The management of epistaxis is a remarkably common and particularly vexing problem for the otolaryngologist. There is a 60% lifetime incidence of epistaxis and, among this group, 6% will seek medical attention. Within the emergency department setting, between 0.5% and 0.9% of all patient presentations are for epistaxis, making this the most common condition for which an otolaryngologist will be urgently consulted. While the vast majority of epistaxis will emanate from an identifiable location on the mucosa of the anterior septum or as a direct result of iatrogenic manipulation of the nasal passages, there is a troubling 5% to 10% of cases with “posterior epistaxis” that lacks a bleeding source amenable to discovery with headlight and speculum. Posterior epistaxis has traditionally been managed under the rubric of initiating care with a conservative measure and then advancing treatment to include more invasive techniques, including surgery, if the conservative measures fail. With the wide acceptance and availability of endoscopic sinus surgery, the established custom has become updated. My experience is aligned with the current literature supporting initiation of care for the patient with posterior epistaxis with endoscopic examination and transnasal ligation of the named vessels that provide the blood supply of the majority of the posterior septum and lateral nasal wall.

Since the most likely site of bleeding in posterior epistaxis is variably reported as the posterior septum or the lateral nasal wall, the vascular supply to this region is the logical target for surgical intervention. The relevant vascular anatomy for this operation begins with the third portion of the internal maxillary artery within the pterygopalatine fossa. The branching pattern of the internal maxillary artery is highly variable, and multiple studies have not produced reliable anatomic landmarks by which the vessel can be located within this space posterior to the maxillary sinus. The internal maxillary artery travels within the adipose tissue of the anterior compartment of the pterygopalatine fossa, and, after giving off the descending palatine artery, the vessel terminally branches into the sphenopalatine and posterior nasal arteries. These terminal branches of the internal maxillary artery can travel together to enter the nasal cavity through the sphenopalatine foramen, but more commonly bifurcate within the pterygopalatine fossa and enter the lateral nasal wall as distinct vessels, and frequently they do so through anatomically separate foramina. The use of advanced surgical instruments allows for identification of all vessels entering the lateral nasal walls and selective ligation of these vessels in the treatment of posterior epistaxis.

The evolution of surgical interventions for epistaxis closely follows the progression of available surgical equipment and our more detailed understanding of the vasculature of the lateral nasal wall. While transcervical approaches for ligation of the external carotid artery were reported as early as 1925, more targeted operations were later developed using the Caldwell-Luc technique as a corridor allowing for transantral ligation of the internal maxillary artery. Transantral ligation, while not technically difficult, was prone to surgical complication rates as high as 28% and failure rates of 10% or more. Transantral surgery within the pterygopalatine fossa has had reported complications of blindness, decreased lacrimation, ophthalmoplegia, facial pain, hemorrhage,
facial and dental paresthesia, devitalization of the teeth, and oroantral fistula. Failure of the transantral ligation was thought to be the result of extensive collateral blood flow supplying the sphenopalatine artery distal to the site of ligation as well as the difficulty in ligating all of the multiple and varied branches of the vasculature within the pterygopalatine fossa. Selective microsurgical ligation of the sphenopalatine artery without pterygopalatine fossa dissection was performed through the transantral approach during the 1970s, and by 1985, a transnasal approach supplanted the external technique for sphenopalatine ligation. By 1992, the endoscope was increasingly adopted by surgeons, and a selective sphenopalatine artery ligation (SPA) using this fundamental instrument of modern sinus surgery had been reported. Expanded endonasal surgical techniques that routinely address the pterygopalatine fossa, lateral sphenoid recess, and infratemporal fossa have improved our understanding of the neurovascular anatomy, and in doing so, have improved the expertise available for aggressively treating epistaxis surgically while minimizing complications.

As the ability to perform selective ligation of the sphenopalatine and posterior nasal arteries became more widespread, a new paradigm emerged emphasizing the surgical management of posterior epistaxis. Although nasal packing would seem to be less invasive than surgery, it is less successful (50%), more costly, uncomfortable for patients, and associated with significantly longer periods of hospitalization in comparison to endoscopic vessel ligation. Transarterial embolization of the internal maxillary artery has long been seen as an alternative to surgical vessel ligation; however, with higher costs and equivalent success rates, interventional radiology is typically reserved for clinical situations that prohibit surgery and general anesthesia or when vessel ligation is unsuccessful.