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Uvular paralysis after dental anesthesia
1369
˜ ARROCHA SANCHIS AND PEN
J Oral Maxillofac Surg 60:1369-1371, 2002
Uvular Paralysis After Dental Anesthesia Jose´ Maria Sanchis, DDS, PhD,* and Miguel Pen ˜ arrocha, DDS, PhD† Cranial nerve motor effects resulting from intraoral anesthesia are infrequent but well documented. Facial nerve involvement caused by diffusion of the anesthetic solution towards the parotid can give rise to a transient facial motor defect that tends to disappear as the anesthetic effect wears off.1,2 Facial paralysis lasting for several days has also been related to intraoral anesthesia, possibly due to reflex spasm and ischemic neuritis.1,3 One report described a patient with isolated involvement of the chorda tympani nerve following inferior alveolar injection, associated with dysgeusia.4 Ophthalmologic complications secondary to intraoral anesthesia include transient blindness result-
Received from the Department of Oral Medicine and Oral Surgery, University of Valencia Medical and Dental School, Valencia, Spain. *Associate Professor. †Assistant Professor. Address correspondence and reprint requests to Dr Pen ˜ arrocha: Clı´nica Odontolo ´ gica, Facultad de Medicina y Odontologı´a, Gasco ´ Oliag 1, 46021-Valencia, Spain; e-mail: [email protected] © 2002 American Association of Oral and Maxillofacial Surgeons
0278-2391/02/6011-0023$35.00/0 doi:10.1053/joms.2002.35751
ing from anesthetic diffusion towards the orbit, with involvement of the optic nerve;5,6 ophthalmoplegia and diplopia due to involvement of the III, IV, and VI cranial nerves;7-10 and effects on the sympathetic plexus of the internal carotid artery with miosis, ptosis, and enophthalmos sensation.11 We report the case of a patient who developed uvular deviation as a result of palatal muscle paralysis following intraoral mandibular block of the inferior alveolar nerve for dental treatment.
Report of a Case A 49-year-old man underwent inferior alveolar nerve block using infiltrating 1.8 mL of 2% lidocaine with adrenaline 1/100,000 for conventional dental treatment. The direct mandibular technique was performed, using the spine of Spix as a reference and inserting the needle 15 to 20 mm from opposing premolars, approximately 1 cm above the occlusal plane and within the internal oblique line. The anesthetic solution was deposited as close as possible to the mandibular foramen. A few minutes after injection, the patient reported swallowing difficulties and a foreign body sensation in the throat. Inspection revealed paralysis of the velum palatinum with deviation of the uvula towards the nonparalyzed side, opposite the point of anesthetic infiltration (Fig 1). The discomfort persisted for approximately 60 minutes, and dental treatment was completed without
1370
UVULAR PARALYSIS
problems. The clinical signs and symptoms disappeared after the anesthetic effect wore off (Fig 2).
Discussion The uvula is located in the lowermost portion of the palatal vault or soft palate. It consists of lax cutaneous tissue covered by nonkeratinized mucosa. Its structure comprises a series of muscles, notably the musculus uvulae. Although the uvular muscle tissue appears to form a single medial bundle, in fact 2 exist: one on each side. Insertion is in the palatal aponeurosis (a type of fibrous tissue similar to the periosteum of the hard palate) immediately beneath the posterior nasal spine and displacing down and posteriorly to the uvular vertex. When both palatostaphyline muscles contract, the velum palatinum shortens longitudinally and the uvula is elevated, curving backwards.12-14 These palatal elevator muscles contribute to uvular morphology and mobility. The levator veli palatini muscle extends from the inferior petrous portion of the temporal bone and cartilaginous part of the eustachian tube to the posterior aspect of the velum palatinum. It forms a midline raphe when it merges with the fibers from the contralateral tensor veli palatini muscle. This muscle displaces from this point to the pterygoid process, the major wing of the sphenoid bone, and the anteroexternal aspect of the eustachian tube. Both muscles elevate and tense the velum palatinum.15 Two other muscles also contribute to the morphology of the palatal vault, although they exert less influence on uvular mobility: the palatoglossal muscle, which forms the anterior pillar of the fauces, and the palatopharyngeal muscle, which forms the posterior pillar. These muscles narrow the isthmus of the fauces and lower the velum palatinum.12-15 It is interesting to point out that all these muscles are innervated by the pharyngeal plexus, with the exception of the tensor veli palatini muscle. This
FIGURE 1. Image showing uvular deviation toward the nonparalyzed side, with asymmetry of the palatal vault.
