a case report mandibular Bilateral nerve injury following maskventilation: DEANESTESIOLOGIA REVISTABRASILEIRA

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RevBrasAnestesiol.2018;68(4):425---429

REVISTA

BRASILEIRA DE

ANESTESIOLOGIA

^Publicação^Oﬁcial^da^Sociedade^Brasileira^deAnestesiologia www.sba.com.br

CLINICAL INFORMATION

Bilateral mandibular nerve injury following mask ventilation: a case report

Bahattin Tuncali

^a^,∗

, Pinar Zeyneloglu

^b

aBaskentUniversityZubeydeHanimPracticeandResearchCenter,DepartmentofAnesthesiology,Izmir,Turkey

bBaskentUniversity,FacultyofMedicine,DepartmentofAnesthesiology,Ankara,Turkey

Received16February2017;accepted28December2017 Availableonline1February2018

KEYWORDS Mandibularnerve injury;

Maskventilation;

Anesthesia

Abstract

Backgroundandobjectives: Nerveinjuryfollowingmaskventilationisararebutseriousanes- thetic complication.The majorityofreportedcases areassociated withexcessivepressure appliedtothefacemask,longdurationofmaskventilation,excessivedigitalpressurebehind themandibletorelieveairwayobstructionandpressureexertedbytheplasticoropharyngeal airway.

Casereport: Wepresentacaseofbilateralmandibularnerveinjuryfollowingmaskventilation withshortduration,mostlikelyduetoasemi-siliconefacemaskwithanover-inﬂatedcushion.

Conclusion: Anover-inﬂatedsealingcushionofafacemaskmaytriggerdifﬁcultmaskventilation leadingtomandibularnerveinjuryfollowingmaskventilation.Alternativeairwaymanagement techniquessuchaslaryngealmaskairwayshouldbeconsideredwhenairwaymaintenancecan onlybeachievedwithstrongpressureappliedtothefacemaskand/ormandible.

PALAVRAS-CHAVE Lesãodonervo mandibular;

Ventilac¸ãocom máscara;

Anestesia

Lesãodonervomandibularbilateralapósventilac¸ãocommáscara:umrelatodecaso

Resumo

Justificativaeobjetivos: A lesão nervosa após ventilaçãocom máscara éuma complicação anestésica rara,mas grave.A maioriados casos relatados está associada àpressão exces- sivaaplicadaàmáscarafacial,aotempoprolongadodeventilação,àpressãodigitalexcessiva atrásdamandíbulaparaaliviar aobstruçãodasviasaéreaseàpressãoexercidapelacânula orofaríngea.

∗Correspondingauthor.

E-mail:tuncali.bahattin@gmail.com(B.Tuncali).

https://doi.org/10.1016/j.bjane.2018.01.005

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Relatodecaso:Apresentamos um caso de lesão do nervo mandibular bilateral após uma ventilaçãodecurtaduraçãoviamáscara,provavelmentedevidoaousodeumamáscarafacial (desemissilicone)cominsuflaçãoexcessivadaalmofada.

Conclusão:Ainsuflaçãoexcessivadaalmofadadeumamáscarafacialpodedesencadearuma ventilaçãocommáscaradifícil,levandoàlesãodonervomandibularapósaventilação.Técnicas alternativasdemanejodasviasaéreas,comoousodemáscaralaríngea,devemserconsideradas quandoamanutençãodasviasaéreassópodeserobtidacomfortepressãoaplicadaàmáscara faciale/oumandíbula.

Introduction

Injury of nerves which innervate lower facial region fol- lowingmask ventilationis arareanesthetic complication.

Themajority ofcasesreportedhavebeen associatedwith excessivepressureappliedtothefacemask,longduration ofmask ventilation, excessivedigital pressure behindthe mandibletorelieveairwayobstructionandpressureexerted bytheplasticoropharyngealairway.^1---9However,thereislit- tleknowledgeabouttherelationshipbetweennerveinjury andthe type of thefacemask or the amount of air in its cushion.

Wepresent a caseof bilateral mandibularnerveinjury following difﬁcult mask ventilation most likely due to a semi-siliconefacemaskwithanover-inﬂatedcushion.Writ- tenconsentforpublicationofthisreportwasobtainedfrom thepatient.

Case description

A 51 years old woman underwent an endometrial biopsy undergeneral anesthesia. Shehad noprior historyof the medicalproblem.Anesthesiawasinducedwithmidazolam 1mg,fentanyl100␮gandpropofol150mgandmaintained withsevoﬂurane in nitrous oxide-oxygen administered by thefacemask.Jawthrustandtightfacemask(size4)seal usingdigitalpressurewithbothhandswererequiredforade- quatemaskventilation.AGuedelairwaywasalsoinserted.

