Clinical anatomy of the maxillary nerve block in pediatric patients

Abstract

Anatomical landmarks in children are mostly extrapolated from studies in adults. Despite this, complex regional anesthetic procedures are frequently performed on pediatric patients. Sophisticated imaging techniques are available but the exact position, course and/or relationships of the structures are best understood with appropriate anatomical dissections. Maxillary nerve blocks are being used for peri-operative analgesia after cleft palate repair in infants. However, the best approach for blocking the maxillary nerve in pediatric patients has yet to be established.In an attempt to define an optimal approach for maxillary nerve block in this age group three approaches were simulated and compared on 10 dried pediatric skulls as well as 30 dissected pediatric cadavers. The needle course, including depth and angles, to block the maxillary nerve, as it exits the skull at the foramen rotundum within the pterygopalatine fossa, was measured and compared. Two groups were studied: Group 1 consisted of skulls and cadavers of neonates (0-28 days after birth) and Group 2 consisted of skulls and cadavers from 28 days to one year after birth.No statistically significant difference (p > 0.05) was found between the left and right side of each skull or cadaver. Only technique B, the suprazygomatic approach from the frontozygomatic 2 angle towards the pterygopalatine fossa, exhibited no statistical significance (p > 0.05) when other measurements made on the skulls and cadavers were compared. Technique A, a suprazygomatic approach from the midpoint on the lateral border of the orbit, as well as technique C, an infrazygomatic approach with an entry at a point on a vertical line extending along the lateral orbit wall, showed statistical significant differences when measurements of the skulls and cadavers were compared.On the basis of these findings technique B produces the most consistent data for age groups 1 and 2 and supports the clinical findings recently reported.

Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

“…It is simple, reliable and an almost risk-free approach for children with effective and prolonged analgesia [8]. Anesthesiologists can reach the maxillary nerve after its emergence from the foramen rotundum, within the pterygopalatine fossa before it branches to innervate the palate [9].…”

Ultrasound-guided maxillary nerve block: an anatomical study using the suprazygomatic approach

“…[15][16][17][18] Among all types of approach, the suprazygomatic approach has been reported to have a more favourable safety profile. 2,4,19,21 While some of the complications are related to the particular anatomical approach used, others are related to the volume of anesthetic injected into the pterygopalatine fossa (PPF). The average volume of the PPF in adults has been reported from studies in dry skulls as close to one mL.…”

“…The location of the pterygopalatine ganglion, and the maxillary nerve and its branches are projected onto the surface bony anatomy in yellow. The pixelated box is located at the level of the orbital cavity Prigge et al, 21 the plane perpendicular to the median plane was considered to be 0°(utilizing the anterior and superior view). If the needle was angled superiorly (in the anterior view) or anteriorly (in the superior view) towards the PPF, it was considered an increase (?)…”

Pediatric regional anesthesia: A review of the relevance of surface anatomy and landmarks used for peripheral nerve blockades in infants and children

“…A cadaveric study (Prigge et al, ) investigated for the first time in the pediatric population the most effective technique for the maxillary nerve blockade used for congenital cleft palate repair. From findings derived from measuring pediatric skulls and cadavers (0–1 year old), the study concluded a commonly described suprazygomatic approach to be most effective due to its easily palpable landmarks.…”