Relation between anterior ethmoidal artery course on computed tomography and supraorbital ethmoid cell and Keros classification.

PURPOSE: The anterior ethmoidal artery (AEA) is an important risk area in endoscopic sinus surgery. This study aimed to evaluate the course of AEA according to the Keros classification and the presence of supraorbital ethmoid cell (SOEC) and to prevent possible complications by emphasizing the importance of preoperative paranasal computed tomography (CT) imaging. This approach will increase the effectiveness of endoscopic sinus surgery and improve patient safety. METHODS: The paranasal CT scan images of patients aged > 18 years between October 2020 and November 2021 from our center were retrospectively analyzed. The images were primarily evaluated in the coronal plane, and the sagittal and axial planes were utilized to evaluate variations in AEA regarding the skull base. Furthermore, the relation of AEA course with Keros classification and SOEC was evaluated. The study included 1000 patients aged 18-80 years (right and left, a total of 2000 samples). RESULTS: Grade 3 AEA was the most common regarding the skull base. Keros Type 2 was the most common classification. Overall, 48.7% patients had SOEC. The incidence of Grade 3 AEA was higher among patients with SOEC and a higher Keros classification compared with those without SOEC and a lower Keros classification. Furthermore, Keros Type 3 was the most associated with SOEC presence. CONCLUSION: Consistent with the literature, the probability of Grade 3 AEA in patients with high Keros classification and SOEC was significantly higher in our study. Therefore, we consider that preoperative imaging according to Keros classification and SOEC presence can predict AEA course and guide surgery.

Radiological relationship of the ethmoid slit with the frontal sinus and the anterior ethmoidal artery and applications to the frontal sinus drillout.

PURPOSE: To compare two types of CT acquisition parameters: CT scan of the facial bone and CT scan of the sinuses, for studying the ethmoidal slit and its relationship with the frontal sinus and anterior ethmoidal artery. MATERIALS AND METHODS: Retrospective study of 145 scans of the sinuses and 79 of the facial bones performed between 2012 and 2016. On each scan, the visibility of the ethmoidal slits, their length, their distance from the ethmoidal artery, and their relationship with the anterior and posterior wall of the frontal sinus were studied. RESULTS: The ethmoidal slit was better visualized on CT scans of the facial bone (58.2%) than on those of the sinuses (43.1%) (p = 0.02). The distance between the anterior ethmoidal artery and the anterior part of the cribriform plate was 9.3 mm for CT scans of the facial bone and 8.4 mm for CT scans of the sinuses. The theoretical risk of damaging the glabellar soft tissue and that of damaging the meninges during a frontal sinusotomy was evaluated, respectively, at 9.6% and 26.1% for CT scans of the facial bone, and at 6.2% and 21.5% for sinus scans. CONCLUSIONS: CT scans of the facial bone are better than CT scans of the sinuses for identifying ethmoidal slits and their distance from the canal of the anterior ethmoidal artery. The identification of these elements is relevant for the surgeon during frontal sinus surgery and makes it possible to assess the risk of damaging the glabellar soft tissue or meninges. Performing a CT scan of the facial bone seems preferable to that of a CT scan of the sinuses in certain pathological situations, such as cerebrospinal rhinorrhea or revision surgeries of the frontal sinus.

Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study.

PURPOSE: The anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection. METHODS: Eighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks. RESULTS: Distances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99). CONCLUSION: The middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.

Angiographic study of the transdural collaterals at the anterior cranial fossa in patients with Moyamoya disease.

