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Sphenoidal
https://t.me/med1917
sinus
(pink)
Frontal
sinus
Sphenoidal
sinus
Frontal
sinus
Ethmoidal
sinus
Maxillary
sinus
Chapter 22 • Nasal Symptoms and Sinus Congestion 281
facial or tooth pain, or headache over the affected sinus,
as well as morning periorbital swelling, fever, and mal-
aise. Other less common causes include anatomical ab-
normality, adenoid hypertrophy, and contiguous infec-
tion, such as a dental abscess or periorbital cellulitis.
Location of Pain
An adult patient with sinusitis most often reports a pro-
longed cold with symptoms of nasal congestion and
facial pain. Children rarely complain of headache or
facial pain. The location of pain may indicate which
sinus is involved. Pain of maxillary sinusitis occurs
over the sinuses and is sometimes perceived as a maxil-
lary toothache. Frontal sinusitis produces a frontal
headache that is worse on morning wakening. Ethmoid
sinusitis causes pain that refers to the vertex, forehead,
or occipital or temporal region, whereas the pain of
sphenoid sinusitis is perceived on the top of the head.
FIGURE 22-1 Anterior and lateral views of the paranasal
sinuses. (From Barkauskas VH, Baumann L, Darling-Fisher C:
Health and physical assessment, ed 3, St Louis, 2002, Mosby.)
feathers, and cockroaches. Seasonal allergies usually
occur in early spring (tree pollens), early summer
(grass pollens), and early fall (weed pollens).
Family History
Family history of asthma or allergies is frequently associated with allergic rhinitis. Other symptoms may
include a sensation of head stufness, ear discomfort,
fatigue, and a scratchy or mild sore throat.
If I suspect sinus problems, what do I need
to know?
Key Questions
n How long have you had these symptoms?
n Do you have pain? Can you point to the areas of pain?
n Do your symptoms change with position changes?
n Do you have a history of sinus problems?
Acute Symptoms
Acute sinusitis is an abrupt onset of infection of one or
more of the paranasal sinuses, and it occurs when the
sinus ostia become obstructed, usually after an upper respiratory tract infection. Sinusitis is frequently associated
with a sore throat, often irritated by postnasal discharge,
Position Change
Maxillary sinusitis produces pain that worsens with
bending or leaning forward. The postnasal discharge
associated with sinusitis produces a cough that worsens
while lying down.
Chronic Symptoms
Chronic symptoms can be caused by prolonged obstruc-
tion of the osteomeatal complex, which leads to dysfunc-
tion of ciliary motility and movement of mucus within
the sinuses. Local factors that cause mechanical obstruc-
tion include adenoid hypertrophy, conchae bullosa, nasal
polyps, foreign bodies, and nasal deviations. Adults with
symptoms that last more than 3 weeks experience upper
molar pain or headache, postnasal drip, and rarely have a
fever. In children, chronic sinusitis is dened as the pres-
ence of symptoms for longer than 30 days.
Do associated symptoms provide any clues?
Key Questions
n Do you have other acute symptoms, such as cough,
fever, or muscle aches?
n Do you have other chronic symptoms, such as eye
pain, bad breath, or fatigue?
Other Acute Symptoms
Acute bacterial infection of the nasal and sinus mucosa
is characterized by the presence of purulent nasal dis-
charge. Acute rhinitis caused by a bacterial or viral
282 Chapter 22 • Nasal Symptoms and Sinus Congestion
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infection produces systemic symptoms, such as fever,
myalgia, and chills. Allergic rhinitis is associated with
sneezing, nasal congestion, clear and profuse rhinorrhea, and pruritus of the nose, palate, pharynx, and
middle ear. Eye complaints include conjunctival irritation, itching, erythema, and tearing. Ear complaints
involve a feeling of fullness in the ears with popping.
Sinus complaints are pressure and/or pain of the
cheeks, forehead, or behind the eyes.
Acute sinusitis in children involves the presence of
symptoms for less than 30 days, a persistent cough,
fever with a temperature greater than 39º C (102.2º F)
for more than 3 days, and malodorous breath. The
maxillary and ethmoid sinuses are most commonly
affected, with the frontal sinus occasionally and the
sphenoid sinus rarely affected.
Chronic Symptoms
Chronic sinusitis involves long episodes of inammation or repeated infections that lead to anatomical
destruction. The recurrent symptoms interfere with
daily activities and are not relieved with nonpharmacological measures or over-the-counter medications.
