Combined greater auricular and lesser occipital nerve block in cochlear implant for an ear-to-ear smile

To the Editor

Cochlear implant is commonly performed for irreversible hearing loss in the paediatric age group to facilitate their early rehabilitation (Vincenti et al. 2014) The surgery itself is associated with moderate to severe pain and a high incidence of postoperative nausea vomiting (PONV) (Pairaudeau and Mendonca 2019) Pain in this population subgroup is difficult to treat due to the inability of these children to express pain and assess the response to analgesics. Furthermore, the use of opioids to treat pain can exacerbate the PONV in this susceptible surgical subgroup which can lead to delayed recovery. A pre-emptive block can be highly effective to decrease the incidence of pain and reduce the postoperative opioid consumption. The use of greater auricular nerve (GAN) block has been defined in the paediatric age group undergoing tympanomastoid surgery (Santhanam et al. 2002) A concomitant lesser occipital nerve (LON) block has been described for cochlear implantation in the elderly age group under local anaesthesia (Connors et al. 2021) We combined both the blocks in this case series of two children, 2–3 years male, who presented for cochlear implant surgery to our institute after informed consent from the parents.

Anaesthesia was induced with fentanyl 2 µg/kg, propofol in titrated doses and atracurium 0.5 mg/kg. The trachea was intubated with appropriate-sized cuffed tube. After head positioning, under all aseptic precautions, ultrasound-guided GAN and LON block were given using a 5-cm echogenic needle using a hockey stick linear probe (6–13 MHz) (Sonosite®). The probe was placed over the sternocleidomastoid muscle at its midpoint. Both the nerves were blocked in the same approach from medial to lateral direction using 1 ml 0.375% ropivacaine (Fig. 1). The patients did not show any response to skin incision. Additional bolus of 0.5 µg/kg fentanyl was only needed during mastoid drilling and no further opioid was used intraoperatively and postoperatively. I.V. paracetamol was administered (15 mg/kg) at the end of surgery and ibugesic (ibuprofen + paracetamol) syrup, when required was advised for postoperative analgesia. Both the children were comfortable postoperatively and required analgesia only after 12 h. However, the FLACC (pain) scale was less than 4 till 24 h follow-up (Merkel et al. 2002).

Fig. 1

Figure showing the direction of needle entry and the sonoanatomy of greater auricular and lesser occipital nerve

Therefore, a combined greater auricular nerve block and lesser occipital nerve block may provide effective analgesia in paediatric patients undergoing cochlear implant surgery.