Delayed trigeminocardiac reflex after maxillofacial surgery: case report / Reflexo trigêmino-cardíaco tardio após cirurgia buco-maxilo-facial: relato de caso

Abstract Background: Trigeminocardiac reflex is a physiological phenomenon that may occur in head and neck surgery, and is usually benign. However, it may present with exaggerated responses with severe morbidity. Case report: Male patient, 26 years old, candidate for surgical treatment of zygomatic-orbital complex fracture. The surgery with bilateral nasal packing placed at the end of the procedure was uneventful. After being admitted to the post-anesthesia care unity, the patient complained of shortness of breath and nausea. Pulse oximetry fell below 90% in ambient air, and 100% O2 was then offered through a Hudson mask. He showed no improvement in oximetry and presented with worsening dyspnea, diffuse wheezing, reduced heart rate, and blood pressure. Atropine was given, which raised the heart rate, but without resolution of hypotension and bronchospasm. Our suspicion was of a trigeminal-cardiac reflex, and then the removal of the nasal packing was done with complete remission of the signs and symptoms. Discussion: Florian Kratschmer (1870) was the first to describe the influences of nasal mucosal reflexes on respiration and circulation, which became known as Kratschmer's reflex. It is a reflex arc whose afferent originates in the nerve endings of the trigeminal nerve. The clinical presentation of trigeminocardiac reflex is the occurrence of sudden bradycardia, hypotension, apnea, and gastric hypermotility. Conclusion: Trigeminocardiac reflex may be a protective neurogenic, oxygen-conserving response with low morbidity, however, exacerbated in certain situations. The interaction between surgeon and anesthesiologist, together with a careful monitoring of blood pressure and heart rate are fundamental for diagnosis and treatment.

Resumo Justificativa: O reflexo trigêmino-cardíaco é um fenômeno fisiológico passível de ocorrer em cirurgias da cabeça e pescoço, e normalmente é benigno. Contudo, pode apresentar respostas exageradas, com grave morbidade. Relato de caso: Paciente masculino, 26 anos, candidato a tratamento cirúrgico de fratura do complexo zigomático-orbitário. Ato cirúrgico sem intercorrências com tamponamento nasal bilateral ao final. Após admitido na sala de recuperação pós-anestésica, queixou-se de "falta de ar" e náusea. A oximetria de pulso caiu abaixo 90% em ar ambiente e foi ofertado então O2 a 100% sob máscara de Hudson. Não houve melhora da oximetria e apresentou piora da dispneia, com sibilos difusos, redução da frequência cardíaca e da pressão arterial. Administrada atropina, que elevou a frequência cardíaca, mas sem resolução da hipotensão arterial e broncoespasmo. Aventamos a hipótese de reflexo trigêmino-cardíaco e então foi feita a remoção do tamponamento nasal com remissão completa dos sinais e sintomas. Discussão: Florian Kratschmer (1870) foi o primeiro a descrever as influências de reflexos da mucosa nasal na respiração e na circulação, o que ficou conhecido como reflexo de Kratschmer. Trata-se de um arco reflexo cuja aferência é originária nas terminações nervosas do nervo trigêmeo. A apresentação clínica do reflexo trigêmino-cardíaco é a ocorrência de súbita bradicardia, hipotensão, apneia e hipermotilidade gástrica. Conclusão: O reflexo trigêmino-cardíaco pode ser uma resposta neurogênica protetora, oxigênio-conservadora, de baixa morbidade, contudo exacerbada em determinadas situações. A interação entre cirurgião e anestesiologista, aliada à monitoração criteriosa da pressão arterial e do ritmo cardíaco, é fundamental para o diagnóstico e o tratamento.

[Delayed trigeminocardiac reflex after maxillofacial surgery: case report]. / Reflexo trigêmino­cardíaco tardio após cirurgia buco­maxilo­facial: relato de caso.

BACKGROUND: Trigeminocardiac reflex is a physiological phenomenon that may occur in head and neck surgery, and is usually benign. However, it may present with exaggerated responses with severe morbidity. CASE REPORT: Male patient, 26 years old, candidate for surgical treatment of zygomatic-orbital complex fracture. The surgery with bilateral nasal packing placed at the end of the procedure was uneventful. After being admitted to the post-anesthesia care unity, the patient complained of shortness of breath and nausea. Pulse oximetry fell below 90% in ambient air, and 100% O2 was then offered through a Hudson mask. He showed no improvement in oximetry and developed a worsening dyspnea, diffuse wheezing, reduced heart rate, and blood pressure. Atropine was given, which raised the heart rate, but without resolution of hypotension and bronchospasm. Our suspicion was of a trigeminal-cardiac reflex, and then the removal of the nasal packing was done with complete remission of the signs and symptoms. DISCUSSION: Florian Kratschmer (1870) was the first to describe the influences of nasal mucosal reflexes on respiration and circulation, which became known as Kratschmer's reflex. It is a reflex arc whose afferent originates in the nerve endings of the trigeminal nerve. The clinical presentation of trigeminocardiac reflex is the occurrence of sudden bradycardia, hypotension, apnea, and gastric hypermotility. CONCLUSION: Trigeminocardiac reflex may be a protective neurogenic, oxygen-conserving response with low morbidity, however, exacerbated in certain situations. The interaction between surgeon and anesthesiologist, together with a careful monitoring of blood pressure and heart rate are fundamental for diagnosis and treatment.

