Glossopharyngeal Nerve Block Research Articles

The Effects of Glossopharyngeal Nerve Block on Postoperative Pain Relief After Tonsillectomy: The Importance of the Extent of Obtunded Gag Reflex as a Clinical Indicator

We evaluated the efficacy of glossopharyngeal nerve block (GNB) for the control of post-tonsillectomy pain in adult patients, and correlated the extent of obtunded gag reflex as a clinical indicator of GNB with the extent of pain relief. Seventy-five patients undergoing tonsillectomy received bilateral GNB with 0.75% ropivacaine with epinephrine (Group R), 0.5% bupivacaine with epinephrine (Group B) at the end of the operation, or no intervention (Group C). To evaluate the effects of GNB, we assessed throat pain (100 mm visual analog scale) and severity of gag reflex response 0.5, 8, and 24 h after surgery. In the immediate postoperative period, pain scores at rest and when swallowing in Groups R and B were significantly lower than those in Group C (21 +/- 17 and 23 +/- 13 vs 42 +/- 16, 28 +/- 22 and 32 +/- 19 vs 62 +/- 14, P < 0.001). The analgesic effect of GNB was strongly correlated with the extent of obtunded gag reflex (P < 0.01). GNB is a useful method for the palliation of post-tonsillectomy pain. An obtunded gag reflex response may be a clinical indicator for analgesia from GNB.

The Management of a Patient With Tracheal Compression Undergoing Combined Resection of an Anterior Mediastinal Mass and Aortic Valve Replacement With Coronary Artery Bypass Graft Surgery: Utility of the Laryngeal Mask Airway and Aintree Intubation Catheter

T HAS LONG BEEN recognized that the presence of an anterior mediastinal mass can lead to respiratory and cardiovascular collapse. Importantly, the severity of airway compromise may not be apparent in the awake patient. There have been numerous reports in the literature of life-threatening complications or death during anesthetic induction, maintenance, and emergence, as well as in the early postoperative period. 1,2 Symptoms attributable to anterior mediastinal masses include airway compression with obstruction, obstruction of the major vessels and heart, and superior vena cava syndrome. 3,4 Airway management in these patients can prove challenging and demands proper planning and communication on the part of the anesthesia and surgical teams. This case describes the airway management of a high-risk patient with significant tracheal narrowing and a large retrosternal goiter undergoing combined resection of this mass with major cardiac surgery. CASE REPORT A 54-year-old woman presented with a 3-day history of shortness of breath, cough, and an inability to lie flat because of worsening dyspnea. Past medical history was significant for morbid obesity (weight 112 kg, height 162 cm), emphysema, angina, hypertension, non‐insulin-dependent diabetes mellitus, anxiety/depression, hyperlipidemia, osteoarthritis, gastroesophageal reflux, gastroparesis, and a more than 30 pack/year current smoking history. Two years earlier, she had undergone emergency tracheostomy for upper-airway obstruction after a dental infection. This was complicated by acute respiratory distress syndrome requiring mechanical ventilation for 2 weeks. Medications at the time of presentation included lasix, potassium chloride, prednisone, Nexium (AstraZeneca LP, Wilmington, DE), Lipitor (Pfizer Inc, New York, NY), Singulair (Merck, Whitehouse Station, NJ), Diovan (Novartis, Cambridge, MA), Lexapro (Forest Laboratories, New York, NY), reglan, Allegra (Sanofi Aventis, Bridgewater, NJ), Vioxx (Merck), Paxil (SmithKline Beecham, Philadelphia, PA), metoprolol, and albuterol. A computed tomography scan of the chest showed an enlarged thyroid gland extending down into the superior mediastinum and surrounding the upper trachea. The trachea was maximally narrowed to 5 mm at the level of the thyroid cartilage (Fig 1), with intrathoracic extension of airway narrowing. A transthoracic echocardiogram showed a left-ventricular ejection fraction of 55%, left-ventricular hypertrophy, mild mitral regurgitation, severe aortic insufficiency, and a small pericardial effusion. Cardiac catheterization revealed a 70% proximal left circumflex coronary artery stenosis. Pulmonary function tests showed the following: forced expiratory volume in 1 second of 1.3 L (61% predicted), forced vital capacity of 1.8 L (68% predicted), forced expiratory volume in 1 second/forced vital capacity of 72.3%, and FEF25-75 (forced expiratory flow from 25% to 75% of vital capacity) of 0.75 L/s (28% predicted). Spirometry showed flattening of the expiratory limb of the flow-volume loop (Fig 2). Laboratory data including complete blood count, electrolyte panel, coagulation profile, and thyroid function studies were all within normal limits. The patient was premedicated intravenously with midazolam, 1 mg, glycopyrollate, 0.2 mg, ranatidine, 50 mg, and metaclopromide, 10 mg. Preoperatively, her airway was anesthetized with 4 mL of nebulized 4% lidocaine. Intraoperative monitors included the standard American Society of Anesthesiologists monitors, a brachial arterial catheter, and a pulmonary artery catheter that was placed after intubation. Bilateral glossopharyngeal nerve blocks were performed by using 1% lidocaine. For anesthetic induction, she was maintained in 30 degrees of reverse Trendelenburg positioning and preoxygenated for 5 minutes. Eighty milligrams of propofol were administered, and a no. 4 laryngeal mask airway (LMA) was easily inserted. The patient maintained spontaneous respiration during this time, and sevoflurane was incrementally administered to 2.3% end-tidal concentration. With the patient breathing spontaneously, a fiberoptic bronchoscope loaded with an Aintree intubation catheter (Cook Critical Care, Bloomington, IN) was introduced into the trachea via the LMA by using a swivel adaptor to allow continued delivery of oxygen and sevoflurane. The Aintree intubation catheter is an airway-exchange catheter with a 4.8-mm internal diameter that can be loaded onto a 4.0-mm fiberoptic bronchoscope. The vocal cords were sprayed with 1% lidocaine through the suction port of the bronchoscope, the airway was examined for degree of patency, and the catheter was easily advanced across the narrowed portion of the trachea. The LMA was then removed, and a 7.0 armored endotracheal tube was gently advanced over the intubating catheter past the obstruction. After median sternotomy, the patient underwent total thyroidectomy, breathing spontaneously. End-tidal CO2 ranged between 40 and 50 mmHg, and PaCO2 measured during spontaneous ventilation was 47 mmHg. The surgeon confirmed by direct palpation that there was no tracheomalacia. Pancuronium was then administered, and the patient underwent uneventful aortic valve replacement and single-vessel coronary artery bypass grafting to the left circumflex coronary artery with cardiopulmonary bypass. She remained intubated overnight and was extubated the next morning after having met standard extubation criteria and the demonstration of a leak around the endotracheal tube with cuff deflation. Her postoperative course was uneventful, and she was discharged on postoperative day 6 with significant improvement in her respiratory complaints.

