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Introduction
Epistaxis is the commonest ENT emergency.1 Between 90 and 95 per cent2,3 of nosebleeds arise from the anterior part of the septum. There remains a common area of debate and uncertainty about the location of bleeding sites in cases of posterior epistaxis. Historically, some authors4 have supported the idea that the septum is the commonest site of bleeding, whilst others5,6 have favoured the lateral nasal wall, commonly referring to Woodruff's plexus7 as a source.
In 1949, Woodruff, using a rigid nasopharyngoscope, noticed 'a group or plexus of rather large blood vessels in the lateral wall of the inferior wall of the inferior meatus well posteriorly' which he termed the 'naso-nasopharyngeal plexus'. Reference to the original article shows that Woodruff himself merely suggested an association between this plexus and epistaxis, without offering evidence to support this view. However, from this time, numerous textbooks8,9 and journal articles10-12 have asserted that Woodruff's plexus is the commonest source of bleeding in posterior epistaxis, despite the continued lack of supporting evidence. In spite of its supposed importance, the nature of Woodruff's plexus is unclear and poorly understood.
Some authors13,14 state that the plexus is arterial; however, on endoscopy (Figure 1), it looks more likely to be venous in nature.
Fig. 1
An endoscopic view of the posterior nasal cavity. Woodruff's plexus (WP) is easily seen in most patients. Anecdotally, it is said to be more prominent with increasing age.7 IT = inferior turbinate; NP = nasopharynx
An anatomical investigation was undertaken to test the hypothesis that Woodruff's plexus was indeed a venous plexus.
Materials and methods
A number of complementary methods were combined to establish the exact nature of Woodruff's plexus: (1) anatomical dissection and microdissection, (2) histological analysis, and (3) Spalteholz 'clearing' techniques.
A total of 21 cadaveric heads belonging to the anatomy department of the University of Glasgow were used in this anatomical study.
Microdissection
After normal embalming by arterial injection through the common carotid artery, seven cadavers were further injected through the same cannula with a mixture of latex and Indian ink, and another seven were left uninjected as controls. Subsequently, in all 14 specimens, the heads...