Sphenopalatine Ganglion Block
If you suffer from chronic headaches and/or facial pain that has failed to improve with conventional therapy or medication, you may benefit from this simple treatment option. A sphenopalatine ganglion (SPG) block takes just minutes to perform and the results are almost immediate!
What is a Sphenopalatine Ganglion Block?
A sphenopalatine ganglion block is a minimally invasive procedure used to treat at treat head and facial pain. While the procedure itself is short and performed in your doctor’s office, it requires a great deal of technical proficiency, hence very few physicians are trained how to do it. A sphenopalatine ganglion block is an established treatment method for a wide variety of pain syndromes.
The sphenopalatine ganglion is a little-known region in the face that transmits pain signals from the head and face. By placing a small amount of local anesthetic on it, pain management specialists can effectively treat everything from trigeminal neuralgia to migraine headaches!
The sphenopalatine ganglion block is versatile procedure that has been used by pain management doctors for decades to treat pain. This truly amazing procedure is an established treatment method for a wide variety of pain syndromes:
Trigeminal neuralgia[1][2]
Sphenopalatine neuralgia
Migraine headaches
Cluster headaches
Atypical facial pain[3]
Cancer pain of the head and neck
Tongue and mouth pain
Temporomandibular joint (TMJ) pain[2]
Sluder’s neuralgia[4]
Paroxysmal hemicrania[5]
Other possible therapeutic uses reported in literature include:
Herpes Zoster[6]
Postherpetic neuralgia[5]
Vasomotor rhinitis
Complex regional pain syndrome (CRPS) [7][8][9]
Reflex Sympathetic Dystrophy (RSD)
Low back pain[10]
Post-traumatic headache[11]
What Are The Benefits of a Sphenopalatine Ganglion (SPG) Block?
The Sphenopalatine ganglion block is a safe, effective and established procedure for treating refractory head and face pain. Any patient suffering from facial pain, chronic headaches, trigeminal neuralgia and the like will attest to how debilitating their pain can be. Classically, these types of pain are treated with a series of medications – cycling from one to the next based on trial and error. Most medications are ineffectual and those that are effective either have intolerable side effects or are the fourth or fifth medication tried. This life changing procedure can offer immediate relief and potentially allow pain sufferers to avoid the nuisance of daily medications.
This procedure can be performed as a diagnostic block or a therapeutic block. In most cases (especially in nonmalignant pain syndromes), you physician will choose to perform a diagnostic block first.
- Diagnostic Block – The injection will consist of a local anesthetic, like Lidocaine or Bupivacaine, to test the pain’s response to a block of the superior hypogastric plexus.
- Therapeutic Block – In patients with a documented response to the diagnostic block (i.e. a temporary decrease in pain and symptoms), a therapeutic block will follow with the administration of a neurolytic agent such as dehydrated alcohol or phenol. This can also be performed via radiofrequency neurolysis.
Where is the Sphenopalatine Ganglion?
The sphenopalatine ganglion (also known as the pterygopalatine ganglion, Meckel’s ganglion, or nasal ganglion) is a parasympathetic ganglion approximately 4-5 mm in size suspended from the maxillary nerve by the pterygopalatine nerves. It is located medial to the maxillary nerve (a division of the trigeminal nerve). The ganglion is found in the pterygopalatine fossa. This fossa is bordered:
- anteriorly by the maxillary sinus
- posteriorly by the medial pterygoid plate
- medially by the palatine bone
- superiorly by the sphenoid sinus
A large venous plexus overlies the fossa, however the pterygomaxillary fissure allows passage of a needle into the fossa. Additionally, the pterygopalatine foramen is located medial to the ganglion and is just posterior to the middle turbinate. A mucous membrane and a thin layer of connective tissue cover the ganglion itself allowing it to be blocked topically as well as via the nasal cavity.
