Anatomical Bases of the Temporal Muscle Trigger Points.

Method: Temporal muscles of 14 adult cadavers were studied. The muscle bellies were divided into six areas, three superior (1.2 and 3) and three inferior areas (4, 5, and 6) lower, according to a Cartesian plane to analyze and describe the entry points of the branches of the deep temporal nerves into the muscle. The branching distribution was analyzed using Poisson log-linear tests with Bonferroni post hoc tests for comparison between groups (sextants) (p < 0.05). Results: Deep temporal nerve entry points were found in the temporal muscle in all areas. Most of the branches were observed in areas 2 and 5, which coincide with the muscle fibers responsible for mandible elevation and related to the previously described MTPs. Fewer branches were found in areas 1 and 6, where contraction produces mandible retraction. Conclusion: There is an anatomical correlation between the branching pattern of the deep temporal nerve and temporal muscle trigger points. Adequate knowledge of the innervation of the temporal muscle may help elucidate the pathophysiology of myofascial syndromes and provide a rational basis for interventional or conservative approaches and help surgeons avoid iatrogenic lesions to the deep temporal nerve lesion.

Anatomy of the anterior jugular veins: anatomical study of 30 cadavers

Introduction: Human anatomy is essential for both clinical and surgical practice. Although the anterior jugular veins (AJVs) are of great importance in many surgeries, there are few studies addressing the anatomic variations of these vessels. This study highlights the venous drainage of the head and neck and the importance of anatomical variations in the AJVs. Objective: To observe and describe the anatomy of the jugular veins and evaluate whether there are patterns influenced by anthropometric factors or comorbidities. Methods: Neck dissections were performed on 30 cadavers. The anatomical characteristics of the AJVs were described considering diameter, midline distance, anastomosis, and presence of the jugular venous arch. Results: Cadavers of 14 women and 16 men were dissected. Ninety percent (90%) of the jugular veins had a rectilinear path and 37% presented anastomosis: H-shaped (63.7%),N-shaped (27.3% ), and Y-shaped (9%). In relation to the number of veins, 20% of the cadavers had only one AJV, 63.3% had two, 10% had three, and 6.7% presented a total of four. Mean distance between jugular veins was 12 mm, and most veins (60%) had a diameter <5 mm. There was no statistically significant correlation between anatomical variations and anthropometric factors. Conclusion: AJVs were always present in the dissected cadavers, and the configuration most commonly found was two veins, each <5 mm in diameter. They were less than 10 mm away from the cervical midline and, when they presented anastomosis, it was H-shaped in most cases.

Knowledge about head and neck cancer among adolescents

Introduction: The expansion of knowledge about head and neck cancer can provide greater care and the ability to identify risk factors and symptoms of the disease, as well as the incorporation of healthy habits. The younger these concepts are sedimented, the better results will be, making society healthier and more aware. Objective: To assess knowledge about head and neck cancer among adolescents from private schools, aged between 13 and 22 years. Methods: 200 questionnaires were applied among students, about the profile of adolescents and their knowledge about head and neck neoplasms, treatment, and teaching in schools on this topic. The results were analyzed both quantitatively and qualitatively. Results: Only 55 students (29.9%) identified HPV as a risk factor for the disease. 137 students (74.5%) identified the brain as an organ treated by head and neck surgery. As for the therapeutic strategies used for the treatment of neoplasms in the region, only 67 students (36.4%) are aware. On the topic of teaching in schools, 153 students (83.1%) relate to some deficiency in the approach and learning. Conclusion: Knowledge about head and neck cancer is insufficient. It is necessary to introduce in the curriculum basic cancer education in biology classes. The expansion of acquirements about cancer can provide better care and the ability to identify risk factors, initial signs, and symptoms of the disease, as well as the incorporation of healthy habits in families because these students can propagate valid information in their environment.

Left Nonrecurrent Laryngeal Nerve: A Very Unusual Finding during Thyroid Surgery.

Background: Identifying the inferior laryngeal nerve is one of the main concerns in thyroid surgery. The typical recurrent position occurs due the relative position between the vagus nerve and the larynx during the last 3 branchial arches development. In rare cases, this nerve does not loop under the right subclavian artery or the aortic arch. This abnormality is present in 0.7% of patients and is associated with the presence of anatomical vascular anomalies. The left non-recurrent inferior laryngeal nerve is an even rarer abnormality, with only six cases described in the literature to date. Method: A 46- years old female patient referred to total thyroidectomy for symptomatic multinodular benign goiter. Results: A left non-recurrent inferior laryngeal nerve was found with difficulty and then a partial thyroidectomy was performed. CT scan showed dextroposition of the vessels of the base of the heart and an aberrant left subclavian artery. Conclusion: An association of a right-sided aortic arch and aberrant left subclavian artery, or the presence of situs inversus, although rare anatomical variations, are associated to a non-recurrent inferior left laryngeal nerve. Proper identifying these abnormalities may help to properly identify and salvage this structure.

