Morphometric and Clinical Evaluation of Sphenopalatine Foramen on Computed Tomography Images

Morphometric and Clinical Evaluation of Sphenopalatine Foramen on Computed Tomography Images | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Morphometric and Clinical Evaluation of Sphenopalatine Foramen on Computed Tomography Images Büşra Şeker, Gülay Açar, Aynur Emine Çiçekcibaşı, Demet Aydoğdu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1949586/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Purpose This study aimed to investigate the effect of anatomical variations in the sphenopalatine foramen and the lateral nasal wall on sphenopalatine foramen-related morphometric measurements. Methods Temporal bone multidetector computed tomography records of 153 patients were evaluated. Morphometric measurements were made between the fixed anatomical landmarks and the sphenopalatine foramen. Number, shape, localization variation of the sphenopalatine foramen, concha bullosa, and septum deviation were noted. Results No significant difference was detected between the right-left sides for all distances measured except SPF-CA and SPF-BL and most of the measurements were higher in males. In addition, statistical analysis of the obtained morphometric data was performed according to age groups. Classified the shape of the sphenopalatine foramen five types and reported that the most common irregularly shaped (37.3%). In our study, 91.2% single, 7.8% double, and 1% triple sphenopalatine foramen were detected. The location of sphenopalatine foramen was reported as the most common type I. No statistically significant relationship could be determined between morphometric data and septum deviation types. SPF-NF, SPF-ML, OSPF-ANS, and HSPF-ANS measurements were found to be significantly smaller in the presence of concha bullosa, whereas SPFA was found to be higher. Conclusion This study revealed a significant relationship between the morphometric measurements of the sphenopalatine foramen and concha bullosa, while septum deviation types did not affect morphometric results. For a safer and more effective surgery with prevention of iatrogenic complications, a surgeon should be aware of this correlation, especially in endoscopic sphenopalatine foramen approaches. Anatomical variation epistaxis computed tomography concha bullosa sphenopalatine foramen Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Epistaxis, seen in 60% of the population, of which 10% require medical attention, is one of the most common problems in otolaryngological emergencies [ 9 , 12 , 19 ]. Anatomically, it is classified as anterior epistaxis originating from Little's area where the Kiesselbach plexus is located, and posterior epistaxis originating from Woodruff's area where sphenopalatine artery (SPA) branches are located [ 9 , 12 ]. Epistaxis treatment, in which the first aim is to find and stop bleeding, has a wide range from non-surgical procedures including the anterior and posterior packing to arterial ligation, to surgical interventions in case of failure. The more severe and recurrent form of posterior epistaxis commonly requires ligation of the SPA due to its high success (87–100%) among surgical treatment options [ 1 , 9 , 19 ]. The SPA passes through the sphenopalatine foramen (SPF) and branches within it [ 3 , 15 , 16 ]. The notch between the orbital and sphenoid processes at the upper border of the perpendicular plate of the palatine bone is closed with the body of the sphenoid bone and called the SPF [ 16 ]. Difficulty in determining the localization of the SPF may occur in patients with active bleeding during the ligation procedure. Therefore, the identification of fixed anatomical landmarks in computed tomography (CT) images makes it easier to determine a more accurate incision location with the removal of a smaller mucoperiosteal flap directly over the SPF and to identify the SPA [ 10 ]. Some studies have shown that there are many variations of the shape and number of the SPF [ 5 ]. The morphometry of the SPF and the relationship between the SPF variations and the position of the middle turbinate have been investigated in many studies [ 14 , 18 ]. On the other hand, the septal deviation and the pneumatization of the middle turbinate (concha bullosa) may lead to nasal obstruction, persistent headache, postnasal discharge, and epistaxis, which may affect the localization of the SPF. Detailed information about the anatomical variations of the SPF and lateral nasal wall contributes is important for more accurate identification of the SPF during surgical operations. However, the anatomy of the region is complex and not suitable for working on cadavers. For this reason, CT images, which are the best method for imaging bone structure, facilitate an appropriate preoperative localization of the SPF and make the procedure safer with a lower incidence of morbidity [ 3 , 4 , 8 , 13 , 15 ]. Our radiological study aimed to describe the localization and variations of the SPF with adjacent structures. Also, we aimed to analyze the relationship of the SPF with the septal deviation and concha bullosa. Materials And Methods This study was performed using paranasal CT images of 153 patients, aged 18–73 years, who presented at the department of radiology between January 2019 and May 2020 and approved by our local Ethics Committee with an approval number 2020/2906. For inclusion, healthy individuals without any pathology in the region were included in the study. Exclusion criteria included previous bony fracture or paranasal surgery, paranasal pathology, congenital craniofacial anomaly, and the imaging files with low-resolution. CT images were obtained using Somatom Drive (Siemens Healthineers, Germany) 256 multislice scanner with the following study parameters, exposure 120 kV, 74 mA, 60 mAs, rotation time 0.28 s, slice thickness 0.625 mm. CT images were evaluated by two experienced anatomists and one radiologist in consensus by use of Snygo-Via (Siemens, Germany) software. Measurements in sagittal, transverse, and coronal sections and images 3D were made at least twice by a radiologist and two anatomists, and their mean values were recorded. Based on data provided in El-Anwar et al. [4], Maxwell et al. [10], and Sir et Eksert [17], all reformatted images were used to measure these surgical morphometric parameters from each side and gender discrimination: 1. On axial images, - SPF-CA, the vertical distances from the SPF to the choanal arch (Fig. 1A), - SPF-ML, the vertical distances from the SPF to the maxillary line (Fig. 1B), - SPF-AH and SPF-BL, the anteroposterior distances from the SPF to the anterior head and basal lamella of the middle turbinate (Fig. 1C, D). 2. On coronal images, - SPF-NF, the vertical distance from the SPF to the nasal floor (Fig. 2a), - SPF D , the vertical diameter of the SPF (Fig. 2b), 3. On sagittal images, - SPFA, the angle between SPF and the anterior nasal spine of the maxilla (Fig. 2*), - OSPF-ANS, the oblique distance between the SPF and the anterior nasal spine of the maxilla (Fig. 2c), - HSPF-ANS, the horizontal distance between the SPF and the anterior nasal spine of the maxilla (Fig. 2d). Additionally, morphological variations of the SPF and the lateral nasal wall were evaluated as follows: 1. Septum deviation was classified into three types in the axial plane: Type A: Deviation at the anterior part of the septum (Fig. 3A). Type B: Deviation at the middle part of the septum (Fig. 3B). Type C: Deviation at the posterior part of the septum (Fig. 3C). 2. The location of the SPF was identified according to the position of the middle turbinate as follows: Type I: The posterior tip of the bony crest of the middle turbinate at the superior border of the SPF (Fig. 3D). Type II: The posterior tip of the bony crest of the middle turbinate at the inferior border of the SPF (Fig. 3E). Type III: The posterior tip of the bony crest of the middle turbinate at the middle of the SPF (Fig. 3F). 