1. The Sphenopalatine Ganglion (SPG) and Maxillo-Facial Health Dietrich K.Klinghardt, MD, PhD Bellevue, WA tel: 425 637 9339 www.neuraltherapy.com Presented at the 23 rd Annual International Symposium on Man and His Environment June 9-12, 2005, Dallas, Tx American Environmental Health Foundation

2. Anatomy/location: aka: nasal ganglion, Meckel’s ganglion, pterygopalatine ggl. aka: nasal ganglion, Meckel’s ganglion, pterygopalatine ggl. Size/ Appearance: 6-8 mm, flattened, reddish-grey Size/ Appearance: 6-8 mm, flattened, reddish-grey Outside the cranial bowl Outside the cranial bowl Adjacent to the cranium near the sphenopalatine foramen Adjacent to the cranium near the sphenopalatine foramen Deeply in the sphenopalatine fossa Deeply in the sphenopalatine fossa Cranial to the mandibular nerve Cranial to the mandibular nerve Close and lateral to (and below) the maxillary nerve (as it crosses the fossa) Close and lateral to (and below) the maxillary nerve (as it crosses the fossa) 4 branches: orbital, palatine, nasal, pharyngeal 4 branches: orbital, palatine, nasal, pharyngeal

5. Neurology 1. Nerve fibers leading into the SPG sensory nerve supply: via the sphenopalatine nerve and the maxillary nerve (establishing a strong “fine- fiber”connection between trigeminal fibers and parasympathetic fibers inside the ganglion) sensory nerve supply: via the sphenopalatine nerve and the maxillary nerve (establishing a strong “fine- fiber”connection between trigeminal fibers and parasympathetic fibers inside the ganglion)  Trigeminal fiber collaterals storing substance P in the sphenopalatine ganglion of the rat. An axon reflex modulating parasympathetic ganglionic activity? Suzuki N et al.; Neuroscience 1989;30(3): 595-604 Suzuki N et al.; Neuroscience 1989;30(3): 595-604

6. Neurology Parasympathetic: Connection from the vagus nerve and the 3 vagal ganglia in the brain stem. Parasympathetic nerves traveling piggyback on the N.petrosus major and fibers of the facial nerve originating at the ganglia geniculi (establishing a connection to the 7th cranial nerve) Parasympathetic: Connection from the vagus nerve and the 3 vagal ganglia in the brain stem. Parasympathetic nerves traveling piggyback on the N.petrosus major and fibers of the facial nerve originating at the ganglia geniculi (establishing a connection to the 7th cranial nerve) Sympathetic connection via the N.petrosus profundus (establishing a connection with the superior cervical ganglion and the SNS) Sympathetic connection via the N.petrosus profundus (establishing a connection with the superior cervical ganglion and the SNS)

7. 2. Nerve fibers emerging from the SPG Connection to the parasympathetic fibers of the submandibular gland, the lacrimal gland and the parotid gland Connection to the parasympathetic fibers of the submandibular gland, the lacrimal gland and the parotid gland Connection to the ciliary ganglion and various functions of the eye Connection to the ciliary ganglion and various functions of the eye Connections to the inner ear Connections to the inner ear Connections to olfactory nerve and lingual nerve (smell and taste) Connections to olfactory nerve and lingual nerve (smell and taste) Connection to the arterial blood supply of the brain Connection to the arterial blood supply of the brain Connection to the dental pulp and osteoblasts of the jaw bone Connection to the dental pulp and osteoblasts of the jaw bone

8. Physiology a. Secreto-motor function Eustachian tubes Eustachian tubes Larynx Larynx Tonsils Tonsils Mucous membranes of nose and sinuses (incl. Sphenoidal- and ehtmoidal sinuses). Trigeminal and SPG parasympathic fibers synapse inside the SPG Mucous membranes of nose and sinuses (incl. Sphenoidal- and ehtmoidal sinuses). Trigeminal and SPG parasympathic fibers synapse inside the SPG Origin and distribution of capsaicin-sensitive substance p-immunoreactive nerves in the nasal mucosa Origin and distribution of capsaicin-sensitive substance p-immunoreactive nerves in the nasal mucosa Lundblad L et al; Acta Oto-Laryngologica, 1983, 96 (5-6) 485-493 Lundblad L et al; Acta Oto-Laryngologica, 1983, 96 (5-6) 485-493 Soft, hard palate and maxilla Soft, hard palate and maxilla Lacrimal gland Lacrimal gland Saliva producing glands (together with otic ganglion) Saliva producing glands (together with otic ganglion)  Badtke and Mudra: Neuraltherapie: Lehrbuch und Atlas. Ullstein Medical 1998, pg 108-109  Gray’s Anatomy(1986), pg 1235-1236

