O R I G I N A L A R T I C L E

In-office vasovagal response a�er rhinologic manipulationBrian M. Radvansky, BA1, Qasim Husain, BS1, Deepa V. Cherla, BS1, Osamah J. Choudhry, MD1 and

Jean Anderson Eloy, MD, FACS1–3

Background: Advances in endoscopic sinus surgery haveled to a greater number of in-office procedures away fromthe traditional operating room se�ing. Rhinologists actingindependently of anesthesiologists must be prepared forpotential complications, such as vasovagal response (VVR),that may arise during in-office rhinologic manipulations. Inthis study, we review our experience with this conditionand discuss risk factors and a management algorithm forin-office VVR.

Methods: A retrospective analysis at a large tertiary re-ferral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulationbetween July 2008 and June 2012. A total of 4973 patientsunderwent in-office endoscopic procedures and 8 patientswith VVR were identified. Demographic data, diagnosis,procedure performed, and outcomes were reviewed.

Results: Eight patients out of 4973 (0.16%) experiencedVVR during in-office endoscopic procedures. Seven (87.5%)of these 8 patients recovered from the VVR within30 minutes and subsequently completed their scheduledprocedure. One (12.5%) of the 8 patients did not fully

recover a�er 30 minutes and was sent to the Emer-gency Department, where he was stabilized and subse-quently discharged. The most common comorbidities inthese 8 patients with VVR were hypercholesterolemia in3 patients (37.5%), and hypertension and benign prostatichyperplasia, each found in 2 patients (25.0%).

Conclusion: Although the incidence of VVR during rhino-logic procedures is low, rhinologists should be familiar withthis condition and be prepared for its management. C© 2012ARS-AAOA, LLC.

Key Words:vasovagal response; vasovagal; vasovagal management;vasovagal response evaluation; rhinologic procedure; syn-cope; seizure; in-office manipulation; endoscopic sinussurgery; case series

How to Cite this Article:Radvansky BM, Husain Q, Cherla DV, Choudhry OJ, EloyJA. In-office vasovagal response a�er rhinologic manipu-lation. Int Forum Allergy Rhinol, 2013; 3:510–514.

O ver the past decade, instrumentation and surgicaltechniques in otolaryngology have considerably ex-

panded, resulting in a shift toward more minimally in-

1Department of Otolaryngology–Head and Neck Surgery, University ofMedicine and Dentistry of New Jersey–New Jersey Medical School,Newark, NJ; 2Department of Neurosurgery, University of Medicine andDentistry of New Jersey–New Jersey Medical School, Newark, NJ;3Center for Skull Base and Pituitary Surgery, Neurological Institute ofNew Jersey, University of Medicine and Dentistry of New Jersey–NewJersey Medical School, Newark, NJ

Correspondence to: Jean Anderson Eloy, MD, FACS, Rhinology and SinusSurgery, Department of Otolaryngology–Head and Neck Surgery,UMDNJ-New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ07103; e-mail: jean.anderson.eloy@gmail.com

Potential conflict of interest: None provided.Presented orally at the Annual ARS Meeting on September 8, 2012,Washington, DC.

Received: 18 August 2012; Revised: 4 October 2012; Accepted:10 October 2012DOI: 10.1002/alr.21121View this article online at wileyonlinelibrary.com.

vasive in-office outpatient procedures.1,2 With the in-creasing prevalence of in-office endoscopic proceduresperformed without the assistance of an anesthesiologist,otolaryngologists must be prepared to independently man-age potential complications. The vasovagal response (VVR)is a possible complication that may occur during in-office rhinologic manipulation. A treatment algorithm forthis phenomenon has not been previously established inrhinology.

Cases of VVR during endoscopy have been describedduring gastrointestinal3 and gynecological4 procedures.Hypotensive/bradycardic episodes have also been re-ported during arthroscopic shoulder surgery under localanesthesia.5 However, guidelines on the diagnosis, eval-uation, and management of VVR during and after in-office rhinologic manipulation have not been adequatelydefined in the literature.6 In this study, we discuss our ex-perience with patients who have suffered a VVR after in-office nasal manipulation and propose a simple protocol formanagement.

