American Society of Regional Anesthesia and Pain Medicine November 2017 - 43

Figure 11: Superficial cervical plexus block.

The superior laryngeal nerve innervates the base of the tongue, the
posterior surface of the epiglottis, and the arytenoids.
To perform the block, the patient lies supine and the head is turned
away from the side to be blocked. The free hand is used to palpate
the hyoid bone or the thyroid cartilage, which can be reliably identified
in the majority of patients, and hold it between the index finger
and thumb. The superior laryngeal nerve runs slightly lateral to the
tubercle of the greater horn of the hyoid bone, and this is the target
for the single shot block.5 The index finger is left on the opposite side
of the hyoid, pushing down for hyoid stabilization and identification.
A 25-gauge needle is inserted until resistance is felt as it hits the
greater horn of the hyoid bone or thyroid cartilage. The needle is then
withdrawn 1 mm and checked for negative aspiration, and then 2 ml
of 2% lidocaine are injected. This block is done bilaterally.

process and the prominent tubercle of C6 or Chassaignac tubercle
at the level of the cricoid cartilage are then demarcated on this
border. This midway point is the estimated location of where
the cervical plexus emerges.5,6 The block can be performed
either awake or asleep, depending on the procedure and patient
preference. Next, a 1.5-inch, 25-gauge needle is used to inject
10 cc of 0.5% bupivacaine superficially along this demarcated
border (Figure 11). It is important to remain superficial throughout
the injection and to aspirate multiple times during injection to
ensure a vessel has not been entered. Risks are minimal for
this procedure because the injection is superficial along the
border of the muscle. Newer techniques with ultrasound have
been described, and several of our faculty use this technique
effectively. 9
RECURRENT (TRANSTRACHEAL) AND SUPERIOR LARYNGEAL
BLOCKS
For awake intubations, we routinely perform a transtracheal block
to anesthetize the recurrent laryngeal nerves and a direct bilateral
superior laryngeal nerve block. We use these blocks to supplement
our topicalization of the oropharynx before performing an awake
intubation technique, but we also use them for laryngoscopy,
bronchoscopy, and transesophageal echocardiography. The superior
laryngeal nerve can be blocked at the thyrohyoid membrane
(between the superior cornu of the thyroid and the hyoid bone).

The recurrent laryngeal or transtracheal block is performed to
anesthetize the recurrent laryngeal nerve. The recurrent laryngeal
nerve innervates the glottis and the trachea. For the transtracheal
block, the patient is positioned supine and the cricothyroid membrane
is palpated. A 20-gauge peripheral venous catheter with local
anesthesia is inserted into the space while aspirating with a 5-cc
catheter until a pop is felt and air bubbles return, confirming position
within the trachea. The needle is then removed, leaving the catheter in
place to provide immediate access to the airway. A 5-ml syringe filled
with 4 ml of 4% lidocaine is reattached and aspirated again to confirm
correct position (air bubbles seen on aspiration, negative for blood). The
patient is then asked to take a deep breath as the local anesthesia is
injected. The patient will typically cough as the local anesthesia coats
the vocal cords, so we inform the patient to anticipate this event during
consent and again right before we inject.
In addition to being an effective method for anesthetizing the
recurrent laryngeal nerve, this technique simultaneously can
be used in learning how to perform an emergency needle
cricothyrotomy. If this block cannot be performed because of
pathology in the area or difficulty in confirming the location, the
recurrent laryngeal can also be blocked by inserting an epidural
catheter into the fiberoptic scope and injecting 4 ml of 4% lidocaine
under direct visualization of the vocal cords.
CONCLUSION
Despite having described several regional blocks commonly used
in our day-to-day practice, this is not an exhaustive list of the
nerve blocks for head and neck surgical procedures. By forming
strong relationships with the hospital's otolaryngologists over the
years, we were able to collaborate and build our current repertoire
of regional block techniques. The combination of anatomic and
ultrasound-based regional techniques helps us to educate our
residents in different techniques for regional blocks. In addition,
because our hospital has adopted enhanced recovery after surgery
(ERAS) protocols for different surgical procedures, we have

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