Download Head and neck blocks in children

Head and neck blocks in children
Polina Voronova and Santhanam Sureshb
a
Department of Anesthesiology and bDepartment of
Anesthesiology and Pediatrics, Children’s Memorial
Hospital, Northwestern University, Feinberg School of
Medicine, Chicago, Illinois, USA
Correspondence to Dr Santhanam Suresh, MD, FAAP,
Director of Research, Children’s Memorial Hospital,
Associate Professor of Anesthesiology and Pediatrics,
Northwestern University, Feinberg School of Medicine,
Chicago, IL, USA
Tel: +1 773 880 4415; fax: +1 773 880 3331;
e-mail: [email protected]
Current Opinion in Anaesthesiology 2008,
21:317–322
Purpose of review
The present article will review the current technology and available literature
regarding regional anesthesia in infants and children undergoing head and neck
surgery.
Recent findings
Regional anesthesia can be utilized in a variety of surgical procedures on the
head and neck. The reporting of multiple techniques along with prospective
randomized trials that have looked into the efficacy of these blocks in children
have led to a sweeping increase in their use in children for postoperative
pain relief.
Summary
The trigeminal nerve, along with the cervical nerve roots, supplies most of the
sensory supply to the head and neck. The knowledge and application of the
anatomical distribution of this area can increase the utilization of these blocks
for a variety of different settings. The increased use of these blocks can reduce the
need for additional postoperative analgesic that could in turn lead to fast-tracking of
these patients and decrease the incidence of nausea and vomiting in the postoperative
period.
Keywords
children, head and neck, nausea, nerve blocks, postoperative pain, trigeminal nerve
Curr Opin Anaesthesiol 21:317–322
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0952-7907
Introduction
The trigeminal nerve
Children undergo a variety of minor and major surgical
procedures to the head and neck. They are also prone to
developing airway obstruction and respiratory depression
if they are given an analgesic dose of opioids [1]. We have
been successfully utilizing regional anesthesia to provide
adequate intraoperative and postoperative analgesia
during neurosurgical, ear, nose and throat (ENT), and
plastic surgery procedures in our institution for the last
decade. Using these techniques we have been able to
decrease the incidence of nausea and vomiting in the
postoperative period and have been able to fast-track these
children, thereby facilitating early discharge [2]. Head and
neck blocks can be performed safely in children using well
described and easily identified anatomical landmarks. The
nerves are sensory, terminal branches and the potential
risk of nerve damage is lower than motor nerve blocks used
for most extremity surgery. The low volume of local
anesthetics needed for performance of these blocks
decreases the potential for toxic effects of the local
anesthetic solution. The primary sensory supply of
the head and neck is through the three branches of the
trigeminal nerve with the addition of the cervical nerve
roots C2–C4 providing the sensory supply to the occipital
and postauricular area (Table 1).
The trigeminal nerve with its three terminal sensory
branches – the ophthalmic nerve, the maxillary nerve,
and the mandibular nerves – provide the sensory innervation of the anterior face. They exit the cranium through
three distinct foramens – the supraorbital, infraorbital,
and the mental foramen that usually lie in the midline, in
line with the pupil.
Anatomy
The ophthalmic branch of the trigeminal nerve, a pure
sensory nerve, divides into three branches – lacrimal,
frontal, and nasociliary – just before entering the orbit
through the superior orbital fissure. The frontal nerve
divides into two terminal nerves – the supraorbital and
the supratrochlear nerves that innervate the frontal scalp
anterior to the coronal suture. The supraorbital nerve exits
through the supraorbital foramen and continues superiorly
in between the levator palpebrae superioris and the periosteum. The supratrochlear nerve appears more medial
through the supraorbital notch to supply sensation to the
medial part of the upper eyelid and middle forehead.
Indications
These nerve blocks are utilized for frontal craniotomies,
frontal ventriculo-peritoneal shunts placements, Ommaya
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318 Pediatric anesthesia
Table 1 Head and neck blocks
Nerve
Indication
Supraorbital/supra-trochlear
Infraorbital
Greater palatine
Mental
Superficial cervical plexus
Greater occipital nerve
Scalp lesions
Cleft lips, sinus surgery
Cleft palate
Lower lip surgery
Mastoid surgery, otoplasty, thyroid
Posterior fossa craniotomy
reservoir placement [3], and also for plastic surgical procedures, including excision of anterior scalp pigmented
nevus or dermoid cyst excision [4].
