Anatomic variations of the arteries of the nasal fossa

Analysis of Olfaction after Bilateral Nasoseptal Rescue Flap Transsphenoidal Approach with Olfactory Mucosal Preservation

OBJECTIVE

To ascertain the impact of septal olfactory strip preservation and bilateral rescue flap elevation on the incidence of olfactory dysfunction.

STUDY DESIGN

Case series with chart review of patients undergoing endoscopic endonasal skull base surgery (2012-2014).

SETTING

Providence Saint John's Health Center and John Wayne Cancer Institute.

SUBJECTS AND METHODS

The incidences of postoperative epistaxis, hyposmia, and anosmia were analyzed using the Brief Smell Identification Test (B-SIT), which was completed in 110 of the 165 patients.

RESULTS

Seventy-eight patients required extended approaches. Bilateral nasoseptal rescue flaps were elevated in 144 patients (87.3%) and pedicled nasoseptal or middle turbinate flaps in 21 patients (12.7%). The neurovascular pedicles were preserved in all patients, and there were no episodes of postoperative arterial epistaxis. Normal olfaction was noted in 95 patients (86%), with new hyposmia noted in 5 patients (5.5%). Within the rescue flap cohort, new hyposmia occurred in 6.3% (P < .01) of patients, balanced by improvement of olfaction in 43% of patients with preoperative dysfunction (overall pre- and postoperative olfactory function: 85% vs 86%). Patients with pedicled nasoseptal flaps did not have new hyposmia, with a net improvement of olfaction (71% vs 86%, P = .07). No patients experienced new anosmia. There was no difference between flap type within either subgroup.

CONCLUSIONS

Superior olfactory strip preservation during elevation of reconstructive flaps preserves olfactory function and maintains adequate surgical exposure. In addition, rescue flaps have significantly diminished the rate of arterial postoperative epistaxis while maintaining the ability to harvest nasoseptal flaps for future reconstruction.

Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study

Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity.

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.

Avoidance of postoperative epistaxis and anosmia in endonasal endoscopic skull base surgery: a technical note

BACKGROUND

Most endoscopic transsphenoidal approaches jeopardize the sphenopalatine artery and septal olfactory strip (SOS), increasing the risk of postoperative anosmia and epistaxis while precluding the ability to raise pedicled nasoseptal flaps (NSF). We describe a bilateral "rescue flap" technique that preserves the mucosa containing the nasal-septal vascular pedicles and the SOS. This approach can reduce the risk of postoperative complications, including epistaxis and anosmia.

METHODS

A retrospective analysis was conducted of all patients who underwent endoscopic transsphenoidal surgery with preservation of both sphenopalatine vascular pedicles and SOS. In a recent subset of patients, olfactory assessment was performed.

RESULTS

Of 174 consecutive operations performed in 161 patients, bilateral preservation of the sphenopalatine vascular pedicle and SOS was achieved in 139 (80 %) operations, including 31 (22 %) with prior transsphenoidal surgery. Of the remaining 35 operations, 18 had a planned formal NSF and 17 had prior surgery or extensive lesions precluding use of this technique. Of pituitary adenomas, RCCs or sellar arachnoid cysts, 118 (94 %) underwent this approach, including 91 % of patients who had prior surgery. Preoperative olfaction function was maintained in 97 % of patients that were tested. None of the patients had postoperative arterial epistaxis.

CONCLUSION

Preservation of bilateral sphenopalatine vascular pedicles and the SOS is feasible in over 90 % of patients undergoing endonasal endoscopic surgery for pituitary adenomas and RCCs. This approach, while not hindering exposure or limiting instrument maneuverability, preserves the nasoseptal vasculature for future NSF use if needed and appears to minimize the risks of postoperative arterial epistaxis and anosmia.

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.