Active Surveillance of Thyroid Microcarcinomas: a Critical View.

PURPOSE OF THE REVIEW: There has been an increasing interest on active surveillance for papillary thyroid microcarcinomas (PTMC) in the literature. We will analyze the contributions of those authors who support this approach in most patients with low-risk tumors. RECENT FINDINGS: The development of molecular methods to effectively detect aggressive PTMC at the fine-needle aspiration biopsy will enable the sound indication of immediate surgery in those patients, assuring the other individuals with the far more frequent indolent PTMC will undergo active surveillance with less anxiety. Several studies compared the quality of life between patients with PTMC who underwent active surveillance with immediate total thyroidectomy. However, thyroid lobectomy is a quite acceptable intermediate alternative for most patients with PTMC, with less surgical morbidity. It is important to wait for worldwide validation, with reports from low- and middle-income areas, before recommending the routine adoption of active surveillance for patients with PTMC, due to difficult logistic obstacles in those environments.

Conventional thyroidectomy: what is the impact of the scar on the lives of operated patients?

OBJECTIVE: This study was aimed at investigating the aesthetic impact of scars on the lives of patients who undergo conventional thyroidectomy. METHODS: This cross-sectional study was based on a retrospective analysis of 98 electronic medical records of patients who underwent conventional thyroidectomy performed by the same surgeon. The impact was determined through a qualitative question and categorized into three levels of dissatisfaction. RESULTS: Among the 98 patients, 96 (97.95%) reported experiencing no functional or visual discomfort with their scars. The two unsatisfied individuals were women, and both classified their discomfort as moderate. Although the diseases that indicated surgery varied, papillary thyroid carcinoma predominated. CONCLUSION: The sample's satisfaction level indicates that, in line with the current literature, the decision to opt for cosmetically appealing methods is not justified by aesthetic complaints about scars. The benefits of lower cost and fewer complications make conventional thyroidectomy an old but reliable option for afflictions of the thyroid gland that require surgery.

Novel COVID-19 Intersections with Dentistry: Approaches to protection.

BACKGROUND: COVID-19 outbreak brought many challenges to the society and to health care systems. Health care professionals in dental practices are a high-risk population, due to close contact to saliva and aerosols. Specific guidance for those professionals is essential to control disease transmission and guarantee dentist's health. MATERIAL AND METHODS: We performed a literature review based on online search in Pubmed, Scientific Electronic Library, Literatura Latino-Americana e do Caribe em Ciências da Saúde and Scopus databases. Included articles were fully read and analysed regarding infection control measurements, use of personal protective equipment (PPE), conditions for procedures and use of mouthrinse. RESULTS: Nineteen articles were added to this review. The majority of them recommended maintaining only urgency treatments, with use of rubber dam and mouthrinse before procedures. CONCLUSIONS: The data collected suggests dental care should be performed under strict protection measures such as a pre-check questionnaire prior to any dental procedure; postponing elective dental treatments and following infection control security procedures may be strategic at this point. The use of adequate PPE for procedures is recommended. Supplementary measures should rise from further understanding of the pandemics. Key words:COVID-19, dentistry, practice.

Corona Mortis: A Systematic Review of Literature.

Our systematic review evaluates surgically relevant information about corona mortis (CM), such as anatomical structure, size, laterality, incidence, and anthropometric correlations. This study aimed to provide data about anastomosis in an attempt to avoid iatrogenic damage during surgery. Articles were searched online using the descriptor "Corona Mortis" in PubMed, Biblioteca Virtual em Saúde (BVS) (Literatura Latino-Americana e do Caribe em Saúde [LILACS], MEDLINE, indice bibliografico espaãol en ciencias de la salud [IBECS]), and SciELO database. The time range was set between 1995 and 2020. The articles were selected according to their titles and later the abstracts' relation to our research purpose. All the selected articles were read entirely. A manual search based of the references cited in these articles was also conducted to identify other articles or books of interest. Forty references fulfilled the criteria for this review. The mean incidence of CM was 63% (the majority venous) among 3,107 hemipelvises. The incidence of bilateral CM was lower than that of unilateral variations based on the analysis of 831 pelvises. The mean caliber of the anastomosis was 2.8 mm among 1,608 hemipelvises. There is no consensus concerning the anthropometric influences in CM. Finally, we concluded that CM is not an unusual anatomical variation and that we must not underestimate the risk of encountering the anastomosis during surgery. Anatomical knowledge of CM is, therefore, essential in preventing accidents for surgeons who approach the inguinal and retropubic regions.

