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.

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.

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 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.

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.

Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta-analysis.

OBJECTIVES: Epistaxis, especially posterior epistaxis, is occasionally refractory to treatment. In these cases, sphenopalatine artery surgeries, including cauterization and ligation, are required. Previous reports have demonstrated treatment results for these procedures but failed to provide high-level evidence. The aim of this study was to quantify the rates of failure and perioperative complications of these procedures by using a meta-analysis technique. METHODS: We systematically searched electronic databases and identified articles regarding epistaxis, sphenopalatine artery ligation, or cauterization. Pooled rebleeding and complication rates were calculated by using a random effects model. RESULTS: A total of 896 cases of sphenopalatine ligation or cauterization for epistaxis were analyzed. Pooled rebleeding rates for the entire cohort, cauterization group, and ligation group were 13.4% (95% confidence interval [CI] 10.0-17.8, P < 0.001), 7.2% (95% CI 4.6-11.0, P < 0.001), and 15.1% (95% CI 9.8-22.5, P < 0.001), respectively. Pooled perioperative complication rates for the entire cohort, cauterization group, and ligation group were 8.7% (95% CI 4.9-15.1, P < 0.001), 10.2% (95% CI 3.8-24.5, P < 0.001), and 6.4% (95% CI 1.8-20.9, P < 0.001), respectively. CONCLUSION: Overall, sphenopalatine surgery for refractory epistaxis is an effective method because of its low rates of failure and complications. Cauterization is more effective than ligation, whereas complications are comparable between the two procedures. Laryngoscope, 129:1731-1736, 2019.

Neurovascular Surgical Keys Related to Sphenoid Window: Radiologic Study of Egyptian's Sphenoid.

OBJECTIVES: The anatomic variations of the sphenoid sinus and its relation to the surrounding neurovascular structures are a subject of interest. The purpose of this study was to radiologically assess the frequency of protrusion/dehiscence of key neurovascular landmarks surrounding the Egyptians' sphenoid. METHODS: This is a cross-sectional descriptive study of sinonasal computed tomography of the sphenoid sinus in 500 adult Egyptians, conducted at Mansoura University Hospitals; Egypt, over a period of 1 year. Two archives were used for collecting the data; the hard archive and the electronic archive. Variables of interest included the extent of sphenoid sinus pneumatization; intersphenoid septation pattern; protrusion/dehiscence of the internal carotid artery, optic nerve, maxillary nerve, and vidian nerve; and detection of the Onodi cell. RESULTS: Population of this study included 265 women and 235 men. Their ages ranged from 18-68 years. The bilateral sellar-type pneumatization was shown as the most common pneumatization type (96.8%). Pneumatizations of the pterygoid process, anterior clinoid process, and greater wing of the sphenoid were identified in 9.3%, 8.9%, and 31.8% consequently. A single intersphenoid septum was detected in 85.2%, whereas multiple intersphenoid septums were noted in 11.6%. Protrusion of the internal carotid artery, optic nerve, vidian nerve, and maxillary nerve was recorded in 8.5%, 9.1%, 6.6%, and 3.4% consequently, while dehiscence was reported in 7.2%, 15%, 11.9%, and 4.2% consequently as well. Onodi cell was recognized in 18%. CONCLUSIONS: This radiologic study highlights significant variations of surgically important anatomic structures related to the sphenoid sinus in Egyptians.

Transnasal Endoscopic Sphenopalatine Artery Ligation Compared With Embolization for Intractable Epistaxis: A Long-term Analysis.

Background Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and selective embolization both provide excellent treatment success rate in the management of intractable epistaxis. Few long-term studies comparing these approaches have been previously published. Recommendations often present these techniques as alternatives, but there is no clear consensus. Objective The purpose of this study was to evaluate and compare the clinical efficacy of sphenopalatine artery ligation versus embolization to control intractable epistaxis. Methods We performed a retrospective study including all patients referred to our tertiary medical center for severe epistaxis and treated by surgical ligation and/or embolization. The patients were classified into 2 groups: those who underwent TESPAL only and those who underwent endovascular embolization only. We evaluate and compare long-term clinical outcomes after surgical ligation or embolization for the control of intractable epistaxis in terms of effectiveness (recurrence rate) and safety (complication rate). Results Forty-one procedures of supraselective embolization and 39 procedures of surgical ligation for intractable epistaxis are reported and analyzed. No significant difference was observed between the groups in terms of demographic factors, comorbidities, or average length of hospital stay. The 1-year success rate was similar (75%) in both groups. Complications (minor and/or major) occurred in 34% cases in the embolization group and in 18% in the surgical group ( P = .09, ns). Bilateral embolization including facial artery was the only treatment method associated with a significant risk of complications ( P = .015). Conclusion TESPAL seems to provide a similar control rate with a decrease in the number of complications compared to selective embolization in the context of intractable epistaxis. Further studies are required.

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.

