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Objectives: The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The objective is to define the anatomical patterns of vascularization of the S-point area that could explain its clinical relevance., Methods: Thirty-three nasal septums of latex-injected formalin-embalmed and fresh human cadaveric heads were dissected to analyze the arterial arrangement of the S-point area. Measurements and patterns of vascularization were described., Results: The S-point area, was consistently surrounded by a single or multiple arterial anastomotic arches consistently formed superiorly by the anterior ethmoidal and posterior ethmoidal artery branches, and inferiorly by the posterior septal artery. The caliber of the arterial arches was typically larger than the caliber of the arterial branches supplying them. A single arch was present in 36.3% of septums, and multiple arches in 63.6%. The mean distance from the S-point to the anterior limit of the arch was 9 mm, to the posterior arch when the present was 3 mm, to the superior limit 6 mm, to the inferior limit 6 mm, and to the nasal roof was 10 mm., Conclusion: This study demonstrates the dense arterial configuration of the S point area, which is characterized by a single or multiple vascular arches of greater caliber than the branches of origin. This finding could explain why the S-point area is a frequent source of epistaxis, and guide its surgical cauterization when an obvious vascular ectasia is not visualized., Level of Evidence: N/A Laryngoscope, 133:2075-2080, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Surgical interventions for epistaxis management in hereditary hemorrhagic telangiectasia (HHT) demonstrate short-term success and require repeated procedures for disease control. Although electrocautery and/or laser photocoagulation (C ± L) are most frequently performed, sodium tetradecyl sclerotherapy (STS) is emerging as a promising newer treatment. We hypothesized that in a 24-month time period, STS would require fewer treatments than C ± L to maintain epistaxis severity within the mild range., Study Design: Retrospective study., Methods: We retrospectively assessed 67 patients with HHT with moderate and severe epistaxis that were treated periodically with C ± L (34 patients) versus STS (33 patients). The primary outcome was the number of procedures needed to maintain the epistaxis severity score (ESS) as mild. Secondary outcomes assessed for differences in postoperative complications, hemoglobin levels, iron stores, hematologic support, and quality-of-life (QoL) scores., Results: To maintain ESS in the mild range, 1.6 STS procedures (range, 1-4) were performed versus 3.6 C ± L procedures (range, 1-8) (P = .003). Significant postoperative differences included reduction in nasal crusting (3% vs. 32%, P = .001), foul odor (3% vs. 35%, P < .001), and septal perforation (3% vs. 29%, P = .006) after STS. There were no significant differences between the two treatments in hemoglobin levels, iron stores, hematologic support, or QoL scores., Conclusion: STS is able to attain satisfactory epistaxis control with significantly fewer procedures and lower postoperative complications than C ± L. STS should be considered as the initial surgical intervention for epistaxis in patients with HHT., Level of Evidence: 4 Laryngoscope, 132:920-925, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluated the efficacy and safety of in-office potassium titanyl phosphate (KTP) laser treatment for the management of epistaxis in hereditary hemorrhagic telangiectasia (HHT) patients., Methods: A retrospective case series of all HHT patients over age of 18 who underwent in-office KTP laser treatment from July 1, 2017 to December 31, 2019 was performed. The primary outcome measure was the epistaxis severity score (ESS) pre- and post-procedure. Secondary outcome measures included patient reported pain (on a 10-point Likert-type scale), and procedural adverse events and complications., Results: A total of 16 patients underwent KTP in-office laser treatment during the review period. There was both a clinically and statistically significant decrease in the ESS after in-office laser treatment, baseline ESS -7.24, SD 1.71, follow up ESS -4.92, SD 1.83 (mean difference 2.94, 95% confidence interval, 1.83-4.04, P < .0001). There were no reported adverse events or complications associated with the procedure. The mean pain score reported was 0.19, SD 0.75. The average blood loss was 10.8 mL, SD 37.3. The majority of patients (62.5%, 10/16) had no blood loss during the procedure., Conclusion: Clinically and statistically significant decreases were noted in the ESS of HHT patients after in-office KTP laser photocoagulation. The procedure was well tolerated by patients, without any adverse events or complications., Level of Evidence: 4 Laryngoscope, 131:E689-E693, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Epistaxis, especially posterior epistaxis, is occasionally refractory to treatment. In these cases, sphenopalatine artery surgeries, including cauterization and ligation, are required. Previous reports have demonstrated treatment results for these procedures but failed to provide high-level evidence. The aim of this study was to quantify the rates of failure and perioperative complications of these procedures by using a meta-analysis technique., Methods: We systematically searched electronic databases and identified articles regarding epistaxis, sphenopalatine artery ligation, or cauterization. Pooled rebleeding and complication rates were calculated by using a random effects model., Results: A total of 896 cases of sphenopalatine ligation or cauterization for epistaxis were analyzed. Pooled rebleeding rates for the entire cohort, cauterization group, and ligation group were 13.4% (95% confidence interval [CI] 10.0-17.8, P < 0.001), 7.2% (95% CI 4.6-11.0, P < 0.001), and 15.1% (95% CI 9.8-22.5, P < 0.001), respectively. Pooled perioperative complication rates for the entire cohort, cauterization group, and ligation group were 8.7% (95% CI 4.9-15.1, P < 0.001), 10.2% (95% CI 3.8-24.5, P < 0.001), and 6.4% (95% CI 1.8-20.9, P < 0.001), respectively., Conclusion: Overall, sphenopalatine surgery for refractory epistaxis is an effective method because of its low rates of failure and complications. Cauterization is more effective than ligation, whereas complications are comparable between the two procedures. Laryngoscope, 129:1731-1736, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Our objective was to measure short- and long-term outcomes of children presenting with recalcitrant idiopathic epistaxis. The study was an 11-year (2000-2011) retrospective chart review of children evaluated and treated for epistaxis. A retrospective review of patients with diagnostic International Classification of Diseases, Ninth Revision code 784.7 (epistaxis) and 21.5/21.88 (septoplasty) was completed reviewing age at presentation, type of surgery, and number of bleeding events prior to and after surgery. In our cohort, almost 100% of children with idiopathic recurrent epistaxis responded to topical treatments. About 0.2% were refractory (20/9239), and 90% of those (18/20) resolved with either a traditional septoplasty (14/20) or modified septoplasty (6/20) without cartilage excision, with a mean follow-up of 35 months. One of the patients who did not show resolution was found to have Von Willebrand disease, which likely contributed to this outcome. Septoplasty surgery, with or without cartilage removal, appears beneficial for refractory idiopathic epistaxis in children., Level of Evidence: 4 Laryngoscope, 126:2833-2837, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents., Study Design: Prospective cohort study., Methods: A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures., Results: There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods., Conclusion: This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety., Level of Evidence: NA. Laryngoscope, 126:1501-1503, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To describe the anatomy of the incisive foramen and the transnasal endoscopic approach to the greater palatine artery at this foramen, and to evaluate the importance of the greater palatine artery as a cause of recurrent anterior epistaxis., Study Design: Anatomical dissection, radiographic study, and prospective case series., Setting: Academic Medical Center., Methods: Sixty-nine computed tomography scans were reviewed, and measurements were made of the incisive foramina's distance to the anterior nasal spine and subnasale. Twenty-two cadavers had sagittal split craniotomies performed prior to the measurements. The distance from the anterior nasal spine to the incisive foramen was documented. We also present an illustrative case series of patients who underwent endoscopic cautery of the greater palatine artery at the incisive foramen., Results: Radiographic review of the incisive foramen revealed a mean anterior nasal spine to incisive foramen distance on the right and left of 7.9 and 8.1 mm, respectively. The mean distance from the subnasale to incisive foramen on the right and left were 24.7 and 24.9 mm, respectively., Conclusions: Endoscopic cauterization of the greater palatine artery at the incisive foramen is a safe and effective method to control recurrent anterior epistaxis. The incisive foramen can be predictively found within 1 cm of the anterior nasal spine. Our case series corroborates the above., Level of Evidence: 4. Laryngoscope, 126:1033-1038, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: A dural arteriovenous fistula (DAVF) with cortical venous reflux (CVR) is a dangerous neurovascular entity. A DAVF at the cribriform plate is typically silent until its inevitable presentation with intracranial hemorrhage., Case Summary: A 67-year-old male presented with severe epistaxis. Following unsuccessful conventional measures and a surgical exploration, a catheter angiography showed a DAVF at the cribriform plate, with its nidus extending into the nasal cavity. The DAVF was treated via a small craniotomy., Conclusion: In case of atypical or unexplained nosebleeds, the possibility of a DAVF or other neurovascular pathology should be excluded by MRI/MRA or catheter angiography., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Emergency management of epistaxis may include the use of local pressure and vasoconstrictors, chemical or electric cautery, hemostatic agents, nasal packing, embolization, and surgical arterial ligation. There is no definitive protocol for the management of epistaxis, although various protocols have been proposed in the literature. As approaches to surgical ligation of the arterial supply of the nasal cavity have evolved from external carotid ligation to minimally invasive approaches, surgical management of epistaxis has become more effective than embolization and may be less risky. In the surgical management of epistaxis, arterial ligation immediately proximal to the bleeding site is preferred. We propose a simple variation of the endoscopic sphenopalatine artery ligation that may be used to manage epistaxis arising from the nasal septum and floor., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Nasal dermoplasty is effective in controlling epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT). Skin graft take failure occurs mostly in cases of large septal perforation. The MW method was developed as a modification of nasal dermoplasty designed for patients with HHT having a large septal perforation. It seems to be a safe and effective approach and should be tried for recurrent bleeders with septal perforation., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: Access to the medial orbit traditionally has been gained transcutaneously, with potential for associated soft tissue and lacrimal disruption. Endoscopic transnasal approaches to the medial orbit may be limited in certain scenarios by tumor presence or patient-specific factors. The medial transconjunctival approach, or transcaruncular approach, has been recently described for access to the medial orbit in orbital decompression and repair of medial blowout fractures. The aim of this study is to determine the utility of this minimally invasive external approach in the endoscopic management of advanced sino-orbital disease., Methods: This is a cadaver study with additional clinical correlations. The transcaruncular approach was combined with a transnasal endoscopic approach in cadaver dissections performed on eight sides. Five cases are described in which the transcaruncular approach was used as an adjunctive technique in advanced endoscopic sinus surgery., Results: In cadaver dissection, the transcaruncular approach is a simple, reliable method to ligate the ethmoid arteries and place bony cuts along the medial orbital wall. In certain anatomic configurations, supraorbital dissection into the frontal sinus or anterior fossa may be achieved. In the cases examined, exposure of the medial orbital subperiosteal plane allowed for ligation of ethmoid arteries, assessment of periorbital invasion of disease, assistance in tumor dissection, and placement of a malleable retractor for protection of orbital contents., Conclusions: The transcaruncular approach to the medial orbit has certain advantages over the traditional open approach. Ligation of the ethmoid arteries, assessment of the lacrimal sac and periorbita for tumor invasion, protection of orbital contents, and en bloc resection of the periorbita and lamina papyrecea are possible through this route.

