Effects of a sphenopalatine ganglion block on postcraniotomy pain management: a randomized, double-blind, clinical trial

OBJECTIVE

Postcraniotomy pain (PCP) is a common finding after neurosurgical procedures, occurring in as many 87% of patients. The sphenopalatine ganglion (SPG) has a pivotal role in several headache syndromes, and its anesthetic block is currently used in different clinical conditions with benefit. The aim of this study was to evaluate the efficacy of an SPG block (SPGB) via a transnasal approach as adjunctive therapy in reducing pain scores during the postcraniotomy period.

METHODS

In this single-center, double-blind, randomized controlled trial, patients undergoing elective surgery with a supratentorial craniotomy were randomly assigned to a scalp block, local anesthetic infiltration of the wound, and systemic analgesia during the first 48 postoperative hours (standard therapy), or to standard therapy as well as an SPGB (experimental therapy). According to the available evidence, assuming a 50% reduction in the incidence of the main outcome in patients with an SPGB (vs standard treatment), 82 patients were needed to achieve 80% statistical power in an intent-to-treat analysis. Pain intensity was recorded during the first 180 postoperative days at selective time points (5 times in the hospital, 3 times by telephone interview) with different pain rating systems (a visual analog scale [VAS], numeric rating scale [NRS], and pain assessment in advanced dementia [PAINAD] scale), together with demographic, clinical, and surgical variables and complications. Heart rate and blood pressure were recorded during surgery. Differences in all variables were evaluated using a paired t-test and confirmed through Wilcoxon matched-pairs signed-rank and Kruskal-Wallis tests.

RESULTS

No complications occurred among the 83 patients enrolled. Statistically significant differences were found in the mean VAS score at postoperative days 0 (p = 0.05), 2 (p = 0.03), and 3 (p = 0.03). The PAINAD scale score showed significant differences between groups at postoperative days 1 (p = 0.006), 2 (p = 0.001), 3 (p = 0.03), and 4 (p = 0.05). The proportion of patients reporting a VAS score ≥ 3 in the first day after surgery was lower in the SPGB group than in the standard treatment group (71.9% vs 89.5%), although this difference did not reach statistical significance. At postoperative day 180, 5 patients (2 in the control group, 3 in the treatment group) had developed chronic PCP (NRS score ≥ 3).

CONCLUSIONS

SPGB is a safe and effective procedure as an adjunctive treatment for PCP management in elective supratentorial craniotomy during the first 4 postoperative days compared with standard therapy. Further studies are needed to better define the clinical impact of SPGB use and its indications. Clinical trial registration no.: NCT05136625 (ClinicalTrials.gov).

A Case Report of Sphenopalatine Ganglion Block Relieving Chronic Pain Post-Dental Bone Graft Surgery

Chronic orofacial pain, by definition, is a pain that can anatomically extend anywhere between the area just under the orbitomeatal line, anterior to the pinnae, and above the neck. It occurs for 15 days or more per month, lasting four or more hours daily, for at least three months. Chronic orofacial pain, including persistent idiopathic facial pain syndrome, can significantly impact patients' quality of life and pose challenges for effective management. This case report describes a successful transnasal approach in treating a patient with severe oral pain following a bone graft surgery by blocking the sphenopalatine ganglion. The block provided significant pain relief and improved the patient's daily functioning. This minimally invasive treatment option offers an alternative for managing chronic orofacial pain after dental procedures such as bone graft surgery.

Effects of bilateral transmucosal sphenopalatine ganglion block on intraoperative anesthetic requirements and recovery profile in children undergoing palatoplasty under general anesthesia

Background and Aims

Sphenopalatine ganglion block (SPGB) given as injection provides excellent perioperative analgesia during palatoplasty. Our objectives were to assess the effect of transmucosal SPGB on anesthetic requirements, intraoperative hemodynamics, recovery time, and emergence delirium in children undergoing palatoplasty.

