Abstract

Introduction

Head and neck cancers are common cancers, with a prevalence rate of 57.5% in India. It accounts for 30% of all cancers in India.[1] Due to high consumption of tobacco, these types of cancers are significantly prevalent in Gujarat. Pain[2] in patients with head and neck cancer is most frequent symptom; it is severe, intractable and sometimes difficult to treat with pharmacological therapy. Hence, the need for intervention rises.[3]  THE DESCRIPTION OF SEVERE  INTRACTABLE PAIN BRINGS REAL MEANIG TO THE IMMEDIATE RELIEF SPG BLOCKS PROVIDE.

Sphenopalatine ganglion is one of the four ganglion in head and neck area, situated in pterygopalatine fossa found outside the cranium.[4,5] THE SPHENOPALATINE GANGLION IS THE LARGERST PARASYMPATHETIC GANGLION OF THE HEAD AND HAS SYMPATHETIC FIBERS FROM SUPERIOR CERVICAL GANGLIO RUNNING THRU IT.     It is mainly a parasympathetic ganglion and is exposed to the environment through our nasal cavity. Science has proved that sphenopalatine ganglion block (SPGB) provides excellent analgesia in various types of acute and chronic orofacial pain.[4,5,6,7] There are various approaches[4,5,6,7,8] described for this procedure, of which transnasal approach using local anesthetic agent is a less invasive, easy and safe method of pain relief but provides temporary analgesia, hence, needs to be performed repeatedly.   MANY SEVERE PAIN PATIENTS SEE A CUMULATIVE EFFECT THAT CAN DECREASE OR ELIMINATE PAIN LONG TERM BUT CANCER PAIN THERE IS AN ONGOING INSULT TO THE BODY .  INCREASING FREQUENCY CAN VASTLY IMPROVE PATIENTS LIFE QUALITY.  Conventional methods of transnasal block require the use of endoscope,[9] image guidance,[10,11,12] or special catheter like Tx360[10] Spinocath, or[11] Allevio.[12] We modified the technique using cotton swab/ear buds so that it can be performed at home.  THE THREE DEVICES,  THE TX360, THE SPHENOCATH AND THE ALLEVIO ARE DESIGNES SINGLE USE IN THE PHYSICIANS OFFICE OR ER.  THEY CAN BE REUSED BY A SINGLE PATIENT BUT ARE DESIGNED FOR SINGLE USE.  THE TX360 CANNOT BE REUSED IN ANY FASHION.

We used various devices such as intravenous cannula, cotton swab sticks, and ear buds during our pilot study of SPGB in head and neck cancer pain management on 385 patients at our institute and developed a standard technique using ear buds to be inserted transnasal.

This study was undertaken with the primary aim of providing immediate pain relief to head and neck cancer patients attending our outpatient department (OPD) with moderate to severe pain. It was also aimed to study effects of SPGB, its duration of analgesia, morphine requirement, ease of performance of procedure at home.  IT WOULD MAKE SENSE TO ALSO UTILIZE THIS TECHNIQUE FOR MILDER PAINS INSTEAD OF OTHER DRUGS.  A SIDE EFFECT OF SPG BLOCKS IS REDUCED ANXIETY AND A SENSE OF WELL BEING.  THIS IS A GIFT TO CANCER PATIENTS.

Methods

This was a prospective, single-arm, observational study performed at State Cancer Institute. The study duration was 2 years, i.e., from January 2014 to December 2015 for 100 patients. The study was approved by the Institutional Review Board. Patients were reviewed for detailed history, pain assessment, investigations, and examination including examination of both nostrils. Patients and caretakers were explained the procedure thoroughly. Those who expressed willingness to participate in the study were enrolled in this study, and their written informed consent was obtained.

Results

A total of hundred patients of head and neck cancer were enrolled in this study. There were 66 males and 34 females. Three patients were excluded from study either due to difficult procedure or due to procedure related complication [Table 1].  THIS IS IMPRESSIVE THAT ONLY 3 PATIENTS WERE EXCLUDED FROM THE STUDY OR 3%..

The diagnosis of patients was carcinoma of buccal mucosa (50), tongue (22), alveolus (12), larynx (4), pharynx (4), and floor of mouth (8) [Table 2].

