[The Ascending Pharyngeal Artery, Accessory Meningeal Artery, Lingual Artery, Vasa Nervorum, and Potential Anastomotic Channels].

The ascending pharyngeal, accessory meningeal, and lingual arteries branch from the proximal segment of the external carotid artery. These branches give rise to smaller branches that contribute blood supply to the pharyngeal mucosa, parapharyngeal tissue, middle ear, submandibular tissues, tongue, and dura mater of the middle and posterior fossa. These arteries may also supply the cranial nerves and have potential anastomotic channels that function with the internal carotid and vertebral arteries. M igration of embolic material into the vasa nervorum and potential anastomoses may cause complications. Therefore, knowledge of these functional anatomies is crucial for neuro-interventionalists.

Assessing Early Cardiac Outflow Tract Adaptive Responses Through Combined Experimental-Computational Manipulations.

Mechanical forces are essential for proper growth and remodeling of the primitive pharyngeal arch arteries (PAAs) into the great vessels of the heart. Despite general acknowledgement of a hemodynamic-malformation link, the direct correlation between hemodynamics and PAA morphogenesis remains poorly understood. The elusiveness is largely due to difficulty in performing isolated hemodynamic perturbations and quantifying changes in-vivo. Previous in-vivo arch artery occlusion/ablation experiments either did not isolate the effects of hemodynamics, did not analyze the results in a 3D context or did not consider the effects of varying degrees of occlusion. Here, we overcome these limitations by combining minimally invasive occlusion experiments in the avian embryo with 3D anatomical models of development and in-silico testing of experimental phenomenon. We detail morphological and hemodynamic changes 24 hours post vessel occlusion. 3D anatomical models showed that occlusion geometries had more circular cross-sectional areas and more elongated arches than their control counterparts. Computational fluid dynamics revealed a marked change in wall shear stress-morphology trends. Instantaneous (in-silico) occlusion models provided mechanistic insights into the dynamic vessel adaptation process, predicting pressure-area trends for a number of experimental occlusion arches. We follow the propagation of small defects in a single embryo Hamburger Hamilton (HH) Stage 18 embryo to a more serious defect in an HH29 embryo. Results demonstrate that hemodynamic perturbation of the presumptive aortic arch, through varying degrees of vessel occlusion, overrides natural growth mechanisms and prevents it from becoming the dominant arch of the aorta.

The Pharyngolaryngeal Venous Plexus: A Potential Pitfall in Surveillance Imaging of the Neck.

BACKGROUND AND PURPOSE: Among patients undergoing serial neck CTs, we have observed variability in the appearance of the pharyngolaryngeal venous plexus, which comprises the postcricoid and posterior pharyngeal venous plexuses. We hypothesize changes in plexus appearance from therapeutic neck irradiation. The purposes of this study are to describe the CT appearance of the pharyngolaryngeal venous plexus among 2 groups undergoing serial neck CTs-patients with radiation therapy-treated laryngeal cancer and patients with medically treated lymphoma-and to assess for changes in plexus appearance attributable to radiation therapy. MATERIALS AND METHODS: For this retrospective study of 98 patients (49 in each group), 448 contrast-enhanced neck CTs (222 laryngeal cancer; 226 lymphoma) were assessed. When visible, the plexus anteroposterior diameter was measured, and morphology was categorized. RESULTS: At least 1 plexus component was identified in 36/49 patients with laryngeal cancer and 37/49 patients with lymphoma. There were no statistically significant differences in plexus visibility between the 2 groups. Median anteroposterior diameter was 2.1 mm for the postcricoid venous plexus and 1.6 mm for the posterior pharyngeal venous plexus. The most common morphology was "bilobed" for the postcricoid venous plexus and "linear" for the posterior pharyngeal venous plexus. The pharyngolaryngeal venous plexus and its components were commonly identifiable only on follow-up imaging. CONCLUSIONS: Head and neck radiologists should be familiar with the typical location and variable appearance of the pharyngolaryngeal plexus components so as not to mistake them for neoplasm. Observed variability in plexus appearance is not attributable to radiation therapy.

Clinical Effects of Radiofrequency Coblation for Adult Laryngopharyngeal Vascular Lesions.

