Local anaesthesia in ent

2. Local Anaesthetics:
 Local anaesthetics are drugs which upon topical
application or local injection cause reversible loss of
sensory perception, especially of pain, in a restricted
area of the body.
 They block generation and conduction of nerve
impulse at all parts of neuron where they come in
contact.

3. Classification:
 Injectables:
 Low potency, short duration:
 Procaine
 Chlorprocaine.
 Intermediate potency and duration:
 Lidocaine
 Prilocaine
 High potency, long duration:
 Tetracaine
 Bupivacaine
 Ropivacaine

4.  Surface anaesthetics:
 Soluble
 Cocaine
 Lidocaine
 Tetracaine
 Benoxinate
 Insoluble
 Benzocaine
 Oxetacaine

5. Mechanism of action:
 LAs block nerve conduction by decreasing the entry of
Na+ ions during upstroke of action potential.
 As concentration of LA increases, rate of rise of AP and
maximum depolarization decreases
 The LAs interact with a receptor situated within the
voltage sensitive Na+ channel and hence raise the
threshold of channel opening I response to an impulse
or stimulus.

7. Additional points:
 LA fails to afford pain control in inflammed tissue:
 Inflammations lowers pH – LA s in ionized form.
 Blood flow in inflammed tissue increases – LA removed
more rapidly from site.
 Effectiveness of adrenaline used with LA reduced at
inflammed site.
 Inflammatory products oppose LA action.

8.  Addition of adrenaline(1:50,000 to 1: 2,00,000):
 Prolongs duration of action.
 Enhances intensity of nerve block.
 Reduces systemic toxicity.
 Provides bloodless field.
 But
 Makes injection more painful.
 Increases chances of tissue oedema and necrosis and
delays wound healing.
 May raise BP and promote arrhythmias.

9. Uses and techniques:
 Surface anaesthesia:
 Application of LA to mucous membrane or abraded
skin.
 Onset of action for lignocaine: 2-5min of application
and lasts for 30-45min.
 Absorption is rapid, blood concentration can be similar
to those attained on IV injections.
 Only eutectic lidocaine/prilocaine mixture can
anesthetize skin.

10.  Infiltration anaesthesia:
 Dilute solution of LA infiltrated under the skin at the site of
surgery. Blocks sensory nerve endings.
 Onset of action is immediate, duration: 30-60 min in case of
lidocaine and 120-180 min for bupivacaine.
 Motor function not affected.
 Conduction block:
 LA injected around nerve trunks hence area distal to it is
anaesthetized and paralysed.
 Lidocaine 1-2% has intermediate duration of action
 Bupivacaine 0.5% has longer duration of action.
 Spinal anaesthesia
 Epidural anaesthesia
 Intravenous regional anaesthesia.

11. Lignocaine:
 It is a versatile LA used both for surface application as
well as injection.
 Causes vasodilation in the injected area.
 Onset of action is 3 min.
 Available as 4% topical solution, 1% or 2% injections,
2%jelly, 2% viscous, 5% ointment, 5% heavy(for
spinal), and 10% spray.

12.  A 1% solution of any drug contains 1 gram (i.e. 1000
mg) of drug per 100 ml of solution.
Therefore, a 1% lidocaine solution contains 1000 mg of
lidocaine per 100 ml (which is the same as 10 mg/ml)
 Xylocaine 2% with Adrenaline (Epinephrine) 1:200,000:
 Each ml of solution for injection contains lidocaine
hydrochloride monohydrate Ph. Eur., equivalent to 20
mg of lidocaine hydrochloride anhydrous (400 mg per 20
ml vial), 5 micrograms of adrenaline (epinephrine) as the
acid tartrate (100 micrograms per 20 ml vial).

