[Study on the consistency between CBCT image features of sphenopalatine foramen and those seen in nasal endoscopy].

Objective:To study the clinical anatomy of the sphenopalatine foramina by dissecting the sphenopalatine foramina during Vidian nerve branch neurotomy. The anatomy and CBCT images of sphenopalatine foramen were analyzed to facilitate the navigational of clinical operation using CBCT images. Methods:From October 2017 to September 2023, 84 cases（168 sides） of Vidian nerve branch neurotomy in our department were collected. The clinical summary was made according to the anatomy of sphenopalatine foramen during the operation. Preoperative CBCT imaging findings of the sphenopalatine foramina were also studied. Results:The clinical anatomy of sphenopalatine foramen could be divided into four types: middle meatus type（1.19%）, trans-meatus type（62.29%）, superior meatus type（33.33%） and double foramen type（1.19%）. The incidence of ethmoidal ridge was 98.81%. The distance from sphenopalatine foramina to posterior nasal canal were（14.63±2.66） mm to left and（14.65±2.63） mm to right, The position Angle ∠a of lower margin of sphenopalatine foramina were（62.36±10.05）° to left and（61.51±11.82）° to right, respectively. Axial CT images can be used to divide the sphenopalatine foramen into five levels: the upper edge of the sphenopalatine foramen level, the Vidian nerve level, the basal plate interaction level, the lower edge of the sphenopalatine foramen level and the pterygopalatine canal level. The agreement between endoscopic anatomy of sphenopalatine foramen and imaging navigation was 100%. Conclusion:The sphenopalatine foramina exhibit various anatomical types. The preoperative navigational CBCT reading can effectively identify the type of sphenopalatine foramina, guide the choice of surgical method, and help avoid serious complications. This has significant clinical application value.

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.

Morphometric analysis of sphenopalatine foramen on computed tomography images with clinical significance.

PURPOSE: This study aimed to investigate the effect of anatomical variations in the sphenopalatine foramen and the lateral nasal wall on sphenopalatine foramen-related morphometric measurements. METHODS: Paranasal sinus multidetector computed tomography records of 153 patients were evaluated. Morphometric measurements were made between the fixed bony landmarks and the sphenopalatine foramen. Number, shape, localization variations of the sphenopalatine foramen, concha bullosa, and septum deviation were noted and the results were compared with respect to sex, age, and laterality. RESULTS: No significant difference was detected with respect to laterality, whereas most of the measured distances were higher in males than females. There was a significant difference between the obtained morphometric data according to age groups. In our study, 91.2% single, 7.8% double, and 1% triple sphenopalatine foramen were detected and the most common irregularly shaped (37.3%). The location of sphenopalatine foramen was reported as the most common type II. Septum deviation types have no potential influence on the location of the foramen, but most of the measured parameters were found to be significantly smaller in the presence of concha bullosa, whereas the angle was found to be higher. CONCLUSION: This study revealed a significant relationship between the morphometric measurements of the sphenopalatine foramen and concha bullosa, while septum deviation types did not affect these results. For a safer and more effective surgery with prevention of iatrogenic complications, a surgeon should be aware of this correlation, especially in endoscopic transnasal approaches.

A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation.

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

High-Resolution Computed Tomography Imaging of the Cranial Arterial System and Rete Mirabile of the Cat (Felis catus).

The objective of this study was to investigate the possibility of obtaining high-resolution multiplanar computed tomography (CT) imaging of the cranial arterial circulation of the cat (Felis catus), the rete mirabile, and components of the skull, utilizing preserved cat specimens with an arterial system that was injected with a radiopaque contrast compound in the early 1970s. Review of the literature shows no high-resolution CT studies of the cat's cranial circulation, with only few plain radiographic studies, all with limited cranial vascular visualization. In view of the inability of the radiographic techniques available from 1970s to mid-2000s to provide high-resolution imaging of the arterial circulation within the intact skull and brain of the cat, without dissection and histologic sectioning and disruption of tissues, no further imaging was performed for many years. In 2010, a high-resolution micro CT scanner became available, large enough to scan the entire nondissected head of the arterially injected cats. All the obtained CT images were processed with a software program that provided 3D volume rendering and multiplanar reconstruction with the ability to change the plane angulation and slab thickness. These technical features permitted more precise identification of specific arterial and bony anatomy. The obtained images demonstrated, with a nondestructive method, high-resolution vascular anatomy of the cerebral, orbital, facial arterial system, the rete mirabile, and skull bone components of the cat, with details not previously described in the literature. Anat Rec, 302:1958-1967, 2019. © 2019 The Authors. The Anatomical Record published by Wiley Periodicals, Inc. on behalf of American Association of Anatomists.

