Transantral ligation of the internal maxillary artery is the most widely used surgical technique for control of intractable epistaxis. It is a major contributor to the rich arterial plexus known as kiesselbachs plexus on the anteroinferior nasal septum. Anatomy, threedimensional reconstruction, and surgical technique pdf by peterjohn wormald by peterjohn wormald author the fact that peterjohn wormalds book on endoscopic sinus surgery is now entering its third edition speaks volumes about the popularity of his work. Posterior septal branches of sphenopalatine artery wikipedia. This article is the sixth in a series of 10 articles discussing the 31 root operations of icd10pcs. An instructional video on the surgical technique of a sphenopalatine artery ligation. Bilateral sphenopalatine ganglion block in functional endosc. Endoscopic ligation of sphenopalatine artery anatomy. Over the last decade endoscopic sphenopalatine artery spa ligation has become a popular treatment option for posterior epistaxis and. Sphenopalatine artery definition of sphenopalatine. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic ligation of the sphenopalatine artery as a. We investigated the surgical anatomy of the sphenopalatine artery.
It was performed endoscopic endonasal approach to the pterygopalatine fossa and ligation of the artery inside the pterygopalatine fossa for a proximal control. With an endoscopic approach, removal of the crista ethmoidalis helps visualize these branches. Sphenopalatineinternal maxillary artery ligation sciencedirect. Surgical anatomy of the sphenopalatine artery in lateral nasal wall. This book is distributed under the terms of the creative commons.
Endoscopic sphenopalatine artery ligation csurgeries. Here we present a case of epistaxis arising from the sphenopalatine artery in a patient who had previously had the ipsilateral external carotid artery ligated due to previous epistaxis. Pdf epistaxis is the commonest emergency in otorhinolaryngology. Endoscopic ligation of the anterior ethmoidal artery. The failure rate of the sphenopalatine artery ligation has been described varying from 2 to 10%, and it may occur because of anatomical variations found in these region. The sphenopalatine artery and its branches were identified in 75 specimens. Epistaxis is the most common emergency presenting to the ent surgeon. Current trends dictate that posterior packing should be replaced by the endoscopic ligation of the sphenopalatine artery in cases of posterior bleeding to reduce morbidity and patient discomfort levels 6.
We evaluated the number of branches emerging from the. Knowledge of the vascular anatomy and important landmarks is necessary to avoid intraoperative bleeding and to lower the risk of postoperative bleeding. A new technique that is gaining popularity is dopplerguided hemorrhoidal artery ligation hal or transanal hemorrhoidal dearterialization thd. Health, general arteries medical examination nosebleed case studies. Endoscopic cauterization of the sphenopalatine artery to. Selection of our books indexed in the book citation index. Endoscopic sphenopalatine artery ligation hns preferences. Internal maxillary artery surgery requires a caldwellluc procedure to be performed as the first step, which results in cheek pain in many cases. This technique is increasingly considered to be an essential component of training for any otolaryngologist and can greatly reduce periods of nasal packing and active bleeding for your patients and length of.
The technique we describe involves the use of standard fess instruments and a ligge clip applicator. Surgical management of epistaxis is typically only for those patients whose bleeding is refractory to more conservative therapies. Spa ligation is generally indicated for intractable posterior. Posterior epistnxis from branches of the sphenopalatine artery can be rapidly and effectively controlled by a new ligation technique. Pdf the anatomy of the sphenopalatine artery for the endoscopic. The sphenopalatine artery is nowhere near the external portion of the nose during the rhinoplasty procedure. Article information, pdf download for sphenopalatine artery ligation for epistaxis, open epub for. Spa ligation is usually performed under general anesthesia. Endoscopic ligation of the sphenopalatine artery for epistaxis. It is colloquially know as the artery of epistaxis given its common involvement in cases of nose bleeds. The other two failures were successfully corrected with anterior ethmoidal ligation. Rudmik and leung evaluate the costeffectiveness of transnasal endoscopic sphenopalatine artery ligation vs endovascular arterial embolization for intractable e. Costeffectiveness analysis of endoscopic sphenopalatine. Epistaxis may be classified clinically into anterior and posterior bleeds.
The patients hemoglobin and hematocrit at presentation were 8. Endoscopic sphenopalatine artery ligation in posterior. Here it gives off its posterior lateral nasal branches crossing the under surface of the sphenoid, the sphenopalatine artery ends on the nasal septum as the posterior septal branches. Endoscopic clip appliers facilitate clip application. Sphenopalatine artery an overview sciencedirect topics. It provides 90% of the blood supply to the nasal cavity i. This simple, inexpensive procedure may provide a relatively lowrisk option for the treatment of chronic migraines. Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis.
