The posterior pedicled inferior turbinate-nasoseptal flap: a potential combined flap for skull base reconstruction.

OBJECTIVES: To develop a combined pedicled flap comprising the mucoperiosteum and mucoperichondrium of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum based on the posterior lateral nasal artery, a branch of the sphenopalatine artery, for the reconstruction of skull base defects resulting from endoscopic expanded endonasal approaches. METHODS: Eleven fresh adult cadaver heads were dissected. Arterial distribution patterns of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum were investigated. The posterior pedicled inferior turbinate-nasoseptal flap was designed, measured, and harvested, and its ability to cover ventral skull base defects was examined. RESULTS: The inferior turbinate artery and/or posterior lateral nasal artery had 3.19 ± 1.47 (range 2-7) branches [mean outer diameter of largest branch, 0.40 ± 0.10 (range 0.24-0.60) mm] that anastomosed with the nasoseptal artery. These anastomosing arteries allowed the posterior lateral nasal artery to supply arterial blood to the nasoseptal mucoperichondrium and mucoperiosteum. Mean flap length was 100.65 ± 5.61 (range 91.43-109.44) mm, and minimum and maximum widths were 25.21 ± 2.29 (range 22.36-30.23) and 44.53 ± 5.02 (range 36.45-54.10) mm, respectively. Mean flap area was 3090.69 ± 288.08 (range 2612.97-3880.09) mm(2). The flap covered defects extending from the frontal sinus to the foramen magnum in all specimens. CONCLUSIONS: Harvesting of a posterior pedicled inferior turbinate-nasoseptal flap is feasible. It should be considered a useful option for the reconstruction of large defects involving the anterior skull base, planum sphenoidale, sella turcica, and/or clivus.

Model demonstrates functional purpose of the nasal cycle.

BACKGROUND: Despite the occurrence of the nasal cycle being well documented, the functional purpose of this phenomenon is not well understood. This investigation seeks to better understand the physiological objective of the nasal cycle in terms of airway health through the use of a computational nasal air-conditioning model. METHOD: A new state-variable heat and water mass transfer model is developed to predict airway surface liquid (ASL) hydration status within each nasal airway. Nasal geometry, based on in-vivo magnetic resonance imaging (MRI) data is used to apportion inter-nasal air flow. RESULTS: The results demonstrate that the airway conducting the majority of the airflow also experiences a degree of ASL dehydration, as a consequence of undertaking the bulk of the heat and water mass transfer duties. In contrast, the reduced air conditioning demand within the other airway allows its ASL layer to remain sufficiently hydrated so as to support continuous mucociliary clearance. CONCLUSIONS: It is quantitatively demonstrated in this work how the nasal cycle enables the upper airway to accommodate the contrasting roles of air conditioning and the removal of entrapped contaminants through fluctuation in airflow partitioning between each airway.

The clinical value of the novel cauterization procedure for the inferior turbinate artery during turbinate surgery.

The objective of the study was to evaluate the efficacy and the safety of the novel cauterization procedure of the inferior turbinate artery, which may be performed with any kind of inferior turbinate procedures in reducing the intra and the post-operative bleeding in partial inferior turbinectomy. A prospective controlled study was conducted in a referral center. Sixty patients (38M, 22F) who underwent partial turbinectomy were included. In 20 patients, partial turbinectomy was performed with the cauterization in one nasal cavity and the other one without it. The remaining 40 patients were divided into two groups which comprised cauterization positive and negative patients and are assessed in terms of post-operative bleeding. The area of the cauterization was 1 cm(2) field which is 1 cm anterior to the posterior attachment of the inferior turbinate on the lateral nasal wall, very close to the inferior turbinate, where the pulsating vessel is most commonly seen. Mean operation time, mean intra-operative blood loss and post-operative bleeding incidence are the main outcome measures. Post-operative bleeding was seen in three patients (15%) in the cauterization negative group. No patient had post-operative bleeding in the cauterization positive group. Mean operation time and mean intra-operative bleeding amount were significantly lower in the cauterization positive side. Cauterization of the inferior turbinate artery on the lateral nasal wall is a safe and effective method which may also be performed with any kind of inferior turbinate procedures to reduce both the operation time and intra and post-operative bleeding.

