Endoscopic SPA Ligation..

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Endoscopic Sphenopalatine Artery Ligation:

Prof. Hossam Thabet, M.D . Otolaryngology-Head & Neck Surgery Department Alexandria University Endoscopic Sphenopalatine Artery Ligation

بِسْمِ اللَّهِ الرَّحْمَنِ الرَّحِيمِ  قَالُوا سُبْحَانَكَ لاَ عِلْمَ لَنَا إِلاَّ مَا عَلَّمْتَنَا إِنَّكَ أَنْتَ العَلِيمُ الحَكِيمُ:

بِسْمِ اللَّهِ الرَّحْمَنِ الرَّحِيمِ قَالُوا سُبْحَانَكَ لاَ عِلْمَ لَنَا إِلاَّ مَا عَلَّمْتَنَا إِنَّكَ أَنْتَ العَلِيمُ الحَكِيمُ

Topics:

Topics Introduction Anatomy Indications Instruments Technique and pitfalls Results Conclusions

Introduction:

Introduction Around 20% of nose bleeds are posterior (Schaitkin, 1987) Posterior epistaxis poses a challenge. (O ’ Flynn and Shadaba, 2000) Failure rates of AP packing varies widely from 0%-52% (Pollice PA, 1997. Cannon CR,1993)

Anterior Epistaxis:

Anterior Epistaxis Kesselbach’s Plexus/ Little’s area: Located over lower ant. part of the septum Made by the anastmoses of: Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX )

Posterior Epistaxis:

Posterior Epistaxis Woodruff’s Plexus: Located at the posterior part of the middle turbinate Made by the anastmoses between : Pharyngeal & Post. Nasal A of Sph.P. A (IMAX) & the Ascending Pharyngeal Artery

Woodruff’s Plexus:

Woodruff ’ s Plexus

Introduction:

Introduction Transnasal endoscopic sphenopalatine artery (SPA) ligation has become a popular technique Published data suggest cessation of epistaxis in 90-100% of patients Individual study sample sizes are small,continuing audit of surgical outcome is required to validate these early results (Kumar et al, 2003 )

Epistaxis Treatment Cascade:

Epistaxis Treatment Cascade Sp.P.A ligation is not the 1st line therapy Direct therapy is best Nasal packing – if direct treatment fails Ligation or embolisation if packing fails

Epistaxis Treatment Cascade:

Epistaxis Treatment Cascade Focal application of SurgiFlo or FloSealTM Matrix (FM) to a bleeding focus in SPA region. The excess material should be suctioned or irrigated from the cavity after cessation of bleeding Hyaluronic acid ester rolled fabric ( a ) & carboxymethyl cellulose wafer ( b ) change in consistency to a gel-like form that coats mucosal surfaces when hydrated. ( c )

Epistaxis Treatment Cascade:

Epistaxis Treatment Cascade Ligation Hierarchy: Ligate as close to bleeder as possible Sphenopalatine Internal Maxillary External Carotid ? Anterior ethmoidal

Nasal Vascular Anatomy:

Nasal Vascular Anatomy The mucosa of the nasal cavity receives terminal branches from ICA & ECA with numerous anastomoses between these systems. A thorough understanding of this vascular anatomy is paramount in developing a stepwise approach to the management of epistaxis

PowerPoint Presentation:

a Arterial system of the head shown using latex infusion. b Detail showing the extensive blood supply to the nose. a b

PowerPoint Presentation:

Nasal Vascular Anatomy

Nasal Vascular Anatomy:

Nasal Vascular Anatomy The external carotid A: The internal maxillary artery (IMA) The facial artery. The internal carotid A: The anterior ethmoid A. The posterior ethmoid A. From The Ophthalmic A.

PowerPoint Presentation:

Diagram showing the distribution of nerve and arterial branches medial and lateral to the sphenopalatine foramen (after Janfaza et al. 2001, Lee et al. 2002, Pearson et al. 1969 1 Maxillary artery 2 Sphenopalatine artery 3 Foramen rotundum 4 Maxillary nerve 5 Inferior alveolar artery & nerve 6 Ostium of sphenoid sinus 7 Pterygopalatine ganglion 8 Mandibular nerve 9 Middle meningeal artery 10 Pharyngeal arterial branch 11 Optic chiasm 12 Inferior turbinate 13 Sphenomandibular ligament 14 Medial pterygoid muscle 15 Parotid gland 16 Oculomotor nerve 17 Pterygoid canal with vidian N.(from the greater superior petrosal nerve) and artery 18 Posterior septal artery (medial branch of Sp.P.A) 19 Superior and inferior posterolateral branches of Sp.P.A 20 Descending palatine artery 21 Posterior superior alveolar A 22 Infraorbital artery

