Efficacy of ultrasound-guided combined sphenopalatine and stellate ganglion block in the treatment of allergic rhinitis
Introduction
Allergic rhinitis (AR) is a non-infectious inflammatory disease of the nasal mucosa in atopic individuals after exposure to allergens. It is mainly mediated by immunoglobulin E (IgE)-triggered mediator release and involves various immune-active cells and cytokines. The typical symptoms of AR include paroxysmal sneezing, clear watery nasal discharge, nasal itching, and nasal congestion; it may also be accompanied by ocular symptoms such as itchy eyes, tearing, redness, and burning sensations. Patients with AR often also have bronchial asthma and are at increased risk for other diseases. This condition is estimated to affect 40% of the global population, shows a trend toward younger onset, and seriously affects the quality of life and health of affected individuals (1).
Currently, the clinical management principles for AR include environmental control, pharmacotherapy, immunotherapy, and health education (2). The aim of pharmacotherapy is to alleviate symptoms, with glucocorticoids, antihistamines, and leukotriene receptor antagonists serving as first-line medications. Immunotherapy, which is recommended in clinical practice, induces immune tolerance through allergen extracts, thereby reducing or relieving symptoms on re-exposure to allergens. Surgical treatment is considered an adjunct method for AR, with procedures mainly including inferior turbinate plasty and septoplasty to improve nasal ventilation, or nerve severance procedures to reduce the hyperreactivity of the nasal mucosa. Because these are invasive procedures, strict adherence to surgical indications and contraindications is required.
In recent years, the use of ganglion block to modulate autonomic function has gradually emerged as an alternative to surgical intervention (3). Autonomic modulation for AR is achieved by blocking the sphenopalatine ganglion and the stellate ganglion to regulate nasal autonomic innervation, thereby restoring the dynamic balance between sympathetic and parasympathetic tone, reducing nasal mucosal congestion and edema, and decreasing secretions, thus relieving the symptoms of AR (4). Early sphenopalatine and stellate ganglion blocks were performed using blind puncture techniques, which lacked precision and were prone to complications, resulting in suboptimal outcomes (5). With advances in ultrasound technology, ultrasound-guided sphenopalatine and stellate ganglion blockade for AR has emerged as a more precise therapeutic approach that addresses the shortcomings of traditional blind puncture, and enhances the accuracy and safety of autonomic regulation therapy (6,7). This approach is characterized by rapid onset, simple operation, and a relatively long duration of effect (8), and has gradually gained patient acceptance.
In recent years, some patients have undergone ultrasound-guided sphenopalatine ganglion block combined with stellate ganglion block for the treatment of AR at Ultrasound Medicine Center of Gansu Provincial Maternity and Child-care Hospital. This retrospective study examined the effectiveness of this treatment approach for patients with AR. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1784/rc).
Methods
Study population
Between March 2022 and September 2024, 61 patients with AR at the Ultrasound Medicine Center of Gansu Provincial Maternity and Child-care Hospital, who had not been successfully treated with conventional medical therapy (intranasal corticosteroids and antihistamines) and who underwent ultrasound-guided combined sphenopalatine and stellate ganglion blockade, were enrolled in the study. All the patients completed follow-up. The patients were classified into different groups based on the symptom onset time; if the symptoms occurred <4 days/week or for <4 consecutive weeks, the patients were allocated to the intermittent group (group A); if the symptoms occurred ≥4 days/week and for ≥4 consecutive weeks, the patients were allocated to the persistent group (group B). Group A comprised 29 patients, and group B comprised 32 patients.
Inclusion criteria: patients were included in the study if they (I) met the diagnostic criteria for AR; (II) had not been successfully treated by conventional medical therapy; (III) received ultrasound-guided combined sphenopalatine and stellate ganglion; and (IV) had complete case and follow-up data available.
Exclusion criteria: patients were excluded from the study if they (I) showed poor compliance, and were unable to complete the prescribed treatment; and/or (II) were unable to complete follow-up.
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Board of Gansu Provincial Maternity and Child-care Hospital (No. 2023-GSFY-77), and informed consent was obtained from all the individual participants.