Unlike its parietal, temporal, and occipital counterparts, the frontal lobe has a broad basal surface directly facing the anterior cranial fossa dura mater which could permit establishment of transdural collaterals (TDCs) with the frontal lobe. Studies on the TDCs from the anterior cranial fossa in moyamoya disease (MMD) are scarce and inadequately investigated. A retrospective study of 100 hemispheres in 50 patients who were diagnosed with MMD by catheter angiography between January 2015 and June 2019 was performed in our institution. TDCs through the anterior ethmoid artery (AEA) or posterior ethmoid artery (PEA) were divided into 3 types respectively based on their respective angioarchitecture. Furthermore, we also studied TDCs to the temporal, parietal, and occipital lobes and collaterals from the posterior circulation to the territory of the anterior cerebral artery. TDCs through the AEA and PEA were identified in 89 (89/100, 89%) and 73 (73/100, 73%) of the hemispheres. The vascularization state of the frontal lobe was good in 89 (89/100, 89%) hemispheres. Rete mirabile and TDCs through the PEA were statistically different among patients with different Suzuki stages. No statistical difference was noted in TDCs through the AEA, frontal TDCs from other sources, and the vascularization state of the frontal lobe with regard to different Suzuki stages. TDCs through the AEA and PEA at the anterior cranial fossa play a very important role in compensating the ischemic frontal lobe. The frontal lobe could be well compensated in most of the patients with TDCs at the anterior cranial fossa.

Longstanding diplopia after ethmoidal artery ligation for epistaxis.

PURPOSE: In the rare case of intractable, posterior, non-sphenopalatine artery epistaxis, ligation of ethmoidal arteries using an external approach like a Lynch-type incision is required. Orbital complications, especially extra-ocular motility disorders with diplopia, are known, but in the literature rarely described. Our aim was to analyse the complication type, rate, and outcome of ethmoidal artery ligation for epistaxis. MATERIALS AND METHODS: Data between 2012 and 2017 of patients treated with ethmoidal artery ligation were analysed retrospectively and through a telephone interview using a non-standardized questionnaire. RESULTS: Data of 18 patients (m/f = 3/15) aged 53-83 years were reviewed. Epistaxis recurred in only one patient after 1 month. Five patients (28%) suffered from diplopia shortly after surgery. Motility analysis revealed full recovery with free motility in four out of five reported cases after 4-8 months, one patient still reports intermittent mild diplopia more than 1 year postoperatively. CONCLUSION: In patients with intractable, non-sphenopalatine artery epistaxis, anterior ethmoidal artery ligation was highly effective. Diplopia, however, occurred in one-third of our patient group. Information about motility restriction with longer standing diplopia are mandatory when consenting patients for ligation of ethmoidal arteries. Special care needs to be taken during dissection in the region of the trochlea and superior oblique muscle. LEVEL OF EVIDENCE: Case Series, level 4.

Analysis of anatomical variation of the inclination of lamellas attached to the skull base and its correlation with the anterior ethmoidal artery floating in the ethmoid sinus for use in endoscopic sinus surgery.

PURPOSE: Attention to the inclination of lamellas attached to the skull base, including the basal lamella of the middle turbinate, facilitates the intraoperative identification of each lamella without requiring the use of a navigation system. We classified the inclination between the lamella and the skull base in preoperative computed tomography (CT) images and examined the relationship between the lamellas attached to the skull base, including the basal lamella of the middle turbinate, and the position of the anterior ethmoidal artery (AEA). We aimed to develop a preoperative classification to help prevent intraoperative injury of the AEA. METHODS: We retrospectively investigated the paranasal sinus sagittal section CT slices of 366 sides of 183 patients to assess the inclination of lamellas attached to the skull base and the AEA location. We also reviewed the AEA position, its correlation with the supraorbital ethmoid cell, and the lateral lamella of the cribriform plate. RESULTS: We classified the lamella inclination at the skull base as the anterior direction, perpendicular direction, and posterior direction types. Lamellas containing a floating AEA inclined in the anterior direction toward the skull base were observed in 68.9% of sides, inclination in the perpendicular direction was noted in 30.5% of sides, and inclination in the posterior direction was noted in 0.5% of sides. CONCLUSION: It is easier to identify the AEA intraoperatively when the lamella inclination of the skull base attachment is recognized based on preoperative CT findings. This approach could be applied to all paranasal sinus lamellas and assist in identifying the AEA and other nearby structures.

