Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

Sphenopalatine ganglion block - a new treatment for burning mouth syndrome?: a case report

Abstract Burning mouth syndrome is a poorly understood entity for which current treatment modalities fail to provide effective relieve. Branches of the maxillary and mandibular nerves are responsible for the innervation of the affected area. These are also the nerves involved in trigeminal neuralgia, an entity where sphenopalatine block has proved to be effective. We present a case of a patient with burning mouth syndrome in whom a bilateral sphenopalatine ganglion block was successfully performed for pain treatment. It is an easy and safe technique that can be a valuable treatment option for these patients, although more studies are needed.

Early versus late sphenopalatine ganglion block with ropivacaine in postdural puncture headache: an observational study

Abstract Background Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients' discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. Methods We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n = 41) was divided in two groups: an early (less than 24 hours after diagnosis) and a late (more than 24 hours after diagnosis) SPGB group. Pain was evaluated 15 minutes after the block and follow up occurred daily until patients were discharged. Patients' demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. Results Early SPGB resulted in a significant reduction in length of stay (p = 0,009) and symptom recurrence (p = 0,036), showing equally effective pain relief, compared to late SPGB. Conclusions SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.

Modified acupuncture at sphenopalatine ganglion for allergic rhinitis: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the effect of modified acupuncture at sphenopalatine ganglion for allergic rhinitis (AR).@*METHODS@#A total of 80 patients with AR were randomly divided into an observation group and a control group, 40 cases in each group. In the observation group, modified acupuncture at sphenopalatine ganglion was given, 30 min each time, 2 times a week and with an interval of 3-4 days. In the control group, budesonide nasal spray was given. Both groups were treated for 4 weeks. The total nasal symptom score (TNSS) and total non-nasal symptom score (TNNSS) were observed before treatment, after first treatment, after last treatment and 4 weeks after treatment; the scores of visual analogue scale (VAS) and rhinoconjunctivitis quality of life questionnaire (RQLQ) were observed before treatment, after last treatment and 4 weeks after treatment; the recurrence condition was evaluated 4 weeks after treatment; the clinical efficacy was evaluated after last treatment in the two groups.@*RESULTS@#Compared with before treatment, the total scores and each score of TNSS, TNNSS scores after first treatment, after last treatment and 4 weeks after treatment were decreased in both groups (P<0.01, P<0.05). After first treatment, the total score, stuffy nose score, itchy nose score of TNSS and TNNSS score in the observation group were lower than the control group (P<0.01, P<0.05). After last treatment, the total score, stuffy nose score, itchy nose score of TNSS in the observation group were lower than the control group (P<0.01). Four weeks after treatment, the total score and each score of TNSS, TNNSS score in the observation group were lower than the control group (P<0.01, P<0.05). Compared with before treatment, the scores of VAS and RQLQ after last treatment and 4 weeks after treatment were decreased in both groups (P<0.01), and those in the observation group were lower than the control group (P<0.01). The recurrence rate was 13.5% (5/37) in the observation group, which was lower than 44.8% (13/29) in the control group (P<0.01). The total effective rate was 92.5% (37/40) in the observation group, which was higher than 72.5% (29/40) in the control group (P<0.05).@*CONCLUSION@#Modified acupuncture at sphenopalatine ganglion could effectively improve symptoms and quality of life in patients with AR, and the recurrence rate is lower.

A Prospective Cross‑sectional Study to Analyze the Effect of Transnasal Sphenopalatine Ganglion Blockin Carcinoma Buccal Mucosa Patients

Introduction: Cancer pain is known to be one of the Most severe pain anyone in life and is the primary reason for discontinuation of treatment.Sphenopalatine ganglion block (SPGB) can be useful in alleviating pain of carcinoma buccal mucosa. The study aims to analyze the effect of transnasal SPGB in pain management of patients suffering from carcinoma buccal mucosa. Materials and Methods: It was a hospital‑based study done on 150 patients with carcinoma buccal mucosa using a prospective cross‑sectional study design. To do statistical analysis, paired t‑test was used having SPSS software. Results: On visual analogue scale, intensity of pain was found to be notably reduced from 7.42±2.02 to 3.45±1.21 (P < 0.0001), after first sitting. Preprocedure and postprocedure morphine requirement were 90.24 ± 30.24 and 60.42 ± 0.93 mg/day (P > 0.05) At the conclusion of study, the results were found to be statistically significant. Conclusion: Transnasal SPGB is beneficial in improving patient compliance and reducing pain scores and morphine requirement in patients suffering from carcinoma buccal mucosa

