The LaryngoscopeVC 2010 The American Laryngological,Rhinological and Otological Society, Inc.

Transcaruncular Electrocoagulation of Anterior Ethmoidal Artery forthe Treatment of Severe Epistaxis

Eduardo Morera, MD; Christian Artigas, MD; Francisca Trobat, MD;

Luis Ferren, MD; Manuel Tomas, MD

Objective: The irrigation of the upper third of the nasal fossa is supplied by the anterior ethmoidal artery. We describea 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 arterywas 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 seque-lae were present in any of the patients.

Discussion/Conclusions: Transcaruncular electrocoagulation of the anterior ethmoidal artery is a safe and effectivetechnique to deal with upper third nasal fossa bleeding.

Key Words: Epistaxis, anterior ethmoidal artery, transcaruncular approach.Level of evidence: 4.

Laryngoscope, 121:446–450, 2011

INTRODUCTIONEpistaxis is a common health problem with a

reported incidence of 7% to 14% of the general popula-tion.1 Most nose bleeds are self-limiting and do notrequire any specific medical treatment at all; nonetheless,an important part of them are referred to the emergencydepartments of university hospitals representing 9.5% to16% of ENT emergencies in our country.2

Silver nitrate cauterization with or without nosepacking and control of medical comorbidities (hyperten-sion and hemostasis disorders mainly) are successful inmost cases.3 Conservative treatment is not effective in12.5% of patients in our institution; those patientsrequire emergency surgical control of epistaxis.

Endoscopic electrocoagulation or clipping of sphenopa-latine artery is the surgical procedure of choice forsevere epistaxis. Anterior ethmoidal artery is responsiblefor 2% to 15% of these cases.4 We describe the transcarun-cular ethmoidal artery coagulation technique to treatsevere nasal bleeding refractory to sphenopalatine arterycoagulation.

PATIENTS AND METHODSFifty-nine patients have been operated on in our institu-

tion for severe epistaxis from June 2006 to March 2010.Endoscopic sphenopalatine artery coagulation was initially per-formed on 55 (93.2%) of them; endoscopic sphenopalatinecoagulation plus transcaruncular anterior ethmoidal arterycoagulation was performed on the rest of them (four patients,6.8%). Surgery was successful in all four sphenopalatine arteryplus transcaruncular anterior ethmoidal artery coagulationpatients and in 47 out of 55 sphenopalatine artery coagulationpatients (85.5%); persistent bleeding occurred in eight (14.5%),who were scheduled for revision sphenopalatine artery surgerywithin 5 days of the first procedure. In five of those eightpatients (62.5%) a transcaruncular coagulation of the anteriorethmoidal artery was made in addition to revision sphenopala-tine artery coagulation due to superior nasal fossa bleeding. Atotal of nine patients then had a transcaruncular anterior eth-moidal artery procedure performed (Table I).

Five out of eight patients (55.5%) who went through trans-caruncular anterior ethmoidal artery coagulation were men andfour were women. Average age was 63.3 6 21.5 years, with arange from 26 to 91. Seven of them (78%) had hypertension,and four (44.5%) were on anticoagulant therapy. The youngestpatient was an active cocaine user and had a recent nosetrauma.

Transcaruncular approach was performed following theoriginal description by Garcia et al.5 (Fig. 1). After anestheticinfiltration with 2 cc of 2% lidocaine þ 1/100,000 epinephrineand corneal protection with ocular ointment, a 1-cm vertical cutanterior to the semilunar fold was done on the caruncle. Ste-vens scissors were used to widen the incision and thesubperiosteal plane was reached with the electric knife. A widepocket was dissected preserving the periostium in order to pre-vent orbital fat from entering the surgical field. Anteriorethmoidal artery appeared on the frontoethmoidal junction 24mm from the posterior lachrymal crest (Fig. 2). After arteryidentification, bipolar coagulation was done.

From the Servicio de Otorrinolaringologıa y Patologıa Cervico-facial,Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares,Spain.

Editor’s Note: This Manuscript was accepted for publicationAugust 10, 2010.

The authors have no financial disclosures for this article.The authors have no conflicts of interest to declare.

Send correspondence to Dr. Eduardo Morera Serna, Servicio deOtorrinolaringologıa y Patologıa Cervico-facial, Hospital UniversitarioSon Espases, Carretera de Valdemosa 79. Palma de Mallorca 07120.Islas Baleares, Spain.E-mail: e_morera@hotmail.com

DOI: 10.1002/lary.21372

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Two separate 7.0 vycril stitches were used for conjunctivaclosure. Saline corneal rinsing every 6 hours and painkillerswere prescribed; no additional ocular care was necessary.

