Fixation of bilateral condylar fractures with maxillary and mandibular nerve blocks.

Mandibulo facial injuries present special problems to the anesthesiologist in terms of the difficult airway. Hence, if regional anesthesia could be possible, it necessarily removes the major concern with airway access. We present a case of bilateral mandibular condylar fracture dislocation with the maxillary and mandibular nerve blocks on both sides. The surgery went on smoothly without any perioperative problems.

INTRODUCTION

Maxillary and mandibular nerves are branches of the trigeminal nerve. Blockade of the nerves can either be useful in selected surgical cases or diagnosis of pain syndromes.[1] Condylar fractures usually present to anesthesiologists with difficult airways. Airway aids like video laryngoscopes, fiberscopes are often used to anaesthetize such patients.[2] Regional anesthesia alone is rarely used to anesthetize such cases. We report one such case where we used bilateral combined maxillary and mandibular nerve block for a case of reduction and fixation of bilateral condylar fracture dislocation.

CASE REPORT

A 65-year-old 66 kg male patient presented to us with h/o fall followed by difficulty in opening the mouth of 10 days duration. He had no history of any prior systemic illness. On clinical examination, he was conscious, afebrile with stable vitals. The patient was an occasional wheezer. He had restricted mouth opening with an inter incisor distance of <0.5 cm. There was no clinical evidence of head, chest and abdominal injuries. Routine laboratory evaluation showed hemoglobin of 9 g%, random blood sugar of 93 mg%, serum creatinine of 0.8 mg%. A routine, electrocardiography, X-ray chest, an echo heart were normal. A computed tomography scan of the face showed bilateral mandibular condylar fracture dislocation. He was posted for reduction of dislocation with internal fixation in the dental chair. A preoperative nebulization with budesonide and levosalbutamol was done half an hour prior. Monitoring included pulse oximetry and noninvasive blood pressure. As the surgery involved reduction, screwing of both maxilla and mandible in both sides, a plan of bilateral maxillary and mandibular nerve blocks by extraoral approach was made. A local anesthetic solution of 20 ml of 0.5% bupivacaine with 0.1 ml of sodium bicarbonate was made. After aseptic precautions, with the patient sitting, the condylar notch was identified. The needle was inserted into the space below the midpoint of the zygomatic process till the needle hits the lateral pterygoid plate. After that, it was slided posterior and superior to get paresthesia of the mandibular region, and 3 ml was deposited. The needle then was withdrawn till subcutaneous plane to go back and hit the pterygoid plate. Then for accessing maxillary nerve, the needle was slided anterior and lower to deposit around 3–4 ml. The procedure was repeated for other side, but the right side had a distorted anatomy, which made identification of condylar notch difficult. Still we managed to elicit paresthesia and administer the block [Figure 1]. Anesthesia was complete on both nerves on two sides in around 10 min. The technique is similar to Braun's method of blocking these said nerves. The surgeon proceeded with vigorous pulling of the lower jaw to reduce the dislocation, followed by screws and wires both sides of upper and lower jaws to maintain the reduction [Figure 2]. The procedure which lasted for 30 min was absolutely painless. The ophthalmic nerve was spared. Complete recovery of the block was noticed in 3 h. There were no side effects.

Figure 1

Extra oral approach of blocking maxillary and mandibular nerves

Figure 2

Screws in both the maxillary and mandibular regions

DISCUSSION

A mandibular nerve block is usually administered to patients undergoing surgical procedures of the mandible – may be done either as an isolated nerve block or as a complement to general anesthesia. This includes several dental procedures on the lower teeth and surrounding soft tissues. The mandibular nerve block[3] has a success rate of 95–98%. Distortion of the regional anatomy is a relative contraindication to block, still we did it as we were able to identify the pterygoid plate and get paresthesia. Vazirani-Akinosi[4] (closed-mouth) technique is an intraoral technique, which can be used in patients with limited mouth opening, but hematoma, persistent paresthesia are some of the described complications, which did not occur in our case. Our case was different in that the upper teeth also need screws and plating. Hence, we need to combine maxillary block on both sides. We did not use any form of narcotics or sedatives If the fracture is fresh, mostly after induction, the spasm declines to post any problems in airway access. In our case, the patient presented to us after 10 days, which makes the patient prone for airway complications. Chadha et al. from India[5] investigated the effect of bilateral maxillary nerve block in suppressing the responses to the incision after general anesthesia in patients posted for transsphenoidal surgery. We resorted to Braun's technique[6] as we were used to that method in unilateral blocks. The technique used is not different from established ones but blocking both nerves on two sides to conduct the case is a new approach. Usually, sodium bicarbonate is not combined with bupivacaine, still we used the same to get possible benefits.[7] On a complete search of the internet, we could not get any reference to our mode of management. Elective fiberoptic intubation with controlled general anesthesia is the described method for such cases. We opted out to make it cheaper and safe as described mishaps are described with intubation. It is difficult to mobilize gadgets in anesthesia in a dental chair scenario. Hence, we state that this could possibly be the first reported case of bilateral combined maxillary and mandibular block for the management of condylar fractures.

CONCLUSION

Management of bilateral mandibular condylar fractures is possible with regional anesthesia alone without sedatives with the establishment of bilateral maxillary and mandibular blocks.