Tratamiento con bloqueo esfenopalatino de la cefalea refractaria por trombosis del seno cavernoso / Treatment with sphenopalatine blockade against refractory headache due to thrombosis of the cavernous sinus

Introducción: Entre las cefaleas secundarias se encuentra la atribuida a flebotrombosis cerebral producida por trombosis séptica del seno cavernoso. El ganglio esfenopalatino interviene en la génesis y mantenimiento de cefaleas unilaterales; pues envía conexiones a la cavidad nasofaríngea y meninges, así desempeña una función importante en la modulación neuronal; el bloqueo de dicho ganglio es un método fácil, seguro, económico y efectivo de tratamiento del dolor irruptivo de algunos tipos de cefalea. Objetivo: Presentar los resultados del bloqueo GEFP en el tratamiento de la cefalea grave refractaria secundaria a trombosis séptica del seno cavernoso. Presentación de caso: Paciente de 71 años de edad, al que se realizó de forma exitosa bloqueo transnasal del ganglio esfenopalatino, para tratamiento de cefalea grave refractaria secundaria a trombosis séptica del seno cavernoso, consiguiéndose analgesia efectiva con disminución progresiva de la cefalea y control total de la misma a las 72 h de tratamiento. Conclusiones: El bloqueo podría constituir una opción en la terapéutica de este tipo de cefalea(AU)

Introduction: Among secondary headaches, one is attributed to cerebral phlebothrombosis produced by septic thrombosis of the cavernous sinus. The sphenopalatine ganglion (SPG) is involved in the genesis and maintenance of unilateral headaches, since it sends connections to the nasopharyngeal cavity and meninges, playing thus an important role in neuronal modulation; therefore; the blockade of this ganglion is an easy, safe, economic and effective method for treating breakthrough pain in some types of headache. Objective: To present the results of SPG blockade in the treatment of refractory severe headache produced by septic thrombosis of the cavernous sinus. Case presentation: A 71-year-old male patient is presented, who was successfully performed a transnasal SPG blockade, as a treatment for refractory severe headache caused by septic thrombosis of the cavernous sinus. Effective analgesia is achieved, together with progressive decrease of headache until it was totally controlled at 72 hours. Conclusions: Blockade was an option in the therapy of this type of headache(AU)

Pterion: Morphometry and Surgical Significance

Introduction: Pterion is a H-Shaped formation of sutures and cranio-metric point on the lateral side of skull. It is marked by the junction of frontal, parietal, greater wing of sphenoid & squamous temporal bone. Objective: The study is aimed to determine prevalence of types of pterions, presence of epipteric bone. We also tried to find pterion’s relationship with anterior branch of middle meningeal artery Materials and methods: Study was done in department of Anatomy, GMCH-32, Chandigarh on 40 adult dried skulls without calvaria, of unknown age, gender and race. The skulls with broken lateral wall were excluded. Skulls were examined for 1. A. prevalence of pterion shape B. Prevalence of bilaterality of similar shape of pterion. C. Prevalence of unilateral variation of pterion on two sides of skull. 2. Epipteric bone A. Presence of epipteric bone B. relation to the suture on both sides. 3. Distance of pterion center point to frontozygomatic suture and upper border of zygomatic arch. 4. relationship of pterion on external and internal surface of skull and on inner side its relationship with anterior branch of Middle meningeal artery. Observations: In the present study 3 types of pterions i.e., Sphenoparietal, stellate, frontotemporal were observed. Sphenoparietal was found to be present bilaterally 40% on both sides. Frontotemporal & stellate were 2.5%. Sphenoparietal type of pterion was 55% on right side & 67.5% on left side. frontotemporal type of pterion was 5% on right side & 2.5% on left side, stellate type was 7.5% on right side & 2.5% on left side. epipteric bone were present in pterion on right side in 32.5% & on left side 27.5%. Pterion was lying approximately 3.5 cm above the zygomatic arch and 2.83 cm behind the posterior margin of frontozygomatic suture. Conclusion: in our study the commonest type of pterion shape was Sphenoparietal. This type was most common to be present bilaterally. Epipteric bone was found in Sphenoparietal type both unilaterally & bilaterally. The anterior branch of MMA was closest and farthest in stellate type.

