Supraorbital Nerve Blocks Indications
This is a useful block for pain after herpes zoster and for supraorbital neuralgia.
N. Vadivelu et al. (eds.), Essentials of Pain Management,
DOI 10.1007/978-0-387-87579-8_13, © Springer Science+Business Media, LLC 2011
The supraorbital nerve is a branch of the frontal nerve which enters the orbit via the superior orbital fissure. A smaller branch of the frontal nerve is the supratrochlear nerve.
To perform this block, the supraorbital notch is identified on the affected side and a 1.5-in. 25-gauge needle is advanced medially at the level of the supraorbital notch to avoid the supraorbital foramen. Depot steroid can be added to the local anesthetic up to 80 mg for the initial block and 40 mg of depot steroid for subsequent blocks. Three cubic centimeters of solution is then injected in a fan-like manner.
This block is done lateral to the junction of the bridge of the nose and the supraorbital ridge. A local anesthetic and depot steroid up to 80 mg for the first block and up to 40 mg for blocks thereafter can be used with a 1.5-in. 25-gauge needle. Approximately 3 cc of the solution is injected in a fan-like manner.
This block can be used to treat pain associated with herpes zoster, facial pain in the supply region of the infraorbital nerve, and infraorbital neuralgias.
The inferior orbital nerve is a branch of the maxillary nerve and enters the orbit via the infraorbital foramen. It innervates the lower eyelid, the upper lip, and the lateral nares. Its superior alveolar branch is a sensory nerve which provides innervation to the upper incisor and canine teeth as well as associated gingivae.
(i) The extraoral infraorbital block is performed with a 25-gauge 1.5-in. needle inserted at the level of the infraorbital notch and directed medially to avoid entering the foramen. Along with local anesthetic solution a total of 80 mg of depot steroid can be used for the initial block and 40 mg of depot steroid can be used for subsequent blocks. A total of 3 cc of solution is injected in a fan-like manner.
(ii) The infraoral intraorbital block is done after the administration of topical anesthesia with 10% cocaine or 2% viscous lidocaine given into the mucosa of the alveolar sulcus inferior to the infraorbital foramen. A 25-gauge 1.5-in. needle is directed toward the infraorbital foramen to avoid entering the foramen. Paresthesia may be elicited during the procedure, and local anesthetic and depot steroid can be injected in a manner similar to the extraoral approach.
The most common complications of the above blocks are hematoma and compression neuropathy.
This block is useful for pain in the areas supplied by the auriculotemporal nerve such as atypical facial pain of the temporomandibular joint, neuralgias after trauma, malignant pain, and acute herpes zoster of the external auditory meatus.
The auriculotemporal nerve is a branch of the mandibular nerve going upward through the parotid gland. It provides sensory innervation to the temporomandibular joint, to the external auditory meatus, and to portions of the pinna of the ear. It continues upward with the temporal artery and provides further sensory innervation to the lateral scalp and the temporal region.
The temporal artery provides a useful landmark for this block and is identified above the origin of the zygoma of the affected side (Fig. 13.1). A 25-gauge 1.5-in. needle is used to enter this area perpendicularly until the periosteum is reached. A total of 5 cc of solution of the local anesthetic and depot steroid can be injected with 3 cc at this point and another 2 cc in a fan-like fashion with a more cephalad redirection.
Greater Auricular Nerve Blocks Indications
This block is useful for pain secondary to herpes zoster and for the treatment of painful conditions supplied by the greater auricular nerve.
The greater auricular nerve arises from the ventral rami of the second and the third cervical nerves. It provides sensory innervation to the ear, the skin over the parotid gland, and the external auditory canal.
The mastoid process is identified on the side of the pain in the area of the greater auricular nerve. After skin preparation at the level of the mastoid process a 22-gauge 1.5-in. needle is inserted and advanced perpendicularly until the periosteum is reached. After aspiration, a total of 5 cc of a solution of local anesthetic and depot steroid is injected. After the first 3 cc of the mixture is given, the needle is redirected medially and the remainder of the 2 cc of solution is injected in a fan-like fashion. As with several of the blocks described above, depot steroid can be used up to 80 mg for the first block with 40 mg used for subsequent blocks.
