Osteologic classification of the sphenopalatine foramen

Survey Anatomical Features and Related Factors of the Sphenopalatine Foramen on Computed Tomography

The aim of the research is to define anatomical features of the sphenopalatine foramen (SPF) and be related to the SPF on computed tomography (CT) such as shape, location, size of the SPF, the appearance of the ethmoidal crest, and the distance from SPF to some landmarks in the nasal cavity. As a result, surgeons could quickly determine the SPF location in transnasal endoscopic sphenopalatine artery ligation (TESPAL). A cross-sectional study was conducted. This study was carried out at Cho Ray hospital from August 2019 to June 2020. Image data from 55 patients who had been indicated sinuses CT. Results show that the SPF had a wide range of shapes: oval (20.9%), triangle (19.1%), circle (18.2%), racket shape (7.3%), hourglass shape (6.4%), and other shapes. In the anteroposterior dimension, the mean SPF was 5.72 ± 1.22 mm. In the craniocaudal dimension, the mean SPF measured 5.62 ± 1.99 mm. The SPF was mainly located in the superior meatus and in the transition between the middle and superior meatus. The most reliable anatomical landmark to find the SPF was the ethmoidal crest with an appearance rate of about 95.5%. The mean distances from SPF to anterior nasal spine, nasal floor, nasal septum, maxillary line, anterior head of the middle turbinate, choanal arch, and base lamella were 57.04 ± 3.11, 24.71 ± 2.90, 11.26 ± 2.09, 34.93 ± 2.07, 32.69 ± 3.30, 8.82 ± 1.65, and 8.07 ± 1.28 mm, respectively. CT scan images in this study can provide information about anatomical features of the SPF, which contribute to the quick and efficient identification of the SPF before and during TESPAL.

An image-guided (CT) assessment of a new asymmetric balloon for the treatment of epistaxis

PURPOSE

The main objective was to perform an image-guided (CT) assessment of the efficacy of the CAVI-T™ balloon to compress the sphenopalatine artery (SPA) on cadaver heads, for the management of epistaxis. The secondary objectives were to analyse the deployment and stability of this balloon according to the volume injected into the nasal cavity, to optimise its use.

METHODS

A descriptive anatomical study was performed. The catheterization of the SPA was performed on four fresh-frozen heads with a SPA approach through the maxillary sinus, leaving the nasal cavity unscathed. Computed Tomography images were acquired without and with the balloon, inflated by injections of progressive volumes of diluted iodine, for optimal contrast with the surrounding tissues. We evaluated the positioning of the balloon according to two predetermined markers on the device.

RESULTS

Out of 68 image-guided acquisitions, the CAVI-T™ balloon compressed the SPA in 88% of cases. The other nasal cavity structures were compressed in 86% to 100% of the cases, depending on the positioning of the CAVI-T™ balloon, therefore allowing a complete obstruction of the nasal cavity. The device remained stable upon inflation and did not obstruct the nasopharynx.

CONCLUSION

The CAVI-T™ balloon provided effective compression of the SPA and the different structures of the nasal cavity.

Sphenopalatine Foramen Computed Tomography Landmarks

OBJECTIVE

The aim of the study was to assess different radiologic bony landmarks for endoscopic localization of the sphenopalatine foramen (SPF).

METHODS

Paranasal computed tomography (CT) scans of adults without sinonasal pathology were included. On axial cuts, the anteroposterior distances from the SPF to maxillary line, anterior head of the middle turbinate, basal lamella of the middle turbinate, choanal arch, and posterior fontanel of the maxillary sinus ostium were measured. While on coronal cuts, the vertical distances from the SPF to the nasal floor was measured. The registered measurements were then studied and statistically analyzed.

