Technique

Transnasal Approach

Intranasal delivery of 4% lidocaine or 2% viscous lidocaine or 10% cocaine in the posterior pharynx superior to the middle turbinate is an effective and noninvasive approach. Cotton-tipped applicators soaked with local anesthetic left in the superior border of the middle turbinate for 20 min is a useful technique via the transnasal approach.

Lateral Approach

This is achieved by the placement of a needle through the coronoid notch. Opening and closing the mouth helps in identifying the area anterior inferior to the acoustic auditory meatus. A 3.5-in., 22-gauge needle through the middle of the coronoid notch is advanced until it touches the lateral pterygoid plate, after which the needle is redirected anterior-superiorly to reach close to the sphenopalatine ganglion. Fluoroscopy or needle stimulation at 50 Hz helps to confirm correct placement of the needle tip. An injection of 2 cc of local anesthetic is usually sufficient.

Greater Palatine Foramen Approach

Sphenopalatine ganglion block can also be performed by the greater palatine foramen approach (Fig. 13.3). This involves the identification of the greater palatine ganglion, which is present on the posterior portion of the hard palate medial to the gum line of the third molar. About 2 cc of local anesthetic is injected 2.5 cm after entering the foramen in a superior posterior fashion at 120° angle.

Radiofrequency lesioning of the sphenopalatine ganglion can be effective in the presence ofchronic cluster headache, intractable pain due to cancer, and painful facial neuralgias. This is usually done with the lateral approach. Confirmation by sensory stimulation is first done

Sphenopalatine ganglion

Greater palatine foramen Palatine nerves 3rd molar Needle

Management Local Anesthesia Toxicity
Figure 13.3 Sphenopalatine ganglion block: greater palatine foramen approach.

with 75 pulses with a pulse width of 0.25-0.5 ms, followed by radiofrequency lesioning for 80 sat 80o C.

Complications

Most common complications associated with sphenopalatine ganglion blocks include local anesthetic toxicity, orthostatic hypotension, bradycardia, and epistaxis.

Glossopharyngeal Blocks Indications

Glossopharyngeal block is useful to provide anesthesia along the distribution of the glossopharyngeal nerve, including pharyngeal mucosa, soft palate, and the posterior third of the tongue region. Thus, glossopharyngeal neuralgia results in pain in the sensory distribution of the ninth cranial nerve, the tongue, the mouth, and the pharynx.

Talon Haut Dessin

Sphenopalatine ganglion

Greater palatine foramen Palatine nerves 3rd molar Needle

Anatomy

The glossopharyngeal nerve contains motor and sensory fibers with the motor nerve innervating the stylopharyngeus muscle and the sensory portion of the nerve innervating the posterior third of the tongue, the mucous membrane of the mouth and pharynx, and the palatine tonsil. The glossopharyngeal nerve exits from the jugular foramen close to the internal jugular vein and the vagus and the accessory nerves.

Technique

The glossopharyngeal nerve can be blocked from a lateral (extraoral) approach, posterior and inferior to the styloid process (Fig. 13.4). In this approach the midpoint of a line between the mastoid process and the angle of the mandible is accessed with a 1.5-in. 22-gauge needle until the styloid process is reached. The needle is then walked off the styloid process inferiorly, and approximately 7 cc of preservative-free 0.5% lidocaine is injected with 80 mg of depot steroid such as methylprednisolone for the first block and 40 mg of methylprednisolone for

Mandibular Nerve
Figure 13.4 Sagittal of head showing major branches of the trigeminal nerve as well as the above-mentioned ganglia.

subsequent blocks. The injection is done slowly after negative aspiration for CSF or blood, and it is always important to inject in incremental doses.

The glossopharyngeal nerve can also be blocked by an intraoral approach. Here, the submucosal area over the medial portion of the palatine tonsil is accessed with a 22-gauge 3.5-in. spinal needle bent at 25°, after anesthetizing the tongue with 2% viscous lidocaine. The mucosa at the lower lateral portion of the posterior tonsillar pillar is entered, and after negative aspiration to blood or CSF, usually 7 cc of preservative-free 0.5% lidocaine combined with 80 mg methylprednisolone for the initial block with 40 mg methylprednisolone for subsequent blocks is injected in incremental doses.

Complications

It must be remembered that the internal carotid artery is posterolateral to the glossopharyngeal nerve when the intraoral approach is used. Nerve damage, intravascular and subarachnoid injection, and worsened pain are all possible complications.

Occipital Blocks Indications

The occipital block is typically utilized for the treatment of occipital neuralgia. Occipital neuralgia usually manifests as tenderness and pain at the posterior occiput and may be the result of nerve entrapment or neck injuries such as whiplash. Inflammation of the occipital nerves, C2 and C3, can cause headaches as well as precipitate migraines. Occipital neuralgias can affect the greater and the lesser occipital nerves.

