Sphenopalatine Artery Ligation for Epistaxis

History of present illness

• a.

  How did it start?

  • 1)

    Epistaxis following external nasal trauma (blunt force) is more likely to originate from the AEA.

  • 2)

    Spontaneous severe epistaxis is more likely to originate from the SPA.

• b.

  Is it severe? The volume of the bleeding should be assessed: number of cups or tissues. What is the duration? Severe bleeding is usually from a larger vessel such as the AEA or SPA.

• c.

  What is the source of the bleeding?

  • 1)

    Is the bleeding on one side or both sides? Bleeding that is bilateral may indicate multiple sites or the blood is starting on one side and then crossing to the other side in the nasopharynx. Even with brisk posterior bleeding, one side usually predominates.

  • 2)

    When the patient is sitting upright, does the bleeding primarily run from the front or the back of the nose? Anterior drainage of blood may indicate bleeding from the AEA, and drainage into the pharynx may indicate posterior bleeding from the SPA. Severe epistaxis, however, often drains anteriorly and posteriorly at the same time.

• d.

  How is it controlled? If the epistaxis is controlled with anterior compression of the nose, then the source is likely to be the small vessels of the anterior nasal septum. If bleeding continues down the back of the throat with anterior nasal compression, the AEA and SPA are likely sources.

• e.

  Associated symptoms. It is important to ask about associated symptoms such as nasal obstruction, visual changes, facial hypesthesia, pain, or trismus. Such symptoms may indicate a neoplasm, and the epistaxis may be secondary to the tumor.

Past medical history

• a.

  Age. Severe epistaxis in a young patient (<20 years) is unusual and suggests a neoplasm or hereditary bleeding disorder. In older individuals, spontaneous hemorrhage is often associated with multiple medications, particularly anticoagulants.

• b.

  Prior treatment. Previous episodes of epistaxis should be explored. Were they similar in location and severity? What is the frequency? How were they treated? Failure of prior surgery or embolization may indicate improper identification of the source or incomplete occlusion and may affect treatment choices. Failure of surgical ligation is typically due to missed terminal branches or dislodgement of hemoclips. Failure of embolization suggests bleeding from the AEA.

• c.

  Medical illness. Medical illnesses such as liver or renal failure and hematologic cancers are associated with bleeding disorders due to impaired platelet aggregation and coagulation. Overt hypothyroidism has been linked to an increased risk of bleeding. Hypertension may contribute to epistaxis, but this theory is controversial. A cross-sectional, population-based study showed no association between hypertension and epistaxis; in a prospective study of patients with hypertension who had epistaxis, the incidence of epistaxis was not related to the severity of hypertension.

• d.

  Surgery. A history of recent sinus surgery should alert the surgeon to a possible injury to the ICA, especially if there is documentation of brisk intraoperative hemorrhage that required packing for control. A sphenoidotomy is also likely to injure the posterior septal branch of the SPA, which courses over the anterior face of the sphenoid sinus.

• e.

  Family history. A family history of recurrent epistaxis may indicate a bleeding diathesis from an inheritable coagulation disorder. In particular, a family history of epistaxis in the absence of other bleeding problems may be associated with hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu syndrome.

• f.

  Medications. Many medications are associated with an increased risk of epistaxis. A thorough history is necessary to elicit this information because it is often not volunteered by patients. Categories of products with antiplatelet effects include the following:

  • 1)

    Antiplatelet drugs. These include over-the-counter nonsteroidal anti-inflammatory drugs as well as the newer long-acting antiplatelet prescription medications.

  • 2)

    Herbal products. Remember the 4 G’s: garlic, ginger, gingko biloba, and ginseng. There are many other herbs and nutritional supplements (fish oil, vitamin E) that also affect bleeding.

  • 3)

    Alcohol. Episodes of epistaxis are often associated with recent alcohol ingestion.

