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LETTER TO EDITOR
Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 246-247

Ultrasound-guided trigeminal nerve block for faciomaxillary surgeries


1 Department of Anesthesia, AIIMS, Patna, Bihar, India
2 Department of Anaesthesia, AIIMS, New Delhi, India

Correspondence Address:
Chandni Sinha
112, Block 2, Type 4, AIIMS Residential Complex, Khagaul, Patna - 801 505, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.203033

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Date of Web Publication27-Mar-2017
 


How to cite this article:
Kumar A, Kumar A, Sinha C, Singh AK. Ultrasound-guided trigeminal nerve block for faciomaxillary surgeries. Saudi J Anaesth 2017;11:246-7

How to cite this URL:
Kumar A, Kumar A, Sinha C, Singh AK. Ultrasound-guided trigeminal nerve block for faciomaxillary surgeries. Saudi J Anaesth [serial online] 2017 [cited 2020 Apr 3];11:246-7. Available from: http://www.saudija.org/text.asp?2017/11/2/246/203033



Sir,

Faciomaxillary surgeries are associated with severe postoperative pain difficult to manage even with opioids. Adequate pain relief perioperatively is important for the patient's early and smooth recovery and uneventful postoperative course.[1] Blocking of maxillary and mandibular nerve helps in the adequate management of pain. We present a case of maxillary fracture wherein ultrasound-guided injection in pterygopalatine fossa helped us to achieve adequate analgesia perioperatively.

A 50-year-old female with fracture maxilla was scheduled for elective open reduction and internal fixation. Anesthesia was induced with propofol 2 mg/kg and fentanyl 2 μg/kg. Muscle relaxation was achieved with vecuronium 0.08 mg/kg. Anesthesia was maintained with isoflurane and nitrous oxide in oxygen. Ultrasound-guided trigeminal nerve block (TNB) was administered using a high-frequency linear probe. The probe was positioned longitudinally on the affected side of the face just below the zygomatic bone, superior to mandibular notch, and anterior to the mandibular condyle. We visualized the zygomatic bone, lateral pterygoid muscle, lateral pterygoid plate, maxillary bone, and mandibular condyle by sonography. Maxillary artery was identified using color power Doppler in the pterygopalatine fossa. An insulated echogenic needle (22 G, 8 cm, Sonoplex, Pajunk, Germany) was inserted out-of-plane and advanced from lateral to medial and posterior to anterior direction in pterygopalatine fossa [Figure 1]. Patient's mouth was kept open with the help of an oral airway and the probe tilted slightly in the superior direction to avoid acoustic shadow of coronoid process. Following negative aspiration, 5 ml 0.25% bupivacaine was injected around the maxillary artery. The surgery lasted for 4 h. Intraoperative period was uneventful with no further requirement of analgesics. At the end of the surgery, the patient was extubated and was shifted to postanesthesia care unit. The demand for the first analgesic was after 4 h of surgery. Thereafter, the pain was managed with 1 g paracetamol intravenous 6th hourly with tramadol 1 mg/kg b.w.
Figure 1: Ultrasound image of the block

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Fluoroscopy-guided blocks have long been considered the gold standard practice in head and neck pain management. Computed tomography-guided procedures provide a useful alternative but are expensive and have radiation hazard. Lately, ultrasonography (USG) has been used extensively for perioperative pain relief providing excellent visualization of soft tissue, vasculature with real-time needle placement.

The Gasserian ganglion lies in the middle cranial fossa within the Meckel's cave and gives rise to three branches (1) ophthalmic, (2) maxillary, and (3) mandibular which exit from skull through three distinct foramina: the superior orbital fissure, the foramen rotundum, and the foramen ovale. The injection anterior and medial to lateral pterygoid plate into the upper part of pterygopalatine fossa will place the injectate in close vicinity to foramen rotundum from where drug migrates into the middle cranial fossa. Since the pterygopalatine fossa is extremely vascular, visualizing vascular and soft tissue structures in real time minimize the potential inadvertent complications.

Our technique was similar to that done by Nader et al. wherein they performed this USG-guided block in trigeminal neuralgia patients.[2],[3] Parate et al. reported the use of peripheral nerve stimulator (PNS) to block mandibular nerve in faciomaxillary surgeries.[4] Ultrasound is a safer alternative to PNS because of real-time visualization of the needle and the structures.

Hence, we would like to conclude that USG-guided TNB is useful not only for chronic pain patients but also for other faciomaxillary and oral procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar A, Banerjee A. Continuous maxillary and mandibular nerve block for perioperative pain relief: The excision of a complicated pleomorphic adenoma. Anesth Analg 2005;101:1531-2.  Back to cited text no. 1
    
2.
Nader A, Kendall MC, De Oliveria GS, Chen JQ, Vanderby B, Rosenow JM, et al. Ultrasound-guided trigeminal nerve block via the pterygopalatine fossa: An effective treatment for trigeminal neuralgia and atypical facial pain. Pain Physician 2013;16:E537-45.  Back to cited text no. 2
    
3.
Nader A, Bendok BR, Prine JJ, De Oliveria GS, Kendall MC. Ultrasound-guided pulsed radiofrequency application via the pterygopalatine fossa: A practical approach to treat refractory trigeminal neuralgia. Pain Physician 2015;18:E411-5.  Back to cited text no. 3
    
4.
Parate LH, Tejesh CA, Geetha CR, Mohan C. Peripheral nerve stimulator-guided mandibular nerve block: A report of three cases. Saudi J Anaesth 2016;10:491-2.  Back to cited text no. 4
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