The effect of glossopharyngeal nerve block with ropivacaine on immediate postoperative pain relief after tonsillectomy in adult patients

Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seong-Nam, Republic of Korea

The effect of bilateral glossopharyngeal nerve anaesthesia on swallowing in horses

Dysfunction of the glossopharyngeal nerve has been implicated as a cause of dysphagia in horses. However, recent studies have indicated that this is not the case. To determine whether bilateral glossopharyngeal nerve anaesthesia would cause dysphagia in horses or result in measurable alterations in the timing, function, or sequence of swallowing. Swallowing was evaluated in 6 normal horses with and without bilateral glossopharyngeal nerve anaesthesia. Swallowing dynamics were assessed subjectively and objectively based on time from prehension of food until swallowing, number of tongue movements until initiation of swallowing, depth of bolus at the base of the tongue prior to initiation of swallow and evidence of tracheal aspiration using fluoroscopy and endoscopy. There was no evidence of aspiration or dysphagia in horses before or after bilateral glossopharyngeal nerve block. No observed or measured differences in swallowing sequence or function could be detected in blocked compared to unblocked horses. However, there was a trend in blocked horses for the number of tongue pushes and the time to swallowing to be increased. Glossopharyngeal nerve function may not be essential for normal swallowing function in otherwise healthy horses. Clinically, normal swallowing is not an appropriate test of glossopharyngeal nerve function and dysphagic horses should not be assumed to have glossopharyngeal nerve dysfunction.

Effects of stylopharyngeus muscle dysfunction on the nasopharynx in exercising horses.