13.  Adrenaline 1:1000 CONTAINS 1 mg OF Adrenaline PER
ML.
 It follows that a 1:10,000 solution of epinephrine
contains 0.1 mg of epinephrine (or 100 micrograms) per
ml
OR a 1:100,000 solution contains 10 micrograms per ml
OR a 1:200,000 solution contains 5 micrograms per ml
OR a 1:400,000 solution contains 2.5 micrograms per ml

14.  To prepare a 1:200,000 solution of Adrenaline in 2%
lidocaine
 Take 0.1 ml of adrenaline from a 1:1000 ampoule and add
it to 19.9 ml of 2% plain lidocaine. Adrenaline-
containing solutions should not be used in parts of the
body which are supplied by end arteries (fingers, toes,
penis, nose, ears).
 The maximum safe dose of epinephrine is controversial.
Concentrations of 1:400,000 is adequate in most cases.
Concentrations of 1:200,000 in the skin and for
peripheral nerves is allowed.

15.  MAXIMUM SAFE DOSE OF ADRENALINE = 4
MICROGRAMS PER KG.
 Therefore, an 80 kg man = 320 micrograms = 64 ml of a
1:200,000 solution.
 This maximum dose should be reduced in cases of
serious ischaemic heart disease, thyrotoxicosis and
hypertension.
 Maximum dose of lignocaine without adrenaline is 3
mg/kg.
 Maximum dose of lignocaine with adrenaline is 7 mg/kg.
 Thus, in a 70-kg patient do not use more than:
 20 mL 1% plain lignocaine or 10 mL 2% plain lignocaine
 48 mL 1% lignocaine with adrenaline or 24 mL 2%
lignocaine with adrenaline

16. Bupivacaine:
 A remarkably stable in solution and is commercially available
in 0.25% and 0.5% solutions (with and without epinephrine).
 It is four times more potent than lidocaine. Therefore, 0.25%
bupivacaine is equipotent with 1% lidocaine.
 Bupivacaine is particularly cardiotoxic.
 Bupivacaine binds tightly to tissues and thus has a long
duration of action (up to 24 hours in some cases). Adding
epinephrine will decrease its toxicity by delaying the drug
absorption but will have minimal effect on the duration of the
block.
The recommended maximum safe doses of bupivacaine are as
follows:
BUPIVACAINE WITHOUT EPINEPHRINE ------- 2.0 mg/kg
BUPIVACAINE WITH EPINEPHRINE ------- 2.5 mg/kg

17. Ropivacaine:
 Concerns about bupivacaines toxicity led to the development
of ropivacaine.
 Ropivacaine is an aminoamide local anaesthetic. Clinical
evidence indicates thst it is indeed less toxic than bupivacaine.
In particular, it is less cardiotoxic.
 The addition of epinephrine does not appear to alter the speed
of onset or duration of the block.
 The intensity and duration of the motor block are lower than
with bupivacaine. It is slightly less potent than bupivacaine (in
peripheral nerve blockade, 0.5% bupivacaine is equipotent
with 0.6% ropivacaine).
 The recommended maximum safe dose of ropivacaine is as
follows:
ROPIVACAINE (WITH or WITHOUT EPINEPHRINE ) --- 3-4
mg/kg

18.  In summary, the following principles apply in the
clinical usage of local anaesthetics:
 For surgical cases where rapid onset peripheral blockade
is required, use lidocaine 1-2%.
 If prolonged postoperative analgesia is required, use
bupivacaine 0.25-0.5% (or ropivacaine 0.4–0.7%)
 If large doses of local anaesthesia are used, it is safer to
use ropivacaine.

19. Lignocaine preparations:
 Lignocaine jelly:
 Lignocaine 2% i.e 20mg/ml, 30ml tube.
 Inactive contents
 Hypromellose, methylparaben, propylparaben ,sodium
hydroxide hydrochloric acid.
 Used on intact mucus membrane of oral cavity or nose for
surface anaesthesia, ineffective on intact skin.
 Onset of action 3-5 min of application
 Max dose is 600mg/12hrs.

21.  Lignocaine ointment
 Lignocaine 5%, 50mg/g, 30g tube.
 Inactive ingredients:
 Polyethylene glycol 400, polyethylene glycol 3350, propylene
glycol.
 Lidocaine Ointment is indicated for production of
anaesthesia of accessible mucous membranes of the
oropharynx.
 It is also useful as an anaesthetic lubricant for intubation
and for the temporary relief of pain associated with minor
burns, including sunburn, abrasions of the skin, and
insect bites.
 Onset of action 3-5 min.