Acupuncture at sphenopalatine ganglion combined with conventional acupuncture for episodic cluster headache: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical effect of acupuncture at sphenopalatine ganglion combined with conventional acupuncture for episodic cluster headache (CH).@*METHODS@#One hundred and eighty patients with episodic CH were randomly divided into a combined group (60 cases, 3 cases dropped off)，an acupuncture group (60 cases, 2 cases dropped off) and a sphenopalatine ganglion group (60 cases, 2 cases dropped off and 1 case was removed). The patients in the acupuncture group were treated with conventional acupuncture at Touwei (ST 8), Yintang (GV 24+), Yangbai (GB 14), Hegu (LI 4), etc., once a day, 6 times a week. The patients in the sphenopalatine ganglion group were treated with acupuncture at sphenopalatine ganglion, once every other day, 3 times a week. On the basis of the conventional acupuncture, the combined group was treated with acupuncture at sphenopalatine ganglion once every other day. Two weeks were taken as a course of treatment, and 3 courses of treatment were required in the 3 groups. The score of visual analogue scale (VAS), the number of headache attacks per week, the duration of each headache attack and the score of migraine-specific quality of life questionnaire version 2.1 (MSQ) were observed before and after treatment and in follow-up of 3 months after treatment. The clinical efficacy of each group was compared.@*RESULTS@#After treatment and in follow-up, the VAS score of headache, the number of headache attacks per week, the duration of each headache attack, and each various scores and the total score of MSQ of each group were lower than those before treatment (P<0.01). Except that the number of headache attacks per week in the combined group was lower than the sphenopalatine ganglion group (P<0.01), other indexes in the combined group were lower than the other two groups (P<0.05, P<0.01). The total effective rate in the combined group was 93.0% (53/57), which was higher than 75.9% (44/58) in the acupuncture group and 73.7% (42/57) in the sphenopalatine ganglion group（P<0.05, P<0.01).@*CONCLUSION@#Acupuncture at sphenopalatine ganglion combined with conventional acupuncture could reduce the degree of pain in patients with episodic CH, reduce the number and duration of headache attacks, and improve the quality of life of patients. It is more effective than simple conventional acupuncture or acupuncture at sphenopalatine ganglion alone.

New approaches and therapeutic options for post-dural puncture headache treatment / Nuevos abordajes y alternativas terapéuticas en el tratamiento de la cefalea pospunción dural

Abstract Post-dural puncture headache is a frequent complication in neuraxial approaches. It may result in disability, healthcare dissatisfaction and potentially serious complications. The traditional initial management includes general and analgesia measures with poor evidence. The treatment approach best supported by the literature is the epidural blood patch for which rates of up 70% improvement have been reported. Regional techniques have been recently described that may be helpful because they are less invasive than the epidural blood patch, under certain clinical circumstances. This article suggests an algorithm that uses such techniques for the management of this complication.

Resumen La cefalea pospunción dural es una complicación frecuente del abordaje del neuroeje. Puede producir incapacidad, insatisfacción con la atención en salud y complicaciones potencialmente graves. Tradicionalmente su manejo inicial incluye medidas generales y de analgesia las cuales tienen baja evidencia. La medida para su tratamiento, con mejor soporte en la literatura, es la realización de parche hemático, el cual informa tazas de mejoría hasta del 70 %. Recientemente se han descrito técnicas regionales, que pueden resultar útiles por ser menos invasivas que el parche hemático, en ciertos contextos clínicos. En este artículo se propone un algoritmo que permite incorporar dichas técnicas al manejo de esta complicación.

Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports / Bloqueio do gânglio esfenopalatino autoaplicado para cefaleia pós-punção dural: relato de quatro casos

Abstract Background and objectives The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

Resumo Justificativa e objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.

