Comprehensive understanding of vascular anatomy for endovascular treatment of intractable oronasal bleeding

Abstract

Oronasal bleeding that continues despite oronasal packs or recurs after removal of the oronasal packs is referred to as intractable oronasal bleeding, which is refractory to conventional treatments. Severe craniofacial injury or tumor in the nasal or paranasal cavity may cause intractable oronasal bleeding. These intractable cases are subsequently treated with surgical ligation or endovascular embolization of the bleeding arteries. While endovascular embolization has several merits compared to surgical ligation, the procedure needs attention because severe complications such as visual disturbance or cerebral infarction can occur. Therefore, comprehensive understanding of the head and neck vascular anatomy is essential for a more effective and safer endovascular treatment of intractable oronasal bleeding.

Keywords: Bleeding; Embolization; Epistaxis; External carotid artery; Intractable.

Fig. 1.

Blood supply of nasal cavity. (1) Sphenopalatine, (2) anterior ethmoidal, (3) greater palatine, (4) superior labial, and (5) posterior ethmoidal arteries.

Fig. 2.

Internal maxillary collateral via the foramen or canal. so, superior orbital fissure; fs, foramen spinosum; fo, foramen ovale; fr, foramen rotundum; ECA, external carotid artery; pvc, palatovaginal canal; pc, palatine canal.

Fig. 3.

A 20-year-old man with Le Fort II and mandibular fracture. (A) Computed tomography scan of the face shows multiple fractures of turbinates (black arrow). (B) Superselective angiogram (lateral view) of the left sphenopalatine artery shows extravasation of the contrast material from the lateral (black arrow) and medial (white arrow) branches. Medial or septal branches supply the septum, and the lateral branches supply the turbinates.

Fig. 4.

A 56-year-old man with maxillary sinus carcinoma, post operation and radiotherapy. (A) Magnetic resonance imaging scans of the face show an enlarged and curved vascular structure (black arrow) in the destructed posterior portion of the right maxillary sinus. (B) Superselective angiogram of the lesser palatine artery (black arrow) shows the same shape as that on the magnetic resonance image and extravasation of the contrast material into the oral cavity.

Fig. 5.

A 19-year-old man with a zygomaticomaxillary fracture. External carotid angiogram shows contrast extravasation and pseudoaneurysm (black arrow) from the branches of the infraorbital artery (white arrow), which may anastomose with the posterior superior alveolar and transverse facial arteries.

Fig. 6.

A 20-year-old man with angiofibroma. (A) Right internal carotid angiogram (lateral view) shows partial tumor staining by the hypertrophic posterior ethmoidal artery (black arrow) of the ophthalmic artery. (B, C) Superselective angiogram (lateral and anteroposterior views) shows the artery of the foramen rotundum (black arrow) appearing as a corkscrew and supplying the tumor.

Fig. 7.

A 67-year-old man with a pleomorphic adenoma, post operation. (A) Preoperative neck computed tomography scan shows a retropharyngeal mass (black arrow). (B) Superselective angiogram of the ascending pharyngeal artery shows a pseudoaneurysm (black arrow) from the superior pharyngeal artery from the pharyngeal and neuromeningeal trunk (white arrow).

Fig. 8.

Ascending pharyngeal collateral via the foramen or canal. jf, jugular foramen; hf, hypoglossal foramen; fl, foramen lacerum; vc, Vidian canal; ECA, external carotid artery.

Fig. 9.

A 38-year-old man with a tongue bite. (A) Computed tomography scan of the oral cavity shows the lesion of the tongue base with mixed densities (black arrow). (B) The selective angiogram(lateral view) of the right lingual artery shows a pseudoaneurysm(black arrow) from the branch of the deep lingual artery supplying the tongue. Faint facial artery (white arrow) is shown by the linguofacial collateral pathway from the lingual artery (arrow head).

Fig. 10.

Linguofacial collateral pathway.

Fig. 11.

A 74-year-old man with a hypopharyngeal carcinoma. (A) Contrast-enhanced neck computed tomography scan shows an enhancing mass filling the pyriform sinus (black arrow) with multiple lymph node metastases. (B, C) Right common carotid angiogram (anteroposterior view) and superselective angiogram(lateral view) of the superior laryngeal artery show a pseudoaneurysm of the superior laryngeal artery (black arrows).