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Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to Have a Difficult Airway: A Case Report

Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to... E Case RepoRt Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to Have a Difficult Airway: A Case Report Nozomi Wada, MD,* Akiko Furutani, MD,† Joho Tokumine, MD, PhD,* Harumasa Nakazawa, MD, PhD,* Keisuke Shimazu, MD,* and Tomoko Yorozu, MD, PhD* A peripheral nerve block may be used to improve patient tolerance of awake intubation. During an awake intubation, the glossopharyngeal, superior laryngeal, and recurrent laryngeal nerves can mediate discomfort, pain, cough, glottic closure, and gag reflexes. We describe the use of ultrasound-guided superior laryngeal, recurrent laryngeal, and glossopharyngeal nerve blocks to facilitate awake intubation in a patient predicted to have a difficult airway. The glos- sopharyngeal nerve block was performed via the parapharyngeal space approach targeting the distal glossopharyngeal nerve. This procedure resulted in an uneventful awake intubation. (A&A Practice. 2023;17:e01682.) wake intubation is often performed in patients Written informed consent was obtained from the patient 1,2 anticipated to have a difficult airway. During for publication of this report. This article adheres to the Aawake intubation, patients may experience discom- CAse REports (CARE) guidelines. fort, and multiple reflexes (cough, glottic closure, and/or gag) may be triggered by manipulations inside the oral cav- CASE DESCRIPTION ity and pharynx. An 87-year-old man (height, 161 cm; weight, 51 kg) was Analgesic techniques for awake intubation include diagnosed with an exacerbation of arm muscle weakness regional anesthesia, which is divided into topical anesthe- due to cervical spondylolisthesis and osteonecrosis of the sia and nerve blocks. In topical anesthesia, lidocaine spray, right mandible. Simultaneous cervical laminectomy and viscous lidocaine, and nebulized lidocaine have been used. mandibulectomy were planned. The patient could only Nerve blocks include superior laryngeal, recurrent laryn- open his mouth to less than 1 finger ’s breadth (Mallampati 4,5 geal, and glossopharyngeal nerve blocks, which are usu- class IV). 3,6 ally used in combination. A study using a combination of Based on the physical findings, an awake intubation was superior laryngeal, recurrent laryngeal, and glossopharyn- planned. The patient was placed in a semisitting position, geal nerve blocks was reported in which a glossopharyngeal and the cervical collar was removed. Initially, 50 μg fentanyl neve block was performed using the anatomic landmark was administered intravenously. Glossopharyngeal, supe- technique for a peristyloid approach. rior laryngeal, and recurrent laryngeal nerve blocks were We performed ultrasound-guided superior laryngeal, planned. recurrent laryngeal, and glossopharyngeal nerve blocks to The parapharyngeal space approach was used to per- facilitate awake intubation in a patient predicted to have a form a glossopharyngeal nerve block with 1.5 mL 1% lido- difficult airway. In particular, we performed a glossopharyn- caine (Figures 1–2). An ultrasound probe was placed on the geal nerve block via the parapharyngeal space approach. lateral neck inferior to the mandible. The landmark for the block was the hyoid bone, which has a specific structure because of its greater horn. The probe was tilted slightly cephalad to locate the pharyngeal wall. The pharyngeal wall near the tonsil was targeted (Figure 1). From the *Department of Anesthesiology, Kyorin University School of On the right side, the initial plan was to insert the needle Medicine, Tokyo, Japan; and †Department of Anesthesia, Ogikubo Hospital, from the right lateral edge of the ultrasound probe using Tokyo, Japan. an in-plane technique. However, the intended puncture Accepted for publication March 15, 2023. site was near the proximal facial artery. To avoid an arterial Funding: Supported by Department sources. injury, the puncture site was changed to the superior side The authors