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Endoscopic Sphenopalatine Artery Ligation

A 58-year-old female on Plavix presented to the ER with recurrent left-sided epistaxis after two prior endoscopic control of epistaxis at an outside hospital.  The patient’s hemoglobin and hematocrit at presentation were 8.3 gm/dL and 25.4%.  Given the unilateral presentation, antiplatelet therapy, and recently failed endoscopic control, the patient was taken to the operating room for transnasal endoscopic sphenopalatine artery ligation (TESPAL) with bipolar cautery.

Contributors:

Mathew Geltzeiler and Eric Wang

Transnasal endoscopic sphenopalatine artery ligation (TESPAL)
Posterior epistaxis, refractory epistaxis on anticoagulant or antiplatelet therapy, recurrent unilateral epistaxis
Thrombocytopenia, uncorrected coagulopathy, severe medical illness precluding general anesthesia
The patient is intubated with an oral-RAE endotracheal tube, which is secured to the contralateral side, depending upon the handedness of the surgeon. The head of bed is rotated 90 degrees from the anesthesia team to the side of surgeon handedness. The table is then placed in reverse-Trendelenberg to approximately 15 degrees HOB elevation. Topical oxymetazoline or topical epinephrine (1:1000) soaked pledgets are then placed in the nasal cavity for decongestion. Depending upon the amount of trauma in the nasal cavity and the amount of active hemorrhage, the surgeon may elect to perform transoral anterior palatine/incisive canal blocks and sphenopalatine blockade using Lidocaine 1% with epinephrine 1:100,000 via the greater palatine foramen or incisive canal to reduce bleeding and improve visualization.1 The patient is then prepped and draped in standard fashion for endoscopic sinus surgery.
Vital signs particularly heart rate and blood pressure. Laboratory work-up including CBC and coagulation panel are recommended to rule out other risk factors for bleeding, other diagnoses, and guide administration of blood products. Special tests and hematology consult may be advised pending history, physical exam, laboratory work-up, and clinical suspicion.
The nasal cavity is examined for mucosal trauma and adequate hemostasis achieved prior to proceeding with SPA ligation. The attachment of the middle turbinate to the lateral nasal wall is identified in the posterior middle meatus. A curvilinear incision is made just medial to the middle turbinate attachment to the lateral nasal wall.2,3 The subperiosteal plane is identified and elevated until the crista ethmoidalis (the ethmoidal crest of the palatine bone) is identified and adequately exposed. The sphenopalatine foramen is then identified with palpation and then enlarged. The sphenopalatine artery is then identified and isolated from the periosteum as it exits the foramen. Bipolar forceps or the suction Bovie can be utilized to cauterize the vessel. The vessel is then divided in order to insure hemostasis. The areas of mucosal trauma are then cauterized according to surgeon preference. Surgicel is used to line the mucosal incision in the posterior middle meatus.
Advantages: Definitive management of unilateral epistaxis, prevention of nasal packing and antistaphyloccocal antibiotics, shortened hospitalization, increased cost-effectiveness, avoidance of endovascular embolization, which includes a significant risk of cerebrovascular events.3-5 Disadvantages: Need for general anesthesia and the need for operating room staff, equipment, and operating room time on urgent, unscheduled notice.4,5
Major: There are no major complications other than recurrent epistaxis, which was noted in 13% of patients as originally described.2 This number may be lowered by including the anterior ethmoid artery in those patients for whom there is significant risk of anesthetic complications or in whom there is suspicion.3 Minor: Nasal crusting occurs in 34% of patients and temporary paresthesia of the palate and nose may occur in up to 13%.2
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1. Guthrie CC, Karnezis TT, Orosco RK, Bishop ML, Davidson TM. The effect of anterior palatine blocks on bleeding in hereditary hemorrhagic telangiectasia nasal surgery. Laryngoscope. 2013;123(11):2598-2600. 2. Snyderman CH, Goldman SA, Carrau RL, Ferguson BJ, Grandis JR. Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis. Am J Rhinol. 1999;13(2):137-140. 3. Rudmik L, Smith TL. Management of intractable spontaneous epistaxis. Am J Rhinol Allergy. 2012;26(1):55-60. 4. Dedhia RC, Desai SS, Smith KJ, et al. Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis. Int Forum Allergy Rhinol. 2013;3(7):563-566. 5. Leung RM, Smith TL, Rudmik L. Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis. JAMA Otolaryngol Head Neck Surg. 2015;141(5):405-409.

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