Endoscopic identification of the pharyngeal (palatovaginal) canal: an overlooked area

Objective The pharyngeal or palatovaginal canal (PC) is a small tunnel that lies between the sphenoid process of the palatine bone and the vaginal process of the sphenoid bone. Currently, little endoscopic information is available about this region. Design and Setting Endoscopic endonasal cadaveric study. Subjects and Methods Twenty sides in 10 adult cadaver heads were studied endoscopically. The sphenopalatine foramen (SPF) and the adjacent pterygopalatine fossa were exposed. Dissection medial to the vidian canal demonstrated a tunnel that runs posteromedially in the sphenoid floor. Endoscopic data were documented. Additionally, canal measurements were obtained on 20 sides from coronal CT scans of paranasal sinuses. Results The PC was identifiable in 85% of the sides, although thickness of its bony wall was variable. The endoscopic relationship of the canal and its artery with other landmarks is described. Radiologically, the diameter of the PC averaged 1.7 mm, and the mean distance from the PC to the vidian canal was 3.78 mm. Conclusion The current study provides a novel endoscopic identification of an overlooked canal. The pharyngeal artery can be a source of bleeding during extended endoscopic procedures. The PC itself could be a place for finger-like projections of anatomically related neoplasms.

The inferior turbinate flap in skull base reconstruction

Background

As the indications for expanded endonasal approaches continue to evolve, alternative reconstructive techniques are needed to address increasingly complex surgical skull base defects. In the absence of the nasoseptal flap, we describe our experience with the posterior pedicle inferior turbinate flap (PPITF) in skull base reconstruction.

Design

Case series.

Setting

Academic tertiary care centre.

Methods

Patients who underwent reconstruction of the skull base with the PPITF were identified. Medical records were reviewed for demographic, presentation, treatment, follow-up, surgical and outcomes data.

Main outcome measures

Flap survival, adequacy of seal, and complications.

Results

Two patients with residual/recurrent pituitary adenomas met the inclusion criteria. The nasoseptal flap was unavailable in each case due to a prior septectomy. Salvage of the original nasoseptal flap was not possible, as it did not provide adequate coverage of the resultant defect due to contraction from healing. All PPITFs healed uneventfully and covered the entire defect. No complications were observed in the early post-operative period. Endoscopic techniques and limitations of the PPITF are also discussed.

Conclusions

Our clinical experience supports the PPITF to be a viable alternative for reconstruction of the skull base in the absence of the nasoseptal flap.

Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base

BACKGROUND

Indications for expanded endoscopic approaches continue to grow, resulting in larger and more complex skull base defects. Reconstructive developments, however, have lagged our extirpative capabilities. As the complexity of clinical scenarios continues to escalate, challenging our current reconstructive strategies, we are compelled to develop alternative techniques to prevent cerebrospinal fluid leaks and protect neurovascular structures. In this article we show the anatomic basis for a new posterior pedicled flap from the lateral wall of the nose (Carrau-Hadad [C-H] flap) for the reconstruction of median skull base defects and present our early clinical experience.

METHODS

Using a cadaveric model, we designed a posterior pedicle flap comprising the nasal inferolateral wall mucoperiosteum. We applied this information clinically, to reconstruct transmural skull base defects.

RESULTS

In our cadaveric model, we harvested and transposed C-H flaps into various defects of the planum sphenoidale, sella turcica, clivus, and nasopharynx. Then, we used the C-H flap in four patients, successfully reconstructing their clival (n = 3) and sellar (n = 1) surgical defects. All patients healed uneventfully.

CONCLUSION

Our anatomic study and early clinical experience support the use of the posterior pedicle lateral nasal wall flap to reconstruct large cranial base defects resulting from endoscopic skull base surgery in properly selected patients.

Study of the nasoseptal flap for endoscopic anterior cranial base reconstruction

OBJECTIVES/HYPOTHESIS

Measure the dimensions of the nasoseptal (NS) flap and the anterior skull base (ASB) defect. Verify whether the flap is sufficient to cover the defect. Study the anatomy of the septal artery (SA).

STUDY DESIGN

Anatomical and radiological study.

METHODS

After endoscopic craniofacial resection, sufficiency of the flap to cover the ASB defect was assessed. The SA was dissected. The number of branches in the pedicle and the distance between the artery and the sphenoid ostium were noted. Radiologic study analyzing CT scans of 30 patients for comparison among measurements of the NS flap and the ASB defect was performed.

RESULTS

In all cases the flap was sufficient to cover the ASB. Two branches of the SA were found in the pedicle in 71.4%. The distance between the SA and the sphenoid ostium was 9.3 mm. The reconstruction area of the flap (17.12 cm(2) ) was larger than the defect area (8.64 cm(2) ) (P < .001). The difference between the superior length of the flap and the anterior-posterior distance of the defect was ≤ 5 mm in 26.7%. Comparison between the anterior flap width and the anterior defect width revealed that in 33% the difference was ≤ 5 mm.

