543
GOMEZ AND VAN GILDER
J Oral Maxillofac 49:543-544.
Surg
1991
Reflex Bradycardia During TMJ Arthroscopy: Case Report TIMOTHY
M. GOMEZ, DDS,* AND JOHN W. VAN GILDER, DDSt
The occurrence of cardiac dysrhythmias during oral and maxillofacial surgery has been well documented. Severe bradycardia has been previously described during zygoma and zygomatic arch fracture reduction, Le Fort I osteotomy, repair of orbital blowout fractures, and manipulation of midfacial fractures. l-6 This is the first reported incidence of profound bradycardia occurring during arthroscopy of the temporomandibular joint (TMJ). The possible mechanism and treatment are discussed. Report of a Case A 3 l-year-old woman in excellent health was scheduled to undergo bilateral TMJ arthroscopy. The patient had bilateral anteriorly displaced reducing discs and a long history of pain and dysfunction. She was to undergo lysis of adhesions, lavage, and lateral capsular release. She had no drug allergies and the only daily medication was birth control pills. Her past surgical history was significant for fusion of a bone in her left foot and removal of third molars under general anesthesia without complications. The review of systems was negative. Physical examination showed a 6 ft 0 in, 170 lb, well developed, well nourished, alert white woman in no acute distress. Other than bilateral preauricular tenderness, clicking, and limited opening, the remainder of the examination was unremarkable. Preoperative laboratory results were within normal limits. The patient was taken to the operating room, where her preoperative vital signs were blood pressure (BP), 120/70 mm Hg; pulse, 72 beats/min; respirations, 18/min; and temperature, 99°F. No preoperative medications were given and the patient
underwent
an uneventful
induction
and nasoendotracheal intubation. She was maintained on 2% isoflurane, 4 L of N,O, and 2 L of 0,. The arthroscopic procedure was initiated on the right side after the injection of 2 mL of 2% xylocaine with 1:200,000 epinephtine into the superior joint space. The blunt trocar was placed through the capsule into the posterior recess of the superior joint space. A 20-mL syringe containing room temperature lactated Ringer’s solution was attached to the cannula of the trocar and the joint space was insufflated and deflated. By blocking the exit port of the cannula an increase in pressure within the joint space was accomplished. At this point, the anesthetist reported a sudden drop in pulse rate from 65 to 30 and a decrease in the magnitude of the QRS complex. Surgical manipulation was immediately stopped, correct placement of all electrocardiography leads was verified, and 0.2 mg of glycopyrrolate was administered. Approximately 30 seconds after the onset of the bradycardia, the pulse rate returned to 70 beats/min, with normal QRS configuration. A tentative diagnosis of trigeminovagal reflex (TVR) was made. The procedure was continued and once again on insufflation of the joint space with lactated Ringer’s solution there was a sudden drop in the heart rate from 65 to 36 beats/min, and an alteration of the QRS complex. Surgical manipulation was stopped and 0.4 mg of atropine was given. In 20 seconds, the heart rate was up to 70 beats/ min and there was a normal QRS complex. The arthroscopic procedure was completed on the right side and a similar procedure was performed on the left TMJ with no further complications. The patient remained normotensive throughout the entire surgery. The patient was extubated in the operating room and transferred to the recovery room. Initial vital signs in recovery were BP, 138170 mm Hg; pulse, 80 beats/mitt; and respirations, 20/min. The patient recovered uneventfully and was discharged later that day.
