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How To Do an Infraorbital Nerve Block, Percutaneous

By

Richard Pescatore

, DO, Delaware Division of Public Health

Last full review/revision Oct 2021| Content last modified Oct 2021
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An infraorbital nerve block anesthetizes the ipsilateral lower eyelid, upper cheek, side of the nose, and upper lip.

Indications

  • Laceration or other surgically treated lesion of the midface

A nerve block has advantages over local anesthetic infiltration when accurate approximation of wound edges is important (eg, in facial skin repair), because a nerve block does not distort the tissue as local infiltration does.

Contraindications

Absolute contraindications

  • History of allergy to the anesthetic agent or delivery vehicle (choose a different anesthetic)

  • Absence of anatomic landmarks needed to guide needle insertion (eg, due to trauma)

Relative contraindications

* Therapeutic anticoagulation (eg, for pulmonary embolism) increases the risk of bleeding with nerve blocks, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.

Complications

Most complications result from inaccurate needle placement.

Equipment

  • Nonsterile gloves

  • Barrier precautions as indicated (eg, face mask, safety glasses or face shield, cap and gown)

  • Antiseptic solution (eg, chlorhexidine, povidone-iodine, alcohol)

  • Injectable local anesthetic* such as lidocaine 2% without epinephrine† or, for longer-duration anesthesia, bupivacaine 0.5% without epinephrine

  • Syringe (eg, 3 mL) and needle (eg, 25 or 27 gauge) for anesthetic injection

† To prevent vasoconstriction of the facial artery (which lies very close to the site of anesthetic deposition in this approach), epinephrine is not recommended for percutaneous infraorbital nerve block.

‡ Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg; bupivacaine, 1.5 mg/kg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 g/100 mL).

Additional Considerations

Relevant Anatomy

  • The infraorbital nerve is a termination of the maxillary nerve, which is the 2nd branch of the trigeminal nerve.

  • The infraorbital nerve exits the cranium through the infraorbital foramen, which is palpable 1 cm below the inferior border of the infraorbital ridge, directly below the pupil when the patient is looking straight ahead.

  • Several cutaneous branches of the infraorbital nerve spread over the ipsilateral midface, lower lid, side of the nose, and upper lip.

Thus, an infraorbital block anesthetizes the ipsilateral lower eyelid, upper cheek, side of the nose, and upper lip.

Positioning

  • Position the patient inclined or supine.

Step-by-Step Description of Procedure

  • Check sensation in the infraorbital nerve distribution.

  • Wear gloves and use appropriate barrier precautions.

  • Palpate the infraorbital ridge and identify the infraorbital foramen (the injection site).

  • Cleanse the skin site with antiseptic solution.

  • Place a skin wheal of anesthetic, if one is being used, at the needle-entry site.

  • Insert the needle just below the infraorbital foramen pointing slightly cephalad and advance it until paresthesia is elicited or the needle meets the maxillary bone just superior to the foramen. Do not insert the needle into the infraorbital foramen. If paresthesia occurs during insertion,withdraw the needle 1 to 2 mm.

  • Aspirate to exclude intravascular placement and then slowly (ie, over 30 to 60 seconds) inject about 2 to 3 mL of anesthetic adjacent to, but not into, the infraorbital foramen. Press your finger lightly over the infraorbital rim to prevent lower eyelid swelling.

  • Massage the area for about 10 seconds to hasten the onset of anesthesia.

  • Allow about 5 to 10 minutes for the anesthetic to take effect.

Aftercare

  • Ensure hemostasis at the injection site.

  • Instruct patient regarding anticipated time to anesthesia resolution.

Warnings and Common Errors

  • To minimize the risk of needle breakage, do not bend the needle, insert it to its full depth (ie, to the hub), or attempt to change the direction of the needle while it is inserted.

  • To help prevent nerve injury or intraneural injection, instruct patients to report paresthesias or pain during the nerve-block procedure.

  • To help prevent intravascular injections, aspirate before injecting.

Tricks and Tips

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