CONCLUSIONS

The dimensions of NS flap are sufficient to cover completely the ASB defect. The anterior edge of the defect presents increased risk for failure in coverage. Additional width adding the nasal floor mucosa to the flap is important to decrease the risk of gap in the anterior orbit-orbit defect. It is more common to find two branches of the SA in the pedicle.

Reconstruction techniques in skull base surgery

One of the major challenges of cranial base surgery is reconstruction of basal dural defects. Ineffective reconstruction may result in potentially life-threatening complications such as cerebrospinal fluid leak, meningitis, and tension pneumocephalus. Goals of reconstructive procedures are to repair the dural defect and to separate intracranial contents from bacteria-laden secretion of the mouth, nose, and sinus. Different reconstructive techniques have been reported. Multiple factors may influence the surgical choice of reconstructive technique and its outcome. Regional pedicled flap and vascular free flaps represent the best reconstructive options because vascularized tissues promote fast and complete healing. A variety of endoscopic pedicled mucosal flaps within the nasal cavity have also been described. The different reconstruction techniques are described and discussed in terms of indications, advantages, and drawbacks.

Endoscopic devascularisation of sphenopalatine bundle in intractable posterior epistaxis: technique, efficacy and safety

OBJECTIVE

To evaluate endoscopic cauterisation of the sphenopalatine neurovascular bundle, as treatment for intractable posterior epistaxis, with regard to efficacy, safety and post-operative sequelae.

PATIENTS AND METHODS

A prospective study reviewed 42 patients with severe posterior epistaxis who were treated with endoscopic cauterisation of the sphenopalatine neurovascular bundle, over a 17-month period.

RESULTS

Hypertension and hepatic disease were present as predisposing factors in 66.7 and 35.7 per cent of patients, respectively. Branching of the sphenopalatine artery at its foramen was present in more than 85 per cent of patients. The success rate was 100 per cent, with no recurrent epistaxis in the follow-up period. Severe nasal dryness was present in only four patients (9.5 per cent); hypoaesthesia was found in the nasal mucosa of eight patients, without any patient complaints.

CONCLUSION

Endoscopic sphenopalatine neurovascular bundle cauterisation is an effective treatment for refractory posterior epistaxis. In this study, neurovascular bundle cauterisation did not cause any neurological deficits or major complications.

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.

Anatomic Variations of Sphenopalatine Artery and Minimally Invasive Surgical Cauterization Procedure

Background

Sphenopalatine artery (SPA) ligation or cauterization stands to be one of the most common management options of refractory epistaxis. Ramification pattern of SPA as it passes through sphenopalatine foramen (SPF) has not been clearly established. The aim of this study is to investigate situations in which middle meatal approach may fail due to anatomic variations of SPA and to define a minimally invasive surgical cauterization procedure. Anatomic variations of SPA were determined by microdissection of 20 adult sagittally cross-sectioned head specimens.

Methods

Branching characteristics of SPA and its anatomic relations were evaluated and anatomic variations were noted.

Results

SPA was generally (80%) forming branches within SPF before entering into the nasal cavity. In 20% of the specimens, SPF was located superior to the horizontal lamella of the middle turbinate, and accessory foramen was present in 10%. In 10% of the cases, the posterior lateral nasal branch was situated as two branches in a deep sulcus in the middle meatus.

Conclusion

The ramification pattern of SPA can not be fully exposed without resection of the posterior part of the middle turbinate via the middle meatal approach. Two-step procedures are advocated in reducing failure rates. Previously defined two-step procedures are relatively invasive. A less invasive procedure is defined based on the variations of SPA and SPF.

Morphological characteristics of the anterior ethmoidal artery in ethmoid roof and endoscopic localization

OBJECTIVES

To provide anatomical data to help identify and locate the anterior ethmoidal artery (AEA) precisely during endoscopic procedures.

METHOD

We dissected 15 adult cadaver heads, which provided 30 specimens, to study morphological characteristics, courses, and several types of variations.