declare no conflicts of interest. of the ultrasound probe, using an out-of-plane technique Illustration copyright: All illustrations are newly created for this paper and the copyright holder is Joho Tokumine. (Figure 2). Address correspondence to Joho Tokumine, MD, PhD, Department of Bilateral superior laryngeal nerve blocks were performed Anesthesiology, Kyorin University School of Medicine, 6-20-2 Sinkawa, using an out-of-plane approach. The probe was placed near Mitaka, Tokyo 181-8611, Japan. Address e-mail to dg274825@cf6.so-net.ne.jp. the lateral edge of the thyroid cartilage and oriented slightly Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, medially in a sagittal direction, providing an image to guide Inc. on behalf of the International Anesthesia Research Society. This is an open-access article distributed under the terms of the Creative Commons insertion of the needle. The lesser horn of the hyoid bone Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), was easily visualized, as it appeared like 2 protrusions. One where it is permissible to download and share the work provided it is prop- erly cited. The work cannot be changed in any way or used commercially mL 1% lidocaine was injected into the thyrohyoid mem- without permission from the journal. brane between the hyoid bone and the thyroid cartilage on each side using a 25-G needle (25 mm). DOI: 10.1213/XAA.0000000000001682 May 2023 Volume 17 Number 5 cases-anesthesia-analgesia.org 1 • • Figure 1. Parapharyngeal space approach with an in-plane technique. A, In-plane technique. B, The yellow dashed arrow indicates the needle entry path. A local anesthetic (✳) is injected in the submucosal PW. C and D, Anatomy for the parapharyngeal space approach. FA indicates facial artery; PW, pharyngeal wall; SMG, submandibular gland. Bilateral recurrent laryngeal nerve blocks were per- toward the deep right upper nasal meatus to block the ante- formed using a translaryngeal out-of-plane approach. First, rior ethmoid nerve. The pterygopalatine ganglion block the thyroid cartilage was visually differentiated from the was performed with 2 puffs 8% lidocaine sprayed deep into laryngeal prominence (“Adam’s apple”) as a surface land- the right middle nasal meatus. A right nasal fiberoptic intu- mark. The ultrasound probe was placed transverse to the bation was performed smoothly. At the postoperative visit, thyroid cartilage, which appeared as a triangular roof. The the patient reported no memory of any discomfort during probe was moved caudally until the triangular thyroid the awake intubation. cartilage disappeared, and a bright white line appeared in the midline, which was the cricothyroid membrane. After DISCUSSION the cricothyroid membrane was identified, a 25-G 25-mm An awake intubation was successfully performed for a needle was inserted approximately 1.5 cm toward the crico- patient predicted to have a difficult airway. An ultrasound- thyroid membrane. After confirming air backflow, a trans- guided glossopharyngeal nerve block was performed using laryngeal block of the recurrent laryngeal nerve at the level a parapharyngeal space approach, a superior laryngeal of the cricothyroid membrane was performed with 2 mL 4% nerve block, and a recurrent laryngeal nerve block. The cri- lidocaine. cothyroid muscle of the larynx is innervated by the supe- An additional 50 μg fentanyl was administered intrave- rior laryngeal nerve, and the other muscles of the larynx nously, and 1 puff 8% lidocaine was sprayed intranasally are innervated by the recurrent laryngeal nerves. Therefore, 2 cases-anesthesia-analgesia.org a & a pRaCtICe Figure 2. Parapharyngeal space approach with an out-of-plane technique. A, The ultrasound probe is placed under the patient’s right mandible, and a 25-G needle (25 mm) is used to puncture the parapharyngeal space using an out-of-plane technique. B, The yellow dashed arrow indicates the needle entry path. A local anesthetic (✳) is administered to the submucosal PW. C and D, Anatomy of the par- apharyngeal space approach. PW indicates pharyngeal wall; SA, sublingual artery; SMG, sub- mandibular