Material and Methods

This prospective, randomized study was conducted in 30 children with cleft palate undergoing palatoplasty, divided into two equal groups. After induction and intubation, patients in Group B received bilateral SPGB using cotton-tipped applicators soaked in 2% lignocaine, which were passed through both the nares, and the distal tip was positioned just superior to middle turbinate and anterior to pterygopalatine fossa and sphenopalatine ganglion. In Group C, saline-soaked cotton applicators were used. All patients received general anesthesia as per a standardized protocol. Intraoperative heart rate, mean arterial pressure, the requirement of anesthetics, extubation time, and emergence delirium were compared.

Results

Compared with Group C, patients in Group B had significantly lower sevoflurane consumption (17.2 ± 2.6 vs. 27.5 ± 5.0mL, P < 0.001) and fentanyl consumption (2.2 ± 0.5 vs. 3.2 ± 0.6 μ/kg, P < 0.001).The extubation time was significantly shorter in Group B (3.9 ± 0.7 vs. 9.5 ± 1.6 minutes, P < 0.001). PAED (Pediatric Anesthesia Emergence Delirium Scale) scores at 5and 10 minutes were significantly higher in Group C (P < 0.001). Intraoperative heart rate was significantly higher in Group C. Group C had significantly higher mean arterial pressure at 15, 60, and 75 minutes.

Conclusion

Preoperative, SPGB administered by mucosal application of local anesthetic significantly reduced sevoflurane and fentanyl requirements, with stable hemodynamics, quicker recovery, and less emergence delirium in children undergoing palatoplasty.

Persistent Coronavirus Disease 2019 Headache Relieved with Sphenopalatine Ganglion Block

According to the World Health Organization, as of September 2021, there have been over 226.8 million people diagnosed with coronavirus disease 2019 and over 4.6 million deaths from this disease. Out of those who have survived the coronavirus disease 2019 infection, many individuals have symptoms that linger on. We would like to describe the first report of a patient with a 5-month history of a persistent coro- navirus disease 2019 headache, which was finally successfully aborted with a single transnasal sphenopalatine ganglion block. A female in her early 50s presented to our pain clinic after suffering from a new, debilitating headache that began with the coronavirus disease 2019 illness and persisted for 5 months. Every evening the patient would experience a severe headache located deep inside/behind the left eye that would be resistant to analgesic medications. After 1 transnasal sphenopalatine ganglion block, the patient's coronavirus disease 2019 headache was completely resolved.

Comparison of Temperature and Pain Changes between the Drip and Topical Methods of Administering the Transnasal Sphenopalatine Ganglion Block

The objective of this study was to compare facial temperatures and the visual analogue scale (VAS) between the drip method and the topical method of transnasal sphenopalatine ganglion block (SPGB). The transnasal SPGB is administered to patients with facial or head and neck pain. In the transnasal approach, the drip and topical methods are frequently used. We compared facial temperatures and VAS after transnasal SPGB. Medical records of 74 patients who visited the pain clinic and underwent transnasal SPGB were retrospectively reviewed. A total of 156 transnasal SPGB were performed. The patients were divided into the drip-method and topical-method groups. Facial temperatures were measured in six areas of the right and left forehead, maxilla, and mandible before and 30 min after completion of the transnasal SPGB. Temperatures were compared before and 30 min after SPGB in each group and between the two groups. VAS scores were compared at the same times of SPGB in each group and between the two groups. In the drip-method group, there were significant increases at four areas of the face in temperature changes at 30 min after SPGB. In the topical-method group, there was no significant difference in the temperature changes at 30 min after SPGB. There were statistically significant differences in the facial temperature changes between the two groups in the right forehead (p = 0.001), left forehead (p = 0.015), and right maxillary area (p = 0.046). In herpes zoster, there were statistically significant differences in the VAS scores between before and 30 min after SPGB in both groups (p < 0.001, p = 0.008) and between two groups (p < 0.001). In migraine, there were statistically significant differences in VAS scores between before and 30 min after SPGB in both groups (p < 0.001, p = 0.004) and between two groups (p = 0.014). Transnasal SPGB using two methods showed different temperature changes and VAS scores.

Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey

OBJECTIVE

This national postal survey aimed to examine Canadian emergency physicians' practice patterns with respect to drug treatment and perspectives on peripheral nerve blocks.

BACKGROUND

The treatment of primary headache disorders in the emergency department is variable.

METHODS

We surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman's method: an initial invitation was followed by up to four reminders to nonresponders. Physicians were asked questions regarding their frequency of medication administration and perspectives toward peripheral nerve blocks.

RESULTS

Of 500 mailed surveys, 468 were delivered and 179 physicians responded (response rate = 38.2%). The majority of physicians were men (92/144, 63.9%); 80.6% (116/144) had been in practice for greater than or equal to 10 years with 50.7% (75/148) in a community or district general teaching hospital. Commonly used pharmacotherapies for primary headaches were intravenous dopamine receptor antagonists (69%), co-administration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), nonsteroidal anti-inflammatory drugs (NSAIDs) alone (53.5%), and acetaminophen (51.4%). Only 80 of 144 physicians (55.6%) reported previous experience with peripheral nerve blocks (95% confidence interval [CI] = 48%-65%). The majority (68/80, 85.0%) agreed peripheral nerve blocks are safe and 55.1% (43/78) agreed they are effective. The vast majority (118/140, 84.3%) would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial (95% CI = 78%-90%).

CONCLUSION

NSAIDs alone, as well as dopamine receptor antagonists with or without ketorolac are commonly used for primary headache in Canadian emergency departments. A large proportion of physicians have never used a peripheral nerve block in their practice; among those who have experience with peripheral nerve blocks, the majority find them safe and effective. The majority of respondents would consider peripheral nerve blocks as a first-line treatment option given sufficient evidence from a future trial.

Peripheral Nerve Blocks for Postdural Puncture Headache: A New Solution for an Old Problem?

BACKGROUND/AIM

Postdural puncture headache (PDPH) is one of the earliest recognized complications of regional anesthesia after inadvertent dural puncture. Epidural blood patch (EBP) is the "gold standard" for the treatment of PDPH. Several alternatives have been suggested as peripheral nerve blocks. The aim of this systematic review was to find out the potential efficacy and safety of peripheral nerve blocks for the treatment of PDPH.

MATERIALS AND METHODS

The main databases were systematically searched in September 2020 for studies examining regional anesthesia and PDPH.

RESULTS

Nineteen studies were identified, including a total of 221 patients. Sphenopalatine ganglion block, greater occipital nerve block, and lesser occipital nerve block were performed. All participants reported a numeric rating scale (NRS) <4 after peripheral nerve blocks at 1, 24 and 48 h. Only patients with PDPH after diagnostic lumbar puncture reported NRS ≥4 after 48 h. No major adverse events were reported. Approximately, 17% of patients underwent a second or more peripheral nerve blocks. In 30 participants, EBP was required.

CONCLUSION

To our knowledge, this is the first systematic review on the use of peripheral nerve blocks to treat PDPH. Peripheral nerve blocks can be considered as analgesic options in the management of PDPH.

Transnasal Sphenopalatine Ganglion Block for Management of Postdural Puncture Headache in Non-Obstetric Patients

BACKGROUND

This study investigated the efficacy and safety of transnasal sphenopalatine ganglion block (SPGB) for treatment of postural puncture headache (PDPH) in non-obstetric patients.

