Download Head and neck blocks in children: an anatomical and procedural

Pediatric Anesthesia 2006
16: 910–918
doi:10.1111/j.1460-9592.2006.02018.x
Review Article
Head and neck blocks in children: an anatomical
and procedural review
SANTHANAM SURESH MD
POLINA VORONOV MD†
FAAP*
AND
*Pain Treatment Services, Children’s Memorial Hospital, Associate Professor of Anesthesiology
and Pediatrics and †Children’s Memorial Hospital, Instructor in Anesthesiology, Feinberg
School of Medicine, Northwestern University, Chicago, IL, USA
Summary
Children undergo a variety of neurosurgical, otorhinolaryngology and
plastic surgery procedures to the head and neck. Although opioids are
utilized for pain control, they are associated with adverse side effects
including postoperative nausea and vomiting, respiratory depression,
somnolence and itching. The utilization of peripheral nerve blocks
provides analgesia while reducing the need for opioids. This review
will provide a summary of a variety of commonly used head and neck
nerve blocks in children with a brief anatomical and technical
summary.
Keywords: head; neck; trigeminal nerve; bupivacaine; regional
anesthesia; pediatrics; cervical plexus
Introduction
The increasing demand for safer recovery after
surgery with earlier discharge criteria in the past
decade (fast-track anesthesia) has led to the utilization of many peripheral nerve blocks in children for
postoperative pain control. Although the literature is
lacking in data to corroborate the greater use of
regional anesthesia techniques for most pediatric
surgical procedures, the greater acceptance and
awareness of available techniques with a demand
by families for better postoperative pain control has
led to a resurgence in the use of regional anesthesia.
In this review, we will discuss head and neck nerve
blocks for specific pediatric indications for postoperative pain control and also their applications to
chronic pain management in children. One major
advantage to performing head and neck nerve
Correspondence to: Santhanam Suresh, MD FAAP, Children’s
Memorial Hospital, 2300 Children’s Plaza, Box 19, Chicago,
IL 60614, USA (email: [email protected]).
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blocks in children or adults is that most of these
nerves are terminal sensory branches and hence the
risk for nerve damage is likely lower than for motor
nerves. Our vast experience with the use of these
nerve blocks on a routine basis in a busy outpatient
pediatric surgical setting over the past decade has
not demonstrated any significant adverse events
associated with the use of these blocks.
Local anesthesia
Our choice of local anesthetic has been 0.25%
bupivacaine with 1 : 200 000 epinephrine. Although
ropivacaine or levobupivacaine can be utilized for
these nerve blocks, there are no prospective data to
support the advantage of one agent over the other.
The volume of local anesthetic solution needed is
approximately 1–2 ml for each of these nerve blocks
since these are sensory nerves with vast arborizations at the point of exit from the cranial vault. The
choice of finer needles (27-G or 30-G) will reduce the
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REGIONAL ANESTHESIA FOR THE HEAD AND NECK
Table 1
Head and neck nerves that can be blocked
V-1 Division of trigeminal nerve
Supraorbital nerve
Supratrochlear nerve
V-2 Division of the trigeminal nerve
Maxillary division of the trigeminal nerve (Infraorbital nerve)
Greater palatine nerve
V-3 Division of the trigeminal nerve
Mental nerve
Mandibular nerve
Superficial cervical plexus
Occipital nerve
Great auricular nerve
Transverse cervical nerve
likelihood of the formation of hematomas at the site
of injection. A thorough anatomical as well as a
procedural methodology to perform these nerve
blocks will be elucidated (Table 1).
The trigeminal nerve, the largest cranial nerve, is
the sensory nerve of the head and face and the motor
nerve of the muscles of mastication. The fibers of the
sensory roots arise from the cells of the semilunar
temporal bone. It enters the pons and divides into
upper and lower roots. The semilunar ganglion
(Gasserian ganglion) occupies a cavity (cavum
Meckelii) in the duramater covering the trigeminal
impression near the apex of the petrous part of the
temporal bone. Three large branches proceed from
its convex border, the ophthalmic, the maxillary and
the mandibular divisions. The ophthalmic and maxillary divisions consist exclusively of sensory fibers
while the mandibular nerve is joined outside the
cranium by the motor root (1).
