Sphenopalatine Ganglion Block

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 20 February, 2011

GENERAL

Sphenopalatine ganglion is a parasympathetic ganglion, no more than 5mm in width, located in the pterygopalatine fossa of the skull. The sphenopalatine ganglion sends nerve fibres to the lacrimal glands, glands of the nasal cavity, paranasal sinuses, palate and upper pharynx. Postganglionic sympathetic fibres and afferent somatosensory branches of the maxillary nerve pass through the sphenopalatine ganglion without terminating there. All postganglionic parasympathetic and sympathetic branches, as well as all afferent somatosensory branches, can be blocked with the application of sphenopalatine ganglion block.

INDICATIONS

•    Cluster headache
•    Atypical prosopalgia
•    Trigeminal neuralgia

TECHNIQUE

The patient is placed in the supine position, with head stabilized on a doughnut-cushion. The pterygopalatine fissure (that looks like a vase turned upside down) is localized under fluoroscopic guidance. Above the fissure lies the sphenoid sinus and below is the maxillary sinus. The needle entry site is targeted with a metallic indicator and is identified right below the zygomatic arch. After applying local anaesthesia, a blind needle, 10cm long, is slowly advanced frontwards and upwards through an inserter. The fluoroscopic view is directed posterolaterally and the needle is advanced until it meets the nasal wall.At this exact point the drug solution is injected.

The same technique is followed when radiofrequency is applied to the ganglion. The only difference is that a special needle and electrode are used, with the electrode being inserted through the needle. The ganglion is stimulated with a sensory testing by using a radiofrequency generator and -once the ganglion identified- either conventional or pulsed radiofrequency is applied. During the sensory testing, the patient experiences paraesthesia that should be localized at the sides and the posterior nasal wall, with low voltage electric current. There should not be paraesthesia induced in the soft palate or maxilla because this would indicate that the tip of the needle is near the maxillary nerve or near a branch of this nerve. If conventional radiofrequency is applied in such a case, it is the maxillary nerve that will be ablated instead of the sphenopalatine ganglion. Should pulsed radiofrequency be applied, even if the tip of the needle is wrongly placed, no harm will be done. (1-21)

LITERATURE

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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.
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