Objective: The irrigation of the upper third of the nasal fossa is supplied by the anterior ethmoidal artery. We describe a surgical technique to deal with epistaxis due to anterior ethmoidal artery bleeding., Patients and Methods: From January 2006 to March 2010 transcaruncular coagulation of the anterior ethmoidal artery was done on nine patients with epistaxis of the upper third of the nasal fossa., Results: The procedure was successful on all cases. No bleeding relapse, major complications, or nasal or orbital sequelae were present in any of the patients., Discussion/conclusions: Transcaruncular electrocoagulation of the anterior ethmoidal artery is a safe and effective technique to deal with upper third nasal fossa bleeding., (Copyright © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: To describe the anatomy of the sphenopalatine foramen (SPF) region and possible anatomical variations., Study Design: Prospective study accomplished from September, 2006, to January, 2007., Methods: The sphenopalatine foramen (SPF) of 61 cadavers were carefully dissected. Presence of the ethmoidal crest, location of sphenopalatine and accessory foramens, and the number of arterial branches emerging through foramens were observed. Data were analyzed in relation to gender, racial group, and symmetry of the cadaver. Prediction of the presence of accessory foramen was evaluated., Results: Mixed race cadavers prevailed in 122 nasal fossae dissected (75% males). Ethmoidal crest was present in 100% of the cadavers, being anterior to the SPF in 98.4% of the cases. The most frequent SPF location was the transition of the middle and superior meatus (86.9%). Mean distance from the SPF and accessory foramen to anterior nasal spine was 6.6 cm and 6.7 cm, respectively. Accessory foramen was present in 9.83% of the cases. A single arterial stem emerged through the SPF in 67.2% of the cases, and 100% through accessory foramens. The prevalence analyses showed no differences that were statistically significant (P > 0.05) between gender and racial group. The symmetry analyses showed a strong conformity (P < 0.01) between nasal fossae in relation to the SPF location. There was no statistically significant conformity between nasal fossae and accessory foramen (P = 0.53). None of the variables of interest presents any statistically significant (P > 0.05) association with the presence of the accessory foramen., Conclusions: There are anatomical variations in the lateral nose wall that should be considered for successful endoscopic surgical treatment of severe epistaxis.

