The pneumatization of the sphenoid sinus, its variations and relations with surrounding neurovascular anatomic structures: A computerized tomography study.

INTRODUCTION AND OBJECTIVES: The wide range of variability of SS pneumatization and relation with surrounding structures can result in serious complications; seeing that, the assessment of regional anatomy is essential for both surgeons and radiologists. We mainly aim to reveal the possible correlation between the SS pneumatization types and protrusion/dehiscence of the adjacent neurovascular structures in a larger population by using computerized tomography (CT) images. METHODS: The type of SS pneumatization (I-IV), pneumatization of anterior clinoid process (ACP), greater wing of sphenoid (GWS), and pterygoid process (PP) was evaluated. Protrusion and dehiscence of ICA, ON, MN, and VN was noted. RESULTS: 1003 patients were included into the study. ICA, ON, and MN protrusions were not seen in patients with the type I or II SS on both sides. These protrusions were most frequently seen along with the type IV SS on both sides (p < 0.05). ICA, ON, MN, and VN dehiscence was not found in any patients with the type I SS. The rate of ICA protrusion increased with presence of GWS and PP; ICA dehiscence was found to be positively correlated with ACP, GWS, and PP pneumatization. CONCLUSIONS: Variations, either amount or the extent, of the pneumatization of the SS are related with the presence of protrusion/dehiscence of ICA, ON, MN and VN. Knowing and reporting these relations can decrease the rate of complications during skull base surgery.

Variations in utilization and clinical outcomes for endoscopic sphenopalatine artery ligation and endovascular arterial embolization in a single multi-hospital network.

PURPOSE: Endoscopic sphenopalatine artery ligation (ESPAL) and endovascular arterial embolization (EAE) are increasingly common treatment options for patients with refractory epistaxis. The objective of this study was to compare the utilization pattern and clinical outcomes between these interventions within our single multi-hospital network. MATERIALS AND METHODS: A retrospective study of all patients undergoing ESPAL and/or EAE within any of the hospitals in a single healthcare network between 2008 and 2017 was conducted. We compared differences in procedure utilization with various hospital characteristics. Secondarily, we evaluated clinical outcomes and costs associated with each procedure. RESULTS: Forty-three ESPAL and 33 EAE procedures were performed across 7 hospitals, with the majority of procedures being performed at teaching institutions (65% and 91%, p = .013). The majority of both interventions were performed in larger hospitals and EAE patients were more likely to undergo inter-hospital transfer compared to ESPAL patients (48.5% and 16.3%, p = .02). Success rates for ESPAL and EAE were comparable (95% and 93%); however, the median direct cost of treatment for EAE was significantly higher than the cost for ESPAL ($12984.89 and $5002.02, p < .0001). CONCLUSIONS: The majority of both ESPAL and EAE interventions were performed at teaching and larger hospitals. Transfers occurring prior to EAE may have been due to the limited availability of interventional radiology services, and likely contributed to the increased cost of treatment. ESPAL is a known cost-effective management strategy and should be considered early in treatment algorithms of refractory epistaxis.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience.

PURPOSE: Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15 years in a single academic center. METHODS: A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL). RESULTS: The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients. CONCLUSIONS: This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

Cost-effectiveness of trans-nasal endoscopic sphenopalatine artery ligation vs arterial embolisation for intractable epistaxis: Long-term analyses.

OBJECTIVES: Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. DESIGN: We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. SETTING: This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. PARTICIPANTS: Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. MAIN OUTCOME MEASURES: The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. RESULTS: Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. CONCLUSIONS: The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.

Septal branches of the anterior ethmoidal artery: anatomical considerations and clinical implications in the management of refractory epistaxis.

