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TESPAL by drtbalu

Tespal: (Trans nasal endoscopic sphenopalatine artery ligation)

History:  This procedure was first reported by Budrovich and Saetti in 1992.

This procedure can safely be performed under GA. / L.A.


Epistaxis not responding to conventional conservative management.

Posterior epistaxis


The nose should first be adequately decongested topically using 4% xylocaine mixed with 1 in 50,000 units adrenaline.

A 4mm 0 degree nasal endoscope is introduced into the nasal cavity.  The posterior portion of the middle turbinate is
visualized.  2% xylocaine with 1 in 1lakh units adrenaline is injected in to this area to further reduce bleeding.

Incision:  An incision ranging between 10 - 20 mm is made vertically about 5 mm anterior to the attachment of
the middle turbinate.  The mucosal flap is gently retracted posteriorly till the crista ethmoidalis is visualized.  The
crista ethmoidalis is a reliable land mark for the sphenopalatine artery.  The artery enters the nose just posterior
to the crista.  The crista can infact be removed using a Kerrison's punch for better visualization of the artery. 
The sphenopalatine artery is clipped using liga clip or cauterized as it enters the nasal cavity.  This is done as close
to the lateral nasal wall as possible, this would ensure that the posterior branches may also be reliable included.
Following successful ligation / cauterization, the area is explored posteriorly for 2 - 3 mm to ensure that no more
vessels remain uncauterized.

Nasal packing is not needed.

Complications of TESPAL:

1. Palatal numbness
2. Sinusitis
3. Decreased lacrimation
4. Septal perforation
5. Inferior turbinate necrosis

This procedure in combination with transnasal anterior ethmoidal artery ligation  ensures that epistaxis is controlled

Image showing cauterized sphenopalatine artery area