Biotechnological

Communication

Biosci. Biotech. Res. Comm. 10(3): 557-563 (2017)

Assessment of location of anterior ethmoidal artery using

cone beam computed tomography (CBCT)

Shima Javdan

, Roshanak Ghaffari

and Saeed Sohilipour

Postgraduate Student, Department of Oral Radiology, Dental School, Islamic Azad University, Isfahan

Khorasgan Branch Isfahan Iran

Department of Oral and Maxillofacial Radiology, Dental Faculty, Isfahan Khorasgan Branch, Islamic Azad

University

Otolaryngology, Isfahan University of Medical Sciences, Isfahan, Iran

ABSTRACT

Anterior ethmoidal artery (AEA) is an important landmark, which may be accidentally injured or traumatized during

surgical procedures. This study aimed to determine the position of AEA on CBCTscans. In this descriptive analytical

study, CBCT scans of 129 patients evaluated. The mean distance from AEA to anterior base of the skull, posterior

frontal sinus wall, nasion, anterior nasal spine (ANS), orbital roof, inferior turbinate and the mean angle between

AEA and ANS were evaluated using SIDEXIS 3D software. Independent and paired t-test and Fisher’s test were used

for statistical analyses with P<0.05 level of signi cance. The mean distance from AEA was 11.60±1.94 mm to orbital

roof, 32.66±4.33 mm to inferior turbinate, 8.96±4.51 to posterior wall of the frontal sinus, 2.09 ±2.18mm to the

anterior base of the skull, 18.01±3.90 mm to the nasion and 58.69±4.24 mm to the ANS. The angle between AEA

and NS was 55.15±4.36°. The distances from AEA to orbital roof, inferior turbinate, nasion and ANS in men were

signi cantly greater than those in women (P<0.05). nasion. ( = 0/05) Surgical procedures in areas close to AEA are

high-risk. Determination of the position of AEA prior to endoscopic surgery of the sinus is highly important. CBCT

can help determine the location of AEA prior to surgery to prevent unwanted surgical complications.

KEY WORDS: CONE-BEAM COMPUTED TOMOGRAPHY; ETHMOID; ARTERY

557

ARTICLE INFORMATION:

*Corresponding Author: Roshanak Ghaffari

Received 23

June, 2017

Accepted after revision 26

Sep, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at:

http//www.bbrc.in/

DOI: 10.21786/bbrc/10.3/33

558 ASSESSMENT OF LOCATION OF ANTERIOR ETHMOIDAL ARTERY USING (CBCT) BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Javdan, Ghaffari and Sohilipour

INTRODUCTION

In ammatory diseases of paranasal sinuses are a com-

mon serious problem. In the recent decades, functional

endoscopic sinus surgery (FESS) has revolutionized

surgical treatment of paranasal sinuses. In this tech-

nique, due to the proximity of paranasal sinuses to

some important structures such as anterior base of skull,

orbit and ethmoidal artery, unintentional injury to these

anatomical structures may cause serious complications

(Basak et al. 1998). Anterior ethmoidal artery (AEA) is

an important landmark, which may be accidentally trau-

matized or injured during surgical procedure of anterior

ethmoidal sinus. Injury to AEA may cause severe nasal

bleeding, intra-orbital hemorrhage, posterior orbital

hematoma, spinal  uid leak and intracranial bleeding in

rare cases (Ding et al. 2012 Eren et al. 2016).

In FESS, superior lateral border of AEA and its infe-

rior border in contact with inferior turbinate are marked

(Rontal et al. 1991). The distance between AEA and the

contact area with the inferior turbinate outlines the safe

area for surgical manipulation. Since in FESS the width

of ethmoid forceps is maximally 10mm when opened, the

surgeon must have adequate knowledge about the space

limitations in this area (Rontal et al. 1991; Basak et al.

1998). Knowledge about the anatomical location of AEA

and its detection on images can help prevent unwanted

complications during surgery (Ding et al. 2012). AEA

is among the most important reference landmarks for

endoscopic surgery since it determines the posterior

location of recess. Its detection in frontoethmoidal

suture determines the location of anterior base of skull

(Monjas-Cánovas et al. 2012; Ko et al. 2014).

Ethmoidal artery originates from the orbital artery.