Dose (ml)
0.5–1
0.5–2
0.5–1
0.5–1
1–2
1–2
Complications
Hematoma
Upper lip numbness, hematoma
Intravascular injection
Hematoma
Intravascular injection, hematoma
Intravascular injection, hematoma
Maxillary nerve
The maxillary division of the trigeminal nerve provides
the sensory supply for the midportion of the face.
Technique
The procedure is usually performed in the supine position
after child is anesthetized. The supraorbital foramen can
easily be palpated in children by following the orbit rim
from the midline. A 30-G needle is inserted subcutaneously at the level of the foramen; after negative
aspiration 1 ml of 0.25% bupivacaine with epinephrine
(1 : 200 000) is injected creating a subcutaneous wheal. If
the supratrochlear nerve block needs to be performed, the
needle is withdrawn and directed about 0.5 cm medial and
an additional 0.5 ml of the local anesthetic is injected.
Pressure should be applied to the infiltrated areas for better
anesthetic distribution and prevention of the ecchymosis
(Fig. 1).
Complications
Hematoma formation, intravascular injection, and eye
globe damage could be the possible but rare complications
during the performance of the block.
Figure 1 Supraorbital nerve: the supraorbital nerve can be
palpated along the upper rim of the orbit
Anatomy
The terminal branch of the maxillary division of the
trigeminal nerve, the infraorbital nerve, exits the cranium
through the infraorbital foramen and divides into four
sensory branches: the inferior palpebral, the external
and internal nasal, and the superior labial. The nerve is
in close proximity to the infraorbital artery and vein. It
innervates the lower eyelid, the upper lip, the lateral
portion of the nose, cheek, roof of the mouth, teeth, and
maxillary sinus. Most of the studies to identify the
anatomic characteristics of the location of the foramen
have been performed in cadavers or in adults. Bosenberg
and Kimble [5] examined 15 neonatal cadavers and successfully applied the knowledge to perform the block in
four patients undergoing the cleft lip repair surgery. We
were able to analyze the anatomical location of the infraorbital foramen in children undergoing CT-guided images
and were able to conclude that it was located about 2.5 cm
from the midline at the level of the lower orbital rim.
Infraorbital foramen can easily be palpated in children. In
cases in which the location of the foramen cannot be
appreciated, a simple mathematical formula can be utilized [distance from the midline ¼ 21.3 mm þ 0.5 age
(in years)] [6]. Ahuja et al. [7] used infraorbital nerve blocks
with local anesthetic compared with normal saline infiltration of the nerve in children scheduled for cleft lip repair
and found a significant improvement in pain score in the
local anesthetic block group. In 1999 the first double-blind,
randomized study [8] published demonstrated the significant improvement in pain scores and decrease in analgesic
requirements in children who had an infraorbital nerve
block compared with the conventional peri-incisional
infiltration by surgeons.
Indications
The skin over the nerve is elevated and a subcutaneous injection is
performed at this level. Gentle massage is provided to avoid the
formation of a hematoma.
The interest in the infraorbital nerve block has been
increased over the last several years. The variety of
indications, easy localization, adequate intraoperative
and postoperative pain relief allow the routine use of
this block in our institution for endoscopic sinus surgery
and cleft lip repair. Other indications include rhinoplasty
[9], pulse dye laser for the portwine stain, and excision of
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Head and neck blocks in children Voronov 319
the congenital nevus. We have demonstrated the efficacy
of this block for postoperative pain control following
transsphenoidal hypophysectomy on an 11-year-old child
[10].
Figure 2 Infraorbital nerve: the upper lip is everted, a needle is
inserted through the subsulcal groove toward the infraorbital
foramen
Technique
There are two known approaches for the infraorbital
nerve block: the extraoral approach and the intraoral
approach. In our experience, we note that the risk of
hematoma is much lower with the intraoral approach.
Extraoral approach: Eipe et al. [11] used an extraoral
technique and confirmed the duration of analgesia up to
24 h. Their landmarks were the intersection of a vertical
line through the pupil and a horizontal line through the ala
nasae. As mentioned above, the infraorbital foramen can
be identified by gently palpating the floor of the orbital rim.
A 27-G needle is advanced perpendicularly toward the
foramen till bony resistance is appreciated. A finger is
always placed at the level of the infraorbital foramen
to avoid further cephalad advancement of the needle.
0.5–2 ml of 0.25% bupivacaine with 1 : 200 000 of epinephrine is injected after confirmation of extravascular placement. Gentle pressure is recommended to prevent the
hematoma formation.
