• Authors: • Nnaemeka Nweke, MD. Baylor College of Medicine PM&R • Saba Javed, MD. MD Anderson Cancer Center
Bilateral Stellate Ganglion Block in Long Covid Patients Dealing with Anosmia/Ageusia Demonstrates Successful Long-Term Result: A case report
Dec 09, 2022
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Bilateral Stellate Ganglion Block in Long Covid Patients Dealing with Anosmia/Ageusia Demonstrates Successful Long-Term Results: A Case Report • Autho rs:
• Nnae m e ka Nw e ke , MD. Baylor Colleg e of Med icine PM&R
• Sab a J ave d , MD. MD And e rson Cance r Cente r
Introd uction Pathop hysio log y Case Inte rve ntion
Comp lications Re sult Discussion Conclusion
• SARS-CoV-2 virus has caused a global pandemic which has resulted in millions of deaths and left many survivors with residual effects altering their life experience significantly.
• The residual symptoms that plague many victims have been collectively termed as “Long COVID.”
• Symptoms include fatigue, orthostatic, elevated resting heart rate, shortness of breath, brain fog, sleep disturbance, fevers, gastrointestinal symptoms, anosmia, ageusia, anxiety, and depression.1
• Here we highlight anosmia and dysgeusia which are both loss of smell and taste that are often reported together by patients.
• Olfactory and gustatory systems function together to give rise to flavors due to dependency on perceived smell giving rise to gustatory receptors on the tongue.2
• Thus, understanding the mechanism of injury by SARS-CoV-2 virus on the olfactory pathway has led to promising intervention in dealing with anosmia and ageusia.
• It has been hypothesized that the cause of anosmia during COVID-19 is due to altered function of olfactory sensory neurons leading to death of supporting cells leading to neuronal dysfunction.2
• In this case study, Stellate ganglion block which has been shown to treat many autonomic dysfunction was attempted in 4 Long COVID patients in hope to successfully treat Anosmia/Ageusia.
• Direct action of the virus and inflammatory reaction mediated by interleukin-6 in olfactory receptors resulting in impaired sense of smell
• Occupation of sialic acid receptors by the virus itself, accelerating the degradation of taste buds
• Affection of the taste buds leading to ageusia. Viruses bind to sialic acid receptors located on the taste buds, causing inflammation and edema with further degradation and apoptosis of the taste receptors. In addition, it is believed that there is a reduction in salivary flow which may distort the sense of taste and/or ageusia.
Patie nt d e m o g rap h ics
Diag no sis o f COVID
Lo ng -COVID sym p to m (s)
The rap y
32-year-o ld -male 2 months ag o Anosmia for 2 months Bilate ral ste llate g ang lion b lock
55-year-o ld -fe male 1 month ag o Ag e usia fo r 1 month Bilate ral ste llate g ang lion b lock
67-year-o ld -male 2 months ag o Anosmia for 2 months Bilate ral ste llate g ang lion b lock
49-year-o ld -fe male 2 months ag o Anosmia and ag e usia fo r 2 months
Unilate ral ste llate g ang lion b lock
• Stellate ganglion block was performed at the level of C6 under fluoroscopic guidance. The right-sided stellate ganglion was targeted at the C6 Chassaignac tubercle and, after negative aspiration, a 7ml treatment mixture consisting of 1ml of dexamethasone and 6ml of 0.25% bupivacaine was injected. Immediately after the procedure, the patient exhibited Horner’s syndrome and was elevated on the same side of the upper extremity. The patient noted a marked improvement in his ability to taste and smell. Same procedure was also performed on the opposite side one week later.
• Second injection was a week apart due to concern for hypotension.
• Other immediate effects: Nasal stuffiness, Hoarse voice, Feeling of a “lump” in your throat, Difficulty swallowing, Warmth or tingling in your arm or hand.
