Endoscopic Sphenopalatine Artery Ligation

Consideration

- Many epistaxis protocols now include endoscopic sphenopalatine artery ligation for bleeding that is refractory to packing.
- Other invasive options for refractory epistaxis are anterior ethmoid artery ligation and embolization of the internal maxillary artery by neurointerventional radiology.
- Consider obtaining a CT of the sinuses with navigation protocol to evaluate for possible unknowns such as unusual anatomy or presence of tumors.
- Sphenopalatine artery ligation is also done during removal of vascular tumors, such as juvenile nasopharyngeal angiofibromas.

Preparation

- Review CT if done.
- Optimize the CT images on the Medtronic Stealth station.
- General anesthesia with orotracheal intubation.

Procedure

1. Prep and drape the patient in the semi-sterile manner as shown in the FESS protocols.
2. Set up the image navigation system as documented in the FESS protocols.
3. Remove the nasal packing.
4. Perform diagnostic nasal endoscopy with the 0 degree scope.
5. Use the bipolar cautery as needed to help control bleeding.
6. Perform an uncinectomy as documented in the FESS protocols.
7. Switch to the 30-degree endoscope.
8. Identify the natural maxillary sinus ostium, looking laterally with the 30-degree endoscope.
9. Examine the sinus cavity for abnormalities.
10. Identify the ethmoid bulla. This is not typically dissected or removed.
11. Carry the dissection posteriorly into the posterior fontanelle using a curved suction.
12. Identify the posterior rim of the maxillary sinus ostium; straight through-cutting instruments can be used as well to dissect the posterior fontanelle.
13. Incise the mucosa, with the Freer elevator, on the medial side of the posterior wall of the maxillary sinus ostium.
14. Raise a mucosal flap with the Freer elevator.
  1. Suction-Freer is also helpful in performing this step.
  2. Do not tent the flap too much; this can stretch or tear the sphenopalatine artery that is tethered laterally behind the maxillary sinus where it remains undissected.
15. Identify the crista ethmoidalis.
16. This is the key landmark.

- 1. Just posterior (deep) to this is the sphenopalatine artery.

1. Remove the crista ethmoidalis if needed to improve exposure.

- 1. One can use a Kerrison ronguer or mushroom punch for this step.

1. Place vascular clips on the sphenopalatine artery.

- 1. This requires experience to place.
  2. If pressed too lightly, the clip will not be secure and can fall off.
  3. If pressed too firmly, it can cut the artery.

1. Cauterize the artery with bipolar forceps.
2. Lay the mucosal flap back down.
3. Place dissolvable packing onto the flap.
4. Place a larger nasal pack if desired.
5. Suction the nasopharynx, oropharynx, and stomach

Sample Operative Report

The patient was transported to the operating room and laid supine on the table. A time out was performed. Anesthesia was administered, and the patient underwent orotracheal intubation. The bed was turned 90 degrees. Image guidance with Medtronic Fusion navigation system was set up per the standard protocol. The reference array was secured to the patient's forehead. The navigation system was registered, and there was good configuration of the reference points. The navigation system was used at critical points throughout the procedure.

The right nasal packing was removed (10 cm Merocel) was removed. There was no brisk, active bleeding. Several areas of the medial aspect of the inferior turbinate were slowly oozing. These were treated with bipolar cautery. We then turned our attention towards performing an uncinectomy. A 30-degree endoscope was used. The middle turbinate was gently medialized with a Freer elevator. Pledgets soaked in 1:1000 epinephrine were placed into the middle meatus. The uncinate process and axilla of the middle turbinate were infiltrated with 1% lidocaine with 1:100,000 epinephrine. The pledgets were removed. The uncinate process was reflected anteriorly with a maxillary sinus seeker. A rotating pediatric backbiter was used to incise the uncinate process at the junction of its superior two-thirds and inferior one-third aspect. The remaining uncinate process was then removed with an up-biting through-cutting instrument. The natural maxillary sinus ostium was visualized. This was enlarged posteriorly through the posterior fontanelle in a blunt manner using the curved suction. This was carried further with a straight through-cutting instrument. The posterior rim of the maxillary sinus ostium was identified. A Freer elevator was used to incise the mucosa of the medial side of the posterior rim of the maxillary sinus ostium. This mucosal flap was then elevated posteriorly using a suction Freer catheter. This maneuver exposed the crista ethmoidalis. The sphenopalatine artery was seen just posterior to this landmark. The crista ethmoidalis was taken down with a Kerrison rongeur to improve exposure. Two vascular clips were then placed on the sphenopalatine artery. The portion of the artery lateral to the clips was then cauterized with bipolar cautery. The mucosal flap was laid back down. Gelfoam and Nasopore packing were then placed.

The airway and stomach were suctioned. Anesthesia was discontinued. The patient was awakened and transported to the recovery room in stable condition.

Post-op

- Most patients are admitted to the hospital ward for monitoring.
- Avoid antiplatelet and anticoagulant agents, if possible.
- Have humidified air if admitted.
- Some attendings prefer antibiotic use, especially if a nasal pack is in place.

Pearls & Pitfalls

- When raising the mucosal flap to expose the crista ethmoidalis and sphenopalatine artery, do not tent up the flap too much as this can stretch or tear the sphenopalatine artery.