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TABLE 1. Cases with VVR

Patient # Age (years) Sex Diagnosis Comorbidity Procedure Outcome

1 52 F Pituitary adenoma HTN; hypercholesterolemia Debridement Recovery within 30 minutes

2 50 M Craniopharyngioma History of skin melanoma Debridement Recovery within 30 minutes

3 38 M Frontal sinus osteoma Migraine; kidney stone; BPH; anxiety; depression Nasal endoscopy Recovery within 30 minutes

4 66 M Epistaxis CAD; CVA; history of carotid endarterectomy;hypercholesterolemia

Debridement Recovery within 30 minutes

5 65 M Epistaxis None Nasal endoscopy Recovery after ED stabilization

6 77 M Epistaxis HTN; BPH; hypercholesterolemia Nasal endoscopy Recovery within 30 minutes

7 58 M OSA; DNS; BITH None Nasal endoscopy Recovery within 30 minutes

8 27 M CRS History of previous PNA Debridement Recovery within 30 minutes

BITH = bilateral inferior turbinate hypertrophy; BPH = benign prostatic hyperplasia; CAD = coronary artery disease; CRS = chronic rhinosinusitis; CVA = cerebrovascularaccident; DNS = deviated nasal septum; ED = emergency department; HTN = hypertension; OSA = obstructive sleep apnea; PNA = pneumonia.

Materials and methodsBetween July 2008 and June 2012, all patients undergoingin-office endoscopic procedures with rhinologic manipula-tion at University of Medicine and Dentistry of New Jersey(UMDNJ)-University Hospital by the senior author (J.A.E)were retrospectively reviewed to identify patients who expe-rienced a VVR during or immediately after the procedure.Using the following Current Procedural Terminology (CPT)codes (31231, 31237, 31238, 31295, 31296, 31297, and31575), 4973 cases met the inclusion criteria. Demographicdata, diagnosis, procedure performed, comorbidities, andoutcomes were reviewed. The protocol for this study wasreviewed and approved by the Institutional Review Boardof University of Medicine and Dentistry of New Jersey–New Jersey Medical School (UMDNJ-NJMS), Newark, NJ.

Vasovagal response was suspected if the patient reporteddizziness, lightheadedness, or another related symptom re-quiring the procedure to be stopped; the patient’s bloodpressure and pulse rate were subsequently measured. AVVR was then diagnosed if the patient had suspicioussymptoms such as hypotension with bradycardia (systolicblood pressure <80 mmHg, pulse rate <60 beats perminute [bpm]) that spontaneously corrected after haltingthe procedure. Subsequent disappearance of the malaiseand discomfort, and recovery of the blood pressure andpulse rate (systolic blood pressure >100 mmHg and pulserate >80 bpm) were used as criteria for recovery from theVVR.

ResultsA total of 4973 patient visits matched the aforementionedCPT codes. In-office procedures that resulted in rhinologicmanipulation included diagnostic nasal endoscopy, nasalendoscopy with biopsy, polypectomy, debridement, con-trol of hemorrhage, dilation of sinus ostium (maxillary,frontal, and/or sphenoid), and flexible fiber-optic laryn-

goscopy. Of these total visits, VVR were found in 8 cases(0.16%, 7 males, 1 female, average age 54.1 years old,range 27-77 years old). Only 2 procedure types (diagnosticnasal endoscopy and nasal endoscopy with debridement)resulted in a VVR. Patient demographic data, diagnoses,comorbidities, procedures, and outcomes are presented inTable 1. The most common comorbidities in these 8 pa-tients with VVR were hypercholesterolemia, which waspresent in 3 patients (37.5%), and hypertension and be-nign prostatic hyperplasia, which were each reported in 2patients (25.0%).

Observed and reported symptoms were those commonof VVR: dizziness, light-headedness, malaise, headache, di-aphoresis, and loss of consciousness. Seven (87.5%) of the8 patients recovered uneventfully after 30 minutes of rest,and their procedures were completed as planned. One pa-tient (12.5%) continued to experience lightheadedness andmalaise after 30 minutes, and was sent to the EmergencyDepartment for further evaluation. This patient was dis-charged the same day without pharmacological interven-tions.

DiscussionVasovagal response is defined as the “triggering of a neuralreflex that results in a usually self-limited episode of sys-temic hypotension characterized by both bradycardia (asys-tole or relative bradycardia) and peripheral vasodilation.”7

Although it has been reported that 22% of the general pop-ulation will experience at least 1 vasovagal episode in theirlifetime,8 the actual incidence of VVR may be much higherdue to inadequate patient and physician documentation.The efferent pathway of the VVR involves a combinationof increased parasympathetic output (via the vagus nerve)and decreased sympathetic output. The increased parasym-pathetic output to the heart causes reduced filling as well asbradycardia, and can result in a transient loss of conscious-ness.