• Resolves in 4-6 hours
• This experiment did not have any complications. • Potential complication include:
• Recurrent laryngeal nerve blockade • Phrenic nerve blockade (leading to ipsilateral diaphragmatic paralysis) • Pneumothorax • Total spinal anesthesia • Severe hypertension • Paratracheal hematomas • Generalized seizures • Hematoma • Local Anesthetic Systemic effects • Performing bilateral at the same in individuals with potential lung disease can cause respiratory paralysis,
ultimately death
Patie n t d e m o g rap h ics
Diag no sis o f COVID
Lo ng -COVID sym p to m (s)
The rap y Clin ica l Co urse Po st-p ro ce d ure O utco m e
32-year-o ld - male
Bilate ral ste llate g ang lion b lock
Im m e d ia te g a in o f sm e ll a fte r le ft sid e d p ro ce d ure , fu ll g a in o f sm e ll a fte r rig h t sid e d p ro ce d ure
2 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f sm e ll
55-year-o ld - fe male
1 month ag o
Bilate ral ste llate g ang lion b lock
5 0 % se nse o f ta ste a fte r le ft sid e d in je ctio n ; 1 0 0 % se nse o f ta ste a fte r rig h t sid e d in je ctio n
3 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f ta ste
67-year-o ld - male
Bilate ral ste llate g ang lion b lock
Im m e d ia te g a in o f sm e ll a fte r le ft sid e d p ro ce d ure , fu ll g a in o f sm e ll a fte r rig h t sid e d p ro ce d ure
3 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f sm e ll
49-year-o ld - fe male
2 months ag o
Unilate ral ste llate g ang lion b lock
Im m e d ia te (6 0 -7 0 %) g a in o f sm e ll and fu ll se nse o f ta ste a fte r le ft sid e d p ro ce d ure – p atie nt d id no t show for the rig ht sid e d p roce d ure d ue to family e me rg e ncy
2 m o nths fo llo w -up , st ill e nd o rsing 6 0 - 7 0 % o f se nse o f sm e ll and fu ll se nse o f ta ste
• This case demonstrates that Stellate Ganglion Block when performed bilateral, can alleviate Anosmia/ageusia.
• In our case, patients did not need to undergo bilateral injections to experience improvement.
• Larger prospective and case control studies can be used to develop a definite conclusion.
1. Soriano, J. B., Murthy, S., Marshall, J. C., Relan, P., & Diaz, J. V. (2022). A clinical case definition of post- covid-19 condition by a delphi consensus. The Lancet Infectious Diseases, 22(4). https://doi.org/10.1016/s1473-3099(21)00703-9
2. Mastrangelo A, Bonato M, Cinque P. Smell and taste disorders in COVID-19: From pathogenesis to clinical features and outcomes. Neurosci Lett. 2021 Mar 23;748:135694. doi: 10.1016/j.neulet.2021.135694. Epub 2021 Feb 15. PMID: 33600902; PMCID: PMC7883672.
Bilateral Stellate Ganglion Block in Long Covid Patients Dealing with Anosmia/Ageusia Demonstrates Successful Long-Term Results: A Case Report
Slide Number 2
• Nnae m e ka Nw e ke , MD. Baylor Colleg e of Med icine PM&R
• Sab a J ave d , MD. MD And e rson Cance r Cente r
Introd uction Pathop hysio log y Case Inte rve ntion
Comp lications Re sult Discussion Conclusion
• SARS-CoV-2 virus has caused a global pandemic which has resulted in millions of deaths and left many survivors with residual effects altering their life experience significantly.
• The residual symptoms that plague many victims have been collectively termed as “Long COVID.”
• Symptoms include fatigue, orthostatic, elevated resting heart rate, shortness of breath, brain fog, sleep disturbance, fevers, gastrointestinal symptoms, anosmia, ageusia, anxiety, and depression.1
• Here we highlight anosmia and dysgeusia which are both loss of smell and taste that are often reported together by patients.
• Olfactory and gustatory systems function together to give rise to flavors due to dependency on perceived smell giving rise to gustatory receptors on the tongue.2
• Thus, understanding the mechanism of injury by SARS-CoV-2 virus on the olfactory pathway has led to promising intervention in dealing with anosmia and ageusia.
• It has been hypothesized that the cause of anosmia during COVID-19 is due to altered function of olfactory sensory neurons leading to death of supporting cells leading to neuronal dysfunction.2
• In this case study, Stellate ganglion block which has been shown to treat many autonomic dysfunction was attempted in 4 Long COVID patients in hope to successfully treat Anosmia/Ageusia.
• Direct action of the virus and inflammatory reaction mediated by interleukin-6 in olfactory receptors resulting in impaired sense of smell
• Occupation of sialic acid receptors by the virus itself, accelerating the degradation of taste buds
• Affection of the taste buds leading to ageusia. Viruses bind to sialic acid receptors located on the taste buds, causing inflammation and edema with further degradation and apoptosis of the taste receptors. In addition, it is believed that there is a reduction in salivary flow which may distort the sense of taste and/or ageusia.
