Juvenile nasopharyngeal angiofibroma in prepubertal males: A diagnostic dilemma.

OBJECTIVES/HYPOTHESIS: To highlight the presentation and management of juvenile nasopharyngeal angiofibroma (JNA) in prepubertal children. STUDY DESIGN: Single-institution 10-year retrospective review. METHODS: All identified cases of pathologically confirmed JNA in children <10 years of age were assessed from a gender, imaging and embolization findings, tumor stage, surgical approach, and clinical outcomes standpoint, and compared to a group of stage-matched older patients from the same time period. RESULTS: Of 45 patients over the 10-year study period, four male children between 8 to 9.8 years of age were identified. One patient had University of Pittsburgh Medical Center stage 1 disease, and the other three had stage 3 disease at presentation. A malignant process other than JNA was of concern preoperatively in two of the four children due to a combination of aggressive imaging characteristics and an absence of pterygopalatine fossa involvement. Such pterygopalatine fossa involvement was comparatively uniformly present in a group of stage-matched JNA patients aged 15 to 21 years. All four prepubescent children underwent surgical resection via transnasal endoscopic approach following ipsilateral sphenopalatine artery embolization without the need for blood transfusion. There were no recurrences in three of the four cases at a median follow-up duration of 2.3 years (range, 0.8-6.4 years). CONCLUSIONS: JNA may pose a diagnostic challenge in prepubertal males due to the atypical age at presentation and absence of classic imaging characteristics. Successful endoscopic transnasal resection is possible despite anatomic constrictions. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1777-1783, 2019.

Outcomes of sphenopalatine and internal maxillary artery ligation inside the pterygopalatine fossa for posterior epistaxis.

OBJECTIVE: Analysis of the efficacy of sphenopalatine artery (SPA) and internal maxillary artery (IMAX) ligation within the pterygopalatine fossa to control posterior epistaxis. METHODS: Demographic and clinical data were collected in sixty-two consecutive patients who had SPA/IMAX ligation surgery. Clinical outcomes such as re-bleed rates and complications were acquired. RESULTS: A total of 62 patients were studied. Thirty-eight percent of patients had previously undergone silver nitrate nasal cautery for epistaxis. Nine patients had undergone previous attempt of SPA procedure or embolization in other services. Two patients returned to the operating room for anterior ethmoid ligation. There was one mortality within 30 days of surgery. Follow up ranged from 3 months to 56 months (median= 28 months). CONCLUSIONS: Dual SPA and IMAX ligation is effective in the control of difficult epistaxis cases, even in those patients with prior surgical intervention.

Divided maxillary artery in relation to the lateral pterygoid muscle.

We describe an anatomical variation of the right maxillary artery. The variation loops deep, giving off a middle meningeal artery with an extremely short extracranial segment, then bifurcates into unequal branches. The smaller branch passes superficial to the lateral pterygoid head and distributes primarily to the masticatory muscles. The larger partially pierces the lateral pterygoid lower head, re-emerges superficially, branches again and passes into the pterygopalatine fossa. The larger lies superficial to the lingual and inferior alveolar nerves and deep to the buccal nerve. An embryonic development origin of the cranial arteries is suggested.

[Iatrogenic palatine necrosis by embolization of sphenopalatine arteries during management of a rebel epistaxis]. / Nécrose palatine iatrogène par embolisation des artères sphéno-palatines au décours du traitement d'une épistaxis rebelle.

INTRODUCTION: The treatment of epistaxis sometime requires an embolization. This may result in ischemic palate necrosis, oronasal communication and dental losses. The repair of these lesions is complex. OBSERVATION: A 53-year-old patient, suffering from high blood pressure and hypercholesterolemia, benefited from bilateral embolization of the sphenopalatine arteries in order to treat a persistent epistaxis. He developed a middle cerebral artery stroke in the aftermath. During the treatment of the neurological sequelae, a necrosis of the 2/3 of the posterior aspect of the hard palate was discovered. The angio-MRI showed an obstruction of both sphenopalatine arteries and of their vascular supplies resulting in a bilateral involvement of the alveolar bone. The diagnosis of iatrogenic palate necrosis was made. Tissue repair was successfully achieved by two loco-regional flaps. The dental rehabilitation was made by mean of a removable prosthesis. DISCUSSION: Palatine necrosis following embolization of the sphenopalatine arteries is uncommon. Ischemia resulted in a loss of substance in form of a punch, similar to noma's lesions. It could also be a consequence of the vascular background. The management of these lesions is complex and calls for forensic reflection about the iatrogenic origin.

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.

Neurostimulation at pterygopalatine fossa for cluster headaches and cerebrovascular disorders.

