How is arterial ligation performed on the internal maxillary artery in the treatment of epistaxis (nosebleed)?

Updated: May 08, 2020
  • Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Internal maxillary artery ligation has a higher success rate than ECA ligation because of the more distal site of intervention.

Traditionally, the internal maxillary artery is accessed transantrally via a Caldwell-Luc approach. With the help of an operating microscope, the posterior sinus wall is removed in a piecemeal fashion, and the posterior periosteum is carefully opened. The internal maxillary artery and 3 of its terminal branches (ie, sphenopalatine, descending palatine, pharyngeal) are elevated with nerve hooks, then clipped. The posterior sinus wall is then packed with Gelfoam, and the gingivobuccal incision is closed.

More recently, transoral and transnasal endoscopic approaches have been described. The transoral approach is useful in patients with midface trauma, hypoplastic antra, or maxillary tumors.

In the transoral approach, the buccinator space is first entered through a gingivobuccal incision. The buccal fat pad is removed, and the attachment of the temporalis to the coronoid process is identified. This process facilitates the identification of the internal maxillary artery. The vessel is then doubly clipped and divided. This procedure has a higher failure rate than the transantral approach because the site of ligation is more proximal.

The transnasal endoscopic method requires skills with endoscopic instruments. A large middle meatal antrostomy is made to expose the posterior sinus wall. The middle turbinate can be partially resected to ensure adequate exposure. The remaining steps are similar to those of the traditional transantral approach.

Endoscopic technique can also be used to ligate the sphenopalatine artery at its exit from the sphenopalatine foramen. [24, 25] An incision is made just posterior to the posterior attachment of the middle turbinate. The mucosal flap is then carefully elevated to reveal the sphenopalatine artery, which is then clipped and ligated.

A study by de Bonnecaze et al indicated that transnasal endoscopic sphenopalatine artery ligation (TESPAL) is about as effective as embolization in controlling intractable epistaxis but results in a lower complication rate. Both procedures had a 1-year success rate of 75%, while the minor and/or major complication rate was 18% for TESPAL, compared with 34% for embolization. [26]

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