Next Article in Journal
A Rare Case of Multiple Oblique Facial Clefts with Supernumerary Teeth: Case Report
Previous Article in Journal
An Analysis of Malar Fat Volume in Two Age Groups: Implications for Craniofacial Surgery
 
 
Craniomaxillofacial Trauma & Reconstruction is published by MDPI from Volume 18 Issue 1 (2025). Previous articles were published by another publisher in Open Access under a CC-BY (or CC-BY-NC-ND) licence, and they are hosted by MDPI on mdpi.com as a courtesy and upon agreement with Sage.
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Case Report

Iatrogenic Oculocardiac Reflex in a Patient with Head Injury

by
Panagiotis Stathopoulos
*,
Michael Mezitis
,
George Kostakis
and
George Rallis
Department of Oral and Maxillofacial Surgery, General Hospital of Attica “K.A.T.”, Kifissia, 98, Tatoiou Street, Nea Erythrea, 14671 Attica, Greece
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2012, 5(4), 235-237; https://doi.org/10.1055/s-0032-1322532
Submission received: 8 April 2011 / Revised: 16 August 2011 / Accepted: 16 August 2011 / Published: 24 July 2012

Abstract

:
A 16-year-old girl with a history of a recent fall from the third floor was transferred to the emergency room. On presentation, the patient, who had sustained multiple facial fractures, was in clinical shock with a blood pressure 80/40 mm Hg, heart rate 130/min, tachypnea (>30/min), Po2 50 mm Hg, and So2 82%, and she was intubated for airway protection. Severe nasal hemorrhage was detected (hematocrit: 22%), therefore a bilateral anteroposterior balloon nasal catheter was inserted and inflated with air. Bleeding was controlled. A few minutes later, her heart rate dropped to 40/min. Atropine was administered intravenously and the rate increased to 60/min. Computed tomography of the head revealed brain and subarachnoid hemorrhage, multiple fractures of the facial skeleton, and a round foreign body, full of air, compressing the left eye. The medial wall and the floor of the ipsilateral orbit were also fractured, establishing a naso-orbital communication. The left catheter was immediately removed. Heart rate was restored to normal. Facial fractures were addressed surgically. Patient’s vision is intact.

Several case reports and reviews describe the oculocardiac reflex in ophthalmologic, anesthetic, and maxillofacial surgery literature. The increase of the parasympathetic tone produced by pressure applied on the globe or orbital and periorbital tissues may lead to nausea, vomiting, bradycardia, and even asystole [1,2]. The incidence of fatal cardiac arrhythmias in patients with an oculocardiac reflex is 1 per 3500 [1]. The occurrence of the reflex during reduction of zygomatic [3] and nasal fractures [4], midface disimpaction [5], orbital floor fractures [6,7], maxillary osteotomy [2], and insufflation of the temporomandibular joint [8] has been well reported. We describe a case of the oculocardiac reflex leading to severe bradycardia in a young patient after compression of the eye caused by a balloon nasal catheter inserted into the orbit as a result of a traumatic naso-orbital communication.

Case Report

A 16-year-old girl with a history of a recent fall from the third floor was transferred to the emergency room. On presentation, the patient was in clinical shock. Her blood pressure was 80/40 mm Hg, heart rate 130, and respiratory rhythm >30/min. Clinical examination revealed a left zygomaticoorbital com-plex fracture, comminuted nasoethmoidal fractures, and severe nasal hemorrhage (hematocrit: 22%). the patient’s blood gas values were Po2 50 mm Hg and So2 82% due to upper airway obstruction, and therefore shewas intubated for airway protection. After resuscitation, a bilateral anteroposterior balloon nasal catheterwas inserted and inflated with air. Bleeding was controlled and the vital signs of the patient were restored to normal. Few minutes later, heart rate dropped to 40/min. Atropinewas given intravenously and the rate increased to 60/min. Computed tomography of the head, whichwas performed 15 min later, revealed brain and subarachnoid hemorrhage, multiple fractures of the facial skeleton, and a round foreign body, full of air, compressing the left eye (Figure 1). The medial wall and floor of the ipsilateral orbit were also fractured, establishing a naso-orbital communication (Figure 2). The left catheter was removed at once. Heart rhythm was restored to normal. Facial fractures of the patient were addressed surgically with open reduction and internal fixation 8 days later. Ophthalmologic examination disclosed that the patient’s vision was intact.