RESULTS

In 70 patients (140 sides, 840 measurements), the mean distances from the SPF to nasal floor, choanal arch, maxillary line, anterior head of the middle turbinate, basal lamella, and posterior fontanel were 25.6 ± 2.4, 8.5 ± 1.38, 36.4 ± 2.6, 34.6 ± 4.26, 8.1 ± 1.27, and 13.7 ± 1.7 mm, respectively, without significant differences between right and left sides. Females showed significantly shorter mean distances between SPF and the nasal floor (P = 0.0011), choanal arch (P = 0.0459), and posterior fontanel (P < 0.0001) than males. While no significant differences were detected between both sexes as regard distances from SPF to maxillary line (P = 0.5579), anterior head of middle turbinate (P = 0.8581), and basal lamella (P = 0.0638).

CONCLUSION

Preoperative CT can provide multiple easily detected, reliable, and simple bony landmarks that can help SPF endoscopic localization. Thus the authors recommend adding these measurements to the preoperative CT checklist for patients scheduled for sphenopalatine artery ligation and/or excision of vascular lesions.

Morphological Description and Clinical Implication of Sphenopalatine Foramen for Accurate Transnasal Sphenopalatine Ganglion Block: An Anatomical Study

Objective:

Transnasal sphenopalatine ganglion block is a commonly used approach for treatment of a variety of headache disorders. However, no standard technique has yet been defined for this less invasive approach. In this study, our aim was to investigate morphometric and anatomical features of the sphenopalatine foramen, and to describe a more efficient approach for transnasal sphenopalatine ganglion block.

Method:

The present study was designed retrospectively. Ten cadaver semi- heads and 18 adult dry skulls (28 samples totally) were included in the study. The distances between the sphenopalatine foramen and palatum durum, and also between the sphenopalatine foramen and the spina nasalis anterior, angle of elevation of the sphenopalatine foramen from palatum durum, and the length and width of the sphenopalatine foramen were measured.

Results:

The mean width and length of the foramen were 3.79±0.35 and 6.44±0.94 mm, respectively. The mean distance between the palatum durum and the sphenopalatine foramen was 15.58±1.68 mm. The mean angle of elevation of the sphenopalatine foramen from the palatum durum was 26.10±3.97 degrees. The mean distance between the sphenopalatine foramen and the anterior nasal spine was 52.90±2.98 mm.

Conclusions:

In the transnasal sphenopalatine block, we suggest advancement of nasal applicator through superolateral direction for approximately 5.3 cm, and at an angle of about 26° from the nasal base..

Endoscopic Anatomy of the Sphenopalatine and Posterior Nasal Arteries: Implications for the Endoscopic Management of Epistaxis

Background

Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity.

Methods

We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined.

Results

In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen.

Conclusion

Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.

Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis

Background:

Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery.

Objective:

This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen.

Methods:

By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis.

Results:

Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (−9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor.

Conclusion:

Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.

Surgical Management of Severe Epistaxis

Many patients with severe epistaxis benefit from endoscopic intervention for control of bleeding. Critical maneuvers to improve endoscopic visualization during surgery include head-of-bed elevation, application of topical vasoconstrictors, and local injection of vasonstrictors. Controlled, hypotensive anesthesia may also decrease intraoperative blood loss and improve visualization during surgery. Intractable posterior epistaxis can be controlled with high rates of success with endoscopic sphenopalatine artery ligation. Although less common, intractable anterior epistaxis may be controlled by anterior ethmoid artery ligation once this artery is identified as the primary source. Less common sources of severe epistaxis are also discussed in this article.

Optimizing the outcome of transnasal endoscopic sphenopalatine artery ligation in managing refractory posterior epistaxis: A case-control analysis

OBJECTIVE

To optimize the outcome of transnasal endoscopic sphenopalatine artery ligation (TESPAL) by determining the key surgical steps and applying them accordingly.

METHODS

This is a case-control study carried out in a tertiary care teaching institution on subjects who underwent TESPAL during the period of October 2010 to September 2015. Their surgical and clinical records were reviewed, and success (no re-bleed) and failure (return with re-bleed) were considered the main outcome measures of TESPAL. Accordingly, depending on whether the subjects returned with re-bleed or not, they were classified as "failure" and "success" groups. After appropriate matching in terms of age, gender and a given set of exclusion criteria that could influence per-operative decision-making or contribute to post-operative epistaxis, the groups were considered as cases (subjects undergoing TESPAL and returned with re-bleed; part of the "failure" group following matching) and controls (subjects undergoing TESPAL and did not return with re-bleed; part of the "success" group following matching). Per-operative/surgical factors executed or followed in varied combinations in each group that influenced the outcome of TESPAL were then identified from the surgical notes and were subsequently analyzed statistically.

