ENDOSCOPIC LIGATION OF THE

SPHENOPALATINE ARTERY FOR EPISTAXIS

CARL H. SNYDERMAN, MD, RICARDO L. CARRAU, MD

There are a variety of methods that are available for the treatment of severe epistaxis. These include nasal packing,
endoscopic electrocautery, arterial embolization, and surgical ligation of the internal maxillary artery and anterior
ethmoid artery. A transantral approach is most commonly used for ligation of the internal maxillary artery.
Disadvantages of this approach include significant postoperative pain, infraorbital nerve hypesthesia, and
incomplete identification of the terminal branches of the internal maxillary artery. An endoscopic transnasal approach
is described for ligation of the terminal branches of the internal maxillary artery. An endoscopic antrostomy is
performed, and the tissues are elevated in a subperiosteal plane. Using this approach, the pterygopalatine fossa can
be visualized, and terminal branches of the internal maxillary artery can be ligated where they enter the nasal cavity.
Our experience with this approach in patients with epistaxis is described. Although this approach may not be feasible
in all patients requiring surgery for epistaxis, distinct advantages include decreased surgical time, decreased
morbidity, and a shorter recovery period.

Most episodes of epistaxis are minor in severity and
duration, and are adequately managed using simple tech-
niques in the office setting. The bleeding is usually local-
ized to Kiesselbach's plexus on the anterior nasal septum
and results from drying of the nasal mucosa and minor
trauma. Bleeding from this area may be controlled by
direct external pressure, topical vasoconstrictive agents,
anterior nasal packing, chemical cautery, or electrocautery.
Recurrent episodes may require more extensive electrocau-
tery or correction of a septal deformity with a septoplasty.
More severe episodes of epistaxis usually reflect bleed-
ing from branches of the sphenopalatine or anterior eth-
moid arteries. A number of treatment options exist, includ-
ing anterior with or without posterior nasal packing,
endoscopic cauterization, angiography with embolization,
and surgical ligation. Considerable controversy exists re-
garding the optimal treatment algorithm based on issues of
efficacy, morbidity, and cost. Our current strategy is to
recommend surgical ligation for all patients requiring
hospitalization for epistaxis, in an attempt to shorten the
duration of hospitalization, prevent recurrent bleeding
after removal of nasal packing, and minimize patient
discomfort. Embolization is reserved for patients who have
medical contraindications to surgery or have failed a
• surgical attempt.
If the site of the bleeding can be adequately localized,
selective surgical ligation of the anterior ethmoid artery or
sphenopalatine artery can be performed. Frequently, pro-
fuse bleeding or prior placement of nasal packing prevents
adequate localization, for which ligation of both the sphe-
nopalatine and anterior ethmoid arteries is indicated. The
anterior ethmoid artery is ligated using a standard external
approach along the frontoethmoid suture. The internal
maxillary artery and its branches (sphenopalatine artery)
From the Department of Otolaryngology, University of Pittsburgh Medi-
cal Center, Pittsburgh, PA.
Address reprint requests to Carl H. Snyderman, MD, Department of
Otolaryngology, University of Pittsburgh Medical Center, The Eye & Ear
Institute Bldg, Suite 500,200 Lothrop St, Pittsburgh, PA 15213.
Copyright © 1997 by W.B. Saunders Company
1043-1810/97/0802-0008505.00/0
may be ligated using buccal, transantral, or intranasal
approaches.
The transantral approach has been considered the gold
standard due to the ease of identification of the internal
maxillary artery and all of its branches, and a high success
rate of 80% to 95%. Although most investigators have
considered the perioperative complication rate to be low,
there may be significant morbidity, including a painful
sublabial incision, hypesthesia and neuralgia of the infraor-
bital nerve, scarring of the gingivolabial sulcus, and oroan-
tral fistula formation. Additionally, because the terminal
branches of the internal maxillary artery may not all be
ligated, there is a risk of collateral blood flow and contin-
ued bleeding.
To address the shortcomings of the transantral approach,
a number of transnasal techniques have been introduced.
With endoscopic cauterization, nasal endoscopes are used
to localize the site of the bleeding, which is then coagulated
using electrocautery. 1,2 Advantages of this technique in-
clude better localization of the bleeding site, decreased
hospitalization, and avoidance of nasal packing. Disadvan-
tages include the frequent use of general anesthesia,
potential difficulty identifying the bleeding site, and a
lower success rate compared with that of ligation or
embolization. In our experience, patients are often referred
after several nasal packs have failed and the nasal mucosa
is widely excoriated, making identification of the initial
bleeding site difficult. Additionally, because the vessel is
being cauterized, there is a risk of rebleeding when the
eschar is sloughed.
Microsurgical ligation of the sphenopalatine artery was
first introduced by Prades 3-5 in the 1970s. Simpson et al 6
showed that the sphenopalatine artery may be selectively
ligated where it exits the sphenopalatine foramen using a
transantral approach, thereby avoiding the pterygomaxil-
lary fossa. A transnasal microsurgical approach for the
control of posterior epistaxis was described by Stamm et al
in 19827 and 1985. 8 Using an operating microscope, a
vertical incision is made about 1 cm anterior to the caudal
border of the middle turbinate. A subperiosteal dissection
is performed to expose the sphenopalatine artery and its