Nasal endoscopy

Nasal endoscopy is the most important part of the examination. It may be limited by the presence of nasal packing or active bleeding. Prior attempts at treatment (cautery and packing) may result in secondary sources of bleeding.

Examination of the nasopharynx is important to rule out cancer or other tumors such as angiofibromas. In the absence of active bleeding, a small clot may signify the site of the bleeding. A small angioma on a turbinate or lateral nasal wall can be easily overlooked. Multiple telangiectasias are indicative of HHT (see Chapter 100 ).

Oral cavity

Examination of the oral cavity may reveal other causes of epistaxis such as HHT or a neoplasm of the palate or maxilla.

Orbit

Proptosis or restriction of extraocular movements suggests a neoplasm with extension to the orbit.

Trigeminal nerve

Neoplastic involvement of the trigeminal nerve may result in decreased sensation or weakness of the muscles of mastication (decreased contraction, jaw drift with forceful opening).

Neck

Cervical metastases are a late presentation of sinonasal malignancy.

None

Most patients with severe epistaxis do not require any imaging prior to surgical intervention.

Computed tomography

A computed tomography (CT) scan with contrast should be considered in patients with concerning symptoms or physical findings suggestive of a neoplasm.

Computed tomography angiogram

If there is a history of recent sinus surgery, a CT angiogram rules out a possible injury to the ICA with formation of a pseudoaneurysm.

Angiography is reserved for patients undergoing embolization or who have failed prior surgical therapy. Angiography is essential if there is concern for ICA injury following trauma or surgery.

Severe epistaxis from the posterior nasal cavity

The primary indication for endoscopic ligation of the SPA is severe unilateral epistaxis that appears to be posterior or without an obvious source. It is often difficult to differentiate bleeding from the AEA and SPA in the absence of active bleeding, and both vessels may need to be addressed at the time of surgery. Rarely, an inability to localize the bleeding to one side of the nasal cavity requires bilateral SPA ligation.

Recurrent acute epistaxis from the posterior nasal cavity

Some patients give a history of multiple episodes of significant unilateral epistaxis controlled with nasal packing and without treatable risk factors. In such cases, elective SPA ligation may be considered.

Vascular tumor

As an alternative to embolization, SPA ligation may be used to devascularize a tumor prior to surgical excision. Most commonly, this is performed for early-stage angiofibromas but may be considered for sinonasal malignancies as well. Rarely, SPA ligation may be performed emergently for the treatment of a bleeding neoplasm prior to radiation therapy. This may be performed at the same time as a biopsy or palliative debulking of the tumor to relieve obstructive symptoms.

Transpterygoid surgical approach

A transpterygoid approach is a common starting point for many endoscopic approaches to the skull base. Ligation of the SPA allows displacement of the contents of the pterygopalatine space to gain access to the base of the pterygoid and lateral recess of the sphenoid sinus.

Correctable coagulopathy

In a patient with a correctable coagulopathy, nonoperative treatment is preferable.

Medical comorbidities with increased risk for general anesthesia

If a patient is a poor medical risk for general anesthesia, alternative therapies for epistaxis should be considered (nasal packing or embolization).

Large vascular tumor with variable vascular supply

A large vascular tumor may block access to the SPA and have multiple sources of vascular supply from branches of the external carotid artery and ICA. In such cases, angiography with embolization is preferred.

Discontinue antiplatelet drugs if possible. SPA ligation can be safely performed in patients who are anticoagulated or on antiplatelet drugs in an emergency situation. In an elective situation, these drugs and supplements should be discontinued prior to surgery.

Control acute bleeding with nasal packing. Bleeding from the SPA can be temporarily managed with anterior and posterior packing with an Epistat balloon or a Foley catheter and sponge/gauze packing.

Control the airway. If active bleeding persists, emergent intubation may be necessary to secure a safe airway.

Monitor hemoglobin/hematocrit, coagulation parameters, and transfuse if necessary.

Base-level hemoglobin and hematocrit are necessary, and type and cross for blood transfusion may be necessary based upon the results.