Middle turbinate vascularized flap for skull base reconstruction after an expanded endonasal approach.

INTRODUCTION: The expanded endonasal approaches to the skull base are modular approaches that arise from the sphenoidal sinus. The reconstructive techniques in these approaches are key to avoid postoperative complications. Available flaps for reconstruction include the pedicled nasoseptal flap, the transpterygoid temporoparietal fascia flap, and the posterior pedicle inferior turbinate flap (PPITF), among others. Recently, the middle turbinate flap has been described in a cadaveric study. We report our preliminary experience in the use of this middle turbinate vascularized flap for skull base reconstruction after expanded endonasal approaches. MATERIAL AND METHODS: Ten patients underwent reconstructive procedures with the mucoperiostial vascularized middle turbinate flap. Capability to cover the defect, closure success, operative time and complications related to the procedure are retrospectively analyzed. RESULTS: A satisfactory closure was obtained in all procedures, and there were no complications related to the technique. Required operative time was similar to the time employed for the nasoseptal flap. CONCLUSIONS: The vascularized middle turbinate flap is a reliable reconstructive technique for the reconstruction of moderate-sized skull base defects. It can be considered either as the first choice of closure or as an alternative to the nasoseptal flap when this is not available. Different flap combinations may facilitate skull base defect reconstruction.

The blood supply of the inferior nasal concha (turbinate): a cadaveric anatomical study.

The blood supply of the lateral nasal wall acquires a great deal of interest for many reasons especially for the treatment of clinical conditions such as epistaxis that sometimes needs surgical interventions and endoscopic sinus and skull base surgeries that requires a good choice of endonasal flaps including inferior nasal concha (commonly named as inferior turbinate by clinicians) flap to close the dural defects. Successful treatment of epistaxis and closure of such defects depends on detailed anatomical knowledge of lateral nasal wall vasculature and a vital flap with good blood supply, respectively. Because of these we aimed to study the blood supply of inferior turbinate, regarding the sources and courses of the blood vessels. Forty formalin-fixed hemisected cadaveric heads were used at Hacettepe University Anatomy Dissection Laboratory. Anatomical dissection of the inferior nasal concha and the lateral nasal wall was done by dissecting microscope. Coloring dye injection to the arteries was performed. After a detailed examination of the lateral nasal wall; the position of the sphenopalatine foramen (SPF) and the sphenopalatine artery (SPA) were identified. The posterior lateral nasal artery (PLNA) found to give middle and inferior conchal (turbinate) arteries. The average length of the inferior turbinate artery (ITA) was 9.057 ± 1.674 mm, the diameter was 1.452 ± 0.172 mm, the distance from posterior end of inferior turbinate was 7.879 ± 1.52 mm. Anastomosis in the lateral nasal wall between the ITA and the anterior ethmoidal and the lateral nasal (branch of the facial artery) arteries were established. The blood supply of inferior nasal concha is mainly provided by ITA and its anastomotic contributors. Detailed knowledge related to it, before surgical interventions, may reduce intraoperative bleeding and increase endoscopic exposure.

Ultrasound submucosal inferior nasal turbinate reduction technique: histological study of wound healing in a sheep model.

