International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29500878 A new year, a new Journal 1 2 EN W.J. Fokkens Academic Medical Centre, Amsterdam, The Netherlands 1792 10.4193/Rhin18.401 Let us start this first editorial of 2018 with wishing you all a marvelous year where most of your dreams come true. In the last years, the editors of Rhinology felt often very unhappy when again we had to refuse papers send to us for Rhinology. Unfortunately, every year we can only accept around 15% of the papers we receive. With pain in our hearts, we often have to refuse papers of good quality but just not innovative enough or with slight methodological imperfections. The editorial board of Rhinology recognized this feeling and we decided to start a new journal: Rhinology Online to have space for all those papers that are good but just do not make the cut for Rhinology. Rhinology Online is a journal of the European Rhinologic Society, and will provide a platform for the dissemination of rhinologic research and reviews, as well as position papers, task force reports and guidelines, amongst an international scientific audience.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29166422 Intranasal bevacizumab in the treatment of HHT -related epistaxis: a systematic review 3 10 EN P. Stokes Department of Surgery, St Vincents Hospital, Melbourne, Victoria, Australia J. Rimmer Department of ENT, Monash Health, Melbourne, Victoria, Australia and Department of Surgery, Monash Health, Melbourne, Victoria, Australia 1764 10.4193/Rhin17.166 BACKGROUND: Hereditary haemorrhagic telangiectasia (HHT) remains a difficult disease for the ENT specialist to manage. Affected patients often report recurrent epistaxis as the most debilitating symptom. The pathogenesis of the disease is due to genetic mutations affecting angiogenesis. For this reason, the anti-angiogenic therapy bevacizumab has gained popularity in the local treatment of epistaxis in patients with HHT. OBJECTIVE: A systematic review of the efficacy of bevacizumab in local treatment of epistaxis in patients with HHT based on epistaxis duration, frequency, severity and impact on quality of life. METHODS: A systematic search was performed using the PubMed, MEDLINE and EMBASE databases. The Preferred Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies that measured the efficacy of intranasal bevacizumab treatment of epistaxis in patients with HHT were included for qualitative analysis. RESULTS: Thirteen studies (four randomised controlled trials, three prospective studies, three retrospective studies, one case series and two case reports) with a total of 357 patients were included. Local administration (either by submucosal injection or topically) did not have a significant impact on epistaxis duration, frequency, severity or quality of life compared to placebo or other local treatments. CONCLUSIONS: The available evidence suggests that intranasal bevacizumab treatment does not have a significant effect on epistaxis in patients with HHT. There are several limitations that require further investigation to confidently rule out local bevacizumab as an effective therapy in HHT related epistaxis.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29396960 Monoclonal antibodies for the treatment of chronic rhinosinusitis with nasal polyposis: a systematic review 11 21 EN N. Tsetsos Department of Otorhinolaryngology-Head and Neck Surgery, 424 General Military Hospital, Thessaloniki, Greece J.K. Goudakos Department of Otorhinolaryngology-Head and Neck Surgery, 424 General Military Hospital, Thessaloniki, Greece D. Daskalakis Department of Otorhinolaryngology-Head and Neck Surgery, Diana Princess of Wales Hospital, Grimsby, United Kingdom I. Konstantinidis 2nd Academic Otorhinolaryngology-Head and Neck Surgery Department, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece K. Markou 2nd Academic Otorhinolaryngology-Head and Neck Surgery Department, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece 1780 10.4193/Rhin17.156 BACKGROUND: Monoclonal antibodies have been proposed as a novel therapy in patients suffering from chronic rhinosinusitis with nasal polyposis (CRSwNP). The purpose of this systematic review was to evaluate their efficacy and safety. METHODOLOGY: A literature search was performed in MEDLINE, Web of Science, the Cochrane Library and multiple trial registries followed by extensive hand-searching for the identification of relevant studies. Only randomized controlled trials (RCTs) comparing the use of monoclonal antibodies with placebo or another therapy in adult