PowerPoint Presentation:

Coronal view of the Lt. pterygomaxillary space demonstrating the IMA and its branches. Note the sphenopalatine ganglion and its branches more posteriorly

PowerPoint Presentation:

a Sagittal view of the lateral nasal wall demonstrates the branching pattern of the sphenopalatine, anterior ethmoid, and posterior ethmoid arteries. b Sagittal view of the nasal septum demonstrates the branching pattern of the posterior septal, anterior ethmoid, and posterior ethmoid arteries Nasal Vascular Anatomy

The Sphenopalatine Artery:

The Sphenopalatine Artery The IMA gives off numerous small branches while still proximal to the foramen, and it becomes the sphenopalatine artery close to the sphenopalatine ostium. The SPA is usually 3-5 mm in diameter, and divides into two larger branches 1.5-2mm in diameter; usually this occurs in front of the ostium and less commonly past it.

The Sphenopalatine Artery:

The Sphenopalatine Artery The smaller medial arterial branch (septal artery) runs under the lower part of the anterior wall of the sphenoid sinus to the posterior nasal septum The larger branch (posterior lateral nasal artery) distributes variable branches to the middle turbinate and posterior fontanelle and passes downward over the perpendicular plate of the palatine bone approximately 1 cm in front of the end of the middle turbinate (usually, but not always, behind the level of the posterior sphenoid sinus wall)

The Sphenopalatine Artery:

The Sphenopalatine Artery The SPA has 3-4 branches coming out of its foramen that lie at least 0.5 cm deep to the mucosa on the lateral nasal wall. The vessels split up as soon as they leave the foramen. The anterior branch of the SPA comes around the crista and can be found as it runs forward in the lateral nasal wall over the posterior fontanelle

:

Right lateral nasal wall after injection of pink latex into the arterial system, showing three branches of the sphenopalatine artery above the crista ethmoidalis (arrow) and one large branch below. The Sphenopalatine Artery

PowerPoint Presentation:

Arterial supply of the fontanelles in the posterior part of the middle turbinate (the posterior portions of the middle turbinate have been removed in the diagram). Variant a is the most common, and variants b-d are shown in descending order of frequency (from Lee et al. 2002). sT Superior turbinate mT Middle turbinate iT Inferior turbinate

PowerPoint Presentation:

UP ANPL Diagram of the right posterior middle turbinate, with portions of the middle turbinate (mT) removed. Variants of the posterior lateral nasal artery (ANPL). The yellow line represents the level of the anterior wall of the sphenoid sinus (from Lee et al. 2002). Sphenoidotomy extending far posteriorly will cause significant bleeding. UP Uncinate process sT Superior turbinate iT Inferior turbinate

Arterial Blood Supply Of The Nose:

Post.septal a Sp.P.A Sp.P.F Woodruff’s Plexus Post.lat.N.A Arterial Blood Supply Of The Nose

Arterial Blood Supply Of The Nose:

Arterial Blood Supply Of The Nose Ant. Ethmoid A. (septal br.) Post.Ethmoid A (Septal br.) Gr.P.A Incisive canal

PowerPoint Presentation:

The Sphenopalatine Artery

Ethmoid Arteries:

Ethmoid Arteries The posterior ethmoid artery was noted to be absent In up to 31% of cadaver dissections The anterior ethmoid artery was only absent in 10% of cases [17]. The average distance from the anterior lacrimal crest to the anterior ethmoid artery foramen was 18 mm , with the posterior ethmoid foramen located 10 mm more posterior. The posterior ethmoid artery can lie 1 – 2 mm anterior to the optic nerve.

Ethmoid Arteries :

Ethmoid Arteries Ophthalmic a. Optic N. Ant. Ethmoid A . Post.Ethmoid A. ICA

Ethmoid Arteries :

Ethmoid Arteries Ant. Ethmoid A . Post.Ethmoid A. Optic N.