Anatomical variations of anterior ethmoidal artery and their significance in endoscopic sinus surgery: a systematic review.

PURPOSE: Anterior ethmoidal artery (AEA) is at risk of injury in endoscopic sinus surgery due to its location. The aim of this review was to assess the anatomical variations of AEA and their significance. METHODS: A literature search was performed on PUBMED, SCOPUS AND EMBASE. The following keywords were used: ethmoidal artery; anterior ethmoidal artery; anterior ethmoidal canal; ethmoid sinus; ethmoid roof; skull base. The search was conducted over a period of 6 months between October 2016 and April 2017. RESULTS: 105 articles were retrieved. 76 articles which were either case reports or unrelated topics were excluded. Out of the 29 full text articles retrieved, 16 articles were selected; 3 were cadaveric dissection, 5 combined cadaveric dissection and computed tomography (CT) and the rest were of CT studies. All studies were of level III evidence and a total of 1985 arteries were studied. Its position at the skull base was influenced by the presence of supraorbital ethmoid cell (SOEC) and length of the lateral lamella of cribriform plate (LLCP). Inter population morphological variations contribute to the anatomical variations. CONCLUSIONS: The average diameter of AEA was 0.80 mm and the intranasal length was 5.82 mm. 79.2% was found between the second and third lamellae, 12.0% in the third lamella, 6% posterior to third lamella and 1.2% in the second lamella. Extra precaution should be taken in the presence of a well-pneumatized SOEC and a long LLCP as AEA tends to run freely below skull base.

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.

Classification of suprabullar pneumatization according to the skull base attachment of the second lamella.

The skull base attachment of the second lamella and suprabullar pneumatization are likely to be consistent landmarks if they are systematically classified. This study aimed to classify the pneumatization pattern according to the second lamella skull base attachment. A total of 202 computed tomography sides of 101 patients who underwent endoscopic sinus surgery were studied. Suprabullar pneumatization was defined as air cells present above the ethmoid bulla between the second and third lamellae. Its pattern was classified according to the air cell number and location as in the frontal cell classification. Type 0 suprabullar pneumatization was defined as no air cells between the ethmoid bulla and skull base; type 1, as a single suprabullar cell; and type 2, as multiple suprabullar cells above the ethmoid bulla. In type 3 pneumatization, the second lamella extended into the frontal sinus forming a frontal bullar cell. Type 2 was the most prevalent (40.1 %), followed by types 1, 3, and 0 (24.3, 23.3, and 12.4 %, respectively). The distance between the second lamella and anterior ethmoid artery was 8.93, 8.30, 8.50, and 11.25 mm in types 0, 1, 2, and 3 pneumatization, respectively. No patients had intraoperative injuries in the anterior ethmoid artery or lateral lamella. The second lamella skull base attachment and suprabullar pneumatization pattern could be systematically classified and be a consistent landmark to identify the frontal sinus opening.

Frontal Sinus Pneumatization Affects Height of the Lateral Lamella and Position of Anterior Ethmoidal Artery.

Preoperative evaluation of the frontal sinus (FS) and associated anatomical structures may reduce the risk of intraoperative complications and facilitate the management of potential complications. In this study, the authors aimed to evaluate relationship between FS pneumatization and critical anatomical structures. Paranasal sinus computerized tomography scans of 350 sides of 175 patients were evaluated. The pneumatization pattern of the FS, FS dimensions (on the axial, coronal, and sagittal slices), anterior ethmoidal artery, and depth of the of olfactory fossa were evaluated for every patient on both sides. There were 111 (63.4%) male and 64 (36.6%) female patients. The authors found a statistically significant correlation between the depth of olfactory fossa and the anterior ethmoidal artery position (P <0.001). As the FS pneumatization increases, the likelihood of the anterior ethmoid artery to run separately from the skull base also increases. Also, there was a statistically significant difference among the types in terms of the depth of the olfactory fossa (Kruskal-Wallis P = 0.002). The depth of the olfactory fossa increases depending on the increase of FS pneumatization.Our study shows that the olfactory fossa depth (skull-base depth) increases as FS pneumatization increases. In light of this information, the evaluation of the preoperative sinus computerized tomography scans will help in performing safer endoscopic sinus surgeries.

