Blocks of the face Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology),( IDRA)

Trigeminal nerve – prime nerve supply Fifth cranial nerve- preganglionic fibres Ganglion in meckels cave Starts from the trigeminal ganglion Three branches Ophthalmic Maxillary Mandibular Motor component separate from beginning Sensory Mixed

Remember that cranial nerve five trigeminal Sensory supply for the face Not the facial nerve

Foraminae and fissure

After leaving these foramina, the maxillary and mandibular nerves follow courses that place them in the immediate proximity of the lateral pterygoid plate. important landmark for effective maxillary or mandibular block

Ophthalmic branch First and smallest branch of V (V1) Superior orbital fissure Frontal nerve Lacrimal nerve Nasociliary nerve ( ant and post ethmoidal) Why ? (For FESS ant ethmoidal to be blocked) Frontal ends as supra orbital

Four ganglia

Ophthalmic per se cant be blocked Supra orbital and supratrochlear only can be blocked

Supraorbital & Supratrochlear 2 cm lateral to midline Palpate the notch- 27 G needle Pupil and eyebrow level Needle perpendicular subcutaneous infiltration of 2 ml - ecchymosis possible Edema of eyelid if 5 ml Prick at the midline Go both directions and infiltrate subcutaneous Supraorbital Supratrochlear

Keep above the eyebrow - A1 slowly bring the probe down - A2

Palpate the medial canthus 1 cm above the canthus Go perpendicular or slightly medially and cranially 1.5 to 2 cm Aspirate 2 -3 ml local

See blood vessels closeby Maxillary branch V2 – foramen rotundum Anterior to lateral pterygoid plate Zygomatic nerve Pterygopalatine fossa Spheno palatine nerves and end up as infra orbital nerve with superior alveolar nerves and in the infra orbital groove pupil line See blood vessels closeby

- Maxillary nerve block - Made to sit or a lateral position In front of tragus palpate the intercondylar notch ( crucial step) Perpendicular to the notch , needle to hit the bone ( maximum 5 cm) Slide anterior off the bone – may be cephalic ! Maximum 5 ml.

Complications Hematoma Resolves in two weeks Horners syndrome – rare Transient visual disturbances – reassurance

Pterygopalatine fossa and maxillary nerve

Maxillary nerve in the pterygopalatine fossa – block indications Diagnostic • Differential diagnosis of facial pain Therapeutic • Trigeminal neuralgia in the second branch, postherpetic neuralgia • Cluster headache , histamine headache, • Facial pain in the area of supply • Pain in the eye region (iritis, keratitis, corneal ulcer), root of the nose, upper jaw, • Postoperative pain in the area of the maxillary sinus and teeth • Pain after dental extraction Neural Therapy • Hay fever, vasomotor rhinitis • Diseases of the oral mucosa • Localized paresthesias

the puncture is made medial to the posterior edge of the upper seventh tooth (second maxillary molar) through the greater palatine foramen. The needle is introduced at an angle of about 60°. The vicinity of the ganglion is reached at a depth of 3.5–4 cm. The greater palatine canal is about 3.4 cm long in adults 1 – 2 ml..

Vasoconstriction one applicator near the septum towards the roof – 5 cm second applicator – floor – bone – 6-7 cm Packing with local anesthetics-cocaine paste 20 minutes Sphenopalatine ganglion block with anterior ethmoidal nerves for nasal surgeries ( pledget )

Alternate approach for V2 when other site is not possible Inferior and temporal edge of the orbit 4 cm usual depth Perpendicular Passes through the inferior orbital fissure Deposit 5 ml Hematoma possible

Terminal branch – infra orbital nerve – intra oral approach The cheek - retracted and needle was introduced in the mucosa just opposite the upper second premolar approximately 0.5 cm away from the buccal surface. The needle- further introduced towards the palpating finger of the left hand and 3 ml of 0.5 % bupivacaine was injected after aspiration. The approximate depth was 2 .5 cm

extra oral approach Palpate for the dip in the infra orbital region Straight down – the same vertical plane Need not go to the foramen Subcutaneous arborization present In the groove – 3 – 5 ml of local for nose both sides Just 1 ml for analgesia for cleft lip repair

Posterior Middle Anterior Superior Alveolar nerve

Mandibular nerve Mental

Mandibular Intercondylar notch Medial Hit the pterygoid plate Slid posterior Not more than 0.5 cm depth 5 ml local Vascular entry possible

Pictures from the internet for closed academic purpose only Look for the gap between bones Maxillary artery Look for the mandibular nerve 5 ml of local anesthetic Pictures from the internet for closed academic purpose only

Parotid surgery = auriculotemporal (V3) + greater auricular ( SCP)

Mandibular nerve block and cyst excision

Look for the dip in the bone Mental nerve Look for the dip in the bone Inject two to three ml

Beware of facial vessels 6 mm into the canal Beware of facial vessels

Occipital nerve block Occipital neuralgia Part of the scalp block 3- 5ml after palpating the occipital artery lateral to the midpoint External occipital protuberance

Auriculotemporal nerve – TMJ arthritis Anterior to tragus Posterior to superficial temporal artery Subcutaneous line of infiltration 3 – 5 ml

Lingual nerve Stomatodynia Or burning mouth syndrome

The whole of scalp

Bilateral maxillary with anterior ethmoidal nerve block

Complications in general High spinal and brain stem spread ?? Generalized seizures Hematoma – airway compromise Airway anesthesia ( respiratory distress) Systemic absorption

In the face, head neck also Blocks are useful That too ultrasound is useful