Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis

Management of uncontrolled/recurrent epistaxis by ligation or cauterization of the sphenopalatine artery: a scoping review

PURPOSE

The control of epistaxis has always posed a significant challenge for otolaryngologists. One of the most viable options to address refractory cases is the ligation or cauterization of the sphenopalatine artery. The objective of this study was to assess the efficacy, safety, and long-term outcomes of these interventions.

MATERIALS AND METHODS

Two independent otolaryngologists conducted a comprehensive search for studies dealing with management of uncontrolled/recurrent epistaxis by consulting the main scientific databases on the web, including PubMed, Google Scholar, Medline, EMBASE, Web of Science, and the Cochrane Library. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The criteria for considering studies for the review were based on the population, intervention, comparison, outcome, timing and setting (PICOTS) framework.

RESULTS

Sixteen studies were included in the systematic review, comprising a total of 454 patients. Among these, 289 individuals underwent ligation of the sphenopalatine artery, while 100 underwent cauterization of the same artery. Additionally, 56 patients underwent both ligation and cauterization of the sphenopalatine artery during the same surgery. The incidence of rebleeding and complications was respectively 12.1% (55/454) and 3% (14/454), resulting in relatively low rates in both cases.

CONCLUSIONS

Our review emphasizes the increasing importance of surgical approaches, specifically ligation or cauterization of the sphenopalatine artery, in addressing refractory cases. The low incidence of complications, predominantly temporary decreased lacrimation in patients undergoing ligation of the sphenopalatine artery, highlights the safety and feasibility of these interventions.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications

Today, there are still no uniform guidelines for the treatment of epistaxis. Furthermore, it is widely debated whether embolization or surgical approaches should be the first choice of treatment for intractable posterior epistaxis after conservative measures have failed. In several meta-analyses, it is reported that endoscopic sphenopalatine artery ligation and embolization have similar success rates, but embolization was associated with more severe neurological complications. Regarding existing literature, there are many comparative analyses of surgical methods but none for embolization protocols. Against this backdrop of a lack of uniform standards in embolization techniques, we present a retrospective evaluation of what has emerged to be best procedural practice for endovascular treatment of epistaxis in our department using microsphere particles and microcoils, in particular regarding precaution measures to avoid neurological complications. In our retrospective data analysis of 141 procedures in 123 patients, performed between 2008 and 2019, we find success rates very similar to those reported in other studies (95.1% immediate-stop-of-bleeding success and 90.2% overall embolization success) but did not encounter any major neurological complication opposed to other reports. We suggest some aspects of our protocol as precaution measure to avoid neurological complications. More generally and perhaps even more importantly, we make a strong case for standardization for embolization techniques to the level of details in surgical procedure standardization to enable an apples to apples comparison of embolization techniques to each other and of intervention vs. surgery.

Usefulness of computed tomography in predicting ethmoidal arterial bleeding in refractory epistaxis

PURPOSE

Epistaxis that is refractory to conservative management can be treated with endoscopic sphenopalatine artery ligation (ESPAL). Although rare, ethmoidal artery (EA) bleeding can be a cause of rebleeding after successful ESPAL. EA bleeding is diagnosed by angiography and can also be identified during surgical exploration. However, since the angiographic embolization of the EA is contraindicated, surgical hemostasis is mandatory. This study investigated whether paranasal sinus (PNS) CT could provide information for predicting EA bleeding without angiography in patients with refractory epistaxis requiring ESPAL.

METHODS

Forty-seven patients, who were surgically treated [with ESPAL or EA ligation (EAL)] for refractory epistaxis from March 2010 to June 2019, were retrospectively analyzed. A positive PNS CT finding for EA bleeding was defined as the presence of soft tissue densities having continuity with the EA pathway, accompanied by a partially deficient surrounding bony canal. These findings as well as soft tissue densities in each paranasal sinus were compared between the ESPAL and EAL groups.

RESULTS

All patients in the EAL group had positive CT findings of EA bleeding, compared to only 12.2% in the ESPAL group (P < 0.001). The rate of soft tissue densities within the frontal and sphenoid sinuses were noted in 26.8% and 17.1% of patients in the ESPAL group, compared to 83.3% and 83.3% of patients in the EAL group (P = 0.013 and P = 0.003, respectively).

