Author's: Guincho, Joana ¹; Gilberto, Nelson ¹; Sousa, Carlota ¹; Cerdeira, Pedro ¹; Cabral, Rui ¹; Escada, Pedro ¹

Affiliations: 1 – Department of Otorhinolaryngology, Hospital Egas Moniz – Unidade Local de Saúde Lisboa Ocidental (ULSLO);  

Corresponding author: Joana Guincho; joana.guincho@live.com.pt; ORCID: https://orcid.org/0009-0006-4630-831X   

Hospital Egas Moniz, Unidade Local de Saúde Lisboa Ocidental 

Rua da Junqueira 126, 1349-019, Lisboa, Portugal 

Nelson Gilberto, https://orcid.org/ 0000-0002-8622-0172

Carlota Sousa, https://orcid.org/  0009-0002-2905-1496

Rui Cabral, https://orcid.org/ 0009-0007-0976-1139

Pedro Escada, https://orcid.org/0000-0002-5898-946X

ABSTRACT

Introduction: The increasing shift of rhinologic procedures toward office-based settings has reinforced the importance of locoregional anesthesia in contemporary otolaryngology practice. Selective blockade of the peripheral branches of the trigeminal nerve allows several nasal procedures to be performed safely and effectively while minimizing the need for general anesthesia.

Aim: To describe our institutional regional anesthesia protocol for office-based nasal procedures, emphasizing systematic stepwise anesthesia of the nasal pyramid through a sublabial approach.

Methods: A narrative review of the literature was conducted and complemented by a detailed description of the anatomical basis and anesthetic techniques routinely employed at our center. The protocol includes infraorbital, anterior ethmoidal, infratrochlear, and maxillary nerve branches blocks, as well as field block techniques. Clinical indications, benefits, and potential complications were analyzed.

Published evidence suggests that locoregional anesthesia may reduce opioid consumption, facilitate shorter recovery times, and achieve high patient satisfaction in selected office-based rhinologic procedures. In our institutional experience, systematic sublabial infraorbital blockade combined with stepwise anesthesia of the nasal pyramid has become the cornerstone of office-based rhinologic surgery. Procedures successfully performed under this protocol include inferior turbinoplasty, functional endoscopic sinus surgery, closed reduction of nasal fractures, posterior nasal nerve cryoablation, and functional rhinoplasty with absorbable implants.

Conclusion: Regional anesthesia of the midface is a safe, reproducible, and cost-effective strategy for office-based nasal surgery. Structured anesthetic protocols may facilitate the expansion of ambulatory rhinologic procedures while maintaining patient comfort and procedural safety.

Keyword's: Locoregional anesthesia; Trigeminal nerve; Office-based procedures; Nasal surgery; Infraorbital nerve block

INTRODUCTION

Over recent decades, otolaryngology practice has progressively shifted several procedures from the operating room to ambulatory and office-based settings. This trend has been driven by economic considerations, optimization of healthcare resources, and patient preference for minimally invasive approaches performed under local anesthesia. Consequently, the increasing adoption of office-based rhinologic procedures has underscored the need for safe, reproducible, and efficient anesthetic techniques adapted to the outpatient setting.

Locoregional anesthesia of the midface, particularly selective blockade of the trigeminal nerve branches, represents a valuable strategy for office-based nasal surgery. The ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve provide sensory innervation to the nasal pyramid, septum, lateral nasal wall, paranasal sinuses, and surrounding soft tissues. Selective blockade of these territories allows adequate analgesia for multiple nasal procedures without the need for general anesthesia or deep sedation [1–4].

The advantages of locoregional anesthesia include reduced anesthetic risk, improved postoperative recovery, lower opioid consumption, reduced bleeding due to vasoconstriction, earlier discharge, and lower healthcare costs [3–8]. Additionally, office-based procedures may reduce surgical waiting lists and improve patient convenience [3-5].