23.  Lignocaine viscous:
 Lignocaine hydrochloride 2%, 20mg/ml, 100ml bottle.
 Inactive ingredients:
 Methylparaben, propylparaben, carboxymethylcellulose,
sodium saccharin, sodium dihydrate.
 Lidocaine Viscous is indicated for the production of topical
anaesthesia of irritated or inflamed mucous membranes of
the mouth and pharynx.
 The usual adult dose is one 15 mL tablespoonful undiluted
viscous. For use in the mouth, the solution should be
swished around in the mouth and spit out. For use in the
pharynx, the undiluted solution should be gargled and may
be swallowed. This dose should not be administered at
intervals of less than three hours, and not more than eight
doses should be given in a 24-hour period.

25. Lignocaine Spray Lidocaine 10% ( 10 mg / dose )
For Surface anaesthesia
 Lignocaine Spray is intended for mucous membrane
and provides a prompt and efficient surface anaesthesia
 Content:
 Lignocaine 10%, 100mg/ml, 50ml bottle with 500 metered
dose
 Inactive ingredient: Ethanol
 Indications:
 In otorhinolaryngology: Surface anaesthesia for e.g.
puncture of the maxillary sinus and procedures in the
nasal cavity, pharynx and epipharynx paracentesis

26.  Precautions:
 Absorption from wound surfaces and mucous membranes is
relatively high, especially in the bronchial tree. To avoid toxic
reactions the lowest dosage providing adequate analgesia should be
used. If a toxic reaction should occur, treatment is recommended as
for injection solutions.
 Side effects:
 In rare cases local anaesthetic preparations have been associated
with allergic reactions (in the most severe instances anaphylactic
shock).
 Dosage:
 Puncture of the maxillary sinus: 3 applications. Onset time is at least
2-3 minutes.
- During delivery: up to 20 applications (200 mg Lidocaine).
 Recommended maximum dosage:
 In adults: (70 kg body weight) 200 mg = 20 sprays with the metering
valve of the spray bottle.
 Debilitated, elderly, and acutely ill patients and children: Should be
given reduced doses according to age and physical status.

28. DRUG LIDOCAINE PRILOCAINE BUPIVACAINE
LEVOBUPIVAC
AINE
ROPIVACAINE
Description Amide Amide Amide Amide Amide
Relative
potency
2 2 8 8 6
Onset 5-10 min 5-10 min 10-15 min 10-15 min 10-15 mins
Duration
without
epinephrine
1-2 hours 1-2 hours 3-12 hours 3-12 hours 3-12 hours
Duration
with epinephrine
2-4 hours 2-4 hours 4-12 hours 4-12 hours 4-12 hours
Max dose
without
epinephrine
3 mg/kg 6 mg/kg 2 mg/kg 2.5 mg/kg * 3 mg / kg *
Max dose
with epinephrine
7 mg/kg 9 mg/kg 2.5 mg/kg 3 mg/kg * 4 mg / kg *

29. Adverse effects:
 CNS: causes light headedness, dizziness, auditory and
visual disturbances, mental confusion, disorientation,
shivering, twitching, involuntary movements,
convulsions and respiratory arrest.
 CVS: bradycardia, hypotension, cardiac arrythmias and
vascular collapse.
 Hypersensitivity: rashes, angioedema, dermatitis,
contact sensitization, asthma and rarely anaphylaxis.
 Delayed wound healing and chances of tissue necrosis
especially with addition of adrenaline.