RESULTS

In 89% of cases, the sphenopalatine artery (SPA) pedicle was either clipped or cauterized, whereas in 90% of the controls, it was both clipped and cauterized. The posterior nasal artery (PNA), when found, was cauterized in 25% of the cases, compared to 85% in the controls. Also, the septal artery region was cauterized in only 33% of cases. Both cauterization/clipping of the SPA along with cauterization of PNA was done in 69% of the controls, whereas in 59% the septal artery region was also cauterized. However, there were no cases when all these steps were combined. The results were statistically significant.

CONCLUSION

When only the per-operative/surgical factors were considered, the outcome of TESPAL was most favorable when the procedure could be done combining both clipping and cauterization of the SPA, along with cauterization of the PNA and the septal artery region.

The arterial supply of the nasal cavity

With the development of endonasal flaps, an understanding of the arterial anatomy of the nasal cavity has become increasingly important for clinicians. Despite this, there is a lack of current, accurate overviews in the literature. We have used both endoscopic and gross dissection of six fresh frozen cadaveric heads, alongside a literature review, to produce a comprehensive description of the anatomy. Four heads had their arterial systems injected with red latex. Three injected and two uninjected heads were dissected endoscopically, to provide a total of seven sides. The fourth injected head was hemisected for gross examination. The arterial systems were dissected and examined. The posterior septal artery was found to enter the nasal cavity from the sphenopalatine foramen in five sides. It bifurcated on the sphenoid rostrum in seven sides with a bifurcation lateral to the sphenoid ostium occurring in five sides and a medial bifurcation in two sides. The posterior septal artery supplied Kiesselbach's plexus on the nasal septum along with the greater palatine artery and septal branches of the superior labial and anterior ethmoidal arteries. The posterior lateral nasal artery arose from the sphenopalatine foramen in five sides to supply the lateral wall. The lateral wall branch of the anterior ethmoidal and the anterior lateral nasal artery anastomosed at the head of the inferior turbinate. These findings were mostly consistent with the current literature. We have produced a detailed and up-to-date description and diagram of the arterial supply to the nasal cavity, which may be of use to clinicians, anatomists and students.

Changing Trends in the Management of Epistaxis

Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment modalities including cautery, nasal packing, maxillary artery ligation, anterior artery ligation, and sphenopalatine artery ligation. The paper also proposes an algorithm for managing such cases.

Sphenopalatine foramen: endoscopic approach with bony landmarks

OBJECTIVE

To establish whether nasal bony landmarks on computed tomography could be utilised reliably in endoscopic approaches to the sphenopalatine foramen.

METHODS

A prospective analysis of 102 consecutive helical computed tomography scans of the paranasal sinuses was carried out by 2 senior ENT surgeons. Distances from the sphenopalatine foramen to endoscopically palpable bony landmarks were measured.

RESULTS

There were a total of 102 patients (45 females and 57 males), with a mean age of 62 years. The mean distance from the posterior fontanelle to the sphenopalatine foramen was 14.1 mm (standard deviation = 2.13). The average vertical distance of the sphenopalatine foramen opening from the bony attachment of the inferior turbinate was 14.13 mm. There were no statistically significant differences between any of these measurements (foramen width p-value = 0.714, distance from fontanelle p-value = 0.43 and distance from inferior turbinate p-value = 0.48).

CONCLUSION

Determination of reliable bony landmarks is clinically useful in endoscopic surgery and can aid identification of the sphenopalatine foramen. The inferior turbinate concha and posterior fontanelle may be used as reliable computed tomography landmarks for endoscopic approaches to the sphenopalatine foramen.

Endoscopic localization of the sphenopalatine foramen: do measurements matter?

