Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis

Transantral ligation of the internal maxillary artery is the most widely used surgical technique for control of intractable epistaxis. Although this technique is highly efficacious, significant complications may occur, including oroantral fistula, damage to the infraorbital nerve, and recurrent bleeding. An endoscopic transnasal approach for ligation of the terminal branch of the internal maxillary artery, the sphenopalatine artery, provides an alternative to transantral ligation. We have used endoscopic ligation of the sphenopalatine artery to treat 38 patients requiring surgical therapy for epistaxis. These cases were retrospectively reviewed to analyze the efficacy and morbidity of our technique. Five patients (13%) had significant recurrence of their epistaxis, of whom two required further surgical intervention. There were no major complications in this series. There were some minor sequelae including nasal crusting (34%) and paresthesia of the palate and nose (13%). The median hospital stay was 3 days (range 1 to 10). Endoscopic transnasal sphenopalatine artery ligation seems to be a safe and effective technique for management of posterior epistaxis.     

Surgical anatomy of the sphenopalatine artery in lateral nasal wall

OBJECTIVE: We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed. STUDY DESIGN: Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study. METHODS: The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification x6). RESULTS: The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%). CONCLUSIONS: The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.     

Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis

BACKGROUND: Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity. METHODS: We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined. RESULTS: In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen. CONCLUSION: Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.     

Ligation of the sphenopalatine artery in posterior epistaxis. Retrospective study of 50 patients

ObjectivesThe aim of this study was to evaluate the efficacy of endoscopic ligation of the sphenopalatine artery in the treatment of severe posterior epistaxis.MethodsWe have carried out a retrospective study on 50 patients hospitalised with posterior recurrent epistaxis, in whom posterior nasal packing was not effective. All of them underwent surgical treatment, with endoscopic ligation of the sphenopalatine artery to control the epistaxis.ResultsOnly seven patients had a new epistaxis after surgery. One of them is being studied for some kind of coagulopathy, another patient was controlled by ligation of the anterior ethmoidal artery and it was necessary to ligate the contralateral sphenopalatine artery in a third patient. The other four patients were controlled with posterior nasal packing and discharged two days after surgery, without any complications.ConclusionsWe believe that endoscopic ligation of the sphenopalatine artery is a safe technique, with fewer complications than other methods such as posterior packing or embolisation.     

Direct cauterization of the nasal septal artery for epistaxis

Emergency management of epistaxis may include the use of local pressure and vasoconstrictors, chemical or electric cautery, hemostatic agents, nasal packing, embolization, and surgical arterial ligation. There is no definitive protocol for the management of epistaxis, although various protocols have been proposed in the literature. As approaches to surgical ligation of the arterial supply of the nasal cavity have evolved from external carotid ligation to minimally invasive approaches, surgical management of epistaxis has become more effective than embolization and may be less risky. In the surgical management of epistaxis, arterial ligation immediately proximal to the bleeding site is preferred. We propose a simple variation of the endoscopic sphenopalatine artery ligation that may be used to manage epistaxis arising from the nasal septum and floor.     

Endoscopic electrosurgical management of posterior epistaxis: shifting paradigm

Recent literature has embraced the use of electrosurgery, sphenopalatine vascular clipping, and endoscopy in posterior epistaxis. With the advent of endoscopy, the surgical treatment of posterior epistaxis has shifted from internal maxillary ligation to endoscopic sphenopalatine artery control. This article introduces an endoscopic electrosurgical approach for patients suffering from idiopathic posterior epistaxis that combines one or more of the following methods: endoscopic selective branch cauterization, endoscopic sphenopalatine artery cautery, and endoscopic posterior nasal cauterization. This approach is currently used in a hospital-based community otolaryngology practice and is presented from a Canadian health care perspective (Quebec). This article presents the experience in a series of 17 patients treated during a 35-month period and prospectively followed and discusses the surgical technique, patients' outcome, and the implications of such a practice.     

Surgical management of intractable epistaxis: audit of results

We have audited our results after changing the management practice in patients with intractable epistaxis. These patients are offered trans-nasal endoscopic sphenopalatine artery diathermy with or without anterior ethmoid artery diathermy instead of conventional surgical procedures. During the first year after the change in practice, 145 patients were treated as inpatients for epistaxis. Ten patients (seven per cent) required a surgical procedure under general anaesthesia due to the recurrent nature of bleeding. All 10 patients had endoscopic sphenopalatine artery diathermy, whereas in four patients anterior ethmoid artery diathermy was also performed concurrently. The post-operative hospital stay ranged from one to three days (mean 2.1 days). The mean follow-up was 10 months. The epistaxis recurred in one patient and this was managed conservatively. There were no complications related to surgery. In the previous year, 132 patients were admitted for epistaxis and eight patients had surgical procedures, which included septoplasty, nasal packing and external carotid artery ligation. The post-operative stay ranged from three to six days (mean 3.9 days). Our audit shows that endoscopic sphenopalatine artery diathermy is a safe, successful and effective management option for patients with refractory epistaxis. The morbidity is reduced and the hospital stay is shortened. The sphenopalatine artery diathermy can be combined with anterior ethmoid surgery, when necessary.     