Discussion Received from the Dentofacial Deformities and Orofacial Pain Center, St Louis, MO. * Fellow in Oral and Maxillofacial Surgery, St Mary’s Health Center. t In private practice, St Louis, MO. Address correspondence and reprint requests to Dr Gomez: Orofacial Pain Center, 1031 Bellevue, Suite 310, St Louis, MO
63117. 0 1991 geons
American
Association
0278-2391/91/4905-0019$3.00/O
of Oral
and Maxillofacial
Sur-
Bradycardia associated with maxillofacial surgery has been previously described.lT6 The mechanism proposed has been patterned after the oculocardiac reflex (OCR). This reflex was first described in 1908 by Aschner and Dagnini in independent reports. ‘*’ The reflex consists of an afferent pathway from the globe through the long and short ciliary nerves and the ophthalmic division of
544
the trigeminal nerve to the Gasserian ganglion and then to the main sensory nucleus of the trigeminal nerve. 9 Fibers in the reticular formation connect with the efferent pathway from the motor nucleus of the vagus nerve to the heart and produce slowing of the sinus rhythm, depression of the intracardiac conduction system, and a decrease in myocardial contractility. lo The reflex consists of bradycardia, nausea, and faintness, and can progress to cardiac arrythmias, ectopic beats, and asystole. l1 The dysrhythmia may persist as long as the stimulus is present, but the critical period is during the first few seconds when cardiac depression is at its maximum.12 Previous authors have described a similar reflex that has occurred during manipulation of various facial bones.‘,3,6 The pathway proposed for this TVR consists of an afferent arch from a branch of the trigeminal nerve supplying the sensory input to the involved region; the efferent pathway would be via the vagus nerve. We feel that increasing the pressure within the joint space stimulates the sensory innervation of the TMJ capsule, which activates the afferent arc of the reflex. Another cause could possibly be stimulation of the periosteal innervation to the zygomatic arch. Use of intravenous atropine (0.01 mg/kg body weight for adults) preoperatively has been suggested as prophylaxis against the occurrence of OCR.r3 This case of TVR was initially treated with glycopyrrolate, but with the recurrence of the bradycardia, supplemental atropine was needed to successfully suppress the reflex. It is important to realize that medications are not always successful and surgery on any portion of the facial skeleton should be preformed with the knowledge of the possible occurrence of this reflex. Although arthroscopy can be performed under local anesthesia,14 careful mon-
REFLEX BRADYCARDIA
DURING TMJ ARTHROSCOPY
itoring and intravenous access in the event of occurrence of the TVR are still recommended. Summary
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. References 1. Ragno J, Marcot R, Taylor S: Aystole during Le Fort I osteotomy. J Oral Maxillofac Surg 47: 1082, 1989 2. Robideux V: Oculocardiac reflex caused by midface disimpaction. Anesthesiology 99:433, 1978 3. Loewinger J, Cohen M, Levi E: Bradycardia during elevation of a zygomatic arch fracture. J Oral Maxillofac Sum 45710, 1987 4. Chesley L, Shapiro R: Oculocardiac reflex during treatment of an orbital blowout fracture. 47:522. 1989 5. Shearer ES, Wenstone R: Bradycardia during elevation of zygomatic fractures. Anesthesia 42:1207, 1987 6. Stott DG: Reflex bradycardia in facial surgery. Br J Plast Surg 42595, 1989 7. Aschner B: Ueber einen bisher nocn nicht beschriebenen reflex von Auge auf krieslauf und Atmung. Verschwinden des Radialpulses bei Druck auf das Auge Wien Klin Woschenser 21:1529, 1908 8. Dagnin G: Intomo ad un roglesso provocato in alcune emi: Legici co110 stimolo della comes e colla pressione sal bulbo oculare. Bull Sci Med 8:380, 1908 9. Miller NA: Clinical neuro-opthalmology. Baltimore, MD, Williams & Wilkins, 1982, p 1050 10. Kirsch RE: The prevention of cardiac arrest in earlier surgery. S Med J 51:1448, 1958 11. Miller RD: Anesthesia. New York, NY, Churchill Livingstone, 1986, p 1844 12. Moonie GT, Ress EL, Elton D: The oculocardiac reflex during strabismus surgery. Can Anaesth Sot J 11:621, 1964 13. Dripps RD, Eckenhoff JE, Vandam LD (eds): Introduction to Anesthesia. The Principles of Safe Practice. Philadelphia, PA, Saunders, 1977, p 45 14. Hohnlund A, Hellsing G, Wradmark T: Arthroscopy of the temporomandibular joint: A clinical study. Int J Oral Maxillofac Surg 15:715, 1986
GOMEZ AND VAN GILDER
J Oral Maxillofac 49:543-544.
