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Anterior Ethmoidal Artery Ligation for Epistaxis Control

See also:

Nose Bleed Management and Epistaxis Control
Epistaxis

    1. GENERAL CONSIDERATIONS
      1. Anterior ethmoidal artery ligation is considered for continued epistaxis uncontrolled by other means. The anterior ethmoid artery is an extension of the ophthalmic artery, which is a branch of the internal carotid artery system. As such, this is branch is unable to be addressed by embolization techniques. If epistaxis is severe enough to consider addressing the anterior ethmoid artery, additional consideration of ligating the sphenopalatine artery should be entertained. The posterior ethmoid artery, also a branch of the ophthalmic artery, is not routinely ligated due to its proximity to the optic nerve and inherent risk of injury to the nerve.

      2. The anterior ethmoidal artery is identified via subperiostial elevation through a Lynch incision. The artery is approximately 24mm from the anterior lacrimal crest and lies along the frontoethmoidal suture line. The following drawing demonstrates the artery as a distal branch of the ophthalmic artery. 

        Gray, Henry. Anatomy of the Human Body. 20th edition, 1918. Plate 514. Lea and Febiger, pub. Philidelphia. Public Domain image. Accessed from https:\\commons.wikimedia.org/wiki/File:Gray514.png

    2. PREOPERATIVE PREPARATIONS
      1. Consider CT imaging, if available, to identify the location of the anterior ethmoidal artery pre-operatively (note the distance from anterior lacrimal crest and the height of skull base to help localize intra-op)
      2. If actively hemorrhaging, consider other means of temporizing the hemorrhage while accessing the artery for ligation (i.e. nasal packing or balloon pack).
      3. Consider pre-op H&H, type and screen, and transfusion if necessary.
    3. NURSING CONSIDERATIONS
      1. Room Setup
        1. Endoscopic sinus surgery setup
          1. Turn bed 180 degrees
          2. Arms tucked at patient's side
      2. Instrumentation and Equipment
        1. Endoscopic tower with 0 degree 4mm sinus telescope
        2. Stortz endoscopic clip appliers - this is separate from any sinus tray and needs to be ordered specifically 
          1. "Ethicon Alligator Ligaclip applier"
        1. Medium clips for clip applier
        2. Small malleable retractor
        3. Bipolar cautery 
      3. Medications (specific to nursing)
        1. 1% Lidocaine with 1:100,000 epinephrine, off field
        2. Surgicel, on field
        3. Bacitracin ophthalmic
        4. Afrin
      4. Closure
        1. 4-0 or 5-0 Monocryl / Biosyn for deep closure
        2. 5-0 fast absorbing gut for superficial closure
    4. ANESTHESIA CONSIDERATIONS
      1. Extended tubing for 180 degree turn
      2. If actively hemorrhaging, rapid sequence intubation may be necessary give potential for swallowed blood and risk for aspiration.
    5. OPERATIVE PROCEDURE (modified)
      1. A Lynch incision is marked along the lateral nasal dorsum, arcing along the path of the orbicularis oculi. The area is injected with 1% lidocaine with 1:100,000 epinephrine. The area is prepped and draped. A 15 blade is used to incise the skin. The angular artery/vein is often identified just below the skin and should be clipped to prevent bleeding on the field. The incision is carried down to the nasal bone. The incision should remain superior to the lacrimal sac and inferior to the trochlea. A sub-periosteal plane is developed with a cottle between the above anatomical landmarks. The lacrimal crest should be clearly visualized. The frontoethmoidal suture line should then be identified. A small malleable retractor is very useful in retracting the orbit to allow further visualization. At this point, using a 0 degree endoscope will allow for easier visualization of the deeper dissection. Using a cottle or freer, carefully advance down the medial orbital wall along the suture line. The anterior ethmoidal artery is consistently around 24mm from the anterior lacrimal crest or maxillolacrimal suture line. When the artery is identified, a pocket around the artery is created with blunt dissection superiorly and inferiorly. Of note, orbital fat may be seen protruding with the artery as it crosses the periorbita. Endoscopic clip appliers are used to place two clips along the course of the artery between the periorbita and the lamina papyricea.  Alternatively, bipolar may be used to cauterize the artery fully.  Do not cut the artery, as this increases the risk of retraction and bleeding behind the orbit. The endoscope is removed and the incision is closed with Monocryl/Biosyn and Fast-absorbing gut ensuring that the periosteal layer is closed separately.
      2. Endoscopic evaluation of the nasal cavity after ligation of the artery is often warranted to ensure epistaxis control. 

      3. Incision along lateral nasal dorsum, carried down to the lacrimal crest
         

        Retractor on right. Frontoethmoidal suture line seen along left.


        Anterior ethmoidal artery seen perforating the periorbita and the lamina.
        Medium clips are placed on the artery in position, without cutting the artery.


        Incision closed with monocryl deep, 5-0 fast superficially.

    6. POSTOPERATIVE CARE
      1. Consider removal of nasal packing if adequate epistaxis control is obtained.
      2. Consider ophthalmology consult vs vision checks 
      3. Bacitracin or erythromycin ophthalmic ointment to incision line

  1. SUGGESTED READING
    1. Snyderman, CH and Carrau, RL. "Epistaxis." Operative Otolaryngology: Head and Neck Surgery. Eugene N Myers, editor. Saunders Elsevier. 2008.