Global Journal of Dentistry and Oral Hygiene ISSN: 2167-0467 Vol. 2 (2), pp. 062-065, March, 2014. © Global Science Research Journals Case Report Trigeminocardiac reflex in zygomaticomaxillary complex fractures: a case report 1 Rohit Sharma*, 2Vandana Esht and 3Pallvi Goomer 1 Yamuna institute of dental sciences and research, Yamuna Nagar, Haryana, India M.M. institute of physiotherapy and rehabilitation, Mullana (Ambala), Haryana, India 3 B.R.S. dental college and hospital, Panchkula, Haryana, India 2 Accepted 11th March, 2014 The Trigeminocardiac reflex (TCR) during maxillofacial trauma surgeries has not yet been sufficiently studied and knowledge of its behaviour is limited to some case reports. The present report describes a case of displaced zygomaticomaxillary complex (ZMC) fracture eliciting TCR during reduction. The pulse rate pressure was recorded before the induction of general anaesthesia, after the induction of general anaesthesia, immediately after fracture reduction and immediately after surgery. It was noted that the pulse rate remained more or less consistent before and after the induction of general anaesthesia, dropped markedly immediately after fracture reduction, and returned to around the initial readings when recorded immediately after the surgery. Keywords: Trigeminocardiac Reflex, Zygomaticomaxillary complex fractures, Aschner phenomenon, Bradycardia, Cardiac Arrest INTRODUCTION Trigeminocardiac reflex (TCR), also known as Aschner phenomenon, is a well known phenomena seen during ocular surgeries, seen as a decrease in pulse rate associated with traction applied to extraocular muscles 1 and/or compression of the eyeball. It was first 2, 3 described as Oculocardiac Reflex (OCR) in 1908. The reflex is mediated by nerve connections between the ophthalmic branch of the trigeminal nerve via the ciliary ganglion, and the vagus nerve. Nerve fibres from the maxillary and mandibular divisions of the trigeminal 2 nerve have also been documented to cause this reflex. Although TCR has been well reported during ocular surgeries, its incidence in maxillofacial surgeries has not been very well documented. We also encountered a case of TCR caused during the reduction of zygomaticomaxillary complex (ZMC) fracture, which we report herein along with the study of literature. Case Report A 64 year old male reported to the Department of Oral Corresponding Author’s Email: [email protected], Phone No.: +919915607043 and Maxillofacial Surgery at D.A.V. Dental College and Hospital, Yamuna Nagar with a chief complaint of inability to open the mouth fully for the past 3 days. There was history of trauma 3 days ago as the patient had fallen from a motorbike. There was no history of any underlying systemic disorder. The mouth opening was around 20 mm. Water’s view and submento-vertex view radiographs were done and a diagnosis of left ZMC fracture was made. The treatment planned was elevation of the zygomatic arch through Gillie’s approach and fixation of the zygomatic buttress under general anesthesia. The blood pressure and pulse rate of the patient was constantly being monitored throughout the surgery. It was noted that the blood pressure and pulse of the patient remained fairly constant before and after the induction of general anesthesia. However, as soon as the zygomatic arch was reduced, a sharp fall in both the blood pressure and the pulse rate was observed, which could be attributed to TCR. The surgery was discontinued and the anesthetist informed who gave 0.5 mg intravenous atropine to restore the blood pressure and pulse rate. The surgery was continued only once the blood pressure and the pulse rate Glob. J. Dent. Oral Hyg . 063 Figure I: Pre-operative frontal view of the patient Figure III: Pre-operative maximum mouth opening Figure II: Pre-operative bird’s eye view of the patient returned to normal, and the anesthetist gave a thumbs up to go ahead with the surgery. The elevation of the zygomatic arch and the fixation of the zygomatic buttress were then carried on without any further consequence. DISCUSSION Different theories have been suggested to describe TCR. However, the exact mechanism of action remains unclear. Many authors suggest anxiety as a 4 contributing factor. Others have described the type of 5 anesthetic agents as an influential factor. A third theory Figure IV: Pre-operative Water’s view radiograph describes the stimulation of branches of the trigeminal 6 nerve as the triggering factor. TCR and its complications cannot be considered a rare event. The incidence of TCR during maxillofacial procedures has 7 been reported to be 1.6%. The various maxillofacial procedures where TCR has been reported are zygomatic fracture elevation, disimpaction of fractured maxilla, LeFort I osteotomy, blepharoplaty, correction of 8 TMJ ankylosis and TMJ arthroscopy. Very little is known regarding the prevention of TCR. It has been revealed that light anesthesia, hypoxia, hypercapnia and acidosis augment the incidence of Sharma et al. Figure V: Pre-operative Submento-vertex view Figure VIII: Post -operative maximum mouth opening Figure VI: Post-operative frontal view of the patient Figure IX: Post -operative Water’s view radiograph Figure VII: Post -operative bird’s eye view of the patient Figure X: Post -operative Submento-vertex view 064 Glob. J. Dent. Oral Hyg . 065 TCR, and should be taken care of while performing the 9 surgical procedure. potent narcotics and calcium channel blockers may also increase the incidence of TCR, increasing the vagal tone via their inhibitory 10 action on the sympathetic nervous system. Every surgeon performing surgery in the maxillofacial region should be aware of the occurrence of the TCR during a surgical procedure. Because the occurrence of TCR may be associated with life-threatening consequences without any significant signs, its prevention and management are crucial to the surgeon and anesthesiologist. Bradycardia is even known to cause cardiac arrest. If at all any significant bradycardia, due to vagal stimulation is seen, the anaesthetist should promptly revert the bradycardia and the blood pressure back by administering the required drugs (e.g. atropine, dopamine, ephedrine), so that threat of cardiac arrest is averted and, in turn, the blood pressure and the pulse rate remains within normal limits. REFERENCES 1. Ghaffari M S, Marjani M, Masoudifard M. Oculocardiac reflex induced by zygomatic arch fracture in a crossbreed dog; J. Vet. Cardiol (2009). 11(1): 67-69 2. Lang S, Lanigan D, van der Wal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth (1991) 38 (6): 757–60 3. Roberts R S, Best J A, Shapiro R D. Trigeminocardiac reflex during temporomandibular joint arthroscopy: report of a case. J Oral Maxillofac Surg (1999). 57 (7) :854-856 4. Schaller B. Trigeminocardiac reflex: A clinical phenomenon or a new physiological entity? J Neurol (2004). 251(6): 658-665 5. Cha S T, Eby J B, Katzen J T, Shahinian H K. Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy. J Craniomaxillofac Surg (2002). 30(2): 108-111 6. Kayikçioglu O, Kayikçioglu M, Erakgün T, Güler C. Electrocardiographic changes during subconjunctival injections. Int Ophthalmol (1999). 23(1): 37-41 7. Precious D S, Skulsky F G. Cardiac dysrhythmias complicating maxillofacial surgery. Int J Oral Maxillofac Surg (1990) 19(5): 279-282 8. Bohluli B, Abbas Kazemi Ashtiani A K, Khayampoor A, Sadr-Eshkevari P. Trigeminocardiac reflex: A MaxFax literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod (2009) 108(2):184-188 9. Schaller B. Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas. Clin Neurol Neurosurg (2005) 107(6): 468-474 10. Schaller B J, Buchfelder M. Trigemino-cardiac reflex in skull base surgery: from a better understanding to a better outcome? Acta Neurochir (2006) 148: 1029-1031