Discussion

Stimulation of the ophthalmic nerve, first division of the trigeminal, by compression of the eye leading to inhibition of heart rate due to excitation of the vagus nerve is believed to be the mechanism of the oculocardiac reflex [9]. The afferent pathway commences with pressure receptors in the ocular and periocular tissues, follows the ciliary nerves to the gasserian ganglion along the ophthalmic nerve, and ends in the trigemi- nal sensory nucleus, located in the floor of the fourth ventricle. The impulses reach the visceral motor nuclei of the vagus nerve through the reticular formation. The efferent limb travels via the vagus nerve to the myocardium. Stimulation of the reflex arc results in negative inotropic and chronotropic effects [10].
In our patient, sinus bradycardia developed after left eye compression owing to a balloon nasal catheter inserted and inflated with air. A pathological communication had been already established between the nasal cavity and the orbit as the result of the severe trauma sustained. As the lamina papyracea is the most vulnerable part of the medial orbital wall, most fractures occur around it [11]. It is most likely that the probe of the catheter passed through this deficit and when the balloon was inflated with air, the globe was compressed, generating the oculocardiac reflex. This hypothesis is further supported by the fact that when the catheter was removed, heart rate was restored to normal.
It has been reported that the force and type of the trigeminal nerve stimulation seem to affect the occurrence of the oculo- cardiac reflex. Interestingly enough, it is supported that the more acute the onset and the more powerful the pressure applied on the eye, the more likely the reflex is to appear [3]. In our case, both the rapid onset and the intensity of the force produced inside the orbit by the nasal catheter seem to have activated the trigeminovagal reflex. It is also widely accepted that surgical intervention should be performed early in patients with severe and persistent oculocardiac reflex [12,13]. As soon as a sudden bradycardia is noted, any compression applied on the eye should be immediately eliminated. Communication with the anesthetist and monitoring of the cardiac rhythm during maxillofacial surgery are essential measures for the detection and treatment of the oculocardiac reflex. Usually, as soon as the stimulus cessation is achieved, the patient will regain sinus rhythm. As the reflex is initiated by parasympathetic stimula- tion, the use of anticholinergic agents is logical. In the case presented, intravenous administration of atropine together with the nasal catheter removal resulted in restoration of the heart rate to normal. To the best of our knowledge, this is the first case in the English literature of an oculocardiac reflex occurrence as a result of a direct compression of the eye by a balloon nasal catheter. This case indicates that extreme care and vigilance should be demonstrated when a nasal catheter is inserted to control hemorrhage in a patient with head injury.

