Chronic Pain in Head and Neck Cancer Survivors: SPG Blocks and Neuromuscular Orthotics May Provide Desperately Needed Pain Relief

A recent article in Support Care Cancer describes the problems of severe pain and from Myofascial Trigger Points and Hyperalgesia in survivors of head and neck cancer. (Abstract Below)

Neuromuscular Dentistry is very successful in treating a wide variety of TMD disorders as well as orofacial pain, headaches and migraines and other pain associated with the Trigeminal Nervous System.  A diagnostic neuromuscular orthotic can often provide remarkable relief. can improve patients quality of life without medication.

Opioids have been used to treat severe pain in cancer survivors but this frequently diminishes the patients quality of life. The chronic pain is often due to Central Sensitization and the use of Sphenopalatine Ganglion Blocks and/or Stellate Ganglion Blocks should be considered as a First Line Treatment of the pain these patients suffer.

The use of Self-Administered Sphenopalatine Ganglion Blocks would be ideal as an extremely safe method of pain management without negative side effects.  Patients and caregivers can easily learn to Self-Administer Sphenopalatine Ganglion Blocks with Cotton-Tipped Catheters passed gently thru the nose to the medial wall of the Pterygopalatine fossa which houses the Ganglion.

Self Administration of SPG Blocks or SASPGB gives patients a tool to control both pain and annxiety secondary to cancer.

A 1996 article :”Patient-administered sphenopalatine ganglion block
E Saade 1, G B Paige” Discussed the use of Self-Administered SPG Blocks in a patient with a midline Granuloma. (Abstract Below)

The Sphenopalatine Ganglion (SPG) is the largest parasympathetic ganglion of the head and it has been safely blocked with anesthetic for over 100 years to treat Trigeminal Neuralgia, Headaches, Migraines and many other disorders.. The SPG also carries Post Ganglionic Fibers from the entire Cervical Sympathetic Chain and from the Stellate Ganglion. This was first described by Sluder in 1908 in the Annals of Internal Medicine (JAMA).

The use of Spenopalatine Ganglion Blocks utilized in conjunction with Neuromuscular Dentistry is discussed in my paper “Neuromuscular dentistry and the role of the autonomic nervous system: Sphenopalatine ganglion blocks and neuromodulation.” (Abstract Below). A copy of the entire article can be found at: https://www.sphenopalatineganglionblocks.com/spg-blocks-and-neuromodulation/

The subject of SPG Blocks has been explored in detail in a medical textbook “Nasal Neurology” by Greenfield Sluder MD and in a popular book “Miracles on Park Avenue” by Benjamin Gerber in 1986.

The book describes the work of Dr Milton Reder an Octogenerian Otolaryngologist in NYC whose entire practice was the use of SPG Blocks for a wide variety of Chronic conditions and pain that was unresponsive to other treatments,

Dr David Ho had an excellent paper in 2017 on the many varied methods of utilizing both blocks and stimulation of the Sphenopalatine Ganglion for treating pain. “Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation – a systematic review” (Abstract Below)

Support Care Cancer
. 2020 Jun;28(6):2891-2898. doi: 10.1007/s00520-019-05173-6. Epub 2019 Nov 21.
Myofascial pain, widespread pressure hypersensitivity, and hyperalgesia in the face, neck, and shoulder regions, in survivors of head and neck cancer
L Ortiz-Comino 1, C Fernández-Lao 2, E Castro-Martín 1, M Lozano-Lozano 3, I Cantarero-Villanueva 4, M Arroyo-Morales 4, L Martín-Martín 3
Affiliations expand
PMID: 31754834 DOI: 10.1007/s00520-019-05173-6
Abstract
Purpose: Medical treatment for head and neck cancer may induce the presence of inflammation, pain, and dysfunction. The purpose of the current study was to assess the presence of myofascial trigger points (TrPs) and their relationship with widespread pressure hypersensitivity and hyperalgesia in survivors of head and neck cancer (sHNC).

Methods: TrPs and pressure-pain thresholds (PPTs) were quantified in different muscles/joints in the head and neck of 30 sHNC (59.45 ± 13.13 years) and 28 age- and sex-matched controls (58.11 ± 12.67 years).

Results: The sHNC had more TrPs in all muscles on the affected side (p < 0.05) than did the healthy controls, and in the temporalis, masseter, and suboccipitalis muscles on the unaffected side (p < 0.05). They also had lower PPTs in all places (p < 0.05) except for the temporalis muscle (p = 0.114) and C5-C6 joint (p = 0.977). The intensity of cervical pain correlated positively with the presence of upper trapezius TrPs.

Conclusions: sHNC suffering cervical and/or temporomandibular joint pain have multiple active TrPs and experience widespread pressure hypersensitivity and hyperalgesia, suggestive of peripheral and central sensitization.

