The Journal of Laryngology & Otology

October 2005, Vol. 119, pp. 810–812

Short Communications

Sphenopalatine artery ligation: technical note

DAVID D POTHIER, MRCS, DOHNS, SAMUEL MACKEITH, MBCHB, ROBIN YOUNGS, MD FRCS

Abstract
Epistaxis is a common problem. Most patients presenting to hospital will stop bleeding with simple first-aid
measures or with nasal packing. Those who do not stop will usually require surgical management. For persistent
posterior epistaxis, the sphenopalatine artery may be ligated as the artery leaves the sphenopalatine foramen
to enter the nasal mucosa of the lateral wall of the nose. This may be performed endoscopically. We describe
the anatomy of the area and the surgical technique. We also present a brief review of the literature on this
technique.
Key words: Epistaxis; Surgical Procedures, Operative

Introduction superior turbinate.8 This study also used a digital calliper to

Epistaxis is a common problem. Most patients presenting to measure the distance from the anterior part of the nose to
hospital will stop bleeding with first-aid measures or with the SPF. The distance from the SPF to the nasal sill was
nasal packing. The small number who do not stop will 59.4
4.2 mm and to the limen nasi was 49.1
3.7 mm.
usually require surgical management.1 The traditional This may serve as a useful reference point when trying to
surgical approach for posterior epistaxis involves a locate the foramen in the nasal cavity. During surgery, an
transmaxillary approach to the maxillary artery. This important landmark is the crista ethmoidalis, a small crest
requires a Caldwell-Luc incision and is associated with a arising from the palatine bone anterior to the SPA. Bolger
relatively high morbidity.2 Endoscopic ligation of the et al.9 dissected to the SPA in 22 cadavers and found the
sphenopalatine artery (ELSPA) achieves a higher success crista ethmoidalis closely related to the SPA in all
rate with fewer complications.3,4 The only reported 22 dissections. The artery was posterior in 21 dissections
and 3 mm inferior to the crista in the remaining dissection.
complication of ELSPA is necrosis of the inferior turbinate.5
The SPA usually divides into two or more branches prior
to its entry into the nasal cavity. In a study by Babin et al.,10
Anatomy in which 20 dissections were examined, the SPA divided in
The sphenopalatine artery (SPA) is one of the main vessels the infratemporal fossa in 18 cases, with only two cases
supplying the mucosa of the nasal cavity. It is the end-artery dividing in the nasal cavity. Passing through the foramen, 10
of the internal maxillary artery, a branch of the external of these had two branches, six had three branches, one had
carotid artery. It leaves the pterygopalatine fossa through four and one had five. Lee et al.8 confirmed these findings
the sphenopalatine foramen to enter the nasal cavity. The and showed that the most consistently identified vessels
SPA, through its branches, supplies the posterior nasal were the posterior lateral nasal branch and the nasal septal
septum and the most of the lateral nasal wall.6 artery. This is important to consider when attempting
The location of the sphenopalatine foramen (SPF) has ligation or cautery of the SPA as it may be necessary to
been described in Gray’s Anatomy as lying in the posterior identify more than one vessel exiting the foramen.
part of the superior meatus.7 However, more recent
cadaveric studies suggest there may be some variation in Equipment
this. Padgham and Vaughan-Jones6 described 16 out of 18 A standard equipment set used for functional endoscopic
dissections in which the SPF was under the cover of the sinus surgery (FESS) is usually sufficient. There are,
posterior part of the attachment of the middle turbinate; in however, extra instruments that can make the procedure
the other two it was above in the superior meatus. A more easier to perform:
recent cadaveric study involving 50 dissections found that
in 45 cases (90 per cent) the foramen was located within (1) Freer suction elevator (Karl Storz Endoscopy, Slough,
the superior meatus, between the middle turbinate and the UK). The suction fenestrations just proximal to the tip
posterior horizontal end of the lamella of the superior of this instrument reduce the amount of blood that can
turbinate. In the remaining five cases (10 per cent), the collect between the mucosal flap and the lateral bony
foramen was superior to the horizontal lamella of the nasal wall.

