|Year : 2017 | Volume
| Issue : 1 | Page : 13-17
Radiofrequency ablation of sphenopalatine ganglion for head and neck cancer pain management
Priti R Sanghavi, Dipak D Patel, Geeta M Joshi
Department of Palliative Medicine and Neurooncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
|Date of Web Publication||5-May-2017|
Priti R Sanghavi
15, Arunodaypark Society, St. Xaviers College Corner, Navrangpura, Ahmedabad - 380 009, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Pain in advanced head and neck cancer is intractable and many a times difficult to manage with pharmacological agents. Sphenopalatine ganglion (SPG) block provides excellent pain relief in patients who are suffering from various types of orofacial pain. Role of radiofrequency ablation (RFA) of SPG is described for orofacial cancer pain. Aim: The aim of the study was to observe efficacy and duration of pain relief by RFA of SPG in advanced head and neck cancer patients. Materials and Methods: Thirty-three patients suffering from advanced head and neck cancer were enrolled in this study between September 2013 and February 2016. All patients underwent RFA of SPG, under fluoroscopy guidance following a successful diagnostic block of SPG with local anesthetic. Pain was assessed before the procedure, immediately after the procedure, and during each follow-up visit. Follow-up visits were weekly for 4 weeks and then monthly till the end of life. Patients were continued on oral morphine, but the dose was reduced to one-third of total dose and was adjusted according to patients' requirement during each follow-up. Duration of analgesia, morphine requirements, and incidence of complications were noted. Results: There were 32 males and one female. Mean age of patients was 43.24 ± 13.52 (mean ± standard deviation [SD]), ranging from 19 to 58 years. Three patients did not undergo RFA due to cheek hematoma formation during the procedure. Visual analog score was reduced from 8.43 ± 1.10 (preprocedure) to 1.36 ± 1.61 (postprocedure) (mean ± SD). Mean duration of analgesia was 17.55 ± 26.12 (mean ± SD) weeks. Mean reduction in the dose of morphine was from 124.65 ± 46.78 to 40.00 ± 18.05 mg (mean ± SD) immediately after the procedure. One patient was followed up for 30 months. Sixteen patients died within 3 months and had good pain relief. None of the patients had any serious complications. Conclusion: RFA of SPG is a good adjuvant method of pain management in head and neck cancer patients. It gives significant pain relief and reduces morphine requirement. It is safe and it can be carried out as day-care procedure.
Keywords: Cancer pain management, head and neck cancer, radiofrequency ablation, sphenopalatine ganglion block
|How to cite this article:|
Sanghavi PR, Patel DD, Joshi GM. Radiofrequency ablation of sphenopalatine ganglion for head and neck cancer pain management. Indian J Pain 2017;31:13-7
|How to cite this URL:|
Sanghavi PR, Patel DD, Joshi GM. Radiofrequency ablation of sphenopalatine ganglion for head and neck cancer pain management. Indian J Pain [serial online] 2017 [cited 2017 Jun 28];31:13-7. Available from: http://www.indianjpain.org/text.asp?2017/31/1/13/205713
| Introduction|| |
Head and neck cancer ,, is common and usually presents in very advanced stage. Sphenopalatine ganglion block (SPGB),, is indicated for relief of facial pain and headache arising from sphenopalatine neuralgia, trigeminal neuralgia, atypical facial pain, acute migraine, acute and chronic headache, pain due to herpes zoster involving the ophthalmic nerve, and head and neck cancer pain. Approaches , for SPGB are transnasal, transoral, and lateral infrazygomatic approach. Role of Radiofrequency ablation (RFA),,,,,,, of SPG has been described by many for atypical facial pain, but few for cancer pain. Up till now, no prospective study on RFA of SPG has been carried out for cancer pain management. Therefore, we conducted this prospective study to observe the efficacy of the procedure and duration of pain relief by RFA of SPG in head and neck cancer pain management.
| Materials and Methods|| |
After getting Institutional Review Committee and Ethical Committee approval, we obtained informed consent from patients and relatives. Thirty-three patients with advanced stage of head and neck cancer were enrolled for this study between September 2013 and February 2016. After successful diagnostic SPGB (transnasal) with 2 ml (1 ml + 1 ml at 5 min interval) of 0.5% bupivacaine without steroid, patients were enrolled in the study.