Nasopharyngeal collapse has been observed in horses as a potential cause of exercise intolerance and upper respiratory noise. No treatment is currently available and affected horses are often retired from performance. To determine the effect of bilateral glossopharyngeal nerve block and stylopharyngeus muscle dysfunction on nasopharyngeal function and airway pressures in exercising horses. Endoscopic examinations were performed on horses at rest and while running on a treadmill at speeds corresponding to HRmax50, HRmax75 and HRmax, with upper airway pressures measured with and without bilateral glossopharyngeal nerve block. Bilateral glossopharyngeal nerve block caused stylopharyngeus muscle dysfunction and dorsal nasopharyngeal collapse in all horses. Peak inspiratory upper airway pressure was significantly (P = 0.0069) more negative at all speeds and respiratory frequency was lower (P = 0.017) in horses with bilateral glossopharyngeal nerve block and stylopharyngeus muscle dysfunction compared to control values. Bilateral glossopharyngeal nerve anaesthesia produced stylopharyngeus muscle dysfunction, dorsal pharyngeal collapse and airway obstruction in all horses. The stylopharyngeus muscle is probably an important nasopharyngeal dilating muscle in horses and dysfunction of this muscle may be implicated in clinical cases of dorsal nasopharyngeal collapse. Before this information can be clinically useful, further research on the possible aetiology of stylopharyngeus dysfunction and dysfunction of other muscles that dilate the dorsal and lateral walls of the nasopharynx in horses is needed.

Fluoroscopy Guided Glossopharyngeal Nerve Block in a Patient with Short Styloid Process -A case report-

Glossopharyngeal nerve block is usually carried out for glossopharyngeal neuralgia and can be performed easily by a blind technique. Anatomically, the glossopharyngeal nerve is located posteromedial to the styloid process, which is an important anatomic landmark for blockade. The internal carotid artery and internal jugular vein are located just medial to the glossopharyngeal nerve. If the styloid process is short or difficult to palpate, it is difficult to perform the block using the blind technique, and may cause hematoma formation and local anesthetic toxicity. Herein, a case of glossopharyngeal nerve block under the guidance of C-arm, in a patient with a short styloid process, is presented.

Efficacy of modified glossopharyngeal nerve block in cancer and non-cancer pain

Efficacy of modified glossopharyngeal nerve block in cancer and non-cancer pain

Efficacy of modified glossopharyngeal nerve block in cancer and non-cancer pain

Efficacy of modified glossopharyngeal nerve block in cancer and non-cancer pain

Nefopam for refractory postoperative hiccups.

R efractory postoperative hiccups is an uncommon but distressing condition that may cause deleterious effects such as wound dehiscence, infection, fatigue, and dehydration. Hiccups–brief bursts of intense inspiratory activity involving the diaphragm and inspiratory intercostal muscles, with reciprocal inhibition of the expiratory intercostal muscles–might result from structural or functional disturbances of the medulla or of afferent or efferent nerves to the respiratory muscles (1). The first line of management is to reverse or treat any underlying cause such as esophageal obstruction or gastric distention. In most cases, hiccups respond to stimulation of the pharynx or the external auditory meatus, or to vagal maneuvers. Increasing the partial pressure of inspired carbon dioxide (rebreathing) reduces the frequency of hiccups, and reducing carbon dioxide pressure (hyperventilation) increases the amplitude of hiccups (2). Patients with persistent hiccups have been treated with several classes of drugs: chlorpromazine, carbamazepine, nifedipine, nimodipine, baclofen, metoclopramide, haloperidol, ketamine, phenytoin and lidocaine (2–4). All have potentially serious adverse effects and some may be contraindicated in the postoperative setting. Invasive techniques proposed for the control of refractory hiccups include glossopharyngeal nerve block (5) and phrenic nerve block (6). Both procedures reduce vital capacity, may cause dyspnea or hypoxia, and may fail to stop hiccups (7). We previously reported (8) that severe hiccups in medical patients responds to treatment with nefopam– 3,4,5,6-Tetrahydro-5-methyl-l-phenyl-1H-2.5-benoxazocine hydrochloride (Oxadol, Kedrion, Italy)–a nonopioid analgesic drug with shivering suppression properties (9). In this study we describe the use of nefopam in seven patients with postoperative hiccups refractory to standard therapeutic maneuvers: gastric decompression, vagal maneuvers (Valsalva maneuver, carotid and optic compression), pharynx and external auditory meatus stimulation, and carbon dioxide rebreathing. This series includes all cases of refractory postoperative hiccups we observed over the past 2 yr as anesthesiologists in a university hospital.

Pathophysiology of dorsal displacement of the soft palate in horses.