Bloqueo del ganglio esfenopalatino, una opción para el tratamiento de la cefalea postpunción dural / Sphenopalatine ganglion block, an option for treatment of post dural puncture headache

Post-dural puncture headache is a complication of neuroaxial anesthesia. The initial approach consists of supportive treatment. In case of therapeutic failure, the epidural blood patch (PSE) is the treatment of choice. The case of a sphenopalatine ganglion block is presented for its management with good results.

La cefalea postpunción dural es una complicación de la anestesia neuroaxial. El abordaje inicial consiste en tratamiento de soporte. En caso de falla terapéutica, el parche sanguíneo epidural (PSE) es el tratamiento de elección. Se presenta el caso de un bloqueo de ganglio esfenopalatino para su manejo con buenos resultados.

Sphenopalatine ganglion block for post-dural puncture headache after invasive cerebrospinal fluid pressure monitoring. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: Post-dural puncture headache is a common complication in neuraxial anesthesia and lumbar puncture diagnostic procedures. The pathogenesis of the headache is thought to be due to a leak of cerebrospinal fluid from the puncture site that exceeds the rate of cerebrospinal fluid production, causing a downward traction of the meninges and vasodilation of the meningeal vessels mediated by the autonomous nervous system. Nowadays, the conservative treatment involves hydration, and the use of caffeine, analgesics, hydrocortisone, gabapentin, and theophylline. However, an autologous epidural blood patch is considered the definitive treatment for post-dural puncture headache and has an efficacy of up to 75%. Since this procedure comes with intrinsic risks, an alternative is the sphenopalatine ganglion block. CASE REPORT: We describe a case report using a sphenopalatine ganglion block to treat post-dural puncture headache in a patient submitted to cerebrospinal fluid pressure monitoring with a subarachnoidal catheter inserted with a low-gauge needle. CONCLUSION: This is the first case report of a post-dural puncture headache caused by a subarachnoid monitoring catheter successfully treated with sphenopalatine ganglion block. This technique can be a non-invasive option in the management of post-dural puncture headache, which requires more study to evaluate its efficacy and safety.

CT-guided low temperature plasma coblation of sphenopalatine ganglion for treating sphenopalatine neuralgia / 中国介入影像与治疗学

Objective To: evaluate the efficacy and safety of CT-guided low temperature plasma coblation of sphenopalatine ganglion for treating sphenopalatine neuralgia. Methods: Totally 37 patients with sphenopalatine neuralgia underwent CT-guided low temperature plasma coblation of sphenopalatine ganglion. Visual analogue scale (VAS) and numerical rating scale (NRS) were obtained at 24 hours, 7 days, 1 month, 3 months and 6 months after operation. The efficacy and postoperative incidence of facial numbness were evaluated and calculated,and the postoperative adverse reactions were recorded. Results: VAS scores significantly decreased 24 hours, 7 days, 1 month, 3 months and 6 months after operation (all P<0.01). The effective rate of coblation 24 hours, 7 days, 1 month, 3 months and 6 months after operation was 89.19% (33/37), 97.30% (36/37), 100% (37/37), 100% (37/37) and 100% (37/37), respectively, and the incidence of facial numbness was 67.57% (25/37), 54.05% (20/37), 29.73% (11/37), 8.11% (3/37) and 5.41% (2/37), respectively. No severe numbness was observed. Facial hematoma and postural hypotension were noticed in 18 (18/37, 48.65%) and 3 (3/37, 8.11%) patients 24 hours after operation, respectively. All the symptoms remitted completely within 72 hours after expectant treatment. No other adverse reaction was found. Conclusion: CT-guided low temperature plasma coblation is effective and safe for treating sphenopalatine neuralgia.

Clipaje endoscópico de la arteria esfenopalatina para el tratamiento de la epistaxis posterior / Endoscopic sphenopalatine artery ligation for posterior epistaxis