Objective/hypothesis: To evaluate the efficacy of surgical sphenopalatine artery occlusion (SAO) for treating intractable epistaxis, and identify factors associated with long-term success or failure of this procedure., Methods: A retrospective chart review of patients undergoing SAO surgery between January 1995 and 2005 was undertaken. Clinical and hematologic information, preoperative and surgical care, short-term complications, and long-term outcome were recorded. Binary logistic regression was used to identify risk factors for early re-bleeding, and log-rank statistics with Cox regression were used to identify risk factors for long-term operative failure., Results: Sixty-seven patients underwent 71 SAO operations. The average age at surgery was 56 +/- 18 years. Thirty percent of patients were being treated for hypertension, 19% were taking aspirin, and 11% were anticoagulated with warfarin. Many patients (46%) had >72 hours of epistaxis before admission, and 25% required preoperative transfusion. There were 13 (19%) bilateral procedures, six patients underwent concomitant anterior ethmoid artery occlusion, and 12 patients had concomitant septoplasty. Eight patients had significant early re-bleeding. Platelet levels on admission and not using diathermy to occlude the sphenopalatine artery were independent risk factors for this (P values .03, and .02, respectively). Not using diathermy was also an independent risk factor for late operative failure on Cox regression, reducing the mean re-intervention-free interval from 94 +/- 7 to 32 +/- 7 months (P < .007; hazard ratio 6.4; 95% confidence interval 1.7-24.9)., Conclusions: SAO is an effective operation and, in trained hands, an appropriate first-line procedure for treating intractable epistaxis. Use of diathermy significantly improves the short- and long-term outcome of this surgery.