Immediate pain relief was observed by a reduction in VAS score after the procedure, which was reduced from 8.56 ± 1.05 to 2.46 ± 1.23 (P < 0.0001). The mean duration of analgesia was 4.95 ± 3.43 days, (range 1–7 days).  THIS LEVEL OF IMMEDIATE PAIN RELIEF IS AWESOME.  TALK TO ANYONE IN PAIN MANAGEMENT FIELD TO APPRECIATE THE VALUE OF THIS PROCEDURE.

Pre- and post-procedure mean morphine requirements were 128.2 ± 84.64 and 133.8 ± 81.93 (P > 0.05), mg per day, at the end of 2 months [Table 3].

Totally, 42 patients required it to be performed every week, 25 patients, once in 4 days, while 21 patients received SPGB every alternate day [Table 4].

The ease of performance was observed in 88 patients, and it was found to not easy to perform in nine patients. Two patients did not receive SPGB at home as their caretaker found difficulty in administration.

INCREASING BOTH FREQUENCY AND THE TIME OF ADMINISTRATION WILL SERVE TO ENHANCE THESE RESULTS SIGNIFICANTLY.

No serious complications were observed in any patients except giddiness GIDDINESS IS ACTUALLY A SIGN OF PATIIENTS FEELING GOOD, PROBABLY DUE TO DECREASE IN SYMPATHETIC (STRESS) ACTIVITY AND SHOULD BE CONSIDERED POSITIVE EFFECT.  I OFTEN SEE SEVERE CHRONIC PAIN PATIENTS BREAK INTO SMILES WHEN THE HEAVY BURDEN OF CONSTANT PAIN IS REMOVED.  FAMILY MEMBERS SOMETIMES STATE THE PATIENT IS “BACK TO OLD SEL”. in three patients and temporary numbness in throat in three patients which resulted in temporary difficulty in swallowing. All patients felt the bitter taste of drugs [Table 5].  THE GRADUAL CAPILLARY FLOW HAS LESS BITTER TASTE AND LESS THOAT NUMBNESS.

The cost of the materials used in the procedure is 22 Rs. per procedure. NOT SURE WHAR THIS IS IN US DOLLAR BUT SELF ADMINISTRATION IS LESS THEN $1.00 US DOLLAR FOR BILATERAL ADMINISTRATION WITH THE METHOD I TEACH.  IN SPITE OF THIS INCREDIBLY LOW COST INSURANCE COMPANIES ARE NOW REWRITING INSURANCE POLICIES TO DECLARE THE SAFE EFFECTIVE BLOCKS EXPERIMENTAL.   BCBS HAS BEEN WRITING NEW POLICIES STATE BY STATE THAT THESE WILL NO LONGER BE COVERED.

Discussion

Although sphenopalatine ganglion[4,5,6,7,8] is considered mainly as a parasympathetic ganglion, it also has sympathetic and sensory innervations. Its parasympathetic preganglionic fibers arise from superior salivatory nucleus of facial nerve in medulla which traverses as a greater petrosal nerve. These parasympathetic fibers along with sympathetic from deep petrosal nerve create nerves to viridian canal and enter sphenopalatine ganglion. The postganglionic parasympathetic fibers supply to nasal gland, palatine gland, and lacrimal gland. The sympathetic fibers projecting to sphenopalatine ganglion arise from upper thoracic spinal cord T1–T2. The postganglionic fibers synapse in superior cervical ganglion. Postganglionic sympathetic fibers from superior cervical ganglion entries in sphenopalatine ganglion via deep pterosal nerve which are an extension of carotid plexus. Superior cervical ganglion is connected with upper cervical nerve roots (C1, C2, and C3) and so cervical ganglion has connection with sphenopalatine ganglion. Sensory innervations of sphenopalatine ganglion are through the maxillary nerve of trigeminal nerve. Hence, the pain from upper cervical and back gets referred to head and facial area and vice versa. This might explain why SPGB would relieve a headache, facial pain, and pain in the neck as well as upper back.  SPHENOPALATINE GANGLION BLOCKS OFTEN GIVE AMAZING RELIEF EVEN FOR THE WORST MIGRAINES AND CLUSTER HEADACHES.  IT IS IMPORTANT TO NOTE THAT EVEN THE THE SPHENOPALATINE  (PTERYGOPALATINE) GANGLION SITS ON THE MAXILLARY DIVISION OF THE TRIGEMINAL NERVE THE SYMPATHETIC AND PARASYMPATHETIC FIBERS TRAVEL ALONG ALL BRANCHES OF THE TRIGEMINAL DISTRIBUTION ALONG THE THE SOMATOSENSORY NERVES.  THE TRIGEMINAL NERVE CONTROLS BLOOD FLOW TO ANTERIOR TWO THIRDS OF THE MENINGES OF THE BRAIN.  ALMOST 100% OF ALL HEADACHES AND MIGRAINES ARE TRIGEMINALLY INNERVATED .

