Infratrochlear Research Articles

Infraorbital and infratrochlear nerve blocks combined with general anaesthesia for outpatient rhinoseptoplasty: A prospective randomised, double-blind, placebo-controlled study

IntroductionWe conducted a study to determine the efficacy of bilateral extraoral infraorbital and infratrochlear nerve blocks during outpatient rhinoseptoplasty under general anaesthesia. Patients and methodsIn this prospective, double-blind, randomised, controlled trial, 40 adult patients undergoing outpatient rhinoseptoplasty under general anaesthesia were assigned to receive bilateral infraorbital and infratrochlear nerve blocks with either 10mL of 0.25% levobupivacaine (Group LB) or isotonic saline (control group). Patients in Group LB received 0.1mL/kg of isotonic saline as a placebo and patients in the control group received 0.1mL/kg of morphine. The primary endpoint was total perioperative morphine consumption (intraoperative and in the post-anaesthesia care unit). The secondary endpoints were pain scores, time spent in the post-anaesthesia care unit and the outpatient ward, block-related complications and patient satisfaction. ResultsThe total dose of perioperative morphine was lower in Group LB than in the control group (2.5±2.8mg versus 9.5±3.5mg, respectively, P<0.001). The mean±SD or median [IQR] times spent in the post-anaesthesia care unit (60±10min and 78±33min, respectively, P<0.03) and in the outpatient ward (210 [178–223] min versus 275 [250–300] min, respectively, P<0.001) were lower in Group LB than in the control group. There were no differences between groups for other endpoints. ConclusionBilateral extraoral infraorbital and infratrochlear nerve blocks performed with 0.25% levobupivacaine during general anaesthesia combining remifentanil and desflurane reduce the perioperative dose of morphine and the time spent in the post-anaesthesia care unit and the outpatient ward in adult patients undergoing outpatient rhinoseptoplasty.

Infratrochlear neuralgia.

The infratrochlear nerve supplies the medial aspect of the upper eyelid, the superolateral aspect of the nose and the lacrimal caruncle. This nerve may contribute to the pain stemming from the trochlea, but infratrochlear neuralgia has not been identified as a specific cause of pain. Over a 10-year period we have been recruiting patients with pain in the internal angle of the orbit that did not show features of trochlear pain. Seven patients (six female, one male; mean age, 46.1 ± 18.9) presented with pain in the territory of the infratrochlear nerve. The pain appeared in the internal angle of the orbit and upper eyelid (n = 3), the superolateral aspect of the nose (n = 3), or the lacrimal caruncle (n = 1). All patients had a paroxysmal pain, with the attacks lasting five to 30 seconds. Pain attacks were mostly spontaneous, but two patients had triggers. Between attacks, all patients had local allodynia. Pain did not increase with vertical eye movements. Six patients were treated with gabapentin with complete response, and one patient experienced long-lasting relief with an anesthetic blockade of the infratrochlear nerve. Infratrochlear neuralgia should be considered as a possible cause of pain in the internal angle of the orbit.

Ultrasound guidance horn anesthesia in Water buffaloes, Bubalus bubalis (Linnaeus, 1758)

Successful and adequate regional horn anesthesia in buffaloes was achieved using ultrasound-guided nerve block of the zygomatico-temporal (cornual) and infratrochlear nerves with only 2ml of mevipacaine HCl 3%.

Cortisol and pain-related behavior in disbudded goat kids with and without cornual nerve block

Plasma cortisol and behavior were measured in disbudded goat kids with and without the use of cornual nerve block. A total of 45 kids were used in 5 experimental groups (n=9, males and females). Group LidoD was infiltrated with 1mL of 2% lidocaine locally at the cornual branches of lacrimal and infratrochlear nerves, 15min before thermal disbudding. Group Lido was similarly infiltrated and was not disbudded. In group Sim, the disbudding procedure was simulated. A control group (CD) was disbudded without lidocaine infiltration, and group SD was infiltrated with saline before disbudding. The cornual nerve block did not prevent the short-term increase in cortisol levels during and after disbudding. LidoD, CD and SD groups showed higher cortisol concentrations than Lido and Sim (p<0.05) during the first 20min after the procedure. Frequency of vocalizations during the procedure was significantly different between groups and was higher in SD (29.6±3.1; mean±SE) and CD (28.4±3.1) than in Sim (16.6±3.1; p<0.05). Infiltrating lidocaine did not decrease this response to disbudding (21.1±3.1; p>0.05). Struggles tended to be higher in SD (16.5±2.5), CD (17.8±2.5) and LidoD (15.6±2.5) than Sim (10.6±2.5; p=0.1). The total behavioral response was different between groups (CD, 59.6±6.8; LidoD, 52±6.8; SD, 62.6±6.8; Sim, 36.8±6.8; p=0.05), and disbudded animals showed the strongest reactions (disbudded, 58.1±3.9 vs non-disbudded, 36.8±6.8; p=0.01). It was concluded that cornual nerve block (lacrimal and infratrochlear) using 2% lidocaine did not prevent pain during thermal disbudding of goat kids.

