4. *
*Avoid anesthetizing the ear if the patient
has cellulitic periauricular skin or a severe
allergy to the chosen anesthetic.
5. *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.
*
6. *Position the patient so that
both clinician and patient
are comfortable.
*Laying the patient supine is
usually the optimal position.
*
7. *Allows for intraoperative monitoring of facial nerve
function.
*Optimises the surgical field without excessive arterial
hypotension
*Minimise the chances of excessive anaesthesia
8. Technique
The choice of technique
depends on the area of the
ear that requires anesthesia.
*RING BLOCK is used to
anesthetise entire auricle.
*
9. *Provides anesthesia to the
earlobe and lateral helix
(greater auricular and lesser
occipital nerve branches).
*
11. 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
12. *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.
*
13. *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.
16. I. External Approach-
Resurfacing procedures
Soft-tissue work(including local flaps and scar revision)
II. Internal Approach
Septoplasty
turbinate reduction
Polypectomy
balloon catheter
dilation.
Examination with nasal
speculum
Foreign body removal
Placement of nasal packing
Abscess drainage
Incision of septal hematoma
17. *
*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.
18.
19. 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
20. 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.
21. 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.
22. *
*Block the external nasal nerve with an
intercartilaginous injection of the nasal dorsum
from the region of the rhinion to the supratip
region.
24. Approach: Place the index finger of
the nondominant hand over the above
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
25. *
*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).
29. • Superior laryngeal Block
• Recurrent laryngeal Block
• Mainly for awake intubation
• Bronchoscopy
•In adjuvant with
Glossopharyngeal block
30. *
Approach
Midway of
Mastoid process
and Angle of
mandible.
Advanced till styloid process is
contacted
Withdraw and direct 1 cm
posteriorly
Aspirate and inject 3- 5cc.
31. • Submucosally in
caudal portion of
posterior tonsillar
pillar
• Or to a depth of 5mm from
caudal portion of anterior pillar
*
