Severe epistaxis management remains a challenge to otolaryngologists. Despite the large choice of treatment strategies to control epistaxis, the method of regional haemostasis via edoscopic arterial ligation has become frequently used. Arterial supply occlusion is usually performed by electrocautery or application of titanium clips. After placement of titanium clips, they will remain in place forever and could surprisingly be rediscovered later on CT-scan. Most of otolaryngologists are familiar with this method and are able to identify these clips, however, it could be more difficult for radiologists and other practitioners. In order to draw the attention of other specialists to the existence of this method and to help them correctly interpret such CT-scans, the authors present an example of a case that troubled radiologists. In addition, the authors also discussed the vascular supply of the nasal fossa and methods of severe epistaxis management.
Severe epistaxis management remains a challenge to otolaryngologists. Despite the large choice of treatment strategies of epistaxis control, the method of regional hemostasis via endoscopic arterial ligation has become frequently used [
A 76-year-old man, who recently arrived in our region, presented to the emergency department with recurrent headache, without other neurological symptoms. He had a remote history of epistaxis managed under general anesthesia. On physical examination, the blood pressure was normal; the funduscopic examination did not reveal papilledema. A cranial CT-scan was performed to eliminate intracranial lesion; and did not show any cause of headache. However, several strange findings troubled our radiologists. The unidentified findings were located in the nose (Figures 1(a) and (b)) and in the orbits (Figures 1(c) and (d)). For further clarification, the patient with CT-scan images was referred to our department. The nasal endoscopic exam was perfect and the following explanation for the images was proposed: “These images correspond to titanium hemostatic clips that were used during endoscopic regional hemostasis to control an epistaxis; both sphenopalatine (Figures 1(a) and (b)) and anterior ethmoidal (Figures 1(c) and (d)) arteries were bilaterally ligated” [
In the past years, the main therapy of severe epistaxis has become the surgical endoscopic ligation of the arterial supply of the nasal cavity [
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The vascular anatomy of the nasal fossa is complex. This radiological case reminds us that the intranasal blood supply depends of two arterial systems that could anastomose between each other. There is the system of external carotid artery (ECA) and the system of internal carotid artery (ICA) [6,7]. In addition, veins always accompany arteries.
Five main arteries supply the mucoperiosteum of the nasal cavity on each side: three arteries depend on the ECA and two arteries depend on the ICA (
The anterior and posterior ethmoidal arteries originate from the ophthalmic artery, branch of the ICA. To supply the ethmoid they pass through the successive foramina, which lie in the medial wall of the orbit along the frontoethmoidal suture line.
During severe epistaxis management only the branches of the sphenopalatine arteries and anterior ethmoidal arteries could be considered to occlusion without serious consequences. In the opposite case, complications may occur [
To ligate arterial branches we usually use the Montgomery-Youngs Rhinoforce® II Clip Applicator 452650 C or D (Karl Storz GmbH & Co. KG, Germany) with titanium clips 8665T (Karl Storz GmbH & Co. KG, Germany). Once the sphenopalatine artery, arising from shenopalatine foramen, was identified in the nasal fossa, one titanium clip is placed on each main branch of it with care taken to ensure that the entire width of the artery is enclosed within the clip [
This case demonstrates that severe epistaxis could be managed surgically and that some practitioners may not be aware of it. Secondary signs of surgical treatment of epistaxis may be discovered later on CT-scan and sometimes not interpreted correctly. In order to provide timely and most efficient care to patients, it is important for radiologists and other specialists to be aware of such method and to be able to read and fully understand such CT-scans.