Repair of nasal septal perforation

The management of nasal septal perforation remains unsatisfactory. Various operative techniques have been described, with modest success. A novel method for repair of septal perforations up to 2.6 cm in diameter was investigated. A double layer closure of nasal septal perforation was designed, one with the cartilage and the other by a flap based on the anterior septal branches of the sphenopalatine artery. Fourteen patients have been operated upon. The current analysis reveals a success rate of 13 patients (93%) who had complete closure and one patient (7%) with incomplete closure. The operative techniques and results are reported here.

The meningohypophyseal trunk and its blood supply to different intracranial structures. An anatomical study

50 meningohypophyseal trunks of the intracavernous internal carotid artery were studied in 25 human cadavers. Special attention was given to the main variations of branching patterns of this trunk. The dorsal meningeal arteries were found in all cases and three typical variations were observed in their origins and courses: a prominent medial branch (52%), a bifurcating type (38%) or a single lateral branch was present (10%). The tentorial artery of Bernasconi-Cassinari arised as a single branch in 64% of the cases, while in 36% two or more branches took a direct origin from the main trunk. The inferior hypophyseal artery was prominent in 82% of the cases. The inferolateral trunk had a common origin with the meningohypophyseal trunk in 8% of our dissections. A large number of anastomoses between these vessels was observed. As a number of tumorous and vascular pathologies, which can be treated with microsurgical techniques, take their origin from the cavernous sinus, the knowledge of the smaller vessels arising from the intracavernous internal carotid artery as well as their main variations is important.

Direct intraoperative sclerotherapy of an aneurysmal bone cyst of the sphenoid

A young boy presented with a symptomatic aneurysmal bone cyst of the left great wing of the sphenoid bone. Arterial embolization had failed to produce thrombosis, and the lesion could not be resected surgically. Direct intraoperative sclerotherapy resulted in immediate thrombosis of 80% of the volume of the vascular malformation with no progression of symptoms. Two years later, the symptoms had completely resolved, and CT scans showed total ossification of the lesion.

Sphenoidal artery, ramus orbitalis persistens and pterygospinosus muscle--a unique cooccurrence of first branchial arch anomalies in man

In a 76-year-old Caucasian male, the right middle meningeal was replaced by a branch of the ipsilateral ophthalmic artery (O), i.e. the sphenoidal artery (S); the right foramen spinosum was found to be absent. In the orbit, the right O bifurcated into a medial (merely orbital) and a lateral division, i.e. a meningolacrimal trunk. From that trunk, the S branched off and entered the middle cranial fossa at the superolateral angle of the superior orbital fissure. In addition, an anastomotic channel was formed by a remnant of the ramus orbitalis, connecting the right infraorbital with the deep orbital artery. The right accessory meningeal (AM) regularly arose from the maxillary artery and entered the cranial cavity through the foramen ovale, separated from the mandibular nerve by a pterygospinosus muscle. This muscle was merely present in the right infratemporal fossa. Interestingly, the left AM originated from the posterior deep temporal artery. No other anatomical variations were found in this individual. Since the coexistence of an S with variations of other structures derived from the first branchial arch has not been previously reported in man, the embryology and comparative anatomy of this irregular vessel are discussed.

Subperiosteal, subperiorbital dissection and division of the anterior and posterior ethmoid arteries for meningiomas of the cribriform plate and planum sphenoidale: technical note

Removal of meningiomas from the region of the cribriform plate and the planum sphenoidale may entail a bifrontal craniotomy and an interruption of the tumor's blood supply along the floor of the anterior cranial base. However, with this approach, the presence of bulky tumor above makes it difficult to control bleeding from multiple bony foramina in the anterior cranial base and to expose these foramina. The blood supply to the dura in this region, and, therefore, to these tumors, is predominantly from the anterior and posterior ethmoid arteries. Preoperative embolization of ethmoid arteries is not without a significant and prohibitive risk of blindness. A frontoethmoidal approach to the arteries on both sides requires two separate skin incisions. Therefore, a subperiosteal, subperiorbital dissection and division of these arteries via a bicoronal skin incision is a practical alternative.