Patients often report a cold that does not go away, eye
pain, halitosis, chronic cough, fatigue, anorexia, and
malaise.
Are there risk factors that will narrow
the diagnosis?
Key Questions
n Do you smoke?
n Are you exposed to others who smoke?
n Do you have any other health problems?
n Have you had a recent history of head or facial trauma?
n Have you been diving or swimming?
n Have you been exposed to infections in day care,
school, or work settings?
n Are you pregnant?
Smoking History
Smokers have an increased risk of sinusitis. Smoking
can lead to the production of more tenacious mucus
and to temporary paralysis of the nasal cilia. Exposure
to passive smoke causes an increased risk of upper and
lower respiratory tract infections.
Trauma History
Nasal trauma or fracture may lead to nasal congestion.
A rare but serious post-trauma cerebrospinal uid rhinorrhea can be present. Up to 80% of head injuries
involve the paranasal sinuses.
Is it viral or bacterial?
Key Questions
n What color is your nasal drainage?
n How long have you had these symptoms?
Acute rhinitis caused by a bacterial or viral infection
produces yellow or green purulent nasal discharge.
Watery or clear discharge occurs with allergic reactions. Symptoms of viral upper respiratory tract infections in children persist 5 to 10 days and then gradually
subside. Many children may have up to eight colds
per year.
Are symptoms unilateral or bilateral?
Key Question
n Is the symptom on one side or both sides?
Infectious rhinitis and allergic rhinitis are usually
bilateral. Unilateral symptoms are more indicative of an
anatomical cause, such as nasal polyps, septal deviation,
or a foreign body (typically occurs in children).
Diving and Swimming
Sinusitis from diving or swimming is secondary to
barotrauma, infection from contaminated water, or an
allergic response to chlorine.
Exposure
Exposure to viral infections increases when children
are exposed to other children. The spread of a virus
occurs by direct secretion of droplets or contact with
contaminated objects.
Pregnancy
The hormonal changes of pregnancy can cause nasal
congestion.
Is the patient using any drugs that would
cause nasal congestion?
Key Questions
n Are you using nasal sprays or drops?
n Do you use cocaine or other illicit drugs?
n What other medications are you taking?
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Nasal Spray
The use of topical sympathomimetic sprays or drops
for more than 1 week can lead to rebound nasal con-
gestion or vasodilation after short periods of vasocon-
striction. The use of decongestants and antihistamines
with low ambient humidity leads to excessive dryness
and impaired ciliary function.
Drug Use
Chronic or acute cocaine use can cause rebound nasal
congestion. Nasal congestion associated with conjunc-
tivitis and irritation of the eyes may be seen in persons
who abuse drugs by inhalation.
Medications
Oral contraceptives, phenothiazines, angiotensin-
converting enzyme (ACE) inhibitors, and ß-blockers
may cause nasal congestion.
Is there systemic disease present?
Key Questions
n Have you noticed any other body symptoms?
n Do you have any chronic health problems?
Systemic Disorders
Systemic causes of decreased mucociliary clearance
include cystic brosis, ciliary dyskinesia syndrome,
and immunoglobulin deciency. Persons with con-
genital or acquired immune deciencies, such as dia-
betes mellitus, leukemia, acquired immunodeciency
syndrome, and cystic brosis, have an increased risk
of developing acute and chronic sinusitis. Hypothy-
roidism, acromegaly, Horner syndrome, neoplasm,
and granulomatosis disorder can also cause nasal
symptoms.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Perform a General Inspection
Note the patient’s general appearance. Observe for signs
of impaired mental status. A severe unremitting or new-
onset headache, vomiting, or alteration in consciousness
requires consideration for immediate referral.
Take Vital Signs
Persons with acute viral rhinitis or acute sinusitis
may be afebrile or have a low-grade fever. Persons
with allergic rhinitis are afebrile. The presence
of mouth breathing suggests chronic nasal obstruction caused by hypertrophied pharyngeal lymphoid
tissues.
Inspect the Face
Children with chronic allergic conditions have an
allergic “salute”; this is a crease on the nose from
continued wiping up of nasal drainage. Allergic
“shiners” are dark circles under the eyes suggestive
of venous congestion and stasis. Observe for facial
symmetry and signs of periorbital edema. Periorbital
cellulitis is the most common serious complication
of severe bacterial sinusitis.