RESULTS

We found the average diameter of the AEA to be 0.80 +/- 0.24 mm. In 85.7% of the cases, the artery was seen between the second and third lamella. Other locations were over the roof of the frontal recess cells (10.7%) and the roof of the posterior ethmoid sinus (3.6%). The AEA ran parallel to the ethmoid roof and formed a slight curve. When viewed from the superior side, the angle formed by the long axis of the artery and the lamina papyracea was 60.5 degrees +/- 16.4 degrees. In 83.3% of the cases, the anterior ethmoidal canal (AEC) was identified as a separate canal, and in 16.7% the canal was embedded in the ethmoid roof. In 10 of the 30 cases (33.3%), the AEC presented some degree of dehiscence.

CONCLUSION

As a result of these dissections, we found that the AEA's course in the ethmoid roof varies. The morphological characteristics-that the AEA runs parallel to the ethmoid roof, forming a slight posterolateral to anteromedial curve as it passes from the orbit to the cribriform plate-are the most reliable factors used to identify the artery during surgery.

Endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis

BACKGROUND

Intractable posterior epistaxis sometimes requires intensive treatment, such as surgery or embolization. Maxillary artery ligation has been widely used for the treatment of intractable posterior epistaxis. It is highly effective, but significant complications may occur, including an oroantral fistula and damage to the infraorbital nerve. Embolization is less invasive and can be performed in poor surgical candidates. However, it has more serious complications, such as facial nerve paralysis and hemiplegia. This investigation evaluates the effectiveness and complications of endoscopic ligation of the sphenopalatine or maxillary artery for the treatment of intractable posterior epistaxis.

METHODS

Between April 2003 and March 2007, 46 patients were hospitalized for the treatment of severe posterior epistaxis in our University Hospital. Thirty patients were successfully treated by anterior and/or posterior nasal packing, and five patients were treated by electrocoagulation. Endoscopic ligation was performed under general anesthesia in 11 patients (6 men and 5 women; age range, 50-80 years).

RESULTS

Eight patients underwent endoscopic ligation of the sphenopalatine artery, and three patients underwent endoscopic ligation of the maxillary artery through the middle meatus and posterior antral wall opening. There were no complications, and the patients' postoperative courses were uneventful. Recurrent epistaxis occurred in one patient on oral anticoagulants 15 months after ligation of the sphenopalatine artery, and it was successfully treated by anterior nasal packing.

CONCLUSION

Endoscopic ligation of the sphenopalatine or maxillary artery is safer than arterial embolization and is less invasive than transantral ligation of the maxillary artery. This technique appears to be a simple and highly effective surgical treatment for patients with intractable posterior epistaxis.

Endoscopic Reconstruction of the Cranial Base Using a Pedicled Nasoseptal Flap

Objective:

Reconstruction of the cranial base using vascularized tissue promotes rapid and complete healing, thus avoiding complications caused by persistent communication between the cranial cavity and the sinonasal tract. The Hadad-Bassagasteguy flap (HBF), a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, seems to be advantageous for the reconstruction of the cranial base after endonasal cranial base surgery

Methods:

We performed a retrospective review of patients who underwent endonasal cranial base surgery at the University of Pittsburgh Medical Center from January 30, 2006 to January 30, 2007, identifying patients who experienced reconstruction with a vascularized septal mucosal flap (HBF). We analyzed the demographic data, pathological characteristics, site and extent of resection, use of cerebrospinal fluid (CSF) diversion techniques, and outcome.

Results:

Seventy-five patients who underwent endonasal cranial base endoscopic surgery received repair with the HBF. In this population, we encountered eight postoperative CSF leaks (10.66%), all in patients who required intra-arachnoidal dissection. When we correct the statistical analysis to include only patients with intra-arachnoidal lesions, the postoperative CSF leak rate is 14.5% (eight of 55 patients). It is notable that six CSF (33%) leaks occurred in our first 25 repairs, whereas we encountered only two postoperative leaks (4%) in the last 50 patients. The corrected CSF leak rate, considering only intra-arachnoidal lesions, was two (5.4%) of 37 patients. This improvement in the CSF leak rate reflects our growing experience and comfort with this reconstructive technique. All of our failures could be matched to a specific technical mistake In addition, we modified the flap-harvesting technique to allow for staged procedures and the removal of caudal lesions. These special circumstances require storage of the flap in the antrum during the removal of caudal lesions, and suturing of the flap in its original position for staged procedures. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with bipolar electrocautery, thereby preserving the flap blood supply. We encountered no infectious or wound complications in this series of patients. The donor site accumulates crusting, which requires debridement until mucosalization is complete; this usually occurs 6 to 12 weeks after surgery.

