|Ahead of print publication
Comparison of extraoral and intraoral routes of glossopharyngeal nerve block for pain relief in patient with carcinoma tongue: A prospective randomized study
Neetu Singh1, Sarita Singh1, Neel Kamal Mishra1, Vijay Kumar2, Hemlata1, Shefali Gautam1
1 Department of Anaesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Surgical Oncology, King George Medical University, Lucknow, Uttar Pradesh, India
Department of Anaesthesiology, King George Medical University, H No-18/248, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background and Objective: Glossopharyngeal nerve block (GNB) technique has been used as alternative of treatment of cancer and noncancer pain of the oral cavity. The objective of the study is to compare the two approaches (extraoral and intraoral) of GNB in patients of carcinoma of the tongue in terms of efficacy, duration, and complications.
Materials and Methods: This was a prospective comparative randomized study over a period of 1 year. Fifty patients of either sex of ASA physical status and 2, between 21 and 70 years of age, suffering from carcinoma of the tongue, were selected. The patients were randomly divided into two groups. Group I received 4 mL of 0.5% bupivacaine combined with 40 mg, of triamcinolonacetonide by extraoral approach of GNB, and Group II received the same amount of drug by intraoral approach of GNB. Hemodynamic parameters, degree of pain relief using visual analog scale (VAS), number of attempts, effect on quality of life (QOL), and complication were noted during the performance of GNB.
Results: Demographic profile in both groups was comparable. Rate of complication and number of attempts to complete intervention were higher in Group I, which was found to be statistically significant. However, mean VAS scores in Group I were significantly higher as compared to those in Group II during most of the study period starting from the 1st follow-up at 30 min to the 2nd month postintervention (P < 0.05). No statistically significant difference in mean QOL scores of two groups was observed for the entire study period except at 1 week when mean scores in Group I were higher as compared to those in Group II (P = 0.011).
Conclusion: The intraoral approach of GNB was better with respect to pain control and improvement in QOL whereas the rate of complication and number of attempts was lower in extraoral approach of GNB.
Keywords: Bupivacaine, comparative, glossopharyngeal nerve block, glossopharyngeal neuralgia, oral cancer, triamcinolonacetonide
|How to cite this URL:|
Singh N, Singh S, Mishra NK, Kumar V, Hemlata, Gautam S. Comparison of extraoral and intraoral routes of glossopharyngeal nerve block for pain relief in patient with carcinoma tongue: A prospective randomized study. J Can Res Ther [Epub ahead of print] [cited 2020 Apr 5]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=264694
| > Introduction|| |
Oral cancer or mouth cancer is a type of head-and-neck cancer. There are several types of oral cancers, but around 90% are squamous cell carcinomas originating in the tissues that line the mouth and lips. Oral or mouth cancer most commonly involves the tongue. It may also occur on the floor of the mouth, cheek lining, gingiva, lips, or palate.
Most of the oral cancer present as ulceration or nodules inside oral cavity and patients may have difficulty in chewing, mastication, and swallowing. Pain and paraesthesia are late symptoms. Burning sensation or pain may occur when the tumor gets advanced behind the wisdom tooth. Pain may even radiate behind the ear.
Many treatment modalities have been developed for relief of pain and its consequences. These modalities include intravenous analgesics (opioids and nonopioids), central neuraxial blockade, nerve plexus block, isolated nerve block, and local infiltration. Some nonpharmacological methods such as transcutaneous electrical nerve stimulation (TENS), acupuncture, and acupressure have also been tried with variable success treatment of cancer pain has seen many milestones with remarkable success in cancer pain management; however, some patients have refractory pain and require advanced techniques such as nerve blocks.
Systemic drugs do relieve pain but invariably have troublesome side effects. These side effects are often severe enough to prevent adequate therapy, and fear of them constitutes one of the most important causes of inadequate opioid prescription by physicians and its use by patients.
