sphenopalatin injection techniques

CHAPTER 3

Sphenopalatine Ganglion Block:Transnasal Approach

CPT-2009 CODE

Local AnestheticNeurolytic

6450564640

Relative Value Units


820

INDICATIONS

Sphenopalatine ganglion block may be used in the treat-ment of acute migraine headache, acute cluster head-ache, and a variety of facial neuralgias including Sluder's,Vail's, and Gardner's syndromes. This technique is alsouseful in the treatment of status migrainosus and chroniccluster headache.

Neurodestmctive procedures of the sphenopalatineganglion with neurolytic agents, radiofrequency lesions,and freezing may be indicated for the palliation of cancerpain and rarely for headache and facial pain syndromesthat fail to respond to conservative management.

CLINICALLY RELEVANT ANATOMY

The sphenopalatine ganglion (pterygopalatine, nasal, orMeckel's ganglion) is located in the pterygopalatinefossa, posterior to the middle nasal turbinate. It is coveredby a 1-to 1.5-mm layer of connective tissue and mucousmembrane. This 5-mm triangular stmcture sends majorbranches to the gasserian ganglion, trigeminal nerves,carotid plexus, facial nerve, and superior cervical gan-glion. The sphenopalatine ganglion can be blocked bytopical application of local anesthetic or by injection.

TECHNIQUE

Sphenopalatine ganglion block through the transnasalapproach is accomplished by the application of suitable

local anesthetic to the mucous membrane overlyingthe ganglion. The patient is placed in the supine posi-tion, and the anterior nares are inspected for polyps,tumors, and foreign bodies. Three milliliters of either 2%viscous lidocaine or 10% cocaine is drawn up in a 5-mLsterile syringe. The tip of the nose is then drawn upwardas if to place a nasogastric tube, and 0.5 mL of localanesthetic is injected into each nostril. The patient isasked to sniff vigorously to draw the local anestheticposteriorly, which serves the double function of lubricat-ing the nasal mucosa as well as providing topicalanesthesia.

Two 3,7i-inch cotton-tipped applicators are soakedin the local anesthetic chosen, and one applicator isadvanced along the superior border of the middle tur-binate of each nostril until the tip comes into contactwith the mucosa overlying the sphenopalatine ganglion(Fig. 3-1). Then 1 mL of local anesthetic is instilled overeach cotton-tipped applicator. The applicator acts as atampon that allows the local anesthetic to remain incontact with the mucosa overlying the ganglion. Theapplicators are removed after 20 minutes. The patient'sblood pressure, pulse, and respirations are monitored foruntoward side effects.

SIDE EFFECTS AND COMPLICATIONS

Because of the highly vascular nature of the nasal mucosa,epistaxis is the major complication of this technique.This vascularity can lead to significant systemic absorp-tion of local anesthetic with resultant local anesthetictoxicity, especially when cocaine is used.

Patients occasionally may experience significantorthostatic hypotension after sphenopalatine ganglionblock. This can be a problem because postblock moni-toring may be lax because of the benign appearance ofthe technique. For this reason, patients who undergosphenopalatine ganglion block should be monitoredclosely for orthostatic hypotension and allowed to ini-tially ambulate only with assistance.

12 Current Procedural Terlll;noloJ{)' @ 2009 American Medical Association. All Rights Reserved.

Chapter 3 Sphenopalatine Ganglion Block: Transnasal Approach 13

\

Cotton-tipped applicator

Middle nasal turbinate

Sphenopalatine ganglion

Figure 3-1.

14 Section 1 Head

CLIN ICAl PEARLS

Clinical experience has shown that sphenopalatineganglion block with local anesthetic is useful in abort-ing the acute attack of migraine or cluster headache.The simplicity of the trans nasal approach lends itself touse at the bedside, in the emergency room, or in thepain clinic. Although cocaine is probably a superiortopical anesthetic for use with this technique, thevarious political issues surrounding the use of con-trolled substances make the use of other local anesthet-ics such as viscous lidocaine a more logical choice.

For the acute headache sufferer, this technique canbe combined with the inhalation of 100% oxygen viamask through the mouth while the cotton-tippedapplicators are in place. Experience has shown thatthis technique aborts about 80% of cluster headaches.Sphenopalatine ganglion block should be carried outon a daily basis with the endpoint of complete painrelief. This usually occurs within five blocks.

