Combined Use of Infraorbital and External Nasal Nerve Blocks for Effective Perioperative Pain Control During and After Cleft Lip Repair Mariah L. Salloum, M.D., Kyle R. Eberlin, M.D., Navil Sethna, M.D., Usama S. Hamdan, M.D., F.I.C.S. ; Perioperative analgesia in patients undergoing cleft lip and palate repair is complicated by the risk of postoperative airway obstruction. We describe a technique of combined infraorbital and external nasal nerve blocks to reduce the need for opioid analgesia. Using this technique, we have successfully performed cleft lip repair under local anesthesia alone, without general anesthesia or intravenous sedation, in adolescents and adults. In children, this technique can reduce the need for postoperative opioids. We describe this novel analgesic approach to decrease opioid requirements and minimize perioperative risk. KEY WORDS: cleft lip repair, external nasal block, infraorbital block Postoperative analgesia in patients undergoing cleft lip repair under general anesthesia by reducing the need for and palate repair is associated with the potential risk of postoperative opioids (Rajamani et al., 2007). airway obstruction secondary to soft tissue swelling, This technique allows efficient utilization of operating bleeding, and reduced respiratory drive from administra- room time, decreases the use of general anesthetics, and tion of perioperative opioids to control pain (Stephens et requires minimal postoperative recovery monitoring or al., 1997). Administration of opioids requires close hospitalization. To our knowledge, this combination monitoring and admission to the hospital due to the risk technique has not been reported previously. We wish to of respiratory depression (Doyle and Hudson, 1992). We describe the safety and effectiveness of this local anesthetic describe a combination technique of infraorbital and technique for cleft lip repair and rhinoplasty in three external nasal nerve blocks for repair of cleft lip defects. illustrative cases. In our experience, this technique can be used as the sole anesthetic, without general anesthesia or intravenous PATIENTS AND METHODS sedation, for the repair of primary and secondary cleft lip deformities with and without primary rhinoplasty in This technique was carried out in three patients in the adolescents and adults. This combination of nerve blocks setting of an international medical mission. Permission for produces effective prolonged analgesia and reduces the reporting these cases was approved by the local hospital need for a postoperative opioid analgesic, thereby mini- scientific/advisory boards, and all patients or their parents mizing the potential side effects of opioid-related sedation gave informed surgical consent. In the first two cases of and respiratory depression. Additionally, it can be used as adolescent and adult cleft repair, surgical anesthesia was an effective analgesic adjunct in children requiring cleft lip provided solely by the combination nerve block technique, without general anesthesia or intravenous sedation. The third patient described is an infant who underwent cleft lip repair Dr. Salloum is Resident, Department of Otolaryngology–Head and under general anesthesia; the described nerve blocks were Neck Surgery, Tufts Medical Center, Boston, Massachusetts. Dr. Eberlin performed following induction of general anesthesia as an is Resident, Harvard Plastic Surgery Training Program, Massachusetts adjunct for intraoperative and postoperative pain control. General Hospital, Boston, Massachusetts. Dr. Sethna is Senior Associate, Anesthesiology, Children’s Hospital Boston; Associate Director, Pain In awake patients, the nerve blocks were performed after < Treatment Service, Children’s Hospital Boston; and Associate Professor, anesthetizing the injection sites with application of the topical Anesthesiology, Harvard Medical School, Boston, Massachusetts. Dr. anesthetic EMLATM for 45 to 60 minutes to minimize the Hamdan is President, Global Smile Foundation; Assistant Clinical discomfort of multiple injections (EMLATM was not applied Professor, Otolaryngology, Tufts University School of Medicine; Clinical = Instructor, Otology & Laryngology, Harvard Medical School; and in the infant patient undergoing general anesthesia). The Clinical Instructor, Otolaryngology, Boston University School of Med- infraorbital nerve was located bilaterally by drawing a line icine, Boston, Massachusetts. extending from the oral commissure to the midpupillary line We would like to acknowledge Stryker Corporation for an educational (Rajamani et al., 2007). The infraorbital injections were grant that helped to support travel stipends of the primary author. placed at the midpoint of these landmarks. The needle was Submitted December 2008; Accepted