Acta Oto-Laryngologica

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ioto20

Endoscopic sphenopalatine artery

electrocoagulation for refractory epistaxis: a
clinical study

Liang Yu , Xiaofei Li , Shujuan Sun , Li Shi & Yuzhu Wan

To cite this article: Liang Yu , Xiaofei Li , Shujuan Sun , Li Shi & Yuzhu Wan (2020): Endoscopic
sphenopalatine artery electrocoagulation for refractory epistaxis: a clinical study, Acta Oto-
Laryngologica, DOI: 10.1080/00016489.2020.1808241

To link to this article: https://doi.org/10.1080/00016489.2020.1808241

Published online: 30 Aug 2020.

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ACTA OTO-LARYNGOLOGICA
https://doi.org/10.1080/00016489.2020.1808241

RESEARCH ARTICLE

Endoscopic sphenopalatine artery electrocoagulation for refractory epistaxis:

a clinical study
Liang Yu, Xiaofei Li, Shujuan Sun , Li Shi and Yuzhu Wan
Department of Otolaryngology–Head and Neck Surgery, Shandong Provincial ENT Hospital, Cheeloo College of Medicine,
Shandong University, Jinan, China

ABSTRACT ARTICLE HISTORY

Background: The electrical coagulation of sphenopalatine artery(SPA) under nasal endoscopy has Received 29 June 2020
gradually become an important surgical intervention for epistaxis Revised 29 July 2020
Aim: To investigate the effectiveness and complications of SPA electrocoagulation for epistaxis. Accepted 30 July 2020
Material and methods: The clinical data of 47 patients undergoing SPA electrocoagulation were ana-
KEYWORDS
lyzed, retrospectively. Refractory epistaxis; nasal
Results: Forty-seven patients were enrolled, with a male to female ratio of approximately 3:1. 11of 36 endoscopy; sphenopalatine
were under 45 years old, 25 of 36were 45 years old and above. Among female patients, one was under artery electrocoagulation
45 years old, and the others were 45 years old and above, but there was no significant difference in
gender composition between different age groups (v2 ¼ 1.069, p ¼ .301). All patients were unilateral
epistaxis. The effective control rates of epistaxis within 24 h after surgery, early postoperative, and late
postoperative were 100%, 100%, and 97.9%, respectively. There were 6 patients with complications,
including 3 patients with nasal dryness and ecdysis on the affected side, 2 patients with numbness on
upper lip, 1 patient with nasal adhesion and pus on affected side.
Conclusion and significance: Refractory epistaxis has no relationship with age and sex, SPA electrcoa-
gulation can effectively control refractory epistaxis and is an effective surgical method.

Introduction it is rarely reported worldwide on the effectiveness and

Refractory epistaxis is characterized by unclear bleeding
blood vessel, which mostly origins from the posterior nasal
cavity, and rebleeding after treatment. some patients would
rebleed after nasal packing and need further treatment in
the hospital [1]. Besides, the high recurrence rate and com-
plications, such as bradycardia, asphyxia and upper airway
obstruction, may threaten the patient life, especially for eld-
erly patients [2]. Sphenopalatine artery (SPA) electrocoagu-
lation should be considered as an option for the patients of
refractory epistaxis with unclear bleeding vessel. Budrovich
and Saetti [3], firstly reported that sphenopalatine artery
was ligatured to treat refractory epistaxis by endoscopic
combined microscope. However, at the early times of endos-
copy enrollment, the surgeons were unfamiliar with nasal
anatomy under nasal endoscopy, SPA is difficult to identify.
Thus, endoscopic mucosal surface diathermy in the sphen-
oid foramen area became a popular surgical procedure [4].
Closure of the sphenopalatine artery with vascular clipping
for refractory epistaxis under endoscopy was later reported
with the development of endoscopic surgery [5].
In recent years, with the improvement of nasal endos-
copy technology, the electrical coagulation of SPA under
nasal endoscopy has gradually become an important surgical
intervention for intractable nasal hemorrhage [6]. However,
complications with large samples. In the present study, 47
patients with refractory epistaxis were recruited and retro-
spectively analyzed, the effectiveness and complications of
SPA electrocoagulation in the treatment of refractory epi-
staxis were analyzed.
Materials and methods
Clinical data
Forty-seven patients with refractory epistaxis from January
2014 to December 2016 were retrospectively analyzed.
Patients with refractory epistaxis caused by trauma, nasal
sinus and nasopharyngeal tumors, nasal surgery, hereditary
telangiectasia, blood diseases, aneurysms, were excluded.
SPA electrocoagulation was performed on the affected side
after no bleeding vessel was identified in the nasal cavity
through nasal endoscopy.
Surgical procedure
All patients underwent operation in the general anesthesia,
gauze strips or other packing materials were removed from
the nasal cavity and 2% lidocaine cotton sheets containing
0.1% adrenaline were used to shrink the nasal mucosa.