Anatomy

The greater occipital nerve arises from the dorsal posterior ramus of the second cervical nerve and the third cervical nerve, while the lesser occipital nerve arises from the ventral rami of the second and the third cervical nerves.

Technique

Injection of local anesthetic can be diagnostic and therapeutic in treating the pain and halting progression of the headache. Addition of a depot steroid may prolong the duration of relief. The injection is usually done in an examination room as fluoroscopic guidance is not required. The approach is to identify the greater occipital protuberance and the mastoid process of the affected side. An imaginary line is drawn between them and divided into thirds. The junction between the medial first and second thirds is the approximate location of the nerve. Palpation of the arterial pulse can help, and if found the injection should be medial to it, but it is not always discernable. The point is usually tender. A fine-gauge needle is then inserted and directed slightly cephalad until bone is contacted. The needle is then withdrawn a few millimeters, aspirated, and then 5 cc of local anesthetic with or without steroid is injected. The lesser occipital nerve may be blocked by a similar procedure at the junction of the outer thirds along the same line. The third occipital nerve from C3 may be blocked slightly caudal to these in the midline (Rosenberg and Phero 2003, Moore 1965) (Fig. 13.5).

Left Occipital Nerve

Complications

Complications include subarachnoid block, bleeding, infection, and intravascular or intraneural injection. Patients with a previous history of posterior cranial surgery can potentially have a higher risk for complications.

Atlanto-occipital Nerve Blocks Indications

The Atlanto-occipital nerve block can be used to treat pain associated with flexion-extension of the neck. This is the predominant motion between the base of the skull and the first cervical vertebrae. This joint may cause referred pain from the occiput to the base of the neck.

Technique

The block is performed with a 25-gauge 3-in. spinal needle under fluoroscopy in the prone position. Biplanar imaging, viewing the joint from two different axes, is utilized to guide the needle into the joint. Contrast is injected to outline the joint space and check for arterial blush/venous runoff. A combination of local anesthetic and steroid are injected. Complications may include intravascular and subarachnoid injection, as well as intraneu-ral injection. The joint is deeper than the cord at this level, and the vertebral artery, venous vessels, and nerve roots are in close proximity. A similar procedure may be done for the Atlanto-axial joint, between the second and the third cervical vertebrae where the predominant motion is rotation (Ogoke 2000) (Fig. 13.6).

Ganglion Radiofrequency
Figure 13.6 Illustration of vertebral anatomy of the bottom of the skull, C1, C2, and C3. C2g = C2 ganglion; C2vr = C2 ventral ramus; AO = atlanto-occipital; LAA = lateral atlanto-axial.

The performance of neural blockade in the head and neck mandates the use of flu-oroscopy, dexterity in needle manipulation, and an intricate knowledge of anatomical relationships. Inadvertent subarachnoid or intravascular injection can lead to devastating complications. Diagnostic blocks with short-acting local anesthetic to assess the efficacy usually precede longer lasting treatments such as neurolytic injections and radiofrequency neurolysis. The sensitivity of the area as well as the importance of precise placement sometimes requires deeper anesthesia for the patient.

Facial Nerve Blocks Indications

Facial nerve block is a useful block for the diagnosis and treatment of a variety of conditions. These include pain associated with Bell's palsy, herpes zoster of the geniculate ganglion also called Ramsay Hunt syndrome, facial spasms in the areas supplied by the facial nerve, and geniculate neuralgia.

Anatomy

The facial nerve arises from the brain stem and has both motor and sensory fibers. The sensory part of the facial nerve is called the nervus intermedius, and it is susceptible to compression, leading to geniculate neuralgia, especially as it exits the pons. It enters the internal auditory meatus and exits the base of the skull through the stylomastoid foramen.

Technique

To perform the block, the anterior border of the mastoid process below the external auditory meatus at the level of the middle of the ramus of the mandible of the affected side is identified. A 22-gauge 1.5-in. needle is inserted perpendicular to the skin until the needle encounters the mastoid bone. The needle is then walked off the mastoid anteriorly to a depth of 0.5 in. After negative aspiration of blood and cerebrospinal fluid, a total of 3-4 cc of local anesthetic is injected slowly in incremental doses along with 80 mg of depot steroid for the initial block.

Superior Cervical Plexus Blocks Indication

The superior cervical plexus block is utilized for either superficial neck operations or as a supplement for deeper surgical procedures, such as a carotid artery endarterectomy. In many facilities, this type of surgery is only done under a regional approach, with a combination of deep and superficial cervical plexus blocks, to limit the use of shunting and to reduce intraoperative surgical time.