OBJECTIVE: To explore the feasibility and efficacy of transoral radiofrequency coblation surgery (TRS) in the treatment of adult laryngopharyngeal vascular lesion (LVL). METHODS: A total of 15 patients with LVL were retrospectively studied, including 11 capillary lesions and five cavernous lesions (there was one case with two separate lesions). All of the lesions were treated with TRS alone (capillary lesion) or with a combination of TRS and sclerotherapy (cavernous lesion). The treatment efficacy was evaluated according to the modified Achauer criteria: grade 1, no change in size; grade 2, a decrease of < 50% in size; grade 3, a decrease of ≥ 50% but < 100%; and grade 4, the disappearance of the lesion with no recurrence for at least 6 months. RESULTS: The surgical procedures were successfully completed in all patients. According to the modified Achauer criteria, the treatment outcomes were grade 4 for 10 capillary lesions and one cavernous lesion; grade 3 for one capillary lesion and one cavernous lesion; grade 2 for one cavernous lesion; and grade 1 for two cavernous lesions, respectively. No complications related to the surgery, including bleeding, dysphagia, and infections, occurred after treatment. CONCLUSION: The TRS is an effective treatment option for LVL, especially for patients with laryngopharyngeal capillary lesions. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:566-570, 2021.

Serum interleukin-16 significantly correlates with the Vasculitis Damage Index in antineutrophil cytoplasmic antibody-associated vasculitis.

BACKGROUND: Interleukin (IL)-16 is a T cell chemoattractant produced by peripheral mononuclear cells. We investigated whether IL-16 plays a pro- or an anti-inflammatory role in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Furthermore, we investigated whether the level of IL-16 could predict the activity and extent of organ damage in AAV based on AAV-specific indices. METHODS: Seventy-eight patients with AAV from a prospective observational cohort were included in this analysis. Blood sampling and clinical assessments, including the Birmingham Vasculitis Activity Score (BVAS), Five-Factor Score (FFS), Short Form 36-item Health Survey (SF-36), and Vasculitis Damage Index (VDI), were performed, and laboratory data were collected. Serum IL-16 was measured from stored sera. RESULTS: The median age was 62.0 years, and 27 patients were male. The median serum IL-16 concentration was 84.1 pg/dL, and the median BVAS, FFS, VDI, and SF-36 scores were 7.0, 1.0, 3.0, and 48.0, respectively. Among the AAV-related indices, the serum IL-16 concentration was correlated with VDI (R2 = 0.306, P = 0.006), but not with BVAS (R2 = 0.024, P = 0.834), FFS (R2 = - 0.069, P = 0.550), or SF-36 (R2 = - 0.015, P = 0.898). The serum IL-16 concentration also did not correlate with either the erythrocyte sedimentation rate or the C-reactive protein concentration. Per our analysis based on organ involvement, only patients with ear, nose, and throat manifestations had higher serum IL-16 concentrations relative to those with other conditions (P = 0.030). CONCLUSIONS: This was the first study to elucidate the clinical implication of serum IL-16 in patients with AAV. We found that the serum IL-16 level may reflect the cross-sectional VDI scores among AAV-specific indices. Future studies with larger numbers of patients and serial measurements could provide more reliable data on the clinical implications of serum IL-16 in AAV.

Visualization and Analysis of Pharyngeal Arch Arteries using Whole-mount Immunohistochemistry and 3D Reconstruction.

Improper formation or remodeling of the pharyngeal arch arteries (PAAs) 3, 4, and 6 contribute to some of the most severe forms of congenital heart disease. To study the formation of PAAs, we developed a protocol using whole-mount immunofluorescence coupled with benzyl alcohol/benzyl benzoate (BABB) tissue clearing, and confocal microscopy. This allows for the visualization of the pharyngeal arch endothelium at a fine cellular resolution as well as the 3D connectivity of the vasculature. Using software, we have established a protocol to quantify the number of endothelial cells (ECs) in PAAs, as well as the number of ECs within the vascular plexus surrounding the PAAs within pharyngeal arches 3, 4, and 6. When applied to the whole embryo, this methodology provides a comprehensive visualization and quantitative analysis of embryonic vasculature.

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes.

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Variant ascending pharyngeal artery maintaining flow in a subocclusive internal carotid artery.

Ectopic branches of the external carotid artery are rare but have critical diagnostic and therapeutic implications. We present a case involving a 70-year-old man who presented with recurrent left hemispheric strokes in the setting of a subocclusive left internal carotid stenosis. A left ascending pharyngeal artery with variant origin from the internal carotid artery helped maintain flow distal to the area of stenosis and allowed for safe and successful internal carotid artery stenting. Identification of this variant and recognition of the anastomotic network involving this connection were crucial to determine the safety of stenting. The patient had no further recurrent events and had sustained improvement on his 90-day follow-up.

