Outcomes of endoscopic sphenopalatine artery ligation for epistaxis: a five-year series from a single institution.
Epistaxis is a common emergency seen by the otolaryngologist. A minority of cases require surgical intervention. Multiple surgical procedures have been tried in the past, including endoscopic ligation of the sphenopalatine artery (ELSPA), which is considered an effective surgical modality in the management of epistaxis. This study examines the outcome of 33 ELSPA procedures over a 5-year period. Three of 4 cases that were not controlled with ELSPA were successfully managed with subsequent anterior ethmoidal ligation. Failed ELSPA procedures may represent an incorrect choice of procedure rather than a failure of the procedure. High-resolution computed tomography can identify the position of the anterior ethmoidal artery; it may be possible to infer vulnerability to hemorrhage from this artery and hence target procedure selection.
Epistaxis is a common emergency presentation seen by the otolaryngologist. Severe or persistent epistaxis may require surgical intervention. In recent years, the advent of endoscopic instruments has facilitated minimal-access ligation of the sphenopalatine artery. This has been reported repeatedly to be effective in the control of epistaxis with a low complication rate. (1-3) It has been shown to result in shorter inpatient stays and high patient satisfaction compared with other treatment modalities. (4) In cases in which nasal trauma has caused epistaxis, ligation of the anterior ethmoidal vessels is often the procedure of choice. Anterior ethmoidal artery ligation has traditionally been performed by an external approach, although an endoscopic option is possible. (5)
This article reviews the outcomes of ELSPA at a district general hospital over a 5-year period and specifically examines the reasons for failure. It is standard practice at our facility to consider patients for ELSPA if their epistaxis does not resolve promptly after nasal packing. Patients who continued to have persistent hemorrhage for more than 24 hours despite nasal packing, either with Merocel (Medtronic; Mystic, Conn.) or BIPP (Bismuth Iodoform Paraffin Paste; Orion Laboratories; Balcatta, Western Australia) were considered for ELSPA. Patients receiving anticoagulation therapy had their clotting corrected. Antiplatelet therapy was discontinued on admission and, if appropriate, restarted following discharge.
Patients and methods
A retrospective study was conducted of all patients undergoing ELSPA surgery for treatment of epistaxis between 2002 and 2007 at Royal Shrewsbury Hospital. Cases were identified by operating procedure codes.
All cases identified as having undergone ELSPA surgery for epistaxis following unsuccessful use of nasal packing were included in this study. There were no exclusion criteria.
Over the study period, 33 patients underwent ELSPA surgery for epistaxis. The patients' mean age was 58.4 years; 5 patients (15.2%) were male. All patients underwent surgery following significant epistaxis that had required nasal packing for a minimum of 24 hours and had not resolved despite this. All surgery was performed under general anesthesia.
Following successful ligation of the sphenopalatine artery and control of hemorrhage, no further nasal packing was placed in the operating room. Of the 33 patients, 29 (87.9%) underwent ELSPA with successful control of their epistaxis. The median postoperative stay was 2 days (range: 1 to 22 days).
Of 18 patients seen once for follow-up, only 5 complained of crusting or nasal dryness following surgery. No other complications were reported. Two patients (6%) returned after 12 months with mild, self-limiting epistaxis that required no intervention. One patient underwent contralateral ELSPA 5 years after the original procedure.
ELSPA did not control bleeding in 4 patients. Two of these patients had presented following head trauma, and their epistaxis was subsequently controlled with anterior ethmoidal artery ligation performed via an external approach. The other 2 patients in whom ELPSA failed had not experienced trauma. Both of these patients underwent external carotid artery ligation, with 1 successfully controlling the patient's epistaxis. The other patient's epistaxis was controlled by anterior ethmoidal artery ligation.
The findings of this study agree with those of previous reports, that ELSPA is a safe, effective surgical modality for the management of epistaxis. The success of ELSPA surgery is high--in this series, 87.9%. All 4 patients in whom ELSPA failed required further surgical intervention; 3 of these patients (2 of whom had experienced trauma leading to epistaxis) were successfully managed with external anterior ethmoidal ligation.
The anatomic location of the anterior ethmoidal artery makes it susceptible to injury during head trauma and therefore should always be considered early on as a source of epistaxis following head trauma. Arterial bleeding may be phasic, with periods of vasospasm followed by profuse bleeding. During ELSPA surgery, often with the benefit of hypotensive anesthesia and topical vasoconstrictors, bleeding points are not always visible; the artery is identified anatomically and ligated. Hence, the selection of the sphenopalatine artery for ligation is often empirical as hemorrhage from it may not be obvious during surgery.
The high success rate of ELSPA indicates that in the majority of cases it is the sphenopalatine artery that is responsible for epistaxis. The majority of cases in which ELSPA was unsuccessful were controlled by subsequent anterior ethmoidal artery ligation, representing 9% of all cases (75% of failures).
The challenge for clinicians is selecting which technique is appropriate for each case. Ligation of the anterior ethmoidal artery is commonly performed in patients with a history of trauma; in the absence of trauma, ligation of the sphenopalatine artery is often first considered.
The course of the anterior ethmoidal artery is variable, and cadaveric studies have confirmed that the location of the ethmoidal canal is variable, sitting attached to or below the skull base, in some cases via a thin bony mesentery. (6,7) The location of the artery may influence its vulnerability to hemorrhage. Cross-sectional computed tomography can often delineate its location and course.
It is not common practice to obtain imaging in patients prior to surgery for epistaxis. Hence, information regarding the location of the anterior ethmoidal artery from imaging is not available preoperatively.
ELSPA surgery is effective at controlling epistaxis in the majority of patients in whom nasal packing has not sufficed. In cases in which ELSPA is not successful, it is likely to be because of incorrect identification of the arterial source of bleeding, rather than failure of the technique. Anterior ethmoidal artery ligation should be considered as a primary procedure in patients whose epistaxis follows a history of head trauma.
We would like to thank Dr. Umar Wazir for his assistance with data collection for this study.
(1.) Snyderman CH, Goldman SA, Carrau RL, et al. Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis. Am J Rhinol 1999;13(2):137-40.
(2.) Wormald PJ, Wee DT, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery lot refractory posterior epistaxis. Am J Rhinol 2000;14(4):261-4.
(3.) Nouraei SA, Maani T, Hafioff D, et al. Outcome of endoscopic sphenopalatine artery occlusion for intractable epistaxis: A 10-year experience. Laryngoscope 2007; 117(8):1452-6.
(4.) Umapathy N, Quadri A, Skinner DW. Persistent epistaxis: What is the best practice? Rhinology 2005;43(4):305-8.
(5.) Woolford TJ, Jones NS. Endoscopic ligation of anterior ethmoidal artery in treatment of epistaxis. J Laryngol Otol 2000; 114(11):858-60.
(6.) Moon HJ, Kim HU, Lee JG, et al. Surgical anatomy of the anterior ethmoid canal in ethmoid roof. Laryngoscope 2001;111(5):900-4.
(7.) Becket SP. Applied anatomy of the paranasal sinuses with emphasis on endoscopic surgery. Ann Otol Rhinol Laryngol Suppl 1994; 162:3-32.
David J. Howe, FRCS ORL-HNS, SpR ENT; Derek W. Skinner, FRCS Eng(Otol)
From the Head and Neck Centre, Royal Shrewsbury Hospital, Shrewsbury, UK.
Corresponding author: Mr. David J. Howe, Head and Neck Centre, Royal Shrewsbury Hospital, Mytton Rd., Shrewsbury, SY38XQ UK. Email: email@example.com
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Howe, David J.; Skinner, Derek W.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Feb 1, 2012|
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