Surgical Treatment of Posttraumatic Laterognathia: A Case Report and a Literature Review, Focused on the Effects of a Condylar Fracture on the Face.

Facial asymmetry, following early childhood condylar trauma, is a common complaint among patients who seek surgical treatment. G.D.M., a 27-year-old male patient, sought professional help to correct his cosmetic flaw, caused by a condylar fracture when he was 8-years-old. After the proper orthodontic treatment, he underwent a double jaw orthognathic surgery and, 9 months later, a second one to correct the remaining asymmetry. Two years after this second procedure, the patient is still under surveillance and has no complaints.

Hybrid fixation in the bilateral sagittal split osteotomy for lower jaw advancement.

Miniplate and screw fixation has been widely used in bilateral sagittal split osteotomy, but some issues remain unclear concerning its lack of rigidity when compared to Spiessl's bicortical technique. This paper demonstrates the hybrid fixation technique in a case report. A 34-year-old female patient underwent a double jaw surgery with counter-clockwise rotation of the mandible fixed using the hybrid fixation technique. The patient evolved well in the postoperative period and is still under follow up after 14 months, reporting satisfaction with the results and no significant deviation from the treatment plan up to now. No damage to tooth roots was done, maxillomandibular range of motion was within normality and regression of the inferior alveolar nerve paresthesia was observed bilaterally. The hybrid mandibular fixation is clearly visible in the panoramic and cephalometric control radiographs. It seems that the hybrid fixation can sum the advantages of both monocortical and bicortical techniques in lower jaw advancement, increasing fixation stability without significant damage to the mandibular articulation and the inferior alveolar nerve. A statistical investigation seems necessary to prove its efficacy.

Hybrid fixation in the bilateral sagittal split osteotomy for lower jaw advancement

Miniplate and screw fixation has been widely used in bilateral sagittal split osteotomy, but some issues remain unclear concerning its lack of rigidity when compared to Spiessl's bicortical technique. This paper demonstrates the hybrid fixation technique in a case report. A 34-year-old female patient underwent a double jaw surgery with counter-clockwise rotation of the mandible fixed using the hybrid fixation technique. The patient evolved well in the postoperative period and is still under follow up after 14 months, reporting satisfaction with the results and no significant deviation from the treatment plan up to now. No damage to tooth roots was done, maxillomandibular range of motion was within normality and regression of the inferior alveolar nerve paresthesia was observed bilaterally. The hybrid mandibular fixation is clearly visible in the panoramic and cephalometric control radiographs. It seems that the hybrid fixation can sum the advantages of both monocortical and bicortical techniques in lower jaw advancement, increasing fixation stability without significant damage to the mandibular articulation and the inferior alveolar nerve. A statistical investigation seems necessary to prove its efficacy.

Tratamento da hipertrofia muscular mastigatória com toxina botulínica tipo A / Masticatory muscles hypertrophy treatment with botulinum toxin type A

O tratamento da hipertrofia do músculo masseter e/ou temporal engloba métodos conservadores e cirúrgicos. A terapia com Toxina Botulínica Tipo A surgiu como um método alternativo de tratamento conservador. O propósito deste estudo foi revisar as características da Toxina Botulínica e os resultados de sua aplicação no tratamento da hipertrofia muscular mastigatória.

The treatment of the masseter and/or temporal muscles hypertrophy can be based on conservative and surgical approaches. The use of Botulinum Toxin A arised as an alternative conservative treatment. The purpose ofthe following study was to review Botulinum Toxin Type A characteristics and the results of its application in the treatment of masticatory muscles hypertrophy.

Estudo laboratorial de teste de resistência ao tracionamento da resina composta fotopolimerizável fill magic® destinada à colagem de braquetes para tracionamento ortodôntico de dentes retidos / Laboratorial study to test traction resistance of fill magic® light-cured resin intended for orthodontic traction of unerupted teeth

OBJETIVO: Avaliar a resistência à tração de duas resinas utilizadas para colagem de acessórios para tracionamento dentário. METODOLOGIA: o presente estudo comparou a adesividade e praticidade de duas resinas destinadas ao tracionamento ortodôntico de dentes impactados: a Concise® da 3M®, presente no mercado há alguns anos e tida como referência na realização deste procedimento; e a Fill Magic® da Vigodent®, cuja técnica é julgada mais simples pelo fabricante. Foram incluídos 40 terceiros molares em corpos de prova e estes divididos em dois grupos de 20, um para cada resina. Uma vez colados os braquetes, os corpos de prova foram submetidos à força de tração horizontal (10 de cada grupo) e vertical (10 de cada grupo), até que os braquetes se soltassem. Os valores obtidos na máquina universal de ensaios foram registrados e comparados por meio de médias para que fosse possível estabelecer as vantagens e desvantagens de cada resina. RESULTADO E CONCLUSÃO: apesar dos valores obtidos com a resina Fill Magic® terem sido menores que os da resina Concise®, comprovou-se que eles são suficientes para a realização do tracionamento ortodôntico.

