|Year : 2018 | Volume
| Issue : 1 | Page : 21-26
Experience with the use of local anesthesia in maxillofacial surgery
Kelvin Uchenna Omeje1, Otasowie D Osunde2, Benjamin Fomete3, Roland Agbara4, Thomas Owobu5, Abdul Rasheed Suleiman1
1 Department of Oral and Maxillofacial Surgery, Bayero University, Kano, and Visiting Consultant for Maxillofacial Surgery, Murtala Mohammed Specialist Hospital, Nigeria
2 Department of Dental Surgery, University of Calabar, Calabar, and Formerly Visiting Consultant for Maxillofacial Surgery, Murtala Mohammed Specialist Hospital, Kano, Nigeria
3 Department of Oral and Maxillofacial Surgery, Ahmadu Bello University, Zaria, Nigeria
4 Department of Dental and Maxillofacial Surgery, University of Jos, Jos, Nigeria
5 Federal Medical Center, Nguru, Yobe, Nigeria
|Date of Web Publication||14-Mar-2019|
Dr. Kelvin Uchenna Omeje
Department of Oral and Maxillofacial Surgery, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Background: Recent advances in anesthesia and the need to manage patients' perioperative anxiety along with escalating healthcare costs have resulted in an increasing number of surgical procedures being performed under local anesthesia (LA) especially as day-case surgeries worldwide. To report our experience with performing oral and maxillofacial surgeries under LA highlighting the advantages and limitations.
Patients and Methods: This study was a retrospective analysis of patients who underwent maxillofacial surgical procedures under LA at Murtala Mohammed Specialist Hospital, Kano, Nigeria, over a 2-year period (January 2014–December 2015). Information collated included the patients' demographics, clinical features, diagnosis, surgical operations performed, duration of hospitalization, and complications recorded. The data obtained were analyzed using Statistical Package for Social Sciences version 15.0.
Results: A total of 92 patients comprising 58 males and 34 females with varying maxillofacial conditions were operated during the period of the study. Their ages ranged from 12 to 60 years with a mean age of 32 ± 4.4 years. The complications recorded in the patients included three cases of malocclusion (3.2%), one case of wound dehiscence (1.1%), paraesthesia of the lower lip in one patient (1.1%), and cardiac arrest in one patient (1.1%).
Conclusion: Maxillofacial surgery under LA is a cost-effective approach to surgery with good outcomes in this environment.
Keywords: Good outcome, local anesthesia, maxillofacial surgery
|How to cite this article:|
Omeje KU, Osunde OD, Fomete B, Agbara R, Owobu T, Suleiman AR. Experience with the use of local anesthesia in maxillofacial surgery. Arch Int Surg 2018;8:21-6
|How to cite this URL:|
Omeje KU, Osunde OD, Fomete B, Agbara R, Owobu T, Suleiman AR. Experience with the use of local anesthesia in maxillofacial surgery. Arch Int Surg [serial online] 2018 [cited 2020 Oct 21];8:21-6. Available from: https://www.archintsurg.org/text.asp?2018/8/1/21/254142
| Introduction|| |
Oral and maxillofacial surgery is the specialty of dentistry that includes the diagnosis as well as surgical and adjunctive treatment of diseases, injuries, and defects, including both the functional and esthetic aspects of hard and soft tissues of oral and maxillofacial region. A majority of maxillofacial cases are performed under general anesthesia because of the complex anatomy of the face and profound neurovascular supply in the orofacial region. Some oral and maxillofacial surgical procedures can, however, be performed under local anesthesia (LA), with or without conscious sedation depending on the extent of the lesion and the ease of surgical access. Other factors that determine whether surgery can be performed under LA include surgical skill of the operator and age of the patient. LA is often preferred for less extensive lesions, where access is favorable and in adults especially when the surgeon is experienced with the use of LA. Other factors guiding the choice of anesthesia for maxillofacial procedures include patient's choice of anesthesia, infection at the site of LA injection, comorbid medical conditions, available financial resources to cater for the cost of surgery, operating facilities, manpower, and surgeons' choice.
Many oral and maxillofacial surgical procedures including forceps extraction of teeth, suturing of simple linear lacerations, and incisional biopsies are routinely performed under LA. Several techniques can be used to achieve anesthesia of the dentition and the surrounding hard and soft tissues of the maxilla and mandible. Local anesthetic techniques in the oral and maxillofacial region range from infiltration, field block, and nerve block depending on the site and procedure to be performed.
