Indian J Otolaryngol Head Neck Surg

https://doi.org/10.1007/s12070-021-02414-1

ORIGINAL ARTICLE

Endoscopic Sphenopalatine Artery Cauterization in Refractory

Hypertensive Epistaxis
Sajilal Manonmony1 • Sreelakshmi Balakrishnan1 • Rejee Ebenezer Renjit1 •

Avinash Mohan1

Received: 29 December 2020 / Accepted: 19 January 2021

 Association of Otolaryngologists of India 2021

Abstract Epistaxis is a commonly occurring phenomenon
which is defined as ‘‘bleeding from inside the nose’’ and
often presents as an emergency. The management of
epistaxis involves many factors with regard to the treat-
ment and ultimate control of the condition. Each patient
presenting with epistaxis should be well assessed clinically
and managed accordingly. Endoscopic sphenopalatine
artery cauterization is a safe, simple and effective proce-
dure in the management of refractory epistaxis. Moreover,
in view of minimal morbidity, higher success rate, shorter
hospital stays and higher patient satisfaction, our current
practice is to consider this treatment option in the man-
agement of cases not responding to conservative treatment
modalities. A total of 11 patients (8 males and 3 females)
underwent sphenopalatine artery cauterization during the
study period. All patients were hypertensive and were
refractory to treatment with general measures, anterior
nasal packing and Foley catheter. The mean age of the
study population was 58.36 and the range was 39–70 years.
The epistaxis was rapidly controlled in all patients without
any intraoperative or postoperative complications. The
follow up period was 60–90 days. Strict control of
hypertension was done throughout the follow up period.
None of the patients developed epistaxis in the follow up
period. The sphenopalatine artery cauterization technique
using nasal endoscope was safe, simple, fast and effective
with low rates of morbidity and complications for the
management of refractory epistaxis. It was concluded that
endoscopic sphenopalatine artery cauterization should be
considered as an immediate second line treatment where
conservative measures fail and it is proved to be of low
morbidity and cost effective.
Keyword Hypertensive epistaxis
Treatment modalities

Endoscopic sphenopalatine artery cauterization
Abbreviations
SPA Spheno Palatine Artery
ESPA Endoscopic SphenoPalatine Artery
ESPAL Endoscopic SphenoPalatine Artery Ligation
Introduction

& Sreelakshmi Balakrishnan Epistaxis is a commonly occurring phenomenon which is

srkbalak@gmail.com defined as ‘‘bleeding from inside the nose’’ and often
Sajilal Manonmony presents as an emergency. It is a problem which may cause
drsajim@rediffmail.com great anxiety to the patients. It is estimated to affect 60% of
Rejee Ebenezer Renjit the population, of which 6% may need medical attention
rejee72@gmail.com [1]. It is observed that intervention is required only for a
Avinash Mohan small population. Common aetiologies of epistaxis include
avinashmohan88@gmail.com trauma, hypertension, infection, nasal polyp, malignancy,
1 deviated nasal septum, hypothyroidism, bleeding abnor-
Department of Otorhinolaryngology, Dr. Somervell
Memorial CSI Medical College, mality and angioma [2].
Karakonam, Thiruvananthapuram, Kerala 695504, India

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The management of epistaxis involves many factors
with regard to the treatment and ultimate control of the
condition. There should be a complete understanding of the
available treatment modalities and a step wise plan before
initiating the management [3]. Each patient presenting with
epistaxis should be well assessed clinically and managed
accordingly.
Treatment of epistaxis can be divided into two groups—
conservative and interventional. Any patient with epistaxis
must be given the best treatment modality whether it may
be conservative or interventional.
Endoscopic sphenopalatine artery ligation is a safe,
simple and effective procedure in the management of
refractory epistaxis. Moreover, in view of minimal mor-
bidity, higher success rate, shorter hospital stays and higher
patient satisfaction, our current practice is to consider this
treatment option in the management of cases not
responding to conservative treatment modalities [4].
Materials and Methods
The study was conducted in the department of otorhino-
laryngology in a tertiary care centre in South Kerala. The
duration of the study was 18 months after obtaining the
institutional ethics committee clearance. Data collection
period was from November 2018 to April 2020. The study
included 11 patients as per the inclusion and exclusion
criteria.
Inclusion Criteria
Patients presenting with hypertensive epistaxis in the out-
patient and emergency department of ENT in the age group
of 18–70 years who gave consent for the study.
Exclusion Criteria
• Pregnancy and lactation
• Altered mental status
• Intra cranial injury
• Post-operative epistaxis after surgeries like septoplasty
and functional endoscopic sinus surgery (FESS).
Informed written consent mentioning the type of proce-
dure, possible outcome and associated risks was obtained
from the patients and appropriate councelling was done.
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Indian J Otolaryngol Head Neck Surg
Results
All 11 cases were initially treated with conservative
methods like general first aid and anterior nasal packing for
48 h along with strict control of blood pressure. As the
bleeding persisted, some required a Foley balloon catheter
which kept in place for 24–48 h. These are summarized in
Table 1 given below.
All these cases had associated comorbid conditions, with
hypertension in common.
Removal of Foley catheter on day 2 led to rebleeding,
requiring packing again and then they were offered the
option of endoscopic cauterization of sphenopalatine
artery.
No patient had an identifiable alternate cause for
epistaxis.
Surgical Procedure
Under general anaesthesia, after decongesting with adre-
naline packs in both nostrils for 10 min, middle turbinate
was medialized and infiltration given over sphenopalatine
region with 2% xylocaine and adrenaline. A vertical inci-
sion made posterior to the posterior fontanellae over the
palatine bone and mucosl flaps raised and crista eth-
moidalis identified. The sphenopalatine foramen is situated
posterior to crista ethmoidalis. By using 1 mm Kerrison’s
punch, the crista ethmoidalis was gently punched out, so
that the sphenopalatine artery was very well visualized,
coming out of sphenopalatine foramen, which was cau-
terized with bipolar.
The time taken to complete the procedure was about
30–45 min. There were no intraoperative complications.
The merocele nasal packs kept at the end of the procedure,
were removed on post op day 2.
All patients were kept in ICU for 2 days and observed
for rebleeding and any other complications. The course of
hospital stay was uneventful.
All patients were discharged on post op day 3 with
antibiotics and post-operative advice.
Discussion
The arterial supply of nasal septum is from external and
internal carotid arteries. Anastomotic connections occur in
two places of the nasal cavity. On the antero-inferior part
of septum ‘‘Little’s area’’ or ‘‘Kiesselbach’’ plexus and on
the posterior part of nasal cavity ‘‘Woodruff plexus’’ [5].
The management of epistaxis involves many factors
with regard to the treatment and ultimate control of the
Indian J Otolaryngol Head Neck Surg

