|Year : 2016 | Volume
| Issue : 4 | Page : 173-178
Evaluation of the efficacy of bilateral sphenopalatine ganglion block in endoscopic sinus surgery under general anesthesia: a randomized prospective controlled trial
Susmita Bhattacharyya, Mandeep K Tewari, Sarmila Ghosh, Jayanta Chakroborty, Writuparna Das, Utpal Barman
Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
|Date of Submission||04-Oct-2015|
|Date of Acceptance||19-Mar-2016|
|Date of Web Publication||16-Dec-2016|
Department of Anaesthesiology, Burdwan Medical College, Burdwan, PIN - 713104, West Bengal
Source of Support: None, Conflict of Interest: None
The major problem of functional endoscopic sinus surgery is impaired visibility of the surgical field due to excessive bleeding. Although controlled hypotension has been used to minimize intraoperative blood loss, it may invite several problems. To avoid these complications, this randomized controlled study was designed to evaluate the efficacy of bilateral sphenopalatine ganglion block (SPGB) under general anaesthesia, which could provide better hemodynamic parameters, good surgical condition, decreased blood loss, rapid recovery, better postoperative pain control and fewer complications during functional endoscopic sinus surgery.
Patients and methods
Sixty adult patients of both sexes between 15 and 55 years of age of American Society of Anaesthesiologists Physical Status I–II were randomly allocated into two equal groups. Group A patients received bilateral SPGB with 2.5 ml of 0.25% levobupivacaine on each side after induction of general anaesthesia. Group B patients received only general anaesthesia. Baseline and intraoperative heart rate, mean arterial blood pressure, oxygen saturation, end tidal carbon dioxide, temperature and blood loss were recorded. Surgical field, recovery score and postoperative pain were assessed using the average category scale, Aldrete recovery score and the visual analogue scale, respectively. The time to first rescue analgesic was noted.
Intraoperative mean arterial blood pressure, heart rate, blood loss, average category scale and postoperative visual analogue scale were significantly lower in the block group compared with the control group. Aldrete recovery score was significantly higher in the block group compared with the control group. First rescue analgesic requirement was delayed in the block group compared with the control group.
SPGB is effective for providing better haemodynamic control, good surgical field, lesser blood loss, early recovery and prolonged postoperative analgesia in this surgery.
Keywords: average category scale, functional endoscopic sinus surgery, general anaesthesia, levobupivacaine, sphenopalatine ganglion block, visual analogue scale
|How to cite this article:|
Bhattacharyya S, Tewari MK, Ghosh S, Chakroborty J, Das W, Barman U. Evaluation of the efficacy of bilateral sphenopalatine ganglion block in endoscopic sinus surgery under general anesthesia: a randomized prospective controlled trial. Res Opin Anesth Intensive Care 2016;3:173-8
|How to cite this URL:|
Bhattacharyya S, Tewari MK, Ghosh S, Chakroborty J, Das W, Barman U. Evaluation of the efficacy of bilateral sphenopalatine ganglion block in endoscopic sinus surgery under general anesthesia: a randomized prospective controlled trial. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Feb 20];3:173-8. Available from: http://www.roaic.eg.net/text.asp?2016/3/4/173/195878
| Introduction|| |
Functional endoscopic sinus surgery (FESS) is the minimally invasive surgical method for the treatment of sinus pathology. General anaesthesia with controlled ventilation is usually preferred during FESS as it provides an immobile surgical field, effective protection of the respiratory tract and adequate analgesia. The anaesthetic goals of this surgery are minimum intraoperative blood loss leading to better visibility of the surgical field and rapid awakening with return of protective airway reflexes in pain-free patients at the end of the surgery. Bleeding is one of the most serious problems of FESS. Reduced visibility of the surgical field due to bleeding may lead to prolongation of duration of surgery, reduced quality of intervention and an increased risk for complications . Various factors may reduce intraoperative bleeding, such as hypotension, decreased venous pressure through elevation of the surgical field above the level of the heart, elimination of raised intrathoracic pressure and hypothermia. Risk for bleeding is greater even in insignificant hypothermia due to the altered function of platelets and coagulation . Bilateral haemostatic posterior nasal packing, which is usually applied at the end of the surgery, may obstruct the normal upper airway and may be responsible for postoperative hypoxaemia. Early recovery from anaesthesia and return of protective airway reflexes are essential in the immediate postoperative period. Hence, several options can be used for early recovery.