Intraoral approach: The infraorbital foramen is palpated; a
27-G needle is bent about 458 and inserted into the buccal
mucosa in the subsulcal groove at the level of canine or
the first premolar. The needle is advanced cephalad until
it reaches the bony landmark. Spreading of the local
anesthetic has to be appreciated by the externally placed
finger while preventing damage of the globe by a cephalad
advancement of the needle (Fig. 2).
Complications
Intravascular injection, hematoma formation, eye globe
damage.
Parents and older children have to be informed about the
long-lasting numbness of the upper lip as the child may
bite on the lip or it may interfere with the oral feeding.
Greater palatine nerve
The greater palatine nerve is the sensory suspension of
the maxillary division of the trigeminal nerve that is
suspended in the palatal mucosa providing the sensory
supply to the palate.
After aspiration, 0.5 ml local anesthetic is injected. Gentle massage is
provided to spread the local anesthetic solution.
groove parallel to the molar teeth. The nerve provides the
sensory innervation to the gums, mucous membrane of
the hard palate, uvula, tonsils, and soft palate.
Indications
Cleft palate repair.
Technique
With the patient mouth open, and with a Dingman’s
mouth gag placed, the second molar is identified, the
palatine foramen is located medial and anterior. A 27-G
needle is inserted and 1 ml of 0.25% bupivacaine with
1 : 200 000 epinephrine is injected after negative aspiration.
Complications
Although it is rare for intravascular injections using this
block, it may be prudent to aspirate and determine the
position of the needle prior to injection.
Mandibular nerve
The mandibular nerve is a mixed sensory and motor
nerve.
Anatomy
The nerve with its three main branches – the anterior,
middle, and posterior – are the terminal sensory endings
of the sphenopalatine branches of the maxillary nerve as
they lay suspended in the palate. It emerges through the
greater palatine foramen and anterior branch lies in a
Anatomy
The mandibular division of the trigeminal nerve is both
motor and sensory. In our practice the terminal nerve of
interest is the mental nerve, the sensory nerve to the chin,
lower lip and mucous membrane of the inferior alveolar
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320 Pediatric anesthesia
nerve. It exits the mandible through the mental foramen
located between canine and the first premolar.
Indications
Hemangioma of the lower lip, plastic surgery involving
the skin of the chin.
nausea, or vomiting. Two studies from our institution
suggest that the great auricular nerve block provides the
same degree of pain relief as intravenous morphine with
lower incidence of vomiting [2,13]. Preemptive performance of the block did not prove to be beneficial in
enhancing pain control in children undergoing tympanomastoid surgery [13].
Technique
We prefer to use an intraoral approach. The lower lip is
everted and a 27-G needle inserted into the buccal mucosa
in the subsulcal groove, between the canine and first
premolar, and gently advanced about 1 cm; 1 ml of
0.25% bupivacaine with epinephrine 1 : 200 000 is injected.
Complications
Potential for hematoma formation and intravascular
injection.
Superficial cervical plexus
The superficial cervical plexus wraps around the belly of
the sternocleidomastoid and provides the sensory innervation of the neck, the postauricular area as well as the
shoulder.
Anatomy
The anterior primary rami of C2–C4 form the superficial
cervical plexus and provide the sensory innervation of the
anterior lateral skin of the neck, part of the posterior
scalp, skin in the above and posterior of the ear and
anterior lower third of the ear. Four major superficial
branches that derive from the plexus include the lesser
occipital, the great auricular, supraclavicular, and
transverse cervical nerves. They appear at the level of
midpoint posterior border of the clavicular head of the
sternocleidomastoid muscle (SCM) and can be blocked
by subcutaneous infiltration of that area.
Other indications for the block: brachial cleft cyst excision, thyroidectomy [14], parathyroidectomy, clavicular
fracture reduction, and thyroplasty surgery [15].
Technique
The block is performed with the head turned to the
opposite side. The cricoid cartilage (C6) is identified and
a line is drawn to the posterior border of the sternal head
of SCM. In some patients the external jugular vein may
be noticed to cross the neck at the point in which the
cervical plexus wraps around the belly of the sternocleidomastoid. A 27-G needle, bent at 458 to facilitate a
superficial subcutaneous insertion, is advanced cephalad
along the posterior border of the SCM. After negative
aspiration 2–3 ml of 0.25% bupivacaine with 1 : 200 000 of
epinephrine is injected in the incremented doses to form
a small wheal. We prefer a ‘peu de orange’ (orange peel)
appearance of the skin overlying the superficial cervical
plexus (Fig. 3).
Adverse effects
Intravascular injection, hematoma, deep cervical nerve
block, potential phrenic nerve block.
Figure 3 Great auricular nerve block: the posterior border of the
sternocleidomastoid is identified
The great auricular nerve
This branch of the superficial cervical plexus supplies the
sensory innervation to the pinna and the postauricular
area.