Diagnostic criteria
Diagnosis of AR—this study adopted the diagnostic criteria for AR outlined in the “Guidelines for the Diagnosis and Treatment of AR in China [2022]” —(I) symptoms: the presence of at least two of the following—paroxysmal sneezing, clear watery nasal discharge, nasal itching, and nasal congestion—for more than 1 hour per day, possibly accompanied by ocular symptoms such as tearing, itchy eyes, and redness; (II) signs: common findings include pale, edematous nasal mucosa, and watery nasal discharge; (III) allergen test: a positive response to at least one allergen in the skin prick test (SPT) and/or serum-specific IgE, or positive nasal provocation test (NPT) results.
Treatment methods
Before treatment, all the patients completed the NPT and quality of life scale (QLS) (9). After completing preoperative examinations and preparation, the patients in both groups received ultrasound (Siemens Acuson Redwoods, Issaquah, USA)-guided block of the unilateral sphenopalatine ganglion and contralateral stellate ganglion. The specific procedure was as follows: the patient was placed in the lateral decubitus position, using the subzygomatic approach and a linear array probe. The appropriate depth was selected. First, the coronoid notch of the mandible was confirmed by having the patient open and close their mouth. After confirmation, the patient was instructed to open the mouth and maintain a natural state to obtain the standard “wild goose sign” view of the pterygopalatine fossa, formed by the maxilla and lateral pterygoid plate (Figure 1). Using an in-plane puncture technique, the needle was inserted between the maxilla and the lateral pterygoid plate (Figure 2). After negative aspiration, 0.2 mL of triamcinolone acetonide and 3 mL of lidocaine, diluted with normal saline to a total volume of 10 mL, were injected. The patient was then turned to the opposite lateral decubitus position, and ultrasound was used to identify the level of the sixth cervical transverse process to obtain a cross-section of the longus colli muscle (Figure 3). Using an in-plane puncture technique, the needle was advanced to the space between the surface of the longus colli muscle and the prevertebral fascia (Figure 4). After negative aspiration, 0.2 mL of triamcinolone and 3 mL of lidocaine, combined with normal saline to a total volume of 10 mL, were injected. The injections were administered every other day, for a total of six sessions. NPT and QLS scores were assessed at 1, 3, and 6 months after treatment, and any adverse reactions during treatment were recorded.
Observation indicators and efficacy evaluation
The main observation indicators in this study included NPT scores (Table 1) and QLS scores before and after treatment (Table 2), as well as adverse reactions experienced by patients after treatment.
Table 1
| Symptoms | Scoring criteria |
|---|---|
| Sneezing | 0 points: 0–2; 1 point: 3–5; 2 points: >5 |
| Nasal discharge | 0 points: none; 1 point: small amount (≤1 mL); 2 points: large amount (>1 mL) |
| Extranasal symptoms | 0 points: none; 1 point: palatal itching, eye itching, ear itching; 2 points: conjunctivitis, bulbar conjunctival edema, urticaria, cough, dyspnea |
NPT, nasal provocation test.
Table 2
| Symptoms | Scoring criteria |
|---|---|
| Sleep | 0 points: no impact; 1 point: mild impact; 2 points: moderate to severe impact |
| Daily life | |
| Work | |
| Learning |
QLS, quality of life scale.
Statistical analysis
This study used SPSS 27.0 (version 27.0, Chicago, IL, USA) to conduct statistical analysis. The measurement data are expressed as the mean ± standard deviation. Differences between groups were assessed using the independent samples t-test, while differences before and after treatment within groups were analyzed using the paired t-test. Comparisons of data at different time points were performed using repeated-measures analysis of variance. A P value <0.05 was considered statistically significant.
Results
Comparison of general information between the two groups of AR patients
There were no statistically significant differences between the two groups of AR patients in terms of age, height, weight, and gender (all P>0.05; Table 3).
