THE ENDONASAL COAGULATION OF THE SPHENOPA LATINE ARTERY IN SEVERE POSTERIOR EPISTAXIS

Background: Until a few years ago the surgical method of choice in tre ating uncontrollable nosebleeds from the posterior part of the nose wa s the transantral ligation of the maxillary artery as described by Sei ffert (Caldwell-Luc approach). We introduce a surgical method to expos e and coagulate the sphenopalatine artery through an endonasal approac h. Method: The middle meatus of the nose is exposed with a self suppor ting nasal speculum under the microscope (focus: 300 mm) and the maxil lary sinus is opened through the posterior fontanelle. The medial wall of the maxillary sinus is removed from this opening to its end. Three to five millimeters posterior to this site, the foramen sphenopalatin um is exposed. The osseous lateral margin of the foramen is resected w ith the drill and the fossa pterygopalatina is thereby opened from the nose. The sphenopalatine artery can be exposed all the way to its ori gin from the maxillary artery and then coagulated. Results: Thirty-one patients with severe epistaxis have been operated by this method sinc e October 1993. No postoperative complications were observed in any ca ses. Thirty patients have had no further nosebleed since than (average follow-up 22.9 months). In one case of a patient with renal insuffici ency a nose bleed occured 15 day postoperatively following dialysis. I t was controlled by ligation of the anterior ethmoid artery and of the peripheral branches of the external carotid artery. Conclusion: The e ndonasal coagulation of the sphenopalatine artery is the safest method to control bleeding from the posterior parts of the nose. It can be p erformed by anyone who is familiar with endonasal surgery. The disadva ntages of the transanteral ligation of the maxillary artery as describ ed by Seiffert (Caldwell-Luc approach, ligation not sufficiently perip heral) are avoided. The only competing method would be the embolizatio n of the sphenopalatine artery which can not be applied in every hospi tal and which has a higher complication and failure rate. Since Octobe r 1993 when this method was introduced no additional bellocq tamponade was required in epistaxis.