Cough, Hiccups, Neck Pain and Phrenic Nerve Injury

Ross Hauser, MD., Brian Hutcheson, DC

Many people contact our center to discuss the challenges they face with chronic cough, throat clearing and hiccups. They may have a hiccup that comes every 5 to ten minutes. It disrupts their sleep, their ability to eat, their ability to talk. The hiccups are accompanied by cough and throat clearing as if something is stuck in their throat. Unfortunately this is not the only symptoms they have. They may also have other neurological symptoms such as hearing and vision problems, dizziness and balance issues, radiating pain into the back, shoulders and arms.

Chronic hiccups and coughs can be caused by many problems. In this article and video we will try to explain that in some people, the cause of their problems may be rooted in cervical spine instability and compression of the vagus and phrenic nerves.

Chronic cough or hiccups – Irritation of the phrenic nerve – Strange Sensations Series

Explanatory notes and supportive research to this video are provided throughout this article.

Phrenic Nerve Injury and Diaphragm Dysfunction

If you have been from one specialist to another and been suggested to many tests to look for possible causes in gastrointestinal distress, thyroid function, the presence of tumors or cysts in your neck, diabetes, kidney disease, a response to medications, and many other possible culprits, you, like many others are likely upset that nothing can be found once all these possible causes are ruled out. Now what? This is a significant problem understood by doctors as well. Now what?

Here is a brief, yet detailed understanding that doctors understand that a patient may have to take all these examinations, which for some people can take years, until they find a true diagnosis of their problem.

Patients may need to undergo repeated examinations before reaching a diagnosis

Here is a brief, yet detailed understanding that doctors understand that a patient may have to take all these examinations, which for some people can take years, until they find a true diagnosis of their problem. This is from a November 2020 paper, published in the European journal of internal medicine (1). It may describe your medical journey.

“Cough is a physiological response to mechanical and chemical stimuli due to irritation of cough receptors located mainly in the epithelium (nerve tissues) of the upper and lower respiratory tracts, pericardium (the membrane that covers the heart), esophagus, diaphragm, and stomach. A complex reflex arc through the vagus, phrenic, and spinal motor nerves to the expiratory musculature (the muscles that help you exhale) generates an inspiratory (breathing in) and forced expiratory effort (breathing out)to clear the airways.

Under pathological (disease) conditions of known and unknown etiologies, chronic refractory cough may become a major medical problem because patients may need to undergo repeated examinations before reaching a diagnosis, and/or try several treatments with sometimes poor symptom control, worsening their quality of life and increasing economic burden (the costs on the patients and healthcare).

We are going to look at a November 2020 study (2) in the medical journal Lung. What we are looking at is the importance of the phrenic nerve in respiratory function, or more simply the ability to breath correctly. Disruption the to the diaphragm function can lead to not only breathing problems, but problems of chronic cough and chronic hiccups.

This study we are going to examine is from surgeons discussing the side-effects of cardiovascular surgery. Why this study? Because it gives us a great independent assessment of what happens when the phrenic nerve is injured. Such as in cardiovascular surgery and such as in cervical spine instability causing compression on the nerve.

Phrenic Nerve Injury and Diaphragmatic Dysfunction is the heading of this section of this study: Here are the learning points:

  • The left and right phrenic nerves originate from C3, C4, and C5 within the cervical spine, moving caudally (to the rear and) within the thorax (where the lungs and diaphragm are).
  • Eventually these nerves pierce the two diaphragmatic domes, relaying sensory and motor innervation. (The nerve impulses that control the diaphragm and from whose sensations coughs and hiccups come).
  • The phrenic nerves are key components to maintain successful independent respiratory function.

So that is one of the paths of the right and left sided pairs of the phrenic nerve. It winds through C3-C5 and makes its ways down towards the diaphragm.

The concern in this paper is when surgeons performing cardiac surgery they may cut or injure the phrenic nerve. What happens if this occurs?

  • “Surgical injury typically causes complete unilateral (one side) suspension of diaphragmatic function, commonly while the surgeon dissects near the internal thoracic artery”

When the phrenic nerve is injured, half of your diaphragm does not work properly or at all

What happens when half your diaphragm does not function properly?

  • Reduced breathing capabilities and spasm because the injured phrenic nerve is sending confusing or improper signals, or not getting any message through to the diaphragm to relax or contract.