PURPOSE: Epistaxis is a commonly presenting complaint. In severe cases, nosebleeds may occur despite antero-posterior nasal packing and often in the absence of identifiable sources of bleeding. In such cases, epistaxis may occur from septal branches of the anterior ethmoidal artery (sbAEA). The purposes of this study are to highlight the clinical role of the sbAEA in different fields of endoscopic endonasal surgery and to evaluate the efficacy and safety of their selective endoscopic endonasal ligation in the management of refractory epistaxis. METHODS: A retrospective review was performed of all patients presenting with epistaxis who underwent endoscopic endonasal coagulation of sbAEA in three Italian tertiary-care referral centers between October 2010 and October 2017. RESULTS: A total of 30 patients met the inclusion criteria. Sixteen patients had never experienced nosebleeds before, while 14 patients recalled previous epistaxes. Seventeen patients were treated under local anesthetic, while 13 required general anesthesia. No intra- or post-operative complications were observed and none of the patients received nasal packing after the procedure. In all cases the coagulation was effective in controlling the bleeding, with only two relapses in the series (2/30, 6.7%). CONCLUSIONS: The sbAEA are of great interest in endoscopic endonasal surgery, both as surgical landmarks and as feeding vessels for a variety of pedicled nasal flaps. What is more, they can be crucial for the management of refractory epistaxis. Their selective endoscopic coagulation represents an effective and safe procedure in cases of difficult-to-control epistaxis from the upper nasal fossa, with several advantages over nasal packing.

Study of the relation between medial orbitofrontal artery and anterior skull base performed by computed tomography angiography.

BACKGROUND: The aims of this study were to analyze the relationships between the medial orbitofrontal artery (MOFA) and the anterior skull base (ASB) including anatomical endonasal landmarks using computed tomography angiography (CTA). METHODS: We studied 52 CTAs using OsiriX software. All CTAs were placed in the same anatomical position. MOFA was identified in the sagittal and coronal plane and its correlation with ASB was analyzed. The distance between the MOFA and landmarks for endonasal surgery were obtained, determining the high risk areas for its injury. RESULTS: After arising from the anterior cerebral artery, the MOFA dives inferiorly towards the ASB, close to the midline (average distance of 1.5 mm), approaching the planum sphenoidale (average distance of 1.8 mm) and then ascends away from the ASB as it runs anteriorly, with an average distance of 4.4 mm in the region of the anterior wall of the sphenoid sinus and 12 mm in the region of the anterior ethmoid artery. CONCLUSIONS: The MOFA has an intimate relationship with the ASB and nasal cavity; the regions with the highest risk of surgical trauma are between the posterior ethmoid and the planum sphenoidale.

Eustachian tube communicating with sphenoid sinus: report of a novel anatomical variant.

Reports of congenital anomalies of the Eustachian Tube (ET) are scarce, and often associated with chromosomal abnormalities. We report a unique case of a completely bony left Eustachian tube which communicated with the sphenoid sinus. This report details these findings and discusses the potential embryological basis and implications of such an unusual anatomy, in the context of a comprehensive literature review.

Venous malformation of the ethmoid and sphenoid sinuses.

OBJECTIVES: The aim of this study was to present a rare case of a venous malformation that occupied the ethmoid and sphenoid sinuses. Prior to resection, it was believed to be a hemangioma. METHODS: This study includes a case report and review of the literature. CONCLUSION: There is often confusion between "hemangiomas" and "vascular malformations," but they are important to differentiate because they have unique approaches to treatment. Venous malformations in the paranasal sinuses are very rare. To our knowledge, this is the first case report that explicitly describes a venous malformation in the ethmoid and sphenoid sinuses. It was treated using endoscopic sinus surgery with intraoperative computer-assisted stereotactic navigation.

Morphological Characteristics of the Sphenoid Sinus and Endoscopic Localization of the Cavernous Sinus.

