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FIGURE 5 The technique of anterior ethmoid artery ligation via a Lynch incision.

intractable epistaxis. Since that time, multiple reports utilizing this basic technique with various catheters and embolic materials have been reported.

The use of this technique is seen in many areas including arteriovenous malformations, pseudoaneurysms, bleeding varices, shrinking of fibroids, and vascular tumors of the head and neck. Diagnostic angiography with embolization is commonly performed under local anesthesia via the femoral approach. A variety of catheters and microcatheters have been developed to get to the different sources of epistaxis. Once in the proper location, an embolic material is injected via the catheter to occlude the offending vessel. The type of embolic utilized depends on the desired level of occlusion, desired duration of occlusion, and catheter system compatibility (Table 1).

The technique most commonly used at our institution is as follows: Prior to embolization, complete diagnostic arteriography of the internal and external carotid circulations is performed bilaterally, and, if indicated, the vertebral arteries' circulation is studied, as well. This is usually performed from a femoral artery approach, utilizing a 4- or 5-French diagnostic catheter. If embolization is to be performed, an open-ended guiding catheter usually is used. The catheter is advanced through a groin sheath and positioned in either the common carotid artery or the external carotid artery trunk. A microcatheter of under 2.8-French in diameter, in conjunction with micro-guidewires, is then utilized for selective catheterization of the appropriate vessel(s).

Embolization is then performed with an appropriate agent. In the case of epistaxis or preoperative tumor embolization, particulate agents are generally employed. Following embolization, which is performed during observation with real-time fluoroscopy, completion arteriography is generally performed through the microcatheter and/or guiding

TABLE 1 Embolic Agents

Absorbable material Gelfoam

Autologous blood clot Avitene Ethibloc Nonabsorbable material Particulate agents Autologous fat and muscles PVA

Spherical PVA Acrylics Injectable agents

NBCA [Onyx (not currently available in United States), silicone] Sclerosing agents Boiling contrast ETOH (absolute alcohol) Sodium morrhuate Sotradecol Occlusion devices Detachable balloons Coils, microcoils Detachable coils Spider, clamp shells Amplatzer

Abbreviations: PVA, polyvinyl alcohol; NBCA, N-butyl cyanoacrylate; ETOH, ethyl alcohol.

catheter, and, depending on the vascular territory and level of embolization, collateral circulation might be evaluated with respect to the need for further embolization.

This technique, even in the best hands, is not without the risk of complication. The major complications reported in the literature have included stroke, blindness, facial paralysis, grand mal seizure, trismus, soft-tissue necrosis, and swelling of the cheek. Most of these cases occurred when utilizing permanent embolic agents such as PVA. Minor complications have been reported to range from 2.2% to 25% (31,49-51). These may include mild-to-moderate temporal pain, headache, and temporofacial pain.


JA is a benign, highly vascular tumor that almost exclusively occurs in the nasopharynx of adolescent males. The average age of onset is 15 years. JA typically originates in the superior margin of the sphenopalatine foramen. It accounts for only 0.5% of all head and neck tumors (11,12,52). The most common presenting symptoms are severe recurrent epistaxis with nasal obstruction. The histologic origin of these tumors is uncertain, but they

FIGURE 6 (A) Catheter in internal maxillary artery (arrow). (B) Right ECA preembolization. The tumor mass can be seen (arrow) (C) Right ECA postembolization. The tumor blush is gone. Abbreviation: ECA, external carotid artery.

have a highly vascularized and proliferative nature (12,53). Bone erosion may occur in the region of the orbit and the skull base. If the disease process is allowed to progress, facial deformity, proptosis, blindness, and cranial nerve palsy may occur. Fisch classified JAs into four types. The stages may help plan the correction (54).

Removal of the tumor depends on its extent and the training of the surgeon. Previously, the majority of these tumors were removed through an open approach, commonly via a lateral rhinotomy (11). Craniofacial resections have been utilized in advanced JAs (52,55,56). More recently, endoscopic removal has been popularized for lower-stage lesions (57). With the increase in interventional radiology and selective embolization, removal of these tumors can be accomplished without major blood loss. Effective preoperative embolization is most important when one wants to attempt endoscopic removal of these tumors (Fig. 6A-C).


1. Santos PM, Lepore ML. Epistaxis in head and neck surgery. In: Bailey BJ, ed. Otolaryngology. Vol. 1. 2nd ed. Philadelphia, PA: Lippincott-Raven, 1998:513-529.