March 2009. Address correspondence to: Dr. Usama S. Hamdan, M.D., F.I.C.S., 28 introduced 0.5 cm lateral to the alar rim and directed Martingale Lane, Westwood, MA 02090. E-mail [email protected]. superolaterally along the vector described. In children, due DOI: 10.1597/08-142.1 to the more medial position of the oral commissure and 0 The Cleft Palate-Craniofacial Journal cpcj-46-05-15.3d 20/7/09 16:50:39 1 Cust # 08-142R 0 Cleft Palate–Craniofacial Journal, September 2009, Vol. 46 No. 5 FIGURE 1 Preoperative injections of the infraorbital foramen. A: Injections are directed along a vector extending from the oral commissure FIGURE 2 Preoperative injections of the external nasal nerve. A and B: to the midpupillary point. B: The infraorbital rim is palpated to avoid The nerve is injected bilaterally as it exits beneath the nasal bone, piercing inadvertent injury to the globe and penetration of the foramen. the cartilage to supply the nasal sidewall and tip. medial position of the infraorbital foramen as compared with mixture of local anesthetics also was administered for adults, this vector is angled slightly more laterally (Suresh et subcutaneous infiltration of the surgical sites, injecting al., 2006). To avoid direct contact with the nerve and injury 10 cc in adolescents and adults and 1.5 cc in infants. to the globe, injections were performed while palpating the A full 10 minutes was allowed for the injection of local infraorbital rim, avoiding penetration of the foramen and anesthetics to take effect prior to incision. Cleft lip repair protecting the orbit (Fig. 1A and 1B). was performed using the previously described modified In adolescent and adult patients older than 12 years, we Millard technique and primary rhinoplasty with alar base used a mixture of equal volumes of 1% lidocaine with flap and suspending suture (Numa et al., 2006). epinephrine 1:100,000 and 0.5% bupivacaine with epineph- > rine 1:100,000, and we injected 0.25 cc into each side. For Case 1 children younger than 12, we used a mixture of equal volumes of 0.5% lidocaine with epinephrine 1:200,000 and A 16-year-old boy with unilateral complete cleft lip 0.25% bupivacaine with epinephrine 1:200,000 and injected presented for repair of his cleft lip deformity with primary 0.25 cc into each side. rhinoplasty. Forty-five minutes following EMLATM appli- The external nasal nerve (a branch of the ophthalmic cation, the patient was brought to the operative suite. The nerve) was then identified as it passes beneath the compressor infraorbital and external nasal nerves were blocked as nasi and supplies the integument of the ala and the tip of the described above. The incision site also was injected nose. The aforementioned mixture of local anesthetics was subcutaneously as described. Ten minutes following the injected (0.25 cc into each side) at the nerve’s exit from the injections, cleft lip repair with primary rhinoplasty was distal nasal bone, superior to the upper lateral cartilage, performed without the use of general anesthesia or approximately 7 mm lateral to the midline of the nasal sedation, with an operative time of 55 minutes (Fig. 3A dorsum (Fig. 2A and 2B) (Han et al., 2004). The same through 3D). The patient tolerated the procedure awake The Cleft Palate-Craniofacial Journal cpcj-46-05-15.3d 20/7/09 16:51:09 2 Cust # 08-142R Salloum et al., INFRAORBITAL, EXTERNAL NASAL BLOCKS IN CLEFT LIP REPAIR 0 FIGURE 3 Adolescent male undergoing repair of unilateral cleft lip under local anesthesia. A: Preoperative, B: Intraoperative, C: Immediately postoperative, and D: 1 week after repair. and without pain. He resumed oral feeds soon after arrival 50 minutes prior to arrival at the operating room. The to the postanesthesia care unit and was discharged home infraorbital and external nasal nerves were blocked as 5 hours postoperatively. described above, and the incision site was marked and infiltrated to anesthetize the subcutaneous tissue. Incision Case 2 was made 10 minutes after injection. The patient tolerated the surgical procedure well under local anesthesia alone A 25-year-old woman presented for repair of bilateral (Fig. 4A through 4C), and the operative time was complete cleft lip deformity. Topical EMLATM was placed 50 minutes. Following the surgery, she was monitored in The Cleft Palate-Craniofacial Journal cpcj-46-05-15.3d 20/7/09 16:51:43 3 Cust # 08-142R 0 Cleft Palate–Craniofacial Journal, September 2009, Vol. 46 No. 5 the postanesthesia care unit, where she reported no pain or discomfort. She resumed oral feeds within 1 hour and was discharged home 5 hours postoperatively. Case 3 A 3-month-old otherwise healthy male infant presented for primary repair of isolated unilateral incomplete cleft lip deformity. After induction of general