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

2. 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

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

4. Foraminae and fissure

5. 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

6. 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

7. Four ganglia

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

9. 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

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

12. 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

13. 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

15. - 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.

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

18. Pterygopalatine fossa and maxillary nerve

19. 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

21. 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..

22. 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 )

25. 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

26. 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

28. 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

30. Posterior
Middle
Anterior
Superior Alveolar nerve

31. Mandibular nerve
Mental

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

33. 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

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

36. Mandibular nerve block and cyst excision

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

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

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

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

42. Lingual nerve
Stomatodynia
Or burning mouth syndrome

43. The whole of scalp

44. Bilateral maxillary with anterior ethmoidal nerve block

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

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