9. b. Major role of the SPG (and otic ganglion) in the regulation of the brain (newer findings based on histochemistry research) Principle of method used: presence of Vasoactive Intestinal Polypeptide (VIP) and Choline Acetyltransferase (ChAT) indicate parasympathetic function. Presence of Substance P pain indicates sensory nerve fiber function Principle of method used: presence of Vasoactive Intestinal Polypeptide (VIP) and Choline Acetyltransferase (ChAT) indicate parasympathetic function. Presence of Substance P pain indicates sensory nerve fiber function Connection from SPG to the internal carotid ganglion (considered an aberrant sphenopalatine ganglion with about 70 cells each) inside the carotid artery) Connection from SPG to the internal carotid ganglion (considered an aberrant sphenopalatine ganglion with about 70 cells each) inside the carotid artery) The intracranial portion of the internal carotid artery has fibers from SPG. Activation of these nerves causes edema, pain, dilatation, low grade encephalitis (cluster headache, ophthalmoplegic symptoms) The intracranial portion of the internal carotid artery has fibers from SPG. Activation of these nerves causes edema, pain, dilatation, low grade encephalitis (cluster headache, ophthalmoplegic symptoms)  Anatomical basis for a parasympathetic and sensory innervation of the intracranial segment of the internal carotid artery in man. Suzuki N, Hardebo JE J Neurolo Sci 1991 July; 104(1): 19-31 Suzuki N, Hardebo JE J Neurolo Sci 1991 July; 104(1): 19-31

10. The SPG is a major source for postganglionic parasympathetic fibers to the vascular beds of the cerebral hemispheres. Treating the SPG can increase brain blood flow The SPG is a major source for postganglionic parasympathetic fibers to the vascular beds of the cerebral hemispheres. Treating the SPG can increase brain blood flow  Selective electrical stimulation of postganglionic cerebrovascular parasympathetic nerve fibers originating from the sphenopalatine ganglion enhances cortical blood flow in the rat Suzuki N, Hardebo JE, Kahrstrom J, Owman C J Cereb Blood Flow Metab 1990 May; 10(3): 383-91 Suzuki N, Hardebo JE, Kahrstrom J, Owman C J Cereb Blood Flow Metab 1990 May; 10(3): 383-91 Abnormal cranial parasympathetic outflow from the SPG induces vasodilation of cerebral and meningeal blood vessels, enhances plasma protein extravasation and the release of pro-inflammatory mediators. It can mediate the intracranial hypersensitivity found in MCS patients and is often responsible for sensitizing central nociceptive neurons in the spinal trigeminal nucleus. Abnormal cranial parasympathetic outflow from the SPG induces vasodilation of cerebral and meningeal blood vessels, enhances plasma protein extravasation and the release of pro-inflammatory mediators. It can mediate the intracranial hypersensitivity found in MCS patients and is often responsible for sensitizing central nociceptive neurons in the spinal trigeminal nucleus.  2003 Wolff Award: Possible parasympathetic contributions to peripheral and central sensitization during migraine Yarnitzky D et al; Headache, 2003, 43 (7) 704-714 Yarnitzky D et al; Headache, 2003, 43 (7) 704-714

11. Fibers from the otic ganglion contribute to the innervation of the pial arteries  The pathway of parasympathetic nerve fibers to cerebral vessels from the otic ganglion in the rat Hardebo JE, Suzuki N J Auton Nerv Syst 1991 Oct; 36(1): 39-46 Hardebo JE, Suzuki N J Auton Nerv Syst 1991 Oct; 36(1): 39-46

