A n c r e ~ t h e ~ i n1988.
, Volume 43, pages 4 8 0 4 8 1
CASF RFPORT
The nasocardiac reflex
M . L. BAXANDALL
Summary
s well tiescribed and rect~gnisrdin anacstlzesiu. The nasocumiuc reflies is ILJSS bvcll-known. We describe u
The oculocarcliac r ~ f l e is
clinical marzifestution of this reJlex and describe the relevant m a t o r n j ~ .This w f l e . ~rmq' be obturided during general anaesthesia.
( h i r i g generul unuesthesiu.
Key words
Sitrpr-j,; car.
nose and throat
Coniplications; dysrhythniia.
The oculocardiac reflex is well described and recognised in
anaesthesia.' The nasocardiac reflex3 is less well-known.
We present a manifestation of this reflex which occurred
during a routine rhinological operalion.
Case history
A 69-year-old male was admitted for intranasal antros-
tomies. The patient's history revealed rcspiratory difficulty
caused by a nasal blockage but no other respiratory
problcm. Hc took regular exercise, had no symptoms of
cardiac ischacmia, was taking no medication and admitted
to no allergies. Hc had a dircct laryngoscopy under local
anaesthesia 2 months prcviously and a general anaesthetic
in the past for hacmorrhoidectomy. That anaesthetic passed
without incident. On cxamination he was an obese inan
and weighed 92 kilograms with a pre-operative blood pre-
ssure of 170/100 mmHg. A pre-operative electrocardio-
gram revealed sinus rhythm with a rate of 65 beats/minute
and n o evidence ofischaemic heart disease. The PR interval
was at the upper limit of normal at 0.2 second.
The patient was premedicaled one hour pre-operatively
orally with temarepam 30 mg. Blood pressure on arrival in
thc anacsthetic room was 170j100 mmHg as measured with
;z mcrcury sphygmomanometer. He was pre-oxygenated
and anaesthesia induced with thiopentone 400 mg, fentanyl
100 pg and suxamethoniuin 100 mg. Tracheal intubation
was performed and adcquatc vcntilation of thc lungs
vcrilicd by auscultation. Anaesthesia was maintaincd
w i t h nitrous oxide 66%, oxygen 33% and isoflurane
I YO.Muscular relaxation was maintaincd with atracuriuin
30 mg. The patient was connected to a noninvasive pre-
ssure monitor and electrocardiogram and the pulse was
M.L. Baxandall, BSc, MB. ChB, Registrar, J.L. Thorn, M B ChB, FFARCS, Consultant Anaesthetist, Department of
.4nacsthcsia. Torbay Hospital, Lawes Bridge, Torquay, Devon TQ2 7AA.
Correspondence should be addressed to Dr J.L. Thorn please.
.4cccptcd 10 November 1987.
0003-2409/88/060480 + 02 $03.00/0 @ 1988 The Association of Anaesthctists of G t Britain and Ireland
AND J . L. THORN
monitored by digital plethysmometry. The surgeon intro-
duced a nasal speculum into the right naris and the
turbinate bones were manipulated. A profound bradycardia
was noted immediately with only one complex seen on the
clcctrocardiogram monitor for two complete sweeps (8
scconds duration). The surgeon was asked to stop operating
and the inspired oxygen concentration increased to 100%.
Atropine 0.5 mg was given intravenously and normal salinc
500 ml was infused rapidly. The electrocardiogram
indicated sinus rhythm with a rate of 65 beatshninute,
2 minutcs aftcr thc administration of atropine, and over
the next 10 minutes the blood prcssurc was restored to
100 mmHg systolic having previously bccn unrecordable.
Nitrous oxide and isoflurane were re-introduccd at this
stage and. having given atropine intravenously, it was con-
sidered safe to continue. Howcvcr, as soon as the nasal
speculum was re-introduccd into the nose and the inferior
turbinatcs wcre touched with forceps a further profound
bradycardia was precipitated once more. The instruments
wcre removed from the nose and sinus rhythm returned,
this time without associated hypotension. The procedure
was abandoned and the patient allowed to breathe sponta-
neously wlicn thc atracuriiim had worn off, thus the use of
cholinergic drugs was avoided. The patient was transferred
postoperatively to thc intcnsivc care unit for 12 hours
during which time his blood prcssurc and pulsc were stable
at the pre-operative levels. Scrial clcctrocardiograms and
cardiac enzymes did not suggest myocardial infarct. Thc
patient niade a full recovery.
A nut o r n j
Thc nerve supply to the nose can be divided into thal to
480

the la(era.1 wall and that to the nasal ~ e p t u mIf. ~the lateral
wall is bisected by a vertical and horizontal line each
quadrant receives a separate supply.
The posterosuperior quadrant. This is supplied by the pos-
terior superior lateral nerves from the pterygopalatine
ganglion.
The poslero-inferior yuudrunt. This is supplied by the an-
terior palatine nerve, which pierces the perpendicular plate
of the palatine bone and passes forwards into the nasal
mucous membrane.
The (interior-superior quadrant. This is supplied by the
anterior ethmodial nerve which passes down through the
nasal slit in the cribriform plate. The nerve gives off lateral
branches and medial branches and passes out of the surface
betwcen thc nasal bone and upper nasal cartilage, where it
is called the external nasal nerve.
The anteriorinferior quadrant. This is supplied by the
anterior superior alveolar nerve.
The nerve supply of the septum is as follows. The naso-
palatine nerve enters the sphenopalatine foramen and
passes medially across the roof of the nose to the upper
part of the posterior border of the septum and supplies the
postcro-inferior part of the septum. The anterosuperior
part of the septum is innervated by the septa1 branches of
the anterior cthmoidal nerve.
The sensory nerve supply of the nose arises from the
maxillary branch of the trigeminal nerve. Sympathetic and
parasympathetic (vagal) fibres enter the sphenopalatine
ganglion from the deep petrosal nerve. Thus every branch
from the sphenopalatine ganglion carries a mixture of
three kinds of fibres: sensory, secretomotor (parasym-
pathetic) and sympathetic. The afferent stimulus of the
nasocardiac reflex travels in the maxillary division of the
Nusocardiac reflex 48 1
trigeminal nervc, and the efferent pathway to the heart is
via the vagus nerve.
Discussion
The anatomy of the nerve supply to the nose is outlined
above. The patient we describe had a very pronounced naso-
cardiac reflex and if surgery was contemplated in this region
again the reflex would have to be obtunded either by
pharmacological methods, such as a parasympathetic
blockade with atropine, or with local anaesthesia. The
insertion of a temporary transvenous cardiac pacing wire
should also bc considered. We believe that this case also
emphasises the need for adequate monitoring of all patients
who undergo anaesthesia regardless of how trivial the
surgery may be.
Acknowledgments
We thank M r F.P. Houlihan for permission to report this
case and Ms P. Affleck for secretarial assistance.
References
DEWAKKMS, WISHARTHY. The oculocardiac reflex. Pro-
ceedings of the Royul Society of Medicine 1976; 6 9 3 7 3 4 .
ADAMS AK, JONESRM. Anaesthesia for eye surgery: general
considerations. Brirish Journal uf Anaesthesia 1980; 52: 663-9.
SLOME D. Physiology of the nose and paranasal sinuses.
Reflexes initiated from the nose. In: BALLANTYNE J, GROVES J.
eds. Scott-Broun’s Diseuses of the ear. nose and throat. Vol I .
Basic sciences. 3rd edn. London: Buttenvorths, 1971; 169-73.
LASTRJ. Anatomy: regional and applied. Edinburgh: Churchill
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