Sphenopalatine Artery Ligation Research Articles

Sphenopalatine artery pseudoaneurysm masquerading as a second primary maxillary carcinoma.

Maxillary sinus carcinomas usually present as a locally advanced disease at the time of diagnosis and it is extremely unusual to have a second primary maxillary carcinoma on the contralateral side after many years of completion of treatment of the first malignancy. We present here a case report of a sphenopalatine artery (SPA) pseudoaneurysm mimicking the second primary maxillary carcinoma. We reviewed the literature for SPA pseudoaneurysm. This report describes the case of a 90-year-old man with a background of adenoid cystic carcinoma of the right maxillary sinus, diagnosed and treated with surgery and radiotherapy 14years ago, who presented with a history of multiple episodes of epistaxis. The radiological evaluation showed a heterogeneously enhancing mass with a central hemorrhagic component and surrounding bony erosions in the left maxillary sinus and the patient was planned for biopsy from the suspicious mass along with SPA ligation. However, on opening the maxillary antrum there was excessive bleeding and it was determined unsafe to proceed further. The patient was subsequently taken to interventional radiology for diagnostic angiography which revealed an SPA pseudoaneurysm that was subsequently embolized successfully. Sphenopalatine artery pseudoaneurysms should be considered as a differential for recurrent epistaxis in patients with a history of sinonasal malignancy. In such cases, endovascular embolization is a viable management option.

An update on simulation training in rhinology: a systematic review of evidence.

Rhinological procedures demand a high degree of technical expertise and anatomical knowledge. Because of limited surgical opportunities, ethical considerations and the complexity of these procedures, simulation-based training has become increasingly important. This review aimed to evaluate the effectiveness of simulation models used in rhinology training. Searches were conducted on PubMed, Embase, Cochrane and Google Scholar for studies conducted between July 2012 and July 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis ('PRISMA') protocol defined a final list of articles. Each validated study was assigned a level of evidence and a level of recommendation based on the Oxford Centre of Evidence-Based Medicine classification. Following exclusions, 42 articles were identified which encompassed six types of simulation models and 26 studies evaluated validity. The rhinological skills assessed included endoscopic sinus surgery (n = 28), skull base/cerebrospinal fluid leak repair (n = 14), management of epistaxis and/or sphenopalatine artery ligation (n = 8), and septoplasty and septorhinoplasty (n = 6). All studies reported the beneficial impact of their simulation models on trainee development. Simulation training in rhinology is a valuable adjunct to traditional surgical education. Although evidence is of moderate quality, the findings highlight the importance of simulation-based training in rhinology training.

Surgical management of intractable epistaxis:Endoscopic sphenopalatine artery coagulation

<b>Introduction:</b> Epistaxis is one of the most common challenges for emergency departments. Hypertension is regarded as a risk factor of epistaxis. Anticoagulant therapy in hypertensive patients increases the risk of nosebleed even more. Approximately 10% of patients with epistaxis require hospital admission for this condition, some of which need surgical intervention. Management can be problematic, mainly in case of recurrent posterior epistaxis. Over the past decade, with the widespread popularization of endoscopic sinus surgery and the deeper understanding of local regional anatomy, endoscopic control of the sphenopalatine artery (SPA) has been advocated as an effective alternative for the control of posterior epistaxis.</br></br> <b>Aim:</b> The aim of this article is to familiarize the reader with local anatomy and surgical technique of SPA ligation/coagulation.</br></br> <b>Material and method:</b> The SPA ligation or coagulation is indicated for intractable epistaxis, which is defined as recurrent bleeding despite adequate anterior and posterior nasal packing. The sphenopalatine artery (SPA) is a terminal branch of the internal maxillary artery, which is a branch of the external carotid artery. The SPA supplies the turbinates, the lateral nasal wall and nasal septum. The most important anatomical landmark enabling to identify the artery at its entry to the nasal cavity is crista ethmoidalis, which is typically located above the sphenopalatine foramen. The artery can be localized with or without creating the middle antrostomy. Locating the SPA without opening of the maxillary sinus can be challenging for inexperienced surgeon. The middle-meatal antrostomy prior to SPA ligation reveals more anatomical landmarks. Efficacy of SPA coagulation/ligation ranges between 74 to 100%. Failure to localize all the branches of the SPA is regarded as the most common reason for re-bleeding. Complications of the procedure are rare, mild and transient.</br></br> <b>Conclusion:</b> Endoscopic sphenopalatine artery coagulation or ligation is a safe and effective technique for controlling persistent posterior epistaxis. Understanding the anatomic relationships is important in performing this procedure. It has become established standard treatment for intractable epistaxis.

