Download Direct cauterization of the nasal septal artery for epistaxis

The Laryngoscope
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How I Do It
Direct Cauterization of the Nasal Septal Artery for Epistaxis
Sarah E. Cooper, MD; Vijay R. Ramakrishnan, MD
Emergency management of epistaxis may include the use of local pressure and vasoconstrictors, chemical or
electric cautery, hemostatic agents, nasal packing, embolization, and surgical arterial ligation. There is no definitive
protocol for the management of epistaxis, although various protocols have been proposed in the literature. As
approaches to surgical ligation of the arterial supply of the nasal cavity have evolved from external carotid ligation
to minimally invasive approaches, surgical management of epistaxis has become more effective than embolization
and may be less risky. In the surgical management of epistaxis, arterial ligation immediately proximal to the bleeding site is preferred. We propose a simple variation of the endoscopic sphenopalatine artery ligation that may be
used to manage epistaxis arising from the nasal septum and floor.
Key Words: Epistaxis, sphenopalatine artery, nasal septal artery, posterior nasal artery, posterior septal
artery.
Laryngoscope, 122:738–740, 2012
INTRODUCTION
Approximately 60% of the population will be affected
by epistaxis at some point in time, with 6% requiring
professional medical attention.1 The etiology of epistaxis
is typically idiopathic, but it may also result from neoplasm, trauma, medication use, or iatrogenic causes.
Emergency management of epistaxis may include the use
of local pressure and vasoconstrictors, chemical or electric cautery, hemostatic agents, nasal packing,
embolization, and surgical arterial ligation. There is no
definitive protocol for the management of epistaxis,
although various protocols have been proposed in the literature.2 Most would agree that in a more controlled
setting, it is preferable to attempt to identify the site of
bleeding and apply a focused treatment to that area.
As approaches to surgical ligation of the arterial
supply of the nasal cavity have undergone evolution
from external carotid ligation to minimally invasive
approaches, surgical management of epistaxis has
become more cost effective than embolization and may
be less risky.2–4 We propose a simple variation of the endoscopic sphenopalatine artery (SPA) ligation that may
From the Department of Otolaryngology, University of Colorado,
Aurora, Colorado, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
January 5, 2012.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Vijay R. Ramakrishnan, MD, Department
of Otolaryngology, University of Colorado, 12631 E. 17th Ave., B205,
Aurora, CO 80045. E-mail: [email protected]
DOI: 10.1002/lary.23225
Laryngoscope 122: April 2012
738
be used to manage epistaxis arising from the nasal septum and floor.
ANATOMY
Approximately 5% to 10% of epistaxis is estimated
to arise from the posterior nasal cavity, an area supplied
by the sphenopalatine artery. Thornton and colleagues
examined 36 patients with posterior epistaxis in whom a
bleeding source could be identified, and found that 29/36
originated from the lateral nasal wall and 7/36 from the
nasal septum.5 As the terminal branch of the internal
maxillary artery, the SPA exits the pterygopalatine fossa
through the sphenopalatine foramen (SPF). The location
of the SPF is traditionally described as above and behind
the posterior aspect of middle turbinate within the superior meatus. Wareing et al. proposed a classification
system in which class I was described as opening solely
into the superior meatus (35%), class II as spanning the
ethmoidal crest with opening of the SPF into both the
superior and middle meati (56%), and class III as two
separate openings into both the superior and middle
meati.6 There is variety in both the number of branches
and site of branching, either proximal or distal to the
SPF. Simmen et al. showed that >97% of SPAs had more
than one branch and 64% had three or more branches
prior to entering the nasal cavity.7
Despite its wide anatomic variability, two branches
are consistently identified: the nasal septal branch and
the posterior lateral nasal artery.8,9 The Hadad-Bassagasteguy nasoseptal flap has become widely used in
endoscopic skull base reconstruction, and relies on the
Cooper and Ramakrishnan: Cauterization of the Nasal Septal Artery
Fig. 1. Endoscopic view (0 telescope) of the right nasal septal artery. The superior turbinate (ST) is gently lateralized, and the artery
(*) can be seen in the submucosal plane superior to the choanal
arch, coursing medially toward the nasal septum (NS). [Color figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]
consistent presence and location of the nasal septal
branch as it courses distally across the anterior face of
the sphenoid.10 Based on growing experience with this
reconstructive technique, we have found the nasal septal
artery to be a simple reliably located target for surgical
management of epistaxis arising from its vascular territory. The artery can be found coursing along the anteroinferior wall of the sphenoid sinus just above the choanal
arch, and supplies large portions of the nasal septum
and floor.8 The nasal septal artery and surrounding vascular plexus are consistently seen in a submucosal plane
in this location, which occurs just proximal to the point
at which two to three variable branches are given off to
the septum and nasal floor.11 Given that SPA branching
occurs within or near the SPF, the lateral nasal wall and
turbinates will have a distinct blood supply (posterior lateral nasal artery) and would not be affected by ligation
of the nasal septal branch.