AIM: comparisson of two composite adhesives used for orthodontic traction procedures. METHODS: this article compared the bonding capability and practice of two resins for direct orthodontic traction: the 3M®'s Concise®, been sold in the market for a few years and the reference for this kind of procedure; and Vigodent®'s Fill Magic®, which technique is much simpler according to the manufacturer. Forty third molars were included into acrylic resin and divided in two groups of 20, one for each resin. Once the brackets were bonded, the specimens were submitted to horizontal force (10 of each group) and vertical (10 of each group), till the bracket got lost. The score obtained in the universal testing machine were recorded and compared by the average to set the advantages and disadvantages of each one.RESULTS AND CONCLUSION: Despite the recorded values of the Fill Magic® were much lower than the Concise®'s, they were far enough for direct orthodontic traction.

Rat subcutaneous tissue response to macrogranular porous anorganic bovine bone graft.

The ideal bone graft must present biocompatibility, osteoconductive and osteoinductive properties, resistance and plasticity. Xenogenic grafts of bovine cancellous bone origin are particularly interesting due to their biologically designed porous structure that enhance both cellular and vascular invasion. The purpose of this study was to evaluate the tissue response induced by bovine macrogranular porous anorganic bone implanted in rat subcutaneous tissue. Forty rats were assigned to 2 groups, as follows: the control group received empty collagen capsules and the test group received subcutaneous implants of the test material. Samples were collected after 10, 20, 30 and 60 days and processed histologically. Histological analysis showed at 10 days a granulomatous inflammatory infiltrate, rich in multinucleated giant cells and free of lymphocytes or plasma cells, similarly to mineralized allograft implanted in rat subcutaneous. In later periods, there was a significant decrease in the inflammatory infiltrate and an increase in fibrosis around graft particles. In conclusion, the test material induced a foreign body-type granuloma with subsequent fibrosis around the graft particles implanted in rat subcutaneous and did not elicit any immune response, thus being considered biocompatible.

Rat subcutaneous tissue response to macrogranular porous anorganic bovine bone graft

The ideal bone graft must present biocompatibility, osteoconductive and osteoinductive properties, resistance and plasticity. Xenogenic grafts of bovine cancellous bone origin are particularly interesting due to their biologically designed porous structure that enhance both cellular and vascular invasion. The purpose of this study was to evaluate the tissue response induced by bovine macrogranular porous anorganic bone implanted in rat subcutaneous tissue. Forty rats were assigned to 2 groups, as follows: the control group received empty collagen capsules and the test group received subcutaneous implants of the test material. Samples were collected after 10, 20, 30 and 60 days and processed histologically. Histological analysis showed at 10 days a granulomatous inflammatory infiltrate, rich in multinucleated giant cells and free of lymphocytes or plasma cells, similarly to mineralized allograft implanted in rat subcutaneous. In later periods, there was a significant decrease in the inflammatory infiltrate and an increase in fibrosis around graft particles. In conclusion, the test material induced a foreign body-type granuloma with subsequent fibrosis around the graft particles implanted in rat subcutaneous and did not elicit any immune response, thus being considered biocompatible.

O enxerto ósseo ideal deve possuir características como biocompatibilidade, capacidade osteocondutora, osteoindutora, resistência e plasticidade. Dentre os implantes xenogênicos de origem bovina, os produzidos com o osso esponjoso revestem-se de particular interesse devido a sua arquitetura constituída de poros biologicamente desenhados que favorecem a invasão celular e vascular até o centro do defeito. O objetivo deste estudo foi avaliar a resposta tecidual ao material de osso inorgânico medular bovino macrogranular. Quarenta ratos foram divididos em 2 grupos (n=20): o grupo controle recebeu cápsulas de colágeno vazias, e o grupo experimental recebeu implante subcutâneo do material teste. As amostras foram coletadas após 10, 20, 30 e 60 dias de implantação e processadas histotecnicamente. A análise histológica mostrou aos 10 dias pós-cirúrgicos que o infiltrado inflamatório era do tipo granulomatoso rico em células gigantes multinucleadas, mas livre de linfócitos ou plasmócitos, quadro similar ao observado para aloenxertos mineralizados implantados em subcutâneo de ratos. Com o avançar do tempo experimental houve significante diminuição do infiltrado inflamatório inicial concomitantemente ao aumento no grau de fibrosamento ao redor das partículas implantadas. Concluiu-se que o material de enxerto testado em tecido conjuntivo subcutâneo de ratos induziu um granuloma tipo corpo estranho e fibrose ao redor das partículas implantadas, resposta semelhante do mesmo tecido aos aloenxertos mineralizados, e não desencadeou nenhuma resposta imune, sendo portanto biocompatível.