Assisted resection of lateral extension of juvenile nasopharyngeal angiofibroma using a sphenopalatine fossa dissector.

BACKGROUND: Juvenile nasopharyngeal angiofibroma often attaches firmly to the adjoining bony region around the sphenopalatine foramina-sphenopalatine fossa-pterygomaxillary fissure. This can result in hourglass-shaped constriction and predispose to incomplete resection (residual disease) with a transpalatal approach. This paper describes attempts to address this 'inaccessible' area with a novel instrument, used since 2012. METHODS: Measurements of the sphenopalatine foramen, nasal septum, posterior nasopharyngeal wall and hard palate were undertaken in 20 skulls and 10 computed tomography scans (lateral extension). A device was designed (in terms of angulation and length) following several trials with malleable wire. A search of patents was also undertaken. Recurrence rates were compared in cases of device use and non-use. RESULTS: The novelty of the sphenopalatine fossa dissector was established and the device was patented. This device has significantly improved our 17.59 per cent recurrence rate of the past 4 decades; of 63 cases over 3 years, there were only 3 recurrences and 2 residual disease cases. Findings of our previous studies with or without the device are compared. CONCLUSION: Existing evidence supports the incorporation of this inexpensive instrument in the armamentarium for resecting lateral extension of juvenile nasopharyngeal angiofibroma during a transpalatal approach.

The sphenopalatine foramen in man: anatomical, radiological and endoscopic study.

BACKGROUND: Epistaxis is a frequent problem otorhinolaryngologists faces of in their practice. The variations of the sphenopalatine foramen (SPF) and consequ-ently the artery may be one of the major sources of such bleeding. The present work aimed to localise the site of SPF and also to illustrate its different shapes, number and any other variation. MATERIALS AND METHODS: In the current study, 20 adult skulls of both sexes with total 40 half skulls were used in addition to 20 heads of adult living subjects of both sexes aged between 30 and 60 years examined with multislice helical com-puted tomography with 3-dimensional reconstruction of SPF. Then, examination of another ten dried skulls with endoscope was performed. RESULTS: The number of the SPF is varied being single in nearly 80% and multiple in 20% of examined cases. The shape of the foramen also is varied; regular in 67.5% and irregular in 32.5% of all cases. The site of the foramen on the lateral nasal wall is placed in the superior meatus in most of examined skulls (62.5%) while in the rest (37.5%) they are found in the superior meatus and extending to the middle one. CONCLUSIONS: There are variation of the number, shape and site of the SPF, and consequently of the branches of the sphenopalatine artery, and this may explain the surgical failure in management of severe epistaxis. The data obtained from the current work support the predication of more than one sphenopalatine ar-teries and gives ample knowledge on the endoscopic study of the lateral nasal wall and consequently the surgical treatment of severe epistaxis. (Folia Morphol 2018; 77, 2: 345-355).

An Unusual Variant of the Sphenopalatine Foramen and Artery with an Absent Crista Ethmoidalis: An Intra-Operative Challenge

Sphenopalatine artery ligation (SPL) is a surgical remedy for severe epistaxis. This procedure requires extensive knowledge of the various anatomical variants. Its topographical anatomy varies and reliable landmark such as the crista ethmoidalis may be absent. These variations are crucial and they dictate the outcome of the surgery. We present a peculiar case of a postero-superiorly located variant of the sphenopalatine foramen and artery with an absent crista ethmoidalis. The sphenopalatine foramen was found superiorly at the superior meatus beyond the horizontal part of the lamella of the superior concha. Only one trunk was seen exiting the sphenopalatine foramen. The sphenopalatine foramen was measured from the anterior part of the nose. It was 69mm from the nasal sill and 54mm limen nasi.

Usefulness of Curved-Shaft Needles for Infiltrating the Sphenopalatine Area.

The objective of this study is to evaluate what types of needles are optimal and efficient for infiltrating the sphenopalatine area during endoscopic sinus surgery. Prospective, randomized, open-labeled study was designed. Sixty-three sides of nasal cavities of 45 patients were randomly assigned to three groups with different needle shapes. The group 1 needles had a straight shaft, the group 2 had an obtuse curved shaft, and the group 3 had an arch-shape shaft. The infiltration time for group 1 was longer than that for group 2 and group 3. There was significant difference in the secondary infiltration time between group 1 and group 3 (p = 0.005). We devised new curved-shaft needles that can utilize the 'lever effect' and showed that they are more efficient than straight shaft needles for infiltrating the sphenopalatine area.

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.

[Anatomic variations and references of the sphenopalatine foramen in cadaveric specimens: a Mexican study]. / Variantes y referencias anatómicas del foramen esfenopalatino en especímenes cadavéricos: un estudio en población mexicana.