Conclusion:

The HBF is a versatile and reliable reconstructive technique for repairing defects of the anterior, middle, clival, and parasellar cranial base. Its use has resulted in a significant decrease in our incidence of CSF leaks after endonasal cranial base surgery. Attention to technical details is of paramount importance to achieve the best outcomes.

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.

The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction

BACKGROUND

Expanded endonasal approaches (EEA) for the resection of lesions of the anterior and ventral skull base can create large defects with a significant risk of postoperative cerebrospinal fluid (CSF) leaks or exposure of the internal carotid artery. In these cases, a reconstruction using a vascularized flap facilitates rapid and complete healing of the defect. The Hadad-Bassagasteguy flap (HBF), a posterior pedicle nasoseptal flap, is our preferred reconstructive option; however, a prior posterior septectomy or prior wide sphenoidotomies preclude its use. We have developed two additional pedicled flaps to reconstruct these selected patients: the transpterygoid temporoparietal fascia flap, which is suitable for large defects, and the posterior pedicle inferior turbinate flap (PPITF), the subject of this paper.

METHODS

We developed a flap comprising the inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a terminal branch of the posterior lateral nasal artery, which arises from the sphenopalatine artery. We retrospectively reviewed the clinical data of four patients who underwent a skull base reconstruction using a PPITF.

RESULTS

Four patients underwent a reconstruction with the PPITF after undergoing an EEA that produced a skull base defect associated with a CSF fistula (n = 2), an exposed internal carotid artery (n = 1), or a basilar aneurysm clip (n = 1). All patients had undergone posterior septectomies as part of previous EEAs. All flaps healed uneventfully and covered the entire defect.

CONCLUSION

The PPITF is a viable reconstructive option for patients with skull base defects of a limited size defect and in whom the HBF is not available.

[Practical aspects regarding endoscopic treatment for epistaxis]

INTRODUCTION

A prospective study is presented to evaluate some practical and financial aspects regarding surgical endoscopic ligation or cauterization of sphenopalatine (SP) and anterior ethmoidal (AE) arteries performed to control posterior nasal bleeding.

PATIENTS AND METHODS

35 patients admitted at the ENT ward between 2004 and 2006 were included in the study, and distributed into two groups depending on the protocol applied in each case. Until March 2005 the surgery was performed if there was failure or insecurity of the posterior packing, and since that date a substitutive surgical protocol (not including posterior packing) was applied.

RESULTS

82.9% of the patients were male, with a mean age of 55.74 years and a left bleeding in a 60% of the cases. Ligature/cauterization was performed on SP in 28 (80%) patients, on AE in 4 (11.4%), and on both arteries in 3 cases (8.6%). 38.7% of the SP approach only one sphenopalatine foramen was observed, through which an only branch of the artery passed; 42% of the cases two branches passed through an only foramen, and in 19.3% two or more branches were present, breaking into the nose through two or more independent clefts. AE was intradural in 3 cases, intranasal attached to the cranial base in other 3 and intranasal detached to the cranial base in 1 patient. Besides, highly significant differences were found between the two protocols, observing a mean reduction of hospital stay of 3.1 days, which throws up savings of 939.3 euros per patient.

DISCUSSION AND CONCLUSIONS

Surgical treatment for epistaxis has proved to be effective (91.2% in our experience) and safe, determining an important reduction in hospital stay and avoiding the morbility of posterior packing. Accurate knowledge of the anatomy of the arteries implied and specific actuation upon the correct bleeding territory are essential to perform this surgery.

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.

A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap

BACKGROUND

In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients.

METHODS

We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap.

RESULTS

Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved.

CONCLUSION

The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.