METHODS

This retrospective study was conducted at the Ankara Research and Educational Hospital, in Turkey, and included 26 non-obstetric patients (age, ≥18 years) who were diagnosed with PDPH and unresponsive to conservative therapy or unable to continue it because of side effects. Transnasal SPGB was performed in each nostril. Pain severity was assessed with the Visual Analogue Scale (VAS) at 15 min, 30 min, 24 h, and 48 h after the procedure, while patients were seated. The patients were monitored for 48 h for adverse effects (AEs). Patient treatment satisfaction was assessed at 48 h after the procedure by using the Patient Global Impression of Change (PGIC) scale.

RESULTS

Headache at 15 min post-procedure was relieved rapidly. At 24 h post-procedure, nearly half of patients (42.3%) had no pain, and all patients (100%) had a VAS score of <3. Nasal discomfort, throat numbness, and nausea were AEs reported after SPGB; however, these AEs were completely relieved at 24 h after the procedure. According to the PGIC scale scores at 48 h post-procedure, 73.1% of patients evaluated themselves as "much improved" and 26.9% evaluated themselves as "very much improved".

CONCLUSION

When PDPH does not respond to conservative treatment, it may be treated effectively with transnasal SPGB, which is a noninvasive, safe, well-tolerated, and straightforward method with a low complication rate.

Transnasal sphenopalatine ganglion block for post-dural puncture headache and associated tinnitus

Lumbar epidurals are frequently inserted for women in labour as they provide excellent analgesia. One of the more common procedural complications is post-dural puncture headache which can be associated with auditory symptoms such as hearing loss and tinnitus and can be treated with an epidural blood patch. Sphenopalatine ganglion blocks have also been used to treat post-dural puncture headache but have not been previously shown to resolve the associated tinnitus. We report a case where postural neck pain and tinnitus from an accidental dural puncture during lumbar epidural insertion for labour analgesia was treated successfully with a sphenopalatine ganglion block. Further, we explore the literature on the cause of tinnitus in post-dural puncture headache and the possible mechanism by which a sphenopalatine ganglion block relieves both post-dural puncture headache and the associated tinnitus.

Acute effect of sphenopalatine ganglion block with lidocaine in a patient with SUNCT

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNCT/SUNA) is a rare severe headache. At the time of an attack, it can hinder a patient from eating and requires acute intervention. The sphenopalatine ganglion is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. Sphenopalatine ganglion block has long been used in the treatment of headache, particularly when conventional methods have failed. Here, we present a patient who was resistant to intravenous lidocaine, but responded rapidly to sphenopalatine ganglion block during an acute episode of SUNCT/SUNA.

Sphenopalatine Ganglion Block: Treatment of Migraine and Trigeminal Neuralgia Associated With Multiple Sclerosis

Head and facial pain are a burden to many people both directly and indirectly. This is manifested not only as a personal burden but also as a financial one in the form of sick leaves from work and loss of workplace productivity. These costs stem from emergency department visits, hospitalizations, preventative treatments, and medical management. Medical management of migraine headaches and other causes of facial pain often proves insufficient, and sphenopalatine ganglion block (SPGB) provides an innovative, adjunctive outpatient treatment option with excellent results in alleviating symptoms. We present a case of a young female suffering from headache and orofacial pain secondary to multiple sclerosis (MS) and trigeminal neuralgia (TN) refractory to traditional medical management, who underwent SPGB with immediate relief of her symptoms. Due to its effectiveness, the role of the SPGB in the treatment of various other conditions causing headache and orofacial pain, such as MS or even TN, continues to expand providing relief and restoring functionality.

The effectiveness of endoscopic sphenopalatine ganglion block in management of postoperative pain after septal surgery

BACKGROUND

This study evaluated the effect of bilateral endoscopic sphenopalatine ganglion block (SPGB) for management of postoperative pain in patients undergoing septoplasty.