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V1 – Division of the trigeminal nerve
Anatomy. The ophthalmic division of the trigeminal
nerve is a pure sensory nerve. It is the smallest
division of the trigeminal nerve. It supplies branches to the cornea, ciliary body, and iris, to the
lacrimal gland and conjunctiva, mucous membranes of the nasal cavity and to the skin of the
eyebrow, eyelids and forehead and nose. The
frontal nerve is the largest branch and may be
regarded as the continuation of the first division of
the trigeminal nerve. It enters the orbit through the
superior orbital fissure and runs forward between
the levator palpebrae superioris and the periosteum. It divides into two branches, the supraorbital
and the supratrochlear nerve (Figure 1). The supraorbital and supratrochlear nerves, branches of the
ophthalmic division of the trigeminal nerve (1)
supply sensory innervation of the forehead and
anterior scalp.
The supraorbital nerve and vessels emerge from
the supraorbital foramen or notch and continue
superiorly. The supraorbital nerve trunk divides
into a deep and a superficial branch. The deep
branch courses superiorly and laterally, running
parallel to the superior temporal line of the skull in
the loose areolar tissue between the galea and the
pericranium. The terminal branches of the deep
supraorbital nerve branch pierce the galea near the
coronal suture to supply scalp sensation. The
superficial division lies medially at its origin and
quickly divides into multiple branches that pierce
the frontalis muscle. These smaller branches pass
cephalad to supply the forehead and up to 3.5 cm
of the frontal scalp.
Figure 1
Division of the trigeminal nerve
(15).
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S. SURESH ET AL.
The supratrochlear nerves exit the orbit at the
superior orbital rim through a notch, above the
trochlea and medial to the supraorbital notch. Most
skulls (97%) possess bilateral supratrochlear
notches; however, 1% possess unilateral foramina,
and 2% have a notch on one side and a foramen on
the other. At the supraorbital rim, the nerves
penetrate the corrugator muscle and the frontalis
muscle. The nerves supply cutaneous sensation to a
central vertical strip of forehead and to the medial
upper eyelid.
Indications. This nerve block can be utilized for
surgery that is performed on the scalp, anterior to
the coronal suture including frontal craniotomies,
anterior midline dermoid excisions, frontal ventriculoperitoneal shunts, Omayya reservoir placement
in neonates (2) and nevus excisions on the anterior
portion of the scalp (Table 2) (3).
(a)
(b)
Position. The patient can be supine for this block to be
performed. Placing the head on a pillow may prevent
the head from moving while placing the nerve block.
Technique. The supraorbital foramen can be palpated
easily at the roof of the orbital rim. It is located
approximately at the level of the pupil in most
patients. Once the foramen is palpated, a 30-G
needle is utilized, the syringe is aspirated for blood
and a subcutaneous injection of local anesthetic
solution is performed at the site of the needle
insertion in the subcutaneous plane. A total volume
of 1–1.5 ml is adequate to provide analgesia. Once
the block is performed, the needle is removed and
firm pressure is applied to the area. This will prevent
the formation of a hematoma (Figure 2a,b).
Complications. Hematoma formation, intravascular
injection.
Table 2
Supraorbital and supratrochlear nerve blocks
Indications
Frontal craniotomy
Midline dermoid excision
Nevus removal of the scalp
Volume of local anesthesia
1–2 ml
Adverse effects
Hematoma formation
Figure 2
(a) Supraorbital and supratrochlear nerve block: the supraorbital
notch is palpated by running a finger from the midline laterally
along the eyebrow. A 27-gauge needle is inserted into the
supraorbital notch perpendicularly; 1 ml of bupivacaine (0.25%
with epinephrine 1 : 200 000) is injected into the space after
careful aspiration. To block the supratrochlear nerve, the needle is
withdrawn to skin level and directed medially several millimeters
toward the apex of the nose. A dose of 1 ml of bupivacaine (0.25%
with 1 : 200 000 epinephrine) is injected. (b) Reproduced with
permission (15).
V2 – Maxillary division of the trigeminal
nerve
Anatomy. The maxillary nerve (V2 – second division
of the trigeminal nerve), a purely sensory nerve, is
called the infraorbital nerve when it reaches the
infraorbital fossa. It arises from the infraorbital
foramen and divides into four branches: the inferior
palpebral, the external nasal, the internal nasal, and
the superior labial. The infraorbital artery and vein
run parallel to the nerve. The nerve is superficial
and can be easily accessed. The posterior superior
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Journal compilation ! 2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 910–918
REGIONAL ANESTHESIA FOR THE HEAD AND NECK
alveolar branch arises from the trunk of the nerve
just before it enters the infraorbital groove. They
enter the infratemporal surface of the maxilla
communicating with the middle superior alveolar
branch giving off branches to the lining membrane
of the maxillary sinus and branches to the molar
teeth. The middle superior alveolar branch arises
from the nerve in the posterior part of the infraorbital canal and runs downward and forward in a
canal along the lateral wall of the maxillary sinus.
