Introduction

Pterygopalatine fossa block (PPFB) is used across a wide range of procedures involving V2-innervated structures, management of primary vascular headaches and post–dural puncture headaches and less frequently, for ophthalmic procedures and as part of scalp blocks for craniotomy. Multiple landmark-based and ultrasound-guided (USG) approaches to PPFB have been described. However, the optimal technique remains undetermined. During a series of USG PPFBs, we identified recurring technical patterns and came up with a simplified, reproducible landmark-based method.

Materials and Methods

Informed consent was obtained from the patient’s mother for submission of case report as patient is a minor. Patient identifying information was not included, therefore no IRB review was required.

Results/Case Report

A 9 year-old male with history of recurrent streptococcal tonsillitis presented to outpatient surgical center for scheduled adenotonsillectomy. The patient was seen in the preoperative area and a nerve block was offered for perioperative analgesia. After induction of general anesthesia, PPFBs were performed bilaterally with the patient in supine position. The head was rotated laterally, away from the injection side, so that the sagittal plane was angled approximately 25° relative to the operating table. The cephalad portion of the table was then elevated by an additional 25° relative to the floor. After palpating the frontozygomatic angle, the needle was introduced approximately 5mm posterior and 5mm cephalad to the bony counters. Needle was advanced 4-5 cm vertically toward the floor — the “plumb-bob” trajectory. 4 ml of 0.5% Ropivacaine was injected and an ultrasound was used to confirm injectate spread at the sphenopalatine fossa. Patient underwent surgery with no acute issues. On evaluation postoperatively, patient was comfortable with no reported pain. The patient was discharged home once all requirements were met with nerve block still in effect. On follow-up telephone call, patient’s mother reported that the block lasted for three days postoperatively, and the patient did not require any oral analgesics.

Discussion

In comparison to previously described approaches for PPFB, the method that we are suggesting offers several advantages. The “double 25°” head positioning is intuitive and easy to remember. The plumb-bob trajectory simplifies needle control and minimizes reliance on variable external facial landmarks. Importantly, this trajectory also reduces the risk of unintended orbital penetration — a complication reported with several suprazygomatic anatomical techniques that require anterior (philtrum) needle advancement.

References

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