Loco regional anaesthesia for face and scalp Dr Anuradha Pandey CONSULTANT Anaesthesiologist Mayom hospital

principle Fundamental to the success of regional anesthesia is the correct positioning of the needle tip in the perineural sheath, prior to injection of local anesthetic

layout Brief introduction Indications and contraindications preparation Facial nerve blocks Scalp nerve blocks

CONTRAINDICATION Uncooperative patient Bleeding diathesis Infection Local anesthetic toxicity2 Peripheral neuropathy Patients refusal

Pre-requisites Explain the procedure Informed consent Emergency cart preparation Sedation if needed Position of patient Well lit room Cooperative patient practice

Facial loco-regional anaesthesia

NERVE BLOCK OF FACE FACE Trigeminal nerve blocks Orbit and contents, sphenoid sinus , eyelids, anterior two thirds of scalp Ophthalmic nerve block Forehead Supraorbital nerve block and supratrochlear nerve block Upper jaw, maxillary antrum distribution of infraorbital nerve Maxillary nerve block Lower eyelid, upper lip, temple, lateral aspect of the nose Infraorbital nerve block

The Trigeminal Nerve (V) [Mixed] Largest cranial nerve sensory – touch, pain & thermal 1.Ophthalmic branch sensory – upper eyelid, eyeball lacrimal glands, side of nose, forehead and scalp 2.Maxillary branch sensory – nose, palate, part of pharynx, upper teeth, upper lip and lower eyelid 3.Mandibular branch sensory – tongue, cheek, lower teeth, skin over mandible and side of head anterior to ear -motor – muscles of chewing -inferior alveolar nerve (branch of mandibular) -often anesthetized in dental procedures – lower jaw -numbs to mental nerve (branch of the IAN) -superior alveolar nerve (branch of the maxillary) -numbs the upper jaw

Trigeminal nerve(V) leaving the SKULL

Opthalmic Nerve And its Branches S.o- Supraorbital S.t.- supratrochlear I.t- Infratrochlear

OPHTHALMIC NERVE BLOCK Imp-To avoid keratitis- ophthalmic division Itself not block, so only the suproptic br. is Blocked. Technique:- -2 ml LA injected at supraoptic notch which located on supraoptic ridge Above pupil . -Insert needle lateral to supraorbital foramen Direct needle medially, parallel to brow, toward nose Infiltrate mid-two thirds of lower edge of eyebrow. -Inject just above bone level. -Redirect needle if paresthesia or sharp pain.

Supraorbital Medial edge of Cornea Infra orbital: Above first maxillary premolar Mental Nerve: Inferior to the second

THREE FORAMINA Ask the patient to look straight Draw a straight line from the centre of the cornea

Supra trochlear block Supratrochlear block - 1 ml of LA at Superior medial corner Of orbital ridge Sensation to the skin of the upper eyelid,forehead, ant. Scalp and part of nose.

Supraorbital/Supratrochlear Blocks Landmark - superior orbital rim

INFRAORBITAL BLOCK EXTERNAL APPROCH Procedure- Location- - IOF approx. 1 cm below orbit and usually located with a needle -Inserted about 2 cm lateral to Nasal Ala and directed superiorly , and slightly laterally -Blocked with 2 ml of LA . -Anesthesia to lower eyelid, lateral inferior nose and lower lip

Intra-oral approach • Advance needle, bevel toward bone • Approx 1.5 cm deep

2. MAXILLARY NERVE BLOCK Maxillary branch (V2) – This supplies the midface and upper jaw; it exits via the foramen rotundum, and its branches include the 1.Zygomaticotemporal 2.Zygometicofacial 3infraorbital,

TECHNIQUE - With the patient's mouth slightly opened, - An 8- to 10-cm 22-gauge needle is inserted between the zygomatic arch and the notch of the mandible - After contact with the lateral pterygoid plate (at about 4-cm depth), the needle is partially withdrawn and angled slightly superiorly and anteriorly to pass into the pterygopalatine fossa. - Anesthetic (4–6 mL) is injected once paresthesias are elicited. Both the maxillary nerve and the pterygopalatine ganglia are anesthetized by this technique.