2. Shaheen OH. Arterial epistaxis. J Laryngol Otol 1975; 89(1):17-34.

3. Kirchner JA, Yanagisawa E, Crelin ES Jr. Surgical anatomy of the ethmoidal arteries. A laboratory study of 150 orbits. Arch Otolaryngol 1961; 74:382-386.

4. Hollinshead WH. Anatomy for Surgeons. Vol. 1: The Head and Neck. 3rd ed. Philadelphia, PA: Harper & Row, 1982.

5. Pearson BW, MacKenzie RG, Goodman WS. The anatomical basis of transantral ligation of the maxillary artery in severe epistaxis. Laryngoscope 1969; 79(5):969-984.

6. Woodruff GH. Cardiovascular epistaxis and the naso-nasopharyngeal plexus. Laryngoscope 1949; 59 (11):1238-1247.

7. Lang J. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. Stell PM, trans. New York, NY: Thieme Medical Publishers, 1989.

8. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg 2002; 109(3):1128-1146.

9. Rappai M, Collop N, Kemp S, et al. The nose and sleep-disordered breathing: what we know and what we do not know. Chest 2003; 124(6):2309-2323.

10. Diamantopoulos II, Jones NS. The investigation of nasal septal perforations and ulcers. J Laryngol Otol 2001; 115(7):541-544.

11. Mann WJ, Jecker P, Amedee RG. Juvenile angiofibromas: changing surgical concept over the last 20 years. Laryngoscope 2004; 114(2):291-293.

12. Bales C, Kotapka M, Loevner LA, et al. Craniofacial resection of advanced juvenile nasopharyngeal angiofibroma. Arch Otolaryngol Head Neck Surg 2002; 128(9):1071-1078.

13. Scholtz AW, Appenroth E, Kammen-Jolly K, et al. Juvenile nasopharyngeal angiofibroma: management and therapy. Laryngoscope 2001; 111(4 Pt 1):681-687.

14. Karabulut AB, Aydin H, Mezdegi A, et al. Recurrent bleeding following rhinoplasty due to Factor XIII deficiency. Plast Reconstr Surg 2001; 108(3):806-807.

15. Andreoli TE, Bennet JC, Carpenter CC. Cecil Essentials of Medicine. 3rd ed. Philadelphia, PA: Saunders, 1993:400-416.

16. Burrows RF, Ray JG, Burrows EA. Bleeding risk and reproductive capacity among patients with factor XIII deficiency: a case presentation and review of literature. Obstet Gynecol Surv 2000; 55 (2):103-108.

17. Gerlach R, Raabe A, Zimmermann M, et al. Factor XIII deficiency and postoperative hemorrhage after neurosurgical procedures. Surg Neurol 2000; 54(3):260-265.

18. Klepfish A, Berrebi A, Schattner A. Intranasal tranexamic acid treatment for severe epistaxis in hereditary hemorrhagic telangiectasia. Arch Intern Med 2001; 161(5):767.

19. Peery WH. Clinical spectrum of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). Am J Med 1987;82(5):989-997.

20. Bowie EJW, Owen CA Jr. Primary vascular disorders. In: Colman RW, Hirsch J, Marder VI, et al., eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice. Philadelphia, PA: JB Lippincott Co., 1994:134-168.

21. Porteous ME, Burn J, Proctor SJ. Hereditary haemorrhagic telangiectasia: a clinical analysis. J Med Genet 1992; 29(8):527-530.

22. Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med 2005; 45(2):134—139.

23. Wurman LH, Sack JG, Flannery JV Jr, et al. The management of epistaxis. Am J Otolaryngol 1992; 13(4):193-209.

24. Wild DC, Spraggs PD. Treatment of epistaxis in accident and emergency departments in the UK. J Laryngol Otol 2002; 116(8):597-600.

25. Josephson GD, Godley FA, Stierna P. Practical management of epistaxis. Med Clin North Am 1991; 75(6):1311—1320.

26. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995; 25(5):592-596.

27. Perretta LJ, Denslow BL, Brown CG. Emergency evaluation and management of epistaxis. Emerg Med Clin North Am 1987; 5(2):265-277.

28. Beer HL, Duvvi S, Webb CJ, et al. Blood loss estimation in epistaxis scenarios. J Laryngol Otol 2005; 119(1):16—18.

29. Hassard AD, Kirkpatrick DA, Wong FS. Ligation of the external carotid and anterior ethmoidal arteries for severe or unusual epistaxis resulting from facial fractures. Can J Surg 1986; 29(6): 447-449.