Approximately, 67%–91% of patients with head and neck cancer have relatively high prevalence of pain.[1,2] About 80%–90% of cancer pain can be eliminated by pharmacological method according to the WHO Analgesic Ladder, but nearly half of all these patients receive less than optimum care[1] and require intervention for their pain management.[3]  THIS HOPEFULLY WILL IMPROVE WITH ADDITION OF SPHENOPALATINE GANGLION BLOCKS TO TREATMENT REGIMENS.  I STRONGLY SUGGEST THAT THE WHO ANALGESIC LADDER SHOULD BE RECONSIDERED FOR HEAD AND NECK PAIN TO ADD SPG BLOCKS AS A FIRST LINE TREATMENT.

Sphenopalatine block[6,16] alone or as an adjuvant has been utilized by many authors for management of wide varieties of orofacial pain such as Sluder’s neuralgia, trigeminal neuralgia, cluster headache, migraine, complex regional pain syndrome of head and neck and pain due to advanced malignancy of head and neck. Saade and Paige,[14] Varghese and Koshy,[9] and Prasanna A[15] have reported its role in immediate pain relief in head and neck cancer pain management.  T AND WHY THEY ARE SOMETIMES REFERRED TO AS THE “MIRACLE BLOCK”HESE ARE THE EXACT PATIENTS THAT NEUROMUSCULAR DENTISTS ADDRESS.  THAT  IS WHY I HAVE MADE IT MY PERSONAL MISSION TO MAKE THEM COMFORTABLE WITH USING THESE BLOCKS.  THESE ARE THE SAME BLOCKS UTILIZED BY DR MILTON REDER AND DISCUSSED IN THE BOOK “MIRACLES ON PARK AVENUE”

For sphenopalatine block, various techniques,[6] superficial to highly invasive have been described such as transnasal, endoscope-guided transnasal, intraoral and infrazygomatic lateral approach.  THE INTRA-ORAL APPROACH TO SPG BLOCKS IS ANYTHING BUT HIGHLY INVASIVE OR DANGEROUS.  PALTAL ANESTHESIN IS ROUTINE IN ALL FIELDS OF DENTISTRY AND INJECTION THRU THE GREATER PALATINE FORAMEN IS A RELATIVELY ROUTINE PROCEDURE.  IT MAY ACTUALLY BE WHY MANY PATIENTS FEEL BETTER AFTER THIRD MOLAR EXTRACTION.  RELIEF IS FROM SPG BLOCK NOT THE SURGICAL PROCEDURE.  SPGB by transnasal approach[6,7,8,9,10,11,12,13,14,15] is a very easy and safe method of pain relief.[16] Cotton tipped applicator dipped in topical anesthetic agent is placed on nasopharyngeal mucosa posterior to middle turbinate in the conventional method.[13] Several modifications of transnasal technique have been published which includes Mingi’s modification[7] of technique using an intratracheal cannula. Intranasal device such as Sphenocath,[11] Allevio,[12] and have been used to block the ganglion. Windsor and Jahnke[8] and Cady et al.[10] have modified the techniques to minimize drug requirement.  I FIRMLY BELIEVE THAT THE COTTON TIPPED NASAL CATHETER THAT GIVES SLOW CONTROLLED RELEASE OF ANESTHETIC BY CAPILLARY ACTION TO THE MUCOSA OVER THE MEDIAL ANTERIOR WALL OF THE PTERYGOPALATINE FOSSA TO INFILTRATE THROUGH THE MUCOSA TO THE SPHENOPALATINE GANGLION IS THE BEST APPROACH FOR THE MAJORITY OF PATIENTS.  I WOULD LOVE TO WORK WITH INSURANCE COMPANIES TO DEVELOP PROTOCOLS TO IMPROVE THE QUALITY OF PATIENTS LIVES AND DRASTICALLY REDUCE COSTS AND USE OF OPIODS. THIS IS ESPECIALLY IMPORTANT DURING OUR  CURRENT OPIOD CRISIS.  We used sterile cotton swab stick or sterile ear bud instead of a cotton-tipped applicator. It makes the procedure more easy, safe, and cost-effective so that caretaker can perform it at home.