Endoscopic Management of Sinonasal Vascular Tumors Without Embolization: Our Experience with Vessel Ligation

ABSTRACT Objective: To present our surgical experience and technique in performing endoscopic sinus surgery for vascular sinonasal tumors without pre-operative embolization using intraoperative ligation of the external carotid artery or its distal branches. Methods: Design: Retrospective Series Setting: Tertiary Private Teaching Hospital Participants: Seven Patients Results: Out of 7 patients (5 males, 2 females, aged 12 to 64 years old) with non-embolized vascular sinonasal tumors, 2 had juvenile angiofibroma, 3 had a benign vascular tumor (hemangiopericytoma, hemangioma and a vasoformative solitary fibrous tumor), and 2 had a malignancy (rhabdomyosarcoma, squamous cell carcinoma). Four (57.1%) had external carotid artery ligation, two (28.6%) had internal maxillary artery ligation and one (14.2%) had sphenopalatine artery ligation. The mean intraoperative blood loss was 2447.1 mL (range 900mL to 5,000mL) and average operation duration was 7.6 hours (range 2.9 hours to 14.5 hours). The average amount of transfused blood products was 1785.7mL (zero to 3,000mL). The average hospital stay was 7 days (range 2 to 13 days) with one post-operative complication (ICU admission for hypotension from intraoperative blood loss). Conclusion: Intraoperative ligation of the ECA or its distal branches to disrupt the vascular supply of sinonasal tumors may provide a viable means of preventing excessive intraoperative blood loss in patients with non-embolized vascular sinonasal tumors.

Peri and Postoperative Compli-cations of Endoscopic Posterior Limited Septoplasty Versus Con-ventional Method Septoplasty in Endoscopic Nasal Surgery

Background: A significant percentage of patients undergone endoscop-ic sinus surgery has septal deviation, that disturb adequate access to the osteomeatal complex or to the region of axilla of the middle turbinate. The good exposure is the most important key to a successful surgery. Straightening such a deflection improve the access to the work site on the lateral wall of the nasal cavity. Objective: To compare the peri and post operative complications be-tween conventional septoplasty (cottle's method) and the endoscopic posterior limited septoplasty in endoscopic sinus surgery. Patients and Methods: Forty patients (all of them had a limited posterior nasal septal deviation ,nasal and paranasal sinus pathology in addition to septal deformity),were selected and divided randomly into two equal groups, (by the type of surgery for septal correction. group A which underwent conventional (Cottle's septoplasty), while group B that had endoscopic type septoplasty). All patients were assessed in the otolaryn-gology department in AL- Immamain Al khadimain medical city, from October 2016 to November 2017.patients were evaluated pre and post operatively by clinical and endoscopical examination, and followed in a period of 1week, 1month and 3months post operatively. Results: Functional endoscopic sinus surgery was the most primary sur-gery done, followed by Dacrocystorhinostomy and Endoscopic spheno-palatine artery ligation .Most common intraoperative complication was mucosal flap tear which observed more in conventional group, .Regarding mean operative time for limited septoplasty it was shorter in endoscopic group .Synechia and delay wound healing as a post opera-tive complication was more in endoscopic group, while hematoma and perforation was more in conventional group. Conclusion: During endoscopic sinus surgery, limited posterior septal deviation can be corrected by endoscopic method which provides better direct visualization of the deviation, more conservative surgical manipu-lation, shorter in time and less intra and post-operative complications. Keywords: Functional Endoscopic Sinus Surgery( FESS), Dacrocysto-rhinostomy (DCR), ostiomeatal complex(OMC), deviated nasal sep-tum(DNS)

Comparative Study between Transnasal Endoscopic Sphenopalatine Artery Ligation and Cauterization in Posterior Epistaxis

Comparative Study between Transnasal Endoscopic Sphenopalatine Artery Ligation and Cauterization in Posterior Epistaxis

Peri-operative complications of sphenopalatine artery ligation: a 10-year series from two secondary care centres.

