Arterial Ligation for Pediatric Epistaxis: Developmental Anatomy

Abstract

Background Anatomic studies of adult skulls have aided in the design of operations for the surgical ligation of nasal feeding vessels in the treatment of severe epistaxis. Lack of appropriate specimens has prevented similar studies in children. We performed an anthropometric study of archeological specimens to learn the effects of growth on key anatomic relationships. Methods We studied the skulls of children who died between 200 and 8000 years ago, recovered from archeological digs around the world. Measurements of the distances from the posterior lacrimal crest to the foramina of anterior and posterior ethmoidal arteries and optic canal and the pyriform aperture to the foramen of the sphenopalatine artery were made and compared with postnatal age, estimated from facial growth and dental eruption patterns. Results There is rapid growth in the orbit and midface during the first 6 years of life and gradual growth between 7 years and adulthood. The length of the medial wall of the orbit doubles during development with disproportionate enlargement of its anterior half. Conclusion Arterial ligation is sometimes required for intractable pediatric epistaxis, especially after trauma. The changing relationships of critical structures in the orbital must be understood to allow safe ethmoidal artery ligation. The transantral approach to the maxillary artery is greatly limited by lack of midfacial development and maxillary pneumatization. We describe the necessary parameters for endoscopic, transnasal sphenopalatine artery ligation in growing children.