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 8, NO 2 (JUN), 1997: PP 85-89 85
branches at the sphenopalatine foramen. Of 145 patients
undergoing this procedure, the immediate and delayed
failure rate was 6.1%. 8 Potential advantages of this tech-
nique include better illumination and magnification, less
trauma, selective arterial ligation avoiding collateral ves-
sels, fewer complications, shortened hospitalization, better
patient acceptance, and applicability at all ages. A similar
experience with this technique was reported by Sulsenti et
al in 1987. 9
Endoscopic ligation of the sphenopalatine artery was
first reported by Budrovich and Saetti in 1992.1° They make
a vertical incision above the posterior portion of the middle
turbinate, 1 cm anterior to its posterior tip to expose the
artery. They successfully applied this technique to three
patients with epistaxis under local anesthesia. White
thought that the sphenopalatine artery was potentially
difficult to isolate on the medial side of the foramen, and
advocated an endonasal approach to the pterygomaxillary
fossa through a large middle meatal antrostomy. 11 Endo-
scopic ligation was successfully performed in two patients.
This is the technique that we have adopted and is de-
scribed in greater detail in this article.
ANATOMY
The internal maxillary artery and its terminal branches,
especially the sphenopalatine artery, supply the posterior
part of the nasal cavity. 12-14The pterygopalatine portion of
the internal maxillary artery gives rise to the posterior
superior alveolar artery, the infraorbital artery, the descend-
ing palatine artery, the artery of the pterygoid canal, a tiny
pharyngeal branch, and the sphenopalatine artery. The
sphenopalatine foramen is situated at the posterior attach-
ment of the middle turbinate, and the artery enters the
nasal cavity immediately anterior to the canal of the
descending palatine artery. The sphenopalatine artery
passes through the sphenopalatine foramen with the poste-
rior superior nasal nerves and divides into lateral and
septal posterior nasal arteries. The larger lateral nasal
arteries run along the middle and inferior conchae. The
septal portion of the artery crosses the anterior face of the
sphenoid sinus before giving off branches to the septum.
TECHNIQUE
If necessary, temporary control of bleeding is obtained by
placement of a balloon catheter or anterior and posterior
nasal packs. Although other investigators have described
endoscopic sphenopalatine artery ligafion under local
anesthesia, we prefer general anesthesia due to increased
patient comfort, decreased risk of aspiration of blood, and
better control of blood pressure. After induction of general
anesthesia, anterior nasal packing is removed and replaced
with 0.5 × 3-inch cottonoids soaked in oxymetazoline
(0.05%) solution. It may be helpful to leave the posterior
pack or balloon catheter in place temporarily to control
bleeding, but we have not found this to be necessary in the
majority of cases. Removal of the posterior pack or balloon
catheter also allows blood to drain away from the opera-
tive site, thereby improving endoscopic visualization.
After 5 to 10 minutes, the cottonoids are removed and
the nasal cavity is inspected with a 30 ° 4-ram endoscope.
An actively bleeding vessel may be initially controlled
with peripheral injection of 1% lidocaine with epinephrine
(1:100,000) or with direct pressure with a cottonoid soaked
in oxymetazoline (0.05%). Alternatively, the vessel may be
initially cauterized using bayonet bipolar or suction electro-
86
cautery. In some cases, an endoscopic anterior ethmoidec-
tomy is needed to gain access to the bleeding vessel.
Similarly, if a septal deviation limits access to the middle
meatus, a septoplasty is performed first. Resection of the
anterior inferior portion of the middle turbinate may also
be performed to maximize surgical access to the middle
meatus. Nevertheless, direct access to the middle meatus is
feasible in most patients.
Initially, we approached the sphenopalatine foramen by
making an incision at the anterior limit of the inferior
meatus and elevating a subperiosteal flap. Dissection
continued in a subperiosteal plane along the lateral nasal
wall to the antrum and sphenopalatine foramen. Subse-
quently, we have abandoned this approach for a more
direct approach through the middle meatus. The uncinate
process is resected and a large middle meatal antrostomy is
created, taking care to avoid injury to the nasolacrimal
duct. The posterior edge of the antrostomy is removed so
that it is flush with the posterior wall of the maxillary sinus
(Fig 1). The bulla ethmoidalis and anterior ethmoid air cells
are usually opened to provide additional exposure and
prevent postoperative obstruction of the ethmoid sinus.
Using a Cottle elevator, the mucosa of the lateral nasal wall
is elevated subperiosteally at the posterior edge of the
