Posterior Auricular Artery Research Articles

Anatomic Study of Vascular Supply of the External Ear Using CT Angiography in Congenital Microtia.

The morphology of the arteries of the external ear on the affected side of congenital microtia differs from normal. The present study aimed to use computed tomography angiography (CTA) to describe the anatomic variations of arteries in microtia and provide theoretical guidance for the first stage of autologous auricular reconstruction by the 2-stage method. Ten patients with unilateral microtia from May 2021 to August 2021 were included. Computed tomography angiography and 3-dimensional reconstruction were used to analyze the supply and branches of the main arteries of the auricle. The number of the superficial temporal artery (STA) and posterior auricular artery (PAA) branches to the auricle, vessel diameter, and the presence or absence of the STA and PAA branches were documented. The skin flap and incision were designed combined with the anatomic of auricular arteries. The blood supply of the auricle mainly came from the STA and PAA. The STA's preauricular branch and PAA's posterior auricular branch were absent to varying degrees, and the middle branch was more prominent. The average diameter of the STA on the healthy auricle was 3.07±0.96mm, and the average diameter of the PAA was 1.72±0.50mm. The average diameter of the STA on the microtia auricle was 2.65±0.42mm, and the average diameter of the PAA was 1.53±0.67mm. There was a statistically significant difference in the diameter of STA between the healthy auricle and the microtia auricle (P=0.006). However, there was no significant difference in the diameter of the PAA between the healthy auricle and the microtia auricle (P=0.112). The skin flap and incision were designed and combined with the preoperative CTA images, and no flap necrosis was observed in all patients. The vascular distribution of arteries in microtia patients was clearly and accurately assessed by CTA. In our experience, the data and detailed imaging were useful in designing skin flaps and incisions during the first stage of autologous auricular reconstruction by the 2-stage method.

External Carotid Artery:Essential Knowledge of the External Carotid Artery Required for Neuroendovascular Surgery, with a Focus on the Middle Meningeal Artery and Occipital Artery

The perfusion territory of the external carotid artery is often underestimated; however, this blood vessel forms abundant "dangerous anastomoses" with the internal carotid and vertebral arteries. An understanding of these vascular anastomoses is crucial to ensure safe cerebrovascular interventions. There are several important aspects of the middle meningeal artery that should be considered, including anastomoses with the anterior(frontal)branch and ophthalmic artery through the sphenoidal artery(recurrent meningeal artery)and meningolacrimal artery. Additionally, the blood supply to the facial nerve via branches of the petrosal branch, such as the superior tympanic artery, and the formation of the facial arcade by the superior tympanic and stylomastoid arteries, which often originate from the posterior auricular artery, is significant. The occipital artery demonstrates rich anastomoses with vessels, such as the ascending pharyngeal and vertebral arteries, forming what is known as the pharyngo-occipital system.

Posterior auricular artery

Introduction: The posterior auricular artery (PAA) is the preterminal branch of the external carotid artery (ECA), arising superiorly to the occipital artery (OA). The PAA has quite a few anatomical variations and established neurosurgical applications. We conducted this study as an overview to illustrate all neurosurgical aspects regarding this artery, its reconstructive uses, and anatomical variation. Method: We performed a literature review in Google Scholar and PubMed medical databases for studies discussing the PAA, its anatomical variations, and neurosurgical applications. Results: We identified 30 articles that discuss the anatomical variations and neurosurgical applications of the PAA. While reviewing the available articles and original works regarding PAA. Conclusion: The PAA has considerable anatomical variations regarding its origin, course, branches, and length. The related neurosurgical applications of PAA include bypass, embolization, aneurysm, AVM, and reconstruction flaps.

DWI scrolling artery sign for the diagnosis of giant cell arteritis: a pattern recognition approach

ObjectivesTo investigate the diagnostic accuracy of a pattern recognition approach for the evaluation of MRI scans of the head with diffusion-weighted imaging (DWI) in suspected giant cell arteritis (GCA).MethodsRetrospectively, 156...

The topographical anatomy of the posterior auricular artery: a computed tomography angiography analysis with implications for reconstructive surgery

The topographical anatomy of the posterior auricular artery: a computed tomography angiography analysis with implications for reconstructive surgery

Diffusion-weighted magnetic resonance imaging for the diagnosis of giant cell arteritis: a comparison with T1-weighted black-blood imaging.

