Measurement and implications of the distance between the sphenopalatine ganglion and nasal mucosa: a neuroimaging study

Joan Crespi, Daniel Bratbak, David Dodick, Manjit Matharu, Kent Are Jamtøy, Irina Aschehoug, Erling Tronvik, Joan Crespi, Daniel Bratbak, David Dodick, Manjit Matharu, Kent Are Jamtøy, Irina Aschehoug, Erling Tronvik

Abstract

Background: Historical reports describe the sphenopalatine ganglion (SPG) as positioned directly under the nasal mucosa. This is the basis for the topical intranasal administration of local anaesthetic (LA) towards the sphenopalatine foramen (SPF) which is hypothesized to diffuse a distance as short as 1 mm. Nonetheless, the SPG is located in the sphenopalatine fossa, encapsulated in connective tissue, surrounded by fat tissue and separated from the nasal cavity by a bony wall. The sphenopalatine fossa communicates with the nasal cavity through the SPF, which contains neurovascular structures packed with connective tissue and is covered by mucosa in the nasal cavity. Endoscopically the SPF does not appear open. It has hitherto not been demonstrated that LA reaches the SPG using this approach.

Methods: Our group has previously identified the SPG on 3 T-MRI images merged with CT. This enabled us to measure the distance from the SPG to the nasal mucosa covering the SPF in 20 Caucasian subjects on both sides (n = 40 ganglia). This distance was measured by two physicians. Interobserver variability was evaluated using the intraclass correlation coefficient (ICC).

Results: The mean distance from the SPG to the closest point of the nasal cavity directly over the mucosa covering the SPF was 6.77 mm (SD 1.75; range, 4.00-11.60). The interobserver variability was excellent (ICC 0.978; 95% CI: 0.939-0.990, p < 0.001).

Conclusions: The distance between the SPG and nasal mucosa over the SPF is longer than previously assumed. These results challenge the assumption that the intranasal topical application of LA close to the SPF can passively diffuse to the SPG.

Keywords: Block; Intranasal; Local anaesthetics; Pterygopalatine ganglion; Sphenopalatine ganglion.

Conflict of interest statement

Competing interests

The authors declare that they have no conflict of interest.

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Figures

Fig. 1
Fig. 1
Axial images through the SPG in one of the patients. Left: T1 weighted MRI. Right: CT scan. Both images show the same anatomical plane. The SPG (red dot) is first localized in the MRI scan and the closest point of the nasal mucosa through the SPF is localized in fusioned CT images. In this example, the distance was 8.1 mm (yellow line). Notice the typical crescent form of the SPG anterior to the opening of the Vidian canal
Fig. 2
Fig. 2
Illustration of the relation between the nasal cavity and the sphenopalatine fossa (axial plane). In order to reach the SPG, a drug applied intranasally over the sphenopalatine foramen will have to diffuse through mucosa, the sphenopalatine foramen, which is packed with neuro-vascular structures and connective tissue, and the fat tissue filling the sphenopalatine fossa. SPF: sphenopalatine foramen; SPG: sphenopalatine ganglion
Fig. 3
Fig. 3
Rhinoscopy showing the mucosa over the sphenopalatine foramen (SPF) and the sphenopalatine artery (arrow). The SPF does not appear as an open foramen communicating directly with the sphenopalatine fossa. The SPF is covered by mucosa and packed with neurovascular structures and connective tissue
Fig. 4
Fig. 4
Diagram showing the involvement of the sphenopalatine ganglion (SPG) in the physiopathology of trigeminoautonomic headaches. The afferent part of this loop is mediated by the trigeminal nerve, which sends nociceptive signals from the dural blood vessels to the trigeminocervical complex. This information projects to higher brain structures, resulting in cephalic pain. The efferent part of this loop conveys mostly through the superior salivatory nucleus, exiting the brain stem via the facial nerve and reaching the sphenopalatine ganglion through the greater petrosal nerve. Postganglionic fibres exit the sphenopalatine nerve towards the dural vessels, closing the loop. Blocking the SPG might reduce the afferent input of signals towards the trigeminal system and reduce the activation of the trigeminocervical complex. CNS: central nervous system

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