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Medial Maxillectomy
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Fig. 6.13 Endoscopic view of the osteitis at the area of
papilloma attachment—lateral maxillary sinus.
• Remember to send the whole specimen (including any
parts of the specimen within the debrider trap) for
histology. Although the chance of malignant transformation of a papilloma is minimal, the probability of a
synchronous malignant tumor is not insignificant.
References
1. Georgalas C. Learning from a difficult case: inverted papilloma
involving the anterior wall of the maxillary sinus. In: Duncavage J,
Backer S, eds. The Maxillary Sinus: Medical and Surgical
Management. New York, N Y: Thieme Medical Publishers, Inc; 2010;
224-226
2. Tomenzoli D, Castelnuovo P, Pagella F, et al. Different endoscopic
surgical strategies in the management of inverted papilloma of
the sinonasal tract: experience with 47 patients. Laryngoscope
2004;114(2):193–200
Fig. 6.14 Medial maxillectomy cavity of the same patient in
Fig. 6.13, 6 months later. Note the good epithelialization.
3. Falcon RT, Rivera-Serrano CM, Miranda JF, et al. Endoscopic
endonasal dissection of the infratemporal fossa: Anatomic relationships and importance of eustachian tube in the endoscopic
skull base surgery. Laryngoscope 2011;121(1):31–41
4. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;136(2):261–267
5. von Buchwald C, Bradley PJ. Risks of malignancy in inverted papilloma of the nose and paranasal sinuses. Curr Opin Otolaryngol
Head Neck Surg 2007;15(2):95–98
6. Sadeghi N, Joshi A. Management of the nasolacrimal system
during transnasal endoscopic medial maxillectomy. Am J Rhinol
Allergy 2012;26(2):e85–e88
7. Verillaud B, Bresson D, Sauvaget E, et al. Exposure techniques in
endoscopic skull base surgery: posterior septectomy, medial maxillectomy, transmaxillary and transpterygoid approach. Eur Ann
Otorhinolaryngol Head Neck Dis 2012;129(5):284–288
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Chapter 7
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7.1 Indications to Expose the
Ethmoidal Arteries 68
Anterior and Posterior
Ethmoidal Arteries
7.2 Surgical Steps 69
7.3 Case Example 71
7.4 Complications 73
7.5 Tips and tricks 74
Anterior and Posterior Ethmoidal Arteries
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7 Anterior and Posterior Ethmoidal Arteries
Humbert Massegur-Solench, Juan Ramón Gras-Cabrerizo, Elena Garcia-Garrigós, Joan M. Ademá-Alcover
Introduction
Anterior and posterior ethmoidal arteries (AEA and PEA)
are branches of the ophthalmic artery, which traverses
within the orbit from the internal carotid artery (Fig. 7.1).
The ethmoidal arteries pass between the oblique and medial rectus muscles heading to the roof of the ethmoidal
sinus through the ethmoidal foramina traversing the lamina papyracea (Figs. 7.2–7.4). The arteries run along the
ethmoidal roof from lateral to medial, giving branches to
supply the turbinates, the septum, and terminal branches
intracranially (Fig. 7.5). The most superior part of the basal
lamella of the bulla ethmoidalis is the landmark to find the
AEA because in most cases it is located behind its anterior
wall. The computed tomography (CT) landmarks to find
the AEA are the corticated break in the anterior lamina papyracea between the oblique and medial rectus muscles
just behind the globe. The PEA crosses the ethmoid roof
through a canal located anteriorly to the superior attachment of the anterior wall of the sphenoid sinus. Depending on the pneumatization, the bulging of the bony canal
at the ethmoid roof is more evident for the anterior than
for the PEA. The CT landmarks to find the posterior artery
are more difficult to define except for a corticated sulcus
in the skull base where the artery leaves the orbit. The
knowledge of these arteries is crucial for endonasal procedures, such as endoscopic sinus surgery, endoscopic skull
base surgery, orbit decompression, and epistaxis, bearing
always in mind that the damage to them can produce a catastrophic orbital retrobulbar hemorrhage.
1–5
7.1 Indications to Expose the
Ethmoidal Arteries
• In severe epistaxis not controlled by the ligature of the
sphenopalatine artery, the AEA can be an additional
source of bleeding and has to be localized.
• Trauma with fracture of the nasofrontal complex or the
skull base can produce bleeding of the ethmoidal arteries that may need to be coagulated or ligated.
• The first step to approach an anterior skull base menin-
gioma is to dissect and to coagulate both arteries bilaterally by bipolar diathermy, to improve bleeding control.