Perform a Regional Examination
of the Head and Neck
Examine the eyes (including visual acuity), ears, and
cervicofacial lymph nodes. Complications of severe
fulminate sinusitis are rare and are caused by the direct
spread of infection, secondary to destruction of the
wall between the sinuses and the orbit. Symptoms can
include a sudden increase in pain, acute edema of the
eyelids, periorbital edema and erythema, decreased
visual acuity, diplopia, and displacement of the eye
laterally. The patient may experience pain on testing of
extraocular muscles. These symptoms mandate immediate referral.
Observe for symptoms of coryza (acute rhinitis) as
well as ear and eye drainage. Erythematous tympanic
membranes are seen in acute viral rhinitis.
Examine the Mouth and Teeth
Examine the teeth for the presence of abscesses,
especially the rst and secondary maxillary molars
and the alveolar margin of the teeth. Tenderness
elicited by tapping on the maxillary teeth with a
tongue blade may indicate dental root infection or
maxillary sinusitis. Mouth breathing is associated
with hypertrophied gingival mucosa and halitosis.
Halitosis can also be a sign of dental abscess or
sinusitis.
Children with acute viral rhinitis have mild erythema of the tonsils and posterior pharynx. If there is
vasomotor rhinitis, mucus is present in the posterior
pharynx.
Test for Smell
Severe nasal congestion or ethmoid sinusitis causes
anosmia.
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Inspect Condition of Nasal Mucosa
and Turbinates
Use a nasal speculum and head mirror to optimally
visualize the condition of the nasal mucosa and turbinates. A topical vasoconstrictive agent may be needed
to shrink the swollen mucosa to visualize the middle
meatus.
In infants and young children, the nares tend to
open forward, and tilting the tip of the nose up with the
thumb and directing the light into the nares will allow
inspection of the nasal cavities.
Pale, boggy turbinates are seen with allergic rhinitis. Inamed mucous membranes are seen with acute
coryza or hay fever. Allergic rhinitis may also produce
a violet-colored mucous membrane. Ulceration of the
nasal mucosa may be found in persons who abuse
drugs by inhalation.
Inspect for Masses
Observe for the presence of nasal polyps, which look
like skinned grapes and are usually bilateral and hang
from the middle turbinate into the lumen of the nose.
Septal deviation or anatomical anomalies may predispose to infection. Nasal septum deviation can also
lead to nasal obstruction. Squamous cell carcinoma
usually occurs unilaterally. Masses that increase in
size and pulsate on Valsalva maneuver may indicate
an encephalocele or a meningocele.
Note the Presence and Color of Any
Discharge
Pus in the ostium of the middle turbinate suggests a
bacterial sinusitis. Cerebrospinal uid (CSF) drainage
will increase in a forward position. Identify CSF by
testing nasal drainage for glucose and protein levels
comparable to those of CSF. Foul-smelling nasal discharge is a characteristic feature of sinusitis of dental
origin. Foul-smelling unilateral purulent discharge
may indicate a foreign body in the nasal cavity.
nonspecic, such as reduced illumination, and do not
lead to a diagnosis.
Transillumination of maxillary sinuses can be done in
two ways. Place a transilluminator over the infraorbital
rim, blocking light from the examiner’s vision with the
free hand, and judge the amount of light transmission
(opaque, dull, normal) through the hard palate. This should
be performed in a completely darkened room. Dentures
must be removed. A second method is to place the transilluminator in the patient’s mouth, sealing the lips, and observe the amount of light transmitted through the maxillary sinuses. Frontal sinuses can be transilluminated by
placing the instrument below the supraorbital rim.
Palpate and Percuss Frontal and
Maxillary Sinuses for Tenderness
Percuss and palpate the cheeks for tenderness and
swelling, indicating maxillary sinusitis of dental origin.
To assess the frontal sinuses, exert pressure over the
eyebrow or slightly upward pressure under the brow to
assess for tenderness. Direct percussion may elicit tenderness over the affected sinus.
Test for Facial Fullness and Pressure
Bending forward from the waist (with head dropping
downward) or performing a Valsalva maneuver will
worsen the symptoms if a partial or complete sinus
obstruction is present.
Examine the Lungs
Auscultate the lungs for signs of wheezing, rales, and
loudness of breath sounds. Peak ow volume or Po2
saturation as measured using a pulse oximeter will
detect the presence of reactive upper airway disease.
Perform Neurological Testing If Indicated
To detect any complications from sinusitis, assess neurological and cranial nerve function if the patient appears
severely ill. Severe complications of sinusitis are cavernous sinus thrombosis and brain abscesses.
