ULTRASOUND-GUIDED

GREATER AURICULAR NERVE BLOCK

CLINICAL PERPECTIVES
Ultrasound-guided greater auricular nerve As a stand-alone technique
block is most commonly utilized in
conjunction with lesser occipital nerve and
auriculotempora
• The diagnosis and treatment
of painful conditions
To provide complete surgical anesthesia • greater auricular
and/or postoperative pain relief for the neuralgia
surgery of the external ear. • red ear syndrome
• pain secondary to acute
herpes zoster
• postherpetic neuralgia
• To provide surgical anesthesia
for lesion removal and
laceration repair.

Patient with both Ramsay Hunt syndrome and acute

herpes zoster involving the trigeminal nerve.
RELEVANT ANATOMY
The largest sensory branch of the cervical plexus,
the greater auricular nerve

It arises from fibers of the primary ventral ramus

of the second and third cervical nerves.

At a point just inferior and lateral to the lesser

The auriculotemporal nerve ascends in front of the ear
occipital nerve, along with the superficial temporal artery.

The greater auricular nerve pierces the cervical

fascia and passes superiorly and forward and
then curves around the sternocleidomastoid
muscle.

It then pierces the superficial cervical fascia to

move more superiorly and superficially
The sensory distribution of the greater auricular
nerve.
The greater auricular nerve ascends more superiorly and
superficially to provide cutaneous sensory innervation
• To both surfaces of the auricle
• The external auditory canal
• Angle of the jaw
• The skin overlying a portion of the parotid gland.

The auriculotemporal nerve ascends in front of the ear along

with the superficial temporal artery.
ULTRASOUND-GUIDED TECHNIQUES
Supine position with the head turned away
from the side to be blocked

5 mLof local anesthetic is drawn up and 40

to 80 mg of depot steroid is added id there
is thought to be an inflammatory
component

Transducer is then placed over the

posterior border of the sternocleidomastoid
muscle at the level of the cricoid

It is placed transverse oblique position at

essentially a right angle
ULTRASOUND-GUIDED TECHNIQUES

At this point, The greater auricular nerve will

be visible twice in the same image and
once in its position deep to the
sternocleidomastoid muscle
Transverse short-axis ultrasound image demonstrating both
the deep and superficial segments of the greater auricular
nerve and the nerves relationship to the sternocleidomastoid
muscle
Then again in its superficial position as it
curves back around the more superficial
surface of the muscle.

A 22-gauge, 1½-inch needle is inserted in

proximity to the superficial portion of the
nerve

Transverse ultrasound image showing the relationship of the greater

auricular nerve to the carotid artery and jugular vein.
ULTRASOUND-GUIDED TECHNIQUES
After gentle aspiration, 2 mL of solution is
injected

The needle is removed and pressure is

placed on the injection site

Note The Functions of ultrasound imaging

• Pressure is placed on the injection
site to avoid hematoma or
ecchymosis.
• A paresthesia may be elicited, and
the patient should be warned of
such.
To help the practitioner identify the
relationship of the carotid artery and
jugular vein to the greater auricular nerve
To avoid inadvertent
intravascular injection
COMPLICATIONS

• Given the proximity of the external jugular view and

carotid artery, the clinician should carefully
• Calculate the total milligram dosage of local anesthetic
that may be safely given, especially if bilateral nerve
blocks are being performed.

Complications
Postblock ecchymosis and major vascular structures are
hematoma formation injured during the procedure.