BACKGROUND: The sphenopalatine foramen is located on the lateral nasal wall and has multiple variants and anatomic landmarks that are important to know to optimize RESULTS in the surgical management of posterior epistaxis. OBJECTIVE: This study describes the endoscopic anatomy of the sphenopalatine foramen, related structures and anatomic variations in a Mexican population. METHODS: We performed a prospective, observational, and experimental study. Five cadaveric specimens were included. Dissections were performed to identify the anatomy of the sphenopalatine foramen and anatomic variants. Measurements were obtained from different anatomic references to the columella. RESULTS: Of a total of ten dissections, in 100% of cases ethmoid crests were identified anterior to the sphenopalatine foramen. Localization of the sphenopalatine foramen in the lateral nasal wall in 60% cases was in the transition from middle meatus with superior meatus. The vidian nerve in 90% of cases was located superior and posterior to the sphenopalatine foramen. For the measurements, no significant differences between the two sides of each specimen were noticed. CONCLUSIONS: The sphenopalatine foramen presents multiple anatomic variants and numerous landmarks, which are important to comprehend in order to perform a successful and safe endoscopic sinus surgery.

ANTECEDENTES: el foramen esfenopalatino se localiza en la pared nasal, con múltiples variantes y referencias anatómicas que es importante conocer para optimizar los RESULTADOS del tratamiento quirúrgico y la epistaxis posterior. OBJETIVO: describir la anatomía endoscópica del foramen esfenopalatino, las estructuras relacionadas, y las variantes anatómicas en población mexicana. MATERIAL Y MÉTODOS: estudio prospectivo, observacional y experimental. Se incluyeron 5 especímenes cadavéricos, se realizaron las disecciones para identificar la anatomía del foramen esfenopalatino y sus variantes anatómicas, se midieron diferentes referencias anatómicas a la columela. RESULTADOS: de 10 disecciones realizadas, en 100% de los casos se identificó la cresta etmoidal anterior al foramen esfenopalatino, la localización en la pared nasal en 60% de los casos fue en la transición del meato medio con el meato superior, el nervio Vidiano en 90% de los casos se localizó posterosuperior al foramen esfenopalatino. En relación con las mediciones no se encontraron diferencias significativas entre ambos lados de cada fosa nasal. CONCLUSIONES: las variantes anatómicas del foramen esfenopalatino son múltiples, por lo que contar con referencias anatómicas es de suma importancia para poder localizarlo durante la cirugía endoscópica nasal. Palabras clave: foramen esfenopalatino, arteria esfenopalatina, nervio vidiano, epistaxis posterior, cresta etmoidal, pared nasal.

Surgery for juvenile nasopharyngeal angiofibroma with lateral extension to the infratemporal fossa.

OBJECTIVE: The study aimed to assess the usefulness of skull base surgery for large juvenile nasopharyngeal angiofibroma (JNA) with lateral extension to the infratemporal fossa. MATERIALS AND METHODS: Eleven cases were enrolled for this study, and the mean age was 17.7 years old (range: 8-32). Six out of 11 cases underwent surgery as an initial treatment, and the other five underwent secondary surgery after initial surgery or radiotherapy in other institutions. The range of extension of tumor, feeding arteries, surgical approach, and treatment outcome were estimated. RESULTS: All tumors originated from the sphenopalatine foramen. Based on the imaging study, there was extension to the cavernous sinus observed in eight cases, as well as to the middle cranial fossa (8), orbit (4), and anterior cranial fossa (1). These tumors were diagnosed as Andrews' Stage IVa (3) and IVb (8). However, infiltration into the cavernous sinus was observed in one case only during surgery. Ten tumors were separated carefully from the cavernous sinus or dura and were accurately diagnosed as Stage IIIb. In all cases, the main arterial feeders of the JNAs were branches of the external carotid artery, which were embolized prior to surgery. However, 10 cases were also fed by branches of the internal carotid artery (branches of the ophthalmic artery), in which these arteries could not be embolized. Coronal skin incision (1) and a facial dismasking flap (9) were used, and in one case, wide lateral skin incision with temporary incision of the facial nerve was applied. The orbito-zygomatic approach and its modification was applied to all the cases. Fronto-lateral craniotomy was applied in four cases and lateral craniotomy in seven cases. Total resection was achieved in 10 cases and subtotal resection in one case. No mortality was noted in this series. Temporal trismus was observed in all cases which subsided gradually. Cheek numbness and facial palsy were observed in three and two cases, respectively. CONCLUSION: Coupled with craniotomy, tumor removal was successfully carried out in 11 patients with JNAs, which showed large lateral extension. Our surgical strategy is a safe and effective approach for the removal of JNAs with infratemporal fossa extension.

