Download anatomic variations and references of the sphenopalatine foramen

Original article
Cir Cir 2014;82:321-325.
Anatomic variations and references
of the sphenopalatine foramen in
cadaveric specimens: a Mexican
study
Mauricio Morales-Cadena
Fernando González-Juárez
Liliana Tapia-Álvarez
Luis Fernando-Macías Valle
1
Facultad Mexicana de Medicina, Universidad La
Salle, México, DF.
ABSTRACT
Background: The sphenopalatine foramen is located on the lateral
nasal wall and has multiple variants and anatomic landmarks that are
important in order to optimize results in the surgical management of
posterior epistaxis. This study describes the endoscopic anatomy of the
sphenopalatine foramen, related structures and anatomic variations in
a Mexican population.
Methods: We performed a prospective, observational, and experimental
study. Five cadaveric specimens were included. Dissections were
performed to identify the anatomy of the sphenopalatine foramen and
anatomic variants. Measurements were obtained from different anatomic
references to the columella.
Results: Of a total of ten dissections, in 100% of cases ethmoid crests
were identified anterior to the sphenopalatine foramen. Localization of
the sphenopalatine foramen in the lateral nasal wall in 60% cases was in
the transition from the middle meatus with superior meatus. The vidian
nerve in 90% of the cases was located superior and posterior to the
sphenopalatine foramen. For measurements, no significant differences
between the two sides of each specimen were noticed.
Conclusions: The sphenopalatine foramen presents multiple anatomic
variants and numerous landmarks, which are important to comprehend
in order to perform successful and safe endoscopic sinus surgery.
Key words: Sphenopalatine foramen, sphenopalatine artery, vidian
nerve, posterior epistaxis, ethmoid crest, lateral nasal wall.
www.amc.org.mx
Received: 9-2-2013
Accepted: 2-18-2014
Correspondence:
Dr. Gabriel Mauricio Morales Cadena
Calderón de la Barca 359-103,
Col. Polanco, Deleg. Miguel Hidalgo
CP. 11560 México, DF., México.
Tel: 55-31-32-30 (to 32)
E-mail: [email protected]
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Cirugía y Cirujanos
BACKGROUND
The sphenopalatine foramen is located in the
lateral nasal wall near the posterior insertion of
the middle turbinate. The vertical diameter is
6.2 mm (4.5-7.5) and the horizontal is 5.1 mm
(3.5-6.0).1 Its anatomic boundaries are anterior
to the palatine orbital process; inferior to the
perpendicular plate of the palatine; posterior
to the sphenoidal process of the palatine, and
the lateral is found in the pterygopalatine fossa.
The sphenopalatine artery emerges through the
sphenopalatine foramen, which is the terminal
branch of the internal maxillary artery and, in
turn, separates into two branches and gives
rise to the posterior nasal artery and nasoseptal
artery.2 The anatomic references for locating the
sphenopalatine foramen in the nasal wall are the
ethmoidal crest of the palatine bone, which is
located in 95% of patients, vidian nerve, anterior
wall of the sphenoid sinus and posterior wall of
the maxillary sinus.3
Recognizing the anatomic variants and references of the sphenopalatine foramen allows
performing an adequate vascular control of
patients with nasosinus tumors of varied histology, safer approaches to the base of the skull,
performance of neurectomies of the vidian nerve
and clipping of the sphenopalatine artery for
epistaxis control.4
Volume 82, No. 4, July-August 2014
cadaveric adult specimens of Mexican origin; the
age and nationality of the specimens was corroborated with the data recorded by the forensic
medical service in Mexico City. Specimens with
a history of brain injury or facial traumatic injury,
craniofacial malformations and sinus tumors
were excluded. Dissections were carried out in
the forensic medical service of Mexico City with
permission (SP/DIS/083/2012) from February 1
to November 30, 2012.
The surgical technique was performed with
endoscopic vision with 0° and 30° rigid endoscopes, the middle turbinate was medialized,
and the anatomic references were identified
(posterior insertion of the middle turbinate,
choana, anterior wall of the sphenoid and posterior fontanelle) (Figure 1). A vertical incision of
~1 cm was made behind the posterior fontanelle,
and the submucosal flap was elevated until the
ethmoid crest was identified (Figure 2). Behind
it the sphenopalatine foramen and the arterial
trunk and its branches were found (Figure 3). The
dissection was continued in a posterosuperior
direction until the vidian nerve was localized
(Figure 4). Subsequently, different measurements
of the columella were carried out to the anatomic
The objective of this article is to describe the
endoscopic anatomy of the sphenopalatine foramen, the related structures and the anatomic
variants in the Mexican population as well as
to determine the distance of the columella to
the different anatomic references used in nasal
endoscopic surgery.
322
METHODS
MT: middle turbinate, IT: inferior turbinate.
We carried out a prospective, observational,
and experimental study. There were five adult
Figure 1. Image of cadaveric dissection in the left
nasal fossa.
Morales-Cadena M et al. Anatomic variations and references of the sphenopalatine foramen
VN: vidian nerve, PPP: perpendicular palatine plate.
