{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T00:55:15Z","timestamp":1781744115843,"version":"3.54.5"},"reference-count":30,"publisher":"American Dental Society of Anesthesiology (ADSA)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:p>The trigeminocardiac reflex (TCR) is clinically defined as the sudden onset of increased parasympathetic activity resulting from stimulation of the trigeminal nerve. This reflex increases parasympathetic tone and can lead to significant bradycardia and hypotension. We report the case of severe bradycardia and hypotension that occurred under general anesthesia during insertion of a cotton swab into the nasal cavity. A 57-year-old woman was scheduled for nasotracheal intubation for oral surgery, and following loss of consciousness, intubation was initiated using cotton swabs soaked in a solution of 2% lidocaine and 1:100,000 epinephrine that were inserted through the left nostril. The patient immediately developed severe bradycardia and hypotension which were managed with intravenous ephedrine after removing the cotton swabs rather than atropine due to concerns related to closed-angle glaucoma. The patient responded promptly to the ephedrine bolus, and no further complications occurred. It was assumed that the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve were stimulated by the cotton swabs being inserted into the nasal cavity, triggering the TCR. Anesthesiologists need to be aware of the risks associated with administering mydriatic drugs such as ephedrine and epinephrine, which are relatively contraindicated, as well as atropine to patients with closed-angle glaucoma.<\/jats:p>","DOI":"10.2344\/24-0050","type":"journal-article","created":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T00:30:49Z","timestamp":1781742649000},"page":"106-109","source":"Crossref","is-referenced-by-count":0,"title":["A Case of Severe Bradycardia Induced by Mechanical Stimulation of the Nasal Cavity Under General Anesthesia"],"prefix":"10.2344","volume":"73","author":[{"given":"Masanori","family":"Tsukamoto","sequence":"first","affiliation":[{"name":"Systemic Management for Dentistry, Kagoshima University Hospital, Kagoshima, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yukie","family":"Shirakawa","sequence":"additional","affiliation":[{"name":"Section of Anesthesiology, Department of Diagnostics and General Care, Fukuoka Dental College, Fukuoka, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miyoko","family":"Yutoku","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitsutaka","family":"Sugimura","sequence":"additional","affiliation":[{"name":"Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1191","reference":[{"issue":"1","key":"i1878-7177-73-2-106-b01","series-title":"Anesth Prog","first-page":"13","article-title":"Asystole and bradycardia during maxillofacial surgery","volume":"41","author":"Campbell","year":"1994","unstructured":"Campbell R,\nRodrigo D,\nCheung L. Asystole and bradycardia during maxillofacial surgery. Anesth Prog. 1994;41(1):13\u201316."},{"key":"i1878-7177-73-2-106-b02","series-title":"J Physiol","first-page":"5431","article-title":"Differentially modulate the trigeminocardiac reflex excitatory synaptic pathway in the brainstem","volume":"589","author":"Wang","year":"2011","unstructured":"Wang X,\nGorini C,\nSharp D,\nBateman R,\nMendelowitz D. Differentially modulate the trigeminocardiac reflex excitatory synaptic pathway in the brainstem. J Physiol. 2011;589:5431\u20135442."},{"issue":"3","key":"i1878-7177-73-2-106-b03","series-title":"Int J Oral Maxillofac Surg","first-page":"389","article-title":"Determination of trigeminocardiac reflex during rhinoplasty","volume":"41","author":"Yorgancilar","year":"2012","unstructured":"Yorgancilar E,\nGun R,\nYildirim M,\nBakir S,\nAkkus Z,\nTopcu I. Determination of trigeminocardiac reflex during rhinoplasty. Int J Oral Maxillofac Surg. 2012;41(3):389\u2013393."