Three-dimensional CT reconstruction anatomy of vidian canal, foramen rotundum and the sphenopalatine foramen / 解剖学报

Objective To investigate the three-dimensional spatial relationships of the sphenopalatine foramen ( SPF) , vidian canal ( VC ) , and foramen rotundum ( FR ) with regard to an endoscopic endonasal approach to the pterygopalatine fossa(PPF)using three-dimensional reconstruction of high resolution computed tomography (HRCT) scans. Methods The HRCT scans of 17 patients and a cadaver specimen were retrospectively evaluated .The morphology of the SPF, VC, and FR as well as the spatial relationship between the SPF and VC were measured on the image of three -dimensional CT reconstruction.Results The mean diameters of the SPF, VC, and FR were(6.26 ±1.59)mm,(2.35 ± 0.77)mm and(2.75 ±0.77)mm, respectively.The mean distance between the VC and posteroinferior margin of SPF was (4.03 ±1.15) mm.The mean vertical and horizontal distances on the image of three-dimensional CT reconstruction were between the VC and FR were(4.94 ±1.35)mm and(9.22 ±3.07)mm, respectively.The whole or partial margin of the VC was above the inferior margin of the SPF in 92%(33/36) of the VC and lateral to the posterior margin of the SPF in 97%(35/36) of the VC.Conclusion The endoscopic endonasal approach to the PPF is performed with greater safety through comprehension of the spatial relationships between the SPF , VC, and FR.

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 Morphology and Anatomical Location of the Sphenopalatine Foramen / 체질인류학회지

This study aims to investigate the anatomical information of the sphenopalatine foramen with special reference to the bleeding control of the sphenopalatine artery and to the blockage of the pterygopalatine ganglion during functional endoscopic sinus surgery. Forty-three midsagittal sectioned Korean heads were used in the study. The mucosa on the lateral nasal wall was removed for showing the sphenopalatine foramen. The shapes of the sphenopalatine foramen were classified by 4 types. Angle from the akanthion and distances from akanthion, conchae, sphenoidal sinus and greater palatine foramen were measured. The sphenopalatine foramen was frequently found as oval shape and bilateral symmetry of 28.6%. The vertical length was 5.5 mm, the horizontal length was 5.3 mm. The most anterior point of the sphenopalatine foramen was located on 54.4 mm few and angles were between 15.9degrees and 22.1degrees from akanthion. The distances were 36.2 mm from anterior end of middle nasal concha, 6.2 mm from posterior end of middle nasal concha, 27.2 mm from greater palatine foramen. The uppermost point of the sphenopalatine foramen was located on 22.3 mm from the most superoanterior end of the sphenoidal sinus, 18.6 mm from the lowermost end of the sphenoidal sinus. This study could be useful to provide the confidence about the location of the sphenopalatine foramen during functional endoscopic sinus surgery.

Trans-Inferior Turbinate Approach for Endoscopic Sphenopalatine Artery Ligation

BACKGROUND AND OBJECTIVES: With the recent development of endoscopic nasal surgery, endoscopic sphenopalatine artery ligation allows for secure control of posterior epistaxis with considerably low recurrence and complications. Surgical approaches to the sphenopalatine foramen to ligate the sphenopalatine artery are transantral, intranasal, and transseptal. However, the procedures have considerable limitations. Therefore, we have revised the transturbinal approach, which was described by Togawa for intranasal vidian neurectomy in 1977, to ligate the sphenopalatine artery in two patients of intractable posterior epistaxis, and describe our technique of the trans-inferior turbinate approach for endoscopic sphenopalatine artery ligation. SURGICAL TECHNIQUE: A longitudinal incision is made along the lower border of the inferior turbinate, and the mucoperiosteal flaps are developed to the lateral nasal wall. The posterior two-thirds of the inferior turbinate bone is removed from the lateral nasal wall. The posterior lateral nasal artery on the upper flap is positively identified, and followed to the posterior end of the middle turbinate bone. The sphenopalatine foramen can be localized after removing the posterior end of the middle turbinate bone, and the sphenopalatine artery is ligated with hemoclips or divided with bipolar electrocautery. RESULTS: With the trans-inferior turbinate approach, it was possible to identify and ligate the sphenopalatine artery and its branches in the sphenopalatine foramen with no immediate or delayed complications. CONCLUSION: The trans-inferior turbinate approach provides unobscured surgical access to the posterior nasal cavity, and enough working space for endoscopic manipulation. The posterior lateral nasal artery is a reliable surgical landmark leading to the sphenopalatine foramen.