patients with CRSwNP were included. RESULTS: Anti-immunoglobin E (IgE) therapy with omalizumab was assessed in two studies, anti-interleukin (IL)-5 therapy in three studies (1 reslizumab, 2 mepolizumab) and finally anti-IL-4 and anti-IL-13 therapy in only one. With the exception of one study, biologic therapy was proved to be effective in reducing total nasal endoscopic polyp score (TPS) in treatment as compared to placebo groups. Monoclonal antibodies brought about improvement in several other outcomes, such as opacification in computed tomography (CT), quality of life measures, nasal airflow, olfaction and type 2 helper T-cell (Th2) associated biomarkers. Overall, the use of these agents was deemed safe and well-tolerated. CONCLUSIONS: This is the first systematic review showing encouraging results for the use of all three main categories of monoclonal antibodies in CRSwNP patients and highlights the need for further well-designed and with larger sample sizes RCTs.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29306959 CHronic Rhinosinusitis Outcome MEasures (CHROME), developing a core outcome set for trials of interventions in chronic rhinosinusitis 22 32 EN C. Hopkins ENT Department, Guys Hospital, London, United Kingdom R. Hettige Wexham Park Hospital, Wexham, United Kingdom A. Soni-Jaiswal Manchester Royal Infirmary, Manchester, United Kingdom R. Lakhani St Georges Hospital, London, United Kingdom S. Carrie Freeman Hopsital, Newcastle, United Kingdom A. Cervin Royal Brisbane Hospital, Brisbane, Australia R. Douglas Auckland City Hospital, Auckland, New Zealand W.J. Fokkens Academic Medical Centre, Amsterdam, The Netherlands R. Harvey St Vincents Hospital, Sydney, Australia P.W. Hellings Univerity Hospital Leuven, Leuven Belgium A. Leunig HNO-Klinik Muenchen-Bogenhausen, Munich, Germany V.J. Lund Royal National Throat Nose and Ear Hospital, London, United Kingdom C. Philpott University of Easy Anglia, Norwich, United Kingdom T. Smith Oregon Sinus Centre, Portland, OR, USA D.Y. Wang Yong Loo Lin School of Medicine, Singapore, Singapore L. Rudmik University of Calgary, Calgary, Canada 1775 10.4193/Rhin17.247 STATEMENT OF PROBLEM: Evaluating the effectiveness of treatments in chronic rhinosinusitis (CRS) have been limited by both a paucity of high quality randomised trials, and the heterogeneity of outcomes in those that have been reported. Core outcome sets (COS) are an agreed, standardized set of outcomes that should be measured and reported by future trials as a minimum and will facilitate future meta-analysis of trial results in systematic reviews (SRs). We set out to develop a core outcome set for interventions for adults with CRS. METHOD(S) OF STUDY: A long-list of potential outcomes was identified by a steering group utilising a literature review, thematic analysis of a wide range of stakeholders' views and systematic analysis of currently available Patient Reported Outcome Measures (PROMs). A subsequent e-Delphi process allowed 110 patients and healthcare practitioners to individually rate the outcomes in terms of importance, on a Likert scale. MAIN RESULTS: After 2 rounds of the iterative Delphi process, the 54 initial outcomes were distilled down to a final core-outcome set of 15 items, over 4 domains. PRINCIPAL CONCLUSIONS: The authors hope inclusion of these core outcomes in future trials will increase the value of research on interventions for CRS in adults. It was felt important to make recommendations regarding how these outcomes should be measured, although additional work is now required to further develop and revalidate existing outcome measures.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 28942457 MP-AzeFlu provides rapid and effective allergic rhinitis control: results of a non-interventional study in Romania 33 41 EN I. Agache Transylvania University of Brasov, Faculty of Medicine, Department of Allergy and Clinical Immunology, Brasov, Romania I.C. Doros University of Medicine and Pharmacy Victor Babes, ENT Department, Timisoara, Romania P.M. Leru Carol Davila University of Medicine and Pharmacy, Family Medicine Department, Bucharest, Romania and Colentina Clinical Hospital, Internal Medicine Department, Bucharest, Romania I. Bucur Nicolae Malaxa Hospital, Allergology Outpatient Unit, Bucharest, Romania M. Poenaru University of Medicine and Pharmacy Victor Babes, ENT Department, Timisoara, Romania C. Sarafoleanu Carol Davila University of Medicine and Pharmacy, Family Medicine Department, Bucharest, Romania and Santa Maria Hospital, University of Medicine and Pharmacy, Department