Prevention of Back Bleeding During Carotid Endarterectomy: Analysis of Clamping Techniques.

OBJECTIVE: Complete control of back bleeding during carotid endarterectomy (CEA) is important. We investigated the causes of back bleeding during CEA and techniques for the control of bleeding. METHODS: A retrospective review was performed of 214 CEA procedures. We assessed the results of routine preoperative examinations, instruments used for arterial clamping (vessel loop and crude or bulldog clamps), and severity of carotid artery stenosis and arterial wall calcification. The study end point was incomplete control of back bleeding before arteriotomy. Factors associated with back bleeding were identified by univariate analysis. The culprit artery and intraoperative technique used in patients with back bleeding were also determined. RESULTS: Transient back bleeding occurred in 19 CEA procedures (8.9%). Back bleeding was from the ascending pharyngeal artery in 9 cases, common carotid artery in 8 cases, and external carotid artery in 2 cases. Univariate analysis identified the following factors as being related to incomplete control of back bleeding: moderate carotid artery stenosis (20 mm thick) and use of bulldog clamps. CONCLUSIONS: Transient back bleeding during CEA was uncommon, with the risk factors being severe carotid calcification and moderate carotid stenosis. Transient back bleeding was managed by clamping an undetected ascending pharyngeal artery or by additional clamping of the common carotid or external carotid artery. The vessel loop and crude were superior to the bulldog clamp for clamping the carotid artery.

The parapharyngeal adipose corpus: anatomic and radiologic study.

PURPOSE: Although the morphology of the parapharyngeal adipose corpus (PAC) has been already described, the clinical interest of its volume and weight in the genesis of obstructive sleep apnea syndrome (OSAS) is still controversial. The volume of the PAC has been determined in OSAS patients but not in a normal population. The aim of our study was to investigate the morphology of the PAC by dissection and MRI in a normal population and to determine if there is a relation between the dimensions and volume of the PAC and the Body Mass Index (BMI). METHODS: Thirty hemifaces of 15 fresh cadavers have been dissected after silicone injection with dissection of the external carotid artery and its main branches, with harvesting of the PAC. The PAC has been measured and weighed. Twenty-nine MRI of healthy subjects have been examined to determine the volume of the PAC, the palate-pharynx distance, and epiglottis-pharynx distance. RESULTS: In dissection study the weight of the PAC was 18.57 g ± 2.24, the vertical dimension (height) was 4.61 cm ± 0.51, the frontal dimension (width) was 1.62 cm ± 0.24. The blood supply of the PAC constituted of branches coming from the ascending palatal and ascending pharyngeal arteries. The volume of the PAC on the right side was 1.56 cm3 ± 0.38, on the left side 1.54 cm3 ± 0.37. Its horizontal greater dimension was 1.70 cm ± 0.07. CONCLUSIONS: There is a correlation between the volume of the PAC and the BMI in a normal population. A surgical resection of the PAC in OSAS patients by transoral robotic-assisted surgery can be proposed with preservation of the ascending palatal and ascending pharyngeal arteries.

Lateral pharyngotomy.

Based on a review of the medical literature, the authors document the key technical points, variants, technical errors to avoid and main functional results of lateral pharyngotomy for resection of cancers originating from the lateral oro and/or hypopharynx.

The Use of the Carotid Sheath as a Rotation Anchor to Detect an Anomalous Ascending Pharyngeal Artery in Carotid Endarterectomy.

Carotid endarterectomy (CEA) requires complete control of the blood backflow. An anomalous ascending pharyngeal artery (AphA) has been reported to result in incomplete control of the blood flow during CEA. Here, we present a case of symptomatic right internal carotid stenosis for which CEA was performed. An anomalous AphA was confirmed based on its origin from the distal internal carotid artery (ICA) on 3-dimensional rotational angiography (3DRA). The anomalous AphA arose near the distal end of the plaque, and the origin of the AphA was located in the dorsal wall of the ICA, hidden from the surgical view. The origin of the AphA was detected with rotation of the ICA within the carotid sheath (CS). Intraoperatively, the blood flow from the AphA was completely controlled with clamping of the origin of the AphA. We emphasize the importance of the 3DRA to detect an anomalous AphA and propose the use of the CS as an anchor to rotate the ICA for optimizing the surgical view behind the ICA. This simple surgical technique facilitates to detect and clamp an anomalous AphA arising from the ICA.