The aim of this study was to investigate the relationship between the morphological characteristics of the sphenoid sinus and endoscopic localization of the cavernous sinus (CS) using an extended endoscopic endonasal transsphenoidal approach. Thirty sides of CS in 15 adult cadaver heads were dissected to simulate the extended endoscopic endonasal transsphenoidal approach, and the morphology of the sphenoid sinus and anatomic structures of CS were observed. The opticocarotid recess (OCR), ophthalmomaxillary recess (V1V2R), and maxillomandibular recess (V2V3R) in the lateral wall of the sphenoid sinus were presented in 16 sides (53.3%), 6 sides (20%), and 4 sides (13.3%) of the 30 sides, respectively. OCR is a constant anatomic landmark in endoscopy and coincides with the anterior portion of the clinoidal triangle. The C-shaped internal carotid artery (ICA) in the lateral wall of the sphenoid sinus was presented in 11 sides (36.7%), the upper one-third of which corresponds to the middle portion of the clinoidal triangle, and the lower two-thirds of which correlates to the supratrochlear triangle, infratrochlear triangle, and ophthalmic nerve in CS, around which the medial, lateral, and anteroinferior interspaces are distributed. From a front-to-behind perspective, the C-shaped ICA consists of inferior horizontal segment, anterior vertical segment, clinoidal segment as well as partial subarachnoid segment of the ICA. OCR and C-shaped ICA in the lateral wall of the sphenoid sinus are the 2 reliable anatomic landmarks in the intraoperative location of the parasellar region of CS.

Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm.

BACKGROUND: Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage. METHODS: Case report and review of the literature. RESULTS: We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence. CONCLUSIONS: Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.

[A case of transverse-sigmoid sinus dural arteriovenous fistula that became symptomatic after removal of coexisting sphenoid ridge meningioma].

Here, we describe a case with a transverse-sigmoid sinus(TSS)dural arteriovenous fistula(DAVF)with sinus occlusion at its proximal and distal ends;the TSS DAVF turned symptomatic after removal of a coexisting symptomatic sphenoid ridge meningioma. The patient was a 70-year-old man presenting with decreased daily activities and mentation due to dysphasia. Magnetic resonance imaging revealed a large, left sphenoid ridge meningioma. Angiography revealed a tumor stain and a coexisting left TSS DAVF with sinus occlusion at its proximal and distal ends. Cortical venous reflux(CVR)into the temporal veins was observed. After successful tumor removal, the superficial middle cerebral vein was arterialized intraoperatively. However, the patient showed worsened consciousness and dysphasia after the operation. Repeated angiography revealed CVR into the superficial middle cerebral vein through a sphenopetrosal sinus. Transvenous embolization was performed via the contralateral inferior petrosal and intercavernous sinus, which allowed access to the ipsilateral superior petrosal sinus(SPS);the procedure successfully eliminated CVR, while preserving the SPS. The patient demonstrated full recovery. This case exemplifies a coexisting TSS DAVF after tumor resection, and superficial middle cerebral vein decompression due to the sphenopetrosal sinus, an alternate drainage pathway for the superficial middle cerebral vein.

Evaluation of the relationship between sphenoid sinus morphology and area and volume by computed tomography.

OBJECTIVES: The aim of this study is to investigate the effect of sphenoid sinus pneumatization types, Onodi cell (OC), internal carotid artery (ICA), optic nerve (ON) on sinus volume and area on computed tomography (CT) images. METHODS: The CT images of 150 patients were evaluated. Sphenoid sinus pneumatization types, OC prevalence, protrusion and dehiscence of ICA and ON, the volume and area were evaluated. RESULTS: The sinus volume and area were statistically higher in patients with bilateral protrusion of ICA and ON then patients without protrusion of ICA and ON. The mean volume and area of sinus were 9949.4 ± 351.0 mm3 and 4570.9 ± 1604.9 mm2, respectively. The volume and area of sphenoid sinus did not differ significantly between groups with and without OC. The postsellar b type sphenoid sinus had the highest volume, while conchal type has the least volume. CONCLUSIONS: Bilateral protrusion and dehiscence of ICA and bilateral protrusion of ON caused a significant increase in the sphenoid sinus volume and area. The presence of ICA and ON, the pneumatization of the sinus is an anatomical structure that can affect the sinus volume and area. Before the operation, three-dimensional evaluation should be performed to determine whether these structures are bilateral/unilateral and it should be remembered that the sinus volume and area can change.

The Wexham Criteria: defining severe epistaxis to select patients requiring sphenopalatine artery ligation.