The ethmoidal arteries: a cadaveric study based on cone beam computed tomography and endoscopic dissection.

PURPOSE: To describe the anatomical variability of the ethmoidal arteries (EAs). To evaluate the reliability of cone beam computed tomography (CBCT) in preoperative assessment of EAs. METHODS: Fourteen cadaver heads underwent CBCT and endoscopic dissection. The following anatomical features were evaluated for anterior (AEA), middle (MEA), and posterior (PEA) EAs: presence, cranio-caudal position, antero-posterior position, and dehiscence of the bony canal. Accuracy of radiological assessment was calculated. RESULTS: AEA, MEA, and PEA were identified in 100, 28.6, and 100% of sides. They were caudal to the skull base in 60.7, 25, and 17.9%, respectively. CBCT showed a high accuracy in identifying these features. The antero-posterior position of EAs, which was highly variable, was correctly assessed by CBCT. A dehiscent bony canal of AEA, MEA, and PEA was found in 46.4, 12.5, and 28.6% of sides, respectively. Accuracy of CBCT in picking up this feature was poor but negative predictive value was high. CONCLUSIONS: CBCT was adequate in identifying and localizing EAs. In addition, it can be used to exclude the presence of MEA and dehiscence of ethmoidal canals, whereas the accuracy in detecting these anatomic variants was low.

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.

A study of the anterior ethmoidal artery and a new classification of the ethmoid roof (Yenigun classification).

Aims of this study are to analyze the association of the anterior ethmoidal artery's (AEA) visualization with variations in its adjacent structures in coronal, axial, and sagittal CT images, to assess its relation with the ethmoid roof, and, based on this relation, to introduce a new classification for the ethmoid roof. A retrospective, cross-sectional study was performed in a tertiary referral center. In this retrospective, cross-sectional study, the coronal, axial, and sagittal CTs of 184 patients have been surveyed and the AEA canal, the ethmoid roof, and their relations with surrounding structures have been assessed. The Keros classification used to measure the depth of the lateral lamella of the cribriform plate (LLCP) in the ethmoid roof has been modified to include anterior-posterior length of the LLCP. It was shown that the visualization of the AEA canal increases in a statistically significant manner with an increase in the superior-inferior depth and the anterior-posterior length of the LLCP bilaterally. In the presence of supraorbital pneumatization, AEA visualization was shown to increase bilaterally significantly. This study demonstrated a positive correlation between the AEA canal, the LLCP superior-inferior depth, and the anterior-posterior length. It was shown that with the increased depth and length of the LLCP and in the presence of supraorbital pneumatization, the visualization of the artery and hence the injury risks are increased. The LLCP anterior-posterior length is as clinically relevant as is its depth, and a radiologic classification has been defined according to the anterior-posterior length of the LLCP.

Pre-caruncular approach to the medial orbit and landmarks for anterior ethmoidal artery ligation: a cadaveric study.

OBJECTIVE: In epistaxis and skull base surgery, the anterior ethmoidal artery sometimes needs to be ligated. We describe a novel, quick and scar-free surgical technique to ligate this artery with salient landmarks allowing rapid identification. PATIENTS AND METHODS: Twenty medial orbital walls from 10 randomly selected fresh-frozen, non-formalinised cadaver heads were examined. Dissection was performed by a pre-caruncular external approach to expose the AEA in all cases. RESULTS: The Horner's muscle and nasion, two salient landmarks, have been identified for use during the pre-caruncular approach. DISCUSSION/CONCLUSION: The pre-caruncular approach is a novel combined open and endoscopic surgical approach to the anterior ethmoidal artery. It is a simple, quick and scar-free technique. The identification of the artery is easy when using the two anatomic landmarks we describe in our study, that is Horner's muscle and the nasion.

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo's flap): CT cadaver study.

