Missed pituitary microadenoma during endoscopic transsphenoidal surgery for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing with symptom relief: illustrative case.

BACKGROUND: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare headache disorder that has been associated with pituitary adenomas. Resection has been posited to be curative. OBSERVATIONS: A 60-year-old female presented with a 10-year history of SUNCT, which had been medically refractory. Sellar magnetic resonance imaging (MRI) showed a 2 × 2 mm nodule in the right anterolateral aspect of the pituitary. Endoscopic endonasal transsphenoidal resection of the pituitary microadenoma with neuronavigation was performed. The patient felt immediate relief from the headaches. Postoperative MRI showed persistence of the pituitary microadenoma and the resection tract to be inferomedial to the lesion. The right middle and partial superior turbinectomy site was close to the sphenopalatine foramen (SPF). The patient was discharged on postoperative day 1 and remained headache-free without any medications at the 4-month follow-up. LESSONS: Resection of pituitary lesions associated with SUNCT may not necessarily be the cause of SUNCT resolution. Manipulation of the middle and superior turbinate close to the SPF may lead to a pterygopalatine ganglion block. This may be the mechanism of cure for SUNCT in patients with related pituitary lesions who undergo endonasal resection.

Ultrasound-Guided Nerve Blocks in the Head and Neck for Chronic Pain Management: The Anatomy, Sonoanatomy, and Procedure.

BACKGROUND: Ultrasound guided nerve blocks have become a popular tool in the armamentarium for pain physicians because of its advantages over fluoroscopy by offering portable, radiation-free and real-time imaging. But ultrasound guided procedures require training and practice to gain the expertise. There is a scarcity of review articles describing ultrasound guided injections techniques for nerve blocks of the head and neck. OBJECTIVE: To elucidate the anatomy, sonoanatomy, indications, techniques, side effects and complications for the most frequently utilized nerve blocks of the head and neck in chronic pain management. STUDY DESIGN: Narrative review. SETTING: Academic medical center. METHODS: Literature review of publications in English language of the related topics using Medline (Ovid) search engine. RESULTS: Deep cervical plexus block, cervical sympathetic ganglion block, trigeminal nerve and pterygopalatine ganglion block at the pterygopalatine fossa, greater occipital nerve block, third occipital nerve and medial branch block, and cervical selective nerve root block are discussed in this paper. The review begins with in depth discussion about the anatomy of the target nerve, followed by reviewing the available literature on the indications for the procedures. Detailed description of the procedure techniques is also presented. The volume and selection of medications is also discussed if there is available research. The review will conclude with summary of side effects, complications and precautions. LIMITATION: We only review those nerve blocks of the head and neck that would benefit from ultrasound guided injections in chronic pain management. Other nerve blocks such as transnasal sphenopalatine ganglion block, the interscalene brachial plexus block, superficial and intermediate cervical plexus block, anterior suprascapular nerve block, superficial trigeminal nerve block are not discussed due to either that ultrasound guidance is not warranted or they are rarely utilized in chronic pain management. This paper is not a systematic review, thus it might not include all the available evidence. Many of the available evidence is case series and case reports. More randomized control studies are warranted in the future to validate these techniques. CONCLUSION: Ultrasound guided nerve blocks of the head and neck are useful techniques for pain physicians to learn.

Pterygopalatine Ganglion Block as a Rescue Technique for Failed Epidural Blood Patch.

Placement of an epidural blood patch is the gold standard treatment for a postdural puncture headache when conservative measures have failed. If unsuccessful in relieving the symptoms, a second epidural blood patch may be warranted. However, when the accepted gold standard treatment has failed, alternative therapies may be pursued. A pterygopalatine ganglion block has been shown to be effective as an alternative to epidural blood patch placement. This case demonstrates the use of a suprazygomatic pterygopalatine ganglion block as a rescue technique for failed repeated epidural blood patch, with complete and permanent resolution of the headache.

Clinical Anatomy of Blockade of the Pterygopalatine Ganglion: Literature Review and Pictorial Tour Using Cadaveric Images.

Pterygopalatine ganglion block (sphenopalatine ganglion block) is a well-known procedure for treating cluster headache and for relieving cancer pain. In this review, the history and anatomy of the pterygopalatine ganglion are discussed, and images, including computed tomography and endoscopy, are presented to improve understanding of the clinical anatomy of the ganglion regarding the block procedure.