Background: In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients., Methods: We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap., Results: Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved., Conclusion: The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.

Objective: The objective of this study was to determine common bleeding sites in the nasal cavity of patients with posterior epistaxis and thus review our management protocol., Study Design: A prospective study was carried out from 1989 to November 2003 in the otolaryngology-head and neck surgery department of a tertiary referral center. This study included patients who presented with posterior epistaxis uncontrolled with standard nasal packing and with no identifiable bleeding point on examination under local anesthesia., Method: All patients underwent a formal examination under general anesthesia by the senior author of this article. Findings at examination were documented along with subsequent management and its outcome., Results: Forty-three patients were included in this study. Bleeding points were identified in 36 cases. Seven patients had septal bleeding points (20%). The rest were located on the lateral nasal wall (81%). Of these, 4 were on the lateral wall of inferior meatus, 7 on the lateral surface of inferior turbinate, 8 on the lateral wall of middle meatus, and 10 on the lateral surface of middle turbinate. All were located posteriorly., Conclusions: We recommend examination under general anesthesia when conservative measures fail to control bleeding, concentrating on the posterior aspect of the lateral nasal wall. In addition, the lateral aspect of the middle and inferior turbinates may contain a groove within which bleeding points may be concealed. The lateral position of most bleeding sites indicates that use of nasal packing can only attempt to indirectly tamponade blood flow and is rarely justified bilaterally. Electrothermocautery can achieve excellent results with minimal complications. Failure to identify a bleeding point, after thorough examination under general anesthesia, does not require further intervention unless complicated by further bleeding.

