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Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

  • A Ellinas (a1), P Jervis (a1), G Kenyon (a2) and L M Flood (a3)
Abstract Background:

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.


This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Corresponding author
Address for correspondence: Mr Liam M Flood, ENT Department, James Cook University Hospital, Marton Rd, Middlesbrough TS4 3BW, UK E-mail:
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1 Khan MK, Reda El Badawey M, Powell J, Idris M. The utility of FloSeal haemostatic agent in the management of epistaxis. J Laryngol Otol 2015;129:353–7
2 White PS. Endoscopic ligation of the sphenopalatine artery (ELSA): a preliminary description. J Laryngol Otol 1996;110:2730
3 Malcomson KG. The surgical management of massive epistaxis. J Laryngol Otol 1963;77:299314
4 Budrovich R, Saetti R. Microscopic and endoscopic ligature of the sphenopalatine artery. Laryngoscope 1992;102:1391–4
5 Sharp HR, Rowe-Jones JM, Biring GS, Mackay IS. Endoscopic ligation or diathermy of the sphenopalatine artery in persistent epistaxis. J Laryngol Otol 1997;111:1047–50
6 Wormald PJ, Wee DT, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis. Am J Rhinol 2000;14:261–4
7 Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl 1996;78:444–6
8 Spielmann PM, Barnes ML, White PS. Controversies in the specialist management of adult epistaxis: an evidence-based review. Clin Otolaryngol 2012;37:382–9
9 Hall AC, Simons M, Pilgrim G, Theokli C, Roberts D, Hopkins C. Epistaxis management at Guy's Hospital, 2009–2011: full audit cycles. J Laryngol Otol 2014;128:82–5
10 Hall AC, Blanchford H, Chatrath P, Hopkins C. A multi-centre audit of epistaxis management in England: is there a case for a national review of practice? J Laryngol Otol 2015;129:454–7
11 Syed I, Sunkaraneni VS. Evidence-based management of epistaxis in hereditary haemorrhagic telangiectasia. J Laryngol Otol 2015;129:410–15
12 Dedhia RC, Desai SS, Smith KJ, Lee S, Schaitkin BM, Snyderman CH et al. Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis. Int Forum Allergy Rhinol 2013;3:563–6
13 McDermott AM, O'Cathain E, Carey BW, O'Sullivan P, Sheahan P. Sphenopalatine artery ligation for epistaxis: factors influencing outcome and impact of timing of surgery. Otolaryngol Head Neck Surg 2015;154:547–52
14 Walen SG, Rudmik LR, Lipkewitch S, Dixon E, Mechor B. Training, practice, and referral patterns in rhinologic surgery: survey of otolaryngologists. J Otolaryngol Head Neck Surg 2010;39:297303
15 Feusi B, Holzmann D, Steurer J. Posterior epistaxis: systematic review on the effectiveness of surgical therapies. Rhinology 2005;43:300–4
16 Kumar S, Shetty A, Rockey J, Nilssen E. Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation? Clin Otolaryngol Allied Sci 2003;28:360–3
17 Aval S, Pabla L, Flood LM. The National Institute for Health and Clinical Excellence, and otolaryngology: review of the evidence. J Laryngol Otol 2014;128:212
18 Rockey JG, Anand R. A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy. Rhinology 2002;40:147–9
19 National Institute for Health Research. PROSPERO: International prospective register of systematic reviews. In: [19 January 2017]
20 McClurg SW, Carrau R. Endoscopic management of posterior epistaxis: a review. Acta Otorhinolaryngol Ital 2014;34:18
21 Loughran S, Hilmi O, McGarry GW. Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial. Clin Otolaryngol 2005;30:539–43
22 Cooper SE, Ramakrishnan VR. Direct cauterization of the nasal septal artery for epistaxis. Laryngoscope 2012;122:738–40
23 Daudia A, Jaiswal V, Jones N. Guidelines for the management of idiopathic epistaxis in adults: how we do it. Clin Otolaryngol 2008;33:618–20
24 Moshaver A, Harris JR, Liu R, Diamond C, Seikaly H. Early operative intervention versus conventional treatment in epistaxis: randomized prospective trial. J Otolaryngol 2004;33:185–8
25 Cassano M, Marioni G, Russo L, Cassano P. Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation. Acta Otolaryngol 2012;132:525–32
26 Cassano M, Russo L, Del Giudice AM, Gelardi M. Cytologic alterations in nasal mucosa after sphenopalatine artery ligation in patients with vasomotor rhinitis. Am J Rhinol Allergy 2012;26:4954
27 Cassano M, Cassano P. Epistaxis after partial middle turbinectomy: the role of sphenopalatine artery ligation. Am J Otolaryngol 2012;33:116–20
28 Asanau A, Timoshenko AP, Vercherin P, Martin C, Prades JM. Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis. Ann Otol Rhinol Laryngol 2009;118:639–44