Glossopharyngeal nerve block (GNB) with local anesthetic may be used to palliate acute pain of glossopharyngeal neuralgia for those patients with failure to respond to medical management or those who are not candidates for surgical treatment., This technique has also been used for posttonsillectomy pain palliation.,,
To our study, the objective was to compare the two approaches (extraoral and intraoral) of GNB in patients of carcinoma of the tongue in terms of efficacy, duration, and ease of technique and complications.
| > Materials and Methods|| |
This prospective comparative randomized study conducted in the Department of Anesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India, over a period of 1 year (September 2014 to August 2015) after getting approval from the Institutional Ethics Committee and written informed consent from patients. Fifty patients of either sex of ASA physical status 1 and 2, between 21 and 70 years of age, suffering from carcinoma of the tongue, were selected. Patients with carcinoma of tongue, visual analog scale (VAS) more than 7, and adequate mouth opening were included in the study. Exclusion criteria for study were patient with not giving consent, inadequate mouth opening, allergic to local anesthetic, fungating growth, uncontrolled diabetes and hypertension, and uncooperative patients. The patients were randomly divided into two groups (25 each) using a computer-generated random number table. Group I received 4 mL of 0.5% bupivacaine combined with 40 mg of triamcinolonacetonide by extraoral approach of GNB and Group II received the same amount of drug by intraoral approach of GNB. Hemodynamic parameters, degree of pain relief using VAS score, number of attempts, effects on quality of life (QOL), and complications were noted during the performance of GNB.
Patients were kept nil orally as per the ASA preoperative fasting guidelines. An IV access was obtained using 18G IV cannula, and sensitivity to lignocaine was assessed using 0.1 mL intradermal injection. After that, IV ondansetron (0.1 mg/kg), IV midazolam (0.02 mg/kg), and IV ceftriaxone antibiotic (25–50 mg/kg) were given 30 min before performing procedure. After shifting the patient to operation theater, the patient was preloaded with intravenous fluid (Ringer's lactate) at the dose of 10 mL/kg body weight before the procedure. Meanwhile, monitors such as pulse-oximeter, noninvasive blood pressure (BP), and electrocardiogram were attached.
Group I patient received extraoral GNB, for that patient was placed in the supine position, and an imaginary line was visualized running from the mastoid process to the angle of mandible. The styloid process should lie just below the midpoint of the line. The skin was prepared with antiseptic solution. A 22 gauge, 1.5-inch needle attached to a 10 mL syringe, was advanced through this midpoint location in the plane perpendicular to the skin. The styloid process was encounter within 3 cm after contact was made and then needle withdrawn and “walked off” the styloid process posteriorly. As soon as bony contact was lost, and if careful aspiration revealed no blood or cerebrospinal fluid, 4 mL of 0.5% bupivacaine combined with 1 mL (40 mg) of triamcinolonacetonide was injected in incremental dosage.
Group II patients received GNB by intraoral approach. After betadine gargle, the tonsillar pillar was anesthetized with 0.5% 1 mL lidocaine gauze. The patient was asked to open the mouth widely, and a tongue was retracted inferiorly with a tongue depressor or laryngoscope blade. A 22 gauge, 3.5-inch spinal needle that had been bent about 25° from horizontal, was inserted through the mucosa at the lower lateral portion of posterior tonsillar pillar. The needle was advanced approximately 0.5 cm after the careful aspiration revealed no blood or cerebrospinal fluid, and the local anesthetic agent with steroid was injected as in the extraoral approached GNB. Our primary outcome measures were pain relief and duration of analgesia, and secondary outcomes were ease of technique, QOL, and complications if any were recorded, following parameters were recorded in both groups:
- Hemodynamic parameters, heart rate, systolic, diastolic and mean arterial BP, and SpO2 were monitored at 1, 15, and 30 min. After 30 min of monitoring, patients send their home. Hypotension was defined as decrease in systolic arterial pressure ≥20% from baseline and was treated with fluid boluses and intermittent IV mephentermine (0.1 mg/kg). Bradycardia was defined as decrease in heart rate <60 beats/min and was treated with IV atropine (0.01 mg/kg)
- The degree of pain relief was assessed using VAS scale (0–10) at 30 min, 6 h, 24 h, 2nd day, weekly up to 1 month, and then monthly up to 6 months. Based on 10 cm line, the left extremity represented no pain at all (score 0) and right extremity represented unbearable pain (score 10), the procedure was considered successful if there was satisfactory pain relief VAS ≤4 without morphine
- The requirement of rescue analgesia was also assessed which was given to patient when his VAS >4.
