Superior Laryngeal and Glossopharyngeal Nerve Blocks for Patient with Cardiopulmonary Comorbidities Including PaCO2 92
Eric Kim, D.O.*; Justin Christensen, D.O.*; Justo Gonzalez, M.D.⁺
*Department of Anesthesia, Cleveland Clinic South Pointe Hospital
⁺Regional Practice Anesthesiology, Cleveland Clinic
Superior laryngeal and glossopharyngeal nerve blocks blunt sensory innervation to the oropharynx and may be useful for endoscopic procedures.
We present a case of said blocks successfully administered for a patient with significant cardiopulmonary comorbidities undergoing percutaneous endoscopic gastrostomy (PEG) placement.
•A 77-year-old, ASA physical status IV, male with severe cardiopulmonary morbidities was admitted to our facility for planned PEG placement. Past medical history included: parotid cancer, lung metastasis, radiation pneumonitis, severe chronic obstructive pulmonary disease with an admission partial pressure of carbon dioxide in arterial blood of 92, recurrent aspiration pneumonia, history of coronary artery disease status post double coronary artery bypass graft, and moderate pulmonary hypertension
•For block placement, 1 milligram of midazolam and 0.1 milligrams of glycopyrrolate were administered for anxiety and increased oral secretions respectively.
•A glossopharyngeal block with 2 cubic centimeters (cc) of alkanized Chloroprocaine 3% was administered bilaterally via a 22-guage Quincke spinal needle. A superior laryngeal block with 2 cc of alkanized Chloroprocaine 3% was administered bilaterally via a 25-gauge needle. The patient felt anxiety due to oral numbness sensation and was only initially given 30 mg of propofol twice at initiation and fell asleep.
•The PEG was placed uneventfully without the use of opioids or long acting agents. The patient maintained spontaneous respirations on oxygen simple mask throughout maintaining 100% oxygen saturation.
•Multiple conservative anesthetic techniques were deferred given the patient’s delicate pulmonary status and advanced age. General anesthesia was deferred given risk of: residual sedation, barotrauma, and volutrauma. 100% oxygen therapy was deferred to avoid: oxygen atelectasis, and diminished hypoxic drive. Opioids were avoided, as respiratory depression would exacerbate pulmonary hypertension.
•Our patient had copious oral secretions attributed to prior parotid radiation therapy. There was concern the secretions would impair application of topical agents. The decision was made to proceed to airway blocks.
•Glossopharyngeal, superior laryngeal, and translaryngeal blocks are useful to anesthetize the upper airway1 and reduce intravenous sedation requirements2. Like most regional anesthetic techniques, risks include: bleeding, direct nerve injury, and unintentional intravenous injection. In addition, these blocks can blunt protective airway reflexes. To minimize the latter, alkanized Chloroprocaine was used for its decreased burning sensation, short 45-minute duration and low toxicity profile.
•The glossopharyngeal nerve innervates sensation to the posterior third of the tongue to the aryepilgottic fold4. A successful block blunts the gag reflex. The glossopharyngeal nerve was blocked by placing a submucosal wheal at intersection of tongue and anterior tonsilar pillar.
•The superior laryngeal nerve's internal branch innervates sensation to the tongue base, posterior epiglottis, and arytenoids3. This block was placed externally through the thyrohyoid membrane adjacent to the greater cornu of the hyoid.
•For our patient, the translaryngeal block was deferred to preserve the cough reflex.
•In summary, glossopharyngeal and superior laryngeal nerve blocks can be considered for patients undergoing oropharyngeal instrumentation.
1 Pani N, Rath SK. Regional and Topical Anesthesia of Upper Airways. Indian J Anaesth. 2009; 53(6):641-8.
2 Ramirez MO, Segovia BL, Cuevas MA et al. Glossopharyngeal Nerve Block versus Lidocaine Spray to Improve Tolerance in Upper Gastrointestinal Endoscopy. Gastroenterol Res Pract. 2013: 264509.
3 Pintaric TS. Upper Airway Blocks for Awake Difficult Airway Management. Acta Clin Croat. 2016; 55:85-9.
4 Yoshida Y et al. Sensory innervation of the pharynx and larynx. Am J Medicine. 2000; 108 (4):51-61.
5 Regional and Topical Anesthesia for Endotracheal Intubation (2017, May 5). Retrieved Mar 4, 2018, from https://www.nysora.com/regional-topical-anesthesia-for-endotracheal-intubation