The objective of this study was to evaluate different methods and measurements for localization of the sphenopalatine foramen (SPF) during endoscopic transnasal exposure. The study design consisted of descriptive anatomical study and the setting was in Microsurgical Cadaver Dissection Lab. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the SPF. Multiple measurements were obtained from nasal sill (NS) to SPF, ethmoid crest (EC), and other related landmarks. The results showed that EC was identified in all sides with different degrees of projection. SPF extended below the inferior edge of EC, i.e., lying both in the superior and middle meatus, in 12 sides (75 %), while it was laying only in the superior meatus in 4 sides (25 %). An accessory foramen was identified in 3 sides (18.7 %), all of which were located in middle meatus. The distance from NS to SPF ranged widely from 55 to 76 mm (mean ± SD 64.4 ± 6 mm). The average angle of elevation formed between SPF to NS and nasal floor was 11.4° (range 11-12°). Although many previous studies have reported measurements to SPF, we do not believe these measurements are of practical help due to the wide range of measurements and the lack of standard reference points. The main constant landmark for SPF remains the EC. Since SPF frequently extends below EC, the mucoperiosteal flap should be extended below the inferior edge of this crest to avoid missing the middle meatal part of SPF or any accessory foramina.

Anatomical and surgical study of the sphenopalatine artery branches

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76% of the patients (13/17) and a double trunk in 24% (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88% of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61%), 30 had 2 arterial trunks (33%) and in only 5 nasal fossae we observed 3 arterial trunks (6%). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.

Management of intractable spontaneous epistaxis

BACKGROUND

Epistaxis is a common otolaryngology emergency and is often controlled with first-line interventions such as cautery, hemostatic agents, or anterior nasal packing. A subset of patients will continue to bleed and require more aggressive therapy.

METHODS

Intractable spontaneous epistaxis was traditionally managed with posterior nasal packing and prolonged hospital admission. In an effort to reduce patient morbidity and shorten hospital stay, surgical and endovascular techniques have gained popularity. A literature review was conducted.

RESULTS

Transnasal endoscopic sphenopalatine artery ligation and arterial embolization provide excellent control rates but the decision to choose one over the other can be challenging. The role of transnasal endoscopic anterior ethmoid artery ligation is unclear but may be considered in certain cases when bleeding localizes to the ethmoid region.

CONCLUSION

This article will focus on the management of intractable spontaneous epistaxis and discuss the role of endoscopic arterial ligation and embolization as it pertains to this challenging clinical scenario.

Sphenopalatine artery pseudoaneurysm after endoscopic sinus surgery: a case report and literature review

Previously reported cases of iatrogenic sphenopalatine artery (SPA) pseudoaneurysm have occurred only after trans-sphenoidal surgery for pituitary tumors or maxillofacial surgery. In this article, the author presents what to the best of her knowledge is the first reported case of an SPA pseudoaneurysm that developed following endoscopic sinus surgery (ESS). The patient was a 76-year-old woman with myelodysplastic syndrome who presented with a 6-month history of unilateral sinus symptoms. She underwent septoplasty and unilateral ESS, which included frontal recess clearance and sphenoidotomy. However, during surgery, severe generalized bleeding was encountered. The bleeding was arrested only after anterior and posterior nasal packing. After two attempts to remove the packing failed, angiography was obtained. It revealed an SPA pseudoaneurysm, which was immediately and successfully embolized. SPA pseudoaneurysm is a rare but significant complication of ESS, and it should be considered in patients with posterior epistaxis after ESS or prolonged posterior nasal packing. The pathogenesis may include intraoperative trauma, infection, pressure necrosis from packing, or a combination of these factors. Optimal management includes either ligation or embolization, depending on anatomic, patient, staff, and resource factors. The author reviews the pertinent anatomy and the pathophysiology, diagnosis, management, and prevention of this rare complication.

Direct cauterization of the nasal septal artery for epistaxis

Emergency management of epistaxis may include the use of local pressure and vasoconstrictors, chemical or electric cautery, hemostatic agents, nasal packing, embolization, and surgical arterial ligation. There is no definitive protocol for the management of epistaxis, although various protocols have been proposed in the literature. As approaches to surgical ligation of the arterial supply of the nasal cavity have evolved from external carotid ligation to minimally invasive approaches, surgical management of epistaxis has become more effective than embolization and may be less risky. In the surgical management of epistaxis, arterial ligation immediately proximal to the bleeding site is preferred. We propose a simple variation of the endoscopic sphenopalatine artery ligation that may be used to manage epistaxis arising from the nasal septum and floor.

