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Nerve blocks for the head and neck
1
What are the indications for regional anesthesia in head and neck operations?
The abundant nerve supply and reliably identifiable bony landmarks of the head and neck allow for the effective use of regional anesthesia techniques for head and neck operations. Depending on the patient and the type of surgery, regional anesthesia can be used as the primary anesthetic, or as part of a balanced anesthetic, in conjunction with monitored anesthesia care or general anesthesia. Nerve blocks provide intraoperative and postoperative analgesia, which may reduce perioperative opioid use. As enhanced recovery after surgery (ERAS) protocols have become increasingly used by hospitals for head and neck surgery, regional techniques have been incorporated in an attempt to decrease perioperative opioid consumption and to increase the speed of recovery. In addition to providing analgesia, certain regional techniques may also decrease intraoperative bleeding and thus improve intraoperative visibility for specific procedures, particularly when epinephrine is used in conjunction with local anesthetics. Regional nerve blocks can also be used to augment local anesthesia topicalization for awake intubation, to improve patient comfort and optimize intubating conditions for the clinician. Finally, regional blocks that were performed intraoperatively for analgesic purposes can be used as the sole anesthetic for emergent bedside surgical re-exploration and hemostasis, in the unexpected and catastrophic event of postoperative bleeding.
2
What are some unique considerations for head and neck regional anesthesia compared with other regional anesthesia techniques?
The proximity of the surgical site to the airway necessitates that minimal oxygen supplementation and airway support be used to decrease the risk of airway fire. Thus if the anesthetic plan relies solely on regional anesthesia, close communication with the surgical team regarding the appropriateness of such a plan is required. In addition, patients should be informed and educated about the regional technique so that they have a clear understanding of the anesthetic expectations and the surgical requirements. Because deep sedation is not recommended in this setting, effective analgesia from the nerve block is critical, as is patient cooperation.
3
What are the contraindications to head and neck nerve blocks?
The contraindications for head and neck nerve blocks are essentially the same as for other regional techniques. Absolute contraindications are patient refusal, localized infections or neoplasms at the site of injection, and true allergic reactions to local anesthetics. Relative contraindications include coagulopathy and other bleeding disorders, bloodstream infections, and preexisting neuropathies. Although not unique to head and neck surgeries, neoplasms, and arteriovenous malformations are common indications for head and neck operations that would preclude regional anesthesia. Hence, a thorough understanding of the specific pathology involved in the surgery is essential.
4
What are the risks in performing head and neck regional anesthesia?
In addition to the usual risks of nerve blocks, such as local anesthetic toxicity and nerve damage, there exists the potential to damage surrounding structures. Depending on the block that is performed, these may include injury to the eye or even the brain. Because of the abundance of critical blood vessels that surround the head and neck region, great care must be taken to avoid intravascular injections. Therefore aspiration before injection is mandatory. A comprehensive knowledge of head and neck anatomy and of the pharmacology of local anesthetics is critical to minimize complications.
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