This study aims to provide guidance regarding patient selection and timing of intervention with sphenopalatine artery (SPA) ligation by defining 'severe epistaxis'. An analysis of all patients undergoing SPA ligation (January 2002-2010) was performed. SPA ligation was deemed necessary if at least one of the four identified criteria was fulfilled. The same analysis was also performed on all patients admitted with epistaxis who did not undergo SPA ligation over a 6-month period. All 27 patients who underwent SPA ligation met at least one of the criteria selected. Uncontrolled epistaxis (21/27) was fulfilled most often. In comparison, only 4/71 patients admitted with epistaxis who did not undergo SPA ligation fulfilled any single criterion. All criteria were satisfied in a significantly higher number of cases in the SPA group (p < 0.001) The criteria studied proved helpful in identifying patients admitted to hospital with epistaxis who had failed conservative measures.

A Comprehensive Computed Tomographic Analysis of Pneumatization Pattern of Sphenoid Sinus and Their Association with Protrusion/Dehiscence of Vital Neurovascular Structure in a Pakistani Subgroup.

AIM: To determine the clinically significant association between pneumatization types of the sphenoid sinus (SS) and protrusion/ dehiscence of the optic nerve (ON) and the internal carotid artery (ICA). MATERIAL AND METHODS: This prospective cross-sectional study was conducted between November 2020 and April 2021 at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi. This study examined 300 computed tomography (CT) PNS patients aged 18-60 years. The forms of SS pneumatization, extent of pneumatization to the greater wing (GW), anterior clinoid process (ACP), and pterygoid process (PP), as well as the protrusion/dehiscence of the ON and ICA were examined. A statistical relationship was identified between pneumatization type and protrusion/dehiscence of the ON and ICA. RESULTS: The study included 171 men and 129 women with an average age of 39.28 ± 10.9 years. The most commonly encountered pneumatization type was postsellar (63.3%), followed by sellar (27.3%), presellar (8.7%), and conchal (0.75%). The most frequent extended pneumatization was observed up to PP (44%), followed by ACP (31.33%), and GW (16.67%). The rate of dehiscence of the ON and ICA was less than that of protrusion of the same structures. The association between postsellar and sellar pneumatization types and protrusion of the ON and ICA was statistically significant (p < 0.001), with the postsellar type showing more protrusions of the ON and ICA than the sellar type. CONCLUSION: The pneumatization type of SS has a significant impact on the protrusion/dehiscence of adjacent vital neurovascular structures and should be mentioned in CT reports to alert surgeons for any disastrous intraoperative complications and outcomes.

Analysis of pneumatization and neurovascular structures of the sphenoid sinus using cone-beam tomography (CBT).

BACKGROUND: The sphenoid sinus is a frequent target of paranasal sinus surgery. Because of the high risk of injuring the surrounding structures (e.g. internal carotid artery, optical nerve) a preoperative imaging is absolutely necessary. PURPOSE: To analyze the possibilities of cone-beam computed tomography (CBCT), which is especially quite a new technique in ENT, in the evaluation of the sphenoid sinus, its surrounding structures, and the corresponding anatomical variations. MATERIAL AND METHODS: This was a retrospective, single-centre study of 580 patients (1160 sides = cases). The Accu-I-Tomo-F17 was used. Pneumatization of sphenoid sinus, course of internal artery, course of optical nerve, and dehiscence of the bony canals were evaluated. RESULTS: In the case of pneumatization a type I (completely missing or minimal sphenoid sinus) was found in two patients (0.3%), type II (posterior wall of sphenoid sinus is in front of the anterior wall of the sella) in 38 patients (6.6%), type III (posterior wall is between anterior and posterior wall of sella) in 332 patients (57,2%), type IVa (posterior wall is behind the posterior wall of sella without air dorsal the sella) in 104 patients (17.9%), and type IVb (similar to type IVa but with air dorsal the sella) in 104 patients (17.9%). In 1025 cases (89.5%) a smooth course of the internal carotid artery was found whereas a free course could be detected in 120 cases (10.5%). Defects of the bony canal of the optical nerve were found in 16.7% and of the internal carotid artery in 2.7% of the cases. The optical nerve showed a free course through the sphenoid in 151 cases (13.7%) and a smooth course in 1007 cases (87.0%). CONCLUSION: CBCT could evaluate all relevant anatomic structures and answer the questions of different anatomical variants. A modified classification of the pneumatization of the sphenoid sinus could be described. Frequencies of anatomical variations are in accordance with the current literature of CT research.