The anterior superior alveolar branch branches
just as it exits the infraorbital foramen and descends in a canal in the anterior wall of the
maxillary sinus. It communicates with the middle
superior alveolar branch which supplies the mucous membrane of the anterior part of the inferior
meatus and the floor of the nasal cavity, communicating with the branches from the sphenopalatine
ganglia. The external nasal branches supply the
skin of the nose and of the septum mobile nasi and
joins with the terminal branches of the nasociliary
nerve. The superior labial branches, the largest,
descend behind the quadratus labii superioris and
are distributed to the skin of the upper lip, the
mucous membrane of the mouth and the labial
glands. They are joined, immediately below the
orbit by filaments from the facial nerve forming
with them the infraorbital plexus (1). Using CT
guided images we were able to demonstrate that
the infraorbital foramen is located about 2 cm
lateral to the midline in most children at the level
of the inferior rim of the orbit.
Indications. Cleft lip repair (4,5), endoscopic sinus
surgery (6), nasal septal repair, transsphenoidal
hypophysectomy (7).
Position. Supine with the head on a pillow or a soft
donut to prevent the head from moving.
Technique. There are two approaches to the infraorbital nerve block.
(i) Extraoral approach: The location of the infraorbital foramen is approximately 25 mm from
the midline at the floor of the orbital rim. They
are located directly inferior to the pupils. The
foramen is located by palpation of the floor of
the orbit and a 27-G needle is inserted through
the skin (transcutaenously) towards the
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foramen. The needle need not be placed into
the foramen since the nerve arborizes outside
the foramen to provide the sensory supply to the
mid-face. This will also prevent intraneural
injections with the potential for dysesthesia
and chronic pain. Approximately 0.5 ml (for
cleft lip repairs) to 2 ml (for endoscopic sinus
surgery) is injected on each side. Careful pressure to the area is provided to reduce the
formation of a hematoma with gentle massage
of the area.
(ii) Intraoral approach: This is the most frequent
approach that we use in our institution. The
infraorbital foramen is located at the floor of
the orbital rim at about the level of the pupil.
The external landmarks include the incisor
and the first premolar. A needle is inserted in
the buccal mucosa in the subsulcal groove at
about the level of the canine or the first premolar.
The needle is inserted until it reaches proximal
to the infraorbital foramen (Figure 3a,b). A
finger is placed externally at the level of the
infraorbital foramen to prevent the needle from
cephalad insertion into the globe of the eye.
Bending the needle about 70" before injection
facilitates passage of the needle on the maxillary
process towards the infraorbital foramen. After
careful aspiration, 2 ml of local anesthetic solution is injected.
Complications. Intravascular injection, hematoma formation. It is important to stress the potential for
numbness of the upper lip to older patients since this
can lead to significant concern after the block is
performed.
Palatine nerve
Anatomy. The palatine nerves are distributed to
the roof of the mouth, soft palate, tonsil, and lining
membrane of the nasal cavity. Most of their branches
are derived from the sphenopalatine branches of
the maxillary nerve. There are three main branches,
the anterior, middle and posterior branches.
The anterior palatine nerve descends through the
pterygopalatine canal and emerges in the hard
palate through the greater palatine foramen. It
passes in a groove in the hard palate as far as the
incisor teeth. It supplies the gums, the mucous
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S. SURESH ET AL.
(a)
membrane and glands of the hard palate. The
middle palatine nerve emerges through one of the
minor palatine foramen and provides the sensory
supply to the uvula, the tonsils, and the soft palate.
The posterior palatine nerve descends through the
pterygopalatine canal and emerges through a special
opening behind the greater palatine foramen. It
supplies the sensory branches to the soft palate, the
tonsils and the uvula.
The middle and posterior palatine branches join
the tonsillar branch of the glossopharyngeal to form a
plexus (cirrus tonsillaris) around the tonsils (1).
Indications. Cleft palate repairs.
Position. Supine, with a mouth gag placed to keep
the mouth open.
Technique. With the patient supine and with the
mouth open, the first molar is identified. The greater
palatine foramen is located medial and slightly
anterior to the first molar. Using a 27-G needle 1 ml
of local anesthetic solution is injected in the mucosa
over the palate after careful aspiration to prevent
intravascular injection. It is best to avoid placing the
needle directly into the greater palatine foramen.
(b)
Complications. Intravascular injection, intraneural
injection.
V3 – Mandibular division of the trigeminal
nerve
A common nerve block performed in children is a
blockade of the terminal branch of the mandibular
division of the trigeminal nerve, the mental nerve
(Table 3).