Transilluminate the Sinuses
Light will pass through air-lled sinuses. Transillumination is used to assess the presence of uid in the frontal
and maxillary sinuses and cannot be used to examine the
ethmoid or sphenoid sinuses. Normal transillumination
of the frontal sinus rules out frontal sinusitis in 90%
of cases. Complete opacity of sinuses suggests infection.
However, the results of transillumination are often
LABORATORY AND DIAGNOSTIC STUDIES
Nasal Smear
A nasal smear performed to look for eosinophils conrms the diagnosis of allergic rhinitis. Nasal scraping
of the surface epithelium along with a sample of secretions is more reliable in detecting the presence of
eosinophils than is the sampling of secretions alone.
Either method can be used to detect the presence of
Chapter 22 • Nasal Symptoms and Sinus Congestion 285
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neutrophils. Specimens are graded using a semiquantitative scale of 0 to 41, based on the concentration of
cells. Table 22-1 illustrates the diagnostic classications found with varying nasal smears.
Sinus Radiographs
Radiographs are not routinely indicated but may be obtained in patients who have severe symptoms and fail to
respond to treatment. Severe symptoms may indicate
complications of sinusitis, such as orbital cellu litis, brain
abscess, osteomyelitis, or cavernous sinus thrombosis.
A sinus radiographic series consists of four views: an
anteroposterior (Caldwell) view of the ethmoid sinus, a
view (Chamberlain) of the frontal sinus, a lateral view of
the sphenoid and frontal sinuses, and an occipitomental
(Waters) view of the maxillary sinuses.
Computed Tomography Scan
A computed tomography (CT) scan shows air, bone,
and soft tissue and optimally facilitates denition of
regional anatomy and the extent of disease. A CT scan
is done when sinusitis becomes chronic and does not
respond to symptomatic or antibiotic treatment. A CT
scan may also show causes for chronic sinusitis by
visualizing many disorders not detected by plain
lms, such as facial fractures, nasal polyps, cysts,
chronic mucosal thickening, temporomandi bular joint
(TMJ) disorders, foreign bodies, and tumors.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is an excellent
technique for imaging soft tissue pathology of the face
and neck, especially neoplastic conditions. CT does
not delineate soft tissue pathology as well as MRI.
Sinus Aspiration
Sinus aspiration is the only way to conrm the diagno-
sis of bacterial sinusitis and is performed by an otolar-
yngologist. A trocar is introduced into the maxillary
sinus through the upper gingival recess.
Nasal Endoscopy
Nasal endoscopy allows direct observation of the nasal
passages, larynx, pharynx, and surrounding tissue, and
aids in the diagnosis of nasal polyps, chronic sinusitis,
or laryngeal trauma. Before a exible beroptic scope
is threaded through the nasal passages, an anesthetic
spray is applied to the nasal tissue while the patient is
in a sitting position.
Allergy Skin Testing
Results of skin testing can conrm immunological dis-
ease and identify specic antigens responsible for aller-
gic rhinitis, which may come from exposure to irritants
in the patient’s environment. The presence of serum IgE
antibody suggests an allergic response.
DIFFERENTIAL DIAGNOSIS
Infectious Rhinitis
Infectious rhinitis is an acute condition frequently associ-
ated with a history of recent upper respiratory tract infec-
tion. A denitive sign of this condition is the presence of
yellow or green purulent discharge and red nasal mucosa.
Allergic Rhinitis
Allergic rhinitis is distinguished by a recurrent rhinor-
rhea with clear watery mucus, sneezing, and pruritus.
Nasal turbinates are pale and swollen. Family history
Table 22-1
NASAL SMEAR DIAGNOSTIC CLASSIFICATION
Increased eosinophils Allergic or nonallergic eosinophilia; aspirin intolerance
Increased basophils Same as above; nonallergic basophilia
Increased neutrophils
With intracellular bacteria Nasopharyngitis; sinusitis
With ciliary tophthora Viral upper respiratory infection (URI)
With fungi Fungal URI
With no bacteria Irritant reaction
Bacteria (2-41)—intracellular Nasopharyngitis or sinusitis
No eosinophils or basophils, 21 or fewer neutrophils,
few bacteria
From Mygind N, Naderio R: Allergic and non-allergic rhinitis, Copenhagen, Denmark, 1993, Munksgaard International Publishers.
