Outcome of endoscopic sphenopalatine artery occlusion for intractable epistaxis: a 10-year experience

OBJECTIVE/HYPOTHESIS

To evaluate the efficacy of surgical sphenopalatine artery occlusion (SAO) for treating intractable epistaxis, and identify factors associated with long-term success or failure of this procedure.

METHODS

A retrospective chart review of patients undergoing SAO surgery between January 1995 and 2005 was undertaken. Clinical and hematologic information, preoperative and surgical care, short-term complications, and long-term outcome were recorded. Binary logistic regression was used to identify risk factors for early re-bleeding, and log-rank statistics with Cox regression were used to identify risk factors for long-term operative failure.

RESULTS

Sixty-seven patients underwent 71 SAO operations. The average age at surgery was 56 +/- 18 years. Thirty percent of patients were being treated for hypertension, 19% were taking aspirin, and 11% were anticoagulated with warfarin. Many patients (46%) had >72 hours of epistaxis before admission, and 25% required preoperative transfusion. There were 13 (19%) bilateral procedures, six patients underwent concomitant anterior ethmoid artery occlusion, and 12 patients had concomitant septoplasty. Eight patients had significant early re-bleeding. Platelet levels on admission and not using diathermy to occlude the sphenopalatine artery were independent risk factors for this (P values .03, and .02, respectively). Not using diathermy was also an independent risk factor for late operative failure on Cox regression, reducing the mean re-intervention-free interval from 94 +/- 7 to 32 +/- 7 months (P < .007; hazard ratio 6.4; 95% confidence interval 1.7-24.9).

CONCLUSIONS

SAO is an effective operation and, in trained hands, an appropriate first-line procedure for treating intractable epistaxis. Use of diathermy significantly improves the short- and long-term outcome of this surgery.

[The reconstruction of neovascularization of posterior pharyngeal flap: an experimental study in dogs]

OBJECTIVE

To elucidate the reconstruction of neovascularization that occurred in the superiorly and inferiorly based posterior pharyngeal flaps in different time postoperatively.

METHODS

Ten mongrel dogs were randomly divided into two experimental groups, which were performed superiorly or inferiorly based posterior pharyngeal flap surgery respectively. Each group was then subdivided into five subgroups, and were sacrificed immediately after operation or on 3, 7, 30, 90 day postoperative respectively. Microangiography was used to exhibite the vessel.

RESULTS

1. The blood vessel reconstruction of the superiorly based posterior pharyngeal flap was more rapid compared with the inferiorly based flap. The 3-day flap has established an axial vascular network, which was mature on the 30-day flap. The superiorly based posterior pharyngeal flap was mainly supplied by the pedicle. 2. The blood vessels reconstruction of the inferiorly based posterior pharyngeal flap was firstly occurred in the pedicle and apex of the flap, which grew slowly to the middle of the flap. The inferiorly based posterior pharyngeal flap was supplied by the pedicle and the soft palate. A mature axial vascular network was exhibited on the 90-day flap, which was not mature on the 30-day flap.

CONCLUSION

Both superiorly and inferiorly based posterior pharyngeal flap can establish an axial vascular network and gain ample blood supply.

Endovascular treatment of hemorrhage after tonsillectomy in children

SUMMARY

Endovascular therapy for hemorrhage after tonsillectomy or adenoidectomy is an important adjunct to the definitive treatment of this life-threatening occurrence. We report two cases of hemorrhage after tonsillectomy and/or adenoidectomy and describe the endovascular management of this complication in children.

[Applied anatomy of arterial supply for the soft palate]

OBJECTIVE

The correct design of a myomucosal or mucosal flap of the soft palate in the surgical procedure for cleft palate and velopharyngeal incompetence should be made with a thorough knowledge of the arterial supply for the soft palate, which is an important premise for functional rehabilitation of the soft palate postoperatively.

METHODS

Anatomical dissection was undertaken in 14 cadavers (10 normal adults, 2 normal newborns and 2 newborns with cleft lip & palate). The arteriography and histological studies have been used in 10 newborn and 6 aborted fetuses.

RESULTS

The results showed that the arterial supply of the soft palate is multi-original and the principal artery is the ascending palatal artery. Its anterior and posterior branches are myomucosal perforators. The other vessels to supply the soft palate are direct mucosal branches, which include the lesser palatine artery, the palatal branch of the ascending pharyngeal artery and the tonsillar artery. All above arteries anastomose under the mucosal, muscular and fascial layers in the soft palate. In cleft cases, all arteries in the soft palate are displaced anterior-laterally because of the deformities of the palatal muscles and bone structure.