• The AEA can be useful as a landmark to find the fron-
tal recess, but the variation in its location and bulging
on the ethmoid roof is not always safe. Thus, the basal
lamella of the ethmoidal bulla is a better landmark.
• The PEA can be a good landmark to find the optic nerve
knowing that the distance between both is approximately 6 mm.
• The anterior meningeal artery, branch of the anterior
ethmoid artery, and the first olfactory fiber can be useful as landmarks to know the posterior limit of skull
base exposure to perform the Draf III procedure.
• Both arteries need to be identified as anterior and pos-
terior limits for endoscopic orbital decompression.
• Visualization of the ethmoidal arteries is important to
avoid retrobulbar hemorrhage in endoscopic transnasal approaches in the treatment of medial and inferior
orbital lesions.
Fig. 7.1 CT scan with contrast (cadaver). Anterior ethmoidal
arteries. Intraorbital and ethmoidal course. On the left side,
the septal (*) and anterior meningeal branches (**) can be
seen. AEA, anterior ethmoidal artery.
68
AEA
**
*
AEA
AEA
Fig. 7.2 Coronal CT scan: sulcus of the anterior ethmoidal
arteries through the anterior ethmoidal foramen.
AEA
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Anterior and Posterior Ethmoidal Arteries
FS
Fig. 7.3 Axial CT scan: anterior ethmoidal arteries crossing
the anterior ethmoidal complex taking an oblique route from
posterolateral to anteromedial.
AMA
AEA
O
AEA
Fig. 7.4 Left anterior ethmoidal artery dissected from the
orbit. The orbital fat has been removed to appreciate the
origin from ophthalmic artery and the course between the
superior oblique and medial rectus muscle. AEA, anterior
ethmoidal artery; FS, frontal sinus; MRM, medial rectus muscle;
OA, ophthalmic artery; SOM, superior oblique muscle.
MT
SOM
OA
MRM
EB
Fig. 7.5 Left anterior ethmoidal artery entering from the
orbit through the anterior ethmoid foramen and giving the
anterior meningeal artery. AEA, anterior ethmoidal artery;
AMA: anterior meningeal artery; O, orbit.
7.2 Surgical Steps
After a gentle medialization of the middle turbinate, the
uncinate process is identified and removed from its superior insertion to its horizontal aspect. The basal lamella of the bulla ethmoidales is then opened and removed
(Fig. 7.6). The AEA will be found behind the insertion
of the basal lamella (Fig. 7.7), which corresponds to the
anterior wall of the ethmoidal bulla and not behind the
frontal recess. The artery crosses the ethmoidal roof, taking an oblique route from the posteromedial break in the
lamina papyracea to the lateral lamella of the cribriform
Fig. 7.6 Left nasal fossae. Bulla ethmoidalis with the basal
lamella partially removed as the fi rst step to localize the
anterior ethmoidal artery. EB, ethmoid bulla; MT, middle
turbinate.
plate (Fig. 7.8). Depending on the pneumatization of the
ethmoidal roof, the artery can be more or less evident;
it can even have a mesentery suspended from the skull
base. There is the possibility of a dehiscence inferiorly
(Fig. 7.8). In very few cases, the artery may be found anterior to the basal lamella (Fig. 7.9).
The PEA enters the ethmoid roof from the orbit through
the posterior ethmoidal canal embedded in the skull base
and is thus less identifiable in the CT scan or during the
dissection (Figs. 7.10–7.12).
The next step is to open and remove the basal lamella
of the middle turbinate and, following the slope of the
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Anterior and Posterior Ethmoidal Arteries
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FR
FS
BLEB
AEA
Fig. 7.7 Left nasal fossae. Anterior ethmoid roof after
removal of the ethmoid bulla. Relationship of the anterior
ethmoidal artery with the basal lamella of the ethmoidal bulla
and frontal recess. AEA, anterior ethmoidal artery; BLBE, basal
lamella of the bulla ethmoidalis; FS, frontal sinus.
BLBE
LP
AEA
Fig. 7.8 Pneumatized left anterior ethmoidal roof with
the oblique route of the anterior ethmoidal artery (partially
dehiscent) from the posteromedial break in the lamina
papyracea to the lateral lamella of the cribriform plate. The
basal lamella of the ethmoidal bulla anterior to the artery and
posterior to the frontal recess. AEA, anterior ethmoidal artery;
BLBE, basal lamella of the bulla ethmoidalis; FR, frontal recess;
LP, lamina papyracea.