Objectives/hypothesis: Septal dermoplasty has been recommended as the treatment of choice for life-threatening epistaxis in patients with hereditary hemorrhagic telangiectasia. The purpose of the study was to evaluate the effectiveness and outcomes of septal dermoplasty for management of transfusion-dependent epistaxis., Study Design: Retrospective study., Methods: Between 1994 and 2004, septal dermoplasty was performed on 67 consecutive patients with severe epistaxis attributable to hereditary hemorrhagic telangiectasia. The numbers of units of blood received 1 year before and 1 year after septal dermoplasty were obtained. A subjective appraisal of the results of the surgery as well as second procedures after septal dermoplasty was determined. Patients were screened for pulmonary and cerebral arteriovenous malformations, gastrointestinal tract bleeding, and symptomatic liver disease., Results: Data were obtained in 66 of 67 (98%) patients with a mean age of 61.5 years (mean follow-up, 3.9 y). Accurate transfusion requirements 1 year before and 1 year after septal dermoplasty were available in 32 of 66 (48%) patients. In these 32 patients, the mean units of blood received decreased from 21 units (range, 2-100 units) 1 year before septal dermoplasty to 1 unit (range, 0-10 units) in the year after septal dermoplasty (P < .001). Improved quality of life was claimed in 57 patients. Second therapies, ranging from cautery to repeat partial septal dermoplasty, were required in 15 patients during follow-up. Among the 67 patients, 31 (46%) had pulmonary arteriovenous malformation, 14 (21%) had gastrointestinal tract bleeding, 7 (10%) had symptomatic liver disease, and 5 (7%) had cerebral arteriovenous malformation. During the follow-up, 14 patients died of other complications of hereditary hemorrhagic telangiectasia (11 patients) and unrelated causes (3 patients)., Conclusion: Septal dermoplasty remains an effective way of reducing transfusion requirements in patients with hereditary hemorrhagic telangiectasia and subjectively improves their quality of life. The otolaryngologist caring for patients with hereditary hemorrhagic telangiectasia should be familiar with other organ involvement by hereditary hemorrhagic telangiectasia to prevent complications during surgery.

Objective: To demonstrate that surgery, as the initial treatment option for posterior epistaxis, can provide comparable success and complication rates to nonsurgical management with fewer associated costs., Study Design: A retrospective chart review and cost analysis., Methods: Two hundred three consecutive charts were reviewed for patient outcome, complications, and hospitalization time. Average costs were calculated from hospital department and physician fee schedules., Results: Average success rate of all surgical procedures performed for posterior epistaxis was 90%, anterior-posterior packing success was 62%, and embolization success was 75%. The packing-only group had a significantly greater mean hospitalization time (5.29 d) than patients who were treated either surgically (2.1 d) or with embolization (2.6 d). The average per-patient admission charges were, for successful posterior packing, $5136 per patient; for surgical treatment, $3851 per patient; and for embolization, $5697 per patient. Surgery offered a cost savings of $1846 per patient over traditional packing. There was no significant difference in complication rates between the groups., Conclusion: The review suggests that a better success rate, a comparable complication rate, and a cost savings can be achieved with surgical intervention as the first-line treatment for intractable epistaxis when compared with traditional anterior-posterior packing and embolization.

Objectives: Patients with (HHT) often suffer from recurrent epistaxis, which poses considerable therapeutic problems. Theoretical considerations render argon plasma coagulation (APC) a promising new therapeutic approach., Study Design: In a prospective study 12 patients (aged 8-68 y) who presented with a long history of treatment for epistaxis were treated with telangiectasia in the nasal mucosa. After 2 weeks and again after 4 months the treatment results were evaluated by questionnaire., Methods: APC is based on high-frequency electric energy transmitted through ionized argon gas to the tissue in a noncontact mode. Coagulation and desiccation of tissue are limited to 1 to 2 mm of penetration and therefore risk of tissue damage is low. Coagulative effects are best in tissue with high electrical conductivity, especially blood vessels., Results: All patients were satisfied with the postoperative results. Frequency and intensity of bleeding were significantly reduced. All patients reported better postoperative results than with any other treatment they had received previously., Conclusion: First clinical experience shows that APC is a useful alternative for the treatment of telangiectasia in the nasal mucosa and should be a therapeutic option for this disease.