The surgical procedure lasted 9min and the patient was ventilatedfor14min.Shewasthentransferredtotherecov- ery room and discharged home the same day. Five hours aftertheprocedure,thepatientpresentedtotheanesthetic departmentcomplainingofnumbness atboth sidesofher chin and lower lip. She described her sensationsas simi- lartothenumbfeelingafterdentaltreatmentunderlocal anesthesia. Clinical assessment showed bilateral parotid tendernessandloss of temperature andtouch perception atbothsidesofherchinandlowerlip.Therewasnomotor deﬁcit.Neurologicalevaluationperformedbyaneurologist revealed that the areaof numbness corresponded tothe areaofinnervationofthemandibulardivisionsoftheright andlefttrigeminalnerves(Fig.1A).Treatmentwithanon- steroidanti-inﬂammatoryagentandvitaminBwasstarted.

Follow-upofthepatientrevealedthatbilateralparotidten- dernessandthenumbnessattheleftsideofherfacewere improved gradually and recovered completely in 1 week (Fig.1B).Thenumbnessattherightsideofherfacewasalso regressedgraduallyfromherchintoasmallareaunderthe rightsideofherlowerlipafter3weeks(Fig.1C).Complete remissionoccurredwithin5weeks.

Discussion

Sensory and/or motor nerve dysfunction of the mental nerve, inferior alveolar nerve, mandibular division of trigeminal nerve and facialnerve following mask ventilation have been reported with several case reports since 1950s.¹ Reported cases of nerve injuries associated with mask ventilation under general anesthesia are presented in Table 1. The majority of cases were associated with long duration of mask ventilation and/or difﬁcult mask ventilation.^2---7 However, cases with easy ventilation and short duration were also reported.^1,8,9 Although digital pressure is frequently applied to the facemask and/or the mandible to relieve airway obstruction during mask ventilation in anesthesia practice, the reported cases of nerveinjury areinfrequent. Possibleexplanations maybe individualdifferences,anatomicalvariationsor hereditary predisposition. Moreover, there may be many unreported cases.

Difficult mask ventilation is described as the clinical situation that develops when it is not possible for the anesthesiologisttoprovideadequate maskventilation due to inadequate mask seal, excessive gas leak or excessive resistance to the ingress or egress of gas.¹⁰ Additionally, technicalproblems,inadequatedepthofanesthesia,patient and equipment related factors, separately or combined, may lead to difficult mask ventilation.¹⁰ Several authors reportedtheincidenceofdifficultmaskventilationbetween 1.4% and 5% and found various risk factors such as male gender, age older than 55 year, body mass index more than 26kg.m⁻², lack of teeth, history of snoring, pres- ence of a beard, Mallampati Class III or IV and limited mandibular protrusion test.¹¹ Although none of the risk factors werepresent inour patient,mask ventilationwas

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Maskventilationandbilateralmandibularnerveinjury 427

Figure1 (A)Fivehoursaftertheprocedure,numbnessatbothsidesofherchinandlowerlip.(B)Oneweekaftertheprocedure, numbnessattheleftsideofherfacewasimprovedgradually andrecoveredcompletely. (C)Threeweeksaftertheprocedure, numbnessattherightsideofherfacewasregressedgraduallyfromherchintoasmallareaundertherightsideofherlowerlip.

difﬁcult requiring chin liftand jaw thrust maneuvers and two-person.

The type, size and design of the mask can affect the effectivenessofventilation.¹² Bhuiyanetal.,⁶ pointedout that,whenadifficultairwayisencountered,alotofpres- sure is needed to get a good seal around the face with a semisilicone face mask than withthe traditional black rubber facemask. Therefore,following readmission of the patient we checked the facemask we used. In our case, weusedatransparent,disposable,semi-siliconefacemask withan inflatingvalveandcushionrimwhichiscommonly usedin anesthesia practice.Moreover,we found that the wallofitscushionwasover-stretchedduetoover-inflation with150mL of air volume.The type of the facemask we used and/or the excessive volume of air in its cushion mighthave partlycontributedtothiscomplication.Ensur- ing properinflation of the sealingcushion is importantin providinganeffectivesealandreducingtheriskofinadver- tentpressureovertheface.Ifthecushionisover-inflated, pressureisconcentratedtoasmallercontactareaoverthe face, leadingtodifficulty in maintainingthe seal,requir- inghigherdigitalpressures tothe maskand/or jaw-thrust maneuverbybilateraldigitalpressurebehindthemandible.

Moreover, these higher pressures may lead to compres- sionandinjuryof nerveswhichinnervate thelowerfacial region.¹³Thepotentialmechanismsofinjuryinourpatient were the combined effects of excessive direct pressure by therim of thefacemask againstthe mandibleand the stretchingforcescaused bystrongforward tractionduring jaw-thrustmaneuverduetodifﬁcultmaskventilationtrig- geredby thesemi-silicone facemaskwithan over-inﬂated cushion.