鼻内镜下蝶腭动脉区的外科解剖

目的探讨鼻内镜下蝶腭动脉区的解剖学特点。方法采用鼻内镜对10例(20侧鼻腔)经10%福尔马林溶液固定的正常成人尸头标本的蝶腭动脉及其与相关结构的关系进行解剖,观察蝶腭孔定位,筛骨嵴的形态、大小及其与蝶腭孔的关系;测量筛骨嵴与前鼻棘的间距以及筛骨嵴与中鼻甲尾端的间距,观察蝶腭动脉分支及其走行。结果筛骨嵴略呈三角棘状骨性结构,表面粗糙,位于蝶腭孔的前上方。去除筛骨嵴后可见蝶腭动脉血管束从蝶腭孔中穿出,蝶腭动脉常有2~3支不等分支。筛骨嵴与前鼻棘间距为(50.1±2.6)mm,筛骨嵴与中鼻甲尾端的间距为(9.1±1.1)mm。结论蝶腭动脉在出蝶腭孔之前可能有分支;筛骨嵴位置固定,是经鼻内镜下定位蝶腭动脉及蝶腭孔的重要解剖标志。     

Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation?

Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation? The optimal surgical management for failed conservative measures in epistaxis remains unclear. Given the growing enthusiasm for endoscopic transnasal sphenopalatine artery ligation, it is prudent and timely to evaluate the evidence base for this technique. This study aims to analyse the current evidence for transnasal endoscopic sphenopalatine artery ligation by reviewing the literature and also by comparing the results with other approaches to the management of epistaxis. A detailed literature search identified 11 publications relating to endoscopic sphenopalatine artery ligation. The total number of patients in the pooled series was 127, of which 98% had control of epistaxis following surgery. These results compared favourably to the results of most other techniques used in the modern treatment of epistaxis. Nonetheless, the total number of patients in the 11 case series is small. It is therefore recommended that all units using this technique audit their results to see if the high success rates achieved in the literature are reproducible. If this is the case, then endoscopic sphenopalatine artery ligation may indeed be the surgical answer to intractable posterior epistaxis.     

Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery

Posterior epistaxis poses a challenge to the otolaryngologist as the bleeding point itself cannot easily be identified. Haemostasis by conventional means is usually nasal packing and this results in repeated/persistent haemorrhage, morbidity and prolonged bed occupancy. In recent years the increased availability of rigid endoscopes and a better understanding of the anatomy of the nasal cavity have facilitated a direct approach to the sphenopalatine artery. Using a 0 degrees or 30 degrees rigid nasendoscope the sphenopalatine artery-the main blood supply to the nose-can be clearly identified and treated. Over the last 12 months we have employed endoscopic intranasal clipping of the said artery under a general anaesthetic to control persistent posterior nasal bleeding. Twelve patients have undergone 14 procedures within 48 h of failure of their conservative management. In all the epistaxis was controlled no complications were noted. The average follow-up period in our series was nine months. We believe that intranasal endoscopic clipping of the sphenopalatine artery is effective and less traumatic than either any other site of arterial ligation technique or repeated packing. In this series we employed only clipping of the artery and not diathermy/electrocautery to reduce the theoretical risk to adjacent structures     

顽固性鼻腔后部出血的手术治疗

本文综述了近年国外对顽固性鼻腔后部出血手术治疗的相关文献，对前-后鼻腔填塞术、颈外动脉结扎术、血管造影颌内动脉栓塞术、鼻内镜下经鼻腔蝶腭动脉结扎术等手术方法及其疗效进行分析，提出对顽固性鼻腔后部出血病人应根据具体情况选择最合适的手术治疗方法。     

鼻内镜下蝶腭动脉电凝术治疗严重后段鼻出血

目的 评价鼻内镜下蝶腭动脉电凝术治疗严重后段鼻出血的疗效。方法 对25例后鼻孔填塞治疗无效的鼻出血住院患者,行鼻内镜下蝶腭动脉电凝术,其中24例全身麻醉,1例局部麻醉。25例中有2例患者同时行双侧蝶腭动脉电凝术。结果 术中所有蝶腭动脉均能明确识别,并在出蝶腭孔处将其成功电凝。22例术后未再出血;1例术后6h再次出血,经后鼻孔填塞2d后出血治愈;2例术后当天轻微鼻出血,药物治疗后停止。出院后随访3~6个月,患者均无再次鼻出血,除2例出现轻度鼻腔黏连外无其他并发症。结论 鼻内镜下蝶腭动脉电凝术治疗严重后段鼻出血是一种安全、有效的治疗方法。     

Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation?

