Clinics and Practice 2016; volume 6:856

Ultrasound-guided greater comorbidities who successfully underwent sur- gical resection of an ear skin lesion using Correspondence: Matthew B. Ellison, Department auricular nerve block as sole ultrasound-guided GAN block. of Anesthesiology, West Virginia University anesthetic for ear surgery School of Medicine, PO Box 8251, 1 Medical Center Dr, Morgantown, WV, USA. Michael K. Ritchie, Colin A. Wilson, Tel.: +1.304.598.4000 / ext. 7.5135 - Fax: +1.304.598.4930. Brian W. Grose, Pavithra Ranganathan, Case Report E-mail: [email protected] Stephen M. Howell, Matthew B. Ellison Department of Anesthesiology, West An 80-year old, 92-kg male presented for Key words: Ear surgery; greater auricular nerve resection of right posterior-auricular and left block; ultrasound; cervical plexus; ambulatory Virginia University School of Medicine, infra-orbital skin lesions. The patient was ini- surgery. Morgantown, WV, USA tially assessed by the faculty anesthesiologist Contributions: the authors contributed equally. upon arrival to the pre-operative area the day of surgery. He had an extensive past medical Conflict of interest: the authors declare no poten- history including diabetes mellitus-type I, pre- tial conflict of interest. Abstract vious myocardial infarction which resulted in cardiac stent placement, congestive heart fail- Received for publication: 22 April 2015. A greater auricular nerve (GAN) block was ure, pacemaker placement, mitral valve dis- Accepted for publication: 3 May 2016. used as the sole anesthetic for facial surgery in ease, hypertension, hypercholesterolemia, an 80-year-old male patient with multiple obstructive sleep apnea, and gout. Because the This work is licensed under a Creative Commons Attribution NonCommercial 4.0 License (CC BY- comorbidities which would have made general patient was at increased risk for complications NC 4.0). anesthesia challenging. The GAN provides from a general anesthetic, local or regional sensation to the ear, mastoid process, parotid anesthesia was considered. After a discussion ©Copyright M.K. Ritchie et al., 2016 gland, and angle of the mandible. In addition to with the patient and surgeon, we decided to Licensee PAGEPress, Italy anesthesia for operating room surgery, the perform an ultrasound guided GAN block for Clinics and Practice 2016; 6:856 GAN block can be used for outpatient or emer- excision of the skin lesions, allowing the doi:10.4081/cp.2016.856only gency department procedures without the patient to avoid general anesthesia. The need for a separate anesthesia team. Although patient was taken to the operating room and this nerve block has been performed using standard monitors were placed. A high fre- 1 landmark-based techniques, the ultrasound- quency linear ultrasound (Sonosite S-Nerveusethe concha (Figure 2). Although the greater guided version offers several potential advan- Ultrasound with L25x 13-6 Megahertz transducer; auricular nerve block was described over five tages. These advantages include increased Sonosite, Inc., Bothell, WA, USA) was used to decades ago, it has traditionally involved block- reliability of the nerve block, as well as preven- image the superficial cervical plexus posterior to ade of the entire superficial cervical plexus at tion of inadvertent vascular puncture or block- the midpoint of the sternocleidomastoid muscle. the border of the sternocleidomastoid muscle ade of the phrenic nerve, brachial plexus, or The GAN was identified by moving the ultrasound utilizing large local anesthetic volumes rather 4,5 deep cervical plexus. The increasing access to probe cranially as it arose from the cervical plexus than the selective procedure. Landmark tech- ultrasound technology for medical care and coursed in an anteromedial direction to lie on niques for selective blockade of this nerve providers outside the operating room makes the anterior surface of the sternocleidomastoid have been attempted with varying degrees of this ultrasound guided block an increasingly (Figure 1). Once identified, the GAN was success with different volumes of local anes- viable alternative. blocked using a 22 gauge B-bevel needle thetic. The greater auricular nerve ranges in (Stimuplex Ultra 22 Gauge x 2 inch Echogenic diameter from 1.4-2.0 mm with a median size Needle;commercial B. Braun Medical, Inc., Bethlehem, PA, of 1.7 mm in anatomical studies.1,6 The wide USA) and 100 milligrams of 1% lidocaine with availability and utilization of ultrasound has Introduction 1:400,000 epinephrine. Next, a right infra- provided physicians with the ability to directly orbital nerve block was performed by infiltra- image small peripheral nerves and perform The greater auricular nerve (GAN) is the tion of 60 milligrams of 1% lidocaine with blockade with reduced volumes of local anes- major sensory branch of the cervicalNon plexus.1 1:400,000 epinephrine near the infra-orbital thetic. Because of its superficial location on Its innervation includes the inferior part of the foramen. After several minutes, satisfactory the anterior surface of the sternocleidomas- ear and the skin over the mastoid process, anesthesia was achieved. The surgery was per- toid muscle, ultrasound acquisition of the GAN parotid gland, and angle of the mandible.1,2 The formed uneventfully using only the nerve is relatively easy to perform yielding excellent GAN is readily amenable to local anesthetic blocks and a small 12.5 microgram bolus of imaging. Thallaj and colleagues noted a suc- blockade as it lies in a superficial location intravenous fentanyl. cess rate of 100% in identifying the GAN using passing over the sternocleidomastoid muscle. ultrasound imaging with a block success rate While anatomical landmarks can guide a field of near 100% when pinprick testing was per- block technique, the use of ultrasound for nee- formed and compared to the contralateral ear. dle guidance may improve block success.1 A Discussion It should be noted that the Thallaj study was GAN block can be used for multiple urgent performed on healthy male volunteers and care, emergency department and surgical pro- The GAN is the principal sensory branch of increased difficulty in nerve identification may cedures to enhance patient comfort, decrease the cervical plexus and is comprised of the sec- be encountered in obese patients.1 Selectively pain, and decrease the need for intravenous ond and third cervical nerves. It provides sen- identifying the GAN versus a field blockade of anesthetics.3 Despite its utility and the relative sory innervation to segments of the external the entire cervical plexus may result in ease of blockade, limited literature is available ear including the tail of the helix, the antitra- decreased incidence of complications and side describing use of the technique. We describe gus, and the lobule of the auricle with variable effects including vascular puncture, blockade the case of an 80 year-old male with multiple supply to the spine of the helix, the tragus, and of the phrenic nerve, brachial plexus or deep