Sensory fibers from the maxillary nerve pass through the sphenopalatine ganglion and provide sensation to the:
- Upper teeth
- Nasal membranes
- Soft palate
- Lacrimal glands
- Glands of the nasal cavity
- Paranasal sinuses
- Palate
- Parts of the pharynx
- Mid Face (through the Maxillary Division of the Trigeminal Nerve)
A small number of motor nerves are believed to travel with the sensory trunks. Its branches include:
- Orbital Branches
- Nasopalatine Nerve
- Greater Palatine Nerve
- Lesser Palatine Nerve
- Posterior Superior Lateral Nasal Branch
- Pharyngeal branch of Maxillary Nerve
Since only pre-ganglionic parasympathetic axons are believed to synapse within the ganglion, it is classified as a parasympathetic ganglion. However, post-ganglionic sympathetic neurons as well as the fibers from the maxillary division of the trigeminal nerve are contained within the sphenopalatine ganglion. Because of this unique combination, both sympathetic and parasympathetic neurons as well as somatic and sensory fibers can all be affected when performing a sphenopalatine ganglion block.
The diagnostic portion of the procedure is typically performed twice to make certain the sphenopalatine ganglion is indeed a source of pain. Once this has been confirmed, the neurolysis is a one time procedure that will offer pain relief for several months at a time.
When Will I Feel Better?
The relief from a positive diagnostic block is almost immediate, as the effects of the local anesthetic should be felt even before the patient leaves the office. The medication will wear off in just a few hours and the pain will return – THIS IS NORMAL. This will let your doctor know that the sphenopalatine ganglion is transmitting pain, verifying it as a target for the therapeutic procedure.
The relief from the therapeutic procedure make take up to a few days to reach maximum effect. In the case of pulsed radiofrequency ablation, the relief may take as long as 2 weeks to be truly noticeable. Conventional radiofrequency ablation may begin to work much quicker.
Is a Sphenopalatine Ganglion Block Right for Me?
If you suffer from facial pain, headaches (including migraines), or even trigeminal neuralgia that has failed to resolve with medications and other conservative therapies, this treatment may be an option for you. A sphenopalatine ganglion block should be performed under the strict supervision of a board-certified pain management specialist.
Contact the Ainsworth Institute to set up an initial evaluation to find out if you are a candidate for this procedure.
There are three possible approaches your physician can utilize to perform a sphenopalatine block:
1. Intranasal
2. Infrazygomatic
3. Transoral
The intranasal approach is the simplest and most common – however this takes much longer and can cause a great deal of discomfort. The location of the ganglion in relation to the middle turbinate as well as the lateral nasal mucosa allows absorption of local anesthetic from a cotton-tipped applicator inserted into the nare.
This technique is performed by having you lie down your back with your head extended backward slightly. At this point your physician will inspect your nasal airway for any obstructions (septal deviation, large polyps, etc). Next, a small of amount lidocaine will be introduced to your nose, at which point you will be asked to quickly inhale – this will allow the anesthetic to be drawn upward in the posterior nasal pharynx. The nasal passage will now be lubricated and anesthetized to make the procedure more comfortable.
Once the nasal passage is numb, your physician will introduce a sterile cotton-tipped applicator soaked in anesthetic into the nare and slowly advance it into the nose. Typically, 2% to 4% lidocaine or 0.25% to 0.5% bupivacaine are used for this technique. The applicator is advanced in a line parallel to the zygoma, with the tip angled laterally, along the superior border of the middle turbinate until it reaches the posterior wall of the nasopharynx. At this point, a second applicator may be inserted into the nare using the same technique, except advanced approximately 0.5 to 1.0 cm deeper and superior to the first. The applicator is usually left in place for approximately 30 to 45 minutes.
Signs of a successful block of the sphenopalatine ganglion include tearing and nasal congestion. If the sphenopalatine ganglion is a pain generator or transmitter, pain relief should begin quickly. If after 20 to 30 minutes there are no signs of a block, or the patient has not received any pain relief, additional local anesthetic may be needed and can be trickling down the shaft of the applicator.
