5.6 Head & Neck Flashcards
Facial nerve block is performed
to
aid to which eye block
Where is it blocked
attain akinesia of
orbicularis oculi along
with retrobulbar block
not needed with peribulbar block
proximally along its course
(causing lower facial hemiparesis
and
anaesthesia)
or
distally (preferable).
Various approaches of facial nerve block for ocular surgery
Approach Landmark Needle direction Side effects
Classic
Van Lint
Classic
Van Lint
Lateral orbital rim
Subcutaneously
superlaterally and
inferolaterally
Lid oedema and
periorbital
ecchymosis
Classic Atkinson
Various approaches of facial nerve block for ocular surgery
Classic Atkinson
Zygomatic arch
.Superiorly and posteriorly along zygoma
nil
Various approaches of facial nerve
block for ocular surgery
Modified Atkinson
Modified Atkinson
2 cm away from lateral orbital rim
Subcutaneously superlaterally and
inferolaterally
Less periorbital
ecchymosis
Various approaches of facial nerve
block for ocular surgery
O’Brien
O’Brien
Mandibular condyle
Injection over condyle and
then redirected inferiorly
along posterior edge of ramus
Total facial paralysis
Various approaches of facial nerve
block for ocular surgery
Nadbath– Rehman
Nadbath–Rehman
Stylomastoid foramen
Between mastoid process
and mandibular ramus,
directed toward top of the opposite ear
Total facial paralysis
Various approaches of facial nerve
block for ocular surgery
Nadbath– Rehman
other s/e
Nadbath–Rehman block may also result in paralysis of
glossopharyngeal, vagus and spinal accessory nerves, as they exit via jugular
foramen 1 cm medial to the stylomastoid foramen.
Scalp is supplied by the following nerves.
Cervical nerve (C2):
Trigeminal nerve:
Scalp is supplied by the following nerves.
Cervical nerve (C2):
Cervical nerve (C2):
greater occipital nerve (C2)
posteriorly up to the vertex
lesser occipital nerve (C2)
behind the ear.
Trigeminal nerve:
Trigeminal nerve:
ophthalmic division –
supratrochlear and supraorbital nerve
maxillary division:
zygomaticotemporal nerve
mandibular division:
auriculotemporal nerve
Blockade of nerves supplying the scalp
used for
Blockade of nerves supplying the scalp
(scalp block)
is used for awake craniotomy.
The landmarks for blocking these are
outlined in Table
5.26.
scalp block) nerves blocked x 7
1.
Greater occipital
2.
Greater and lesser occipital
3.
Lesser occipital
4.
Auriculotemporal
5.
Zygomaticotemporal
6.
Supraorbital
7.
Supratrochlear
Greater occipital
2–3 cm lateral to occipital protuberance
Greater and lesser
occipital
Along line joining occipital protuberance and mastoid process
Lesser occipital
Superficial cervical plexus block along posterior border of sternocleidomastoid,
on its middle third; or posterior to the auricle, above mastoid
Auriculotemporal
At the temporal fossa (in front of auricle)
Zygomaticotemporal
Against the zygomatic arch
Supraorbital
Above the supraorbital notch
Supratrochlear
Between the eyebrows (blocks both sides)
Scalp block using
Scalp block using (image page 230/363 pdf) 0.5% bupivacaine has been shown to be successful in blunting the haemodynamic response to head pinning.
Nerve supply of face is by
Nerve supply of face is by
trigeminal nerve
and C2 spinal nerve is
outlined in Table 5.27
Nerve supply of face - various portions
Ophthalmic division (V1) Forehead, nose, upper eyelid
Maxillary division (V2) Cheeks, lower eyelid, upper lip
Mandibular division (V3) Lower lip, chin, most of jaw
Cervical nerve (C2) Angle of jaw
What gives motor supply to face
facial nerve gives motor but
not sensory supply to face.
Largest CN
Largest CN Trigeminal
Longest CN
Longest CN Vagus
CN with longest intracranial course
CN with longest intracranial course Abducens
CN emerging from posterior surface of brainstem
CN emerging from posterior surface of brainstem Trochlear
Trigeminal nerve (CNV)
Trigeminal nerve (CNV) is the largest cranial nerve.
Trigeminal nerve (CNV)
Supply
sensory or motor or both?
It supplies sensory, proprioceptive and pain nerve fibres to the head and face,
and the motor supply to the muscles of mastication.
