Pediatric patients undergoing many types of head and neck procedures can benefit from peripheral nerve blockade for postoperative analgesia. Common procedures include cleft lip and palate repair, otoplasty, rhinoplasty and septoplasty, mastoidectomy, craniotomy, and ventricular shunt placement.

The scalp is innervated by two groups of nerves: the first division of the trigeminal nerve, which divides into the supraorbital and supratrochlear nerves, and cervical root C2, which gives rise to the occipital nerves. The supraorbital and supratrochlear nerves supply the anterior part of the scalp, and the occipital nerves supply the posterior part of the scalp. These two blocks are often performed together for analgesia of the frontal scalp.

For the first block, the supraorbital notch is palpated. After antiseptic preparation of the skin, a 27-gauge needle is inserted perpendicularly into the notch and 1 mL of bupivacaine (0.25% with 1:200,000 epinephrine) is injected after aspiration to prevent intravascular injection (Fig. 55-1).

To then block the supratrochlear nerve, the needle is withdrawn to the skin level and directed medially toward the tip of the nose; 1 mL of bupivacaine is injected. Gentle pressure should then be applied to the supraorbital area to prevent the dissection of local anesthetic and the formation of ecchymosis (Fig. 55-2).

The greater occipital nerve provides cutaneous innervation to the major portion of the posterior scalp. Blocking this nerve provides relief of occipital pain following posterior fossa surgery and posterior shunt revisions. For this block, the patient’s head is turned to one side, or with the patient prone, the occipital artery is palpated at the level of the superior nuchal line. The occipital nerve is located medial to the occipital artery; 1 to 2 mL of bupivacaine (0.25% with 1:200,000 epinephrine) is injected to form a skin wheal. Blockade of these three nerves together can provide effective analgesia for most craniotomies (Fig. 55-3).

The infraorbital nerve is the termination of the second division of the trigeminal nerve. It is entirely sensory. The nerve emerges in front of the maxilla through the infraorbital foramen and divides into four branches, innervating the lower eyelid, lateral inferior portion of the nose and its vestibule, the upper lip, and the vermilion. Blocking this nerve helps provide postoperative pain relief in cleft lip repair, septoplasty, rhinoplasty, and in patients undergoing endoscopic sinus surgery. An intraoral approach or an extraoral approach can be used. The intraoral approach may be more aesthetic, in that any small hematoma that is formed will be less obvious (Fig. 55-4).