A retrospective review is presented of 44 consecutive patients requiring hospitalization for epistaxis at a tertiary care center. The study had the following objectives: 1. to identify predictors of surgical treatment, and 2. to compare the effectiveness of different surgical treatments. Length of stay, complications, and cost analysis are also presented. Eighteen patients were successfully treated nonsurgically, whereas 26 patients received surgical treatment. Posterior epistaxis (P<0.05) and an admission hematocrit less than 38% (P<0.05) were significant predictors of surgical treatment. The rebleed rate after first surgical therapy was 33% for embolization, 33% for endoscopic cautery, and 20% for ligation. Since embolization, ligation, and endoscopic cautery may have nearly equivalent failure rates, other factors, such as cost and institutional expertise, should guide the selection of surgical treatment.

Surgical control of severe epistaxis is usually reserved for cases refractory to more conservative techniques. We present our experience with intraoral ligation of the maxillary artery as it courses through the buccal fat pad before it enters the pterygopalatine fossa and branches posterior to the maxilla. This technique has been found useful in the control of nasal hemorrhage as well as an adjunct to other surgical procedures, such as removal of benign and malignant neoplasms involving the maxilla and paranasal sinuses. This technique was used for ligation of the maxillary artery in 20 patients. The artery was readily identified in some cases, but required more extensive dissection in others; therefore, an anatomic study in 18 preserved and fresh cadaver specimens was undertaken to investigate the variability of the maxillary artery in the region of the buccal fat pad. There appeared to be significant variation in the distance from the buccal mucosal incision site, as well as variation in the relationship to the pterygoid muscles. This relationship to the pterygoids explains the occasional difficulty in locating the artery for ligation. This technique represents a reasonable alternative to the more traditional transantral approach to ligation of the maxillary artery, as long as the surgeon understands the anatomy of the region, its variations, and where the artery may be located if not immediately apparent. No major complications have been experienced.

Transantral internal maxillary ligation for epistaxis is becoming more and more popular. The intention of this paper is to bring home three points: 1. only the arterial trunk need be ligated to obtain the anticipated results, 2. by following certain guidelines the operating time can be cut down by at least 45 minutes, and 3. if the procedure is carried out in time, it can be cost-effective. As time goes on, more and more patients will be added to this analysis and eventually reported.

Intraoral ligation of the maxillary artery for intractable posterior epistaxis has been used effectively in 14 consecutive patients, all of whom had failed conventional anterior and posterior packing techniques. Fresh cadaver material was dissected in order to define the anatomic relationships of the infratemporal portion of the maxillary artery, as well as to develop the surgical technique prior to clinical application. The results indicate that this technique is rapid, safe, versatile, and effective in the majority of patients that require surgical interruption of the blood supply to the nose. The results of this study and the surgical technique are discussed.

Previous clinical reports indicate that nasal packing is frequently associated with arterial hypoxemia. Anesthesia and surgery in hypoxemic patients can be hazardous, especially when it is associated with acute blood loss. Nine patients with severe epistaxis, who failed to respond to anterior and posterior nasal packing, were anesthetized for emergency internal maxillary artery ligation. Arterial blood-gas and pH changes during the procedure were evaluated. The results indicate some degree of arterial hypoxemia and high alveolar/arterial PO2 difference without significant change in PaCO2 and pH in most of the patients observed. Arterial PO2 was within normal range 24 hours after operation. The anesthetic management is described and the various causes of such arterial hypoxemia are reviewed. It is important to recognize the presence of arterial hypoxemia and treat accordingly during surgery for such patients.

Hereditary hemorrhagic telangiectasia is a challenging problem for the otolaryngologist since frequent, often severe epistaxis is the major symptom. Options for therapy in the past have included nasal packing, electrocautery, systemic estrogens, septal dermatoplasty, arterial embolization, and arterial ligation. Although successful treatment has been achieved with some of these methods, particularly septal dermatoplasty, other forms of therapy are needed prompting the use of laser photocoagulation. The neodymium yttrium-aluminum-garnet (Nd-YAG) laser was used to treat a group of 19 patients with hereditary hemorrhagic telangiectasia over a 4-year period without complications. Endonasal laser photocoagulation was effective in decreasing epistaxis in patients not requiring frequent transfusions prior to laser therapy. Three patients with the most severe epistaxis received minimal or no benefit from Nd-YAG laser photocoagulation. In most patients Nd-YAG photocoagulation is successful in treating epistaxis associated with hereditary hemorrhagic telangiectasia and should be a therapeutic option for this chronic disease having no available cure.