There are numerous neural structures (parasympathetic, sympathetic, and trigeminal sensory) that are compacted in a small well defined area of the pterygopalatine fossa (PPF). These targets can be readily accessed via minimally invasive neuromodulation techniques making the methods more desirable than neurosurgical deep brain or hypothalamic intervention. Recent research has shed light over the important role of the sphenopalatine ganglion (SPG), which is located within the PPF, in cerebrovascular autonomic physiology as well as in the pathophysiology of different headache disorders (cluster headache, migraine, and trigeminal autonomic cephalalgias). Accordingly, neuromodulation of the autonomic fibers (parasympathetic and sympathetic) may play a key role in the management of headaches, stroke, or cerebral vasospasm. Another important structure within the PPF is the maxillary nerve (V2), which passes through the roof of the fossa. Here the trigeminal system is accessible for a reliable neuromodulation by targeting its second branch -the maxillary nerve- and this could be utilized in various painful conditions of the head and face.

Anatomical study of critical features on the posterior wall of the maxillary sinus: clinical implications.

OBJECTIVES/HYPOTHESIS: Endonasal approaches to the pterygopalatine fossa for epistaxis or as part of a transpterygoid approach have been popularized somewhat by the ability to control the terminal branches of the maxillary artery (MA). Surgical landmarks are useful to identify these arteries. Therefore, identification of surface features on the posterior wall of the antrum that reflect the position of deeper structures within the pterygopalatine fossa would help predict anatomical position and orientation. STUDY DESIGN: Describe the incidence of identifiable markings on the posterior wall of the maxillary sinus and ascertain their nature. METHODS: An anatomical study of 18 cadaveric specimens noting and recording the presence, location, and number of prominences on the posterior wall of the antrum. After removing the bony wall, structure in the pterygopalatine fossa corresponding to the surface markings was noted. RESULTS: Two prominences were identified. Prominence (P)1 extended from the upper part of the posterior wall of the maxillary sinus to the inferior orbit and corresponded to the infraorbital nerve. P2 was located at the middle part of the posterior wall, below P1, and corresponded to the MA. P2 was located medial to a vertical "drop line" where P1 connected to the posterior wall. P1 and P2 were found in 41.7% and 22.2%, respectively, of the specimens. CONCLUSIONS: This study defines features on the maxillary sinus posterior wall from an endoscopic perspective. These landmarks may be useful to identify the MA and its branches during surgery within the pterygopalatine fossa. LEVEL OF EVIDENCE: N/A.

[Blood supply in maxilla after segmental osteotomy].

Anthropometric measurements allowed us to obtain anatomical data on the topography of large and small palatine canals, sprouts sphenoid bone pterygoid, pterygopalatine and pterygomaxillary sutures. These structures are important because they contain blood vessels and nerves located in the area of jaw osteotomy. A study of maxilla blood supply sources after segmental osteotomy found that the descending palatine artery, the pterygopalatine artery, the upper posterior alveolar and infraorbital arteries usually remain intact by osteotomy. There are numerous anastomoses between all the arteries supplying the maxilla.

Intracranial nonjugular venous pathways: a possible compensatory drainage mechanism.

BACKGROUND AND PURPOSE: The IJVs are considered to be the main pathway draining the intracranial venous system. There is increasing evidence for the existence of alternative venous pathways. Studies using extracranial sonography techniques have demonstrated a nonjugular venous system. In the current study, we used MR images to investigate the NJV drainage system and its components (vertebral plexus, pterygopalatine plexus). The exact visualization and measurement of the intracranial NJVs could be of diagnostic importance and may have clinical importance. MATERIALS AND METHODS: A total of 64 participants with no history of neurologic disease were included in the study. All participants underwent scanning with a 2D time-of-flight, multisection sequence in the supine position. Image processing software was developed to identify and quantify the size of the IJVs and NJVs in the plane of the internal JF. For evaluation of software accuracy, all images were reviewed by a neuroradiologist experienced in neurovascular imaging preprocessing and postprocessing. RESULTS: The CSA of the NJVs correlated inversely with the CSA of the IJVs (r(2) = 0.25; P < .0001). An inverse correlation was also significant when comparing IJV with NJV components (vertebral plexus: r(2) = 0.19; P = .0004; pterygopalatine plexus: r(2) = 0.11; P = .0069). Furthermore, only NJV cumulative CSA correlated inversely with participant age (r(2) = 0.2; P = .0002). CONCLUSIONS: Our study indicates that the NJVs might serve as a compensatory drainage mechanism in the intracranial compartment. This mechanism appears less significant as the age of the patient progresses.

Ligation of the pterygopalatine and external carotid arteries induces ischemic damage in the murine retina.

