Images in Otorhinolaryingology
Left lower hemilabium necrosis as a complication of infiltration under local anesthesia
Necrosis de hemilabio inferior izquierdo como complicación de infiltración con anestesia local
María Teresa Cervilla Martín
, María Romero Marchante, Rafael Sanz Trenado, Marta García Jimenez
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Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario de Cáceres, Cáceres, Spain
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Although infrequent, side effects, either local or systemic, may occur. Examples include: rapid diffusion of anaesthetic, intravascular injection, cardiovascular reactions, central nervous system reactions, allergic reactions, etc. Some of the complications include: sudden unilateral deafness, cranial nerve palsies, skin complications.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Below we describe a case of a cutaneomucosal complication, which we suspect was a consequence of post-infiltration LA vasospasm.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case study</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 9-year-old female patient, whose parents consulted due to the appearance of a mucosal lesion on the inner surface of the left lower hemilabium, following a dental procedure (filling) performed by her dentist 4 days earlier.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the initial ENT assessment, a whitish lesion with an indurated appearance was observed on the left lower lip, with a doubtful area of central fluctuation, affecting both the mucosa of the inner side of the lip and the vermilion, which was almost entirely covered by a large hard, dehydrated crust with a necrotic appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The procedure from which the clinic symptoms developed consisted of a dental filling. It was performed under local anaesthesia: infiltration of a 1.8 ml lidocaine carpule.</p><p id="par0030" class="elsevierStylePara elsevierViewall">She was admitted for intravenous treatment with methylprednisolone and Augmentine® according to weight, as well as analgesia and serotherapy. She was also treated with nasal Bactroban® and nitroglycerin ointment, both for topical use on the mucosal lesion.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After 4 days of hospitalisation, the patient showed a clear improvement in the lesion and was discharged with oral Augmentine® for 7 days, and application of topical Bactroban® nasal and Aloclair® Plus gel on the lesion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). She was reviewed 3 days later and the lesion was found to be completely healed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The inferior alveolar artery is a collateral branch of the internal maxillary artery that follows a descending and anterior course until it enters the mandibular foramen, where it divides into 2 terminal branches: the incisor branch, which perfuses the incisor-canine area, and the mentonian branch, which perfuses the lower lip and chin area.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Contact between a needle and an artery can cause vasospasm, resulting in transient ischaemia of the inferior alveolar artery, which would manifest with discomfort and pallor in the area. In addition, a perivascular injection can lead to stimulation of the sympathetic nerve and subsequent vasospasm of the vessels, which again can lead to necrosis of peripheral tissue.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The inferior alveolar nerve block is one of the most commonly used anaesthetic techniques in dental surgery. The main vascular structures possibly affected by this anaesthetic technique are the maxillary artery, the inferior alveolar artery and vein and the pterygoid venous plexus. During this process it is essential to aspirate prior to administration of any type of anaesthetic block to prevent both systemic and locoregional complications secondary to intravascular injection of the anaesthetic solution.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In a non-negligible percentage of cases, LA injection may accidentally be performed intra-arterially if aspiration is not performed prior to infiltration, so it is important to be aware of possible side effects and to inject the LA slowly<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>; even so, negative aspiration test results are not an absolute guarantee against anaesthetic complications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is controversy as to the ideal needle size to use during the procedure (25, 27 or 30 gauge). Larger needles will provide greater certainty as to whether the aspiration is in intravascular territory, while smaller needles could, according to the visual analogue scale, cause less pain to the patient during the procedure, although there is no scientific evidence to support the latter assumption.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the event of an adverse reaction following LA infiltration, the most important thing is to diagnose the problem early, inform the patient and apply treatment as soon as possible to avoid further complications.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Post-infiltration necrosis with AL is a complication to be considered when a whitish lesion on the labial mucosa begins to appear hours after a dental procedure. Its initial treatment is conservative, with antibiotherapy and intravenous corticotherapy. 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