Revisiting the Anatomy of the Facial Recess: The Boundaries of the Round Window Exposure.

BACKGROUND: The exposure of the round window (RW) through the facial recess (FR) is sometimes partial. The anatomic variations that alter RW exposure during cochleostomy have not been clearly defined to date. AIMS: The aim of this study was to assess the best FR position in which to achieve the widest exposure of the RW niche and to define the topographic relationship between two other important anatomical structures, the facial nerve (FN) and the chorda tympani (CT). STUDY DESIGN: Cadaver study. METHODS: Twenty-four temporal bones were included in the study. Anterior and posterior epitympanectomy and posterior tympanotomy were performed after mastoidectomy. Bone was removed until the FN and CT were skeletonized and the CT branching point was visible. Two pictures were taken. The first was taken when the facial recess was at its widest exposure, while the second was taken when the RW niche was maximally exposed through the facial recess. Various measurements were taken. RESULTS: The RW niche was totally visible in 19 temporal bones (79.2%). The RW was partially visible in the remaining five bones (20.8%). The unexposed part of the RW lay posteromedial to the FN in these five bones. While the branching point of the CT could be visualized in all cases at the widest exposure of RW, the part of the FN distal to the branching point was hidden in eight subjects (33.3%) under the posterior wall of the external ear canal. CONCLUSIONS: The RW niche was totally visible in most of the temporal bones. The RW lay posteromedial to the FN in some cases and total exposure was impossible.

The clinical value of the novel cauterization procedure for the inferior turbinate artery during turbinate surgery.

The objective of the study was to evaluate the efficacy and the safety of the novel cauterization procedure of the inferior turbinate artery, which may be performed with any kind of inferior turbinate procedures in reducing the intra and the post-operative bleeding in partial inferior turbinectomy. A prospective controlled study was conducted in a referral center. Sixty patients (38M, 22F) who underwent partial turbinectomy were included. In 20 patients, partial turbinectomy was performed with the cauterization in one nasal cavity and the other one without it. The remaining 40 patients were divided into two groups which comprised cauterization positive and negative patients and are assessed in terms of post-operative bleeding. The area of the cauterization was 1 cm(2) field which is 1 cm anterior to the posterior attachment of the inferior turbinate on the lateral nasal wall, very close to the inferior turbinate, where the pulsating vessel is most commonly seen. Mean operation time, mean intra-operative blood loss and post-operative bleeding incidence are the main outcome measures. Post-operative bleeding was seen in three patients (15%) in the cauterization negative group. No patient had post-operative bleeding in the cauterization positive group. Mean operation time and mean intra-operative bleeding amount were significantly lower in the cauterization positive side. Cauterization of the inferior turbinate artery on the lateral nasal wall is a safe and effective method which may also be performed with any kind of inferior turbinate procedures to reduce both the operation time and intra and post-operative bleeding.

Blood supply of the inferior turbinate and its clinical applications.

One of the most effective treatments of inferior turbinate (IT) hypertrophy is surgical reduction. Bleeding from the IT branch of the posterior lateral nasal artery (ITB) may interfere with the outcome of IT surgery. The aim of this study is to define the anatomic localization of the ITB and its variations and to investigate its clinical importance. Anatomic relations of the ITB were determined by microdissecting 20 adult, sagittally cross-sectioned head specimens. Branching characteristics of the ITB and its anatomical relations were evaluated. The most consistent two markers to define the ITB on the lateral nasal wall were the posterior attachment of the IT (PAIT) and the posterior attachment of the middle turbinate (PAMT). Mean horizontal distances of the ITB from the PAIT and the PAMT were 7.2 mm ± 2.8 mm (2.5-11.8 mm) and 8.2 mm ± 2.8 mm (4-14.6 mm), respectively. ITB was the only major artery that supplied the IT in 85% of the specimens, and, in 15%, there was more than one artery. ITB was located lateral to the IT in 95% and medial to the IT in 5%. The ITB coursed on the lateral nasal wall, vertically between the middle and ITs and always anterior to the PAIT. All the variations of blood supply to the IT were within a one square centimeter area, ∼1-cm anterior to the PAIT. Successful cauterization of this particular area may be an alternative cauterization site in IT surgery.

A quite rare condition: absence of sphenoidal sinuses.