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Age, female gender, comorbidities, psychological fac-tors (including anxiety), environmental factors (such asfirst rhinological procedure), and family history have beenproposed to play a role in the physiologic response ofsyncope.9–13 Patients with prior episodes of VVR may ben-efit from reassurance, patient education, counter-pressuremaneuvers, and possibly midodrine, selective serotonin re-uptake inhibitors (SSRIs), and beta-blockers.7,14 Althoughhyper-cholesterolemia (37.5%), hypertension (25.0%), andbenign prostatic hyperplasia (25.0%) were the most fre-quent comorbidities noted among the 8 patients with VVRin our cohort, and there may be an association betweenthese conditions and VVR, the relatively high prevalenceof these disorders in the general population and the lim-ited number of cases of VVR in this study would make anypotential association erroneous.

The average age of patients in this group was 54.1 years;3 patients were younger than or equal to 50 years (37.5%),and 5 patients were over 50 years (62.5%). These ages arehigher than the 18- to 29-year-old demographic at whichmost people have been reported to experience vasovagalepisodes.9 A large-scale 2011 study indicated that althoughthe elderly are more likely to have orthostatic hypotensionand carotid sinus sensitivity (both of which can cause syn-cope), the median age of patients who experienced episodesduring tilt-table testing was 30 years.15

Gender has also been suggested as a risk factor for syn-cope, with previous studies indicating that females are bothmore likely to experience a VVR during blood donation,and are more likely to experience recurrent VVR.16–18 Inour study, 7 of the 8 affected patients were male. The smallsample size of the affected patients in this study may pre-clude any conclusions regarding the gender of patients mostlikely to experience VVR and may account for any discrep-ancy with established literature.

Comorbidities, such as diabetes, may weaken physiolog-ical autonomic responses, resulting in vasovagal episodes(ie, cardiovascular autonomic neuropathy).16 Other factorsthat have been associated with VVR include strong emo-tional responses such as fear and pain. In a 1996 study,patient sensitivity to the sight of blood and injury were themost significant predictors of VVR.17 Because pain is oftenan inciting event that evokes an emotional response, it isminimized in our office by providing pretreatment analgesiaprior to rhinologic manipulation. It is possible that the re-duction in discomfort provided by the analgesic spray maybe responsible for the low rate of VVR in our patient pop-ulation. Although no official screening for patients’ levelof fear was performed in our office, we propose that thisis also a possible precipitating factor in the syncope expe-rienced by our patients. Although the exact mechanism inhumans remains uncertain, it has been demonstrated thatemotional activation of higher centers, particularly the lim-bic system, may temporarily inhibit sympathetic output,leading to bradycardia and hypotension.18,19

The trigeminal-cardiac reflex (TCR) may also accountfor VVR. Surgical manipulation of the trigeminal nerve

during its intra- or extracranial course may elicit the TCR.TCR has been formally defined as at least a 10% decline inheart rate and has been characterized by cardiac arrhyth-mia, ectopic beats, atrioventricular lock, vomiting, brady-cardia, syncope, asystole, arterial hypotension, and possi-bly death.20–22 Distinguishing between a purely VVR anda TCR is difficult, because the only difference is the bipha-sic response seen in VVR (a transient rise in blood pressureand heart rate followed by hypotension and bradycardia).23

TCR may be responsible for syncope during oral surgery,24

and bradycardia and hypotension during dermatologicalsurgery,25 neurosurgery,20,26 and skull-base surgery.27 Bydirectly triggering branches of the trigeminal nerve, thenasal endoscope may elicit the TCR. Further studies areencouraged to elucidate the relationship between the TCR,bradycardia, and hypotension.

Management of VVRThe following steps (Fig. 1) can be taken in the event apatient begins to experience a VVR:

1. Halting of procedure immediately upon patient’s com-plaint of lightheadedness, dizziness, and/or loss of con-sciousness.

(a) If patient has lost consciousness, use of ammoniumcarbonate (smelling salt) for resuscitation.

2. Assessment of patient’s blood pressure and heart rate.

3. If the patient is confirmed to be suffering from a VVR(as determined by a systolic blood pressure <80 mmHgand a pulse rate <60 bpm), he/she should be moved to adark, quiet room for 15 to 30 minutes with appropriateobservation.

4. Elevation of the patient’s lower extremities to aid invenous return to the heart.

5. If patient has fully recovered within 30 minutes, asindicated by a rise in systolic blood pressure to >100mmHg and a pulse rate >60 bpm, cautiously proceedwith the scheduled procedure.

(a) If patient has not fully recovered within 30 minutes,consider Emergency Department referral for further as-sessment and care.

6. In the event of a second VVR when the procedure isreattempted, the procedure should again be halted andthe above protocol followed through step 5. No furtherrhinologic procedure should be attempted that day.