There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed. A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0-2657 days). Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0-8 times). Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

Efficacy of Trans-nasal Endoscopic Sphenopalatine Artery Ligation in the Management of Recurrent Posterior Epistaxis

Background: Recurrent posterior epistaxis is a challenging problem for most otolaryngologists. Of the several proposed treatment modalities, endoscopic ligation of SPA (Sphenopalatine artery) provides a simple and effective solution with relatively minor complications. Objectives: Aim of this study was to find out the success rate and complications of endoscopic ligation of SPA in the management of recurrent posterior epistaxis. Materials and Methods: This was an observational study conducted from Jan 2019 to Jan 2021. Total 60 patients were included in this study. Inclusion criteria were - recurrent epistaxis (at least 4 episodes in last 2 months) with bleeding point not seen in anterior rhinoscopy, Failure of previous conservative management with medications and nasal packing, age between 18–60 years of both sexes. All the patients underwent trans-nasal endoscopic Sphenopalatine artery ligation, and patients were followed up for 12 weeks to identify repeated bleeding and to evaluate complications. Results: In this study male to female ratio was 1.5:1. Mean age of study group was 44.66 (±8.62) years. No recurrent bleeding occurred in 51 (85%) and in 9 (15%) nasal bleeding occurred in the 2 months postoperative period. Anesthesia of incisor teeth occurred in 18 patients (30%), 22 patients (37%) complained about increased nasal crusting. Conclusion: Endoscopic ligation of Sphenopalatine artery shows good outcome in prevention of further episodes of epistaxis in most patients. Although some minor complications can occur, these are manageable. KYAMC Journal. 2021;12(3): 133-137

Variations in utilization and clinical outcomes for endoscopic sphenopalatine artery ligation and endovascular arterial embolization in a single multi-hospital network

PurposeEndoscopic sphenopalatine artery ligation (ESPAL) and endovascular arterial embolization (EAE) are increasingly common treatment options for patients with refractory epistaxis. The objective of this study was to compare the utilization pattern and clinical outcomes between these interventions within our single multi-hospital network. Materials and methodsA retrospective study of all patients undergoing ESPAL and/or EAE within any of the hospitals in a single healthcare network between 2008 and 2017 was conducted. We compared differences in procedure utilization with various hospital characteristics. Secondarily, we evaluated clinical outcomes and costs associated with each procedure. ResultsForty-three ESPAL and 33 EAE procedures were performed across 7 hospitals, with the majority of procedures being performed at teaching institutions (65% and 91%, p = .013). The majority of both interventions were performed in larger hospitals and EAE patients were more likely to undergo inter-hospital transfer compared to ESPAL patients (48.5% and 16.3%, p = .02). Success rates for ESPAL and EAE were comparable (95% and 93%); however, the median direct cost of treatment for EAE was significantly higher than the cost for ESPAL ($12984.89 and $5002.02, p < .0001). ConclusionsThe majority of both ESPAL and EAE interventions were performed at teaching and larger hospitals. Transfers occurring prior to EAE may have been due to the limited availability of interventional radiology services, and likely contributed to the increased cost of treatment. ESPAL is a known cost-effective management strategy and should be considered early in treatment algorithms of refractory epistaxis.

Survey Anatomical Features and Related Factors of the Sphenopalatine Foramen on Computed Tomography.

The aim of the research is to define anatomical features of the sphenopalatine foramen (SPF) and be related to the SPF on computed tomography (CT) such as shape, location, size of the SPF, the appearance of the ethmoidal crest, and the distance from SPF to some landmarks in the nasal cavity. As a result, surgeons could quickly determine the SPF location in transnasal endoscopic sphenopalatine artery ligation (TESPAL). A cross-sectional study was conducted. This study was carried out at Cho Ray hospital from August 2019 to June 2020. Image data from 55 patients who had been indicated sinuses CT. Results show that the SPF had a wide range of shapes: oval (20.9%), triangle (19.1%), circle (18.2%), racket shape (7.3%), hourglass shape (6.4%), and other shapes. In the anteroposterior dimension, the mean SPF was 5.72 ± 1.22mm. In the craniocaudal dimension, the mean SPF measured 5.62 ± 1.99mm. The SPF was mainly located in the superior meatus and in the transition between the middle and superior meatus. The most reliable anatomical landmark to find the SPF was the ethmoidal crest with an appearance rate of about 95.5%. The mean distances from SPF to anterior nasal spine, nasal floor, nasal septum, maxillary line, anterior head of the middle turbinate, choanal arch, and base lamella were 57.04 ± 3.11, 24.71 ± 2.90, 11.26 ± 2.09, 34.93 ± 2.07, 32.69 ± 3.30, 8.82 ± 1.65, and 8.07 ± 1.28mm, respectively. CT scan images in this study can provide information about anatomical features of the SPF, which contribute to the quick and efficient identification of the SPF before and during TESPAL.