The absence of sphenoidal sinuses (SS) in an adult is an extremely rare condition. We investigated in agenesis of the sphenoid, maxillary, ethmoid, and frontal sinuses in 20 male adult cadavers. In a 50-year-old man, bilateral absence of the SS was observed. On the macroscopic examination, opening of the SS was not found on the lateral wall of the nasal cavity. There were multiple small mucosal grooves between the sphenoidal rostrum and the superior nasal turbinates. The bulging of the sphenoidal rostrum at the choanal level was flat. The body of the sphenoid bone was normal and consisted of a symmetrical bony structure with a total lack of pneumatization. Other paranasal sinuses agenesis was not observed. Surgeons should also consider the possibility of sphenoidal agenesis before transsphenoidal hypophysectomy. As a supplement to the traditional classification, agenesis of the SS can be described as the fourth type of pneumatization.

A surgical view of the superior nasal turbinate: anatomical study.

Differences of the superior nasal turbinate (SNT), presence of the supreme nasal turbinate (SpNT) and measurements of opening sphenoid sinus (OSS) are consistent anatomical landmarks that allow for safe entrances, such as posterior ethmoidectomy and sphenoid sinusotomy. The purpose of study was to investigate the anatomical details of the SNT for approaching the OSS on 20 specimens of adult cadavers under an operating microscope. The SNT and SpNT were localized more perpendicular than parallel to their axes. The SpNT structure was observed in 12 specimens (60%) and it was classified into three types. Type A SpNT was shortest of all turbinates (58.3%). In types B and C, SpNT was equal or larger than the SNT. These types were seen in 41.7% of specimens. In 11 specimens, posterior ethmoidal cells opened to supreme nasal meatus. In 7 specimens, there was one opening to supreme nasal meatus, while 2 openings were detected in 12 specimens, and 3 openings were seen in 1 specimen. All these openings belonged to posterior ethmoidal cells. To determine the position of the OSS, distances between some anatomical points were measured. In cases where the SpNT is present or the SpNT is bigger than the SNT, it is certain that a different method will be applied during the procedure in the nasal cavity. The SNT and the SpNT may easily be injured by unrecognized dissection in types B and C, leading to the disruption of its olfactory neuroepithelium and possibly to postoperative hyposmia.

Anatomical analysis of the prevalence of agger nasi cell in the Turkish population.

OBJECTIVES: The aim of this study is to give information about the anatomy of agger nasi cell for the surgery of the nasal cavity lateral wall. MATERIAL AND METHODS: Twenty mid-sagittal head sections were obtained at random from formalin fixed male Turkish cadavers (12 left sides, 8 right sides). The presence and anatomical structure of agger nasi cell were investigated under operating microscope. RESULTS: Agger nasi cell, which lies between nasal cavity and lacrimal sac, was observed in eight of 20 specimens (40%). Whereas three of them showed a remarkable swelling along the lateral nasal wall, in five specimens of agger nasi cells there was superficially no swelling observed. CONCLUSION: This anatomic study presents microsurgical information on the convoluted anatomy of agger nasi cell.

Anatomical features of the opening of the nasolacrimal duct and the lacrimal fold (Hasner's valve) for intranasal surgery: a cadaveric study.

The location and size of the opening of the nasolacrimal duct and the lacrimal fold (Hasner's valve) are variable. These features have clinical importance in nasal surgery because of the difficulty in determining their location. The aim of this study was to demonstrate the anatomical features of the opening of the nasolacrimal duct and the lacrimal fold and to discuss the importance of such knowledge in minimizing the risk of injury at surgery. Twenty sagittal head sections from formalin-fixed cadavers were examined. The sections showed no evidence of pathology or trauma. The type of opening of the nasolacrimal duct was a vertical sulcus in 14 of 20 (70%), an oblique sulcus in 2 of 20 (10%), an oblique fissure in 2 of 20 (10%), a vertical fissure in 1 of 20 (5%), and an anteroposterior fissure in 1 of 20 specimens (5%). The lacrimal fold was present in 16 of 20 specimens (80%). Five different forms of this fold were observed. Some morphological features were evaluated quantitatively. We believe that detailed anatomical knowledge of the opening of nasolacrimal duct will be useful in surgical approaches to this area.

Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure.

