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SPHENOPALATINE
GANGLION BLOCK － A SIMPLE
BUT UNDERUTILIZED THERAPY FOR PAIN CONTROL
Mingi Chan-Liao
Department of Anesthesia,
Jen-Ai Hospital, Taichung, Taiwan, R.O.C.
INTRODUCTION
Sphenopalatine ganglion consists of the largest aggregate
of neurons in the head outside of the brain It is conveniently
located in the sphenopalatine (pterygopalatine) fossa which makes
it very accessible to be blocked. Sphenopalatine ganglion block
has been reported to be effective in the relief of a wide variety
of pain conditions ranging from headache to low back pain (1-9).
However, due to the fact that many of the reports in the literature
concerning its application were published in the 1930s the clinical
use of this therapeutic modality, in our opinion, has been much
underutilized at the present. In this report we would like to
arouse the interest of the modern day clinicians in the use of
sphenopalatine ganglion block with description of a modified technique
which is more acceptable to the patient, and presentation of 15
cases as illustration of its clinical effect.
METHOD
The sphenopalatine ganglion (also called
pterygopalatine, nasal, or Meckel’s ganglion) is a small triangular
structure located in the pterygopalatine fossa, posterior to the
middle turbinate and inferior to the maxillary nerve. It is covered
by a thin layer, about 1 to 5 mm, of connective tissue and mucous
membrane. Anesthetization of the sphenopalatine ganglion can be
accomplished either via the transnasal approach,using applicator
of local anesthetic, or via the transoral approach with injection
of local anesthetic through the greater palatine foramen. Since
the transoral route is technically more difficult to perform and
carries the risk of intra-orbital hematoma, the transnasal approach
is the preferred technique at present. Following this tradition
we have been employing the transnasal technique using 2 cotton
applicators soaked with 4%lidocaine in the past until two patients
fifteen outpatients(9 males and 6 females) with mixed type headaches
and /of upper back myofascial pain of various pain duration were
subjected to this study. Patient characteristics are listed in
Table1. Their indications for treatment include lack of response
to medications of standard techniques bittterly complained about
the discomfort caused
by the introduction of the cotton applicator into the nasal cavity.
We therefore modified the technique by using an intratracheal
cannula to deliver
the local anesthetic instead of cotton applicator and found much
better patient acceptance.
This technique is carried out as follows:
the patient is placed supine on the treatment table and the anterior
aspect of the nasal turbinate of either nare is first anesthetized
with 4% lidocaine aerosol spray. Five minutes later, with the
patient remained in supine
position and the nose pointed at the ceiling, an intratracheal
cannula (Hakko Co. Tokyo, Japan) with preloaded 5 ml of 4% lidocaine
is inserted into the nose passing along the upper border of the
inferior turbinate and directed backwards until the upper posterior
wall of the nasopharynx is reached. The patient is observed for
20 minutes with monitoring of vital signs, then discharged home.
We determined that an “excellent” response
to this treatment was no pain at ant time of the day after only
one block; a “good result implied pain that was never worse than
mild; minor changes in pain were classified as “poor” responses;
then no pain relief or increases of pain were considered as “failure”.
RESULT
In
the past 3 months 15 patients (9 male and 6 female) with mixed
type headache or myofascial pain of the neck/upper back were treated
with sphenopalatine ganglion block and the clinical data are summarized
in Table 1. Two of the patients who had cotton applicator insertion
refused further treatment because of the discomfort associated
with the therapy; whereas all the patients using cannula insertion
reported very little discomfort and all expressed willingness
to accept further treatment.
DISCUSSION
Sphenopalatine
ganglion has been implicated in a wide variety of pain problems
ranging from head and neck pain to low back pain since the beginning
of this century when Sluder first reported a case of headache
being relieved by sphenopalatine ganglion block (1).Due to the
fact that many of the early reports in the literature were anecdotal
in nature lacking well controlled studies to substantiate their
efficacies, the commonly accepted indications for sphenopalatine
ganglion block nowadays have been in the management of migraine,
cluster, tension, mixed type headaches, and facial neuralgias
(10). More recently indications for sphenopalatine ganglion block
has been expanded to the treatment of musculoskeletal pain, especially
that of the neck and back (11-13).
The reason why sphenopalatine ganglion would
produce pain relief in remote body part remains poorly understood
at the present; however, looking at the anatomic connections of
the sphenopalatine ganglion one is impressed by its pivotal role
as an important relay center of the autonomic nervous system.
Sphenopalatine ganglion receives sensory afferents from the maxillary
nerve of the trigeminal nerve system. The parasympathetic fibers
arising from the medulla pass through the geniculate ganglion
joining the sphenopalatine ganglion via the superficial petrosal
nerve which is a branch of the facial nerve. A number of somatic
sensory neurons with cell bodies located in the geniculate ganglion
are also part of the motor root of sphenopalatine ganglion, passing
through the greater superficial petrosal nerve. The parasympathetic
fibers carries secretomotor impulses and is concerned with gustatory
function. The sympathetic fibers to the sphenopalatine ganglion
is via the deep petrosal nerve which is an extension of the carotid
plexus. Most of the fibers are post ganglionic arising from cell
bodies located in the superior cervical sympathetic ganglion (14,15).