OBJECTIVE: We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap. STUDY DESIGN: We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients. METHODS: Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum. RESULTS: The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients. CONCLUSION: The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

Searching for the cheese: does ethmoid pneumatization affect the location of the anterior ethmoid artery?

Endoscopic sinus surgery is a widely used technique in otolaryngologic practice. To avoid complications, the locations of important anatomical structures, such as the anterior ethmoid artery (AEA), should be determined preoperatively. We want to evaluate the effect of ethmoid cavity pneumatization on the location of the AEA and to determine consistent landmark(s) for locating the AEA. 524 consecutive patients undergoing sinus CT scans between February and October 2012 were reviewed retrospectively. After the exclusion criteria were applied, 150 CT scans (300 sides) were selected for the study. A statistically significant positive correlation was found between ethmoid pneumatization and the distance of the AEA to the attachment of the inferior turbinate to the lateral nasal wall (Spearman's rho = 0.305; p < 0.001). Likewise, a statistically significant positive correlation was found between ethmoid pneumatization and the distance between the AEA and the frontonasal junction (Spearman's rho = 0.219; p < 0.001). We found that the artery was located mostly between the second and third lamellae [n 211 (71 %) cases]. There was no statistically significant correlation between ethmoid pneumatization and AEA location in terms of the lamellae. Increased ethmoid volume increases the distance of the AEA from the frontonasal junction and the lateral attachment of the inferior turbinate. However, increased pneumatization of the ethmoid cavity did not affect AEA localization in terms of the lamellae. Based on our findings, we suggest that using the lamellae to locate the AEA is reliable.

Transnasal approach to the anterior skull base: an endoscopic anatomic study.

OBJECTIVE: The purpose of this study was to locate the constant anatomic landmarks for anterior skull base surgery via endoscopic transnasal approach in Chinese subjects. METHODS: Eight cases of adult skull specimens (all Chinese) were dissected by the endoscopic transnasal approach. The relationships of the anatomic landmarks under endoscopic view were characterized. The distance between the columella and the anterior ethmoid artery (AEA) or the posterior ethmoid artery (PEA) was measured. RESULTS: The uncinate process attached to the lamina papyracea in 7 sides (43.8%), to the skull base in 4 sides (25%), and to the middle turbinate in 3 sides (18.8%). In addition, the uncinate process was found to have bifurcated attachment in 2 sides (12.5%).The mean ± SD distance from the columella to the AEA was 62.71 ± 2.18 mm on the right side and 63.38 ± 1.69 mm on the left side. The mean ± SD distance from the columella to the PEA was 70.91 ± 1.99 mm on the right side and 71.79 ± 1.95 mm on the left side. CONCLUSIONS: The frontal recess, the AEA, and the PEA can serve as the constant landmarks in the transnasal endoscopic approach to the anterior skull base.

Study on measurements for margin of safety in lateral operation of a transnasoethmoid-sphenoid approach to decompress the optic canal.

OBJECTIVE: The surgical approach through nasal and ethmoid cells to sphenoid sinus is a common clinical method to do the decompression of the optic canal. During this surgery, we can follow landmarks such as ethmoidal arteries. However, when we do the surgery, it is possible to open excessively in lateral operation and damage orbital medial wall. To prevent this from happening, we do a lot of measurements to estimate the distance in lateral operation. We hope to give surgeons some help in clinical use. METHODS: We chose 120 brain imaging findings that showed a normal appearance in our measuring area by means of three-dimensional reconstruction based on high-resolution spiral computed tomography scans. We chose several anatomic landmarks and measured the distances in lateral operation and located a projection point for directing this surgery. RESULTS: The mean values of distance from dacryon and the anterior foramen of the optic canal to the index plane were 5.439 ± 2.4496 and 9.334 ± 2.0628 mm. The mean values of distance from trisection points to the orbital medial wall were 7.359 ± 2.2262 and 6.911 ± 2.3102 mm. The mean value of distance from the projection point to the ipsilateral outer edge of the supraorbital notch was 30.379 ± 5.3676 mm. There are no significant differences for all the distance between the left side and right side. The median of right-side angle between the straight line connecting both sides of the outer edge of supraorbital notch and the straight line connecting the projection point with the ipsilateral outer edge of the supraorbital notch is larger than the left one and has a less variation than the left one. CONCLUSIONS: The lateral distance in surgical operation is consistent among individuals, which can give a safe area to surgeons in lateral operation. The location of the projection point gives surgeons an indication of direction to this surgery.

