Pictorial Essay
Epistaxis: Vascular Anatomy, Origins, and Endovascular
Treatment
Elsie Koh 1, Vincent I. Frazzini, Nolan J. Kagetsu
A B
Fig. 1.Arterial anatomy of medial and lateral nasal wall. Ant. = anterior, Post. = posterior, a. = artery.
A, Drawing of medial nasal wall shows blood supply of nasal septum. Note Kiesselbachs or Littles area, where most anterior epistaxis occurs.
B, Drawing shows blood supply of lateral nasal wall.
A B
Fig. 2.63-year-old woman with epistaxis refractory to nasal packing.
A, Anteroposterior angiogram shows injection in right distal internal maxillary artery. Medial or septal branches supply septum (straight arrow ), and lateral branches sup-
ply turbinates (curved arrow ).
B, Angiogram in lateral projection shows branches of sphenopalatine artery (arrows).
branches supply the nasal septum (Figs. 2A tion of the facial artery should be performed seen on angiograms with normal findings.
and 2B). with caution because of the potential risk of The presence of prominent ethmoidal
The terminal branch of the greater palatine necrosis of the nasal ala with occlusion of branches indicate that embolization of
artery enters the incisive foramen and supplies the alar artery, the terminal branch of the fa- ECA branches may fail to control the
the inferior nasal septum, where it anasto- cial artery. epistaxis. Kiesselbachs plexus, also known
moses with medial branches of the sphenopa- The anterior and posterior ethmoidal as Littles or Kiesselbachs area, is a local-
latine artery. The superior labial artery, branches of the ophthalmic artery, usually a ized region of mucosa of the anteroinferior
arising from the facial artery, also supplies branch of the ICA, pass through the cribri- nasal septum. It is supplied by branches of
the medial wall of the nasal vestibule via a form plate to anastomose with the nasal the sphenopalatine, greater palatine, and fa-
septal branch. This branch is rarely seen on branches of the sphenopalatine artery cial arteries and is the site of most anterior
angiograms with normal findings. Emboliza- (Figs. 3A and 3B). These vessels are rarely epistaxis (Fig. 1A).
Treatment sinusitis, exacerbation of sleep obstructive ital subtraction angiography with road map-
Initial treatment attempts may include apnea, and pack-induced hypoxia [24]. Al- ping is used to selectively guide the catheter
chemical or electric cautery of distal ternatively, studies of posterior endoscopic to the region of interest that is typically the
branches and the bleeding site [2]. When cauterization report success rates of 8090% distal portion of the internal maxillary ar-
cautery is unsuccessful, nasal packing may [2]. Studying endovascular therapy for idio- tery (Fig. 4). One must identify potentially
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be necessary. The relatively high failure rate pathic intractable epistaxis in 30 patients, dangerous anastomoses to the carotid si-
of anterior nasal packing for superior and Vitek [5] found an 87% success rate after phon (such as the artery of the foramen ro-
posterior epistaxis is not surprising because embolization of the internal maxillary artery tundum) and ophthalmic artery to avoid the
the posterior extent of an anterior nasal pack- and a 97% success rate (with a 3% complica- complications of stroke or blindness. The
ing is limited and may not tamponade the tion rate) after embolization of the internal microcatheter is routinely advanced distal
posterior turbinates. More aggressive use of and facial arteries. to branches with high potential for danger-
posterior packing with inflatable balloon Because interventional neuroradiology ous anastomosis collaterals, such as the
packs tamponades more of the nasal fossa. is increasingly available, embolization has middle meningeal, accessory meningeal,
However, packing has a reported failure rate become an option when initial treatment and superficial temporal arteries, to avoid
of 2652% [3, 4]. In addition, posterior nasal fails. The protocol should include evalua- nontarget embolization. Injection should not
packing has caused severe complications tion of the ICA to determine if the ICA or be performed too forcefully because reflux into
such as alar and septal necrosis, aspiration, its branches are the source of bleeding. Dig- the ICA can occur [5]. Control angiography is
A B
A B
C D
performed after embolization to assess the imal occlusion. Gelfoam powder may embo- Selected Causes of Epistaxis
results (Fig. 4C). lize too distally and cause necrosis or cranial Spontaneous
nerve palsy.