PURPOSE: This study aimed to characterize the functional and morphologic changes in a murine model of ocular ischemic disease caused by vascular occlusion. METHODS: Retinal ischemia was induced by unilateral ligation of the pterygopalatine artery (PPA) and the external carotid artery (ECA) in anesthetized mice. Changes in ocular blood flow and retinal circulation were evaluated by three different methods: laser speckle blood flow imaging, fundus imaging, and fluorescein isothiocyanate angiography. Five days after reperfusion following 3- or 5-hour ischemia, an electroretinogram (ERG) was recorded, and the retinal histology was examined and quantified. The effects of a free radical scavenger, edaravone, using the model were evaluated by ERG and histologic analysis. RESULTS: The ligation of both the PPA and the ECA significantly reduced ocular blood flow and narrowed the blood vessels. Five hours of ischemia reduced the a-wave, b-wave, and oscillatory potential amplitudes of the ERG. The number of cells in the ganglion cell layer and the thickness of both the inner plexiform layer and the inner nuclear layer were reduced in the ischemic group. Retinal ischemia caused an increase in terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)-positive cells in the inner layer after 21-hour reperfusion following 3-hour ischemia and 19-hour reperfusion following 5-hour ischemia. Edaravone (1 mg/kg, administered intraperitoneally) significantly reduced the retinal ischemic damage. CONCLUSIONS: These findings indicate that the murine model in which both the PPA and the ECA are ligated may be useful to clarify the pathologic mechanisms of retinal ischemic diseases and to evaluate neuroprotective drugs that target retinal ischemic injury.

Microanatomy of the neural scaffold of the pterygopalatine fossa in humans: trigeminovascular projections and trigeminal-autonomic plexuses.

The pterygopalatine fossa (PPF) is an anatomically-hidden deep extracranial space. The neural scaffold of the PPF remains anatomically understudied in humans. Moreover, there are no anatomical data in humans pointing out the extracranial trigeminovascular distributions, in contrast to the trigeminal supratentorial ones. By anatomical microdissections, the neural scaffold of the PPF and the presence of trigeminovascular projections were evaluated. The anterior and superior approaches of the pterygopalatine fossae in nine dissected blocks of human middle skull base and the frontal cuts of two different specimens, led to several results: (1) the neurovascular contents of the PPF, embedded in the pterygopalatine adipose body, have a layered disposition; (2) the posterior neural layer is represented by a pterygopalatine cross, centred by the pterygopalatine ganglion (PPG) that sends off ascending, descending, and medial branches and has a lateral connection with the maxillary nerve - 4 quadrants could have been defined as referring to this cross; (3) at the level of the upper lateral quadrant there are two superposed layers (i) a superficial plexus contributed by the maxillary nerve, the maxillary artery plexus and the PPG and its orbital branches (OBs) and (ii) a deep layer, consisting of the OBs proper of the PPG; (4) within the PPF and on the posterior wall of the maxillary sinus distinctive trigeminovascular projections were evidenced. The anastomoses involving autonomic and trigeminal fibres, located in the PPF passage to the orbital apex, support the complicate and polymorphous neural input to the orbit, while the evidence of a pterygopalatine trigeminovascular scaffold offers a substrate for a better understanding of various facial algias.

Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomic study.

AIM: Our aim in this study was to recognize the endoscopic anatomy of the pterygopalatine fossa (PPF) and the anatomic variations of the related neurovascular structures, to define the endoscopic endonasal approach to this region. METHODS: Six fresh adult cadavers were studied (N=6) by endoscopic endonasal approach. To reach the pterygopalatine fossa endonasally, we performed the middle meatus transpalatine approach in 2 cadavers, the middle meatus transnasal approach in 2 cadavers and the inferior turbinatectomy transnasal approach in 2 cadavers. The superior and posterior walls of the maxillary sinus were defined and studied. The sphenopalatine foramen is widened by drilling the orbital process of the foramen and the sphenopalatine artery was exposed. The posterior wall of maxillary sinus was opened to expose the pterygopalatine fossa and its neurovascular contents, which were studied and documented. RESULTS: The PPF was easily approached by endoscopic transnasal transmaxillary approach. The PPF region was best exposed by the middle meatus tranasal approach. In the PPF; infraorbital nerve, vidian nerve, major palatine nerve, the infraorbital artery, internal maxillary artery, sphenopalatine artery, descending palatine artery, posterior superior alveolar artery and buccal artery were exposed. According Morton and Khan morphologic classification of the third portion of the internal maxillary artery we found intermediate type in 2 cadavers (33.3%), M' type in 2 cadavers (33.3%), T' type in 1 cadaver (16.7%) and Y' type in 1 cadaver (16.7%). Also, according to Chio and Park classification of the branching type of the infraorbital artery, posterior superior alveolar artery and deep palatine artery, we found type I in 4 cadavers (66%) and type II in 2 cadavers (33%). CONCLUSIONS: During the endoscopic transnasal transmaxillary approach to the PPF, it is possible to face wide range of variations in every phase of the approach. Understanding the anatomy of this region and the neurovascular relations from the endoscopic view by cadaver dissections will help us to performed more controlled and safe surgery.