Technical considerations for approaches to the ultrasound-guided maxillary nerve block via the pterygopalatine fossa: a literature review

Abstract

Background and objectivesBlockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF.MethodsThe literature search was performed by searching the National Library of Medicine’s PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009–March 2019 for keywords targeted toward “trigeminal nerve,” “maxillary nerve,” or “pterygopalatine fossa,” “ultrasound,” and “nerve block,” using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study.ResultsThere are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1–5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg.ConclusionsThese studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored.

Quantification of the Interventional Approaches Into the Pterygopalatine Fossa by Solid Angles Using Virtual Reality

“…The posterior infrazygomatic approach was significantly larger than suprazygomatic approach, however, this does not necessarily mean that posterior infrazygomatic approach is superior to suprazygomatic approach because in the present pilot study we did not take the course of maxillary artery into account and the number of included subjects was only five. In clinical setting it is very important to avoid puncture of the maxillary artery to prevent unnecessary complications (Anugerah et al, 2020), therefore, further studies using CT angiographic volumes to reconstruct virtual reality and determine the size of solid angles for each approach considering the course of maxillary artery are warranted.…”

“…Target access is affected by the beforementioned structures, and this is even more pronounced where several structures conjointly affect the target access. This is the case in pterygopalatine fossa injections where several bony structures need to be accounted for to gain precise access into this narrow anatomical region on the skull base (Anugerah et al, 2020). The pterygopalatine fossa contains sympathetic and parasympathetic nerves, maxillary nerve and maxillary artery that supply nasal cavity, oral cavity and middle third of the face (Chiono et al, 2014).…”

Comparison of the feasibility and safety of infrazygomatic and suprazygomatic approaches to pterygopalatine fossa using virtual reality

“…With fluoroscopic guidance, the needle can be depicted; however, it is limited by the lack of maxillary artery visualization (without contrast injection) and exposure to radiation. Ultrasound-guided approaches provide real-time needle imaging with the potential for vessel depiction, without exposure to radiation 14. In recent years, three ultrasound-guided approaches via the infratemporal fossa were introduced.…”

Bilateral Sphenopalatine Ganglion Block With Liposomal Bupivacaine Followed by Severe Hypertension: A Case Report

“…Preoperatively, his vital signs were blood pressure (BP), 127/73; heart rate (HR), 56; respiratory rate (RR), 14, a & a pRaCtICe and pulse oximetry (Spo 2 ), 100% on room air. Preoperative regional anesthesia was provided via bilateral, ultrasoundguided, suprazygomatic SPG blockade similar to the technique described by Anugerah et al 7 The ultrasound was placed below the zygomatic process, and a 22-gauge, 4-inch spinal needle was advanced perpendicular to the skin at the frontozygomatic angle. A mixture of 6 mL of 0.5% bupivacaine and 6 mL of liposomal bupivacaine (13.3 mg/mL) was prepared, divided into 6-mL aliquots, and injected bilaterally.…”