BACKGROUND: Sphenopalatine artery (SPA) ligation or cauterization stands to be one of the most common management options of refractory epistaxis. Ramification pattern of SPA as it passes through sphenopalatine foramen (SPF) has not been clearly established. The aim of this study is to investigate situations in which middle meatal approach may fail due to anatomic variations of SPA and to define a minimally invasive surgical cauterization procedure. Anatomic variations of SPA were determined by microdissection of 20 adult sagittally cross-sectioned head specimens. METHODS: Branching characteristics of SPA and its anatomic relations were evaluated and anatomic variations were noted. RESULTS: SPA was generally (80%) forming branches within SPF before entering into the nasal cavity. In 20% of the specimens, SPF was located superior to the horizontal lamella of the middle turbinate, and accessory foramen was present in 10%. In 10% of the cases, the posterior lateral nasal branch was situated as two branches in a deep sulcus in the middle meatus. CONCLUSION: The ramification pattern of SPA can not be fully exposed without resection of the posterior part of the middle turbinate via the middle meatal approach. Two-step procedures are advocated in reducing failure rates. Previously defined two-step procedures are relatively invasive. A less invasive procedure is defined based on the variations of SPA and SPF.

Intranasal localization of the lacrimal sac.

OBJECTIVE: To optimize the approach to the lacrimal sac during intranasal dacryocystorhinostomy. DESIGN: Microscopic measurement of anatomical landmarks in cadaver sagittal head sections. SETTING: The anatomy department of a large university hospital. PARTICIPANTS: Twenty adult cadaver sagittal head sections (12 right and 8 left) fixed with 10% formaldehyde solution were evaluated. INTERVENTION: During endoscopic dissections, the maxillary line, lacrimomaxillary suture, nasolacrimal duct, and lacrimal sac were exposed. MAIN OUTCOME MEASURES: Greater knowledge of the relationship among anatomical structures. RESULTS: The entire lacrimal sac was in 2 of 20 sides anterior and in 3 of 20 sides posterior to the axilla of the middle nasal concha. The fornix of the lacrimal sac was situated above the axilla in all sides. We evaluated the localization of the lacrimal sac to the maxillary line, which is of clinical importance in intranasal osteotomy during dacryocystorhinostomy. In 17 of 20 sides it is possible to reveal the axilla of the middle nasal concha during osteotomy. CONCLUSIONS: Underexposure or lack of true localization of the sac are the most frequently encountered reasons for dacryocystorhinostomy failure. The maxillary line and adhesion point of the middle nasal concha are the 2 most important landmarks in localization of the sac. A mucosal incision anterior to the maxillary line and dissection up to the point where the middle concha adheres, followed by osteotomy on the lacrimomaxillary suture, nearly always ensure the exposure of the sac.

Anatomical details used in the surgical reconstruction of the lacrimal canaliculus: cadaveric study.

PURPOSE: The purpose of this study was to investigate the proximal part of the lacrimal tract. METHODS: The dissection was performed on 20 specimens of adult cadavers under an operating microscope. RESULT: The upper lacrimal canaliculus (ULC) and the lower lacrimal canaliculus (LLC) were opened to the lacrimal sac (LS) in three types. In Type A, the ULC and the LLC unite before opening to the LS and form the a common canaliculus (CC). In Type B, the ULC and the LLC unite at the wall of the LS and open to the LS via common hole. In Type C, however, the ULC and the LLC open to the LS separately. Type A, Type B and Type C were observed in 85%, 5% and 10% cases, respectively. Type A and Type B opened to the LS from back to front at an acute angle in 72% of the specimens, and at a right angle in 22%. The opening angles of the CC with lacrimal canaliculus; the ULC with the LS, and the LLC with the LS were realized at an acute angle. CONCLUSION: Crucial parameters, which have not been previously mentioned such as the opening angles of the ULC and the LLC, were investigated as they might be used during the procedure.

The incidence and anatomical features of the McKenzie branch: a cadaver study.

AIM: The aim of this study was to demonstrate the morphological characteristics of the connections between the spinal accessory nerve and the anterior root of the first cervical nerve (C1) which is also called the McKenzie branch. MATERIAL AND METHODS: The cranial cervical regions of 49 specimens from 27 human cadavers were used for this study under an operating microscope. The topographical relationship of the accessory nerve to the anterior roots of C1 were studied. RESULTS: One cadaver had a connection branch (McKenzie branch) on both sides. CONCLUSION: The knowledge of the anatomy of these connections may help the clinician in determining treatments and surgical approaches in this anatomical area.

Connection types between the spinal root of the accessory nerve and the posterior roots of the C2-C6 spinal nerves.

PURPOSE: The aim of this study was to demonstrate the connection types and frequency between the accessory nerve and the posterior roots of the C2-C6 cervical nerves. METHODS: The cranial cervical regions of 49 specimens from 27 human cadavers were used for the present study under an operating microscope. RESULTS: Five different connection types between the accessory nerve and the posterior roots of the cervical nerves were recorded and photographed (types A-F). One of these types was not described previously in literature (type F). All connections between the posterior roots of the C2-C6 spinal nerves and the accessory nerve were at the level of the C2 segment. Type B was the most frequently seen type in our series. One of the rootlets of the cervical posterior root joined the accessory nerve without a connection to the spinal cord in type B. CONCLUSIONS: The clinical importance of these connections is especially noticed during the radical neck dissection as it may lead to the development of the shoulder-arm syndrome.

