Airway Blocks

Dr Arvind Kumar, Dr Bijaya K. Shadangi, Dr Shashidhar TB

consultants ,Medanta-The Medicity. Gurgaon,New Delhi.
drbijayakumars@gmail.com
RELEVANT ANATOMY OF UPPER AIRWAY:
External Anatomic Features
Important external landmarks are the mental protuberance of the mandible, thyroid cartilage, hyoid bone,
and cricoid cartilage.
Anatomical features of direct relevance to flexible fiberoptic laryngoscopy include mouth opening, extent
of jaw subluxation, ability to flex and extend the neck, neck circumference, tongue size and protrusion,
ability to visualize the uvula or soft palate with mouth opened and tongue protruded in the sitting posting
without phonation (Mallampati score), mandibular size, mentohyoid distance, thyromental distance, and
protuberant dentition.

Internal Anatomy
Mouth
Examination of mouth should include the following:
Size of the mouth opening, size and distribution of teeth, and size of the tongue play important
roles.
Clear assessment and documentation of dentition with special care given to patients with fragile
dentition, including caps; implants; crowns;
and loose, missing, or decaying teeth
Identification and removal of any personal
ornamentation, such as tongue piercings,
should occur before undertaking airway
manipulation, to avoid aspiration of the
ornament or trauma and edema in the
oropharynx.

Nasal Cavity and Nasopharynx

On the sides of the nasal cavity are three
horizontal protuberances called turbinates or
conchae.
The nasal cavity is divided in half vertically by the
nasal septum.
The nasopharynx lies behind the nose, above the
soft palate, and is bounded posteriorly by the
pharyngeal tonsils.

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Airway Blocks
Oropharynx:
Includes the structures of the upper airway from the soft palate to the level of the hyoid bone
The laryngopharynx includes the epiglottis and larynx, which in turn consists of the vocal folds and vocal
cords; the thyroid, cricoid, and arytenoid cartilages; and the intrinsic muscle of the larynx.
The larynx begins where the upper airway divides to form the laryngeal inlet and the upper esophagus.

The epiglottis is a cartilaginous flap attached to the posterior tongue, which forms a protective flap
between the trachea and the upper esophagus.

Innervations of the Airway

Innervations to the airway may be divided into nasal and oral, pharyngeal, laryngeal, and tracheal
compartments.
Nasal Cavity: Branches of the trigeminal nerve
(cranial nerve V) supply sensation to all parts of
the nasal cavity.
Tongue: In the oral cavity, somatosensory inputs
to the anterior two thirds of the tongue are
supplied by the lingual nerve (cranial nerve V3).
Somatosensory input to the posterior third of
the tongue arises from the glossopharyngeal
nerve (cranial nerve IX).
The glossopharyngeal nerve also supplies
sensation to the pharynx, including the fauces
and tonsils, epiglottis, and the soft palate.
Sensory inputs to the glottis and supraglottis
arise from the superior laryngeal nerve.
Motor supply to the pharynx and larynx is
primarily via the vagus nerve (cranial nerve X).
Motor innervation to all other muscles of the
larynx as well as sensory innervation of the
subglottis originates from the recurrent
laryngeal nerve.
Subglottic region is supplied by branches of
vagus nerve.

AIRWAY BLOCKS:
Topical anaesthesia of nose, mouth and larynx:
The simplest and easiest way to achieve anesthesia for oral or nasal fiberoptic intubation is by spreading
LA over mucosa. It acts by local uptake and neural blockade of the region. This can be achieved by
many commercially available spray e.g. 10% lignocaine, viscous lidocaine solution and mixture of
benzocaine and tetracaine.

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Airway Blocks
Alternatively, a 10-mL syringe can be filled with lidocaine 24% and sprayed via a small-bore single or
multi-perforated catheter or the working channel of the fiberoptic bronchoscope. This arrangement
produces a fine stream of local anesthetic liquid, which with sufficient aliquots directed at the target
mucosa achieves an adequate topical anesthetic effect. The safety and efficacy of both techniques are
well established.
Topicalization can also be accomplished by the use of local anesthetic-soaked cotton pledgets or
swabs. These are soaked in either viscous or aqueous solutions of local anesthetic and then left for 515
minutes on the region of mucosa that requires anesthesia. The cotton acts as a reservoir for the
anesthetic agent, producing a dense block.
This technique is especially effective in the nasal passages. Prior to using LA or along with LA small
concentration of epinephrine (1:200,000 or less) or phenylephrine (0.05%) can be used. It helps in drying
the mucosa, which then can be more easily anesthetized with local anesthetic because the local
anesthetic does not get diluted with nasal secretions or saliva.