[Sphenopalatinum foramen: an anatomical study]

INTRODUCTION

The position of the sphenopalatine artery is essential for the endoscopic treatment of severe posterior epistaxis. This artery passes through its own foramen, which has a wide range of locations and anatomic relations.

OBJECTIVE

To carry out a descriptive osteological study on the sphenopalatine foramen area. Its anatomy, size, position and relations with turbinates and choanae are described, as well as the existence of accessory foramina.

MATERIAL AND METHODS

Exploration and anatomical study was carried out in 32 human hemi-crania.

RESULTS

The area between middle and superior meatus was considered the most common location of the sphenopalatine foramen in 56.24% of the cases (18 specimens), followed by the superior meatus, with 37.5% (12 hemi-skulls). The foramen was located in middle meatus in just two cases. We found accessory foramina in 50% of the cases, most commonly positioned below the middle meatus. The ethmoidal crest appeared in every skull, producing an anterior osseous projection on the sphenopalatine foramen.

CONCLUSION

There are variations in position, number and anatomic relations that may cause changes in the sphenopalatine artery orifice and its branches into the nasal fossa. The ethmoidal crest, located on the anterior side of the sphenopalatine foramen, can be considered a permanent landmark to find the foramen.

[Clinical anatomy of the paranasal sinuses. Descriptive anatomy, topography and important variations]

Detailed knowledge of the complicated anatomy and topography of the paranasal sinuses is an essential requirement for successful surgery in this region. The topographical relationship to essential neighbouring structures (vessels, nerves and spaces) must be borne in mind. Typical landmarks play a particularly important role, especially for reliable orientation in endoscopic procedures. Therefore, it must be stressed that detailed anatomical knowledge of the complicated nasal and paranasal architecture is very important for the success of nasal and paranasal surgery, as well as for the avoidance of serious complications. However, this knowledge can only be acquired by performing numerous dissections of the nasal and paranasal system once a good theoretical grasp of the various structures, regions and their nomenclature has been gained. Common anatomical variations, which may lead to complicated and hazardous changes in normal anatomy, are also of particular importance and the surgeon must be familiar with these variations.

Anatomical study of the sphenopalatine foramen

Anatomical variations of the sphenopalatine foramen may correspond to alterations at the arterial nasal irrigation input, which is a relevant condition to treat severe epistaxis through ligation of the sphenopalatine artery. Aim: To study the sphenopalatine foramen in terms of its numeric variation and its location on the lateral nasal wall in relation to the bony ethmoidal crest of the palatine bone. Materials and methods: The anatomical studies were carried out in 54 hemifaces. Results: the sphenopalatine foramen presented the following numeric variation: single (87%, or 47 specimens), double (11,1%, or 6 specimens), and triple (1.9% or one specimen); it was located at the superior nasal meatus in 81.5%, or 44 specimens; 14.8% (8 specimens) between the middle and superior nasal meatus and in the middle nasal meatus in only one case (1.9%). Conclusion: We have been able to show a numeric variation of the SPF, its relation with the bony ethmoidal crest and its location in the superior meatus, middle meatus, and in both.

Sphenopalatine artery ligation under local anesthesia: A report of two cases and review of the literature

Epistaxis is the commonest emergency in otorhinolaryngology. Over the last decade endoscopic sphenopalatine artery (SPA) ligation has become a popular treatment option for posterior epistaxis and has been shown to be the most effective and cost-efficient definitive treatment for posterior epistaxis. SPA ligation is usually performed under general anesthesia. The majority of epistaxis patients are elderly, frail and have multiple medical conditions. These patients are therefore not always amenable to general anesthesia. In this article we describe two cases where posterior epistaxis was successfully treated with sphenopalatine artery ligation under local anesthesia and should be considered suitable for patients with severe posterior epistaxis who are not fit for a general anesthetic.

Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis

OBJECTIVES

We describe the surgical treatment of severe epistaxis and evaluate the recurrence of bleeding in a nonrandomized retrospective trial.

METHODS

We performed a retrospective study comparing bilateral endoscopic ligation of the sphenopalatine artery alone (ELSPA) and bilateral endoscopic ligation of the sphenopalatine artery with concomitant bilateral external ligation of the anterior ethmoidal artery (ELSPEA) in the management of persistent epistaxis. Clinical and hematologic information, preoperative and surgical care, and short- and long-term outcomes were analyzed. The main outcome measure was recurrence of epistaxis in the short- and long-term follow-up periods.

RESULTS

Forty-five patients were enrolled in the study. There were 20 patients in group A (ELSPA) and 25 in group B (ELSPEA). Three patients in group A and no patients in group B had long-term (more than 2 weeks after surgery) rebleeding. The difference between the two groups was not statistically significant (p > 0.05).

CONCLUSIONS

We conclude that ELSPA and ELSPEA are effective, well-tolerated, reliable procedures if performed by an experienced surgeon. Their failure can be explained by anatomic lateral nasal wall variations and perioperative technical difficulties. They can be appropriate methods to treat severe recurrent epistaxis refractory to repeated nasal packing.

Mapping surgical coordinates of the sphenopalatine foramen: surgical navigation study

OBJECTIVES

To identify measurements that may help intra-operative localisation of the sphenopalatine foramen.

DESIGN

The study used three-dimensional surgical navigation software to study radiological anatomy, in order to define the distances and angulations between identifiable bony landmarks and the sphenopalatine foramen.

RESULTS

The distance from the anterior nasal spine to the sphenopalatine foramen was 59 mm (+/-4 mm; inter-observer variation = 0.866; intra-observer variation = 0.822). The distance from the piriform aperture to the sphenopalatine foramen was 48 mm (+/-4 mm; inter-observer variation = 0.828; intra-observer variation = 0.779). The angle of elevation from the nasal floor to the sphenopalatine foramen was 22 degrees (+/-3 degrees; inter-observer variation = 0.441; intra-observer variation = 0.499).

CONCLUSIONS

The sphenopalatine foramen is consistently identifiable on three-dimensional, reconstructed computed tomography scans. Repeatable measurements were obtained. The centre point of the foramen lies 59 mm from the anterior nasal spine at 22 degrees elevation above the plane of the hard palate and 48 mm from the piriform aperture. We discuss how these data could be used to facilitate intra-operative location of the sphenopalatine foramen in difficult cases.

Severe posterior epistaxis-endoscopic surgical anatomy

OBJECTIVE

To describe the anatomy of the sphenopalatine foramen (SPF) region and possible anatomical variations.

STUDY DESIGN

Prospective study accomplished from September, 2006, to January, 2007.

METHODS

The sphenopalatine foramen (SPF) of 61 cadavers were carefully dissected. Presence of the ethmoidal crest, location of sphenopalatine and accessory foramens, and the number of arterial branches emerging through foramens were observed. Data were analyzed in relation to gender, racial group, and symmetry of the cadaver. Prediction of the presence of accessory foramen was evaluated.

RESULTS

Mixed race cadavers prevailed in 122 nasal fossae dissected (75% males). Ethmoidal crest was present in 100% of the cadavers, being anterior to the SPF in 98.4% of the cases. The most frequent SPF location was the transition of the middle and superior meatus (86.9%). Mean distance from the SPF and accessory foramen to anterior nasal spine was 6.6 cm and 6.7 cm, respectively. Accessory foramen was present in 9.83% of the cases. A single arterial stem emerged through the SPF in 67.2% of the cases, and 100% through accessory foramens. The prevalence analyses showed no differences that were statistically significant (P > 0.05) between gender and racial group. The symmetry analyses showed a strong conformity (P < 0.01) between nasal fossae in relation to the SPF location. There was no statistically significant conformity between nasal fossae and accessory foramen (P = 0.53). None of the variables of interest presents any statistically significant (P > 0.05) association with the presence of the accessory foramen.