The hypotensive anaesthesia in FESS has been used for better surgical field and easy surgical intervention by decreasing intraoperative blood loss ,,,. The limitations of controlled hypotension are related to reduced perfusion in the various organs. Cerebrovascular insufficiency, ischaemic heart disease, increased intracranial pressure, hypertension, pulmonary, hepatic and renal dysfunction, severe anaemia and hypovolaemia are considered as contraindications for controlled hypotension. Ideally, this technique demands special monitoring such as invasive blood pressure, ST-segment analysis in ECG, acid–base status, and estimation of haemoglobin, haematocrit and electrolytes. Excessive bleeding can still occur despite using controlled hypotension . Fall of mean arterial blood pressure (MAP) below 70 mmHg during FESS may increase intraoperative bleeding due to local vasodilatation and tachycardia . Good surgical conditions during FESS could be achieved with opioid-based total intravenous or inhalational anaesthesia ,. However, the use of these drugs may produce decreased alertness, respiratory depression, hypoxia, nausea and vomiting. Regional analgesic techniques along with general anaesthesia are devoid of these side effects and can be used as a better alternative to high doses of narcotics . The sphenopalatine ganglion block (SPGB) is one of the regional anaesthetic techniques that was used effectively before removal of nasal packing and in patients undergoing endoscopic sinus surgery under general anaesthesia to control bleeding or for postoperative analgesia ,. However, there are few available research studies to clarify the benefits of bilateral SPGB under general anaesthesia in FESS. Therefore, this randomized double-blinded study was designed to test the hypothesis that this block under general anaesthesia could provide better haemodynamic parameters, good surgical conditions, decreased blood loss, early recovery, better postoperative pain control and lesser incidents of complications such as dizziness, nausea and vomiting, headache, dental numbness and a sense of retroocular pressure in patients undergoing FESS.
| Patients and methods|| |
After obtaining institutional ethics committee approval and informed written consent from patients, this prospective, randomized study was performed. Sixty adult patients of both sexes between 15 and 55 years of age and American Society of Anaesthesiologist Physical Status I–II were included in this study. Patients were randomly allocated into two equal groups: group A (n=30) and group B (n=30). Group A (the block group) received bilateral SPGB after administration of general anaesthesia. Group B (the nonblock group) received only general anaesthesia and no block was administered. Patients with clinically significant cardiovascular, pulmonary, hepatic, neurologic or metabolic diseases, those with hypersensitivity to levobupivacaine, patients with difficult airway and those with bleeding diathesis or on anticoagulant therapy were excluded from this study. Diazepam (5 mg) was administered orally the night before operation. Ranitidine (150 mg) and domperidone (10 mg) were given orally 2 h before induction. On arrival to the operating room, standard monitoring equipments were applied, such as ECG, automated noninvasive blood pressure, pulse oximetry and end tidal carbon dioxide (ETCO2). Intravenous cannulation was performed with an 18-G cannula, and lactated Ringer’s solution was administered at the rate of 6 ml/kg/h. Glycopyrrolate (0.04 mg/kg) and fentanyl 2 µg/kg were given. After preoxygenation for 5 min, general anaesthesia was induced intravenously with 2 mg/kg of propofol and the trachea was intubated with cuffed endotracheal tube with 0.1 mg/kg of vecuronium. Anaesthesia was maintained with isoflurane 1% dial concentration and 60% nitrous oxide in oxygen with fresh gas flow at a rate of 3 l/min. Positive pressure ventilation was carried out to attain ETCO2 of 35–45 mmHg. All patients were placed in 15° head-up position to improve venous drainage. After induction of anaesthesia, patients in group A (the block group) received bilateral SPGB with 2.5 ml of 0.25% levobupivacaine on each side, whereas patients in group B did not receive the block (the control group).
Technique of SPGB: the intraoral greater palatine canal approach to block the sphenopalatine ganglion was used. The greater palatine foramen is situated posteromedial to the third maxillary molar and anteromedial to the maxillary tuberosity and pterygoid hamulus. A 25-G needle was bent about 60°, ∼25–30 mm from the tip, and used for administration of block. The greater palatine foramen was located by means of finger palpation, and the needle was pushed through the mucosa after depressing the tongue with tongue depressor until bone was encountered. With slight exploratory movements to localize the foramen, when the needle slipped up the canal with ease, a negative pressure was applied to ensure the correct position. If air bubbles or bloody aspirate were found, the needle was repositioned to avoid entering into the nasopharynx or any vessel. After repeated aspiration, 2.5 ml of 0.5% levobupivacaine was injected on each side of the greater palatine canal.