Sihler staining study of anastomosis between the facial and trigeminal nerves in the ocular area and its clinical implications

The trigeminal nerve (CN V) supplies mostly sensory innervation to the face, and the facial nerve (CN VII) conveys primarily motor fibers. The aim of this study was to elucidate their distributions and anastomoses. Fourteen specimens of hemisectioned faces were gathered from human cadavers and stained with Sihler staining. The temporal (Tbr), zygomatic (Zbr), and buccal (Bbr) branches of CN VII formed trigeminofacial anastomoses in the ocular area. Communications were observed between the supraorbital nerve and the Tbr (85.7%), the infraorbital nerve and the Bbr (100%) and Zbr (28.6%), and the zygomaticofacial nerve and the Zbr (41.7%). Anastomoses were formed between the supratrochlear nerve and the Tbr (57.1%) and Bbr (50%), and the infratrochlear nerve and the Bbr (85.7%). Motor and sensory axons to the face contribute to trigeminofacial anastomoses, which may play key roles in subtle movements of muscles of facial expression.

The Nerve Supply to the Eye of the Yak (Bos Grunniens) in the Qinghai-Tibetan Plateau

Fifteen head specimens of the yak (Bos grunniens) were dissected to study the anatomical characteristics of the nerves supplied to a yak's eye. In the orbit, the optic nerve was “S” shaped and received 1–2 twigs from the ciliary ganglion. The ciliary ganglion was a grayish fusiform structure, located between the ventral branch of oculomotor nerve and retractor bulbi muscle, which gave off 2–3 long ciliary nerves—one penetrated the sclera, and the others penetrated into the optic nerve. In addition, there were 3–4 communicating branches from the nasociliary nerve and the ventral branch of the oculomotor nerve. The oculomotor nerve divided into dorsal and ventral branches; the dorsal branch divided into 4–6 twigs, two of which supplied the rectus dorsalis muscle and the others supplied levator palpebra superioris. The ventral branch furnished 3–5 twigs to the rectus medialis and ventralis muscles. After it received a branch from the maxillary nerve, it finally supplied the obliquus ventralis muscle. The trochlear nerve supplied the obliquus dorsalis muscle. The ophthalmic nerve divided into zygomaticotemporal, frontal sinus, and nasociliary nerves. After the zygomaticotemporal branch received a branch of maxillary nerve, it supplied the skin of the temporal region, the lacrimal gland and the upper eyelid; the frontal nerve supplied the lateral portion of upper eyelid; the nasociliary nerve divided into ethmoidal and infratrochlear nerves. The ethmoidal nerve penetrated the ethmoidal foramen, and the infratrochlear nerve supplied the upper eyelid and skin of the frontal region. The abducent nerve supplied the rectus lateral and retractor bulbi muscles. Therefore, the yak does not have accessory ciliary ganglion.

Periocular nerve blocks in horses

Periocular nerve blocks allow safe, precise ophthalmic examination and enable surgical procedures, such as placing a subpalpebral lavage system, or minor corneal and conjunctival surgeries under additional deep sedation. Licensed local anaesthetic are mepivacaine hydrochloride 2% (Intra-epicaine®) and lidocaine hydrochloride which contains adrenaline (Locaine 2%®, Lignol 2%®); 1 – 2 millilitre of this local anaesthetic using a 25 gauge 5/8 needle is usually sufficient. The auriculopalpebral nerve block is a motor nerve block, and will not permit corneal or conjunctival desensitisation. The infratrochlear, supraorbital, lacrimal and zygomatic nerve block will desensitise the periocular skin.

