is determined by the relationship of the tonsillar fossa to the internal carotid artery. With increasing age and weight, the distance between the tonsillar fossa and the internal carotid artery increases in a regular fashion to a value approaching 25 mm.5 The first angle of 135 in the modified needle is at 18 mm from the needle tip. Extending up to this point is a clear plastic sheath therefore only 18 mm of the needle is exposed. These two features ensure that at maximal penetration the needle tip is a safe distance away from the internal carotid artery hence reducing the risk of per- forating the carotid sheath. The plastic sheath acts as a physical stopper or barrier preventing the operator from advancing the needle any further. The second angle of 15 ensures that the operator is completely and always orientated as to the position of the tip of the needle. The two angles create a distance of 0.5 cm of the tip of the needle from the horizontal plane. This allows the needle tip better access into the abscess cavity, hence enhancing the drainage of the pus. Ensuring the tip of the needle reaches multiple areas in the region of the peritonsillar abscess is of importance especially in loculated collections which are often more difficult to drain completely. Conflict of interest None to declare. Sivaji, N.,* Arshad, F.A.* & Karkos, P.D. *Department of ENT, Head and Neck Surgery, Royal Hallamshire Hospital, Sheffield, UK and Center for Voice and Swallowing, UC Davis, Sacramento, CA, USA. E-mail:
[email protected] References 1 Mehanna H.M., Al-Bahnasawi L. & White A. (2002) National audit of the management of peritonsillar abscess. Postgrad. Med. J. 78, 545–547 2 Hall S.F. (1990) Peritonsillar abscess: the treatment options. J. Otol. 19, 226–229 3 Wolf M., Even-Chen I. & Kronenberg J. (1994) Peritonsillar Abscess: repeated needle aspiration versus incision and drainage. Ann. Otol. Rhinol. Laryngol. 103, 554–557 4 Spires J.R., Owens J.J., Woodson G.E. et al. (1987) Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch. Otolarngol. Head Neck Surg. 113, 984–986 5 Deutsch M.D., Kriss V.M. & Willging P. (1995) Distance between the tonsillar fossa and the internal carotid artery in children. Arch. Otolaryngol. Head Neck Surg. 121, 1410–1412 Cervical plexus block in the management of acute otitis externa and severe laryngeal pain post trauma 2 February 2011 Sir, Painful conditions can pose a significant challenge to ENT surgeons despite the use of conventional analgesics includ- ing opiates. We describe the use of cervical plexus nerve block in the control of intractable pain in three patients. Patient details Patient 1 Twenty-seven year old male presented with worsening left ear pain due to acute otitis externa that was not relieved despite maximum analgesia. Patient 2 Twenty-eight year old lady presented with excruciating pain around her thyroid cartilage, which started after voice strain. Clinical examination was normal. Patient was admitted for pain management. Patient 3 Sixty-eight year old lady was admitted for severe left ear pain secondary to acute purulent mastoid infection along side cholesteatoma and extensive granulations. For all these patients, conventional analgesics and opi- ates failed to address the pain adequately and we had to perform cervical plexus nerve block for effective pain relief, while the underlying condition was treated by anti- biotics (patient 1) and surgical intervention (patient 3). Surgical technique Under aseptic technique, 2 mLs of 0.5% Bupivacaine was injected into subcutaneous tissue of neck at Erb’s point CORRESPONDENCE: LETTERS 190 Correspondence 2011 Blackwell Publishing Ltd • Clinical Otolaryngology 36, 180–194
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