gland. blocking both the superior laryngeal nerves and the recur- the present patient, intravenous fentanyl was administered rent laryngeal nerves should be sufficient to prevent reflex- for analgesia during the block. An alternative would be a ive contractions as the endotracheal tube passes through the titrated infusion of remifentanil. glottis and enters the trachea. The glossopharyngeal nerve In the present patient, the parapharyngeal space approach block suppresses airway reflexes, particularly the gag and to the glossopharyngeal nerve block was performed using a 4,5,7 cough reflexes, and provides analgesia. Performing a nonechogenic needle. An echogenic needle is an alternative glossopharyngeal nerve block is not mandatory for awake to improve visibility and decrease the chance of an acciden- 4,5,7 intubation, but it facilitates the procedure. tal arterial puncture. A glossopharyngeal nerve block can be performed using The administration of local anesthetic agents into the 4,5 5 an intraoral or an extraoral approach. The extraoral parapharyngeal space is technically straightforward and approach, also known as the peristyloid approach, is per- has a low risk of inducing hemorrhage. The utility of the formed from the lateral neck, targeting the styloid process parapharyngeal space approach to a glossopharyngeal 5,7 using an anatomic landmark technique or ultrasound- nerve block for awake intubation should be further investi- 9–11 guided techniques. The peristyloid approach is consid- gated in larger multicenter studies. ered less desirable because of the risk of bleeding. In the present patient, an extraoral approach for the glos- DISCLOSURES sopharyngeal nerve block was used due to limited intra- Name: Nozomi Wada, MD. oral accessibility. The anatomical details of this approach Contribution: This author helped in writing the original have been reported previously. However, there are few clin- draft. 12–14 ical reports of its use. To our knowledge, this is the first Name: Akiko Furutani, MD. report of using the parapharyngeal approach to perform a Contribution: This author helped with chart review and glossopharyngeal nerve block for an awake intubation in a manuscript preparation. patient predicted to have a difficult airway. The recurrent Name: Joho Tokumine, MD, PhD. laryngeal nerve block was performed with a translaryngeal Contribution: This author helped with editing the 3,5 block at the level of the cricothyroid membrane. manuscript. One drawback of nerve block techniques in the neck is Name: Harumasa Nakazawa, MD, PhD. that they usually require the administration of analgesics Contribution: This author helped with the conceptualiza- and sedatives to reduce the patient’s pain and anxiety. In tion of the case report. May 2023 Volume 17 Number 5 cases-anesthesia-analgesia.org 3 • • 4. Doyle DJ. Airway anesthesia: theory and practice. Anesthesiol Name: Keisuke Shimazu, MD. Clin. 2015;33:291–304. Contribution: This author helped with chart review and 5. Pani N, Kumar Rath S. Regional and topical anaesthesia of manuscript preparation. upper airways. Indian J Anaesth. 2009;53:641–648. Name: Tomoko Yorozu, MD, PhD. 6. Mathur PR, Jain N, Kumar A, Thada B, Mathur V, Garg D. Contribution: This author helped with the validation of Comparison between lignocaine nebulization and airway nerve block for awake fiberoptic bronchoscopy-guided nasotra- results and supervision. cheal intubation: a single-blind randomized prospective study. This manuscript was handled by: BobbieJean Sweitzer, Korean J Anesthesiol. 2018;71:120–126. MD, FACP. 7. Chatrath V, Sharan R, Jain P, Bala A, Ranjana S. The efficacy of combined regional nerve blocks in awake orotracheal fiberoptic intubation. Anesth Essays Res. 2016;10:255–261. ACKNOWLEDGMENTS 8. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound- The authors thank Dr Takashi Yoshimatsu, MD, PhD guided glossopharyngeal nerve block: a cadaver and a volun- (Director, Department of Anesthesiology, Ogikubo Hospital, teer sonoanatomy study. Reg Anesth Pain Med. 2017;42:252–258. Tokyo, Japan) and Dr Alan Kawarai Lefor, MD, MPH, PhD, 9. Liu Q, Zhong Q, Tang G, He G. Ultrasound-guided glossopha- ryngeal nerve block via the styloid process for glossopharyngeal FACS (Professor, Department of Surgery, Jichi Medical neuralgia: a retrospective study. J Pain Res. 2019;12:2503–2510. University, Tochigi, Japan). 