Diagnostic Classications of Nasal Smear Specimens
Normal finding
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of allergies is often positive. About 25% of the population has some type of allergy. IgE-mediated reactions
to aeroallergens are based on a combination of history,
physical examination, and skin tests. Nasal smears can
be tested for the presence of eosinophils to conrm an
allergenic response.
Seasonal allergies are associated with short bursts
of intense exposure to an allergen that creates symptoms consistent with a histamine-mediated response,
such as pruritus, swelling, sneezing, and rhinorrhea. A
common seasonal allergy is pollenosis or hay fever.
A history or pattern of symptoms and exposure is critical in diagnosis.
Perennial allergies are caused by continuous exposure to allergens associated with chronic congestion.
Common indoor allergens are animal dander, dust
mites, and cockroaches. Outdoor allergens include
grasses, trees, pollens, and weeds.
Nonallergic Rhinitis
Nonallergic rhinitis can be associated or not associated
with eosinophilia on nasal smear. Nonallergic rhinitis
with eosinophilia syndrome (NARES) is a diagnosis
based on nasal cytology and involves symptoms similar to allergic rhinitis without an identiable allergen
cause. A history will reveal aspirin or nonsteroidal
anti-inammatory drug intolerance and rhinorrhea.
Noneosinophilia is associated with any other nonallergic cause of rhinitis.
Rhinitis Medicamentosa
Drug-induced rebound congestion can follow the longterm use of topical nasal decongestants. Rhi nitis medicamentosa is also used to describe nasal symptoms
secondary to other medications, such as nasal congestion associated with hormone changes of pregnancy.
Other drugs that have vasodilatory effects include antihypertensives that interfere with adrenergic neuronal
function and hormones in oral contraceptives. Nasal
vasoconstriction response is completely abolished after
the administration of reserpine.
Acute Sinusitis
Acute sinusitis is characterized by purulent nasal
discharge, postnasal drip, and localized facial pain
over the sinus involved. It often follows a viral upper
respiratory tract infection. However, symptoms such
as halitosis, reduced sense of smell, or morning
cough have been reported in children in the absence
of facial pain. Physical examination will elicit localized tenderness to palpation or percussion over the
affected sinus. Pressure and pain will increase in a
forward-bending position. Purulent discharge may be
visible in the posterior pharynx or may be seen
emerging from the ostia of the middle turbinate.
Transillumination will indicate unilateral or bilateral
obstruction. Ciliary function is impaired with infection and may not be completely restored for 2 to
6 weeks. The diagnosis of sinusitis in children
requires two of three major criteria (cough, purulent
nasal discharge, or purulent pharyngeal drainage)
or one major and two minor criteria (sore throat,
wheezing, foul breath, facial pain, periorbital edema,
headache, earache, fever, and toothache).
Chronic Sinusitis
An incompletely treated acute sinusitis can lead to
a chronic condition. The patient presents with
persistent symptoms of low-grade infection and intermittent acute exacerbations typical of acute
sinusitis. Symptoms are recurrent and not controlled
with over-the-counter or nonpharmacological remedies. Multiple pathogens may be causative organisms, with the most common being Moraxella
catarrhalis, H. inuenzae, and S. pneumoniae. Sinus
radiographs or a CT scan will reveal mucosal thickening of 5 mm or greater. Allergy testing may
reveal a perennial allergy that creates chronic
inammation.
Nasal or Sinus Obstruction
A history of aspirin intolerance or asthma with
polyps is associated with obstruction. Acute obstruction suggests edema secondary to infection, allergic
response, exposure to irritants, or foreign body (in
children). Chronic obstruction may be secondary to
congenital deformity, nasal polyps, or septal deviation. In infants, congenital choanal atresia can cause
obstruction.
Nasal Polyposis
This syndrome has multiple causative factors, including a history of asthma and aspirin intolerance. The
polyps are translucent grapelike growths that are mobile, rarely bleed, and prolapse into the nasal cavity.
The resulting obstruction can be associated with
chronic sinusitis. Any suspicious polyps should be
biopsied.