Neuroanatomy of cervical sympathetic trunk: a cadaveric study.

To reduce the risk of iatrogenic injury to sympathetic chain during anterior and anterolateral approaches to the cervical spine, its location has to be well defined and known by surgeons. We analyzed the course of sympathetic chain and its ganglia from C7 up to its entry into the cranial base and its relationship mainly with the longus colli (LC). Formalin fixed 20 human cadavers were dissected under operating microscope. Measurement of the dimensions of the ganglia, distance of the trunk to the LC, and the angles identifying the course of the chain were performed. Superior and inferior cervical/cervicothoracic ganglion were observed in all specimens, the middle cervical ganglion was observed in 48% of the specimens. The middle ganglion consisted of two ganglia in 10% of the dissected sides. Forty percent of the inferior cervical/cervicothoracic ganglion was at the C7 level, 25% was at C7-Th1 disc level, and 35% was at Th1 level. Vertebral ganglion was detected in only 8% of the specimens. The course of the sympathetic trunk converges medially descending from upper cervical levels to the lower levels. Anterior surgical approach to the cervical spine is a commonly used procedure. Although Horner syndrome due to sympathetic injury is not a common sequence of cervical operations, our findings support the current few reports on the subject and should be useful to any surgeon who operates in the cervical region to avoid this uncommon complication.

Connections between the accessory nerve and the posterior root of the first cervical nerve.

The aim of this study was to demonstrate the incidence of absence of the posterior root of the first cervical nerve, and the relation between the accessory nerve and the posterior root of the first cervical nerve in Turkish population. Dissections of the accessory nerve and the posterior root of the first cervical nerve were performed in 49 specimens from 27 formalin fixed cadavers (25 male and 2 female). The type of the connections between the accessory nerve and the posterior root of the first cervical nerve was classified into four types. Type III was the most common type in present study (30.6%). There was a connection between the accessory nerve and the posterior root of the first cervical nerve in this type. The connections demonstrated in this study are important in the etiology and surgical treatment of the spasmodic torticollis.

Localization of the marginal mandibular branch of the facial nerve.

The aim of this study was to observe the course of the marginal mandibular branch of the facial nerve (MMBFN) in relation to the inferior border of the mandible and parotid gland and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 50 specimens were dissected. The relationships between the MMBFN and the inferior border of the mandible were recorded and analyzed. We found that posterior to the facial artery, the MMBFN ran above the inferior border of the mandible in 37 (74%) of the specimens. In 11 (22%) specimens, below the inferior border of the mandible it was divided into two branches at the crossing point with the facial artery. In 2 (4%) specimens the MMBFN divided into two branches at the point of emergence from the parotid gland. There were no statistical differences between the left and right sides, and both sexes. The MMBFN is one of the most vulnerable branches to surgical injury because of its location. For this reason, the surgeons who are willing to operate on this area, especially for the rhytidectomies, should have a true knowledge about the anatomy of this branch.

Anatomic landmarks of the buccal branches of the facial nerve.

The aim of this study was to classify the buccal branches of the facial nerve in relation to the parotid duct and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 30 cadaver heads (60 specimens) were dissected. The vertical and horizontal relationships between the buccal branches of the facial nerve and tragus, and parotid duct were recorded and analyzed. The buccal branches of the facial nerve were classified into four types: Type I: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and inferior to the parotid duct. Type II: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and superior to the parotid duct. Type III: buccal and other branches of the facial nerve formed a plexus. Type IV: two branches of buccal branch; one superior and one inferior to the duct at the point of emergence from the parotid gland. The buccal branches of the facial nerve are very vulnerable to surgical injury because of its location in the midface. For this reason, the surgeons who are willing to operate on this area should have a true knowledge about the anatomy of these branches.

Reduced hippocampal volume in drug-free depressed patients.

