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Review
. 2024 Jul-Aug;35(5):1356-1363.
doi: 10.1097/SCS.0000000000010343. Epub 2024 Jun 11.

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration

Jess J Peters  1   2 , Karl Jacobs  3   4 , Montserrat Munill  5 , Anke P C Top  6 , Markus F Stevens  6 , Elsa M Ronde  1   2 , J Peter W Don Griot  1 , Nadia Lachkar  1 , Corstiaan C Breugem  1   2
Affiliations
Review

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration

Jess J Peters et al. J Craniofac Surg. 2024 Jul-Aug.

Abstract

Introduction: Although the maxillary nerve block (MNB) provides adequate pain relief in cleft palate surgery, it is not routinely used globally, and reported techniques are heterogeneous. This study aims to describe relevant anatomy and to present the preferred technique of MNB administration based on the current literature and the expert opinion of the authors.

Method and materials: First, a survey was sent to 432 registrants of the International Cleft Palate Master Course Amsterdam 2023. Second, MEDLINE (PubMed interface) was searched for relevant literature on maxillary artery (MA) anatomy and MNB administration in pediatric patients.

Results: Survey response rate was 18% (n=78). Thirty-five respondents (44.9%) used MNB for cleft palate surgery before the course. A suprazygomatic approach with needle reorientation towards the ipsilateral commissure before incision was most frequently reported, mostly without the use of ultrasound. Ten and 20 articles were included on, respectively, MA anatomy and MNB administration. A 47.5% to 69.4% of the MA's run superficial to the lateral pterygoid muscle and 32% to 52.5% medially. The most frequently described technique for MNB administration is the suprazygomatic approach. Reorientation of the needle towards the anterior aspect of the contralateral tragus appears optimal. Needle reorientation angles do not have to be adjusted for age, unlike needle depth. The preferred anesthetics are either ropivacaine or (levo)bupivacaine, with dexmedetomidine as an adjuvant.

Conclusion: Described MNB techniques are heterogeneous throughout the literature and among survey respondents and not routinely used. Further research is required comparing different techniques regarding efficacy and safety.

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Conflict of interest statement

The authors report no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
(A) Reported MNB use before the course and used techniques of administration. (B) Landmark to which the needle is directed when using a suprazygomatic approach for MNB administration before the course. (C) Type of local anesthetics used by respondents that used MNB before the course. (D) Type of adjuvants used by respondents that used MNB before the course. MNB indicates maxillary nerve block.
FIGURE 2
FIGURE 2
The palatine nerves arise from the pterygopalatine ganglion of the maxillary nerve within the pterygopalatine fossa (PPF). The maxillary nerve is the second branch of the trigeminal nerve.
FIGURE 3
FIGURE 3
Deep (left) and superficial (right) course of maxillary artery (MA) in relation to the lower head of the lateral pterygoid muscle (LPM). ECA indicates external carotid artery; MA, maxillary artery; STA, superior temporal artery (based on an illustration by Uysal et al).
FIGURE 4
FIGURE 4
Placement of the needle perpendicular to the skin at the frontozygomatic angle formed by the lateral orbital rim and the zygomatic arch when performing a SZMNB (based on figure by Chiono et al.) SZMNB indicates suprazygomatic maxillary nerve block.
See this image and copyright information in PMC

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References

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