The Sphenopalatine Foramen:

The Sphenopalatine Foramen The sphenopalatine foramen lies in the superior meatus near the posterior end of the middle turbinate in 90% of cases (Lee et at. 2002). Next to it, the sagittally oriented perpendicular plate of the palatine bone forms an ethmoid crest to which the posterior part of the middle turbinate is attached. This bony prominence can serve as a landmark: in 35% of cases the foramen is directly behind the crest, in 56% the bony ridge is interrupted by the foramen, in 9% there are two foramina - one in front of and one behind the ethmoid crest, i.e., in the middle and superior meatus (Bolger et at. 1999, Warning and Padgham 1998)

The Sphenopalatine Foramen:

The Sphenopalatine Foramen Lateral to the sphenopalatine foramen is the highly variable pterygopalatine fossa (Bagatella 1986). The opening of the pterygoid canal with the "vidian nerve" lies posteriorly, 3 mm lateral to the sphenopalatine foramen. The canal and nerve can be demonstrated on the lateral floor of the sphenoid sinus in almost 20% of cases. The foramen rotundum (maxillary nerve) is located higher than the pterygoid canal and 8 mm farther laterally. In approximately 30% of cases this nerve forms a rominence in the lateral wall of the sphenoid sinus (Bagatella 1986, Lang 1988)

The Sphenopalatine Foramen:

The Sphenopalatine Foramen The foramen becomes a slit whose anterior margin is a lateral “ knuckle ” of bone called the crista ethmoidalis (Wareing and Padgham, 1998). The crista ethmoidalis comes off the lateral nasal wall near the root or posterior−inferior base of the middle turbinate .

PowerPoint Presentation:

Relationship of the posterior extension of the middle turbinate to the spheno-palatine foramen. The ethmoid crest is interrupted by the sphenopalatine foramen (from Wareing and Padgham 1998).

PowerPoint Presentation:

The palatine bone is composed of a perpendicular and a horizontal plate. The perpendicular plate of the palatine bone covers the posterior border of the maxillary hiatus. It has articular surfaces for the articulation of the inferior and middle turbinates

PowerPoint Presentation:

a Right endoscopic view in a skull showing the crista ethmoidalis (arrow). b , c Closer views showing the sphenopalatine foramen (*) lying more laterally. a b C

PowerPoint Presentation:

A B C E D

Instrumentation:

a Stammberger endoscopic bipolar device (Karl Storz Endoscopy America). Instrumentation

Instrumentation:

b Wormald endoscopic bipolar device (Medtronic) Instrumentation

Instrumentation:

Endoscopic clip applier (Karl Storz Endoscopy America; recommended clips: ligating clip cartridge, medium titanium clips. Ligaclip Extra by Ethicon, Cincinnati, OH, USA) Instrumentation

PowerPoint Presentation:

Instrumentation

Technique and pitfalls:

Technique and pitfalls 3 techniques – Via a middle meatal antrostomy – Direct via middle meatus – Combined antroscopic approach -

Technique and pitfalls:

Technique and pitfalls The MMA approach – Infundibulotomy – MMA – Resect fontanelle – Create tunnels Accessory nasal artery 10%

Technique and pitfalls:

Technique and pitfalls The MMA approach a Endoscopic view of the left nasal cavity illustrates elevation of a medially based flap with exposure of the sphenopalatine artery (SPA) and its associated branches. The crista ethmoidalis is an important landmark for identification of the SPA ( asterisk ). b Endoscopic view of the left nasal cavity demonstrating bipolar cautery of the SPA

PowerPoint Presentation:

e Cutting the anterior branch of the sphenopalatine artery with microscissors. Note the crista ethmoidalis in front of the artery. f Drilling of the crista ethmoidalis to expose the foramen of the sphenopalatine artery. g The crista ethmoidalis has been removed to reveal several branches of the artery. h Note two cut branches of the sphenopalatine artery and an intact higher septal branch that will run on the anterior wall of the sphenoid e g f h

Technique and pitfalls:

Technique and pitfalls The Middle meatal approach – Good if meatus wide – May miss branches – Avoids antrosotmy

Technique and pitfalls:

Technique and pitfalls Combined MMA & antroscopic approach – Time consuming – Access to main trunk – Bi- manual technique Antroscope Ipisilateral nasal airway - instruments

Technique and pitfalls:

Technique and pitfalls Combined MMA & antroscopic approach

PowerPoint Presentation:

The left sphenopalatine artery ( SPA ) can be seen exiting posterior to the crista ethmoidalis ( CE ) on the endoscopic view. The cross-hairs on the CT panels show the spheno palatine foramen (best seen on axial CT) in the orthogonal planes. Note its relation to the lateral attachment of the middle turbinate and the posterior wall of the maxillary sinus

PowerPoint Presentation:

A large sphenoidotomy has cut the septal branch of the sphenopalatine artery as it runs across the anterior wall The septal branch being coagulated with unipolar suction diathermy

Technical Pitfalls:

Technical Pitfalls Anatomical Variations Arterial trauma Failed superior tunnel Failure to check for 2nd branch

Conclusion:

Conclusion Endoscopic intranasal diathermy or clipping of the SpA is a reliable procedure in controlling posterior epistaxis but has a consistent failure rate ~ 10%

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