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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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PLACEMENT

Anatomy.

The glossopharyngeal nerve exits from the jugular foramina at the base of the skull, as illustrated in Figure 28-1 , in close association with other structures of the carotid sheath, vagus nerve, and styloid process. The glossopharyngeal nerve descends in the neck, passes between the internal and external carotid arteries, and then divides into pharyngeal branches and motor branches to the stylopharyngeus muscle as well as branches innervating the area of the palatine tonsil and the posterior third of the tongue. These distal branches of the glossopharyngeal nerve are located submucosally immediately posterior to the palatine tonsil, deep to the posterior tonsillar pillar.

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Figure 28-1  Glossopharyngeal block: peristyloid anatomy, cross-sectional view with detail.


Position.

Glossopharyngeal block can be carried out intraorally or in a peristyloid manner. If the block is to be carried out intraorally, the patient must be able to open the mouth, and sufficient topical anesthesia of the tongue must be provided to allow needle placement at the base of the posterior tonsillar pillar. If the block is to be carried out in a peristyloid manner, the patient does not need to be able to open the mouth.

Needle Puncture—Intraoral Glossopharyngeal Block.

For an intraoral glossopharyngeal block, after topical anesthesia of the tongue, the patient’s mouth is opened widely, and the posterior tonsillar pillar (palatopharyngeal fold) is identified using a No. 3 Macintosh laryngoscope blade. An angled 22-gauge, 9-cm needle (see comment in Pearls section) is then inserted at the caudad portion of the posterior tonsillar pillar. The needle tip is inserted submucosally; and after careful aspiration for blood, 5 mL of local anesthetic is injected. The block is then repeated on the contralateral side ( Fig. 28-2 ).

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Figure 28-2  Glossopharyngeal block: intraoral anatomy and technique.


Needle Puncture—Peristyloid Approach.

For the peristyloid approach, the patient lies supine, with the head in a neutral position. Marks are placed on the mastoid process and the angle of the mandible, as illustrated in Figure 28-3 . A line is drawn between these two marks, and at the midpoint of that line the needle is inserted to contact the styloid process. To facilitate styloid identification, a finger palpates the styloid process with deep pressure; although this may be uncomfortable for the patient, the short 22-gauge needle is inserted until it impinges on the styloid process. This needle is then withdrawn and redirected off the styloid process posteriorly. As soon as bony contact is lost and aspiration for blood is negative, 5 to 7 mL of local anesthetic is injected. The block can then be repeated on the contralateral side.

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Figure 28-3  Glossopharyngeal block: peristyloid technique.


Potential Problems.

Both the intraoral and peristyloid blocks have few complications if careful aspiration for blood is carried out during the technique. With the peristyloid approach, the glossopharyngeal nerve is closely related to both the internal jugular vein and the internal carotid artery. With the intraoral approach, the terminal branches of the glossopharyngeal nerves are closely related to the internal carotid arteries, which lie immediately lateral to the needle tips if they are correctly positioned.

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