AEA
BLBE
Fig. 7.9 Left anterior ethmoidal artery exposed just
anterior to the basal lamella of ethmoidal bulla. AEA, anterior
ethmoidal artery; BLBE, basal lamella of the bulla ethmoidalis.
skull base, to identify the anterior wall of the sphenoid
sinus. The PEA crosses the ethmoidal roof in front of this
wall (Figs. 7.13–7.15). The identification of the sulcus of
the artery may be used as a landmark to localize the optic
canal. The distance between the artery and the nerve is
about 6 mm (Figs. 7.16 and 7.17). In case the pneumatization has originated a sphenoethmoidal cell (formerly
known as Onodi cell), there is no wall between the PEA
and the optic canal, but it can be also useful as landmark
in this anatomic variation.
After the identification of both arteries, they can
be dissected following their intraorbital course to the
PEA
Fig. 7.10 Coronal CT scan with contrast (cadaver). Posterior
ethmoidal arteries. Intraorbital and ethmoid roof courses. PEA,
posterior ethmoidal artery.
ophthalmic artery. The orbital fat must be removed to
clearly distinguish the relationship between the arteries
and the superior oblique muscle and medial rectus muscle
(Figs. 7.18–7.21). There are variations in the number and
situation of the arteries: they can be absent in one or both
sides, or a middle ethmoidal artery (a so-called “tertia”)
can be found in around 30% (Fig. 7.22).
6
Through-cutting forceps, Kuhn-Bolger probes, and
curved curettes are recommended as the best instruments for this approach. In special cases, it can be useful
to employ a diamond burr to thin the skull base when a
PEA is embedded in thick bone.
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Anterior and Posterior Ethmoidal Arteries
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AEA
OA
SOM
PEA
Fig. 7.11 Coronal CT scan. Cortical sulcus of the posterior
ethmoidal artery crossing the ethmoidal roof. PEA, posterior
ethmoidal artery.
PEA
PEA
SS
Fig. 7.12 Left anterior and posterior ethmoidal arteries
dissected from the orbit passing through the superior oblique
muscle and medial rectus muscle. The orbital fat has been
removed. AEA, anterior ethmoidal artery; MRM, middle rectus
muscle; OA, ophthalmic artery; PEA, posterior ethmoidal
artery; SOM, superior oblique muscle.
PEA
MRM
LP
AWSS
Fig. 7.13 Left posterior ethmoidal artery and nerve crossing
the ethmoidal roof just in front of the superior part of the
anterior wall of the sphenoid sinus. AWSS, anterior wall of
the sphenoid sinus; LP, lamina papyracea; PEA, posterior
ethmoidal artery.
7.2.1 Landmarks
• Insertion on the skull base of the basal lamella of the
bulla ethmoidalis.
• Basal lamella of the middle turbinate.
• Anterior wall of the sphenoid sinus.
• Lamina papyracea.
• Frontal and suprabullar recess.
LP
ON
OCR
Fig. 7.14 Left posterior ethmoidal artery and nerve.
Relationship between the artery and the optical nerve after
the removal of the anterior wall of sphenoid sinus. LP, lamina
papyracea; OCR, opticocarotid recess; ON, optic nerve; PEA,
posterior ethmoidal artery.
7.3 Case Example
A 34-year-old man was involved in a car accident and
arrived to our ENT department with bleeding from right
nasal cavity. Anterior rhinoscopy and nasal endoscopy
revealed active hemorrhage, but the exact site of bleeding could not be localized. We performed an anterior
nasal packing, but the epistaxis was not controlled. A
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PEA
PEA
PEA
PEA
PEN
PEN
PEN
LP
LP
LP
Fig. 7.15 Course of the left posterior ethmoidal artery
and nerve crossing the ethmoid roof from the sulcus in the
posterior lamina papyracea to the cribriform plate. LP, lamina
papyracea; PEA, posterior ethmoidal artery; PEN, posterior
ethmoidal nerve.
AEA
AWSS
ON
AEA
AEA
OCR
ICA
Fig. 7.16 Left posterior ethmoidal artery. Relationship
between the artery, anterior wall of the sphenoid sinus,
optic nerve, and carotid artery. AWSS, anterior wall of the
sphenoid sinus (partially removed); ICA, internal carotid
artery; OCR, opticocarotid recess; ON, optic nerve; PEA,
posterior ethmoid artery.
AEA AEA
AEA
AEA
CP
CP
CP
LP
PEA
Fig. 7.17 Left ethmoidal roof after removal of the basal
lamellas with anterior and posterior ethmoidal arteries crossing
from the orbit to the cribriform plate. AEA, anterior ethmoidal
artery; LP, lamina papyracea; PEA, posterior ethmoidal artery.
