Acute cervical pain syndrome resulting from suppressed sneezing.

Sir, A unique fundamental concept in Ayurveda for the pathogenesis of many diseases is Pragnyaaparaadha – which implies the transgression of wisdom resulting in unhealthy thoughts and actions. One of its subset is the illadvised suppression of natural urges and certain reflexes called ‘Vegadhaarana’. Charaka describes specific dysfunctions or disorders which may ensue by the suppression of individual reflexes. Vegadhaarana of a sneeze can lead to stiffness of the neck, headache, migraine, facial palsy and visual or auditory disturbances. There exist, in literature, documented clinical reports of similar complications. Here we present a case report of acute cervical pain syndrome after an attempt to control a sneeze, to create academic interest in Vegadhaarana. A 23 yr old girl, with a long history of allergic rhinitis presented with acute and painful spastic restriction of all movements of the neck, more on the right side. Two days earlier, she had a sudden precipitation of a painful spasm of the scalenotrapezius while trying to suppress an explosive sneeze. Within a day, she developed sharp shooting pain on the right, along the medial arm and forearm upto the palm which was aggravated on abduction. On physical examination, there was tender stiffness of the right trapezius, and tenderness over the 3rd, 4th, 5th cervical spines. The arm could only be elevated ventrally upto 100°, lateral abduction was 40° and posterior abduction was restricted to 30°. The sensory examination was suggestive of neuropraxia of the right median nerve. The patient was advised for X-ray and MRI of the cervical spine, but was reluctant for the investigation. The painful spasm, unrelieved by repeated cold compression or conventional muscle relaxants subsided gradually over a period of three weeks with a residual stiffness lasting for eight weeks. Other complications reported in literature include a sudden cervical quadruplegia due to a C4/5 disc herniation in a 42 yr old man who developed weakness and numbness in his arms and legs immediately following a violent sneeze.1 Despite emergency anterior cervical discotomy and fusion, the patient continued to be quadriplegic. It would be worthwhile to follow up on those patients who have baseline cervical spondylosis and who develop repeated bouts of sneezing; this may aggravate the complaints or precipitate them. A pneumomediastinum and cervico-facial emphysema has been reported following a useful obstruction nasal sneeze.2 Delayed traumatic ocular emphysema after sneezing and blowing the nose was reported in a 47 yr old man with a surgically untreated fracture of the facial bone. He developed severe exophthalmos, diplopia and reduction of vision. Besides, inner ear damage even facial nerve injury too can occur due to a significant pressure, caused by the suppression of a sneeze with a velocity of 300 mph. The pressure gets transmitted via the Eustachian tube to the middle ear damaging to the membranous labyrinth. One patient had developed sudden permanent sensorineural hearing loss. And another had a severe vertigo due to vestibular injury and needed surgical section of the tensor tympani tendon for relief. 3 Sneezing is only one of the thirteen types of vegadhaarana described in Ayurveda. Amongst the others the suppression of flatus and bowel movement can be a contributory factor to reverse peristalsis and aging diverticular disease.4 Sushruta collectively refers to these dysfunctions as Udaavarta, subsets of which are intestinal counterperistalsis and the vesico-ureteric reflux. In Ayurveda, healthy habits include the concern for sudden suppression of responses to stimuli coupled with self-restraint on excesses or indulgence in food, sex, exertion or sleep, as recommended by modern medicine. It would be interesting to investigate clinically the events which may follow the habitual suppression of urges like micturition, belching, hunger, thirst, sleep, crying and ejaculation. Vegadhaarana proposed as a pathogenic factor in Ayurveda may offer a shift in the paradigm for understanding the putative lesions caused by dissipation of the built-up massive pressure resulting from a suppressed reflex. Namyata Pathak*, A Raut**, A Vaidya*** *Jr. Research Fellow; **Director – Clinical Research and Visiting Rheumatologist; ***Research Director; MMRC, Kasturba Health Society, ICMR Advanced centre for Reverse Pharmacology in Traditional Medicine, MMRC (SJAD), K Desai Road, Vile Parle (W), Mumbai – 400056. Received : 1.10.2007; Revised : 13.3.2008; Accepted : 30.7.2008