Asystole during Le Fort I osteotomy

Sick sinus syndrome diagnosed after a sinus arrest during treatment for zygomatic fracture: a case report

BACKGROUND

Intraoperative sinus arrest is rarely seen during zygomatic fracture treatment. The patient was diagnosed with sick sinus syndrome based on repeated postoperative sinus arrest, which could have resulted in death if diagnosed late, making this case very significant to report.

CASE PRESENTATION

Sick sinus syndrome is an arrhythmia associated with reduced automaticity of the sinoatrial node or impaired sinoatrial node conduction. We report the case of a 67-year-old man diagnosed with the syndrome after a sinus arrest that occurred during a zygomatic fracture treatment. The patient had cheek pain and mouth opening disorder, dizziness after fainting and sustaining a facial injury. Preoperative examination determined that the syncope was due to drug-induced arrhythmia, and surgery was authorized after drug withdrawal. During the operation, sinus arrest was observed due to trigeminal vagal reflex, and heart rate was restarted by stopping the operation and chest compressions. After the surgery, the patient showed symptoms of dizziness and palpitations, and sinus arrest following atrial fibrillation and supraventricular tachycardia, which was diagnosed as sick sinus syndrome, and a pacemaker was implanted. Currently, 8 years have passed since the surgery, and there are no symptoms of mouth opening disorder, dizziness, or palpitations.

CONCLUSIONS

In the case of maxillofacial injuries due to syncope, cardiogenic syncope is a possibility, and repeated syncope is a risk for death due to delayed diagnosis. There are no reports of maxillofacial trauma leading to a diagnosis of sick sinus syndrome. The purpose of this case report is to disseminate the importance of diagnosing the cause of syncope as well as injury treatment.

Reflejo trigémino cardíaco durante artroscopia de la articulación temporomandibular. Reporte de caso clínico

Introducción: el reflejo trigémino cardíaco es una respuesta fisiológica parasimpática repentina, que ocasiona alteraciones cardiovasculares importantes durante la estimulación nerviosa en el trayecto del V par craneal, generalmente ocurre al realizar procedimientos quirúrgicos en cirugía oral y maxilofacial, neurocirugía, oftalmología y dermatología. La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones neuro y cardiovasculares. Objetivo: presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior, y que, bajo monitoreo continuo del anestesiólogo, reportó una bradicardia súbita. Conclusión: el diagnóstico intraoperatorio de reflejo trigémino cardíaco, fue descrito por el servicio de anestesiología recibiendo un tratamiento farmacológico temprano para esta condición, lo que permitió obtener una adecuada evolución trans y postoperatoria.La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones.El objetivo de este artículo es presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior sufrió una bradicardia súbita, con un diagnóstico intraoperatorio de reflejo trigémino cardíaco, recibiendo un tratamiento temprano por parte del servicio de anestesiología de esta condición, obteniendo una adecuada evolución trans y postoperatoria.

Asystole in Orthognathic Surgery: A Case Report

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A previously healthy 26-year-old man presented for elective Le Fort I osteotomy, bilateral mandibular osteotomy, and genioplasty. During the intraoperative course, the patient developed sudden bradycardia and asystole on placement of a bite block. Asystole is an extremely rare consequence of the trigeminocardiac reflex, and awareness of this potentially life-threatening complication is pivotal in its management.

Total Maxillary Alveolar Osteotomy: Surgical Technique and Review of Its Efficacy

PURPOSE

The total maxillary alveolar osteotomy (TMxAO) is not commonly used to manage maxillary skeletal deformities. This article describes the technique, reviews its stability, and discusses its advantages over the more popular Le Fort I osteotomy.

MATERIALS AND METHODS

A series of 177 TMxAO patients satisfying the inclusion criteria from a cadre of 234 patients undergoing TMxAO between 1985 and 1993 were evaluated in a retrospective cohort study regarding achievement of predicted anatomic movements, stability of skeletal results, and preservation of inter-alar dimension. The patients were evaluated early postoperatively and at 11 to 14 months postoperatively, and the data were exposed to the Shapiro-Wilk test and analysis of variance and analyzed using SPSS software (version 21; IBM, Armonk, NY) at the 99% level of confidence (P ≤ .01).