of ORL 1646 10.4193/Rhin16.278 BACKGROUND: Allergic Rhinitis and its Impact on Asthma (ARIA) and the European Union (EU) recommend a shift to guide allergic rhinitis (AR) treatment decisions from symptom severity to disease control, using a simple visual analogue scale (VAS). Using this VAS we assessed, in a real-life study in Romania, the effectiveness of MP-AzeFlu nasal spray. METHODOLOGY: In this multi-centre, prospective, non-interventional study, 253 patients (over 11 years old) with moderate-to-severe AR were prescribed MP-AzeFlu and assessed their symptoms on a VAS (0 (not at all bothersome) to 100 mm (very bothersome)) on Days 0, 1, 3, 7 and 14. The proportion of patients who achieved a defined VAS score cut-off for well-controlled (38 mm) AR were also calculated. Patients perception of disease control was assessed on Day 3. RESULTS: MP-AzeFlu use was associated with a mean (standard deviation) VAS score reduction from 78.4 (15.1) mm at baseline to 14.7 (15.1) mm on the last day. Effectiveness was consistent irrespective of disease severity, phenotype or patient age. 83.4% of patients achieved the smaller than 39 mm well-controlled VAS score cut-off by last day and 95.2% considered their symptoms to be well- or partly controlled at Day 3. CONCLUSIONS: MP-AzeFlu provided rapid, effective and sustained AR symptom control in a real-life setting in Romania, irrespective of severity, phenotype or patient age, aligning with ARIA and EU recommendations and supporting the position of MP-AzeFlu as the drug of choice for the treatment of moderate-to-severe AR.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29288573 Omalizumab treats chronic rhinosinusitis with nasal polyps and asthma together-a real life study 42 45 EN T. Bidder Thoracic Medicine, University College London Hospital NHS Foundation Trust, London, United Kingdom J. Sahota Thoracic Medicine, University College London Hospital NHS Foundation Trust, London, United Kingdom C. Rennie Rhinology Section, Royal National Throat Nose and Ear Hospital London, London, United Kingdom V.J. Lund Rhinology Section, Royal National Throat Nose and Ear Hospital London, London, United Kingdom D.S. Robinson Thoracic Medicine, University College London Hospital NHS Foundation Trust, London, United Kingdom H.H. Kariyawasam Thoracic Medicine, University College London Hospital NHS Foundation Trust, London, United Kingdom 1769 10.4193/Rhin17.139 INTRODUCTION: Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma often coexist and thus treating both with one intervention is an attractive strategy. OBJECTIVE: To prospectively evaluate whether treatment with the monoclonal antibody against IgE Omalizumab for severe allergic asthma also effectively treats co-existent CRSwNP. METHODS: SNOT-22 and the ACQ-7 scores were recorded at 4 and 16 weeks of treatment in a cohort of patients with both CRSwNP and severe refractory allergic asthma treated with Omalizumab (n=13) according to UK guidelines for their severe asthma. SNOT-22 in a surgery only treated CRSwNP with asthma group (n=24) was compared. RESULTS: Rapid improvement was seen at 4 weeks and 16 weeks of treatment in both CRSwNP and asthma control. The improvement in CRSwNP with Omalizumab was similar to that seen in a group of patients who received upper airway surgery. CONCLUSION: Omalizumab treatment for severe allergic asthma also improves co-existent CRSwNP. Further clinical studies of current and emerging biological agents for severe asthma should include upper airway outcomes. These agents may be effective for severe CRSwNP and comparative studies with surgery are warranted.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29289975 How deep is the inflammation in chronic rhinosinusitis? Sinus wall thickness and blood eosinophilia 46 53 EN K.Y. Lin Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan P.Y. Chen Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan T.H. Yeh Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan 1770 10.4193/Rhin15.250 Various factors have been proposed to be related to refractory chronic rhinosinusitis (CRS). Treatment for refractory CRS is challenging for ear, nose, and throat (ENT) surgeons. The aim of the study was to determine the clinical features associated with the severity of CRS that may necessitate revision surgery by eliminating the bias of the surgeons technique using standardizing surgical procedures. Sinus wall thickness and blood eosinophilia, which may represent the depth of inflammation in CRS, are associated with the need for revision surgery. We found that, when the thickness of the postero-lateral maxillary sinus wall is more than 3.03 mm, there is an increased probability for a need for revision surgery. CRS patients with thickened sinus walls were found to have poorer outcomes. Further research is needed in order to justify this type of surgical procedure for CRS.