33. Regional blocks in ENT:
 Trigeminal nerve block:
 Maxillary nerve block and block of its individual
branches.
 Mandibular nerve block and block of its individual
branches.
 Superior laryngeal nerve block
 Translaryngeal block
 Glossopharyngeal block
 Auriculotemporal and greater auricular nerve blocks.
 Sphenopalatine ganglion block
 Anterior ethmoidal nerve blocks
 Superficial and deep cervical nerve blocks

34. Maxillary Nerve block:
 Indications:
 Provides anaesthesia for superficial surgical procedures
of the face in V2 distribution & upper teeth and gums.
 Treatment of trigeminal neuralgia in maxillary
distribution
 Technique:
 Patient in supine position with head turned to
contralateral side.
 Following local anaesthesia to the skin a 22 gauge 8 cm
needle is inserted posterior to the coronoid process
under the zygomatic arch perpendicular to the skin.

35.  TECHNIQUE:
 Needle advanced perpendicular to skin until lateral
pterygoid plate is reached (apprx 4-5cms).
 Then needle is slightly withdrawn and reinserted in a
antero-superior direction (450 angle towards eye) to reach
pterygopalatine fossa. Paresthesia obtained along the
maxillary distribution. 2-4ml of local anaesthetic is
injected.
 For neurolytic procedure 6% phenol or absolute alcohol
is injected in similar fashion.

38.  Complications:
 Injection in to CSF possible. Careful aspiration before
injecting is must.
 Involvement of orbit due to its close proximity during the
procedure leading to orbital swelling, ophthalmoplegia,
loss of visual acuity, diplopia can occur.
 Haemorrhage into orbit can cause blindness.
 Hematoma formation.
 Intravascular injection.

39. Supraorbital & Supratrochlear
nerve block:
 Indications:
 Local anaesthesia along the distribution of the nerves
along the root and dorsum of nose upto the tip.
 Neuropathies along the distribution of these nerves.
 Localized trigeminal neuralgias
 Technique:
 Patient in supine position with head in neutral position
 A 3-4 cms, 25 gauge needle is inserted into the skin
perpendicular to the supraorbital foramen located at the
superior orbital rim above the pupil.

40.  Needle advanced until bone is encountered or foramen is
entered or paresthesia is elicited.
 2-5ml of local anaesthetic is injected just lateral and
medial to this point.
 In case of supratrochlear nerve block, needle is advanced
subcutaneously and medially approximately 2-3cms and
the same volume is injected.
 Complications:
 Hematoma formation.
 Temporary facial disfigurement.
 Upper eyelid swelling.
 Intravascular injection

43. Infraorbital nerve block (anterior and middle
superior alveolar nerve):
 Indications:
 Primarily for localized trigeminal neuralgia and infraorbital
neuropathies.
 Anaesthesia of maxillary incisors and surrounding soft tissue,
upper lip, lower eyelid and side of the nose.
 Technique:
 2 approaches:
 A) Extraoral:
 Infraorbital foramen palpated 1-1.5cm below the inferior edge of the
orbit at the mid pupillary line
 22 or 25 gauge 1-3cm needle is inserted at a 300 angle to skin with
needle directed towards eye.
 Paresthesia elicited and 2-5ml local anaesthetic solution injected.

44.  B) Intraoral approach:
 25 gauge, 3-4cm needle is inserted into the alveolar area above
the teeth in the gingivo labial sulcus.
 Needle directed towards a point 1 cm below the infraorbital
foramen.
 2-5ml of anaesthetic solution is injected
 Complications:
 Hematoma formation
 Direct injury to the nerve bundle.

47. Posterior superior alveolar nerve
block:
 Indication:
 For anaesthesia of first, second and third maxillary molar
and adjacent soft tissue.
 Technique:
 A 25 gauge needle is inserted after retracting the buccal
mucosa at the height of gingivo buccal sulcus over the
second molar.
 Needle is advanced upwards, inwards and backwards upto
about 16mm depth to reach the foramen.
 0.9 to 1.8 ml of local anaesthetic is injected slowly after
careful aspiration

48. Palatal anaesthesia:
 Greater palatine nerve block:
 Indication: for pain control during procedure involving
posterior aspect of palate.
 Technique:
 Location of foramen:
 A cotton swab is taken and placed at junction of maxillary alveolar
process and hard palate.
 Palpation started at the region of first molar and continued
posteriorly
 Swab falls into the depression of the foramen usually against
second molar.

