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Head and Neck Blocks in Infants, Children, and Adolescents Santhanam Suresh1 & Polina Voronov2

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Head and Neck Blocks in Infants, Children, and Adolescents Santhanam Suresh1 & Polina Voronov2 Pediatric Anesthesia ISSN 1155-5645 REVIEW ARTICLE Head and neck blocks in infants, children, and adolescents Santhanam Suresh1 & Polina Voronov2 1 Vice Chairman & Director of Research & Pain Medicine, Children’s Memorial Hospital, Department of Anesthesiology & Pediatrics, North- western University’s Feinberg School of Medicine, Chicago, IL, USA 2 Children’s Memorial Hospital, Department of Anesthesiology, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA Keywords Summary head; neck; peripheral nerves; block; postoperative pain control This review will discuss the use of peripheral nerve blocks of the head and neck and its application to the practice of pediatric anesthesia using simple, Correspondence landmark based approaches. Santhanam Suresh, Vice Chairman & Director of Research & Pain Medicine, Children’s Memorial Hospital, Department of Anesthesiology & Pediatrics, Northwestern University’s Feinberg School of Medicine, 2300 Children’s Plaza, Chicago, IL 60611, USA Email: [email protected] Accepted 17 August 2011 Section Editor: Per-Arne Lonnqvist doi:10.1111/j.1460-9592.2011.03701.x Introduction Anatomy and innervations of the head and neck Regional anesthesia is gaining popularity in children. The sensory supply of the head and neck is primarily Head and neck blocks are used more frequently in made by three major branches of the trigeminal nerve: children than in adults and offer excellent analgesia ophthalmic, maxillary, and mandibular along with the with little or no adverse effects. These blocks may also C2–C4 cervical roots, which supply the neck and the facilitate a significant decrease in the need for addi- occipital portion of the scalp. tional opioids or analgesics, thereby decreasing adverse The terminal sensory nerves of the trigeminal nerve side effects including nausea and vomiting (1). The V1 (supraorbital), V2 (infraorbital), and V3 (mental wide array of common surgical procedures performed and auriculotemporal) become superficial when they in children allow the application of head and neck exit the facial bones through the corresponding foram- blocks in plastic surgery, otolaryngology, dermatology ina that usually lie in the midline (generally recognized as well as neurosurgery. This review will deal with as the midpoint of the pupil with the head in the neu- commonly performed head and neck blocks with an tral position) (Table 1). evidence-based approach to the use of these blocks for We will discuss individual nerves, the specific indication, common use. As most of these blocks are sensory in and the technique for the performance of these blocks. nature, not only is it easy to perform but they also require less equipment and have very few adverse Supraorbital and supratrochlear blocks effects. A basic understanding of the anatomy of the distribution of sensory nerves of the head is essential The terminal branches of V1, the supraorbital and for the understanding of these blocks. supratrochlear, supply the sensory innervation of Pediatric Anesthesia 22 (2012) 81–87 ª 2011 Blackwell Publishing Ltd 81 Head and neck blocks in infants, children, and adolescents S. Suresh and P. Voronov Table 1 Head and neck blocks Nerves Anatomy Innervation Indication Trigeminal nerve ‘The great sensory nerve of head Innervates the face and the and neck’ scalp up to the coronal sutures Arises from the trigeminal ganglion through three major divisions: ophthalmic (V1), maxillary (V2), and mandibular (V3) V1 – Ophthalmic Exit the cranium through the Innervate the frontal scalp, Scalp nevus excision, supraorbital, superior orbital fissure forehead, median portion of midline dermoid supratrochlear nerves Divide into three branches: the upper eyelid, and bridge of excision, and lacrimal, frontal, and nasociliary the nose ventriculoperitoneal Frontal nerve branches into shunt supraorbital and supratrochlear Supraorbital and supratrochlear emerge through the notches V2 – Maxillary Exits the cranium through the Innervates the lower lip, lateral Cleft lip repair and infraorbital nerve inferior orbital fissure portion of the nose, median endoscopic sinus Infraorbital nerve is the largest and cheek, the roof of the mouth, surgery appears through the infraorbital upper teeth, and maxillary foramen sinus Divides into multiple branches, the biggest are: the inferior palpebral, the external nasal, and the superior labial V2 – Greater palatine Arises from pterygopalatine Innervates the gums and the Cleft palate repair nerve ganglion mucous membrane of the Emerges through the greater hard palate palatine foramen Lies in the groove of the hard palate V3 – Mandibular division Sensory and motor