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 28988260 The significance of Computed Tomography in invasive paranasal mucormycosis 54 58 EN G. Slonimsky Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel E. Slonimsky Department of Diagnostic Imaging, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel A. Yakirevitch Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel D. Sagiv Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel S. Duvdevani Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel Y.P. Talmi Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel M. Wolf Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel E.E. Alon Department of Otolaryngology-Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel 1706 10.4193/Rhin17.153 INTRODUCTION: Early diagnosis of acute invasive fungal rhinosinusitis (AIFR) is crucial for patients prognosis and may reduce the extent of surgical debridement. Initial evaluation usually includes paranasal Computed Tomography (CT), with an emphasis on bony erosion which is considered a specific but insensitive radiologic sign. Most studies made no distinction between Aspergillus and Mucor species while addressing CT findings. In this study, we seek to evaluate whether bony erosion on paranasal CT is a significant and reliable finding in the initial evaluation of invasive paranasal mucormycosis. METHODS: A retrospective review of pre-operative non-contrast craniofacial CT scans of patients diagnosed with acute invasive fungal rhinosinusitis (AIFR) caused by Mucor species for the presence of bony erosion. RESULTS: A total of 13 patients (9 males, 4 females) were included. Twelve patients were immunosuppressed due to various hematological malignancies. Six patients underwent debridement due to gross intraoperative findings of bony fungal invasion, but only one patient had evidence of bony erosion on the pre operative paranasal CT. CONCLUSION: Bony erosion on paranasal CT is an exceptionally insensitive radiologic sign for establishing or rejecting the diagnosis of Mucor induced AIFR. The mainstay of confirming or rejecting the diagnosis of AIFR is by physical examination, endoscopy and oriented biopsy of suspicious mucosal lesions

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29166423 Exhaled and nasal nitric oxide in chronic rhinosinusitis patients with nasal polyps in primary care 59 64 EN M. Frendo Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark K. Hakansson Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark S. Schwer Susanne Schwer ear, nose and throat clinic, Valby, Copenhagen, Denmark A.T. Ravn Frederiksberg ear, nose and throat clinic, Frederiksberg, Copenhagen Denmark H. Meteran Department of Respiratory Medicine L, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark C. Porsbjerg Department of Respiratory Medicine L, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark V. Backer Department of Respiratory Medicine L, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark C. von Buchwald Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark 1766 10.4193/Rhin17.111 BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disorder associated with lower airway disease. However, only few studies of CRSwNP from outside secondary/tertiary care centres have been published. We recently reported an asthma frequency of 44% and 65% in primary and secondary care patients respectively. Therefore, we hypothesise that inflammation of the lower airways could be present in all CRSwNP patients, even without asthma. Here, we assessed the degree of lower and upper airway inflammation using exhaled and nasal nitric oxide (NO) in primary care CRSwNP patients with and without asthma. METHODS: Fifty-seven patients who met the EPOS criteria for CRSwNP were prospectively recruited from primary care ear, nose and throat clinics. Nasal endoscopy was performed by an ear, nose and throat specialist upon enrolment. Additionally, 30 healthy controls were enrolled. Expiratory and nasal NO measurements and thorough pulmonary evaluation were performed. Pulmonary disease was diagnosed by a respiratory physician. RESULTS: Fifty-nine percent of CRSwNP patients with asthma showed elevated expiratory NO; the same was seen in 29% of non-asthmatic CRSwNP patients. Compared with controls, a high level of exhaled NO was significantly more prevalent in CRSwNP irrespective of asthma-status. Nasal NO was significantly lower in patients with CRSwNP compared with controls. CONCLUSION: Subclinical eosinophilic lower airway inflammation is common in CRSwNP in the primary sector, even in the absence of asthma.