CHAPTER 4

Sphenopalatine Ganglion Block:Greater Palatine Foramen Approach

CPT-2009 CODE

Lo(al Anestheti(

Neurolyti(6450564640


Lo(al Anestheti(Neurolyti(

820

INDICATIONS

Sphenopalatine ganglion block may be used in the treat-ment of acute migraine headache, acute cluster head-ache, and a variety of facial neuralgias including Sluder's,Vail's, and Gardner's syndromes. The technique is alsouseful in the treatment of status migrainosus and chroniccluster headache. The greater palatine foramen approachto sphenopalatine ganglion block is useful in patientswho have an alteration of the nasal anatomy secondaryto trauma or malignancy that would preclude use of thetransnasal approach.

Neurodestructive procedures of the sphenopalatineganglion with neurolytic agents, radiofrequency lesions,and freezing may be indicated for the palliation of cancerpain and rarely for headache and facial pain syndromesthat fail to respond to conservative management. Thetransnasal or lateral approach to the sphenopalatine gan-glion block may be more suitable for these neurodestruc-tive techniques.


The sphenopalatine ganglion (pterygopalatine, nasal, orMeckel's ganglion) is located in the pterygopalatinefossa, posterior to the middle nasal turbinate. It is covered

by a "1-to 1.5-mm layer of connective tissue and mucousmembrane. This 5-mm triangular structure sends majorbranches to the gasserian ganglion, trigeminal nerves,carotid plexus, facial nerve, and superior cervical gan-glion. The sphenopalatine ganglion can be blocked bytopical application of local anesthetic via the transnasalapproach or by injection via the lateral approach orthrough the greater palatine foramen.

TECHNIQUE

Sphenopalatine ganglion block via the greater palatineforamen approach is accomplished by the injection oflocal anesthetic onto the ganglion. The patient is placedin the supine position with the cervical spine extendedover a foam wedge. The greater palatine foramen isidentified just medial to the gum line of the third molaron the posterior portion of the hard palate. A dentalneedle with a 120-degree angle is advanced about 2.5 cmthrough the foramen in a superior and slightly posteriortrajectory (Figs. 4-1 and 4-2). The maxillary nerve is justsuperior to the ganglion, and if the needle is advancedtoo deep, a paresthesia may be elicited. After careful,gentle aspiration, 2 mL of local anesthetic is slowlyinjected.


Because of the highly vascular nature of this anatomicregion, significant systemic absorption of local anestheticwith resultant local anesthetic toxicity is a distinctpossibility.

Patients occasionally may experience significantorthostatic hypotension after sphenopalatine ganglionblock. Therefore, patients who undergo sphenopalatineganglion block should be monitored closely for ortho-

static hypotension and allowed to initially ambulate onlywith assistance.

Cun'ellt Procedural Termillology @ 2009 American Medical Association. All Rights Reserved. 15

16 Section 1 Head

Greater palatine foramen

Sphenopalatine ganglion

Greater palatine foramen

Palatine nerves

Figure 4-1.

Figure 4-2.

Tip of needle placed through greaterpalatine foramen.

Chapter 4 Sphenopalatine Ganglion Block: Greater Palatine Foramen Approach 17

CLINICAL PEARLS

Clinical experience has shown that sphenopalatineganglion block with local anesthetic is useful in abort-ing the acute attack of migraine or cluster headache.The simplicity of the trans nasal approach lends itselfto use at the bedside, in the emergency room, or inthe pain clinic. Although cocaine is probably a supe-rior topical anesthetic for use with this technique, thevarious political issues surrounding the use of con-trolled substances make the use of other local anes-thetics such as viscous lidocaine a more logicalchoice.

If previous trauma or tumor precludes the use ofthe trans nasal approach to sphenopalatine ganglionblock, injection via the greater palatine foramen rep-resents a good alternative. Because of the proximity ofthe sphenopalatine ganglion to the maxillary nerve,

care must be taken to avoid inadvertent neurolysis ofthe maxillary nerve when performing neurodestruc-tive procedures on the sphenopalatine ganglion.Because of the ability to more accurately localize thesphenopalatine ganglion by stimulation, radiofre-quency lesioning via the lateral approach probablyrepresents the safest option if destruction of the sphe-nopalatine ganglion is desired.