Recent advances in anesthesia and surgical techniques, along with escalating healthcare costs, have resulted in an increasing number of surgical procedures being performed under LA especially on a day-case basis worldwide. The introduction of new anesthetic applications enables patients to undergo lengthy and complex procedures as outpatients and then promptly and safely be discharged home. These newer methods include the use of vibrotactile devices, computer-controlled local anesthetic delivery systems, jet injectors, safety dental syringes, and devices for intraosseous anesthesia.
With a rise in the level of awareness of the role of the maxillofacial surgeon in the management of maxillofacial and related head and neck lesions, the number of oral and maxillofacial surgical procedures performed under LA with or without conscious sedation has been on the increase. This may be attributed to greater demand for theater operating space following the need to perform more surgeries. Paucity of qualified anesthetists especially in resource-limited countries and global economic recession have reduced the capability of patients to cater for the cost of surgeries in countries with poorly funded health systems, thus increasing the demand for surgeries under LA. Although there is a limit to the use of LA in certain maxillofacial procedures, its advantages of simplicity, lower cost, and safety over general anesthesia makes it a readily available option in the hands of practitioners who are conversant with the techniques. Other benefits of performing maxillofacial surgery under LA include reduction in surgical waiting list and postoperative morbidity owing to early ambulation.
In Murtala Muhammed Specialist Hospital (MMSH), Kano state, a government secondary healthcare center adjudged the biggest and most patronized general hospital in the entire Sub-Saharan Africa,, a majority of the oral and maxillofacial surgical procedures are performed under LA with or without conscious sedation due to paucity of qualified physician anesthetist in the center.
This article is a review of oral and maxillofacial surgeries performed under LA at MMSH, Kano, with emphasis on its advantages and limitations. This review may be beneficial to other similar health facilities.
| Patients and Methods|| |
This study was a retrospective analysis of oral and maxillofacial surgeries performed at MMSH, Kano state, Nigeria, over a 2-year period (January 2014–December 2015). Sources of clinical information included accident and emergency records; oral and maxillofacial surgical records, and patients' case files. All surgeries performed under general anesthesia, forceps extraction of teeth, incisional biopsies, and suturing of simple linear lacerations were excluded. Information collated included patients' age, gender, working diagnosis, duration of admission, treatments carried out, and postoperative complications.
The mode of anesthesia used in the patients included LA with or without conscious sedation. Local anesthetic procedures used the use of lignocaine with 1:80,000 adrenaline except when tumescent technique was used in which case further dilution up to 1:1,000,000 was done. Adult patients who required conscious sedation were given parenteral administration of a combination of 30 mg pentazocine and 10 mg diazepam in addition to the local anesthetic agent. Patients who had significant soft tissue and bone manipulation or unanticipated prolonged procedure had infiltration of bupivacaine (long-acting LA) around the surgery site to reduce postoperative pain.
The data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc, Chicago, IL, USA). Absolute numbers and simple percentages were used to describe categorical variables. Quantitative variables were described using measures of central tendency (mean, median) and measures of dispersion (range, standard deviation) as appropriate.
| Results|| |
A total of 102 surgeries were carried out among 64 males and 38 females during the study period. Five surgical cases involving three male and two female patients were excluded from the study on account of incomplete or missing data. Another five cases also involving three male and two female patients carried out under GA were also excluded. Thus, a total of 92 cases (58 males and 34 females) were studied giving a gender ratio of 1.7:1.
The distribution of patients according to age and gender is shown in [Table 1]. The ages of the patients ranged from 12 to 60 years with a mean age of 32 ± 4.4 years. There were significantly more males than females (χ2 = 0.049; P = 0.043). The indications for surgery and the procedures are shown in [Table 2]. Local anaesthesia was supplemented with conscious sedation in certain cases such as enucleation of jaw cyst [Figure 1], [Figure 2], [Figure 3]. There was a complication rate of 6.5%; the complications recorded in the patients included three (3.2%) cases of malocclusion in patients who had mandibular fracture treatment, one case of wound dehiscence (1.1%) following excision of lipoma of the scalp, paraesthesia of the lower lip in one patient (1.1%) who had excision of a benign parotid tumor, and cardiac arrest in one patient (1.1%) during cleft lip repair. The duration of hospital stay is also displayed in [Table 2]. The additional time spent by patients who were required to be admitted before surgery because of the long distance they had to travel to arrive at the hospital were not included in the duration of admission. Most of the patients treated under LA were managed as day-case surgeries, thus were discharged home on the same day after the procedure.