Surg
1991
Reflex Bradycardia During TMJ Arthroscopy: Case Report TIMOTHY
M. GOMEZ, DDS,* AND JOHN W. VAN GILDER, DDSt
The occurrence of cardiac dysrhythmias during oral and maxillofacial surgery has been well documented. Severe bradycardia has been previously described during zygoma and zygomatic arch fracture reduction, Le Fort I osteotomy, repair of orbital blowout fractures, and manipulation of midfacial fractures. l-6 This is the first reported incidence of profound bradycardia occurring during arthroscopy of the temporomandibular joint (TMJ). The possible mechanism and treatment are discussed. Report of a Case A 3 l-year-old woman in excellent health was scheduled to undergo bilateral TMJ arthroscopy. The patient had bilateral anteriorly displaced reducing discs and a long history of pain and dysfunction. She was to undergo lysis of adhesions, lavage, and lateral capsular release. She had no drug allergies and the only daily medication was birth control pills. Her past surgical history was significant for fusion of a bone in her left foot and removal of third molars under general anesthesia without complications. The review of systems was negative. Physical examination showed a 6 ft 0 in, 170 lb, well developed, well nourished, alert white woman in no acute distress. Other than bilateral preauricular tenderness, clicking, and limited opening, the remainder of the examination was unremarkable. Preoperative laboratory results were within normal limits. The patient was taken to the operating room, where her preoperative vital signs were blood pressure (BP), 120/70 mm Hg; pulse, 72 beats/min; respirations, 18/min; and temperature, 99°F. No preoperative medications were given and the patient
underwent
an uneventful
induction
and nasoendotracheal intubation. She was maintained on 2% isoflurane, 4 L of N,O, and 2 L of 0,. The arthroscopic procedure was initiated on the right side after the injection of 2 mL of 2% xylocaine with 1:200,000 epinephtine into the superior joint space. The blunt trocar was placed through the capsule into the posterior recess of the superior joint space. A 20-mL syringe containing room temperature lactated Ringer’s solution was attached to the cannula of the trocar and the joint space was insufflated and deflated. By blocking the exit port of the cannula an increase in pressure within the joint space was accomplished. At this point, the anesthetist reported a sudden drop in pulse rate from 65 to 30 and a decrease in the magnitude of the QRS complex. Surgical manipulation was immediately stopped, correct placement of all electrocardiography leads was verified, and 0.2 mg of glycopyrrolate was administered. Approximately 30 seconds after the onset of the bradycardia, the pulse rate returned to 70 beats/min, with normal QRS configuration. A tentative diagnosis of trigeminovagal reflex (TVR) was made. The procedure was continued and once again on insufflation of the joint space with lactated Ringer’s solution there was a sudden drop in the heart rate from 65 to 36 beats/min, and an alteration of the QRS complex. Surgical manipulation was stopped and 0.4 mg of atropine was given. In 20 seconds, the heart rate was up to 70 beats/ min and there was a normal QRS complex. The arthroscopic procedure was completed on the right side and a similar procedure was performed on the left TMJ with no further complications. The patient remained normotensive throughout the entire surgery. The patient was extubated in the operating room and transferred to the recovery room. Initial vital signs in recovery were BP, 138170 mm Hg; pulse, 80 beats/mitt; and respirations, 20/min. The patient recovered uneventfully and was discharged later that day.