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Osteomyelitis of the Frontal Bone
Osteomyelitis can occur as a complication of sinus-
itis. Osteomyelitis occurs in children and young
adults and may follow head trauma or scuba diving.
are causative organisms. Patients appear severely ill
and may have edema of the upper eyelid and puffy
swelling over the frontal bone. Diagnosis is by radiography and blood culture.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Nasal Symptoms
and Sinus Congestion
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Staphylococcus pyogenes or anaerobic streptococci
Infectious rhinitis Perennial but more common
in winter months; recent URI
Allergic rhinitis Family history of allergies;
sneezing; recurrent pattern;
more common in children
and young adults
Nonallergic
rhinitis
Rhinitis
medicamentosa
Acute sinusitis Smoker; recent URI; winter
Chronic
sinusitis
Obstruction History of asthma, aspirin
Nasal polyposis History of asthma, aspirin
Osteomyelitis of
No allergenic cause identified Similar to allergic rhinitis Absence of eosinophilia
History of medication use:
oral contraceptives, nasal
sprays, antihypertensives;
nasal congestion
months; frontal headaches
made worse with forward
bending; sensation of
fullness or pressure
History of previous sinus
infections; dull ache or no
pain; persistent symptoms
intolerance; foreign body
in children; tumor in adults;
infants with choanal atresia:
difficulty feeding; cyanosis
if bilateral
intolerance
History of head trauma,
Red, swollen mucosa; purulent
discharge
Pale, boggy mucosa; rhinorrhea
with clear, watery mucus
Swollen mucosa; clear mucus or
dry mucosa
Purulent discharge; maxillary
toothache on percussion,
postnasal drainage; decreased
transillumination
Same as in acute sinusitis;
decreased or no transillumination; obstruction such as
deviated septum, polyps
Increased pain with forward
motion or Valsalva; pain with
percussion and palpation of
sinuses; no transillumination;
septal deviation
Presence of polyps Nasal endoscopy; may
Appears severely ill; periorbital
Nasal smear for neu-
trophils, intracellular
bacteria
Nasal smear for
eosinophils; allergy
testing
on nasal cytology
None
None
CT scan; nasal endos-
copy; allergy testing
Sinus radiographs; CT
scan
require biopsy
Sinus and skull radio-
CT, computed tomography; URI, upper respiratory infection.
REFERENCES AND READINGS
Gendo K, Larson EB: Evidence-based diagnostic strategies for evalu-
ating suspected allergic rhinitis, Ann Intern Med 140:4, 2004.
Leung A, Kellner J: Acute sinusitis in children: diagnosis and
management, J Pediatr Health Care 18:72, 2004.
Marple BF, Stankiewicz JA, Baroody FM, Chow JM, Conley DB,
Corey JP et al.: Diagnosis and management of chronic rhinosinusitis
in adults, Postgrad Med 121:121, 2009.
Nash D, Wald E: Sinusitis, Pediatr Rev 22:111, 2001.
Novelline RA: Squire’s fundamentals of radiology, ed 6, Cambridge,
Mass, 2004, Harvard University Press.
Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S,
Ganiats TG et al.: Clinical practice guideline: adult sinusitis,
Otolaryngol Head Neck Surg 137:S1, 2007.
Skoner DP: Allergic rhinitis: denition, epidemiology, patho-
physiology, detection and diagnosis, J Allergy Clin Immunol
108:S2, 2001.
Zacharisen M, Casper R: Pediatric sinusitis, Immunol Allergy Clin
North Am 25:313, 2005.
C H A P T E R
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23
Palpitations
alpitations are dened as an unpleasant awareness
of the forceful, rapid, or irregular beating of the
P
heart. It is a common presenting symptom that is
usually benign; however, occasionally palpitations can
indicate a life-threatening arrhythmia.
Palpitations are described by patients as a “thumping,” “pounding,” or “uttering” sensation in the chest.
This sensation can be either intermittent or sustained, and
either regular or irregular. Patients often note palpitations
when quietly resting, a time when other stimuli are
minimal.
Causes of palpitations can be cardiac arrhythmias,
psychological factors, drugs and medications, nonarrhythmic cardiac problems, and systemic (extracardiac) conditions. Arrhythmias include premature
atrial and ventricular contractions, supraventricular
and ventricular arrhythmias, and atrial brillations.
Psychological causes of palpitations include panic
attack or disorder, anxiety states, and somatization.
Drugs and medications including alcohol, tobacco,
caffeine, aminophylline, atropine, thyroxine, cocaine, and amphetamines enhance the strength of
myocardial contraction and can cause the sensation
of palpitations. Nonarrhythmic cardiac problems,
such as mitral valve prolapse, pericarditis, congestive heart failure, valvular disease, congenital heart
disease, and cardiac myopathy, can produce palpations. Systemic conditions, such as hyperthyroidism, vasovagal syncope, and hypoglycemia, can
cause palpitations. Hyperdynamic cardiovascular
states caused by catecholaminergic stimulation from
exercise, stress, or pheochromocytoma can cause
palpitations. In many cases, the cause of the palpitations is unknown.