Damage to the brachial

if the needle is placed too deeply
plexus
CLINICAL PEARLS

• The Ultrasound guidance greatly increases the accuracy and safety and
allows of much smaller doses of local anesthetic

• Greater auricular nerve block with long- An excellent palliation of pain

acting local anesthetics such as secondary to acute herpes
bupivacaine zoster

Treating acute herpes zoster with • It helps dry weeping lesions

aluminum acetate solution applied as a around the ear
tepid soak • It helps the patient more
comfortable
ULTRASOUND-GUIDED
TRIGEMINAL NERVE BLOCK:
CORONOID APPROACH
CLINICAL PERPECTIVES
• Blockade of the maxillary and mandibular nerve as they pass
through the pterygopalatine space.
• To the diagnosis and treatment of a variety of painful conditions

Indication Acute Pain

• Trauma
• Pain of malignant origin
Chronic Pain
• Postsurgical pain
• Atypical facial pain
• Dental pain
• Temporomandibular joint
• Trigeminal neuralgia
dysfunction
• Atypical facial pain
• Postherpetic neuralgia
• Trismus
• Acute herpes zoster
RELEVANT ANATOMY

• The trigeminal nerve is the fifth

cranial nerve. it derives its name
from its three branches
 the ophthalmic (V1) : sensory
fibers
 the maxillary (V2) : sensory
fibers
 the mandibular (V3) : sensory
and motor fibers
• The trigeminal nerve exits the pons as a
single nerve root on each side of the pons.

• These bilateral nerve roots travel forward

and laterally to form the gasserian
ganglion (also known as the trigeminal
ganglion) which is located in Meckel cave
in the middle cranial fossa

• The canoe-shaped gasserian ganglion is

bathed in cerebrospinal fluid and is
surrounded by dura mater.
RELEVANT ANATOMY
Three sensory divisions exit the anterior
convex portion of the gasserian ganglion:
• The ophthalmic (V1)
• The maxillary (V2)
• The mandibular (V3)

The sensory fibers of the trigeminal nerve

provide :
• Afferent light touch
• Proprioceptive and nociceptive functions

The mandibular nerve is responsible

• The light touch
• Proprioception
• Pain and temperature sensation within its
area of innervation
• it does not transmit taste sensation, which is
transmitted by the chorda tympani.
RELEVANT ANATOMY

The motor fibers of the mandibular nerve

provide efferent innervation :
• The muscles of mastication
• The mylohyoid muscle
• The anterior belly of the digastric
muscle
• The tensor tympani and tensor veli
palatini muscles.
ULTRASOUND-GUIDED TECHNIQUES
• Ultrasound-guided trigeminal nerve block via the
coronoid approach is a straightforward
technique if attention is paid to the clinical
relevant anatomy.
• The coronoid (mandibular) notch provides easy
access to the pterygopalatine fossa and the
maxillary and mandibular nerves.

The patient is placed in supine position with the

cervical spine in the neutral position

Asking the patient to open and close his or her

mouth several times while palpating the area just
anterior and slightly inferior to the acoustic
auditory meatus
ULTRASOUND-GUIDED TECHNIQUES
Once the coronoid notch is identified, the patient
is asked to hold his or her mouth open in a
relaxed, neutral position

The temporomandibular joint should be

readily apparent in the posterior portion of the
image with the acoustic shadow of the curved
bony mandibular condyle and mandibular neck
just below it

7 mL of local anesthetic is drawn up in a 10-mL

sterile syringe. 40 to 80 mg of depot-steroid
preparation may be added.
ULTRASOUND-GUIDED TECHNIQUES

A 22-gauge, 1½-inch needle is inserted just

below the zygomatic arch directly in the
middle of the coronoid notch using an out-
of-plane approach

After careful aspiration is carried out, 7 mL

of solution is slowly injected in incremental
doses

The patient must be observed carefully for

signs of local anesthetic toxicity.
COMPLICATIONS

• The potential for trauma to the

The pterygopalatine fossa is
vasculature, especially the maxillary
highly vascular
artery

• Facial hematoma formation Needle damage to the artery

• Local anesthetic toxicity.