},{"issue":"6","key":"i1878-7177-73-2-106-b04","series-title":"J Neurol","first-page":"658","article-title":"A clinical phenomenon or a new physiological entity","volume":"251","author":"Schaller","year":"2004","unstructured":"Schaller B. Trigeminocardiac reflex. A clinical phenomenon or a new physiological entity? J Neurol. 2004;251(6):658\u2013665."},{"issue":"11","key":"i1878-7177-73-2-106-b05","series-title":"J Oral Maxillofac Surg","first-page":"2355","article-title":"Trigeminal nerve repair: Is the trigeminocardiac reflex a concern","volume":"79","author":"Hammad","year":"2021","unstructured":"Hammad Y,\nMootz A,\nKlein K,\nZuniga JR. Trigeminal nerve repair: Is the trigeminocardiac reflex a concern? J Oral Maxillofac Surg. 2021;79(11):2355\u20132357."},{"issue":"2","key":"i1878-7177-73-2-106-b06","series-title":"J Dent Sci","first-page":"878","article-title":"Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: a retrospective cohort study","volume":"19","author":"Wakita","year":"2024","unstructured":"Wakita R,\nBaBa Y,\nFukayama H,\nMaeda S. Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: a retrospective cohort study. J Dent Sci. 2024;19(2):878\u2013884."},{"issue":"18","key":"i1878-7177-73-2-106-b07","series-title":"Medicine (Baltimore)","first-page":"e807","article-title":"Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review","volume":"94","author":"Meuwly","year":"2015","unstructured":"Meuwly C,\nChowdhury T,\nSandu N,\nReck M,\nErne P,\nSchaller B. Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review. Medicine (Baltimore). 2015;94(18):e807."},{"issue":"1","key":"i1878-7177-73-2-106-b08","series-title":"Anesth Prog","first-page":"46","article-title":"Severe bradycardia occurring after assisted mouth opening: a case report","volume":"69","author":"Hayakawa","year":"2022","unstructured":"Hayakawa Y,\nFujii-Abe K,\nNakano T,\nSuzuki M,\nKawahara H. Severe bradycardia occurring after assisted mouth opening: a case report. Anesth Prog. 2022;69(1):46\u201348."},{"issue":"1","key":"i1878-7177-73-2-106-b09","series-title":"JA Clin Rep","first-page":"2","article-title":"Prevention of trigeminocardiac reflex-induced severe bradycardia during cerebral aneurysm clipping surgery by topical anesthesia of the dura surface and atropine administration: a case report","volume":"8","author":"Yoshida","year":"2022","unstructured":"Yoshida A,\nSeki T,\nAratani Y,\nTanioku T,\nKawamata T. Prevention of trigeminocardiac reflex-induced severe bradycardia during cerebral aneurysm clipping surgery by topical anesthesia of the dura surface and atropine administration: a case report. JA Clin Rep. 2022;8(1):2."},{"key":"i1878-7177-73-2-106-b10","series-title":"BMJ Case Rep","first-page":"2018226427","article-title":"Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa","volume":"2018","author":"Meuwly","year":"2018","unstructured":"Meuwly C,\nLeibundgut G,\nRosemann T,\nSchaller B. Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa. BMJ Case Rep. 2018;2018:2018226427."},{"issue":"39","key":"i1878-7177-73-2-106-b11","series-title":"Medicine (Baltimore)","first-page":"e35226","article-title":"A case report: a patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery","volume":"102","author":"Zhang","year":"2023","unstructured":"Zhang X,\nSun B,\nPac-Soo C,\nMa D,\nWang L. A case report: a patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery. Medicine (Baltimore). 2023;102(39):e35226."},{"issue":"9","key":"i1878-7177-73-2-106-b12","series-title":"J Oral Maxillofac Surg","first-page":"1862","article-title":"Asystole triggered by the mouth opening with a dental mouth gag under general anesthesia during pediatric oral surgery: report of a rare case","volume":"79","author":"Hoshijima","year":"2021","unstructured":"Hoshijima H,\nTakeuchi R,\nKikuchi K,\nMizuta K. Asystole triggered by the mouth opening with a dental mouth gag under general anesthesia during pediatric oral surgery: report of a rare case. J Oral Maxillofac Surg. 2021;79(9):1862\u20131865."