The idiopathic or spontaneous form of
Embolic Materials epistaxis is the most common cause, often
Failure of Embolization related to cigarette use, hypertension, and
Embolic materials frequently used for atherosclerotic disease (Fig. 4). Although hy-
treatment of epistaxis include Gelfoam (Up- Failure of endovascular treatment of pervascularity is commonly seen, angio-
john, Kalamazoo, MI) pieces, polyvinyl al- epistaxis is often related to continued bleed- graphic demonstration of the bleeding point
cohol particles (Figs. 46), platinum coils ing from the ethmoidal branches of the oph- (extravasation) is rare [7].
(Figs. 7 and 8), or a combination of materials thalmic artery (Fig. 3A). Embolization of
[6]. Polyvinyl alcohol particles (149250 these branches is contraindicated because Primary Neoplasms
m) are typically used. Platinum coils and ophthalmic artery embolization carries a Juvenile angiofibroma is the most com-
Gelfoam pieces can be used to achieve prox- high risk of blindness. However, the surgeon mon benign tumor arising from the na-
imal occlusion quickly. However, collateral can ligate the ethmoidal vessels as they per- sopharynx and comprises 0.5% of all head
formation and bleeding can occur after prox- forate the medial wall of the orbit [2]. and neck neoplasms [8]. It occurs almost ex-
A B C
Fig. 6.57-year-old woman with right-sided nasal mass and epistaxis caused by solitary fibrous tumor.
A, Conventional spin-echo T1-weighted sagittal MR image after gadolinium administration shows peripheral
enhancement (arrow ).
B, Mass is of low signal intensity (arrow) on T2-weighted MR sequence.
C, Mid to late arterial phase right external carotid artery arteriogram in lateral projection shows peripheral
vascularity.
D, Peripheral vascularity shown in C is completely obliterated after distal internal maxillary artery embolization.
A B C
Fig. 7.32-year-old pregnant woman with epistaxis after gunshot wound.
A and B, Left common carotid arteriogram in anteroposterior projection (A) and left external carotid arteriogram in lateral projection (B) show active extravasation of con-
trast material from sphenopalatine artery (arrows ).
C, Lateral projection of left external carotid angiogram shows hemostasis after embolization of distal external carotid artery with platinum coil.
clusively in boys. Cross-sectional imaging supply of a juvenile angiofibroma can arise ization of the surgical field, and result in a
usually identifies the mass with bowing or from ICA or ECA branches (Fig. 5). Angiog- more complete and uncomplicated resection.
erosion of adjacent bony structures within raphy and embolization before surgery can A solitary fibrous tumor of the nasophar-
the nasal cavity or nasopharynx. The arterial reduce surgical blood loss, improve visual- ynx is a rare cause of epistaxis (Fig. 6). This
A B
A B
Fig. 9.37-year-old man with sinusitis who presented with epistaxis after functional endoscopic sinus surgery.
A and B, Left external carotid artery arteriograms in anteroposterior (A) and lateral (B) projections show active ex-
travasation (arrows).
C, Superselective angiogram in anteroposterior projection shows extravasation (arrow) from sphenopalatine
branches more clearly than A and B.
C
spindle cell tumor has pathologic features neck of the pseudoaneurysm was above the 1981;89:10011006
similar to those of angiofibromas, hemangio- arch of C1. 4. Schaitkin B, Strauss M, Houck JR. Epistaxis: med-
ical versus surgical therapya comparison of effi-
pericytomas, and fibrous histiocytomas [9].
Summary cacy, complications, and economic considerations.
TraumaticIatrogenic Embolization can play an important role Laryngoscope 1987;97:13921396
in controlling epistaxis. However, one must 5. Vitek JJ. Idiopathic intractable epistaxis: endovas-
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