CLINICAL PEARLS
• An excellent option for uncontrolled pain
or breakthrough pain of trigeminal
neuralgia and cancer pain
• Careful gentle aspiration and attention to
the total milligram dose of local anesthetic
• The patients should be warned about
 Small punctate facial scars secondary
to needle trauma
 Infection, especially in the
immunocompromised patient.
• Early detection of infection
• Unexplained pain in areas subserved by
the trigeminal nerve and its branches :
evaluation as tumors
Trigeminal schwannoma of the right gasserian
ganglion. T1-weighted coronal image shows
the mass to be of relatively low signal intensity
and to involve the mandibular division (arrow).
ULTRASOUND-GUIDED
MAXILLARY NERVE BLOCK
CLINICAL PERPECTIVES
• Selective blockade of the maxillary nerve as it
passes through the pterygopalatine space.
• To the diagnosis and treatment of a variety of
painful conditions.

Indication
Acute herpes zoster involving the
Acute pain maxillary nerve.
Trauma
pain of malignant origin Chronic pain
postsurgical pain
dental pain atypical facial pain
trigeminal neuralgia temporomandibular joint
atypical facial pain dysfunction
the pain of acute herpes postherpetic neuralgia
zoster
RELEVANT ANATOMY
The motor fibers of the mandibular
nerve provide efferent innervation :
• The muscles of mastication
• The mylohyoid muscle
• The anterior belly of the digastric
muscle
• The tensor tympani and tensor
veli palatini muscles.
Three sensory divisions exit the anterior
convex portion of the gasserian ganglion:
• The ophthalmic (V1)
• The maxillary (V2)
• The mandibular (V3)
The sensory fibers of the trigeminal nerve
provide :
• Afferent light touch
• Proprioceptive and nociceptive functions
The mandibular nerve is responsible
• The light touch
• Proprioception, and pain and temperature
sensation within its area of innervation
• it does not transmit taste sensation, which is
transmitted by the chorda tympani.
RELEVANT ANATOMY
The ophthalmic division (V1) of the trigeminal nerve

It exits the cranial fossa via the superior

orbital fissure

It transmits sensory information from

• The scalp
• The forehead
• The upper eyelid, the conjunctiva and
cornea of the eye, most of the nose
except the nasal ala, the nasal mucosa,
the frontal sinuses, and the dura and
some intracranial vessels
 The maxillary division of the trigeminal nerve (V2)
It exits the cranial fossa via the foramen
rotundum
It transmits sensory information from :
The mandibular division of the trigeminal nerve (V3)
It exits the cranial fossa via the foramen
ovale
It transmits sensory information from
• The lower eyelid and cheek
• The nasal ala
• The upper lip, upper dentition,
and gingiva
• The nasal mucosa
• The palate and roof of the
pharynx
• The maxillary, ethmoid, and
sphenoid sinuses
• Portions of the meninges
• The lower lip
• The lower dentition and gingiva
• The chin and jaw (except the
angle of the jaw, which is
supplied by C2–C3)
• Parts of the external ear
• Parts of the meninges
• Dorsal aspect of the anterior two-
thirds of the tongue
ULTRASOUND-GUIDED TECHNIQUES

The patient is placed in supine position

with the cervical spine in the neutral
position.

Asking the patient to open and close his or

her mouth several times while palpating
the area just anterior and slightly inferior to
the acoustic auditory meatus

Once the coronoid notch is identified, the

patient is asked to hold his or her mouth
open in a relaxed, neutral position

The skin overlying the mandibular notch is

prepped with antiseptic solution
ULTRASOUND-GUIDED TECHNIQUES
A linear transducer is placed in the transverse
position directly over the coronoid notch

The temporomandibular joint should be

readily apparent in the posterior portion of the
image with the acoustic shadow of the curved
bony mandibular condyle and mandibular neck
just below it

7 mL of local anesthetic is drawn up in a 10-mL

sterile syringe. 40 to 80 mg of depot-steroid
preparation may be added.
Ultrasound image of the
pterygopalatine fossa via the coronoid
notch.
ULTRASOUND-GUIDED TECHNIQUES

a 22-gauge, 3½-inch styletted spinal needle is inserted

just below the zygomatic arch directly in the middle of the
coronoid notch using an out-of-plane approach

The needle is advanced until it impinges on the lateral

pterygoid plate.