10. Bedder MD, Lindsay D. Glossopharyngeal nerve block using ultrasound guidance: a case report of a new technique. Reg REFERENCES Anesth. 1989;14:304–307. 1. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus 11. Punj J, Sundaram S. Ultrasound-guided glossopharyngeal Group updated consensus-based recommendations for man- nerve block: description of a new technique. J Anaesthesiol Clin agement of the difficult airway: part 2. Planning and imple- Pharmacol. 2021;37:483–485. menting safe management of the patient with an anticipated 12. Sirohiya P, Kumar V, Yadav P, Bharti SJ. Ultrasound-guided glos- difficult airway. Can J Anesth. 2021;68:1405–1436. sopharyngeal nerve block at pharyngeal wall level in a patient 2. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American with carcinoma tongue. Indian J Palliat Care. 2020;26:140–141. Society of Anesthesiologists practice guidelines for manage- 13. Manoharan D, Bharati SJ, Yadav MK. A novel technique of ment of the difficult airway. Anesthesiology. 2022;136:31–81. ultrasound-guided glossopharyngeal nerve block to relieve 3. Mohanta J, Kumar A, Kaushal A, Talawar P, Gupta P, Jain G. cancer pain. Saudi J Anaesth. 2019;13:279–280. Anaesthesia for awake fiberoptic intubation: ultrasound- 14. Sundaram S, Punj J. Randomized controlled trial comparing guided airway nerve block versus ultrasonic nebulisation with landmark and ultrasound-guided glossopharyngeal nerve in lignocaine. Discoveries (Craiova). 2021;9:e125. eagle syndrome. Pain Med. 2020;21:1208–1215. 4 cases-anesthesia-analgesia.org a & a pRaCtICe http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png A & A Case Reports Wolters Kluwer Health

Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to Have a Difficult Airway: A Case Report

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Wolters Kluwer Health
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Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.
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Abstract

E Case RepoRt Ultrasound-Guided Glossopharyngeal Nerve Block for an Awake Intubation in a Patient Predicted to Have a Difficult Airway: A Case Report Nozomi Wada, MD,* Akiko Furutani, MD,† Joho Tokumine, MD, PhD,* Harumasa Nakazawa, MD, PhD,* Keisuke Shimazu, MD,* and Tomoko Yorozu, MD, PhD* A peripheral nerve block may be used to improve patient tolerance of awake intubation. During an awake intubation, the glossopharyngeal, superior laryngeal, and recurrent laryngeal nerves can mediate discomfort, pain, cough, glottic closure, and gag reflexes. We describe the use of ultrasound-guided superior laryngeal, recurrent laryngeal, and glossopharyngeal nerve blocks to facilitate awake intubation in a patient predicted to have a difficult airway. The glos- sopharyngeal nerve block was performed via the parapharyngeal space approach targeting the distal glossopharyngeal nerve. This procedure resulted in an uneventful awake intubation. (A&A Practice. 2023;17:e01682.) wake intubation is often performed in patients Written informed consent was obtained from the patient 1,2 anticipated to have a difficult airway. During for publication of this report. This article adheres to the Aawake intubation, patients may experience discom- CAse REports (CARE) guidelines. fort, and multiple reflexes (cough, glottic closure, and/or gag) may be triggered by manipulations inside the oral cav- CASE DESCRIPTION ity and pharynx. An 87-year-old man (height, 161 cm; weight, 51 kg) was Analgesic techniques for awake intubation include diagnosed with an exacerbation of arm muscle weakness regional anesthesia, which is divided into topical anesthe- due to cervical spondylolisthesis and osteonecrosis of the sia and nerve blocks. In topical anesthesia, lidocaine spray, right mandible. Simultaneous cervical laminectomy and viscous lidocaine, and nebulized lidocaine have been used. mandibulectomy were planned. The patient could only Nerve blocks include superior laryngeal, recurrent laryn- open his mouth to less than 1 finger ’s breadth (Mallampati 4,5 geal, and glossopharyngeal nerve blocks, which are usu- class IV). 