Answer
If bleeding occurs high in the nasal vault, consider ligation of the anterior ethmoidal artery, the posterior ethmoidal artery, or both. These arteries are approached through an external ethmoidectomy incision.
The anterior ethmoidal artery is usually found approximately 22 mm (range, 16-29 mm) from the anterior lacrimal crest. If clipping the artery does not stop the bleeding, then the posterior ethmoidal artery may be ligated. This artery is found approximately 12 mm posterior to its anterior counterpart. It should be clipped, not cauterized, because it is only 4-7 mm anterior to the optic nerve.
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Media Gallery
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Posterior epistaxis from the left sphenopalatine artery.
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Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery.
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Nasal speculum.
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Vaseline gauze packing.
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Expandable (Merocel) packing (dry).
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Nasal vascular anatomy
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