AIM OF THE STUDY: To describe histological changes after application of an ultrasound tissue reduction (UTR) technique in a newly introduced sheep model to study inferior nasal turbinate mucosal wound healing. MATERIALS AND METHODS: An experimental study in a sheep model. Stromal fibrosis, submucosal interstitial space volume (ISV), mucosal epithelial cell necrosis, mucosal inflammation and blood vessels' engorgement in inferior turbinate samples were assessed after application of UTR using hematoxylin/eosin staining in 12 turbinate samples after different time points. Histological grading was performed using a 4-point scale RESULTS: After one week, extensive development of fibrosis (p = 0.006) and significant reduced stromal ISV (p < 0.001) compared to controls were observed. The degree of fibrosis and the stromal ISV remained constant during the 8-week period. The extensive epithelial cell necrosis observed at week 1, diminished later, so that at 8 weeks no significant difference with controls in the necrosis extent was noted. Significant reduction of engorgement of blood vessels in the submucosal layer was noted after 8 weeks (p = 0.008, compared with baseline). Mucosal inflammation, while pronounced at week 1 (p = 0.005, compared with baseline), was normalized at week 8. CONCLUSION: Due to the rapid induction of extensive fibrosis, to the limited inflammation reaction, to the moderate degree of epithelial necrosis, to the reduction of subepithelial ISV and the persistence of these features till week 8 at least, UTR emerges as an effective minimally invasive technique for inferior nasal turbinate volume reduction.

Blood supply of the inferior turbinate and its clinical applications.

One of the most effective treatments of inferior turbinate (IT) hypertrophy is surgical reduction. Bleeding from the IT branch of the posterior lateral nasal artery (ITB) may interfere with the outcome of IT surgery. The aim of this study is to define the anatomic localization of the ITB and its variations and to investigate its clinical importance. Anatomic relations of the ITB were determined by microdissecting 20 adult, sagittally cross-sectioned head specimens. Branching characteristics of the ITB and its anatomical relations were evaluated. The most consistent two markers to define the ITB on the lateral nasal wall were the posterior attachment of the IT (PAIT) and the posterior attachment of the middle turbinate (PAMT). Mean horizontal distances of the ITB from the PAIT and the PAMT were 7.2 mm ± 2.8 mm (2.5-11.8 mm) and 8.2 mm ± 2.8 mm (4-14.6 mm), respectively. ITB was the only major artery that supplied the IT in 85% of the specimens, and, in 15%, there was more than one artery. ITB was located lateral to the IT in 95% and medial to the IT in 5%. The ITB coursed on the lateral nasal wall, vertically between the middle and ITs and always anterior to the PAIT. All the variations of blood supply to the IT were within a one square centimeter area, ∼1-cm anterior to the PAIT. Successful cauterization of this particular area may be an alternative cauterization site in IT surgery.

Old and new aspects of middle turbinate histopathology.

OBJECTIVE: To study the histology of the normal and pathologic middle turbinate (MT). STUDY DESIGN: Nonrandomized, controlled study. SUBJECTS AND METHODS: Qualitative and quantitative assessment of soft tissue and bony elements of 14 normal and 10 chronic rhinosinusitis (CRS) MT samples (patients' mean CT score, 6.5 +/- 6.7). A comparison with 14 normal inferior turbinate (IT) samples was accomplished. Quantitative assessment was limited to the lateral mucosal layer (LML). RESULTS: The thickness of the LML was significantly greater in pathologic MT than in normal MT (P = 0.002). Except for veins that underwent significant increase (P = 0.036), other soft tissue constituents of the pathologic MT did not change significantly. Glands were more abundant in normal MT and veins in normal IT (P < 0.001, P = 0.001, respectively). Qualitative assessment showed larger veins in the normal IT compared with the normal MT. Inflammatory cell infiltrate, edema, and fibrosis were found in CRS. None of our MT bones exhibited osteomyelitic changes. CONCLUSIONS: The different proportion of glands suggests varied functional roles for both the MT and IT. The significant involvement of the MT in the inflammatory process of CRS and the relatively small size and paucity of veins with relatively little effect on nasal airflow justify partial excision of the MT.

A study of the maxillary and sphenopalatine arteries in the pterygopalatine fossa and at the sphenopalatine foramen.