The infrazygomatic approach is much less common due to the amount of technical proficiency required to perform it, as well as the need for x-ray imaging for guidance. However, this approach is advantageous as the anesthetic is delivered directly onto the ganglion through a needle with more accuracy due to the use of x-ray. Also, the time needed to complete this approach is considerably less than that needed for the intranasal.
Before the procedure begins, the medical staff will start an IV and provide some light sedation for your comfort. You will be placed in the supine position with a pillow under your head. Your physician will sterilize your face on the appropriate side and then numb the skin with local anesthetic to make you as comfortable as possible throughout the entire procedure. The pterygopalatine fossa (appearing as a “V” or an “inverted vase”) is identified using fluoroscopy – a real time X-ray device that will allow your physician to visualize the needle the entire way up the skull and make sure it is properly placed inside the pterygopalatine fossa. Afterward, a thin needle is introduced into the fossa until it reaches the sphenopalatine ganglion.
Once the needle is properly positioned, a small amount of anesthetic is injected into the fossa. When the injection is complete, a small bandage covers the injection site. Signs of a successful block of the sphenopalatine ganglion include tearing and nasal congestion. If the sphenopalatine ganglion is a pain generator or transmitter, pain relief should be profound and begin quickly.
With either approach, your physician will monitor your pain and vital signs (pulse, blood pressure) during and after the procedure.
In cases where you have a good response the block, but the relief is temporary, performing a neurolysis or radiofrequency ablation of the sphenopalatine ganglion may be considered for longer duration of pain and symptom relief.
The intranasal approach typical requires 30-40 minutes to complete; the infrazygomatic approach can take little as a third of that (10-15 minutes).
Risk Factors
Any medical procedure carries with it some inherent risk, but the risk for this particular procedure is very low. It is considered an appropriate non-surgical treatment for patients suffering from a variety of head and facial pain. Bleeding and infection, while very rare, are a potential complication. The most common side effects of this procedure result from the local anesthetic dripping down from the nasopharynx into the throat and oropharynx causing a bitter taste in your mouth or numbness in the back of the throat.[12] Other side effects include nose bleed from either the needle or the cotton-tipped applicator causing a minor abrasion within the nasal passageway.
Mild lightheadedness can occur on occasion but typically resolves on its own 20-30 minutes after the procedure. Other potential risks include bruising, dysesthesias, paresthesias, and low probability of nerve damage. Lastly, there are theoretical risks due to the use of local anesthetic should it be injected into a blood vessel (i.e. seizure or tremors). If you have a documented allergy to iodine or local anesthetic, this should be discussed with your physician prior to scheduling the procedure.
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Evidence of Performance
The sphenopalatine ganglion block is a well-established treatment for head and facial pain that was first described by Sluder in 1908.[13] It was in that publication that the sphenopalatine ganglion was first implicated in the pathogenesis of pain and a blockade was performed to successfully alleviate the discomfort. In the 100 years since its inception, this procedure has been repeatedly described and studied due to its efficiency in treating acute and chronic pain in the face and head. Clinical trials have shown this procedure to be effective in treating headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection.[14]
In 1925, Ruskin suggested the sphenopalatine block in the treatment of trigeminal neuralgia – the first physician to make such a claim.[15] He believed since the maxillary branch of the trigeminal nerve is directly connected to the ganglion via the pterygopalatine nerves, it would make for a proper target in relieving symptoms associated with trigeminal neuralgia.
Another interesting indication for sphenopalatine blocks is headache – more specifically, migraine and cluster headaches. Due to the recalcitrant nature of headaches and the growing subset of patients who fail to respond to oral medications, doctors have been in constant search for more effective means to treat them. Over the last 30 years, physicians have been studying the effects of sphenopalatine blocks on headaches were varying degrees of success.[16] Bayer et al published the results of a study in 2005 on 30 patients with chronic face and head pain treated with this block.[17] In the study, patients received pulsed radiofrequency ablation (RFA) of the ganglion for the treatment of their pain. The authors reported that 86% of the patients in the study reported pain relief.
