Accidental facial nerve injection

[TheTruckGuy]

ER doc here. Saw a patient the other day, sent by ambulance from the dentist without any paperwork or anything. According to the patient he was sent because he started having facial swelling and trouble talking. By the time I saw him, it was roughly 2 hours after he had received local anesthetic and the symptoms started. He did have some right sided facial droop and slurred speech, but otherwise normal exam. Perhaps a little uvula deviation away from the affected side, but minimal if so. Felt as though his throat was feeling weird as well.

Based off the acute onset immediately after local anesthetic injection, and the patient stating that it was getting a little better than it was an hour earlier, I presumed it was all anesthetic related. Observed the patient another 2 hours, and symptoms almost gone.

Question to y'all is, did this dentist think there was a stroke going on? Is there some complication I should be aware of that I should have evaluated the patient for?

I know I could have called the dentist, but it was a Monday and we had a steady stream of ambulances lined up almost all day long. Thanks in advance.

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[veryhappylabrador]

He/she probably suspected a stroke. Can be scary in a dental office when you're solo and the patient can't move half their face and starts freaking out.

Transient Delayed Facial Nerve Palsy After Inferior Alveolar Nerve Block Anesthesia

Facial nerve palsy, as a complication of an inferior alveolar nerve block anesthesia, is a rarely reported incident. Based on the time elapsed, from the moment of the injection to the onset of the symptoms, the paralysis could be either immediate or delayed. ...

www.ncbi.nlm.nih.gov

 

[yappy]

They may have suspected an allergic reaction. Some dentists use a topical ester anesthetic that can, in rare circumstances, cause an allergic reaction. Some stronger versions are compounded by pharmacy that can inadvertently anesthetize the upper airway and give the patient a choking sensation. I agree that they may have also suspected stroke if they were not aware that accidental numbing of CN7 can occur when doing a mandibular block, especially in small patients. If that is the case, the symptoms resolve after the medication wears off. Most last a few hours, but bupivacaine can last up to 6.

 

[Molar Whisperer]

As a dentist, I would follow up that pt. Practicing for 26 yrs, I had similar complications a hand full of times. I had notice the Facial nerve branches blanch (tongue twister) from either Facial nerve anesth or epi getting into the vascular circulation. Fortunately, those cases clear up fast and the pts were able to be dismissed without incidence. I had much worse complications such as NaOCl getting past the root apex and routine syncope. I had a pt swallow topical anesth and with his throat getting numb, he had to stop in the middle of a root canal and leave (he never came back).

 

[TheTruckGuy]

As a dentist, I would follow up that pt. Practicing for 26 yrs, I had similar complications a hand full of times. I had notice the Facial nerve branches blanch (tongue twister) from either Facial nerve anesth or epi getting into the vascular circulation. Fortunately, those cases clear up fast and the pts were able to be dismissed without incidence. I had much worse complications such as NaOCl getting past the root apex and routine syncope. I had a pt swallow topical anesth and with his throat getting numb, he had to stop in the middle of a root canal and leave (he never came back).

You mean the dentist that did the injection should follow up that patient? Or you think I should follow up and see how things turned out?

I can imagine pharyngeal anesthesia would be quite uncomfortable and unnerving when you're pinned down reclined.

Another random question, but do dentists do much/any facial suturing? I know OMFS does. But curious if general dentists can, for example, suture a lip lac that crosses the vermilion border?

 

[veryhappylabrador]

You mean the dentist that did the injection should follow up that patient? Or you think I should follow up and see how things turned out?

I can imagine pharyngeal anesthesia would be quite uncomfortable and unnerving when you're pinned down reclined.

Another random question, but do dentists do much/any facial suturing? I know OMFS does. But curious if general dentists can, for example, suture a lip lac that crosses the vermilion border?

If I injected, I would follow up the next day. I’ve had post-anesthetic complications last 6 weeks in some instances.

Dentists have varying levels of suturing comfort. Anything inside the mouth most dentists would be fine with and some are comfortable suturing lips as well. Personally when it comes to lips, I would rather a plastic surgeon or OMFS or dermatologist with more soft tissue and cosmetic experience take care of those.

 

[Molar Whisperer]

You mean the dentist that did the injection should follow up that patient? Or you think I should follow up and see how things turned out?

I can imagine pharyngeal anesthesia would be quite uncomfortable and unnerving when you're pinned down reclined.

Another random question, but do dentists do much/any facial suturing? I know OMFS does. But curious if general dentists can, for example, suture a lip lac that crosses the vermilion border?

Yes, the dentist that admin the injection and you. It creates goodwill and good relations to minimize deteriorating risk mgt (legal). Yes, Pharyngeal anesth is not pleasant and can lead to claustrophobic anxiety especially with a Rubber Dam on for RCTs. We GP dentists don't do any extraoral suturing for many reasons including liability and comfort level. I had a colleague whose wife had metastatic cancer in the middle ear spreading to the face. They needed OMFS, ENT, and plastics all doing their own thing and not encroaching on other's domain...fascinating dynamic of medical/dental specialties.