Management of Refractory Posterior Epistaxis by Endoscopic Electrocautery or Ligation of the Sphenopalatine Artery

Lee, Hyun Sun; Roh, Hwan Jung

Abstract

BACKGROUND AND OBJECTIVES
The treatment modalities of refractory posterior epistaxis includes external carotid artery ligation, transantral ligation of the internal maxillary artery (IMA), transantral ligation of the sphenopalatine artery (SPA) and embolization of the internal maxillary artery (IMA) and its branches. More recently the endoscopic electrocautery or ligation of SPA has been proposed. Authors introduce our operative methods of endoscopic SPA cautery/ligation and analyze the results of experienced cases. SUBJECTS AND METHOD: Retrospective review was carried out of 9 patients who have undergone endoscopic electrocautery or ligation of SPA due to refractory posterior epistaxis from January 2002 to June 2004. Frequency of preoperative nasal bleeding episodes, number of performing anterior or posterior nasal packing, preexisting local and systemic factors, operative method, patterns of SPA branches, duration of preoperative and postoperative hospital stay were analyzed. The simple description of operative technique is as follows: under the general anesthesia, a large middle meatal antrostomy is created. Septoplasty and resection of the anterior or inferior portion of middle turbinate can be performed to maximize surgical assess to sphenopalatine area. A mucoperiosteal flap is raised from posterior edge of the antrostomy and dissection is made posteriorly until the sphenoplatine foramen and its emerging branches are identified. Dissection can be proceed to anterior face of the sphenoid to ensure that the posterior septal artery is identified. The SPA branches are ligated with a titanium Ligaclip(R) or nasal forcep styled bipolar electrocautery, and the mucoperiosteal flap is then redrapped. RESULTS: Endoscopic electrocautery or ligation of SPA stopped the refractory posterior bleeding successfully in all patients (male 6/female 3, mean age 41.4 years) without recurrence. The frequency of preoperaive nasal packing was 3.6 times and all cases showed posterior nasal rebleeding. The mean duration of preoperative and postoperative hospital stay were 10.1 and 2.6 days. The most frequent preexisting local and general factor were nasal septal deviation and hypertension, respectively. The pattern of SPA branches included 3 cases of type A, 4 of type B and 2 of type C. Of the 9 patients, 3 cases were managed with clipping and 6 with electrocautery of SPA branches. CONCLUSION: Endoscopic electrocautery or ligation of SPA and its branches are simple, less invasive and more effective methods that can be used to control refractory posterior epistaxis and reduce complications, the duration of hospital stay and rebleeding episodes.