For the acute headache sufferer, this technique canbe combined with the inhalation of 100% oxygen viamask after the injection of local anesthetic. Experiencehas shown that this technique aborts about 80% ofcluster headaches. Sphenopalatine ganglion blockshould be carried out on a daily basis with the end.point of complete pain relief. This usually occurswithin five blocks.

CHAPTER 5

Sphenopalatine Ganglion Block:Lateral Approach

CPT-2009 CODE


6450564640


Local Anesthetic 8Neurolytic 20

INDICATIONS

Sphenopalatine ganglion block may be used in the treat-ment of acute migraine headache, acute cluster head-ache, and a variety of facial neuralgias including Sluder's,Vail's, and Gardner's syndromes. The technique is alsouseful in the treatment of status migrainosus and chroniccluster headache. The lateral approach to sphenopala-tine ganglion block is useful in patients who have analteration of the nasal anatomy secondary to trauma ormalignancy that would preclude use of the transnasalapproach. It is also the preferred route for neurodestruc-tive procedures of the sphenopalatine ganglion. Theseneurodestructive procedures of the sphenopalatineganglion may be performed with neurolytic agents,radiofrequency lesions, and freezing and are indicatedfor the palliation of cancer pain and rarely for headacheand facial pain syndromes that fail to respond to con-servative management.


The sphenopalatine ganglion (pterygopalatine, nasal, orMeckel's ganglion) is located in the pterygopalatinefossa, posterior to the middle nasal turbinate. It is coveredby a 1- to I.5-mm layer of connective tissue and mucousmembrane. This 5-mm triangular structure sends majorbranches to the gasserian ganglion, trigeminal nerves,carotid plexus, facial nerve, and superior cervical gan-glion. The sphenopalatine ganglion can be blocked bytopical application of local anesthetic via the transnasalapproach, by injection via the pterygopalatine fossa or

through the greater palatine foramen, or by lateral place-ment of a needle via the coronoid notch.

TECHNIQUE

Sphenopalatine ganglion block via the lateral approachis accomplished by the injection of local anesthetic ontothe ganglion via a needle placed through the coronoidnotch. The patient is placed in the supine position withthe cervical spine in the neutral position. The coronoidnotch is identified by asking the patient to open andclose the mouth several times and palpating the area justanterior and slightly inferior to the acoustic auditorymeatus. After the notch is identified, the patient is askedto hold the mouth open in the neutral position.

A total of 2 mL of local anesthetic is drawn up in a3-mL sterile syringe. Some pain management specialistsempirically add a small amount of depot-steroid prepara-tion to the local anesthetic. After the skin overlying thecoronoid notch is prepared with antiseptic solution, a22-gauge,3Yz-inch styletted needle is inserted just belowthe zygomatic arch directly in the middle of the coronoidnotch. The needle is advanced about 1.5 to 2 inches ina plane perpendicular to the skull until the lateral ptery-goid plate is encountered. At this point, the needle iswithdrawn slightly and redirected slightly superior andanterior, with the goal of placing the needle just abovethe lower aspect of the lateral pterygoid plate so that itcan enter the pterygopalatine fossa below the maxillarynerve and in close proximity to the sphenopalatine gan-glion (Fig. 5-1). If this procedure is performed underfluoroscopy, the needle tip is visualized just under thelateral nasal mucosa, and its position can be confirmedby injecting 0.5 mL of contrast medium (Fig. 5-2). Addi-tional confirmation of needle position can be obtainedby needle stimulation at 50 Hz. If the needle is in thecorrect position, the patient experiences a buzzing sen-sation just behind the nose with no stimulation into thedistribution of other areas innervated by the maxillarynerve.

After correct needle placement is confirmed, carefulaspiration is carried out, and 2 mL of solution is injectedin incremental doses. During the injection procedure,

18 Currel/t Procedural Termil/olo!iJ' @ 2009 American Medical Association. All Rights Reserved.

Chapter 5 Sphenopalatine Ganglion Block: Lateral Approach 19

Pterygopalatine fossa

Sphenopalatine ganglion Coronoid notch

Figure 5-1.

I

,

HD

flrll1:r:V?:

Figure 5-2.Needle tip in pterygopalatine fossa. (From Waldman SD: Interventional PainManagement, 2nd ed. Philadelphia, WB Saunders, 2001, P 309.)