Then The needle is withdrawn slightly and redirected toward the

pupil of the eye until it slips past the anterosuperior margin of the
lateral pterygoid plate into the pterygopalatine fissure and into
proximity of the maxillary nerve
COMPLICATIONS
• Trauma to the vasculature, especially the maxillary artery, remains
an ever-present possibility
• Facial hematoma formation

Specialist should carefully aspirate the needle prior to injecting any

medications and should then inject small, incremental doses of
local anesthetic to avoid local anesthetic toxicity.
CLINICAL PEARLS

• An excellent option for uncontrolled pain or breakthrough pain of

trigeminal neuralgia and cancer pain.
• The patients should be warned about
 Small punctate facial scars secondary to needle trauma to the
skin overlying the coronoid notch may occur
 Infection, although rare, especially in the immunocompromised
patient.
• Early detection of infection is crucial to avoid potential life-threatening
sequelae including spread of the infection to the central nervous
system.
CLINICAL PEARLS

A patient presenting with atypical facial pain limited mainly to what was believed to be a V2
distribution. The findings were slowly progressive over months. A: Contrast-enhanced computed
tomography showing a subperiosteal abscess adjacent to the maxilla (arrow). B: Bone windows
showing periodontal disease extending through the buccal cortex, explaining the pain as due to a
periapical dental abscess with secondary subperiosteal spread.
ULTRASOUND-GUIDED
MANDIBULAR NERVE BLOCK
CLINICAL PERPECTIVES
• Selective blockade of the mandibular nerve
• To the diagnosis and treatment of a variety of
painful conditions subserved by the
mandibular nerve

Indication
Acute pain Chronic pain
• Trauma • Manage atypical
• Pain of malignant facial pain
origin • Chronic dental pain
• Postsurgical pain • Postherpetic
• Dental pain neuralgia. CT Scam in a patient with chronic left jaw pain.
• Breakthrough pain of A: The prior extraction site (arrow) is irregular, and there is
chronic erosion and periosteal thickening on its buccal surface
trigeminal neuralgia and loss of endosteal bone on the buccal surface (arrowheads).
• Atypical facial pain B: There is no evidence of significant soft tissue swelling within
what appears to almost be a dry socket (arrow). A
• Trismus subperiosteal abscess has actually manifested more near the
angle to the mandible (arrowhead).
• The pain of acute C: That subperiosteal abscess continues to spread between the
herpes zoster. masseter and ascending ramus of the mandible (arrows).
RELEVANT ANATOMY
Three sensory divisions exit the anterior
convex portion of the gasserian ganglion:
• The ophthalmic (V1)
• The maxillary (V2)
• The mandibular (V3)

The sensory fibers of the trigeminal nerve

provide :
• Afferent light touch
• Proprioceptive and nociceptive functions

The mandibular nerve is responsible

• The light touch
• Proprioception
• Pain and temperature sensation within its
area of innervation
• it does not transmit taste sensation, which is
transmitted by the chorda tympani.
RELEVANT ANATOMY

The motor fibers of the mandibular nerve

provide efferent innervation :
• The muscles of mastication
• The mylohyoid muscle
• The anterior belly of the digastric
muscle
• The tensor tympani and tensor veli
palatini muscles.
RELEVANT ANATOMY
The ophthalmic division (V1) of the trigeminal nerve