Some branches of ethmoidal artery originate from

supraclinoid portion of the internal carotid artery and

pass through the optical foramen towards the orbit in

a lateral position. In coronal plane, a conical groove in

the medial orbital wall may be seen, which indicates

the exit point of ethmoidal artery between the superior

oblique muscle and medial rectus muscle. It indicates

anterior ethmoidal foramen and can serve as a refer-

ence anatomical landmark to determine the location of

AEA (Monjas-Cánovas et al. 2012). The location of AEA

relative to the ethmoidal air cells may be variable but it

is often located between the second and third lamellae

next to basal lamella (Ding et al. 2012).

Ko et al, in 2014 evaluated the ef cacy of AEA to

determine the location of frontal sinus in endoscopic

sinus surgery using computed tomography (CT) and

offered a classi cation for the position of AE. Guldner et

al. provided a similar classi cation in 2012 using CBCT

(Guldner et al. 2012). At present, CBCT is increasingly

used for implant imaging and endodontic treatments

and is a new technique in ENT for assessment of sinuses.

It is superior to CT since it has lower cost and lower

patient radiation dose compared to CT. Studies on deter-

mination of location of AEA using CBCT are limited.

Thus, this study has aimed to determine the position of

AEA on CBCT scans.

MATERIALS AND METHODS

This descriptive analytical study was conducted on 129

CBCT scans of patients (70 females and 59 males) over

18 years of age presenting to the Oral and Maxillofacial

Radiology Department of Isfahan University of Medi-

cal Sciences, School of Dentistry. All CBCT scans had

been taken with one CBCT unit (Galileos-Sirona Ben-

sheim, Germany) with the exposure settings of 85 kVp

and 21-35 mAs (depending on the patient’s weight). The

inclusion criterion was age over 18 years. The exclusion

criteria were history of surgery or trauma to parana-

sal sinuses and skull base, congenital facial anomalies,

malignancies or lesions causing opacity of frontal recess

and anterior ethmoidal cells. Multiplanar (coronal, sag-

ittal and oblique sagittal) reconstructed images were

assessed using SIDEXIS 3D software. Next, notch in the

medial orbital wall and bony sulcus of lateral wall of the

olfactory fossa (anterior ethmoidal sulcus) on coronal

sections which indicate the anterior ethmoidal foramen

were used for detection of the AEA (Figure 1).

Due to the presence of variations in the path of artery,

distance from the artery to the base of skull was meas-

ured. In type I, the entry point of AEA is adjacent to the

anterior base of the skull. In type II, it has less than 1mm

distance from the base of the skull. In type III, AEA has a

distance equal or more than 1mm from the anterior base

of the skull (Guldner et al. 2012) (Figure 2). To determine

the position of AEA relative to the frontal sinus in the

sagittal plane, distance from the AEA to the posterior

wall of the frontal sinus was measured (Monjas-Cánovas

et al. 2011) (Figure 3). Distance from the AEA to the

orbital roof and inferior turbinate (site of attachment

FIGURE 1. Anterior ethmoidal foramen notch

in the medial orbital wall (arrow) and anterior

ethmoidal sulcus (arrow head)

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS ASSESSMENT OF LOCATION OF ANTERIOR ETHMOIDAL ARTERY USING (CBCT) 559

Javdan, Ghaffari and Sohilipour

FIGURE 2. Location of the AEA on the sagittal plane (up). Schematic

views (down): (A) Attached to the base of skull; (B) distance less than 1

mm; (C) distance of 1 mm or more

FIGURE 3. Distance from the

anterior ethmoidal foramen to

the posterior wall of the frontal

sinus on the sagittal plane

FIGURE 4. Distance from the anterior

ethmoidal foramen to the orbital roof and

inferior turbinate

of bony lamella of inferior concha with medial wall of

the maxillary sinus) in the coronal plane (Figure 4) was

measured. To estimate the distance from the AEA to the

nasion and also the distance from the AEA to the ANS,

the oblique sagittal plane was used. In this plane, the

angle between the hypothetical line connecting the AEA

and ANS and horizontal line passing through the hard

palate and ANS was measured (Monjas-Canovas et al.

2011) (Figure 5). Independent and paired t-test were used

for statistical analyses. P<0.05 was considered statisti-

cally signi cant.