METHODS

Sixty septoplasty patients (51.7% male, 48.3% female, aged 18 to 45 years) were randomly assigned to general anesthesia (GA) alone (control) (n = 30) or GA plus endoscopic SPGB (n = 30). Demographic data, duration of surgery, blood loss, postoperative visual analogue scale (VAS) pain scores (upon arrival at the postanesthesia care unit [PACU] and 2, 6, 12, and 24 hours after surgery), overall analgesic usage (end of 24 and 168 hours after surgery), overall satisfaction with the pain control (end of 24 and 168 hours after surgery), and complications (bleeding, nausea and vomiting, and visual disturbance) were recorded.

RESULTS

Pain scores upon arrival to the PACU and 2, 6, 12, and 24 hours after surgery were significantly lower in the SPGB group compared to the control group (p < 0.001). Moreover, the SPGB group had significantly lower analgesic requirements and higher satisfaction scores with their pain control at the end of 24 and 168 hours after surgery compared to the control group (p < 0.001). The 2 groups significantly differed in terms of intraoperative blood loss (p = 0.024), and surgery time was longer in the SPGB group compared to the control group (p < 0.001).

CONCLUSION

SPGB with bupivacaine is a safe and effective method to reduce pain after septoplasty, and it is a cost-effective alternative to high doses of analgesics.

Are repetitive pericranial nerve blocks effective in the management of chronic paroxysmal hemicrania?: A case report

INTRODUCTION

Paroxysmal hemicrania (PH) is a chronic headache disorder characterized by unilateral pain attacks accompanied by cranial autonomic symptoms and responds to indomethacin completely. There are few alternative treatment options for the patients who cannot tolerate indomethacin. Studies exploring the effects of repetitive peripheral cranial nerve blocks in the management of chronic PH are limited.

PATIENT CONCERNS AND DIAGNOSIS

A 34-year-old woman with a 4-year history of PH was evaluated. Her pain was prevented by indomethacin without side effects; however, she wanted to try to conceive.

INTERVENTIONS

Repetitive pericranial nerve blocks, great occipital nerve, infraorbital nerve, supraorbital nerve, and sphenopalatine ganglion block, using local anesthetics and steroids were performed once a week for a 6 weeks period.

OUTCOMES

A follow-up of 3 months showed that there was no pain relief following the injections and patient was needed to be maintained on indomethacin.

CONCLUSION

Although pericranial nerve blocks have been tried in chronic PH cases with positive influences, this case indicated that repetitive nerve blocks were not always a successful therapy option.

Changes in facial temperature measured by digital infrared thermal imaging in patients after transnasal sphenopalatine ganglion block: Retrospective observational study

Sphenopalatine ganglion block (SPGB) is a technique developed in the 1990s for the management of head and neck pain patients. Recently, transnasal sphenopalatine ganglion block (TN-SPGB) has been widely used for these patients; however, no objective methods exist for validating the success of TN-SPGB. In this study, we measured the changes in facial temperature before and 30 minutes after TN-SPGB by using digital infrared thermal imaging (DITI) to validate its success.The medical records of patients, who underwent TN-SPGB and facial DITI between January 2016 and December 2017, were reviewed. TN-SPGB and facial DITI were performed 36 times in 32 patients. The changes in facial temperatures measured at the forehead (V1), maxillary area (V2), and mandibular area (V3) by using DITI before and 30 minutes after TN-SPGB were recorded and compared. The temperatures on the ipsilateral and contralateral sides of these areas were also compared. The comparison between pain relief group and pain maintenance group was analyzed.After TN-SPGB, the temperature decreased significantly on both sides of V1 (P = .0208, 0.0181). No significant differences were observed between the ipsilateral and contralateral sides (P > .05). There was no correlation between changes in temperature and changes in pain score in the pain regions after the procedure (P > .05).The temperature decreased significantly in V1 area at 30 minutes after TN-SPGB compared with the temperature before TN-SPGB. Based on these results, we propose using DITI to measure temperature changes as an objective method for verifying the success of TN-SPGB.

Effect of Sphenopalatine Ganglion Block With Bupivacaine on Postoperative Pain in Patients Undergoing Endoscopic Sinus Surgery

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.