12. Postganglionic fibers from the SPG are involved in tone regulation of the cerebral vessels Postganglionic fibers from the SPG are involved in tone regulation of the cerebral vessels  The cerebrovascular parasympathetic innervation Suzuki N, Hardebo JE Cerebrovasc Brain Metab Rev 1993 Spring; 5(1):33-46 Suzuki N, Hardebo JE Cerebrovasc Brain Metab Rev 1993 Spring; 5(1):33-46 Cell bodies of the SPG project along the 7th and 9th cranial nerve to the middle cerebral artery Cell bodies of the SPG project along the 7th and 9th cranial nerve to the middle cerebral artery  Cerebrovascular projections from the sphenopalatine and otic ganglia to the middle cerebral artery of the cat Walters B, Gillespie B Moskowitz A Stroke Vol 17, No3 1986 Walters B, Gillespie B Moskowitz A Stroke Vol 17, No3 1986

13. Fibers from the SPG and Otic ganglion innervate the dental pulp  Otic ganglion parasympathetic neurons innervate the pulp of the mandibular incisor or the guinea pig: Segade L, Suarez-Quintanilla D Neuroscience Letters 1988, 90(1-2) 33-38  Local actions of acetylcholine on vasomotor regulation in rat incisor pulp Olgart L et al; Acta physiologica scandinavica 1996, 158(4) 311-316  The excitatory action of acetylcholine on intradental sensory units  Maegerstam et al, Acta physiologica scand. 1975, 93(1) 113-118  Occurrence of axons with certain immunohistochemical markers in teleost of gingival and teeth, Tuisku F, Hildebrand C, Brain Research, 1996, 729(1), 137-141  Cat dental pulp after denervation and subsequent re-innervation: changes in blood flow regulation and distribution of neuropeptideY, GAP-43 and neurotrophin receptor-like immunoreactivity, Olgart L, Edwall L, Fired K; Brain Research 1993, 625(1) 109-119

14. Reported symptoms of SPG dysfunction prior to 1979 Convulsive disorders pain of the head and neck facial pain Convulsive disorders pain of the head and neck facial pain Muscle spasm of both voluntary and involuntary muscles Muscle spasm of both voluntary and involuntary muscles Rage reactions Rage reactions Psychosomatic symptoms, including fatigue and extreme sensitivity Psychosomatic symptoms, including fatigue and extreme sensitivity Blindness and glaucoma Blindness and glaucoma Metallic taste Metallic taste Ophthalmic migraine and herpes Ophthalmic migraine and herpes “Lower half headache” “Lower half headache” Abdominal pain Abdominal pain Diarrhea Diarrhea

15. Reported symptoms of SPG dysfunction prior to 1979 Pain in shoulder and upper extremity, low back pain, sciatica Pain in shoulder and upper extremity, low back pain, sciatica Asthma Asthma Angina pectoris Angina pectoris Intractable hiccup Intractable hiccup Menstrual pain Menstrual pain Hyper- and hypothyroidism Hyper- and hypothyroidism Nasal congestion, sneezing, tearing, photophobia, hayfever Nasal congestion, sneezing, tearing, photophobia, hayfever Glossodynia, Glossodynia, Otalgia Otalgia Nausea Nausea  Sphenopalatine(nasal) ganglion: remote effects including “psychosomatic” symptoms, rage reaction, pain and spasm Ruskin A Arch Phys Med Rehabil Vol 60 Aug 1979 142-147 Ruskin A Arch Phys Med Rehabil Vol 60 Aug 1979 142-147

16. The SPG and MCS The superficial location in the pharynx explains the extraordinary sensitivity of this ganglion to odors, chemicals and particles in the air The superficial location in the pharynx explains the extraordinary sensitivity of this ganglion to odors, chemicals and particles in the air Studies do not show increased sensitivity of the olfactory system but increased sensitivity/dysfunction of the parasympathetic system Studies do not show increased sensitivity of the olfactory system but increased sensitivity/dysfunction of the parasympathetic system Symptoms consistent with parasympathetic SPG- dysfunction induced by rose oil and a common solvent (methyl ethyl ketone) have been described in a study on 18 MCS patients (with a normal control group) Symptoms consistent with parasympathetic SPG- dysfunction induced by rose oil and a common solvent (methyl ethyl ketone) have been described in a study on 18 MCS patients (with a normal control group) –Decreased airway patency –Decreased pulse rate –Decreased blood pressure –Increased depression –No greater olfactory threshold sensitivity  Olfactory sensitivity, nasal resistance and autonomic function in patients with multiple chemical sensitivities Doty R et al; Arch Otolaryngol Head Neck Surg, Vol 114, Dec 1988, pg 1422 ff

