by Elizabeth Cudilo M.D, Paul Lynch M.D, and Tory McJunkin M.D

A Sphenopalatine ganglion block is a short, minimally invasive procedure that is effective at treating some acute and chronic facial and head pain.

Anatomy

Top Pain Doctor Performs Sphenopalatine Ganglion Block, Phoenix, AZThe sphenopalatine ganglion is a parasympathetic ganglion that is superficially-located, triangularly-shaped, and no more than 5mm in size. It is located in the pterygopalatine fossa, posterior to the middle nasal turbinate, and anterior to the pterygoid canal.

The sphenopalatine ganglion is covered by approximately 1- to 1.5mm-thick layer of connective tissue and mucous membrane which allows its block to be preformed either topically or by injection. 17,18,19

The sphenopalatine ganglion sends nerve fibers to the lacrimal gland, glands of the nasal cavity, paranasal sinuses, palate, and upper pharynx.

It “is classified as a parasympathetic ganglion because only pre-ganglionic parasympathetic axons are believed to synapse within the ganglion.” 19

Post- ganglionic sympathetic neurons as well as somatic sensory afferent branches of the maxillary division of the trigeminal nerve also pass through the ganglion, though they do not terminate there.18

Nonetheless, both the postganglionic parasympathetic and sympathetic neurons and the somatic sensory afferents can be all inhibited by performing a sphenopalatine block.

Procedure

Phoenix AZ Pain Doctor Performs Sphenopalatine Ganglion BlockThere are many approaches your physician can use to perform the sphenopalatine ganglion block including the transnasal, transoral, and lateral approach.

The transnasal approach is the simplest and most common technique among the three. You will be asked to lie down on your back and extend your neck into a sniffing position.

Your physician will inspect your anterior nares for any visible polyps, tumors, or significant septal deviation before beginning. A small amount of 2% viscous lidocaine is instilled into the nare(s) being treated, after which you will be asked to briskly inhale.

This draws the local anesthetic toward the posterior nasal pharynx, lubricating it and anesthetizing it in the process, while making the procedure more comfortable for the patient.

Pain Doctor Performs Sphenopalatine Ganglion Block, Phoenix, ArizonaIf your physician decides to perform the sphenopalatine ganglion block topically, he or she will introduce a sterile 10-cm cotton tipped applicator dipped in the chosen anesthetic and slowly advance it along your superior border of the middle turbinate until it reaches the posterior wall of the nasopharynx.10,16,20.

The applicator is usually left in place for approximately 20-30 minutes. If your physician decides to perform the sphenopalatine ganglion block via injection your physician will anesthetize part of your cheek. Next he or she will advance a small needle under x-ray guidance through anesthetized tissue.

Phoenix Arizona Top Pain Doctor Performs Sphenopalatine Ganglion BlockYour physician will carefully advance the needle to the correct location, after which he or she will confirm correct positioning under fluoroscopy before injecting the anesthetic.21 No matter whether placed topically or via injection a successful block is marked by profound pain relief.

For patients who have a documented response to administration of local anesthetic onto the sphenopalatine ganglion, you and your physician may decide upon performing a neurolysis or radioablation of the sphenopalatine ganglion for longer duration of pain and symptom relief.

Depending on whether your physician performs this block topically or via injection this procedure may take anywhere from 15 minutes to 30 minutes at most. Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable.

Your physician will monitor your pain and vital signs (pulse, blood pressure) after the procedure.

Risks

Sphenopalatine Ganglion BlockThe risk for this procedure is very low. The most common side effects of this procedure include developing a bitter taste in your mouth from the local anesthetic potentially dripping down from the nasopharynx down into your oropharynx or developing a slight numbness in the back of the throat from the local anesthetic dripping down into your throat.19

Occasionally some patients may develop epistaxis (nose bleed) from your physician accidently abrading your internal nare anatomy from placing of the block.

Some patients may also experience slight lightheadedness that usually resolves after 20-30 minutes after the procedure. With any procedure that involves local anesthetic the theoretical risk of drug allergy and seizure (if the medication is injected into a blood vessel). Lastly with any penetration of skin and soft tissues, the risk of infection always exists.