RESULTSAll the procedures were made by three different

surgeons. Transcaruncular anterior ethmoidal arterycoagulation surgical time was less than 30 minutes inall cases. One of the patients showed loss of integrity ofthe lamina papiracea due to previous endoscopic nasalsurgery, which did not add to the difficulty to theoperation.

An anterior nasal packing was left for 48 hours inall patients. No bleeding relapse occurred and averagepostop stay was 3.5 6 0.9 days. One of the patients pre-sented epistaxis during an admittance to the CardiologyClinic due to an acute coronary episode; he was not dis-charged until his coronary problem improved 4 weeksafter the procedure. No ophthalmoplegia, ectropion,medial canthal tendon disruption, orbital emphysema, orhematoma was found after the surgery. One patient pre-sented transient epiphora, caused by postoperative lowerlid swelling, that lasted 6 weeks. Caruncle scar was

inconspicuous in every case at the 1 month postoperativecontrol (Fig. 3).

DISCUSSIONTranscaruncular approach-reported applications are

medial orbital wall fracture repairment.6,7 Graves dis-ease orbital decompression,8 orbital abscess drainage,9

enophthalmos treatment,10 medial cantopexy,11 andmanagement of frontoethmoidal mucoceles.12

Transcaruncular anterior ethmoidal artery coagula-tion for epistaxis treatment has not previously beenreported. Our study is the first one to show the efficacyof this approach to treat upper nasal fossa bleeding on aseries of patients.

Anterior ethmoidal artery endoscopic cauterizationis limited by the anatomic variants of the artery. On acadaveric study, only 30% to 40% of the cases showed amesenterium separating the artery from the skull baseand thus allowing a secure and comfortable clipping orcoagulation of the vessel.13 Additionally, identification ofthe artery on the upper ethmoid may be further jeopar-dized in epistaxis patients by blood and swollen mucosa.

TABLE I.Patients Operated on for Severe Epistaxis from June 2006 to March 2010.

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Traditional medial orbital wall approach wasdescribed by Lynch in 1921, and has been the techniqueof choice for decades. A vertical incision midway betweenthe medial orbital canthus and the nasal bridge is per-formed and dissection goes through the medial canthaltendon, which has to be cut, and deep to the lachrymalpathway, creating a wide exposure of medial orbitalwall. The main drawbacks of the Lynch technique are avisible scar in an area prone to web formation and therisk of telecanthus, ectropion, and permanentepiphora.14

Anterior ethmoidal artery embolization may be avalid option in tumoral, posttraumatic, or base ofskull arteriovenous fistula epistaxis. Reported rate of

success of the procedure is less than 65%; inherentrisks of internal carotid artery system embolization areminor and major neurologic damage and even death.15

We consider that arterial embolization is not the proce-dure of choice to treat standard upper nasal fossableeding.

Transcaruncular approach is a simple, fast, andsafe scar-free technique. The placement of the incisionon the caruncle and the dissection, posterior to themedial canthal tendon and the lachrymal pathway, mini-mize the risk of postoperative complications andsequelae (Fig. 4). The dissection plane is avascular andthe identification of the artery is extremely easy due tothe extraordinary anatomic references.

Fig. 1. Surgical technique.

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Anterior ethmoidal artery coagulation success forthe treatment of upper nasal fossa epistaxis was com-plete; no postoperative bleeding relapse occurred. It isimportant to point out that 50% of the cases wereactually sphenopalatine artery coagulation failures. An-terior ethmoidal artery bleeding must be considered onthe differential diagnosis of persistent epistaxis aftersphenopalatine artery clipping or coagulation.

CONCLUSIONS

1. Anterior ethmoidal artery bleeding is one of the maincauses of persistent epistaxis after sphenopalatine ar-tery clipping or coagulation.

2. Transcaruncular approach is a quick, simple, and safetechnique for anterior ethmoidal artery identification.

3. Transcaruncular anterior ethmoidal artery coagula-tion is a highly effective procedure for upper nasalfossa bleeding control.

4. Complications and postoperative functional and es-thetic sequelae of transcaruncular approach are lessfrequent than those of other medial orbital wall surgi-cal techniques.

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Fig. 3. Five-day postoperative control. [Color figure can be viewedin the online issue, which is available at wileyonlinelibrary.com.]

Fig. 4. Axial view of the transcaruncular approach.

Fig. 2. Transcaruncular view of the anterior ethmoidal artery. [Colorfigure can be viewed in the online issue, which is available atwileyonlinelibrary.com.]

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