The role of the crista ethmoidalis in endoscopic sphenopalatine artery ligation

Posterior epistaxis is a significant medical problem that can be challenging to treat. Endoscopic surgery could potentially reduced operative time and patient risk; however, surgeons report difficulty in endoscopically isolating the major offending artery, the sphenopalatine. These difficulties could be reduced if a recognizable anatomic structure marked the region of the artery. The study objective is to characterize the relationship of a relatively unknown anatomic structure, the crista ethmoidalis, to the sphenopalatine foramen/artery, in an effort to facilitate location of the sphenopalatine artery during endoscopic ligation. Using 22 human cadaveric sagitally sectioned heads and standard gross anatomic dissection techniques, the presence of the crista ethmoidalis was sought and recorded as well as its relative location to the sphenopalatine foramen/artery. The crista ethmoidalis was present and closely related to the sphenopalatine foramen and artery in all specimens. In 21/22 specimens, the crista was located just anterior to the sphenopalatine foramen, whereas in one specimen it was located 3 mm directly inferior to the foramen. Our investigation indicates that the crista ethmoidalis is a helpful and reliable landmark for endoscopically locating the sphenopalatine artery and foramen. Using this landmark, the initial problems reported with endoscopic ligation, i.e., locating the foramen and artery, should be greatly reduced. We offer our observations regarding the crista ethmoidalis to assist endoscopic surgeons in the care of their difficult epistaxis patients.