We read with interest the article by Persson et al. describing Harlequin syndrome following epidural analgesia [1]. We recently observed another presentation of sympathetic blockade at the high thoracic level following epidural anaesthesia, where the primary symptom was nasal congestion.
A primiparous 31‐year‐old with no comorbidities required caesarean delivery due to slowly progressing labour in the context of suspected maternal sepsis. A lumbar epidural, sited 12 h previously with good effect, was topped up with 15 ml of ropivacaine 0.75% with 100 µg of fentanyl. Motor blockade and sensory block (to cold) to the T4 dermatome was observed bilaterally. There was no cardiovascular instability or respiratory symptoms.
Twenty‐five minutes post epidural bolus, the patient complained of nasal congestion and difficulty in nasal breathing. This persisted for 2 h before resolving spontaneously. No signs of Horner’s syndrome were observed. The patient denied prior sinonasal symptoms.
The vasculature of the nasal mucosa is responsive to changes in autonomic tone. Blockade of the T1 sympathetic innervation can cause venous sinusoid dilatation and, therefore, nasal obstruction [2, 3]. This has been previously observed in combination with Horner’s syndrome in the obstetric setting [4] but appears not to have been reported in isolation.
Sinonasal symptoms indicate sympathetic blockade higher than T2 and should alert the anaesthetist to a potentially ascending neuraxial block. Although they may be otherwise benign (as in our case), these symptoms are potentially distressing for patients and a greater awareness of their significance among anaesthesia providers allows for greater vigilance, patient reassurance and satisfaction.
Acknowledgements
Published with the written consent of the patient. No external funding or competing interests declared.
References
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