An infraorbital nerve block anesthetizes the ipsilateral lower eyelid, upper cheek, side of the nose, and upper lip.
The percutaneous (extraoral) approach is used less often than the intraoral approach (please see How To Do an Infraorbital Nerve Block, Intraoral), which is less painful and may provide a longer duration of anesthesia.
(See also Local anesthesia for laceration treatment.)
Indications for Infraorbital Nerve Block, Percutaneous
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 for Infraorbital Nerve Block, Percutaneous
Absolute contraindications
History of allergy to the anesthetic agent
Absence of anatomic landmarks needed to guide needle insertion (eg, due to trauma)
Relative contraindications
Infection in the path of needle insertion: Use procedural sedation or a different approach to anesthesia.
Coagulopathy*: When feasible, correct prior to procedure or use a different means of analgesia.
* Anticoagulant medications (eg, for atrial fibrillation) increase 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 of Infraorbital Nerve Block, Percutaneous
Adverse reaction to the anesthetic (see Local anesthesia for laceration treatment)
Hematoma (eg, due to puncture of the infraorbital venous plexus)
Neuritis
Spread of infection, by passing the needle through an infected area
Most complications result from inaccurate needle placement.
Equipment for Infraorbital Nerve Block, Percutaneous
Gloves (sterile gloves are not required)
Appropriate personal protective equipment (eg, face mask, safety glasses or face shield, cap and gown)
Syringe (eg, 3 mL) and needle (eg, 25 or 27 gauge) for anesthetic injection
* Local anesthetics are discussed separately (see Local anesthesia for laceration treatment).
Additional Considerations for Infraorbital Nerve Block, Percutaneous
Document any preexisting nerve deficit in the medical record before doing a nerve block.
Stop the nerve block procedure if you are unsure where the needle is or if the patient is uncooperative. Consider procedural sedation for patients who are unable to cooperate or remain still.
Relevant Anatomy for Infraorbital Nerve Block, Percutaneous
The infraorbital nerve is a termination of the maxillary nerve, which is the second 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 for Infraorbital Nerve Block, Percutaneous
Position the patient seated or supine such that the injection site is accessible for the procedure.
Step-by-Step Description: Infraorbital Nerve Block, Percutaneous
Check sensation in the infraorbital nerve distribution.
Wear gloves and use other appropriate personal protective equipment.
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 for Infraorbital Nerve Block, Percutaneous
Ensure hemostasis at the injection site.
Instruct patient regarding anticipated time to anesthesia resolution.
Warnings and Common Errors: Infraorbital Nerve Block, Percutaneous
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.