Skull-base foramina of the middle cranial fossa: reassessment of normal variation with high-resolution CT

PURPOSE

To evaluate by means of high-resolution CT the anatomic variations of the middle cranial fossa foramen.

METHODS

We examined 123 CT studies of the temporal bone in patients with no evidence of disease that might alter foraminal anatomy. A checklist of known variants and suspected structures was used as each case was systematically examined for the presence or absence of these foramina; variations in size, shape, and location; and relationship of structures to each other. Inclusion criteria were established to eliminate error.

RESULTS

The foramen rotundum had a constant appearance. We identified the inferior rotundal canal in 16% of patients and the lateral rotundal canal in 8%. The foramen of Vesalius was present, at least unilaterally, in 80% of our cases. Asymmetry of the foramen of Vesalius did not indicate disease in our patient group. We did not find an inverse relationship between the size of the foramen of Vesalius and that of the ipsilateral foramen ovale. We found variations in the size and shape of the foramen ovale and its confluence with the foramen spinosum (n = 2) and the foramen of Vesalius (n = 8). We did not find an inverse relationship between the size of the foramen ovale and that of the foramen spinosum. The canaliculus innominatus for the lesser superficial petrosal nerve was identified in 16.3% of our patients. Variations of the foramen spinosum that we found include a medial bony defect (26.8%) and absence (3.2%).

CONCLUSION

Although it is unlikely that well-formed foramen will be misinterpreted as diseased, it is nonetheless important to recognize foraminal variants and associated neurovascular anatomy.

Meningiomas involving the anterior clinoid process

We report a series of 34 clinoidal meningiomas treated surgically and analyse the results according to cavernous sinus involvement. Fifteen tumours extended into the cavernous sinus. Only four of these could be resected completely, and global outcome was improved or stable in 10 cases. Overall, 20 tumours had a total resection and 14 had a partial resection. Complete removal of the sphenoid wing, including the anterior clinoid and part of the planum sphenoidale, allows early devascularization of the tumour and minimizes brain retraction when associated with resection of the zygomatic arch. The most frequent postoperative complication was transient CSF leak, occurring in three patients. Two patients died postoperatively, and three suffered permanent complications. There was no recurrence after total removal, but five patients showed signs of progressive tumour growth after partial removal, treated by radiotherapy in three and by surgery in two cases. Twenty patients showed preoperative visual impairment. Outcome of vision was improved or stable in 13 (68%) and worse in six cases (32%). We suggest that progressive visual impairment should lead to aggressive surgical treatment, especially when complete resection of cavernous sinus involvement can be performed.

Internal maxillary artery variability in the pterygopalatine fossa

The third segment or pterygopalatine branch of the internal maxillary artery has variable branching in the pterygopalatine fossa. This variability in branching can lead to failure in controlling persistent nasal epistaxis by transantral ligation. Although the surgical approach has been previously studied, a systematic classification of this branching has not been previously reported. Through the performance of serial cadaver dissections in the PPF, we have demonstrated the anatomic course and variations of this third segment and offer a relatively simple classification system.

The groove in the orbital face of the greater wing of the sphenoid. A new interpretation

A presumed arterial groove on the orbital face of the greater wing of the sphenoid in the human skull has been shown to be artefact produced by an abrupt thinning of bone. There is no evidence from this study to support the presence of a ramus orbitalis in man.

[Changes in the sphenoid bone in the upper third of the carotid groove]

The article discusses the changes of the bone plate of the sphenoid bone in the upper third of the carotid groove; the plate separates the siphon of the internal carotid artery from the cavity of the sphenoid sinus. Both carotid grooves were examined on blocks removed from the base of the skull of 65 cadavers and on 45 macerated skulls. Two types of bone changes were found in the upper third of the carotid groove, namely, osteoporosis and perforating defects. Osteoporosis was revealed in 50 grooves and defects only in the upper third in 45 grooves. Osteoporosis and defects were encountered about five times more frequently between the ages of 41 and 60 than till the age of 40 and 10 times more frequently after the age of 60. The same relations were found when osteoporosis was combined with a defect. These bone defects are an anatomical precondition for profuse nasal bleeding because the wall of the internal carotid artery ruptures during a craniocerebral trauma and blood flows freely from it into the sphenoid sinus and then into the nasopharynx.