In our experience, almost all patients who experienceda VVR within the office recovered after resting for 15 to30 minutes and were subsequently able to complete theprocedure without further complications. Although hyper-cholesterolemia (37.5%), hypertension (25.0%), and be-nign prostatic hyperplasia (25.0%) were the most frequentcomorbidities noted among the 8 patients with VVR in

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FIGURE 1. Flow diagram for the management of VVR.

our cohort, the relatively high prevalence of these disor-ders in the general population and the limited number ofcases of VVR in this study makes any potential associationerroneous. If it is suspected that a patient may be experi-encing symptoms leading to a vasovagal episode, he/shecan be instructed to use preventative physical counter-pressure maneuvers, such as crossing the legs and flexingthe buttocks, linking hands in front of the body and iso-metrically pulling them apart, muscle tensing, or simplesquatting, to avoid syncope.28,29 Other effective preven-tative measures include adequate hydration (2-3 L/day),and increased dietary intake of salt.28 Pharmacological pro-phylaxis with beta-blockers, alpha-agonists, SSRIs, fludro-cortisone, disopyramide, scopolamine, and anticholinergicagents, may also prevent syncope.30 A standardized educa-tion protocol, along with explanation of syncope as a gen-erally benign disease, has also been shown to decrease theincidence of traumatic syncope and syncope recurrence.31

While VVR was only reported to occur in 0.16% of ourpatients undergoing in-office rhinologic manipulation, theactual prevalence may be much higher given that some pa-tients may not have reported the onset of such clinical symp-toms. TCR, a related entity, which involves similar clinicalsymptoms and signs, has been reported to occur in 1.6%of patients undergoing maxillofacial surgeries, in 32% to90% of patients undergoing strabismus surgery in, 1% to2% of patients undergoing craniofacial surgery, and in 8%to 18% of patients undergoing skull-base surgery.21 In ourstudy, no patient required pharmacological intervention,and only 1 patient necessitated observation longer than30 minutes.

Limitations of this study include its retrospective na-ture and the small number of affected patients. Moreover,our reliance on patients’ reports of symptomatology mayhave influenced the observed incidence of VVR in oursample. Additionally, because of our reliance on medical

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record data, the numbers of events may be underreported,especially in cases of mild VVRs. Future prospective studiesmay be needed to validate these early findings.

ConclusionAs more in-office rhinologic procedures are being per-formed, rhinologists will encounter and need to managenew and different complications, such as VVRs, which mayresult in injury or even death if managed inadequately.Following a VVR, if a patient’s condition does not im-

prove within 30 minutes, Emergency Department referralmay be appropriate. This represents the first study to pro-vide a treatment algorithm for the management of VVRby a rhinologist performing in-office procedures acting in-dependently of an anesthesiologist. Although hypercholes-terolemia, hypertension, and benign prostatic hypertensionwere the most common comorbidities noted in this cohortof patients, the high prevalence of these conditions in thegeneral population and the limited number of VVR cases inthis study precluded any valid correlation of these potentialrisk factors.

References1. Albritton FDt, Casiano RR, Sillers MJ. Feasibility of

in-office endoscopic sinus surgery with balloon sinusdilation. Am J Rhinol Allergy. 2012;26:243–248.

2. Prickett KK, Wise SK, DelGaudio JM. Cost analysisof office-based and operating room procedures in rhi-nology. Int Forum Allergy Rhinol. 2012;2:207–211.

3. Lee JG, Leung JW, Cotton PB. Acute cardiovascularcomplications of endoscopy: prevalence and clinicalcharacteristics. Dig Dis. 1995;13:130–135.

4. Agostini A, Bretelle F, Ronda I, Roger V, CravelloL, Blanc B. Risk of vasovagal syndrome during out-patient hysteroscopy. J Am Assoc Gynecol Laparosc.2004;11:245–247.

5. Song SY, Roh WS. Hypotensive bradycardic eventsduring shoulder arthroscopic surgery under intersca-lene brachial plexus blocks. Korean J Anesthesiol.2012;62:209–219.

6. Vyas A, Swaminathan PD, Zimmerman MB, Olshan-sky B. Are treatments for vasovagal syncope effective?A meta-analysis. Int J Cardiol. 2012 May 22 [Epubahead of print]

7. Benditt DG, Ferguson DW, Grubb BP, et al. Tilt ta-ble testing for assessing syncope. American College ofCardiology. J Am Coll Cardiol. 1996;28:263–275.

