Extra-Oral Nerve Blocks*

Robert D. Thompson, D.D.S.t

In that the management of pain is mechanism responsible for the parox-

one of the most serious clinical prob- ysm of pain can be given. The proce-
lems that conifronts the dental surgeon, dural approach to blocking the maxil-
a discussion of the procedure and some lary and mandibular division of the
of the problems associated with extra- 5th cranial nerve with alcohol or
oral anesthesia and alcohol blocks in diagnostically blocking the glosso-
the treatment of these cases, should pharyngeal nerve with a suitable local
always be of interest. Pain about the anesthetic will be presented.
head or face often brings patients to Most available techniques for extra-
their dentist through the conviction, oral alcohol blocks give average meas-
true or not, that a tooth must be at urements concerning the depth of pen-
fault. Often times, the origin of the etration. These do not fully describe
pain is directly related to various den- the anatomical structures within the
tal pathoses. However, the concern of area to be injected, and may result in
this paper is to deal solely with the serious consequences unless caution
problem of trigeminal neuralgia. and extreme awareness of these adja-
In June of 1966, a group of leading cent vital structures is appreciated.
scientific investigators held a workshop The patient should initially have a
devoted to the structural changes re- head plate radiograph taken in a sub-
lated to trigeminal neuralgia. Consist-
ent pathological changes of unknown
etiology have been demonstrated in
the trigeminal ganglia; they are most
marked in patients with trigeminal neu-
ralgia. These "degenerative" changes
could be the basis for altered neuronal
function. Mechanical factors, such as
petrous ridge compression of vascular
pulsation, which might otherwise be of
little significance, may combine with
"degenerative" changes to produce an
abnormal paroxysm of pain and re-
sponse to a light sensory stimulus ap- Fig. 1. Patient positioned for submental
plied to the appropriate receptive field vertex projection.
(trigger point). No definitive state- mental-vertex position. Prior to posi-
ment as to the neural-physiological tioning the patient for the radiograph,
a lead bead is taped to the patient's
*Presented at the Scientific Meeting of the subzygomatic preauricular area, corre-
American Dental Society of Anesthesiology, sponding to the anticipated region of
Atlantic City, October, 1967.
f Assistant Professor, Oral Surgery, UCLA injection. A cone-to-target distance can
School of Dentistry, Los Angeles, California be worked out resulting in a film from
90024. which direct measurements can be
MARCH, 1968 65

Fig. 2. Radiograph depicting lead-bead on
skin surface, lateral pterygoid plate and
foramen ovale.
made of exact distances, in milli-
meters, from the skin (lead bead) to
the lateral pterygoid plate, and more
postero-medially, the foramen ovale.
This individualizes the injection for
each patient, and does not depend
upon "average" measurements. Ob-
viously, not everyone has the same
bony and soft tissue thickness which
would make the techniques of "aver-
age" depth of penetration measure-
ments amenable to one and all.
In the operating room, the patient
is seated in an upright position with
the occlusal plane parallel to the floor.
The field to be injected is surgically
prepared with Phisohex soap and
washed clean with sterile saline. In
the region of the sigmoid notch and
the subzygomatic area, with a 25
gauge short needle, a skin wheal is
66
raised with 2 % xylocaine, 1:100,000
epinephrine. The same needle is ad-
vanced for a short distance to anes-
thetize the subcuticular muscle layer.
A 22 gauge spinal needle with an in-
dwelling stilette, which has been pre-
viously marked to the proper depth of
the lateral pterygoid plate with a
piece of rubber dam, is not introduced
and advanced through the previously
anesthetized area, until the pterygoid
plate is encountered. This point should
be exactly where the rubber marker
contacts the skin surface. The struc-
tures passed through to reach the
plate will have been skin, subcutane-
ous fat, masseter muscle, temporalis
muscle, intemal and extemal pter-
ygoid muscles, in addition to penetrat-
ing or pushing aside the veins and
arteries contained within this region.
While the needle is in contact with
the lateral pterygoid plate, the rubber
marker is reset, corresponding to the
measurement taken directly from the
radiograph, relating the distance from
the skin to the foramen ovale. With
the marker in this new position, the
needle is withdrawn slightly and re-
directed postero-superiorly.
At this point, the tip of the needle
should be directly inferior to the fora-
men ovale. With the patient awake,
but sedated with approximately 50
mg. of Vistaril I.V., a response in the
form of a- parasthesia in the periphe-
ral distribution of the mandibular
branch of the trigeminal nerve is
elicited. Prior to the injection of any
medium, the stilette is removed and
the needle hub is inspected for san-
guinous return indicative of an intra-
vascular position of the needle. An
intravascular position of the needle is
not impossible, as the area is richly
supplied with a venous plexus and
various branches of the internal max-
illary artery. With the needle-rfow in
A6EsTImsiA PRoGREss

