Sphenopalatine Endoscopic Ganglion Block: A Revision of a Traditional Technique for Cluster Headache

Abstract

The diagnosis of chronic cluster headache (CH), the most painful form of headache, is based on typical clinical features characterized by strictly unilateral pain with no side shift and ipsilateral oculofacial autonomic phenomena. The attacks occur several times a day for periods of 1 to 2 months in the episodic form of the disease or less frequently on a daily basis in the chronic form. The pathogenesis of CH involves the activation of parasympathetic nerve structures located within the sphenopalatine ganglion (SPG), which explains many of the associated symptoms, whereas the activation of the ipsilateral hypothalamic gray matter may explain its typical circadian and circannual periodicity. A number of surgical approaches have been tried in cases of chronic CH resistant to pharmacologic therapy, of which SPG blockade has been shown to have certain efficacy. We have adopted a new technique based on endoscopic ganglion blockade that approaches the pterigo-palatine fossa by way of the lateral nasal wall and consists of the injection of a mixture of local anesthetics and corticosteroids, which was performed in 20 selected patients with chronic CH, according to the International Headache Society criteria (18 male, 2 female; mean age 40 yr), who were selected for SPG blockade because they were totally drug resistant. The symptoms improved significantly, but always only temporarily, in 11 cases. These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches.

Multimodal Frequency Treatment for Facial Pain Caused by Chronic Rhinosinusitis: A Pilot Study

“…In a study by Ansari et al [53], 95% of patients with facial pain at the beginning of the study reported significant improvement after the study. The facial pain effect size observed in our study (d = 0.96) was much higher than that estimated from Young et al's data (d = 0.51), likely due to the application of multimodal frequencies (70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80) Hz and 1 MHz) in the AxioSonic system. Our effect size for quality of life measures using the SNOT-22 questionnaire (d = 0.45) was lower than Young et al's paper [40] (d = 0.9).…”

“…The SPG is involved in tissue inflammation, lacrimation, mucus production and other parasympathetic processes [71][72][73][74]. Low frequency neurostimulation (20 Hz, much lower than ultrasound frequencies) of the SPG or the Vidian nerve leads to vasodilation and associated inflammation [75,76].…”

Surgical Interventions for Cluster Headache, Including Implanted Stimulators

“…Another study with 20 patients reported on good results, which were always temporarily (Felisati et al 2006).…”

“…Percutaneous radiofrequency ablation of the sphenopalatine ganglion is performed in many centers, but the evidence base is rather poor. The parasympathetic sphenopalatine ganglion is located in the sphenopalatine fossa, close to the maxillary nerve and the internal maxillary artery, and can be targeted via an infrazygomatic approach or via the lateral nasal wall (Felisati et al 2006). In the most recent published series of 15 patients, the mean attack frequency improved from 17 attacks/week to 8 attacks per week at 18 months follow-up ).…”

Stimulation of the sphenopalatine ganglion in intractable cluster headache: Expert consensus on patient selection and standards of care

“…After alcohol injection into the SPG, 85% of patients (n¼120) had a relevant decrease of pain (30). Other approaches include radiofrequency ablation (31) ganglionectomy (32), and -less invasive -injections of local anaesthetics (33) or corticosteroids (34) into the SPG. As most of these procedures offer only temporary benefit, and most are destructive and non-adjustable, high-frequency stimulation of the SPG has been suggested as an alternative with promising results in a single case report (35) and a case series (36).…”