Sleep time on back as a predictor of adherence to positive airway pressure therapy.

Upper airway collapse can be effectively dealt with positive airway pressure (PAP), and patient adherence is considered as a major determining factor for success of PAP therapy. This study was performed to determine the potential factors affecting the adherence to PAP in patients with OSA by using polysomnography (PSG) parameters recorded for diagnosis of OSA. The data of 158 patients between December 2018 and July 2021 were collected. They were prescribed with PAP and used the device during the adaptation period for 90 days. They were categorized into adherent and non-adherent group according to the criteria of good adherence as use of PAP ≥ 4 h per night on 70% of nights. Demographic, clinical characteristics, and PSG results were reviewed. Among 158 patients engaged in PAP therapy, 121 patients (76.6%) met the criteria of good adherence. No significant differences were found in good adherence rate regarding demographic and clinical characteristics. None of the polysomnographic factors showed significant differences between adherent and non-adherent groups. However, the percentage of sleep time on back in the adherent group was significantly higher than non-adherent group (p = 0.041). The cut-off value was determined to be 41.45% (95% confidence interval 0.43 to 0.79) by receiver operating characteristic curve analysis and the odds ratio was calculated as 2.97. Only the percentage of sleep time on back appeared to be polysomnographic predictor for identifying good adherence to PAP therapy in OSA patients. However, the conclusions may be limited in generalization due to the small sample size.

Retrodural space of Okada in the posterior ligamentous complex region: clinical and anatomical findings relevant to lumbar interlaminar epidural injection.

BACKGROUND: The retrodural space of Okada is a potential space posterior to the ligamentum flavum that allows communication with the bilateral facet joints. However, the actual anatomy of this space has not been clearly visualized to date. We sought to investigate the characteristics of patients showing contrast spreading to the facet joint space during epidural injection and to clarify the anatomical structures of the retrodural space and adjacent ligamentous tissues in cadaveric specimens. METHODS: Fluoroscopic images of patients who underwent fluoroscopy-guided lumbar interlaminar epidural injection were assessed for contrast flow to the facet joints. Patient demographics, preprocedural imaging study findings, and epidural approaches were analyzed. The anatomical study included the sectional dissection, micro-CT imaging, and histological evaluation of lumbar spine specimens from 16 embalmed cadavers. RESULTS: Fluoroscopic images of 605 epidural injections were analyzed. Among them, 36 with inadvertent spread into the facet joints (5.9%) were identified. Multivariate analysis revealed that facet joint pathologies were significantly associated with inadvertent spread into the facet joints (OR 4.382; 95% CI 1.160 to 16.558; p=0.029). Micro-CT and histological findings consistently showed a retrodural space between the ligamentum flavum and interspinous ligament. Various anatomical communication routes in the posterior ligamentous complex leading to this space were observed in specimens with degenerative and pathological changes. CONCLUSION: Degenerative and pathological facet joint changes were associated with a higher incidence of spread into the retrodural space during epidural injection. Our findings confirm anatomical evidence for a false loss of resistance before the needle enters the epidural space.

Resection of Huge Nasal Septal Chondroma Via Endoscopic Septoplasty Approach Through Modified Killian Incision.

Chondromas are benign cartilaginous tumors that frequently occur in the long bones, pelvis, sternum, ribs, and scapula. They seldom develop in the head and neck region, and there have been rare reports of them arising in the nasal septum. Although the mainstay of management is surgery, surgical treatment strategies vary depending on the size, location, and extent of the disease. Herein, we describe a case of huge chondroma originated from the anterior nasal septum, which was completely removed by endoscopic septoplasty approach thorough modified Killian incision.

α-Mangostin Induces Apoptosis and Cell Cycle Arrest in Oral Squamous Cell Carcinoma Cell.

Mangosteen has long been used as a traditional medicine and is known to have antibacterial, antioxidant, and anticancer effects. Although the effects of α-mangostin, a natural compound extracted from the pericarp of mangosteen, have been investigated in many studies, there is limited data on the effects of the compound in human oral squamous cell carcinoma (OSCC). In this study, α-mangostin was assessed as a potential anticancer agent against human OSCC cells. α-Mangostin inhibited cell proliferation and induced cell death in OSCC cells in a dose- and time-dependent manner with little to no effect on normal human PDLF cells. α-Mangostin treatment clearly showed apoptotic evidences such as nuclear fragmentation and accumulation of annexin V and PI-positive cells on OSCC cells. α-Mangostin treatment also caused the collapse of mitochondrial membrane potential and the translocation of cytochrome c from the mitochondria into the cytosol. The expressions of the mitochondria-related proteins were activated by α-mangostin. Treatment with α-mangostin also induced G1 phase arrest and downregulated cell cycle-related proteins (CDK/cyclin). Hence, α-mangostin specifically induces cell death and inhibits proliferation in OSCC cells via the intrinsic apoptosis pathway and cell cycle arrest at the G1 phase, suggesting that α-mangostin may be an effective agent for the treatment of OSCC.

