Wilkinson, A.J., Ege, E., Osborne, A., Driver, L., Chai, T.
The management of head, neck, and facial pain due to oncologic origin in patients is difficult and often undertreated. Many patients experience pain refractory to common treatment modalities, both non-interventional and interventional.1, 3 The sphenopalatine ganglion (SPG) is considered to be the autonomic hub of the skull, with association with the sensory nerve fibers of the maxillary nerve. Blockade of the SPG has been previously shown to be useful in headache syndromes and is considered safe and minimally invasive.1 Yet, there is limited literature on the use of SPG blockade for head, neck, and facial pain due to oncologic origin.1, 2, 3 We present the successful use of sphenopalatine ganglion blockade for the treatment of refractory head, neck, and facial pain of oncologic origin.
In highly prevalent head and neck cancer, pain is difficult to manage, with many patients failing conventional treatment with oral analgesics and adjuvant therapies.1, 3 Interventional techniques can be beneficial to treat such patients. The association of the sphenopalatine ganglion (SPG) with the maxillary nerve sensory fibers makes it an area of interest in treating pain in this population. The SPG blocks can be used to treat the pain of the hard and soft palate tonsils, nasal cavities, paranasal sinuses, oral gingiva, premaxillary soft tissue maxilla, and orbital floor.1 We present the successful use of an SPG nerve block for the treatment of head and neck cancer pain due to a cervicomedullary-junction glioma.
A 62-year-old male with an oncologic history of a cervicomedullary-junction glioma status post proton therapy presented to the clinic due to a severe, persistent headache, skull base/neck pain, and left-sided facial pain. (Figure 1) Multiple treatment modalities were attempted in this patient, including multi-modal pain therapies and opioids. The patient also failed to respond to other interventional treatments including occipital nerve blocks, cervical facet joint injections, onabotulinum-A toxin chemodenervation of the craniofacial muscles, ketamine infusions, and intrathecal trials with opioids and ziconotide. After the failure of these above treatments, he was deemed a candidate for a sphenopalatine ganglion blockade for refractory pain.
He later underwent a left-sided sphenopalatine ganglion (SPG) block via a transnasal approach utilizing a catheter designed specifically for the procedure.4 He was placed in a supine position with his neck slightly extended. The tip of the catheter was advanced intranasally through the left nostril, superior to the middle nasal turbinate. 1.5 ml of 2% viscous lidocaine was injected, flowing toward the nasal mucosa overlying the SPG. Afterward, the patient’s position was held for five minutes. He reported substantial pain relief which was not felt with any of his other previously discussed treatment modalities. This relief lasted for several weeks, prompting the patient to undergo repeated, monthly SPG blocks.
The sphenopalatine ganglion (SPG) is considered the autonomic hub within the skull. The SPG is located within the pterygopalatine fossa, and numerous sympathetic and parasympathetic fibers synapse at or course through the ganglion.1 The SPG blockade, considered safe and minimally invasive, can be performed via transnasal, infrazygomatic or transoral approaches.1, 5 Based on the highest level of evidence available, the SPG blockade is indicated for the treatment of cluster headaches, trigeminal neuralgia of the maxillary division, and migraine headaches. There is sparse evidence in the literature for the use of SPG blockage in the treatment of neoplasm-related head, neck, and facial pain.1, 2, 3 (Figure 2)
The management of head, neck, and facial pain continues to be an area of needed improvement in the treatment of oncologic patients. The sphenopalatine ganglion (SPG) blockade presented in this case report should be considered as a potential addition to the treatment modalities in this patient population.
- Pena I, Knoepfler ML, Irwin A, Zhu X, Kohan LR. Sphenopalatine Ganglion Blocks in the Management of Head and Neck Cancer-Related Pain: A Case Series. A A Pract. 2019 Dec 15;13(12):450-453. doi: 10.1213/XAA.0000000000001106. PMID: 31609721.
- Sanghavi PR, Shah BC, Joshi GM. Home-based Application of Sphenopalatine Ganglion Block for Head and Neck Cancer Pain Management. Indian J Palliat Care. 2017 JulSep;23(3):282-286. DOI: 10.4103/IJPC.IJPC_39_17. PMID: 28827931; PMCID: PMC5545953.
- Mirabile A, Airoldi M, Ripamonti C, Bolner A, Murphy B, Russi E, Numico G, Licitra L, Bossi P. Pain management in head and neck cancer patients undergoing chemoradiotherapy: Clinical practical recommendations. Crit Rev Oncol Hematol. 2016 Mar;99:100-6. DOI: 10.1016/j.critrevonc.2015.11.010. Epub 2015 Dec 3. PMID: 26712589.
- Candido KD, Massey ST, Sauer R, Darabad RR, Knezevic NN. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. Pain Physician. 2013 Nov-Dec;16(6):E769-78. PMID: 24284858.
- Forrest, A., Cantos, A., & Butani, D. (2018). How we do it: Sphenopalatine ganglion blockade for migraine treatment. American Journal of Interventional Radiology, 2, 14. https://doi.org/10.25259/ajir-34-2018
Figure 1: Magnetic resonance image of the cervical spine in sagittal view showing a T2 hyperintense expansile mass extending from the posterior caudal medulla to the C2-3 region (arrow).
Figure 2: Transnasal approach for the sphenopalatine ganglion blockade.