8. Kapoor WN. Syncope. N Engl J Med.2000;343:1856–1862.

9. Goncalez TT, Sabino EC, Schlumpf KS, et al. Vasova-gal reactions in whole blood donors at three REDS-IIblood centers in Brazil. Transfusion. 2012;52:1070–1078.

10. Cooke J, Carew S, Costelloe A, Sheehy T, Quinn C,Lyons D. The changing face of orthostatic and neuro-cardiogenic syncope with age. QJM. 2011;104:689–695.

11. Tondon R, Pandey P, Chaudhary R. Vasovagal reac-tions in ‘at risk’ donors: a univariate analysis of effect

of age and weight on the grade of donor reactions.Transfus Apher Sci. 2008;39:95–99.

12. Negrusz-Kawecka M, Bankowski T, Tabin M, et al.Familial predisposition to vasovagal syncope. ActaCardiol. 2012;67:279–284.

13. Ditto B, Gilchrist PT, Holly CD. Fear-related pre-dictors of vasovagal symptoms during blood dona-tion: it’s in the blood. J Behav Med. 2012;35:393–399.

14. Aydin MA, Salukhe TV, Wilke I, Willems S. Man-agement and therapy of vasovagal syncope: a review.World J Cardiol. 2010;2:308–315.

15. Park J, Jang SY, Yim HR, et al. Gender differencein patients with recurrent neurally mediated syncope.Yonsei Med J. 2010;51:499–503.

16. Vinik AI, Ziegler D. Diabetic cardiovascular auto-nomic neuropathy. Circulation. 2007;115:387–397.

17. Meade MA, France CR, Peterson LM. Predicting vaso-vagal reactions in volunteer blood donors. J Psycho-som Res. 1996;40:495–501.

18. van Lieshout JJ, Wieling W, Karemaker JM, Eck-berg DL. The vasovagal response. Clin Sci (Lond).1991;81:575–586.

19. Smith JJ. General response to orthostatic stress. In:Smith JJ, ed. Circulatory response to the upright pos-ture. Boca Raton, FL: CRC Press; 1990.

20. Schaller B, Probst R, Strebel S, Gratzl O.Trigeminocardiac reflex during surgery in the cere-bellopontine angle. J Neurosurg. 1999;90:215–220.

21. Bohluli B, Schaller B, Sadr-Eshkevari P, Momen-Heravi F. Trigeminal cardiac reflex: another all-or-none law? J Oral Maxillofac Surg. 2010;68:2922; au-thor reply 2922-2923.

22. Yorgancilar E, Gun R, Yildirim M, Bakir S, AkkusZ, Topcu I. Determination of trigeminocardiac re-

flex during rhinoplasty. Int J Oral Maxillofac Surg.2012;41:389–393.

23. Edmondson HD, Gordon PH, Lloyd JM, MeesonJE, Whitehead FI. Vasovagal episodes in the dentalsurgery. J Dent. 1978;6:189–195.

24. Arakeri G, Arali V. A new hypothesis of cause ofsyncope: trigeminocardiac reflex during extraction ofteeth. Med Hypotheses. 2010;74:248–251.

25. Holmes WD, Finch JJ, Snell D, Sloan SB. Thetrigeminocardiac reflex and dermatologic surgery.Dermatol Surg. 2011;37:1795–1797.

26. Jaiswal AK, Gupta D, Verma N, Behari S.Trigeminocardiac reflex: a cause of sudden asystoleduring cerebellopontine angle surgery. J Clin Neu-rosci. 2010;17:641–644.

27. Potti TA, Gemmete JJ, Pandey AS, Chaudhary N.Trigeminocardiac reflex during the percutaneous in-jection of ethylene vinyl alcohol copolymer (Onyx)into a juvenile nasopharyngeal angiofibroma: a re-port of two cases. J Neurointerv Surg. 2011;3:263–265.

28. Vaddadi G, Corcoran SJ, Esler M. Management strate-gies for recurrent vasovagal syncope. Intern Med J.2010;40:554–560.

29. Krediet CT, van Dijk N, Linzer M, van LieshoutJJ, Wieling W. Management of vasovagal syn-cope: controlling or aborting faints by leg cross-ing and muscle tensing. Circulation. 2002;106:1684–1689.

30. Chen-Scarabelli C, Scarabelli TM. Neurocardiogenicsyncope. BMJ. 2004;329:336–341.

31. Aydin MA, Mortensen K, Salukhe TV, et al. A stan-dardized education protocol significantly reduces trau-matic injuries and syncope recurrence: an observa-tional study in 316 patients with vasovagal syncope.Europace. 2012;14:410–415.

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