Clinical anatomy of the maxillary nerve block in pediatric patients

Abstract

BACKGROUND : Anatomical landmarks in children are mostly extrapolated from studies in adults. Despite this, complex regional anesthetic procedures are frequently performed on pediatric patients. Sophisticated imaging techniques are available but the exact position, course and/or relationships of the structures are best understood with appropriate anatomical dissections. Maxillary nerve blocks are being used for peri-operative analgesia after cleft palate repair in infants. However, the best approach for blocking the maxillary nerve in pediatric patients has yet to be established. OBJECTIVE : To determine the best approach for blocking the maxillary nerve within the pterygopalatine fossa. METHODS : In an attempt to define an optimal approach for maxillary nerve block in this age group three approaches were simulated and compared on 10 dried pediatric skulls as well as 30 dissected pediatric cadavers. The needle course, including depth and angles, to block the maxillary nerve, as it exits the skull at the foramen rotundum within the pterygopalatine fossa, was measured and compared. Two groups were studied: Group 1 consisted of skulls and cadavers of neonates (0–28 days after birth) and Group 2 consisted of skulls and cadavers from 28 days to 1 year after birth. RESULTS : No statistically significant difference (P > 0.05) was found between the left and right side of each skull or cadaver. Only technique B, the suprazygomatic approach from the frontozygomatic angle towards the pterygopalatine fossa, exhibited no statistical significance (P > 0.05) when other measurements made on the skulls and cadavers were compared. Technique A, a suprazygomatic approach from the midpoint on the lateral border of the orbit, as well as technique C, an infrazygomatic approach with an entry at a point on a vertical line extending along the lateral orbit wall, showed statistical significant differences when measurements of the skulls and cadavers were compared. CONCLUSIONS : On the basis of these findings technique B produces the most consistent data for age groups 1 and 2 and supports the clinical findings recently reported.