Accepted Manuscript

Suprazygomatic access for continuous bilateral mandibular nerve block for pain and
trismus relief in the tetraplegic patient
Mikhail A. Dziadzko, M.D., Ph.D., practitioner, Fabrice Heritier, M.D., practitioner
PII:

S0278-2391(16)30160-4

DOI:

10.1016/j.joms.2016.05.013

Reference:

YJOMS 57271

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 8 March 2016

Revised Date:

12 May 2016

Accepted Date: 12 May 2016

Please cite this article as: Dziadzko MA, Heritier F, Suprazygomatic access for continuous bilateral
mandibular nerve block for pain and trismus relief in the tetraplegic patient, Journal of Oral and
Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.05.013.
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Title: Suprazygomatic access for continuous bilateral mandibular nerve block for pain and
trismus relief in the tetraplegic patient
Authors:

2,3

Mikhail A. Dziadzko, M.D., Ph.D., practitioner

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1, 2

Fabrice Heritier, M.D., practitioner

Institutional affiliations:

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1. Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA

2. Department of Anesthesiology, Regional Hospital, Roanne, France

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3. Department of Anesthesiology, CH du Forez, Montbrison, France

Institution: This work was performed at Regional Hospital of Roanne, France

Correspondence:

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Running Head: Retrozygomatic mandibular block

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Mikhail A. Dziadzko, MD, PhD

Department of Anesthesiology

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Mayo Clinic, 200 First Street SW, Rochester, MN, 55905

Email: dzonline@gmail.com

Phone: +1 507-255-5654

Running Head: Retrozygomatic mandibular block

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Title: Suprazygomatic access for continuous bilateral mandibular nerve block for pain and
trismus relief in the tetraplegic patient
Authors:
1, 2

2,3

Mikhail A. Dziadzko, M.D., Ph.D., practitioner

Fabrice Heritier, M.D., practitioner

Institutional affiliations:
1. Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA

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2. Department of Anesthesiology, Regional Hospital, Roanne, France

3. Department of Anesthesiology, CHU de Saint Etienne, Saint Etienne, France
Institution: This work was performed at Regional Hospital of Roanne, France

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Running Head: Retrozygomatic mandibular block

Mikhail A. Dziadzko, MD, PhD

Department of Anesthesiology

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Correspondence:

Mayo Clinic, 200 First Street SW, Rochester, MN, 55905

Phone: +1 507-255-5654

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Email: dzonline@gmail.com

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ABSTRACT
Background

Extraoral mandibular nerve block (MNB) is used in oropharyngeal surgery for analgesia and/or
anesthesia. Repeated or continuous MNB has been used successfully as a treatment for
uncontrollable pain, masseter spasticity, and airway assessment. The usual technique is a
transcutaneous infrazygomatic access. However, in some specific settings this approach is not
always feasible.

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Methods
A continuous bilateral MNB with a suprazygomatic approach to the pterygomandibular space
was used to resolve a case of refractory and painful trismus in tetraplegic patient.
Result
Analgesia

was

achieved

and

maintained

by

bilateral

catheter

placement

to

the

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pterygomandibular space and repeated injection of local anesthetic for 48 hours. The right-side

catheter was accidentally withdrawn; the left-side catheter was maintained up to 72 hours. The
efficiency of analgesia was not affected. This block provided effective analgesia within the first

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few hours after local anesthetic injection, helped to improve mouth opening, and resolved acute
pain. As kinesitherapy could then be introduced, the patient was left on non-opioid analgesics.
Conclusion

Continuous bilateral mandibular nerve block via the suprazygomatic approach was used safely
and efficiently. The suggested approach is quite unique as well as the clinical circumstance, and

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may be considered when the usual technique is challenging.

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KEY WORDS: Mandibular nerve; continuous block; trismus; tetraplegic

INTRODUCTION
Extraoral mandibular nerve block (EMNB) is used in oropharyngeal and laryngeal surgery for
analgesia and/or anesthesia. It has been demonstrated to reduce morphine consumption at 12
hours and 24 hours after surgery [1]. EMNB is also frequently used for reducing postoperative
pain after third molar surgery [2]. Case reports suggest a role for EMNB for other indications.

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Repeated or continuous mandibular nerve block has been used successfully as a treatment for
uncontrollable pain [3, 4], for patients with terminal mouth floor and tongue cancer [5], trigeminal
neuralgia [6, 7], fracture of the mandible [8], excision of pleomorphic adenoma [9], and masseter
spasticity due to progressive bulbar palsy [10] as well as in cases requiring the removal of

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dentures during trismus caused by tetanus [11] and for airway assessment [12].

