Spinal anesthesia in a patient with grade IV Bell's palsy for caesarean section

Abstract

Dear Editor, A 25-year-old primigravida with 39-weeks of gestation was referred with complaints of inability to close the right eyelid and deviation of the right side of the mouth for the past one day. There was no history of ear discharge, decreased hearing, hyperacusis, diminished salivation and lacrimation, loss of taste sensation in the anterior two third of the tongue and fever. The patient was diagnosed as right-side grade IV facial nerve palsy. The patient was advised on an antiviral, multivitamins and steroids. Laboratory investigations were normal. The patient was scheduled for an elective caesarean section because of cephalopelvic distortion and tablet Metoclopramide and Ranitidine were administered. On shifting to the operating room, the heart rate was 82 beats·min-1, non-invasive blood pressure was 160/108 mmHg, respiratory rate was 21 breaths·min-1, and SpO2 99% on room air were recorded. Left uterine displacement was applied by a 15° left-tilt of the operation table. In the left lateral position, a subarachnoid block was performed in L3-L4 space with 27G Quincke’s spinal needle, 0.5% heavy Bupivacaine 2 ml (10 mg) was administered. Oxygen was administered via face mask at 6 L/min. A female baby was delivered with Apgar scores of 9 at 1 min and 5 min and 10 at 10 min. Intraoperative fluid administration was 800 mL. Urine output was 200 mL. Oxytocin was administered 1 unit every 30 sec to a total of 5 units. There was no episode of any adverse events intraoperatively. Injection Paracetamol 1 gram intravenously was given after skin closure. TAP block was performed by posterior approach using the Fujifilm sonosite mini-Dock (serial no Q4XK8D, Ref P17000-17) ultrasound machine using linear array transducer probe (6-13 MH z). 0.5% Ropivacaine 15 ml was given on either side. She was shifted to recovery room. She was discharged on seventh postoperative day. Bell’s palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy, with facial nerve weakness/paralysis.[1] Few theories have been postulated but most common are nerve compression syndrome due to the fluid retention during pregnancy and immunosuppression during pregnancy may lead to flaring of a latent viral infection.[2] Although typically self-limited, Bell’s palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury and inability to blow out the cheek on the affected side, and the Bell’s phenomenon, an upward and out-ward motion of the eye when the patient attempts to close the eyelid. The treatment modalities include medical therapy with steroids and antivirals, surgical decompression and complementary and alternative therapies such as acupuncture.[3] Following House-Brackmann Facial Nerve Grading System the patient was diagnosed as grade IV Bell’s Palsy which moderately severe dysfunction.[4] Pregnant women are three times more vulnerable than non-pregnant women to develop Bell’s palsy. During the third trimester (71%) and early postpartum period (21%) in majority of cases.[5] Our patient also developed Bell’s palsy in late third trimester. It has been postulated that Bell’s palsy could be a predictor of pre-eclampsia. Our patient too showed signs of sudden onset of pregnancy induced hypertension. Following general anesthesia, the facial nerve injury has been documented to be 0.03-1.4% owing to inappropriate size endotracheal tube, supraglottic airway and tightly holding a mask. The facial nerve has a variable course and may be superficial at times this may make it more prone for injury.[6] We opted for spinal anesthesia, as there is no documentation that Bell’s palsy is associated with meningitis and systemic blood borne viremia. 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.