RESULTS AND DISCUSSION

A total of 129 patients (59 males and 70 females) with

a mean age of 41.59 years in males and 38.44 years in

females were evaluated. Both sides were evaluated in

each patient (n=258). Independent t-test showed that the

mean age of males and females was not signi cantly

different (P=0.220). In most cases, the AEA was detect-

able on coronal sections of the anterior ethmoidal fora-

men in the medial wall of the orbit (96.1%) in the form

of a notch and anterior ethmoidal sulcus in the lateral

wall of the olfactory fossa (94.2%). The Fisher’s exact

test showed that the frequency distribution of pres-

ence of the AEA in the medial orbital wall and ante-

rior ethmoidal sulcus was not signi cantly different in

the right and left sides (P>0.05).The mean total distance

from the AEA to the orbital roof on coronal sections was

11.601.94mm. This distance to the inferior turbinate

was 32.664.33mm. As seen in Table 1, t-test showed

no signi cant difference between the distance from the

AEA to the orbital roof and to the inferior turbinate in

the two sides (P>0.05). The mean distance from the AEA

to the posterior frontal sinus wall (8.964.51mm) and

anterior base of the skull (2.092.18mm) on sagittal sec-

tions is shown in Table 1; according to t-test, the differ-

560 ASSESSMENT OF LOCATION OF ANTERIOR ETHMOIDAL ARTERY USING (CBCT) BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Javdan, Ghaffari and Sohilipour

FIGURE 5. Distance from the AEA to the nasion and ANS; angle

between the AEA and ANS and hard palate plane on oblique sag-

ittal plane

Table 1. Mean distance from the AEA to the orbital roof, inferior turbinate, posterior wall of the frontal

sinus and anterior base of the skull in millimeters

Distances

Right (mean±SD)

Left (mean±SD)

Total (mean±SD)

P value

Distance from AEA to orbital roof 11.73±2.03 11.48±1.85 11.60±1.94 0.13

Distance from AEA to inferior

turbinate

32.42±4.46 32.90±4.21 32.66±4.33

0.20

Distance from AEA to posterior

wall of frontal sinus

8.66±4.46 9.27±4.56 8.96±4.51

0.11

Distance from AEA to anterior base

of skull

2.10±2.27 2.07±2.09 2.09±2.18

0.81

Table 2. Location of AEA relative to the anterior base of the skull on CBCT sagittal

sections in millimeters

Right Left Total

0 <1 ≥1 0 <1 ≥1 0 <1 ≥1

Number 58 1 70 50 2 77 108 3 147

Percentage 45% 8% 54.3% 38.8% 1.6% 59.7% 41.9% 1.2% 57%

ence in the mean distance from the AEA to the posterior

wall of the frontal sinus and anterior base of the skull

was not signi cant (P>0.05).

Table 2 shows the position of the AEA relative to the

anterior base of the skull on sagittal CBCT sections based

on the presented classi cation.

Table 3 shows the mean distance from the AEA rela-

tive to the nasion and ANS and angle of AEA relative

to ANS in oblique sagittal plane. As seen in Table 3,

according to paired t-test, no signi cant difference was

noted in the mean variables in the right and left sides

(P>0.05).

As demonstrated in Table 4, independent t-test

showed that the distance from the AEA to the orbital

roof and inferior turbinate and distance from the AEA to

the nasion and ANS in males were signi cantly greater

than those in females (P<0.05) but no signi cant differ-

ence was noted between males and females in the AEA

and ANS angle (P>0.05).

Many anatomical studies have assessed the location

of the AEA and most of them used endoscopic meas-

urements while some others used CT (Monjas-Canovas

et al. 2012). On the other hand, studies on detection of

AEA on CBCT scans are limited (Guldner et al. 2012).