Table 3
| Variable | Intermittent group (n=29) | Persistent group (n=32) | P value | Chi-squared/F |
|---|---|---|---|---|
| Age (years) | 37.3±10.8 | 34.8±10.8 | 0.45 | 0.577 |
| Gender (female/male) | 14/15 | 16/16 | 0.89 | 0.018 |
| Height (cm) | 167.6±9.7 | 166.9±9.7 | 0.66 | 0.190 |
| Weight (kg) | 67.9±12.8 | 67.1±11.4 | 0.65 | 0.202 |
Data are expressed as mean ± standard deviation or n unless otherwise indicated.
Comparison of NPT scores
The NPT scores of the two groups of AR patients at different time points showed improvement after treatment compared to before treatment. There was a significant difference between the two groups at 3 months post-treatment (P<0.05), while no significant differences were observed at 1 month and 6 months post-treatment (Table 4).
Table 4
| Group | Cases | Before treatment | 1 month after treatment | 3 months after treatment | 6 months after treatment |
|---|---|---|---|---|---|
| A | 29 | 3.72±1.162 | 1.72±1.066† | 1.38±0.728† | 1.86±1.217† |
| B | 32 | 3.75±1.047 | 1.44±0.948† | 1.00±0.622†‡ | 1.34±0.971† |
Data are expressed as mean ± standard deviation or n. †, indicates a significant difference within the same group before and after treatment (P<0.05). ‡, indicates a significant difference between group B and group A at the same time point (P<0.05). Group A: intermittent group. Group B: persistent group. AR, allergic rhinitis; NPT, nasal provocation test.
Comparison of QLS scores
The QLS scores of the two groups of AR patients at different time points showed improvement after treatment compared to before treatment. There was a significant difference between the two groups at 1 month post-treatment (P<0.05), while no significant differences were observed at 3 and 6 months post-treatment (Table 5).
Table 5
| Group | Cases | Before treatment | 1 month after treatment | 3 months after treatment | 6 months after treatment |
|---|---|---|---|---|---|
| A | 29 | 4.62±1.678 | 2.14±1.457† | 1.45±1.055† | 1.79±1.840† |
| B | 32 | 5.22±1.338 | 1.81±1.061†‡ | 1.34±0.937† | 1.63±1.601† |
Data are expressed as mean ± standard deviation or n. †, indicates a significant difference within the same group before and after treatment (P<0.05). ‡, indicates a significant difference between group B and group A at the same time point (P<0.05). Group A: intermittent group. Group B: persistent group. AR, allergic rhinitis; QLS, quality of life scale.
Adverse reactions
During the treatment and after the treatment, neither group of patients experienced puncture site infection or nerve injury. During the treatment, some patients developed transient symptoms such as facial numbness, pain, hoarseness, ptosis, and difficulty swallowing, all of which spontaneously resolved within 2–3 hours.
Discussion
Numerous domestic and international epidemiological studies have shown that the prevalence of AR has significantly increased in recent years, making it a major chronic inflammatory disease of the respiratory tract. This condition severely affects patients’ quality of life and imposes significant socioeconomic burdens (10). AR is primarily an IgE-mediated non-infectious chronic inflammatory disease of the nasal mucosa, characterized by symptoms such as paroxysmal sneezing, watery nasal discharge, nasal itching, and nasal congestion. It may also be accompanied by bronchial asthma and ocular symptoms (11). China’s unique national circumstances result in varying regional distributions, allergens, and seasonal patterns of AR incidence (12).
The treatment principles for AR include etiological treatment and symptomatic treatment. Etiological treatment mainly involves allergen-specific immunotherapy, while symptomatic treatment includes pharmacotherapy and surgical interventions. Corticosteroids remain the frontline medication for AR treatment (13). Vidian neurectomy, as an adjunctive surgical treatment, reduces nasal mucosal sensitivity and decreases glandular secretions by interrupting the autonomic innervation of the nasal cavity (14). In recent years, the development of nerve blockade techniques has achieved effects similar to nerve resection while being non-invasive and associated with relatively fewer complications (6,7).