To investigate the diagnostic performance of diffusion-weighted imaging (DWI) of the superficial cranial arteries in the diagnosis of GCA. Retrospectively, 156 patients with clinically suspected GCA were included. A new 4-point ordinal DWI rating scale was developed. A post-contrast, fat-suppressed, T1-weighted 'black-blood' sequence (T1-BB) was rated for comparison. Ten arterial segments were assessed: common superficial temporal arteries, temporal and parietal branches, occipital and posterior auricular arteries bilaterally. The expert clinical diagnosis after ≥6 months of follow-up was the diagnostic reference standard. Diagnostic accuracy was evaluated for different rating methods. The study cohort consisted of 87 patients with and 69 without GCA. For DWI, the area under the curve was 0.90. For a cut-off of ≥2 consecutive pathological slices, DWI showed a sensitivity of 75.9%, a specificity of 94.2% and a positive likelihood ratio of 13.09. With a cut-off of ≥3 consecutive pathological slices, sensitivity was 70.1%, specificity was 98.6% and the positive likelihood ratio was 48.38. For the T1-BB, values were 88.5%, 88.4% and 7.63, respectively. The inter-rater analysis for DWI with a cut-off of ≥2 pathological slices showed a kappa of 1.00 on the patient level and 0.85 on the arterial segment level. For the T1-BB the kappa was 0.78 and 0.79, respectively. DWI of the superficial cranial arteries demonstrates a good diagnostic accuracy and reliability for the diagnosis of GCA. DWI is widely available and can be used immediately in clinical practice for patients with suspected GCA.

Manejo multimodal de aneurisma cirsoideo. Reporte de un caso y revisión de la literatura

Scalp arteriovenous malformations (AVMs), commonly known as cirsoid aneurysms, are complex collections of arteries and veins that communicate directly. It has been postulated that AVMs occur both through the activation of inactive fistulous lesions and through the formation of new fistulous vascular channels through the canalization of injured vessels. Depending on their size and complexity, a variety of strategies can be used to treat them. The case of a 53-year-old male is presented who came for evaluation due to an increase in the volume of a pulsating lesion that extended from the right parietotemporal region accompanied by holocraneal headache and tinnitus. A cerebral angiotomography was performed in which a lesion composed of ectatic serpentine images, with a right extracranial location, subsequently diagnostic cerebral angiography was performed demonstrating a right frontoparietal fistulous and plexiform arteriovenous shunt fed by afferents from the right superficial temporal, posterior auricular, occipital and middle meningeal arteries, with drainage through a varicose and ectatic vein towards the external jugular vein. An endovascular embolization of the arteriovenous shunt was performed via the femoral route in two stages, achieving a “pressure cooker” construction to perform the injection of embolizing fluid and have a subtotal embolization of 93%, with this it was possible to perform a microsurgical resection with a right fronto-parietal-temporal approach resecting the deepest part, leaving the scalp with embolized vessels without resecting. To close the surgical wound, a simple flap rotation was performed to cover the skin defect derived from its resection. The patient underwent post-resection cerebral panangiography, identifying the absence of arteriovenous shunt. Depending on the extent and anatomical complexity of the malformation, clinical manifestations may vary. More than 80% of AVMs will be present at birth and the rest may develop after head trauma or surgical interventions. Appropriate therapeutic intervention is needed through selective angiography, during which endovascular embolization of the major feeding vessels can be performed before open surgical intervention. Volume-based three-dimensional computed tomography reconstructions can be used for further planning. Surgical reduction of post-embolization arterial supply will reduce intraoperative hemorrhage, facilitating total surgical resection. Removal can result in large, full-thickness skin defects that may be difficult to reconstruct without compromising functional and cosmetic results. Keywords: Cirsoid aneurysm; multimodal management; treatment; endovascular; giant

Surgical treatment of postauricular hidradenitis suppurativa with delayed diagnosis: a case report and literature review.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that is difficult to diagnose, with a period of 10.0± 9.6 years from symptom onset to diagnosis. A 32-year-old Asian man presented with bilateral postauricular abscesses that first appeared 5 years previously. Despite several incisions and drainage, the symptoms only temporarily improved and continued to recur. On physical examination, chronic scars and sinus tracts were observed around the lesion. Postauricular HS was diagnosed, and surgical treatment was performed. We performed a wide excision and reconstructed the defect using a posterior auricular artery perforator-based keystone flap. Histological examination confirmed the diagnosis of HS. The reconstruction was successful, and there was no recurrence for 2 years after surgery. HS is difficult to diagnose without specific attention. Although the postauricular region is not a typical site of HS, it can occur in this area. Therefore, if a patient presents with recurrent abscesses in the postauricular region, HS should be considered. Additionally, if HS is diagnosed in the postauricular region, wide excision with reconstruction using a posterior auricular artery perforator-based keystone flap can lead to a favorable outcome.