Resumen Antecedentes Los casos de epistaxis posterior representan alrededor del 10 al 20% de las epistaxis. El tratamiento convencional para este tipo de padecimientos son los taponamientos nasales. El abordaje quirúrgico (cauterización y/o clipaje) está indicado cuando existe falla del tratamiento médico convencional; sin embargo, en la actualidad, se considera como primera opción. Material y métodos Se revisaron todos los casos de epistaxis posterior tratados en el Hospital Español de México de enero de 2007 a enero de 2017. Se realizó estadística descriptiva e inferencial para comparar al grupo conservador (taponamiento nasal) versus el grupo quirúrgico (clipaje). Resultados Se revisaron 242 expedientes; de ellos, se excluyeron 108. Se incluyeron 134 pacientes: 96 correspondieron al grupo quirúrgico y 38 al conservador. El 60.20% perteneció al género masculino y el 39.80% al femenino. La media para la edad fue de 60 años. El grupo quirúrgico (3.4 ± 1.9 días) requirió menos días de estancia hospitalaria en comparación con el conservador (4.8 ± 3.0 días), p < 0.01. Los pacientes con una epistaxis del lado derecho en el grupo quirúrgico tuvieron un mayor tiempo quirúrgico (p = 0.001) y más días de estancia hospitalaria (p = 0.006). Conclusiones La epistaxis sucede en la mayoría de los casos de forma idiopática; es frecuente en hombres mayores de 60 años con enfermedades cardiopulmonares, sin conocerse de forma precisa su fisiopatología. La epistaxis derecha tratada quirúrgicamente resulta tener más morbilidad. El abordaje quirúrgico es seguro, eficaz y acorta los días de estancia hospitalaria en comparación con el tratamiento conservador.

Abstract Background The cases of posterior epistaxis represent approximately 10 to 20% of all epistaxis. The conventional treatment for this type of ailment is nasal packing. A surgical approach (cauterization and/ or clipping) is indicated when there is a failure of the conventional medical treatment; however, it is currently considered as the first option. Material and methods All the epistaxis cases treated at the Hospital Español de México from January 2007 to January 2017 were reviewed. Descriptive and inferential statistics were used to compare the conservative group (nasal packing) versus the surgical one (clipping). Results 242 dossiers were reviewed, of which 108 were excluded. 134 patients were included: 96 belonged to the surgical group and 38 to the conservative one. 60.20% were male and 39.80% were female. The mean age was 60 years. The surgical group (3.4 ± 1.9 days) required fewer days of hospital stay compared to the conservative group (4.8 ± 3.0 days), p < 0.01. Patients with right-sided epistaxis in the surgical group had a longer surgical time (p = 0.001) and more days of hospital stay (p = 0.006). Conclusions Epistaxis occurs in most cases idiopathically, often in men over 60 years with cardiopulmonary diseases, without a precise knowledge of its physiopathology. Right epistaxis treated surgically results in more morbidity. The surgical approach is safe, effective and shortens the days of hospital stay compared to the conservative treatment.

Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós-punção dural em pacientes obstétricas - série de casos

Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.

Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.

Clinical observation on the treatment of severe perennial allergic rhinitis with acupuncture on sphenopalatine ganglion / 国际中医中药杂志

Objective To evaluate the clinical efficacy of acupuncture on sphenopalatine ganglion in the treatment of severe perennial allergic rhinitis (PAR) in a randomized controlled clinical trials. Methods A total of 81 patients with severe perennial allergic rhinitis were randomly divided into three groups: 27 in the observation group, 27 in the drug control group and 27 in the acupuncture control group. The patients in the observation group were treated with acupuncture on sphenopalatine ganglion; and the patients in the drug control group took Desloratadine; and the patient in the acupuncture control group were treated with acupuncture on Yintang (GV 29) and Yingxiang (LI 20). All the groups were treated for 4 weeks. The TNNS and VAS score system were tested before and after the treatment, and the nasal exhalation of nitric oxide (eNO) concentration level wa detected at baseline and each week's during treatments. Results After the treatment,the effective rate [80.8%(21/26)vs.64.0%(16/25),65.4%(17/26),x2=13.811]of the observation group was significantly higher than either the drug control group or the acupuncture control group (P<0.01). Compared to the score of the three group before treatment, the TNNS score was significantly lower (P<0.01) after the treatment. Compared with the drug control group, the level of eNO in nasal exhalation air (265.377 ± 36.475 ppb vs. 281.769 ±45.823 ppb vs. 295.231 ± 24.595 ppb, F=4.247) of the observation group and the acupuncture control group were significantly higher (P<0.05). Conclusions Acupuncture on the sphenopalatine ganglion can not reduce the eNO concentration level of nasal exhaled air in patients with perennial allergic rhinitis, but it can improve the symptoms of rhinitis. The clinical effect of acupuncture on the sphenopalatine ganglion was better than the desloratadine and acupuncture on GV 29 and LI 20.