Inhalation of Aerosolized (Atomized) Local Anesthetic

Inhalation of aerosolized local anesthetic is another simple
technique to achieve oropharyngeal anesthesia. To perform
this technique, local anesthetic is added to a standard nebulizer
with a mouthpiece or face mask attached. The patient is then
asked to inhale the local anesthetic vapor deeply.
After a period of approximately 1530 minutes, the patient
should have inhaled a sufficient quantity of local anesthetic to
achieve a reasonably good level of topical anesthesia
throughout the oropharynx and trachea.
Focused aerosolized local anesthetic from an atomizer is ideal for nasal intubation. A number of
disposable commercially available syringe-powered atomizers are available but are deficient in achieving
small particle size unless outfitted with a side-stream air/oxygen flow to enhance dispersion by virtue of
the Venturi principle.

Nerve blocks:
Glossopharyngeal nerve block:
Glossopharyngeal nerve innervates oropharynx, soft palate, posterior
portion of tongue & pharyngeal surface of epiglottis.
Its block helps in avoiding gag reflex which is stimulated by direct
laryngoscopy and also facilitates nasotrachial intubation by anesthetizing
posterior pharyngeal wall.
Course:of nerve:It travels anterior long lateral surface of pharynx. It

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Airway Blocks
branches into three, providing sensory supply to the posterior third
of the tongue, the vallecula, the anterior surface of the epiglottis
(lingual branch), the walls of the pharynx (pharyngeal branch), and
the tonsils (tonsillar branch).

Block: it can be blocked by two approaches.

Intraoral approach: the mouth is opened and after

anesthetizing the tongue with topical anesthesia, a caudal
aspect of posterior tonsillar piller (palatopharyngeal fold) is
blocked by 22-g needle with 5 ml of LA. (adjacent picture)

Peristyloid approach: The patient is placed supine and a line between the angle mandible and the
mastoid process, is drawn. Using deep pressure, the styloid process is palpated just posterior to
the angle of the jaw along this line, and a short, small-gauge needle is seated against the
styloid process. The needle is then withdrawn slightly and directed posteriorly off the styloid
process. 5-7 ml of LA injected after careful aspiration for blood since it is deposited in the vicinity
of carotid artery.

Superior laryngeal nerve block:

It is a branch of vagus nerve and its internal branch supplies
sensory innervation to the base of the tongue, posterior
surface of the epiglottis, aryepiglottic fold, and the arytenoids
Course: The internal branch originates from superior laryngeal
nerve of vagus nerve lateral to the greater cornu of hyoid
bone. In majority of the patients it passes 2-4 mm inferior to
greater cornu of hyoid bone and pierces the thyrohyoid
membrane then it travels under the mucosa in the pyriform
sinus.

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Airway Blocks
Recurrent laryngeal nerve block:
Sensory innervation of vocal cord & trachea is supplied by recurrent
laryngeal nerve block. Coughing in the patient can be avoided by
blocking of this nerve. It can be blocked either by LA nebulization or
by trans- tracheal block.

Translaryngeal (or trans-tracheal) block is achieved by locating the

cricothyroid membrane between the thyroid & cricoids cartilage. The
cricothyroid membrane is identified as the spongy fibromuscular
band between the thyroid and cricoid cartilages.
A 22 or 20 gauge needle attached to a 10 ml syringe passed
perpendicular to the axis of the trachea and pierces the membrane.
2ml of 2- 4% lidocaine is injected into the trachea/larynx at the end of
normal expiration.
While injecting LA patient coughs which helps in spreading the LA
widespread. Care must be taken at this time since needle may
dislodge or cause trauma.

Greater & lesser palatine nerve blockade:

Sensory blockade nasal turbinates & posterior two third of nasal septum can be achieved by
anesthetizing greater & lesser palatine nerve. This becomes necessary for nasotracheal intubation.
It can either blocked by topical application of LA or by pterygopalatine ganglion block. Noninvasively in
can be done by taking a cotton-tipped applicator soaked in local anesthetic and passing it along the upper
border of the middle turbinate to the posterior wall of the nasopharnx,
where it is left for 510 minutes.
With needle it can be blocked through oral rout. The needle is passed
through the greater palatine foramen into the pterygopalatine fossa.
A percutaneous approach via the mandibular notch is usually performed
under fluoroscopic guidance for pain management. This technique is
rarely needed & has complications like vascular injury.

Anterior ethmoidal nerve block:

This is needed to anesthetized the rest of the passage of nose for
fiberoptic bronchoscopy. It can easily be blocked by inhalational or spray topicalization. LA soaked cotton
can also be used along the dorsal surface of nose until the anterior cribriform plate is reached to get the
effect. It takes 5-10 minutes to anesthetize.

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