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29069120 Lateral lamella of the cribriform plate, a keystone landmark: proposal for a novel classification system 65 72 EN R. Gera Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy F. Mozzanica Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy A. Karligkiotis Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy A. Preti Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy F. Bandi Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy S. Gallo Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy A. Schindler Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy C. Bulgheroni Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy F. Ottaviani Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy P. Castelnuovo Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy 1739 10.4193/Rhin17.067 BACKGROUND: The aim of this study is to propose a classification of the angle formed by the lateral lamella of the cribriform plate (LLCP) and the horizontal plane passing through the cribriform plate. In particular, the angle was classified into class I (over 80 degrees), class II (45 to 80 degrees, and class III (under 45 degrees) METHODOLOGY: A total of 190 computed tomography scans were retrospectively reviewed in order to obtain four sets of measurements. 1) depth of the cribriform, 2) angle, 3) length of the LLCP, 4) width of the fovea ethmoidalis. The relationship among these measurements were analyzed. RESULTS: The angle was significantly correlated with the depth of the cribriform and the length of the fovea, while it was negatively correlated with the length of the LLCP. Significant negative correlation was also found between the length of the LLCP and the width of the fovea. CONCLUSIONS: This angle classification is based on the theoretical risk of iatrogenic injuries, but it could be helpful also in clinical practice by providing indirect information on the thickness of the anterior skull base. As the angle decreases, in fact, the portion of the anterior skull base composed by the LLCP, increases.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29150922 Prospective evaluation of a nonsurgical device for rhinoplasty 73 81 EN M.A. Deggeller Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland D. Holzmann Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland M.B. Soyka Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland 1760 10.4193/Rhin17.133 BACKGROUND: Rhinoplasty represents one of the most challenging and frequently performed procedures in plastic surgery and non-surgical rhinoplasty is rarely considered. The aim of this study was to investigate whether the Nasella Nose Former (NNF), a newly developed non-surgical rhinoplasty device, could improve objective and subjective results following surgical rhinoplasty and even correct the shape of the nose without any surgery at all. METHODOLOGY: In this prospective, monocentric, two-armed, non-blinded randomized, controlled clinical trial, a total of 43 participants were included. In the Surgical group, 22 patients undergoing open or closed rhinoplasty with osteotomies were randomised based on their birth year; 15 of them got to wear the NNF over 8 weeks postoperatively and 7 patients getting surgery without the NNF formed the control group. In the Cosmetic group, 21 participants wore the NNF without surgery over 14 months. At every follow-up exam, angles for crookedness, nasal hump and width were measured, the investigator assessed the patients nose and asked for patient satisfaction using a Likert-scale. RESULTS: Patients in the Surgical group wearing the NNF did not show any significant difference concerning objective measurements, investigator assessments and patient satisfaction compared to those not wearing the NNF. In the Cosmetic group, participants did not show objective improvements in measurements and investigator assessment. However, participants were significantly more satisfied after 14 months with their nasal back, nasal axis and outer nose in general. CONCLUSIONS: Considering the results of this study, we conclude that this perfectly customised external device to enhance surgical rhinoplasty outcomes or correct the shape of the nose without surgery does not seem to be effective and that further investigations in this field are not meaningful.