CONCLUSIONS

There are anatomical variations in the lateral nose wall that should be considered for successful endoscopic surgical treatment of severe epistaxis.

Update on epistaxis

PURPOSE OF REVIEW

The treatment of epistaxis has undergone significant changes in recent years. Gone are the days when patients had an uncomfortable posterior nasal pack inserted then spent several days on the ward only to bleed again on its removal. New packing devices, ingenious haemostatic agents and endoscopic surgical approaches have been developed to provide a variety of effective and well-tolerated treatment options. This paper will discuss the evolution and utility of these devices and techniques for managing difficult epistaxis patients.

RECENT FINDINGS

Modern packing devices are much easier to insert than traditional gauze packs and are no less effective. A major advance in the management of posterior epistaxis has been the development of the technique of endoscopic ligation.

SUMMARY

Anterior epistaxis is generally easy to control with local cautery. The optimal management of posterior epistaxis is to insert a pack to control the bleeding before taking the patient to the operating theatre to ligate the sphenopalatine artery endoscopically.

The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon

BACKGROUND

This study was performed to determine the variations in the branching pattern of the sphenopalatine artery medial to the crista ethmoidalis. Seventy-seven cadaver head sides that had been sectioned sagittally in the midline with their septum removed were used after injecting pink latex to highlight the arterial vessels.

METHODS

The mucosa from the middle meatus from the level of the basal lamella was removed until the artery and its branches were seen and then was examined under the microscope to identify the position of the arterial branches.

RESULTS

The sphenopalatine artery and its branches were identified in 75 specimens. Of these 75 specimens, 73 (97%) had 2 or more branches medial to the crista ethmoidalis, 49 (67%) had 3 or more branches, 26 (35%) had 4 or more branches, and 1 specimen had 10 branches. In two specimens the artery presented as a single trunk.

CONCLUSION

The sphenopalatine artery normally starts to branch lateral to the crista ethmoidalis and these branches vary widely. It is important that the surgeon who undertakes ligation or cautery of the artery is aware of these variations, otherwise they may overlook some of the branches. With an endoscopic approach, removal of the crista ethmoidalis helps visualize these branches.

[Surgical versus non-surgical treatment of posterior epistaxis]

A study was performed in order to compare the efficiency of surgical versus non-surgical treatment in patients hospitalized for epistaxis regarding the source of bleeding, and to identify failure-predicting factors related to specific treatments. 62 patients were included in the study, 36 (58%) of whom suffered from posterior epistaxis and 26 (42%) experienced anterior bleeding. The single factor associated with failure of the non-surgical treatment was the posterior source of the bleeding (p = 0.001). These patients were also hospitalized for a longer period (8, 17 days) than those with anterior epistaxis (4, 62 days) (p = 0.001). The percentage of success for the primary non-surgical treatment in patients with posterior epistaxis was 45% (14/31), significantly smaller (p = 0.0001) than the successful reached in the primary surgical procedure, 87% (13/15); endoscopic cauterization of the sphenopalatine artery. These results support endoscopic cauterization of the sphenopalatine artery as primary care in posterior epistaxis.

Surgical anatomy of the sphenopalatine artery in lateral nasal wall

OBJECTIVE

We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed.

STUDY DESIGN

Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study.

METHODS

The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification x6).

RESULTS

The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%).

CONCLUSIONS

The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.

Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis

The management of patients with posterior epistaxis remains a challenging problem for the ENT surgeon. In most units, failure of conservative management results in more invasive techniques, involving either major artery ligation or percutaneous embolization of the internal maxillary artery. However, there are complications in more than 25% of patients undergoing these techniques. Endoscopic ligation of the sphenopalatine artery (ELSPA) is emerging as a minimally invasive alternative. We report our experience of ELSPA in 13 patients with a mean follow-up of 13 months. Epistaxis was controlled in 92% and to date no complications have been associated with the procedure. We conclude that ELSPA is a treatment option that is easy to perform and is safe and effective for patients with refractory posterior epistaxis.