Outcomes

Sphenopalatine Ganglion Block - ProcedureSphenopalatine block is a well-established treatment modality for acute and chronic facial and head pain. Sphenopalantine Radiofrequency Ablation: Narouze et al. (2009) demonstrated that percutaneous radiofrequency ablation of the sphenopalatine ganglion is an extremely effective modality of treatment for patients with intractable chronic cluster headaches.

They accessed the mean attack intensity (MAI), mean attack frequency (MAF), and pain disability index (PDI) before and after the procedure at 1-, 3-, 6-, 12-, 18-month follow up intervals in 15 patients suffering from chronic cluster headaches and found sustained statistically significant reduction in MAI, MAF, and PDI at each follow up (P <0.001) in all categories.5

A previous study Sanders (1997) cited similar success with 34 (60.7%) of 56 patients in with episodic cluster headaches and in three (30%) of 10 patients with chronic cluster headaches achieving complete pain relief based on 12- to 70- month follow up data.13 The sphenopalatine ganglion block can also provide effective and adjunctive pain alleviation in patients with head and neck cancer.

LidocaineVarghese et al. (2001) preformed endoscopically guided neurolytic sphenopalatine ganglion blocks on 22 patients with advanced head and neck cancer with associated cancer-related pain that was not adequately controlled with conventional oral medications. 17 out of the 22 patients achieved immediate good control of their cancer-associated pain that continued to be significantly reduced at the 1-month follow up and was more manageable with oral medications.15

In another study published in 1997, researchers demonstrated that the sphenopalatine ganglion block provided relief from chronic vasomotor rhinitis in 29 out of 30 patients without recurrence of symptoms during the follow up period of 12-20 months. The number of blocks needed to achieve complete relief in these patients was 3 at weekly intervals.8

There are some conditions however, that the sphenopalatine ganglion block is no more effective than placebo as a pain alleviation modality. Janzen et al. 1997 investigated whether the sphenopalatine ganglion block could help patients experiencing facial or head pain secondary to fibromyalgia and/or myofascial pain syndrome. These authors found no statistical differences between the lidocaine and the placebo groups.2

Another study published a year later found also that 4% lidocaine when used in a sphenopalatine block is no more efficacious than placebo in the treatment of myofascial pain of the head, neck, and shoulders.1 Nonetheless, many studies from randomized, double-blinded, placebo-controlled to case reports come out annually about new treatment populations and applications of this block.

Therefore, it is best to contact Arizona Pain Specialists and discuss with our team of physicians if your pain and symptoms can be alleviated by the sphenopalatine ganglion block. The benefits of this block can be temporary for some people and the amount and duration of pain relief can vary from person to person. Some tend to have relief for weeks where others can benefit from the block for years.

Fortunately, the procedure is a low risk, nonsurgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments. If you are suffering with acute or chronic facial or head pain, the sphenopalatine ganglion block may be of great benefit for you. Contact Arizona Pain Specialists today to see if you’re a good candidate for a sphenopalatine ganglion block.

Indications

Pain especially in the face and head secondary to:

  • Acute and cluster headaches
  • Trigeminal neuralgia. 3,7
  • Temporomandibular joint (TMJ) pain. 7
  • Herpes zoster. 12
  • Sluder’s neuralgia. 6
  • Paroxysmal hemicrania. 4
  • Atypical facial pain. 14
  • Head and neck cancer
  • Complex regional pain syndrome (CRPS) 9
  • Reflex Sympathetic Dystrophy (RSD) 9

Miscellaneous

  • Vasomotor rhinitis
  • Pre- and postoperative anesthesia in oral and maxillofacial surgery. 11

We are happy to offer this exciting treatment option to patients in Scottsdale, Glendale, Chandler, Gilbert and the Phoenix metro area. Call today for an appointment.

At Arizona Pain our goal is to relieve your pain and improve function to increase your quality of life.
Give us a call today at 480-563-6400.

