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Year: 2010

Classification of potential risk factors for trigeminocardiac reflex in

craniomaxillofacial surgery

Lübbers, H T ; Zweifel, D ; Grätz, K W ; Kruse, A

Abstract: PURPOSE: Trigeminocardiac reflex (TCR) in craniomaxillofacial surgery can lead to severely
life-threatening situations. At least mild forms are probably much more common than the existing surgical
literature suggests. Therefore, the aim of this presentation of cases and literature review was to evaluate
the predisposing factors leading to a classification of risk factors for potential TCR and to give informa-
tion concerning preventive measures and management procedures. PATIENTS AND METHODS: All
surgery reports from the Department of Cranio-Maxillofacial and Oral Surgery in the University Hospital
in Zurich between 2003 and 2008 were searched for severe intraoperative cardiovascular complications,
and a literature review was performed for publications concerning asystole or bradycardia during max-
illofacial surgical procedures. RESULTS: Three incidents were revealed in which severe bradycardia–in
2 cases followed by asystole–had occurred. All incidents were successfully managed. CONCLUSION:
All craniomaxillofacial surgeons involved in orbital surgery in general and in the treatment of midface
fractures, eyelid surgery, and orthognathic procedures in particular should be aware of the possibility of
the TCR and should be familiar with its prevention and therapy.

DOI: https://doi.org/10.1016/j.joms.2009.12.039

Posted at the Zurich Open Repository and Archive, University of Zurich

ZORA URL: https://doi.org/10.5167/uzh-35091
Journal Article
Accepted Version

Originally published at:

Lübbers, H T; Zweifel, D; Grätz, K W; Kruse, A (2010). Classification of potential risk factors for
trigeminocardiac reflex in craniomaxillofacial surgery. Journal of Oral and Maxillofacial Surgery, 68(6):1317-
1321.
DOI: https://doi.org/10.1016/j.joms.2009.12.039
฀lassification of Potential Risk Factors for Trigeminocardiac Reflex

in ฀raniomaxillofacial Surgery

Dr Heinz-Theo Lübbers: Department of Oral and Cranio-Maxillofacial Surgery, University

Hospital, Frauenklinikstraße 24, CH-8091 Zürich, Switzerland

Purpose: Trigeminocardiac reflex (TCR) in craniomaxillofacial surgery can lead to

severely life-threatening situations. At least mild forms are probably much more

common than the existing surgical literature suggests. Therefore, the aim of this

presentation of cases and literature review was to evaluate the predisposing factors

leading to a classification of risk factors for potential TCR and to give information

concerning preventive measures and management procedures.

Patients and Methods: All surgery reports from the Department of Cranio-

Maxillofacial and Oral Surgery in the University Hospital in Zurich between 2003 and

2008 were searched for severe intraoperative cardiovascular complications, and a

literature review was performed for publications concerning asystole or bradycardia

during maxillofacial surgical procedures.

Results: Three incidents were revealed in which severe bradycardia – in 2 cases

followed by asystoly – had occurred. All incidents were successful managed.

฀onculsion: All craniomaxillofacial surgeons involved in orbital surgery in general

and in the treatment of midface fractures, eyelid surgery, and orthognathic

procedures in particular should be aware of the possibility of the TCR and should be

familiar with its prevention and therapy.

1
The surgeon is much more aware of most complications in maxillofacial surgery (eg,

Bleeding, infections, and injury of nearby structures) than the trigeminocardiac reflex

(TCR), of which mild forms regularly appear in this field of surgery. In 1870,

Kratschmer described the influence of reflexes on manipulation of the nasal mucosa.1

In 1908, the TCR was first described as an oculocardiac reflex.2 However,

descriptions of the occurrence of the reflex during temporomandibular joint surgery

and mandibular osteotomies emphasize that the maxillary and mandibular divisions

can be involved as well as the ophthalmic branch of the trigeminal nerve. Besides

this oculocardiac reflex, the oculorespiratory reflex, which results in a reduction of

respiratory rate and volume, has also been mentioned.3 Today, this phenomenon is

well known and not just with regard to manipulation of the nasal mucosa.