Mental nerve
Figure 3
(a) Infraorbital block: intraoral approach. The infraorbital foramen
is located by palpation of the infraorbital notch. The lip is folded
back and a 27-gauge needle is inserted through the buccal mucosa
approximately parallel to the maxillary second molar. The tip of
the needle is directed toward the infraorbital foramen. A finger is
placed over the infraorbital foramen to assess the proper location
of the needle tip and to avoid accidental placement of the needle
into the orbit. After careful aspiration to avoid intravascular
injection, 0.5 ml to 1.5 ml of bupivacaine (0.25% with 1 : 200 000
epinephrine) is injected. (b) Reproduced with permission (15).
Anatomy. The mental nerve emerges at the mental
foramen, and divides beneath the triangularis muscle
into three branches; a descending branch to the skin of
the chin, and two ascending branches to the skin and
mucous membrane of the lower lip; these branches
communicate freely with the facial nerve (1). The
mental foramen is located in-line with the pupil on the
mental process of the mandible, in close approximation to the canine or the first premolar (Figure 4).
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REGIONAL ANESTHESIA FOR THE HEAD AND NECK
Table 3
Maxillary division of trigeminal nerve
Indications
(a) Infraorbital nerve
Cleft lip repairs
Endoscopic sinus surgery
Nasal tip reconstruction
Nasal septal surgery
(b) Greater palatine nerve
Cleft palate surgery
Local anesthetic solution: 1–2 ml
Adverse effects:
Hematoma formation
Paresthesias along the distribution of the nerves
Indications. Surgery involving the lower lip, cutaneous surgery involving the lower front teeth, skin of
the chin.
Position. Supine.
Technique. Similar to the infraorbital nerve block an
intraoral or an extraoral route can be utilized. The
intraoral route is our preferred choice for performing this block. After eversion of the lip, the lower
canine or the first premolar is identified. The needle
is then gently passed into the buccal mucosa until it
approximates the mental foramen. Two ml of local
anesthetic solution is injected after careful aspiration
to prevent intravascular placement.
Figure 4
Mental nerve block: the lower lip is everted. A 27-G needle is
inserted at the level of the incisor towards the infraorbital
foramen. After careful aspiration 1–1.5 ml 0.25% bupivacaine
with 1 : 200 000 epinephrine is injected.
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Complications.
Hematoma, intravascular injection.
Superficial cervical plexus
Anatomy. The cervical plexus is formed by the
ventral rami of the upper four cervical nerves. Their
dorsal and ventral roots combine to form spinal
nerves as they exit through the intervertebral foramen. The anterior rami of C2 through C4 form the
cervical plexus. The cervical plexus lies behind the
clavicular head of the sternocleidomastoid giving
out both the superficial and deep branches. The
superficial cervical plexus wraps around the belly of
the clavicular head of the sternocleidomastoid to
form four branches, the lesser occipital, the great
auricular, the transverse cervical and the supraclavicular nerves. The great auricular nerve is the
largest of the ascending branches. It arises from the
second and third cervical nerve roots, winds around
the posterior border of the sternocleidomastoid and
after perforating the deep fascia, ascends behind the
clavicular head of the sternocleidomastoid beneath
the platysma to the parotid gland where it divides
into an anterior and posterior branch. The anterior
branch (ramus anterior; facial branch) is distributed
to the skin of the face over the parotid gland and
communicates in the substance of the gland with the
facial nerve. The posterior branch (ramus posterior;
mastoid branch) supplies the skin over the mastoid
process and on the back of the auricle, except at its
upper part; a filament pierces the auricle to reach its
lateral surface, where it is distributed to the lobule of
the ear and the lower part of the concha. The
posterior branch communicates with the smaller
lesser occipital, the auricular branch of the vagus
and the posterior auricular branch of the facial nerve
(1).
Indications. Blockade of the superficial cervical
plexus can provide sensory analgesia for the postauricular area of the scalp (lesser occipital) (2) the
external pinna and the posterior auricular area as
well as the temporoparietal area of the scalp (greater
auricular) (9) the anterior portion of the neck
(transverse cervical) and supply to the supraclavicular area (supraclavicular branch). The greater
auricular nerve block has been successfully used
for pain relief following tympanomastoid surgery (8)
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S. SURESH ET AL.
and otoplasty (9). Children who undergo tympanomastoid surgery may have a greater predisposition
to nausea and vomiting which can be decreased by
performing a greater auricular nerve block and
avoiding or reducing the need for opioids in the
perioperative period (8). A prospective randomized
trial comparing the greater auricular nerve block to
intravenous morphine demonstrated equal analgesia
between both arms of the study. However, the
overall incidence of postoperative nausea and vomiting was increased in children receiving intravenous morphine (75%) and significantly reduced in
children undergoing a great auricular nerve block
with local anesthetic solution (35%) (P ¼ 0.026) (8).