Despite these benefits, regional anesthesia techniques for nasal surgery remain underutilized, partly because of limited familiarity with surgical anatomy and the absence of standardized anesthetic protocols. This work primarily reflects the experience of our center in the systematic use of stepwise nasal pyramid anesthesia through a sublabial approach for office-based nasal procedures. Our institutional protocol has progressively evolved into a reproducible, well-tolerated, and structured anesthetic strategy for ambulatory rhinologic surgery.

AIM

The aim of this study is to describe our institutional sequence of regional anesthesia for office-based nasal procedures and to review its anatomical basis, indications, advantages, and limitations.

METHODS

A narrative review of the literature was conducted using articles focused on office-based rhinologic surgery, regional anesthesia, trigeminal nerve anatomy, and peripheral nerve blocks applied to nasal procedures. This review was complemented by a detailed description of the anesthetic protocol routinely employed at our institution. The selection of the procedures described was based on the clinical experience of the team and on recommendations from national and international otorhinolaryngology scientific societies.

Articles were selected according to their relevance to office-based rhinologic surgery, regional anesthesia techniques, and trigeminal nerve blockade.

RELEVANT FUNCTIONAL ANATOMY

The midface is primarily innervated by the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve. The ophthalmic division (V1) contributes through the nasociliary nerve and its branches: the anterior ethmoidal nerve, which exits the orbit through the anterior ethmoidal foramen, traverses the cribriform plate, and supplies the anterior septum, nasal dorsum, and osteocartilaginous pyramid via its internal and external nasal branches; and the infratrochlear nerve, which remains within the orbit and provides sensory innervation to the nasal root and medial canthus [1,2,9].

The maxillary division (V2) exits the cranial cavity through the foramen rotundum and enters the pterygopalatine fossa, where it gives rise to several sensory branches relevant to rhinologic surgery. The infraorbital nerve provides sensory innervation to the upper lip, lateral nose, infraorbital region, and nasal ala. Posterior superior lateral nasal branches and greater palatine branches contribute to the innervation of the posterior nasal cavity, septum, and turbinates [1,2,9]. Precise understanding of these anatomical territories is fundamental for safe and effective regional anesthesia [1,2,9].

SELECTIVE NERVE BLOCKS

Our institutional anesthetic protocol is centered on systematic stepwise anesthesia of the nasal pyramid through a sublabial approach. The sublabial route was selected over direct percutaneous facial injection for several reasons. First, needle entry through the gingivolabial sulcus leaves no visible cutaneous marks, which is particularly relevant in the context of rhinologic and aesthetic nasal procedures. Second, it provides direct anatomical access to the infraorbital foramen through the superior gingivolabial sulcus, allowing precise deposition of the anesthetic solution in close proximity to the nerve trunk. Third, it enables a single-entry stepwise infiltration of the nasal pyramid: from the infraorbital foramen, the needle can be progressively redirected superiorly to reach the anterior ethmoidal and infratrochlear territories, minimizing the number of skin punctures. Finally, patient tolerance is generally superior with the sublabial approach compared with multiple percutaneous facial injections, which are often perceived as more uncomfortable and anxiety-inducing in the awake office-based patient.

The protocol is structured around three sequential principles: topical preparation, selective regional infiltration, and the anesthetic synergy window. This final stage corresponds to the simultaneous peak effect of topical vasoconstriction and peripheral nerve blockade, creating optimal surgical conditions through enhanced analgesia and improved hemostasis during office-based nasal procedures.

Prior to infiltration, topical anesthesia is achieved using cottonoids soaked in 10% lidocaine and a vasoconstrictor solution (phenylephrine 0.5%) placed bilaterally within both nasal fossae and along the superior gingivolabial sulcus. This maneuver reduces mucosal sensitivity, promotes local vasoconstriction, and significantly improves patient comfort during subsequent infiltrations.