A number of studies have used magnetic resonance imaging to examine the volumetric differences in temporal lobe structures especially the hippocampus in patients suffering from major depressive disorder (MDD). Although some studies reported lower hippocampal volume, others did not. It is proposed that the inconsistency among studies may be due to the heterogeneity of patients and antidepressant treatment during scanning. In this study, we aimed to evaluate the hippocampus in drug-free patients. Twenty-four patients (6 males and 18 females) diagnosed as having MDD according to the DSM-IV criteria and 24 healthy controls (6 males and 18 females) were included in the study. Eleven of the patients had their first mood episode and were drug-naïve. Other patients were drug-free for at least 4 weeks. The Hamilton depression rating scale (HAM-D) assessed the severity of depression. Magnetic resonance imaging was performed on a 1.5-T MR unit. The Cavalieri method of modern design stereology in conjunction with point counting was used to estimate hippocampal volume. The data were evaluated by a repeated measure of ANOVA and the intracranial volume was taken as a covariate. A significant hippocampal volume difference was observed between the patients and healthy controls (F=4.43, df=1.45, P<0.05); however, laterality had no effect on the volumes (F=0.03, df=1.45, P>0.05). The left hippocampus of patients was significantly lower than those of controls (t=1.98, df=46, P<0.05). Correlation analysis showed a correlation between HAM-D scores and the right hippocampal volume. The results of this study indicate that hippocampus volume is reduced in depressed patients especially in the left side. This finding in the drug-free depressed outpatients without a history of alcohol dependence supports previous studies that have reported lower hippocampal volume.

Anatomic guides to precisely localize the zygomatic branches of the facial nerve.

UNLABELLED: Descriptions of superficial anatomic landmarks for the identification of the zygomatic branches of the facial nerve, and their relevance for plastic surgery, are lacking in the literature. This paper provides such a description and discusses its relevance to facial surgery. MATERIALS AND METHODS: Sixty-six specimens, including the parotid region, from 33 adult cadavers were dissected and studied. All specimens were fixed in formaldehyde, and the superficial tissues were removed and the zygomatic branches of the facial nerve, the parotid gland, the tragus and the lateral palpebral commissure were identified. The vertical and horizontal relationships were recorded and analyzed. RESULTS AND CONCLUSIONS: A total of 69.7% of the cadavers had two branches, 25.8% had three branches, and 4.5% had a single zygomatic branch. The mean horizontal distance of the zygomatic branch (the most upper one) as it emerged from the anterior border of the parotid gland and the tragus was 30.71 mm, whereas the mean vertical distance of the zygomatic branch from the midpoint between the tragus and the lateral palpebral commissure was 19.29 mm. The branching patterns with the buccal branches were reported. There were no statistical differences between the left and right sides or between the sexes. The zygomatic branches of the facial nerve were always under the oblique line between the tragus and the lateral palpebral commissure and have a close relationship with the buccal branches of the facial nerve under this anatomic landmark. Application of the results in facial surgery is discussed.

Orientation lesson in anatomy education.

Dissection of a human body during an anatomy course raises questions about invasion of privacy, cadaver sources, dying and death for medical students. The technical orientation in any medical education process tends to motivate students towards a purely biological view of the human body. An orientation lesson was performed, including technical instructions, with particular emphasis on how to deal with emotions. Two hundred and forty-two second-year students were asked to complete a questionnaire and two State-Trait Anxiety Inventory (STAI) self-reports. One hundred and two students participated in an orientation lesson (group A) and 140 students did not (group B). Data were analyzed using SPSS. The t-test and chi-square test were used to evaluate differences between the groups. Group A students showed significantly better performance in both a verbal anatomy examination and multiple-choice test than group B students (p=0.001). There were no differences between group A and B students in the state and trait anxiety levels, willingness to donate their body or organs, belief in life after death, social activity or gender. The goal of including consideration of psychosocial factors in an anatomy course would allow students a thoughtful interpretation of their laboratory experience in the context of their professional development as physicians.

The existence of the vomeronasal organ in human beings.

The frequency, location, and function of the vomeronasal organ, also known as the Jacopson organ, in human beings remains poorly understood. In this study, a search for the frequency of the vomeronasal organ was performed by nasal examinations of 346 adult patients and 21 cadaver heads by anterior rhinoscopy and videotaped rigid 30 degrees endoscopy. The vomeronasal organ was identified in 112 patients (32%) and in 8 cadaver heads (38%). The location, shape, type, and relation to sex of the vomeronasal organ were described. Ten specimens were examined histologically and histochemically for neuron-specific enolase (anti-neuron-specific enolase), high-molecular-weight cytokeratin (anti-high-molecular-weight cytokeratin), and low-molecular-weight cytokeratin (anti-low-molecular-weight cytokeratin). Considering its variability in shape and the lack of immunohistochemical characteristics of nerve tissue, the present results are not suited to argue for functional significance of the vomeronasal organ in human beings.