Sources

  1. Ferrante FM, Kaufman AG, Dunbar SA, Cain CF, Cherukuri S. Sphenopalatine ganglion block for the treatment of myofascial pain of the head, neck, and shoulders. Reg Anesth Pain Med. 1998 Jan-Feb;23(1):30-6.
  2. Janzen VD, Scudds R. Sphenopalatine blocks in the treatment of pain in fibromyalgia and myofascial pain syndrome. Laryngoscope. 1997 Oct;107(10):1420-2.
  3. Manahan AP, Malesker MA, Malone PM. Sphenopalatine ganglion block relieves symptoms of trigeminal neuralgia: a case report. Nebr Med J. 1996 Sep;81(9):306-9.
  4. Morelli N, Mancuso M, Felisati G, Lozza P, Maccari A, Cafforio G, Gori S, Murri L, Guidetti D. Does sphenopalatine endoscopic ganglion block have an effect in paroxysmal hemicrania? A case report. Cephalalgia. 2009 May 5.
  5. Narouze S, Kapural L, Casanova J, Mekhail N. Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache. 2009 Apr;49(4):571-7. Epub 2008 Sep 9.
  6. Olszewska-Ziaber A, Ziaber J, Rysz J. [Atypical facial pains–sluder’s neuralgia–local treatment of the sphenopalatine ganglion with phenol–case report] Otolaryngol Pol. 2007;61(3):319-21. [Article in Polish]
  7. Peterson JN, Schames J, Schames M, King E. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Cranio. 1995 Jul;13(3):177-81.
  8. Prasanna A, Murthy PS. Vasomotor rhinitis and sphenopalatine ganglion block. J Pain Symptom Manage. 1997 Jun;13(6):332-8.
  9. Quevedo JP, Purgavie K, Platt H, Strax TE. Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option. Arch Phys Med Rehabil. 2005 Feb;86(2):335-7.
  10. Raj P, Lou L, Erdine S et al. Radiographic imaging for regional anesthesia and pain management. New York, Churchill Living-stone, 2003, pp 66-71.
  11. Robiony M, Demitri V, Costa F, Politi M. [Percutaneous maxillary nerve block anesthesia in maxillofacial surgery] Minerva Stomatol. 1999 Jan-Feb;48(1-2):9-14. Italian.
  12. Saberski L, Ahmad M, Wiske P. Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia. Headache. 1999 Jan;39(1):42-4.
  13. Sanders M, Zuurmond WW. Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12- to 70-month follow-up evaluation. J Neurosurg. 1997 Dec;87(6):876-80.
  14. Stechison MT, Brogan M. Transfacial transpterygomaxillary access to foramen rotundum, sphenopalatine ganglion, and the maxillary nerve in the management of atypical facial pain. Skull Base Surg. 1994;4(1):15-20.
  15. Varghese BT, Koshy RC. Endoscopic transnasal neurolytic sphenopalatine ganglion block for head and neck cancer pain. J Laryngol Otol. 2001 May;115(5):385-7.
  16. Waldman S. Atlas of Interventional Pain Management. Philadelphia, WB Sanders, 1998, pp 10-12.
  17. Waldman, S. Sphenopalatine ganglion block- 80 years later. Reg Anesth 1993; 18:274-276.
  18. Waxman, S. Correlative Neuroanatomy, 23rd ed. Stamford, Appleton & Lange, 1996. Pp 265-266.
  19. Windsor RE, Jahnke S. Sphenopalatine ganglion blockade: a review and proposed modification of the transnasal technique. Pain Physician. 2004 Apr;7(2):283-6.
  20. Windsor R, Gore H, Merson M: Interventional sympathetic blockade. In Lennard T (ed.) Pain Procedures in Clinical Practice, 2nd ed. Philadelphia, Hanley & Belfus, 2000, pp 321-324.
  21. Yang Y, Oraee S. A novel approach to transnasal sphenopalatine ganglion injection. Pain Physician. 2006 Apr;9(2):131-4.