},{"issue":"1","key":"i1878-7177-73-2-106-b13","series-title":"Anesth Analg","first-page":"126","article-title":"Case report: bilateral angle closure glaucoma after general anesthesia","volume":"112","author":"Gayat","year":"2011","unstructured":"Gayat E,\nGabison E,\nDevys JM. Case report: bilateral angle closure glaucoma after general anesthesia. Anesth Analg. 2011;112(1):126\u2013128."},{"issue":"11","key":"i1878-7177-73-2-106-b14","series-title":"A A Pract","first-page":"385","article-title":"Postoperative acute angle-closure glaucoma: a rare but serious complication: a case report","volume":"12","author":"Roor","year":"2019","unstructured":"Roor TL,\nKooijman JA,\nvan der Ploeg JM,\nde Boer HD. Postoperative acute angle-closure glaucoma: a rare but serious complication: a case report. A A Pract. 2019;12(11):385\u2013387."},{"issue":"4","key":"i1878-7177-73-2-106-b15","series-title":"Anesth Prog","first-page":"162","article-title":"Acute angle-closure glaucoma after general anesthesia for bone grafting","volume":"61","author":"Nitta","year":"2014","unstructured":"Nitta Y,\nKamekura N,\nTakuma S,\nFujisawa T. Acute angle-closure glaucoma after general anesthesia for bone grafting. Anesth Prog. 2014;61(4):162\u2013164."},{"issue":"1","key":"i1878-7177-73-2-106-b01","series-title":"Anesth Prog","first-page":"13","article-title":"Asystole and bradycardia during maxillofacial surgery","volume":"41","author":"Campbell","year":"1994","unstructured":"Campbell R,\nRodrigo D,\nCheung L. Asystole and bradycardia during maxillofacial surgery. Anesth Prog. 1994;41(1):13\u201316."},{"key":"i1878-7177-73-2-106-b02","series-title":"J Physiol","first-page":"5431","article-title":"Differentially modulate the trigeminocardiac reflex excitatory synaptic pathway in the brainstem","volume":"589","author":"Wang","year":"2011","unstructured":"Wang X,\nGorini C,\nSharp D,\nBateman R,\nMendelowitz D. Differentially modulate the trigeminocardiac reflex excitatory synaptic pathway in the brainstem. J Physiol. 2011;589:5431\u20135442."},{"issue":"3","key":"i1878-7177-73-2-106-b03","series-title":"Int J Oral Maxillofac Surg","first-page":"389","article-title":"Determination of trigeminocardiac reflex during rhinoplasty","volume":"41","author":"Yorgancilar","year":"2012","unstructured":"Yorgancilar E,\nGun R,\nYildirim M,\nBakir S,\nAkkus Z,\nTopcu I. Determination of trigeminocardiac reflex during rhinoplasty. Int J Oral Maxillofac Surg. 2012;41(3):389\u2013393."},{"issue":"6","key":"i1878-7177-73-2-106-b04","series-title":"J Neurol","first-page":"658","article-title":"A clinical phenomenon or a new physiological entity","volume":"251","author":"Schaller","year":"2004","unstructured":"Schaller B. Trigeminocardiac reflex. A clinical phenomenon or a new physiological entity? J Neurol. 2004;251(6):658\u2013665."},{"issue":"11","key":"i1878-7177-73-2-106-b05","series-title":"J Oral Maxillofac Surg","first-page":"2355","article-title":"Trigeminal nerve repair: Is the trigeminocardiac reflex a concern","volume":"79","author":"Hammad","year":"2021","unstructured":"Hammad Y,\nMootz A,\nKlein K,\nZuniga JR. Trigeminal nerve repair: Is the trigeminocardiac reflex a concern? J Oral Maxillofac Surg. 2021;79(11):2355\u20132357."},{"issue":"2","key":"i1878-7177-73-2-106-b06","series-title":"J Dent Sci","first-page":"878","article-title":"Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: a retrospective cohort study","volume":"19","author":"Wakita","year":"2024","unstructured":"Wakita R,\nBaBa Y,\nFukayama H,\nMaeda S. Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: a retrospective cohort study. J Dent Sci. 2024;19(2):878\u2013884."},{"issue":"18","key":"i1878-7177-73-2-106-b07","series-title":"Medicine (Baltimore)","first-page":"e807","article-title":"Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review","volume":"94","author":"Meuwly","year":"2015","unstructured":"Meuwly C,\nChowdhury T,\nSandu N,\nReck M,\nErne P,\nSchaller B. Anesthetic influence on occurrence and treatment of the trigemino-cardiac reflex: a systematic literature review. Medicine (Baltimore). 