Management of a ruptured pseudoaneurysm of the sphenopalatine artery following a Le Fort I osteotomy

A case of extreme, recurrent epistaxis secondary to a ruptured aneurysm of the sphenopalatine artery is reported and diagnosis of the condition by angiography and its treatment by Gianturco coil embolization is discussed.

Orbital infarction in sickle cell disease

Bone infarction is common in sickle cell disease; however, involvement of the orbit is not. Only four cases have been reported in the English literature. We describe a patient who presented with headache, proptosis and lid edema due to infarction of the sphenoid bone. The combination of radionuclide bone imaging and computed tomography (CT) of the orbit were useful in differentiating bone infarction from other etiologies of proptosis.

[The canalis basilaris medianus on the x-ray and computed tomogram (author's transl)]

The canalis basilaris medianus is a persistent venous canal in the Clivus, which was first described by Gruber. Depending on the type of the canal, course and projection the canal is mostly recognized on the x-ray as a longitudinal or diagonal translucent band, seldom as a round translucence; on the computed tomogram depending on the directional course in the layer as a round translucence of a longitudinal translucent band. It was detectable in 4,3% (14/332) of the examined x-rays (occipitomental projection, skull base) and in 6/154 (3,8%) of the computed tomograms of the skull base. By measuring computer-tomographically the increase of the CT-absorption values in the canal lumen after injection of a contrast medium, it was confirmed that there is a vessel in the canal. The differential diagnosis to canalis cranio-pharyngeus, foveola pharyngea and fracture is discussed.

The vidian artery: normal and pathologic anatomy

Arising as a branch of either the distal maxillary artery or the petrous portion of the internal carotid artery, the vidian artery (artery of the pterygoid canal) participates in two complex vascular networks through its anastomoses in the pterygopalatine fossa and oropharyngeal mucosa. The vidian artery may become a major source of blood supply to a variety of deep facial and paracavernous lesions. The embryology, anatomy, and pathology of this vessel are described and implications of its anastomotic patterns in therapeutic embolization procedures are discussed.

Vascular changes in the pterygopalatine fossa after craniofacial dysjunction surgery

A study was undertaken to determine vascular changes and the timing of these changes after craniofacial dysjunction surgery. Ten adult male Macaca cynomulgus monkeys were studied with techniques using angiograms and vascular vinyl cast preparations before and after unilateral Le Fort III osteotomy. After surgical disruption of the maxillary artery, the flow of blood was initially maintained by anastomotic branches of the ipsilateral internal carotid artery. Stepwise reconstruction of the disrupted maxillary artery took place via numerous collateral vessels that bridged the site of disruption; continuity of the artery was nearly normal by five weeks.

Surgical anatomy of the pterygopalatine fossa

The pterygopalatine fossa is the distribution centre for the main vessels and nerves of the middle third of the face. Its surgical anatomy is discussed, with particular emphasis on the relationship between the medical plate of the pterygoid process of the sphenoid bone and the vertical plate of the palatine bone; the position of the several foramina is reviewed also. It is stressed that the vascular contents of the pterygopalatine fossa lie in a coronal plane, anterior to the neural contents. Finally, a short review is given of the different surgical approaches to the pterygopalatine fossa. It is concluded that the transantral approach to the fossa, as originally described by Carnochan (1858), still seems to be the best way to gain access to this space.

The trans-sphenoidal vascular route in relation to the human pharyngeal hypophysis

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Vascularity of the environs of the human pharyngeal hypophysis as a possible indiction of the mechanism of its control

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