Hair Tourniquet Syndrome in the Dental Patient
Abstract
Hair tourniquet syndrome is a condition where a hair becomes entangled around an appendage. In some cases a knot will form and the resulting tightened noose will slowly strangulate the appendage. Rarely, this condition will affect the oral cavity, but even more rarely, this condition will affect a dental structure.
Hair tourniquet syndrome (HTS) is a condition where a hair strand will circle and become entangled around an appendage. In some cases a formidable knot will form, and the resulting tightened noose will slowly strangulate the appendage. Unfortunately, the first instinct of the patient or parent is to tug at the loose hair, which only further complicates the problem, and pain from ischemia may start. Without immediate release, the appendage may be lost.
HTS usually affects the fingers, toes, wrists, penis or scrotum, vaginal labium, ear lobe, remaining umbilicus, or nipple.1 Rarely, this syndrome may also affect the tongue and uvula, with very little reference of oral effects found in medical literature. There is no mention of the dental effects of HTS in either medical or dental literature. Like most body growth, hair growth is dynamic and a single hair can vary in its growth cycle from its neighbor. On average, as many as 50–100 hairs per day enter and complete the telegenic phase of hair growth and exfoliate.2 Factors that influence exfoliation are recent birth, chemotherapy, frequent clothing removal, or frequent clothing washing.3 In the dental office or dental ambulatory surgery center setting, it is common practice to frequently remove head lamps, dental loupes, surgical caps, and face masks, all of which can increase the normal periodic shedding of hair.
Removing the offending hair can be difficult, and according to Krishna and Paul, “exploration under sedation of general anesthesia is a safe and effective way of releasing… tourniquets in the uncooperative child…”4 Further complicating this condition is the fact that a human hair is thin, is easily overlooked, and has high tensile strength, especially when exposed to moisture, which causes stretching, and then it contracts as it dries.5
During the author's dental anesthesiology residency, a 24-month-old child was seen in the surgical suite for HTS that was contributing to uvular strangulation. The events leading up to the surgical visit were as follows.
The previous morning, the child began gagging and coughing at the breakfast table. In an attempt to track down the cause of the gagging, the mother discovered a hair in her 2-year-old's mouth and tried to remove it. When she pulled the hair, the child gagged and vomited. A second attempt caused the same result. The mother visited the pediatrician, who attempted the same removal technique without success, and gagging and vomiting again occurred. The pediatrician then consulted an otolaryngologist, who scheduled the patient the following morning for a brief general anesthetic.
On the day of the anesthetic, the child was reluctant and combative for the preanesthetic airway exam. The mother stated that any attempt to open the child's mouth would likely result in gagging, so the oral evaluation was aborted.
Following induction of general anesthesia, uvula hair tourniquet was seen during the uneventful intubation, and the otolaryngology resident was able to remove the tourniquet (Figures 1 and 2).
Citation: Anesthesia Progress 61, 3; 10.2344/0003-3006-61.3.111
Citation: Anesthesia Progress 61, 3; 10.2344/0003-3006-61.3.111
Despite HTS's being a fairly rare event, a second case of HTS occurred following the author's residency. A mother entered an dental ambulatory surgery center and complained of a hair stuck to her child's tooth (Figure 3).
Citation: Anesthesia Progress 61, 3; 10.2344/0003-3006-61.3.111
HTS has not been reported around a tooth or dental papilla. In this case, the 4-year-old child was attempting to remove a hair that was stuck between his teeth. In all probability, he tightened the tourniquet around the tooth. When the mother attempted to remove the hair, she likely tightened it further. She stated that when she forcibly attempted to remove the hair, the end she was holding broke, but the hair remained “stuck.” The family dentist was visited, but the dentist could not obtain enough patient cooperation for hair tourniquet removal, so the child was referred to the dental ambulatory surgery center. The child was given a low-dose ketamine/midazolam intramuscular injection, and the hair tourniquet was successfully removed within minutes with an explorer and iris scissors. The child had full recovery within 20–30 minutes.
Medicine classifies HTS as an emergency. In the above case, only the tooth was circumferentially wrapped; however, if the dental papilla were to become involved, then this might constitute a dental emergency. Because blood flow could be restricted to soft tissue, there is risk of papillary necrosis and auto-amputation. As we work routinely in the oral cavity, we should be aware of the possibility of the presence of HTS and its potential for significant morbidity .
The initial view.
After hair tourniquet was released.
Picture taken once top hair layers removed to show initial circumferential strand.
Contributor Notes