CONCLUSION

PNS CT might be useful for predicting EA bleeding in patients with refractory epistaxis requiring surgical hemostasis.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study

Introduction  The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective  To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods  Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results  The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion  This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta-analysis

OBJECTIVES

Epistaxis, especially posterior epistaxis, is occasionally refractory to treatment. In these cases, sphenopalatine artery surgeries, including cauterization and ligation, are required. Previous reports have demonstrated treatment results for these procedures but failed to provide high-level evidence. The aim of this study was to quantify the rates of failure and perioperative complications of these procedures by using a meta-analysis technique.

METHODS

We systematically searched electronic databases and identified articles regarding epistaxis, sphenopalatine artery ligation, or cauterization. Pooled rebleeding and complication rates were calculated by using a random effects model.

RESULTS

A total of 896 cases of sphenopalatine ligation or cauterization for epistaxis were analyzed. Pooled rebleeding rates for the entire cohort, cauterization group, and ligation group were 13.4% (95% confidence interval [CI] 10.0-17.8, P < 0.001), 7.2% (95% CI 4.6-11.0, P < 0.001), and 15.1% (95% CI 9.8-22.5, P < 0.001), respectively. Pooled perioperative complication rates for the entire cohort, cauterization group, and ligation group were 8.7% (95% CI 4.9-15.1, P < 0.001), 10.2% (95% CI 3.8-24.5, P < 0.001), and 6.4% (95% CI 1.8-20.9, P < 0.001), respectively.

CONCLUSION

Overall, sphenopalatine surgery for refractory epistaxis is an effective method because of its low rates of failure and complications. Cauterization is more effective than ligation, whereas complications are comparable between the two procedures. Laryngoscope, 129:1731-1736, 2019.

Surgical and interventional radiological management of adult epistaxis: systematic review

BACKGROUND

There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery.

METHOD

A systematic review of the literature was performed using a standardised published methodology and custom database search strategy.

RESULTS

Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73-100 per cent and 75-92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1-1.5 per cent). No articles directly compared the two techniques.

CONCLUSION

Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

Intractable epistaxis: which arteries are responsible? An angiographic study

PURPOSE

Epistaxis constitutes a significant proportion of the Otolaryngologist's emergency workload. Optimal management differs in relation to the anatomic origin of the bleeding. The outcome of our study was to determine which artery(ies) could be considered as the cause of severe bleeding in the context of severe epistaxis.

METHODS

Fifty-five procedures of embolization preceded by angiography were reviewed. Medical records of interventionally treated patients were analysed for demographics, medical history, risk factors and clinical data. Angiographic findings were also assessed for active contrast extravasation (blush), vascular abnormality and embolised artery.

RESULTS

Previous angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoïdal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors.

CONCLUSIONS

A better understanding of the potential bleeding source might help and limit the risk of treatment failures. Our study confirms that the SPA is the most common cause of severe bleeding. We also emphasise the role of the AEA not only in traumatic context. Others arteries are rarely involved except in patients with comorbidities or frequent recurrences.

Ptosis and vertical diplopia after ligation of ethmoidal arteries

The treatment of epistaxis is well codified, ligation of the ethmoidal arteries being the last resort. We report the case of a 25-year-old pregnant patient, who has had a ligation of the anterior and posterior ethmoidal arteries after a persistent epistaxis. Postoperatively, she presented a complete ptosis and an impaired eye elevation without any visual acuity disorders, evoking a lesion of the upper branch of the common oculomotor nerve (third cranial nerve). The patient totally recovered after 3 months. Anatomical study shows that the upper branch of the third cranial nerve is lying very close to the optic nerve and cannot be affected by surgery without any associated damage of the optic nerve. Thus, a vascular etiology seems to be the best explanation of the complication experienced by our patient. Ligation of the posterior ethmoidal artery should be done with caution.

Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

BACKGROUND

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

OBJECTIVES

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Endoscopic Sphenopalatine Artery Ligation in Posterior Epistaxis: Retrospective Analysis of 30 Patients

Objective

Although posterior epistaxis is rarely seen, it is an important medical problem that both decreases the quality of life of the patient and causes difficulties in the management for otorhinolaryngologists. In this study, we aimed to present the results of 30 patients who underwent transnasal endoscopic sphenopalatine artery ligation (TESPAL) for posterior epistaxis in our department.

