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LETTER TO THE EDITOR

Mandibular Nerve Block for the Removal of Dentures During Trismus Caused by Tetanus

Department of Anaesthesiology and Critical Care; Military Teaching Hospital Sainte Anne; Toulon-Naval, France; meaudre{at}club-internet.fr (Meaudre, Palmier) Department of Anaesthesiology and Critical Care; University Hospital Center; Nîmes, France (Ripart)

In Response:

We thank Dr. Singh for his comments (1) regarding our report on using a mandibular nerve block to treat trismus caused by tetanus (2). As pointed out, we did not insist on obtaining a paresthesia. Paresthesia during needle insertion is associated with increased risk of nerve injury (3). Although this point is still debated (4,5), the French anesthesia society guidelines encourage identifying the nerve by observing the motor response to a nerve stimulator when possible. However, the tetanic contraction precluded use of a nerve stimulator, so we used contact between the needle and the lateral pterygoid plate as the sole landmark to localize the nerve. This might explain imperfect needle position, and perhaps accounts for the 20-min delay in relief of masseter spasm, more than we expected with mepivacaine. The delay might also have been a consequence of the 48 h of masseter contracture before placing the block.

We agree with the technical details, precautions, and adverse effects of mandibular nerve block mentioned by Dr. Singh. In our case, we did not measure the distance to reach the lateral pterygoid plate before redirecting the needle posteriorly. We agree that the needle should be advanced cautiously beyond the distance to the lateral pterygoid plate to reach the mandibular nerve (6). We also agree that patients should be nil per os and that the intraoral approach appears to be associated with more complications than the extraoral approach.

REFERENCES

1. Singh B. Mandibular nerve block for the removal of dentures during trismus caused by tetanus. Anesth Analg 2006; 103.
2. Meaudre E, Pernod G, Gaillard PE, et al. Mandibular nerve blocks for removal of dentures during trismus caused by tetanus. Anesth Analg 2005;101:282–3.[Abstract/Free Full Text]
3. Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology 1997;87: 479–86.[Web of Science][Medline]
4. Karaca P, Hadzic A, Yufa M, et al. Painful paresthesiae are infrequent during brachial plexus localization using low-current peripheral nerve stimulation. Reg Anesth Pain Med 2003;28:380–3.[Medline]
5. Urmey WF, Stanton J. Inability to consistently elicit a motor response following sensory paresthesia during interscalene block administration. Anesthesiology 2002;96:552–4.[Web of Science][Medline]
6. Singh B, Srivastava SK, Dang R, et al. Anatomic considerations in relation to the mandibular nerve block. Reg Anesth 1993;18:181–3.[Medline]

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