FIGURE 2. The uvula returned to normal after the anesthetic effect wore off.
muscle is innervated by the internal trunk of the third trigeminal division which also supplies the tensor muscle of the tympanic membrane and the internal pterygold muscle. Consequently, a high block of the inferior alveolar nerve can easily affect the mandibular nerve if the anesthetic solution diffuses to the internal trunk of the third trigeminal branch and the supply to the tensor veli palatini. Paralysis of this nerve and its corresponding muscle would deprive the uvula of one source of tension, thereby causing it to deviate to one side. As with other cases of complications described in the literature,11 uvular musculature involvement is the result of simple diffusion of the anesthetic solution or a consequence of the vasoconstriction-induced ischemic effect of anesthetic solution on the vessels feeding the muscles.16,17 We have found no mention in the literature of uvular palsy occurring as a side effect of intraoral anesthesia.
References 1. Ling KC: Peripheral facial nerve paralysis after local dental anesthesia. Oral Surg Oral Med Oral Pathol 60:23, 1985 2. Bernsen PL: Peripheral facial nerve paralysis after local upper dental anaesthesia. Eur Neurol 33:90, 1993 3. Shuaib A, Lee MA: Recurrent peripheral facial nerve palsy after dental procedures. Oral Surg Oral Med Oral Pathol 70:738, 1990 4. Paxton MC, Hadney JN, Hadney MN, et al: Chorda tympani nerve injury following inferior alveolar injection: A review of two cases. J Am Dent Assoc 125:1003, 1994 5. Ing E, Ing HC, Ing M, et al: Diagnosing oral disease that affect the eyes. J Am Dent Assoc 125:608, 1994 6. Allen GD: Complications of local anesthesia, in Allen GD (ed): Dental Anesthesia and Analgesia (Local and General) (ed 3). Baltimore, MD, Williams & Wilkins, 1984, pp 163-177 7. Petrelli A, Steller RE: Medial rectus muscle palsy after dental anesthesia. Am J Ophthalmol 90:422, 1980 8. Marinho RM: Abducent nerve palsy following dental local analgesia. Br Dent J 179:69, 1995 9. Goldenberg AS: Transient diplopia as a result of block injections mandibular and posterior superior alveolar. NY State Dent J 63:29, 1997
1371 10. Pen ˜ arrocha M, Sanchis JM: Ophthalmologic complications after intraoral anesthesia with articaine. Oral Surg Oral Med Oral Pathol 90:21, 2000 11. Kronman JH, Kabani S: The neuronal basis for diplopia following local anesthetic injections. Oral Surg 58:533, 1984 12. Huang MH, Lee ST, Rajendra K: Structure of the musculus uvulae: Functional and surgical implications of an anatomic study. Cleft Palate Craniofac J 34:466, 1997 13. Borman JG, Sommerlad BC: Musculus uvulae and levator palati:
14. 15. 16. 17.
