This presentation includes indications,contraindication, anesthetic technique,position,approaches,types of nerve blocks,complications.

1. *
BY
-PADMA .N

3. *
*Anesthesia of the ear is useful for repair of
lacerations, hematoma incision and drainage,
and other painful procedures of the ear.

4. *

5. *The greater auricular nerve is a branch of the cervical
plexus. It innervates the posteromedial, posterolateral,
and inferior auricle (lower two-thirds both anteriorly and
posteriorly).
*The lesser occipital nerve innervates a small portion of
the helix.
*The auricular branch of the vagus nerve innervates the
concha and most of the area around the auditory meatus.
*The auriculotemporal nerve originates from the
mandibular branch of the trigeminal nerve. It innervates
the anterosuperior and anteromedial aspects of the
auricle.
*The external auditory canal and tympanic membrane
have separate innervation. Indications for anesthetizing
these areas are distinct from those for performing an
auricular block.

7. * 1. External carotid artery
* 2. Posterior auricular artery
* 3. Internal jugular vein
* 4. Stylomastoid artery
* 5. Posterior tympanic artery
* 6. Facial Nerve
* 7. Stapedius muscle
* 8. Superior tympanic artery
* 9. Tensor tympani muscle
* 10. Middle meningeal artery
* 11. Anterior tympanic artery
* 12. Maxillary artery
* 13. Inferior tympanic artery.
* 14. Ascending pharyngeal artery.

8. Procedure Description
Cochlear implant
Placement of a multichannel electrode in the scala tympani
through the medial wall of the middle ear. Used in patients with
severe and profound sensorineural hearing loss. It partially
replaces the function of cochlea transforming sound energy into
electrical signals.
Myringoplasty
Isolated repair of the tympanic membrane (also known as a type 1
tympanoplasty). A suitable graft, often temporalis facia, is placed
and acts as a scaffold over which new epithelium will grow to
repair the hole. Inlay or underlay techniques can be used.
Tympanoplasty
Myringoplasty combined with a repair of chronic middle ear
changes to eradicate any chronic infection and restore middle ear
function. This can be performed endoscopically.
Ossicular chain reconstruction
Repair (ossiculopasty) or partial replacement of one or more
bones of the ossicular chain.
Canal wall up mastoidectomy (includes cortical mastoidectomy
and combined approach tympanoplasty)
Removal of bone and disease from the mastoid air system, with
preservation of the posterior/superior wall of the external
acoustic meatus. In general, this gives a better chance of good
functional outcome but a higher chance of disease recurrence.
The middle ear can be accessed via this route to remove disease
and repair structures inside it.
Common middle ear procedures.

9. Canal wall down mastoidectomy (includes atticotomy,
atticoantrostomy, modified radical mastoidectomy, and radical
mastoidectomy)
Removal of bone and disease from the mastoid air system along
with the posterior/superior wall of the external acoustic meatus.
The hollowed-out mastoid may be reconstructed or if left open
forms part of the external ear canal.
Atticotomy
Removal of disease from the attic, performed for limited attic
disease.
Atticoantrostomy
Performed for removal of more extensive disease, starting from
the attic and proceeding into the mastoid antrum.
Stapedectomy
Removal of part of the stapes and placement of a prosthesis to
improve hearing.
Stapedotomy Fenestration of the stapes footplate to improve hearing

10. *
*Suture of a large laceration of the ear or the
skin surrounding the ear
*Painful procedures of the ear, such as incision
and drainage of an abscess or hematoma.

11. *
*Avoid anesthetizing the ear if the patient
has cellulitic periauricular skin or a severe
allergy to the chosen anesthetic.

12. *
*Local anesthetic agents (eg, lidocaine 1% [Xylocaine],
bupivacaine 0.25% [Marcaine]) may be used.
*2 % lidocaine solution with 1: 20,000 adrenaline.
* AS should not exceed 7mg/ kg body weight i.e. 20 ml in
average adult. In most patients 12-15 ml were needed.
*If a regional block is performed, lidocaine mixed with
epinephrine can be used; however, epinephrine is
contraindicated in direct infiltration of the ear.

