Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology
Oral and maxillofacial surgeryTrigeminocardiac reflex: A MaxFax literature review
Section snippets
The Trigeminocardiac Story
Joseph Breuer described the self-regulation of breathing through the vagus nerves in 1868, and Florian Kratschmer described the influences of reflexes of the nasal mucosa on breathing and circulatory in 1870.1 These are considered as the first steps in the description of trigeminal-mediated bradycardia or asystole, which is well known especially for anesthetists and surgeons dealing with the craniomaxillofacial structures.2, 3 Based on the studies of Kratschmer on cats and rabbits, a sudden
Problem Statement
Dysrhythmias as a result of surgical manipulation of the eye and relevant orbital structures have been well documented in the ophthalmology literature5; however, the occurrence of this reflex during other maxillofacial surgeries is not as recognized and no review article has discussed this phenomenon based on oral and maxillofacial surgery literature. To the best of our knowledge, about 23 cases of sudden bradycardia and/or asystole thought to be attributed to trigeminal-mediated reflex during
Maxillofacial Literature Review
In 1987, Bainton and Lizi11 reported a case of cardiac asystole complicating the operation of a zygomatic arch fracture. Another case of bradycardia during the elevation of a zygomatic arch fracture was reported in the same year by Loewinger et al.12 Also Shearer and Wensione13 reported episodes of bradycardia during elevations of zygomatic fractures in 1987. Robideaux10 documented a case of a sudden decrease in heart rate (from 90 to 54 beats per minute) consonant with surgical disimpaction of
Anatomic Description
The afferent limb of the oculocardiac reflex arc is via the ophthalmic division of the trigeminal nerve. It begins with afferent fibers of the long and short ciliary nerves that travel with the ophthalmic division of the trigeminal nerve, continues to the gasserian ganglion, and then joins the main sensory nucleus of the trigeminal nerve in the floor of the fourth ventricle. Short internuncial fibers in the reticular formation connect them with the efferent pathway from the motor nucleus of the
Biologic Relevance
There are endogenous physiological protective mechanisms detected in brain against ischemia. The TCR is seemingly an example of these protective physiologic entities.3 It may be part of a group of related responses generally defined as “oxygen-conserving reflexes.” Within seconds after the initiation of such a reflex, there is a powerful and differentiated activation of sympathetic nerves and consequently a primary cerebrovascular vasodilatation. The hibernation and ischemic tolerance appear to
Predisposing and Triggering Factors
It is well known that hypercarbia, hypoxemia, and insufficient anesthesia are predisposing factors in the occurrence of OCR. Also, the nature of the provoking stimulus, meaning its strength and duration, contribute to the significance of the HR and blood pressure decrease.2 On the other hand, OCR occurs more pronouncedly in children.6, 32 This is attributed to the higher resting vagal tone.3 The relation of these factors and the incidence of TCR have not been addressed through the
Clinical Implementation and Management
As Schaller and Buchfelder26 have mentioned, “The clinical importance of the TCR lies in the fact that its clinical features range from sudden onset of sinus bradycardia, bradycardia terminating asystole, asystole with no preceding bradycardia, arterial hypotension, apnea, and gastric hypermobility.” Recognition of bradycardia is the first step in treatment. Avoidance of predisposing or triggering factors, halting the surgical stimulus, IV administration of atropine or glycopyrrolate, and
Preventive Measures
It has been shown that OCR, airway irritability, and ventilatory interventions occur with lower incidence in spontaneously breathing children undergoing strabismus correction with 1.3 MAC sevoflurane in N2O than with halothane. Baseline heart rate and respiratory rate are higher with sevoflurane. Also, considerably fewer dysrhythmias are observed in children receiving sevoflurane than in those receiving halothane. It is then concluded that a comparatively greater depression of vagal activity by
Conclusions
Being familiar with the presentations, preventive measures, and management procedures are seemingly the most important aspects of the TCR to oral and maxillofacial surgeons and anesthesiologists. Further studies, preferably with a multicenter design, are necessary to confirm the nature, description, predisposing and triggering factors, and other aspects of this seemingly physiologic phenomenon.
References (33)
Kratschmer and nasal reflexes
Respir Physiol
(2001)- et al.
Cardiac asystole complicating zygomatic arch fracture
Oral Surg Oral Med Oral Pathol
(1987) - et al.
Bradycardia during elevation of a zygomatic arch fracture
J Oral Maxillofac Surg
(1987) - et al.
Complications encountered during LeFort I osteotomy in a patient with mandibulofacial dysostosis
J Oral Maxillofac Surg
(1988) Reflex bradycardia in facial surgery
Br J Plast Surg
(1989)- et al.
Asystole during Le Fort I osteotomy
J Oral Maxillofac Surg
(1989) - et al.
Sinus arrest complicating a bitemporal approach to the treatment of pan-facial fractures
Br J Oral Maxillofac Surg
(1990) - et al.
Cardiac dysrhythmias complicating maxillofacial surgery
Int J Oral Maxillofac Surg
(1990) - et al.
Bradycardia and the trigeminal nerve
J Craniomaxillofac Surg
(1990) Cardiac dysrhythmias complicating maxillofacial surgery
Int J Oral Maxillofac Surg
(1992)
Oculocardiac reflex induced by zygomatic fracture: a case report
J Craniomaxillofac Surg
Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy
J Craniomaxillofac Surg
Proposal for the existence of a nasogastric reflex in humans, as a potential cause of upper gastrointestinal symptoms
Med Hypotheses
The nasogastric reflex in humans, proposed as a potential cause of upper gastrointestinal symptoms, was previously described as the trigemino-cardiac reflex
Med Hypotheses
Nasogastric versus trigemino-cardiac reflex: two sides of a coin
Med Hypotheses
Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex
Can J Anaesth
Cited by (41)
Asystole induced by trigeminocardiac reflex during zygomatic fracture repositioning: A rare case report
2023, Journal of Oral and Maxillofacial Surgery, Medicine, and PathologyTrigeminal Nerve Repair: Is the Trigeminocardiac Reflex a Concern?
2021, Journal of Oral and Maxillofacial SurgeryThe trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?
2021, Journal of Cranio-Maxillofacial SurgeryDoes Surgical Release of TMJ Bony Ankylosis Increase the Risk of Trigeminocardiac Reflex? A Retrospective Cohort Study
2019, Journal of Oral and Maxillofacial SurgeryOccurrence of trigeminocardiac reflex during dental implant surgery: An observational prospective study
2017, Journal of the Formosan Medical AssociationCitation Excerpt :During the course of implant surgery, drilling or implant placement may trigger the sensory branches of trigeminal nerve and send signals from the Gasserian ganglion to the sensory nucleus of trigeminal nerve. Then, the signals are transferred to the vagus motor nucleus via short nerves and directed to the myocardium via the cardiac branch of vagus nerve.11–13 Schematic of implant surgery triggering the possibly of TCR pathway is shown in Fig. 1.