CONTACT Yuzhu Wan wanyuzhu001@sina.com Department of Otolaryngology–Head and Neck Surgery, Shandong Provincial ENT Hospital, Cheeloo
College of Medicine, Shandong University, 4 Duan Xing West Road, Huaiyin District, Jinan, 250021, Shandong, PR China
ß 2020 Acta Oto-Laryngologica AB (Ltd)
2 L. YU ET AL.

Table 1. Gender composition of patients with refractory epistaxis in different

age groups.
gender <45 years old 45 years old Total
male 11 25 36
Female 1 10 11

Table 2. Effective rates of sphenopalatine artery electrocoagulation in different

time periods after surgery.
Within 24 h Early late
after postoperative postoperative
surgery (24h to 2 weeks) (> 2 weeks)
Cases with rebleeding 0 0 1
Cases without rebleeding 47 47 46

Table 3. Different type of complications after sphenopalatine artery

Figure 1. The sphenopalatine foramen and sphenopalatine artery of the right
nasal cavity were located by the cribriform cristae.
Common bleeding sites in the nasal cavity were examined
and excluded. Through the middle meatus of the affected
side, a curved incision was made in the lateral wall of the
nasal cavity 1 cm in front of the posterior end of the middle
turbinate. The upper end of the incision started at the hori-
zontal part of the middle turbinate plate, and the lower end
did not extend beyond the attachment point of then inferior
turbinate. The mucosa was cut through into the bone sur-
face, expose the top of the vertical plate of the palatine bone
and the sphenoid palatine notch, or find the ethmoid crest
and locate the sphenoid palatine aperture (Figure 1), the
ethmoidal ridges were bitten to reveal the sphenopalatine
notch, locate the sphenopalatine hole, reveal the sphenopala-
tine artery. The bipolar electrocoagulation cauterized and
disconnected the SPA. The mucosal flap is recovered and
the hemostatic gelatin sponge covers the mucosal flap.
Follow-up
The follow-up duration of all enrolled patients was
4–39 months, with a median of 9 months and no
lost visitors.
Statistical analysis
Statistical analysis software SPSS20.0 was used to analyze
the difference. Chi-square test was used for analysis, and
p < .05 was regarded as a statistical difference.
Results
Clinical characteristics of the patients
The cohort of 47 patients consisted of 11 women and 36
men. The mean age was 52 years (range 22–73years). As
shown in Table 1, eleven patients were under 45 years old
(30.6%), 25 patients were over 45 years old (69.4%) among
the male patients. Among female patients, 1 patient was
electrocoagulation.
complications The number of cases Incidence（%）
Nasal dryness and crusting 3 6.38
Numbness of the upper lip 2 4.26
Nasal adhesions and pus 1 2.13
Total 6 12.77
under 45 years old (8.3%), and 10 patients were over
45 years old (91.7%). Statistical analysis showed that there
was no significant difference in gender composition among
different age groups (v2 ¼1.069, p ¼ .301). In addition, all
the cases were unilateral nasal hemorrhage, among which,
25 cases on the left side and 22 cases on the right side, with
a ratio close to 1:1. No patients with bilateral simultaneous
nasal bleeding.
The effectiveness of electrical coagulation of SPA in the
treatment of refractory epistaxis
Forty-seven patients with unilateral nasal bleeding were
treated with electrocoagulation of SPA. We collected the
prognosis at different time points (Table 2), including
within 24 h after surgery, early (24 h to 2 weeks) after sur-
gery, and late (more than 2 weeks) after surgery. The results
showed that the effective rates of control bleeding were
100%, 100% and 97.9%, respectively. There was one case
with nasal bleeding more than 2 weeks after surgery.
Complications and prognosis of electrocoagulation of
the SPA
As shown in Table 3, six of 47 patients had complications,
the percent was 12.77%. Common complications included
nasal dryness and crusting (3/6), numbness of the upper lip
skin (2/6), nasal adhesions (1/6). Nasal endoscopy showed
that the scab disappeared and the mucosal flap healed, local
granulation tissue hyperplasia was seen one month after the
operation (Figure 2). After 3–6 months, the numbness of the
upper lip of the affected side disappeared.