Methods

The records of 30 patients who underwent TESPAL from January 2014 to April 2016 were analyzed retrospectively, and the relationship between perioperative factors and need for revision surgery was assessed.

Results

The success rate of TESPAL in posterior epistaxis was 90%. There was no relationship between surgical failure and antiaggregant use (p=0.224), anticoagulant use (p=0.534), hypertension (p=0.564), previous nasal surgery (p=0.279), and bilateral TESPAL application (p=0.279). TESPAL was seen to be effective in cases with Osler-Weber-Rendu disease, pregnancy, and uncontrollable epistaxis after rhinoplasty surgery. Mortality was seen in one of our patients not related to endoscopic ligation in the follow-up period.

Conclusion

TESPAL is an effective method in the treatment of posterior epistaxis. Hypertension, antiaggregant or anticoagulant use, bilateral sphenopalatine artery ligation, and previous nasal surgery do not seem to be factors leading to surgical failure.

Sphenopalatine Artery Ligation for Epistaxis: Factors Influencing Outcome and Impact of Timing of Surgery

OBJECTIVE

Sphenopalatine artery ligation is a commonly employed surgical intervention for control of posterior epistaxis unresponsive to nasal packing. The objective of the present study was to evaluate the outcome of sphenopalatine artery ligation for control of epistaxis at our institution and the impact of timing and other factors on outcome.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary referral center.

SUBJECTS AND METHODS

Case notes were reviewed for 45 consecutive patients undergoing sphenopalatine artery ligation for control of epistaxis between October 2008 and October 2014.

RESULTS

Forty-one patients had nasal packing prior to sphenopalatine artery ligation, with 33 undergoing ≥2 packings. Postoperatively, 6 patients had rebleeding, which was treated with repacking (n = 4) and return to the operating room (n = 2). The overall success rate of sphenopalatine artery ligation was 87% (39 of 45). Rebleeding rate was not affected by concomitant septoplasty, anterior ethmoidal artery ligation, or postoperative nasal packing. Patients undergoing SPA ligation within the first 24 hours of admission had a significantly shorter hospital length of stay (3 vs 6 days, P = .02) and treatment cost (€5905 vs €10,001, P = .03). Length of stay was not influenced by sphenopalatine artery ligation after ≤1 nasal pack versus ≥2 packs. Timing of sphenopalatine artery ligation did not affect blood transfusion requirement (P = .84).

CONCLUSION

Sphenopalatine artery ligation is an effective management strategy for surgical control of refractory epistaxis. Early timing of sphenopalatine artery ligation may lead to reductions in length of stay.

Computed Tomographic Exploration of the Middle Ethmoidal Artery

Objectives The integral involvement of sinus and skull base surgeries in the field of otolaryngology makes the endonasal vasculature including the ethmoidal arteries important to consider. The anterior ethmoidal artery (AEA) and posterior ethmoidal artery (PEA) are well-known entities, yet the relatively recent notion of accessory or middle ethmoidal vessels complicates our understanding of this arterial system. Study Design Radiographic study. Methods Fifty computed tomographic angiographies were studied for the presence of accessory/middle ethmoidal arteries (MEAs). If contrasted arteries were not visualized reliably, foramina were accepted as evidence of arteries. The accessory arteries/foramina were then compared with the locations of the AEA and PEA. Results A total of 19 of the 50 patient samples studied had evidence of a right, left, or bilateral middle ethmoidal vessels (38%). Overall, 26 arteries total were identified out of the 100 sides (26%). Unilateral middle arteries were more common than bilateral, and right sided were more common than left. There was no evidence of multiple MEAs on a given side. Conclusion The endonasal surgeon must be cognizant of the possible presence of MEAs. These arteries should be considered when working in the medial orbit and anterior skull base region.

Three-dimensional evaluation of the danger zone of ethmoidal foramens on the frontoethmoidal suture line on the medial orbital wall

INTRODUCTION

It is clear that the importance of the ethmoidal foramen (EF) is based on its vascular contents. The frontoethmoidal suture (FS) line is recommended as more reliable navigational landmark for identifying the EF.

