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Neuwersch-Sommeregger S, Köstenberger M, Sandner-Kiesling A, Fürstner M, Igerc I, Trummer B, Wuntschek J, Pipam W, Stettner H, Likar R, Feigl G. Ganglionic Local Opioid Analgesia at the Superior Cervical Ganglion: MRI-Verified Solution Spread. Pain Ther 2024; 13:663-678. [PMID: 38662320 PMCID: PMC11111617 DOI: 10.1007/s40122-024-00596-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) is performed for pain control and is known to be an effective procedure. In this study, we evaluated the spread of the injectate in the area of the SCG. Our expectation was that there would be a correlation between the area and volume of the injectate spread and post-procedural outcome measures. METHODS This was a retrospective blinded review of magnetic resonance imaging (MRI) scans. Assessors evaluated the anatomical area of fluid spread, the furthermost spread from midline, any hampered spread and contact of contrast fluid with other structures. The efficacy of GLOA and complications were estimated. RESULTS The main solution spread reached from the C1 to C3 vertebrae. The furthest spread in the lateral and sagittal planes was 21.2 and 15.2 mm, respectively. The furthest craniocaudal spread was 63.5 mm. In 53.3% and 33% of interventions, the solution was found in the parapharyngeal space and in its "medial compartment," respectively. A correlation was found between pain relief and both solution spread and volume of solution spread. No hampered spread was recorded. A negative correlation between pain reduction and number of GLOA was observed. Higher pre-procedural pain intensity was correlated with higher pain reduction. We estimated pain relief in 93% of procedures correctly. No correlation between post-procedural Numerical Rating Scale (NRS) scores and different needle approaches was found. CONCLUSION For the transoral blocking technique, a strict laterodorsal needle direction is recommended to prevent possible block failures. A total volume of 2 ml injected into the parapharyngeal space and its "medial compartment" is recommended. Higher volumes may lead to uncontrolled distribution patterns. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT05257655; date of registration 2022-02-25; patient enrollment date from 2023-01-09 to 2023-08-31.
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Affiliation(s)
- Stefan Neuwersch-Sommeregger
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- University of Medicine, Graz, Austria
| | - Markus Köstenberger
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria.
- University of Medicine, Graz, Austria.
| | | | - Matthias Fürstner
- Institute of Interventional and Diagnostic Radiology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Isabel Igerc
- Institute of Interventional and Diagnostic Radiology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Brigitte Trummer
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Jessica Wuntschek
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Wolfgang Pipam
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Haro Stettner
- Department of Statistics, Alpen-Adria University Klagenfurt, Klagenfurt am Wörthersee, Austria
| | - Rudolf Likar
- Centre for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- Sigmund Freud University, Vienna, Austria
| | - Georg Feigl
- Institute of Anatomy and Clinical Morphology, Witten/Herdecke University, Witten, Germany
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Nair S, Srivastava N, Brijith KVR, Aishwarya JG. Surgical Landmarks for Parapharyngeal Internal Carotid Artery During Extended Endoscopic Surgery of Nasopharynx: A Cadaveric and Radiological Study. Indian J Otolaryngol Head Neck Surg 2022; 74:4525-4532. [PMID: 36742694 PMCID: PMC9895682 DOI: 10.1007/s12070-021-02508-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023] Open
Abstract
Nasopharynx is a complex region situated at the center of skull surrounded by various vital neurovascular structures. Surgical access to the nasopharyngeal space poses significant challenges due to the position of the internal carotid artery (ICA). Open approaches to nasopharynx utilize the lateral to medial anatomy but the endoscopic endo-nasal approach warrants knowledge about the medial to lateral anatomy. In this study we attempted to find the consistent surgical landmarks for parapharyngeal portion of internal carotid artery at the level of nasopharynx by means of cadaveric and radiological study. Eight fresh frozen cadavers (16 sides) and 30 CT angiography (60 sides) were included in the anatomical and radiological study respectively. Superior aspect of the torus tubarius was taken as the reference point in cadaveric study and C1-C2 interspace was used as the reference point for the radiological study. The distance between the ICA to the landmarks such as fossa of Rosenmullaer, torus tubarius, medial and lateral pterygoid plates were recorded. The mean distance of ICA to the fossa of Rosenmuller was 8.5 ± 1.4 mm and 9.1 ± 1.1 mm in the cadaveric and radiological study respectively. The mean distance between ICA to torus tubarius was 19.8 ± 1.3 mm in cadaveric and 20.6 ± 1.0 mm in radiological study. The mean distance of ICA to medial and lateral pterygoid plates were 25.3 ± 1.4 mm and 18.2 ± 1.4 mm in the cadaveric study and 25.9 ± 1.2 mm and 18.8 ± 1.3 mm in the radiological study respectively. On correlating the measurements between cadaveric and radiological study, the p values were not statistically significant (p > 0.05). The closest landmark to the ICA was the fossa of Rosenmuller. ICA was located at the same sagittal plane as that of the lateral pterygoid plate. The nasopharynx is a complex anatomical region closely related to ICA. Inadvertent injury to ICA is one of the dreaded complications of nasopharyngeal surgery. Fossa of Rosenmuller is only few millimeters away from the ICA and must be treated very cautiously. During the endoscopic approach, the ICA is at the sagittal plane as of the lateral pterygoid plate. This must be kept in mind when advancing toward the ICA by keeping intact the lateral pterygoid plate when possible and one should stay in the plane of medial pterygoid plate as the ICA lies posterolateral to it. Cadaveric dissections supported by radiological data would definitely aid surgeons to successfully perform surgeries in nasopharynx.