Figure 2. Complications after electrocoagulation of the sphenopalatine artery in the right nasal cavity.
Discussion
In this study, 47 patients with refractory epistaxis after SPA
electrocoagulation treatment were recruited. Our results
showed that the number of male patients were 3 times more
than female patients, and male patients were older than
female patients. Some studies reported that the incidence of
nosebleed in men was higher than that in women before
50 years old, while there was no significant gender difference
in the incidence of nosebleed after the age of 50 [7]. The
results of this study are different from previous studies,
there is no significant difference in the gender composition
of patients of different age groups in this study. However,
we found that the incidence of nosebleed in female patients
after the age of 45 was higher than that before the age of
45, which may be caused by the fact that female patients
begin to enter the menopause at the age of 45, during which
estrogen level drops, leading to decreased protective effect
of estrogen on blood vessels [7]. It was reported that the
average age of patients with nosebleed is 60 years old [8].
The patients in this study are ranged from 22 to 73 years
old, with a median age of 52 years old. Our results were
consistent with previous studies that the average age of
nosebleed was 52 years old through analyzing the clinical
data of 189 patients.
Bleeding in the back of the nasal cavity would rebleed
even after anterior and posterior nasal picking treatment.
Surgery or embolization are effective for the refractory nose-
bleed [9]. Before nasal endoscopy was invented, ligation of
external carotid artery, maxillary artery and ethmoid artery
by surgery is the main method for the treatment of intract-
able epistaxis [10]. Although these methods are effective,
they may bring hemiplegia, thrombosis and other risks to
patients and increase the economic burden of patients. After
endoscopy is enrolled into nasal surgery, nasal endoscopy
can help the surgeon have a better vision at the posterior
area of the nasal cavity.
SPA supplies 90% of the nasal mucosa, including the
upper, middle and lower turbinate of the external wall of
the nasal cavity and the posterior lower part of the septum.
Studies have shown that SPA is responsible for most of the
posterior nasal hemorrhage [11]. Therefore, the SPA is the
preferred "target vessel" for the treatment of refractory epi-
staxis [11]. It can effectively avoid the risk of thrombosis
and hemiplegia to patients, reduce the number of days in
the hospital, and reduce the economic cost of health.
ACTA OTO-LARYNGOLOGICA 3
Although many studies have reported that the effective
rate of SPA electrocoagulation is between 77 and 100% [12],
there is still no major cases with large samples reported. It
is reported that the recurrence of nasal bleeding after nasal
surgery were divided into three stages: rebleeding in 24 h
after surgery, rebleeding in the early postoperative period
(24 h to 2 weeks after surgery), and rebleeding in the late
postoperative period (more than 2 weeks after surgery) [13].
According to this classification, the effective rate of SPA
electrocoagulation was 100% at 24 h after the operation and
at the early stage after the operation, and the effective rate
was 97.9% in the late postoperative period, with 1 patient
rebleeding 1 month after the electrocoagulation of SPA.
In this case, endoscopic examination of the nasal cavity
under local anesthesia was performed after rebleeding, and
pulsatile arterial bleeding was found in the nasal septum in
the olfactory fissure area. Bipolar electrocoagulation was
performed to stop the blood, and no rebleeding was
observed during follow-up. Considering the branch of the
septal surface of the anterior ethmoid artery may cause
bleeding, therefore, it is necessary to eliminate the common
position at the posterior end of the nasal cavity before the
SPA electrocoagulation. The SPA electrocoagulation should
be regarded as the ultimate treatment method for refractory