Regarding anesthetic agents, all selective nerve blocks described in this protocol are performed using 1–2 mL per injection site of either 2% lidocaine or 0.5% ropivacaine, both combined with a vasoconstrictor (epinephrine 1:100,000). Lidocaine offers rapid onset (2–5 minutes) with a duration of approximately 60–90 minutes, making it suitable for shorter procedures. Ropivacaine provides a longer duration of action (3–6 hours) with inherently lower cardiovascular toxicity, and is preferred when prolonged postoperative analgesia is desired. The total cumulative volume administered across all injection sites should remain within safe dosing limits (maximum lidocaine dose: 4.5 mg/kg without vasoconstrictor; up to 7 mg/kg with epinephrine ; maximum ropivacaine dose: 3 mg/kg). Systemic toxicity is uncommon at the volumes routinely employed in office-based rhinologic procedures.

The infraorbital nerve block is performed through a sublabial approach targeting the infraorbital foramen, which is typically located approximately 1 cm inferior to the infraorbital rim along the midpupillary line. A volume of 1–2 mL of local anesthetic solution is deposited in close proximity to the foramen after careful aspiration to exclude intravascular placement. This technique allows progressive stepwise infiltration of the nasal pyramid, providing effective anesthesia of the nasal ala, vestibule, upper lip, and infraorbital region [1,2,9].

The anterior ethmoidal nerve block targets the external nasal branch of the anterior ethmoidal nerve — a terminal branch of the nasociliary nerve (V1). After exiting the orbit through the anterior ethmoidal foramen, the nasociliary nerve traverses the anterior cranial fossa and re-enters the nasal cavity at the cribriform plate level, giving rise to internal nasal branches (supplying the anterior septum and lateral nasal wall) before emerging between the nasal bone and the upper lateral cartilage as the external nasal branch, which supplies the nasal dorsum and tip. Via the sublabial approach, the needle is redirected superiorly from the infraorbital entry point to target this emergence point. This block is particularly useful for procedures involving the nasal dorsum or anterior septum. Importantly, vasoconstrictor agents (epinephrine) should be used with caution or avoided at this level, given the theoretical risk of retinal artery spasm secondary to retrograde vascular diffusion through the anterior ethmoidal artery; plain local anesthetic is preferred when targeting this nerve. The infratrochlear nerve may be blocked by a sublabial approach near the medial orbital angle when procedures involve the nasal root. Both blocks are performed with 0.5–1 mL of local anesthetic solution [1,9].

For selected functional endoscopic sinus surgery (FESS) cases, blockade of the maxillary nerve branches at the pterygopalatine fossa may be achieved by two approaches: (1) an endoscopic transnasal approach, in which local anesthetic is injected submucosally at the posterior wall of the middle meatus immediately anterior to the sphenopalatine foramen; or (2) an infrazygomatic percutaneous approach, in which a needle is advanced through the infratemporal fossa below the zygomatic arch and anterior to the condylar process of the mandible to reach the pterygopalatine fossa, allowing broader anesthesia of the posterior nasal cavity and lateral nasal wall [1,10].

The field block consists of a circumferential subcutaneous infiltration around the nasal pyramid designed to anesthetize tegumentary collateral branches that may not be fully covered by the main trunk nerve blocks. This technique is particularly useful in procedures with a significant soft tissue component, such as functional rhinoplasty with the Latera® absorbable nasal implant (Stryker) [1,12].

PROCEDURE-BASED ANESTHETIC PROTOCOLS

Different combinations of topical anesthesia and selective nerve blocks may be used according to the anatomical territory involved and the complexity of the planned procedure. Our institutional protocol is based on a modular strategy in which multiple blockade techniques may be combined to optimize analgesia, hemostasis, and patient comfort during office-based nasal surgery (Figure 1).

Fig.1 - Suggested combinations of topical anesthesia and selective nerve blocks according to the planned office-based rhinologic procedure.

Inferior Turbinoplasty

Inferior turbinoplasty may be successfully performed under topical anesthesia combined with bilateral infraorbital blockade through a sublabial approach. Additional blockade of the turbinate at its insertion on the lateral nasal wall may also be performed, given that innervation at this level is terminal. Even when such blockade is not carried out, local infiltration of the turbinate may still contribute to improved haemorrhagic control. This combination provides adequate anesthesia of the inferior turbinate region while maintaining excellent patient tolerance during radiofrequency, microdebrider, or lateralization techniques [3-5].

