Supraorbital Nerve Block


Article Author:
Andrew Napier


Article Editor:
Alan Taylor


Editors In Chief:
Shane Havens
Jim Wang
Koushik Tripathy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/19/2019 12:57:51 AM

Introduction

The supraorbital nerve block is a procedure performed to provide immediate localized anesthesia for a multitude of injuries such as complex lacerations to the forehead, upper eyelid laceration repair, debridement of abrasions or burns to the forehead, removal of foreign bodies from the forehead, or pain relief from acute herpes zoster. A regional block allows for minimal anesthetic use which permits the operator to obtain the intended anesthesia over a larger surface area versus that of local infiltration. Smaller anesthetic volumes also allow for minimal disbursement of anesthetic into tissues which will prevent the distortion of normal anatomy during the intended procedure.[1] One can perform this procedure with knowledge of appropriate anatomical landmarks and minimal equipment.

Anatomy

The recognition of the appropriate anatomy for this procedure is critical as it is landmark based. The supraorbital nerve is one of the terminal branches of the trigeminal nerve. The trigeminal nerve divides into three branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3).[2] The nerve of interest is a branch of the ophthalmic nerve. This sensory nerve branches into two separate terminal branches known as the supratrochlear nerve and the supraorbital nerve. The supraorbital nerve exits the cranium through an opening above the orbit known as the supraorbital foramen. The nerve then ascends the forehead and terminates at the region of the anterior scalp, thus providing sensory input for tissues up to the region of the lambdoidal suture (connection of the parietal and occipital bones). One must then identify the supraorbital nerve exits at the supraorbital foramen. This area can be visually identified by having the patient look straight ahead and then transect the pupil at the level of the patient’s orbital ridge. Palpation of this region reveals the area of interest for performing this nerve block.[3][4]

Indications

Indications for supraorbital nerve block encompass procedures near the ipsilateral side of injection of the forehead and anterior aspect of the scalp which may include: 

  • Debridement of burns or abrasions
  • Immediate relief of acute pain from herpes zoster
  • Repair of complex lacerations
  • Removal of foreign bodies

Contraindications

Contraindications to the supraorbital nerve block include: 

  • Refusal of patient 
  • Distortion of anatomical landmarks 
  • Overlying infection at the site of injection 
  • Allergy to local anesthetics

Equipment

Required equipment for the supraorbital nerve block include: 

  • Anesthetic agent: the choice of an anesthetic agent depends on the patient’s reported allergies and the intended duration of nerve block. Lidocaine for up to 90-minutes of local anesthesia, bupivacaine for up to 8 hours of local anesthesia, and tetracaine for up to 3 hours of local anesthesia. 
  • Consider local diphenhydramine if the patient is allergic to both amides and esters local anesthetics. 
  • 25ga needle for adults, 30ga needle for pediatrics
  • 5-10-mL syringe 
  • Skin cleansing agent such as chlorhexidine 
  • Access to lipid emulsion solution in case of local anesthetic systemic toxicity 

Preparation

Prior to starting the procedure, one should educate the patient regarding the risks and benefits of the supraorbital nerve block and then obtain informed consent from the patient. One should then bring all necessary equipment to the bedside and prepare the materials for the procedure.

Technique

The supraorbital nerve block procedure utilizes the following steps: 

  • Identify appropriate landmarks as indicated above
  • Using aseptic technique clean site using a skin cleansing agent such as chlorhexidine
  • Place the patient in a supine position
  • From a position lateral to the patient’s head, insert a 25-30-gauge needle in a medial and cephalad direction into the inferior edge of the supraorbital ridge approximately 0.5cm below the supraorbital notch
  • Advance the needle slightly being careful not to penetrate the supraorbital foramen
  • Perform a test aspirate
  • Inject 0.5-1 mL of local anesthetic solution to form a subcutaneous wheal and then continue to inject 1-3mL of local anesthetic
  • Firmly place a small roll of gauze above the orbital rim to prevent ballooning of anesthetic at the superior aspect of the eyelid

Due to the various branching of the ophthalmic nerve, this nerve block may not be successful after the first attempt. Inject additional local anesthetic medial and laterally along the orbital rim in order to adequately reach all nerve branches.[4] 

Complications

Complications of the supraorbital nerve block may include: 

  • Formation of hematoma or eyelid swelling
  • Delayed periorbital ecchymosis
  • Infection 
  • Bleeding 
  • Vascular injection of anesthetic 
  • Nerve injury including neurapraxia or neurolysis 
  • Local anesthetic systemic toxicity (LAST) 
  • Allergic reaction to the local anesthetic 

Clinical Significance

There are numerous ways in which to provide anesthesia to patients that are in pain so that they may obtain relief. Aside from the management of pain, this anesthesia will also allow for the clinician to perform procedures effectively and prevent further discomfort to the patient. A method of providing this anesthesia resides in the form of targeting tissues or a peripheral nerve itself, both of which propagates signals of pain from tissues to the cerebral cortex.

