The Posterior Ethmoid Artery in Severe Epistaxis

The transantral ligation of the maxillary artery (MA) was first described and successfully performed by Seiffert in Europe in 1929. I The technique was brought to this country in 1936 by Cesar Hirsch," who helped establish it as the most widely accepted and performed surgery for severe posterior epistaxis. But what happens when a patient who has had a maxillary artery ligation presents with persistent or recurrent bleeding from the same side of the nose? Traditionally, there has been no consensus of opinion amongst practitioners as to which vessel(s) to ligate next in these difficult cases. Subsequent therapies proposed have included anterior ethmoid ligations, submucous resection, electrocautery, external carotid artery ligation, contralateral sphenopalatine artery ligation. and re-exploration of the pterygopalatine fossa, or some combination of these. 3 Embolization of an incompletely ligated MA or collaterals has also been a useful modality.' Embolization of the ethmoid arteries. however, cannot be performed because of the risk of blindness. Therefore. cases of recurrent hemorrhage from the ethmoid arteries must be controlled surgically. We present this article to emphasize the importance of the posterior ethmoid artery (PE) in cases of unsuccessful MA ligation.