Figure 2. Image of cadaveric dissection in the left nasal
fossa. The mucosal flap is elevated, the ethmoid crest
(EC) is identified.
PPE: perpendicular plate of the ethmoids, MT: middle
turbinate.
Figure 4. IImage of cadaveric dissection in the left
nasal fossa. The vidian nerve is identified.
distribution) or Wilcoxon test (rank distribution)
was used (SigmaPlot v.11.0 program).
RESULTS
EC: ethmoid crest, MT: middle turbinate, PPP: perpendicular palatine plate.
Figure 3. Image of cadeveric dissection in the left
nasal fossa. The sphenopalatine artery and two of its
branches are identified. Arrows: sphenopalatine artery
and branches.
references (distances to the ethmoid crest, sphenopalatine foramen, vidian nerve and the nasal
floor to the sphenopalatine foramen) using a
digital calibrator (in centimeters). Descriptive
statistics were used for non-parametric variables.
For parametric variables, paired t test (Gaussian
A total of five cadaveric specimens were included and ten dissections were carried out. The
median age was 61 years (54-68 years); 80% of
the specimens were males. In 60% of the specimens the sphenopalatine foramen was located
in the transition of the middle meatus with the
superior meatus; in all specimens the ethmoid
crest anterior to the sphenopalatine foramen was
identified. In 70% a branch of the sphenopalatine artery was identified and in 20%, two of its
branches and only in 10% three branches. In
90% of the cases the vidian nerve was localized
in posterosuperior direction to the sphenopalatine foramen. In none of the specimens were the
accessory foramens found (Figure 5).
The distance from the columella to the ethmoid
crest on the right side was 7.12 ± 0.165 and on
the left 6.98 ± 0.111. The right sphenopalatine
formaen was 7.42 ± 0.190 and the left 7.36 ±
0.092. The right vidian nerve was 7.94 ± 0.128
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Cirugía y Cirujanos
constant location of the sphenopalatine foramen
is in the transition from the middle meatus with
the superior meatus. In our study we found this
location in 60% of the specimens. In previous
studies, Bolger et al.5 reported an incidence of
this location in 90% of their cases.
EC: ethmoid crest, SPF: sphenopalatine foramen,
SM: superior meatus, MM: middle meatus, MM/SM,
transition from middle meatus with superior meatus.
Figure 5. Image of the different localizations of the
sphenopalatine foramen in relation with the nasal
wall.
and the left 7.8 ± 0.114 and from the nasal floor
to the right sphenopalatine foramen was 1.88 ±
0.159 and to the left 1.90 ± 0.070 (Table 1). There
was no significant difference between nasal fossae
in any of these measurements.
DISCUSSION
The ethmoid crest is the most important reference
for locating the sphenopalatine foramen, which
was found in 100% of the dissections anterior to
the sphenopalatine foramen. This reference is the
most important and constant, according to the
studies by Lee et al. and Bolger et al.4,5 The most
We did not find accessory foramen in our study.
The medical literature reports an incidence of
accessory foramens of < 2%. Padúa6 reports
an incidence of accessory foramens of 2% in
his study. Localization of the vidian nerve in
relation to the sphenopalatine foramen in 90%
of the cases was found posterosuperior to it,
similar to what is reported in the literature.
We identified the sphenopalatine artery with
one branch in 70% of the cases studied in
comparison with the studies reported in the
medical literature where the incidence of one
branch has a range of 60-80%. Various measurements were performed from the columella
because it is a topographic, objective and
easy to locate point of reference. Padua and
Voegels6 use the anterior nasal spine in their
study; however, radiographic control is needed
for its identification.
The distance from the nasal floor to the sphenopalatine foramen was 1.9 ± 0.2 cm. This
measurement is of great use because the sphenopalatine foramen can be localized in the
interior meatus. We did not find studies that
perform and report this measurement in the
medical literature. In our study we did not find
significant differences between the measurements of the left nasal fossa compared with the
Table 1. Distance (in cm) of the columella to the different anatomic references
324
Right
Left
p value
Ethmoid crest
7.12 ± 0.165
6.98 ± 0.111
p = 0.226
Sphenopalatine foramen
7.42 ± 0.190
7.36 ± 0.092
p = 0.62
Vidian nerve
7.94 ± 0.128
7.8 ± 0.114
p = 0.063
Nasal floor of sphenopalatine foramen
1.88 ± 0.159
1.9 ± 0.070
p = 0.854
Morales-Cadena M et al. Anatomic variations and references of the sphenopalatine foramen
right. As far as the authors know, based on the
review of the medical literature, this work is the
first descriptive anatomic study in a Mexican
population.
In conclusion, the endoscopic anatomy of
the sphenopalatine foramen is complex and
has multiple anatomic variants that should be
kept in mind for adequate endonasal vascular
control. The most important reference is the ethmoid crest because in 100% of the cases it was
localized anterior to the sphenopalatine foramen, as well as its localization in the transition
of the middle meatus with the superior meatus.
The distances from the columella to the most
utilized anatomic references for localizing the
sphenopalatine foramen are described, which
can be very useful for optimal results in nasal
endoscopic surgery.
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