3.MANDIBULAR NERVE BLOCK Mandibular branch (V3) – This supplies the lower jaw; it exits via the foramen ovale, and its branches are the:- lingual, Auriculo temporal, inferior alveolar, Buccal , and mental nerves The ophthalmic and maxillary nerves are purely sensory. The mandibular nerve has sensory and motor functions

Continue… It is the procedure for dentist to anesthesize nerve supply of lower teeth and gum before dental treatment. Landmark:Internal and external oblique ridge,retromolar triangle. Space:Pterygomandibular s(locate between medial mandibular ramus and medial pterygoid pace Nerves block:1.Inferior alveolar n.,2.Lingual n. and 3.buccal n

procedure - This procedure is undertaken with the patient's mouth slightly opened. - An 8- to 10-cm 22-gauge needle is inserted between the zygomatic arch and the mandibular notch. - After contact with the lateral pterygoid plate, the needle is partially withdrawn and angled slightly superiorly and posteriorly toward the ear. - Anesthetic (4–6 mL) is injected once paresthesias are elicited.

Lingual nerve block The lingual and inferior mandibular branches of the mandibular nerve may be blocked intraorally utilizing a 10-cm 22-gauge needle The patient is asked to open the mouth maximally and the coronoid notch is palpated with the index finger of the nonoperative hand. The needle is then introduced at the same level (approximately 1 cm above the surface of the last molar), medial to the finger but lateral to the pterygomandibular plicae (fold). It is advanced posteriorly 1.5–2 cm along the medial side of the mandibular ramus, making contact with the bone. Both nerves are usually blocked following injection of 2–3 mL of local anesthetic.

MENTAL NERVE BLOCK The terminal portion of the inferior alveolar nerve may be blocked as it emerges from the mental foramen at the mid-mandible just beneath the corner of the mouth. Local anesthetic (2 mL) is injected once paresthesias are elicited or the needle is felt to enter the foramen.

Mental Nerve Block Retract lip, apply topical & dry. Advance the needle into the muco buccal fold adjacent to the 1st & 2nd premolar JUST BENEATH THE CORNER OF THE MOUTH. Aspirate and deposit anaesthetic at approx. 1 cm depth.

1st Mandibular Premolar Good for labial mucosa,giniva, and the lower lip adjacent to the incisors &canines. Landmarks: 1st Mandibular Premolar

Trigeminal nerve block Trigeminal nerve block can be accomplished either via the classic approach (guided by the anatomic landmarks) or with the help of imaging (guided by fluoroscopy or computed tomography [CT] Preparation of the skin- with iodophor or povidone-iodine and draped. A skin wheal is raised with a local anesthetic . Video fot TGN block

Classic approach The patient is placed in a supine position with the head in a neutral position and the eyes staring straight ahead. The key anatomic landmark—a point 2-3 cm lateral to the angle of the mouth on the side to be blocked—is marked. A 22-gauge 10-cm long spinal needle is inserted here and advanced upward toward the mandibular condyle This plane should be in line with the pupil as the patient’s eyes stare ahead, and the trajectory should be cephalad toward the external auditory meatus. At a depth of 4-6 cm, the greater wing of the sphenoid at the base of the skull is contacted. The needle is withdrawn and redirected more posteriorly so as to enter the foramen ovale. It is then advanced 1-1.5 cm. Paresthesia at the mandible is elicited, followed by paresthesia in the maxilla and orbit

complete Scalp block

Agents Used For Scalp infiltration . Vasoconstricting agents may be added to LA to control bleeding with added advantage of prolongation of the anesthetic action. AGENTS 50/50 mixtures of lidocaine and bupivacaine may provide the most optimal anesthetic. There is no report on the use of ropivacaine in this indication. However, with a 0,2 %, concentration, it should be as effective as bupivacaine. Furthermore, its intrinsic vasoconstrictor effect allows to avoid epinephrine. Short Acting: Lidocaine, which can be given as 1% or 2% mixtures. Epinephrine 1:1000 may be added to both 1% and 2% solutions Lidocaine -300 mg (3-4 mg/kg in children) without epinephrine, the maximum dose is 500 mg (7 mg/kg).with epinephrine Long-acting -Sensorcaine, 0.25% or 0.5% bupivacaine Bupivacaine- 175 mg (2mg/kg) in an adult, is increased to 225 mg (3mg/kg) when mixed with epinephrine Check dose of e[pinepherine in lidocaine

Nerve distribution

Complete scalp block Anterior scalp block-by blocking V1( supra orbital and supra trochlear ) and V2 ( zygomaticotemporal) Posterior- greater and lesser occipital nerve Lateral-greater auricular nerve Cervical plexus and zygomatico temporal – brow block

technique scalp is innervated by branches of the trigeminal and cervical nerves. These nerves can be anesthetized as they penetrate the scalp. They become subfascial along a line that encircles the head (like a skull-cap). This line passes just above the tragus and through the glabella and occiput. A wheal should be raised in the subdermal plane along this line. About 10 ml of lidocaine is required every few centimetres.

