Endoscopic sphenopalatine artery ligation or cauterisation is nowadays the main treatment for epistaxis unresponsive to medical therapy. However, on review of the literature, there appears to be confusion relating to the anatomical nomenclature of the sphenopalatine artery branches and more importantly to their actual number. Many authors have described numerous branches (up to 10) arising from the sphenopalatine foramen but this is rarely the case in clinical practice. The idea of this study was to use a mixed cohort of live epistaxis patients and cadavers to investigate the actual number of branches at the level of the sphenopalatine foramen, the incidence of an accessory foramen and finally describe their surgical outcomes with sphenopalatine artery ligation. Of the 107 nasal cavities that the authors explored (combined live epistaxis and cadaveric cohorts), the sphenopalatine artery consisted of a single branch in 68 cases (63%), divided into two branches in 34 cases (32%) and three branches in five cases (5%). No more than three branches were identified. The presence of an accessory foramen was observed in 7% of cases. In each of these cases only one branch was found to traverse the accessory foramen. Their reported success rate with sphenopalatine artery ligation was 88% (15/17). Following analysis of the two failed cases, the authors found that this was due to one case where the vascular clip had been displaced following application and another where the bleeding point did not arise from a branch of the sphenopalatine artery, but from the anterior ethmoidal artery instead. This study provides useful information that has significant implications in clinical practice:
- In most cases there will be one or two branches arising from the sphenopalatine foramen.
- Coagulation is probably more effective than clipping as the vascular clips may not sit properly on the vessel and as a result become displaced leading to re-bleeding.
- During endoscopic dissection it is advisable that the surgeon extends the subperiosteal flap inferiorly due to the possibility of discovering an accessory foramen through which one additional branch traverses.