Photobiomodulation therapy increases collagen II after tendon experimental injury.

A tendon is a mechanosensitive tissue that transmits muscle-derived forces to bones. Photobiomodulation (PBM), also known as low-level laser therapy (LLLT), has been used in therapeutic approaches in tendon lesions, but uncertainties regarding its mechanisms of action have prevented its widespread use. We investigated the response of PBM therapy in experimental lesions of the Achilles tendon in rats. Thirty adult male Wistar rats weighing 250 to 300 g were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with PBM, whereas the left tendon served as a control. On the third postoperative day, the rats were divided into three experimental groups consisting of ten rats each, which were treated with PBM (Konf, Aculas - HB 750), 780 nm and 80 mW for 20 seconds, three times/week for 7, 14 and 28 days. The rats were sacrificed at the end of the therapeutic time period. The Sca-1 was examined by immunohistochemistry and histomorphometry, and COLA1, COLA2 and COLA3 gene expression was examined by qRT-PCR. COLA2 gene expression was higher in PBM treated tendons than in the control group. The histomorphometric analysis coincided with increased number of mesenchymal cells, characterized by Sca-1 expression in the lesion region (p<0.001). PBM effectively interferes in tendon tissue repair after injury by stimulating mesenchymal cell proliferation and the synthesis of collagen type II, which is suggested to provide structural support to the interstitial tissues during the healing process of the Achilles tendon. Further studies are needed to confirm the role of PBM in tendon healing.

Anatomical Study of the Innervation of the Masseter Muscle and Its Correlation with Myofascial Trigger Points.

BACKGROUND AND PURPOSE: Myofascial pain syndrome (MPS) is widely prevalent in the general population; some reports estimate its prevalence ranges from 9 to 85%. Among the different locations where MPS may arise, pain related to the masseter muscle is referred as masticatory myofascial pain. MPS is characterized by myofascial trigger points (MTPs), which represent tender anatomical areas of a muscle where painful symptoms are elicited whenever stimulated. Previous publications have found MTPs to coincide with neuromuscular junctions at the motor end plate, at the innervation zone (IZ). Our study aimed to describe the innervation of the masseter muscle and relate it to clinically described myofascial trigger points (MTPs). MATERIALS AND METHODS: We mapped the nerve fiber distribution into the masseter muscles from 16 cadavers by anatomical dissection. We divided the muscle into six regions, three superior (I-III) and three inferior (IV-VI), and classified the nerve's branches distribution according to these predetermined areas. Statistical analyses was made by Poisson distribution and logarithm link function followed by Bonferroni multiple comparisons (P<0.05). RESULTS: All six areas received branches from the masseteric nerve. Areas I and II (upper posterior and upper intermediate, respectively) had a significant higher number of nerve entries as compared to the remaining areas. CONCLUSION: The penetration areas of the masseteric nerve have been established and MTPs are found in the innervation zones, clinicians should focus initially on the regions of the penetration points, for diagnostics and therapeutic measures, such as injections, dry needling and soft tissue interventions. Anatomical study of nerve supply to the masseter muscle can provide useful additional knowledge to further understanding masticatory myofascial pain and to direct therapeutic interventions and diagnostic studies of temporomandibular junction dysfunction.

Thyroid cancer surgical indication during pregnancy: systematic literature review and series of illustrative cases

Introduction: Thyroid papillary carcinoma is the second most frequent type of cancer during pregnancy. Its diagnosis is related to patient fear and anxiety. There is little consensus on when to perform surgery in those cases. Objective: To evaluate and discuss timing possibilities for surgical treatment in thyroid cancer in pregnant women. Methods: Systematic literature review based on online search at the Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and National Center for Biotechnology Information (NCBI) databases. Retrospective analysis of thyroidectomies performed in the second trimester of pregnancy by the authors between 1999 and 2019. Results: The systematic review included nine articles. Their conclusions diverge with respect to the optimal timing of thyroid surgery. The medical literature considers thyroidectomy after safe delivery. The most recent studies are more flexible regarding carrying out this surgery during the second trimester of pregnancy. In the authors' experience (n=5), surgical treatment during the second trimester of pregnancy is a good option for more aggressive tumors. Conclusion: More aggressive cases of thyroid papillary carcinoma can be treated with surgery during the second trimester of pregnancy. Performing the surgery after delivery is safer in the case of less aggressive cancer cases. The decision should consider hospital costs, surgery risks, and patient anxiety in relation to cancer.

Is there something new regarding triceps brachii muscle insertion?

