American Society of Regional Anesthesia and Pain Medicine November 2017 - 42
Figure 9: Transoral approach to the sphenopalatine nerve block.
correct location when injecting. The blanching is secondary to
vasoconstriction of the internal maxillary artery, which is located
in the pterygopalatine fossa.4 Epinephrine added to the local
anesthetic helps both decrease absorption in the area as well as
improve the surgical field.
Possible complications include intravascular injection, infraorbital
nerve injury, and transient diplopia. The sphenopalatine nerve
block should be avoided in cases where pathology may involve
the pterygopalatine fossa. If the surgeon will be using computed
tomography guidance for FESS, this block should be placed before
registration because the positioning required for the block (head
extension) can disrupt the imaging band on the forehead.
the notch can be palpated with a finger. The pterygomandibular
raphe is indicated by black dashed lines in the same figure.2 The
needle is then placed at the injection site from the contralateral
premolar region indicated by the black dot in Figure 8b. The needle
is advanced until the mandible is contacted (typically 25-35 mm
deep). Once the mandible is contacted, withdraw the needle one
millimeter and redirect the needle slightly posterior and inject 2-5
ml of 0.5% bupivacaine. Two to four ml of 0.5% bupivacaine should
be injected continuously while the needle is withdrawn to block the
lingual nerve.
SPHENOPALATINE
The sphenopalatine ganglion also originates from the maxillary
branch of the trigeminal nerve. It provides sensation to the hard
palate, soft palate, tonsils, nasal and pharynx mucosa, posterior
portion of the nasal septum, and paranasal sinuses. At our
institution, we routinely perform a transoral approach to place the
sphenopalatine nerve blocks. We perform the block post induction
and endotracheal intubation.
SUPERFICIAL CERVICAL BLOCK
The superficial cervical plexus provides sensation from the
mandible to the clavicle and can be used for central (thyroid,
parathyroid, or thyroglossal cyst) or lateral (neck dissections, lymph
node biopsy) surgical procedures. For central procedures, the block
is placed bilaterally. If the block will be used for postoperative pain,
the landmarks are identified and marked preinduction, and the
block is placed postinduction.
While supine, patients are asked to contract their
sternocleidomastoid muscle (lift their head against your hand
placed on their forehead) to identify the posterior border of
the sternocleidomastoid. 2 The flexed muscle seen in the neck
contralateral to the direction the patient is pushing is the
sternocleidomastoid muscle. The posterior border of this muscle
is demarcated with a marker. The midline between the mastoid
Figure 10: Sphenopalatine nerve blocks.
After extending the neck, we use a Macintosh 3 blade to sweep the
tongue and the endotracheal tube out of the field while illuminating
the palate (Figure 9). We identify the greater palatine foramen by
locating a groove that is medial to the space between the first
and second upper molars (approximately 0.5-1 cm medial). We
then use a 1.5-inch 25-gauge needle for injection. The needle
is bent at a 90-degree angle at 1.5 cm from the tip and then
inserted up to that bend in this groove into the pterygopalatine
fossa where the sphenopalatine ganglion is located (Figure 10).
The needle is aspirated, and 1.5 ml of 1-2% lidocaine with
1:100,000 epinephrine is injected on each side for bilateral surgical
procedures.5 Localized blanching of the hard palate confirms the
42
American Society of Regional Anesthesia and Pain Medicine
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