Various agents,[6] for example, local anesthetic such as 4% cocaine, 2%–4% lignocaine,[7,13,11] or 0.5% bupivacaine,[7,8] depot steroids and neurolytic agent[9] had been tried for SPGB. An injection of neurolytic agent is not always easy and safe, without the use of an endoscope. Repeated use of steroid has its own complications. Cady et al.[10] used 0.5% bupivacaine, 0.3 ml while We used 0.5% injection bupivacaine 2 ml in each nostril.  WHEN I FIRST LEARNED THE PROCEDURE I UTILIZED 4% COCAINE SOLUTION BUT RESTRICTIONS ON THE USE OF COCAINE RULE THAT OUT FOR SELF ADMINISTRATION THOUGH IT IS PROBABLE THE INITIAL DRUG OD CHOICE IN THE ER FOR THE MOST SEVERE PAIN. LIDOCAIINE AND BUPIVICAINE DO NOT PASS THRU MUCOUS MEMBRANES AS FAST.  HISTORICALY, COCAINE WAS THE FIRST ORIGINAL DANTAL ANESTHETIC.

Cancer is a dynamic process in which as the disease progresses; one can never get optimal pain relief with time. Furthermore, it requires a different treatment plan as time passes an increase in opioids requirement and needs to the repetition of the procedure frequently. The use of local anesthetic agent provides excellent immediate pain relief but only temporary in nature.   THIS IS AN EXCELLENT REASON TO INCREASE THE FREQUENCY OF DELIVERY AND TO UTILIZE CONTINUAL FEED TECHNIQUES AS OPPOSED TO EPISODTIC DELIVERY. Varghese and Koshy[9] used 6% phenol for transnasal block under endoscopic guidance in 22 patients. He found immediate pain relief was good but had to repeat the procedure in four patients. Prasanna and Morphy[15] also found good immediate pain relief. In our study, immediate pain relief was excellent in all the patients, but the rate of repetition of the procedure greatly varied between every alternate day to 7 days.  INCREASING FREQUENCY OF DELIVERY IS A FAR MORE LOGICAL APPROACH RATHER THAN INCREASING TOXICITY OF AGENTS UTILIZED.

Our additional observations were SPGB caused mood elevation, relieved insomnia in all patients; patients were able to swallow without pain which helped in the improvement of food intake. Schaffer et al.[17] utilized SPGB for the management of an acute headache in the emergency department and he found that along with a headache it also controls nausea.  THIS ONE ADDITIONAL OBSERVATION SHOULD BE SHOUTED FROM THE MOUNTAIN TOPS!  MOOD ELEVATION, ASK ANY FAMILY MEMBER OF A CANCER SUFFERER IF THEY WANT TO SEE THIS IN THEIR LOVED ONES.  RELIEF OF INSOMNIA WHICH IS AN INCREDIBLE IMPORTANT BOTH FOR IMPROVING HEALTH OF PATIENTS AND FOR THE PATIENTS QUALITY OF LIFE.  INSULIN RESISTANCE, INFLAMMATION, METABOLISM AND MYOFASCIAL CONDITIONS ARE ALL IMPROVED WITH IMPROVED SLEEP.  THE ABILITY TO SWALLOW WITHOUT PAIN  AND ENJOY EATING AGAIN IS CRITICAL TO QUALITY OF LIFE.

I LOST MY WIFE ELISE TO STAGE 4 OVARIAN CANCER BUT THROUGHOUT HER 10 YEARS OF CANCER TREATMENTS SHE UTILIZED  SPG BLOCKS TO DRAMTICALLY INCREASE HER QUALITY OF LIFE AND THE REDUCTION IN ANXIETY WAS PROBABLY THE MOST INCREDIBLE EFFECTS OF THE SPG BLOCKS.

MY  WIFE ANNA FELL ON HER TAILBONE AND WAS SUFFERING SEVERE LOW BACK PAIN THAT IS SUBSTANTIALLY ELIMINATED AFTER DOING SELF ADMINISTERED SPG BLOCKS.  SHE ALSO RECEIVES RELIEF FOR SHOULDER PAIN FROM A SEPERATE INJURY.