One also has to keep in mind that the upper cervical nerve roots
(C2,C3,C4,) have connection with the superior cervical ganglion.
The cervical ganglion in turn has connection with the sphenopalatine
ganglion via the deep petrosal nerve and the sphenopalatine ganglion
is connected with the trigeminal nerve system via maxillary nerve.
Therefore it would not be unreasonable to appreciate that pain
from the upper cervical spine can cause referred symptoms into
the head and facial area, and vice versa, this might explain why
sphenopalatine ganglion block would relieve headache, facial pain,
pain in the neck and upper back.
The
side effects of sphenopalatine ganglion block are few, including
allergy to lidocaine which is rare, irritation to the nose or
epistaxis which rarely happens in the skilled hand. Realizing
the great utility and the simplicity of this therapy one cannot
help but ask why this simple, safe and effective therapy still
remains relatively underutilized. Hopefully, our presentation
here will serve as a nidus to arouse the interest of our colleagues
in this much neglected pain therapy both in terms of clinical
application and research activities in unveiling its neurophysiological
mechanism.
REFERRENCE
1.Sluder G: The syndrome of
sphenopalatine ganglion neuralgia. Am J Med Sci 111,1910:868-878
2.Sluder G: Nasal Neurology,
headaches and eye disorders. Mosby, St. Louis, 1927
3.Ruskin SL : Neurologic aspects
of nasal sinus infection: headache and systemic disturbance and
nasal ganglion origin. Arch Otolaryngol 10, 1929:337-383
4.Dock G: Sluder’s nasal ganglion
sydrome and its relation to internal medicine. JAMA 93,1929:750-753
5.Amster JL: Sphenopalatine
ganglion block for relief of painful vascular and muscular spasm
with special refence to lumbosacral pain. N Y State J Med 48,1948:2472-2480
6.Ruskin SL : Herpes zoster
oticus relieved by sphenopalatine ganglion treatment. Laryngoscope35,1925:301-302
7.Devaghel JC : Cluster headache
and sphenopalatine block. Acta Anaesthesiol Belg 32,1981:101-107
8.Kittrelle JP, Grause DS Seyhold
MS: cluster headache: local anesthetic abortive agent. Arch Neurol
42, 1985:496-498
9.Ruskin SI : Control of muscle
spasm and artheritic pain through sympathetic block at nasal ganglion
and the use of Anenylic Nucleotide. Am J Dig Dis 13,1946:311-320
10.Hahn MB, Mcquillan PM, shiplock GJ : Regional
Anesthesia, an atlas of anatomy and technique. Mosby, St. Louis
1996
11.Berger J, Pyles ST, Segundina
A et al : Does topical anesthesia of the sphenopalatine ganglion
with cocaine or lidocaine relieve low back pain? Anesthe Analg
65,1986:700-702
12.Reder MA, Hamanson As, Reder
M : Sphenopalatine ganglion block in treatment of acute and chronic
pain. In Hendler NH, Long DM, Wise TN, ed, Diagnosis and treatment
of chronic pain, John Wright, Boston, 1982
13.Lebovits A, Howard A, Lefkowitz
M : Sphenopalatine ganglion block : clincial use in the pain management
clinic. The Clin J Pain 6, 1990:131-136
14.Goss CM, ed, Gray’s Anatomy,
29th ed, Lea & Febiger, Philadelphia, 913
15.Netter FH, Ciba Colletion
of M edical Illustration, vol.1, Nervous System. Ciba corp., New
Jersey, 1972
Talbe 1. Patient Characteristics
and Treatment Outcome
|
Patient
|
Age
|
Sex
|
Diagnosis
|
Method
|
Outcome
|
|
1
|
32
|
M
|
Upper back
MFS
|
Applicator
|
good
|
|
2
|
57
|
M
|
Vascular
headache
|
Applicator
|
good
|
|
3
|
43
|
F
|
Neck MFS
|
Applicator
|
good
|
|
4
|
66
|
F
|
Tension
headache
|
Applicator
|
good
|
|
5
|
40
|
F
|
Vascular
headache
|
Applicator
|
fail
|
|
6
|
44
|
F
|
Mixed-type
headache
|
Applicator
|
fail
|
|
7
|
60
|
M
|
Upper back
MFS
|
Cannula
|
poor
|
|
8
|
49
|
M
|
Tension
headache
|
Cannula
|
excl
|
|
9
|
70
|
M
|
Mixed-type
headache
|
Cannula
|
poor
|
|
10
|
63
|
M
|
Vascular
headache
|
Cannula
|
good
|
|
11
|
55
|
M
|
Upper back
neck MFS
|
Cannula
|
good
|
|
12
|
52
|
M
|
Cervical Pain
Syndrome
|
Cannula
|
good
|
|
13
|
28
|
M
|
Vascular
headache
|
Cannula
|
excl
|
|
14
|
72
|
F
|
Mixed-type
headache
|
Cannula
|
fail
|
|
15
|
37
|
F
|
Upper back
MFS
|
Cannula
|
good
|
MFS=Myofascial Syndrome
Treatment outcome assessment was done
Excl=(Excellent)=No pain
within one week after treatment
Good=Mild pain remained
Poor=Slight reduction of
pain
Fail=No improvement at all
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