13. *
*Syringe, 5-10 mL
*Needle, 25-gauge or 27-gauge (5-7 cm in
length)
*Parenteral anesthetic agent
*Light source

14. *Position the patient so that
both clinician and patient
are comfortable.
*Laying the patient supine is
usually the optimal position.
*

15. *
*Optimises the surgical field without
excessive arterial hypotension
*Allows for intraoperative monitoring of
facial nerve function.
*Minimise the chances of excessive
coughing on emergence from
anaesthesia and PONV.

16. Technique
The choice of technique
depends on the area of the
ear that requires anesthesia.
*RING BLOCK is used to
anesthetise entire auricle.
*

17. *Provides anesthesia to the
earlobe and lateral helix
(greater auricular and lesser
occipital nerve branches).
*

18. * Anesthetises the helix and
tragus (auriculotemporal
nerve).
*

19. Points of infiltration of the ear for local anesthesia: (1) postauricular area,
(2,3,4) posterior, superior and inferior walls of the cartilaginous meatus respectively,
(5) infront of the crus of helix (auriculotemporal nerve), (6) incisura,
(7) tragus, (8,9,10,11) superior, posterior, inferior and anterior walls of the bony meatus respectively.
(A) injecting the bony meatus through skin overlying cartilaginous meatus, and proceeding subcutaneous
(B) classical injection of the skin overlying the bony meatus.
(C) needle bevel directed wrongly to skin causing its damage

20. *
*1- Lower adrenaline concentration (1:100,000-
1:200,000) is used in patients with pre-existing cardiac
disease. Presence of severe arrhythmias may
contraindicate the procedure.
*2- LA for tympanostomy tube insertion needs only
infiltration of 5ml on the external meatus and topical
application of lidocaine on TM surface. The latter is
only enough for intra-tympanic injection of drugs.
*3- LA for auricular procedures (auriculoplasty -
evacuation of auricular hematoma or perichondritis -
preauricular sinus excision) involves mainly steps 1-5
with infiltrating around the lesion in preauricular sinus
excision.

21. *4- Supplementary LA may be needed if there is
manipulations on the Eustachian tube or if the TM
or cholesteatoma matrix were adherent to the
middle ear mucosa preventing the anesthetic
solution to reach the tympanic plexus. This is done
by applying pieces of gel foam or cotton soaked in
AS to the desired area of ME mucosa.
*5- Temporary facial nerve anesthesia may occur if
there is excessive infiltration below the mastoid tip
or injection of the lateral surface of the tragus,
thus trickling along the tragal pointer. If it occurs, it
usually recovers within a few hours.
*6- Use of Lidocaine 2% - Bupivacaine 1 % (Marcain)
mixture by mixing 10 cc of each drug and adding
1mg adrenaline aiming to prolong the anesthesia
time, this was used in 100 patients.

22. *
*Infection
*Allergic reactions
*Inadequate anesthesia
*Cannulation of the superficial temporal artery

23. *
*Some procedures can be carried out under
local anaesthesia with conscious sedation, such
as stapes surgery, tympanoplasty, and
mastoidectomy.
* GA is preferred to
• Avoid of pain from local anaesthetic injections
• Reduced potential for sudden patient movements

24. *
ET tube insertion.
*EMG Facial Nerve Monitors
*Nitrous oxide is avoided.
TOTAL INTRAVENOUS ANESTHESIA (TIVA)
• Extubation can be smooth.
• Minimising the effect of coughing on middle
ear pressure.