The TCR is characterized by cardiac arrhythmia, ectopic beats, atrioventicular

lock, bradycardia, syncope, vomiting, and asystole. This life-threatening condition has

been documented during simple zygomatic arch elevations, repositioning of blow-out

and maxillary fractures, orthognathic surgery, and nasoethmoidal fractures (Table 1).

Although this complication occurs only rarely, every head and neck surgeon should

be aware of this severe phenomenon.

Most authors agree that this reflex is rare, but Matarasso et al state that the

oculocardiac reflex occurs in 25% of patients undergoing blepharoplasty.4 Precious

and Skulsky reported the reflex in 1.6% of patients undergoing maxillofacial

surgeries.5 The highest incidence (between 32% and 90%) has been described in

strabismus surgery.6 For craniofacial surgery (Le Fort I osteotomy, midface fracture

reduction, elevation of zygomatic fractures, and temporomandibular joint insufflation)

an incidence of 1% to 2%, and for skull base surgery an incidence of 8% to 18%,

have been reported.7

2
 Concerning these incidence rates, one must be aware that bradycardia during

maxillofacial surgical procedures might happen much more frequently than is

published. On the other hand, clinical features like nausea, vomiting, or bradycardia,

particularly in children, can also be interpreted as commotio cerebri rather than being

attributable to TCR. Therefore, no specific numbers concerning incidence can be

given.

The aim of the present study was to evaluate severe events of the TCR during

surgical procedures performed between 2003 and 2008 and to review the literature in

order to provide information concerning incidence, predisposing factors, and, last but

not least, development of a risk classification.

Patients and Methods

All surgery reports from the Department of Craniomaxillofacial and Oral Surgery in

the University Hospital in Zurich between 2003 and 2008 were searched for severe

intraoperative cardiovascular complications. Three other cases are presented, which

showed either intra- or perioperative bradycardia and/or asystolia due to no other

identifiable pathology than the described trigeminocardiac or oculocardiac reflex.

Electronic databases (Medline and Cochrane) were searched using a set of

predetermined keywords. The search strategy was initially developed and

implemented for PubMed but was revised appropriately to suit the other databases. A

combination of free text terms with Boolean operators and truncation was used. No

restriction was placed on the year or language of publication. The search strategy

was devised in consultation with a senior librarian.

The citations retrieved from each database were exported into the EndNote

bibliometric management software. Duplicates were discarded. The titles and

3
abstracts were screened, and the hard copies of all potentially relevant articles were

retrieved. Their reference lists were manually searched for any related articles.฀

฀ase 1

A 66-year-old male patient, who, after tripping and falling down a short flight of stairs,

suffered a displaced tripod fracture along with minimally dislocated further fractures

of the facial skeleton and subdural hematoma, was referred to the emergency room.

His medical history included type II diabetes and myocardial infarction and

consecutive coronary artery stenting 10 years prior to presentation. He showed no

signs or symptoms relating to cardiac dysfunction. Due to the subdural hematoma,

operative treatment of the facial fractures was postponed for 10 days. The lateral

facial fractures were then visualized by an intraoral approach under general

anesthetic. On repositioning of the zygoma, the patient first became bradycardic and

then asystolic for 23 seconds. The total event lasted for 2 minutes and 11 seconds.

Cardiac massage was performed by the surgeon successfully in combination with

ongoing ventilation and administration of 0.5mg Atropin IV and 1mg epinephrine IV

through the anesthetist. Because the fracture was not stable, minimal plate fixation

was performed. The patient was kept under close supervision 24 hours

postoperatively, and regular checkups were performed during his time as an

outpatient. He suffered no permanent damage of cardiac tissue as demonstrated by

pre-, intra-, and postoperative electrocardiograms. No further cardiac pathology could

be found.