49.  Direct syringe into the mouth with needle entering
injection site at right angle. Bow the needle if in order to
enter the foramen.
 Multiple small injection is done until resistance against
the palatine bone is encountered usually at depth not
more than 1 cm.
 Aspirate and inject slowly 0.45-0.6ml of the anaesthetic
agent.
 Complications
 Ischaemia due to adrenaline
 Hematoma formation.

51. Nasopalatine nerve block
 Provides anaesthesia of palatal hard tissues.
 Relatively painful procedure.
 Technique:
 A 25 gauge needle is inserted into the incisive papilla just
behind the maxillary central incisors.
 Needle need not enter the foramen for successful
anaesthesia.
 Only a drop or two of the solution can be injected due to
sparse soft tissue space.
 Large quantity injection can produce post injection pain
and tissue slough.

53. Mandibular nerve block
 Indication:
 Provides anaesthesia for superficial surgical procedure
of the face in the V3 distribution, lower teeth, gums and
anterior 2/3 of tongue.
 In cases of trigeminal neuralgia along mandibular nerve
distribution.
 Technique:
 Initial approach is similar to that of maxillary nerve
block

54.  Once pterygoid plate is encountered the needle is directed
inferiorly and posteriorly until paresthesia is obtained
 3-5ml of local anaesthetic or neurolytic solution is
injected.
 Complications:
 Similar to those encountered in maxillary nerve blocks.

56. Inferior alveolar nerve blocks
 Indication:
 Blocks Mandibular teeth upto midline
 Body of mandible, inferior portion of ramus.
 Buccal mucous membrane.
 Anterior 2/3 of tongue and floor of mouth (due to
additional blockage of lingual nerve).
 Technique:
 Landmarks:
 Patient asked to open mouth wide open.
 Using thumb mucobuccal fold in the area of the molar teeth
palpated

57.  Thumb moved posteriorly until anterior border of ramus felt and
deepest notch, the coronoid notch palpated.
 Thumb moved medially to the inner edge of the ramus to estimate
width of ramus.
 Thumb moved laterally again retracting all soft tissue.
 Index finger is then placed extraorally to palpate the posterior border
of mandible.
 A 25 gauge syringe is inserted parallel to the occlusal plane in
the region of coronoid notch.
 Point of entry is at an imaginary point joining horizontal line
from the coronoid notch to a vertical line just lateral to the
pterygomandibular raphe.
 Needle advanced parallel to the inner surface of ramus to a
point half way between the thumb and index finger.
 Needle penetrates about 25mm deep and local anaesthetic
injected.

60. Mental nerve block:
 Indication:
 Surgical analgesia.
 Mental nerve neuralgia.
 Technique: 2 approaches:
 Extraoral:
 Mental foramen is palpated on the mandible. It is located along
the midpupillary line.
 A 22 or 25 gauge needle inserted perpendicular to the foramen,
paresthesia may be obtained.
 Needle is withdrawn 2 mm and 2-5ml local anaesthetic is
injected

61.  Intraoral approach:
 Lower lip pulled away from the teeth.
Foramen is palpated just lateral and
inferior to the first premolar tooth.
 A 25 gauge needle is inserted into the
alveolar mucosa at the level of the
foramen perpendicular to the bone and
local anaesthetic injected

64. Glossopharyngeal nerve block:
 Indications:
 Local anaesthetic block for surgical anaesthesia,
 Adjunct to awake endotracheal intubation.
 Neurolytic block in cancer pain management and in
glossopharyngeal neuralgias
 Contraindications:
 Local infection
 Sepsis
 Coagulopathy

65.  Technique: 2 approaches
 Extraoral:
 Patient in supine position, an imaginary line drawn from the
mastoid tip to the angle of mandible.
 Styloid process lie just below the midpoint of this line.
 A 22 gauge, 1.5inch needle attached to a 10ml syringe is advanced at
this midpoint in a plane perpendicular to the skin.
 Styloid process should be encountered within 3 cms.
 Needle is withdrawn and walked off the styloid process posteriorly.
 Syringe carefully aspirated .
 Local anaesthetic is injected.

