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AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Michael Lawrence Hochberg, MD, Clinical Instructor, Emergency Medicine, Albert Einstein College of Medicine; Attending, Emergency Medicine, Montefiore Medical Center
Michael Lawrence Hochberg is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Coauthor(s):
Edward Chew, MD, Staff Physician, Emergency Department, Jacobi Medical Center, Montefiore Medical Center
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
anesthesia to the nose, nose blocks, control of epistaxis, nasal bone fracture reduction, nasal lacerations, incision and drainage of septal hematoma, nasal foreign bodies, infraorbital nerve block, facial blocks, nose anesthesia, nasal anesthesia
Although the neuroanatomy of the nose may appear complicated at first, it is fairly well defined, especially considering that different sensory innervation supplies the inner and outer nose. Each nasal cavity contains a portion of the septum, a roof, and a lateral wall. The roof arises from the cribriform plate; the lateral wall is formed from several bones. However, while the roof is largely mucosa and bony cartilage, the lateral wall contains 3 conchae or turbinates, beneath each of which lies a meatus.
The nasociliary nerve is a branch from the ophthalmic nerve (ie, the first division of the trigeminal nerve). It is the main source of sensory innervation to the anterior inner nose and some aspects of the skin (in particular, the tip of the nose). The nasociliary nerve further divides into its nasal branches (supplies the mucous membranes of the front part of the septum and lateral aspect of the nasal cavity), the external nasal branch (supplies the skin of the ala and the apex of the nose), the infratrochlear nerve (supplies the medial aspect of the eyelids and outer side of the nose), and the ethmoidal branches (anterior branch supplies innervation to both the anterior half of the nasal cavity and the nasal skin from the rhinion to the tip; posterior branch supplies innervation to the superior half of the nasal cavity).
Finally, the sphenopalatine and infraorbital nerve arise from the second division of the trigeminal nerve, the maxillary nerve. The sphenopalatine nerve conveys sensation to the posterior part of the conchae and the palate; the infraorbital nerve supplies the lateral aspects of the external nose. For a more complete discussion of nasal anatomy, see Nose Anatomy.1
Inner nose (see Inner nose) External nose
- Use of internal swabs or pledgets soaked in vasoconstrictors is contraindicated in patients with hypertension or coronary artery disease.
- Uncooperative patients may not be able to undergo anesthesia to the nose.
- Patients must not be administered an anesthetic agent to which they are allergic.
- Local infiltration or infraorbital block is contraindicated in the presence of infected tissue.
Inner nose (For more information, see Topical Anesthesia.)
- Swabs or pledgets soaked in anesthetic and vasoconstrictors
- Lidocaine 1% with epinephrine 1:100,000
- Lidocaine 1% without epinephrine
Infraorbital block - Lidocaine 1% without epinephrine
- Mepivacaine 3%
- Bupivacaine 0.5%
- Viscous lidocaine or tetracaine (These topical agents may be used prior to injection.)
Local infiltration (For more information, see Local Anesthetic Agents, Infiltrative Administration.)
- Lidocaine 1% without epinephrine (for tip suture)
- Lidocaine 1% with epinephrine 1:100,000 or without epinephrine (for repair of sides or superior portion of nose)
Placement of internal swabs or pledgets
- Anesthetic agent of choice
- Cotton swabs
- Cotton gauze and forceps (to make pledgets)
- Proper lighting
Infraorbital block - Anesthetic agent of choice
- Needle, 25-27 gauge (ga), with syringe, 5 mL
- Gauze
- Topical anesthetic (optional)
- Sitting position is ideal for most patients.
- Supine position is acceptable for patients who cannot sit upright.
Anesthesia of the inner nose, tip, ala, and, side of the external nose
- Place the patient in a seated position.
- Make a pledget by first selecting the appropriate size of cotton gauze, which depends on the size of the patient and the extent of nasal cavity anesthesia desired.
- Grasp the cotton gauze in the forceps and rotate it around the forceps until it is rolled into a long cylinder.
Making a pledget.
Making a pledget. - Soak the pledget or cotton swab in the anesthetic agent of choice.
- Squeeze any excess anesthetic from the swab or pledget.
- Place the first pledget horizontally on the floor of the nasal cavity. Stack each subsequent pledget on top of the first (typical maximum of 3 pledgets).
Placement of cotton swabs in the nasal cavity.
Placement of pledgets in the nasal cavity. - Insert swabs either anterior-superiorly (for blockage of the ethmoidal nerves) or posteriorly along the medial meatus (for blockage of the sphenopalatine nerve).
- Anesthesia is typically obtained in 5 minutes. If not, the pledgets or swabs can be replaced with new ones.
Anesthesia of the side of the nose with the infraorbital nerve block - Locate the infraorbital foramen on the infraorbital rim.
- Palpate the infraorbital foramen from the buccal mucosa of the inner upper lip superior to the ipsilateral canine/first premolar of the desired side.
- Retract the upper lip with the nondominant thumb, making sure not to occlude the site of the foramen.
- Insert the needle into the mucolabial fold just anterior to the apex of the first premolar.
- Slowly advance the needle along the axis of the tooth toward the foramen for a depth of approximately 5-10 mm.
- Inject 2-3 mL of anesthetic.
- Do not inject directly into the foramen.
- Pledgets are preferable to cotton swabs if a large area of anesthetic is required.
- Pledgets can be individually made according to the extent of anesthesia desired and the size of the patient.
- When soaking the swab or pledget, remember that the maximum dose of lidocaine 1% without epinephrine is 3-5 mg/kg and the maximum dose of lidocaine with epinephrine is 5-7 mg/kg.
- If the infraorbital foramen cannot be palpated directly from the buccal mucosa, the anesthetic can be injected into the buccal mucosa superior to the first premolar.
- Injecting directly into the infraorbital foramen can cause permanent damage to the neurovascular bundle.
- Lidocaine and cocaine can be readily absorbed into the intravascular compartments because the inner nose is an extremely vascular area. Lidocaine can cause arrhythmia. Epinephrine and cocaine can both induce tachycardia, hypertension, seizures, and hyperpyrexia.
- Complications of a local block or infraorbital nerve block can include the following:
- Bleeding
- Pain at injection site
- Deformity of tissues (specific for a local block)
- Infection
- Needle breakage
- Neurapraxia (secondary to injection into the infraorbital foramen)
| Media file 1:
Placement of cotton swabs in the nasal cavity. |
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| Media file 2:
Placement of pledgets in the nasal cavity. |
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- Chang E. Nose Anatomy. eMedicine from WebMD [serial online]. June 26, 2006;Accessed August 22, 2006. Available at www.emedicine.com/ent/topic6.htm.
- Ophthalmologic, otolaryngologic and dental procedures. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, PA: WB Saunders; 1998:1135-7.
- Taleghani K, Sternbach G. Infraorbital nerve block. In: Rosen P, Chan T, Vilke G, Sternbach G, eds. Atlas of Emergency Procedures. St Louis, Mo: Mosby; 2001:160-1.
Anesthesia, Nose excerpt Article Last Updated: Nov 6, 2007
Topic originally published: Nov 6, 2007
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