Operative Otolaryngology: Anterior and Posterior Ethmoid Artery Ligation for Epistaxis

History

• 1.

  History of present illness

  • a.

    Obtaining the history of presenting illness can be performed only after the patient is stable. In the unstable patient, institutional trauma protocols should be used to resuscitate the patient with appropriate fluid and/or blood.

    • Determine the source of bleeding: Is the bleeding primarily arising anteriorly or posteriorly? On which side did the bleeding begin? If patients can provide a clear history that the bleeding is primarily occurring anteriorly, one should assess the anterior septum followed by the AEA, although rare, as the possible source. If the patient states that the bleeding seemed to arise “somewhere in the back,” one should consider the source to be the SPA or its associated branches, followed by the PEA (rare). Patients often have difficulty identifying the side of the bleeding unless it is a recurrent or bleeding slowly, but if laterality can be determined, this may save time in managing the bleeding.

  • b.

    Determine the severity and quality of the bleeding: How profuse was the bleeding—torrential, sudden, and aggressive (suggestive of an arterial source) or steady/continuous but low grade (perhaps more venous)? When did the bleeding begin? Does the patient feel weak or light headed? Is the bleeding experienced every winter and/or seasonal? Is this bleeding recurrent and readily managed? (The latter three points all suggest Kiesselbach plexus as the likely source from ambient air changes in humidity, seasonal allergies, and anterior, low-grade bleeding.)

  • c.

    Patients are often anxious about events related to epistaxis, and therefore the general amount of blood lost might be requested in terms of “teaspoons,” “tissues,” “cups,” or “buckets.” The patient’s presentation and how long he or she has been bleeding will also assist the clinician to determine the severity of the bleeding. If the severity is unclear, the associated symptoms may indicate how he or she is coping with the blood loss. Any symptoms such as light headedness, “hot and clammy,” palpitations, or feeling weak should alert the clinician to hemodynamically assess and/or resuscitate the patient before completing the history.

  • d.

    Determine where there are any associated symptoms: Do you have facial numbness/hypesthesia, unilateral nasal obstruction, or diplopia? Do you have fevers, sweats, or weight loss? Any of the aforementioned symptoms may indicate a possible more serious etiology as the underlying cause of the epistaxis. One should always consider nasopharyngeal cancer in those of Southeast Asian decent and juvenile nasopharyngeal angiofibroma in adolescent males as the source of persistent unilateral epistaxis.

  • e.

    Additional questions should be asked based on clinical suspicion to help determine the etiology of the nosebleed ( Table 99.1 ).

    TABLE 99.1

    Common Etiologies of Epistaxis

    Local Causes	Systemic Causes
    Chronic rhinosinusitis Digital trauma Foreign bodies Irritants Neoplasm Septal deviation Septal perforations Trauma Vascular malformations	Congenital coagulopathies Hypertension Leukemia Liver dysfunction Medications Platelet dysfunction

• 2.

  Past medical history

  • a.

    Previous epistaxis: How often do you have episodes? Does the onset occur during a particular time of day, season, or activity? Do you know what aggravates your bleeding? How have you managed your previous episodes? Have you seen a doctor regarding epistaxis, and how was it managed?

  • b.

    Medical illness: Do you have a bleeding disorder? Do you have a history of bruising? Is there a history of liver disease, immunosuppression, or vitamin deficiency? If the underlying source of the bleeding is due to a medical source, a hematologist should be consulted to help in the management. Recurrent epistaxis despite management is another reason to consult a hematologist.

  • c.

    Surgery: Have you had sinonasal surgery or rhinoplasty?

    • Recent surgery will guide the clinician in determining the possible source of the epistaxis. If a patient has had a septoplasty or rhinoplasty, one should be cautious when cauterizing the anterior septum because this may lead to a slightly increased chance of a septal perforation.

  • d.

    Family history: History of bleeding disorder?

  • e.

    Medication:

    • 1)

      Anticoagulants (numerous families of agents)

    • 2)

      Herbal products such as omega-3 supplements, garlic, ginseng, and ginkgo biloba

    • 3)

      Alcohol—heavy intake

Physical Examination

• 1.

  Self-protection/universal precautions

  Proper protective equipment including face shield, eye shield, gown, and gloves should be worn.

• 2.

  Preparing the nose for examination

  The entire nasal cavity should be copiously irrigated with saline solution to remove clots. This can be done with a 60-mL syringe or other squeeze bottle irrigation with the patient’s head tilted over a large basin.

• 3.