Outcome of treatment for severe epistaxis: nasal packing and endoscopic sphenopalatine artery ligation

Background: Severe epistaxis is a frequent emergency condition encountered by otolaryngologists and is often treated with nasal packing. In the event of failure surgical treatment is considered. We aimed to evaluate the efficacy of Nasal Packing (NP) and Endoscopic Sphenopalatine Artery Ligation (ESPAL) as treatment of severe epistaxis in terms of failures and recurrences including risk factors. Methodology: Retrospective descriptive study of patients with epistaxis treated with NP, admitted to an ENT department from 2011-2017. If initial treatment with NP failed, patients were considered for ESPAL. Results: An analysis of 511 patients was performed. All patients were treated with NP at the time of admission, and 14% of pa- tients were treated with ESPAL due to failure of NP. The majority of patients was only admitted once. Twelve percent were readmit- ted within 30 days, 7% were readmitted &gt;30 days later. Treatment failure after ESPAL was 7.9%. No significant difference in the risk of readmission was found between patients treated with NP alone and patients treated with ESPAL. Conclusion: The majority of epistaxis patients were effectively treated with NP alone. We found good effect of ESPAL although no significant differences in risk of readmission NP vs. ESPAL were identified.

Epistaxis following post nasal swabbing – the new COVID related emergency?

Case overviewA patient who got admitted at term for an elective caesarean section underwent an ‘on admission’ routine nasopharyngeal swabbing for SARS-CoV-2. She developed resistant epistaxis one day after the procedure and was found to have a mucosal injury over the sphenopalatine artery entry point on the left side. She had to undergo an emergency caesarean section followed by endonasal sphenopalatine artery ligation. The epistaxis was successfully dealt with and the mother and baby were discharged 48 hours after surgery. ConclusionsProper training in nasopharyngeal swab technique is required. Departments need to consider having biodegradable nasal packing material for such instances. In such injuries early endonasal sphenopalatine artery ligation (ESPAL) should be considered as traditional methods available to us were not successful.

Endoscopic Sphenopalatine Artery Ligation in Posterior Epistaxis

Introduction: Posterior epistaxis brings us with a more challenging condition that can even threaten the life of a patient. Approaching the posterior nasal cavity is not an easy task because of its anatomical complexity and impending vision by turbinate. Increase endoscopic anatomic details of lateral nasal wall and endoscopic expertise with high definition camera leads to a higher success rate of endoscopic sphenopalatine artery ligation.Methods: This prospective study was conducted in patients with refractory posterior epistaxis between January 2017 to December 2019. All patient who had undergone Endoscopic Sphenopalatine artery ligation were included in this study. The site of bleeding was confirmed with the help of a rigid endoscope. Bipolar cauterization or clipping was performed to stop bleeding. Data analysis was done by using SPSS 26.0 version.Results: Twenty nine patients who had undergone Endoscopic sphenopalatine artery for posterior epistaxis were included during this study period. The mean age of the patient was 53.31 ± 18.65years. The site of bleeding was mostly from the left in 20 (75.9%) cases and 10 (34.4%) cases had severe bleeding that needed a blood transfusion. No recurrence of bleeding was found during follow up period. The severity of bleeding was significantly correlated with the age of patients (p&lt;0.003). Out of 29 patient, 27 patients had undergone bipolar diathermy and 2 patients clipping was done.Conclusion: Sphenopalatine artery ligation is an effective management strategy for surgical control of refractory epistaxis. The early timing of sphenopalatine artery ligation may lead to reductions in length of stay.

Success Rate of Endoscopic Sphenopalatine Artery Ligation for the Management of Refractory Posterior Epistaxis Patients in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Epistaxis is a common medical emergency with 5% to 15% of patients admitted for epistaxis will require surgical management as nasal packing has high failure rates. A modern endoscopic technique like Endoscopic Sphenopalatine Artery Ligation has increased in popularity for managing intractable posterior epistaxis. It has less complication and a high success rate. The study conducted to estimate the success rate of Endoscopic Sphenopalatine Artery Ligation of refractory posterior epistaxis among admitted patients in a tertiary care hospital. This is a descriptive cross-sectional study conducted from June 2019 to June 2020 at the Department of Otorhinolaryngology, Nobel Medical College and Teaching Hospital among the patient with refractory posterior epistaxis with the help of retrospective data. A convenient sampling method was used. These patients underwent endoscopic sphenopalatine artery cauterization for recurrent/intractable posterior epistaxis. Ethical clearance was taken from the Institutional Review Board. Data were analyzed in Statistical Package for the Social Sciences. Out of the total patient with refractory posterior epistaxis who underwent Endoscopic Sphenopalatine Artery Ligation, the overall success rate was 39 (95.12%). Among them, 25 (60.97%) males and 16 (39.02%) females underwent endoscopic sphenopalatine artery ligation. Twenty (48.78%) of them were unilateral whilst 21 (51.21%) were bilateral disease. About 2 (4.8%) cases had re-bleeding within 48 hours which was managed conservatively. Hypertension was found to be the most common comorbid condition followed by diabetes, chronic kidney. From our study, we conclude that the success rate for Endoscopic Sphenopalatine Artery Ligation in a patient with refractory posterior epistaxis was high.