Manejo de epistaxis posterior en el Hospital Clínico de la Universidad de Chile entre los años 2013 y 2016 / Treatment of posterior epistaxis in the Clinical Hospital of the University of Chile between the years 2013 and 2016

Introducción: La epistaxis corresponde a una de las causas más frecuentes de consulta otorrinolaringológica en los servicios de urgencia. La epistaxis posterior es menos frecuente pero su presentación más severa. Existen varias alternativas terapéuticas, en las últimas décadas el manejo quirúrgico endoscópico de la arteria esfenopalatina (AEP) ha ido en aumento dado las ventajas en comodidad para el paciente y reducción de costos asociados. Objetivo: Revisar el manejo realizado en los cuadros de epistaxis posterior en el Hospital Clínico de la Universidad de Chile (HCUCh). Material y método: Estudio descriptivo en el Servicio de Otorrinolaringología del HCUCh de pacientes que presentaron epistaxis posterior entre el año 2013 y 2016. Resultados: Se revisó un total de 33 casos. La edad promedio de los pacientes fue 61,6 años siendo las comorbilidades más frecuentes la hipertensión arterial (36,3%) y fibrilación auricular (18,1%). Se realizó tratamiento quirúrgico en 57,6% de los pacientes siendo el clipaje de AEP la intervención quirúrgica más frecuente. Discusión y conclusiones: Tanto el manejo tradicional como las técnicas quirúrgicas presentaron eficacia similar en la serie revisada.

Introduction: Epistaxis corresponds to one of the most frequent causes of otorhinolaryngological consultation in the emergency services. Posterior epistaxis is less frequent but more severe. There are several therapeutic alternatives, in recent decades the surgical endoscopic management of the sphenopalatine artery (AEP) has been increasing given the advantages in comfort for the patient and reduction of associated costs. Aim: To review the management of posterior epistaxis in the Clinical Hospital of the University of Chile (HCUCh). Material and method: Descriptive study in the Otorhinolaryngology Service of the HCUCh of patients who presented posterior epistaxis between the years 2013 and 2016. Results: A total of 33 cases were reviewed. The mean age of the patients was 61.6 years, with the most frequent comorbidities being hypertension (36.3%) and atrial fibrillation (18.1%). Surgical treatment was performed in 57.6% of the patients, with AEP clipping being the most frequent surgical intervention. Conclusion: Both traditional management and surgical techniques presented similar efficacy in the revised series.

Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

BACKGROUND: Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention. OBJECTIVES: This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

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.

Sphenopalatine Artery Ligation for Epistaxis: Factors Influencing Outcome and Impact of Timing of Surgery.

OBJECTIVE: Sphenopalatine artery ligation is a commonly employed surgical intervention for control of posterior epistaxis unresponsive to nasal packing. The objective of the present study was to evaluate the outcome of sphenopalatine artery ligation for control of epistaxis at our institution and the impact of timing and other factors on outcome. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary referral center. SUBJECTS AND METHODS: Case notes were reviewed for 45 consecutive patients undergoing sphenopalatine artery ligation for control of epistaxis between October 2008 and October 2014. RESULTS: Forty-one patients had nasal packing prior to sphenopalatine artery ligation, with 33 undergoing ≥2 packings. Postoperatively, 6 patients had rebleeding, which was treated with repacking (n = 4) and return to the operating room (n = 2). The overall success rate of sphenopalatine artery ligation was 87% (39 of 45). Rebleeding rate was not affected by concomitant septoplasty, anterior ethmoidal artery ligation, or postoperative nasal packing. Patients undergoing SPA ligation within the first 24 hours of admission had a significantly shorter hospital length of stay (3 vs 6 days, P = .02) and treatment cost (€5905 vs €10,001, P = .03). Length of stay was not influenced by sphenopalatine artery ligation after ≤1 nasal pack versus ≥2 packs. Timing of sphenopalatine artery ligation did not affect blood transfusion requirement (P = .84). CONCLUSION: Sphenopalatine artery ligation is an effective management strategy for surgical control of refractory epistaxis. Early timing of sphenopalatine artery ligation may lead to reductions in length of stay.

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.

Sphenoid sinus types, dimensions and relationship with surrounding structures.

The human sphenoid sinus is an extremely variable cavity and an important landmark in hypophyseal surgery. The aim of this study was to investigate the relationship between the sphenoid sinus type, size, extent of pneumatization and occurrence of protrusions of the adjacent neurovascular structures. A total of 51 randomly selected skulls (≥20 years of age, 33 male; 102 sinuses) were analyzed using cone beam computed tomography to estimate pneumatization extension beyond the body of the sphenoid (planum sphenoidale, pterygoid process, greater wings, clivus, dorsum sellae) and protrusions of the maxillary, mandibular, optic or pterygoid nerve or the internal carotid artery. Difference in pneumatization type between the left and the right-sided sinus was observed in 45% of the skulls. Conchal pneumatization was registered in 2%, presellar in 24%, sellar in 41% and postsellar in 33% of total sinuses. Presellar sinuses frequently pneumatized planum sphenoidale and sporadically other structures, and were characterized by sporadic optic nerve protrusions. Sellar and particularly postsellar sinuses were characterized by simultaneous pneumatization extensions and neurovascular protrusions. In the case of postsellar-type sinuses, the probability of these multiple interactions was not affected by their actual size, while it increased with the increasing sinus dimensions in the case of sellar-type sinuses. A more detailed analysis indicated that increasing sinus height, length or width increased the probability of interactions and pneumatization of particular surrounding structures. Data suggest that the sphenoid sinus pneumatization type and dimensions might be used to estimate the risks of iatrogenic injury during transsphenoidal surgical procedures.