Epistaxis is a common emergency seen by the otolaryngologist. A minority of cases require surgical intervention. Multiple surgical procedures have been tried in the past, including endoscopic ligation of the sphenopalatine artery (ELSPA), which is considered an effective surgical modality in the management of epistaxis. This study examines the outcome of 33 ELSPA procedures over a 5-year period. Three of 4 cases that were not controlled with ELSPA were successfully managed with subsequent anterior ethmoidal ligation. Failed ELSPA procedures may represent an incorrect choice of procedure rather than a failure of the procedure. High-resolution computed tomography can identify the position of the anterior ethmoidal artery; it may be possible to infer vulnerability to hemorrhage from this artery and hence target procedure selection.