Incidence of pterygospinous and pterygoalar bridges in dried skulls of Koreans.

Understanding of morphological structures such as the sphenoid spine and pterygoid processes is important during lateral transzygomatic infratemporal fossa approach. In addition, osseous variations such as pterygospinous and pterygoalar bridges are significant in clinical practice because they can produce various neurological disturbances or block the passage of a needle into the trigeminal ganglion through the foramen ovale. Two hundred and eighty-four sides of Korean adult dry skulls were observed to carry out morphometric analysis of the lateral plate of the pterygoid process, to investigate, for the first time among Koreans, the incidence of the pterygospinous and pterygoalar bony bridges, to compare the results with those available for other regional populations, and to discuss their clinical relevance as described on literatures. The mean of maximum widths of the left and right lateral plates of the pterygoid process were 15.99 mm and 16.27 mm, respectively. Also, the mean of maximum heights of the left and right lateral plates were 31.02 mm and 31.01 mm, respectively. The ossified pterygospinous ligament was observed in 51 sides of the skulls (28.0%). Ossification of the pterygospinous ligament was complete in four sides (1.4%). In 47 sides (16.6%), the pterygospinous bridge was incomplete. The ossified pterygoalar ligament was observed in 24 sides of the skulls (8.4%). Ossification was complete in eight sides (2.8%) and incomplete in 16 sides (5.6%). This detailed analysis of the lateral plate of the pterygoid process and related ossification of ligaments can improve the understanding of complex clinical neuralgias associated with this region.

Anatomical and radiographic study of the mandibular retromolar canal.

BACKGROUND/PURPOSE: As the demand for surgical procedure in the retromolar area of the mandible has been increasing, the identification of the retromolar foramen (RMF) and canal involving the retromolar triangle (RMT) has become an issue of clinical concern. We examined the shape of the RMT, incidence of the RMF, and intraosseous trajectory of the retromolar canal (RMC). MATERIALS AND METHODS: A total of 118 sides of dry mandibles, 22 sides of mandibles of 13 cadavers, and cone-beam computed tomography (CT) images of 100 patients were examined. Micro-CT data of 13 cadavers were reconstructed using imaging analysis software for the presence of an RMC. RMCs were classified into three types according to the courses. The width and location of the RMCs were evaluated. RESULTS: The shape of the RMT was classified into three categories, with the most common type being the triangular type (81.4%). Forty-seven retromolar foramina (33.6%) were observed in 140 sides of mandibles. The horizontal distances from the RMF to the second and third molars were 12.1 ± 3.3 mm and 5.8 ± 3.6 mm (mean ± standard deviation), respectively, and the distance from the mandibular foramen to the arising point of the RMC and the vertical distance from the RMF to the mandibular canal were 21.5 ± 11.2 mm and 15.3 ± 4.6 mm, respectively. CONCLUSION: This study used various methods to obtain precise anatomical data on the RMT, foramen, and canal in Koreans. The reported findings may be helpful for the clinical management of patients.

Medial muscular band of the orbicularis oculi muscle.

Despite the importance of anatomic variations in the muscular bands around the orbicularis oculi muscle (OOc), little is known about them. The morphology and variations therein of the medial muscular band of the OOc were thus examined in the current study. Sixty-one hemifaces of Korean cadavers were dissected to enable examination of the anatomic organization of the muscles around the OOc. A medial muscular band of the OOc was observed in 40 cases (65.6%). Three patterns of attachment were found. In type A (14 cases, 23%), it attached to the frontal belly without being attached to the medial canthal tendon; in type B (14 cases, 23%), it originated from the medial canthal tendon at the lower portion of the OOc and inserted into the cheek skin, and in type C (12 cases, 19.7%), it was also observed to insert into the cheek skin and attach to the frontal belly without being attached to the medial canthal tendon. The distance between the inferior edge of the OOc and the subnasale was 16.3 (SD, 4.3) mm and 14.5 (SD, 4.4) mm in cases with and without a medial muscular band, respectively. A space was observed on the inferolateral side of the OOc in about 67.2% of cases. These findings regarding the medial muscular band of the OOc increase further the anatomic variations associated with this region. In addition, it appears that this medial muscular band of the OOc can help to prevent drooping of the OOc.

