Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study

PURPOSE: The anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection. METHODS: Eighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks. RESULTS: Distances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99). CONCLUSION: The middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.