Different sources of trauma or pathological conditions of the nose may lesion the sphenopalatine artery and cause profuse posterior nasal bleeding. External carotid artery surgery requires an open neck procedure, which involves neck incision with possible sacrifice of other important arteries such as the facial and lingual arteries. Surgical techniques the technique used for sphenopalatine artery ligation was analyzed. Crista ethmoidalis serves as landmark just anterior to sphenopalatine foramen. Endoscopic sphenopalatine artery ligation or diathermy. The sphenopalatine artery or its branches arc directly ligated. All surgical procedures were performed with the aid of a 0 endoscope. Most professional coders use to recommend 30999 or 31299, but using these codes are also found to be controversial due to. A nasoseptal flap is a surgical technique used in skull base. Request pdf sphenopalatine and anterior ethmoidal artery ligation for severe. No, youll need to use an unlisted code such as 30999. Sphenopalatine and anterior ethmoidal artery ligation for severe. The purpose of this study was to examine the effects of bilateral sphenopalatine ganglion block on the surgical conditions, haemodynamics, intraoperative blood loss, consumption of anaesthetics, recovery characteristics and postoperative pain relief during functional endoscopic sinus.
The sphenopalatine artery is a branch of the maxillary artery which passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus. Relative value update committee ruc process code changes for all medical specialties take effect on january 1, of each year as a result of the cpt editorial panel process. I dont see a cpt code for this procedure can i use 30920. Identifying the artery is not difficult, and this technique avoids external incisions. We analyzed 97 consecutive patients with nasal bleeding. On investigation the epistaxis was determined to arise from an anastamosis with the contralateral sphenopalatine artery. The vessels most frequently ligated to that end are the sphenopalatine and anterior ethmoidal arteries. With the advent of the endoscope, many traditionally open procedures are now being performed endoscopically rather than via the open approach. Crossing the under surface of the sphenoid the sphenopalatine artery ends on the nasal septum as the posterior septal branches. A new look at sphenopalatine ganglion blocks for chronic migraine. The alternative procedure of endoscopic ligation of the sphenopalatine artery at its exit from the sphenopalatine foramen avoids the morbidity associated with the transantral approach.
Discussion endoscopic ligation of the sphenopalatine artery is a simple procedure to perform for surgeons experienced in endoscopic surgical techniques. Given the unilateral presentation, antiplatelet therapy, and recently failed endoscopic control, the patient was taken to the operating room for transnasal endoscopic sphenopalatine artery ligation tespal with bipolar cautery. Other invasive options for refractory epistaxis are anterior ethmoid artery ligation and embolization of the internal maxillary artery by neurointerventional radiology. Subsequent treatment can consist of either surgical ligation or endovascular embolization of the arteries supplying the posterior nasal fossa. Patient with recurrent epistaxis after the nasal packing was removed. The sphenopalatine foramen is a notch on the upper margin of the palatine bone between the orbit and the sphenopalatine process. Pdf analysis of endoscopic sphenopalatine artery surgery. A new look at sphenopalatine ganglion blocks for chronic. Ligation of the anterior ethmoidal artery is commonly performed in patients with a history of trauma. The anterior and superior nasal septum is supplied by the anterior and posterior ethmoidal arteries which originate from the ophthalmic artery internal carotid artery system. Endoscopic sphenopalatine artery ligation is an effective. Sphenopalatine artery ligation and vidian neurectomy. Lee hy1, kim hu, kim ss, son ej, kim jw, cho nh, kim ks, lee jg, chung ih, yoon jh. The sphenopalatine artery ligation procedure was first.
Another administration technique is the lateral infratemporal approach. Coding root operations with icd10pcs understanding. Analysis of endoscopic sphenopalatine artery surgery for. Endoscopic ligation of the sphenopalatine artery as a primary management of severe posterior epistaxis in patients with coagulopathy. To describe the anatomy of the sphenopalatine foramen region and observe possible surgical implications during the ligation of the sphenopalatine artery.