MATERIALS AND METHODS

The vertical orientation between the EF and the FS line was studied in 188 orbits using a computer software program.

RESULTS

146 anterior EFs (77.7 %) and 42 anterior EFs (22.3 %) were situated in the FS line as intrasutural and extrasutural, respectively. 146 posterior EFs (77.25 %) and 8 posterior EFs (4.25 %) were presented as intrasutural and extrasutural, respectively. Although accessory EFs were detected in 25.5 % specimen exhibited an extrasutural location. Majority of the EFs (1-4 EFs) were situated on the FS line. The mean distances from the FS and the anterior EF, the posterior EF and the accessory EF were measured as 2.1 ± 0.5, 2.0 ± 1.5 and 2.3 ± 1.2 mm, respectively. The range of the distances from the FS to the anterior EF, posterior EF and accessory EF were -1.2 to 3.32 , -1.02 to 5.76 and -1.1 to 3.65 mm, respectively.

CONCLUSION

The ranges of EF changed within 1-6 mm. As the FS is not a single point, it is more suitable to make the incision 7 mm above the suture line. The data from this study to help the orbital surgeons explain and avoid unexpected hemorrhage during the orbital procedures such as posttraumatic orbital reconstruction, orbital tumor resections, anterior skull base reconstruction, and orbital decompression surgery.

Transcatheter embolization in the management of epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

Endoscopic localization of the sphenopalatine foramen: do measurements matter?

The objective of this study was to evaluate different methods and measurements for localization of the sphenopalatine foramen (SPF) during endoscopic transnasal exposure. The study design consisted of descriptive anatomical study and the setting was in Microsurgical Cadaver Dissection Lab. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the SPF. Multiple measurements were obtained from nasal sill (NS) to SPF, ethmoid crest (EC), and other related landmarks. The results showed that EC was identified in all sides with different degrees of projection. SPF extended below the inferior edge of EC, i.e., lying both in the superior and middle meatus, in 12 sides (75 %), while it was laying only in the superior meatus in 4 sides (25 %). An accessory foramen was identified in 3 sides (18.7 %), all of which were located in middle meatus. The distance from NS to SPF ranged widely from 55 to 76 mm (mean ± SD 64.4 ± 6 mm). The average angle of elevation formed between SPF to NS and nasal floor was 11.4° (range 11-12°). Although many previous studies have reported measurements to SPF, we do not believe these measurements are of practical help due to the wide range of measurements and the lack of standard reference points. The main constant landmark for SPF remains the EC. Since SPF frequently extends below EC, the mucoperiosteal flap should be extended below the inferior edge of this crest to avoid missing the middle meatal part of SPF or any accessory foramina.

Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis

BACKGROUND

The advent of endoscopic sphenopalatine artery ligation (ESPAL) for the control of posterior epistaxis provides an effective, low-morbidity treatment option. In the current practice algorithm, ESPAL is pursued after failure of posterior packing. Given the morbidity and limited effectiveness of posterior packing, we sought to determine the cost-effectiveness of first-line ESPAL compared to the current practice model.

METHODS

A standard decision analysis model was constructed comparing first-line ESPAL and current practice algorithms. A literature search was performed to determine event probabilities and published Medicare data largely provided cost parameters. The primary outcomes were cost of treatment and resolution of epistaxis. One-way sensitivity analysis was performed for key parameters.

RESULTS

Costs for the first-line ESPAL arm and the current practice arm were $6450 and $8246, respectively. One-way sensitivity analyses were performed for key variables including duration of packing. The baseline difference of $1796 in favor of the first-line ESPAL arm was increased to $6263 when the duration of nasal packing was increased from 3 to 5 days. Current practice was favored (cost savings of $437 per patient) if posterior packing duration was decreased from 3 to 2 days.

CONCLUSION

This study demonstrates that ESPAL is cost-saving as first-line therapy for posterior epistaxis. Given the improved effectiveness and patient comfort of ESPAL compared to posterior packing, ESPAL should be offered as an initial treatment option for medically stable patients with posterior epistaxis.