Ectopic origin of the ascending pharyngeal artery: implications for carotid surgery.

In its normal anatomy, the extracranial internal carotid artery (ICA) does not have branches. The most common cause of an extracranial ICA branch is the ectopic placement of one of the named external carotid artery branches. Other causes of extracranial ICA branches include persistent fetal carotid-vertebrobasilar anastomoses and recannalized intersegmental arteries. In this case, report we describe a 55-year-old male who was found to have an ascending pharyngeal artery (APA) arising from the ICA during neck dissection. The aberrant APA was not identified on pre-operative imaging. The patient underwent a successful carotid endarterectomy (CEA) with preservation of flow through the ascending pharyngeal. We review the literature on the origin of the APA and discuss the clinical implications of extracranial ICA branches.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery.

BACKGROUND: Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA). METHODS: Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed. RESULTS: Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred. CONCLUSIONS: CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

Chemical Amputation and Regeneration of the Pharynx in the Planarian Schmidtea mediterranea.

Planarians are flatworms that are extremely efficient at regeneration. They owe this ability to a large number of stem cells that can rapidly respond to any type of injury. Common injury models in these animals remove large amounts of tissue, which damages multiple organs. To overcome this broad tissue damage, we describe here a method to selectively remove a single organ, the pharynx, in the planarian Schmidtea mediterranea. We achieve this by soaking animals in a solution containing the cytochrome oxidase inhibitor sodium azide. Brief exposure to sodium azide causes extrusion of the pharynx from the animal, which we call "chemical amputation." Chemical amputation removes the entire pharynx, and generates a small wound where the pharynx attaches to the intestine. After extensive rinsing, all amputated animals regenerate a fully functional pharynx in approximately one week. Stem cells in the rest of the body drive regeneration of the new pharynx. Here, we provide a detailed protocol for chemical amputation, and describe both histological and behavioral methods to assess successful amputation and regeneration.

The significance of the pharyngeal veins during carotid endarterectomy: description of an anatomical triangle.

Injuries to the hypoglossal and vagus nerves are the most commonly reported injuries during carotid endarterectomy. While unilateral single nerve injury is usually well tolerated, bilateral or combined nerve injuries can pose a serious threat to life. This study aims to increase awareness of the inferior pharyngeal vein, which usually passes posterior to the internal carotid artery but sometimes crosses anterior to it. Injury to either or both hypoglossal and vagus nerves can occur during control of unexpected haemorrhage from the torn and retracted edges of the inferior pharyngeal vein. We recommend careful ligation and division of this vein. In addition, we observed in 9 (17.3%) of the 52 operations that the pharyngeal vein formed a triangle with the vagus and hypoglossal nerves when it passes anterior to the internal carotid artery.

Treatment of a Large Pharyngeal Venous Malformation using Transoral Sclerotherapy.

Management of venous malformation (VM) in the pharynx is challenging because of difficulties in needle access and the presence of nerves as well as other critical anatomical structures around the lesion. We describe the successful treatment of a large pharyngeal VM using transoral sclerotherapy. The patient, a 21-yearold male, visited our hospital for sclerotherapy treatment consultation after complaining of difficulty in swallowing because of a pharyngeal VM. Transoral sclerotherapy was successful, and the symptoms showed complete alleviation. Using a flat detector-equipped angiographic C-arm CT (CACT) enabled the precise assessment of sclerosant placement, facilitating safer sclerotherapy in the pharynx.

A case of extensive pharyngeal vascular malformation successfully treated with Kampo medicine.

OBJECTIVE: To present the efficacy of Japanese-traditional medicine (Kampo) for a case with vascular malformation. METHODS: A case study and literature review. PATIENT: A 62-year-old female presented with dysphagia and spitting blood. Esophagogastroduodenoscopy showed a longitudinal lobulated and septated mass in the posterior pharynx. On MR imaging, the mass showed hyperintensity on T2-weighted images and heterogeneous enhancement on Gadlinium-enhanced T1-weighted images, suggestive of a low-flow vascular malformation. INTERVENTION: According to the Kampo diagnosis, kamisyouyousan and ninjinyoueito were prescribed to this patient. The effect of Kampo medicine was evaluated with improvement of her symptoms and volumetry of MRI findings. RESULT: The longitudinal pharyngeal mass was markedly decreased and her symptoms disappeared after 2 years of Kampo administration. CONCLUSIONS: Kampo medicine can be a novel alternative therapy for VM.