Journal of Emergencies, Trauma, and Shock
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LETTER TO EDITOR  
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 69-70
A case of Stanford B type aortic dissection in a patient whose initial complaints were a toothache and left shoulder pain


Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan

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Date of Web Publication30-Jan-2015
 

How to cite this article:
Ueno M, Omori K, Yanagawa Y. A case of Stanford B type aortic dissection in a patient whose initial complaints were a toothache and left shoulder pain. J Emerg Trauma Shock 2015;8:69-70

How to cite this URL:
Ueno M, Omori K, Yanagawa Y. A case of Stanford B type aortic dissection in a patient whose initial complaints were a toothache and left shoulder pain. J Emerg Trauma Shock [serial online] 2015 [cited 2020 Mar 28];8:69-70. Available from: http://www.onlinejets.org/text.asp?2015/8/1/69/150404


Dear Editor,

A 49-year-old male experienced an abnormal sound with a toothache and left shoulder pain during sleep. His chief complaint was lumbago at rest, and he had a history of untreated hypertension. The results of a physical examination were negative. Upon arrival, he was conscious with a blood pressure of 184/100 mmHg without significant laterality. A chest roentgen revealed protrusion of the left first and an increase in the cardiothoracic ratio to over 50%. A serum biochemical analysis demonstrated fibrinogen degradation product level of 64.2 μg/ml and negative findings for troponin T. An electrocardiogram showed sinus tachycardia, while cardiac sonography was negative. Although plain CT showed no abnormalities, enhanced CT disclosed Stanford B type aortic dissection from the aortic arch to the bifurcation of the common iliac artery [Figure 1]. A diagnosis of aortic dissection was made within 20 minutes of the patient's arrival. As he did not present with any signs of organ ischemia, conservative therapy to control blood pressure and pain using a β-blocker and fentanyl was selected, and he was discharged on the 15 th hospital day.
Figure 1: Enhanced CT performed on arrival The CT scan shows Stanford B type aortic dissection from the aortic arch to the bifurcation of the common iliac artery

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This case is the first case of Stanford B type aortic dissection without acute coronary syndrome in a patient whose initial complaints was a toothache and left shoulder pain. Fortunately, the patient reported lumbago at rest - a red flag for aortic dissection - following his initial complaints, raising suspicion of this condition.

Referred pain is a term used to describe pain perceived at a site adjacent to or a distance from the site of origin. [1] As the mechanism of referred pain has not been elucidated, the taxonomy committee of the International Association for the Study of Pain has not defined this term. Several neuroanatomical and physiologic theories regarding the phenomenon of referred pain have been suggested, including the hypothesis that nociceptive dorsal horn and brainstem neurons receive convergent input signals from various tissues, thus preventing higher centers from correctly identifying the actual input source. [1] Myers suggested the simple hypothesis that thoracic disorders, such as aortic dissection, pericarditis and lung cancer, induce referred craniofacial pain via the vagus nerve. [2] Meanwhile, all cervical and thoracic cardiac rami are traced consistently to the deep cardiacplexus, which also communicates with the aorta. [3] In the thoracic region, cardiac rami arise from the T2-T6 segment of the thoracic sympathetic trunk. [3] The cervical ganglia acquire communicating branches with spinal cervical nerves and all sympathetic cardiac nerves. [4] The branches of the cervical ganglia also include the internal and external carotid nerves, sympathetic trunk and branches communicating with the glossopharyngeal nerve, pharyngeal branch of the vagus nerve, and hypoglossal nerve. [5] The presence of these communications between the aorta and somatic or pharyngeal nerves via the autonomic nervous system offers a potential explanation of the mechanism underlying the referred pain observed in this case. In addition, variability in the sympathetic pathways to the heart and/or aorta may explain the pathophysiology of this unique case.

 
   References Top

1.
Arendt-Nielsen L, Svensson P. Referred muscle pain: Basic and clinical findings. Clin J Pain 2001;17:11-9.  Back to cited text no. 1
    
2.
Myers DE. Toothache referred from heart disease and lung cancer via the vagus nerve. Gen Dent 2010;58:e2-5.  Back to cited text no. 2
    
3.
Pather N, Partab P, Singh B, Satyapal KS. The sympathetic contributions to the cardiacplexus. Surg Radiol Anat 2003;25:210-5.  Back to cited text no. 3
    
4.
Kawashima T, Sato F. Detailed comparative anatomy of the extrinsic cardiac nerve plexus and postnatal reorganization of the cardiac position and innervation in the great apes: Orangutans, gorillas, and chimpanzees. Anat Rec (Hoboken) 2012;295:438-53.  Back to cited text no. 4
    
5.
Shao BP, Ding YP, Wang JL. The cranial cervical ganglion and its branches in the White yak (Bos grunniens). Anat Histol Embryol 2011;40:321-5.  Back to cited text no. 5
    

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Correspondence Address:
Youichi Yanagawa
Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.150404

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