3. Pneumatization of the middle turbinate was identified as present (concha bullosa) or absent concerning laterality (Fig. 4A-C). 4. The number of SPF was noted (Fig. 5E, F) and the shape of the SPF was classified into five types: oval (Fig. 5A), circular (Fig. 5B), sandglass (Fig. 5C), fissure (Fig. 5D), and irregular. Statistical analysis Statistical analysis was performed using SPSS (the Statistical Package for the Social Sciences software version, Inc., Chicago, IL, the USA). Mann–Whitney U test, paired and unpaired t-tests were used to compare continuous variables concerning gender and sides, respectively. Categorical data was given as frequencies. One-way analysis of variance (ANOVA) was used to evaluate statistical differences between age groups, septum deviation types, and the SPF location types. A p value<0.05 was considered significant. Results Among the patients, 78 (50.9%) were females (mean age 41.05 ± 14.12 years) and 75 (49.1%) males (mean age 42.56 ± 12.20 years). They were divided into three age groups as 50 (30 female, 20 male) in group I (18–34 y), 59 (24 female, 35 male) in group II (35–51 y), and 44 (24 female, 20 male) in group III (52–73 y). Morphometric measurements were analyzed according to gender and laterality. No significant difference was detected between the right and left sides for all distances measured except SPF-CA ( p = 0.019) and SPF-BL ( p = 0.003). Males showed significantly longer mean SPF-CA, SPF-ML, SPF-NF, OSPF-ANS, and HSPF-ANS than females. While females have significantly higher mean SPF-AH and SPFA than males (Table 1 ). In the statistical analysis of the morphometric data obtained according to age groups, SPF-ML and SPFA were decreased with increasing age, whereas SPF-NF was determined as the smallest in group I. SPF-CA and HSPF-ANS were determined as the highest in group II, whereas SPF-AH and SPF-BL were determined as the smallest in group II (Table 2 ). Table 1 Statistical analysis of morphometric parameters by gender Female Male Total p Mean ± SD Mean ± SD Mean ± SD Axial SPF-CA (mm) 7,9 ± 1,5 8,5 ± 1,7 8,2 ± 1,6 0,000* SPF-ML (mm) 34,4 ± 2,2 35,2 ± 2,6 34,8 ± 2,4 0,002* SPF-AH (mm) 33,7 ± 5,2 32,0 ± 6,0 32,9 ± 5,6 0,005* SPF-BL (mm) 9,9 ± 2,1 10,0 ± 2,3 9,9 ± 2,2 0,872 Coronal SPF-NF (mm) 23,5 ± 2,2 26,7 ± 3,1 25,1 ± 3,1 0,000* FSP D (mm) 4,0 ± 1,0 4,1 ± 1,2 4,0 ± 1,1 0,209 Sagittal ASPF (°) 26,50 ± 7,92 22,18 ± 6,31 24,38 ± 7,48 0,000* OSPF-ANS (mm) 50,4 ± 3,5 53,2 ± 4,5 51,8 ± 4,3 0,000* HSPF-ANS (mm) 44,7 ± 4,2 49,2 ± 4,5 46,9 ± 4,9 0,000* SPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF D , vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p < 0.05). Table 2 Statistical analysis of morphometric parameters according to age groups Group I (18–34) Group II (35–51) Group III (52–73) p Mean ± SD Mean ± SD Mean ± SD Axial SPF-CA (mm) 8,3 ± 2,5 8,4 ± 1,8 7,8 ± 1,5 0,014* SPF-ML (mm) 35,3 ± 2,5 34,6 ± 2,3 34,5 ± 2,4 0,030* SPF-AH (mm) 34,3 ± 4,8 31,5 ± 5,3 33,2 ± 5,9 0,001* SPF-BL (mm) 10,7 ± 1,8 9,5 ± 2,4 9,7 ± 2,2 0,000* Coronal SPF-NF (mm) 24,4 ± 2,7 25,4 ± 3,2 25,5 ± 3,3 0,027* FSP D (mm) 4,0 ± 1,1 4,1 ± 1,1 4,0 ± 1,1 0,533 Sagittal ASPF (°) 28,48 ± 7,18 22,59 ± 7,45 22,13 ± 5,87 0,000* OSPF-ANS (mm) 51,4 ± 4,0 52,2 ± 4,7 51,7 ± 3,9 0,438 HSPF-ANS(mm) 45,0 ± 5,0 48,0 ± 5,2 47,8 ± 3,7 0,000* SPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF D , vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p < 0.05). Three-dimensional (3D) CT images showed that the shape of the SPF was variable as follows; oval in 22%, circular in 31.4%, fissure in 1.6%, sandglass in 7.2%, and irregular in 37.3% (Fig. 5 A, B, C, D). The number of SPF was identified as being single in 91.2%, double in 7.8%, and triple in 1% (Fig. 5 E, F). Type I localization of the SPF was observed in 100 (65.4%) patients, Type II in 43 (28.1%), and Type III in 10 (6.5%), respectively. The statistical analysis of the morphometric data according to the pneumatization of the middle turbinate is summarized in Table 3 . SPF-ML, SPF-NF, OSPF-ANS, and HSPF-ANS measurements were found to be significantly smaller in the case of concha bullosa, while SPFA was found to be higher. Table 3 Statistical analysis of morphometric data according to the presence of concha bullosa Concha Bullosa Absent Present p Mean ± SD Mean ± SD Axial SPF-CA (mm) 8,3 ± 1,6 7,9 ± 1,6 0,103 SPF-ML (mm) 35,0 ± 2,4 34,2 ± 2,5 0,011* SPF-AH (mm) 32,5 ± 5,5 33,6 ± 5,9 0,119 SPF-BL (mm) 10,0 ± 2,2 9,7 ± 2,2 0,196 Coronal SPF-NF (mm) 25,5 ± 3,3 24,0 ± 2,4 0,000* FSP D (mm) 4,1 ± 1,1 4,0 ± 1,1 0,441 Sagittal ASPF (°) 23,73 ± 7,63 25,94 ± 6,92 0,018* OSPF-ANS (mm) 52,3 ± 4,3 50,5 ± 3,9 0,001* HSPF-ANS (mm) 47,7 ± 5,0 45,2 ± 4,2 0,000* SPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF D , vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p < 0.05). No significant differences were found in the statistical analysis of morphometric data according to septum deviation types. According to the statistical analysis of the morphometric data according to the types of the location of the SPF, SPF D ( p = 0.003) was found to be significantly higher in the case of type II, while SPF-ML ( p = 0.049) was found to be higher in the case of type I. Discussion Epistaxis is a common condition faced by ENT specialists in the clinic. Most cases can be conservatively controlled with nasal packing or direct cautery, however, arterial ligation is the most common surgical treatment option for dangerous and recurrent posterior epistaxis [ 9 , 10 , 12 ]. The SPA ligation was most commonly preferred method with a high success rate (89%), which can be explained by end artery and very little collateral circulation. Some studies have reported that the treatment cost and hospital stay were smaller in SPA ligation compared to conventional tampons [ 7 , 10 , 11 ]. The anatomical variations of the SPF and lateral nasal wall may cause a 10% failure in success rate. In addition, difficulties may arise in determining the SPF during the ligation procedure in patients, who still have active hemorrhage despite medical anticoagulation or multiple rounds of nasal packings. Therefore, a surgeon must be aware of the surgical anatomy of the SPF and possible complications of the SPA ligation [ 1 , 4 , 10 , 16 ]. To describe the localization of SPF via landmarks can be harder in cadavers, whereas identifying endoscopically detectable surgical landmarks on preoperative CT scans would allow surgeons to reliably identify [ 4 , 13 ]. This study investigated that there might be a significant correlation between morphometric measurements and the variations of the SPF and lateral nasal wall, incorporating the landmarks reported in previous studies based upon the analysis of a large sample of CT images. In the current study, we reported that there was no statistically significant diference with respect to laterality, similar to data provided by El-Anwar et al. [ 4 ] and Maxwell et al. [ 10 ], but all measured distances were greater in males than females, which was consistent with the larger mean nasal cavity dimensions seen in men. The need for a preoperative evaluation of the anatomical variations of the SPF and the branching pattern of the SPA are important in presurgical planning to avoid iatrogenic vascular complications [ 6 , 14 , 17 ]. Sir and Eksert et al. [ 17 ] was reported that only one of the samples had an accessory foramen, while in studies by El-Shaarawy and Hassan et al. [ 5 ]; the number of the SPF was single in 82.5% and double in 17.5% of CT images. Gras-Cabrerizo et al. [ 6 ] reported that an accessory foramen was found in 7% of the cases and the branching pattern of