3,6 ally used in combination. A study using a combination of Based on the physical findings, an awake intubation was superior laryngeal, recurrent laryngeal, and glossopharyn- planned. The patient was placed in a semisitting position, geal nerve blocks was reported in which a glossopharyngeal and the cervical collar was removed. Initially, 50 μg fentanyl neve block was performed using the anatomic landmark was administered intravenously. Glossopharyngeal, supe- technique for a peristyloid approach. rior laryngeal, and recurrent laryngeal nerve blocks were We performed ultrasound-guided superior laryngeal, planned. recurrent laryngeal, and glossopharyngeal nerve blocks to The parapharyngeal space approach was used to per- facilitate awake intubation in a patient predicted to have a form a glossopharyngeal nerve block with 1.5 mL 1% lido- difficult airway. In particular, we performed a glossopharyn- caine (Figures 1–2). An ultrasound probe was placed on the geal nerve block via the parapharyngeal space approach. lateral neck inferior to the mandible. The landmark for the block was the hyoid bone, which has a specific structure because of its greater horn. The probe was tilted slightly cephalad to locate the pharyngeal wall. The pharyngeal wall near the tonsil was targeted (Figure 1). From the *Department of Anesthesiology, Kyorin University School of On the right side, the initial plan was to insert the needle Medicine, Tokyo, Japan; and †Department of Anesthesia, Ogikubo Hospital, from the right lateral edge of the ultrasound probe using Tokyo, Japan. an in-plane technique. However, the intended puncture Accepted for publication March 15, 2023. site was near the proximal facial artery. To avoid an arterial Funding: Supported by Department sources. injury, the puncture site was changed to the superior side The authors declare no conflicts of interest. of the ultrasound probe, using an out-of-plane technique Illustration copyright: All illustrations are newly created for this paper and the copyright holder is Joho Tokumine. (Figure 2). Address correspondence to Joho Tokumine, MD, PhD, Department of Bilateral superior laryngeal nerve blocks were performed Anesthesiology, Kyorin University School of Medicine, 6-20-2 Sinkawa, using an out-of-plane approach. The probe was placed near Mitaka, Tokyo 181-8611, Japan. Address e-mail to dg274825@cf6.so-net.ne.jp. the lateral edge of the thyroid cartilage and oriented slightly Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, medially in a sagittal direction, providing an image to guide Inc. on behalf of the International Anesthesia Research Society. This is an open-access article distributed under the terms of the Creative Commons insertion of the needle. The lesser horn of the hyoid bone Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), was easily visualized, as it appeared like 2 protrusions. One where it is permissible to download and share the work provided it is prop- erly cited. The work cannot be changed in any way or used commercially mL 1% lidocaine was injected into the thyrohyoid mem- without permission from the journal. brane between the hyoid bone and the thyroid cartilage on each side using a 25-G needle (25 mm). DOI: 10.1213/XAA.0000000000001682 May 2023 Volume 17 Number 5 cases-anesthesia-analgesia.org 1 • • Figure 1. Parapharyngeal space approach with an in-plane technique. A, In-plane technique. B, The yellow dashed arrow indicates the needle entry path. A local anesthetic (✳) is injected in the submucosal PW. C and D, Anatomy for the parapharyngeal space approach. FA indicates facial artery; PW, pharyngeal wall; SMG, submandibular gland. Bilateral recurrent laryngeal nerve blocks were per- toward the deep right upper nasal meatus to block the ante- formed using a translaryngeal out-of-plane approach. First, rior