A Novel Revision to the Classical Transnasal Topical Sphenopalatine Ganglion Block for the Treatment of Headache and Facial Pain

Background: The sphenopalatine ganglion (SPG) is located with some degree of variability nearthe tail or posterior aspect of the middle nasal turbinate. The SPG has been implicated as a strategictarget in the treatment of various headache and facial pain conditions, some of which are featuredin this manuscript. Interventions for blocking the SPG range from minimally to highly invasiveprocedures often associated with great cost and unfavorable risk profiles.Objective: The purpose of this pilot study was to present a novel, FDA-cleared medication deliverydevice, the Tx360® nasal applicator, incorporating a transnasal needleless topical approach for SPGblocks. This study features the technical aspects of this new device and presents some limited clinicalexperience observed in a small series of head and face pain cases.Study Design: Case series.Settings: Pain management center, part of teaching-community hospital, major metropolitan city,United States.Methods: After Institutional Review Board (IRB) approval, the technical aspects of this techniquewere examined on 3 patients presenting with various head and face pain conditions includingtrigeminal neuralgia (TN), chronic migraine headache (CM), and post-herpetic neuralgia (PHN).The subsequent response to treatment and quality of life was quantified using the following tools:the 11-point Numeric Rating Scale (NRS), Modified Brief Pain Inventory — short form (MBPI-sf),Patient Global Impression of Change (PGIC), and patient satisfaction surveys. The Tx360® nasalapplicator was used to deliver 0.5 mL of ropivacaine 0.5% and 2 mg of dexamethasone for SPGblock. Post-procedural assessments were repeated at 15 and 30 minutes, and on days one, 7, 14,and 21 with a final assessment at 28 days post-treatment. All patients were followed for one year.Individual patients received up to 10 SPG blocks, as clinically indicated, after the initial 28 days.Results: Three women, ages 43, 18, and 15, presented with a variety of headache and face paindisorders including TN, CM, and PHN. All patients reported significant pain relief within the first 15minutes post-treatment. A high degree of pain relief was sustained throughout the 28 day follow-upperiod for 2 of the 3 study participants. All 3 patients reported a high degree of satisfaction with thisprocedure. One patient developed minimal bleeding from the nose immediately post-treatment whichresolved spontaneously in less than 5 minutes. Longer term follow-up (up to one year) demonstratedthat additional SPG blocks over time provided a higher degree and longer lasting pain relief.Limitations: Controlled double blind studies with a higher number of patients are needed to proveefficacy of this minimally invasive technique for SPG block.Conclusion: SPG block with the Tx360® is a rapid, safe, easy, and reliable technique to accuratelydeliver topical transnasal analgesics to the area of mucosa associated with the SPG. This interventioncan be delivered in as little as 10 seconds with the novice provider developing proficiency veryquickly. Further investigation is certainly warranted related to technique efficacy, especially studiescomparing efficacy of Tx360 and standard cotton swab techniques.Key words: Trigeminal neuralgia, trigeminal neuropathy, migraine, headache, post-herpeticneuralgia, sphenopalatine ganglion block