Discussion Received from the Dentofacial Deformities and Orofacial Pain Center, St Louis, MO. * Fellow in Oral and Maxillofacial Surgery, St Mary’s Health Center. t In private practice, St Louis, MO. Address correspondence and reprint requests to Dr Gomez: Orofacial Pain Center, 1031 Bellevue, Suite 310, St Louis, MO
63117. 0 1991 geons
American
Association
0278-2391/91/4905-0019$3.00/O
of Oral
and Maxillofacial
Sur-
Bradycardia associated with maxillofacial surgery has been previously described.lT6 The mechanism proposed has been patterned after the oculocardiac reflex (OCR). This reflex was first described in 1908 by Aschner and Dagnini in independent reports. ‘*’ The reflex consists of an afferent pathway from the globe through the long and short ciliary nerves and the ophthalmic division of
544
the trigeminal nerve to the Gasserian ganglion and then to the main sensory nucleus of the trigeminal nerve. 9 Fibers in the reticular formation connect with the efferent pathway from the motor nucleus of the vagus nerve to the heart and produce slowing of the sinus rhythm, depression of the intracardiac conduction system, and a decrease in myocardial contractility. lo The reflex consists of bradycardia, nausea, and faintness, and can progress to cardiac arrythmias, ectopic beats, and asystole. l1 The dysrhythmia may persist as long as the stimulus is present, but the critical period is during the first few seconds when cardiac depression is at its maximum.12 Previous authors have described a similar reflex that has occurred during manipulation of various facial bones.‘,3,6 The pathway proposed for this TVR consists of an afferent arch from a branch of the trigeminal nerve supplying the sensory input to the involved region; the efferent pathway would be via the vagus nerve. We feel that increasing the pressure within the joint space stimulates the sensory innervation of the TMJ capsule, which activates the afferent arc of the reflex. Another cause could possibly be stimulation of the periosteal innervation to the zygomatic arch. Use of intravenous atropine (0.01 mg/kg body weight for adults) preoperatively has been suggested as prophylaxis against the occurrence of OCR.r3 This case of TVR was initially treated with glycopyrrolate, but with the recurrence of the bradycardia, supplemental atropine was needed to successfully suppress the reflex. It is important to realize that medications are not always successful and surgery on any portion of the facial skeleton should be preformed with the knowledge of the possible occurrence of this reflex. Although arthroscopy can be performed under local anesthesia,14 careful mon-
REFLEX BRADYCARDIA
DURING TMJ ARTHROSCOPY
itoring and intravenous access in the event of occurrence of the TVR are still recommended. Summary
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. References 1. Ragno J, Marcot R, Taylor S: Aystole during Le Fort I osteotomy. J Oral Maxillofac Surg 47: 1082, 1989 2. Robideux V: Oculocardiac reflex caused by midface disimpaction. Anesthesiology 99:433, 1978 3. Loewinger J, Cohen M, Levi E: Bradycardia during elevation of a zygomatic arch fracture. J Oral Maxillofac Sum 45710, 1987 4. Chesley L, Shapiro R: Oculocardiac reflex during treatment of an orbital blowout fracture. 47:522. 1989 5. Shearer ES, Wenstone R: Bradycardia during elevation of zygomatic fractures. Anesthesia 42:1207, 1987 6. Stott DG: Reflex bradycardia in facial surgery. Br J Plast Surg 42595, 1989 7. Aschner B: Ueber einen bisher nocn nicht beschriebenen reflex von Auge auf krieslauf und Atmung. Verschwinden des Radialpulses bei Druck auf das Auge Wien Klin Woschenser 21:1529, 1908 8. Dagnin G: Intomo ad un roglesso provocato in alcune emi: Legici co110 stimolo della comes e colla pressione sal bulbo oculare. Bull Sci Med 8:380, 1908 9. Miller NA: Clinical neuro-opthalmology. Baltimore, MD, Williams & Wilkins, 1982, p 1050 10. Kirsch RE: The prevention of cardiac arrest in earlier surgery. S Med J 51:1448, 1958 11. Miller RD: Anesthesia. New York, NY, Churchill Livingstone, 1986, p 1844 12. Moonie GT, Ress EL, Elton D: The oculocardiac reflex during strabismus surgery. Can Anaesth Sot J 11:621, 1964 13. Dripps RD, Eckenhoff JE, Vandam LD (eds): Introduction to Anesthesia. The Principles of Safe Practice. Philadelphia, PA, Saunders, 1977, p 45 14. Hohnlund A, Hellsing G, Wradmark T: Arthroscopy of the temporomandibular joint: A clinical study. Int J Oral Maxillofac Surg 15:715, 1986