RESULTS

Only in 58% of patients did the designed millimetric study model changes correspond precisely to the millimetric changes disclosed in a comparison of preoperative and early postoperative cephalograms. Comparison of early and late postoperative cephalograms, with infrequent exceptions, described millimetric instabilities of less than 2 mm and angular instabilities of less than 2°. Despite 2 significant outliers, the average inter-alar instability as determined by direct measurement was 0.19 mm.

CONCLUSIONS

This study suggests that the TMxAO compares favorably in stability with the Le Fort I osteotomy as recorded in the literature and, in terms of versatility, mobility of segments, avoidance of anatomic hazard, and preservation of nasal width, offers advantages in comparison.

The Trigeminocardiac Reflex During the Anterior Transpetrosal Approach

OBJECTIVE

The anterior transpetrosal approach (ATPA), during which the trigeminal nerve (TN) is manipulated, has a risk of eliciting the trigeminocardiac reflex (TCR). The aim of this study was to assess the risk of TCR during ATPA.

METHODS

Surgical records of 92 patients who had surgical treatment via ATPA at the Keio University Hospital between December 2005 and June 2015 were retrospectively analyzed. Patients were divided into 2 groups on the basis of the occurrence of TCR during surgery, and clinical and tumor characteristics were compared. Tumor characteristics were evaluated based on preoperative images and intraoperative findings and included the side of the lesion, size of the lesion, tumor size in Meckel cave, pathology of the disease, cavernous sinus invasion, extension into Meckel cave, and adhesion of lesion to TN.

RESULTS

TCR was observed in 14 of 92 patients (15.2%). TCR occurrence was significantly related to Meckel cave tumor size (P = 0.0264) and adhesion of the lesion to TN (P = 0.0002).

CONCLUSIONS

This study suggests that TCR is related to Meckel cave tumor size and tumor adhesion to TN in ATPA. To our knowledge, this is the first report describing TCR during ATPA.

Trigemino-Cardiac Reflex: A Phenomenon Neglected in Maxillofacial Surgery?

BACKGROUND

Trigemino-cardiac reflex is a physiologic response of the body to pressure effects in the region of distribution of the trigeminal nerve. Oral and maxillofacial surgical procedures can induce the development of this reflex, which leads to significant changes in the heart rate and sinus rhythms. This study intends to evaluate the effects of this reflex in patients with facial fractures and its subsequent management.

PATIENTS AND METHODS

A total of thirty-seven patients with facial fractures who reported to the Department of Oral and Maxillofacial Surgery at Basaveswar Teaching and General Hospital, Gulbarga during a period from July 2015-March 2016 were considered for the study.

RESULTS

A male preponderance is observed with the most susceptible age group being 21-30 years. Twenty-three patients sustained mid-facial fractures alone, nine patients had isolated mandible fractures and five patients had fractures of both the mid-face and mandible. A relative bradycardia was observed in the patients with mid-facial trauma, both at the time of presentation and also during the surgical reduction of midfacial fractures which improved after completion of procedure in most of the patients. However, in two patients, the bradycardia progressed to a cardiac asystole during midface manipulation which required immediate halt of the procedure and intravenous administration of atropine.

CONCLUSION

Trigeminocardiac reflex though physiologic, which usually tends to subside without complications is not to be neglected in the surgeries of the maxillofacial skeleton. A propensity for unforeseen complications due to this reflex has to be avoided by meticulous monitoring of the ECG.

The Importance of the Trigeminal Cardiac Reflex in Rhinoplasty Surgery

BACKGROUND

Trigeminocardiac reflex (TCR) consists of bradycardia or asystole along with hypotension and apnea coinciding with stimulation of the trigeminal nerve. During rhinoplasty procedures, we noticed that local anesthetic solution (LAS) application to the columellar area results in bradycardia. We planned to conduct a randomized prospective study on 47 patients undergoing rhinoplasty to demonstrate the characteristics of TCR arising from the columella.