This is now our routine practice for care of children
undergoing tympanomastoid surgery. Blockade of
the superficial cervical plexus bilaterally can provide
analgesia for surgery on the anterior part of the neck.
This can be used for thyroid surgery (10) as well as
for anterior neck procedures including medialization
thyroplasty (11).
(a)
(b)
Position. Supine with the head turned to the side
opposite to the one that is being blocked.
Technique. After sterile preparation of the neck, the
cricoid cartilage is identified. The posterior border
of the sternocleidomastoid is identified. With a 60"
bend to the needle (Figure 5a,b), a 27G gauge
needle is placed superficially along the posterior
border of the clavicular head of the sternocleidomastoid at the level of C6. A wheal is raised with
2 ml of 0.25% bupivacaine with 1 : 200 000 epinephrine after careful aspiration to prevent intravascular injection.
Complications. Intravascular injection, potential for
deep cervical plexus block with associated Horner’s
syndrome, unilateral phrenic nerve paralysis (12,13)
and hematoma formation.
Occipital nerve block
Anatomy. The greater occipital nerve is derived from
the posterior ramus of the cervical nerve root C2.
After piercing the posterior cervical aponeurosis, the
nerve crosses medial to the occipital artery to the
lateral portion of the posterior portion of the occiput
(15). The nerve innervates the sensory supply to the
Figure 5
(a) Great auricular nerve block: identify the cricoid cartilage. A
line drawn from the superior border of the cricoid cartilage
laterally to the posterior border of the sternocleidomastoid
(McKinney’s point) is identified. A dose of 2–3 ml of bupivacaine
(0.25% with 1 : 200 000 epinephrine) is injected subcutaneously at
this point. Gentle massage after the injection allows spread of the
local anesthetic in the injected site. (b) Reproduced with permission (15).
posterior portion of the scalp. This can be used for
providing pain relief for posterior craniotomies as
well for pain secondary to occipital neuralgia (14).
Indications. Occipital craniotomy, shunt revisions,
occipital neuralgia.
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REGIONAL ANESTHESIA FOR THE HEAD AND NECK
Position. Prone or supine with head turned to
opposite direction.
Technique. The occipital artery is palpated below the
occipital protuberance. A 27-G needle is placed next
to the artery and in the subcutaneous plane while
fanning laterally. After careful aspiration to rule out
intravascular placement, 2–3 ml of local anesthetic
(a)
(b)
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solution is injected (Figure 6a,b). Gentle massage of
the area allows easy spread of the local anesthetic
solution.
Complications. Very rarely seen. Intravascular injection should be avoided by careful aspiration.
Conclusion
Head and neck regional anesthesia although sparsely used in children can provide excellent postoperative pain control. A thorough understanding of
the anatomy of the area will allow the pediatric
anesthesiologist to appreciate the ease with which
one can provide analgesia without the added side
effects of opioid analgesia. Most of the above
mentioned nerve blocks are sensory and hence the
damage to nerves is minimal or absent. Moreover,
due to the arborization of the nerves, it is easy to
target these nerves as long as the needle is placed in
the vicinity of the origin of the nerves. As more
prospective studies are published in the area of
regional anesthesia techniques for head and neck
procedures, the demand and popularity of these
techniques will be increased. The demand in our
own institution for these blocks has been promulgated greatly by our surgeons who perceive the
benefits to their patients over the past decade. A
consistent approach with greater teaching imparted
to residents and fellows with an emphasis for
regional anesthesia utilization in children will eventually change our practice to include these techniques as part of our routine anesthesia care.
References
Figure 6
(a) Greater occipital nerve block: with the patient supine and with
the head turned to one side or with the patient prone, the occipital
artery is palpated at the level of the superior nuchal line. The
occipital artery is located about one-third of the distance from the
external occipital protuberance (broken line) to the mastoid
process on the superior nuchal line. A total volume of 2 ml of
bupivacaine (0.25% with 1 : 200 000 epinephrine) is injected
subcutaneously to form a skin wheal. (b) Reproduced with
permission (15).
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Accepted 17 March 2006
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Journal compilation ! 2006 Blackwell Publishing Ltd, Pediatric Anesthesia, 16, 910–918