Chvostek Sign


Article Author:
Silvan Omerovic


Article Editor:
Joe M Das


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/9/2019 8:51:02 PM

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.


  • Image 11116 Not availableImage 11116 Not available
    Image courtesy Dr Chaigasame
Attributed To: Image courtesy Dr Chaigasame

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Chvostek Sign - Questions

Take a quiz of the questions on this article.

Take Quiz
After a difficult parathyroidectomy, you perform the test shown in the image on postoperative day 2. If the test is positive, what response will you note in the patient?

(Move Mouse on Image to Enlarge)
  • Image 6944 Not availableImage 6944 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You have just completed a difficult parathyroidectomy in a 65-year-old obese woman who had hypercalcemia due to an adenoma. The surgery was difficult because of the short neck and dense adhesions from prior radiation therapy. During the night, the patient complains of tingling sensations around the lips. The resident decides to elicit the Chvostek sign. Where on the face does one elicit this sign?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You have just completed a difficult parathyroidectomy in a 65-year old obese female who has hypercalcemia due to an adenoma. The surgery was difficult because of the short neck and dense adhesions from prior radiation therapy. During the night, the patient complains of tingling sensations around the lips. The Chvostek sign is positive. Which other condition can cause Chovstek sign?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male patient returns to the general medical floor after an elective partial parathyroidectomy. Shortly after surgery, the patent develops numbness and tingling around his mouth. An astute medical student begins tapping anterior to the earlobe which elicits twitching of the muscle superior and lateral to the lip. Which branch of the nerve in question caused the muscle to twitch?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 55-year-old male presents to the general medical floor after a thyroidectomy. Sixteen hours post-op, the patient begins developing perioral tingling and numbness. The physician begins tapping anterior to the patient earlobe, and the patient's buccinator muscle begins twitching. A lack of which of the following hormones is the most likely cause of the elicited clinical exam finding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 32-year-old female patient presents to discuss perioral numbness and fatigue she has been experiencing. Last year she began working from home and had not been going outside much. To compensate for this, she started a vegan diet and began drinking calcium-fortified milk. During the physical exam, you tap anterior to the earlobe, which causes perioral twitching. An extensive laboratory work up to investigate the patient's symptoms is done. What laboratory value is abnormal, and most likely contributing to the patient's presenting symptom?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Chvostek Sign - References

References

The association between serum calcium levels and Chvostek sign: A population-based study., Hujoel IA,, Neurology. Clinical practice, 2016 Aug     [PubMed]
Chvostek sign, frequently found in healthy subjects, is not a useful clinical sign., Méneret A,Guey S,Degos B,, Neurology, 2013 Mar 12     [PubMed]
Ahmed MA,Martinez A,Mariam S,Whitehouse W, Chvostek's sign and hypocalcaemia in children with seizures. Seizure. 2004 Jun;     [PubMed]
Shrimanker I,Bhattarai S, Electrolytes 2019 Jan;     [PubMed]
Humphrey E,Clardy C, A Framework for Approaching Refractory Hypocalcemia in Children. Pediatric annals. 2019 May 1;     [PubMed]
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]
Ashwin Reddy S, Ventricular Arrhythmia Precipitated by Severe Hypocalcaemia Secondary to Primary Hypoparathyroidism. Case reports in cardiology. 2019;     [PubMed]
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]
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]
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]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.