American Society of Regional Anesthesia and Pain Medicine November 2017 - 38

Head and Neck Regional Anesthesia Techniques

T

he head and neck have rich
nerve supplies with reliably
identifiable surface and bony
landmarks. This makes administering
regional anesthesia for head and
neck surgical procedures practical
and effective. Although novel for
otolaryngologic surgical procedures,
the use of regional anesthesia is
commonplace for dental and oralmaxillofacial procedures. Head and
neck regional anesthesia is typically
Samuel DeMaria Jr., MD
Brandon Kandarian, MD, MS
Adam Levine, MD
employed for postoperative analgesia
Associate Professor
Resident Physician, PGY-4
Professor
and placed safely after the induction
Department of Anesthesiology,
Department of Anesthesiology,
Department of Anesthesiology,
of anesthesia, but it can also be used
Perioperative & Pain Medicine
Perioperative & Pain Medicine
Perioperative & Pain Medicine,
effectively as the primary anesthetic
The Mount Sinai Hospital
The Mount Sinai Hospital
Pharmacological Sciences,
(eg, superficial cervical block for
New York, New York
New York, New York
and Otolaryngology
carotid endarterectomy). Additionally,
The Mount Sinai Hospital
patients presenting for head and
New York, New York
neck pathology may require awake
intubation techniques, and regional
Section Editor: Kristopher Schroeder, MD
nerve blocks can be used to augment
local anesthesia topicalization.
Finally, regional blocks placed intraoperatively have been used
it divides into terminal branches called the supraorbital and
effectively as the sole anesthetic for exploration and hemostasis
supratrochlear nerves (Figure 2). The frontal nerve block can be
in the rare and catastrophic event of postoperative bleeding. As
used to block both nerves.1 These single-shot nerve blocks can
with all regional anesthetic techniques, it is important to discuss
be used in ophthalmologic, craniotomies, frontal sinus surgery,
the planned block with the surgeon preoperatively on a patientand cosmetic nasal surgery. It is performed by palpating the
by-patient basis as some blocks are contraindicated based on
supraorbital notch (located at the middle portion of the superior
the patient's pathology,
orbit) and injecting 1-2
covered below. In addition
ml of 0.5% bupivacaine
to providing intraoperative
(blocking the supraorbital
and postoperative analgesia,
nerve) and directing the
certain blocks can be
needle to the medial brow
combined with epinephrine
(Figure 3). It is important
to improve the operative
to palpate the orbit with
conditions for the surgeon. In
the free hand and leave
the following discussion, we
a finger on the orbit
will describe the head and
throughout the block to
neck blocks typically used in our practice.
minimize the risk of injection of local anesthesia into the globe
of the eye.2 The area of anesthesia includes the upper eyelid,
FRONTAL NERVE BLOCK (V1)
forehead, bridge of nose, and scalp (Figure 4).
The trigeminal nerve, the largest of the cranial nerves, provides
sensory and motor innervation to the face. The nerve roots originate INFRAORBITAL (V2)
in the pons, and the sensory fibers are sent to the trigeminal
The infraorbital nerve provides sensation to the cheek, upper lip,
ganglion. From the trigeminal ganglion, the nerve splits into three
eyelid, and lateral aspect of the nose (Figure 5). We routinely use
major branches: The ophthalmic (V1) nerve, the maxillary (V2)
bilateral single shot infraorbital blocks combined with bilateral
nerve, and the mandibular (V3) nerve.
single-shot sphenopalatine blocks for functional endoscopic sinus
surgery (FESS) procedures. A randomized study at our institution
The ophthalmic division of the trigeminal nerve provides pure
showed that this block, when combined with a sphenopalatine
sensory innervation to the top third of the face (Figure 1). The
block, decreases opiate requirements and postanesthesia care
frontal nerve is the largest branch of the ophthalmic nerve, and
unit time.3 An infraorbital block may also be used for procedures

"Although novel for otolaryngologic
surgical procedures, the use of regional
anesthesia is commonplace for dental
and oral-maxillofacial procedures."

38

American Society of Regional Anesthesia and Pain Medicine
2017



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