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Q. I have episodes of near fainting on exhaling, and all my cardiac tests are normal. Kindly help me.

Answered by
Dr. Ilir Sharka
and medically reviewed by Dr. Sushrutha Muralidharan
This is a premium question & answer published on Aug 22, 2021

Hi doctor,

I keep having episodes of near fainting. What triggers it is talking on the phone and yawning. The symptoms will also happen if I purpose to take a deep breath and exhale hard. While talking on the phone at the end of a sentence, my vision gets fuzzy, and I see spots all over, and I almost faint. The same thing happens at the end of the exhale when yawning. The episodes last seven to ten seconds most of the time, but there has been a time where it lasted over a minute.

The symptoms happen whether I am sitting or standing. During an episode, my heart rhythm, blood pressure, pulse oximeter, and glucose are all normal. I know this because I had an episode in the ER when hooked up to telemetry and my heart rhythm was normal. And they also took my blood pressure which was normal during the episode.

I have had blood work done by my primary doctor, which was normal, and I have also had a neurological and cardiac workup that was normal,

MRI, MRA of head and neck, 48 hour EEG, echocardiogram, stress echo, 48 hour Holter monitor, carotid ultrasound, and chest X-ray.

I also saw a retinal specialist to make sure it was not eye-related. Nothing seems to provoke the symptoms besides talking and yawning or exhaling hard. However, the symptoms do not happen every day. Some days it will happen every single time I talk or yawn, and some days it does not happen at all.

I can do hard cardiac exercise fine with no chest pain or anything also. What could be causing these near-fainting episodes? Kindly give your opinion.

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Hello,

Welcome to icliniq.com.

I understand your concern and would explain that your symptoms are not suggestive of any cardiac disorders. As there were no changes in your heart rhythm and blood pressure values during the episode, I would exclude any possible cardiac issues or vaso-vagal syncope.

Coming to this point, I would recommend focusing on a possible neurological disorder, such as possible epilepsy seizures. Although your EEG (electroencephalogram) was normal, I would recommend discussing and starting an antiepilepsy drug (Topiramate or Valproate) and see if your situation improves.

I hope to have been helpful to you. I remain at your disposal for any further questions whenever you need me.

Hi doctor,

Thank you.

My neurologist seems very certain that it is not a seizure because I have had episodes during the EEG test, and it did not show anything. The symptoms only happen when I am talking or at the end of a yawn. What could cause that?

Could it be related to intrathoracic pressure? Could my diaphragm be pushing on the vena cava when exhaling? Could it be the carotid sinuses, and I am not picking up the hypotension on a blood pressure machine? Curious about any thoughts you have on what might be causing this.

It is definitely something that has to do with the mechanism of exhaling that is causing it. I do not know what it is.

Kindly give your opinion.

#

Hello,

Welcome back to icliniq.com.

Carotid sinus syndrome could be an option. After carotid sinus massage, a cardioinhibitory or vasopressor response should be produced to confirm the diagnosis respectively asystole up to three seconds or important blood pressure drop.

To confirm an autonomic nervous dysfunction, a head-up tilt test could be of help. Anyway, seizures cannot be ruled out even when EEG results are normal. Further differential diagnostic workup is necessary.

Let me know in case of any further questions.

Kind regards.


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