Question

A 35 year old male presented with epistaxis. Conservative management was done to stop the bleeding which failed. What is the next step of management?

• A. Endoscopic Sphenopalatine artery ligation
• B. ICA ligation
• C. ECA ligation
• D. Maxillary artery ligation

Hint:

After conservative measures fail, the surgical approach targets the terminal nasal blood supply first before ascending to more proximal vessels.

Answer 1

The Correct Option is A

Step 1: Understand the clinical scenario. A 35-year-old male presents with epistaxis (nosebleed). Conservative management (anterior nasal packing, posterior nasal packing, chemical or electrical cautery) has been tried and has failed to stop bleeding.

Step 2: Know the stepwise management of epistaxis. The management of epistaxis follows a stepwise escalation:
1. First line: Anterior nasal packing (ANP)
2. Second line: Posterior nasal packing (PNP) or balloon tamponade
3. Third line: Endoscopic sphenopalatine artery (SPA) ligation -- this is the next surgical step when conservative measures fail
4. Fourth line: Maxillary artery ligation (transantral or endoscopic)
5. Fifth line: External carotid artery (ECA) ligation

Step 3: Why sphenopalatine artery ligation? The sphenopalatine artery is the terminal branch of the maxillary artery and is the main blood supply to the nasal mucosa. Endoscopic SPA ligation is minimally invasive, highly effective (success rate >90%), and is the preferred surgical intervention when conservative management fails before resorting to more proximal vessel ligation.

Step 4: Eliminate distractors. ICA ligation is never done for epistaxis as it carries risk of stroke. ECA ligation and maxillary artery ligation are done only if endoscopic SPA ligation fails.

Conclusion: Endoscopic sphenopalatine artery ligation is the next step.