Trigeminal nerve (CNV)
It emerges from the side of the pons,
near its upper border,
by a small motor and a large sensory root
CNV Passage
to where
what happens then
It passes laterally to join the
Gasserian (semilunar) ganglion
in Meckel’s cave.
The Gasserian ganglion gives three branches:
ophthalmic (V1),
maxillary (V2)
mandibular (V3).
Which branches of CNV are sensory and motor
The ophthalmic and maxillary branches
comprise sensory fibres exclusively,
while the mandibular branch
carries motor fibres as well.
Any parasympathetic suppy from CNV
Four small parasympathetic ganglia
are associated with the three
divisions of the trigeminal nerve:
1.
ciliary ganglion – ophthalmic nerve
2 sphenopalatine ganglion (pterygopalatine) – maxillary nerve
3. otic & 4. submaxillary ganglia – mandibular nerve.
Trigeminal nerve branches and foramen
cranium exit
assoc foramen
Ophthalmic nerve
Ophthalmic
Superior orbital fissure
Supraorbital notch
(supraorbital nerve)
Trigeminal nerve branches and foramen
cranium exit
assoc foramen
Maxillary nerve
Maxillary nerve
Foramen rotundum
Inferior orbital fissure Infraorbital foramen (infraorbital nerve)
Trigeminal nerve branches and foramen
cranium exit
assoc foramen
Mandibular nerve
Mandibular nerve
Foramen ovale
Mental foramen (mental nerve)
Ophthalmic nerve
Path
ophthalmic nerve
is the first and
smallest branch of the
trigeminal nerve.
It traverses along the
lateral wall of the
cavernous venous sinus
Ophthalmic nerve
Skull exit
what happens then
and exits the skull
through the superior orbital fissure,
dividing into
three branches:
frontal,
lacrimal
and
nasociliary.
Frontal nerve:
divides
branch of Ophthalmic nerve
Frontal nerve: (largest branch of the V1):
supraorbital nerve
supratrochlear nerve
supraorbital nerve –
exit
supply
blocked @
Branch of Frontal nerve
exits skull through the supraorbital notch.
It supplies
upper lid and
the scalp up to the lambdoid suture.
It is blocked at the supraorbital notch
in the middle of the upper margin of orbit.
supratrochlear nerve
emerges
supply
blocked @
Branch of Frontal nerve
Emerges from the
upper medial quadrant
of the orbit.
It supplies medial eyelid
and medial forehead.
A single injection in the
midline between the eyebrows
blocks this nerve from both sides.
Lacrimal nerve:
passage
supply
branch of Frontal Nerve (branch itself of ophthalmic)
Lacrimal nerve:
passes in the lateral part of the
superior orbital fissure.
It supplies the lacrimal gland,
conjunctiva and upper lid.
Nasociliary nerve:
passagee
Nasociliary nerve:
branch of Frontal Nerve (branch itself of ophthalmic)
passes in the central part of
the superior orbital fissure.
Nasociliary nerve:
branches
Its branches include the
anterior ethmoid nerve, posterior ethmoid nerve, internal nasal branch, external nasal branches and two to three long ciliary nerves.
Nasociliary nerve: branches blocked where?
The nasal branches are blocked by placing
nasal pellets soaked with local anaesthetic.
Can all of V1 be blocked??
only the extracranial part of V1 can be blocked.
The maxillary nerve (V2)
type
The maxillary nerve (V2)
is a purely sensory nerve.
The maxillary nerve (V2)
passage
exits skull
fossa
orbit entry
passes at the
lateral wall of the cavernous sinus,
leaves the skull through the
foramen rotundum,
then crosses the pterygopalatine fossa
and enters the
orbit through the inferior orbital fissure
The maxillary nerve (V2)
face appears…
It traverses the infraorbital groove
and canal in the floor of the orbit,
and appears upon the
face at the infraorbital foramen
as the infraorbital nerve.
The maxillary nerve
Its main branches are as follows.
Zygomatic:
Sphenopalatine
Posterior alveolar nerve
Zygomatic
zygomaticofacial (cheek)
and
zygomaticotemporal (temple).
The latter is blocked at the zygomatic arch
for scalp block.
Sphenopalatine
branches to
whats blocked for palatal surgery
supplies nerves to the
orbit, nasal branches, nasopalatine nerve, greater palatine nerve, lesser palatine nerve and pharyngeal branches.
The nasopalatine and greater palatine branches
are blocked for palatal surgery.
Posterior alveolar nerve
Posterior alveolar nerve:
supplies posterior upper alveolus.
It is blocked for molar tooth extraction.