Internal maxillary artery ligation is effective in treating epistaxis. Occasionally a patient may continue to hemorrhage after this procedure. Evaluation of postoperative angiograms reveals several factors accounting for the failure of internal maxillary artery ligation. These factors include incomplete ligation of vessels, alternative dominance of vessels, and reconstitution of flow through collaterals. Eleven such patients have been successfully treated with angiography and embolization. There was one complication of skin slough in the region of the columella. Embolization is a useful modality in the management of these difficult cases.

Posterior epistaxis from branches of the sphenopalatine artery can be rapidly and effectively controlled by a new ligation technique. The sphenopalatine artery or its branches are directly ligated as they exit the sphenopalatine foramen to enter the nose, completely avoiding the pterygomaxillary fossa. The vessels are exposed via a transantral approach, through the posterior portion of the medial antral wall. The mucoperiosteum of the lateral wall of the nose (medial antral wall) is preserved, elevated medially and posteriorly and used to tense the sphenopalatine vessels, bringing them into view and accessible for ligation at the foramen. Advantages of this technique include direct, specific ligation of the end vessels; ease and speed of operation; and avoidance of complications associated with the pterygomaxillary space. The technique was defined in multiple dissections of anatomic specimens and has been successful to date in 14 cases of severe posterior epistaxis.

Human amnion is a readily available allograft with low antigenicity, high antimicrobial potential, and the ability to foster epithelialization. We have used human amniotic membrane in our department for replacing nasal mucosa in Rendu-Osler-Weber disease, as tympanic membrane grafts, and for covering head and neck sites after flap necrosis. Our experience shows moderate success for management of severe epistaxis and excellent results in covering surfaces after flap necrosis. Use of amnion in eardrum perforations was unsuccessful and was discontinued. Properties of human amniotic membrane are listed and its application in the otolaryngologic practice is reviewed.

Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) is an inherited abnormality of the vasculature characterized by abnormal subepidermal vessels. Frequent, sometimes severe, epistaxis often requiring blood transfusions is present in most patients. Septal dermatoplasty and estrogen have proved to be the most successful therapies. However, the frequency of failure in treatment has stimulated a search for an alternative therapy. The Nd-YAG laser was used at low-power settings (20-25 W) to treat 6 patients with hereditary hemorrhagic telangiectasia, all of whom had been treated previously using other modalities. Laser photocoagulation diminished the frequency and severity of hemorrhage in 5 of 6 patients without complications (6 to 9 month follow-up period). The Nd-YAG laser may be used repeatedly when new accessible lesions arise, and it appears to be a useful therapeutic option for this disease that is difficult to treat.

Recurrent epistaxis can be a serious problem in children with coagulation disorders. We present a case of severe, recurrent nosebleeds in a 3-year-10-month-old boy with Glanzmann's thrombasthenia. The nature of Glanzmann's disease and medical treatment of epistaxis in children is reviewed. A method of controlling recurrent epistaxis with a very simple and limited septoplasty is described. This technique should be applicable to patients with recurrent nosebleeds and other more common coagulation disorders.

A retrospective review of 4 years experience with over 32 epistaxis patients requiring hospitalization and using a standard medical or surgical therapy for control is presented. Medical therapy included the use of anterior nasal packing alone or in association with intranasal and nasopharyngeal balloon tamponade. Surgical therapy, for the most part, consisted of ethmoid and/or internal maxillary artery ligations. Most patients were treated initially with packing and balloons. Fifty-two percent of the group failed this therapy and required ligations for control. The patients who did not come to operation had fewer complications, a shorter average hospital stay, and lower average cost of hospitalization without increased risk of future epistaxis. An analysis is made comparing the results, complications, and financial implications of these two approaches.

The records of 100 consecutive patients undergoing transantral ligation of the internal maxillary artery (IMA) for epistaxis, including 15 patients who developed postoperative bleeding, were reviewed. Preoperative parameters predictive of surgical failure were advanced age, anemia, and a history of hypertension. The causes of postoperative epistaxis, as determined by surgical reexploration or angiography in 12 cases, included failure to identify the IMA in the pterygomaxillary space (6 cases), blood flow through partially closed clips on the IMA (2 cases), bleeding from posterior ethmoid arteries (2 cases), and revascularization of the nasal blood supply (2 cases). The incidence of surgical failure may be reduced by proper techniques of IMA identification and ligation.