A commonly used technique of extraoral mandibular block is transcutaneous infrazygomatic

access through the mandibular notch using anatomical and/or ultrasound landmarks or

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electrostimulation guidance. We describe continuous bilateral mandibular block with a

suprazygomatic approach to the pterygomandibular space to resolve a case of refractory
trismus. Verbal informed consent from patient was obtained prior to writing of the case study. A
local Institutional Review Board for ethics waived the need for written informed consent for this
type of study as it concerned routine care.

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CASE REPORT

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A 54-year-old male with history of treated arterial hypertension and type 2 diabetes developed
an infectious spondylodiscitis and a cervical myelitis. Despite emergency decompressive
laminectomy, this led to C5/C6 tetraplegia. There was no neurological recovery. The patient
underwent tracheostomy and gastrostomy. A transesophageal echocardiography (TEE) was
performed to exclude the possibility infectious endocarditis. No evidence for endocarditis was
found. However, introduction of the TEE probe was difficult. This resulted in both
temporomandibular joint (TMJ) pain and painful masseter contraction. These complications

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progressively led to trismus, which caused severe patient distress. All nontraumatic-related
causes of trismus were eliminated, including local or general infection, tumor or articular lesions.
There were no new neurologic abnormalities, metabolic disorder, or fever present. A CT scan of

the TMJ was normal. There was no clinical evidence for tetanus and anti-tetanus vaccine status

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was current.

Intravenous morphine was administered after attempts to control pain with acetaminophen,
NSAIDs, and nefopam failed. However, increasing morphine dosage in the setting of cervical

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spine injury and neurological diaphragmatic dysfunction resulted in impaired alveolar ventilation,
causing significant respiratory failure and increasing sedation without adequate pain control. As
pain continued to increase, 2 mL of 0.2% ropivacaine and 15 g of clonidine was administered
via single-shot injection into the most painful area, the left TMJ. This resulted in a transient
decrease in pain. However, as the effect of the block dissipated, pain continued to increase over
time with a Visual Analog Scale for Pain score (VAS) of 9 (10 maximum pain) at 12 hours after

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block (Table 1). Mouth opening remained impossible.

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As the first block was partially and temporarily efficacious, a bilateral continuous mandibular
nerve block was recommended. Informed consent was obtained. The patient was given detailed
information about possible complications and side effects, such as facial nerve palsy. Accurate
identification of the mandibular notch as an insertion site was impossible: patient was unable to
open and close his mouth, and painful masseter contraction did not allow palpation. Therefore

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anatomic landmarks were undetectable. Thus, we chose a suprazygomatic approach.

After local skin anesthesia, an 18-gauge insulated and stimulating Tuohy-like cannula (PAJUNK

PlexoLong needle), was inserted into the retrozygomatic space, above the midpoint of the
zygomatic arch, and directed to the mandibular angle with medioposterior inclination (Figure 1).

Classic neurostimulation was used as nerve location method. At a distance of 4.5 to 5.0 cm, a

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partial response was obtained from the mastication muscles (0.8 mA). Then, a 20-gauge
catheter was introduced, advanced 1.0 cm, and the needle removed. After a negative aspiration
test, an initial injection of 2 mL of lidocaine 1% with adrenaline was performed. No changes in

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arterial blood pressure or heart rate were detected. After a 5 minute observation period, an
initial bolus of 5 mL of ropivacaine 5 mg/mL and 37.5 g clonidine was injected on each side,
followed by 5 mL of ropivacaine 2 mg/mL every 8 hours. Pain was assessed every 2 hours for
the first 12 hours, then every 4 hours until catheter removal. Facial and joint pain decreased
dramatically after the block (Figure 2). Immediately after the block, morphine was stopped

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completely.

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Trismus resolved the same day and active oral kinesitherapy was initiated 24 hours after the
block. The right-side catheter was accidentally withdrawn during skin care at 48 hours.
However, the left-side catheter was withdrawn at 72 hours without any bilateral local
complications or signs. Unilateral analgesia did not affect the pain score and the patient did not
receive any additional enteral or systemic analgesia. The patient was discharged to a step-down
respiratory unit and further did not experience any orofacial pain or trismus during his

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hospitalization course.

DISCUSSION

Trismus is a well-known as a symptom of tetanus. However, it can also result from a variety of

conditions seen in dental practice [13] and head and neck oncology [14]. It can also occur in the

setting of infection after surgery and trauma, as well as inflammatory disorders of the

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temporomandibular joint [15, 16] and even after a single-shot inferior alveolar nerve block [17].