the SPA was single in 68 (63%), two branches in 34 (32%), and three branches in 5 (5%) cases. We presented the results for the number of the SPF, which were as follows: one in 91.2%, double in 7.8%, and triple in 1% of 153 patients. In accordance with the studies, the number of the SPF was mostly single, while accessory foramen was very low. In addition, numerous authors have evaluated the shape variation of the SPF, which play a key role in presurgical planning during endoscopic sinus surgery, nasal endoscopic procedures. El-Shaarawy and Hassan et al. [ 5 ] classified the shape of the SPF into four types and reported that 35% oval, 25% circular, 32.5% irregular, 7.5% quadrangular SPF, while Sir ve Eksert et al. [ 19 ] observed most commonly a hourglass-shaped SPF and irregularly shaped SPF in four samples. We presented the results for the shape variation of the SPF, which were as follows: 37.5% irregular (n = 114), 31.4% circular (n = 96), 22.5% oval (n = 69), 7.2% hourglass (n = 22) and 1.6% fissure (n = 5) SPF. Similar to the classification of Scanavine et al. [ 16 ] and El-Shaarawy and Hassan et al. [ 5 ], we categorized the location of the SPF into three types based on the position of the middle turbinate and found the following frequencies among the 153 patients as follows: 65.4% (200/306) in Type I, 28.4% (87/306) in Type II and 6.2% (19/306) in Type III. Compared with the outcomes of previous studies, our results showed minimal diversity based on the number of patients who were included, methodology, and ethnicities. Statistically significant relationship was found between sinusitis, septal deviation,concha bullosa, nasal obstruction, postnasal discharge and epistaxis in previous studies. Also, it was reported that precise knowledge of these relationships is crucial in clinical practice for safer and effective surgery [ 8 , 14 , 18 ]. In our study, nasal septum deviation was classified into three types and concha bullosa was identified as present or absent on the axial plane. Notably, we analyzed the relationship between the morphometric measurements and concha bullosa because no study has been found examining this relationship. No significant difference was found in the statistical analysis of morphometric data according to septum deviation types, while the mean SPF-NF, SPF-ML, OSPF-ANS, and HSPF-ANS values were found to be significantly smaller and the SPFA was found to be higher in the case of concha bullosa. Due to the lack of comparative data in the literature, a comparison analysis can not be performed, but this relationship identified in this study can be used to more accurately locate the SPF by raising a smaller flap directly over the foramen. Thus, coagulation can be done directly on the artery with the smaller risk of complications and the success rate of the procedure increases. Different from other studies, which only included morphometric measurements in the literature, we evaluated variations of the SPF and lateral nasal wall and analyzed the relationship between them. We presented that there might be a significant correlation between the morphometric data and variations of the SPF and lateral nasal wall. So, we found that there was a significant correlation between the morphometric data and the incidence of concha bullosa. These anatomical relationships can be used as a reference for safe surgical approach to avoid iatrogenic vascular injury during SPA ligation. Awareness of these relationships can provide valuable information to the surgeon for a good understanding of the nasal vascular anatomy and reference points during nasal endoscopic procedures. So, the success rate of safe and effective surgery may increase and the risk of vascular complications can be decreased. The present study had several limitations. First, this retrospective study only evaluated asymptomatic adult patients. Extensive investigations of control and patient groups, and pediatric age groups can provide researchers with more comprehensive results. Second, further studies including different races and analysing the postoperative outcomes with prognosis are needed. Conclusion Fixed anatomical landmarks which making it easy to identify the localization of the SPF were identified on CT images. Based on the CT scan results, a significant correlation was found between the morphometric data and concha bullosa. In addition, the SPF was most commonly irregular shaped and single orifice. The prevalence of type I localization of the SPF was the highest. For a safer and more effective surgery and the prevention of iatrogenic complications, a surgeon should be aware of a significant correlation between the morphometric data and variations of the SPF. Recognising a significant correlation between the the pneumatization of the middle turbinate and the morphometric measurements of the SPF during SPA ligation, should be taken into account preoperatively. Declarations Ethics approval This study was presented at the department of radiology between January 2019 and May 2020 and approved by our local Ethics Committee with an approval No. 2020/2906. Competing interests The authors declare no competing interests. Author contributions ŞB, AG: Conceptualization, Methodology, Software. AD: Data curation, Writing- Original draft preparation. ŞB, AG, ÇAE: Visualization, Investigation. GA, ÇAE Supervision. 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Indian J Otolaryngol Head Neck Surg 65(1):86–8. https://doi.org/10.1007/s12070-012-0592-8 Traboulsi H, Alam E, Hadi U (2015) Changing trends in the management of epistaxis. Int J Otolaryngol 263987. https://doi.org/10.1155/2015/263987 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 10 Oct, 2022 Reviews received at journal 08 Oct, 2022 Reviews received at journal 23 Sep, 2022 Reviewers agreed at journal 22 Sep, 2022 Reviewers agreed at journal 21 Aug, 2022 Reviewers agreed at journal 18 Aug, 2022 Reviewers invited by journal 17 Aug, 2022 Editor assigned by journal 17 Aug, 2022 Submission checks completed at journal 16 Aug, 2022 First submitted to journal 10 Aug, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1949586","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":129441820,"identity":"0047b3a2-614a-4c8d-a969-e42a31de2998","order_by":0,"name":"Büşra Şeker","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYFACNgYGxgYQg/nwgw8gPjvxWtjSDGeAKGbitfAYSPOAbSOgQb69LfFx5Y7D9ubtxxKMbX5tk+djZmD88DEHtxaDM8cOG549czhxzpnkA49z+24btjEzMEvO3IZHi0R6m2Rj2+EECYa0BOPcntuMQC1szLx4tMjPf97+E6jFXoL/jYG0Zc9te4JaGG6wHWMEamGcIZFjIM3w43YiQS0GZ9KSJRvPpCfOkHiWZtjbcDu5jZmxGa9f5NuPGX5s3GENdFjy4Qc//ty2nd/efPDDR3wOQwGMbWCygVj1IPCHFMWjYBSMglEwUgAA1YVTD7o0ErgAAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Büşra","middleName":"","lastName":"Şeker","suffix":""},{"id":129441821,"identity":"f60fdb17-5218-48b5-b469-68d652c2efed","order_by":1,"name":"Gülay Açar","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gülay","middleName":"","lastName":"Açar","suffix":""},{"id":129441822,"identity":"47cde9ca-cdf0-4191-94f7-6dbdda41a3d3","order_by":2,"name":"Aynur Emine Çiçekcibaşı","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aynur","middleName":"Emine","lastName":"Çiçekcibaşı","suffix":""},{"id":129441823,"identity":"4839d6de-1e1c-43f6-8424-cc564f7f913d","order_by":3,"name":"Demet Aydoğdu","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Demet","middleName":"","lastName":"Aydoğdu","suffix":""}],"badges":[],"createdAt":"2022-08-10 14:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1949586/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1949586/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":25508614,"identity":"845f2e64-950b-4ac0-ac71-3df5173b81d0","added_by":"auto","created_at":"2022-08-22 18:17:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2098077,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT images showing the distances from the sphenopalatine foramen (SPF) to (A) Choanal arch (CA). (B) Maxillary line (ML). (C) Anterior head of the middle turbinate (AH). (D) Basal lamella of the middle turbinate (BL)\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/72dc919aa997353845f8a78e.png"},{"id":25508615,"identity":"e6883c77-c4fc-41ba-8e67-be4988264538","added_by":"auto","created_at":"2022-08-22 18:17:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1462163,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Coronal CT image showing the vertical distance from the sphenopalatine foramen (SPF) to the nasal floor (NF) (a) and the SPF diameter (b). (B) Sagittal CT image showing the oblique (c) and horizontal (d) distance from the SPF to the anterior nasal spine of the maxilla (ANS) and an angle between them (asterisk)\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/1809efbe4dcf5994939ea98e.png"},{"id":25509210,"identity":"f3ca17b7-80cb-4f57-8087-8de04f94a15e","added_by":"auto","created_at":"2022-08-22 18:22:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2105322,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT images showing\u003cstrong\u003e \u003c/strong\u003eseptum deviation types.\u003cstrong\u003e \u003c/strong\u003e(A)\u003cstrong\u003e \u003c/strong\u003eType A (anterior). (B)\u003cstrong\u003e \u003c/strong\u003eType B (middle). (C)\u003cstrong\u003e \u003c/strong\u003eType C (posterior). Coronal MDCT images showing the SPF location types according to the position of the middle turbinate. (D)\u003cstrong\u003e \u003c/strong\u003eType I (superior). (E)\u003cstrong\u003e \u003c/strong\u003eType II (middle). (F)\u003cstrong\u003e \u003c/strong\u003eType III (inferior)\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/967258760609f75a9547b5d3.png"},{"id":25508613,"identity":"779a5e4e-eefa-4dd3-8579-add94b8b7593","added_by":"auto","created_at":"2022-08-22 18:17:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1327747,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT images showing concha bullosa types. (A) Right concha bullosa. (B) Left concha bullosa. (C) Bilateral concha bullosa\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/d1f0ee209c02b12dc711b838.png"},{"id":25508616,"identity":"6fd959de-eb2d-4342-9d50-4a9516e46393","added_by":"auto","created_at":"2022-08-22 18:17:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":8501191,"visible":true,"origin":"","legend":"\u003cp\u003e3D reconstruction CT images of the sphenopalatine foramen (SPF). (A) Oval-shaped. (B) Circular-shaped. (C) Hourglass-shaped. (D) Fissure-shaped. (E) Double. (F) Triple\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/68dd7997fad6b76a20db8790.png"},{"id":25509211,"identity":"7b6aa010-b61f-4b26-af42-730c57a47601","added_by":"auto","created_at":"2022-08-22 18:22:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":260073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1949586/v1/cecae9ea-bec1-4ca4-ac70-8c848e37984b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Morphometric and Clinical Evaluation of Sphenopalatine Foramen on Computed Tomography Images","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpistaxis, seen in 60% of the population, of which 10% require medical attention, is one of the most common problems in otolaryngological emergencies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Anatomically, it is classified as anterior epistaxis originating from Little's area where the Kiesselbach plexus is located, and posterior epistaxis originating from Woodruff's area where sphenopalatine artery (SPA) branches are located [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Epistaxis treatment, in which the first aim is to find and stop bleeding, has a wide range from non-surgical procedures including the anterior and posterior packing to arterial ligation, to surgical interventions in case of failure. The more severe and recurrent form of posterior epistaxis commonly requires ligation of the SPA due to its high success (87\u0026ndash;100%) among surgical treatment options [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The SPA passes through the sphenopalatine foramen (SPF) and branches within it [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The notch between the orbital and sphenoid processes at the upper border of the perpendicular plate of the palatine bone is closed with the body of the sphenoid bone and called the SPF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Difficulty in determining the localization of the SPF may occur in patients with active bleeding during the ligation procedure. Therefore, the identification of fixed anatomical landmarks in computed tomography (CT) images makes it easier to determine a more accurate incision location with the removal of a smaller mucoperiosteal flap directly over the SPF and to identify the SPA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Some studies have shown that there are many variations of the shape and number of the SPF [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The morphometry of the SPF and the relationship between the SPF variations and the position of the middle turbinate have been investigated in many studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. On the other hand, the septal deviation and the pneumatization of the middle turbinate (concha bullosa) may lead to nasal obstruction, persistent headache, postnasal discharge, and epistaxis, which may affect the localization of the SPF. Detailed information about the anatomical variations of the SPF and lateral nasal wall contributes is important for more accurate identification of the SPF during surgical operations. However, the anatomy of the region is complex and not suitable for working on cadavers. For this reason, CT images, which are the best method for imaging bone structure, facilitate an appropriate preoperative localization of the SPF and make the procedure safer with a lower incidence of morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Our radiological study aimed to describe the localization and variations of the SPF with adjacent structures. Also, we aimed to analyze the relationship of the SPF with the septal deviation and concha bullosa.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThis study was performed using paranasal CT images of 153 patients, aged 18\u0026ndash;73 years, who presented at the department of radiology between January 2019 and May 2020 and approved by our local Ethics Committee with an approval number 2020/2906. For inclusion, healthy individuals without any pathology in the region were included in the study. Exclusion criteria included previous bony fracture or paranasal surgery, paranasal pathology, congenital craniofacial anomaly, and the imaging files with low-resolution. CT images were obtained using Somatom Drive (Siemens Healthineers, Germany) 256 multislice scanner with the following study parameters, exposure 120 kV, 74 mA, 60 mAs, rotation time 0.28 s, slice thickness 0.625 mm. CT images were evaluated by two experienced anatomists and one radiologist in consensus by use of Snygo-Via (Siemens, Germany) software. Measurements in sagittal, transverse, and coronal sections and images 3D were made at least twice by a radiologist and two anatomists, and their mean values were recorded.\u003c/p\u003e\n\u003cp\u003eBased on data provided in El-Anwar et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[4], Maxwell et al.