CONCLUSIONS

This study supports the facts that the major blood supply of the soft palate comes from ascending palatine artery and the generous arterial anastomosis of the velum allows it to tolerate the proper dissection during palatoplasty. We believe that decreasing the damage of the intrapalatal vascular supply by carefully dissection around the hamulus is very important to prevent wound break down, muscular fibrosis, flap failure, and also is the basis of design for surgical procedure and postoperative functional recovery in cleft palate patients.

Clinical implications of the velopharyngeal blood supply: a fresh cadaveric study

The aim of this investigation was to examine the blood supply of the normal velopharyngeal musculature and its clinical implications. Detailed dissections were performed on each side of five fresh human adult cadaveric head and neck specimens (n = 10) following carotid artery injection with liquid neoprene latex stained with green pigment. The vascular network of the soft palate was situated within its glandular layer. The velopharyngeal muscles were supplied by the following four branches of the external carotid artery: (1) ascending palatine branch of the facial artery, which supplied the palatoglossus, palatopharyngeus, musculus uvulae, and the intravelar part of the levator veli palatini; (2) ascending pharyngeal artery, which supplied the superior constrictor; (3) the previously undescribed recurrent pharyngeal artery, which supplied the extravelar part of the levator veli palatini; and (4) maxillary artery, which supplied the tensor veli palatini. All muscles except the musculus uvulae had at least a dual blood supply. Analysis of this vascular anatomy suggests that (1) the overall generous blood supply of the velum allows it to tolerate the dissection performed during intravelar veloplasty and the Furlow double opposing Z-plasty; (2) dissection around the hamulus, along the medial pterygoid plate, and in the space of Ernst should be performed carefully to avoid damage to the ascending palatine artery, ascending pharyngeal, and recurrent pharyngeal arteries; (3) vertical pharyngeal flaps are random pattern in nature; and (4) the posterior tonsilar pillar flaps of the sphincter pharyngoplasty are adequately supplied by the hamular branch of the ascending palatine artery.

Evaluation of the vascular reaction in pharyngeal mucosa

The patency of the upper airways during inspiration is maintained by reflexogenic muscular dilation, mediated by afferent nerves. Our hypothesis is that a local disturbance in these nerves might explain the increased tendency of upper airways to collapse in patients with obstructive sleep apnea. The vascular reaction in the mucosal microcirculation is regulated by afferent nerves. To investigate this, we developed the laser Doppler perfusion monitoring method and electrical nerve stimulation for investigations of the soft palatal mucosa in non-snoring subjects. A 12 cm probe with integrated bipolar electrodes and a special probe-holder were designed. The bandwidths 12 and 24 kHz were compared and the latter was better able to detect a high blood-flow. A dose response relation was found between the voltage stimulation level and percentage increase in blood-flow. Three series of stimuli (40 V) in 10 subjects caused reproducible vascular reactions. In conclusion, this method seems to be safe, tolerable and valuable for investigations of patients with obstructive sleep apnea or other pharyngeal disorders, e.g. dysphagia, in the search for local nerve lesions.

Habitual snorers and sleep apnoics have abnormal vascular reactions of the soft palatal mucosa on afferent nerve stimulation

A local disturbance in the afferent nerves involved in the reflexogenic dilation of the upper airways (UAs) could contribute to the increased collapsibility seen in patients with obstructive sleep apnea (OSA). Laser Doppler perfusion monitoring, combined with electrical stimulation, is a method for investigating the afferent nerve regulation of the microcirculation. It was used in the mucosa of the soft palate in 35 patients with various degrees of UA obstruction and in 13 control subjects, all nonsmoking men. In a majority of snorers and patients with mild OSA, stimulation induced an exaggerated vasodilation, compared with controls. In contrast, in patients with severe OSA, the vasodilation was significantly reduced, compared with controls. These signs of disturbances in the microcirculation support the hypothesis of a local progressive afferent nerve lesion in heavy snorers with or without OSA.

The arterial supply of the palate: implications for closure of cleft palates

Little is known of the arterial anatomy of the palate. Injection studies and dissection of a total of 49 cadavers have shown the principal arterial supply of the soft palate to be the ascending pharyngeal artery, which anastomoses with the greater palatine artery at the junction of the hard and soft palates. The position and relations of the branches of the ascending palatine artery put it at risk during palate repair.