Oropharyngeal pack was applied. An additional dose of vecuronium (0.02 mg/kg) was administered if required. Paracetamol (15 mg/kg) was infused over 15 min, and at the end of the surgery isoflurane and nitrous oxide were discontinued. Residual neuromuscular block was antagonized with neostigmine 0.07 mg/kg and glycopyrrolate 0.008 mg/kg. The oropharyngeal pack was removed and patient was extubated. Thereafter, each patient was shifted to the postoperative care unit for 6 h and subsequently to the ward. The same surgeon performed all operations to avoid the biasness in the assessment of the surgical field. The surgical team was also blinded to the pharmacological treatment and the block technique. The anaesthesiologist who collected the data was not involved in administration of block and the technique of general anaesthesia.
The heart rate (HR) and MAP were measured before induction of anaesthesia (baseline) and at 10-min intervals during the perioperative period. Duration of surgery was noted. The mean values of HR and MAP during the intraoperative period were considered in each group. Surgical field was assessed by the surgeons at 10-min intervals using the average category scale (ACS) given in [Table 1], originally described by Fromme et al.  but adapted by Boezaart et al. . The scores were obtained during the intraoperative period and the mean of the scores was compared between the two groups.
Intraoperative ETCO2, pulse oximetry and temperature were recorded. Intraoperative blood loss was measured and was collected in the suction apparatus. Early recovery was considered when Aldrete score was greater than and equal to 9 . Pain intensity was evaluated at 0, 2 and 6 h postoperatively with a 10-cm visual analogue scale (VAS), where 0 is defined as no pain and 10 as the worst possible pain. The time to first rescue analgesic was noted. The incidence of postoperative complications, including nausea, vomiting, dental numbness, headache and sense of retroocular pressure, was recorded.
Statistical analysis was carried out with the help of Epi Info 3.5.3 (Centers for disease control andprevention CDC, 1600 Clifton Road Atlanta, GA 30329-4027, USA). Basic cross-tabulation and calculation of means with corresponding SDs was performed. Numerical data were analysed with the unpaired Student’s t-test. Any P-value less than 0.05 was taken as significant. The results were expressed as mean±SD.
| Results|| |
In our study, both groups were comparable in terms of their age, body weight and duration of surgery ([Table 2]). There was no difference in baseline MAP (mmHg) among the study groups, but intraoperative MAP was much lower in the block group (65.5833±1.0593) compared with the control group (81.0790±8.1541), which was statistically significant (P<0.001) ([Table 3] and [Figure 1]). There was no difference in baseline HR (beats per minute) in the study population, but intraoperative HR was much lower in the block group (74.0633±3.9959) compared with the control group (78.2600±5.7590) with a statistically significant difference (P=0.0018) ([Table 4] and [Figure 2]). ETCO2 and temperature were comparable in both groups ([Table 5]). Blood loss (ml) was significantly higher in the control group (120.6667±40.5295) compared with the block group (75.1667±12.7633) (P<0.0001) ([Table 6] and [Figure 3]). Intraoperative ACS (as per scale) (the block group: 1.4667±0.6814; the control group: 2.8333±0.8743; P<0.0001) and postoperative VAS (the block group: 1.5000±0.9002; the control group: 4.0667±1.2576; P<0.0001) were lower in the block group compared with the control group, which was statistically significant ([Table 7] and [Figure 4]). Postoperative Aldrete recovery score (as per scale) was higher in the block group (9.7667±0.4302) compared with the control group (8.5667±0.8172), with a statistically significant difference (P<0.0001) ([Table 7] and [Figure 4]). Postoperative analgesia (in h) was prolonged and requirement of first rescue analgesic was much later in the block group (12.3000±3.5830) compared with the control group (3.8000±0.1.7100), with a statistically significant difference (P<0.0001) ([Table 8]). Complications such as dental numbness and sense of retroocular pressure were found in four and two patients, respectively, in the block group (n=30) ([Table 9]).
|Table 3: Baseline and intraoperative mean arterial blood pressure (mean±SD)|
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|Figure 1: Baseline and intraoperative mean arterial blood pressure blood(MAP).|
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|Table 5: Intraoperative end tidal carbon dioxide and temperature (mean±SD)|
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|Table 7: Average category scale, Aldrete recovery score and visual analogue scale (mean±SD)|
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|Figure 4: Average category scale (ACS), Aldrete recovery score (ARS), postoperative pain (POP) and visual analogue scale (VAS).|
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| Discussion|| |
Sphenopalatine ganglion (SPG) is the largest parasympathetic ganglion of the head and neck found in the pterygopalatine foramen. It receives sensory, sympathetic and parasympathetic roots. Sensory roots are derived from two sphenopalatine branches of the maxillary nerve, and sympathetic nerve roots are derived from the deep petrosal nerve. Preganglionic parasympathetic fibres, which are derived from the greater petrosal branch of the facial nerve, form synapse with the neurons in SPG, and its axons project into the lacrimal gland and nasal mucosa. The flow of blood to nasal mucosa is regulated by SPG. Thus, SPG is an attractive site for administration of block in FESS.
