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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 93-94
 

A rare case of masseter spasm after propofol


Department of Anaesthesia and Critical Care, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Bhavna Gupta
House No 98, Om Vihar Phase 1a, Uttam Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_46_18

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How to cite this article:
Gupta B, Gupta L. A rare case of masseter spasm after propofol. Indian Anaesth Forum 2018;19:93-4

How to cite this URL:
Gupta B, Gupta L. A rare case of masseter spasm after propofol. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:93-4. Available from: http://www.theiaforum.org/text.asp?2018/19/2/93/245551




Sir,

A 45-year-old male patient (height 165 cm and weight 67 kg) ASA 1, was scheduled to undergo modified radical mastoidectomy under general anesthesia. His preoperative history and examination was insignificant, and laboratory investigations were within normal limits. The patient did not receive any premedication. Routine standard monitors were applied, he was preoxygenated with 100% oxygen, and slow intravenous 150 micrograms fentanyl was given. After 7 min, 150 mg propofol was injected slowly titrated to loss of consciousness and apnea. About 45 s later, the patient stopped breathing, and became unconscious, and developed severe masseter and neck muscle spasm with a locked jaw. The jaw was held forward, and the patient did not resist movement or grimace at forceful opening of the mouth. Jaw thrust is an indirect parameter to assess the adequate depth for insertion of laryngeal mass airway.[1] Ventilation was impaired and insertion of oropharyngeal airway or supraglottic device was impossible. 100% oxygen was provided via intermittent oxygen flush so as to avoid fall in saturation. Further bolus of 50 mg propofol was given, but that too did not relax the jaw. Suxamethonium chloride 100 mg was given to break the spasm and simultaneously ENT personnel were ready for emergency tracheostomy as a backup plan. Subsequently, muscle spasm was relived after 1 min and ventilation and oxygenation could be maintained. Laryngoscopy and intubation were done successfully after adequate relaxation and patient was handed over to surgeons. Long-acting muscle relaxant, vecuronium bromide was given in two-third of induction dose after patient recovered from the effect of suxamethonium, after 15 min. Anesthesia was maintained with O2:N2O and isoflurane. Surgery lasted for 2 h, the patient was extubated and shifted to postoperative recovery area. The patient had no recall of events during intraoperative period, and there was no sign of impaired mouth opening and it was same as that in preoperative period. Neurology consultation was sought, and he was advised computed tomography and magnetic resonance imaging, both of which were in normal limits. The event of propofol-induced muscle rigidity was told to patient and relatives and was also mentioned in the discharge summary.

Masseter spasm after induction of anesthesia is one of the dreaded complications and is considered an anesthesiologist's nightmare. Oxygenation, ventilation, direct laryngoscopy, and intubation become impossible in the event of masseter spasm, as there is almost complete closure of mouth and leads to “cant ventilate cant intubate” scenario. Initially, we thought that spasm is due to insufficient depth of anesthesia; therefore, further bolus of propofol was given, but there was complete apnea, no movement or grimace of any kind was observed. Other differential in the background of masseter spasm was malignant hyperthermia, but there was no known triggering agent, inhalational anesthetics were not started, although traces of volatile agents cannot be completely ruled out. There was no rise in temperature, or rise in heart rate, blood pressure and end-tidal carbon dioxide. We gave suxamethonium to break muscle rigidity, which however itself can trigger masseter spasm. In the event of crisis, we were prepared for emergency tracheostomy as dantrolene was not available at our setup. The use of inhalational anesthetics in intraoperative period after intubation also rules out malignant hyperthermia. Nondepolarizing muscle relaxants such as vecuronium or atracurium could have been considered instead of suxamethonium but were not used due to their long action in the possible event of “cant ventilate cant intubate” scenario. Muscle rigidity is also a known complication of opioid agonists such as fentanyl, but rigidity due to fentanyl is limited to thoracic muscle[2] and is usually not seen in dosage used and we waited for the action of opioids for more than 5 min. Propofol is known to cause myoclonus, mass movements, opisthotonus, and seizure-like activity, but these were not seen in our case, and rigidity is a rare complication of propofol. Our case suggests that suxamethonium chloride was effective to break the muscle rigidity induced by propofol, as also suggested by Asai et al.[3] although on the contrary, many case reports are available in literature that suggests propofol is effective in succinylcholine-induced muscle rigidity.[4]

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drage MP, Nunez J, Vaughan RS, Asai T. Jaw thrusting as a clinical test to assess the adequate depth of anaesthesia for insertion of the laryngeal mask. Anaesthesia 1996;51:1167-70.  Back to cited text no. 1
    
2.
MacGregor DA, Bauman LA. Chest wall rigidity during infusion of fentanyl in a two-month-old infant after heart surgery. J Clin Anesth 1996;8:251-4.  Back to cited text no. 2
    
3.
Asai T, Eguchi Y, Shingu K. Masseter spasm during induction of anaesthesia using propofol and fentanyl. Eur J Anaesthesiol 1998;15:614-5.  Back to cited text no. 3
    
4.
Elsharydah A, Kaminski AC. Propofol reduces succinylcholine-induced muscle rigidity in a patient with paramyotonia congenita. Anesth Essays Res 2017;11:273-4.  Back to cited text no. 4
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