NASAL Ganglion:  “Sphenopalatine Ganglion Blocks in the Management of Head and Neck Cancer-Related Pain”

This new article (abstract below) discusses the utility of Sphenopalatine Ganglion Blocks (aka Pterygopalatine Ganglion Blocks, SPG Blocks) in painful and debilitating pain related to cancer.  This type of pain is often medication resistant.  A second article (abstract below) shows relief of post surgical pain to the sinuses with SPG Blocks: Effect of Sphenopalatine Ganglion Block With Bupivacaine on Postoperative Pain in Patients Undergoing Endoscopic Sinus Surgery.  The next study (abstract below) The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty also shows effectiveness in post operative patients undergoing Septorhinoplasty.  The final study in this report “Trigeminal Nerve Blockade in the Pterygopalatine Fossa for the Management of Postoperative Pain in Three Adults Undergoing Tonsillectomy” discusses the utilization of Trigeminal Blocks in eliminating post-tonsilectomy pain.  Please note that these Trigeminal blocks were into the Pterygopalatine Fossa that holds both the Maxillary Devision of the Trigeminal Nerve and the Sphenopalatine Ganglion.

Nasal Ganglion or SPG Blocks will treat pain of the hard and soft palate, cornea, tonsils, nasal cavity, paranasal sinuses, oral gingiva and mucosa, maxilla and pre-maxilla pain.

While this specific study utilized the TX 360 delivery device there are many other methods to deliver SPG Blocks the Sphenocath is a similar device to the Tx360.

The Sphenopalatine Ganglion located is  located in the Pterygopalatine Fossa and the blocks are delivered over the mucosal wall of the nasal side medial bone. The Nasal Ganglion is the Largest Parasympathetic Ganglion of the head and also carries Sympathetic Fibers from the Cervical Sympathetic Chain including the Stellate Ganglion as well as Somato-Sensory nerves.  The Stellate Ganglion Block is  a Sympathetic Block being studied by the military.  When used to treat shoulder pain and CRPS (Chronic Regional Pain Syndrome) a percentage of patients suffering from PTSD  (Post Traumatic Stress Disorder) will find complete relief of PTSD symptoms.  The Stellate Ganglion Block (SGB) has been called “The Miracle Block” or the “God Block” due to the instant relief of PTSD symptoms.  Stellate Ganglion Fibers pass thru the Sphenopalatine Ganglion.  This response to SGB is  also projected to be a Limbic System Effect.

Injections give the fastest relief and can be done either with an intra-oral or extra-oral approach.  If pain is extremely severe or excruciating injections can offer immediate relief.

The best approach is Self-Administered SPG Blocks (SASPGB) with Cotton-Tipped Catheters that puts patients in charge of their pain relief allowing them to drastically reduce or eliminate other pain medications.  They can be administered on an as needed basis and actually are the most effective approach for a patient who is not hospitalized.  In addition to controlling pain the block has been shown to eliminate about 1/3 of essential hypertension in patients.

The Sphenopalatine Ganglion Block can reduce anxiety as well as pain.  The applicators deliver a continuous capillary flow of small amounts of lidocaine, which is a natural anti-inflammatory.  While the study showed 36-80% relief of pain  increasing frequency of the blocks will likely improve outcomes.  It is empowering for patients that they can personally control  pain as needed without visits to physicians or ER departments.

Pre-operative Sphenopalatine Blocks were utilized it the third study.  Consideration to preoperative SPG Blocks may make sense for any surgery due to the affect on the Limbic System.  Pain is an  emotional response to a stimulus.  Anxiety is also felt in the Limbic System.  Could pre-operative SPG Blocks reduce anxiety preoperatively and post operatively specifically due to this Limbic System effect.  The last study on Post-operative tonsillectomy pain evaluated a peri-operative block.  Based on previous information a pre-operative block could be as valuable or more valuable for pain control.  It also opens up post-op treatment with SPG Blocks as well to control pain.

The use of Sphenopalatine Ganglion Block should always be considered in the treatment of head and neck cancer due to the improvements in quality life (QOL) it bestows on patients.

It is interesting to note that the Sphenopalatine Ganglion Block was originally described by Greenfield Sluder an Otolaryngologist. The ganglion is sometimes called Sluder’s Ganglion and was originally utilized to treat Sluder’s Neuralgia now recognized as TMD or Cluster Headache like syndrome.  The procedure was probably saved from forever being lost due to an Octogenerian ENT in New York City who was the subject of the book “Miracles on Park Avenue”.  The book was published in 1986 and Dr Reder had been utilizing this procedure during his entire professional life.  In 1930 Hiram Byrd MD published an article on 10,000 Nasal Ganglion (SPG) Blocks in 2000 patients with excellent results and essentially no negative side effects.  This was published as Sphenopalatine Ganglion Phenomena in the Annals of Internal Medicine now known as JAMA, Journal of the American Medical Association.

