalities, an electrocardiogram (ECG) and cardiac biomarkers were obtained. Neither ECG nor cardiac biomarkers showed any cardiac abnormalities. Other blood tests were normal. The patient was discharged 6 hours later. On her second arrival at the ED, her complaints were much more severe. Her skin was pale and cold. She was markedly agitated. Her vital signs on arrival at the ED were blood pressure of 143/75 mm Hg, pulse of 75 beats per minute, respiratory rate of 24 breaths per minute, temperature of 36.5°C. Because of a possible atypical presentation related to a referred cardiac pathology, an ECG was ordered immediately. The ECG displayed ST elevations in the inferior leads with reciprocal changes. The patient was then admitted to the intensive coronary care unit. An emergent coronary angiogram revealed 90% occlusion at the proximal part of the right coronary artery (RCA), 40% occlusion at the midpart of the left coronary artery, and 80% occlusion at the distal part of the circumflex artery. Subsequent angioplasty and stent placement for RCA resulted in complete recanalization. Patients presenting with ACSs are classically described as having chest pressure with radiation to the left arm. Pain may be referred to multiple sites including the neck, abdomen, face, and the contralateral arm.
Symptoms of ACS in the absence of chest pain are dyspnea, nausea, sweating, and neck or jaw and arm pain. Symptoms of ear pain for CAD and acute arterial occlusion in a patient have rarely been discussed in the literature [3]. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region, and teeth [4]. The referred earache and sore throat can be explained by autonomic dysfunction of the auricular branch of the vagus nerve. This branch of the vagus innervates the inner portion of the outer ear and also controls the skeletal muscles including the superior, middle, and inferior pharyngeal constrictors. It can be suggested that partial occlusion of the RCA promoted damage of the parasympathetic fibers of the right vagus and was the cause of referred earache and throat pain in our patient [5,6]. At this point, atypical presentations of ACS have been reported in the literature. Sheikh et al [7] reported an 85-year-old case with sudden bilateral ear pain as the sole presentation of ACS. In their case, the patient had CAD history, and the patient died 24 hours after treatment. In our case, there was no CAD history. Similarly, Yolcu and Beceren reported a patient who was admitted to ED because of fever but was diagnosed with ACS [8]. Emergency physicians should be aware and recognize that ear and throat pain may represent symptoms of ACS.
Umut Ocak, MD Department of Emergency Medicine Yuksekova Government Hospital Yuksekova-Hakkari Turkey E-mail address: [email protected] Levent Avşaroğulları Department of Emergency Medicine Erciyes University, Medical School Kayseri Turkey Mehmet Güngör Kaya Department of Cardiology Erciyes University, Medical School Kayseri Turkey Yavuz Özmen, MD Bahadır Taşlıdere, MD Erkan Abdullah Güldeste, MD Şule Yakar, MD Department of Emergency Medicine Erciyes University, Medical School Kayseri Turkey http://dx.doi.org/10.1016/j.ajem.2013.10.059
0735-6757/$ – see front matter. Crown Copyright © 2014 Published by Elsevier Inc. All rights reserved.
487.e6
U. Ocak et al. / American Journal of Emergency Medicine 32 (2014) 487.e5–487.e6
References [1] Ambrose JA, Dango G. Unstable angina: current concepts of pathogenesis and treatment. Arch Intern Med 2000;160:25–37. [2] Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9. [3] Amirhaeri S, Spencer D. Myocardial infarction with unusual presentation of otalgia: a case report. Int J Emerg Med 2010;3:459–60.
[4] Sone M, Koizumi A, Tamiya E, et al. Angina pectoris with pharyngeal pain alone: a case report. Angiology 2009;60:259–61. [5] Trichon BH, Roe MT. Acute coronary syndromes and diabetes mellitus. Diab Vasc Dis Res 2004;1:23–32. [6] Hammoud T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol 2000;36:355–65. [7] Sheikh M, Adlakha S, Chahal M, et al. “Cardiac otalgia”: acute coronary syndrome masquerading as bilateral ear pain. Cardiol J 2010;17(6):623–4. [8] Yolcu S, Beceren NG. Fever; as an atypical presentation of acute coronary syndrome. Bozok Med J 2013;1:76–8.