Anaesthesia for dacryocystorhinostomy

Excessive tearing due to obstruction of the nasolacrimal duct is a common ophthalmic problem. Dacryocystorhinostomy (DCR) is the procedure designed to treat primary or secondary adult anatomical obstruction. External DCR is the traditional surgical approach, however endoscopic DCR can be done. In the past, general anaesthesia (GA) has been considered as the gold standard for DCR surgery; endotracheal intubation and throat pack offer an important function as protective mechanisms of the patient’s airway against blood aspiration. Head up position, hypotensive anaesthesia, incision infiltration with lidocaine/epinephrine together with insertion of nasal pack soaked in decongestant solution are a routine measures to guard against intraoperative bleeding that may hinder surgical site visualization. Increase awareness of regional anaesthesia efficacy contemplated the surgeons towards the use of such techniques. The basic concept of local anaesthesia for DCR involves blockade of infratrochlear, infraorbital and anterior ethmoidal nerves either by separate injections or by local infiltration along with intranasal preparation. It has been found that DCR under regional anaesthesia minimizes intraoperative bleeding, inpatient stay and reduce health care expenditure. Further, many patients prefer regional anaesthesia due to less postoperative pain. These benefits are desirable particularly in elderly population in whom GA constitute a threat for their life.

Post‐Traumatic External Nasal Pain Syndrome (a Trigeminal Based Pain Disorder)

Little has been written about persistent external nasal pain after injury to the nose in the neurologic or headache literature. In clinical practice, this can be a disabling and treatment refractory condition. The external portion of the nose is highly innervated by branches of the ophthalmic and maxillary divisions of the trigeminal nerve including the nasociliary nerve, external nasal nerve, infratrochlear nerve, anterior ethmoidal nerve, and infraorbital nerve. As these nerves are located on the external portion of the nose just deep enough to the skin they can be easily traumatized with any impact to the nose. Four patients with what is termed the post-traumatic external nasal pain syndrome are reported in this paper, describing the clinical presentation of the disorder and providing treatment options. Post-traumatic external nasal pain syndrome appears to be a novel form of trigeminal-based pain not previously reported in the neurologic literature.

Endoscopic Examination on the Nasolacrimal Lesions

Epiphora, or watering eye, is commonly caused by lacrimal duct stenosis or obstruction. Lacrimal endoscopy is useful not only for observation of the inner lumen of the lacrimal duct but also for direct endoscopic probing of obstructive lacrimal lesions. In this procedure, a fine endoscopic probe can be introduced from the upper or lower punctum of the lids to the orifice of nasolacrimal duct (NLD) into the inferior meatus. The endoscopy procedure usually requires local anesthesia, through infratrochlear nerve block and nasal instillation. The occurrence and distribution of the obstruction sites of NLD were studied using endoscopy. The most frequent obstruction site was the lower portion of NLD. By using endoscopy and silicone tube intubation for NLD obstruction, the success rate of the treatment was improved much greater than without endoscopy. The future and limitations of lacrimal endoscopy are discussed.

Re-examination of horn innervation in cattle using Fluorogold

Fluorogold, a neurotracer was applied to horn-bases of two calves and two 15-month-old heifers. The neurotracer was taken up by cut nerves, and was then transported in a retrograde manner along the nerves. The inspection of nerve sections under the fluorescence microscope revealed Fluorogold granules in the zygomaticotemporal and infratrochlear nerves of all four animals, as well as in the frontal nerve of a single animal. Fluorogold granules were not present in either the frontal sinus nerve or the cervical nerves. These preliminary results suggest that, in cattle, the zygomaticotemporal nerve is not the only nerve supplying the horn base. (Zimbabwe Veterinary Journal, 2000, 31 (2&3): 65-72)

Trigeminal primary afferent projections to the peribrachial area in the guinea pig

Transganglionic transport of horseradish peroxidase (HRP) was used to investigate trigeminal primary afferent endings in the peribrachial area of the guinea pig. After HRP application to several nerve branches of the three divisions of the trigeminal nerve, a projection to the caudal region of the ipsilateral peribrachial region was found for the infratrochlear, ethmoidal, supraorbital, zygomatic, zygomaticofacial, zygomaticotemporal and infraorbital-superior alveolar nerves. Random and scarce endings were also observed for the mental, inferior alveolar, buccal and mylohyoid nerves. No trigeminal primary projection to the peribrachial area was detected when HRP was applied to the sphenopalatine, lingual and auriculotemporal nerves. With the exception of the ethmoidal endings described in the muskrat, a primary afferent projection to the peribrachial region from the other trigeminal nerves has not hitherto been reported in mammals.