METHOD

Local anesthetic solution containing 2% prilocaine with 1:80,000 adrenaline was applied under standard general anesthesia protocol. In group 1 (study group, n = 24), 2 mL of LAS was applied to the columella. In group 2 (control group, n = 23), 2 mL of LAS was applied to the nasal dorsum. In group 3 (control group, n = 20), after LAS was applied to nasal dorsum in group 2, we waited for 10 minutes. Then, 2 mL of LAS was applied to the columella. Here, recordings were taken for the columella.Heart rate (HR) and blood pressure (BP) were recorded just before needle insertion (baseline level), at the time of needle insertion (NIT) to the columella or dorsum, and after the 1st, 5th, 10th, 30th, and 60th seconds.

RESULTS

Transient bradycardia (≥20% drop in HR) was observed in 33% of the patients in group 1.Decrease in HR compared to the baseline level in group 1 was significantly greater than that of groups 2 and 3 at all times (P ≤ 0.05).Systolic BP in NIT and in 60th second in group 1, only in NIT in group 2 was significantly lower than that of baseline levels (P ≤ 0.05).

CONCLUSIONS

We concluded that stimulation of a sensory branch of the trigeminal nerve in the columellar area leads to TCR under general anesthesia by eliciting clinical hypotension with a drop in systolic BP and in HR of more than 20% compared to the baseline level.Knowing the existence of a certain TCR area will be helpful to the surgeon and anesthesiologist to exercise extra vigilance and to make continuous and meticulous monitoring of the electrocardiogram, HR, and BP during which the TCR may be precipitated such as local anesthetic infiltration to the columellar area in rhinoseptoplasty operations.

Sudden asystole due to trigeminocardiac reflex during transsphenoidal surgery for pituitary tumor

BACKGROUND

A sudden attack of an asystolic phenomenon is an extremely rare event during transsphenoidal surgery (TSS). It may be caused by an extreme type of trigeminocardiac reflex (TCR) during the manipulation of the trigeminal nerve or its innervated structures.

CASE DESCRIPTION

We report two cases of sudden asystole and a case of severe bradycardia due to TCR during TSS. All patients were managed successfully by cessation of the surgical manipulation or with the injection of an anticholinergic agent.

CONCLUSIONS

Although TCR occurs rarely and usually is self-limiting, surgeons should be cautious of its occurrence, especially when manipulating the cavernous sinus during TSS. This allows the early detection and appropriate treatment of this manifestation. Stopping the surgical procedure as soon as TCR occurs is likely to normalize the vital parameters. In addition, if further manipulations are inevitable, the administration of anticholinergic medication should be considered cautiously to improve surgical outcomes.

Trigemino-cardiac reflex during orbital floor reconstruction: a case report and review

Trigemino-cardiac reflex is occurrence of hypotension and bradycardia upon surgical manipulation of areas supplied by the trigeminal nerve, and has been reported during craniofacial maxillofacial and ocular surgeries. Communication between the anaesthetic and surgical team is essential, and cessation of the precipitating stimulus is the first and most important therapeutic step. We report a case of immediate, reproducible, and reflexive response of Bradycardia and dysrhythmia upon manipulation of orbital fracture during orbital floor reconstruction in a 65-year-old man. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given atropine in an effort to block cholinergic hyperactivity. After atropine administration, no further dysrhythmias occurred and surgery was carried uneventfully.

Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas: Methodological description of a prospective skull base study protocol

A systematic clinical neuroscience protocol is described for the use to examine the trigemino-cardiac reflex (TCR) response in humans. Target neurosurgical conditions are operations that require manipulations around the peripheral and central part of the trigeminal nerve and its branches, e.g. the cerebellopontine angle or the sellar region. To assess the hemodynamic and cardiac responses of patients after TCR initiation, anesthetic monitoring has been applied. The TCR is defined as a drop of more than 20% of the heart rate and the mean arterial blood pressure compared with the baseline values before the stimulus and coinciding with the surgical manipulation at or around any branches of the trigeminal nerve. By help of illustrative cases, we present for the first time preliminary results regarding the differentiation of the TCR in a central and a peripheral induction during transsphenoidal surgery of pituitary adenomas. Based on these results, we can conclude that we have developed a battery of preoperative examination procedures based on event-related diagnostics that was useful to differentiate different subgroups of TCR during transsphenoidal surgery. The presented protocol can be performed directly pre-, intra- and postoperatively and applied for assessment of TCR even in patients with known risk factors.