The sphenopalatine ganglion block inhibits parasympathetic impulses and reduces parasympathetic excitability, thereby restoring the sympathetic-parasympathetic balance, suppressing the release of inflammatory mediators, decreasing nasal mucosal hyperresponsiveness to stimuli, and attenuating the inflammatory response to control the symptoms of AR (4). Historically, pterygopalatine ganglion blocks were performed using a transoral blind approach, which was difficult to perform accurately and carried a risk of infection, yielding unsatisfactory results. Stellate ganglion block, by interrupting sympathetic outflow, reduces nasal mucosal reactivity and sensitivity to allergens, and can effectively relieve symptoms such as nasal congestion and sneezing (15). Previously, stellate ganglion blocks were often performed using landmark-based anatomical techniques, which carried risks of complications such as recurrent laryngeal nerve blockade. Ultrasound-guided sphenopalatine and stellate ganglion blockade overcomes the limitations of traditional blind techniques by enabling precise localization and reducing complication rates, thereby markedly improving the accuracy and safety of the treatment (5). These blocks should be performed unilaterally and in an alternating fashion to minimize the risk of respiratory and circulatory adverse events; in this study, each session comprised blockade of the sphenopalatine ganglion on one side together with the contralateral stellate ganglion.
The present study showed that all AR patients who received ganglion block therapy experienced a significant reduction in NPT scores and a significant increase in QLS scores at 1, 3, and 6 months after treatment. This indicates that, regardless of whether the patients underwent the intermittent or persistent group, combined sphenopalatine and stellate ganglion blockade produced marked improvements in their symptom burden and health-related quality of life. Compared with the intermittent group, the persistent group demonstrated greater overall improvement, which may be attributable to more sustained relief of chronic discomfort.
A significant between-group difference in NPT scores was observed at 3 months post-treatment, possibly reflecting maximal symptom relief resulting from inflammation control at that time point. A significant between-group difference in QLS scores was observed at 1 month, suggesting that the perceived improvements in quality of life were most pronounced early after treatment in patients with long-standing AR, and this difference attenuated with longer follow-up. In summary, for AR patients unresponsive to conventional therapy, ganglion blockade can rapidly alleviate symptoms and improve quality of life; however, its long-term efficacy and effects on relapse warrant further investigation.
In the clinical management of AR, pharmacotherapy is generally the first-line approach. Glucocorticoids are the treatment of choice because of their potent anti-inflammatory, anti-allergic, and anti-edematous effects, which provide rapid symptom relief—an effect comparable to that achieved with ganglion blockade. Allergen immunotherapy, which uses allergen extracts to induce immune tolerance and thereby attenuate symptoms upon re-exposure, is clinically recommended; however, a major unresolved issue is the lack of standardization in vaccine dosing and concentration units. Surgical intervention is another viable option for AR: the interruption of the autonomic innervation of the nasal cavity reduces mucosal hypersensitivity and glandular secretions to achieve therapeutic benefits (3). Although clinical studies have demonstrated the efficacy of surgical treatments, their invasiveness and the risk of associated complications limit their widespread application in the management of AR.
Ultrasound-guided combined pterygopalatine (sphenopalatine) and stellate ganglion blockade exerts its therapeutic effect via local anesthetics to modulate the autonomic innervation of the nasal cavity and relieve symptoms of AR (4). Compared with earlier blind techniques, recent ultrasound-guided blocks offer greater precision and safety. By using ultrasound to precisely identify the pterygopalatine fossa, the C6 transverse process and the longus colli muscle, and by advancing the needle in-plane to deposit the anesthetic around the target, the procedure is both safe and effective. It achieves efficacy comparable to surgical approaches while being minimally invasive and associated with fewer complications, representing a safe alternative to surgery (9). Although repeated injections were required in this study, the treatment course was generally easier for patients than the surgical options. Our findings indicate that combined sphenopalatine and stellate ganglion blockade produces significant benefits in AR, particularly in terms of rapid symptom relief and improvement in quality of life. Compared with conventional therapies, ultrasound-guided ganglion blockade is simpler to perform, can be delivered on an outpatient basis with same-day discharge, and is suitable for most patients with AR, especially those who are refractory to or intolerant of standard treatments.
