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Anesth Analg 2005;101:589-591 © 2005 International Anesthesia Research Society doi: 10.1213/01.ANE.0000155287.54904.EB
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Abstract |
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A blink reflex is a bilateral eyelid closure in response to nociceptive stimuli. We hypothesized that elicitation of a blink by a stimulating needle may enhance performing regional anesthesia of the face. Thirty outpatients undergoing cutaneous surgery of the face were studied. A 2.5-cm insulated beveled stimulating needle was inserted at the emergence of the infraorbital nerve. On elicitation of a bilateral blink with 0.5 mA of stimulating current, bupivacaine 0.5% 3–7 mL was injected. Operative conditions were excellent. Blink response can be used to localize superficial branches of the trigeminal nerve. Elicitation of a blink response during nerve stimulation results in successful trigeminal block.
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Introduction |
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Although stimulation techniques in locating peripheral nerves have considerably improved regional anesthesia, it is uncommon to stimulate and localize branches of the trigeminal nerve for regional anesthesia of the face. The search for a motor response may appear paradoxical because the trigeminal nerve is mainly a sensory nerve. We describe a technique to block the superficial branches of the trigeminal nerve consisting of eliciting a blink response to the nerve stimulation.
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Methods |
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With the local Investigation Committee approval and informed consent, 30 consecutive ambulatory patients undergoing resection of small cutaneous tumors of the nose, cheek, and lower eyelid were studied. Patients suffering from systemic disease with definite functional limitations (ASA physical status IV–V) and those with impaired hemostasis or medical history of peripheral facial palsy were excluded.
No premedication was given. After placement of standard monitoring and insertion of a peripheral IV cannula, unilateral or bilateral infraorbital nerve block was performed, depending on the surgical procedure. The infraorbital nerve is a terminal branch of the maxillary nerve supplying the skin of the nose and the septum mobile nasi, the upper lip and its mucosa, and the lower eyelid and its conjunctiva. The infraorbital nerve was approached at the infraorbitalis foramen, located 5–8 mm below the orbital rim on an imaginary straight line passing through the supraorbital notch, the pupil of the eye looking straight, and the second bicuspid tooth. Intradermal local anesthesia with 0.2–0.3 mL lidocaine 1% (tuberculin syringe) was performed. A 2.5-cm insulated beveled Stimuplex needle connected to a Stimuplex-HNS 11 (B.Braün, Melsungen, Germany) was inserted perpendicularly to the skin. The nerve stimulator was initially set to deliver an intensity of 1.0 mA with a stimulation rate of 2 Hz and duration of 0.1 ms. Stimulation was then reduced to 0.5 mA to confirm accurate positioning of the needle. As the needle was advanced, the electrical stimulation elicited a slight paresthesia in the lower eyelid and a visible wink on both sides, with a greater response on the stimulated side. Three to 7 mL of 0.5% bupivacaine with 1:800,000 adrenaline was injected. Depending on the surgery, a skin infiltration with 1 mL of lidocaine 0.1% was performed at the inner canthus to blunt the skin sensory of the ala and apex of the nose.
The number of corrective maneuvers in the placement of the needle before obtaining acceptable motor responses and the time to localize the nerve were measured. Every 5 min after the injection, sensory block to touch was measured. The patient estimated tolerance of the surgical procedure as excellent, good, fair, or poor. Requirement of sedation (midazolam 0.03 mg/kg) at patient’s request was noted.
At the end of surgery, patients were transferred directly to the step-down unit bypassing the recovery room. All were discharged within a minimum of a 2-h observation after surgery according to our hospital policy.
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Results |
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Demographics and block characteristics are given in Table 1. A total of 53 infraorbital blocks were performed. Seven patients received 1 block, 23 others 2 blocks, i.e., bilateral blocks, and 4 patients received an infiltration at the inner canthus. No failures of the initial blocks necessitated a supplemental block, IV analgesics, or general anesthesia. Administration of midazolam was necessary in 3 patients without exceeding a dose of 0.05 mg/kg. Patients were completely awake and oriented and breathing comfortably with stable vital signs. Tolerance was considered good (n = 4) or excellent (n = 26) by the patients. No patient classified the regional technique as painful. Minor side effects were a little swelling of the upper eyelid and cheek. No hematoma was noticed. At the time of hospital dismissal, patients were pain-free.