It exits the cranial fossa via the superior

orbital fissure

It transmits sensory information from

• The scalp
• The forehead
• The upper eyelid, the conjunctiva and
cornea of the eye, most of the nose
except the nasal ala, the nasal mucosa,
the frontal sinuses, and the dura and
some intracranial vessels
 The maxillary division of the trigeminal nerve (V2)
It exits the cranial fossa via the foramen
rotundum
It transmits sensory information from :
The mandibular division of the trigeminal nerve (V3)
It exits the cranial fossa via the foramen
ovale
It transmits sensory information from
• The lower eyelid and cheek
• The nasal ala
• The upper lip, upper dentition,
and gingiva
• The nasal mucosa
• The palate and roof of the
pharynx
• The maxillary, ethmoid, and
sphenoid sinuses
• Portions of the meninges
• The lower lip
• The lower dentition and gingiva
• The chin and jaw (except the
angle of the jaw, which is
supplied by C2–C3)
• Parts of the external ear
• Parts of the meninges
• Dorsal aspect of the anterior two-
thirds of the tongue
ULTRASOUND-GUIDED TECHNIQUES

The patient is placed in supine position

with the cervical spine in the neutral
position.

Asking the patient to open and close his or

her mouth several times while palpating
the area just anterior and slightly inferior to
the acoustic auditory meatus

Once the coronoid notch is identified, the

patient is asked to hold his or her mouth
open in a relaxed, neutral position
ULTRASOUND-GUIDED TECHNIQUES
A linear transducer is placed in the transverse
position directly over the coronoid notch

5 mL of local anesthetic is drawn up in a 10-mL

sterile syringe. 40 to 80 mg of depot-steroid
preparation may be added. Proper transverse position of the linear transducer for
selective mandibular nerve block via the coronoid
approach.

a 22-gauge, 3½-inch styletted spinal needle is

inserted just below the zygomatic arch directly
in the middle of the coronoid notch using an
out-of-plane approach

Ultrasound image of the pterygopalatine

fossa via the coronoid notch.
ULTRASOUND-GUIDED TECHNIQUES
The needle is advanced until it impinges on the lateral
pterygoid plate.

The needle is withdrawn slightly and redirected toward the the

mastoid process until it slips past the posterior–inferior margin of
the lateral pterygoid plate into the pterygopalatine fissure and into
proximity of the mandibular nerve

After careful aspiration is carried out, 4 to 5 mL of solution

is injected in incremental doses

The proper needle placement for selective

mandibular nerve block via the coronoid
approach.
COMPLICATIONS
• Trauma to the vasculature, especially the maxillary artery, remains
an ever-present possibility
• Facial hematoma formation

Specialist should carefully aspirate the needle prior to injecting any

medications and should then inject small, incremental doses of
local anesthetic to avoid local anesthetic toxicity.
CLINICAL PEARLS

• An excellent option for Uncontrolled pain or breakthrough pain of

trigeminal neuralgia and cancer pain
• Careful gentle aspiration and attention to the total milligram dose of local
anesthetic
• Small punctate facial scars secondary to needle trauma to the skin
overlying the coronoid notch may occur, and the patient should be
warned of this possibility. Infection, although rare, remains an ever-
present possibility, especially in the immunocompromised patient. Early
detection of infection is crucial to avoid potential life-threatening
sequelae including spread of the infection to the central nervous system.
Unexplained pain in areas subserved by the trigeminal nerve and its
branches requires careful evaluation as pathology anywhere along the
path of the nerve may cause pain
CLINICAL PEARLS

• An excellent option for uncontrolled pain or breakthrough pain of trigeminal

neuralgia and cancer pain
• Careful gentle aspiration and attention to the total milligram dose of local
anesthetic
• The patients should be warned about
 Small punctate facial scars secondary to needle trauma
 Infection, especially in the immunocompromised patient.
• Early detection of infection
• Unexplained pain in areas subserved by the trigeminal nerve and its
branches : evaluation as tumors
CLINICAL PEARLS

Two examples of pathologic fracture. A: A severe pathologic fracture in an area of mandibular

osteoradionecrosis. B: Pathologic fracture (arrows) in a patient presenting with temporomandibular joint region
pain from what was believed to be a parotid mass. This was due to metastatic prostate cancer.
ULTRASOUND-GUIDED
SUPRAORBITAL NERVE BLOCK
CLINICAL PERPECTIVES
Diagnosis and treatment of a variety of painful
conditions in areas subserved by the
supraorbital nerve

• supraorbital neuralgia
• supraorbital nerve entrapment
• swimmer’s headache
• pain secondary to herpes zoster.

