Abstract
The oculocardiac reflex is developed by surgical or nonsurgical stimulations to the eyeball including manipulation of extraocular muscles. The authors came across a case of severe arrhythmia due to oculocardiac reflex caused by the stimulation of orbital tissue from the injury of lamina papyracea during endoscopic sinus surgery. Previous heart evaluations of the patient of this case suggested no abnormalities in the heart. This case shows that the oculocardiac reflex can occur during endoscopic sinus surgery but is not limited as the complication from ocular surgery.
1
Introduction
Since the introduction of endoscopic sinus surgery for chronic sinusitis treatment, endoscopic surgery has become the main paranasal sinus surgery because it offers less complications and faster recovery than conventional methods of surgery . However, the endoscopic sinus surgery still has risk factors posed by anatomical variation of the sinuses, difficulty in securing the visual during hemorrhage, and limited visual field . Although most of postoperative complications of endoscopic sinus surgery are reversible and transient in nature, it can also develop irreversible, fatal result. Therefore, it is very important to perform thorough preoperative examinations and to be able to cope immediately with possible complications . For example, oculocardiac reflex, one of the complications from strabismus surgery in ophthalmology caused by the traction of external ocular muscles or the stimulation of eyeball, became important as it was reported by Sorenson and Gilmore as a possible cause of arrest leading to death . We also encountered a case of oculocardiac reflex caused by the stimulation of internal rectus muscle from the damage of lamina papyracea during endoscopic sinus surgery, which we report herein along with the study of literature as there has been no occurrence ever reported yet.
2
Case report
A 53-year-old male patient visited our clinic with several years of posterior nasal dripping as a chief complaint. He had no history of hypertension, diabetes, cardiovascular disease, and other notable disease nor had he received any surgery previously. Blood test revealed no particular manifestation either. After physical examination and paranasal sinus computed tomography (CT), he was diagnosed with both maxillary sinusitis and ethmoid sinusitis ( Fig. 1 ). He was subjected to endoscopic sinus surgery after 2 weeks from his first visit. Left uncinectomy was performed for left middle meatal antrostomy, and then microdebrider was used below lamina papyracea to remove peripheral soft tissue and lesions in the nasal cavity of the lateral wall. There was suspicion of protrusion of soft tissue as periorbital fat tissue was found during the shaving of the nasal cavity of the lateral wall with microdebrider. Later, normal heart rate suddenly did not register followed by an indication of high-degree atrioventricular block in electrocardiogram (ECG) for more than 5 seconds before regaining normal heart rate ( Fig. 2 ). Surgery was discontinued immediately upon this incident and vital signs were closely monitored. The operation wound was examined again as no additional ECG abnormality was observed. Periorbital fat was seen bulging into the nasal cavity at the location where microdebrider has been used for palpation of eye as well as a small dehiscence. No exophthalmos or hemorrhage at the defective region was observed. As the defect was small enough, endoscopic sinus surgery was resumed and completed on the opposite side of the defect after treating the defect by applying a Gelfoam (Pfizer, New York, NY) soaked with ofloxacin and performing only Merocel packing (Medtronic, Mystic, CT). Because no further abnormality in vital signs could be observed and ECG also remained normal after the surgery, the patient was moved to his room after having been monitored in the recovery room for several hours and was instructed to remain at bed rest. The patient was given a high dose of corticosteroid initially followed by gradually reduced doses together with supportive care. A mild diplopia on the left side accompanied by left orbital ecchymosis and headache occurred, but no decreased visual acuity nor impairment of eyeball movement was observed. An orbital CT was performed 1 day after the surgery, which showed a bony defect and emphysema in left lamina papyracea, but there was no defect in external ocular muscle, especially in internal rectus muscle ( Fig. 3 ). The Merocel packing was removed 2 days after the surgery because the patient showed gradual symptomatic improvement without incidences of headache and diplopia. He remained at the hospital until 10 days after the surgery under observation before being discharged. He is well to this day without particular complaints.