Peribulbar Anesthesia for the Repair of Orbital Floor Fractures

Four patients underwent successful repair of an isolated orbital floor fracture under local anesthesia. The surgical approach was by antero-inferior orbitotomy, with placement of a Nylamid plate (S Jackson Inc, Washington, DC). The anesthetic technique used was a peribulbar and infratrochlear nerve block with local supplementation. Digital control of the globe was maintained during the peribulbar injection to prevent ocular perforation. We conclude that local anesthetic for this procedure in carefully selected cases is safe and efficacious, avoiding the morbidity of a general anesthetic.

Intraocular projections from the pterygopalatine ganglion in the cat

The intraocular projection of the cat pterygopalatine (sphenopalatine) ganglion was examined by using retrograde axoplasmic transport techniques in order to investigate the possibility of the involvement of the facial nerve in ocular parasympathetic innervation. Following an injection of horseradish peroxidase (HRP) or wheat germ agglutinin-HRP into the eye, retrogradely labeled cells were observed in the ipsilateral pterygopalatine ganglion, principally in the caudal part. By dissection of silver-impregnated, acetylcholinesterase- and cholinesterase-stained orbital preparations, it was determined that two different nerve pathways link the pterygopalatine ganglion and the eye. One took a retrograde course to join the retro-orbital plexus and then traveled forward accompanying the ciliary artery, the long ciliary nerve, the short ciliary nerve, and/or the optic nerve sheath. The other entered the orbit directly, fused with the ethmoidal nerve or the infratrochlear nerve in a retrograde fashion, and then turned forward along the long ciliary nerve to enter the eye. All these nerves arose from the caudal part of the ganglion. These results are discussed in relation to recent biochemical and histochemical data demonstrating the involvement of the facial nerve in the control of ocular blood flow and intraocular pressure.

Intraocular projections from the pterygopalatine ganglion in the cat

The intraocular projection of the cat pterygopalatine (sphenopalatine) ganglion was examined by using retrograde axoplasmic transport techniques in order to investigate the possibility of the involvement of the facial nerve in ocular parasympathetic innervation. Following an injection of horseradish peroxidase (HRP) or wheat germ agglutinin-HRP into the eye, retrogradely labeled cells were observed in the ipsilateral pterygopalatine ganglion, principally in the caudal part. By dissection of silver-impregnated, acetylcholinesterase- and cholinesterase-stained orbital preparations, it was determined that two different nerve pathways link the pterygopalatine ganglion and the eye. One took a retrograde course to join the retro-orbital plexus and then traveled forward accompanying the ciliary artery, the long ciliary nerve, the short ciliary nerve, and/or the optic nerve sheath. The other entered the orbit directly, fused with the ethmoidal nerve or the infratrochlear nerve in a retrograde fashion, and then turned forward along the long ciliary nerve to enter the eye. All these nerves arose from the caudal part of the ganglion. These results are discussed in relation to recent biochemical and histochemical data demonstrating the involvement of the facial nerve in the control of ocular blood flow and intraocular pressure.

Distribution of postganglionic parasympathetic fibers originating in the pterygopalatine ganglion in the maxillary and ophthalmic nerve branches of the trigeminal nerve; HRP and WGA-HRP study in the guinea pig

The distribution of the postganglionic parasympathetic fibers originating in the pterygopalatine ganglion (PTPG) has been traced in the guinea pig by means of the HRP and WGA-HRP methods. The greatest number of labeled cells were observed when WGA-HRP was injected in the lacrimal gland. After applying HRP to all ramifications of the maxillary and ophthalmic divisions of the trigeminal nerve, labeled neurons were found in the PTPG. Numerous PTPG fibers were detected in the ethmoidal and sphenopalatine nerves. The presence of PTPG fibers in the supraorbital, infratrochlear, zygomaticotemporal, zygomaticofacial-inferior palpebral, sphenopalantine and infraorbital-superior alveolar nerves has not hitherto been reported in mammals.

