Endoscopic Sphenopalatine Artery Ligation (ESPAL) for Epistaxis

Overview

Endoscopic Sphenopalatine Artery Ligation (ESPAL) is a minimally invasive surgical procedure used to control severe or recurrent epistaxis (nosebleed) by ligating the sphenopalatine artery, which is a common source of nasal bleeding.

Anatomy of the Sphenopalatine Artery

The sphenopalatine artery is a branch of the maxillary artery that supplies blood to the nasal cavity. It is a crucial artery in the nasal cavity and plays a significant role in the management of epistaxis (nosebleed).

Origin

The sphenopalatine artery arises from the maxillary artery in the pterygopalatine fossa.

Course

The artery passes through the sphenopalatine foramen, which is located in the posterior aspect of the lateral nasal wall.

Branches

The sphenopalatine artery gives off several branches that supply the nasal cavity, including

Distribution

The sphenopalatine artery supplies blood to the posterior parts of the nasal cavity, including the lateral wall and the nasal septum.

Importance

The sphenopalatine artery is a common source of bleeding in epistaxis, particularly in the posterior nasal cavity. Ligation or cauterization of this artery may be necessary to control severe or recurrent bleeding.

Clinical Significance

Understanding the anatomy of the sphenopalatine artery is essential for:

1. Managing epistaxis

Knowledge of the artery's location and branches is crucial for effective treatment.
2. Nasal surgery

Surgeons need to be aware of the artery's location to avoid injury during procedures.

In summary, the sphenopalatine artery is a vital artery in the nasal cavity that plays a significant role in supplying blood to the posterior parts of the nose. Its anatomy is essential for understanding and managing nasal bleeding and other nasal conditions.

Indications for ligation

1. Severe or recurrent epistaxis

When conservative measures fail to control bleeding.
2. Failed nasal packing or cauterization

When other treatments are ineffective.

Preoperative Preparation

1. Antibiotics

May be administered to prevent infection.
2. Tranexamic acid

May be used to reduce bleeding.
3. Blood transfusion

May be necessary if significant blood loss has occurred.

Operative Process

Anesthesia

The procedure is typically performed under general anesthesia.

Position of Patient

The patient is positioned in a supine position with the head elevated.

Types of Endoscope

0-degree endoscope

Provides a direct view of the nasal cavity.
30-degree endoscope

Offers a wider field of view and is useful for visualizing the sphenopalatine artery.

Procedure

1. Uncinectomy

Removal of the uncinate process to access the posterior fontanelle.
2. Middle meatal antrostomy

Creation of an opening in the middle meatus to access the sphenopalatine foramen.
3. Localization of the sphenopalatine artery

Identification of the artery and its branches.
4. Ligation of the main artery and branches

Clipping or cauterization of the sphenopalatine artery and its branches.

Management

Postoperative Management

1. Nasal packing

May be used to control bleeding and support the nasal mucosa.
2. Monitoring

Close monitoring of the patient's vital signs and nasal bleeding.
3. Nasal irrigation

Saline irrigation may be used to keep the nasal cavity clean and promote healing.
4. Intranasal corticosteroids

May be used to reduce inflammation and promote healing.
5. Liquid paraffin

May be applied to the nasal cavity to prevent crusting and promote healing.

Microscopy Compared to Endoscopy in SPAL

Endoscopy is generally preferred over microscopy for ESPAL due to its ability to provide a wider field of view and better illumination.

Contraindications to Endoscopic SPAL

1. Severe nasal septal deviation

May make it difficult to access the sphenopalatine artery.
2. Nasal tumors or masses

May obstruct the view or make it difficult to access the artery.
3. Previous nasal surgery

May make the procedure more challenging due to altered anatomy.

Endoscopic sphenopalatine artery ligation is a effective and minimally invasive procedure for controlling severe or recurrent epistaxis. Proper preoperative preparation, surgical technique, and postoperative management are essential for optimal outcomes.

Want to Know More of

Epistaxis

Nosebleeds (epistaxis) can be alarming, but most cases can be managed with simple first aid. Here’s what you need to know. . . . . . . . . . . . . . . . . . . . .

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