- Email: [email protected]
Trigeminocardiac reflex
ARTICLE IN PRESS
YBJOM-5059; No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Letter to the Editor
Trigeminocardiac reflex We recently excised a large osteoma (Fig. 1) from the anterior aspect of the zygomatic arch. We gained access to the lesion through a combined modified preauricular approach1 and an incision through the second crease of the extended lower eyelid. To allow for wide exposure of the bony prominence, we had to dissect in the subperiosteal plane around the mass. The patient had two brief periods of asystole during the procedure, which were in quick succession and could not be attributed to the anaesthetic or medical history. On both occasions the tissues overlying the infraorbital foramen were being stretched to gain adequate access to the bony lesion. The operation was suspended until normal cardiac output was regained. We realised that these periods were the result of the trigeminocardiac reflex, and the operation proceeded uneventfully after the patient recovered fully. The trigeminocardiac reflex is activated when sensory branches of the trigeminal nerve are mechanically stimulated by pressure, stretching, or movement. This sets off an arc in which vagal stimulation leads to a cardiac depressor response.2 The manifestation of the reflex can vary from bradycardia and hypotension to asystole,3 as happened on this occasion. The trigeminocardiac reflex may be activated by manipulation of any branch of the trigeminal nerve anywhere along its course, both intracranially and extracranially.4 Any surgical intervention in the distribution of the trigeminal nerve poses a risk, and so maxillofacial surgeons and anaesthetists must be mindful of this potential complication. In procedures where manipulation of the trigeminal nerve is involved, prophylactic treatment with vagolytic drugs, or peripheral nerve blocks, or both, have been suggested to decrease incidence.1 We recommend that the operation is suspended the moment it is suspected, and that vagolytic agents are considered. It is crucial to identify the risk of a trigeminocardiac reflex before the operation, and to discuss it with the anaesthetist,
Fig. 1. Large osteoma of the body of the left zygomatic bone.
who should also be told during operation whenever a sensory branch of the trigeminal nerve is being manipulated.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission No ethics approval required. We gained consent from the patient, but no identifiable details or photographs are included.
References 1. Al-Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Maxillofac Surg 1979;17:91–103. 2. Bhargava D, Thomas S, Chakravorty N, et al. Trigeminocardiac reflex: a reappraisal with relevance to maxillofacial surgery. J Maxillofac Oral Surg 2014;13:373–7. 3. Schaller B, Cornelius JF, Prabhakar H, et al. The Trigeminocardiac Reflex Examination Group (TCREG). The trigemino-cardiac reflex; an update of the current knowledge. J Neurosurg Anesthesiol 2009;21:187–95. 4. Barnard NA, Bainton R. Bradycardia and the trigeminal nerve. J Craniomaxillofac Surg 1990;18:359–60.
http://dx.doi.org/10.1016/j.bjoms.2016.11.006 0266-4356/© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Dillon M, et al. http://dx.doi.org/10.1016/j.bjoms.2016.11.006
Trigeminocardiac reflex. Br J Oral Maxillofac Surg (2016),
YBJOM-5059; No. of Pages 2
2
ARTICLE IN PRESS Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
M. Dillon DCT2 Maxillofacial Surgery, Leeds General Infirmary A. Power ∗ ST4 Maxillofacial Surgery, Leeds General Infirmary C. Mannion Leeds General Infirmary
Please cite this article in press as: Dillon M, et al. http://dx.doi.org/10.1016/j.bjoms.2016.11.006
∗ Corresponding
author. E-mail addresses: [email protected] (M. Dillon), [email protected] (A. Power), [email protected] (C. Mannion)
Trigeminocardiac reflex. Br J Oral Maxillofac Surg (2016),
YBJOM-5059; No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Letter to the Editor
Trigeminocardiac reflex We recently excised a large osteoma (Fig. 1) from the anterior aspect of the zygomatic arch. We gained access to the lesion through a combined modified preauricular approach1 and an incision through the second crease of the extended lower eyelid. To allow for wide exposure of the bony prominence, we had to dissect in the subperiosteal plane around the mass. The patient had two brief periods of asystole during the procedure, which were in quick succession and could not be attributed to the anaesthetic or medical history. On both occasions the tissues overlying the infraorbital foramen were being stretched to gain adequate access to the bony lesion. The operation was suspended until normal cardiac output was regained. We realised that these periods were the result of the trigeminocardiac reflex, and the operation proceeded uneventfully after the patient recovered fully. The trigeminocardiac reflex is activated when sensory branches of the trigeminal nerve are mechanically stimulated by pressure, stretching, or movement. This sets off an arc in which vagal stimulation leads to a cardiac depressor response.2 The manifestation of the reflex can vary from bradycardia and hypotension to asystole,3 as happened on this occasion. The trigeminocardiac reflex may be activated by manipulation of any branch of the trigeminal nerve anywhere along its course, both intracranially and extracranially.4 Any surgical intervention in the distribution of the trigeminal nerve poses a risk, and so maxillofacial surgeons and anaesthetists must be mindful of this potential complication. In procedures where manipulation of the trigeminal nerve is involved, prophylactic treatment with vagolytic drugs, or peripheral nerve blocks, or both, have been suggested to decrease incidence.1 We recommend that the operation is suspended the moment it is suspected, and that vagolytic agents are considered. It is crucial to identify the risk of a trigeminocardiac reflex before the operation, and to discuss it with the anaesthetist,
Fig. 1. Large osteoma of the body of the left zygomatic bone.
who should also be told during operation whenever a sensory branch of the trigeminal nerve is being manipulated.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission No ethics approval required. We gained consent from the patient, but no identifiable details or photographs are included.
References 1. Al-Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Maxillofac Surg 1979;17:91–103. 2. Bhargava D, Thomas S, Chakravorty N, et al. Trigeminocardiac reflex: a reappraisal with relevance to maxillofacial surgery. J Maxillofac Oral Surg 2014;13:373–7. 3. Schaller B, Cornelius JF, Prabhakar H, et al. The Trigeminocardiac Reflex Examination Group (TCREG). The trigemino-cardiac reflex; an update of the current knowledge. J Neurosurg Anesthesiol 2009;21:187–95. 4. Barnard NA, Bainton R. Bradycardia and the trigeminal nerve. J Craniomaxillofac Surg 1990;18:359–60.
http://dx.doi.org/10.1016/j.bjoms.2016.11.006 0266-4356/© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Dillon M, et al. http://dx.doi.org/10.1016/j.bjoms.2016.11.006
Trigeminocardiac reflex. Br J Oral Maxillofac Surg (2016),
YBJOM-5059; No. of Pages 2
2
ARTICLE IN PRESS Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
M. Dillon DCT2 Maxillofacial Surgery, Leeds General Infirmary A. Power ∗ ST4 Maxillofacial Surgery, Leeds General Infirmary C. Mannion Leeds General Infirmary
Please cite this article in press as: Dillon M, et al. http://dx.doi.org/10.1016/j.bjoms.2016.11.006
∗ Corresponding
author. E-mail addresses: [email protected] (M. Dillon), [email protected] (A. Power), [email protected] (C. Mannion)
Trigeminocardiac reflex. Br J Oral Maxillofac Surg (2016),