20 Section 1 Head

the patient must be observed carefully for signs of localanesthetic toxicity. Because of the proximity of the max-illary nerve, the patient also may experience partialblockade of the maxillary nerve.


Because of the highly vascular nature of the pterygopala-tine fossa, significant facial hematoma may occur aftersphenopalatine ganglion block via the lateral approach.

This vascularity means that the pain specialist should usesmall, incremental doses of local anesthetic to avoid localanesthetic toxicity.

Patients occasionally may experience significantorthostatic hypotension after sphenopalatine ganglionblock. Therefore, patients who undergo sphenopalatineganglion block should be monitored closely for ortho-static hypotension and allowed to initially ambulate onlywith assistance.

CLINICAL PEARLS

Clinical experience has shown that sphenopalatineganglion block with local anesthetic is useful in abort-ing the acute attack of migraine or cluster headache.The simplicity of the transnasal approach lends itself touse at the bedside, in the emergency room, or in thepain clinic. Although cocaine is probably a superiortopical anesthetic for use with this technique, thevarious political issues surrounding the use of con-trolled substances make the use of other local anesthet-ics such as viscous lidocaine a more logical choice.

If previous trauma or tumor precludes the use ofthe transnasal approach to sphenopalatine ganglionblock, injection of local anesthetic via the greater pala-tine foramen or the lateral approach represents a goodalternative. Because of the proximity of the spheno-palatine ganglion to the maxillary nerve, care must be

taken to avoid inadvertent neurolysis of the maxillarynerve when performing neurodestructive procedureson the sphenopalatine ganglion. Because of the abilityto more accurately localize the sphenopalatine gan-glion by stimulation, radiofrequency lesioning via thelateral approach represents probably the safest optionif destruction of the sphenopalatine ganglion isdesired.

For the acute headache sufferer, this technique canbe combined with the inhalation of 100% oxygen viamask after the injection of local anesthetic. Experiencehas shown that this technique aborts about 80% ofcluster headaches. Sphenopalatine ganglion blockshould be carried out on a daily basis with the end-point of complete pain relief. This usually occurswithin five blocks.

CHAPTER 6

Sphenopalatine Ganglion Block:Radiofrequency Lesioning

CPT-2009 CODE

Neurolytic 64640

Relative Value Unit

Neurolytic 20

INDICATIONS

Radiofrequency lesioning of the sphenopalatine ganglionblock may be used in the treatment of chronic clusterheadache, cancer pain, and a variety of facial neuralgiasincluding Sluder's, Vail's, and Gardner's syndromes thathave failed to respond to more conservative treatments.The lateral approach to sphenopalatine ganglion blockis used to place the radiofrequency needle, although thetransnasal and greater palatine foramen approach can beused in patients who have an alteration of the nasalanatomy secondary to trauma or malignancy that wouldpreclude use of the lateral approach. Neurodestructiveprocedures of the sphenopalatine ganglion using thelateral approach may be performed with neurolyticagents, freezing, and radiofrequency lesioning. Radiofre-quency lesioning has the added advantage of allowingthe use of a stimulating needle, which enhances correctneedle placement.


The sphenopalatine ganglion (pterygopalatine, nasal, orMeckel's ganglion) is located in the pterygopalatinefossa, posterior to the middle nasal turbinate. It is coveredby a 1- to 1.5-mm layer of connective tissue and mucousmembrane. This 5-mm triangular structure sends majorbranches to the gasserian ganglion, trigeminal nerves,carotid plexus, facial nerve, and superior cervical gan-glion. The sphenopalatine ganglion can be blocked bytopical application of local anesthetic via the transnasalapproach, by injection via the pterygopalatine fossa or

through the greater palatine foramen, or by lateral place-ment of a needle via the coronoid notch.

TECHNIQUE

Radiofrequency lesioning of the sphenopalatine ganglionblock is accomplished by placing a radiofrequencyneedle in proximity to the sphenopalatine ganglion usingthe lateral approach via an introducer needle. The patientis placed in the supine position with the cervical spinein the neutral position. A 3,Y;;-inchcotton-tipped applica-tor is soaked in contrast media and placed between themiddle and inferior turbinates to serve as a radiopaquemarker (Figs. 6-1 and 6-2).

