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Concept: Sphenopalatine artery


This study aims to provide guidance regarding patient selection and timing of intervention with sphenopalatine artery (SPA) ligation by defining ‘severe epistaxis’. An analysis of all patients undergoing SPA ligation (January 2002-2010) was performed. SPA ligation was deemed necessary if at least one of the four identified criteria was fulfilled. The same analysis was also performed on all patients admitted with epistaxis who did not undergo SPA ligation over a 6-month period. All 27 patients who underwent SPA ligation met at least one of the criteria selected. Uncontrolled epistaxis (21/27) was fulfilled most often. In comparison, only 4/71 patients admitted with epistaxis who did not undergo SPA ligation fulfilled any single criterion. All criteria were satisfied in a significantly higher number of cases in the SPA group (p < 0.001) The criteria studied proved helpful in identifying patients admitted to hospital with epistaxis who had failed conservative measures.

Concepts: Natural selection, Patient, Hospital, Selection, Sphenopalatine artery, Epistaxis, Kiesselbach's plexus, Sphenopalatine foramen


Abstract Conclusion: We consider sphenopalatine artery ligation to be a safe and effective treatment of posterior epistaxis as the long-term need for revision surgery and the complication rates are low. Surgery should be considered earlier in the treatment of posterior epistaxis. Objectives: Posterior epistaxis is common and surgical endoscopic ligation of the sphenopalatine arteries is indicated in severe cases. Knowledge about long-term effects and complications is sparse. Methods: Within 2001-2006, 78 patients underwent endonasal endoscopic-guided surgery for posterior epistaxis in one of the eight ENT clinics in Denmark treating these patients. In 2011, 45 patients were still alive and eligible for the study. Patients were contacted by telephone and invited to complete an interview questionnaire on late adverse affects and recurrence. Results: In all, 42 of 45 patients participated in the mean follow-up. The mean follow-up was 6.7 years: 90% of patients (n = 38) obtained an effect of the treatment during follow-up; 78% (n = 33) had no recurrent epistaxis, 12% (n = 5) had recurrent epistaxis but only needed non-surgical specialized treatment; 10% (n = 4) required revision surgery due to recurrent epistaxis within the 6.7 mean years of follow-up; and 26% of the patients had minor postoperative complications, permanent nasal crusting being most persistent and frequent.

Concepts: Blood, Hospital, Effect, Effectiveness, Affect, Sphenopalatine artery, Epistaxis, Kiesselbach's plexus


BACKGROUND: The advent of endoscopic sphenopalatine artery ligation (ESPAL) for the control of posterior epistaxis provides an effective, low-morbidity treatment option. In the current practice algorithm, ESPAL is pursued after failure of posterior packing. Given the morbidity and limited effectiveness of posterior packing, we sought to determine the cost-effectiveness of first-line ESPAL compared to the current practice model. METHODS: A standard decision analysis model was constructed comparing first-line ESPAL and current practice algorithms. A literature search was performed to determine event probabilities and published Medicare data largely provided cost parameters. The primary outcomes were cost of treatment and resolution of epistaxis. One-way sensitivity analysis was performed for key parameters. RESULTS: Costs for the first-line ESPAL arm and the current practice arm were $6450 and $8246, respectively. One-way sensitivity analyses were performed for key variables including duration of packing. The baseline difference of $1796 in favor of the first-line ESPAL arm was increased to $6263 when the duration of nasal packing was increased from 3 to 5 days. Current practice was favored (cost savings of $437 per patient) if posterior packing duration was decreased from 3 to 2 days. CONCLUSION: This study demonstrates that ESPAL is cost-saving as first-line therapy for posterior epistaxis. Given the improved effectiveness and patient comfort of ESPAL compared to posterior packing, ESPAL should be offered as an initial treatment option for medically stable patients with posterior epistaxis.

Concepts: Costs, Decision theory, Sensitivity analysis, Sphenopalatine artery, Decision analysis, Info-gap decision theory, Epistaxis, Kiesselbach's plexus


Nasopharyngeal angiofibroma (NA) is a benign, highly vascularised tumour of the nasopharynx, which typically occurs in young males aged 14-25 years. We report an interesting case of an NA arising de novo in a 32-year-old male. He was referred to our facility for severe nasal haemorrhage after biopsy of a left nasopharyngeal mass. In the operating room, extensive bleeding was noted, and an endoscopic medial maxillectomy was performed, and the left internal maxillary artery was ligated allowing for near total resection of the lesion. The pathological specimen confirmed the diagnosis of NA. To our knowledge, this is one of the oldest patients presenting with a de novo NA, in his fourth decade of life, confirming that this diagnosis must be considered in all those with large nasopharyngeal masses.

Concepts: Blood, Posterior superior alveolar artery, Maxillary artery, Sphenopalatine artery, Infraorbital artery


Analysis of the efficacy of sphenopalatine artery (SPA) and internal maxillary artery (IMAX) ligation within the pterygopalatine fossa to control posterior epistaxis.

Concepts: Arteries of the head and neck, Maxillary artery, Sphenopalatine artery, Pterygopalatine fossa, Sphenopalatine foramen


Pedicle flaps based on the external maxillary (facial) artery were introduced during the World War I, precisely a century ago. Today they remain effective tools in facial soft-tissue repair. Recently, pedicle flaps based on the internal maxillary (sphenopalatine) artery have been chosen to reliably close dural defects after endoscopic skull-base surgery. Pedicle flaps, “biologic” to the extent they are based on a defined arterial blood supply, are the lasting contributions-the diuturnity-of Johannes (“Jan”) Fredericus Samuel Esser (1877-1946) of Leiden, Holland, and Chicago (IL).

Concepts: Blood, Heart, Blood vessel, Artery, External carotid artery, World War II, Maxillary artery, Sphenopalatine artery


Epistaxis is a frequent problem otorhinolaryngologists faces of in their practice. The variations of the sphenopalatine foramen and consequently the artery may be one of the major sources of such bleeding.

Concepts: Blood, Foramina of the skull, Sphenopalatine artery


Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery.

Concepts: Foramina of the skull, Sphenopalatine artery, Morphometrics, Epistaxis, Kiesselbach's plexus, Sphenopalatine foramen


Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

Concepts: Evidence-based medicine, Randomized controlled trial, Effectiveness, Efficacy, Meta-analysis, Sphenopalatine artery, Epistaxis, Kiesselbach's plexus


To optimize the outcome of transnasal endoscopic sphenopalatine artery ligation (TESPAL) by determining the key surgical steps and applying them accordingly.

Concepts: The Key, Sphenopalatine artery, Epistaxis, Kiesselbach's plexus, Sphenopalatine foramen