Table 1 Outcomes of conservative modalities in the management of epistaxis

Patient characteristics Treatment modality used Outcome

39/m General measures, anterior packing, foley catheter Rebleed

43/m General measures, anterior packing Patient did not tolerate
43/m General measures, anterior packing Rebleed
45/m General measures, foley catheter Rebleed
47/f General measures, anterior packing, foley catheter Rebleed
48/m General measures, anterior packing Patient did not tolerate
50/f General measures, anterior packing Patient did not tolerate
55/m General measures, anterior packing, Foley catheter Rebleed
59/m General measures, anterior packing Patient did not tolerate
61/f General measures, foley catheter Rebleed
69/m General measures, anterior packing Patient did not tolerate

condition. Understanding the etiology helps in better
evaluation. As hypertension is the commonest etiology in
older patients, regular blood pressure checkup in epistaxis
patients and due address to blood pressure control through
regular medication is recommended.
There should be a complete understanding of the
available treatment modalities and a step wise plan before
initiating the management [5]. Each patient presenting with
epistaxis should be well assessed clinically and managed
accordingly. Treatment of epistaxis can be divided into two
groups—conservative and interventional. Any patient with
epistaxis must be given the best treatment modality whe-
ther it may be conservative or interventional [6].
Conservative management options include, first aid
measures, chemical cauterization, anterior nasal packing
and posterior nasal packing. In 65–75% cases of epistaxis,
simple first aid measures stop the bleeding [6].
The sphenopalatine artery (SPA) cauterization technique
was safe, simple, fast and effective with low rates of
morbidity and complications for the management of
refractory hypertensive epistaxis. It was concluded that
endoscopic sphenopalatine artery cauterization should be
considered as an immediate second line treatment where
conservative measures fail and it is proved to be of low
morbidity and cost effective [7, 8].
The surgical approach to sphenopalatine artery was first
described by Prades [9]. Later advances in the techniques
of nasal endoscopy resulted in the favourable outcome and
subsequent popularization of ESPAL. Sharp et al. [10]
studied and concluded about the success rate of ESPAL
which was more than 90% without any significant com-
plications. Srinivasan et al. [11] in an audit of results
showed that ESPAL is a safe and effective management for
intractable epistaxis with reduced morbidity and shortened
hospital stay. Also it was proved that endoscopic spheno-
palatine artery ligation is the best practice in persistent
epistaxis with immediate success rate, shorter hospital
stays and recurrence and patient satisfaction [4].
Surgical interventions can be done after conservative
methods fail. However, ease of use, high success rate and
low complication rates of endoscopic sphenopalatine artery
ligation have led to the revision of the management of
epistaxis by early intervention with endoscopic sphenopa-
latine artery ligation [12].
We were able to control the epistaxis successfully in all
the 11 patients, with strict control of hypertension, without
any surgical complications, and avoiding the need and
complications of nasal packings.
Endoscopic sphenopalatine artery (ESPA) cauterization
is simple, cost effective, safe and successful procedure in
the management of refractory hypertensive epistaxis. In
view of this, we propose a new practice with consideration
of SPA cauterization early in the management of epistaxis.
Funding There was no funding or grants involved.
Compliance with Ethical Standards
Conflict of interest The authors declared that they have no conflict
of interest.
Ethical Approval Ethical approval was obtained from the Institu-
tional Ethics Committee.
Informed Consent Informed consent was obtained from all indi-
vidual participants included in the study.
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