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[10], and Sir et Eksert\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[17], all reformatted images were used to measure these surgical morphometric parameters\u0026nbsp;from each side and gender discrimination:\u003c/p\u003e\n\u003cp\u003e1. On axial images,\u003c/p\u003e\n\u003cp\u003e- SPF-CA, the vertical distances from the SPF to the choanal arch\u0026nbsp;(Fig. 1A),\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp;SPF-ML, the vertical distances from the SPF to the maxillary line\u0026nbsp;(Fig. 1B),\u003c/p\u003e\n\u003cp\u003e- SPF-AH and SPF-BL, the anteroposterior distances from the SPF to the anterior head and basal lamella of the middle turbinate\u0026nbsp;(Fig. 1C, D).\u003c/p\u003e\n\u003cp\u003e2. On coronal images,\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp;SPF-NF, the vertical distance from the SPF to the nasal floor (Fig. 2a),\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp;SPF\u003csub\u003eD\u003c/sub\u003e,\u0026nbsp;the\u0026nbsp;vertical diameter of the SPF (Fig. 2b),\u003c/p\u003e\n\u003cp\u003e3. On sagittal images,\u003c/p\u003e\n\u003cp\u003e- SPFA, the angle between SPF and the anterior nasal spine of the maxilla (Fig. 2*),\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp;OSPF-ANS, the oblique distance between the SPF and the anterior nasal spine of the maxilla (Fig. 2c),\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp;HSPF-ANS, the horizontal distance between the SPF and the anterior nasal spine of the maxilla (Fig. 2d).\u003c/p\u003e\n\u003cp\u003eAdditionally, morphological variations of the SPF and the lateral nasal wall were evaluated as follows:\u003c/p\u003e\n\u003cp\u003e1. Septum deviation was classified into three types in the axial plane:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type A: Deviation at the anterior part of the septum (Fig. 3A).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type B: Deviation at the middle part of the septum (Fig. 3B).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type C: Deviation at the posterior part of the septum (Fig. 3C).\u003c/p\u003e\n\u003cp\u003e2. The location of the SPF was identified according to the position of the middle turbinate as follows:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type I: The posterior tip of the bony crest of the middle turbinate at the superior border of the SPF (Fig. 3D).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type II: The posterior tip of the bony crest of the middle turbinate at the inferior border of the SPF (Fig. 3E).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Type III: The posterior tip of the bony crest of the middle turbinate at the middle of the SPF (Fig. 3F).\u003c/p\u003e\n\u003cp\u003e3. Pneumatization of the middle turbinate was identified as present (concha bullosa) or absent concerning laterality (Fig. 4A-C).\u003c/p\u003e\n\u003cp\u003e4. The number of SPF was noted (Fig. 5E, F) and the shape of the SPF was classified into five types: oval (Fig. 5A), circular (Fig. 5B), sandglass (Fig. 5C), fissure (Fig. 5D), and irregular.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS (the Statistical Package for the Social Sciences software version, Inc., Chicago, IL, the USA). Mann\u0026ndash;Whitney U test, paired and unpaired t-tests were used to compare continuous variables concerning gender and sides, respectively. Categorical data was given as frequencies. One-way analysis of variance (ANOVA) was used to evaluate statistical differences between age groups, septum deviation types, and the SPF location types. A p value\u0026lt;0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the patients, 78 (50.9%) were females (mean age 41.05\u0026thinsp;\u0026plusmn;\u0026thinsp;14.12 years) and 75 (49.1%) males (mean age 42.56\u0026thinsp;\u0026plusmn;\u0026thinsp;12.20 years). They were divided into three age groups as 50 (30 female, 20 male) in group I (18\u0026ndash;34 y), 59 (24 female, 35 male) in group II (35\u0026ndash;51 y), and 44 (24 female, 20 male) in group III (52\u0026ndash;73 y).\u003c/p\u003e\n\u003cp\u003eMorphometric measurements were analyzed according to gender and laterality. No significant difference was detected between the right and left sides for all distances measured except SPF-CA (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019) and SPF-BL (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). Males showed significantly longer mean SPF-CA, SPF-ML, SPF-NF, OSPF-ANS, and HSPF-ANS than females. While females have significantly higher mean SPF-AH and SPFA than males (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In the statistical analysis of the morphometric data obtained according to age groups, SPF-ML and SPFA were decreased with increasing age, whereas SPF-NF was determined as the smallest in group I. SPF-CA and HSPF-ANS were determined as the highest in group II, whereas SPF-AH and SPF-BL were determined as the smallest in group II (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab1\" style=\"margin-right: calc(40%); width: 60%;\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStatistical analysis of morphometric parameters by gender\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\" style=\"width: 12.5874%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 18.6003%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 22.0247%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 23.3431%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 15.1986%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 18.6003%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 22.0247%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 23.3431%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 15.1986%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\n \u003cp\u003eAxial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eSPF-CA (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e7,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e8,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e8,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eSPF-ML (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e34,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e35,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e34,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eSPF-AH (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e33,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e32,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;6,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e32,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eSPF-BL (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e9,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e10,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e9,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,872\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\n \u003cp\u003eCoronal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eSPF-NF (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e23,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e26,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e25,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eFSP\u003csub\u003eD\u003c/sub\u003e (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e4,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\n \u003cp\u003eSagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eASPF (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e26,50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;7,92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e22,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;6,31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e24,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;7,48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eOSPF-ANS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e50,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e53,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e51,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.7722%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.8152%;\"\u003e\n \u003cp\u003eHSPF-ANS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.1527%;\"\u003e\n \u003cp\u003e44,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.4753%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.9414%;\"\u003e\n \u003cp\u003e49,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.0052%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.556%;\"\u003e\n \u003cp\u003e46,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3607%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 15.1985%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 55.2816%;\"\u003eSPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF\u003csub\u003eD\u003c/sub\u003e, vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStatistical analysis of morphometric parameters according to age groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\" style=\"width: 14.5501%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 6.8225%;\"\u003e\n \u003cp\u003eGroup I (18\u0026ndash;34)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 10.7907%;\"\u003e\n \u003cp\u003eGroup II (35\u0026ndash;51)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 11.2781%;\"\u003e\n \u003cp\u003eGroup III (52\u0026ndash;73)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 8.8414%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 10.7907%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 11.2781%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 10.1642%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\n \u003cp\u003eAxial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eSPF-CA (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e8,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e7,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eSPF-ML (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e35,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e34,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e34,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,030*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eSPF-AH (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e34,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e31,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e33,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eSPF-BL (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e10,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e9,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e9,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\n \u003cp\u003eCoronal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eSPF-NF (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e24,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e25,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e25,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,027*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eFSP\u003csub\u003eD\u003c/sub\u003e (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e4,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\n \u003cp\u003eSagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eASPF (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e28,48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;7,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e22,59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;7,45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e22,13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eOSPF-ANS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e51,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e52,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e51,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,438\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 6.3352%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.2149%;\"\u003e\n \u003cp\u003eHSPF-ANS(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.2213%;\"\u003e\n \u003cp\u003e45,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 3.6201%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.5948%;\"\u003e\n \u003cp\u003e48,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.196%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 4.6644%;\"\u003e\n \u003cp\u003e47,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6833%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.1642%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 55.6245%;\"\u003eSPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF\u003csub\u003eD\u003c/sub\u003e, vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eThree-dimensional (3D) CT images showed that the shape of the SPF was variable as follows; oval in 22%, circular in 31.4%, fissure in 1.6%, sandglass in 7.2%, and irregular in 37.3% (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eA, B, C, D). The number of SPF was identified as being single in 91.2%, double in 7.8%, and triple in 1% (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eE, F). Type I localization of the SPF was observed in 100 (65.4%) patients, Type II in 43 (28.1%), and Type III in 10 (6.5%), respectively.\u003c/p\u003e\n\u003cp\u003eThe statistical analysis of the morphometric data according to the pneumatization of the middle turbinate is summarized in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. SPF-ML, SPF-NF, OSPF-ANS, and HSPF-ANS measurements were found to be significantly smaller in the case of concha bullosa, while SPFA was found to be higher.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStatistical analysis of morphometric data according to the presence of concha bullosa\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 19.905%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\" style=\"width: 22.1307%;\"\u003e\n \u003cp\u003eConcha Bullosa\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 8.6449%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\" style=\"width: 19.905%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 9.3713%;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 15.1104%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 14.3839%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 15.1104%;\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\n \u003cp\u003eAxial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eSPF-CA (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e8,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e7,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,103\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eSPF-ML (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e35,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e34,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eSPF-AH (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e32,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e33,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eSPF-BL (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e10,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e9,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\n \u003cp\u003eCoronal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eSPF-NF (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e25,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e24,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eFSP\u003csub\u003eD\u003c/sub\u003e (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e4,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e4,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\n \u003cp\u003eSagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eASPF (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e23,73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;7,63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e25,94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;6,92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,018*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eOSPF-ANS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e52,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e50,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;3,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 9.0807%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.8243%;\"\u003e\n \u003cp\u003eHSPF-ANS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.0467%;\"\u003e\n \u003cp\u003e47,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.3372%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;5,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2646%;\"\u003e\n \u003cp\u003e45,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.8458%;\"\u003e\n \u003cp\u003e\u0026plusmn;\u0026thinsp;4,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.6449%;\"\u003e\n \u003cp\u003e0,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 58.0441%;\"\u003eSPF-CA, distance between SPF and choanal arch; SPF-ML, distance between SPF and maxillary line; SPF-AH, distance between SPF and anterior head of the middle turbinate; SPF-BL distance between SPF and basal lamella; SPF-NF, distance between SPF and nasal floor; SPF\u003csub\u003eD\u003c/sub\u003e, vertical diameter of the SPF; SPFA, angle between SPF and anterior nasal spine; OSPF-ANS, oblique distance between the SPF and anterior nasal spine; HSPF-ANS, horizontal distance between the SPF and anterior nasal spine. Statistically significant p value (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eNo significant differences were found in the statistical analysis of morphometric data according to septum deviation types. According to the statistical analysis of the morphometric data according to the types of the location of the SPF, SPF\u003csub\u003eD\u003c/sub\u003e (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) was found to be significantly higher in the case of type II, while SPF-ML (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049) was found to be higher in the case of type I.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEpistaxis is a common condition faced by ENT specialists in the clinic. Most cases can be conservatively controlled with nasal packing or direct cautery, however, arterial ligation is the most common surgical treatment option for dangerous and recurrent posterior epistaxis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The SPA ligation was most commonly preferred method with a high success rate (89%), which can be explained by end artery and very little collateral circulation. Some studies have reported that the treatment cost and hospital stay were smaller in SPA ligation compared to conventional tampons [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The anatomical variations of the SPF and lateral nasal wall may cause a 10% failure in success rate. In addition, difficulties may arise in determining the SPF during the ligation procedure in patients, who still have active hemorrhage despite medical anticoagulation or multiple rounds of nasal packings. Therefore, a surgeon must be aware of the surgical anatomy of the SPF and possible complications of the SPA ligation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo describe the localization of SPF via landmarks can be harder in cadavers, whereas identifying endoscopically detectable surgical landmarks on preoperative CT scans would allow surgeons to reliably identify [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This study investigated that there might be a significant correlation between morphometric measurements and the variations of the SPF and lateral nasal wall, incorporating the landmarks reported in previous studies based upon the analysis of a large sample of CT images.\u003c/p\u003e \u003cp\u003eIn the current study, we reported that there was no statistically significant diference with respect to laterality, similar to data provided by El-Anwar et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and Maxwell et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], but all measured distances were greater in males than females, which was consistent with the larger mean nasal cavity dimensions seen in men.\u003c/p\u003e \u003cp\u003eThe need for a preoperative evaluation of the anatomical variations of the SPF and the branching pattern of the SPA are important in presurgical planning to avoid iatrogenic vascular complications [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Sir and Eksert et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] was reported that only one of the samples had an accessory foramen, while in studies by El-Shaarawy and Hassan et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; the number of the SPF was single in 82.5% and double in 17.5% of CT images. Gras-Cabrerizo et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported that an accessory foramen was found in 7% of the cases and the branching pattern of the SPA was single in 68 (63%), two branches in 34 (32%), and three branches in 5 (5%) cases. We presented the results for the number of the SPF, which were as follows: one in 91.2%, double in 7.8%, and triple in 1% of 153 patients. In accordance with the studies, the number of the SPF was mostly single, while accessory foramen was very low. In addition, numerous authors have evaluated the shape variation of the SPF, which play a key role in presurgical planning during endoscopic sinus surgery, nasal endoscopic procedures. El-Shaarawy and Hassan et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] classified the shape of the SPF into four types and reported that 35% oval, 25% circular, 32.5% irregular, 7.5% quadrangular SPF, while Sir ve Eksert et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] observed most commonly a hourglass-shaped SPF and irregularly shaped SPF in four samples. We presented the results for the shape variation of the SPF, which were as follows: 37.5% irregular (n\u0026thinsp;=\u0026thinsp;114), 31.4% circular (n\u0026thinsp;=\u0026thinsp;96), 22.5% oval (n\u0026thinsp;=\u0026thinsp;69), 7.2% hourglass (n\u0026thinsp;=\u0026thinsp;22) and 1.6% fissure (n\u0026thinsp;=\u0026thinsp;5) SPF.\u003c/p\u003e \u003cp\u003eSimilar to the classification of Scanavine et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and El-Shaarawy and Hassan et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], we categorized the location of the SPF into three types based on the position of the middle turbinate and found the following frequencies among the 153 patients as follows: 65.4% (200/306) in Type I, 28.4% (87/306) in Type II and 6.2% (19/306) in Type III. Compared with the outcomes of previous studies, our results showed minimal diversity based on the number of patients who were included, methodology, and ethnicities.\u003c/p\u003e \u003cp\u003eStatistically significant relationship was found between sinusitis, septal deviation,concha bullosa, nasal obstruction, postnasal discharge and epistaxis in previous studies. Also, it was reported that precise knowledge of these relationships is crucial in clinical practice for safer and effective surgery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our study, nasal septum deviation was classified into three types and concha bullosa was identified as present or absent on the axial plane. Notably, we analyzed the relationship between the morphometric measurements and concha bullosa because no study has been found examining this relationship. No significant difference was found in the statistical analysis of morphometric data according to septum deviation types, while the mean SPF-NF, SPF-ML, OSPF-ANS, and HSPF-ANS values were found to be significantly smaller and the SPFA was found to be higher in the case of concha bullosa. Due to the lack of comparative data in the literature, a comparison analysis can not be performed, but this relationship identified in this study can be used to more accurately locate the SPF by raising a smaller flap directly over the foramen. Thus, coagulation can be done directly on the artery with the smaller risk of complications and the success rate of the procedure increases.