Efficacy of Trans-nasal Endoscopic Sphenopalatine Artery Ligation in the Management of Recurrent Posterior Epistaxis

Background: Recurrent posterior epistaxis is a challenging problem for most otolaryngologists. Of the several proposed treatment modalities, endoscopic ligation of SPA (Sphenopalatine artery) provides a simple and effective solution with relatively minor complications. Objectives: Aim of this study was to find out the success rate and complications of endoscopic ligation of SPA in the management of recurrent posterior epistaxis. Materials and Methods: This was an observational study conducted from Jan 2019 to Jan 2021. Total 60 patients were included in this study. Inclusion criteria were - recurrent epistaxis (at least 4 episodes in last 2 months) with bleeding point not seen in anterior rhinoscopy, Failure of previous conservative management with medications and nasal packing, age between 18–60 years of both sexes. All the patients underwent trans-nasal endoscopic Sphenopalatine artery ligation, and patients were followed up for 12 weeks to identify repeated bleeding and to evaluate complications. Results: In this study male to female ratio was 1.5:1. Mean age of study group was 44.66 (±8.62) years. No recurrent bleeding occurred in 51 (85%) and in 9 (15%) nasal bleeding occurred in the 2 months postoperative period. Anesthesia of incisor teeth occurred in 18 patients (30%), 22 patients (37%) complained about increased nasal crusting. Conclusion: Endoscopic ligation of Sphenopalatine artery shows good outcome in prevention of further episodes of epistaxis in most patients. Although some minor complications can occur, these are manageable. KYAMC Journal. 2021;12(3): 133-137

Surgical field visualization in patients with polyposis rhinosinusitis

Introduction. Patients with nasal polyposis are predisposed to diffuse intraoperative bleeding, that could highly impair surgical field visualization. The absence of a universal technique of improving surgical field visualization became a reason for searching the specific hemostatic methods.Objective: to evaluate the efficiency of sphenopalatine artery and/or its branches coagulation as a method of hemostasis in endoscopic surgery for nasal polyposis and to describe the surgical anatomy of sphenopalatine artery.Materials and methods. Endoscopic coagulation of sphenopalatine artery and/or its branches was performed among 30 patients with nasal polyposis. Surgical field visualization was graded by Boezaart and Wormald scales before and after coagulation.Results and discussion. Intraoperative attempts to achieve the hemostasis using warm (490С) saline irrigation and then application of xylometazoline (0.1%-10ml) and lidocaine (10%-4ml) were ineffective among 28 patients with initial grade 8 and among 2 patients with grade 9 according to Wormald scale. Sphenopalatine artery and/or its branches coagulation was effectively performed in these patients, obtaining the hemostasis in 100% of cases (р < 0,001). The initial surgical field grade improved to grade 5 by Wormald scale in 9 patients (30%), to grade 6 in 17 patients (56,7%) and to grade 7 in 4 patients (13,3%). Only one artery (trunk of sphenopalatine artery) was observed in 18 patients (60%), crossing the sphenopalatine foramen, and 2 arteries (posterior septal artery and posterior lateral nasal artery) – in 12 patients (40%). Endoscopic examination revealed no signs of mucosal atrophy in postoperative period.Conclusion: The appropriate choice of hemostatic technique depends on grades of surgical field visualization. If there is a grade 8–9 by Wormald scale, endoscopic coagulation of sphenopalatine artery and/or its branches is an effective and safe method to improve surgical field visualization.

Intraoperative variations of the sphenopalatine artery between epistaxis and non-epistaxis cases: a comparative endoscopic analysis

Background Severe epistaxis is one of the most common emergencies in rhinology practices. The commonly used endoscopic cauterization of the sphenopalatine artery (SPA), alone or with the anterior ethmoidal artery (AEA), has a high success rate for controlling severe epistaxis. The current study was conducted to evaluate the endoscopic intra-operative variations of SPA between epistaxis and non-epistaxis cases. Forty consecutive patients who underwent exploration of SPA were included in the study. They were distributed into two groups depending upon the indication of SPA exploration; the epistaxis group (group A, n=25 patients, n=26 sides) and the non-epistaxis group (group B, n=15 patients, n=25 sides). Criteria of the main SPA in the two groups were compared regarding four parameters; arterial diameter, arterial adherence to the mucosa of the lower part of the basal lamella, sphenopalatine nerve bundle, and crista ethmoidalis erosion. Results A significant difference was found regarding the diameter of SPA between the two groups; a mean diameter of 4.2±0.64 mm was compared to 3.2±0.35 mm for group A and B, respectively (p=0.043). Moreover, a highly significant tendency was observed regarding the arterial adherence to the mucosa of the lower part of the basal lamella and sphenopalatine nerve bundle in the epistaxis group; (p≤0.01). Conclusion These data clearly signify the importance of intraoperative identification of SPA criteria during surgical management of severe epistaxis. These criteria may help in altering the surgical decision between solely SPA and concomitant SPA/AEA cauterization.

Outcome of treatment for severe epistaxis: nasal packing and endoscopic sphenopalatine artery ligation

Background: Severe epistaxis is a frequent emergency condition encountered by otolaryngologists and is often treated with nasal packing. In the event of failure surgical treatment is considered. We aimed to evaluate the efficacy of Nasal Packing (NP) and Endoscopic Sphenopalatine Artery Ligation (ESPAL) as treatment of severe epistaxis in terms of failures and recurrences including risk factors. Methodology: Retrospective descriptive study of patients with epistaxis treated with NP, admitted to an ENT department from 2011-2017. If initial treatment with NP failed, patients were considered for ESPAL. Results: An analysis of 511 patients was performed. All patients were treated with NP at the time of admission, and 14% of pa- tients were treated with ESPAL due to failure of NP. The majority of patients was only admitted once. Twelve percent were readmit- ted within 30 days, 7% were readmitted >30 days later. Treatment failure after ESPAL was 7.9%. No significant difference in the risk of readmission was found between patients treated with NP alone and patients treated with ESPAL. Conclusion: The majority of epistaxis patients were effectively treated with NP alone. We found good effect of ESPAL although no significant differences in risk of readmission NP vs. ESPAL were identified.