antrostomy (Fig 2). It is helpful to start inferiorly and
sweep the instrument superiorly. This dissection may also
be performed with the tip of the suction. The sphenopala-
fine foramen is found at the superomedial corner of the
maxillary sinus.
The sphenopalatine artery is traced from the medial side
of the foramen into the pterygomaxillary space using a
small Kerrison rongeur so that the identity of the vessel is
confirmed (Fig 3). Once the sphenopalatine artery is
identified, a trocar is used to puncture the anterior wall of
the maxillary sinus. This allows introduction of the endo-
scope through the trocar, providing more room for the
introduction of instruments transnasally. This is not neces-
sary if the patient has a wide middle meatal space that
allows for the placement of multiple instruments simulta-
neously. The surgical site is visualized with the endoscope
through the trocar, while a blunt hook or suction tip is used
to dissect and isolate the vessel adjacent to the sphenopala-
FIGURE 1. A large middle meatal antrostomy is created. The
mucosa is elevated in a subperiosteal plane at the posterior
margin of the antrostomy (dotted line). Abbreviations: MT, middle
turbinate; IT, inferior turbinate; PWA, posterior wall of antrum.
ENDOSCOPIC LIGATION
FIGURE 2. The sphenopalatine foramen is located posterior to
the antrostomy near the superomedial corner of the maxillary
sinus.
tine foramen laterally (Fig 4). It is not necessary to isolate
all of the branches of the internal maxillary artery. Unneces-
sary dissection also increases the risk of hemorrhage from
other branches and injury to sensory and autonomic
nerves.
The sphenopalatine artery may be coagulated or ligated.
A flat hemoclip applier is preferable to a barrel-shaped
applier due to its decreased diameter. A blunt hook is used
to elevate the vessel while the hemoclips are applied. Two
medium-size hemoclips are placed on the sphenopalatine
artery immediately lateral to the sphenopalatine foramen
(Figs 5A and 5B). The distal branches of the sphenopalatine
artery may also be ligated to provide additional security
against a dislodged hemoclip or collateral circulation (Fig
6). Additional hemostasis may be obtained using endo-
scopic bipolar electrocautery. A piece of Gelfoam is placed
over the exposed vessels. Silastic splints are placed intrana-
FIGURE 3. Once the sphenopalatine artery is identified where it
exits the foramen, a fine-tip rongeur is used to trace the artery
laterally into the pterygopalatine fossa.
SNYDERMAN AND CARRAU
FIGURE 4. After removal of bone from the posterior wall of the
antrum (PWA), the course of the sphenopalatine artery in the
pterygopalatine fossa (PTF) can be observed. The distal portion
of the vessel is carefully dissected free from the adipose tissue
using a blunt hook and suction.
sally for 5 to 7 days to prevent postoperative synechiae
between the nasal septum and turbinates. Nasal packing is
rarely needed. If it is necessary to place adsorbent packing
in the nose such as a Merocel splint, it should be carefully
inserted under endoscopic visualization to avoid dislodg-
ing the hemoclips.
The patient may be discharged within 24 hours with
instructions to use a saline nasal spray. Periodic examina-
tions with gentle cleaning of the nasal cavity is performed
over the next few weeks. Mucosalization of the surgical site
is usually complete within several weeks.
PATIENTS AND RESULTS
We have performed endoscopic sphenopalatine artery
ligation on 15 patients for epistaxis. Indications for surgery
included acute epistaxis requiring anterior and posterior
nasal packing (13 patients), a history of frequent recurrent
posterior epistaxis (1 patient), and recurrent epistaxis in
the presence of Osler-Weber-Rendu disease (1 patient).
Patients ranged in age from 49 to 80 years. The ratio of
male to female patients was 8:7. One patient had a
transantral ligation of the internal maxillary artery previ-
ously, and one patient had embolization of the internal
maxillary artery previously.
All patients underwent surgery under general anesthe-
sia. Ten patients (67%) underwent ligation of the anterior
ethmoid artery at the same time due to difficulty in
localizing the site of hemorrhage. Posterior ethmoid artery
ligation was performed in only one patient. The number of
terminal vessels ligated ranged from one to three. These
included intranasal branches of the sphenopalatine artery.
The internal maxillary artery and its branches were ligated
in the pterygopalatine space endoscopically in two pa-
tients. Two patients underwent bilateral sphenopalatine
artery ligations as one surgical event.
The majority of patients were discharged after 24 hours
of observation postoperatively. The two patients who
underwent elective sphenopalatine artery ligation for a
history of recurrent epistaxis were treated as outpatients.
87
 B