In children, fever, anxiety, exercise, and anemia are
common causes of palpitations.
Although palpitations are usually of benign etiology, the principal goal in assessing patients with
palpitations is to determine if the symptom is caused
by a life-threatening arrhythmia.
288
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Could this patient have a life-threatening
arrhythmia?
Key Questions
n Do you have a history of coronary artery disease
(CAD)?
n Are you lightheaded or have you had episodes of
passing out?
n Are you having chest pain?
n Have you had difculty breathing?
n Do you have a family history of sudden cardiac
death?
n Have you had heart surgery?
Coronary Artery Disease
Patients with risk factors for or preexisting coronary
artery disease (CAD) are at greater risk for ventricular
arrhythmias as a cause for palpitations. Risk factors
include smoking, hypertension, diabetes, a history of
myocardial infarction (MI), and a family history of
heart attack or stroke before age 60.
Lightheadedness/Syncope
The association of palpitations with other symptoms
suggesting hemodynamic compromise, including presyncope, syncope, or lightheadedness, may signify a
life-threatening cardiac arrhythmia.
Chest Pain, Dyspnea
Palpitations caused by sustained tachyarrhythmias
in patients with CAD can be accompanied by angina
pectoris or dyspnea. Palpitations associated with chest
pain suggest ischemic heart disease or, if the chest pain
is relieved by leaning forward, peri cardial disease.
Exertional palpitations associated with chest pain,
lightheadedness, or both in the athlete may indicate an
underlying cardiovascular disorder.
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Sudden Cardiac Death
A family history of sudden cardiac death (SCD) may
indicate an inherited cardiac problem.
Cardiac Surgery
Children and adults who have had cardiac surgery are
at risk for arrhythmias and palpitations.
What else do I need to know about the
palpitation?
Key Questions
n Can you describe the palpitation/sensation?
n When do the palpitations occur?
n How long do the palpitations last?
n Do the palpitations start or stop abruptly?
Description of Palpitations
Flip-opping. Single skipped beats or a sensation
of the heart stopping and then starting with a pounding,
ipping, or jumping sensation, especially while sitting
quietly or lying in bed and lasting only for brief periods, are typically attributed to premature contraction of
the atrium or ventricle. The sensation that the heart has
stopped results from the pause following the premature
contraction, and the pounding or ipping sensation results from the forceful contraction following the pause.
Rapid uttering in the chest. A feeling of rapid
uttering in the chest may result from atrial or ventricular arrhythmias, including sinus tachycardia.
Pounding in the neck. A pounding feeling in the
neck is caused by the dissociation of atrial and ventricular contractions so that the atria contract against
closed tricuspid and mitral valves, producing cannon A
waves. The sensation of rapid and regular pounding in
the neck is typical of reentrant supraventricular arrhythmias, particularly atrioventricular nodal tachycardia.
Occurrence of Palpitations
Palpitations that start during sleep or states of increased
vagal tone (e.g., at termination of exercise) may be associated with vagal-mediated atrial brillation or certain subtypes of long QT syndromes. Palpitations that are worse at
night may be caused by benign ectopy or atrial brillation.
Palpitations that start and stop abruptly suggest
supraventricular or ventricular tachycardias. Palpitations that can be stopped using patient-initiated vagal
maneuvers, such as the Valsalva maneuver, suggest
supraventricular tachycardia.
Rapid palpitations during catecholamine excess,
such as during exercise, suggest ventricular tachycardia, sinus tachycardia, or atrial brillation. Palpitations
that occur regularly with exertion suggest hypertrophic
cardiomyopathy or CAD.
Positional palpitations may reect atrioventricular
nodal tachycardia, pericarditis, or a structural process
within the heart (e.g., atrial myxoma) or adjacent to the
heart (e.g., mediastinal mass).
Could this be related to stress or
a psychological condition?
Key Questions
n Have you experienced panic attacks (brief periods
[seconds or minutes] of an overwhelming panic or
terror accompanied by racing heartbeats, shortness
of breath, or dizziness)?
n Can you describe your stress level and how you
cope with stress in your life?
n Do you or does anyone in your family have a prob-
lem with panic attacks, anxiety, or depression?
n What other symptoms are you having?