The optimal surgical management for failed conservative measures in epistaxis remains unclear. Given the growing enthusiasm for endoscopic transnasal sphenopalatine artery ligation, it is prudent and timely to evaluate the evidence base for this technique. This study aims to analyse the current evidence for transnasal endoscopic sphenopalatine artery ligation by reviewing the literature and also by comparing the results with other approaches to the management of epistaxis. A detailed literature search identified 11 publications relating to endoscopic sphenopalatine artery ligation. The total number of patients in the pooled series was 127, of which 98% had control of epistaxis following surgery. These results compared favourably to the results of most other techniques used in the modern treatment of epistaxis. Nonetheless, the total number of patients in the 11 case series is small. It is therefore recommended that all units using this technique audit their results to see if the high success rates achieved in the literature are reproducible. If this is the case, then endoscopic sphenopalatine artery ligation may indeed be the surgical answer to intractable posterior epistaxis.     

Nasal insertion of St John's wort: an unusual cause of epistaxis

We report a case of severe unilateral epistaxis requiring surgical arrest of bleeding, via endoscopic sphenopalatine artery ligation and anterior ethmoidal artery ligation. This followed recreational nasal insertion of St John's wort (Hypericum perforatum). Interactions between this substance and prescribed drugs have been described following oral ingestion. However, this unusual case highlights a further, worrying potential rhinological side effect of this substance.     

Anatomical and surgical study of the sphenopalatine artery branches

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76 % of the patients (13/17) and a double trunk in 24 % (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88 % of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61 %), 30 had 2 arterial trunks (33 %) and in only 5 nasal fossae we observed 3 arterial trunks (6 %). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.     

Lobular capillary hemangiomas: Case report and review of literature of vascular lesions of the nasal cavity

Vascular tumors of the nasal cavity can represent a variety of pathologies. In this case report, we discuss two patients presenting with a large vascular lesion occupying the nasal cavity. Significant bleeding was encountered during the initial attempts for endoscopic surgical resection. One lesion was successfully excised following preoperative embolization while a second following sphenopalatine artery vascular ligation. In both cases, final pathology showed lobular capillary hemangioma (LCH). We present a literature review and discussion of LCH and other vascular tumors that present in the nasal cavity. In addition, we discuss the utility of pre-resection vascular control of these tumors.     

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entively satisfactory because of morbidity, high failure rates, and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior existaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior & posterior nasal packing.     

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty. Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entirely satisfactory because of morbidity, high failure rates and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior epistaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior and posterior nasal packing.     

Persistent epistaxis: what is the best practice?

Epistaxis is the commonest otolaryngological emergency, which is often managed by a nasal pack. A significant number of cases fail to respond to nasal packing and various surgical measures are available to control the nosebleed in these cases. However evidence is sparse regarding the best available surgical option for the management of persistent epistaxis. We designed a retrospective cohort study comparing endoscopic ligation of sphenopalatine artery (ELSA) and all other surgical options (non-ELSA) in the management of persistent epistaxis. All consecutive cases of persistent epistaxis between 1997-2004 (Feb) requiring operative intervention were included in the study and divided in two groups according to the surgical intervention. Postoperative epistaxis was excluded. Non-ELSA group consisted of various procedures including nasal cautery and packing, submucous resection, anterior ethmoid artery ligation, external carotid artery ligation, internal maxillary artery ligation. Both groups were matched for age, sex, risk factors, other medical conditions and medications. The main outcome measures evaluated were immediate success in arresting the bleeding and the mean hospital stay. Recurrence and patient acceptability of the procedure were the secondary variables investigated. We found that ELSA proved to be the best practice to manage persistent epistaxis on all measures of immediate success rate, shorter hospital stay, recurrence rate, and patient satisfaction.     

Endoscopic ligation of maxillary and sphenopalatine artery for intractable epistaxis

We report the endoscopic ligation of the maxillary and sphenopalatine arteries for the treatment of intractable epistaxis. From March 2003 to February 2005, 17 patients (12 men, 5 women) with epistaxis were hospitalized in our department. Patient age ranged from 25 to 83 years, with an average age of 62 years. 8 patients were successfully treated using the conventional packing method, 2 patients were treated using electrocauterization, and 1 patient with macroglobulinemia was treated using plasma exchange therapy. 6 patients underwent endoscopic ligation of the maxillary and sphenopalatine arteries while under general anesthesia. The post operative courses were uneventful, and no recurrent bleeding has been noted. Endscopic ligation of the maxillary and sphenopalatine arteries is safer than intraarterial embolization and less invasive than conventional surgical approach for the ligation of maxillary artery. This technique appears to be a safe and effective surgical treatment for patients with intractable epistaxis.