Treatment for Hiccups Based on Science

So... I came across a few references addressing treatment of hiccups (otherwise known as singultus) based on science rather than heresay. Here are a few methods than can be done at home without the need for medications or procedures.

It is felt that hiccups may be secondary to irritation of the phrenic nerve (which innervates the diaphragm). As such, scientific treatment of hiccups have relied on increasing PaCO2 (breath holding, breathing into a paper bag), therapy using diaphragm relaxation (baclofen or phrenic nerve block), or positive airway pressure.

So, one paper described a technique called supra-supramaximal inspiration that would increase PaCO2, diaphragmatic immobilization, and positive airway pressure. The technique is as follows:

Patients are instructed to inspire maximally, hold the breath for 10 seconds, then add an additional, small, “supra-maximal” inspiration, without any expiration. The breath is held for 5 seconds, followed by a third, “supra-supramaximal” inspiration, held for 5 seconds, before resuming normal breathing.

A variant on this technique requires an assistant. The assistant first applies firm pressure just anterior to the tragus of the ear, firm enough to completely occlude the ear canal. The patient than drinks a glass of water for about 10 seconds. If no liquid is available, the Valsalva manoeuvre would suffice.

In another method, pressure is applied to the sphenopalatine ganglion. This method involves sliding a finger (or thumb) to the junction between the hard and soft palate in the mouth. In this region, firm pressure is appled for 5-10 seconds towards the back-top part of the head. Enough pressure needs to be applied to cause some pain. One can massage this junction as well. I believe this method was reported in the New England Journal of Medicine, but for the life of me, I can't find the reference.

Digital rectal massage has been reported in the literature to help stop hiccups, mainly by disrupting the vagal afferent limb of the hiccup reflex arc. Name says it all. Essentially, you stick a finger up the anus and massage the area firmly until hiccups stop.

Direct vagal stimulation, such as by carotid massage, Valsalva maneuver, and ocular pressure have also been reported.

Reference:
Miracle hiccough cure gets the attention it deserves. BMJ. 2006 December 9; 333(7580): 1222.
doi: 10.1136/bmj.39051.721632.3A.

Bloodletting and miraculous cures. BMJ 2006;333:1127-a (25 November.)

Termination of idiopathic persistent singultus (hiccup) with Supra-Supramaximal Inspiration. J Emerg Med. 2004 Nov;27(4):416-7.

Termination of intractable hiccups with digital rectal massage. J Intern Med. 1990 Feb;227(2):145-6.

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Botox for Chronic Cough

There was a new report in the May 2010 issue of Archives of Otolaryngology-Head & Neck Surgery that discussed the use of botox to achieve significant improvement, if not cure, in adult patients with a chronic cough due to sensory neuropathy. In this report titled "Use of Botulinum Toxin Type A for Chronic Cough: A Neuropathic Model", there are 4 case studies that were presented. The results they reported stated that cough relief occurred after a median of 7 injections with a mean dose of 4.0 Units per treatment session for a mean duration of 25.7 months. To watch a video of how the botox is injected into the voicebox to treat chronic cough, click here or watch below (the procedure is the same as that performed for spasmodic dysphonia).

Of note, this is the 2nd report on use of botox for chronic cough, the first was published in 2007 in ENT Journal and was done on kids. Click here to read that report.

I tend to use botox as a last resort when other medical management strategies have failed. Hidden triggers of cough including reflux, allergies, and asthma need to be addressed prior to consideration of botox. Often, I'll give a trial of neuropathic medications if laryngeal sensory neuropathy is suspected.

To read more about chronic cough, click here.

To read the actual report on use of botox to treat chronic cough, click here.

Botox is performed by Dr. Chang every Friday afternoon for spasmodic dysphonia, laryngospasm, as well as chronic cough! We also use botox for migraines, facial wrinkles, and torticollis.

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