Patie nt d e m o g rap h ics
Diag no sis o f COVID
Lo ng -COVID sym p to m (s)
The rap y
32-year-o ld -male 2 months ag o Anosmia for 2 months Bilate ral ste llate g ang lion b lock
55-year-o ld -fe male 1 month ag o Ag e usia fo r 1 month Bilate ral ste llate g ang lion b lock
67-year-o ld -male 2 months ag o Anosmia for 2 months Bilate ral ste llate g ang lion b lock
49-year-o ld -fe male 2 months ag o Anosmia and ag e usia fo r 2 months
Unilate ral ste llate g ang lion b lock
• Stellate ganglion block was performed at the level of C6 under fluoroscopic guidance. The right-sided stellate ganglion was targeted at the C6 Chassaignac tubercle and, after negative aspiration, a 7ml treatment mixture consisting of 1ml of dexamethasone and 6ml of 0.25% bupivacaine was injected. Immediately after the procedure, the patient exhibited Horner’s syndrome and was elevated on the same side of the upper extremity. The patient noted a marked improvement in his ability to taste and smell. Same procedure was also performed on the opposite side one week later.
• Second injection was a week apart due to concern for hypotension.
• Other immediate effects: Nasal stuffiness, Hoarse voice, Feeling of a “lump” in your throat, Difficulty swallowing, Warmth or tingling in your arm or hand.
• Resolves in 4-6 hours
• This experiment did not have any complications. • Potential complication include:
• Recurrent laryngeal nerve blockade • Phrenic nerve blockade (leading to ipsilateral diaphragmatic paralysis) • Pneumothorax • Total spinal anesthesia • Severe hypertension • Paratracheal hematomas • Generalized seizures • Hematoma • Local Anesthetic Systemic effects • Performing bilateral at the same in individuals with potential lung disease can cause respiratory paralysis,
ultimately death
Patie n t d e m o g rap h ics
Diag no sis o f COVID
Lo ng -COVID sym p to m (s)
The rap y Clin ica l Co urse Po st-p ro ce d ure O utco m e
32-year-o ld - male
Bilate ral ste llate g ang lion b lock
Im m e d ia te g a in o f sm e ll a fte r le ft sid e d p ro ce d ure , fu ll g a in o f sm e ll a fte r rig h t sid e d p ro ce d ure
2 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f sm e ll
55-year-o ld - fe male
1 month ag o
Bilate ral ste llate g ang lion b lock
5 0 % se nse o f ta ste a fte r le ft sid e d in je ctio n ; 1 0 0 % se nse o f ta ste a fte r rig h t sid e d in je ctio n
3 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f ta ste
67-year-o ld - male
Bilate ral ste llate g ang lion b lock
Im m e d ia te g a in o f sm e ll a fte r le ft sid e d p ro ce d ure , fu ll g a in o f sm e ll a fte r rig h t sid e d p ro ce d ure
3 m o nths fo llo w -up , st ill e nd o rsing fu ll se nse o f sm e ll
49-year-o ld - fe male
2 months ag o
Unilate ral ste llate g ang lion b lock
Im m e d ia te (6 0 -7 0 %) g a in o f sm e ll and fu ll se nse o f ta ste a fte r le ft sid e d p ro ce d ure – p atie nt d id no t show for the rig ht sid e d p roce d ure d ue to family e me rg e ncy
2 m o nths fo llo w -up , st ill e nd o rsing 6 0 - 7 0 % o f se nse o f sm e ll and fu ll se nse o f ta ste
• This case demonstrates that Stellate Ganglion Block when performed bilateral, can alleviate Anosmia/ageusia.
• In our case, patients did not need to undergo bilateral injections to experience improvement.
• Larger prospective and case control studies can be used to develop a definite conclusion.
1. Soriano, J. B., Murthy, S., Marshall, J. C., Relan, P., & Diaz, J. V. (2022). A clinical case definition of post- covid-19 condition by a delphi consensus. The Lancet Infectious Diseases, 22(4). https://doi.org/10.1016/s1473-3099(21)00703-9
2. Mastrangelo A, Bonato M, Cinque P. Smell and taste disorders in COVID-19: From pathogenesis to clinical features and outcomes. Neurosci Lett. 2021 Mar 23;748:135694. doi: 10.1016/j.neulet.2021.135694. Epub 2021 Feb 15. PMID: 33600902; PMCID: PMC7883672.
Bilateral Stellate Ganglion Block in Long Covid Patients Dealing with Anosmia/Ageusia Demonstrates Successful Long-Term Results: A Case Report
Slide Number 2
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