Nerveinjuriesmaybeapparentimmediatelyafterrecov- ery from anesthesia or may occur 1---2 days later.^1---9

Rapid onset is more likely to be direct nerve injury.

Various mechanisms included mechanical compression or stretching the nerve, ischemia, needle trauma or injec- tionof a neurotoxic material have been proposed. Other predisposing factors include hypothermia, hypovolemia, dehydration,hypotension,hypoxiaelectrolytedisturbances and anatomic variations.¹⁴ Clinical presentation includes anesthesia,hypoesthesia,paresthesiaandpainintheareas suppliedbytheaffectednerves.Theremayalsobeparesis orparalysisofaffectedmuscles.Fortunately,themajority ofcasesareself-limitedwithafullandspontaneousrecov- eryover10daysand3monthstoresolve.^1---9Inourpatient, bilateralnumbnessdistributedtotheareaofinnervationof themandibulardivisionsofthetrigeminalnervesbeganat thepostoperative5thhourandgraduallyresolved.Consid- eringthenerve anatomy,itappears likelythat theneural damagewas caused by extensive jaw thrust due to difﬁ- cultmaskventilation.Completeremissionoccurredover5 weeks.Despitethe completeresolution, thecomplication reportedherewasextremelydissatisfyingtothepatient.

Inconclusion,nerveinjuryfollowingmaskventilationis multifactorialinorigin.Anover-inﬂatedsealingcushionof afacemaskmaytriggerdifﬁcultmaskventilationrequiring excessivedigital pressuretothemask, jaw-thrustmaneu- ver or oropharyngeal airway use. Although nerve injuries typicallycompletelyresolvewithinafewweekstoseveral months,the loss of sensation maylead to thermal injury or self-induced trauma to the affected areas. Therefore, patientsshouldbealertedtoavoidinjuries tothelipand mouth until any such numbness resolves. Lastly, alterna- tiveairwaymanagementtechniquessuchaslaryngealmask airwayshouldbeconsideredwhenairwaymaintenancecan onlybeachievedwithstrongpressureappliedtothefacemaskand/ormandible.

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B.Tuncali,P.Zeyneloglu Table1 Reportedcasesofnerveinjuriesassociatedwithmaskventilationundergeneralanesthesia.

Author Patient Age Sex Surgicalprocedure DifﬁcultMV Durationof MV(min)

Nerveinjury Possiblecause Onsetof symp- toms

Full recovery

Fuller etal.¹ (1956)

1 54 F Cholecystectomy (+) 30min Facial

nerve

Directpressureonthemask andstrongforwardtraction ofthemandible

After recovery period

After3 months

2 53 M Inguinalherniarepair (+) 10min 24h Within3

weeks Azaar

etal.² (1986)

3 44 F Dilatationandcurettage (−) 30min Mental

nerve

Excessivepressureofthe maskandairwayonthe mentalandinferioralveolar nervesrespectively

24hur Within5 weeks

4 47 F Incisionofbreastmass (−) 45min 24h After45

days Glauber³

(1986)

5 54 M Arthroscopic

menisectomyoftheknee

(+) 75min Facialnerve Liftingthejawforwardby bilateraldigitalpressure

24h Over5

weeks Gimmon⁴

(1988)

6 35 F Righthemicolectomy (−) ? Mental

nerve

Compressionbytheextraoral partofthetrachealtubeand tractionbyit’sﬁxation technique

24h Over5

weeks

Ananthanaryan etal.⁵

(1988)

7 19 M Circumcision (−) ? Facial

nerve

Directpressurebymaskon thenerves,pressurebehind themandibletorelieve airwayobstruction,oral airway,anatomicalvariations

? After10

days

8 48 F Breastbiopsy (−) 45min 24h Within4

weeks

9 58 M Cystoscopyand

hydrocelectomy

(−) ? 48h Within3

months Lorentz

etal.⁸(1988)

10 40 F Derotationosteotomyof femur

(+) 5---6min Mental

nerve

Considerablepressure exertedonthemask

24h Within6 weeks Bhuiyan

etal.⁶(2006)

12 43 F ExcisionofMortons’

neuroma

(+) 30min Mental

nerve

Excessivepressureofthe maskonthelowerlipagainst mandible

24h Within3 weeks Richaetal.⁷

(2008)

11 31 F Gynecologiclaparoscopy (−) 45min Mental

nerve

Pressureappliedbythe airwayonthementalbranch oftheinferioralveolarnerve

24h Within2 weeks Baidyaetal.⁹

(2011)

13 62 F Laporoscopic

hysterectomyand cholecystectomy

(+) 3min Mental,

buccal nerves

Forwarddigitalpressureat therightangleofthejaw

24h After6 weeks MV,maskventilation.

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Maskventilationandbilateralmandibularnerveinjury 429

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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