Surgical Technique

A vertical incision is made through the mucosa over the posterior fontanelle, or a middle meatal an-trostomy is enlarged posteriorly to come near the posterior wall of the maxillary sinus. Then the mucosa is elevated to the crista ethmoidalis (Fig. 14.19 a-h). The crista needs to be curetted away or drilled with a coarse diamond burr to expose the other branches. These branches vary in number and course. They are often convoluted. It helps to make a good wide plane between the mucosoperiosteum and the lateral wall and not to "tunnel" too deeply as this will reduce visibility and access (Simmen and Heinz, 1998). Medial traction on the mucosoperiosteum is needed to place the vessels under tension and help define them.

Some surgeons place clips, but we prefer diathermy to cauterize these vessels and then cut them. There are often one or two branches passing superiorly and another that goes backward around the posterior wall of the nasopharynx just above the posterior choana to supply the septum. This posterior branch may be cut if a large sphenoidotomy is done (Fig. 14.20a, b). If the Ligaclips come off, and this can happen as you are

Fig. 14.19 a Right endoscopic view in a cadaver, incising the > mucosa over the posterior fontanelle. b Elevating the mucosa reveals a branch of the sphenopalatine artery. c Bipolar diathermy. d Unipolar suction diathermy to the anterior branch of the sphenopalatine artery. e Cutting the anterior branch of the sphenopalatine artery with microscissors. Note the crista ethmoidalis in front of the artery. f Drilling of the crista eth-moidalis to expose the foramen of the sphenopalatine artery. g The crista ethmoidalis has been removed to reveal several branches of the artery. h Note two cut branches of the sphenopalatine artery and an intact higher septal branch that will run on the anterior wall of the sphenoid.

Crista Ethmoidalis Diathermy Turbinates

of the sphenoid. b Unipolar suction diathermy is most effective when there is a lot of bleeding.

Sphenoidotomy
Fig. 14.20 a A large sphenoidotomy has cut the septal branch of the sphenopalatine artery as it runs across the anterior wall

of the sphenoid. b Unipolar suction diathermy is most effective when there is a lot of bleeding.

Diathermy Epistaxis

looking for the other branches, then diathermy should be used (Fig. 14.21 a-c). In severe posterior epistaxis, always check the septal branch of the sphenopalatine artery that is posterior to its other branches (Fig. 14.22a, b). OYl* 12,13

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Responses

  • Tommy
    What can happen if a ligaclip does not work?
    7 years ago

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