฀ase 2

A 50-year-old male patient was referred to the Department of Craniomaxillofacial and

Oral Surgery in the University Hospital in Zurich because of a massive fronto-basal,

4
mandible, and midface trauma from a car accident, including a contusion of the bulb

and a foreign body in the right orbit next to other general injuries. His medical history

included hypertonia and hypercholesterolemia, as well as myocardial infarction 3

years prior to presentation. He showed no signs or symptoms relating to cardiac

dysfunction. After primary care the patient was transferred to our hospital for further

treatment. On the patient’s arrival the mandible was provisionally treated and

preparations were made for computer-assisted surgery 4 days later. Revision of the

fronto-basal area was performed as well as reconstruction of both orbits and the right

zygoma under navigation control (Fig 1).

During surgical manipulation of the severely fractured zygoma, a severe

bradycardia occurred, followed by an asystoly. Immediately 0.5mg atropine IV was

administered, and the surgical manipulation was stopped. After the episode totalling

120 seconds, the surgery was completed uneventfully.

About 72 hours after surgery, another event of bradycardia occurred, with the

heart rate dropping to 36 bpm while the patient was still in the intensive care unit.

After administration of 0.5mg atropine IV, the heart rate quickly normalized to 64

bpm. No further pathology was found to explain these incidents.

฀ase 3

A 74-year-old female patient was scheduled for extended tumor resection, including

orbital extenteration and reconstruction of the soft tissue defect by radial forearm flap,

due to T4 squamous cell carcinoma of the orbit. Her medical history did not include

any known risks for TCR.

Surgery was uneventful until the final manipulations at the optic nerve before the

extenteration was done. Despite a prophylactic dose of 0.5 mg atropine IV before the

actual extenteration, a bradycardia occurred down to 33 bpm. Without any further

5
measures except for pausing the surgical manipulations, the heart rate normalized to

70 bpm rhythm within 28 seconds. Further surgery and postoperative course were

uneventful. No further pathology was found to explain this incident.

Discussion

Bradycardia or asystole is a known complication of zygomatic, blowout, and maxillary

fractures.8 On presentation the patient suffers bradycardia or even asystole. Because

most cases can be hypothesized to present during the actual accident8-10, some

cases of bradycardia during manipulation in orthognatic surgery11 or repositioning of

lateral midface fractures5,12,13 have been reported. Besides the aforementioned risk

during surgical procedures, delayed TCR within 48 hours after trauma has also been

described14.

The reflex responsible for this pathology is known under several synonyms, as

follows: oculocardiac reflex (Achener-phenomenon), trigeminocardiac, or trigemino-

vagal reflex. The oculocardiac reflex is caused by traction of the extraocular muscles

or compression of the eyeball, leading to a decrease in pulse rate by the efferent

portion of the vagus nerve from the cardiovascular center of the medulla to the heart.

This reflex is described not only in surgery of the zygomaticum, but also in mandible

procedures.2 A significantly higher incidence has been reported in children6, but it

can be provoked in any patient even without pre-existing cardiac disease.

The neuronal signals of the afferent path of the TCR arch are transmitted by

the sensory ends of the trigeminal nerve via gasserian ganglion. The afferent path

runs along internuncial fibers in the reticular formation and merges with the efferent

path in the nucleus of the vagus nerve, resulting in a chronotropic-inotropic response

by a vagal stimulation of the cardiac branch of the vagus nerve in the myocardium

(Fig. 2).15,16 Kayikcioglu et al mentioned that a minimum period of 15 to 20 seconds

6
of stimulation is necessary to elicit the reflex leading to at least 20% or more

reduction in heart rate, or presence of arrhythmias.17

Cha et al have described the critical period during the first few seconds after

stimulation when bradycardia and cardiac depression are maximized.18 In addition to

cardiac disease, hypoxemia and hypercapnia have both been identified as

predisposing factors leading to an increased risk for TCR.

Concerning prevention, several points are important. Besides evaluation of at-

risk patients (eg, children and patients with a medical history of cardiac disease) and

high-risk surgeries (eg, strabismus), some authors suggested using ketamine for

anesthetic induction to decrease the oculocardiac reflex in children undergoing

strabismus surgery.19,20

Table 2 presents a classification of several risk factors. The first case presented

above would be a high-risk patient because of the previously described cardiac

disease; the second patient would have a median risk due to the type of surgery and

also would be high risk because of the previously described cardiac disease. The

third case would be a high risk because of the type of surgery.