References

  1. Kim, J.; Lee, H.; Chi, M.; Park, M.; Lee, J.; Baek, S. Endoscope-assisted repair of pediatric trapdoor fractures of the orbital floor: Characterization and management. J. Craniofac. Surg. 2010, 21, 101–105. [Google Scholar] [CrossRef] [PubMed]
  2. Campbell, R.; Rodrigo, D.; Cheung, L. Asystole and bradycardia during maxillofacial surgery. Anesth. Prog. 1994, 41, 13–16. [Google Scholar] [PubMed]
  3. Blanc, V.F.; Hardy, J.F.; Milot, J.; Jacob, J.L. The oculocardiac reflex: A graphic and statistical analysis in infants and children. Can. Anaesth. Soc. J. 1983, 30, 360–369. [Google Scholar] [CrossRef] [PubMed]
  4. Locke, M.M.; Spiekermann, B.F.; Rich, G.F. Trigeminovagal reflex during repair of a nasal fracture under general anesthesia. Anesth. Analg. 1999, 88, 1183–1184. [Google Scholar] [PubMed]
  5. Robideaux, V. Oculocardiac reflex caused by midface disimpaction. Anesthesiology 1978, 49, 433. [Google Scholar] [CrossRef] [PubMed]
  6. Sires BS, Stanley RB Jr, Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: An indication for urgent repair. Arch. Ophthalmol. 1998, 116, 955–956. [Google Scholar]
  7. Chesley, L.D.; Shapiro, R.D. Oculocardiac reflex during treatment of an orbital blowout fracture. J. Oral. Maxillofac. Surg. 1989, 47, 522–523. [Google Scholar] [CrossRef] [PubMed]
  8. Gomez, T.M.; Van Gilder, J.W. Reflex bradycardia during TMJ arthroscopy: Case report. J. Oral. Maxillofac. Surg. 1991, 49, 543–544. [Google Scholar] [CrossRef] [PubMed]
  9. Kosaka, M.; Asamura, S.; Kamiishi, H. Oculocardiac reflex induced by zygomatic fracture; a case report. J. Craniomaxillofac Surg. 2000, 28, 106–109. [Google Scholar] [CrossRef] [PubMed]
  10. Osborn, T.M.; Ueeck, B.A.; Ham, L.B.; Assael, L.A. A case of asystole from periorbital laceration manipulation and oculocardiac reflex in an acute trauma setting. J. Trauma. 2008, 65, 228–230. [Google Scholar] [CrossRef] [PubMed]
  11. Lee, W.T.; Kim, H.K.; Chung, S.M. Relationship between small-size medial orbital wall fracture and late enophthalmos. J. Craniofac Surg. 2009, 20, 75–80. [Google Scholar] [CrossRef] [PubMed]
  12. Yano, H.; Suzuki, Y.; Yoshimoto, H.; Mimasu, R.; Hirano, A. Linear-type orbital floor fracture with or without muscle involvement. J. Craniofac Surg. 2010, 21, 1072–1078. [Google Scholar] [CrossRef] [PubMed]
  13. Matic, D.B.; Tse, R.; Banerjee, A.; Moore, C.C. Rounding of the inferior rectus muscle as a predictor of enophthalmos in orbital floor fractures. J. Craniofac Surg. 2007, 18, 127–132. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Axial computed tomography of the head (bone window): balloon nasal catheter compressing the left eye.
Figure 1. Axial computed tomography of the head (bone window): balloon nasal catheter compressing the left eye.
Cmtr 05 00030 g001
Figure 2. Fracture of medial wall of orbit, with balloon nasal catheter compressing the left globe.
Figure 2. Fracture of medial wall of orbit, with balloon nasal catheter compressing the left globe.
Cmtr 05 00030 g002

Share and Cite

MDPI and ACS Style

Stathopoulos, P.; Mezitis, M.; Kostakis, G.; Rallis, G. Iatrogenic Oculocardiac Reflex in a Patient with Head Injury. Craniomaxillofac. Trauma Reconstr. 2012, 5, 235-237. https://doi.org/10.1055/s-0032-1322532

AMA Style

Stathopoulos P, Mezitis M, Kostakis G, Rallis G. Iatrogenic Oculocardiac Reflex in a Patient with Head Injury. Craniomaxillofacial Trauma & Reconstruction. 2012; 5(4):235-237. https://doi.org/10.1055/s-0032-1322532

Chicago/Turabian Style

Stathopoulos, Panagiotis, Michael Mezitis, George Kostakis, and George Rallis. 2012. "Iatrogenic Oculocardiac Reflex in a Patient with Head Injury" Craniomaxillofacial Trauma & Reconstruction 5, no. 4: 235-237. https://doi.org/10.1055/s-0032-1322532

APA Style

Stathopoulos, P., Mezitis, M., Kostakis, G., & Rallis, G. (2012). Iatrogenic Oculocardiac Reflex in a Patient with Head Injury. Craniomaxillofacial Trauma & Reconstruction, 5(4), 235-237. https://doi.org/10.1055/s-0032-1322532

Article Metrics

Back to TopTop