Endoscopic Endonasal Approaches for Arterial Ligation within the Pterygopalatine Fossa: What Is the Risk of Xerophthalmia?

Background Sphenopalatine artery (SPA) ligation is the most common surgical procedure performed for posterior epistaxis refractory to nasal packing. The SPA stems from the internal maxillary artery (IMAX), and exposure to achieve maximal hemostatic control includes dissection and ligation of the artery within the pterygopalatine fossa. Multiple important structures exist within the pterygopalatine fossa. The vidian nerve communicates with the pterygopalatine ganglion within the pterygopalatine fossa and carries postganglionic parasympathetic fibers to the lacrimal gland for tear secretion.

Objectives To highlight the safety of surgical instrumentation and clipping of the SPA and IMAX within the pterygopalatine fossa with regard to possible development of postoperative xerophthalmia.

Methods Retrospective chart analysis was performed for endoscopic endonasal SPA/IMAX ligations within the pterygopalatine fossa performed between 1/1/2013 and 8/31/2017. All surgical cases involved the use of three or four titanium hemoclips for each artery ligated. A total of 62 patients were identified and telephone surveys were performed to analyze for incidence of severe bleeding, xerophthalmia, corneal ulceration, and other ocular symptoms.

Results Telephone surveys were completed by 28 patients, 21 males and 7 females. Mean age of these patients was 63 years with a range between 21 and 90. Of these patients, 19 underwent unilateral arterial ligation and 9 underwent bilateral ligation. Three out of these 28 patients experienced some degree of eye dryness; however, all three patients stated symptoms of bilateral eye dryness preceding SPA/IMAX ligation and denied worsening of symptoms following. No patients experienced severe symptoms such as corneal ulceration. Four patients reported vision changes, all related to cataract formation. Five patients experienced recurrent epistaxis following SPA ligation, three experiencing minor bleeds which resolved without therapy. One patient had unilateral ligation and required surgery to the other side, and another patient who had bilateral ligation required unilateral ligation of the anterior ethmoidal and incisive foramen arteries. For these two patients, no xerophthalmia or other ocular symptoms were experienced postoperatively.

Conclusion Endoscopic endonasal SPA/IMAX ligation within the pterygopalatine fossa is a relatively safe procedure for epistaxis refractory to conservative therapy, especially with regard to postoperative xerophthalmia. In our series, no patients experienced symptoms of eye dryness related to the surgical procedure, and no severe symptoms such as corneal ulceration were noted. Further studies will be completed to quantify degrees of postoperative xerophthalmia via Schirmer testing.