Scanning electron microscopic studies of the palatine mucosa and its microvascular architecture in the rat

Detailed observations were made on the structure and microvasculature of the palatine mucosa of the rat by means of microvascular corrosion casts and epithelium-digested specimens using scanning electron microscopy. The rat palate was divided into four regions according to the characteristics of the palatine plicae. In the atrial region, no transverse palatine plicae were present, but there were longitudinal ridges and folds in the median area. These structures contribute to the transportation of rough and grainy foods with the assistance of the hairy buccal part. Capillary loops in the ridge and folds appeared as continuous, sagittally elongated loops. In the palatine fissure or antemolar region, only three typical transverse palatine plicae contribute to the regurgitation of food. Capillary loops appeared in variant forms on the top, and the anterior and posterior slopes of the plicae. Venous palatine plexus was observed only in the palatine fissure region. In the intermolar region, each of the five transverse plicae was composed of many wedges arranged sagittally. These plicae contribute to the transportation of food toward the larynx. Capillary loops in the plica were in the shape of complicated villi. Filiform protrusions or papillae were aggregated immediately posterior to the last plica. The capillary loops appeared as typical hairpins. They contribute to swallowing of food with active assistance from the epithelial eminence of the lingual dorsum. Palatine plicae showed considerable local differences, which may contribute to the prehension, transportation, and mashing of food.

MR imaging of symptomatic peripheral vascular malformations

We performed a retrospective study of symptomatic peripheral vascular malformations to determine if MR imaging can be used to distinguish slow-flow venous malformations from high-flow arteriovenous malformations and arteriovenous fistulas. Twenty-seven MR examinations in 25 patients with malformations outside the CNS were reviewed. Sixteen venous malformations, nine arteriovenous malformations, and two arteriovenous fistulas were included. In all cases, the MR findings were correlated with the results of angiography. The distinction between slow-flow venous malformations and high-flow arteriovenous malformations and arteriovenous fistulas was made primarily on T2-weighted MR images, which showed high signal intensity in venous malformations and flow voids in high-flow lesions. In addition to the previously described MR features of venous malformations (serpentine pattern with septations, associated muscle atrophy, and typical T1 and T2 signal intensities), several new MR features were apparent. Venous malformations had a propensity for multifocal involvement (37%), orientation along the long axis of extremities or affected muscles (78%), and adherence to neurovascular distributions (64%). Prominent subcutaneous fat was commonly seen adjacent to the malformation. MR images of arteriovenous malformations and arteriovenous fistulas also commonly showed muscle atrophy and subcutaneous fatty prominence. Our results show that slow-flow venous malformations can be distinguished from high-flow arteriovenous malformations and fistulas on the basis of spin-echo MR signal characteristics. The associated imaging characteristics help in the differential diagnosis in problematic cases.

Microvascular architecture of the palatine mucosa in the common squirrel monkey (Saimiri sciureus)

Detailed observations were made of the structure and microvasculature of the palatine mucous membrane of the common squirrel monkey (Saimiri sciureus) by means of the plastic injection method under a scanning electron microscope. The findings obtained were compared with those of the Japanese monkey and other mammals. The osseous palate was flat horizontally and a pair of incisive foramina were apparently open at the anterior end of the hard palate. At the posterior end of the osseous palate, the pterygopalatine incisurae were found bilaterally. The incisive papilla was not obvious in form and size, and a pair of openings of the incisive canal were always situated on both sides of the papilla. The transverse palatine plicae or ridges numbered 7 or 8 symmetrically. They arched posterolaterally with an anterior protrusion near each median end. Posterior plicae were underdeveloped. Numerous openings of the palatine glands were found in the soft palatine mucosa. The arteries supplying the palate were the major palatine artery passing through the major palatine foramen and the soft palatine artery passing through the pterygopalatine incisura. The major palatine artery extended forwards giving off numerous medial and lateral branches, and its end on the respective side entered a small foramen located lateral to the incisive foramen. Medial and lateral branches formed the submucous arterial network. Arterioles diverging from this network were directed to the epithelial surface and formed an arterial network in the lamina propria. Further, capillaries diverging from the latter network built up the subepithelial capillary network immediately beneath the epithelium. Capillary loops sprouting from the capillary network were found in the form of a simple hair-pin without locational differences in their heights. The microvascular architecture thus displayed some similarity with that of the Japanese monkey. However, the vascular networks in the lamina propria and submucous layer were not distinct in size and scale as compared to those of the Japanese monkey. These differences may be related to the stature, living environment and food habits of this species.

Stereo-pair three-dimensional imaging of microvascular architecture in primate dental tissues

The morphology of microvascular beds in dental tissues is poorly documented at the ultrastructural level. SEM stereo-pair imaging of microcorrosion casts reveals the markedly contrasting vascular architecture and capillary anastomoses within the nasopalatine foramen, soft palate and gingival regions of the marmoset. This primate was studied as an analogue for man to further our knowledge of periodontal anatomy and function.

Arteriovenous malformation of the orbit and palate

A patient was reported in which orbital and retinal arteriovenous malformations were noted. The value of oral examination in discovery of another palatal arteriovenous malformation is discussed.