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ewe 2 ad 4 o anesthesia- of % 64 and 26 management,between airway in the made advances Notwithstanding anesthesiologist. forthe achallenge is airway difficult The Ultrasonografía; obstrucción delasvíasaéreas; anestesia laríngeos; local; bloqueo nervioso. nervios Palabras clave estos pacientes. altoéxito,de índice limitarpermita complicacionescual la relacionadas contécnicas las regionales anatómicas facilitarasí y aseguramientoel en aérea vía la de propósito, planteamos el bloqueo laríngeodel nervio superior guiado por ultrasonografía, con el fin de estandarizar una referencia ecográfica reproducible, con translaríngeo o transtraqueal, para lo cual, es necesario el uso de anestesia acceso local y de sedación ungrado I/II evitando la pérdida obtenerde ventilación espontánea. es Con ventilación este adecuada unagarantizar de forma única superior,la aérea vía la de aguda obstrucción con de escenariosabordaje Endespierto. el paciente siendo sigue manejo de estándar el actualidad, la en embargo, sin variables, diversas de depende manejo el anticipada, difícil aérea vía con considera se pacienteunanestesia.Cuando con relacionadamortalidad de frecuentecausa una siendo siguen aérea vía la de manejo el complicacionesen Las Ultrasound; airway obstruction; local anesthesia; ; laryngeal nerve block. Palabras clave anatomic techniques and thusfacilitating thesecuring of theairway inthesepatients. regional to relatedcomplications limiting allows rate,which success high a with reproduceable, is that landmark ultrasound anstandardize to order in block, use local anesthesia and grade I / II sedation, avoiding loss of spontaneous ventilation. For this purpose, we propose ultrasound-guided acuteairwayupper onlyobstruction, waythe to guarantee adequate ventilation translaryngealtoa is orobtain transtracheal access, to for necessary is it which, severalvariables,on of however,awake depends scenariosmanagement In patient approach. the the be tocontinues present,standardmanagementof at the Complications in airway management remain a common cause of anesthesia-associated mortality. When a patient is considered with anticipated difficult airway, Colombian Journal of Anesthesiology. 2021;49(1):e939. How to cite thisarticle: Echeverri-Ospina YC, Zamudio Burbano MA,González Giraldo D. Ultrasound-guided superior nerve laryngeal block-Adescription of thetechnique. Corresponding author: Calle69#51C-24, IPSUniversitaria Clínica León XIII. Medellín, Colombia. c b a Yulian Camilo Echeverri-Ospina Descripción delatécnica laríngeosuperiorguiadopor ecografía.Bloqueo denervio A description of thetechnique Ultrasound-guided superior laryngeal nerve block - doi: https://doi.org/10.5554/22562087.e939 This isan openaccess article under theCC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/). Copyright ©2020Sociedad Colombiana deAnestesiología yReanimación (S.C.A.R.E.). Lea laversión enespañol deeste artículo enwww.revcolanest.com.co Daniela González Giraldo INTRODUCTION Facultad deMedicina, Universidad deAntioquia. Medellín, Colombia Hospital Universitario San Vicente Fundación. Medellín, Colombia IPS Universitaria Clínica León XIII. Medellín, Colombia OPEN Resumen Abstract c a-c eedn o te lncl otx, the context, varied, available clinical resources, and the level of be training the on can depending strategies the airway, difficult anticipated with presents patient problems. airway of result associated perioperative deathsare the , Mario Andrés Zamudio Burbano Received: 3April, 2020 ▶Accepted: 28May, 2020▶Online first:3 September, 2020 (1,2) When a

E-mail: [email protected] the perioperative safety, since it allows for allows it safety,since perioperative the with thepatientawake. approached difficult be shall management that airway agree guidelines practice ofhuman resources. However, clinicalmost c Intubating the patient awake improvesawake patient the Intubating , 1 special article /5 2/5 colombian journal of anesthesiology. 2021;49(1):e939.

spontaneous breathing, maintaining the SENSITIVE INNERVATION folds of the arytenoids and the base of the patency of the airway, and cooperation OF THE . The rest of the sensory information with the operator. (3,4) The flexible fiber of the larynx (glottis, cricothyroid optic technique is the most commonly The sensory information of the larynx membrane, and tracheal mucosa) are the used by anesthesiologists; however, other is transmitted by the . Just responsibility of the internal laryngeal strategies have emerged as an alternative, above the greater hyoid horn, the superior branch of the recurrent laryngeal nerve. such as video laryngoscope-assisted laryngeal nerve divides into the external Both internal laryngeal branches (of the intubation with the patient awake. (5) and internal laryngeal branch. The latter recurrent and the superior laryngeal In situations of an acute upper airway transmits the sensory stimulus of the ) join just below the grater horn of obstruction, the only way to ensure upper mucosa of the vocal folds, the the hyoid bone, to form Galen’s loop (7) adequate ventilation is a translaryngeal posterior mucosa of the , the (Figure 1). or transtracheal approach. Since the standardization of the technique, elective figure 1. Sensory innervation of the larynx and trachea. tracheostomy has been broadly discussed in the literature, and compared to other methods, such as elective cricothyroidotomy, has proven to be safer. When the anesthesiologist considers this technique as the first choice, local anesthesia of the airway and grade I/II sedation are a pressing 1 need in order to conduct a safe procedure, without losing spontaneous ventilation. (6) Several techniques have been 2 described to administer upper airway anesthesia, in order to do an awake intubation in patients with anticipated difficult airway. The objective of the ideal 4 3 technique is the use of the lowest possible dose of the local anesthetic agent, to achieve a successful block that facilitates the intubation conditions, and increases the safety and tolerability of the patient. Ultrasound as a tool for superior laryngeal nerve block has several advantages: first, to standardize an ultrasound landmark that is reproduceable for the 5 operator performing the technique, ensuring the successful injection of the 6 local anesthetic and the spread into the target nerve. Second, to avoid puncturing vascular structures and reduce the risk of intoxication with local anesthetics. Third, to reduce the likelihood of failed blocks, as compared to techniques using anatomic landmarks, by visualizing the needle and the spread of the anesthetic into the indicated landmark. Following is a description of an ultrasound-guided technique to block the (1) Superior laryngeal nerve; (2) external branch of the superior laryngeal nerve; (3) internal internal branch of the superior laryngeal branch of the superior laryngeal nerve; (4) Galen’s loop; (5) recurrent laryngeal nerve; (6) nerve (ibSLN). internal branch of the recurrent laryngeal nerve. source. Authors. colombian journal of anesthesiology. 2021;49(1):e939. 3/5

