Dangerous sandwiches identified by The Lancet

Some conditions seem to be recurring themes for case reports. To stop the danger of sandwiches being missed perhaps we should change how we teach medical students to take the history of someone who complains of fainting.

Even though swallow syncope is mentioned in many textbooks and has a wealth of case reports and reviews, patients with the condition seem to be difficult to diagnose. Those with no other comorbidities such as hiatus hernia or oesophageal cancer even more so. A case report in The Lancet1 by Dr Christopher Boos and colleagues highlights a particular patient that took some 10 years, two hospital admissions six years apart, and many investigations before the correct diagnosis was made.

Most students, presenting patients with a history of syncope, will mention the relation of the symptom to posture, micturition and cough but who remembers to ask about swallowing? Most descriptions of cardiac syncope stress the importance of a ‘thorough history’ so maybe we should teach a more extensive list. Raising your arms above your head (Pemberton’s sign), turning your head (carotid sinus hypersensitivity), having your hair washed at the hairdresser, any toileting activity, exercising, standing still, standing up, doing almost anything … and swallowing a sandwich.

1) Boos JC, Martin U, Cherry RC, Marshall HJ. Dangerous Sandwiches. Lancet 2008;372(9656):2164.