Anesthetic Management of the Trigeminocardiac Reflex During Mesiodens Removal—A Case Report

We describe a case in which reflection of a palatal flap for removal of a mesiodens is presented as the triggering factor for bradycardia caused by stimulation of the trigeminocardiac reflex. The management of the case, as well as the reflex arc, is discussed.

The impact of hypotension due to the trigeminocardiac reflex on auditory function in vestibular schwannoma surgery

Object

Surgical manipulation of the fifth cranial nerve during its intra- or extracranial course may lead to bradycardia or even asystole as well as arterial hypotension, a phenomenon described as the trigeminocardiac reflex (TCR). The authors studied the impact of this reflex on postoperative auditory function in patients undergoing vestibular schwannoma (VS) surgery.

Methods

One hundred patients scheduled for VS surgery were studied prospectively for parameters influencing the postoperative auditory function. The evaluation included sex, age, pre- and postoperative auditory function, preoperative mean arterial blood pressure, preoperative medical diseases or medication (for example, antiarrhythmia drugs), tumor size and localization, and the intraoperative occurrence of the TCR.

The TCR, which occurred in 11% of the patients, influenced the postoperative hearing function in the patients with Hannover Class T3 and T4 VSs.

With an overall hearing preservation of 47%, 11.1% of the patients in the TCR group and 51.4% of those in the non-TCR group experienced preserved hearing function postoperatively. In cases involving larger tumors (Hannover Class T3 and T4), an intraoperative TCR was associated with a significantly worse postoperative hearing function during VS surgery (p = 0.005).

Conclusions

The hypotension following TCR is a negative prognostic factor for hearing preservation in patients undergoing VS surgery. Patients’ knowledge of this can be increased pre- and postoperatively. Further study of this phenomenon will advance the understanding of the underlying mechanisms and may help to improve hearing preservation by controlling the occurrence of the TCR.

Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas

BACKGROUND

The trigemino-cardiac reflex (TCR) is a well-recognized phenomenon consisting of bradycardia, arterial hypotension, apnea, and gastric hypermotility. It occurs during ocular surgery or other manipulations around the orbit and can also be elicited by stimulation of the central part of the trigeminal nerve during surgery for processes of the cerebellopontine angle. The present retrospective study was conducted to determine if TCR occurs during transsphenoidal surgery in the same way.

METHODS

TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20% to the baseline values before the stimulus and coinciding with manipulation of the trigeminal nerve. Pre-, intra-, and postoperative HR and MABP were retrospectively reviewed in 117 patients who underwent resection of pituitary adenomas near the trigeminal nerve at the cavernous sinus in the supine position. Tumor invasiveness was classified according to the modified Hardy criteria.

RESULTS

Of the 117 patients with immunohistochemically and/or electromicroscopically proven pituitary adenoma, 12 (10%) patients demonstrated intraoperative evidence of TCR according to the strict inclusion criteria. In these 12 patients, the HR and MABP decreased by a mean of 43 and 54%, respectively, from the preoperative mean levels during microsurgical manipulation near the cavernous sinus and returned to physiological levels within 10 min after cessation of this surgical maneuver. The percentage of invasive adenomas (grade III-IV) was significantly higher in the TCR subgroup than in the non-TCR subgroup (83% versus 22%).

CONCLUSION

The present results give evidence for the first time that TCR may occur during transsphenoidal surgery in the supine position for resection of pituitary adenomas near the cavernous sinus, leading to a significant decrease in HR and MABP under a standardized anesthetic protocol.

Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy

BACKGROUND

The trigeminocardiac reflex is the sudden-onset of dysrhythmia and hypotension during manipulation of any of the branches of the trigeminal nerve. The trigeminal nerve and cardioinhibitory vagus nerve constitute the afferent and efferent pathways in the reflex arc. The trigeminocardiac reflex has been reported to occur during craniofacial surgery, balloon-compression rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle.