Scalp Block Steps- Pre operative Psychological Preparation Management goals- Adequate sedation, Analgesia , Airway, respiratory & hemodynamic control Scalp Block Insert 1 peripheral IV line LA given at 16 points and about 3ml at each point ( 2 points in each nerve since both nerves are blocked bilaterally) 1)Back of head- Greater and Lesser Occipital nerve- patient sitting with head resting forward at the time of this Block After this patient is made to lie down 2) Greater auricular nerve- 1.5 cm posterior to the tragus 3) Auriculotemporal nerve- between tragus and superficial temporal artery 4) Zygomaticotemporal- halfway down the line joining tragus to the outer corner of the eye 5) Supraorbital nerve 6) Supratrochlear nerve 7) Sternomastoid muscle- Midpoint of the posterior border

ANATOMY Greater occipital nerve arises from the dorsal primary ramus of the second and third cervical nerve.  It gives sensation to the medial portion of the posterior scalp.   The lesser occipital nerve arises form the ventral primary rami of the second and third cervical roots and give supply to the cranial surface of the pinna and adjacent scalp.

GREATER OCCIPITAL NERVE BLOCK TECHNIQUE The patient is usually positioned in the sitting position with the head either vertical or slightly flexed. The nerve is relatively easy to locate along the superior nuchal line,where it lies medial to the occipital artery, bilaterally. The pulsation of the occipital artery is easy to palpate. Assistant provides support for the head anteriorly. The scalp is prepped with alcohol. A mixture of local anesthetic and steroid is used, usually 2% lidocaine with either triamcinolone 10 to 20 mg or betamethasone 2 to 4 mg for a total volume of 3 mL of injectate. Usually a 25 G needle, either 5 ⁄8 inch or 1 1⁄2inch, can be used depending on the size of the patient. The needle is directed at 90 degrees toward the occiput until a bony endpoint is obtained. Aspiration is important to prevent intravascular injection, and in the case of a history of a cranial defect, to prevent injection into the cerebrospinal fluid.

1. 0 cc is injected around the nerve and an additional 1 1.0 cc is injected around the nerve and an additional 1.0 cc on either side of the nerve. When the needle is withdrawn, pressure should be maintained over the site of injection to both bathe the nerve trunk with the mixture and to achieve hemostasis as the scalp has a rich vascular supply The lesser occipital nerves may be included by injecting more of the local anesthetic/steroid mixture lateral to the greater occipital injection along the superior nuchal line

Complications As with any nerve block, bleeding, infection, and nerve damage are possible. Allergic reaction to the anesthetic. Eccchymosis can result from dissection of the local anesthetic into the loose areolar tissue of the eyelid. Puncture of the angular vein causing a hematoma

Greater auricular nerve block Back of the ear- lesser occipital and greater auricular nerve block Area to the rear of the pinna The innervation of this region comes from the lesser occipital nerve and the great auricular nerve. After previously separating the pinna, inject 3-4 ml whilst the needle moves through the posterior sulcus.

Auriculotemporal nerve 22 gauge needle is needed Procedure steps Disinfect the skin with an alcohol swab. Insert the needle anteriorly and superiorly to the tragus. Aspirate and inject 3-4 mL of anesthetic. insert needle Zygomatico temporal nerve and greater auricular nerve can be blocked With a single prick

Cervical plexus block Landmarks- Midpoint between mastoid process and chassaignac tubercle ( upper border of cricoid cartilage ) or midpoint between origin and insertion of SCM with patient in supine position and drug is infilterated at the posterior boarder of SCM 3-5 mm of LA is injected, needle is inserted perpendicular and directed superiorly and inferiorly and well infilterated with 10 ml of drug Careful with phrenic nerve blockage

Topical anaesthesia

Lignocaine toxicity Signs and Symptoms of Lidocaine Toxicity Blood Lidocaine Levels(ug/mL ) Signs and Symptoms 1–5= Tinnitus, lightheadedness, circumoral numbness, diplopia, metallic taste in the mouth 5–8 =Nystagmus, slurred speech, localized muscle twitching, fine tremors 8–12= Focal seizure activity, which may progress to tonic-clonic seizures 20–25= Respiratory depression which can lead to c

Tips and tricks Anatomical landmark History of drug allergy Correct technique and positioning of needle Use fresh drugs in each patient Look for signs of toxicity-cvs and cns including circumoral numbness, disorientation, yawning, tachycardia

Reference http://emedicine.medscape.com/article Regional Anesthesia in Head and Neck Surger SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology http://emedicine.medscape.com/article Atlas of Interventional Pain Management By Steven D. Waldman New York School Of Regional Anaesthesia(Nysora.com)

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