Results

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).

Conclusion

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.

Sphenopalatine Ganglion Block and Radiofrequency Ablation: Technical Notes and Efficacy

Background: Sphenopalatine ganglion (SPG) blockade or lesioning can offer significant pain relief for cluster headaches (CHs) and a variety of other pain syndromes involving the head and face. Methods: We reviewed the literature on the efficacy of SPG block and radiofrequency ablation (RFA) using PubMed and Google Scholar. Results: The infrazygomatic technique can be used to directly access the SPG for injection of local anesthetic or lesioning using RFA. Important technical points to achieve these procedures are described. SPG blockade efficacy is supported by randomized controlled studies but SPG RFA is not. Conclusion: Targeting the SPG is a promising treatment option for refractory CHs. RFA and neuromodulation have the potential to offer long-term significant pain relief, but more randomized studies are needed to demonstrate their efficacy.

Clinical Anatomy of Blockade of the Pterygopalatine Ganglion: Literature Review and Pictorial Tour Using Cadaveric Images

Pterygopalatine ganglion block (sphenopalatine ganglion block) is a well-known procedure for treating cluster headache and for relieving cancer pain. In this review, the history and anatomy of the pterygopalatine ganglion are discussed, and images, including computed tomography and endoscopy, are presented to improve understanding of the clinical anatomy of the ganglion regarding the block procedure.

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus

BACKGROUND

Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

METHODS

Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.

RESULTS

Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).

CONCLUSION

The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.

The Role of Endoscopic Sphenopalatine Ganglion Block on Nausea and Vomiting After Sinus Surgery

Background Postoperative nausea and vomiting (PONV) are among the most common unpleasant and distressing adverse events following surgery under general anesthesia. Functional endoscopic sinus surgery (FESS) is a common otolaryngology procedure. Prevention of PONV and early recovery are cost-effective. Objective The aim of this study was to evaluate the prophylactic effect of bilateral endoscopic injection of lidocaine with epinephrine in the sphenopalatine ganglion (SPG) on PONV in patients undergoing FESS. Methods One hundred patients with chronic rhinosinusitis undergoing general anesthesia for FESS were enrolled in this double-blind, placebo-controlled study. Patients were randomized to receive injection of 2 mL of 2% lidocaine with epinephrine or 2 mL of saline at the end of surgery. Postoperatively, patients were observed for 24 h. PONV was evaluated immediately, 6 h, and 24 h after surgery. Results The 2 groups were comparable in characteristic and intraoperative features. In general, the incidence of PONV after FESS was 36%. The average time that patients can tolerate oral feeding was 3.4 h after surgery. Endoscopic SPG injection with lidocaine significantly reduced the incidence of vomiting and PONV. In addition, SPG injection with lidocaine reduced the incidence of severe vomiting and decreased the number of vomiting episodes. No complications were encountered in either group. Conclusion SPG injection with lidocaine at the end of surgery is a safe, noninvasive, and an effective technique in reducing early PONV in endoscopic sinus surgery patients.

Home-based Application of Sphenopalatine Ganglion Block for Head and Neck Cancer Pain Management

Background:

Head and neck cancer pain is intractable and difficult to manage. Many a times it is difficult to treat with oral opioids and adjuvants.

Aim:

This study aims to study the effects of transnasal sphenopalatine ganglion block (SPGB), administered using cotton swab/ear bud by patients’ caretaker, at home, for pain management.

Study Design:

This is a prospective, single-arm observational study conducted on 100 head and neck cancer patients, from January 2014 to December 2015. Patients and caretaker were given a demonstration of the procedure using sterile cotton swab/ear buds. They were advised to repeat the procedure when their visual analog score (VAS) was more than 5. They continued with the oral analgesics. They kept the records of pre- and post-procedure pain score (VAS), the frequency of repetition, ease of performance of procedure, and morphine requirement. A paired t-test (SPSS software) was used for statistical analysis.

