The Laryngoscope

Lippincott Williams & Wilkins, Inc.

© 2007 The American Laryngological,
Rhinological and Otological Society, Inc.

How I Do It

Endoscopic Ligation of the Anterior

Ethmoid Artery
Steven D. Pletcher, MD; Ralph Metson, MD

Key Words: Epistaxis, anterior ethmoid artery, snasal approach for ligation of the AEA to treat patients
endocopic ligation. with refractory epistaxis.
Laryngoscope, 117:378 –381, 2007
METHODS
INTRODUCTION A retrospective review was performed of three patients, two
When severe epistaxis does not respond to nasal females and one male, who underwent endoscopic AEA ligation.
packing, other treatment modalities must be considered.1 Two of the patients had spontaneous epistaxis; the third bled 3
days after a frontal sinus drillout (Draf 3 or Modified Lothrop
Both arterial embolization and surgical ligation have a
procedure). Both of the patients with spontaneous bleeding un-
high success rate for control of bleeding in the posterior derwent endoscopic examination before packing that suggested
nasal cavity arising from the sphenopalatine artery and an anterior source of bleeding. All patients failed initial anterior
its branches. When bleeding arises from the anterior eth- packing and were hospitalized with anterior–posterior packs in
moid artery (AEA); however, treatment options are more place before their AEA ligation.
limited. As a branch of the internal carotid artery in close
proximity to the ophthalmic artery, the AEA is not a
suitable candidate for embolization resulting from risks of
blindness and stroke.
Intraoral and intranasal approaches that avoid an
external facial scar have been used for many years to treat
posterior epistaxis arising from the sphenopalatine ar-
tery. With the advent of endoscopic techniques, transan-
tral ligation of the internal maxillary artery has largely
been replaced by endoscopic ligation of the sphenopalatine
artery.2– 6 This endoscopic approach appears to provide
both improved efficacy and decreased patient morbidity.6,7
A reliable endoscopic technique for treatment arising from
the AEA and its branches, however, has not been de-
scribed. The purpose of this report is to share the authors’
preliminary experience with the use of an endoscopic tran-

From the Department of Otolaryngology–Head and Neck Surgery

(S.D.P.), University of California, San Francisco, San Francisco, California,
U.S.A.; the Department of Otolaryngology (R.M.), Massachusetts Eye and
Ear Infirmary, Boston, Massachusetts, U.S.A.; and the Department of
Otology and Laryngology (R.M.), Harvard Medical School, Boston, Massa-
chusetts, U.S.A.
Editor’s Note: This Manuscript was accepted for publication October
11, 2006.
Presented at the Meeting of the Combined Sections of the Triological
Society, Marco Island, FL, February 18, 2007.
Fig. 1. View of the right ethmoid roof as seen through a 30° endo-
Send correspondence to Steven D. Pletcher, MD, 400 Parnassus
Avenue, ACC 7th Floor, San Francisco, CA 94143-0342, U.S.A. E-mail: scope demonstrates the bony canal containing the anterior ethmoid
spletcher@ohns.ucsf.edu artery as it exits the medial orbital wall (dashed circle). Note the
posterior-to-anterior slant of the artery as it traverses the ethmoid
DOI: 10.1097/01.mlg.0000250778.29957.a1 roof.

Laryngoscope 117: February 2007 Pletcher and Metson: Anterior Ethmoid Artery Ligation
378

Fig. 2. Coronal computed tomography scan demonstrating the lo-
cation of the anterior ethmoid artery. The artery may be identified in
cuts just posterior to the globe as it enters the ethmoid cavity
through a bony opening in the medial orbital wall (arrow).
Surgical Procedure
The patient is brought to the operating room with nasal
packing in place. After induction of general anesthesia, the
Fig. 3. In these magnified views of the
area within the dashed circle in Figure 1:
(A) A spoon curette is used to penetrate
the lamina papyracea inferior to the an-
terior ethmoid artery, (B) fragments of
the lamina papyracea are elevated and
removed to expose a small area of peri-
orbita adjacent to the anterior ethmoid
artery, (C) the anterior ethmoid artery is
isolated by elevating periorbita anterior
and posterior to the vessel, and (D) an
angled clip applier is used to ligate the
anterior ethmoid artery.
Laryngoscope 117: February 2007
packing material is removed and the nasal cavity inspected
with endoscopic instrumentation. Superficial bleeding sites
caused by mucosal trauma from the packing may be cauterized
with unipolar suction cautery on a low setting or endoscopic
bipolar forceps.
A standard maxillary antrostomy is performed to identify
the level of the orbital floor. The bulla ethmoidalis is resected and
anterior ethmoid cells are cleared to expose the medial orbital
wall and ethmoid roof. A 30° endoscope is then used to visualize
the ethmoid roof. The bony canal of the AEA is typically seen
traversing the ethmoid roof as it slants in an anteromedial direc-
tion running from the orbit to the cribriform plate (Fig. 1). Care-
ful review of the preoperative computed tomography scan or use
of an image guidance system can assist with identification of the
canal, which is seen as a pinch-like protrusion of the lamina
papyracea immediately posterior to the globe on coronal CT scan
(Fig. 2).
After identification of the AEA canal, a small opening is
made through the thin bone of the lamina papyracea with a
small spoon curette just inferior to the canal (Fig. 3A). Care is
taken to avoid injury to the underlying periorbita to prevent
prolapse of orbital fat, which could obscure the surgical field.
Bone fragments are then elevated and removed to expose the
AEA as it enters the ethmoid cavity (Fig. 3B). A periosteal
elevator is used to elevate both anterior and posterior to the
AEA to provide adequate exposure of the artery for vascular
clip placement (Fig. 3C). The elevator can extend in a superior
direction above the level of the ethmoid roof and still remain
safely within the bony orbit.
After the vessel and its overlying fascia have been iso-
lated, an angled clip applier (Instrumentarium, Terrebonne,
Canada; instrumentarium– online.com) is used to ligate the
Pletcher and Metson: Anterior Ethmoid Artery Ligation
379