Anatomy
The great auricular nerve arises from the second and third
cervical nerve roots and ascends up to the mandibular
angle and gives anterior and posterior branches to innervate the skin over the parotid gland and mastoid process.
Indications
We routinely use this procedure for the children undergoing tympanomastoid surgery [2], cochlear implant, and
otoplasty [12]. We have performed many of these procedures in the day surgery centers without the need for
admission to the hospital due to inadequate pain relief,
A line drawn from the cricoid toward the line bisecting the sternocleidomastoid is where the superficial cervical plexus wraps around the belly
of the sternocleidomastoid. Subcutaneous injection of local anesthetic
solution (1–2 ml) will provide adequate analgesia.
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Head and neck blocks in children Voronov 321
Greater occipital nerve
The greater occipital nerve along with the lesser occipital
nerve, a branch of the superficial cervical plexus, supplies
the sensory innervation to the occiput.
Figure 4 Greater occipital nerve: the occipital protuberance is
palpated, the occipital artery is identified close to the midline on
either side
Anatomy
The greater occipital nerve arises from the posterior
ramus of the C2 and travels in the cervical musculature.
It becomes superficial inferior to the superior nuchal line
and emerges through the aponeurosis of the trapezius and
semispinalis capitis muscles. The nerve lies medial to
the occipital artery inferiorly, which could be a helpful
landmark. It gives sensory innervations to the posterior
scalp.
Indications
Several publications could be found in pain and neurology
journals demonstrating the efficacy of the nerve block for
migraine and other occipital neuralgias with significant
improvement in pain score in patients with headaches after
the block [16]. Investigators examined 100 adult cadavers
to identify the landmarks for the greater occipital nerve
and identified that nerve can be found about 2 cm laterally
from the external occipital protuberance and 2 cm inferior
[17]. The other landmark is one-third of a distance from the
midline between the external occipital protuberance and
the mastoid process.
Technique
The block is performed in the prone or lateral position.
One of the above landmarks can be used to locate
the point of the needle entrance. We prefer to use the
pulsation of the artery and advance the 27-G needle
lateral to it and cephalad along the superior nuchal line.
After negative aspiration 3 ml of 0.25% bupivacaine with
1 : 200 000 epinephrine is injected using a ‘fanning’ technique (Fig. 4).
The occipital nerve is located juxta to the artery; local anesthetic solution
is injected with a lateral spread of the local anesthetic.
myringotomy is usually performed for the tube placement for chronic otitis media. We have a large experience
with the use of this nerve block during myrigotomy and
tube (M&T) or paper patch placement.
Technique
The block is generally performed after the induction of
anesthesia. The head is turned to the side opposite to the
block, gentle retraction of the tragus is applied and 0.2 ml
of 0.25% bupivacaine with 1 : 200 000 of epinephrine is
injected to the posterior tragus.
Adverse effects
Hematoma, a very rare side effect.
Conclusion
Supraorbital, supratrochlear, superficial cervical plexus,
and greater auricular nerve blocks can be utilized to
provide ‘band’ anesthesia to the scalp during awake
craniotomy or provide analgesia after general anesthesia
for craniotomy [18].
Nerve of Arnold (auricular branch of the vagus
nerve)
The quest for pain control following myringotomy tube
led to the use of this unique new block.
Anatomy
The nerve of Arnold is the sensory terminal branch of the
auricular portion of the Vagus nerve. It provides the
sensory innervation to the external acoustic canal and
the inferior portion of the tympanic membrane where
The use of regional nerve blocks for head and neck
procedures can be very rewarding in the pediatric population. The potential for excellent pain relief with the
absence of adverse effects makes these an important part
of pediatric regional anesthesia. Further studies are
needed with multi-institutional prospective trials to
demonstrate the efficacy of these blocks. Dedicated
websites for learning these blocks will be available for
learning and performing these blocks. The greatest
advantage of these block techniques is the decreased
need for additional analgesics and the decreased incidence of postoperative nausea and vomiting that allows
these children to be fast-tracked in a busy outpatient
surgical center. These blocks have now become an integral part of our intraoperative care and have provided us
with the opportunity to apply these to increasing number
of surgical techniques.
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322 Pediatric anesthesia
References
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 416).
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Anesth Pain Med 2005; 30:572–573.
11 Eipe N, Choudhrie A, Pillai AD, Choudhrie R. Regional anesthesia for cleft
lip repair: a preliminary study. Cleft Palate Craniofac J 2006; 43:138–
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