CT scan confirmed a bilateral nasal bone fracture. We
decided to perform a sphenopalatine artery and AEA
ligation because of the history of nasal trauma. During
the endoscopic surgery, we confirmed an anterosuperior
bleeding from an injury of some anterior ethmoidal
branches (Fig. 7.23).
The nasal cavity was packed for 24 hours without
intraoperative and postoperative complications. The
patient did not have any further bleeding during the
follow-up.
LP
LP
PEA
PEA
PEA
ON
ON
ON
Fig. 7.18 Global view of the anterior skull base bilaterally
with anterior and posterior ethmoidal arteries crossing
the ethmoidal roof and their relationship with the optic
nerve, lamina papyracea, and cribriform plate. AEA, anterior
ethmoidal artery; CP, cribriform plate; LP, lamina papyracea;
ON, optic nerve; PEA, posterior ethmoidal artery.
PEA
PEAPEA
LPLPLP
LP
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Anterior and Posterior Ethmoidal Arteries
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AEA
PEA
ON
ICA
Fig. 7.19 Course of the anterior and posterior ethmoidal
arteries from the ophthalmic artery to the cribriform plate
crossing the ethmoidal roof. (The orbital fat has been removed
and the medial rectus muscle rejected laterally.) AEA, anterior
ethmoidal artery; ICA, internal carotid artery; MRM, medial
rectus muscle; OA, ophthalmic artery; ON, optic nerve; PEA,
posterior ethmoidal artery; SOM, superior oblique muscle.
SOM
OA
MRM
Fig. 7.20 Scheme of the anterior and posterior ethmoidal
arteries showing the branches for the septum and lateral
nasal wall.
AEA
Fig. 7.21 Sagittal CT scan with contrast (cadaver) with anterior
and posterior ethmoidal arteries in the nasal septum. AEA,
anterior ethmoidal artery; PEA, posterior ethmoidal artery.
PEA
7.4 Complications
The bleeding of the ethmoidal arteries can be controlled by bipolar diathermy, but the complete transection can produce a retraction of the artery into the orbit
with an intraorbital bleeding, hematoma, and the rise
of intraorbitary pressure with a subsequent visual loss
due to compression and elongation of the optic nerve.
An orbital decompression (lateral canthotomy with
inferior cantholysis or an endoscopic decompression) is
AEA
MEA
PEA
Fig. 7.22 Multiple ethmoidal arteries in a left ethmoidal roof,
as an anatomic variation. AEA, anterior ethmoidal artery; MEA,
middle ethmoidal artery; PEA, posterior ethmoidal artery.
mandatory. The AEA is more exposed to injury than the
posterior artery.
7–12
The course of the AEA and the lateral lamella of the
cribriform plate are the thinnest part of the ethmoid
roof, and the possibility of a breach in the skull base and
subsequent cerebrospinal fluid leak is high in this area.
The direct injury to the optic nerve in case the posterior ethmoid artery is not localized intraoperatively is
also a possibility, particularly if a sphenoethmoidal cell
is present.
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Fig. 7.23 CT scan of a traumatic injury of the left anterior ethmoidal artery (*).
7.5 Tips and Tricks
• Gentle removal of the basal lamella of the bulla ethmoid-
alis by through-cutting forceps helps to find the superior
attachment and to localize, right behind it, the AEA.
• In rare cases, the ethmoid bulla may not be pneuma-
tized or presents a thick bony anterior wall; care must
be taken to avoid entering the orbit.
• 45-degree lens improves the vision of the anterior skull
base and the AEA.
• 0-degree lens is recommended for the localization of
the posterior ethmoid artery.
• The frontal recess and the suprabullar recess may be
helpful to find the AEA.
• The AEA is not recommended as a landmark to find the
frontal sinus outflow tract due to the variations in its
localization.
• It is not recommended to use the microdebrider on the
skull base near the ethmoidal arteries due to the risk of
being severed.
• The opening of the basal lamellas of the bulla ethmoid-
alis and the middle turbinate and the anterior wall of
the sphenoid sinus must be done on the most inferior
and medial aspect to avoid injuries to the orbit, optic
nerve, or internal carotid artery.
• The distance between the AEA and posterior is approx-
imately 12 mm and between the PEA and the optic
canal is approximately 6 mm.
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haemorrhage. Injury 1999;30(7):485–490
10. Brouzas D, Charakidas A, Androulakis M, Moschos M. Traumatic
optic neuropathy after posterior ethmoidal artery ligation for
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