The muscles of mastication are innervated by the mandibular branch of the trigeminal nerve. In
a case of severely resistant trismus, mandibular nerve block can be used for diagnostic and/or

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therapeutic purposes [18]. Although the single-shot technique is reported in the majority of case
reports [11, 12, 19, 20], there is limited drawback to continuous mandibular nerve block [5-9].
An approach to the nerve as it is emerging from the foramen ovale for anesthesia has been
describe using different extraoral techniques [21]. These approaches are still used in chronic
pain management and as a component of postoperative analgesia after complex maxillofacial
surgery [22]. The suprazygomatic approach was described in the beginning of twenty century

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for use in major orofacial surgery [23, 24]. However, this approach was abandoned with

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increased safety of general anesthesia, and is not known widely by anesthesiologists in the
modern era.
Classically, EMNB is performed by lateral infrazygomatic approach, with puncture at the
midpoint of the mandibular notch. However, this approach carries a risk of vascular lesion or
foramen ovale insertion. This can result in total spinal anesthesia and even pharyngeal
penetration [19, 25].
The main trunk of the mandibular nerve provides innervation to the medial pterygoid, whereas

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the other muscles involved in trismus are innervated by the anterior division of the
mandibular/third branch of the trigeminal nerve after its division. The mandibular division of the
trigeminal nerve is situated in the pterygomandibular space. This potential space between the

medial pterygoid muscle and the medial surface of the ramus of the mandible also contains the
inferior alveolar artery and vein [25, 26].

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Local anesthetics injection into the pterygomandibular space is usually performed by intraoral
approach, small volume of local anesthetic is needed to block inferior alveolar nerve [27, 28].
In this case, the impossibility of accurate palpation of the painful TMJ, longer skin-nerve

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distance, reliable catheter fixation, and the intent to avoid manipulations in pterygoid fossa led to
the use of the suprazygomatic approach.

Orientation and the depth of insertion of the needle, catheter placement and the volume of local
anesthetic used led to anesthetics diffusion into the pterygomandibular space and toward the
pterygopalatine fossa. It impregnated both the mandibular and maxillary divisions of trigeminal

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nerve and caused reversible maxillary nerve block. No signs of local anesthetic toxicity were

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observed. The total dose of ropivacaine received was 80 mg on day 1, 60 mg on day 2, and 30
mg on day 3.
If used bilaterally, the spread of local anesthetic can theoretically cause tongue motor block and
sensory anesthesia by blocking the hypoglossal nerve, which shares a common portion with the
lingual nerve. Block induced tongue atony can also lead to airway obstruction. In this case
report, the presence of permanent cuffed tracheostomy effectively eliminated concern about
aspiration risk due to pharyngeal fluid collection. Anesthesia-induced difficulties of swallowing

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were not pertinent to this case, as the patient had a gastrostomy for enteral nutrition.

Other techniques could have been used to resolve the trismus described in this case report.

One example is botulinum toxin injection [29, 30]. However, this technique was not common
practice at this hospital. As botulinum toxin is a very long acting agent with less predictable

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length of action, electromyography prior to botulinum injection has been suggested [29]. This
technique also requires a few days to reach full effectiveness. For the case presented in this
report, where time was a critical factor, this was not selected as the preferred approach.

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Echography for accurate detection of mandibular notch or suprazygomatic depression is an

example of another technique. However, echography does not provide reliable information
about catheter trajectory for this particular technique. We did not use fluoroscopic guidance as
the risk of significant injury to the pterygopalatine fossa was remote.

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CONCLUSION

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In this case, continuous bilateral mandibular nerve block via the suprazygomatic approach was
used safely. This block provided effective analgesia within the first few hours of nerve block,
helped improve mouth opening, and resolved acute pain. As kinesitherapy could then be
resumed, the patient was left on non-opioid antalgics (acetaminophen). The suggested
approach may be considered when the usual technique is challenging or ineffective.

DISCLOSURES

reported no conflicts of interest, no financial interests or funding.

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TABLE LEGEND

Pain Score time trend before continuous mandibular block. Pain score in left and right
temporomandibular joint (median value and interquartile range) while using systemic pain
therapy, and punctual pain assessment after single side single shot local anesthesia. Mouth
opening dynamics and analgesic interventions noted as well.
Time after a single-shot block on the left side, hours

After
opioids

0.25

2.25

4.25

6.25

8.25

10.25

12.25

VAS, left (IQR)

7.5 (6-9)

6.6 (5-9)

VAS, right (IQR)

7.5 (6-9)

6.3 (5-8)

Mouth opening

0
NSAID,
non-opioids

opioids

0
stop
opioids

opioids

Treatment

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Basal before
opioids

Table 1: Analgesic interventions followed by Visual Analog Scale for Pain score (VAS) time

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Mouth opening dynamics noted as well.

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trend after continuous mandibular block. VAS=0 is no pain and VAS=10 is maximum pain.

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FIGURE LEGEND

Figure 1: Needle insertion and anatomical considerations

Figure 2: Pain Score time trend.

Pain score in a time span (hours) with bilateral indwelling catheters. Mouth opening was

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estimated as: 0-impossible; 1-minor opening; 2-partial opening; 3-full opening.

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