Embolization of dural arteriovenous fistula of anterior cranial fossa via sphenopalatine artery:a effect analysis / 中国脑血管病杂志

Objective To preliminarily discuss the safety and effectiveness of embolization of dural arteriovenous fistula of anterior cranial fossa via sphenopalatine artery. Methods From January 2002 to June 2017,the clinical data of 7 patients with dural arteriovenous fistula of anterior cranial fossa embolized via sphenopalatine artery at Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively.There were 6 men and 1 woman,their mean age was 60.4 ± 3.6 years.One patient had subarachnoid hemorrhage with hematoma,6 had non-specific symptoms. The technical methods and complications via sphenopalatine artery embolization were analyzed.The occlusion of the proximal drainage vein with the embolization agent was used as the standard for successful embolization.They were all clinically followed up at 6 months after procedure. Results (1)Five patients selected sphenopalatine artery as the preferred treatment.After embolization failed in other treatment approaches,2 patients were re-embolized via sphenopalatine artery. Five lesions were successfully embolized via sphenopalatine artery,including the sphenopalatine artery as the preferred treatment approach in 4 cases,the sphenopalatine artery as a remedial embolization approach after the failure of other arterial approaches in 1 case.Transsphenoidal artery failed to occlude the lesions in 2 cases,including successful embolization of other blood supply artery in 1 case during the operation,and postoperative angiography revealed that the lesion was almost completely occluded in the other 1.All patients recovered well without complications after procedure.(2)All patients were followed up for 6 months after procedure.The patients did not have blurred vision and other new neurological disorders, and they did not have new intracranial hemorrhage and nasal symptoms.Two of them underwent angiographic follow-up at admission.The immediate angiography in 1 patient showed that his lesion completely disappeared,At 6 months after operation,angiography revealed that the lesion was recurrence-free. The immediate angiography in 1 patient showed that his lesion nearly completely disappeared.At 4 months after operation, angiography revealed that the lesion disappeared completely. Conclusions Embolization of dural arteriovenous fistulas of anterior cranial fossa via sphenopalatine artery is a feasible,safe and effective treatment. It is also the treatment option after other poor arterial approach or failure of other arterial approach.

Manejo de epistaxis posterior en el Hospital Clínico de la Universidad de Chile entre los años 2013 y 2016 / Treatment of posterior epistaxis in the Clinical Hospital of the University of Chile between the years 2013 and 2016

Introducción: La epistaxis corresponde a una de las causas más frecuentes de consulta otorrinolaringológica en los servicios de urgencia. La epistaxis posterior es menos frecuente pero su presentación más severa. Existen varias alternativas terapéuticas, en las últimas décadas el manejo quirúrgico endoscópico de la arteria esfenopalatina (AEP) ha ido en aumento dado las ventajas en comodidad para el paciente y reducción de costos asociados. Objetivo: Revisar el manejo realizado en los cuadros de epistaxis posterior en el Hospital Clínico de la Universidad de Chile (HCUCh). Material y método: Estudio descriptivo en el Servicio de Otorrinolaringología del HCUCh de pacientes que presentaron epistaxis posterior entre el año 2013 y 2016. Resultados: Se revisó un total de 33 casos. La edad promedio de los pacientes fue 61,6 años siendo las comorbilidades más frecuentes la hipertensión arterial (36,3%) y fibrilación auricular (18,1%). Se realizó tratamiento quirúrgico en 57,6% de los pacientes siendo el clipaje de AEP la intervención quirúrgica más frecuente. Discusión y conclusiones: Tanto el manejo tradicional como las técnicas quirúrgicas presentaron eficacia similar en la serie revisada.