months follow-up, the patient described sustained subjective improvements in epistaxis frequency and severity.
Under local or general anesthesia, the nasal cavity
is prepared with cottonoids soaked in 0.05% oxymetazoline or 4% cocaine. Under endoscopic visualization, the
affected area of the nasal septum or floor is injected
with 1% lidocaine with 1:100,000 epinephrine, as is the
choanal arch just below the visualized posterior nasal
artery (Fig. 1). A spinal needle can facilitate this injection. Bipolar diathermy using bayonet forceps may be
used to cauterize the affected area of the septum or floor
and ligate the artery. The artery and its surrounding
vascular plexus are identified, and the area between the
superior turbinate and septum just above the choanal
arch is generously cauterized (Fig. 2). Cautery can be
used to expose and thoroughly coagulate the course of
the vessel if there is a concern for recanalization with
simple diathermy. Topical hemostatic dressings may be
applied according to surgeon preference. The procedure
requires no more than a few minutes in total and little
bleeding is encountered.
DISCUSSION
A variety of techniques have been used for control
of epistaxis unresponsive to local application of pressure,
topical vasoconstrictors, or cautery. Anterior or posterior
packing is most often used. However, failure rates up to
52%, as well as patient discomfort, synechia formation,
periorbital cellulitis, sinusitis, toxic shock syndrome, and
hypoxia may be associated with this practice.12 A study
by Vis and Van den Berge found that up to 98% of
patients could be treated successfully by cauterization
without the need for packing, even in serious posterior
epistaxis.13 Angiographic embolization has a success
CASE ILLUSTRATION AND
SURGICAL TECHNIQUE
A 67-year-old male with a history of recurrent
right-sided epistaxis was evaluated for procedural intervention after having undergone several nasal packing
procedures performed in urgent care settings. His medical history was notable for cardiovascular disease
requiring daily antiplatelet therapy. Endoscopic examination confirmed a bleeding source from the right midseptum, and topical cautery with silver nitrate applied
in the clinic offered only temporary benefit. Given that
the lateral nasal wall was unaffected, the decision was
made to proceed with focused cautery to the bleeding
area and ligation of the nasal septal branch of the SPA
under general anesthesia in the operating room. At 6
Laryngoscope 122: April 2012
Fig. 2. Long bayonet bipolar forceps (F) can be used to apply
bipolar diathermy to the artery (*). A number of different endoscopic bipolar forceps exist that may also be used. [Color figure
can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]
Cooper and Ramakrishnan: Cauterization of the Nasal Septal Artery
739
rate of 71% to 95%; however, major complications of this
procedure may include cerebrovascular accident, hemiplegia, ophthalmoplegia, facial nerve palsy, and soft
tissue necrosis.14 A review by Soyka et al. found the best
results with surgical treatment, with a 3% failure rate
compared to 33% to 40% for packing.15
A variety of surgical techniques exist for ligation of
vessels responsible for epistaxis. Ligation of the external
carotid artery has been historically described for cases of
refractory epistaxis, but even then there were frequent
treatment failures thought to result from collateral blood
supply. Transantral ligation of the internal maxillary artery was described in 1965 by Chandler and Serrins,
with reported failure rates of 10% to 15%.16,17 This technique also has complications related to the use of the
Caldwell-Luc approach, such as sinusitis, facial pain,
oroantral fistula, and paresthesias.