The anatomic landmarks of ethmoidal arteries for the surgical approaches

Knowledge of variations in the possible patterns of origins, courses, and distributions of the ethmoidal arteries are necessary for the diagnosis and important for the treatment of orbital disorders. Ethmoidal arteries are damaged in endonasal surgical interventions and in operations performed on the inner wall of the orbita.A description of the anatomic landmarks of the ethmoidal arteries and ethmoidal canals is presented, based on data from microdissection in 19 adult cadavers studied after injection of red-dyed latex into the arterial bed. In all subjects, each of ethmoidal arteries originated from ophthalmic artery. The anterior ethmoidal artery was observed in all specimens except for one case. The diameter of the artery thicker than the posterior ethmoidal artery was 0.92 +/- 0.2 mm on the right and 0.88 +/- 0.15 mm on the left. The branching of the anterior ethmoidal artery from the ophthalmic artery was determined in four different types. The diameter of the posterior ethmoidal artery was measured as 0.66 +/- 0.21 mm on the right and 0.63 +/- 0.19 mm on the left. The anterior ethmoidal canal was located between the second and third lamella in 29 of 38 cases. The mean distance between the limen nasi and anterior ethmoidal canal was 48.1 +/- 3.2 mm.The article confirms the well-known variability of the ethmoidal arteries and their topographic relation to the ethmoidal canals. Advances in surgical techniques, instrumentation, and regional arterial anatomy have resulted in functional operations of endoscopic sinus and orbital surgery with fewer complications.

Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.

Embolization for intractable epistaxis

It is estimated that 60% of the population experiences epistaxis at least once in a lifetime, and that approximately 6% of these patients require treatment. We discuss the risks and benefits of an endovascular approach in our experience. We believe this option is often offered too late. By following basic rules the procedure is very safe and highly effective.

[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.

An anatomical study of the arteries of the anterior nasal septum

OBJECTIVE

The anterior nasal septum is a clinically important area, yet anatomical descriptions of its arterial pattern are hitherto incomplete. This study aimed to test the hypothesis that the arteries of the anterior nasal septum form a fine random network of vessels.

STUDY DESIGN

The arterial pattern of the nasal septum was traced by microdissection of 12 cadaveric septa (24 sides).

SETTING

Each septum was microdissected with a Watson-Barnet dissecting microscope. Specimens were photographed and the vascular patterns were analyzed.

RESULTS

The anterior septum has a consistent large arterial anastomotic triangle receiving major contributions from sphenopalatine, anterior ethmoidal, and superior labial arteries.

CONCLUSION

Systematic microdissections clearly demonstrate that the arteries of the anterior septum do not form a random network. Instead, they form a consistent arterial anastomotic triangle consisting of large, thin vessels.

SIGNIFICANCE

The study provides background material useful to the understanding of nasal physiology and pathology including epistaxis.

Nasal endoscopy and localization of the bleeding source in epistaxis: last decade's revolution

Summary

Epistaxis remains one of the most common otolaryngology emergencies. Despite considerable interest in the subject, there is still no consensus on the most appropriate primary therapeutic modality.

Aim

The purpose of this study was to evaluate the bleeding source of acute or recurrent epistaxis in adults.

Study design

Clinical prospective.

Material and Method

Thirty adults patients with acute or recurrent epistaxis were evaluated through the use of frontal light and endoscope for identification of the bleeding source in the nasal cavity.

Results

Use of the nasal endoscope allowed diagnosis of the bleeding site in all patients.

Conclusion

A careful examination of the posterior nasal cavity allows identification of the bleeding source in most patients and should be a routine procedure.

Endoscopia nasal e a localização do sítio de sangramento na epistaxe: a revolução da última década

A epistaxe continua sendo uma das emergências otorrinolaringológicas mais comuns e preocupantes. Apesar do grande interesse no assunto, ainda não há consenso com relação à sua melhor abordagem inicial. OBJETIVO: Avaliar o sítio de sangramento em pacientes com epistaxe ativa ou recorrente. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Trinta pacientes adultos com epistaxe ativa ou recorrente foram avaliados com rinoscopia anterior clássica e endoscopia para identificação do sítio de sangramento na cavidade nasal. RESULTADO: O uso do endoscópio permitiu o diagnóstico do sítio de sangramento em todos os pacientes. CONCLUSÃO: O exame endoscópico cuidadoso da porção posterior da cavidade nasal permite a identificação do sítio de sangramento na maioria dos casos de epistaxe e deve ser considerado um exame de rotina.