[Treatment of recurrent epistaxis by artery ligation: up to date or old fashioned?]. / Behandlung rezidivierender Epistaxis durch Gefäßligatur: zeitgerecht oder überholt?

UNLABELLED: Treatment of Recurrent Epistaxis by Artery Ligation: Up to Date or Old Fashioned? BACKGROUND: Despite the ongoing development in the field of endoscopic treatment techniques, recurrent epistaxis remains a challenge for otolaryngologists. The aim of the present study was to compare our own results of various interventions for the treatment of recurrent epistaxis. MATERIALS AND METHODS: From 2007 to 2013 we performed surgical treatment of recurrent epistaxis under general anaesthesia in 148 cases. While the majority of causes were idiopathic (n=98), epistaxis also occurred postoperatively (n=30), post-traumatically (n=7) or as a result of M. Osler (n=12). In 141/148 cases the treatment was performed by mono- or bipolar coagulation in the area of the bleeding source - this required an ethmoidectomy in 17 cases. In 19 cases the intervention was combined with a septoplasty. In 4 patients with recurrent bleeding of unknown origin, where electrocoagulation under general anaesthesia failed, we performed a clipping of the ethmoid- and/or the maxillary arteries in the pterygopalatine fossa. Following this intervention no further bleeding episodes occured. In further 3 patients, neuroradiological embolization was successfully performed. CONCLUSION: If conservative measures fail in the treatment of epistaxis, surgical treatment by electrocoagulation of the bleeding site under general anaesthesia is an effective intervention in 95% of cases. However for the remaining 5% where these measures have been proven to be ineffective, clipping of the ipsilateral anterior and posterior ethmoid- and/or the maxillar artery provides a treatment option being equally efficient as neuroradiological interventions.

A Consistent Endoscopic Landmark to Identify the Anterior Ethmoidal Artery.

OBJECTIVE: The anterior ethmoidal artery (AEA) is an important structure to identify during endoscopic sinus surgery. Although identification on imaging is easily taught, a consistent endoscopic landmark for the AEA, independent of anatomic ethmoid cell variation, is lacking, leaving many surgeons unclear about the exact location without dependence on navigation. Here, we describe a consistent endoscopic landmark, regardless of anatomical ethmoid variation. METHODS: We prospectively enrolled adult patients undergoing endoscopic surgery involving frontal and ethmoid sinuses in this observational study. The AEA landmark was defined simply as the septation or ridge one step back along the ethmoid skull base from the posterior table of the frontal sinus. The gold standard to calculate the sensitivity of our endoscopic landmark was an image-navigation system, registered to within 1.5 mm accuracy, locating the AEA within three planes. Both endoscopic and computerized tomography (CT) images of the pointer at the landmark were taken simultaneously. The concordance of endoscopic to navigation images was independently assessed by three blinded rhinologists. RESULTS: Forty patients were included in our study with 73 sides analyzed. Diagnoses included chronic rhinosinusitis without polyps (52.5%), with polyps (22.5%), recurrent acute sinusitis (15%), sinonasal tumors (7.5%), and odontogenic sinusitis (2.5%). The AEA was accurately identified using our endoscopic landmark in 97.3% of the cases (71/73). Of the two cases in which the AEA was not found within the landmark, the artery was located ≤1 mm posteriorly. CONCLUSION: We describe a consistent endoscopic landmark to identify the AEA, conserved across various clinical diagnoses and anatomic variations in sinus structure. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1096-1099, 2024.