Keywords: Head and neck cancer; Hyperalgesia; Neck dissection; Pain; Trigger points.

Patient-administered sphenopalatine ganglion block
E Saade 1, G B Paige
Affiliations expand
PMID: 8826027
Abstract
Background and objectives: Pain resulting from head and neck cancer can be severe and difficult to manage. Avoiding hospitalization for as long as possible with a reasonable level of comfort requires a number of therapeutic modalities. The usefulness of self-administered sphenopalatine ganglion block was evaluated in a patient with lethal midline granuloma requiring large doses of morphine.

Methods: A 30-year-old woman with intractable pain from lethal midline granuloma was taught to self-administer 4% lidocaine, 1.5 mL topically into each nostril three times per day.

Results: A 3-month follow-up examination showed substantial pain relief and reduction in morphine requirement. No adverse side effects or complications developed.

Conclusions: In certain patients, sphenopalatine ganglion block can be effectively self-administered at home to manage chronic pain.

osition Paper
Neuromuscular dentistry and the role of the autonomic nervous system: Sphenopalatine ganglion blocks and neuromodulation. An International College of Cranio Mandibular Orthopedics (ICCMO) position paper
Ira L. Shapira , DDS, D, ABDSM, D, AAPM, FICCMO, MICCMO
Pages 201-206 | Published online: 11 Apr 2019
Download citation https://doi.org/10.1080/08869634.2019.1592807 CrossMark LogoCrossMark

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ABSTRACT
The Sphenopalatine Ganglion (SPG) is known to play an integral role in the pathophysiology of a wide variety of orofacial pains involving the jaws, sinuses, eyes and the trigeminal autonomic cephalalgias. It supplies direct parasympathetic innervation to the trigeminal and facial nerves. Sympathetic innervation from the superior sympathetic chain passes thru the SPG to the trigeminal and facial nerves.This paper reviews relevant and significant literature on SPG Blocks and Neuromodulation published in peer reviewed medical and dental journals. Neuromuscular Dentistry employs ULF-TENS to relax musculature and simultaneously provide neuromodulation to the ganglion.Conclusion: The effects of ULF-TENS on the autonomic nervous system acts on the Limbic System and Hypothalamus (H-P-A) to address Axis II issues during neuromuscular dental procedures. It also directly affects the autonomic component of the trigeminal nerve involved in almost all headaches and migraines as well as the Myofascial and Joint disorders of TMD.

Headache Pain
. 2017 Dec 28;18(1):118. doi: 10.1186/s10194-017-0826-y.
Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation – a systematic review
Kwo Wei David Ho 1, Rene Przkora 2, Sanjeev Kumar 2
Affiliations expand
PMID: 29285576 PMCID: PMC5745368 DOI: 10.1186/s10194-017-0826-y
Free PMC article
Abstract
Background: Sphenopalatine ganglion is the largest collection of neurons in the calvarium outside of the brain. Over the past century, it has been a target for interventional treatment of head and facial pain due to its ease of access. Block, radiofrequency ablation, and neurostimulation have all been applied to treat a myriad of painful syndromes. Despite the routine use of these interventions, the literature supporting their use has not been systematically summarized. This systematic review aims to collect and summarize the level of evidence supporting the use of sphenopalatine ganglion block, radiofrequency ablation and neurostimulation.

Methods: Medline, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were reviewed for studies on sphenopalatine ganglion block, radiofrequency ablation and neurostimulation. Studies included in this review were compiled and analyzed for their treated medical conditions, study design, outcomes and procedural details. Studies were graded using Oxford Center for Evidence-Based Medicine for level of evidence. Based on the level of evidence, grades of recommendations are provided for each intervention and its associated medical conditions.

Results: Eighty-three publications were included in this review, of which 60 were studies on sphenopalatine ganglion block, 15 were on radiofrequency ablation, and 8 were on neurostimulation. Of all the studies, 23 have evidence level above case series. Of the 23 studies, 19 were on sphenopalatine ganglion block, 1 study on radiofrequency ablation, and 3 studies on neurostimulation. The rest of the available literature was case reports and case series. The strongest evidence lies in using sphenopalatine ganglion block, radiofrequency ablation and neurostimulation for cluster headache. Sphenopalatine ganglion block also has evidence in treating trigeminal neuralgia, migraines, reducing the needs of analgesics after endoscopic sinus surgery and reducing pain associated with nasal packing removal after nasal operations.

Conclusions: Overall, sphenopalatine ganglion is a promising target for treating cluster headache using blocks, radiofrequency ablation and neurostimulation. Sphenopalatine ganglion block also has some evidence supporting its use in a few other conditions. However, most of the controlled studies were small and without replications. Further controlled studies are warranted to replicate and expand on these previous findings.

Keywords: Block; Nerve stimulation; Neuromodulation; Neurostimulation; Radiofrequency ablation; Sphenopalatine ganglion.