Their anatomical and functional relationship in velopharyngeal closure. Br J Plast Surg 38:333, 1985 Azzam NA, Kuehn DP: The morphology of musculus uvulae. Cleft Palate J 14:78, 1997 Domenech G: Development and peripheral innervation of the palatal muscles. Acta Anat (Basel) 97:4, 1977 Goldenberg AS: Transient diplopia from a posterior alveolar injection. J Endod 11:550, 1990 Goldenberg AS: Diplopia resulting from a mandibular injection. J Endod 9:261, 1983
˜ ARROCHA SANCHIS AND PEN
J Oral Maxillofac Surg 60:1369-1371, 2002
Uvular Paralysis After Dental Anesthesia Jose´ Maria Sanchis, DDS, PhD,* and Miguel Pen ˜ arrocha, DDS, PhD† Cranial nerve motor effects resulting from intraoral anesthesia are infrequent but well documented. Facial nerve involvement caused by diffusion of the anesthetic solution towards the parotid can give rise to a transient facial motor defect that tends to disappear as the anesthetic effect wears off.1,2 Facial paralysis lasting for several days has also been related to intraoral anesthesia, possibly due to reflex spasm and ischemic neuritis.1,3 One report described a patient with isolated involvement of the chorda tympani nerve following inferior alveolar injection, associated with dysgeusia.4 Ophthalmologic complications secondary to intraoral anesthesia include transient blindness result-
Received from the Department of Oral Medicine and Oral Surgery, University of Valencia Medical and Dental School, Valencia, Spain. *Associate Professor. †Assistant Professor. Address correspondence and reprint requests to Dr Pen ˜ arrocha: Clı´nica Odontolo ´ gica, Facultad de Medicina y Odontologı´a, Gasco ´ Oliag 1, 46021-Valencia, Spain; e-mail: [email protected] © 2002 American Association of Oral and Maxillofacial Surgeons
0278-2391/02/6011-0023$35.00/0 doi:10.1053/joms.2002.35751
ing from anesthetic diffusion towards the orbit, with involvement of the optic nerve;5,6 ophthalmoplegia and diplopia due to involvement of the III, IV, and VI cranial nerves;7-10 and effects on the sympathetic plexus of the internal carotid artery with miosis, ptosis, and enophthalmos sensation.11 We report the case of a patient who developed uvular deviation as a result of palatal muscle paralysis following intraoral mandibular block of the inferior alveolar nerve for dental treatment.
Report of a Case A 49-year-old man underwent inferior alveolar nerve block using infiltrating 1.8 mL of 2% lidocaine with adrenaline 1/100,000 for conventional dental treatment. The direct mandibular technique was performed, using the spine of Spix as a reference and inserting the needle 15 to 20 mm from opposing premolars, approximately 1 cm above the occlusal plane and within the internal oblique line. The anesthetic solution was deposited as close as possible to the mandibular foramen. A few minutes after injection, the patient reported swallowing difficulties and a foreign body sensation in the throat. Inspection revealed paralysis of the velum palatinum with deviation of the uvula towards the nonparalyzed side, opposite the point of anesthetic infiltration (Fig 1). The discomfort persisted for approximately 60 minutes, and dental treatment was completed without
1370
UVULAR PARALYSIS
problems. The clinical signs and symptoms disappeared after the anesthetic effect wore off (Fig 2).
Discussion The uvula is located in the lowermost portion of the palatal vault or soft palate. It consists of lax cutaneous tissue covered by nonkeratinized mucosa. Its structure comprises a series of muscles, notably the musculus uvulae. Although the uvular muscle tissue appears to form a single medial bundle, in fact 2 exist: one on each side. Insertion is in the palatal aponeurosis (a type of fibrous tissue similar to the periosteum of the hard palate) immediately beneath the posterior nasal spine and displacing down and posteriorly to the uvular vertex. When both palatostaphyline muscles contract, the velum palatinum shortens longitudinally and the uvula is elevated, curving backwards.12-14 These palatal elevator muscles contribute to uvular morphology and mobility. The levator veli palatini muscle extends from the inferior petrous portion of the temporal bone and cartilaginous part of the eustachian tube to the posterior aspect of the velum palatinum. It forms a midline raphe when it merges with the fibers from the contralateral tensor veli palatini muscle. This muscle displaces from this point to the pterygoid process, the major wing of the sphenoid bone, and the anteroexternal aspect of the eustachian tube. Both muscles elevate and tense the velum palatinum.15 Two other muscles also contribute to the morphology of the palatal vault, although they exert less influence on uvular mobility: the palatoglossal muscle, which forms the anterior pillar of the fauces, and the palatopharyngeal muscle, which forms the posterior pillar. These muscles narrow the isthmus of the fauces and lower the velum palatinum.12-15 It is interesting to point out that all these muscles are innervated by the pharyngeal plexus, with the exception of the tensor veli palatini muscle. This
FIGURE 1. Image showing uvular deviation toward the nonparalyzed side, with asymmetry of the palatal vault.