How cervical foraminal stenosis can impact the diaphragm.

Here we are illustrating a case study reported in the medical literature to help people, maybe like yourself, understand that neck problems can cause breathing problems. This is a case in the extreme of diaphragm paralysis, but again, the connection is clear the problems in this patient, specifically diaphragm paralysis, came from impingement caused by cervical foraminal stenosis.

This case is reported in the September 2020 edition of the journal Review Medicine. (3)

  • Unilateral diaphragmatic paralysis due to cervical spondylosis has rarely been reported. We present the first case of unilateral diaphragmatic paralysis without radicular pain or motor weakness due to cervical foraminal stenosis and a review of the related literature.
  • Patient concerns: A 59-year-old man presented with dyspnea and fever. His chest radiograph revealed right hemidiaphragmatic paralysis.
  •  The differential diagnosis of phrenic nerve palsy excluded mediastinal and neurodegenerative diseases. Imaging studies showed right foraminal stenosis caused by cervical spondylosis at C3-4 and C4-5.
  • The patient underwent foraminotomy at C3-4 and C4-5 on the right side. The operative findings revealed a severe compression of the C4 root.
  • At 3 months postoperatively, the unilateral diaphragmatic paralysis and dyspnea were recovered.

Coughs, hiccups, voice, breathing and phrenic nerve irritation

Coughs and hiccups are pretty common complaints in our office Another common common complaint is swallowing difficulties and that their food is getting stuck in their throat. Similarly, people who get diagnosed with gastroesophageal reflux. They have a problem with cough and they will go to a gastroentronologist and get treated for digestive distress. Other symptoms or problems that have manifested themselves will also be explored. Some people will move onto an examination by an ENT that will look at problems of speech because of dysfunction of the vocal cords.

The problems of vagus nerve, the laryngeal nerve, and the phrenic nerve. Why you may have he symptoms you do.

We are stopping here to take a closer look at the interaction between the laryngeal nerve and the phrenic nerve and why you may have been sent to an ENT and why your symptoms may include the previously mentioned difficulties in swallowing, hoarseness in voice, and the main focus of this article coughs, hiccups, and breathing dysfunction.

While later we will be exploring the role of the vagus nerve in your symptoms, we are now going to explore one of the vagus nerve’s branches, the laryngeal nerve. The laryngeal nerve is the “nerve of the voice box.”

When the laryngeal and phrenic nerve are injured or damaged

To demonstrate what happens to the laryngeal and phrenic nerve when they are injured or damaged, we are going to look at recommendations doctors are given of how to avoid this damage when offering a patient a stellate ganglion block or nerve block. The side-effects of this injection mimics the symptoms we have seen in our patients with cervical spine instability.

This comes from the medical text book Complications in Regional Anesthesia and Pain Medicine. Complications associated with stellate ganglion and lumbar sympathetic blocks. (4)

Hoarseness and, occasionally, respiratory stridor (a wheezing or grinding type noise with breathing).

  • “Recurrent laryngeal and phrenic nerve blocks are frequent side effects of a stellate ganglion block. They occur from local anesthetic injection that spills from the area of the ganglion. Because diffusion of drug is required to obtain a satisfactory block, it can be expected that these nerves will often be temporarily blocked. Symptoms of a recurrent laryngeal nerve block include hoarseness and, occasionally, respiratory stridor (a wheezing or grinding type noise with breathing).”

A lump in their throats

  • “Patients often complain of difficulty in getting their breath and the sensation of a lump in their throats.”

So what is happening here other than you recognize the symptoms but you may have never had nerve block in your throat. 

Doctors will give a stellate ganglion block injection to block pain sensation in the nerves surrounding  the larynx. These injections are given to patients who are not responding to other treatments for their neck, head, shoulder or arm pain and in some patients with angina type symptoms with or without presence of cardiovascular disease.

What we are demonstrating here is that the laryngeal nerve and the phrenic nerve, when injured or suppressed, in this cases cause by the injection of a nerve block that inadvertently and temporarily shut down the nerve function, you get the problems of we see in cervical spine instability patients. The point and case are made clear.

What are we seeing in this illustration? The possible why of why you have symptoms.

Learning points:

  • The vagus nerves supplies “nerve communications” with the larynx.
  • Proper, non-disruptive nerve input allows for good swallowing and speech. Disruptive nerve inputs impact swallowing and speech
  • Further symptoms of poor vagus functioning, called vagopathy or vagal tone, affecting the larynx can be chronic cough, hoarseness, and as we will see blow the contribution to chronic hiccup.