Results:

A significant reduction in pain was noted by a decrease in mean VAS from 8.57 ± 1.31 to 2.46 ± 1.23 (P < 0.0001), immediately on first administration. The mean duration of analgesia was 4.95 ± 3.43 days. Pre- and post-procedure mean morphine requirement were 128.2 ± 84.64 and 133.8 ± 81.93 (P > 0.05) mg per day, at the end of 2 months. Ease of performance was observed in 88 patients.

Conclusion:

The home-based application of SPGB is an easy, safe, and cost-effective method to manage cancer pain. It provides excellent immediate pain relief with a minimum side effect. It can be performed bilaterally, repeatedly and even with a feeding tube in place.

Hemicrania continua may respond to repetitive sphenopalatine ganglion block: A case report

BACKGROUND

Hemicrania continua (HC) is a chronic headache disorder characterized by a continuous, strictly unilateral head pain accompanied by cranial autonomic symptoms, which completely responds to indomethacin; however, few alternative treatment options exist for the patients with this disorder who cannot tolerate indomethacin. Sphenopalatine ganglion (SPG) block has been used for the treatment of various headaches, with the strongest evidence for efficacy in cluster headache.

CASE REPORT

A 52-year-old woman with a 7-year history of HC was evaluated in our clinic for management of her headaches after she had stopped using indomethacin due to a bleeding gastrointestinal ulcer. After failing multiple pharmacologic therapies, she was treated with repetitive SPG blocks using bupivacaine (0.6 mL at 0.5%) twice a week for 6 weeks and followed by maintenance therapy. This treatment protocol resulted in significant improvement in her headaches, mood, and functional capacity.

CONCLUSION

SPG block using a local anesthetic may be an effective treatment for patients with HC, specifically for those who cannot tolerate indomethacin, or when this drug is contraindicated.

Long-term efficacy of a double-blind, placebo-controlled, randomized study for repetitive sphenopalatine blockade with bupivacaine vs. saline with the Tx360 device for treatment of chronic migraine

Background

This study aims to determine if repetitive sphenopalatine ganglion (SPG) blockades with 0.5% bupivacaine delivered with the Tx360^® device results in long‐term improvement in chronic migraine (CM). The SPG is a small concentrated structure of neuronal tissue that resides within the pterygopalatine fossa in close proximity to the sphenopalatine foramen and is innervated by the maxillary division of the trigeminal nerve. In a previous article, these authors reported repetitive SPG blockades with 0.5% bupivacaine delivered by the Tx360^® device, which was an effective and well‐tolerated intervention to incrementally decrease baseline headache intensity of subjects with CM.

Methods

This was a double‐blind, parallel‐arm, placebo‐controlled, randomized pilot study using a novel intervention for acute treatment in CM. A total of 41 subjects were enrolled at two headache specialty clinics in the USA. Eligible subjects were between 18 and 80 years of age and had a history of CM defined by International Classification of Headache Disorders‐II definition. Subjects were allowed a stable dose of migraine preventive medications that was maintained throughout the study. Following a 28‐day baseline period, subjects were randomized by computer‐generated lists 2:1 to receive 0.3 cc of 0.5% bupivacaine or saline, respectively, delivered with the Tx360^® twice a week for 6 weeks. Secondary end‐points reported in this manuscript include post‐treatment measures including number of headache days and quality of life measures.