The top four symptoms[18] (2014) in head and neck cancer are pain, insomnia, loss of appetite and fatigue. SPGB provides analgesia and adequate sleep. The aim of cancer pain management in palliative care is to relieve pain with less adverse effects thereby improving the quality of life of patients.[1,2,3]  AMAZING, THE SPG BLOCK ADDRESSES ALL FOUR OF TOP SYMPTOMS IN HEAD AND NECK CANCER PAIN.

SPGB using local anesthetic agent have no serious side effects except temporary bitter taste, temporary difficulty in breathing and swallowing, lightheadedness, and sometimes epistaxis.[3,4,5,6,7] One of our patients had vasovagal response, in whom the procedure was abandoned. Three patients had temporary difficulty in swallowing. Bitter taste was complained by almost all patients.  ALL OF THESE SIFDE EFFECTS ARE MINIMAL AND SHOULD NOT PREVENT UTILIZATION OF SPG BLOCKS IN ANTY PATIENT.  A NEW ARTICLE IN INTERNATIONAL JOURNAL OF CARDIOLOGY SHOWS HOW SPG BLOCKS CAN DECREASE OR ELIMINATE ESSENTION HYPERTENSION IN NEWWLY DIAGNOSED PATIENTS.  IT IS LIKELY THE VASOVAGAL EFFECT WAS PRIMARILY

According to the American Institute of Medicine[19] (2011) and American Pain Society[20] (2005) psychological interventions such as patient’s education, communication, and involvement of caretaker in management reduce psychological distress while improving the quality of life of cancer patients.[1] The home-based application of SPGB improves both patients’ and caretakers’ confidence in managing difficult situations.  EVEN MORE IMPORTANT IS THE DIRECT EFFECT OF THE SPG BLOCK ON CONDITIONS LIKE ANXIETY.  THE FEELINGS OF GIDDINESS ARE SOMETHING THAT PATIENTS IN PAIN LOSE.  PAIN IS EXPERIENCED IN THE LIMBIC SYSTEM WHERE WE EXPERIENCE EMOTIONS.  PAIN IS A EXTREMELY NEGATIVE EMOTION, THE RELIEF OF PAIN AND ANXIETY LETS THESE PATIENTS ENJOY MORE POSITIVE EMOTIONAL ASPECTS OF LIFE.  MASLOW IN HIS HEIRARCHY OF PATIENTS NEEDS WHICH ARE REPRESENTED BY THE PYRAMID OF HUMAN NEEDS.  THE PYRAMID DEPICTS BASIC PHYSIOLOGIC NEES AS THE BASE BUT MASLOW FEL THAT THE ENTIRE PYRAMIDS FOUNDATION WAS FREEDOM FROM PAIN.

Saade and Paige[14] utilized the same method, i.e., self-administration of SPGB in patients with lethal midline granuloma requiring high dose of morphine. He taught patients to administer 4% lignocaine 1.5 ml into each nostril three times a day as well as to follow-up after 3 months. There was a substantial pain relief and reduction of morphine dose without any complication.

 THIS STUDY WAS SMALL BUT SHOWED THEDRAMATIC RELIEF AND A REDUCTION IN MORPHINE DOSAGE AND REDUCTION OF ASSOCIATED SYMPTOMS.  With 6% aqueous phenol, Varghese, and Koshy[9] could stop analgesics in two patients and adjuvant in eight patients but only for 1 week. In our study, all our patients were already on oral morphine immediate release, having partial pain relief. Their morphine requirement did not change significantly.

Eighty-eight patients were able to perform the procedure easily at home. All had optimum control of pain while their morphine requirements either remained stable or increased.

Conclusion IS EXCELLENT PAIN RELIEF!!!!

Home-based application of SPGB is an easy, safe, and cost-effective method of management of acute, chronic, and breakthrough pain. It provides excellent immediate pain relief with a minimum side effect. It can be performed bilaterally, repeatedly and even with a feeding tube in place. It can be taught to caregivers so that it can be performed safely as well as effectively at home. Home-based application of SPGB with local anesthetic agent will fulfill the aim of palliation and symptoms management at home. It will eliminate frequent visits to hospitals or doctors.

References