The Wexham Criteria: defining severe epistaxis to select patients requiring sphenopalatine artery ligation

This study aims to provide guidance regarding patient selection and timing of intervention with sphenopalatine artery (SPA) ligation by defining 'severe epistaxis'. An analysis of all patients undergoing SPA ligation (January 2002-2010) was performed. SPA ligation was deemed necessary if at least one of the four identified criteria was fulfilled. The same analysis was also performed on all patients admitted with epistaxis who did not undergo SPA ligation over a 6-month period. All 27 patients who underwent SPA ligation met at least one of the criteria selected. Uncontrolled epistaxis (21/27) was fulfilled most often. In comparison, only 4/71 patients admitted with epistaxis who did not undergo SPA ligation fulfilled any single criterion. All criteria were satisfied in a significantly higher number of cases in the SPA group (p < 0.001) The criteria studied proved helpful in identifying patients admitted to hospital with epistaxis who had failed conservative measures.

Endoscopic transnasal cauterization of the anterior ethmoidal artery

CONCLUSIONS

In our experience, the technique described can be applied independently according to the specific patient's anatomy and disease, allowing simple, easy, and safe identification of the anterior ethmoidal artery (AEA).

OBJECTIVES

The aim of this study was to provide the anatomic rationale for endoscopic cauterization of the AEA and to present our surgical approach to AEA in the treatment of severe nasal bleeding.

METHODS

A retrospective study reviewed 300 endoscopic transnasal AEA cauterizations, over a 20-year period from 1991 to July 2010, at the Instituto Felippu, Sao Paolo, Brazil. All surgeries were carried out under general anesthesia and with the help of a rigid 30° endoscope.

RESULTS

The AEA was identified in all the patients treated. In 299 patients we found the AEA located at the level of the horizontal portion of the frontal bone into the anterior ethmoidal canal; in 88 (29.4%) of these patients the canal bone was partially open and in 211 (70.6%) it was completely closed. In only one patient, we found a dehiscent AEA. No patients presented short-term failure and/or long-term failure.

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

OBJECTIVES

The aim of this study was to evaluate the efficacy of endoscopic ligation of the sphenopalatine artery in the treatment of severe posterior epistaxis.

METHODS

We 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.

RESULTS

Only 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.

CONCLUSIONS

We believe that endoscopic ligation of the sphenopalatine artery is a safe technique, with fewer complications than other methods such as posterior packing or embolisation.

Middle turbinectomy for exposure in endoscopic endonasal transsphenoidal surgery: when is it necessary?

OBJECTIVES

To evaluate the benefits of middle turbinectomy on the exposure of the skull base structures.

DESIGN

An anatomical study on 20 fresh cadaver heads.

METHODS

The extent of the exposure of the skull base structures during endoscopic endonasal approach has not been addressed specifically in respect to the whether or not the middle turbinectomy is performed. We compared the extent of exposure obtained by endonasal transsphenoidal approaches without middle turbinectomy (NMT), with unilateral turbinectomy (UMT), and with bilateral turbinectomy (BMT). Our preselected target points in the skull base consisted of sella turcica, tuberculum sella, planum sphenoidale, clivus (upper and middle third), and ipsilateral sphenopalatine artery (SPA).

RESULTS

Of our preselected anatomic target points, only the middle third of the clivus and ipsilateral SPA had enhanced exposure in UMT (100% for both structures) compared to NMT (45% and 20%, respectively). The addition of a BMT did not provide added exposure to any target compared with a UMT.

CONCLUSIONS

Middle turbinectomy may not be necessary for endonasal transsphenoidal approach to the lesions of the sella, planum sphenoidale, and upper third of the clivus. However, gaining access to the middle clival region is facilitated by resection of middle turbinate.

Sphenopalatine artery ligation under local anesthesia: A report of two cases and review of the literature

Epistaxis is the commonest emergency in otorhinolaryngology. Over the last decade endoscopic sphenopalatine artery (SPA) ligation has become a popular treatment option for posterior epistaxis and has been shown to be the most effective and cost-efficient definitive treatment for posterior epistaxis. SPA ligation is usually performed under general anesthesia. The majority of epistaxis patients are elderly, frail and have multiple medical conditions. These patients are therefore not always amenable to general anesthesia. In this article we describe two cases where posterior epistaxis was successfully treated with sphenopalatine artery ligation under local anesthesia and should be considered suitable for patients with severe posterior epistaxis who are not fit for a general anesthetic.