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Affiliation(s)
- Satish Nair
- Department of ENT-HNS, Apollo Hospitals,, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka, 560076 India
| | - Namrata Srivastava
- Department of ENT-HNS, Apollo Hospitals,, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka, 560076 India
| | - K. V. R. Brijith
- Department of ENT-HNS, Apollo Hospitals,, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka, 560076 India
| | - J. G. Aishwarya
- Department of ENT-HNS, Apollo Hospitals,, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka, 560076 India
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Fang X, Di G, Zhou W, Jiang X. The anatomy of the parapharyngeal segment of the internal carotid artery for endoscopic endonasal approach. Neurosurg Rev 2019; 43:1391-1401. [PMID: 31502030 DOI: 10.1007/s10143-019-01176-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 11/25/2022]
Abstract
Injury to the internal carotid artery (ICA) is a life-threatening complication of endoscopic endonasal approaches. The objective of this study is to illustrate the detail anatomy of the parapharyngeal segment of the ICA (PPICA) to safe endoscopic endonasal surgery. The anatomical dissection was performed in 10 cadaveric specimens and several crucial anatomical landmarks were identified and measured. In addition, 50 dry skulls were studied to further assess the relationship between the pharyngeal tubercle and carotid foramen. From the endoscopic endonasal perspective, in the median plane, the pharyngeal tubercle and the carotid foramen on both sides were located on a line. The average distance between the pharyngeal tubercle and anterior border of the external orifice of the carotid canal was measured as 25.2 ± 3.2 mm. In the paramedian plane, the PPICA was located between the levator veli palatini muscle (LVPM) and the stylopharyngeal muscle (SPM) in upper parapharyngeal space in all specimens, and the distance from the posterior border of the LVPM to the anterior border of the SPM was recorded as 15.1 ± 2.8 mm at the level of the carotid foramen. The distance from the attachment of the LVPM to the anterior border of the external orifice of the carotid canal was about 5.1 ± 0.2 mm. The fully developed stylopharyngeal fascia (SPhF) was observed in 10 cases, and the PPICA was always anteriorly enclosed by and adhered to the SPhF.
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Affiliation(s)
- Xinyun Fang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, No. 2 Zheshan west road, Wuhu, China
| | - Guangfu Di
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, No. 2 Zheshan west road, Wuhu, China
| | - Wei Zhou
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, No. 2 Zheshan west road, Wuhu, China
| | - Xiaochun Jiang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, No. 2 Zheshan west road, Wuhu, China.
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[Superior cervical ganglion: an anatomical variant. Are variations of the cranial carotid artery a risk factor for accidental intravascular injection?]. Anaesthesist 2008; 57:689-92. [PMID: 18463832 DOI: 10.1007/s00101-008-1378-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A variation of the cranial carotid artery is demonstrated in an anatomical specimen revealing possible complications of ganglionic local opioid analgesia at the superior cervical ganglion. Located in the area of the puncture site, a loop of the aberrant carotid artery adheres closely to the pharyngeal wall in the medial position, shortening the distance between the arterial lumen and the oral cavity to 5 mm. With an incidence of 25%, an aberrant carotid artery could possibly facilitate an accidental intravascular injection during ganglionic local opioid application at the superior cervical ganglion.
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