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Septal branches of the anterior ethmoidal artery: anatomical considerations and clinical implications in the management of refractory epistaxis

Abstract

Purpose

Epistaxis is a commonly presenting complaint. In severe cases, nosebleeds may occur despite antero-posterior nasal packing and often in the absence of identifiable sources of bleeding. In such cases, epistaxis may occur from septal branches of the anterior ethmoidal artery (sbAEA). The purposes of this study are to highlight the clinical role of the sbAEA in different fields of endoscopic endonasal surgery and to evaluate the efficacy and safety of their selective endoscopic endonasal ligation in the management of refractory epistaxis.

Methods

A retrospective review was performed of all patients presenting with epistaxis who underwent endoscopic endonasal coagulation of sbAEA in three Italian tertiary-care referral centers between October 2010 and October 2017.

Results

A total of 30 patients met the inclusion criteria. Sixteen patients had never experienced nosebleeds before, while 14 patients recalled previous epistaxes. Seventeen patients were treated under local anesthetic, while 13 required general anesthesia. No intra- or post-operative complications were observed and none of the patients received nasal packing after the procedure. In all cases the coagulation was effective in controlling the bleeding, with only two relapses in the series (2/30, 6.7%).

Conclusions

The sbAEA are of great interest in endoscopic endonasal surgery, both as surgical landmarks and as feeding vessels for a variety of pedicled nasal flaps. What is more, they can be crucial for the management of refractory epistaxis. Their selective endoscopic coagulation represents an effective and safe procedure in cases of difficult-to-control epistaxis from the upper nasal fossa, with several advantages over nasal packing.

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Author information

Correspondence to Mario Turri-Zanoni.

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Conflict of interest

All authors declare no conflict of interest and no financial relationship to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Electronic supplementary material

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Clinical case of a 47-year-old man with refractory epistaxis (right side). His medical history was significant for hypertension (blood pressure was 180/100 mmHg). He had received multiple nasal packing in the previous months. The endoscopic endonasal examination excluded bleeding from the classical sites, namely the Little’s area anteriorly, and the sphenopalatine region posteriorly. After removing some blood clots form the olfactory groove, the source of bleeding was identified on the upper part of the nasal septum in the region supplied by the septal branches of the anterior ethmoidal artery. The endoscopic endonasal ligation of such vessels under local anesthesia was able to successfully control the epistaxis. No nasal packing was placed after the surgical procedure. No recurrences of nosebleeds have been observed after 24 months of follow-up (MOV 43503 KB)

Clinical case of a 47-year-old man with refractory epistaxis (right side). His medical history was significant for hypertension (blood pressure was 180/100 mmHg). He had received multiple nasal packing in the previous months. The endoscopic endonasal examination excluded bleeding from the classical sites, namely the Little’s area anteriorly, and the sphenopalatine region posteriorly. After removing some blood clots form the olfactory groove, the source of bleeding was identified on the upper part of the nasal septum in the region supplied by the septal branches of the anterior ethmoidal artery. The endoscopic endonasal ligation of such vessels under local anesthesia was able to successfully control the epistaxis. No nasal packing was placed after the surgical procedure. No recurrences of nosebleeds have been observed after 24 months of follow-up (MOV 43503 KB)

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Turri-Zanoni, M., Arosio, A.D., Stamm, A.C. et al. Septal branches of the anterior ethmoidal artery: anatomical considerations and clinical implications in the management of refractory epistaxis. Eur Arch Otorhinolaryngol 275, 1449–1456 (2018). https://doi.org/10.1007/s00405-018-4964-x

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Keywords

  • Anterior ethmoidal artery
  • Anterior skull base
  • Endoscopic sinus surgery
  • Epistaxis
  • Extended frontal sinusotomy
  • Nosebleed
  • Sinus anatomy