29 Holzmann D, Kaufmann T, Pedrini P, Valavanis A. Posterior epistaxis: endonasal exposure and occlusion of the branches of the sphenopalatine artery. Eur Arch Otorhinolaryngol 2003;260:425–8
30 Umapathy N, Quadri A, Skinner DW. Persistent epistaxis: what is the best practice? Rhinology 2005;43:305–8
31 Nouraei SA, Maani T, Hajioff D, Saleh HA, Mackay IS. Outcome of endoscopic sphenopalatine artery occlusion for intractable epistaxis: a 10-year experience. Laryngoscope 2007;117:1452–6
32 Cassano M, Longo M, Fiocca-Matthews E, Del Giudice AM. Endoscopic intraoperative control of epistaxis in nasal surgery. Auris Nasus Larynx 2010;37:178–84
33 Lakhani R, Syed I, Qureishi A, Bleach N. The Wexham Criteria: defining severe epistaxis to select patients requiring sphenopalatine artery ligation. Eur Arch Otorhinolaryngol 2013;270:2039–43
34 Abdelkader M, Leong SC, White PS. Endoscopic control of the sphenopalatine artery for epistaxis: long-term results. J Laryngol Otol 2007;121:759–62
35 Gede LL, Aanaes K, Collatz H, Larsen PL, von Buchwald C. National long-lasting effect of endonasal endoscopic sphenopalatine artery clipping for epistaxis. Acta Otolaryngol 2013;133:744–8
36 George A, Smatanova K, Joshi H, Jervis S, Oluwole M. Sphenopalatine, anterior ethmoid and internal maxillary artery intervention in the management of refractory epistaxis: their efficacy in 25 patients. Clin Otolaryngol 2012;37:321–5
37 Howe DJ, Wazir U, Skinner DW. Outcomes of endoscopic sphenopalatine artery ligation for epistaxis: a five-year series from a single institution. Ear Nose Throat J 2012;91:70–2
38 Eladl HM, Elmorsy SM, Khafagy YW. Endoscopic devascularisation of sphenopalatine bundle in intractable posterior epistaxis: technique, efficacy and safety. J Laryngol Otol 2011;125:1136–40
39 Srinivasan V, Sherman IW, O'Sullivan G. Surgical management of intractable epistaxis: audit of results. J Laryngol Otol 2000;114:697700
40 Yung M, Sharma R, Jablenska L, Yung T. A 2-cycle audit on the feasibility, efficacy and patient acceptance of 21 emergency sphenopalatine artery ligations under local anaesthesia: our experience. Clin Otolaryngol 2016;41:407–11
41 Rudmik L, Leung R. Cost-effectiveness analysis of endoscopic sphenopalatine artery ligation vs arterial embolization for intractable epistaxis. JAMA Otolaryngol Head Neck Surg 2014;140:802–8
42 Miller TR, Stevens ES, Orlandi RR. Economic analysis of the treatment of posterior epistaxis. Am J Rhinol 2005;19:7982
43 Leung RM, Smith TL, Rudmik L. Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis. JAMA Otolaryngol Head Neck Surg 2015;141:405–9
44 Shires CB, Boughter JD, Sebelik ME. Sphenopalatine artery ligation: a cadaver anatomic study. Otolaryngol Head Neck Surg 2011;145:494–7
45 Simmen DB, Raghavan U, Briner HR, Manestar M, Groscurth P, Jones NS. The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon. Am J Rhinol 2006;20:502–5
46 Antunes Scanavini AB, Navarro JA, Megale SR, Lima RS, Anselmo-Lima WT. Morphometric evaluation of the sphenopalatine foramen for endonasal surgery. Rhinology 2010;48:441–5
47 Midilli R, Orhan M, Saylam CY, Akyildiz S, Gode S, Karci B. Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure. Am J Rhinol Allergy 2009;23:3841
48 Schwartzbauer HR, Shete M, Tami TA. Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis. Am J Rhinol 2003;17:63–6
49 Nalavenkata S, Meller C, Novakovic D, Forer M, Patel NP. Sphenopalatine foramen: endoscopic approach with bony landmarks. J Laryngol Otol 2015;129(suppl 3):S47–52
50 Biswas D, Ross SK, Sama A, Thomas A. Non-sphenopalatine dominant arterial supply of the nasal cavity: an unusual anatomical variation. J Laryngol Otol 2009;123:689–91
51 Jonas N, Viani L, Walsh M. Sphenopalatine artery ligation under local anesthesia: a report of two cases and review of the literature. Local Reg Anesth 2010;3:14
52 Elsheikh E, El-Anwar MW. Septal perforation and bilateral partial middle turbinate necrosis after bilateral sphenopalatine artery ligation. J Laryngol Otol 2013;127:1025–7
53 Moorthy R, Anand R, Prior M, Scott PM. Inferior turbinate necrosis following endoscopic sphenopalatine artery ligation. Otolaryngol Head Neck Surg 2003;129:159–60
54 Adam S, Sama HD, Chossegros C, Bedrune B, Chesnier I, Pradier JP. Iatrogenic palatine necrosis by embolization of sphenopalatine arteries during management of epistaxis [in French]. Rev Stomatol Chir Maxillofac Chir Orale 2015;116:170–2
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