17. The neighborhood to the teeth and parasympathetic innervations of the teeth suggests a vulnerability to mercury fumes escaping from dental amalgam fillings Patrick Stoertebecker, MD (neurologist at the Karolinska Institute) focused his research of retrograde axonal transport of mercury on the olfactory nerve and hypoglossal nerve, but observed rapid and severe contamination of the facial parasympathetic ganglia as well. Patrick Stoertebecker, MD (neurologist at the Karolinska Institute) focused his research of retrograde axonal transport of mercury on the olfactory nerve and hypoglossal nerve, but observed rapid and severe contamination of the facial parasympathetic ganglia as well.  Mercury poisoning from dental amalgam – a hazard to the human brain Patrick Stoertebecker, Bio-Probe 1992 ISBN 0-941011-01-1 Patrick Stoertebecker, Bio-Probe 1992 ISBN 0-941011-01-1

18. Using the neural therapy technique of injecting the SPG with DMPS has been found extremely valuable in the course of published detoxification protocols Using the neural therapy technique of injecting the SPG with DMPS has been found extremely valuable in the course of published detoxification protocols  Results of dental amalgam removal and mercury detoxification using DMPS and neural therapy Robert Kidd; Alternative Therapies, July 2000, Vol 6, No, 49-55 Robert Kidd; Alternative Therapies, July 2000, Vol 6, No, 49-55  Migraines, seizures and mercury toxicity Klinghardt, D and Leviton R; Alternative MedicineDigest Klinghardt, D and Leviton R; Alternative MedicineDigest Issue 21,1999, pg 63 Issue 21,1999, pg 63

19. The intricate connection to the vagus nerve and the contribution to the innervation of the saliva producing glands predicts many of the digestive symptoms observed in dysfunctional states of the SPG

20. The little explored access of the SPG to the deep cerebral arterial supply can explain many of the brain/limbic system related observations in MCS Many chemicals act as cholinesterase inhibitors, cause therefore disruption of normal parasympathetic function and can lead to dysfunction of the SPG Many chemicals act as cholinesterase inhibitors, cause therefore disruption of normal parasympathetic function and can lead to dysfunction of the SPG  Neuropsychological effects of long-term exposure to pesticides: results from the French Phytoner study Baldi I et al; Environmental Health Perspectives Baldi I et al; Environmental Health Perspectives Vol 109 No 8 Aug 2001 Vol 109 No 8 Aug 2001  A rat mammary tumor model induced by organophosphorus pesticides parathion and malathion, possibly through acetylcholinesterase inhibition Cabello G et al: Environmental Health Persepectives Cabello G et al: Environmental Health Persepectives Vol 109, No5, May 2001 Vol 109, No5, May 2001

21. Sphenopalatine ganglion-related MCS symptoms Exaggerated reactions to inhalants, foods and odors Exaggerated reactions to inhalants, foods and odors Chronic sinusitis Chronic sinusitis Rhinitis Rhinitis Eye problems Eye problems Tinnitus and high pitch hearing loss Tinnitus and high pitch hearing loss Digestive problems Digestive problems Facial pain and headache Facial pain and headache Inappropriate emotional states Inappropriate emotional states Cognitive problems of the brain Cognitive problems of the brain Fatigue Fatigue

22. Diagnosis Clinical: based on symptoms of dysfunctional SPG (Ruskin paper) Clinical: based on symptoms of dysfunctional SPG (Ruskin paper) Thermography (abnormal warmth in the mandibular nerve distribution) Thermography (abnormal warmth in the mandibular nerve distribution) EDS/EAV EDS/EAV Autonomic response testing Autonomic response testing  Using the bi-digital o-ring test to detect dysfunction of the autonomic nervous system Klinghardt D; Program and abstracts 14th international symposium on acupuncture and electrotherapeutics. International J of Acup and Electrotherapeutics Res, Vol 23, No 3 and 4, 1998, 288-289 Klinghardt D; Program and abstracts 14th international symposium on acupuncture and electrotherapeutics. International J of Acup and Electrotherapeutics Res, Vol 23, No 3 and 4, 1998, 288-289