Fig. 3. Inspecting hub of needle for san-
guinous return prior to injection.
direct contact with the mandibular
nerve as it exits from the foramen
ovale, 1.5 cc. of 2% xylocaine is in-
jected at this time to insure the cor-
rect position of the needle. A correct
position will yield complete anesthe-
sia of the mandibular branch of the
trigeminal nerve following the local
anesthetic injection.
If the needle is advanced too far
medially, penetration of the palatal
muscles or the superior constrictor
muscle of the pharynx will result in
the deposition of the solution in the
oro-nasopharynx. If the needle is ad-
vanced too far medially, it may be
possible to deposit the solution into
the auditory tube. The anterior later-
al aspect of the tube actually con-
tacts the mandibular nerve fibers. If
the latter happens, middle ear damage
may result, providing the alcohol solu-
tion travels the extent of the tube.
Following injection of the xylocaine,
the stilette is replaced and the needle
is left in place for a sufficient length
of time to assess anesthesia of the
mandibular branch of the trigeminal
MARCH, 1968
nerve, and hence confirm the position
of the needle. With the correct posi-
tion of the needle thus assured, 1.5
cc. of absolute alcohol is injected.
This amount of absolute alcohol will
cause necrosis of the tissues within a
3 mm. radius. The needle is now com-
pletely withdrawn and a small band-
age is applied over the area.
The patient is observed for a while
post-injection and prior to discharge
is given prescriptions for antibiotic
and analgesic medication. The patient
may experience a burning sensation
which could persist for approximately
48 hours post-injection.
In a series of 20 cases, it was ob-
served that a significant number of
patients developed a contralateral
temporomandibular joint syndrome,
post-injection. Clinically, this has not
been too disturbing in that the syn-
drome is transient in nature, and with
time disappears completely. However,
it raised the question of the effect of
the injection on motor function.
Knowing that the 3rd division of the
trigeminal nerve carries the motor
supply to the muscles of mastication,
electromyograms of the temporalis
and masseter muscles bilaterally,
were taken pre-and post-injection, by
technicians unaware of which side
was affected. The immediate post-in-
jection electromyograph was followed
by further periodic studies. Con-
sistently the immediate post-injection
electromyograph revealed absolutely
no function of the temporalis and
masseter muscles on the side of in-
jection. By two weeks post-injection,
complete return to function of the
muscles of mastication had been at-
tained, however, anesthesia of the
peripheral sensory distribution of the
mandibular branch of the trigeminal
nerve persisted. The prognosis for pa-
tients suffering from trigeminal neu-
67
Fig. 4. Electromyograms showing loss of motor activity following injection with return to
normal 3 months later.

ralgia treated by extra-oral alcohol
injection provides a variable result.
Relief of pain has been observed to
extend from six weeks to what would
be considered a permanent cure. This
variability in consistency of relief of
pain will lead to further investigative
studies which may provide more per-
manent and predictable results.
A stereotactic apparatus is now be-
ing developed which will utilize ac-
curate predetermined measurements
68
for the placement of the needle for
injection, rather than to depend on
visual and manual cues. It is con-
ceivable, that in the near future, such
a patient may yet undergo this pro-
cedure while being rendered un-
conscious by general anesthesia with
a cryoprobe being used rather than a
solution of alcohol. This would result
in an even more predictable area of
controlled necrosis of the nerve as
well as permanent relief from pain.
ANESTHESIA PROGRESS