Anatomy

The primary rami of the first, second, third, and fourth cervical nerves form the cervical plexus after dividing into an ascending and descending branches which give fibers to the nerves above and below. This plexus provides both motor and sensory innervation; the most important motor branch is the phrenic nerve. The cervical plexus also provides motor fibers to the spinal accessory nerve and the paravertebral deep muscles of the neck. The cervical plexus provides sensory innervation to the skin of the lower mandible, neck, and supraclavicular fossa, with some sensory fibers joining the greater auricular and lesser auricular nerves. The sensory nerves converge at the midpoint of the sternocleidomastoid muscle at its posterior margin, which is the first point to be identified for the performance of the superior cervical plexus block.

Technique

The injection is done in a fan-like manner with a total of 15 cc of local anesthetic solution injected with a 22-gauge 1.5-in. needle along with 80 mg of depomedrol for the initial injection and 40 mg of depomedrol for subsequent injections. Injection of local anesthetic is done after negative aspiration of blood and CSF. The first 5 cc is injected just behind the stern-ocleidomastoid muscle at the midline past its posterior border. The next 5 cc is injected in a fan-like fashion along the line passing behind the lobe of the ear, and the remaining 5 cc is injected inferiorly toward the ipsilateral nipple. For surgical anesthesia, only local anesthetics are utilized.

Deep Cervical Plexus Blocks Indications

Some of the indications for this block include posttraumatic pain, intractable pain secondary to malignancy, and provision of anesthesia for surgeries of the neck requiring muscle relaxation. Surgical anesthesia with a deep cervical nerve block is performed as mentioned above for procedures such as carotid endarterectomy, removal of lesions, and laceration repairs in the areas subserved by the deep cervical plexus.

Anatomy

The deep cervical plexus provides sensory and motor innervation to the neck and is formed by the ventral rami of the first, second, third, and fourth cervical nerves. Each of these nerves then gives off an ascending and a descending branch to the nerves above and below to form the cervical plexus. The most important motor nerve of the cervical plexus is the phrenic nerve.

Sternocle

Sternocle

Skin Glue Carotid Endarterectomy

Mastoid process

Clavicle

Figure 13.7 Deep cervical plexus block. Technique

A line is drawn between the mastoid process and the insertion of the sternocleidomastoid muscle at the clavicle (Fig. 13.7). A 22-gauge 1.5-in. needle is used for the block, and a point 2 in. below the mastoid process on the marked line is identified. The needle is inserted about 0.5 in. in front of this point, after appropriate antiseptic preparation of the skin of the entire side of the neck. The needle is advanced up to 1 in. anteriorly and inferiorly until a paresthesia is elicited. After negative aspiration of blood and CSF, a total of 15 cc of local anesthetic solution is injected slowly in incremental doses with 80 mg of depot steroid for the initial block and 40 mgof depot steroid for subsequent blocks, especially for the treatment of painful conditions with an inflammatory component.

Mastoid process

Clavicle

Figure 13.7 Deep cervical plexus block. Technique

A line is drawn between the mastoid process and the insertion of the sternocleidomastoid muscle at the clavicle (Fig. 13.7). A 22-gauge 1.5-in. needle is used for the block, and a point 2 in. below the mastoid process on the marked line is identified. The needle is inserted about 0.5 in. in front of this point, after appropriate antiseptic preparation of the skin of the entire side of the neck. The needle is advanced up to 1 in. anteriorly and inferiorly until a paresthesia is elicited. After negative aspiration of blood and CSF, a total of 15 cc of local anesthetic solution is injected slowly in incremental doses with 80 mg of depot steroid for the initial block and 40 mgof depot steroid for subsequent blocks, especially for the treatment of painful conditions with an inflammatory component.

Complications

Most common complications include inadvertent injection into the epidural, subdural, intrathecal, and vascular compartments.

Superior Laryngeal Nerve Block Indications

The superior laryngeal nerve supplies the pharynx and the larynx above the glottis, and its blockade is useful for the diagnosis and treatment of painful conditions in this region. The blockade of this nerve can also serve as an adjunct to topical anesthesia for procedures such as awake fiberoptic intubation, bronchoscopy, laryngoscopy, and transesophageal echocardiography (TEE).

Anatomy

The superior laryngeal nerve is a branch of the vagus nerve with a contribution from the superior cervical ganglion, and it passes the lateral aspect of the hyoid bone. Its internal branch provides sensation to the mucous membranes of the lower portion of the epiglottis, while the external branch provides innervation to the cricothyroid muscle.

Technique

In order to perform the block, a point between the lateral border of the hyoid bone and the upper outer border of the thyroid cartilage is identified. A 25-gauge, 1.5-in. needle is inserted perpendicular to the skin to a depth of about 0.5 cm. After negative aspiration of CSF and blood a total of 2 cc of local anesthetic is injected slowly. If treating painful conditions with an inflammation component, depot steroid (up to 80 mg) can be added for the initial injection and 40 mg added for subsequent injections.