Dorsal displacement of the soft palate (DDSP) is an intermittent obstructive upper airway condition that occurs in athletic horses during high-intensity exercise. The pathogenesis of this condition is unknown, but may involve epiglottic hypoplasia, malformation, or neuromuscular dysfunction. In this paper, we report on investigations into the pathophysiology of DDSP. In 3 separate experiments, Standardbred horses were exercised on a high-speed treadmill at speeds corresponding to 50, 75 and 100% of maximum heart rate. The upper airway was evaluated by videoendoscopy and measurement of tracheal pressures. In experiment 1, we examined the effect of bilateral hypoglossal and glossopharyngeal nerve block on epiglottic function in exercising horses. This nerve block caused epiglottic retroversion and inspiratory upper airway obstruction. However, DDSP did not occur. In experiment 2, we evaluated the hypothesis that tensor veli palatini muscle dysfunction is involved in the pathogenesis of DDSP. Bilateral tensor veli palatini muscle tenectomy did not cause DDSP, but caused instability of the rostral half of the soft palate and a modest inspiratory upper airway obstruction. In experiment 3, we hypothesised that palatinus and palatopharyngeal dysfunction causes DDSP. The pharyngeal branch of the vagus nerve was blocked bilaterally in the guttural pouch. This block caused DDSP in all horses within 2-15 min after nerve block. Furthermore, DDSP created an expiratory nasopharyngeal obstruction. Because the pharyngeal branch of the vagus nerve is in close proximity to the retropharyngeal lymph node chain, we suggest that retropharyngeal lymphadenopathy may cause neural dysfunction and thereby be involved in the pathogenesis of clinical DDSP.

Relief of Chronic Refractory Hiccups with Glossopharyngeal Nerve Block

To the Editor: A 66-yr-old male patient planned to undergo right cochleosacculotomy for Meniere's disease complained of chronic refractory hiccups that lasted for 8 mo and did not respond to chlorpromazine, metoclopramide, omeprazole, or nifedipine. Because the patient had dilated cardiomyopathy, type II diabetes mellitus, and a permanent transvenous pacemaker, a cardiology consultation recommended that local rather general anesthesia be used. However, when the patient was taken to the operating room, he had hiccups that prevented the surgeons from performing the operation. Initially, nasogastric tube decompression was unsuccessful for the relief of hiccups. We then performed a glossopharyngeal nerve block by injecting 3 mL of 0.5% bupivacaine into each posterior tonsillar pillar. Within minutes, a complete relief of hiccups resulted, allowing surgery to proceed under local anesthesia. Approximately 3.5 h after glossopharyngeal nerve block, hiccups occurred again. We repeated the glossopharyngeal nerve block two times postoperatively, but the relief of hiccups lasted approximately 3 h after each block. Unfortunately, these blocks were not curative. Gallacher and Martin [1] not only were the first to perform and describe this block, but they also showed that this block was curative at the same time in a patient suffering from acute hiccups. In conclusion, we showed that despite the fact that this method was not curative in the patient suffering from chronic hiccups, it maintains a temporary relief of chronic hiccups. Avni Babacan, MD Ertan Ozturk, MD Kadir Kaya, MD The University of Gazi; Faculty of Medicine; Department of Anesthesiology and Reanimation; Ankara, Turkey

Regional anesthesia for bronchoscopy

The use of the superior laryngeal nerve block to ablate nociception above the vocal cords dates back to the turn of this century. When combined with transtracheal instillation of a local anesthetic, topicalization of the nasopharynx, and oropharynx and/or glossopharyngeal nerve blocks, a fiberoptic bronchoscopy can be performed with very little discomfort for the patient. Traditionally, the anesthetic technique of choice for performing bronchoscopy has been application of local anesthetics to the mucosal surfaces of the pyriform sinuses, followed by administration of the agent onto the vocal cords using indirect visualization. This method is time consuming and has been reported to cause discomfort for the patient. With a basic understanding of the anatomy of the neck, a few syringes and needles, and approximately 10 minutes, afferent nociceptive signals from the upper airway can be effectively blocked. The techniques necessary to provide this level of comfort to a patient are surprisingly easy to learn. Another benefit to using this method is that there are very few side-effects associated with the blocks. Moreover, these blocks can also be used to decrease patient's discomfort during other painful procedures such as awake intubation, transesophageal echocardiography, and direct laryngoscopies.