\u003c/p\u003e \u003cp\u003eDifferent from other studies, which only included morphometric measurements in the literature, we evaluated variations of the SPF and lateral nasal wall and analyzed the relationship between them. We presented that there might be a significant correlation between the morphometric data and variations of the SPF and lateral nasal wall. So, we found that there was a significant correlation between the morphometric data and the incidence of concha bullosa. These anatomical relationships can be used as a reference for safe surgical approach to avoid iatrogenic vascular injury during SPA ligation. Awareness of these relationships can provide valuable information to the surgeon for a good understanding of the nasal vascular anatomy and reference points during nasal endoscopic procedures. So, the success rate of safe and effective surgery may increase and the risk of vascular complications can be decreased. The present study had several limitations. First, this retrospective study only evaluated asymptomatic adult patients. Extensive investigations of control and patient groups, and pediatric age groups can provide researchers with more comprehensive results. Second, further studies including different races and analysing the postoperative outcomes with prognosis are needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFixed anatomical landmarks which making it easy to identify the localization of the SPF were identified on CT images. Based on the CT scan results, a significant correlation was found between the morphometric data and concha bullosa. In addition, the SPF was most commonly irregular shaped and single orifice. The prevalence of type I localization of the SPF was the highest. For a safer and more effective surgery and the prevention of iatrogenic complications, a surgeon should be aware of a significant correlation between the morphometric data and variations of the SPF. Recognising a significant correlation between the the pneumatization of the middle turbinate and the morphometric measurements of the SPF during SPA ligation, should be taken into account preoperatively.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003eThis study was presented at the department of radiology between January 2019 and May 2020 and approved by our local Ethics Committee with an approval No. 2020/2906.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eŞB, AG: Conceptualization, Methodology, Software. AD: Data curation, Writing- Original draft preparation. ŞB, AG, \u0026Ccedil;AE: Visualization, Investigation. GA, \u0026Ccedil;AE Supervision. AD: Software, Validation. ŞB, AG, \u0026Ccedil;AE: Writing- Reviewing and Editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eNo funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlherabi A, Marglani O, Herzallah IR, Shaibah H, Alaidarous T, Alkaff H, et al (2014) Endoscopic localization of the sphenopalatine foramen: do measurements matter? Eur Arch Otorhinolaryngol 271(9):2455\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00405-014-2881-1\u003c/span\u003e\u003cspan address=\"10.1007/s00405-014-2881-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChitsuthipakorn W, Seresirikachorn K, Kanjanawasee D, Snidvongs K (2020) Endoscopic sphenopalatine foramen cauterization is an effective treatment modification of endoscopic sphenopalatine artery ligation for intractable posterior epistaxis. 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Int J Otolaryngol 263987. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2015/263987\u003c/span\u003e\u003cspan address=\"10.1155/2015/263987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Anatomical variation, epistaxis, computed tomography, concha bullosa, sphenopalatine foramen","lastPublishedDoi":"10.21203/rs.3.rs-1949586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1949586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the effect of anatomical variations in the sphenopalatine foramen and the lateral nasal wall on sphenopalatine foramen-related morphometric measurements.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTemporal bone multidetector computed tomography records of 153 patients were evaluated. Morphometric measurements were made between the fixed anatomical landmarks and the sphenopalatine foramen. Number, shape, localization variation of the sphenopalatine foramen, concha bullosa, and septum deviation were noted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo significant difference was detected between the right-left sides for all distances measured except SPF-CA and SPF-BL and most of the measurements were higher in males. In addition, statistical analysis of the obtained morphometric data was performed according to age groups. Classified the shape of the sphenopalatine foramen five types and reported that the most common irregularly shaped (37.3%). In our study, 91.2% single, 7.8% double, and 1% triple sphenopalatine foramen were detected. The location of sphenopalatine foramen was reported as the most common type I. No statistically significant relationship could be determined between morphometric data and septum deviation types. SPF-NF, SPF-ML, OSPF-ANS, and HSPF-ANS measurements were found to be significantly smaller in the presence of concha bullosa, whereas SPFA was found to be higher.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study revealed a significant relationship between the morphometric measurements of the sphenopalatine foramen and concha bullosa, while septum deviation types did not affect morphometric results. For a safer and more effective surgery with prevention of iatrogenic complications, a surgeon should be aware of this correlation, especially in endoscopic sphenopalatine foramen approaches.\u003c/p\u003e","manuscriptTitle":"Morphometric and Clinical Evaluation of Sphenopalatine Foramen on Computed Tomography Images","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-22 18:17:54","doi":"10.21203/rs.3.rs-1949586/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-10-10T04:09:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-10-08T09:33:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-23T10:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8162a995-0d8e-4463-b436-0b5ffd2d04d7","date":"2022-09-23T02:57:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55b4e79b-0dfc-4edc-b84f-079dfbb68d2e","date":"2022-08-21T11:43:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4bae0152-ff9d-4bb5-97fd-78d5ca7386d8","date":"2022-08-18T07:20:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-18T02:50:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-17T16:50:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-08-17T02:28:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Surgical and Radiologic Anatomy","date":"2022-08-10T14:32:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ae461667-539c-47d4-9baa-3a3d86549d67","owner":[],"postedDate":"August 22nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-11-07T10:44:33+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-22 18:17:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1949586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1949586","identity":"rs-1949586","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}