Encephalo-Duro-Pericranio-Synangiosis for the Treatment of Moyamoya Disease with Posterior Cerebral Artery Lesions

We describe our experience performing encephalo-duro-pericranio synangiosis for the parieto-occipital region (EDPS-p) as a treatment for moyamoya disease (MMD) with hemodynamic disturbances caused by lesions of the posterior cerebral artery. From 2004 to 2020, 60 hemispheres of 50 patients with MMD (38/50 females, age 1-55 years) underwent EDPS-p as a treatment for hemodynamic disturbances in the parieto-occipital region. A skin incision was made on the parieto-occipital area to avoid the major skin arteries, and the pedicle flap was created by attaching the pericranium to the dura mater under the craniotomy with multiple small incisions. The surgical outcome was assessed on the basis of the following points: perioperative complications, postoperative improvement of clinical symptoms, subsequent novel ischemic events, qualitative assessment of the development of collateral vessels by magnetic resonance arteriography, quantitative assessment of postoperative perfusion improvement based on the mean transit time, and cerebral blood volume on dynamic susceptibility contrast imaging. Perioperative infarction occurred in 7/60 hemispheres (11.7%). The transient ischemic symptoms observed preoperatively disappeared in 39/41 hemispheres (95.1%) during the follow-up period (12-187 months), and none of the patients experienced novel ischemic events. Collateral vessels supplied from the occipital arteries, middle meningeal arteries, and posterior auricular arteries developed postoperatively in 56/60 hemispheres (93.3%). Postoperative mean transit time and cerebral blood volume showed significant improvement in the occipital, parietal, and temporal areas (P < 0.001), as well as the frontal area (P= 0.01). EDPS-p seems to be an effective surgical treatment for patients with MMD who suffer hemodynamic disturbances caused by posterior cerebral artery lesions.

Ascending palatine branch from the lingual artery with multiple other variations of the external carotid artery.

The external carotid artery (ECA) is the major blood supply for structures in the head and neck. Typically, it has 8 separate branches; but there are many anatomical variations, making it difficult to predict surgical outcomes and complications without 3-dimensional imaging. This case study focuses on a cadaver with multiple anatomical variations in the ECA, i.e., lingual, facial, occipital, ascending pharyngeal, and posterior auricular arteries, found during routine dissection of the right cadaveric neck. We also discuss the incidences of several other anatomical variations of the ECA branches and their surgical implications and potential complications.

Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap

ObjectiveUnstable cavities are defined as cavities with cerumen accumulation that need frequent cavity cleaning in the out-patient clinic, cavities that are intolerant to water due to risk of infection or that are subject to frequent infection and otorrhoea. The objective of this study is to address the problem of troublesome mastoid cavities, with the performance of secondary mastoid obliteration and canal wall reconstruction, using a novel posterior auricular artery (PAA) fascia-periosteum flap. Materials and methodsA prospective study was designed, only secondary obliterations were included. Unstable mastoid cavities were defined as Merchant grade 2 or 3 and were included for surgery. ResultsAt 12 months of follow up, a complete external auditory canal (EAC) and a self-cleaning ear were achieved in all 23 patients. Completely dry ears were achieved in 21 patients (91.3%). An air-bone gap improvement of 5dB was achieved. ConclusionMastoid obliteration and EAC reconstruction are effective procedures to treat troublesome post canal wall down mastoid cavities. They improve quality of life and enable patients to overcome ear discharge. A standard EAC size enables the utilization of conventional hearing aids, it also reduces the need for constant mastoid cleaning and decreases healthcare expenses. The PAA flap seems to be an effective procedure to achieve all these features, as it is used to obliterate the mastoid and becomes a structural component of the neo-EAC.

Posterior auricular artery as a novel anatomic landmark for identification of the facial nerve: A clinical study.

BackgroundIn our previous cadaveric study, we highlighted the posterior auricular artery (PAA) as a potential landmark for early identification of facial nerve (FN) when performing parotidectomy. However, further clinical study is critically needed before this landmark could be applied in clinical practice.MethodsFor 31 patients enrolled, we tried to identify the FN by the guide of the PAA during parotidectomy. Additionally, the FN function was evaluated during follow‐up.ResultsPAA could be exposed in 28 out of 31 (90.3%) patients during parotidectomy. Moreover, the FN trunk could be identified by the guide of the PAA in all these 28 patients with identifiable PAA. Furthermore, no iatrogenic FN damage happened in this study and the transient FN dysfunction rate was 5.7%.ConclusionThe PAA is an ideal landmark for early identification of the FN trunk when performing parotidectomy.