66.  Intraoral approach:
 Initially 2% viscous lidocaine is used to anaesthetize the
tongue.
 Tongue is then retracted down.
 A 22 gauge, 3.5inch spinal needle is inserted through the
mucosa at the lower lateral portion of the posterior pillar.
 Needle advanced approx 0.5cm. Carefully aspirated and local
anaesthetic is injected.

69.  Complications:
 Dysphagia
 Hematoma
 Postprocedure dysesthesia
 Weakness of trapezius muscle
 Hoarseness
 Infection
 Tachycardia
 Trauma to nerves
 Sloughing of skin and subcutaneous tissue.

70. Superior laryngeal nerve block
 Indications:
 To supplement analgesia for the upper airway for
laryngoscopy.
 Supplement surgical anaesthesia for bronchoscopy,
endoscopy or tracheal procedures
 Treatment of chronic upper pharyngeal and laryngeal
pain processes

71.  Technique:
 Patient in supine position. Upper neck is palpated, cornu
of thyroid cartilage is identified.
 A 22 to 25 gauge, 2 cm needle is inserted into the skin
angled 45 degrees superiorly and medially.
 Needle advanced 5 mm approximately between thyroid
cartilage and hyoid bone.
 3-5ml of local anaesthetic solution is injected.
 Complications:
 Intravascular injection into superior laryngeal artery or
internal carotid artery. Negative aspiration is necessary.

73. Recurrent laryngeal nerve block
 Indications:
 Supplemental analgesia for the trachea for laryngoscopy
or to prevent hemodynamic responses to laryngoscopy.
 Supplemental anaesthesia for bronchoscopy or tracheal
procedures.
 Treatment of chronic laryngeal nerve processes.

74.  Technique:
 Cricothyroid membrane is identified between thyroid
cartilage and the cricoid cartilage.
 20 or 22 gauge, 4 cm intravenous catheter with an
attached syringe with 4% lignocaine is inserted
perpendicular to the skin.
 Catheter is advanced during aspiration and trachea is
entered when air is aspirated into the syringe.
 Needle is removed and only catheter left in situ to
prevent tracheal injury during coughing
 Coughing helps in even spread of local anaesthetic.

75.  Complications:
 Forceful coughing and movement can cause tracheal
puncture during the injection.
 Loss of airway reflexes and aspiration possible if
combines with superior laryngeal and glossopharyngeal
nerve blocks.

76. Local anaesthesia for Ear surgeries
 Anatomy:
 Four major nerves and their branches supply sensory
innervation to the ear
 The greater auricular (C2 and C3),
 The mandibular (auriculotemporal branch of V3)
 The vagus ( branch of X)
 The glossopharyngeal nerve( branch of IX)

77. For myringotomy with grommet
insertion
 1% lidocaine with 1:2,00,000 adrenaline is injected into
the posterior portion of the meatus about 0.5ml
 Additional 0.25 ml is injected into each of three areas
of the meatus: superiorly, inferiorly and anteriorly.
 Alternately 10% lidocaine spray over the tympanic
membrane can aid in simple procedures like
paracentesis.

79. For middle ear surgeries:
 Greater auricular nerve has to be anaesthetized in order to
achieve local anaesthesia
 Injection of lignocaine 1% with 1:2,00,000 adrenaline into
multiple sites over the mastoid process subcutaneously can
be done.
 Auricular branch is blocked by injecting 2-3ml into the skin
along the floor of the auditory canal.
 Auriculotemporal nerve block, needed for radical
mastoidectomy, can be done by injecting into the bony
cartilagenous junction of the anterior auditory canal and to
the skin and periosteum of incisura terminalis.

81. Field block of the ear:
 Supplied by cutaneous branches of spinal and cranial
nerves.
 Auricle is innervated by the greater auricular nerve
and lesser occipital nerves, supplying medial surface of
the ear and variable portion of lateral surface and by
auriculotemporal branch of mandibular nerve
supplying remainder of anterior surface.
 EAC by terminal branches of facial and Arnold’s nerve.