OBJECTIVES: Arterial ligation remains a key option in the treatment of persistent epistaxis and clarification of the arterial configuration of the distal maxillary/sphenopalatine artery is important for understanding the rationale behind current surgical treatments. Greater understanding of the arterial anatomy will reduce the risk of technical failures and improve the reliability of surgical interventions for persistent epistaxis and will also be useful for surgeries involving the pterygopalatine fossa. STUDY DESIGN: Anatomical study in cadavers. METHODS: This is an anatomical study of 128 cadaveric tissue blocks containing the pterygopalatine fossa. In total, 118 tissue blocks were microdissected using a Watson-Barnet dissecting microscope. Ten injected tissue blocks were cleared by the Spalteholz technique. Photographic records were made. RESULTS: Analysis demonstrated three common configurations of the maxillary artery in the pterygopalatine fossa: a single looped form (18%) and two double-looped forms, 'E' (51%) and 'M' (31%). The maxillary artery bifurcates before the sphenopalatine foramen in 105 cases (89%). The sphenopalatine foramen lies at the posterior end of the middle turbinate; in 58% of cases it lies in both the superior and middle meati. Asymmetry in the size of the maxillary arteries was uncommon; only 3% could be described as 'dominant'. CONCLUSIONS: The arterial configuration of the maxillary artery in the pterygopalatine fossa can be complex but may be classified into one of three forms. Some configurations may be more liable to lead to difficulties with branch identification during surgical treatment of epistaxis particularly in combination with an inadequate osteotomy. Clinicians should expect to find more than one vessel exiting the sphenopalatine foramen and actively search for these during surgery. Asymmetry in the maxillary/sphenopalatine arteries is not common and contralateral ligations are not indicated.

[The influence of different methods of surgical intervention on mucosal microcirculation in the inferior turbinate bone evaluated by laser Doppler flowmetry].

Thirty patients with enlarged inferior turbinate bones were allocated to 3 subgroups depending on the choice of surgical treatment. The control group comprised 10 practically healthy volunteers with unaffected nasal and paranasal cavities. The objective of the study was to compare clinical efficiency of three surgical techniques, viz. submucosal vasotomy, submucosal endoscopic conchotomy, and submucosal osteoconchotomy. Mucosal microcirculation in the nasal cavity was studied by laser Doppler flowmetry in the middle part of the inferior turbinate bone. In all the cases, measurements were performed before and after the adrenaline test; patients of the study group underwent additional measurements on day 7 and 3 months postoperatively. The results of the study confirmed the development of microcirculatory disturbances in patients with enlarged inferior turbinate bones. It is concluded that all the three surgical modalities employed in this study for the correction of enlarged inferior turbinate bone preserve functional capacity of intranasal mucosa and promote normalization of its microhemodynamic patterns. Submucosal endoscopic conchotomy appears to be the most efficacious of the three techniques.

Regional differences in vascular responsiveness of nasal mucosae isolated from naive guinea pigs.

OBJECTIVE: In the present study, the contractile response to norepinephrine (NE) and relaxing response to histamine and leukotriene D(4) (LTD(4)) were compared among the nasal mucosae of septa (S) and lateral (L) and medial turbinates (M) isolated from naive male Hartley guinea pigs. METHODS: The isometrical tension of the isolated nasal mucosae of the above regions was measured at a resting tension of 0.5 g by using a standard organ-bath technique. RESULTS: In each mucosal strip, NE induced a contraction in a concentration-dependent manner. A significant difference in efficacy (maximal response) of NE was found (L>M>S). In mucosal strips precontracted with NE (3x10(-5)M), both histamine and LTD(4) induced relaxing responses. The efficacy of histamine in S was significantly greater than those in L and M. The potency order of LTD(4) was L>M>S; a significant difference was observed between L and S. CONCLUSION: In conclusion, the present study demonstrated a distinct regional difference in the response to contractile and relaxant agonists of isolated nasal mucosae of guinea pigs.

Different swelling mechanisms in nasal septum (Kiesselbach area) and inferior turbinate responses to histamine: an optical rhinometric study.