PURPOSE: Previous studies have questioned whether the triceps brachii muscle tendon (TBMT) has a double or single insertion on the ulna. Aiming to provide an answer, we describe the anatomy of the TBMT and review a magnetic resonance imaging (MRI) series of the elbow. METHODS: Forty-one elbows were dissected to assess the details of the triceps brachii insertion. Elbow plastination slices were analyzed to determine whether there was a space on the TBMT. Magnetic resonance imaging from the records of the authors were also obtained to demonstrate the appearance of the pre-tricipital space on MRI. RESULTS: A virtual space on the medial aspect near the TBTM insertion site in the olecranon was consistently found on anatomic dissections. It was a distal pre-tricipital space. Magnetic resonance imaging demonstrated the appearance of the pre-tricipital space on MRI, and its extension was measured longitudinally either in elbow flexion or extension. There was no statistically significant difference between the measurements of this space in the right and left elbows or between flexion and extension (p > 0.05). The coefficient of variation was <10% for all measurements. CONCLUSION: Knowledge of this structure may be essential to avoid incorrect diagnosis and unnecessary therapeutic interventions.

Head and Neck Practice in the COVID-19 Pandemics Today: A Rapid Systematic Review.

Introduction Head and neck specialists and otorhinolaryngologists are greatly exposed to coronavirus disease 2019 (COVID-19) transmission in their everyday praxis. Many articles are being published regarding medical staff protection and patient management during the pandemic. Objective To provide an easy access to and a trustful review of the main aspects that have changed in the head and neck surgery and otorhinolaryngology practice due to the COVID-19 pandemic. Data Synthesis The search terms used were: ( head and neck or otorhinolaryngology or ORL or thyroid ) AND ( severe acute respiratory syndrome coronavirus 2 [ SARS-COV-2] or COVID-19 or CORONAVIRUS ). The results were limited to the year of 2020. Articles were read in English, Portuguese, French, German, and Spanish or translated from Chinese. All included articles were read by at least two authors. Thirty-five articles were included. Most articles suggest postponing elective surgeries, with exception to cancer surgeries, which should be evaluated separately. Twenty-five articles recommended some kind of screening prior to surgery, using polymerase chain reaction (PCR) tests and epidemiological data. Extra precautions, such as use of personal protective equipment (PPE), are suggested for both tracheostomies and endoscopies. Fifteen articles give recommendation on how to use telemedicine. Conclusion The use of PPE (N95 or powered air-purifying respirator [PAPR]) during procedures should be mandatory. Patients should be evaluated about their COVID-19 status before hospital admission. Cancer should be treated. Tracheostomy tube cuff should be inflated inside the tracheal incision. All COVID-19 precautions should be kept until there is a validated antiviral treatment or an available vaccine.

Morphometry and Frequency of the Pyramidalis Muscle in Adult Humans: A Pyramidalis Muscle's Anatomical Analysis.

OBJECTIVES: To verify the pyramidalis muscle's frequency (bilaterality, unilaterality, or absence) and morphometry (length of the medial border and width of its origin/base) in a sample of the Brazilian population and the anthropometric influence. METHODS: Dissection of 30 cadavers, up to 24h post-mortem. RESULTS: The pyramidalis muscle was present bilaterally and unilaterally in 83.33% and 3.33% of the cadavers, respectively, and absent in 13.33%. The muscles on the right and left sides were symmetrical in length but not in width; the pyramidalis muscles of men were longer, while those of the women were wider. We also found that there was greater variation in the dimensions (length and width) of the men's muscles. Finally, in this sample of the Brazilian population, the pyramidalis muscle's unilaterality was more prevalent than in other populations, and its complete absence was less prevalent. CONCLUSIONS: There were no cases of muscle duplication in one or both sides, as described in some studies. Despite all of its morphometric variation, the pyramidalis muscle maintained its triangular shape with longitudinal fibers in every case. Furthermore, no statistically significant correlation was noted between the muscles' dimensions and person's age, height, weight, or gender.

A brief history of medical uniforms: from ancient history to the COVID-19 time.

Medical Uniforms date back from medieval times. Nursing uniforms were based on nuns clothes whereas doctors used the famous "plague costumes" and black "frock" coats from about 15th to early 19th century. In latter half 19th century medical uniforms started to change. Nursing uniforms gradually lost their similarities to religious outfits. Doctors started to use white clothing. With great emphasis on hygiene and sanitation, the idea of personal protective equipment (PPE) started to evolve with William Stewart Halsted introducing the use of rubber gloves in 1889. In the 1960s-1970s it became more usual to wear green and blue `scrubs in order to look for a greater contrast in clothing with the all-white hospital environment. In contemporary times, some specialties even stopped using specific uniforms, while others still use them. At the same time, PPE became more and more important, up to nowadays "plague costume" in the combat of the COVID-19 epidemics.