Effects of bilateral hypoglossal and glossopharyngeal nerve blocks on epiglottic and soft palate position in exercising horses

Abstract Objective To determine the effect of bilateral hypoglossal and glossopharyngeal nerve block on epiglottic and soft palate position and tracheal and pharyngeal pressures in exercising horses. Animals 5 Standardbreds. Procedure Tracheal and pharyngeal pressures were measured in 5 Standardbreds exercising at the speed at which the horses achieved 50, 75, and 100% of maximal heart rate after bilateral hypoglossal and glossopharyngeal nerve block and without nerve block. Nerve block was achieved by injection of 1 to 2 ml of 2% mepivicaine hydrochloride between the glossopharyngeal and hypoglossal nerves, as they coursed through the medial compartment of the diverticulum of the auditory tube (guttural pouch), using videoendoscopic guidance and an injection apparatus. Results Compared with control values, peak inspiratory tracheal pressure was significantly (P = 0.02) more negative, and peak pharyngeal inspiratory pressure was less negative (P = 0.004) after bilateral hypoglossal and glossopharyngeal nerve block. Respiratory frequency was significantly (P = 0.024) lower after nerve block, compared with control values. The epiglottis was unstable and retroflexed through the rima glottis during inspiration after bilateral hypoglossal and glossopharyngeal nerve block. Despite loss of contact between the epiglottis and the caudal free margin of the soft palate, dorsal displacement of the soft palate did not occur. Conclusions and Clinical Relevance Loss of contact of the epiglottis with the soft palate did not affect soft palate position, suggesting that when the soft palate is normal, the epiglottis does not function as a support, holding the soft palate in a ventral position. Therefore, epiglottic dysfunction is not solely responsible for intermittent dorsal displacement of the soft palate in horses, and neuromuscular dysfunction involving the hyoepiglotticus muscle, geniohyoideus muscle, or the hypoglossal nerve may cause epiglottic retroflexion in horses. (Am J Vet Res 1997;58:1022–1026)

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Treatment of Refractory Hiccups with Glossopharyngeal Nerve Block

Treatment of Refractory Hiccups with Glossopharyngeal Nerve Block

Fiberoptic intubation using intraoral glossopharyngeal nerve block in a patient with severe preeclampsia and HELLP syndrome

Rationale and technique for use of intraoral glossopharyngeal nerve block is described in a parturient with severe preeclampsia and a past history of difficult intubation. Indications and contraindications for administration of other forms of airway anesthesia are discussed.

Local Nerve Block Anesthesia for Peroral Endoscopy

Local glossopharyngeal and superior laryngeal nerve block anesthesia for peroral endoscopy was performed on 500 patients (313 bronchoscopies, 162 esophagoscopies, 25 combined bronchoesophagoscopies). The technique allows easy insertion of rigid and flexible scopes or awake tracheal intubation of conscious patients. Glossopharyngeal nerve block causes temporary abolition of the gag reflex and loss of tactile sensation over the posterior third of the tongue and the lateral and posterior wall of the oropharynx and hypopharynx. Superior laryngeal nerve block results in loss of tactile sensation over the posterior surface of the epiglottis and the mucosa of the larynx and upper trachea. Ten of the 500 patients (2%) had an inadequate glossopharyngeal block, and 4 of the 313 patients who had a bronchoscopic examination had an inadequate superior laryngeal block. In the remaining patients, excellent anesthesia was obtained with good patient acceptance and minimal morbidity.

ASPECTS OF THE MANAGEMENT OF CHRONIC PAIN ILLUSTRATED BY NINTH NERVE BLOCK: Case Report

SUMMARY Glossopharyngeal nerve block, with radiological control, was used to relieve severe pain due to oropharyngeal carcinoma. The clinical course of this patient illustrated the need for early block to obviate the development of narcotic addiction. General principles in the management of chronic pain due to malignancy, as illustrated by this report, are discussed.

Glossopharyngeal Nerve Block

Abstract 1. 1. A new technic for the completion of glossopharyngeal nerve block is described. 2. 2. Case reports are presented which illustrate the use of glossopharyngeal block in anesthetizing the base of the tongue for operative intervention and in providing an accurate diagnostic measure in the selection of patients for surgical section of the ninth cranial nerve.

Glossopharyngeal nerve block

1. 1. A new technic for the completion of glossopharyngeal nerve block is described. 2. 2. Case reports are presented which illustrate the use of glossopharyngeal block in anesthetizing the base of the tongue for operative intervention and in providing an accurate diagnostic measure in the selection of patients for surgical section of the ninth cranial nerve.