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS ASSESSMENT OF LOCATION OF ANTERIOR ETHMOIDAL ARTERY USING (CBCT) 561

Javdan, Ghaffari and Sohilipour

Table 3. Mean distance from the AEA to the nasion, ANS and AEA-ANS angle on oblique sagittal plane

Right (mean±SD) Left (mean±SD) Total (mean±SD) P value

Distance between AEA

and nasion

18.04±3.61 mm 17.95±4.17 mm 18.01±3.90 mm 0.78

Distance between AEA

and ANS

58.58±4.09 mm 58.81±4.40 mm 58.69±4.24 mm 0.21

Angle between AEA and

ANS

55.06±4.16 º 55.24±4.56 º 55.15±4.36º 0.53

Table 4. Mean and standard deviation of data based on gender

Distance Female (mean±SD) Male (mean±SD) P value

Distance to orbital Roof 11.97±1.80 mm 11.17±2.01 mm 0.001

Distance to inferior turbinate 31.51±4.27 mm 34.03±4.02 mm 0.000

Distance to anterior base of

skull

2.17±2.12 mm 1.99±2.25 mm 0.50

Distance to inferior wall of

frontal sinus

8.56±3.83 mm 9.44±5.18 mm 0.132

Distance to nasion 17.25±3.28 mm 18.91±4.38 mm 0.01

Distance to ANS 56.46±3.33 mm 61.33±3.66 mm 0.00

Angle between AEA and ANS 55.44±4.06º 54.79±4.69º 0.23

The AEA passes through three cavities namely the orbit,

the ethmoidal labyrinth and the anterior cranial fossa.

The AEA enters into the olfactory fossa from the anterior

cranial base and then enters into the anterior ethmoi-

dal sulcus through the lateral lamella of the cribriform

plate, which is the weakest point of the anterior base of

the skull. At this point, bone is dangerously thin and it

is considered a high-risk area in nasal endoscopic sur-

gery. Thus, the AEA is susceptible to traumatization and

injury during surgical procedures (Stammberger et al.

1990; Bayram et al. 2001; Moon et al. 2001; White et al.

2005; Araujo Filho et al. 2006; Souza et al. 2009).

In most cases in our study, this artery was detect-

able in the medial wall of the orbit (96.1%) and lateral

wall of the olfactory fossa (94.2%). Similarly, Souza et

al. detected AEA in the medial orbital wall (98%) and

lateral wall of the olfactory fossa (100%) and stated that

medial notch of the orbit and medial ethmoidal sulcus

were reliable landmarks for detection of the AEA (Souza

et al. 2009). Gotwald et al, similarly detected the orbital

medial notch on coronal CT scans in 95% and medial

ethmoidal sulcus in 84% of cases (Gotwald et al. 2004).

Ding et al. used CT angiography and detected AEA in

100% of the cases in the notch in the medial orbital

wall and in 98.4% in the ethmoidal sulcus (Ding et al.

2012). Considering the invasiveness of CT angiography

and high dose of CT, low dose CBCT is more suitable for

detection of AEA. In FESS, superior lateral border of the

surgical site is determined based on the location of AEA

and the inferior border is determined by the inferior tur-

binate (Rontal et al. 1991). Distance from the AEA to

the attachment site of the inferior turbinate determines

the suitable location for surgical procedure. Basak et al.

considered the orbit as a  xed reference point and based

on this point, they determined the location of AEA.

The mean distance from the AEA to the orbital roof

on CT scans was reported to be 13.7 mm (Basak et al.

1998) while in our study, this distance was found to be

11.601.94 mm. Basak et al. measured the mean distance

from the AEA to the inferior turbinate to be 30.05 mm

(Basak et al. 1998) and Eren et al. found this distance to

be 31.6 mm on CT scans (Eren et al. 2016); these values

were close to our  ndings (32.664.33 mm).

The distance from the AEA to the skull base is impor-

tant because when AEA with mesenterium is located

right beneath the skull, it has higher risk of traumatiza-

tion during surgery. Basak et al. evaluated the location

of AEA on coronal CT scans and reported that it was

adjacent to the skull base in 57% of the cases and had

a distance from it in 43%. In cases where AEA has a

distance from the base of skull, risk of traumatization

during FESS is higher (Basak et al. 1998). Moon et al.

assessed both sagittal sections and cadaver dissection

and reported that in 85.7% of cases, AEA was adjacent

to the skull base; in the remaining cases, AEA had 2-3

mm distance from the skull base (Moon et al. 2001).

Guldner et al. (2012) reported similar results. Araujo et

al. reported that AEA was attached to the skull base in

83.3% of the cases (Araujo Filho et al. 2006). Kainz and

Stammberger reported that in most cases, AEA had 5

Javdan, Ghaffari and Sohilipour

562 ASSESSMENT OF LOCATION OF ANTERIOR ETHMOIDAL ARTERY USING (CBCT) BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

mm distance from the skull base. They also stated that

when the roof of ethmoidal sinus is low, anterior ethmoi-

dal canal may be attached to the skull base (Kainz et al.

