Role of Endoscopic Internal Maxillary Artery Ligation in Intractable Idiopathic Epistaxis

Abstract

The protocols for managing intractable idiopathic epistaxis have evolved with advances in endoscopic techniques. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) has been the treatment of choice for idiopathic intractable epistaxis. If TESPAL fails, transantral ligation of internal maxillary artery (IMA) used to be the dictum along with radiological interventions. Here we discuss about the role of endoscopic IMA ligation in cases of failed TESPALs. Retrospective study at a tertiary hospital was performed. 28 cases of intractable idiopathic epistaxis underwent TESPAL in our institution of which 2 cases had rebleed. We also had two referred cases of failed TESPALS. Of this 4 patients, three patients underwent endoscopic IMA ligation and one patient underwent selective embolisation. All the patients who underwent endoscopic IMA ligation for failed TESPAL had no further episodes of epistaxis. One patient who underwent selective embolization also had no further episodes of bleed but had transient facial pain and trismus. When TESPAL fails, endoscopic IMA ligation can be considered as an alternative procedure before resorting to embolization.

Keywords: Endoscopic internal maxillary artery (IMA) ligation; Intractable idiopathic epistaxis; Transnasal endoscopic sphenopalatine artery ligation (TESPAL).

Fig. 1

Internal maxillary artery (IMA) being identified and lifted up in the left pterygopalatine fossa

Fig. 2

Application of liga clips ® (*) over IMA in the left side. (Liga clip® applied on the descending palatine artery can also be seen [blue arrow])

Fig. 3

Right pterygopalatine fossa showing sphenopalatine artery (SPA) and descending palatine artery (DPA) arising from internal maxillary artery (IMA)

Fig. 4

a Anterior and posterior branches (Black arrows) arising from SPA (yellow arrow). b The main SPA trunk being ligated using liga clip® in the left nasal cavity

Fig. 5

a SPA trunk (yellow arrow) in the right nasal cavity being identified and cauterized, b Cauterized Spa trunk cut (blue arrow). c A posterior branch of SPA which branched before exiting the sphenopalatine foramen (marked as blue arrow) being identified by elevating the mucoperiosteal flap posteriorly up to the choana. d Posterior branch cauterized and cut (black arrows showing cauterized and cut branches)

Fig. 6

The scheme of the locations of the division point of the maxillary artery, where it divides into the descending palatine artery and the sphenopalatine artery in the pterygopalatine fossa