ULTRASOUND GUIDED the omohyoid muscle, the sternohyoid of the small nerve diameter; hence, LARYNGEAL BLOCK muscle, and the thyrohyoid membrane. unexperienced operators may use the Figure 2 illustrates an ultrasound window guide of the landmarks described for a Anatomic landmark-guided airway which allows for standardization of the successful block. (8) block may be difficult in some block technique. Once the three infrahyoid The possibility to perform an patients with altered anatomy, obese muscles and the grater horn of the hyoid ultrasound-guided ibSLN block can patients, or patients with short . bone have been identified, using the off- be evidenced using a fresh cadaveric With the advent of perioperative plane approach, a hypodermic 23G needle model. A high frequency probe was ultrasound, identifying and assessing is inserted and 1 mL of 2% lidocaine is used located paramedial to the larynx, the laryngeal structures has become injected between the muscle and the and after identifying the suggested easier, which allows for guiding the thyrohyoid membrane; in order to block ultrasound window, 1 mL of methylene sensory nerve block of the larynx the internal branch of the superior blue was injected into the space of the to achieve translaryngeal access. laryngeal nerve, a bilateral puncture is ibSLN. After the anatomic dissection, Stopping the neural afferent performed. Figure 3 shows the methylene blue transmission of the larynx is possible The transtracheal administration spread over the thyrohyoid membrane by blocking the internal branch of the of the local anesthetic (3 mL of 2% and the ibSLN. This confirms the superior laryngeal nerve and the internal lidocaine) between the cartilage performance of the ultrasound-guided branch of the recurrent laryngeal nerve and the cricoid ring, anesthetizes the approach to block the ibSLN. with local anesthetic. laryngeal and tracheal mucosa, blocking The importance of the ultrasound- the internal branch of the laryngeal guided superior laryngeal nerve block recurrent nerve. is because it facilitates a sensory block DESCRIPTION OF THE This ultrasound window allows while preserving the motor function of ULTRASOUND-GUIDED for adequate reproducibility and the larynx, maintaining the patency, and SUPERIOR LARYNGEAL successful ibSLN block. First, it enables protecting the airway while intubating NERVE BLOCK the standardization of an image the patient awake. The safety of this by identifying the three infrahyoid technique has been demonstrated. In Using the high-frequency ultrasound probe muscles, the hyoid and the thyrohyoid a clinical controlled trial, Uday et all., located in the submandibular area and membrane, to reach the ibSLN space. evidenced the quality of the anesthesia paramedial in a cephalocaudal direction, Second, visualization of the ibSLN under which may even be superior to the the laryngeal structures can be identified: ultrasonography has been reported as mucosal instillation technique to block the greater horn of the hyoid bone, technically challenging, in part because the superior laryngeal nerve. (8) figure 2. *Paramedial laryngeal image.

4 Caudal

* 3 Chephalic 2 7 5 6 1

(1) Grater hyoid horn; (2) sternocleidomastoid muscle; (3) omohyoid muscle; (4) thyrohyoid muscle; (5) ; (6) thyrohyoid membrane; (7) application target. source. Authors. 4/5 colombian journal of anesthesiology. 2021;49(1):e939.

Another scenario in which this block may be faction, pain and coughing, and even com- awake tracheostomy, and this makes the useful is in tracheostomy with the patient plications that may present in up to 16.2 % ultrasound-guided superior airway block a awake and under local anesthesia. Success- of the cases; these complications include safe and highly successful procedure. ful cases with this technique have been re- losing the airway and failed surgical tech- In conclusion, the use of ultrasound ported; however, the skin anesthesia by pla- nique. (9) For these reasons, it is extremely guidance to block the superior laryngeal nes may be insufficient, in addition to being important to ensure adequate conditions nerve may be a valuable tool for the poorly tolerated, results in patient dissatis- for analgesia of the patient undergoing management of anticipated difficult airways.

figure 3. Cadaveric model.

A 1 cm3 of methylene blue injection is administered under ultrasound guidance, in order to block the internal branch of the bilateral superior laryngeal nerve (ibSLN). The spread of the methylene blue over the thyrohyoid membrane is observed, blocking the ibSLN. source. Authors.

ETHICAL RESPONSIBILITIES Medical Association and the Declaration Right to privacy and informed consent of Helsinki. Protection of humans and animals. The authors obtained the informed Confidentiality of the information. consent from all patients and/or The authors declare that the procedures subjects mentioned in this article. The performed were compliant with the ethical The authors declare that they followed the corresponding author is the custodian of standards of the human experimentation institutional protocols on the publication of these documents. committee and consistent with the World patient data. colombian journal of anesthesiology. 2021;49(1):e939. 5/5

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