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Discussion |
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This small series of clinical cases demonstrates the possibility of localizing superficial branches of the trigeminal nerve by eliciting a blink reflex and performing facial surgery under regional anesthesia, avoiding the use of anesthetic and analgesic drugs, including tracheal intubation. No premedication was given. The dose of midazolam required in this study was small. The advantages of local anesthesia were thus preserved (1,2). The time to perform facial blocks with this technique and the average time to full sensory loss were appropriate for the outpatient setting and were not associated with a surgical delay.
Facial surgery may be performed by local anesthetic infiltration. However, facial nerve blocks have theoretical advantages over infiltration, including less tissue swelling and bleeding at the operative site and reduced doses of local anesthetics. However, comparisons between the two techniques are rarely reported. In a cross-over study, Watson and Leslie (3) reported that nerve blocks in the face were more efficient than subcutaneous infiltration, probably because the time between subcutaneous infiltration and skin incision was too short and detrimental to its success. The use of nerve blocks might also have advantages in terms of analgesia during and after surgery (4).
The blink reflex is an eyelid closure in response to an exteroceptive-nociceptive stimulus. This reflex is mediated via the trigeminal sensory afferent fibers and their central connections in the trigeminal and facial brainstem nuclei at the level of the lower pons and medulla oblongata (5). In the laboratory, it can be elicited by electrical stimulation of the supraorbital or infraorbital nerves and inconsistently by electrical stimulation of the mental nerve. The response is recorded on both sides from the orbicularis oculi muscle on both sides and consists of an ipsilateral early component (R1i) followed by ipsilateral and contralateral late components (R2i and R2c). In clinical neurophysiology, the blink reflex is an essential tool for assessment of trigeminal neuralgia, brainstem lesions, and facial nerve palsy (5–7). No electrophysiological evaluation of the trigemino-facial system in regional anesthesia has been made previously.
In conclusion, elicitation of a blink response by nerve stimulation may be successfully used to block the trigeminal nerve for regional anesthesia of the face.
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Footnotes |
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Presented, in part, at the Annual Meeting of the American Society of Anesthesiologists, San Francisco, California, October 11–15, 2003.
Accepted for publication December 14, 2004.
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References |
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- Pavlin DJ, Rapp SE, Polissar NL, et al. Factors affecting discharge time in adult outpatients. Anesth Analg 1998;87:816–26.
[Abstract/Free Full Text] - Gebhard RE, Al-Samsam T, Greger J, et al. Distal nerve blocks at the wrist for outpatient carpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge time. Anesth Analg 2002;95:351–5.
[Abstract/Free Full Text] - Watson R, Leslie K. Nerve blocks versus subcutaneous infiltration for stereotactic frame placement. Anesth Analg 2001;92:424–7.
[Abstract/Free Full Text] - Blakeley KR, Klein KW, White PF, et al. A total intravenous anesthetic technique for outpatient facial laser resurfacing. Anesth Analg 1998;87:827–9.
[Free Full Text] - Kimura J. Clinical uses of the electrically elicited blink reflex. Adv Neurol 1983;39:773–86.[Medline]
- Esteban A. A neurophysiological approach to brainstem reflexes: blink reflex. Neurophysiol Clin 1999;29:7–38.[Web of Science][Medline]
- Jaäskelainen SK, Forssell H, Tenovuo O. Electrophysiological testing of the trigeminofacial system: aid in the diagnosis of atypical facial pain. Pain 1999;80:191–200.[Web of Science][Medline]
This article has been cited by other articles:
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  X. de Lacroix de Lavalette Blink Reflex for Trigeminal Nerve Block or Blind Local Anesthetic Infiltration Anesth. Analg., October 1, 2006; 103(4): 1052 - 1052. [Full Text] [PDF]
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J.-M. Bernard and Y. Pereon Blink Reflex for Trigeminal Nerve Block or Blind Local Anesthetic Infiltration Anesth. Analg., October 1, 2006; 103(4): 1052 - 1053. [Full Text] [PDF]
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