Inferior Alveolar Nerve Blocks Indications
The inferior alveolar nerve is a branch of the mandibular nerve and is a useful block to diagnose and treat painful conditions in the areas supplied by the inferior alveolar nerve.
This nerve passes through the mandibular canal and innervates the molars, the premolars, and the associated gingivae. The inferior alveolar nerve gives off two branches: the incisor branch and the mental branch. The mental branch passes through the mental canal.
To perform this block, the anterior margin of the mandible just before the last molar on the affected side is identified. Topical anesthesia is given over this area with 10% cocaine solution or 2% viscous lidocaine. A 25-gauge 2-in. needle is used to reach the inner surface of the mandible, and 3-5 cc of local anesthetic with depot steroid is slowly injected. In the case of intractable pain due to malignancy 6.5% aqueous phenol can be used to produce neurolysis.
The mental nerve is a branch of the mandibular nerve and exits the mandible via the mental foramen at the level of the second premolar. Upon exiting it makes a sharp turn upward and provides sensory branches to corresponding oral mucosa, the lower lip, and the chin.
(i) Extraoral approach for mental nerve block.
Local anesthetic to the skin is administered after the identification of the mental notch. A 25-gauge 1.5-in. needle is advanced medially at a 15° angle to avoid the foramen, and a total of 3 cc of local anesthetic and depot steroid solution is administered in a fan-like manner. Depot steroid can be used up to 80 mg for the first injection, followed by 40 mg of depot steroid for subsequent injections.
(ii) Intraoral approach for mental nerve block.
This block requires topical anesthesia with 10% cocaine or 2% viscous lidocaine to be applied to the alveolar sulcus just above the mental foramen after pulling down the lower lip. A 25-gauge 1.5-in. needle is advanced toward the mental foramen and a total of 3 cc of the solution used similar to the mental nerve block done by the extraoral approach.
The trigeminal ganglion block is useful in the presence of facial pain and can be used to determine whether the pain is due to somatic or sympathetic causes. It can also be used to treat painful conditions of the region of supply of the trigeminal nerves.
The trigeminal nerve (CNV) is the largest of the cranial nerves and supplies the major sensory innervation to the face. The trigeminal (or Gasserian) ganglion has three sensory divisions: ophthalmic (V1), maxillary (V2), and mandibular (V3). Trigeminal neuralgia, also called tic douloureux, may cause excruciating pain in any of the three sensory dermatomes of the ophthalmic (V1), maxillary (V2), or mandibular (V3) branches.
All three branches of cranial nerve V may be blocked at the level of the trigeminal or (Gasserian) ganglion. The maxillary V2 and mandibular V3 branches may be individually blocked in the pterygopalatine fossa and below the zygomatic arch, respectively.
Trigeminal nerve blockade can be done with a coronoid approach, and the maxillary or the mandibular nerve can be blocked with this approach. The maxillary nerve (V2) is a purely sensory nerve while the mandibular nerve has sensory and motor roots. Usually a 3.5-in. 22-gauge styletted needle is used for this block. The entry point is below the zygomatic arch in the middle of the coronoid notch perpendicular to the skull (Fig. 13.2). The needle is advanced
Needle entry point
Figure 13.2 Gasserian ganglion block.
Foramen ovale Va
Needle entry point
until the lateral pterygoid plate is reached. For both maxillary and mandibular nerves to be blocked, 7-8 cc of local anesthetic agent is administered. For selective blockade of the maxillary nerve the needle is redirected anteriorly and superiorly past the anterior margin of the lateral pterygoid plate up to a depth of 1 cm before the administration of 3-5 cc of local anesthetic solution. For selective blockade of the mandibular nerve, the needle is redirected posterior-inferiorly below the inferior margin of the lateral pterygoid plate to a depth of 1 cm before the administration of 3-5 cc of local anesthetic solution.
A common complication of this block is facial numbness. Some patients may find the resultant facial numbness more unpleasant than the pain from trigeminal neuralgia.
Trigeminal neurolysis is performed to treat chronic facial pain. It is most commonly caused by a malignancy that causes the symptoms of trigeminal neuralgia.
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