- Head and neck cancer patients having pain score visual analog score (VAS) >8 and whose pain was not responding to pharmacological agents
- Patients who were noncompliant to morphine
- Life expectancy of patients more than 3 months
- Patients having pain relief following SPGB with local anesthetic.
- Local site necrotic wound infection and distorted facial anatomy either due to disease or surgery
- Abnormal coagulation profile
- Patients with intracranial extension of the tumor
- Patients having nasopharyngeal growth, for example, cancer of maxilla involving maxillary sinus
- Patients or relatives' refusal.
The procedure was performed through infrazygomatic approach under fluoroscopy guidance.,, Intravenous access was secured and glycopyrrolate 0.2 mg was injected intravenously. Pulse, blood pressure, and peripheral oxygen saturation were monitored. Patients were placed in supine position. Under lateral fluoroscopic view, pterygopalatine fossa was identified as shown in [Figure 1]. The needle entry site was marked using a metallic indicator below the zygomatic arch. After anesthetizing the entry point, a 22-gauge, 10 cm, RFA needle with 5 mm active tip was inserted in a cephalad, medial, and posterior direction to reach the base of the pterygopalatine fossa [Figure 2]. The needle position was confirmed in anteroposterior view at the level of medial turbinate, lateral to the nasal cavity [Figure 3]. After confirmation of location, sensory stimulation of the ganglion was performed with 50 Hz, 0.2–0.5 V to obtain paresthesia behind the roof of the nose, and three lesions were carried out at 90°C for 70 s. Following RFA, 0.5 ml of 0.5% bupivacaine and triamcinolone 10 mg were injected to prevent postprocedure neuritis.
Patients were observed for 24 h for pain relief and untoward side effects. Pain assessment was done using VAS score. Pain relief was considered “Significant” if reduction in VAS score was more than 75%, “Partial” – if between 50% and 75%, and “Poor” if it was <50%.
Immediate and subsequent pain relief was recorded using VAS score. Patients were followed up weekly for the 1st month and monthly thereafter. Patients continued on oral morphine, but total dose of morphine was reduced to one-third of preprocedure dose following successful RFA. Morphine dose was adjusted during each visit. Duration of analgesia was recorded by observing VAS score. Immediate and delayed complications were recorded.
| Results|| |
A total of 33 patients were enrolled. There were 32 males and 1 female. Mean age of patients was 43.24 ± 13.52 (mean ± standard deviation [SD]), ranging from 19 to 58 years [Table 1]. [Table 2] shows diagnosis and treatment status of all 33 patients. Eleven patients were postoperative and 25 patients had received radiotherapy either curative or palliative. In three patients, RFA was abandoned because of cheek hematoma formation during the procedure.
Significant pain relief was observed in all thirty patients [Table 3]. Mean reduction in preprocedure to postprocedure VAS score was from 8.43 ± 1.10 to 1.36 ± 1.61 (mean ± SD). One patient was lost to follow-up within 1 week of procedure.
|Table 3: Pre & Post-procedure VAS, Duration of Analgesia and Morphine Requirement|
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Mean duration of analgesia was 17.55 ± 26.12 (mean ± SD) weeks [Table 3]. Maximum duration of analgesia was 30 months in one patient and minimum duration was 2 weeks in one patient. As shown in [Figure 4], significant pain relief was observed up to 4 weeks in five patients, for 2 months in six patients, for 3 months in 11 patients, and four patients had pain relief up to 4 months. Sixteen patients died within 3 months but had good pain relief.