PATIENT & METHOD

A 2-year-old male patient with haemangioma near the sella turcica underwent rhizotomies of both sides of the dorsal sensory roots, of the trigeminal nerves for palliation of intractable trigeminal pain.

RESULTS

In this report, we experienced two unexpected episodes of asystole after transection of the sensory roots of the trigeminal nerves.

CONCLUSION

Sectioning of the intracranial dorsal sensory root of the trigeminal nerve provides clear evidence of the central role of the trigeminal nerve as the afferent pathway of the trigeminocardiac reflex arc.

Trigeminocardiac reflex during surgery in the cerebellopontine angle

OBJECT

In different experimental studies authors have analyzed the autonomic responses elicited by the electrical, mechanical, or chemical stimulation of the trigeminal nerve system. The trigeminocardiac reflex (TCR) is a well-recognized phenomenon that consists of bradycardia, arterial hypotension, apnea, and gastric hypermotility. It occurs during ocular surgery and during other manipulations in and around the orbit. Thus far, it has not been shown that central stimulation of the trigeminal nerve can also cause this reflex.

METHODS

The TCR was defined as clinical hypotension with a drop in mean arterial blood pressure (MABP) of more than 20% and bradycardia lower than 60 beats/minute. Pre-, intra-, and postoperative heart rate (HR) and MABP were reviewed retrospectively in 125 patients who underwent surgery for tumors of the cerebellopontine angle (CPA), and they were divided into two groups on the basis of the occurrence of the TCR during surgery. Of the 125 patients, 14 (11%) showed evidence of the TCR during dissection of the tumor near the trigeminal nerve at the brainstem. Their HRs fell 38% and their MABPs fell 48% during operative procedures as compared with preoperative levels. After cessation of manipulation, the HRs and the MABPs returned to preoperative levels. Risk factors for the occurrence of the TCR were compared with results from the literature.

CONCLUSIONS

The authors' results show the possibility of occurrence of a TCR during manipulation of the central part of the trigeminal nerve when performing surgery in the CPA.

Bradycardia after orbital injury. Case report

A case of severe bradycardia following orbital trauma is described. This complication caused by the oculocardiac reflex deserves attention when patients are referred for orbital trauma.

Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex

Three case reports are presented to illustrate the existence and importance of reflex bradycardic responses that can occur during maxillofacial surgical procedures. All three patients were healthy young adults undergoing operations which did not include any manipulation of orbital structures. After the patients had been anaesthetized for some time and were haemodynamically stable, profound bradycardia or ventricular asystole occurred suddenly in response to manipulations of the bony structures of the maxilla or mandible, or dissection of, or traction on, the attached soft tissue structures. The parasympathetic supply to the face is carried in the trigeminal nerve. Alternative afferent pathways must exist via the maxillary and/or mandibular divisions, in addition to the commonly reported pathway via the ophthalmic division of the trigeminal nerve in the classic oculocardiac reflex. The efferent arc involves the vagus, regardless of which branch of the trigeminal nerve transmits the afferent impulses. All patients undergoing maxillofacial procedures should be monitored carefully for reflex bradycardia and ventricular asystole.

Reflex bradycardia during TMJ arthroscopy: case report

A case of bradycardia occurring during TMJ arthroscopy is presented. A similar case of the TVR has not previously been reported. This reflex must be recognized by oral and maxillofacial surgeons who perform arthroscopy.

Sinus bradycardia related to temporomandibular joint surgery

The carotid artery lies in close relationship to the temporomandibular joint (TMJ). Manipulation of the mandible during TMJ surgery has been observed in several cases to be directly associated with the development of sinus bradycardia as the joint is distracted during arthrotomy and arthroplasty procedures. We report several cases and discuss differential diagnosis of sinus bradycardia associated with positional changes of the TMJ. This report emphasizes the importance to the surgeon and to the anesthesiologist of recognition of this cardiac phenomenon, mediated through the trigeminovagal reflex, to appropriately manage the patients during TMJ surgery.

Bradycardia and the trigeminal nerve

A review of the literature suggests that the oculocardiac reflex is part of a wider phenomenon involving any structure supplied by the trigeminal nerve. This can lead to potentially fatal complications in maxillofacial surgery. A review of the literature is discussed and two further cases are reported.