1988). The same was stated by Becker et al, who deter-

mined the location of foramen in endoscopic sections.

Jang et al. reported this distance to be 1.32 1.51mm

on CT scans (Jang et al. 2014) while in our study, this

distance was 2.09 2.18mm. These differences may be

due to racial differences or surgical technique. It seems

that in patients with larger supraorbital ethmoid cell and

optimal pneumatization of ethmoidal sinus (Jang et al.

2014), AEA is located right beneath the skull base; oth-

erwise, it is at the same level of the skull base (Lisbona

et al. 2010).

Young et al, in their study measured the distance

from the AEA to the base of skull and categorized it in

three groups of no distance [16%], distance less than 1

mm (33.7%) and equal or higher than 1 mm (50.5%) (Ko

et al. 2014). In our study, 41.9% were categorized in no

distance group, 1.2% were categorized in less than 1 mm

group and 57% were categorized in 1 mm and higher

group. In most cases in both studies, the distance from

the AEA to the skull base was equal or more than 1 mm.

Frontal sinus is the most challenging sinus in endo-

scopic surgery due to its anatomical complexity and

variations. Many studies have suggested anatomical

landmarks to help the surgeon in safe conduction of

frontal sinus surgery (McLaughlin et a;. 1997; Lee et al.

1997; Kew et al. 2002). The AEA is known as a typical

classic reference point for the frontal sinus. Some stud-

ies showed that AEA is located right behind the fron-

tal recess and can serve as an anatomical landmark for

frontal sinus surgery (White et al. 2005). Thus, knowl-

edge about the anatomy of this area is important and

must be obtained prior to endoscopic sinus surgery.

Young et al. reported the mean distance from the AEA

to the posterior wall of the frontal sinus to be 8.585.56

mm, which was in line with our result (8.964.51 mm);

whereas, Jang et al. measured the distance from the AEA

to the anterior wall of the frontal sinus to be 17.362.19

mm [19]; this difference was due to the different refer-

ence points selected. Statistically, similar to our study,

Young et al. found no signi cant association between

the distance from the AEA to the frontal sinus and AEA

to the base of skull (Ko et al. 2014).

In endoscopic surgery of the sinus, zero degree ANS

angle complicates the detection of AEA [9]. Donemez et

al. considered ANS as a  xed landmark and measured its

distance from the AEA on cadavers using an electronic

caliper, and reported the value to be 553 mm (Donmez

et al. 2005). However, Monjas-Cánovas et al. measured

the distance from the AEA to ANS to be 55.515.52 mm

and measured its angle with the horizontal line passing

through the ANS to be 57.71.78; these values were

close to those of Moon et al.(2001), Lee et al. (2000)

and Araujo et al. (2006). Our study reported this distance

to be 58.694.26 mm and the angle was 55.144.37,

which was in line with previous studies. Araujo et al.

(2014) reported that the distance from the AEA to ANS

was signi cantly greater in males than in females; this

difference was not statistically signi cant in our study

and that of Lee et al. (2000).

Nasion is used as a reference point in CT scan stud-

ies for surgical resection of some tumors or manage-

ment of uncontrollable arterial hemorrhage, which is

endoscopically impossible; although external incision is

made from the canthus and not directly on the nasion.

Monjas-Cánovas et al. measured the mean distance from

the AEA to the nasion to be 29.312.5 mm (2011), which

is similar to the study by Cankal et al. (2004); whereas,

the results of Eren et al. (2014)(17.993.91) were closer

to ours (18.013.90 mm). In our study, a weak but signif-

icant association was noted between the distance from

the AEA to the ANS and the distance from the AEA to

the nasion; whereas, Eren et al. (2014) found a signi -

cant association between the distance from the AEA to

the nasion and the distance from the AEA to the inferior

turbinate (Eren et al. 2014).

CONCLUSION

Inadequate knowledge about the anatomy of surgical

site can cause serious iatrogenic surgical complications.

To decrease these risks, a careful dissection must be done

after thorough assessment of the area on CBCT scans.

Therefore, adequate knowledge about the anatomy of

the area and location of the AEA by use of CBCT can be

helpful prior to FESS.

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