Mean reduction in the dose of morphine from pre- to post-procedure was 124.65 ± 46.78 to 40.00 ± 18.05 (mean ± SD) [Table 3]. Dose of morphine was reduced to one-third of total dose immediately after procedure in all patients. One patient, who had pain relief for 30 months, did not require morphine till date. Five patients required increased dose of morphine after 4 weeks, but the increased dose was minimal, and none of the patients required the preprocedural dose of opioid.
One patient had refractory bradycardia during the procedure. None of the patients had delayed complications such as infection or permanent/temporary hyperesthesia or dysesthesia [Table 4].
| Discussion|| |
SPG ,, is a parasympathetic ganglion considered as a nerve center with multiple connections to trigeminal, facial, and sympathetic system. It consists of somatosensory, sympathetic, and parasympathetic fibers. It receives sensory impulse from all mucosal lining of nose, maxillary, posterior ethmoidal, sphenoidal sinuses, roof of mouth, upper two-third of tonsil, soft palate, major part of pharynx, nasopharynx, and taste fibers from anterior two-third of tongue. Sensory fibers join the maxillary nerve and motor root of ganglion connect to facial nerve by superficial petrosal nerve.
Head and neck cancer patients are major recipients of palliative care services at our institute. Ten to twenty percent of the patients with advanced cancer need interventional pain management. Appropriate and timely use of interventional pain management can provide optimum pain relief for patients with advanced cancer. It helps reduce distress in patients and thereby in the families during the difficult period.
Murthy and Prasanna  reported 100% pain relief in four patients having cancer pain following endoscopic SPGB. Varghese and Koshy  used 0.5 ml of 6% phenol for SPGB for pain management in advanced head and neck cancer patients under endoscopic guidance. He found significant pain relief in 17 patients, partial pain relief in one patient, and inadequate pain relief in four patients.
In our study, 33 patients of advanced head and neck cancer were selected for RFA of SPG. Twenty-seven patients had significant immediate pain relief, and then the intensity of pain was moderate in all patients throughout the study period. Two patients had partial pain relief, i.e., reduction in VAS score between 50% and 75% and one patient had poor pain relief, i.e., reduction of VAS score <50%.
Duration of analgesia in weeks was 17.55 ± 26.12 (mean ± SD). Shorter duration of analgesia was observed in our study, as majority of our patients died within 3 months of the procedure and a longer follow-up was not possible. Only five patients survived for more than 6 months. Maximum duration of analgesia noted was 24 months in one patient and 30 months in another patient.
Narouze  reported favorable outcome in the treatment of intractable chronic cluster headaches with RFA of SPG. They reported significant improvement in both, the mean intensity and mean attack frequency for up to 18 months in 15 patients.
Joshi and Chambers  stated that pain is the most feared and common symptom near the end of life in advanced cancer patients. Opioids, given as per the World Health Organization (WHO) ladder, are the cornerstone of pain management in majority of cancer patients having moderate-to-severe pain. Sloan and Melzack  reported that 82% of patients had good to excellent pain control with opioids and adjuvants. Intractable cancer pain resistant to the WHO analgesic ladder afflicts 10%–15% of cancer pain patients. These patients can be treated with interventional techniques. In our study, all the patients were on oral analgesics as per the WHO ladder in the form of nonsteroidal anti-inflammatory drugs and morphine as well as antidepressant and/or anticonvulsant drugs.
Bayer et al. reported mild-to-moderate reduction in oral opioid requirement in their study of pulse radiofrequency of SPG in thirty patients suffering from chronic face and head pain. In our study, mean morphine requirement was reduced from 124.65 ± 46.78 to 48.89 ± 20.82 (mean ± SD) during the 1st month. Due to significantly decreased postprocedure pain intensity, we could also reduce the dose of opioid in most of the patients and one patient is morphine free till today.
Ruiz-López and Erdine  used radiofrequency procedures for the treatment of craniofacial pain. They reported that this procedure can be used as a second-line alternative when pain is refractory to pharmacological therapy. Sanders and Zuurmond, after 29 months of follow-up, reported its efficacy in 60% of patients with refractory cluster headache and Salar et al. reported its efficacy in SPG neuralgia in seven patients after 6–36 months of follow-up.