|Table 2: Diagnosis and procedures performed under local anesthesia with/without conscious sedation|
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|Figure 1: Intra-operative Photograph of a 14-year-old patient undergoing enucleation of a dentigerous cyst under local anesthesia|
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|Figure 2: Photograph of the same patient above, immediately following cyst enucleation|
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|Figure 3: Photograph showing surgical specimen following dentigerus cyst enucleation|
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| Discussion|| |
In contrast to the use of LA, maxillofacial surgical procedures performed under general anesthesia have the following peculiarities among others: need for either nasotracheal or orotracheal intubation (to protect the airway), shared space and proximity with the anesthetists, and need for close anesthetic monitoring. LA with or without conscious sedation is often the anesthesia of choice in patients with chronic obstructive pulmonary disease, short-duration surgical procedures, minor surgeries, or where there is unavailability of trained anesthetist or an anesthetic machine and equipment.
The use of LA allows the performance of surgical procedures outside the operating theater; it also supplements postoperative analgesia and minimizes blood loss. Recent economic pressure has necessitated a shift from operating theater to office-based procedures and has further driven the increase in local anesthetic technique utilization. Local anesthetic techniques used in maxillofacial surgery encompass infiltration of the operative site, tumescent techniques, and nerve blocks. Tumescent technique, which is a commonly used technique, involves administration of larger amounts of anesthetic agent, albeit in dilute concentrations. Adipose tissue is suffused through an infusion cannula in the subcutaneous space, with large volumes of diluted lidocaine (0.05%–0.1%) and a diluted concentration of adrenaline (1: 1,000,000) for both anesthetic and hemostatic effects. The safety of this technique lies in the fact that the anesthetic concentration is extremely small, allowing large amounts of solution to be used without reaching toxic levels. For example, a mixture of 500 mL of normal saline with 50 mL of 2% lidocaine will result in a concentration of lidocaine of less than 0.2%. In addition, a tissue plane is created that aids in later dissection.
Despite the ease of application and versatility of LA, it may, however, be contraindicated in patients with allergy to components of the available of LA and in young children where co-operation may be a problem. Chukwuneke et al. suggested that maxillofacial surgeons from developing and economically disadvantaged nations should master the use of LA in performing maxillofacial surgery as it can be an effective alternative to the use of general anesthesia which may sometimes be difficult and expensive. Management of maxillofacial surgical cases under LA especially when instituted as a day case was noted by Arole to represent a cost-saving phenomenon for both patient and hospital. It was said to also reduce the main operation list and psychological burden of hospitalization for the patients.
Several successful surgeries were performed under LA during the period of the study; this was contrary to the protocol adopted by Ajike et al. who though worked in the same state at a different period managed similar cases as in this study mostly under GA.
Three of the 15 cases of reduction and immobilization performed under LA were complicated by malocclusion. Several factors may be responsible for malocclusion following treatment of mandibular fractures. This may include improper application of osteosynthetic devices and delayed treatment of mandibular fractures with loss of some bone segments and immediate loading of the jaws when a nonrigid fixation technique is applied.
The finding of cardiac arrest as in one of our patients has been well-documented in the literature., Although this is commoner with GA, it has been reported in patients managed under LA as well. The commonest cause of cardiac arrest during GA is prolonged hypoxia during intubation; however, its cause during utilization of LA is mostly related to intravascular injection of LA-containing adrenaline. Although very low concentrations are used, lidocaine and adrenaline may result in toxicity. Lidocaine toxicity has neurological and cardiac effects. The first signs of toxicity include circumoral numbness, tinnitus, and light-headedness in conscious patients. Increasing levels cause tremors, seizures, and eventual cardiac and respiratory arrest. In patients under general anesthesia, arrhythmias may be the only sign.
The case of cardiac arrest in our series may have been as a result of inadvertent intravascular injection; this patient had an uneventful recovery in the intensive care unit following prompt institution of cardiopulmonary resuscitation.