Introduction: Epistaxis corresponds to one of the most frequent causes of otorhinolaryngological consultation in the emergency services. Posterior epistaxis is less frequent but more severe. There are several therapeutic alternatives, in recent decades the surgical endoscopic management of the sphenopalatine artery (AEP) has been increasing given the advantages in comfort for the patient and reduction of associated costs. Aim: To review the management of posterior epistaxis in the Clinical Hospital of the University of Chile (HCUCh). Material and method: Descriptive study in the Otorhinolaryngology Service of the HCUCh of patients who presented posterior epistaxis between the years 2013 and 2016. Results: A total of 33 cases were reviewed. The mean age of the patients was 61.6 years, with the most frequent comorbidities being hypertension (36.3%) and atrial fibrillation (18.1%). Surgical treatment was performed in 57.6% of the patients, with AEP clipping being the most frequent surgical intervention. Conclusion: Both traditional management and surgical techniques presented similar efficacy in the revised series.

Sphenopalatine ganglion block for postdural puncture headache in ambulatory setting / Bloqueio do gânglio esfenopalatino para cefaleia pós-punção dural em contexto de ambulatório

Abstract Background and objectives: Postdural puncture headache (PDPH) is a common complication following subarachnoid blockade and its incidence varies with the size of the needle used and the needle design. Suportive therapy is the usual initial approach. Epidural blood patch (EBP) is the gold-standard when supportive therapy fails but has significant risks associated. Sphenopalatine ganglion block (SPGB) may be a safer alternative. Case report: We observed a 41 year-old female patient presenting with PDPH after a subarachnoid blockade a week before. We administrated 1 l of crystalloids, Dexamethasone 4 mg, parecoxib 40 mg, acetaminophen 1 g and caffeine 500 mg without significant relief after 2 hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5 minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1 g and ibuprofen 400 mg every 8 hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situation. Conclusions: SPGB may attenuate cerebral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatine ganglion. This would be in agreement with the Monro-Kellie concept and would explain why caffeine and sumatriptan can have some effect in the treatment of PDPH. Apparently, SPGB has a faster onset than EBP with better safety profile. We suggest that patients presenting with PDPH should be considered primarily for SPGB. Patients may have a rescue EBP if needed.

Resumo Justificativa e objetivos: Cefaleia pós-punção dural (CPPD) é uma complicação comum após bloqueio subaracnoideo e sua incidência varia de acordo com o tamanho e desenho da agulha usada. Geralmente, a terapia de apoio é a abordagem inicial. O tampão sanguíneo peridural (TSP) é o padrão de terapia quando a terapia de apoio falha, mas tem riscos significativos associados. O bloqueio do gânglio esfenopalatino (BGEP) pode ser uma opção mais segura. Relato de caso: Atendemos uma paciente de 41 anos, com CPPD após bloqueio subaracnoideo uma semana antes. Administramos cristaloides (1 L), dexametasona (4 mg), parecoxib (40 mg), acetaminofeno (1 g) e cafeína (500 mg), sem alívio significativo após 2 horas. Fizemos um bloqueio bilateral do gânglio esfenopalatino, com um aplicador com ponta de algodão saturada com levobupivacaína a 0,5% sob monitoração padrão ASA. O alívio dos sintomas foi relatado 5 minutos após o bloqueio. A paciente foi monitorada por uma hora e depois recebeu alta com prescrição de acetaminofeno (1 g) e ibuprofeno (400 mg) a cada 8 horas para os dois dias seguintes. A paciente foi contatada no dia seguinte e novamente após uma semana e, em ambos os contatos, relatou não sentir dor. Conclusões: O BGEP pode ter atenuado a vasodilatação cerebral induzida pelo estímulo parassimpático transmitido através dos neurônios que têm sinapses no gânglio esfenopalatino. Esse mecanismo estaria de acordo com o conceito de Monro-Kellie e explicaria por que a cafeína e o sumatriptano podem ter algum efeito no tratamento da CPPD. Aparentemente, o BGEP tem um início mais rápido do que o do TSP, com um melhor perfil de segurança. Sugerimos que os pacientes que se apresentam com CPPD devam ser considerados primeiro para BGEP. Os pacientes podem ser submetidos a um TSP de resgate, caso necessário.

Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy

The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture headaches (PDPH) has always been challenging. The epidural block patch (EBP) was the only option until researchers explored the role of the SPG block as a relatively simple and effective way to treat PDPH. Also, since the existing evidence proving the efficacy of the SPG block in PDPH is scarce, the block cannot be offered to all patients. EBP can be still considered if an SPG block is not able to alleviate pain due to PDPH.