In this study, SPGB was performed in anaesthetized patients. The anaesthetic agents may influence the bleeding at the surgical field . Hence, the anaesthetic drugs were used accordingly to reduce the scope of increased bleeding during surgery. The blood supply of the ethmoid, sphenoid and frontal sinuses is derived from the ethmoidal artery and the supraorbital artery, which are the branches of the internal carotid artery. Propofol, by reducing cerebral circulation and metabolism by suppressing the sympathetic tone of cerebral blood vessels, helps in diminishing circulation in the nasal sinuses, thereby improving working conditions in the surgical field. Previous studies also supported the advantages of propofol over inhalational agents during FESS ,,. Although isoflurane relaxes smooth muscles of blood vessels, no significant differences as regards intraoperative bleeding have been found using isoflurane and propofol . Hence, isoflurane was used for the maintenance of anaesthesia. Sympatholytic drugs (dexmedetomidine and clonidine) have been used successfully for better hemodynamic stability, but concomitant use of fentanyl and vecuronium could increase the risk for severe bradycardia ,.
There was no difference in the baseline MAP and HR among the study groups. However, intraoperative MAP was much lower in the block group (65.5833±1.0593) compared with the control group (81.0790±8.1541), which was statistically significant (P<0.001). Intraoperative HR was lower in the block group (74.0633±3.9959) compared with the control group (78.2600±5.7590), which was statistically significant (P=0.0018). Other studies also supported the findings ,. ETCO2 and temperature were recorded and comparable in both the groups ([Table 5]) and did not affect surgical bleeding in this study.
Reduction of blood loss provides good intraoperative endoscopic visibility with the use of topical administration of vasoconstrictors despite having risks for tachycardia and hypertension . SPGB with a local anaesthetic could reduce the mucosal blood flow of the nasal sinuses and the turbinates as a result of blocking effect of vasodilatory parasympathetic fibres of the sphenopalatine ganglion, which innervates the mucous membrane of the nose . In this study, blood loss was significantly greater in the control group compared with the block group (the block group: 75.1667±12.763; the control group: 120.6667±40.5295; P<0.0001). These findings were found to be similar with other studies .
Patients of the control group showed higher ACS (2.8333±0.8743) compared with the block group (4667±0.6814), which was statistically significant (P<0.0001). Eight patients of the control group (n=30) required tranexamic acid (10 mg/kg) to control bleeding and better surgical field was achieved. Tranexamic acid was not required in the block group. This finding was found to be corroborative with other similar studies .It is important to maintain a satisfactory level of analgesia following endoscopic sinus surgery. If the patient becomes agitated, there is risk for bleeding secondary to the rise in venous and arterial pressure. At the same time, the patient should not be oversedated, which may lead to upper airway obstruction. Improved recovery criteria and prolonged postoperative analgesia were evident in this study in the block group. These results were similar to that reported in a previous study . In this study, a lower VAS score was found in the block group (1.5000±9.002) compared with the control group (4.0667±0.1.2576), which was statistically significant (P<0.0001).
Prolonged postoperative analgesia was probably due to pre-emptive blocking of the nociceptive impulses transmitted through the sensory afferent branches of the maxillary nerve while passing into the ganglion. Aldrete recovery score value was higher in the block group (9.7667±0.4302) compared with the control group (8.5667±0.8172) and corroborates with other studies . Position of the greater palatine foramen is variable but found to be opposite or distal to the maxillary third molar and opened in an anterior direction in most of the human skulls, leading to the greater palatine canal containing descending palatine vessels and palatine nerves. Immense care was taken in each patient not to injure these structures during the procedure of the block. Although the needle had to be repositioned in three patients while performing the block, there were no serious complaints later from any of these three patients. Minor anticipated postoperative complications such as dental numbness and a sense of increased retroocular pressure were found in four and two patients, respectively, in the block group and were managed with reassurance only.
Better haemodynamic control, less blood loss, good surgical field with prolonged postoperative analgesia, and early recovery with minor complications were achieved in this study with SPGB under general anaesthesia. Thus, this block can be used safely along with general anaesthesia in FESS.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]