2015;94(18):e807."},{"issue":"1","key":"i1878-7177-73-2-106-b08","series-title":"Anesth Prog","first-page":"46","article-title":"Severe bradycardia occurring after assisted mouth opening: a case report","volume":"69","author":"Hayakawa","year":"2022","unstructured":"Hayakawa Y,\nFujii-Abe K,\nNakano T,\nSuzuki M,\nKawahara H. Severe bradycardia occurring after assisted mouth opening: a case report. Anesth Prog. 2022;69(1):46\u201348."},{"issue":"1","key":"i1878-7177-73-2-106-b09","series-title":"JA Clin Rep","first-page":"2","article-title":"Prevention of trigeminocardiac reflex-induced severe bradycardia during cerebral aneurysm clipping surgery by topical anesthesia of the dura surface and atropine administration: a case report","volume":"8","author":"Yoshida","year":"2022","unstructured":"Yoshida A,\nSeki T,\nAratani Y,\nTanioku T,\nKawamata T. Prevention of trigeminocardiac reflex-induced severe bradycardia during cerebral aneurysm clipping surgery by topical anesthesia of the dura surface and atropine administration: a case report. JA Clin Rep. 2022;8(1):2."},{"key":"i1878-7177-73-2-106-b10","series-title":"BMJ Case Rep","first-page":"2018226427","article-title":"Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa","volume":"2018","author":"Meuwly","year":"2018","unstructured":"Meuwly C,\nLeibundgut G,\nRosemann T,\nSchaller B. Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa. BMJ Case Rep. 2018;2018:2018226427."},{"issue":"39","key":"i1878-7177-73-2-106-b11","series-title":"Medicine (Baltimore)","first-page":"e35226","article-title":"A case report: a patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery","volume":"102","author":"Zhang","year":"2023","unstructured":"Zhang X,\nSun B,\nPac-Soo C,\nMa D,\nWang L. A case report: a patient rescued by VA-ECMO after cardiac arrest triggered by trigeminocardiac reflex after nasal surgery. Medicine (Baltimore). 2023;102(39):e35226."},{"issue":"9","key":"i1878-7177-73-2-106-b12","series-title":"J Oral Maxillofac Surg","first-page":"1862","article-title":"Asystole triggered by the mouth opening with a dental mouth gag under general anesthesia during pediatric oral surgery: report of a rare case","volume":"79","author":"Hoshijima","year":"2021","unstructured":"Hoshijima H,\nTakeuchi R,\nKikuchi K,\nMizuta K. Asystole triggered by the mouth opening with a dental mouth gag under general anesthesia during pediatric oral surgery: report of a rare case. J Oral Maxillofac Surg. 2021;79(9):1862\u20131865."},{"issue":"1","key":"i1878-7177-73-2-106-b13","series-title":"Anesth Analg","first-page":"126","article-title":"Case report: bilateral angle closure glaucoma after general anesthesia","volume":"112","author":"Gayat","year":"2011","unstructured":"Gayat E,\nGabison E,\nDevys JM. Case report: bilateral angle closure glaucoma after general anesthesia. Anesth Analg. 2011;112(1):126\u2013128."},{"issue":"11","key":"i1878-7177-73-2-106-b14","series-title":"A A Pract","first-page":"385","article-title":"Postoperative acute angle-closure glaucoma: a rare but serious complication: a case report","volume":"12","author":"Roor","year":"2019","unstructured":"Roor TL,\nKooijman JA,\nvan der Ploeg JM,\nde Boer HD. Postoperative acute angle-closure glaucoma: a rare but serious complication: a case report. A A Pract. 2019;12(11):385\u2013387."},{"issue":"4","key":"i1878-7177-73-2-106-b15","series-title":"Anesth Prog","first-page":"162","article-title":"Acute angle-closure glaucoma after general anesthesia for bone grafting","volume":"61","author":"Nitta","year":"2014","unstructured":"Nitta Y,\nKamekura N,\nTakuma S,\nFujisawa T. Acute angle-closure glaucoma after general anesthesia for bone grafting. 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