The incidence of side effects/complications, i.e., pain at injection site, hematoma formation, and intravascular injection of local anesthetic with subsequent toxicity, dysphagia, dysphonia, weakness of tongue, tachycardia, bradycardia, and arrhythmias was noted. After administration of GNB in respective groups, patients were advised to come outpatient department weekly or be in contact through telephonic conversation up to 16 weeks.
Sample size formula
n = Z 2 Pq/d 2
= 54.65 ≈ 55
Z = value of two-tailed alpha error, this is 1.96 at 5%; P = proportion; D = allowable error acceptable deviation taken as 10%.
The total sample size is 55.
Data obtained were subjected to statistical analysis and results were obtained. Data were analyzed using the Statistical Package for the Social Sciences, version 15.0 (Chicago, Inc., USA). The results analyzed in mean, standard deviation, and percentages. The confidence level of the study was kept at 95%, and hence, “P” < 0.05 indicated a statistically significant difference.
Randomization: Computer generated tables.
Concealment: Sealed envelope methods.
Blinding: Our study was not a blinded study.
Parametric-t-tests and the analysis of variance that assume the underlying source population(s) to be normally distributed; they generally also assume that one's measures derive from an equal-interval scale. Nonparametric: The various forms of Chi-square tests, the Kruskal–Wallis Test.
| > Results|| |
Demographic profile in both groups was comparable. The rate of complication and number of attempts to complete intervention was higher in Group I (extraoral), which was found to be statistically significant. However, mean VAS scores in Group I were significantly higher as compared to those in Group II during most of the study period starting from the 1st follow-up at 30 min to the 2nd month postintervention (P < 0.05) [Table 1]. No statistically significant difference in mean QOL scores of two groups was observed for the entire study period except at week 1 when mean scores in Group I were higher as compared to those in Group II (P = 0.011) [Table 2].
|Table 2: Comparison of visual analog scale score between two groups at different time intervals (all 25 cases in both groups)|
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The intraoral approach of GNB was better with respect to pain control and improvement in QOL whereas the rate of complication and number of attempts were lower in the extraoral approach of GNB. No complications during intervention or after intervention took place in Group I; however, in Group II, complications during intervention were recorded in five (20%) patients. Statistically, there was a significant difference between two groups with respect to rate of complications during intervention (P = 0.018). Similarly, need of two or more attempts to complete the intervention was higher in Group II (48%) as compared to Group I (20%) and this difference was significant statistically too (P = 0.037) [Table 3].
|Table 3: Comparison of quality of life scores between two groups at different time intervals (after excluding patients who were shifted to morphine)|
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However, meantime taken in the procedure was significantly higher in Group I (14.28 ± 2.48 min) as compared to Group II (7.88 ± 1.62 min) (P < 0.001).
Before intervention, VAS scores ranged from 8 to 9 in both groups. Mean VAS scores of Group I and Group II patients were 8.24 ± 0.44 and 8.28 ± 0.46, respectively, thus showing no statistically significant difference between two groups (P = 0.753) [Table 3].
In Group I, mean VAS scores ranged from 2.80 ± 0.91 (30 min and 6 h after intervention) to 4.20 ± 0.96 (2nd month). Mean VAS score was 3.72 ± 0.46 at the last follow-up (6th month).
In Group II, mean VAS scores ranged from 2.04 ± 0.84 (30 min and 6 h) to 4.00 ± 0.87 (5th month). Mean VAS score was 3.96 ± 0.54 at the last follow-up (6th month).
On comparing the two groups, mean VAS scores in Group I were significantly higher as compared to those in Group II during most of the study period starting from the 1st follow-up at 30 min to the 2nd month postintervention (P < 0.05).