  Anterior rhinoscopy and nasal endoscopy

  Anterior rhinoscopy followed by rigid nasal endoscopy with a 30-degree endoscope should be used to evaluate the entirety of the nasal cavity—anteriorly and posteriorly. Any site of anterior nasal crusting should be removed because the site of spot hemorrhage is often located underneath these “biologic dressings.” The nasopharynx should always be assessed to rule out nasopharyngeal cancer. A rigid endoscope is used preferentially over a flexible scope because it allows the ability to suction and use instruments in the nasal cavity if a bleeding site is seen. Topical decongestants mixed with lidocaine/benzocaine can be placed after the first assessment. Placing a topical decongestant prior to one’s first assessment may put the arterial source under temporary vasospasm, resulting in a negative examination.

  If the source of the epistaxis can be visualized, cautery (e.g., silver nitrate, bipolar electrocautery) can be used directly on the mucosa. If the bleeding is coming from a superior source, dressing material or any version of nasal packing placed under endoscopic visualization can help ensure that the appropriate site is tamponaded. In all cases, especially when the patient is coagulopathic with diffuse mucosal bleeding, minimizing trauma to the mucosa will help prevent further bleeding. It is advised to use absorbable packs in these individuals. If a direct source is seen in these patients and a nonabsorbable pack will not tamponade the source, cautery can be used but with caution because this may cause further bleeding. Alternatively, nasal balloon systems that atraumatically contain the active hemorrhage can be used.

• 4.

  Oral cavity

  Examination of the oropharynx will often reveal whether blood is draining posteriorly. The examination of the oral cavity should also be evaluated for telangiectasias or tumors of the hard palate, maxilla, or tonsil as the cause of the epistaxis.

• 5.

  Examination of the cranial nerves

  A complete neurologic examination should be performed to rule out malignancy extending from the sinonasal cavity.

Imaging

• None necessary

  • External approaches do not require imaging.

• Computed tomography (CT)

  • Those performing an endonasal approach should consider obtaining a CT scan to help localize the AEA. If the institution uses a navigation system, the CT scan can be registered to facial landmarks to help identify the artery intraoperatively. Using the coronal views, the “nipple” sign will help to identify the AEA ( Fig. 99.1 ). This is a triangular evagination in the superomedial orbital wall that reliably falls between the densities of the medial rectus and superior oblique muscles. The PEA also has a nipple sign, which is nearly always in the skull base and not associated with any specific muscle group.

    

• CT angiogram

• Magnetic resonance imaging (MRI)

• Angiography

Indications

• 1.

  Failed epistaxis management at bedside

  If the bleeding site can be visualized endoscopically, chemical or electrocautery can be performed. However, occasionally the exact area from which the bleeding arises cannot be seen due to anatomic obstruction (deviated septum, between the middle turbinate and septum) or the artery in question is under vasospasm after the nasal pack has been removed. In these situations the approach to arterial ligation is institution dependent. In our institution, unilateral SPA ligation before AEA ligation is favored, but others perform combined SPA and AEA ligation as primary treatment. The clinical context may also change depending on history (i.e., facial trauma resulting in high suspicion for AEA injury, or recent SPA ligation been attempted), past medical history (anesthesia risk, requiring combined SPA and AEA ligations to prevent the need for any future general anesthesia), or even social history (i.e., patient lives alone in an area remote from access to medical care).

• 2.

  Refractory epistaxis

  As noted previously, if the rare patient fails a properly performed SPA ligation, and there is convincing evidence of unilateral epistaxis, we may then proceed with an AEA ligation. The PEA is rarely a cause of epistaxis but should be considered a source of epistaxis in the exceedingly rare situation of failure of both SPA and AEA ligations.

• 3.

  Tumors

  Resection of benign and malignant tumors may require ligation of the AEA and PEA before resection of particular anterior skull base tumors. These vessels are not amenable to endovascular approaches due to continuity with the internal carotid system.

Contraindications

Not medically fit for surgery (sometimes that consideration must also be waived in the setting of life-threatening epistaxis)

Preoperative Preparation

• 1.

  Stabilize the patient with nasal and, if necessary, postnasal packing.

• 2.

  Preoperative laboratory studies to assess hemoglobin/hematocrit, international normalized ratio, partial thromboplastin time

• 3.

  Rapidly reverse anticoagulation, if necessary, and optimize medically.

• 4.

  Reduce blood pressure (although data on the efficacy of this strategy are limited).

• 5.

  Obtain consent for surgery and possible transfusion.

Anesthesia