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29166425 Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery 82 88 EN M. Eordogh Department of Neurosurgery, KRH Klinikum Nordstadt, Hannover, Germany A. Grimm Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary I. Gawish Department of Neurosurgery, KRH Klinikum Nordstadt, Hannover, Germany L. Patonay Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary R. Reisch ENDOMIN - Centre for Endoscopic and Minimally Invasive Neurosurgery, Hirslanden Clinic, Zurich, Switzerland H.R. Briner Center for Otorhinolaryngology, Head and Neck Surgery, Hirslanden Clinic, Zurich, Switzerland G. Baksa Center for Otorhinolaryngology, Head and Neck Surgery, Hirslanden Clinic, Zurich, Switzerland 1765 10.4193/Rhin17.181 BACKGROUND: The knowledge of sinonasal vasculature is inevitable in transnasal neurosurgery. We performed an anatomical study on the sphenopalatine artery from the perspective of skull base procedures. METHODOLOGY: To analyse the anatomical landmarks of the sphenopalatine artery, arterial skull corrosion casts (26 head halves) underwent endoscopic transnasal phantom surgery. Furthermore, we performed microsurgical dissection on formaldehyde-fixated cadavers with arterial perfusion (14 head halves) as well as studied Cone Beam CT-scans of anonymised patients and cadavers (115 head sides). RESULTS: In our cadaveric material, the sphenopalatine foramen is located at the transition of the superior and middle nasal meatus (95.0%) or in the superior nasal meatus (5.0%). It is the main entry point of the branches of the sphenopalatine artery into the nasal cavity. In most cadaveric cases (25.0%), at this level there are 2 branches superiorly and 1 vessel inferiorly to the ethmoid crest. An average of 2.4 vessels leave the sphenopalatine foramen superiorly to the ethmoid crest, 97.8% of them belong to the sphenopalatine arterys posterior septal branches. An average of 2.1 branches leave the sphenopalatine foramen inferiorly to the ethmoid crest; all of them belong to the posterior lateral nasal branches. There are no cases with a single artery at the plane of the sphenopalatine foramen. We describe a triangular bony structure bordering the sphenopalatine foramen anteriorly which is built up by the palatine and ethmoid bone as well as the maxilla. According to the radiographic studies, this triangular prominence is surrounded superiorly by a posterior ethmoid cell (57.4%), the sphenoid sinus (41.7%) or the orbit (0.9%) with a varying contribution of the superior nasal meatus; inferolaterally by the maxillary sinus (98.3%) or the pterygopalatine and infratemporal fossa (1.7%) and inferomedially by the middle nasal meatus. The medial vertex of the bony triangle corresponds to the ethmoid crest of the palatine bone. In transnasal endoscopic surgery, the posterior lateral nasal branches of the sphenopalatine artery appear at the triangle´s inferomedial edge, the posterior septal branches emerge at its superior edge. CONCLUSIONS: The triangular bony structure is a landmark to find and differentiate the posterior lateral nasal and posterior septal branches of the sphenopalatine artery and to identify the sphenoid sinus.

International Rhinologic Society Rhinology 0300-0729 56 1 2018 3 1 29286059 Functional anatomy of the nasal bones and adjacent structures. Consequences for nasal surgery 89 95 EN M. Popko Department of Otorhinolaryngology, Division of Dentistry, Medical University of Warsaw, Warsaw, Poland S.A.M.W. Verlinde-Schellekens Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands E.H. Huizing Em. Professor of Otorhinolaryngology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands R.L.A.W. Bleys Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands 1767 10.4193/Rhin17.189 The periosteum of the nasal bones, the periosteal-perichondrial nasal envelope, and the cartilaginous support of the bony vault were studied in serial coronal sections of four human cadaver noses. To differentiate between the various tissue components, the sections were stained according to Mallory-Cason and Verhoeff-Van Gieson stain. The results demonstrated: 1. the presence of clearly distinguishable layers of the periosteum covering the nasal bones; 2. the presence of a continuous periosteal-perichondrial covering of the bony and cartilaginous nasal vaults; 3. the way the cartilaginous support of the bony vault is constructed. The findings described in the present study may have clinical relevance in nasal surgery.