FESS

Limited FESS procedures, including uncinectomy, antrostomy, selected septoplasty, and nasal polypectomy, generally require broader anesthetic coverage. In these cases, topical preparation is complemented by infraorbital blockade, pterygopalatine fossa blockade, anterior ethmoidal and infratrochlear blockade according to the anatomical extent of the procedure [2,5-9].

Closed Reduction of Nasal Bone Fractures

Closed reduction of nasal bone fractures may be effectively performed using bilateral infraorbital blockade associated with anterior ethmoidal and infratrochlear blockade. This approach provides adequate anesthesia of the osteocartilaginous pyramid and anterior septum while avoiding general anesthesia in selected patients [6].

Posterior Nasal Nerve Cryoablation (ClariFix®)

Posterior nasal nerve cryoablation is primarily based on topical anesthesia associated with blockade of the pterygopalatine fossa, providing effective anesthesia of the posterior lateral nasal wall and posterior nasal nerve territories [12].

Functional Rhinoplasty with Latera® Implant

Functional rhinoplasty with Latera® implant may be performed under infraorbital blockade combined with anterior ethmoidal and infratrochlear blockade and circumferential field block infiltration. This combination optimizes anesthesia of both deep sensory territories and superficial soft tissue components of the nasal pyramid.

ADVANTAGES AND LIMITATIONS OF OFFICE-BASED REGIONAL ANESTHESIA

The expansion of office-based rhinologic surgery has increased the need for safe, reproducible, and efficient anesthetic protocols. Several studies have demonstrated that locoregional anesthesia may reduce opioid consumption, shorten recovery time, improve patient satisfaction, and decrease healthcare costs when compared with general anesthesia in selected rhinologic procedures [3–8]. Our experience demonstrates that systematic regional anesthesia of the midface may significantly facilitate ambulatory nasal surgery while maintaining patient comfort and procedural safety.

At our institution, systematic sublabial infraorbital blockade has progressively become the cornerstone of office-based rhinologic surgery. This approach facilitates stepwise anesthesia of the nasal pyramid while minimizing patient discomfort during infiltration. In addition, the sublabial route avoids visible cutaneous puncture sites and allows broad anesthetic distribution across the infraorbital and perinasal territories.

Potential complications associated with locoregional anesthesia of the midface are generally uncommon and mostly self-limited when appropriate technique and dosing are respected. Minor complications include transient paresthesia, local hematoma formation, vasovagal reactions, and mild discomfort at the injection site. Systemic local anesthetic toxicity is rare at the doses typically used in office-based rhinologic procedures. More specific complications may occur during deeper blockade techniques, particularly at the level of the pterygopalatine fossa, including epistaxis and transient diplopia secondary to anesthetic diffusion toward the abducens nerve [1–5,9].

Appropriate patient selection remains fundamental for successful office-based procedures. Patients with severe anxiety, poor tolerance to nasal endoscopy, extensive inflammatory disease, or complex sinonasal anatomy may still benefit from procedures performed under general anesthesia [3,5]. Likewise, adequate monitoring equipment, trained personnel, and immediate access to resuscitation material remain essential safety requirements for ambulatory rhinologic surgery [5].

CONCLUSION

Regional anesthesia of the midface appears to be a safe and effective strategy for selected office-based nasal procedures when performed by appropriately trained surgeons and in carefully selected patients.The systematic use of sublabial stepwise anesthesia of the nasal pyramid, combining topical preparation with selective peripheral nerve blocks using lidocaine or ropivacaine with vasoconstrictor, provides reproducible analgesia and high patient tolerance across a broad spectrum of rhinologic procedures.

The dissemination of structured anesthetic protocols may contribute to the continued expansion of ambulatory rhinologic surgery while reducing dependence on general anesthesia and operating room resources.

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