Although the results of this study demonstrate that ultrasound-guided sphenopalatine ganglion block combined with stellate ganglion block is highly effective in the treatment of AR, it still has some limitations. First, the sample size of this study was relatively small, and the study lacked a control group. Second, the follow-up period was relatively short, making it impossible to assess the long-term efficacy and safety of nerve block therapy. Third, this study was conducted at a single center, which might have introduced selection bias.
Conclusions
This study showed that ultrasound-guided combined sphenopalatine and stellate ganglion blockade therapy, as an emerging treatment for AR, produces significant symptom relief and improves patient quality of life, and thus has the potential to become an important adjunctive therapy for AR.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1784/rc
Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1784/dss
Funding: This study was supported by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1784/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Board of Gansu Provincial Maternity and Child-care Hospital (No. 2023-GSFY-77), and informed consent was obtained from all individual participants.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, van Wijk RG, Ohta K, Zuberbier T, Schünemann HJGlobal Allergy and Asthma European Network. Grading of Recommendations Assessment, Development and Evaluation Working Group. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010;126:466-76. [Crossref] [PubMed]
- Seidman MD, Gurgel RK, Lin SY, Schwartz SR, Baroody FM, Bonner JR, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152:S1-43. [Crossref] [PubMed]
- Kamimura D, Tanaka Y, Hasebe R, Murakami M. Bidirectional communication between neural and immune systems. Int Immunol 2020;32:693-701. [Crossref] [PubMed]
- Saloman JL, Cohen JA, Kaplan DH. Intimate neuro-immune interactions: breaking barriers between systems to make meaningful progress. Curr Opin Neurobiol 2020;62:60-7. [Crossref] [PubMed]
- Tarasov VV, Kudryashov NV, Chubarev VN, Kalinina TS, Barreto GE, Ashraf GM, Aliev G. Pharmacological Aspects of Neuro-Immune Interactions. Curr Pharm Des 2018;24:15-21. [Crossref] [PubMed]
- Ghai A, Kaushik T, Kundu ZS, Wadhera S, Wadhera R. Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi J Anaesth 2016;10:161-7. [Crossref] [PubMed]
- Wang W, Chen H, Gao N, Yu S, Liao J, Wang S, Gao Z, Liu Z. Effect of acupuncture at the sphenopalatine ganglion for the treatment of moderate to severe seasonal allergic rhinitis: Study protocol for a three-armed randomized controlled trial. Front Med (Lausanne) 2022;9:904864. [Crossref] [PubMed]
- Pavlov VA, Tracey KJ. Neural regulation of immunity: molecular mechanisms and clinical translation. Nat Neurosci 2017;20:156-66. [Crossref] [PubMed]
- Chen H, Li J, Cheng L, Gao Z, Lin X, Zhu R, et al. China Consensus Document on Allergy Diagnostics. Allergy Asthma Immunol Res 2021;13:177-205. [Crossref] [PubMed]
- Bousquet J, Anto JM, Bachert C, Baiardini I, Bosnic-Anticevich S, Walter Canonica G, Melén E, Palomares O, Scadding GK, Togias A, Toppila-Salmi S. Allergic rhinitis. Nat Rev Dis Primers 2020;6:95. [Crossref] [PubMed]
- Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med 2015;372:456-63. [Crossref] [PubMed]
- Zheng M, Wang X, Wang M, She W, Cheng L, Lu M, et al. Clinical characteristics of allergic rhinitis patients in 13 metropolitan cities of China. Allergy 2021;76:577-81. [Crossref] [PubMed]
- Wise SK, Lin SY, Toskala E. International consensus statement on allergy and rhinology: allergic rhinitis-executive summary. Int Forum Allergy Rhinol 2018;8:85-107. [Crossref] [PubMed]
- Cheng L, Chen J, Fu Q, He S, Li H, Liu Z, et al. Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis. Allergy Asthma Immunol Res 2018;10:300-53. [Crossref] [PubMed]
- Mi J, Chen X, Lin X, Guo J, Chen H, Wei L, Hong H. Treatment of persistent allergic rhinitis via acupuncture at the sphenopalatine acupoint: a randomized controlled trial. Trials 2018;19:28. [Crossref] [PubMed]