There have been a number of studies reporting on the successes of RFA with the sphenopalatine ganglion, for a variety indications. In a study by Salar et al, patients were treated with traditional RFA (thermal setting) for sphenopalatine neuralgia. The authors reported complete pain relief in those treated at up to 24 months post-treatment.[18]
In a study by Guyatt et al in 2006, 14 peer-reviewed publications on sphenopalatine ganglion blocks were collected and reviewed. Based on a statistical analysis of the published results, the authors made a strong recommendation for the use of the procedure in the treatment of trigeminal neuralgia, cluster headache, posttraumatic headache, tooth pain, and head and neck cancer.[19]
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The Ainsworth Institute is Here to Help
If you are suffering from facial pain, head pain or headaches, acute or chronic, and nothing has seemed to work, you may be a candidate for a sphenopalatine ganglion block. It is a minimally invasive, non-surgical procedure with a great deal of evidence to support its use in a wide-variety of pain syndromes. Contact the Ainsworth Institute of Pain Management to learn more about this procedure and find out if you are a candidate. You could be one phone call away from getting your life back.
References
[1] Manahan AP, Malesker MA, Malone PM. Sphenopalatine ganglion block relieves symptoms of trigeminal neuralgia: a case report. Nebr Med J. 1996; 81:306-9
[2] Peterson JN, Schames J, Schames M, King E. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Cranio. 1995; 13:177-81
[3] 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; 4:15-20.
[4] 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; 61:319-21. [Article in Polish]
[5] 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.
[6] Saberski L, Ahmad M, Wiske P. Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia. Headache. 1999; 39:42-4.
[7] Prasanna A, Murthy P: Vasomotor rhinitis and sphenopalatine ganglion block. J Pain Symptom Manage. 13:332-337 1997
[8] Quevedo J, Purgavie K, Platt H, et al.: Complex regional pain syndrome involving the lower extremity. a report on 2 cases of sphenopalatine ganglion block as a treatment option Arch Phys Med Rehabil. 2005; 86:335-337.
[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; 86:335-7.
[10] Berger J, Pyles S, Saga-Rumley S: Does topical anesthesia of the sphenopalatine ganglion with cocaine or lidocaine relieve low back pain. Anesth Analg. 1986; 65:700-702.
[11] Shah R, Racz G: Long-term relief of posttraumatic headache by sphenopalatine ganglion pulse radiofrequency lesioning. a case report Arch Phys Med Rehabil. 2004; 85:1013-1016.
[12] Windsor RE, Jahnke S. Sphenopalatine ganglion blockade: a review and proposed modification of the transnasal technique. Pain Physician. 2004; 7:283-6.
[13] Waldman S: Sphenopalatine ganglion block – 80 years later. Reg Anesth 1993; 18:274-276.
[14] Paigkou M, Demesticha T, Troupis T. The Pterygopalatine Ganglion and its Role in Various Pain Syndromes: From Anatomy to Clinical Practice. Pain Practice. 2011; 12:399-412.
[15] Ruskin S. Contributions to the study of the sphenopalatine galgnion. Laryngoscope. 1925; 35:87-108.
[16] Cepero R, Miller R, Bressler K. Long-term results of sphenopalatine ganglioneurectomy for facial pain. Am J Otolaryngol. 1987; 8:171-174.
[17] Bayer E., Racz G., Day M., et al: Sphenopalatine ganglion pulsed radiogrequency treatment in 30 patients suffering from chronic face and head pain. Pain Practice 2005; 5:223.
[18] Salar G., Ori C., Iob I., et al: Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia, Acta Neurochir. (Wein) 1987; 84:24.
[19] Guyatt G., Gutterman D., Bauman M., et al: Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American college of chest physician’s task force. Chest 2006; 129:174-181.
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