Allison et al. compared sevoflurane with halothane anesthesia for strabismus

surgery in children and concluded that fewer dysrhythmias were observed in children

receiving sevoflurane than in those receiving halothane because the baseline heart

rate and respiratory rate are higher with sevoflurane, resulting in a less pronounced

bradycardia on stimulation.3 In addition Yilmaz et al mentioned potent narcotic

agents, such as sufentanil and alfentanil, and drugs, such as ß-blockers or calcium

channel blockers.14

Another trigger point that has been described is rinsing with cold water (0 to

20°C) at the distribution of the ophthalmic division of the trigeminal nerve.21

Anticholinergic agents, such as atropine and glycopyrrolate, are the drugs of first

7
choice in cases of refractory bradycardia or asystole. However, besides the

mentioned therapies, recognition of bradycardia is the first step in treatment.22

Predisposing factors besides cardiac disease are hypoxia and hypercarbia,

and use of opioids and ß-blockers. Any of these factors should lead to an upgrade of

the risk assessment according to Table 2. In the first case presented here, the patient

had experienced myocardial infarction and consecutive coronary artery stenting 10

years before presentation; therefore, he was a high-risk patient.

On the other hand, TCR has been identified with a sudden onset of

parasympathetic hypotension, apnea, or gastric hypermotility during stimulation of

any of the sensory branches of the trigeminal nerve.23

Concerning therapy, in some cases stopping the surgery has resulted in recovery of

a normal rhythm; in other cases, anticholinergic drugs and cardiac massage have

been mentioned.

In every case of low and medium risk in the classification presented here, we

recommend informing the anesthesiology team that they should be prepared for

mobilization in case of adverse effects. Although TCR is rare in such cases, it

presents a typical complication with a significant risk to the patient. We propose that

information on TCR should be given as a part of any preoperative procedure.

In every high-risk case presented in the classification, we recommend a

prophylactic administration of, eg, 0.5mg atropine IV, right before any surgical

manipulation known to be risky for TCR. Preoperative information should be included

as part of the informed consent in these cases.

Acknowlegement

The authors would like to thank Hildegard Eschle, senior librarian of the Dental

School at the University Zurich, for helping with the literature research.

8
Table 1: Overview of published cases

Surgical procedure ฀linical feature Authors

elevation of zygomatic bradycardia Shearer Es et al, 1987

arch fractures asystole Bainton R et al, 1987

bradycardia Loewinger J et al, 1987

bradycardia Gillespie IA, 1988

Insufflation of TMJ during Gomez TM et al, 1991

arthroscopy

During orthognathic Lang S et al, 1991

procedure of the mandible asystole Campbell R et al, 1994

Endoscopic asystole Schaller B et al, 2008

transshenoidal surgery

Reposition of Baxandall ML et al, 1988

nasoethmoidal fractures

blepharoplasty asystole Rippmann V et al, 2008

Intraorbital foreign body bradycardia Yilmaz T et al, 2006

Periorbital laceration asystole Osborn TM et al, 2008

manipulation

Mesiodens removal bradycardia Webb MD et al, 2007

Midface disimpaction Robideaux V, 1978

Use of mouth prop asystole Precious DS et al,1990

9
Table 2: Classification of surgical risk factors

Risk Surgery Prevention

Low insufflation of TMJ °Informing the anesthetist

LeFort-I-osteotomy directly before the time of

elevation of zygomatic the highest risk

fractures

Medium skull base surgery °Informing the anesthetist

directly before the time of

the highest risk

High ophthalmic surgery °Informing the anesthetist

strabismus surgery directly before the time of

exenteratio orbitae the highest risk

orbital fractures in children °atropine and/or

patients with cardiac glycopyrolate

disease °ketamine for anesthetic

induction

10
Fig. 1: Reconstruction of the right orbit under navigation – pointer on reconstructed

floor.

11
Fig. 2: TCR pathway

12
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