82.  Technique:
 Posterior aspect of the ear may be anaesthetized by
infiltration close to the posterior aspect of the auricle over
the mastoid process with 6-10ml of local anaesthetic.
 Auriculotemporal nerve is blocked by infiltration of 6-
10ml of local anaesthetic anterior to the ear beginning at
the zygoma.

84. Sphenopalatine ganglion block:
 Sphenopalatine ganglion is located superficially in the
pterygopalatine fossa.
 Technique:
 Block is accomplished by injection/topical anaesthesia
or aerosol spray.
 Injection is with a fine tipped 1200 angled needle
inserted through the greater palatine foramen at the
posterior edge of the hard palate medial to the third
molar.
 Needle advanced 3-5cms and injected.

85.  Other technique involves soaking a cotton tip soaked
with 4% lignocaine solution.
 First applicator is passed along the upper border of the
inferior turbinate, upto its posterior end
 Second applicator is passed along the upper border of the
middle turbinate.
 1 ml of solution is deposited further along the shaft and
left in place for 20 min.

88. Anterior ethmoidal nerve block:
 External nasal branch can be blocked for external nasal
surgery.
 Technique:
 A 25 gauge needle is inserted 1 cm above the inner
canthus , directed backwards and medially pass just
lateral to the inner wall of the orbit and medial to the
medial rectus muscle.
 2-4ml of anaesthetic agent is injected after a depth of
2.5cm is reached.
 Alternatively infiltration at the junction of nasal bones
and cartilage can block anterior ethmoidal external nasal
branch.

89. Nose:
 External nose requires blockade at 3 sites:
 Above the inner canthus of the eyelid
 At the infraorbital foramen
 At the junction of nasal bone and cartilage.
 Maxillary sinus drainage by a Caldwell-Luc approach
can be accomplished by maxillary neural blockade or
infraorbital nerve blockade.

90. Internal nasal blockade:
 Supplied by the sphenopalatine and anterior ethmoidal
nerves.
 Achieved by placing 2 cotton pledgets:
 Pledget A is inserted along the roof of the nasal cavity
until it reaches the superior extent.
 Pledget B is inserted 20-300 with horizontal to reach the
ganglion.
 Alternatively anaesthetic solution instilled into the
nasal cavity with skull turned upside down(by placing a
pillow under the shoulder) leads to pooling of solution
in the above areas

91.  Small remaining area along the floor supplied by
superior alveolar nerve is anaesthetized by direct
application along the floor and holding nares together.

92. Superficial cervical plexus block:
 Indication:
 Superficial neck procedures.
 Excision of thyroglossal and branchial cysts.
 Excision of neck nodes.
 Technique:
 Patient in supine position with head turned slightly away
from the sight to be blocked.
 Mastoid process, transverse cervical process of C6 are
identified and marked with a pen.
 A line is drawn connecting the two.

93.  Posterior border of sternocleidomastoid muscle between
the mastoid process and transverse process of C6 vertebra
is identified.
 Needle insertion site is labelled at the midpoint between
these two landmarks.
 Needle is then inserted perpendicular just behind the
posterior border of SCM muscle.
 5 ml of local anaethetic is injected subcutaneously.
Additional 5 ml each is injected superiorly and inferiorly
from the inserted site.

94. Deep cervical plexus block:
 Indications:
 Same as that mentioned for superior laryngeal nerve
block.
 Technique:
 The patient position is same as that for superficial block.
 Mastoid process and transverse process of C6 marked
and joined by a line.
 Roots of the cervical process are located underneath and
just anterior to the line

95.  Transverse process of C2 through C4 identified.
 After adequate subcutaneous local anaesthesia a 25G
needle is inserted perpendicular to the skin plane at C2
C3 and C4 levels.
 Transverse process is contacted at 1cm to 2cm depth
from the skin.
 Needle is gently pulled back by 1mm and 3-5ml of local
anaesthetic is injected after negative aspiration.