vessel (Fig. 3D). Typically, the clip lies partially within the
orbit and partially within the superior ethmoid cavity (Fig. 4).
A small piece of oxidized cellulose (Surgicel; Johnson and John-
son Medical Inc. Arlington, TX) is placed over the surgical site
at the completion of the procedure. If the AEA has not been
definitively identified as the source of bleeding, endoscopic
sphenopalatine artery ligation may be performed at the same
setting.
RESULTS
Two of the three patients required blood transfusions
before operative intervention. Mean age of the patients
was 56.3 years (range, 46 –72 years). All patients had
normal coagulation studies; none were taking anticoagu-
lant medications. One of the three patients had underly-
ing hypertension.
All three patients underwent concomitant endoscopic
sphenopalatine artery ligation with their endoscopic AEA
ligation and were discharged home on the first postoper-
ative day. Estimated blood loss was 192 mL. Mean oper-
ative time was 116 minutes. There were no intraoperative
or postoperative complications. All three patients have
remained free of further episodes of epistaxis with a mean
follow up of 5.3 months (range, 5.0 –5.5 months).
DISCUSSION
The current study describes an endoscopic technique
for the treatment of refractory epistaxis, which may be
used in lieu of the traditional external approach to ante-
rior ethmoid artery ligation. A case report describing en-
doscopic ligation of the exposed end of a severed AEA has
been reported,8 but the approach described would not be
effective when the AEA is encased within a bony canal,
which represents the majority of cases. Like with any
application of new technology, however, it is important to
ask not just if a procedure is possible, but if the new
procedure is an improvement. The endoscopic approach
described in the current study can be technically challeng-
ing, because it requires manipulations within the bony
orbit in close proximity to the skull base. Thus, there is
potential for injury to the orbital contents and cerebrospi-
nal fluid leak. Furthermore, the scar from an external
ligation of the AEA typically heals in a cosmetically sat-
isfactory fashion.
One potential advantage of endoscopic AEA ligation
over the external approach is that the magnification and
Laryngoscope 117: February 2007
380
Fig. 4. Axial (A) and coronal (B) com-
puted tomography images after endo-
scopic anterior ethmoid artery ligation.
Note placement of the clip (arrow) span-
ning the junction between the ethmoid
cavity and the orbit. A defect in the me-
dial orbital wall (arrowheads) is visible
where bone was removed to access the
artery.
lighting provided by the endoscope enhances the ability to
identify the AEA. The use of an endoscope, however, is not
restricted to the sinonasal cavities and, as described by
Douglas and Gupta,9 enhanced visualization may be
achieved by passing the endoscope through an external
incision. Thus, the primary advantage of the endoscopic
procedure is the avoidance of an external scar. For endo-
scopic surgeons who are not comfortable with working in
such close proximity to the orbit and skull base, the in-
creased technical difficulty and risk of complications with
this approach may outweigh the benefit of avoiding an
external incision.
Because all patients underwent concomitant endo-
scopic sphenopalatine and AEA ligation, it is unclear
which of these procedures was responsible for the suc-
cessful control of epistaxis. Embolization of the internal
maxillary artery and endoscopic sphenopalatine artery
ligation alone both have reported success rates of 85% to
98% for the treatment of patients with “posterior” epi-
staxis2,3,6,10,11–13 Patients who rebleed after such proce-
dures, however, frequently undergo ligation of the ante-
rior ethmoid artery with subsequent control of epistaxis.11
Several authors suggest including ligation of the anterior
ethmoid artery in the treatment of patients with refrac-
tory epistaxis and no clearly identifiable posterior source
of bleeding.4,12 When endoscopic instrumentation is al-
ready being used to ligate the sphenopalatine artery, an
endoscopic approach to the AEA may be more expeditious
than an external approach and avoids the added morbid-
ity of a scar.
CONCLUSION
Ligation of the anterior ethmoid artery is possible
through an endoscopic transnasal approach. The role of
this procedure in the treatment of patients with epistaxis
remains in evolution.
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