QOL scores ranged from 32.86 ± 7.84 (week 2) to 50.00 (5th month) in Group I and from 28.00 ± 5.77 (week 1) to 52.50 ± 7.54 (week 6), thus showing an incremental trend with the passage of time in both groups. However, no statistically significant difference in mean QOL scores of two groups was observed for the entire study period except at week 1 when mean scores in Group I were higher as compared to those in Group II (P = 0.011) [Table 3].
| > Discussion|| |
Cancer patients may experience severe pain that may be resistant to oral opioids and other analgesics. In addition, excessive sedation or other side effects may limit the acceptability and usefulness of oral opioids/analgesics therapy. Nerve block appeared boon to cancer pain. It appears to be a safe, cost-effective approach to treating pain associated with cancer. The benefits include improved analgesia, reduced opioid consumption, favorable economic implications, and superior clinical effects due to the avoidance of deleterious properties of high-dose chronic opioid therapy.
Since previous studies have indicated that patients receiving GNB experienced better pain control than patients receiving pharmacological modalities (NSAIDS, opioids, TENS, and acupuncture), our aim was the comparison of extraoral and intraoral approach of GNB in carcinoma tongue patient for ease of technique, complication, VAS, and quality of life.
In the present study, we observed that need of two or more attempts to complete the intervention was higher in Group II (48%) as compared to Group I (20%) and this difference was significant statistically too (P = 0.037). So that we concluded that extraoral route is easier and accessible than intraoral route in our study. It was contradictory to another study done by Pani and Kumar Rath  that intraoral approach of GNB is easier in comparison to extraoral approach. It was seen that extraoral approach requires the ability to distinguish the bony landmarks whereas in intraoral approach directly see the posterior tonsillar pillar and inject the drug directly into it the only limitations to intraoral route is that it needs adequate mouth opening.
In our study, no complications during intervention or after intervention took place in Group I; however, in Group II, complications during intervention were recorded in 5 (20%) patients. Statistically, there was a significant difference between the two groups with respect to the rate of complications during intervention (P = 0.018). Cerna and Michalek  observed swallowing impairment and irritation to cough in intraoral approach of GNB, but no such complications are seen in our study. DeMeester et al. found in their study that GNB causes temporarily abolition of gag reflex and loss of tactile sensation over posterior third of the tongue, no other complication found in their observation. Singh et al. observed no significant hemodynamic adverse outcome after administration of extraoral GNB, but in our study, we observed bradycardia in five patients during intervention, which was treated by giving injection atropine. Trivedi and Patil (2009) observed stability in mean arterial pressure and heart rate after block. Bean-Lijewski  reported two cases of upper airway obstruction in their study.
In previous study done by Singh et al. observed that over their 90-day follow-up, Group I (received medical therapy alone) and Group II (received medical therapy along with extraoral GNB) both modalities were effective in treating glossopharyngeal neuralgia. However, numerical pain scales were statistically similar by the end of 90 days. Similarly, Isbir  used the intraoral route for GNB for treatment of glossopharyngeal neuralgia, VAS score was used to evaluate the pain, and they observed that pain was successfully controlled with a steroid added to the nerve block and oral medication. Park et al. also established the role of GNB for the palliation of posttonsillectomy pain.
In our study, we observed that mean VAS scores in Group I (who received extraoral GNB) were significantly higher as compared to those in Group II (who received intraoral GNB) during most of the study period starting from the 1st follow-up at 30 min to the 2nd month postintervention (P < 0.05). Hence, we concluded in our study that improvement in pain is better in intraoral approach than extraoral approach. Singh et al. observed in their study that improvement in QOL (mood, interpersonal relationship, and emotions) was higher in Group II than in Group I who receives only oral medication. This study QOL scores ranged from 30.00 ± 0.00 (4th, 5th, and 6th month) to 43.80 (week 1) in Group I and from 30.83 ± 2.89 (6th month) to 54.60 ± 6.28 (week 6), thus showing a declining trend with the passage of time in both groups. At all the time intervals, mean QOL scores in Group II were higher as compared to those in Group I. The difference between two groups was also significant statistically from week 1 to the 3rd month (P < 0.05).
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]