epistaxis. SPA electrocoagulation has little effect on epistaxis
caused by systemic diseases and is not suitable for localized
bleeding points. The former is conducive to the treatment
of primary diseases such as hematological diseases and liver
diseases, while the latter can be treated with nasal packing
or coagulation of bleeding points.
The number of branches from the sphenoid palatine
artery vary, with 2 branches accounting for 76%, 3 for 22%,
and 4 or more for 2% [7]. During the operation, if the main
trunk or branch of the SPA was not clearly identified,
incomplete electrocoagulation treatment would decrease the
success rate of postoperative hemostasis [14]. Therefore, it is
important to identify the main trunk of the SPA.
Anatomical studies have found that the appearance rate
of ethmoid crest was about 96%, which is located in front of
the sphenopalatine foramen [15]. Padua et al. found that the
ethmoid crest were mainly located in front of the sphenopa-
latine foramen [16]. Bolger et al. analyzed the anatomical
structure of 22 cadaver heads and found that the ethmoid
crest was located in front of the sphenoid palatine aperture
in 21 cadaver heads (95.5%), and it was located at 3 mm
4 L. YU ET AL.
behind the sphenoid palatine aperture in 1 cadaver head
(4.5%) [17]. Although studies have found that there are var-
iations in the position of ethmoid crest, ethmoid crest is still
an important bone marker for anatomical location of the
sphenoid palatine foramen [17].
Through anatomical studies of cadaveric heads, Padua
et al. found that the percent of accessory sphenopalatine for-
amen was about 10% [17]. Some authors also reported that
12 accessory sphenopalatine foramen were found in 28
cadaver heads, with the percent of 43% (12/28) [16]. During
electrocoagulation of the SPA, failure to fully dissect the
SPA and accessory sphenopalatine foramen may affect the
treatment of the deformed vessels in the accessory spheno-
palatine foramen. Therefore, the appearance of accessory
sphenopalatine foramen may affect the effective rate of SAP
electrocoagulation [18].
It was reported that the percent of complications after
SPA ligation or heat treatment was ranged from 0 to 53%,
common complications after the SPA electric coagulation
include nasal congestion, nasal crusts, adhesion, teeth, pal-
ate, upper lip skin numbness, acute sinusitis, etc. [1]. In
addition, there is a case reported that inferior turbinate
mucosal was necrosis after SPA ligation [19]. In this study,
we found that the percent of postoperative complications
was 12.77%, including dryness and scabbed formation on
the affected side of the nasal cavity, numbness of upper lip
skin, nasal adhesion and purulent nasal discharge. On one
hand, nasal mucosa could be hurt and cilia swing, glandular
secretion function could be affected during electrical coagu-
lation of the SPA, on the other hand, sphenopalatine gan-
glion and its branches might be damaged by
electrocoagulation due to unclear vision field caused by
nasal stenosis and bleeding of the nasal mucosa [16].
Therefore, some scholars proposed that it was feasible to
expand or open the maxillary sinus through the middle
nasal tract before the SPA was electrocuted [20]. In conclu-
sion, refractory epistaxis has no relationship with age and
sex, SPA eletrocoagulation can effectively control refractory
epistaxis and is an effective surgical method. The certain
controllable complications remain need attention.
Conclusion
Refractory epistaxis has no relationship with age and sex of
the patients, SPA electrocoagulation can effectively control
refractory epistaxis and is an effective surgical method. The
controllable complications remain need attention.
Disclosure
No potential conflict of interest was reported by the author(s).
Funding
This study was supported by the Natural Science Fund of China
[NSFC81900940] and Natural Science Doctor Fund of Shandong
[ZR2019BH022].
ORCID
Shujuan Sun http://orcid.org/0000-0001-5734-8217
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