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Technical considerations for approaches to the ultrasound-guided maxillary nerve block via the pterygopalatine fossa: a literature review
  1. Ariana Anugerah,
  2. Kim Nguyen and
  3. Antoun Nader
  1. Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  1. Correspondence to Dr Ariana Anugerah, Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; arianaanugerahmd{at}


Background and objectives Blockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF.

Methods The literature search was performed by searching the National Library of Medicine’s PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009–March 2019 for keywords targeted toward “trigeminal nerve,” “maxillary nerve,” or “pterygopalatine fossa,” “ultrasound,” and “nerve block,” using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study.

Results There are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1–5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg.

Conclusions These studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored.

  • chronic pain: head and neck
  • chronic pain: imaging
  • chronic pain: diagnostic pain procedures
  • interventional pain management
  • ultrasound in pain medicine

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  • Contributors AN contributed to the conception and design of the research, and critical revision of the manuscript. AA contributed to the literature and drafting of the manuscript. All authors contributed to the final approval of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval IRB approval was not required for this review.

  • Provenance and peer review Not commissioned; externally peer reviewed.