25. *

26. *

27. *
I. External Approach-
resurfacing procedures
soft-tissue work(including local flaps and scar revision)
II. Internal Approach
Septoplasty
turbinate reduction
Polypectomy
balloon catheter dilation.
Nasal fracture reduction, Rhinoplasty, and Nasal valve
correction.
 Examination with nasal speculum
 Foreign body removal
 Placement of nasal packing
 Abscess drainage
 Incision of septal hematoma

28. *
*Use of internal swabs or pledgets soaked in
vasoconstrictors is contraindicated in patients with
uncontrolled hypertension or coronary artery
disease.
*Uncooperative or pediatric patients may not be able
to undergo anesthesia to the nose.
*Patients must not be administered an anesthetic
agent to which they are allergic.
*Local infiltration or infraorbital block is
contraindicated in the presence of infected tissue.

30. *
A. NASAL ENDOSCOPY
*Use of a decongestant spray (eg, oxymetazoline)
before the topical anesthetic spray.
B. FIBEROPTIC NASOTRACHEAL INTUBATION
* Antisialagogues
*Decongestent followed by LA spray.
*Pledget insertion

31. C. SINONASAL PROCEDURES
*Above said procedures + Nerve blocks.
*Ant.Ethmoidal Nerve block 1% lidocaine with
1:100,000 epinephrine is injected at the axilla of the
middle turbinate.
*Sphenopalatine Ganglion Nerve Block Anesthetic is
applied posteriorly to the middle nasal turbinate on the
nasopharyngeal mucosa.
Approaches-
1.Transnasal

32. 2.Transoral -The SPG is reached by passing a
needle through the greater palatine foramen at
the posterior end of the hard palate.
3.Lateral Infratemporal-The cannula is
placed superiorly to the pterygopalatine
fossa, and then anesthetic is delivered
through the cannula.

33. 4. Greater palatine block-The greater palatine
foramen is located posterior and 1 cm medial to
the second maxillary molar. This depression can
typically be palpated prior to injecting.
Insert a 25-gauge needle bent at 2.5 cm from
the tip of the needle at 45-60° into the area of
the greater palatine foramen.

34. *
*Block the external nasal nerve with an
intercartilaginous injection of the nasal dorsum
from the region of the rhinion to the supratip
region.

35. *NASOPALATINE BLOCK- Base of the columella
and nasal tip.

36. Approach: Place the index finger of
the nondominant hand over the above
the intersection mentioned above (ie,
the infraorbital foramen) and retract
the cheek with the thumb. Insert the
needle into the mucobuccal fold at
junction of premolars 1 and 2. Direct
the needle parallel to the long axis of
premolar 2, palpating its location as
the needle is advanced until it is
adjacent to the infraorbital foramen
(approximately 1.5-2 cm). If the
needle is directed at an angle that is
too acute, it will hit the maxillary
eminence; if directed at an angle that
is too superior, the needle will enter
the orbit.
INFRAORBITAL NERVE
BLOCK

37. *
*Topical anesthetics can be readily absorbed into the
intravascular compartments because the inner nose
is an extremely vascular area.
*While the amount of topical and local anesthetics
used in the nose rarely exceeds toxic doses, the
provider should be aware of the toxic dosages and
the signs, symptoms, and treatment of anesthetic
toxicity.
*Manipulation intranasally may elicit a vasovagal
response.
*Complications of a local block or infraorbital nerve
block can include bleeding, pain at the injection
site, deformity of tissues (specific for a local
block), infection, needle breakage, and neurapraxia
(secondary to injection into the infraorbital
foramen).

38. *

39. *
• Cervical plexus : ventral rami
of C2-C4
•Superficial cervical plexus
: Skin and superficial
structures
•Deep cervical plexus : Deeper
structures (Muscles
of anterior neck and
diaphragm)

40. *
dr.tarun52@gmail.com
,9438790500

41. • Superior laryngeal Block
• Recurrent laryngeal Block
• Mainly for awake intubation
• Bronchoscopy
•In adjuvant with
Glossopharyngeal
block

42. *
Approach
Midway
Mastoid
process and
angle of
mandible.
Advanced till styloid process
is contacted
Withdraw and direct 1
cm posteriorly
Aspirate and inject 3- 5cc

43. *
• Submucosally in
caudal portion of
posterior tonsillar
pillar
• Or to a depth of 5mm from
caudal portion of anterior
pillar