When you have unresponsive symptoms “Follow the Neurology.”

The examples of unresponsive system and the connection to cervical spine instability and problems in the neck are problems that we feel can be solved in appropriate candidates for treatment if we “follow the neurology.” What does this mean? It means look for compression or herniation of the cervical nerves that flow through and around the cervical spine.

When we follow the neurology (the nerves) we may find solutions to problems that are not responding to traditional medical care such as arrhythmias, stomach distress and digestive disorders, chronic cough, vision and hearing problems, and other neurologic concerns.

Back to chronic cough and chronic hiccups

If we follow the neurology and look for nerve compression or herniation in solving the problems mentioned above including chronic cough and chronic hiccups, what are we looking for? Generally an understanding of the patient’s current condition. Is there suspected problems with the nerves and sensors in the pharynx (the throat,) the back of the neck, the esophagus? So then we would explore the path of the vagus nerve. As demonstrated above one branch of the vagus nerve, is the laryngeal nerve, whose disruption and the symptoms these disruptions can cause was explained above.

Further disruption of the vagus nerve impacts the Phrenic Nerve

To review: When a patient comes into our clinic for cervical spine instability issues and they describe the problems of respiratory dysfunction, chronic cough and hiccups among a myriad of other problems, we look for compression of the vagus nerve. We have two vagus nerves. The one on the left side of the neck and the one on the right side of the neck. Let’s continue following the path of the vagus nerve and see how the disruption of this path may be leading to your symptoms.

The phrenic nerve is formed from cervical nerve roots III to V which involves cervical vertebrae number two (the axis) through C6. So any type of instability on this side of course could lead to a phrenic nerve problem.

Posterior view of upper cervical region

The phrenic nerve besides originating from the upper cervical spine, also passes between the anterior scalene muscles (the side neck muscles at C3-C6 that control certain neck movements including flexion, chin to chest head down, ear touching shoulder) and middle scalene muscles of the C2-c7 region which also control ipsilateral lateral flexion of the neck, ear touching shoulder movement).

These muscles can get very tight and atrophied when you have any cervical instability, forward neck carriage, or a chronic problem with your neck. So your musculature could pinch down and cause a problem with that phrenic nerve.

What are we seeing in this illustration? The winding path of the vagus nerve and how the scalene muscles may cause compression of the nerve

Research on cervical instability and Prolotherapy treatments

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to some of this research as it relates to cervical instability and a myriad of related symptoms including the problems of cough, hiccups, and disruption of the diaphragm.

In our own research, our Caring Medical research team published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.(5)

This is what we wrote: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs (such as cough, hiccups, and swallowing difficulties) or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of cough, hiccups, and swallowing difficulties type symptoms, cervical instability.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

  • The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based around C1-C2 instability.

In 2015 our research team published our finding in our paper “The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study.” This peer-review research was published in the European Journal of Preventive Medicine.(6)

Here we wrote: “In an effort to facilitate the diagnosis and treatment of clinical cervical spine instability and chronic neck pain, we investigated the role of proliferative injection Prolotherapy in the reduction of pain and recovery of constitutional and neurological symptoms associated with increased intervertebral motion, structural deformity and irritation of nerve roots. . . 95 percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality.”

We propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.”

If this article has helped you understand the problems of the phrenic nerve and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Visca D, Beghè B, Fabbri LM, Papi A, Spanevello A. Management of chronic refractory cough in adults. European Journal of Internal Medicine. 2020 Sep 19:4616. [Google Scholar]
2 Tanner TG, Colvin MO. Pulmonary Complications of Cardiac Surgery. Lung. 2020 Nov 11:1-8. [Google Scholar]
3 Park HY, Kim KW, Ryu JH, Lim CR, Han SB, Lee JS. Cervical foraminal stenosis causing unilateral diaphragmatic paralysis without neurologic manifestation: A case report and review of the literature. Medicine. 2020 Sep 11;99(37). [Google Scholar]
4 Rauck RL, Rathmell JP. Complications associated with stellate ganglion and lumbar sympathetic blocks. Complications in Regional Anesthesia and Pain Medicine. 2012 Jul 18:246. [Google Scholar]
5 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
6 Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar]

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