Abdullah Jan  ( Department of ENT, Khyber Medical College, Peshawar. )

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 aetiology 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 aetiology 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 Syndrome has been described by Gang Elis et al⁵ characterised by attacks of Synocope but the carotid bulb is neither painful nor tender. It is usually found in patients suffering from ischaemic heart disease.

Over the past 8 years, 27 cases of carotid sinus syndrome were seen. Majority of these patients were females between 15-16 years of age, physically and mentally healthy. All patients had unilateral disease and the area of pain radiation was mostly the ear and the pharynx. Some of them had radiation to the face. Except for a palpable tender carotid bulb none of the patients had any localised mass at the time of examination. All presented with pain in the neck, of moderate seve­rity. Only 7 (26%) patients presented to the hos­pital within the first 48 hours of the onset of pain, while 74% had already tried analgesics before seeking medical advice. The patients were divided into two groups, those under the age of 30 years (Group I) were treated with a combination the­rapy of simple analgesics such as Paracetamol 500 mg T.I.D. and a stat dose of Dipomedrol40 mg I/M while those above the age of 30 (Group II) were treated with simple analgesics and a tranquillizer (Table).

The injection was repeated after a week if no relief was obtained. Only 21 patients (78%) came for follow up and they were all free of symptoms. Six patients who did not come for follow up belonged to Group II. During a mean follow up of 6 months those who were symptoms free were declared as cured. The younger age group showed a dramatic response with the combination therapy of analgesics and steroid injections and none of them required a second injection while the other group on simple analgesics and tranquillizer required more than 10 days of treatment and even then two of them had to be started on steroids.

Carotid sinus syndrome is a well documen­ted but mysterious and non-recognised entity. As shown in this study, these patients are otherwise perfectly healthy except for a tender carotid bulb which is recognised by its site, pulsation and immobility in any direction. Many workers have suggested different ae­tiologies including psychological factors but we are convinced that psychological factors are not contributing because our Group I patients did not receive any tranquillizers and were cured with simple analgesics and steroids.

1. Pay, T. Painful carotid artery. Arch. Neurol. Psychiat., 1927; 18:309.
2. Flilger, J.A. Carotid pain. Laryngoscope, 1949; 59:829.
3. Lovshin, L.L. Vascular neck pain - A common syndrome seldom recognised. Cieve. Clin., 1960; 27:5.
4. Chiossone, E, and Quiroga, EM. Carotidynia. Laryngol. Otol., 1973; 9:885.
5. Gang, E. et al. Sinus Node electrogram in patients with the hypersensitive carotid sinus syndrome. J.Am.Coll. Cardiol., 1985; 5:1484.