Results

The final data set included 38 subjects: 26 in the bupivacaine group and 12 in the saline group. Our primary end‐point for the study, difference in numeric pain rating scale scores, was met and reported in a previous article. The supplemental secondary end‐points reported in this manuscript did not reach statistical significance. When looking collectively at these end‐points, trends were noticed and worthy of reporting. Subjects receiving bupivacaine reported a decrease in the number of headache days 1 month post‐treatment (M_diff = −5.71), whereas those receiving saline only saw a slight improvement (M_diff = −1.93). Headache Impact Test 6 scores were decreased in the bupivacaine group at 1 month (M_diff = −5.13) and 6 months (M_diff = −4.78) post‐treatment, but only a modest reduction was seen for those receiving saline at 1 and 6 months, respectively (M_diff = −2.08, M_diff = −1.58). Furthermore, subjects receiving bupivacaine reported a reduction in acute medication usage and improved quality of life measures (average pain in the previous 24 hours, mood, normal work, and general activity) up to 6 months post‐treatment. The changes in these measures for the saline group were minimal.

Conclusions

Data from this exploratory pilot study suggest that there may be long‐term clinical benefits with the use of repetitive SPG blockades with bupivacaine delivered with the simple to use Tx360^® device. These include a sustained reduction of headache days and improvement in several important quality of life assessments. The SPG blockades were not associated with any significant or lasting adverse events. Further research on SPG blockade is warranted.

A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine

Objective

To determine if repetitive sphenopalatine ganglion (SPG) blocks with 0.5% bupivacaine delivered through the Tx360® are superior in reducing pain associated with chronic migraine (CM) compared with saline.

Background

The SPG is a small concentrated structure of neuronal tissue that resides within the pterygopalatine fossa (PPF) in close proximity to the sphenopalatine foramen and is innervated by the maxillary division of the trigeminal nerve. From an anatomical and physiological perspective, SPG blockade may be an effective acute and preventative treatment for CM.

Method

This was a double-blind, parallel-arm, placebo-controlled, randomized pilot study using a novel intervention for acute treatment in CM. Up to 41 subjects could be enrolled at 2 headache specialty clinics in the US. Eligible subjects were between 18 and 80 years of age and had a history of CM defined by the second edition of the International Classification of Headache Disorders appendix definition. They were allowed a stable dose of migraine preventive medications that was maintained throughout the study. Following a 28-day baseline period, subjects were randomized by computer-generated lists of 2:1 to receive 0.5% bupivacaine or saline, respectively. The primary end-point was to compare numeric rating scale scores at pretreatment baseline vs 15 minutes, 30 minutes, and 24 hours postprocedure for all 12 treatments.

SPG blockade was accomplished with the Tx360®, which allows a small flexible soft plastic tube that is advanced below the middle turbinate just past the pterygopalatine fossa into the intranasal space. A 0.3 cc of anesthetic or saline was injected into the mucosa covering the SPG. The procedure is performed similarly in each nostril. The active phase of the study consisted of a series of 12 SPG blocks with 0.3 cc of 0.5% bupivacaine or saline provided 2 times per week for 6 weeks. Subjects were re-evaluated at 1 and 6 months postfinal procedure.

Results

The final dataset included 38 subjects, 26 in the bupivacaine group and 12 in the saline group. A repeated measures analysis of variance showed that subjects receiving treatment with bupivacaine experienced a significant reduction in the numeric rating scale scores compared with those receiving saline at baseline (M = 3.78 vs M = 3.18, P = .10), 15 minutes (M = 3.51 vs M = 2.53, P < .001), 30 minutes (M = 3.45 vs M = 2.41, P < .001), and 24 hours after treatment (M = 4.20 vs M = 2.85, P < .001), respectively. Headache Impact Test-6 scores were statistically significantly decreased in subjects receiving treatments with bupivacaine from before treatment to the final treatment (M_diff = −4.52, P = .005), whereas no significant change was seen in the saline group (M_diff = −1.50, P = .13).

Conclusion

SPG blockade with bupivacaine delivered repetitively for 6 weeks with the Tx360® device demonstrates promise as an acute treatment of headache in some subjects with CM. Statistically significant headache relief is noted at 15 and 30 minutes and sustained at 24 hours for SPG blockade with bupivacaine vs saline. The Tx360® device was simple to use and not associated with any significant or lasting adverse events. Further research on sphenopalatine ganglion blockade is warranted.