FIGURE 2. The uvula returned to normal after the anesthetic effect wore off.
muscle is innervated by the internal trunk of the third trigeminal division which also supplies the tensor muscle of the tympanic membrane and the internal pterygold muscle. Consequently, a high block of the inferior alveolar nerve can easily affect the mandibular nerve if the anesthetic solution diffuses to the internal trunk of the third trigeminal branch and the supply to the tensor veli palatini. Paralysis of this nerve and its corresponding muscle would deprive the uvula of one source of tension, thereby causing it to deviate to one side. As with other cases of complications described in the literature,11 uvular musculature involvement is the result of simple diffusion of the anesthetic solution or a consequence of the vasoconstriction-induced ischemic effect of anesthetic solution on the vessels feeding the muscles.16,17 We have found no mention in the literature of uvular palsy occurring as a side effect of intraoral anesthesia.
References 1. Ling KC: Peripheral facial nerve paralysis after local dental anesthesia. Oral Surg Oral Med Oral Pathol 60:23, 1985 2. Bernsen PL: Peripheral facial nerve paralysis after local upper dental anaesthesia. Eur Neurol 33:90, 1993 3. Shuaib A, Lee MA: Recurrent peripheral facial nerve palsy after dental procedures. Oral Surg Oral Med Oral Pathol 70:738, 1990 4. Paxton MC, Hadney JN, Hadney MN, et al: Chorda tympani nerve injury following inferior alveolar injection: A review of two cases. J Am Dent Assoc 125:1003, 1994 5. Ing E, Ing HC, Ing M, et al: Diagnosing oral disease that affect the eyes. J Am Dent Assoc 125:608, 1994 6. Allen GD: Complications of local anesthesia, in Allen GD (ed): Dental Anesthesia and Analgesia (Local and General) (ed 3). Baltimore, MD, Williams & Wilkins, 1984, pp 163-177 7. Petrelli A, Steller RE: Medial rectus muscle palsy after dental anesthesia. Am J Ophthalmol 90:422, 1980 8. Marinho RM: Abducent nerve palsy following dental local analgesia. Br Dent J 179:69, 1995 9. Goldenberg AS: Transient diplopia as a result of block injections mandibular and posterior superior alveolar. NY State Dent J 63:29, 1997
1371 10. Pen ˜ arrocha M, Sanchis JM: Ophthalmologic complications after intraoral anesthesia with articaine. Oral Surg Oral Med Oral Pathol 90:21, 2000 11. Kronman JH, Kabani S: The neuronal basis for diplopia following local anesthetic injections. Oral Surg 58:533, 1984 12. Huang MH, Lee ST, Rajendra K: Structure of the musculus uvulae: Functional and surgical implications of an anatomic study. Cleft Palate Craniofac J 34:466, 1997 13. Borman JG, Sommerlad BC: Musculus uvulae and levator palati:
14. 15. 16. 17.
Their anatomical and functional relationship in velopharyngeal closure. Br J Plast Surg 38:333, 1985 Azzam NA, Kuehn DP: The morphology of musculus uvulae. Cleft Palate J 14:78, 1997 Domenech G: Development and peripheral innervation of the palatal muscles. Acta Anat (Basel) 97:4, 1977 Goldenberg AS: Transient diplopia from a posterior alveolar injection. J Endod 11:550, 1990 Goldenberg AS: Diplopia resulting from a mandibular injection. J Endod 9:261, 1983