Recurrent Laryngeal Nerve Blocks Indications

This block is useful for painful conditions below the level of the vocal cords. Anatomy

The recurrent laryngeal nerve arises from the vagus nerve. The right laryngeal nerve forms as a loop around the innominate artery and then ascends in the lateral groove between the trachea and the esophagus to supply the inferior portion of the larynx. The left recurrent laryngeal nerve forms a loop around the arch of the aorta and then ascends in the lateral groove between the trachea and the esophagus to supply the inferior portion of the larynx.

Technique

To perform the block, the needle entry point is the medial border of the sternocleidomastoid muscle at the level of the first tracheal ring. A 22-gauge 5/8-in. needle is inserted perpendicular to the skin. After inserting the needle to a depth of about 0.5 in., a total of 2 cc of local anesthetic solution is slowly injected. If the block is being done for a painful condition with the presence of inflammation, then 80 mg of depot steroid can be added to the initial injection, followed by 40 mg of depot steroid for each additional injection.

Vagus Nerve Blocks Indications

Vagus nerve block is useful for patients with vagal neuralgia and when destruction of the nerve is indicated in the presence of intractable pain secondary to malignancy. This block is usually done in aggressive head and neck malignancies.

Anatomy

The vagus nerve has a motor and a sensory component. The motor fibers supply the pharyngeal muscle and the superior and recurrent laryngeal nerves. The sensory fibers supply the mucosa of the larynx below the cords as well as the posterior aspect of the external auditory meatus. The vagus nerve supplies fibers to major intrathoracic viscera such as the heart and the lungs.

Technique

To perform the block, the midpoint of a line between the mastoid process and the angle of the mandible is accessed perpendicular to the skin with a 22-gauge 1.5-in. needle after appropriate preparation of the skin over the area. The styloid process is usually encountered at a depth of 3 cm. The needle is then walked off the styloid process posteroinferiorly. A total of 5 cc of preservative lidocaine 0.5% is injected after negative aspiration of CSF or blood, and 40 mg of methylprednisolone is often given for the initial block.

Complications

The major complications of vagus nerve block are vascular due to the close proximity of the internal jugular vein and the carotid artery. Side effects include dysphonia, difficulty in coughing, and reflex tachycardia.

Spinal Accessory Nerve Blocks Indications

Spasm of the trapezius and sternocleidomastoid muscle can be relieved with a spinal accessory nerve block.

Anatomy

The spinal root of the nerve provides motor innervation to the superior portion of the sternocleidomastoid muscle and to the upper portion of the trapezius muscle.

Technique

To perform the block, the posterior border of the upper third of the sternocleidomastoid muscle is identified with the raising of the patient's head against resistance. A 1.5-in. needle is used to access this area after appropriate preparation with antiseptic solution in an anterior direction. At a depth of approximately 0.75 in., 10 cc of local anesthetic solution is injected slowly after negative aspiration to CSF or blood. Depot steroid (up to 80 mg) can be added to the local anesthetic solution for the initial block and 40 mg depot steroid for subsequent blocks.

Phrenic Nerve Blocks Indications

Phrenic nerve block can be used to assist with diagnosis or as a therapeutic modality. Phrenic nerve neurolysis is useful for the treatment of intractable hicupps. Cryoneurolysis, chemical neurolysis, RF lesioning, and surgical resection of the nerve are some of the procedures that can be done to produce neurodestruction of the phrenic nerve.

Anatomy

The primary ventral ramus of the fourth cervical nerve with fibers from the third and fifth cervical nerves forms the phrenic nerve. The phrenic nerve passes between the omohyoid and the sternocleidomastoid muscles inferiorly in close proximity to the subclavian artery and the subclavian vein. The right phrenic nerve gives motor innervation to the right diaphragm after coursing along with the vena cava. The left phrenic nerve follows the course of the vagus nerve to provide motor innervation to the left side of the diaphragm.

Technique

To perform the block, the groove between the posterior border of the sternocleidomastoid muscle and the anterior scalene muscle is identified. One inch above the clavicle at this groove or behind the posterior border of the sternocleidomastoid muscle a 1.5-in. needle is inserted anteriorly after appropriate antiseptic preparation of the skin. After advancing for approximately 1 in. and following negative aspiration of blood or CSF, 10 cc of local anesthetic solution is injected slowly with 80 mg of depot steroid for the initial block and 40 mg of depot steroid for subsequent blocks.

Complications

Potential significant complications include vascular injury and serious fatal complications associated with inadvertent injection into the epidural, the subdural, and the intrathecal spaces. Recurrent laryngeal nerve can often be blocked unintentionally. Close monitoring and recognition of these complications are extremely important.

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