Cleft palate surgery
Infraorbital block can be used for analgesia in cleft palate surgery
Infraorbital nerve
is a branch of
exits through
Infraorbital nerve is the
terminal branch of maxillary nerve
and exits
through the infraorbital foramen.
Infraorbital nerve
It divides into
inferior palpebral,
lateral nasal and
superior labial branches.
It is blocked at the infraorbital foramen
(intramucosal or extramucosal approach)
for cleft lip surgery
(analgesia to upper lip)
and upper-incisor dental surgery.
The mandibular nerve (V3)
type
The mandibular nerve (V3)
is the largest branch of the trigeminal nerve.
It is made up of a large sensory root
and a small motor root
(supplies the muscles of mastication).
The mandibular nerve (V3)
exit
Main trunk division
They exit through the foramen ovale
and unite to form the main trunk of V3.
The main trunk gives two branches
before it divides into
anterior and posterior divisions,
which give more branches again.
The mandibular nerve (V3)
Of interest are its three branches of posterior division
Auriculotemporal nerve:
Lingual nerve:
Inferior alveolar nerve:
Auriculotemporal nerve:
path
innervates
blocked @
ascends upwards behind the temporomandibular joint (TMJ)
innervating the auricle,
external auditory meatus,
tympanic membrane
and TMJ.
It is blocked at
temporal fossa for scalp block.
Lingual nerve:
supplies sensory innervation to
the anterior two-thirds of the tongue,
floor of mouth
and gingival mucosa.
Inferior alveolar nerve:
traverses the mandibular canal to
emerge as the mental nerve
at the mental foramen.
It supplies the chin and lower lip.
Blockade of terminal branches of trigeminal nerve
nerve
where
Supraorbital
Supratrochlear
Infraorbital nerve
Mental nerve Mental foramen
FIGURE
Supraorbital
Supraorbital
Supraorbital notch
Supratrochlear
Supratrochlear
Just above the medial end of eyebrows or between eyebrows to block bilaterally
Infraorbital nerve
Infraorbital nerve
Infraorbital foramen
Mental nerve
Mental nerve Mental foramen
terminal branches of the trigeminal nerve (CNV)
can be blocked in a vertical line except
Supratrochlear nerve
maxillary nerve can be blocked
where
after it exits the foramen rotundum.
For this, a lateral approach
through the infratemporal fossa
maxillary nerve block
describe
An 8-cm 22-G needle is
passed below the midpoint of zygomatic arch,
overlying the coronoid notch of mandible.
As it is advanced deeper, it
contacts the lateral pterygoid plate
at a depth of 5 cm.
It is then redirected
anteriorly to walk off the edge of the lateral pterygoid plate, to enter the
pterygopalatine fossa.
Paraesthesias/radiological confirmation can be used
to access placement. Local anaesthetic (5 mL) is injected here.
Indications for the maxillary block
Indications for the maxillary block:
1. surgery – lower eyelid, the nose (with the nasal nerve), the cheek, the zygomatic area, the upper lip, superior dental surgery, palate and maxillary bone surgery
2.
trigeminal neuralgias
3. refractory headaches (sphenopalatine ganglion origin).
maxillary block
quirky side effect
does this change approach for other blocks
how are they done
Spread of local anaesthetic here may
cause transient blindness.
For the same reason,
neurolytic blocks are avoided
through this approach; rather,
they are performed at the Gasserian ganglion.
The mandibular nerve can be blocked where
what approach
The mandibular nerve can be blocked
after it exits the foramen ovale.
For this, a lateral approach through the infratemporal fossa is used
The mandibular nerve block
describe (detail)
process
endpoint
An 8-cm 22-G needle is
passed below the
midpoint of zygomatic arch,
overlying the coronoid notch of mandible.
As it is advanced deeper, it
contacts the lateral pterygoid
plate at a depth of 5 cm.
It is then redirected posteriorly to walk off the edge of the lateral pterygoid plate to stimulate V3 near the foramen ovale.
Paraesthesias, motor stimulation or radiological
confirmation can be used to access placement.
Local anaesthetic (5 mL) is injected here.
Indications for the mandibular block:
Indications for the mandibular block:
1.
surgery –
lower lip, mandible, temple surgery, inferior dental surgery
and wound of the anterior two thirds of the tongue
2
pain syndromes
3
TMJ pain.
Risk with mandibular block
side effects
best performed @
Deeper placement of the needle can
result in piercing the pharynx.
Neurolytic blocks can affect the
otic ganglion, resulting in xerostomia.
They are best performed at the Gasserian ganglion
