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Sneezing after local anesthesia linked to medication and depth of sedation

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ATLANTA — Sneezing in patients who received local anesthesia injections while under sedation was linked to the type of anesthesia and the depth of sedation, a speaker said here.

Ana M. Susana Morley, MD, FRCOphth, presented a study of patient sneezing and local anesthesia. Image: Altersitz K, OSN

"It is important for ophthalmologists to be aware of this phenomenon and also some of the risk factors involved to try and reduce any risk of inadvertent injury to the patient because of the sudden movement associated with this sneezing. It may also be pertinent for ophthalmologists to try and reduce their use of midazolam and also deep sedation when giving periocular local anesthetics," Ana M. Susana Morley, MD, FRCOphth, said at the American Academy of Ophthalmology meeting.

This prospective, observational case series was conducted over a 12-month period. Of the 277 patients observed, 46 patients (17%) sneezed.

When researchers analyzed the data, they found strong associations with history of photic sneezing, which increased relative risk by 2.2, and midazolam, which increased relative risk by 2.3, whereas alfentanil reduced the risk and seemed to be protective.

"One of the most strongly correlated factors was the depth of sedation with patients sedated to a Ramsay score of five or six having a three times increased relative risk of sneezing," Dr. Morley said. "Over a third of patients sedated to that level sneezed."

I think your observations about potential mechanism are quite insightful. I’ll share that I do most of my dacryocystorhinostomies under local sedation using these drugs. One of the things I do to reduce sensitivity intraoperatively is that I actually inject the [nose] directly with local anesthetic and those patients almost invariably sneeze. So if you inject into the nose, it’s one of the quickest ways to get someone to sneeze. That’s the ultimate extrapolation of your new hypothesis that you are getting a routing of the sensation through the nasociliary nerve, creating a perceived nasal irritation with periocular injection.

I would also comment that the decrease of sneezing noted with the use of alfentanil may be related to the generalized depression of sensation created by narcotics.

– Stuart R. Seiff, MD, FACS
Professor Emeritus of the University of California San Francisco