He had facial trauma and fracture of the posterior of the maxillary sinus and the palatine bone. Endoscopic sphenopalatine artery ligation surgery video. Endoscopic cauterization of the sphenopalatine artery in. The american medical association ama is responsible for cpt and has convened the cpt editorial panel to develop and. From 2007 to 2012 17 patients were treated with cauterization andor ligature of the sphenopalatine artery with endonasal endoscopic approach. Surgical anatomy of the sphenopalatine artery in lateral. Professor wormald has an exceptional reputation worldwide as a teacher of endoscopic sinus. I did an endoscopic ligation of the left sphenopalatine artery for recurrent epistaxis in a patient with coumadininduced coagulopathy. Many epistaxis protocols now include endoscopic sphenopalatine artery ligation for bleeding that is refractory to packing. Sphenopalatine artery spa ligation vula university of cape town. Pdf sphenopalatine artery ligation under local anesthesia.
A critical audit of the surgical management of intractable. The sphenopalatine artery gives off two main branches. An operated case of inverted papilloma presented to us with recurrent episodes of profuse nasal bleeding necessitating the ligation of sphenopalatine artery. Anatomy of the sphenopalatine artery inferior turbinate the sphenopalatine artery spa is one of the terminal branches of the internal maxillary artery ima which originates from the external carotid artery system. The icer scatterplot is a technique used to visually demonstrate the costeffectiveness of all the different icers generated from the. The sphenopalatine artery, formerly known as the nasopalatine artery, is the terminal branch of the maxillary artery that is the main supply to the nasal cavity. Endovascular treatment of epistaxis american journal of.
Anatomical and surgical study of the sphenopalatine artery. It seems to be as effective as other techniques and has minimal morbidity. Pdf endoscopic endonasal ligation of the sphenopalatine. Epistaxis is the commonest emergency in otorhinolaryngology. Although this technique is highly efficacious, significant complications may occur, including oroantral fistula, damage to the infraorbital nerve, and recurrent bleeding. The sphenopalatine artery is the terminal branch of the maxillary artery and enters the nasal cavity through the sphenopalatine foramen, which is located behind the end of the middle turbinate corresponding to the inferolateral corner of the sphenoidal sinus fig. The guided reduction in arterial blood flow can be coupled with a mucosopexy when there is significant prolapse so that this aspect can be corrected and venous outflow can be improved. Endoscopic sphenopalatine artery ligation has become the standard surgical therapy for posterior. The surgical steps of endoscopic sphenopalatine artery ligation. Anatomy, head and neck, sphenopalatine artery statpearls. Endoscopic ligation of the sphenopalatine artery and the maxillary artery for.
Surgical technique acute haemorrhage in uncontrolled epistaxis is managed initially by injecting the pterygopalatine fossa through the greater palatine foramen in the roof of the hard palate with 1ml of 1. This study aimed to determine the safety and efficacy of sphenopalatine artery spa surgery in patients with refractory epistaxis and to identify factors associated with the indications for surgery to assist clinicians in making prompt and appropriate decisions regarding spa surgery for refractory epistaxis. Endoscopic sphenopalatine artery ligation in posterior epistaxis. The authors discuss and illustrate the possible reasons for failure.
Control of sphenopalatine artery bleeding surgery video. To clarify endoscopic anatomy of the sphenopalatine artery spa in relation to intranasal endoscopic landmarks using a human cadaver model and to simplify the surgical approach to spa ligation. Elective sphenopalatine artery ligation for recurrent epistaxis. After cottons impregnated with topical vasoconstrictor. Endoscopic sphenopalatine artery ligation karenzupko.
Historically, the definitive treatment for intractable posterior epistaxis consisted of transantral surgical ligation of branches of the internal maxillary artery ima, with or without ligation of the aea. It is important that the surgeon who undertakes ligation or cautery of the artery is aware of. To that end, mastery of the endoscopic surgical technique and profound knowledge of the noses vascularization are required for the success of the treatment. Note that the sagittal cuts are as if the patients right nose had been opened like a book. Intraoral ligation of the maxillary artery for intractable posterior epistaxis has been used. Read endoscopic sphenopalatine artery ligation or diathermy, operative techniques in otolaryngologyhead and neck surgery on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Endoscopic ligation of the sphenopalatine artery on vimeo. Further diathermy and division was therefore carried out on the residual branches of the sphenopalatine artery and there was no subsequent epistaxis. Sphenopalatine artery ligation has been shown to be associated with a shorter hospital stay and cost effectiveness compared with other surgical modalities.
Endoscopic cauterization of the sphenopalatine artery to control severe and recurrent posterior epistaxis. You look at those beautiful pictures in netters book of. Anatomy, threedimensional reconstruction, and surgical technique pdf. There are no contraindications for spa cauterization. Surgical implication of the endoscopic sphenopalatine.
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