CC BY-NC-ND 4.0 · Indian J Plast Surg 2020; 53(01): 166-168
DOI: 10.1055/s-0040-1709918
Letter to the Editor

Bradycardia in Maxillofacial Surgery

Krittika Aggarwal
1   Department of Plastic Surgery, King George Medical College, Lucknow, Uttar Pradesh, India
,
Veerendra Prasad
1   Department of Plastic Surgery, King George Medical College, Lucknow, Uttar Pradesh, India
,
A. K. Singh
1   Department of Plastic Surgery, King George Medical College, Lucknow, Uttar Pradesh, India
› Author Affiliations

A 20-year-old male had presented with median cleft lip, maxillary hypoplasia Class-II and mandibular prognathism.

He had history of cleft lip repair at 6 years of age and Le Fort I osteotomy, intraoral distractor application with reduction genioplasty in October 2013. He had mandibular prognathism (preoperative photographs are seen in [Fig. 1]). On assessment, the followings are observed: (1) mesoprosopic face, (2) a 2-mm overbite, and (3) a 4-mm overjet ([Fig. 2] shows lateral and anteroposterior cephalograph).

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Fig. 1 Preoperative photographs.
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Fig. 2 Lateral and anteroposterior cephalograph.

The patient was planned for Le Fort I osteotomy with rigid external distractor device insertion. The horizontal advancement planned was 7 mm, during the procedure on attempting maxillary mobilization, it was noted that the patient had transient bradycardia up to 40/min. This happened as many mobilization was attempted for several times (thrice). It reverted spontaneously, as soon as mobilization was stopped. After some time it settled. No other complications were noted. The procedure was completed uneventfully by doing slow and gradual mobilization.

During past 15 years (23 osteotomies), this was encountered for the first time. On reviewing the literature, it was noted that this is a known phenomenon similar to oculocardiac reflex.[1] [2] [3] [4] Lang et al,[1] in 1991, reported three adults who had profound bradycardia on mandibular or maxillary manipulation.

Campbell et al,[2] in 1994, reported a similar case. It has been postulated that since trigeminal nerve carries the parasympathetic supply, any procedure stimulating the nerve can cause vagal stimulation. Some authors have also suggested to change the name to trigeminocardiac reflex.[1] [3] [4] It is a phenomenon which can occur in any patient undergoing maxillary or mandibular manipulation. There are no predisposing factors documented.

The purpose is to highlight a hitherto rare occurrence during maxillofacial surgery which may have a bearing on patient.



Publication History

Article published online:
17 April 2020

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  • References

  • 1 Lang S, Lanigan DT, van der Wal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991; 38 (06) 757-760
  • 2 Campbell R, Rodrigo D, Cheung L. Asystole and bradycardia during maxillofacial surgery. Anesth Prog 1994; 41 (01) 13-16
  • 3 Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: facts and own experience. Neurol India 2009; 57 (04) 375-380
  • 4 Bhargava D, Thomas S, Chakravorty N, Dutt A. Trigeminocardiac reflex: a reappraisal with relevance to maxillofacial surgery. J Maxillofac Oral Surg 2014; 13 (04) 373-377