Adequate anesthesia may be accomplished by the injection of an anesthetic directly to the tissues, known as local infiltration, or in a targeted manner such as a nerve block. Local infiltration of an anesthetic agent allows for repair of simple injuries to a given anatomic location, but its use is limited in those who have suffered injuries to a larger surface area. Additionally, local infiltration of a wound may distort the area of repair. In such cases, a nerve block is an option to provide a larger region of anesthesia with a smaller relative amount of anesthetic.[5]

Enhancing Healthcare Team Outcomes

The supraorbital nerve block is a procedure best performed with a team of professionals in the healthcare industry which includes a physician or midlevel provider, nursing staff, and a pharmacist. It is very important that the staff elicits a full history and physical before this procedure including a history of adverse drug reactions. In particular, the patient’s history of local anesthetic use, to identify alternatives if needed for this procedure. Approaching this procedure in a team-based manner will help to limit adverse events. The following list should be assessed and adequate provisions identified before the start of the procedure: 

  • Assessment of any adverse events that the patient may have had to local anesthetics 
  • Calculation of maximum weight-based dosage of chosen local anesthetic 
  • Consultation with a pharmacist about the availability of a lipid emulsifying agent in the event of local anesthetic systemic toxicity 
  • Patient monitoring for signs and symptoms of local anesthetic systemic toxicity such as perception of a metallic taste, altered mental status, respiratory distress, seizures, tachycardia, dysrhythmia, atrioventricular block, or cardiovascular collapse.[6] (Level III)
  • Availability of staff trained in advanced cardiac life support in the event of cardiovascular symptoms or emergency

  • Image 7423 Not availableImage 7423 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Supraorbital Nerve Block - Questions

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Lacerations of which area can be done using a supraorbital nerve block?



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A patient was involved in a motor vehicle accident and hit his face with the windscreen. He suffers a 4-inch laceration midway from the scalp and right eyebrow. In order to maintain facial aesthetics, it is decided to perform the cleaning and suturing after performing a nerve block. Which nerve should be blocked?



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Which of the following is an indication for a supraorbital nerve block?



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How may block of the supraorbital nerve be advantageous over local infiltration?



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A patient was involved in a motor vehicle accident and has suffered an injury to the right side of their forehead involving multiple embedded fragments of glass. To debride the large number of fragments, perform a supraorbital nerve block is planned. The patient has multiple other lacerations requiring local anesthetic, so the maximum amount of lidocaine that this patient can receive is calculated as the patient is at risk for local anesthetic systemic toxicity. If the patient weighs 60 kg and 1% lidocaine with epinephrine is used, how much lidocaine may the patient receive?



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Supraorbital Nerve Block - References

References

De Buck F,Devroe S,Missant C,Van de Velde M, Regional anesthesia outside the operating room: indications and techniques. Current opinion in anaesthesiology. 2012 Aug     [PubMed]
Joo W,Yoshioka F,Funaki T,Mizokami K,Rhoton AL Jr, Microsurgical anatomy of the trigeminal nerve. Clinical anatomy (New York, N.Y.). 2014 Jan     [PubMed]
Tomaszewska A,Kwiatkowska B,Jankauskas R, The localization of the supraorbital notch or foramen is crucial for headache and supraorbital neuralgia avoiding and treatment. Anatomical record (Hoboken, N.J. : 2007). 2012 Sep     [PubMed]
Shin KJ,Shin HJ,Lee SH,Song WC,Koh KS,Gil YC, Emerging Points of the Supraorbital and Supratrochlear Nerves in the Supraorbital Margin With Reference to the Lacrimal Caruncle: Implications for Regional Nerve Block in Upper Eyelid and Dermatologic Surgery. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2016 Aug     [PubMed]
Jiménez-Almonte JH,Wyles CC,Wyles SP,Norambuena-Morales GA,Báez PJ,Murad MH,Sierra RJ, Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis. Clinical orthopaedics and related research. 2016 Feb     [PubMed]
Wadlund DL, Local Anesthetic Systemic Toxicity. AORN journal. 2017 Nov     [PubMed]

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