Dr Greenfield Sluder wrote a medical textbook on “Nasal Neurology” while he was Chairman of the Department of Otolaryngology at Washington University School of Medicine in Saint Louis.  He specifically called the book Nasal Neurology in the hope that opthamologists and neurologists would understand that this was also important in their fields.

A A Pract. 2019 Dec 15;13(12):450-453.
Sphenopalatine Ganglion Blocks in the Management of Head and Neck Cancer-Related Pain: A Case Series.
Pena I1, Knoepfler ML, Irwin A, Zhu X, Kohan LR.

Head and neck cancer can be painful, debilitating, and refractory to oral medications. Due to the association of the sphenopalatine ganglion (SPG) with maxillary nerve sensory fibers, SPG blocks may be used to treat the pain of the hard and soft palate, tonsils, nasal cavity, paranasal sinuses, oral gingiva, premaxillary soft tissue, maxilla, and orbital floor. We present the first case series of performing SPG blocks utilizing TX360 nasal atomizers or angiocatheters to treat head and neck cancer-related pain. Pain scores were reduced by 38% to 80% with an average pain relief duration of 23 days.

Allergy Rhinol (Providence). 2019 Jan 23;10:2152656718821282. doi: 10.1177/2152656718821282. eCollection 2019 Jan-Dec.
Effect of Sphenopalatine Ganglion Block With Bupivacaine on Postoperative Pain in Patients Undergoing Endoscopic Sinus Surgery.
Rezaeian A1, Hashemi SM1, Dokhanchi ZS1.
Abstract  /  BACKGROUND:

Postoperative pain is one of the most complications in endoscopic sinus surgery. We aimed to evaluate the effect of the sphenopalatine ganglion block (SPGB) with bupivacaine on postoperative pain in patients undergoing endoscopic sinus surgery.Methods and Materials: In this clinical trial, 40 patients who indicated functional endoscopic sinus surgery were selected and then divided into 2 parallel groups as intervention and control. The intervention group was received 1.5 mL of bupivacaine 0.5% (injected to sphenopalatine ganglion) and while control was injected 1.5 mL of normal saline at the same injection site. Also, the visual analogue scale (VAS) was recorded immediately after anesthesia, along with 6, 12, 24, 48 h, 7 days, and 21 days after the operation for all patients.


Immediately after anesthesia, as well as 6, 12, and 24 h after the operation, VAS in the intervention group was significantly lower than in the control group (P < .05, for all). However, there were no significant differences between the 2 groups regarding VAS 48 h as well as 7 and 21 days after surgery (P > .05, for both). Also, the rescue analgesia in the intervention group was significantly lower than in the control group (P = .01).


SPGB with bupivacaine 0.5% (1.5 mL) was a simple, effective, safe, and noninvasive method for the management of postoperative pain in the patients undergoing endoscopic sinus surgery.


bupivacaine; endoscopic sinus surgery; postoperative pain; sphenopalatine ganglion block

Ann Otol Rhinol Laryngol. 2020 Feb 22:3489420909417. doi: 10.1177/0003489420909417. [Epub ahead of print]
The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty.
Abstract / OBJECTIVES:

This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP).


A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted.


The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05).


Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP.




block; pain; postoperative; septorhinoplasty; sphenopalatine

Pain Med. 2020 Mar 31. pii: pnaa062. doi: 10.1093/pm/pnaa062. [Epub ahead of print]
Trigeminal Nerve Blockade in the Pterygopalatine Fossa for the Management of Postoperative Pain in Three Adults Undergoing Tonsillectomy: A Proof-of-Concept Report.

Post-tonsillectomy pain in adults can be severe and is often poorly controlled. Pain can lead to decreased oral intake, bleeding, longer hospital stays, emergency department visits, dehydration, and weight loss. Due to persistent pain despite scheduled medications, other methods for pain control are needed. Local/regional anesthetic options have been previously studied in this population. Unfortunately, neither the injection of local anesthetics into the tonsillar fossa nor the postoperative topical application of local anesthetics to the tonsillar bed has demonstrated efficacy in large systematic reviews.


Here we report on the post-tonsillectomy pain experience of three patients who were treated with perioperative nerve blocks placed in the pterygopalatine fossa. This represents an as-yet unexplored option for post-tonsillectomy pain control.


After induction of general anesthesia, before surgical incision, a 25-gauge spinal needle was advanced into the pterygopalatine fossa using a suprazygomatic, ultrasound-guided approach. Ropivacaine and dexamethasone were deposited into the pterygopalatine fossa.


All three patients experienced excellent pain control for the duration of their recovery and required ≤10 mg of oxycodone over the two weeks after surgery.


Our case series of three patients provides proof of concept that use of nerve blocks in the pterygopalatine fossa can be useful for the control of post-tonsillectomy pain. Further study is needed to confirm these initial results.


Acute Pain; Narcotics; Nerve Block