23. Treatment-options for the dysfunctional SPG Injections Injections a. techniques a. techniques –intraoral approach medial to 2nd molar tooth (greater palatine foramen) –supra-zygomatic approach  Manual of Neural Therapy Peter Dosch, Haug Publishers Heidelberg, Peter Dosch, Haug Publishers Heidelberg, 1st English Edition 1984, pg 373-375I 1st English Edition 1984, pg 373-375I  llustrated Atlas of the Techniques of Neural Therapy with Local Anesthetics Mathias Dosch;Thieme 2002 (foreword by D. Klinghardt, MD PhD) b. injectible medications: b. injectible medications: preservative free ph-buffered procaine, saline, glutathione-SH, DMPS, phospholipids, Desferal, Ca-EDTA, vit. C, NAC, homeopathic preparations, ozone (N eural Therapy B, www.nerualtherapy.com ) preservative free ph-buffered procaine, saline, glutathione-SH, DMPS, phospholipids, Desferal, Ca-EDTA, vit. C, NAC, homeopathic preparations, ozone (N eural Therapy B, www.nerualtherapy.com )

24. Treatment-options for the dysfunctional SPG Nasal applicator (Q-tip): 5% procaine, essential oils (nasosympatico, Wise Woman Herbals) Nasal applicator (Q-tip): 5% procaine, essential oils (nasosympatico, Wise Woman Herbals)  Sphenopalatine(nasal) ganglion: remote effects including “psychosomatic” symptoms, rage reaction, pain and spasm Ruskin A Arch Phys Med Rehabil Vol 60 Aug 1979 145-146 Ruskin A Arch Phys Med Rehabil Vol 60 Aug 1979 145-146  The use of topical 4% lidocaine in sphenopalatine ganglion blocks for the treatment of chronic muscle pain syndromes : a randomized, controlled trial Scudds R A et al; Pain:(Amsterdam),1995, 62 (1) 69-77 Scudds R A et al; Pain:(Amsterdam),1995, 62 (1) 69-77  Possible parasympathetic contributions to peripheral and central sensitization during migraine ;2003 Wolff Award: Yarnitzky D et al; Headache, 2003, 43 (7) 704-714 Yarnitzky D et al; Headache, 2003, 43 (7) 704-714 Micro-current (KMT technology). Intraoral electrode placement or external temporal approach www.neuraltherapy.com Micro-current (KMT technology). Intraoral electrode placement or external temporal approach www.neuraltherapy.com Cranio-sacral therapy (manual osteopathic therapy to the spheno-basilar junction and sphenoid bone) Cranio-sacral therapy (manual osteopathic therapy to the spheno-basilar junction and sphenoid bone) Good structural dentistry: best for long term results Good structural dentistry: best for long term results

25. Results I have successfully treated more then 400 MCS clients (diagnosis was established by prior treating physicians) My approach includes Life style changes (avoidance, exercise, sauna, meditation or prayer, amalgam/root filled tooth removal) Life style changes (avoidance, exercise, sauna, meditation or prayer, amalgam/root filled tooth removal) Diet changes (diet therapy software) Diet changes (diet therapy software) Treatment of chronic stealth infections Treatment of chronic stealth infections Mental field therapy (www.neuraltherapy.com) Mental field therapy (www.neuraltherapy.com) intravenous therapies with glutathione, vitamin C, NAC and other detoxification strategies intravenous therapies with glutathione, vitamin C, NAC and other detoxification strategies oral orthomolecular program oral orthomolecular program bio-identical hormone replacement bio-identical hormone replacement neural therapy, including regular sphenopalatine ganglion “blocks” neural therapy, including regular sphenopalatine ganglion “blocks”

26. Conclusion: Both the literature and clinical experience suggest that treating the sphenopalatine ganglion can be a rewarding, safe and lasting intervention in the treatment of environmental sensitivity and illness Both the literature and clinical experience suggest that treating the sphenopalatine ganglion can be a rewarding, safe and lasting intervention in the treatment of environmental sensitivity and illness