Differences between anterior and posterior epistaxis
Endoscopic cauterization of intranasal sites of bleeding
Endoscopic ligation of the sphenopalatine artery
- (1)The middle turbinate is gently medialized to provide access to the posterior middle meatus. Cottonoids soaked with 0.05% oxymetazoline or a similar vasoconstrictive agent into the middle meatus may improve visualization of the surgical field.
- (2)To provide local anesthesia into the pytergopalatine fossa, about 1-2 mL of 1% lidocaine with 1:100,000 epinephrine may be injected transorally into the ipsilateral greater palatine canal. This injection may be facilitated with a 90° bend about 2 cm from the tip of a 25-gauge spinal needle. Additional local anesthetic may be infiltrated under endoscopic guidance into the mucosa along the tail of the ipsilateral middle turbinate.
- (3)A vertical mucosa incision is first created along the ascending process of the palatine bone approximately 1 cm anterior to its intersection with the basal lamella. A preceding ipsilateral uncinectomy and maxillary antrostomy may be performed to facilitate identification of the posterior wall of the maxillary antrum, although this is not always necessary. If a maxillary antrostomy is performed, the posterior wall of the maxillary antrum may serve as the anterior boundary for dissection toward the sphenopalatine foramen.
- (4)From either the mucosal incision created in the posterior middle meatus or the mucosal edge of the posterior maxillary ostia, a subperiosteal flap is widely elevated off the lateral nasal wall with a Freer or Cottle periosteal elevator. Flap elevation is continued in the anterior to posterior direction broadly to identify the crista ethmoidalis and then the sphenopalatine foramen with its accompanying neurovascular bundle (Figure 3—figure representing the release of mucosa and exposure of the SPA/PSA).
- (5)Visualization of the sphenopalatine foramen may be improved by removing the crista ethmoidalis and anterior lip of the sphenopalatine foramen with a Kerrison rongeur.
- (6)The sphenopalatine artery and its distal arterial branches are then gently dissected with a ball-tip probe to provide 360° of access around the vessels.
- (7)After adequate skeletonization of the sphenopalatine artery and its associated distal branches, the sphenopalatine artery can be ligated with hemostatic clips or bipolar electrocautery. We recommend placing a miniature titanium clip proximally followed by bipolar electrocautery distally in case the clip falls (Figure 4—illustration representing clips on the SPA/PSA).
- (8)The elevated mucosa over the palatine bone can be repositioned over the palatine bone, followed by placement of hemostatic agents such as Surgicel to complete the procedure.
Endoscopic ligation of the anterior ethmoid artery
- (1)The middle turbinate is gently medialized to provide access to the posterior middle meatus. Cottonoids soaked with a vasoconstrictive agent into the middle meatus may improve visualization of the surgical field.
- (2)Approximately 1-2 mL of 1% lidocaine with 1:100,000 epinephrine is injected into the mucosa of the axilla and tail of the ipsilateral middle turbinate.
- (3)A standard uncinectomy, maxillary antrostomy, and anterior ethmoidectomy are all performed to expose the lamina papyracea and ethmoid skull base. Identification of the frontal recess following completion of the anterior ethmoidectomy can assist in localizing the more posteriorly based anterior ethmoid artery (Figure 6—illustration of the anterior skull base).
- (4)If the anterior ethmoid artery is located within the bony mesentery of the ethmoid roof, the vessel may then be ligated with hemostatic clips or bipolar electrocautery. The site of ligation should ideally be in the mid-nasal portion of the vessel, as this will prevent retraction of vessel into the orbital cavity and thus prevent formation of an orbital hematoma.
- (5)If the anterior ethmoid artery is not easily accessible within the bony mesentery of the ethmoid skull base, partial removal of the lamina papyracea with a small curette provides a window to locate the anterior ethmoid artery within the orbital cavity. Gentle retraction of the orbital contents will better expose the anterior ethmoid artery.
- (6)The anterior ethmoid artery, which is found between the lamina papyracea and the periorbita can be gently ligated endoscopically with hemostatic clips or bipolar electrocautery. The artery should not be ligated at a point too close to the periorbita in order to prevent formation of an orbital hematoma (Figure 7—illustration of Figure 6 with the area of ligation marked).
- (7)The window through the lamina papyracea, if created, does not require additional repair once the anterior ethmoid artery has been ligated.
- Epistaxis: Diagnosis and treatment.J Oral Maxillofac Surg. 2006; 64: 511-518
- Epistaxis and hemostatic devices.Oral Maxillofac Surg Clin North Am. 2012; 24 (viii): 219-228
- On the effectiveness of treatment options in epistaxis: An analysis of 678 interventions.Rhinology. 2011; 49: 474-478
- Clinical practice. Epistaxis.N Engl J Med. 2009; 360: 784-789
- Update on epistaxis.Curr Opin Otolaryngol Head Neck Surg. 2007; 15: 180-183
- Epistaxis: Prospective evaluation of bleeding site and its impact on patient outcome.J Laryngol Otol. 2010; 124: 744-749
- Surgical management of severe epistaxis.Otolaryngol Clin N Am. 2016; 49: 627-637
- Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure.Am J Rhinol Allergy. 2009; 23: e38-e41
- Epistaxis.Otolaryngol Clin N Am. 2008; 41 (viii): 525-536
- Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis.Int Forum Allergy Rhinol. 2013; 3: 563-566
- Management of intractable spontaneous epistaxis.Am J Rhinol Allergy. 2012; 26: 55-60
☆Conflict of interest: A.L. received consulting fees from 480 Biomedical, Aerin Medical, ENTvantage, and Medtronic. The Department of Otolaryngology at the McGovern Medical School received research funds from Intersect ENT and Allakos.