ethmoid nerve. The pterygopalatine ganglion block the thyroid cartilage was visually differentiated from the was performed with 2 puffs 8% lidocaine sprayed deep into laryngeal prominence (“Adam’s apple”) as a surface land- the right middle nasal meatus. A right nasal fiberoptic intu- mark. The ultrasound probe was placed transverse to the bation was performed smoothly. At the postoperative visit, thyroid cartilage, which appeared as a triangular roof. The the patient reported no memory of any discomfort during probe was moved caudally until the triangular thyroid the awake intubation. cartilage disappeared, and a bright white line appeared in the midline, which was the cricothyroid membrane. After DISCUSSION the cricothyroid membrane was identified, a 25-G 25-mm An awake intubation was successfully performed for a needle was inserted approximately 1.5 cm toward the crico- patient predicted to have a difficult airway. An ultrasound- thyroid membrane. After confirming air backflow, a trans- guided glossopharyngeal nerve block was performed using laryngeal block of the recurrent laryngeal nerve at the level a parapharyngeal space approach, a superior laryngeal of the cricothyroid membrane was performed with 2 mL 4% nerve block, and a recurrent laryngeal nerve block. The cri- lidocaine. cothyroid muscle of the larynx is innervated by the supe- An additional 50 μg fentanyl was administered intrave- rior laryngeal nerve, and the other muscles of the larynx nously, and 1 puff 8% lidocaine was sprayed intranasally are innervated by the recurrent laryngeal nerves. Therefore, 2 cases-anesthesia-analgesia.org a & a pRaCtICe Figure 2. Parapharyngeal space approach with an out-of-plane technique. A, The ultrasound probe is placed under the patient’s right mandible, and a 25-G needle (25 mm) is used to puncture the parapharyngeal space using an out-of-plane technique. B, The yellow dashed arrow indicates the needle entry path. A local anesthetic (✳) is administered to the submucosal PW. C and D, Anatomy of the par- apharyngeal space approach. PW indicates pharyngeal wall; SA, sublingual artery; SMG, sub- mandibular gland. blocking both the superior laryngeal nerves and the recur- the present patient, intravenous fentanyl was administered rent laryngeal nerves should be sufficient to prevent reflex- for analgesia during the block. An alternative would be a ive contractions as the endotracheal tube passes through the titrated infusion of remifentanil. glottis and enters the trachea. The glossopharyngeal nerve In the present patient, the parapharyngeal space approach block suppresses airway reflexes, particularly the gag and to the glossopharyngeal nerve block was performed using a 4,5,7 cough reflexes, and provides analgesia. Performing a nonechogenic needle. An echogenic needle is an alternative glossopharyngeal nerve block is not mandatory for awake to improve visibility and decrease the chance of an acciden- 4,5,7 intubation, but it facilitates the procedure. tal arterial puncture. A glossopharyngeal nerve block can be performed using The administration of local anesthetic agents into the 4,5 5 an intraoral or an extraoral approach. The extraoral parapharyngeal space is technically straightforward and approach, also known as the peristyloid approach, is per- has a low risk of inducing hemorrhage. The utility of the formed from the lateral neck, targeting the styloid process parapharyngeal space approach to a glossopharyngeal 5,7 using an anatomic landmark technique or ultrasound- nerve block for awake intubation should be further investi- 9–11 guided techniques. The peristyloid approach is consid- gated in larger multicenter studies. ered less desirable because of the risk of bleeding. In the present patient, an extraoral approach for the glos- DISCLOSURES sopharyngeal nerve block was used due to limited intra- Name: Nozomi Wada, MD. oral accessibility. The anatomical details of this approach Contribution: This author helped in writing the original have been reported previously. However, there are few clin- draft. 