Providing surgical anesthesia in the

distribution of the supraorbital nerve

Acute herpes zoster involving the first division of

• Lesion removal the trigeminal nerve. Note the lesions on the tip of
• Cosmetic procedures the nose (positive Hutchinson sign).
• Laceration repair.
RELEVANT ANATOMY
The supraorbital nerve is a pure sensory nerve

It provides sensory inervation to the forehead, upper

eyelid, and anterior scalp all the way to the vertex of the
skull

It arises from fibers of the frontal nerve which is the

largest branch of the ophthalmic nerve

The frontal nerve enters the orbit via the superior orbital
fissure and passes anteriorly beneath the periosteum of
the roof of the orbit.
 A larger lateral branch, the
supraorbital nerve
Branches of frontal nerve
A smaller medial branch, the
supratrochlear nerve

Both nerves exit the orbit

anteriorly along with the
supraorbital artery via the
supraorbital foramen.
ULTRASOUND-GUIDED TECHNIQUES
Treating conditions involving
the supraorbital nerve, such as
40 to 80 mg of depot
• supraorbital neuralgia
steroid may be added to
• acute herpes zoster
the local anesthetic.
• Neuritis
• postherpetic neuralgia

The patient is placed in a supine position

A total of 2 mL of local anesthetic is drawn up in

a 5-mL sterile syringe

the supraorbital foramen on the affected side is

identified by palpation

Palpation of the supraorbital foramen

ULTRASOUND-GUIDED TECHNIQUES
It can be found 2.5 to 2.8 cm laterally from the
midline

It is then prepped with antiseptic solution.

Avoid allowing the antiseptic solution to flow into

The supraorbital foramen (star) can be
the eye.
viewed as a discontinuity in the orbital
ridge with the nerve and artery exiting
through it.
Transducer is then placed in a transverse plane over
the previously identified supraorbital notch and slowly
moved from a cephalad to caudad direction until a
discontinuity in the supraorbital ridge is identified
 ULTRASOUND-GUIDED TECHNIQUES
Color Doppler can be utilized to identify the
supraorbital artery

Once the nerve and artery are identified

a 22-gauge, 1½-inch needle is inserted in the Color Doppler may help identify the supraorbital
artery.
middle of the inferior border of the ultrasound
transducer

a gauze sponge should be used to apply gentle

pressure on the upper eyelid and supraorbital
tissues.

A gauze sponge should be used to apply gentle

After gentle aspiration, 2 mL of solution is pressure on the upper eyelid and supraorbital tissues
to prevent the injectate from dissecting inferiorly into
injected around the nerve these tissues.
COMPLICATIONS
The area surrounding the carefully calculate the total
supraorbital nerve is highly milligram dosage of local
vascular anesthetic

Complication :
• Postblock ecchymosis
• Hematoma formation

Manual pressure is applied to the

area of the block immediately after
injection.
These bleeding
complications can be
decreased
Application of cold packs for 20-
minute periods after the block
CLINICAL PEARLS
The use of tepid aluminum acetate
• Blockade of the supratrochlear nerve is solution applied as a soak can speed the
also advisable. drying of the weeping herpetic lesions
and enhance patient comfort.

• The palliation of pain secondary to acute

herpes zoster involving the ophthalmic
division or the trigeminal nerve and its
branches.

• Care should be taken to avoid spill-age

of the aluminum acetate solution into the
eye
Keratitis

• patients with acute herpes zoster

It may presage a particularly
involving the first division of the
severe herpes zoster with ocular
trigeminal nerve may first experience
complications (acute glaucoma
vesicular eruptions on the tip of the nose
and keratitis)
(positive Hutchinson sign)