Budrovich and Saetti described endoscopic ligation
of the SPA in 1992.4 It has been proposed as a more
ideal surgical treatment, as it ligates a major arterial
supply to the nasal cavity at a distal point, and therefore
minimizes the risk of refractory bleeding from collateral
circulation. The surgical technique involves making an
incision over the posterior fontanelle and raising a submucosal flap back toward the SPF. The artery and its
branches are identified posterior to the ethmoidal crest
and ligated with clips, diathermy, or a combination of
the two. Surgical exposure may be widened, with some
recommending the routine use of maxillary antrostomy
and uncinectomy, whereas others recommend against
it.18,19 A literature review by Kumar showed 92% to
100% success with endoscopic SPA ligation.20 Failures of
this technique are attributed to the failure to identify all
branches of the SPA, or the significant dissection that
may be required in a patient with suboptimal coagulation properties. As such, a more directed therapy to the
nasal septal artery, which requires minimal dissection,
may be of value in cases of epistaxis arising from the
nasal septum or floor.
CONCLUSION
This technique provides an alternative to SPA ligation for epistaxis arising from the vascular territory of
Laryngoscope 122: April 2012
740
the nasal septal artery, which may be combined with
focused cautery of the bleeding area. The benefits of this
procedure include: rapid procedure time, minimal surgical exposure, ability to perform in the clinic or at the
patient’s bedside, and possibly even treating patients
without discontinuing anticoagulation.
BIBLIOGRAPHY
1. Small M, Murray JA, Maran AG. A study of patients requiring admission
to hospital. Health Bull (Edinb) 1982;40:20–29.
2. Klotz DA, Winkle MR, Richmon J, Hengerer AS. Surgical management of
posterior epistaxis: a changing paradigm. Laryngoscope 2002;112:
1577–1582.
3. Ramakrishnan VR, Suh JD, Chiu AG, Palmer JN. The utility of a minimally invasive medial orbital approach in advanced endoscopic sino-orbital surgery. Laryngoscope 2011;121:437–441.
4. Budrovich R, Saetti R. Microscopic and endoscopic ligature of the sphenopalatine artery. Laryngoscope 1992;102(12 pt 1):1391–1394.
5. Thorton MA, Mahesh BN, Lang J. Posterior epistaxis: identification of
common bleeding sites. Laryngoscope 2005;115:588–590.
6. Wareing M, Padgham ND. Osteologic classification of the sphenopalatine
foramen. Laryngoscope 1998;108:125–127.
7. Simmen DB, Ragavan U, Briner HR, et al. The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon. Am J Rhinol 2006;20:
502–505.
8. Lee HY, Kim HU, Kim SS, et al. Surgical anatomy of the sphenopalatine
artery in the lateral nasal wall. Laryngoscope 2002;112:1812–1818.
9. Prades JM, Asanau A, Timoshenko AP, et al. Surgical anatomy of the
sphenopalatine foramen and its arterial content. Surg Radiol Anat
2008;30:582–587.
10. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle
nasoseptal flap. Laryngoscope 2006;116:1882–1886.
11. Fujii M, Goto N, Shimada K, et al. Demonstration of the nasal septal
branches of the sphenopalatine artery by use of a new intravascular
injection method. Ann Otol Rhinol Laryngol 1996;105:309–311.
12. Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical
therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope 1987;97:1392–1396.
13. Vis E, Van den Berge H. Treatment of epistaxis without the use of nasal
packing, a patient study. Rhinology 2011;49:600–604.
14. Bent JP III, Wood BP. Complications resulting from treatment of severe
posterior epistaxis. J Laryngol Otol 1999;113:252–254.
15. Soyka MB, Nikolaou G, Rufibach K, Holzmann D. On the effectiveness of
treatment options in epistaxis: an analysis of 678 interventions. Rhinology 2011;49:1–5.
16. Chandler JR, Serrins AJ. Transantral ligation of the internal maxillary artery for epistaxis. Laryngoscope 1965;75:1151–1159.
17. Metson R, Lane R. Internal maxillary artery ligation for epistaxis: an
analysis of failures. Laryngoscope 1988;98:760–764.
18. Shires CB, Boughter JD, Sebelik ME. Sphenopalatine artery ligation: a
cadaver anatomic study. Otolaryngol Head Neck Surg 2011;145:494–497.
19. Pothier DD, Mackeith S, Youngs R. Sphenopalatine artery ligation: technical note. J Laryngol Otol 2005;119:810–812.
20. Kumar S, Shetty A, Rockey J, Nilssen E. Contemporary surgical treatment
of epistaxis. What is the evidence for sphenopalatine artery ligation.
Clin Otolaryngol 2003;28:360–363.
Cooper and Ramakrishnan: Cauterization of the Nasal Septal Artery