12–14 ical reports of its use. To our knowledge, this is the first Name: Akiko Furutani, MD. report of using the parapharyngeal approach to perform a Contribution: This author helped with chart review and glossopharyngeal nerve block for an awake intubation in a manuscript preparation. patient predicted to have a difficult airway. The recurrent Name: Joho Tokumine, MD, PhD. laryngeal nerve block was performed with a translaryngeal Contribution: This author helped with editing the 3,5 block at the level of the cricothyroid membrane. manuscript. One drawback of nerve block techniques in the neck is Name: Harumasa Nakazawa, MD, PhD. that they usually require the administration of analgesics Contribution: This author helped with the conceptualiza- and sedatives to reduce the patient’s pain and anxiety. In tion of the case report. May 2023 Volume 17 Number 5 cases-anesthesia-analgesia.org 3 • • 4. Doyle DJ. Airway anesthesia: theory and practice. Anesthesiol Name: Keisuke Shimazu, MD. Clin. 2015;33:291–304. Contribution: This author helped with chart review and 5. Pani N, Kumar Rath S. Regional and topical anaesthesia of manuscript preparation. upper airways. Indian J Anaesth. 2009;53:641–648. Name: Tomoko Yorozu, MD, PhD. 6. Mathur PR, Jain N, Kumar A, Thada B, Mathur V, Garg D. Contribution: This author helped with the validation of Comparison between lignocaine nebulization and airway nerve block for awake fiberoptic bronchoscopy-guided nasotra- results and supervision. cheal intubation: a single-blind randomized prospective study. This manuscript was handled by: BobbieJean Sweitzer, Korean J Anesthesiol. 2018;71:120–126. MD, FACP. 7. Chatrath V, Sharan R, Jain P, Bala A, Ranjana S. The efficacy of combined regional nerve blocks in awake orotracheal fiberoptic intubation. Anesth Essays Res. 2016;10:255–261. ACKNOWLEDGMENTS 8. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound- The authors thank Dr Takashi Yoshimatsu, MD, PhD guided glossopharyngeal nerve block: a cadaver and a volun- (Director, Department of Anesthesiology, Ogikubo Hospital, teer sonoanatomy study. Reg Anesth Pain Med. 2017;42:252–258. Tokyo, Japan) and Dr Alan Kawarai Lefor, MD, MPH, PhD, 9. Liu Q, Zhong Q, Tang G, He G. Ultrasound-guided glossopha- ryngeal nerve block via the styloid process for glossopharyngeal FACS (Professor, Department of Surgery, Jichi Medical neuralgia: a retrospective study. J Pain Res. 2019;12:2503–2510. University, Tochigi, Japan). 10. Bedder MD, Lindsay D. Glossopharyngeal nerve block using ultrasound guidance: a case report of a new technique. Reg REFERENCES Anesth. 1989;14:304–307. 1. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus 11. Punj J, Sundaram S. Ultrasound-guided glossopharyngeal Group updated consensus-based recommendations for man- nerve block: description of a new technique. J Anaesthesiol Clin agement of the difficult airway: part 2. Planning and imple- Pharmacol. 2021;37:483–485. menting safe management of the patient with an anticipated 12. Sirohiya P, Kumar V, Yadav P, Bharti SJ. Ultrasound-guided glos- difficult airway. Can J Anesth. 2021;68:1405–1436. sopharyngeal nerve block at pharyngeal wall level in a patient 2. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American with carcinoma tongue. Indian J Palliat Care. 2020;26:140–141. Society of Anesthesiologists practice guidelines for manage- 13. Manoharan D, Bharati SJ, Yadav MK. A novel technique of ment of the difficult airway. Anesthesiology. 2022;136:31–81. ultrasound-guided glossopharyngeal nerve block to relieve 3. Mohanta J, Kumar A, Kaushal A, Talawar P, Gupta P, Jain G. cancer pain. Saudi J Anaesth. 2019;13:279–280. Anaesthesia for awake fiberoptic intubation: ultrasound- 14. Sundaram S, Punj J. Randomized controlled trial comparing guided airway nerve block versus ultrasonic nebulisation with landmark and ultrasound-guided glossopharyngeal nerve in lignocaine. Discoveries (Craiova). 2021;9:e125. eagle syndrome. Pain Med. 2020;21:1208–1215. 4 cases-anesthesia-analgesia.org a & a pRaCtICe

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Published: May 9, 2023

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