Posterior epistaxis: endonasal exposure and occlusion of the branches of the sphenopalatine artery

Abstract

Intractable posterior epistaxis (PE) is a frequent emergency for which different treatment modalities are available. While nasal packing causes extreme discomfort and angiography with consecutive selective embolization is not available everywhere, recent studies emphasize the value of sphenopalatine artery (SPA) occlusion by different techniques and indicate success rates of 13-33%. In our institution, previously endoscopic management of PE consisted either of isolated coagulation of an identified bleeding source (group A) or cutting and coagulation of arterial branches running through the sphenopalatine foramen (SPF) (group B). According to our neuroradiological and rhinological experience we developed a modification of SPA transsection and coagulation following identification of the division in conchal and septal branches of the SPA (group C). During a 26-month period the success rates of these three techniques in 95 patients were compared prospectively. The three modalities revealed a re-bleeding rate of 3 out of 21 (21%) in group A, 1 in 6 (16.7%) in group B and 3 in 69 (4.3%) in group C. At the level of the SPF, 36 out of 69 patients had one conchal branch, whereas 30 (43.5%) had two and 3 (4.4%) had three. If SPA transsection and coagulation for intractable PE is adopted the anatomic varieties of the SPA with its division in conchal and septal branches have to be taken into account. According to our experience the septal branch of the SPA plays a major role in PE. Its occlusion significantly improves the success rate of PE treatment.

Endovascular Treatment of Epistaxis

“…11,13,14,16,[72][73][74] With the advent of endoscopic surgery, complication rates of surgery have decreased, with only minor complications being reported, including pain, posterior rhinorrhea, numbness of the palate and nose, nasal crusting, intranasal adhesions, and septal perforation. 11,13,14,16,73,74 Thus, success and complication rates are quite comparable between surgical ligation and embolization, except that more serious major complications are associated with embolization. 75 Again, this stresses the need to be aware of angiographic findings that represent a communication between the ECA and the ICA or the OphA.…”

“…More recently, endoscopic surgical procedures have been described for direct cauterization of the active bleeding site or ligation of the SPA. [13][14][15][16] Endovascular treatment of epistaxis was first presented as an alternative to surgery by Sokoloff et al in 1974 17 and consisted of particle embolization of the ipsilateral IMA. The technique was later refined by Lasjaunias et al, 18 stressing the need for a standardized angiographic and therapeutic approach.…”

Is severe epistaxis associated with acetylsalicylic acid intake?

“…Rapid Rhino packing was placed in 124 (21%) patients, and 27 (5%) patients required posterior packing with a Foley catheter. Thirty- five (6%) endoscopic endonasal sphenopalatine artery cauterizations as described elsewhere 8 and five (1%) concurrent external surgical ligations of the ethmoidal arteries were performed in 35 individuals.…”

“…In accordance with one of our previous studies, we attribute this finding to the considerably safe and successful surgical treatment, which has only a very short postoperative recovery period. 8 As we followed a unified treatment protocol, ASA could not influence the decision to go for surgical therapy. In general, however, it could have an impact on the choice of treatment modality.…”

“…If bleeding persisted, a surgical approach was chosen. Endonasal technique was selected for the transsection and cautery of the branches of the sphenopalatine artery, 8 whereas the ligation of ethmoidal arteries was performed through an external Lynch-type incision. 9 Neurovascular interventions were kept as a salvage treatment option.…”