Most common complications , of this procedure are cheek hematoma formation and epistaxis due to lateral nasal bone perforation, requiring abandonment of the procedure. Other immediate complication is refractory bradycardia. Delayed complications are permanent or temporary hyperesthesia/dysesthesia and infection at local site. Sanders and Zuurmond  reported postprocedure epistaxis in 8 patients and cheek hematoma in 11 patients and temporary hyperesthesia of the palate in 9 patients, out of 66 patients. In our study, procedure was abandoned in three patients due to cheek hematoma formation. No other complications were observed in our study.
Limitations of the study
Most of the patients were referred during the advanced stage of the disease. Many of our patients died within few months. Hence, longer follow-up was possible only in a small number of patients.
| Conclusion|| |
RFA of SPG is a good adjuvant method of pain management in head and neck cancer patients. Although it may provide shorter duration of analgesia, it gives significant relief in pain and suffering of patients and caregivers during the advanced stage of the disease. It is safe and can be carried out as day-care procedure.
We are very thankful to Gujarat Cancer Society for financial and administrative support. We acknowledge Dr. Rashmin Sanghavi, Consultant Anesthesiologist, for his guidance, sharing his scientific knowledge, and supporting us throughout the study with his contribution.
Financial support and sponsorship
This study was financially supported by Gujarat Cancer Society, Ahmedabad, Gujarat, India.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kulkarni MR. Head and neck cancer burden in India. Review article. Int J Head Neck Surg 2013;4:29-35.
Chiara B, Francesco M, Laura C, Maria Sole M, Andrea C. Pain in head and neck cancer: Prevalence and possible predictive factors-review article. J BUON 2014;19:592-7.
Joshi M, Chambers WA. Pain relief in palliative care: A focus on interventional pain management. Expert Rev Neurother 2010;10:747-56.
Campbell EH. Affections of the sphenopalatine ganglion. Ann Surg 1935;101:429-37.
Piagkou M, Demesticha T, Troupis T, Vlasis K, Skandalakis P, Makri A, et al.
The pterygopalatine ganglion and its role in various pain syndromes: From anatomy to clinical practice. Pain Pract 2012;12:399-412.
Serdar E. Sympathetic block of the head and neck. In: Prithvi Raj P, editor. Interventional Pain Management – Image Guided Procedure. 2nd
ed. Philadelphia: Saunders Elsevier; 2008. p. 288-91.
Narouze SN. Role of sphenopalatine ganglion neuroablation in the management of cluster headache. Curr Pain Headache Rep 2010;14:160-3.
Ruiz-López R, Erdine S. Treatment of cranio-facial pain with radiofrequency procedures. Pain Pract 2002;2:206-13.
Sanders M, Zuurmond WW. Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: A 12- to 70-month follow-up evaluation. J Neurosurg 1997;87:876-80.
Salar G, Ori C, Iob I, Fiore D. Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia. Acta Neurochir (Wien) 1987;84:24-8.
Dharmavaram S, Kondappan A, Palanjsamy V, Raju SK. Conventional radiofrequency ablation of sphenopalatine ganglion for the treatment of cluster headache. Indian J Pain 2016;30:140-2. [Full text]
Bayer E, Racz GB, Miles D, Heavner J. Sphenopalatine ganglion pulsed radiofrequency treatment in 30 patients suffering from chronic face and head pain. Pain Pract 2005;5:223-7.
Murthy PS, Prasanna A. Endoscopic sphenopalatine ganglion block for pain relief. Clin J Pain 1998;50:99-105.
Varghese BT, Koshy RC. Endoscopic transnasal neurolytic sphenopalatine ganglion block for head and neck cancer pain. J Laryngol Otol 2001;115:385-7.
Sloan P, Melzack R. Long-term patterns of morphine dosage and pain intensity among cancer patients. Hosp J 1999;14:35-47.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]