The successful utilization of LA for these cases in our setting strongly underscores the need for mastery of LA in maxillofacial surgical practice. The age distribution of patients managed under LA showed that there was less number of patients at extremes of ages in the spectrum. Few numbers of the patients in the second and sixth decades of life might demonstrate the age limitations for LA; this may be likely due to the need for more control of various physiologic parameters in such patients thereby indicating the need for GA. The significantly more number of male patients managed under LA compared with females may be related to gender difference with respect to acceptance of surgical procedures under LA. Other reasons for fewer numbers of females seen and treated in this region have been noted by Agbara et al. to be related to the culturoreligious practice in this part of the country that does not encourage women outdoor engagements. The large number of patients treated under LA in the present setting was because of paucity of trained anesthetist, inadequate facilities for GA in the operating rooms, and the inability of patients to afford the cost of treatment under GA, which is about eight times the cost of treatment under LA in our setting.
A very important consideration in the utilization of LA is patients' selection; factors that guide the prescription of LA may include age of the patient as well as size and site of the lesion. LA is often preferred for smaller lesions, where access is favorable as well as in adults especially when the surgeon is experienced with the use of LA.
The protocol adopted by our study center for maxillofacial surgery patients treated under GA involves preoperative admission of patients for evaluation and optimization and postoperative admission for observation and medication. This when compared with that for LA for similar procedures when indicated invariably shows that patients managed under LA may experience better convenience (following earlier discharge to the comfort of their homes), lower treatment cost, and reduced amount of man-hour loss in seeking for healthcare.
The major challenges associated with maxillofacial surgeries under LA may include problems of postoperative pain after discharge; this is more of a problem among patients managed as day-cases. Studies have shown that about 30%–40% of patients discharged following surgeries as outpatients may suffer from moderate to severe pain during the first 24–48 h. This pain, although known to decrease with time, may be severe enough to interfere with sleep and daily functioning. Techniques used in our cases for management of pain following surgery include careful selection of cases to benefit from LA alone or LA in combination with conscious sedation. Patients who had significant soft tissue and bone manipulation or unanticipated prolonged procedure had infiltration of bupivacaine (long acting LA) around the surgery site to reduce postoperative pain. Adequate care must be taken following this infiltration especially in highly vascularized areas to prevent inadvertent intravascular injection and consequent systemic toxicity. Other measures used in our patients to prevent significant postoperative pain were prescription of supplementary potent oral analgesics. This is best taken especially before going to bed on the first night after surgery. Our patients must also meet standard discharge criteria following day surgeries with LA before being discharged. Other prerequisites for the treatment of patients under LA especially as day case in our study were patient's distance from the hospital (in case of complication) and availability of a responsible adult at patients' homes. When patients reside at a considerably far distance from the hospital or lack the availability of a responsible adult at home, even when LA is indicated, such patients were not managed as day cases.
| Conclusion|| |
Considering the low level of complications experienced in the cases reviewed, it can be deduced from this study that more maxillofacial surgical treatments can be carried out under LA than is usually practiced. However, the success of such treatments under LA with or without conscious sedation depends on appropriate case and patient selection. Factors that have prompted the expansion of the scope of maxillofacial surgery under LA in the study center were economic barriers against treatment under GA, lack of trained anesthetists, and perioperative personnel.
- In situations where economic or environmental factors hinder the performance of surgery under GA, maxillofacial surgeons are encouraged to consider the Option of surgery under LA provided proper selection with regards to patient and type of surgery has been made. It is therefore important that maxillofacial surgeons improve their skills in perioperative pain management for surgical cases under LA. This will reduce the number of patients being denied surgical treatment due to inability to perform such procedures under GA
- Adequate number of anesthesist, operative personnel, and surgical facilities should be provided in our healthcare facilities to improve the quality and number of surgical procedures carried out in our health facilities. Surgical procedures that are too complex to be carried out under LA can then be performed under GA with the presence of anesthetist and increased availability of trained perioperative personnel.
- The study was retrospective, thus limited by factors such as data filing and retrieval which may lead to underreporting. This is most important in our environment where electronic preservation of data is relatively unavailable
- Patients' selection is dependent on surgeon's experience in the use of LA; inappropriate patient selection may lead to high number of unprepared conversion of cases from LA to GA.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]