Transcutaneous electrical stimulation applied to the infratrochlear nerve induces a homatropine-resistant miosis in humans

1. Both high- and low-intensity transcutaneous electrical stimuli were applied to the emergence of the infratrochlear nerve in 18 healthy subjects. The effect on the size of the homolateral pupil was investigated. The width of the pupil was also measured when high-intensity transcutaneous electrical stimulation was applied to the contralateral side. 2. The high-intensity pulse resulted in constriction of the pupil when the stimulation was homolateral. The miosis was slow in onset (120 s latency) and long-lasting (80 s). No pupillary changes were detected after either ipsilateral low-intensity or contralateral high-intensity stimuli. 3. In 11 healthy subjects, the pupillary response to transcutaneous electrical stimulation was evaluated during iris parasympathetic blockade induced by homatropine eyedrops. The disappearance of the light reflex due to homatropine was considered an index of the parasympathetic blockade. Afterwards, a high-intensity pulse was transcutaneously delivered to the emergence of the infratrochlear nerve and the ipsilateral pupil size was measured. 4. A reduction in the pupillary size followed the electrical stimulation, still under the effect of homatropine which abolished the light reflex. The time course of this pupillary constriction was similar to that seen without the influence of homatropine. 5. The findings suggest that homolateral miosis, observed after unilateral high-intensity stimulation of the infratrochlear nerve, does not stem from cholinergic activation. It has been suggested that miosis induced by transcutaneous electrical stimulation may be due to an antidromic activation of the iris sensory fibres.

Unilateral impairment of pupillary response to trigeminal nerve stimulation in cluster headache

The pupillary constriction induced ipsilaterally by transcutaneous electrical nerve stimulation (TENS) of the infratrochlear nerve was measured, using an electronic pupillometer, in 26 episodic cluster headache (CH) and 15 migraine sufferers tested during an attack-free period and in 16 healthy controls. In controls, TENS gave rise to a miosis which was slow in onset and long-lasting in duration, and which was comparable to that mediated by tachykinins in animals. A similar miotic response was bilaterally observed in migraine patients and in CH patients examined during the inactive phase. In CH sufferers during the cluster period, TENS only elicited a normal pupillary constriction in the asymptomatic eye, whereas the resulting response in the symptomatic eye was markedly decreased. Although the exact mechanism underlying the dysfunction remains to be clarified, these results seem to indicate that ocular trigeminal pathways are involved in CH.

Corneal and periocular representation within the trigeminal sensory complex in the cat studied with transganglionic transport of horseradish peroxidase.

The central projections of afferent fibers from the cornea, and the infraorbital, infratrochlear, frontal, lacrimal and auriculotemporal nerves were investigated by means of the transganglionic transport of horseradish peroxidase. Afferent projections to the dorsal horn of the medulla are organized along both the rostrocaudal axis and the ventrolateral to dorsomedial margin of the medullary dorsal horn. An inverted but discontinuous facial representation exists through the restrocaudal axis of the dorsal horn of the medulla with perioral and nasal receptive fields innervated by the infratrochlear nerves represented rostral to the progressively more posterior receptive fields innervated by the frontal, lacrimal and auriculotemporal nerves, respectively. The organization of the primary afferents is not uniform over the laminae of the dorsal horn of the medulla; the projections from the different nerves show the least overlap in lamina II, while overlap is most extensive in laminae I and V. The sensory projection from the cornea to the medullary dorsal horn is most dense in laminae I and II. All nerves, including those innervating the cornea, project to the interpolar, oral and principal trigeminal nuclei and are somatotopically organized. Projections to the reticular formation and the contralateral trigeminal sensory complex were not found in this study. These results support the organization of the dorsal horn of the medulla proposed by Déjerine ('14) and show that this organization is most evident for the primary afferent projections to lamina II.

Innervation and blood supply of the antler pedicle of the Red deer

Abstract Dissection of the heads of 12 male Red deer revealed that the innervation and blood supply of the antler resembles those in the goat, in that the infratrochlear and zygomaticotemporal nerves supply the antler pedicle accompanied by two main branches of the superficial temporal artery and vein. Analgesia of the antler should be produced by injecting local anaesthetic solution both dorsal to the orbital rim and immediately caudal to the zygomatic process of the frontal bone.