From the Department of Otolaryngology, Gloucester Royal Hospital, Gloucester, UK.

Accepted for publication: 12 April 2005.

810
SPHENOPALATINE ARTERY LIGATION 811

FIG. 1 FIG. 3
A mucoperiosteal flap is raised from the posterior margin of An endoscopic clip is applied to the artery.
the middle-meatal antrostomy.

(2) Dessi or Wormald diathermy forceps (Medtronic bleeding. The nose is then prepared in the usual way for
Xomed, Bristol, UK). These instruments both have a FESS. This may take the form of topical Moffat’s solution
narrow shaft and fine forceps at the end that can be or 10 per cent cocaine solution. Local anaesthetic with
actively opened and closed using a handle. If a standard adrenaline may be infiltrated into the lateral nasal wall
pair of diathermy forceps is used, it can become and into the middle turbinate. The authors favour creation
difficult to open the ends sufficiently while the shaft of of a middle-meatal antrostomy prior to SPA ligation.
the instrument is in the nasal cavity. The Wormald Removal of the uncinate process prior to middle-meatal
forceps have the added advantage of an integrated antrostomy opens the ethmoidal infundibulum thereby
suction that can be independently advanced. increasing the space for instrumentation. In addition, a
(3) Montgomery-Youngs SPA suction clip applicator (Karl middle-meatal antrostomy allows visualization of the
Storz Endoscopy). This instrument has been designed posterior wall of the maxillary antrum, giving an indication
with a narrow shaft and an angled distal end facilitating of the likely depth of the SPA in the nasal cavity. Not all
clip application. Straight clip applicators are often surgeons feel that an antrostomy is necessary. However, we
difficult to manipulate into the correct position feel that an antrostomy significantly eases SPA
alongside an endoscope. identification, particularly for trainee surgeons.
A mucoperiosteal flap is raised from the posterior
Surgical technique margin of the antrostomy (Figure 1) and dissected
posteriorly. The dissection is continued in a wide-based
The patient will normally come to the operating theatre fashion until the crista ethmoidalis is reached (Figure 2).
with nasal packs in situ and possibly with active epistaxis. As mentioned above, a reliable landmark at this stage is
Once general anaesthesia has been commenced the nasal the posterior wall of the maxillary sinus. The maxillary
packs can be removed and the nasal cavity examined artery runs directly behind this and the SPA usually enters
endoscopically in order to possibly identify the site of the nose directly adjacent to this structure.
Once the crista is identified, the artery is usually seen
tenting the mucosa posterior to it.This can be dissected out to
improve exposure and a clip or bipolar diathermy, or both,
applied (Figure 3). Inspection of the area will reveal whether
there is more than one vessel exiting the foramen. Dissection
may have to continue to the face of the sphenoid sinus in order
to locate and ligate or diathermy any remaining branches.The
flap can then be returned to its original position and the nose
packed if necessary. Post-operative care is as for endoscopic
sinus surgery, although the authors do not feel that rigorous
endoscopic nasal toilet is necessary in these patients.

Discussion
Sphenopalatine artery ligation is a safe and effective
technique for controlling persistent posterior epistaxis. It
can be performed with standard sinus surgery equipment
and is becoming established as the standard surgical
treatment for persistent posterior epistaxis.

FIG. 2 Acknowledgement
The crista ethmoidalis is seen as a crest arising from the We thank Mr D Gatland, Consultant Otolaryngologist, for
palatine bone in the lateral nasal wall. all of the images used in this paper.
812 D D POTHIER, S MACKEITH, R YOUNGS

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7 Gray TPPRH. Gray’s Anatomy. London: Running Press content of the paper.
Book Publishers, 2004 Competing interests: None declared