[Recurrent epistaxis of unknown origin. A rare differential diagnosis and its treatment]. / Rezidivierende Epistaxis bei unklarer Blutungsquelle. Betrachtung einer seltenen Differenzialdiagnose und der Therapie.

We present the case report on a 66-year-old male patient who appeared in our clinic with recurrent epistaxis. Anterior rhinoscopy during acute bleeding yielded no information on the origin of hemorrhage. On renewed epistaxis, angiography was performed on which an arteriovenous malformation in the sphenoid sinus could be identified as the cause of epistaxis. Embolization of afferent vessels successfully reduced the malformation and stopped the bleeding. In cases of recurrent epistaxis, especially in combination with an unremarkable anterior rhinoscopy, angiography is recommended for the detection of life-threatening vessel malformations.

Pulsed laser-induced liquid jet for skull base tumor removal with vascular preservation through the transsphenoidal approach: a clinical investigation.

BACKGROUND: The transsphenoidal approach has recently been used to treat complex lesions beyond the sella turcica, but the difficulties of dealing with small vessels, deep and narrow space, and working angle may limit the procedures. To overcome these problems, we have developed a pulsed laser-induced liquid jet (LILJ) system to dissect tumor tissue with preservation of fine blood vessels within deep and narrow working spaces and evaluated its utility and safety. METHODS: The LILJ system was applied to 14 consecutive patients with uncharacteristically complex skull base tumor treated through the extended transsphenoidal approach. This system consists of a bayonet-shaped catheter incorporating a jet generator formed of stainless tube (external diameter 1.10 mm, internal diameter 0.78 mm), which was surrounded by a coaxial polytetrafluoroethylene 14-G equivalent suction tube to be able to incorporate into the confined working spaces. Minor modifications could be fitted for the catheter (15 to 18 cm length, straight or side flexion tip), and total weight was around 7 g. FINDINGS: Precise dissection and mass reduction of the tumor were obtained in all cases except one recurrent case of chordoma with significant fibrosis due to radiation. Both small arteries and veins were preserved, allowing subsequent microsurgical devascularization. Intraoperative blood loss was minimal, and tumor removal rate was satisfactory after the introduction of the system. No complication was related to use of the LILJ system. CONCLUSION: Although comparison between conventional surgical instruments is mandatory in the future, the present study suggests that the LILJ system can achieve safe and optimum removal of complex skull base tumor. Potential application for minimally invasive endoscopic system, as well as potentials for changing the design of the catheter in according to preference of surgeon with low cost, may give advantages over conventional surgical instruments.

Sphenoid sinus pneumatization and its relation to bulging of surrounding neurovascular structures.

OBJECTIVES: We investigated the bulging and dehiscence of neurovascular structures in the sphenoid sinus and their relationships to the pneumatization of the sphenoid sinus. METHODS: One hundred sagittally hemisected cadaveric heads were examined. The degree of pneumatization of the sphenoid sinus was determined. Bulging and dehiscence of the internal carotid artery (ICA), optic nerve, maxillary nerve, and vidian nerve were examined, and the distances between these structures and the anterior or superior wall of the sphenoid sinus were measured. Additionally, the degree of bony thickness over these structures was determined. RESULTS: The prevalences of bulging of the optic nerve, segments 1 and 3 of the ICA, and the maxillary and vidian nerves were 56%, 34%, 65%, 41%, and 52%, respectively. The greater the degree of pneumatization, the more frequently did the structures bulge into the sphenoid sinus. The optic nerve was found to be in close proximity to the anterior and superior walls of the sphenoid sinus. The bone over the surrounding structures was very thin, especially for the complete sellar type. CONCLUSIONS: The prevalence of bulging of the optic nerve, the ICA, and the maxillary and vidian nerves increased in proportion to the degree of sphenoid sinus pneumatization.