Panic Disorder/Stress/Anxiety
Common psychological causes of palpitations include
panic disorder and anxiety states. Patients with psychological causes for palpitations more commonly report a
longer duration of the sensation (.15 min) and accompa-
nying symptoms than do patients with other causes. Panic
attacks, however, may also indicate pheochromocytoma.
Other Symptoms
Palpitations associated with hyperventilation, hand tingling, nervousness, shortness of breath, or dizziness
are common when anxiety or panic disorder is the underlying cause. Children with serious arrhythmias may
not report palpitations. Young infants may exhibit poor
feeding or be irritable when palpitations are present.
Are drugs/medications or other substances
implicated?
Key Questions
n What prescription and over-the-counter (OTC)
medications are you taking?
n What recreational drugs do you use?
n Are the palpitations associated with caffeine, tobacco,
or alcohol use?
290 Chapter 23 • Palpitations
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Medications
Palpitations can result from OTC and prescription
medications. Medications that prolong the QT interval and predispose patients to arrhythmias include
antidysrhythmics, antimicrobials, antihistamines,
psychotropic drugs, and other miscellaneous drugs,
such as motility drugs, electrolyte-depleting diuretics, and protease inhibitors for human immunodeciency virus. In children, cold medicines may cause
palpitations.
Stimulants
Caffeine, aminophylline, ß-adrenergic agents, thyroxine, cocaine, and amphetamines enhance the
strength of myocardial contraction and can cause
palpitations.
Could this be secondary to a systemic
condition?
Key Questions
n What other symptoms are you having?
n Have you been ill?
n Does your family have any known genetic conditions?
Symptoms/Illness
Noncardiac symptoms should also be elicited because the palpitations may be caused by a normal
heart responding to a metabolic or inammatory condition. Palpitations can be precipitated by vomiting
or diarrhea that leads to electrolyte disorders and
hypovolemia.
Fatigue and shortness of breath suggest anemia.
Weight loss and heat intolerance may indicate hyperthyroidism. Patients with hyperthyroidism also report
nervousness, emotional lability, fatigue, muscle weakness, increased sweating, menstrual changes (oligoamenorrhea), increased appetite, insomnia, thinning
hair, tremors, and anxiety.
Pheochromocytoma can lead to palpitations. Patients
typically report headache (usually severe, pounding, and
paroxysmal), sweating, nausea and vomiting, visual
problems, episodic ushing, weight loss, diarrhea, nervousness, abdominal or chest pain, panic attacks, ank
pain, pallor, tremor, fatigue, anxiety, weakness, dyspnea,
warmth, fever, dizziness, constipation, paresthesias,
painless hematuria, and anorexia.
Genetic Disorders
Germline mutations have been identied that are the
cause of familial syndromes that include a pheochromocytoma: von Hippel-Lindau syndrome, multiple
endocrine neoplasia type 2, neurobromatosis type 1
(von Recklinghausen disease), and familial paragangliomas syndromes.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Most patients with episodic palpitations are asymptomatic on physical examination. Typically, the purpose of the physical examination is to identify structural heart abnormalities to help conrm or rule out
the presence of an arrhythmia (see Evidence-Based
Practice box).
EVIDENCE-BASED PRACTICE
In one study, 127 patients presenting with palpitations and/
or lightheadedness to 41 general practitioners (GPs) in the
Netherlands underwent history and physical examination
and standard electrocardiogram. The GPs’ estimation of the
probability of patients having an arrhythmia was compared
with the diagnostic result of 30 days of continuous event
recording (CER). No correlation was found between the GPs’
assessment of risk and actual diagnoses. GPs were more likely
to predict an arrhythmia in patients who suffer from
Data from Hoefman E, Boer KR, van Weert HC, Reitsma JB, Koster RW, Bindels PJ: Predictive value of history taking and physical examination in
diagnosing arrhythmias in general practice, Fam Pract 24:636, 2007.
Can History and Physical Examination Predict
Arrhythmias?
hypertension (p 5 0.049) or with a history of cardiovascular
disease (p 5 0.006). Vasovagal symptoms (odds ratio [OR] 5
2.91, 95% confidence interval [CI] 1.1–7.6) and bradycardia
(OR 5 4.2, 95% CI 1.3–14.0) were significantly more common
in patients with a CER diagnosis of arrhythmia. The authors
concluded that physical examination and history taking alone
in patients with palpitations and lightheadedness are not accurate in predicting arrhythmias and are insufficient parameters to
determine the need for further diagnostic evaluation.
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