A total of 2 mL of local anesthetic is drawn up in a3-mL sterile syringe. After the skin lateral to the angle ofthe mouth is prepared with antiseptic solution, a 22-gauge, 10-cm insulated blunt curved needle with a 5- to10-mm active tip is inserted through an introducer needleplaced through the previously anesthetized area. Theneedle is advanced toward the tip of the cotton-tippedapplicator, which rests on the mucosa just over the sphe-nopalatine ganglion at the level of the middle turbinate.The trajectory of the needle should be toward the pos-terior clinoid. The needle is slowly advanced under fluo-roscopic guidance into the pterygopalatine fossa belowthe maxillary nerve and in close proximity to the sphe-nopalatine ganglion (Fig. 6-3). The needle tip ultimatelyis visualized just under the lateral nasal mucosa, and itsposition can be confirmed by injecting 0.5 mL of con-trast medium.

Sensory stimulation is then applied to the needle at0.5 V at a frequency of 50 Hz. If the needle is in correctposition, the patient experiences a buzzing sensationjust behind the nose with no stimulation into the distri-bution of other areas innervated by the maxillary nerve,which is often perceived by the patient as a buzzingsensation in the upper teeth (see "Side Effects and Com-plications" for pitfalls in needle placement). After correctneedle placement is confirmed, pulsed radiofrequencylesioning is performed for 90 seconds at 44c. Often asecond lesion and sometimes a third lesion are necessaryto provide long-lasting relief.

Curre1lt Procedural Termi1lology @ 2009 American Medical Association. All Rights Reserved. 21

22 Section 1 Head

Figure 6-1. Figure 6-2.

Figure 6-3.

Chapter 6 Sphenopalatine Ganglion Block: Radiofrequency Lesioning 23


Because of the highly vascular nature of the pterygopala-tine fossa, significant facial hematoma may occur afterradio frequency lesioning of the sphenopalatine ganglion.Owing to the proximity of other nerves, misplacementof the radiofrequency needle can result in damage to theaffected nerve with permanent neurologic deficit. Stimu-lation before lesioning can help detect needle misplace-ment by identification of specific stimulation patterns(fable 6-1). The stimulation pattern associated withproper placement of the needle is felt at the root of thenose. If the needle is mal positioned in proximity to themaxillary division of nerve, the stimulation pattern isexperienced in the upper teeth. Should this occur, thepatient should be positioned more caudad. If the needleis mal positioned near the greater and lesser palatinenerves, the stimulation pattern is experienced in thehard palate. Should this occur, the needle should beredirected more medial and posterior.

Patients occasionally may experience significantorthostatic hypotension or bradycardia during stimula-tion of the sphenopalatine ganglion. This phenomenon

Table 6-1 . IDENTIFICATION OF SPECIFICSTIMULATION PATTERNS

Needle PositionStimulationPattern

CorrectiveManeuver

Needle in properposition

Needle in proximity tomaxillary nerve

Needle in proximity togreater and lesserpalatine nerves

Stimulation atbase of nose

Stimulation inupper teeth

Stimulation inhard palate

None

Redirect needlemore caudad

Redirect needlemore posterior

is thought to be analogous to the oculocardiac reflex andcan be prevented with atropine. Patients who undergostimulation of the sphenopalatine ganglion should bemonitored closely for orthostatic hypotension andbradycardia and allowed to initially ambulate onlywith assistance.

CLINICAL PEARLS

Clinical experience has shown that sphenopalatineganglion block with local anesthetic is useful in abort-ing the acute attack of migraine or cluster headache.The simplicity of the trans nasal approach lends itselfto use at the bedside, in the emergency room, or inthe pain clinic. Although cocaine is probably a supe-rior topical anesthetic for use with this technique,the various political issues surrounding the use ofcontrolled substances make the use of other localanesthetics such as viscous lidocaine a more logicalchoice.

If previous trauma or tumor precludes the use ofthe transnasal approach to sphenopalatine ganglionblock, injection of local anesthetic via the greaterpalatine foramen or the lateral approach representsa good alternative. Because of the proximity of thesphenopalatine ganglion to the maxillary nerve, caremust be taken to avoid inadvertent neurolysis of themaxillary nerve when performing neurodestructiveprocedures on the sphenopalatine ganglion. Becauseof the ability to more accurately localize the sphe-nopalatine ganglion by stimulation, radiofrequencyIesioning via the lateral approach represents proba-bly the safest option if destruction of the sphenopala-tine ganglion is desired.

sphenopalatin injection techniques

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