30. Kurata A, Kitahara T, Miyasaka Y, et al. Superselective embolization for severe traumatic epistaxis caused by fracture of the skull base. AJNR Am J Neuroradiol 1993; 14(2):343-345.

31. Oguni T, Korogi Y, Yasunaga T, et al. Superselective embolisation for intractable idiopathic epistaxis. Br J Radiol 2000; 73(875):1148-1153.

32. Chambers EF, Rosenbaum AE, Norman D, et al. Traumatic aneurysms of cavernous internal carotid artery with secondary epistaxis. Am J Neuroradiol 1981; 2(5):405-409.

33. Jackson KR, Jackson RT. Factors associated with active, refractory epistaxis. Arch Otolaryngol Head Neck Surg 1988; 114(8):862-865.

34. Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg 1986; 94(3): 412-415.

35. Montgomery RR, Coller BS. Von Willebrand disease. In: Colman RW, Hirsch J. Marder VJ, et al., eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice. 3rd ed. Philadelphia, PA: JB Lippincott Co., 1994:134-168.

36. Hirsch C. Ligation of the internal maxillary artery in patients with nasal hemorrhage. Arch Otolaryngol 1936; 24:589-596.

37. Bernstein L. The Caldwell-Luc operation. Otolaryngol Clin North Am 1971; 4(1):69-77.

38. Macbeth R. Caldwell-Luc operation 1952-1966. Arch Otolaryngol 1968; 87(6):630-636.

39. Metson R, Lane R. Internal maxillary artery ligation for epistaxis: an analysis of failures. Laryngoscope 1988; 98(7):760-764.

40. Prades J. Abord endonasal de la fosse pterygo-maxillaire. LXXIII Cong Franc Compt. Rendus des Seanc 1976; 290-296.

41. Prades J, Bosch J, Tolasa A. Garsi DLM, ed. Microcirugia Endonasal. Madrid, Espana, 1977.

42. Prades J. Salvat, ed. Microcirugia Endonasal de la Fosa Pterigomaxilar y del Meato Medio. Barcelona, Espana, 1980.

43. Snyderman CH, Carrau RL. Endoscopic ligation of the sphenopalatine artery for epistaxis. Operative techniques in Otolaryngology—Head and Neck Surgery 1997; 8(2):85-89.

44. Simpson GT II, Janfaza P, Becker GD. Transantral sphenopalatine artery ligation. Laryngoscope 1982; 92(9 Pt 1):1001-1005.

45. Goddard JC, Reiter ER. Inpatient management of epistaxis. Outcomes and cost. Otolaryngol Head Neck Surg 2005; 132(5):707-712.

46. Saunders WH. Epistaxis. In: Paparella MM, Shumrick DA, Glusckman JL, eds. Otolaryngology. Vol. 3. 2nd ed. Philadelphia, PA: WB Saunders Company, 1980:1994-2000.

47. Small M, Murray JA, Maran AG. A study of patients with epistaxis requiring admission to hospital. Health Bull (Edinb) 1982; 40(1):20-29.

48. Sokoloff J, Wickbom I, McDonald D, et al. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974; 111(2):285-287.

49. Vitek J. Idiopathic intractable epistaxis: endovascular therapy. Radiology 1991; 181(1): 113-116.

50. Tseng EY, Narducci CA, Willing SJ, et al. Angiographic embolization for epistaxis: a review of 114 cases. Laryngoscope 1998; 108(4 Pt 1):615-619.

51. Moreau S, De Rugy MG, Babin E, et al. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope 1998; 108(6):887-888.

52. Wormald PJ, Van Hasselt A. Endoscopic removal of juvenile angiofibromas. Otolaryngol Head Neck Surg 2003; 129(6):684-691.

53. Schiff M, Gonzalez AM, Ong M, et al. Juvenile nasopharyngeal angiofibroma contain an angiogenic growth factor: basic FGF. Laryngoscope 1992; 102(8):940-945.

54. Fisch U. The infratemporal fossa approach for nasopharyngeal tumors. Laryngoscope 1983; 93(1): 36-44.

55. Mishra SC, Shukla GK, Bhatia N, et al. Angiofibromas of the postnasal space: a critical appraisal of various therapeutic modalities. J Laryngol Otol 1991; 105(7):547-552.

56. Herman P, Lot A, Chapot R, et al. Long-term follow-up of juvenile nasopharyngeal angiofibromas: analysis of recurrences. Laryngoscope 1999; 109(1):140-147.

57. Tseng HZ, Chao WY. Transnasal endoscopic approach for juvenile nasopharyngeal angiofibroma. Am J Otolaryngol 1997; 18(2):151-154.

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