Reconstruction of Half of the Forehead Traumatic Defect with Single Rotation Flap and Hemi-Brow Transposition in a Resource Constrained Setting: A Case Report

Forehead reconstruction is very challenging due to limited availability of matching skin for coverage. This is even more challenging in acute traumatic events characterized by gross contamination, presence of open wounds and injury to surrounding tissues. The use of loco-regional flap option may be the only available resort where facility and expertise for free flaps are not adequate. We present a 50 year old lady that had traumatic avulsion of slightly over half of the forehead with an extension wound to the ipsi-lateral temporal region following road traffic accident. There were crushing of ipsi-lateral eye and periosteal stripping of the underlying bone. She had an immediate flap cover after resuscitation using a single rotation scalp flap based on the ipsi-lateral occipital, posterior auricular and superficial temporal arteries. The adjoining temporal region wound was covered with split-thickness skin graft. She had excellent flap survival and satisfactory graft take. We observed that this flap could be successfully used in the setting of trauma to transfer a like for skin in the setting of trauma. This is especially useful in resource constrained setting where free tissue transfer is still insufficiently used. Keywords: Periosteal stripping, Rotational scalp flap reconstruction, Traumatic forehead avulsion

Comparison of the Pathway to the Inner Ear Between Postauricular and Intramuscular Injection of Dexamethasone in Guinea Pigs

BackgroundPostauricular injection as a local therapy has been confirmed to be effective for inner ear diseases. However, the mechanism for the drugs entering the inner ears remains unknown. This study aims to compare the distribution of dexamethasone by intramuscular injection with that by postauricular injection, and explore the pathway of the drugs entering the inner ears.MethodsAn in vivo optical imaging system was used to conduct a time course observation to compare the distribution of dexamethasone by intramuscular injection with that by postauricular injection in male guinea pigs. The drug availability in the tympanic mucosa, tympanum, endolymphatic sac, and cochlea was observed by a confocal laser scanning microscope.ResultsThe local fluorescent intensity by postauricular injection was significantly higher in the inner ears, and lower in partial peripheral organs, than that by the intramuscular injection. The drug metabolism by postauricular injection exhibited an obviously sustained release effect in the inner ears. Drugs by postauricular injection might enter the endolymphatic sac through the posterior auricular artery and occipital artery, as well as the connections of the mastoid emissary vein, sigmoid sinus and endolymphatic sac.ConclusionMore drugs concentrated in the inner ear for longer therapeutic time and less systemic delivery implied more effective and less risk of side effects through postauricular injection than intramuscular injection safer for the treatment of inner ear diseases.

A Case of Scalp Arteriovenous Malformation Treated by Transvenous Embolization Using Onyx.

We treated a case of scalp arteriovenous malformation (sAVM) by transvenous embolization using Onyx. We describe the case of a 17-year-old woman with a pulsatile mass at the right temporal area. DSA identified sAVM with the venous pouch between the right occipital artery (OA) and the right two occipital veins (OVs), which was also fed by multiple branches of the right posterior auricular artery (PAA) and superficial temporal artery (STA). The shunts were completely occluded by the reverse pressure cooker technique (RPCT), which involves navigating the balloon catheters just distal to the shunt point in the OVs approaching from the right external jugular vein (EJV) and injecting Onyx to each feeder retrogradely with balloons inflated. This technique may be useful for treating sAVM with venous angioarchitecture enabling a transvenous approach.

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Abstract Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Posterior auricular artery helix root free flap—part I: radio-anatomical study

Full-thickness defects of the distal nose are an ongoing surgical challenge. Among the available techniques, pre-auricular chondrocutaneous free flaps based on the superficial temporal artery (STA) have good aesthetic and functional outcomes. However they often require autologous venous grafts. The aim of this radio-anatomical study was to evaluate the feasibility of the helix root free flap based on the posterior auricular artery (PAA). Vascular lengths, diameters, and networks were investigated in flaps harvested from cadavers. The perfusion of the flaps was studied by injecting patent blue. Some flaps were also injected with contrast agent and studied by angiography and computed tomography. Ten flaps from seven fresh cadavers were dissected and analysed. The mean length of the PAA was 114.2 mm and the mean diameter was 2.2 mm. Perfusion was investigated in six flaps and considered good in three of these. The study results demonstrate the feasibility of PAA-based helix root free flaps. This alternative technique provides an 11 cm pedicle with vessels of appropriate calibre, facilitating any potential microsurgery. The scar is mostly hidden behind the ear. This PAA-based helix root free flap could be a reliable and promising single-stage procedure to repair complex defects of the alae nasi.

