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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