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Figure 2. Image depicting origin of greater auricular nerve (GAN) in cervical plexus (yellow circle), typical location of ultrasound guided nerve block (red square), and areas anesthetized by the GAN block (highlighted area). Image published with permission Figure 1. Image showing course of greater auricular nerve (GAN) from volunteer model. from inferior (bottom image) to superior (top image) with unen- hanced images on left and enhanced images on right. As the ultra- sound probe is moved superiorly along the sternocleidomastoid (blue highlighting), the GAN (yellow highlighting) is best visual- ized passing from the lateral border of the muscle across its super- ficial surface in a medial direction. only cervical plexus.5 Volumes as low as 0.1 mL have in the emergency room or office environ- 2. Christ S, Kaviani R, Rindfleisch F, been shown to be effective if administered ment.3,6,8 Physicians in multiple specialtiesuse Friederich P. Brief report: identification of under ultrasound guidance whereas classic should become familiar with both anatomic the great auricular nerve by ultrasound descriptions of the superficial cervical plexus and ultrasound-guided techniques to perform imaging and transcutaneous nerve stimu- blockade describe the usage of 15-20 mL of this safe and effective nerve block. lation. Anesth Analg 2012;114:1128-30. local anesthetic.1,4 One study also reported the 3. Herring AA, Stone MB, Frenkel O, et al. successful use of transcutaneous nerve stimu- The ultrasound-guided superficial cervical lation in combination with ultrasound to plexus block for anesthesia and analgesia improve the identification of the great auricu- Conclusions in emergency care settings. Am J Emerg lar nerve in patients with challenging Med 2012;30:1263-7. 2 anatomy. Imaging and blockade of the GAN for The GAN has predictable anatomy and is 4. Choi DS, Atchabahian A, Brown AR. multiple surgical procedures and conditions readily amenable to local anesthetic blockade Cervical plexus block provides postopera- has been described including uncommon syn- by both anatomical landmark and ultrasound- tive analgesia after clavicle surgery. dromes such as tic douloureux and red ear syn- commercialguided techniques. Ultrasound imaging may Anesth Analgesia 2005;100:1542-3. drome.7 Surgical anesthesia or supplemental improve success and allow for the use of much 5. Pandit JJ, Satya-Krishna R, Gration P. pain control can be provided for any surgery lower volumes of local anesthetic, which may Superficial or deep cervical plexus block involving the inferior portion of the external lead to reduced side effects and increased for carotid endarterectomy: a systematic ear, the area overlying the mastoidNon process, safety. GAN block techniques are relatively procedures of the parotid gland, or procedures easy to learn and have a variety of uses both in review of complications. Br J Anaesth involving the angle of the mandible. In the operating room and outpatient environ- 2007;99:159-69. patients with multiple comorbidities, such as ments for all practitioners. 6. Thallaj A. Ultrasound guidance of uncom- in the case described above, GAN block can mon nerve blocks. Saudi J Anaesth serve as the sole anesthetic for a procedure 2011;5:392-4. minimizing or eliminating intravenous seda- 7. Selekler M, Kutlu A, Uçar S, Almaç A. tives and opioids. Outside of the operating References Immediate response to greater auricular room environment, greater auricular nerve nerve blockade in red ear syndrome. block has potential uses for excision of lesions 1. Thallaj A, Marhofer P, Moriggl B, et al. Cephalalgia 2009;29:478-9. in any of the above mentioned areas, drainage Great auricular nerve blockade using high 8. Gleeson AP, Gray AJ. Management of of auricular hematoma, laceration repair, resolution ultrasound: a volunteer study. retained ear-rings using an ear block. J removal of retained ear-rings, or cyst removal Anaesthesia 2010;65:836-40. Accid Emerg Med 1995;12:199-201.

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