Posterior auricular artery helix root free flap—part II: clinical application

The surgical repair of full-thickness defects involving the alae nasi is complex. Pedicle flaps such as frontal and nasolabial flaps can be used, but require several interventions with different techniques. In contrast, free flaps from the foot of the ear helix allow the three layers of the nasal wings to be reconstructed in a single operation. Nevertheless, in the classical approach, the vascular pedicle is short. Although some authors have proposed raising the flap in a retrograde manner, this still yields a relatively short pedicle with narrow vessels. In the companion paper, we demonstrated that a posterior auricular artery helix root free flap (PAAHF) can be harvested from the posterior auricular vessels, thus increasing the useful pedicle length. The case of a patient with basal cell carcinoma of the left ala is presented here. A right helix root free flap was anastomosed with the facial vessels at the left mandibular notch. This new flap overcomes the main limitation of the classical helix root flap, namely the length of the pedicle. It has all of the morphological qualities of the classical flap, but with simpler vascular assembly, since autologous venous grafts and complex anastomoses are not required.

Revisited Arterial Supply of the Anterior Ear.

Since arterial supply of the anterior ear was described in 1992 by Park et al, various anatomical studies and surgical techniques have been published in the literatures. Although anatomic studies about the vascular pattern of the ear have been previously reported, most were incomplete to understand the vascular anatomy of the ear and its surgical outcomes. In this report, the authors defined further detailed vascular pattern of the arterial networks and of the main perforators of the anterior ear. The authors dissected in a total of 11 auricles that had been fixed in 10% formalin solution. Prior to dissection, a red latex solution was injected into the common carotid artery. The anteroauricular and postauricular skin was dissected to expose the arterial network under ×10 microscope magnification. There are 2 arterial networks in the anteroauricular surface of the ear: triangular-scapha fossa and concha network. In this study, triangular-scapha fossa network has 2 vascular patterns by a dominant arterial supply: the superficial temporal artery (STA) type (6/11, 54.5%) and the posterior auricular artery (PAA) type (5/11, 45.4%). The STA type is distributed by a subbranch of the ascending helical artery of the STA, whereas the dominant arterial supply of the PAA type is a perforator of the triangular fossa from the PAA. We describe an important inflow to the triangular-scapha fossa network as blood supply from the middle division of the PAA, which directly emerges from the posterior to the anterior surface over the cartilage border at midhelix. The detailed vascular anatomy of this report allows surgeons to perform surgical procedures safely and to develop various flaps in the field of the ear reconstruction.

Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective.

Jugular paragangliomas represent a surgical challenge due to their vascularity and proximity to vital neurovascular structures. Preoperative embolization aids in reducing intraoperative blood loss, transfusion requirements, and improves surgical visualization. Several embolization agents have been used. The aim of this study is to evaluate the safety and efficacy of PVA in pre-operative embolization of jugular paragangliomas. A retrospective review of all patients who underwent jugular paraganglioma resection with pre-operative embolization between 2000 and 2020 was performed. Pre-operative data including baseline patient and tumor characteristics were documented. Outcomes of preoperative embolization including extent of devascularization and post-embolization complications were recorded. Early and long-term postoperative outcomes were reported. Twenty-nine patients met study criteria with a median age of 38 years. Average tumor size was 3.4±1.8 cm. The most commonly encountered arterial feeder was the ascending pharyngeal artery followed by the posterior auricular artery. More than 50% reduction in tumor blush was achieved in 25 patients (86.2%). None of the patients experienced new or worsening cranial neuropathy following embolization. Gross total or Near total resection was achieved in 13 patients (44.8%). A STR or NTR was chosen in these patients to preserve cranial nerve function or large vessel integrity. Average intraoperative estimated blood loss was 888 ml, 9 patients (31%) required intra-operative transfusion of blood products. Extent of resection and post-operative complications did not correlate with extent of devascularization. Pre-operative embolization of jugular paraganglioma tumors with PVA particles is an effective strategy with a high safety profile.