FIGURE 5. If there is adequate space

for instrumentation, hemoclips may be
applied to the sphenopalatine artery
under endoscopic guidance through
the middle meatus (A). If there is too
much bleeding or insufficient space, it
is helpful to use a transantral approach
for the endoscope (B). This allows the
introduction of a hook or suction
intranasally in addition to the hemoclip
applier.

Recurrent epistaxis developed in two patients within 24 ethmoid artery. In the other patient, nasal endoscopy
hours of surgery. In one of these, the bleeding site was revealed dislodgment of the hemoclips from the spheno-
localized to the anterior ethmoid artery, and the patient palatine artery, which was thought to be secondary to the
was successfully treated with ligation of the anterior placement of an intranasal tampon at the end of the

88 ENDOSCOPIC LIGATION

FIGURE 6. After completion of the arterial ligation, hemoclips
have been placed on the sphenopalatine artery lateral to the
sphenopalatine foramen and its distal anterior and posterior
branches. ST, superior turbinate.
procedure. Repeat endoscopic ligation of the sphenopala-
tine and internal maxillary arteries was p e r f o r m e d success-
fully with no further bleeding.
There have been no complications directly attributable
to the endoscopic sphenopalatine artery ligation. Mucosal
erosions and synechiae have been observed secondary to
p r o l o n g e d nasal packing before surgery. Three patients
noted hypesthesia of the palate or gingiva postoperatively.
One of these had extensive nasal packing and cautery
preoperatively, and another patient had dissection and
ligation of the internal maxillary artery at the same time.
There have been no delayed hemorrhages with a m e d i a n
follow-up of 2 months (range, 1 to 13 months).
DISCUSSION
Endoscopic ligation of the sphenopalatine artery is a
simple p r o c e d u r e to p e r f o r m for surgeons experienced in
endoscopic surgical techniques. It seems to be as effective
as other techniques and has minimal morbidity. Specific
advantages c o m p a r e d with transantral approaches include
i m p r o v e d visualization, ligation of the terminal vessels,
decreased surgical time, decreased morbidity, decreased
hospitalization, and better patient acceptance. Because of
SNYDERMAN AND CARRAU
the low m o r b i d i t y and ability to p e r f o r m the surgery as an
outpatient, it m a y have applicability for the treatment of
patients with less severe but recurrent epistaxis.
The surgical technique continues to evolve. The availabil-
ity of smaller hemoclip appliers and endoscopic bipolar
electrocautery devices has greatly facilitated the surgery.
Additional experience is n e e d e d to refine the technique
and determine its limitations. We have also f o u n d endo-
scopic sphenopalatine artery ligation to be a useful adjunct
to endoscopic approaches for the resection of nasal or skull
base tumors.
CONCLUSIONS
Endoscopic ligation of the sphenopalatine artery m a y be
p e r f o r m e d transnasally with minimal morbidity. It is an
effective alternative to transantral ligation of the internal
maxillary artery for patients with epistaxis.
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