nerve Innervates anterior 2/3 of the Temporoparietal of the nerve Exists the cranium through the tongue, lower teeth, lower lip, incision of the foramen ovale and branches into and chin skin of the scalp several nerves temporal-parietal area of the The major branches are the buccal scalp nerve, the lingual nerve, the Motor innervation to the inferior alveolar nerve, and muscle of mastication auriculotemporal nerve V3 – Mental nerve A branch of the inferior alveolar Innervates the skin of the chin, Lower lip surgery nerves lower lip, anterior teeth, and Emerges through the mental buccal mucosa foramen in the mandible Greater occipital nerve Arises from the posterior rami of Innervates the skin of the Occipital neuralgia C2, C3 nerve roots posterior scalp and posterior fossa Becomes superficial at the level of surgery the superior nuchal line and travels cephalad and medial to the artery Superficial cervical Forms by the ventral rami of C2–C4 Innervates the anterior-lateral Tympanomastoid plexus Becomes superficial when skin of the neck, lateral scalp, surgery, ear surgery, emerges from the midpoint of the posterior auricular area, and anterior cervical posterior border of parotid gland surgery, and thyroid sternocleidomastoid muscle surgery At that point, divides into four distinctive nerves: the lesser occipital, the great auricular, the transverse cervical, and the supraclavicular nerve 82 Pediatric Anesthesia 22 (2012) 81–87 ª 2011 Blackwell Publishing Ltd S. Suresh and P. Voronov Head and neck blocks in infants, children, and adolescents the forehead and can be blocked effectively in chil- dren. Indications Frontal craniotomy, ventriculoperitoneal shunt, Omayya reservoir placement, dermatologic procedures (2–4). Position Supine, with the patient’s head in midline. Equipment 0.25% bupivaciane or 0.2% ropivacaine; 30-G needle; 3-ml syringe; sterile preparation either with chlorhexi- dine or with betadaine. Figure 1 The supraorbital foramen is located at the level of the Technique mid-pupillary line, a 30-G needle is used and subcutaneous injection The supraorbital foramen is located as described previ- of local anesthetic solution is placed, gentle massage follows the ously at the superior part of the orbital rim in the mid- injection to prevent a hematoma formation and allow spread of the local anesthetic solution. line, in line with the pupil. After careful preparation using betadaine or chlorhexidine (note: please cover the eye and make sure that it is protected), a 30-G nee- tomy (10). The use of this block has been demon- dle is used to inject subcutaneously with the needle ori- strated to be efficacious for cleft lip repair while ented in a lateral-to-medial direction. After careful allowing the children to adequately feed (7). This block aspiration, 1–2 ml of 0.25% bupivacaine with 1 : 200 has far-reaching implications especially when there is a 000 epinephrine is injected, gentle massage followed by paucity of the availability of opioids for pain control pressure application to the eyebrow is provided to pre- especially in developing countries. vent the formation of a hematoma. We prefer using an epinephrine-containing solution to facilitate vasocon- Position striction to prevent excessive bleeding from the injec- Supine with a shoulder roll to extend the head. tion site. If surgery for a midline dermoid is performed, it is important to place the needle more Equipment medial to block the supratrochlear nerve (Figure 1). 27-G needle, 0.25% bupivacaine or 0.2% ropivacaine, and sterile gauze. Complications Intravascular injection and hematoma formation. It is Technique rare to see any persistent paresthesia in this distribu- There are two approaches to the infraorbital nerve, tion even if paresthesia was obtained at the time of an intraoral technique and an extraoral technique. injection. The intent of this block is to deposit the local anes- thetic solution at the level of the infraorbital fora- men where the maxillary division of the trigeminal Infraorbital nerve nerve exits. Our preference is to utilize the intraoral The V2 branch of the trigeminal nerve exits the infra- approach because it has two advantages: there is (i) orbital foramen and supplies the sensory supply to the absence of a needle stick and the potential of a upper lip, tip of the nose, and the maxillary process. hematoma formation on the skin surface and (ii) the Anatomically, the infraorbital foramen location has potential for a more adequate blockade of the maxil- been demonstrated in cadavers as well as CT imaging lary division. The upper lip is everted and the and the distance from midline is located at approxi- mucosa is cleaned with a sterile gauze. A 27-G mately 21 mm + 0.5· age (in years) (5,6). needle is inserted with the needle directed toward the infraorbital foramen. A finger is placed at the level Indication of the infraorbital foramen
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