OBJECTIVE: To determine whether the inferior turbinate, which contains swelling bodies, and the nasal septum (Kiesselbach area), characterized by a dense arterial mesh, exhibit different swelling mechanisms in allergic nasal reactions. DESIGN: Two optical rhinometers were used to examine 11 patients in the clinic. Optical rhinometry is based on the transillumination of the nasal septum and inferior turbinate or the whole nose with monochromatic light. The instrument's wavelength can be adjusted to the absorption characteristics of reduced hemoglobin, oxygen-saturated hemoglobin, and water. SETTING: Outpatient university otolaryngology clinic. PATIENTS: Eleven young, healthy, nonsmoking, nonpregnant subjects (6 men and 5 women), mean age, 32.4 years (age range, 27-37 years), with no history of exposure to toxic substances, allergies, or other significant diseases. INTERVENTIONS: Optic rhinometry evaluation during the course of nasal histamine administration. MAIN OUTCOME MEASURES: Light extinction at various wavelengths. RESULTS: Following administration of histamine, in the nasal septum, the wavelength of 950 nm (edema) showed the strongest increase of light extinction; in the inferior turbinate, it was the wavelength of 786 nm (oxygenated hemoglobin). In the whole nose, the wavelength of 880 nm (edema plus hemoglobin) exhibited the largest increase of extinction. CONCLUSIONS: Swelling of the nasal septum (Kiesselbach area) in nasal allergic reactions is caused mainly by edema, whereas swelling of the inferior turbinate is due mainly to an increase in volume of blood that is highly saturated with oxygen. Swelling of the whole nose is characterized by the combination of both, edema and increase in blood volume.

Radiological Assessment of the Anatomy of Frontal Recess Cells and the Anterior Ethmoidal Artery.

It is necessary for the surgeon to be familiar with frontal recess anatomy during an endoscopic approach to the frontal sinuses. The aim of this study was to evaluate the prevalence of frontal recess cells in Japanese adults as well as the association between the frontal recess and the location of the anterior ethmoidal artery (AEA). The frontal recess cells and the AEAs were retrospectively evaluated in CT scans of the nasal and paranasal sinuses for 89 patients. The prevalence of agger nasi cells was 90.7%. The frequency of frontal cell types 1, 2, 3 and 4 was 28.8, 0.6, 2.6 and 0%, respectively. Suprabullar cells (SBCs) and frontal bullar cells (FBCs) were identified in 78/96 sides (81.3%) and 24/96 sides (24%), respectively. The prevalence of the medial group of frontal recess cells (interfrontal sinus septal cells) was 12.4%. In 42/61 sides (68.9%), the AEAs were located within the posterior margin of the SBCs or the FBCs. Therefore, SBCs, FBCs and the vertical portion of the middle turbinate are reliable landmarks for the identification of AEAs.

Merkel cell carcinoma: a rare cause of hypervascular nasal tumor.

Cutaneous neuroendocrine carcinoma, first described in 1972, is an aggressive disease usually occurring in sun-exposed skin. Other sites have been described, however; such tumors occasionally occur within the nasal fossa. A high rate of metastasis (>30%) explains the poor prognosis. Descriptions of the imaging features of these tumors, mainly located in cutaneous region, are rare. We therefore present the imaging features of two cases of Merkel cell carcinoma involving the sinonasal region, suggestive of a hypervascular tumor.

Osteologic classification of the sphenopalatine foramen.

Textbook descriptions and illustrations of the opening of the sphenopalatine foramen (SPF) into the nasal cavity place it above and behind the posterior end of the middle turbinate (i.e., within the superior meatus). Although true for some skulls, this is not the situation for the majority and may be of importance, because the major blood supply to the nasal cavity enters via this route. Having studied 238 lateral nasal walls, the authors propose a classification of the osteology of the sphenopalatine foramen. In class I (35%) the opening of the SPF is purely into the superior meatus with a notch or foramen in the middle turbinate/ethmoidal crest of the palatine bone. In class II (56%) the SPF spans the ethmoidal crest (i.e., opens into both the superior and middle meati). In class III (9%) there are two separate openings into the superior and middle meati. These findings may explain the route of the artery to the inferior turbinate and indicate the need for care in dealing with the posterior end of the middle turbinate. They may also suggest a potential site for dealing with "difficult" epistaxis via an intranasal route.