Trans-nasal Endoscopic Sphenopalatine Artery Ligation in Epistaxis: Coblation Versus Electrocauterization.

Epistaxis is one of the most common emergencies encountered by otorhinolaryngologist. Although anterior epistaxis is easy to manage but posterior epistaxis is usually refractory. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) is now a well established surgical technique for the management of refractory epistaxis. Electrocauterization and clipping are the most common methods used for ligation. Coblation is an upcoming tool with promising results in endoscopic skull base surgeries and tonsillectomies but has not been explored much in TESPAL. It was a randomised observational study.50 patients of refractory epistaxis were included in the study. The patients were divided into 2 groups. Group A underwent TESPAL using electrocauterization while Group B underwent TESPAL using coblation. The data was collected and analysed for various parameters like experience of the surgeon, time taken for surgery, episodes of rebleeding and postoperative crusting. Out of 50 cases in our study 27 were males and 23 were females. Most common age group was 60-70years (68%). Most common cause was hypertension (86%). Surgeons were happy 21/25 times in coblation group compared to 9/25 times in electrocauterization group. There were 4/25 rebleeding episodes in electrocauterization group compared to none in coblation group. Post-operative crusting was also less in coblation group compared to electrocauterization. Though electrocauterization is a well established method for TESPAL our experience with coblation in TESPAL has been extremely satisfying. We suggest our colleagues to conduct more research studies on use of coblation in TESPAL to reach a consensus.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience.

Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15years in a single academic center. A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL). The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients. This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

Sphenopalatine Artery Ligation

Sphenopalatine Artery Ligation

Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications.

Today, there are still no uniform guidelines for the treatment of epistaxis. Furthermore, it is widely debated whether embolization or surgical approaches should be the first choice of treatment for intractable posterior epistaxis after conservative measures have failed. In several meta-analyses, it is reported that endoscopic sphenopalatine artery ligation and embolization have similar success rates, but embolization was associated with more severe neurological complications. Regarding existing literature, there are many comparative analyses of surgical methods but none for embolization protocols. Against this backdrop of a lack of uniform standards in embolization techniques, we present a retrospective evaluation of what has emerged to be best procedural practice for endovascular treatment of epistaxis in our department using microsphere particles and microcoils, in particular regarding precaution measures to avoid neurological complications. In our retrospective data analysis of 141 procedures in 123 patients, performed between 2008 and 2019, we find success rates very similar to those reported in other studies (95.1% immediate-stop-of-bleeding success and 90.2% overall embolization success) but did not encounter any major neurological complication opposed to other reports. We suggest some aspects of our protocol as precaution measure to avoid neurological complications. More generally and perhaps even more importantly, we make a strong case for standardization for embolization techniques to the level of details in surgical procedure standardization to enable an apples to apples comparison of embolization techniques to each other and of intervention vs. surgery.

Lasers in Rhinology-An Update.

A wide and evolving range of lasers and their applications often makes it difficult for a busy surgeon to choose the ideal laser for a specific indication. With this in mind, this article aims to summarize the most recent literature concerning laser application in rhinology. A literature search from 2000 to 2020 using the PubMed database was employed. Keywords used included "laser," "rhinology," "endonasal endoscopic surgery," "hereditary haemorrhagic telangiectasia," "rhinitis," "refractory rhinitis," "Inferior turbinate hypertrophy," "dacryocystorhinostomy," "septoplasty," "cartilage reshaping" and "choanal atresia." The most up to date studies published for each rhinology condition that could potentially be treated with laser surgery was included. Rhinological conditions appropriate for laser applications are discussed. We identified articles related to a number of applications including hereditary hemorrhagic telangiectasia, rhinitis, turbinate surgery, dacryocystorhinostomy, septoplasty, choanal atresia, and sphenopalatine artery ligation, paying attention to the outcomes of the studies and their limitations. There is currently no one-size-fits-all laser and therefore being up to date on the latest clinical application results can help the clinician decide which are the best treatments to offer their patients.

Endoscopic Sphenopalatine Artery Ligation

Endoscopic Sphenopalatine Artery Ligation