Endoscopic Endonasal Approach to the Pterygopalatine Fossa and Ligation of the Sphenopalatine Artery in 48 Consecutive Patients with Severe Epistaxis

Background: Epistaxis is a common complaint. Approximately 60% of people will experience an episode in their lifetime. The bleeding site of a posterior epistaxis is located at Woodruff’s plexus, supplied by the sphenopalatine artery (SPA). SPA ligation is now the most common surgical procedure performed for posterior epistaxis that is refractory to nasal packing. The SPA may terminate in as many as ten branches, and it is therefore important to both identify and ligate all branches to prevent recurrent bleeding.

Objective: Analysis of the success rates of SPA ligation laterally within the pterygopalatine fossa to control posterior epistaxis. Comparison between two different populations of patients who underwent this procedure: inpatients vs outpatients.

Methods: A total of 48 patients underwent SPA ligation inside the pterygopalatine fossa. The posterior wall of the maxillary sinus was opened, the artery was exposed and ligated with titanium hemoclips. Two groups of patients were studied: patients who had the surgery in a more urgent situation, while they were inpatient after admission from the emergency department; and patients who had elective surgery in the outpatient setting. Demographic data, previous interventions for epistaxis and history of blood transfusion were collected. Data were analyzed with SPSS software.

Results: A total of 33 inpatients and 15 outpatients were studied. Intervention with nasal packing was statistically different (p = 0.0006) between the two groups, with inpatients undergoing an average of 2.2 ± 0.75 instances of packing versus 1.1 ± 0.3 packs for outpatient population. Forty two percent of patients had previously undergone nasal cautery. Thirty nine percent (13/33) of the inpatient population required preoperative blood transfusion, whereas none of the outpatients had reported blood transfusion requirements for previous episodes of epistaxis. Eight patients had previously underwent sphenopalatine artery cautery, ligation or embolization procedures to control epistaxis with failure and recurrence. The mean follow-up was 22 months (from 2 to 44 months). No recurrent epistaxis was observed in our series. There were no intraoperative, immediate postoperative complications, or follow up complications related to the SPA ligation procedure recorded.

Conclusion: The published rate of failure for SPA cauterization or ligation varies from 2% to 10%. Anatomic variations of the sphenopalatine artery branches and foramen location may contribute to surgical failure. This study demonstrates that SPA ligation is appropriate for inpatient as well as outpatient control of epistaxis. No failure was observed in our series despite treating a population in which almost 20% of the patients had an SPA ligation/cauterization and/or embolization with failure prior to referral. The success rate at control of posterior bleeds was 100% for our patient population with the ligation of the SPA inside the pterygopalatine fossa.