Chvostek Sign

Article Author:
Silvan Omerovic
Article Editor:
Joe M Das
Updated:
6/9/2019 8:51:02 PM
PubMed Link:
Chvostek Sign

Definition/Introduction

In the late 1800s, Dr. Chvostek noticed that mechanical stimulation of the facial nerve (as with the fingertip of the examiner, for example) could lead to twitching of the ipsilateral facial muscles.[1] [Level IV] The long-accepted explanation is that this resulted from hypocalcemia, and this relationship became known as the Chvostek sign.[2] [Level IV] When corrected for albumin, a calcium level of less than 8.8 mg/dl is considered deficient.[3] [Level V] Calcium is an essential electrolyte in the body. It is associated with many functions, and of significance; muscle contractions and propagation of nerve impulses. Deficiencies in calcium may lead to seizures, cardiomyopathy, QT prolongation, and congestive heart failure[4] [Level IV] Secondary to this; patients often receive replacement therapy in the hospital setting. One common cause of hypocalcemia is a complication during thyroidectomies.[5] [Level IV] The parathyroid gland is located on the posterior surface of the thyroid gland, and during the procedure, a lobe of the gland may get resected. The parathyroid gland produces parathyroid hormone (PTH), and resection can lead to a decrease in PTH levels.[6] [Level IV] PTH regulates calcium levels in the body; hence, a reduction in its serum level will lead to hypocalcemia.

Issues of Concern

The correlation of hypocalcemia and Chvostek sign has long had acceptance in the medical community, despite there being very little literature to support this claim.[1] [Level III] A population-based study performed by Dr. Hujoel found that there was no correlation of Chvostek sign and hypocalcemia, and furthermore, for every 1 mg/dl increase in calcium, there was a 4% higher chance of a positive Chvostek sign. It was, in turn, concluded that hypercalcemia had a more significant correlation with facial nerve tetany upon stimulation. Further studies have shown that a positive Chvostek sign can be elicited in 25% of healthy individuals, and 29% of those with hypocalcemia did not produce a positive sign.[7] [Level V] 

Clinical Significance

Among the most common postoperative complications following thyroid surgery is hypocalcemia.[5] [Level IV] According to Rio Del, et al. there is a 13.8% incidence of hypocalcemia status post a thyroid lobectomy, and a 38.8% incidence status post total thyroidectomy. QT prolongation is a severe complication of hypocalcemia because it can precipitate deadly arrhythmias.[8] [Level V] Ventricular arrhythmias are among the most critical and can lead to cardiac arrest. Supplementation with calcium carbonate in a patient who has undergone thyroid surgery has become common practice because of the potential for hypocalcemia. Patients receiving calcium supplementation should avoid proton pump inhibitors because they are well known to cause worsening of hypocalcemia.[9] [Level V] As discussed above, there is a minimal correlation with calcium levels and Chvostek sign; although this may be true, if tetany presents with stimulation of the facial nerve, it may be beneficial to check the serum calcium level.

Nursing Actions and Interventions

One of the common physical exam findings with hypocalcemia is perioral numbness or tingling.[10] [Level V] If a patient complains of these clinical symptoms, coupled with a good history and physical exam findings, further evaluation may be necessary. The nursing staff has the most contact with patients, and they may be the first to find these new symptoms. The nursing staff should notify the physicians if the patient has any new physical exam finding. A close relationship between nursing staff and physicians is an integral part of patient care, as this leads to better interprofessional communication, which leads to better patient outcomes.



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References

[1] The association between serum calcium levels and Chvostek sign: A population-based study., Hujoel IA,, Neurology. Clinical practice, 2016 Aug     [PubMed PMID: 29443134]
[2] Ahmed MA,Martinez A,Mariam S,Whitehouse W, Chvostek's sign and hypocalcaemia in children with seizures. Seizure. 2004 Jun;     [PubMed PMID: 15121128]
[3] Shrimanker I,Bhattarai S, Electrolytes 2019 Jan;     [PubMed PMID: 31082167]
[4] Humphrey E,Clardy C, A Framework for Approaching Refractory Hypocalcemia in Children. Pediatric annals. 2019 May 1;     [PubMed PMID: 31067338]
[5] Del Rio P,Rossini M,Montana CM,Viani L,Pedrazzi G,Loderer T,Cozzani F, Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery. BMC surgery. 2019 Apr 24;     [PubMed PMID: 31074401]
[6] Philips R,Nulty P,Seim N,Tan Y,Brock G,Essig G, Predicting transient hypocalcemia in patients with unplanned parathyroidectomy after thyroidectomy. American journal of otolaryngology. 2019 Apr 16;     [PubMed PMID: 31027850]
[7] Chvostek sign, frequently found in healthy subjects, is not a useful clinical sign., Méneret A,Guey S,Degos B,, Neurology, 2013 Mar 12     [PubMed PMID: 23479466]
[8] Ashwin Reddy S, Ventricular Arrhythmia Precipitated by Severe Hypocalcaemia Secondary to Primary Hypoparathyroidism. Case reports in cardiology. 2019;     [PubMed PMID: 31089428]
[9] Milman S,Epstein EJ, Proton pump inhibitor-induced hypocalcemic seizure in a patient with hypoparathyroidism. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2011 Jan-Feb;     [PubMed PMID: 21041166]
[10] Gandhi K,Prasad D,Malhotra V,Agrawal D, Gitelman's syndrome presenting with hypocalcemic tetany and hypokalemic periodic paralysis. Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia. 2016 Sep-Oct;     [PubMed PMID: 27752015]