Surgical anatomy of the sphenopalatine artery in lateral nasal wall.

OBJECTIVE: We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed. STUDY DESIGN: Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study. METHODS: The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification x6). RESULTS: The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%). CONCLUSIONS: The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.

Anatomic variations of the arteries of the nasal fossa.

OBJECTIVE: This study was performed for knowledge about the vascular supply of the nasal fossa and a description of the site of division and number of branches of the sphenopalatine artery. STUDY DESIGN: This study was performed on 10 fresh nonembalmed cadavers. Anatomic variations of nasal fossa arteries were studied. METHODS: First, 10 cephalic anatomic preparations were injected with red color latex into the right and left carotid arteries. Then, these specimens were sagittaly cut to dissect the sphenopalatine artery. Twenty vascularization cases were studied for the external branch of the sphenopalatine artery, and 10 cases were studied for the internal branch. RESULTS: The principal observations were: 1. the sphenopalatine artery division is 18 times in the infratemporal fossa and twice in the nasal fossa; 2. the nasopalatine artery supplies blood to the lower part of the septum and its anterosuperior area; and 3. the vascularization of the external wall is via the sphenopalatine artery through the arteries of the meatus and conchae. CONCLUSION: This study defines the vascular territories of the nasal fossa arteries and includes photographs of dissections.

Intervascular smooth muscle fibers and muscular bolsters in nasal swell bodies of humans.

There is strong clinical evidence that the cavernous tissue (swell bodies) of nasal mucosa plays an important role in congestion of the nose. Still, the complex mechanisms responsible for the unique behavior of these vessels have not yet been identified, and even the morphology of these structures is still a matter of controversy. The present study was performed on nasal mucosal specimens from inferior turbinates of humans by means of histology and transmission electron microscopy. Besides the evaluation of the vascular wall structure of the nasal swell bodies, special attention was given to two morphological peculiarities: intervascular smooth muscle fibers and muscular bolsters. Intervascular smooth muscle fibers are composed of bundles of smooth muscle cells varying in diameter between 14 and 35 microns; they are attached to the muscular coat of the vessels of the cavernous tissue. Muscular bolsters are distinct protrusions of the vascular wall in nasal swell bodies; they are found not only at the transition between different vessels, but also irregularly within the course of veins of the cavernous tissue. The authors report on their understanding of the functional significance of intervascular smooth muscle fibers and muscular bolsters within the cavernous tissue for swelling mechanisms in the nose and discuss their results in light of the literature.

Nasal reconstruction using the inferior turbinate mucosal flap.

Reconstruction of nasal defects can be a difficult task if large amounts of nasal mucosa are missing. We have found the inferior turbinate mucosal flap to be a reliable and effective flap in a series of 16 patients undergoing nasal reconstruction or repair of septal perforations. Most of these patients had insufficient mucosa to use traditional flaps harvested from the nasal floor or the lateral nasal wall. Eight patients underwent reconstruction of septal perforations, 9 patients underwent nasal reconstruction of large nasal defects after tumor extirpation, and 1 patient underwent closure of a palatal fistula. Six of the septal perforations were closed completely and 3 were reduced in size by 50%. All 11 turbinate flaps used for nasal reconstruction (2 patients had bilateral flaps) survived. Two flaps underwent mild superficial epidermolysis without flap necrosis or exposure of overlying cartilage grafts. The turbinate flap is based anteriorly and provides large amounts of well-vascularized mucosa. The turbinate is rotated anteriorly and bivalved and the conchal bone is removed to increase the dimensions of the flap. The flap is sometimes staged to allow transfer of mucosa to distant sites, such as the septum, the nasal ala, and the nasal wall. An anatomical dissection of 10 turbinate flaps on 5 fresh cadaver specimens demonstrated an average flap size of 4.97 cm2. The average length of the flap was 2.83 cm, which is sufficient length to reach the nasal dorsum. A description of the surgical technique and the vascular supply of this flap will be discussed.