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Sphenopalatine block in the management of trigeminal neuralgia
ARTICLE IN PRESS
YBJOM-4731; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
Sphenopalatine block in the management of trigeminal neuralgia Grant Isherwood a,∗ , Mark Ansell b a b
Oral and Maxillofacial Senior House Officer Specialist Registrar in Oral and Maxillofacial Surgery
Accepted 26 August 2015
Keywords: Trigeminal neuralgia; pain
Trigeminal neuralgia is characterised by episodes of intense pain in the distribution of the trigeminal nerve that last for a few seconds to several minutes or even hours. It can be triggered by common activities such as eating, talking, and brushing teeth, and the attacks are said to feel like stabbing electric shocks, burning, pressing, crushing, exploding, or shooting pains that become unbearable.1 As the evidence for surgical treatment is poor, it is recommended only if medical management is not effective, although medical management alone may not be sufficient to relieve symptoms quickly. We describe a novel technique for a sphenopalatine block, which can be useful in providing symptomic relief for acute exacerbations or for diagnostic purposes. A flexible nasoendoscope, microbiology transport swab, 24-gauge spinal needle, local anaesthetic, and a 5 ml syringe are collected. The tip of the transport swab is removed using scissors and the tube is cut to length 2 mm shorter than the spinal needle. The plastic sheath fits perfectly over the needle leaving 1-2 mm of the needle extruding from the end to prevent it inadvertently passing into deeper structures (Fig. 1). Local anaesthetic is drawn up, usually 0.5% bupivacaine for its duration of anaesthesia, and attached to the needle (Fig. 2). A flexible nasal endoscope is used to identify the mucosa overlying the sphenopalatine ganglion, which is found in the
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, ML6 0JS. Tel.: +01236 748 748. E-mail addresses: [email protected] (G. Isherwood), [email protected] (M. Ansell).
lateral nasal mucosa just posterior to the middle turbinate. The plastic sheath is positioned under direct vision and held against the mucosa (Fig. 3). The endoscope is withdrawn if the procedure is done single-handed, but safety can be improved if an assistant
Fig. 1. Spinal needle and transport swab, which is cut using surgical scissors.
http://dx.doi.org/10.1016/j.bjoms.2015.08.274 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Isherwood G, Ansell M. Sphenopalatine block in the management of trigeminal neuralgia. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.274
YBJOM-4731; No. of Pages 2
2
ARTICLE IN PRESS
G. Isherwood, M. Ansell / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 2. Plastic sheath placed over the spinal needle and the syringe.
Fig. 4. Injection of local anaesthetic.
injects the local anaesthetic using the hollow tube as a guide sheath, as the injection and blanching of the nasal mucosa can be observed (Fig. 4). This is a simple, safe, and effective technique for a sphenopalatine ganglion block. We have successfully used it on about 15 occasions to treat or diagnose trigeminal neuralgia affecting the maxillary division of the nerve. To date, no complications have been encountered. Conflict of Interest We have no conflicts of interest.
Reference Fig. 3. Locating the lateral nasal mucosa just posterior to the middle turbinate.
1. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014;348:g474.
Please cite this article in press as: Isherwood G, Ansell M. Sphenopalatine block in the management of trigeminal neuralgia. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.274
YBJOM-4731; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
Sphenopalatine block in the management of trigeminal neuralgia Grant Isherwood a,∗ , Mark Ansell b a b
Oral and Maxillofacial Senior House Officer Specialist Registrar in Oral and Maxillofacial Surgery
Accepted 26 August 2015
Keywords: Trigeminal neuralgia; pain
Trigeminal neuralgia is characterised by episodes of intense pain in the distribution of the trigeminal nerve that last for a few seconds to several minutes or even hours. It can be triggered by common activities such as eating, talking, and brushing teeth, and the attacks are said to feel like stabbing electric shocks, burning, pressing, crushing, exploding, or shooting pains that become unbearable.1 As the evidence for surgical treatment is poor, it is recommended only if medical management is not effective, although medical management alone may not be sufficient to relieve symptoms quickly. We describe a novel technique for a sphenopalatine block, which can be useful in providing symptomic relief for acute exacerbations or for diagnostic purposes. A flexible nasoendoscope, microbiology transport swab, 24-gauge spinal needle, local anaesthetic, and a 5 ml syringe are collected. The tip of the transport swab is removed using scissors and the tube is cut to length 2 mm shorter than the spinal needle. The plastic sheath fits perfectly over the needle leaving 1-2 mm of the needle extruding from the end to prevent it inadvertently passing into deeper structures (Fig. 1). Local anaesthetic is drawn up, usually 0.5% bupivacaine for its duration of anaesthesia, and attached to the needle (Fig. 2). A flexible nasal endoscope is used to identify the mucosa overlying the sphenopalatine ganglion, which is found in the
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, ML6 0JS. Tel.: +01236 748 748. E-mail addresses: [email protected] (G. Isherwood), [email protected] (M. Ansell).
lateral nasal mucosa just posterior to the middle turbinate. The plastic sheath is positioned under direct vision and held against the mucosa (Fig. 3). The endoscope is withdrawn if the procedure is done single-handed, but safety can be improved if an assistant
Fig. 1. Spinal needle and transport swab, which is cut using surgical scissors.
http://dx.doi.org/10.1016/j.bjoms.2015.08.274 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Isherwood G, Ansell M. Sphenopalatine block in the management of trigeminal neuralgia. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.274
YBJOM-4731; No. of Pages 2
2
ARTICLE IN PRESS
G. Isherwood, M. Ansell / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 2. Plastic sheath placed over the spinal needle and the syringe.
Fig. 4. Injection of local anaesthetic.
injects the local anaesthetic using the hollow tube as a guide sheath, as the injection and blanching of the nasal mucosa can be observed (Fig. 4). This is a simple, safe, and effective technique for a sphenopalatine ganglion block. We have successfully used it on about 15 occasions to treat or diagnose trigeminal neuralgia affecting the maxillary division of the nerve. To date, no complications have been encountered. Conflict of Interest We have no conflicts of interest.
Reference Fig. 3. Locating the lateral nasal mucosa just posterior to the middle turbinate.
1. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. BMJ 2014;348:g474.
Please cite this article in press as: Isherwood G, Ansell M. Sphenopalatine block in the management of trigeminal neuralgia. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.274