Topography of the arteries supplying the masseter muscle: Using dissection and Sihler's method.

Various surgical procedures require surgeons to have detailed knowledge of the course of blood vessels in the masseter muscle, such as masseter muscle flap formation, mandibular angle resection, parotidectomy, and mandibular ramus osteotomy. Without this knowledge serious complications can occur, endangering the lives of patients. Occasionally, during routine dissections we sometimes encounter an additional branch. The purpose of this study was to provide a comprehensive detailed anatomic description of the blood supply of the masseter muscle. This will provide critical information for various surgical procedures. Twenty-five Korean cadavers were dissected and subjected to modified Sihler's method to reveal the branching patterns of the arteries surrounding the masseter muscle, and its intramuscular blood supply. The masseter can be supplied by seven branches from the external carotid artery. Among these, the masseteric branch from the deep temporal artery has not been described previously. This previously undescribed branch enters the medial surface of the masseter, turning medially around the anterior border of the ramus immediately after the branching point of the deep temporal artery. The branch originating from the transverse facial artery was the largest, and the branches originating from the external carotid artery and deep temporal artery were the smallest. Examination of intramuscular patterns revealed that the branches of the transverse facial artery were the most widely distributed. When considering arterial diameters and distribution areas, the branches of the transverse facial artery can be considered the main components of the seven branches supplying the masseter muscle.

Topography of the nasolacrimal duct on the lateral nasal wall in Koreans.

PURPOSE: The aim of this study was to describe in detail the gross anatomy of the nasolacrimal apparatus in relation to the lateral nasal wall by the various steps of cadaver dissection and to measure the distances of surgically important landmarks from relevant structures to improve the safety and efficiency of endoscopic surgical procedures. METHODS: Thirty-six half-heads of embalmed Korean adult cadavers were dissected under a surgical microscope. After removal of the nasal septum, the lateral wall of the nasal cavity was examined. RESULTS: The orifice of the nasolacrimal duct (NLD) was most frequently observed in the form of a vertical sulcus in 14 cases (39%) and the lacrimal fold was present in 28 cases (77.8%). A total of 15 morphometric items between the orifice of the NLD and the adjacent anatomical structures were measured. The location of the orifice of the NLD was observed at a mean of 17.5 ± 3.1 mm from the limen nasi, 22.8 ± 4.8 mm from the anterior nasal spine, and 21.4 ± 3.5 mm from the axilla of the middle nasal concha. In the positional relationships, the most frequent finding was that the lacrimal sac was posterior to the axilla of the middle nasal concha in 23 cases (64%), and overlap of the NLD with the maxillary line was observed in 24 cases (67%). CONCLUSIONS: This study was conducted to accumulate anatomic data on the lacrimal sac and duct with regard to the positional relationships among the surrounding structures to establish the information for use in endoscopic dacryocystorhinostomy.

Expression of chitinases in hypertrophied adenoids of children.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis (CRS), otitis media with effusion (OME), and allergic rhinitis (AR) are common conditions that have been associated with hypertrophied adenoids in children, and adenoidectomy is clinically recommended. The investigators assayed the expression level and site of acidic mammalian chitinase (AMCase) and chitotriosidase (ChT) in hypertrophied adenoids of children to determine the expression levels of 2 chitinases in relation to CRS, OME, and AR. STUDY DESIGN: A prospective cohort study. SETTING: A tertiary care facility. METHODS: Hypertrophied adenoids from 41 children were harvested during adenoidectomy. Medical records were reviewed and the subjects were grouped according to the presence of CRS, OME, and AR. Messenger RNA (mRNA) and protein expression of AMCase and ChT in adenoid tissues was assessed by reverse transcription polymerase chain reaction and Western blotting. Immunohistochemical staining revealed the sites of AMCase and ChT expression. RESULTS: mRNA and protein of AMCase and ChT were present in adenoids of all subjects. CRS was a significant variable in AMCase mRNA and protein expression. CRS, OME, and AR were significant variables in ChT mRNA and protein expression. Both AMCase and ChT were expressed in histiocytes and vascular endothelial cells of adenoid tissues. CONCLUSIONS: The findings suggest that chitin-containing pathogens or dysregulated immune responses to them in the hypertrophied adenoids of children could be factors contributing to CRS, OME, and AR via AMCase or ChT overexpression.

Clinical and anatomical approach using Sihler's staining technique (whole mount nerve stain).

Sihler's staining allows visualization of the nerve distribution within soft tissues without extensive dissection and does not require slide preparation, unlike traditional approaches. This technique can be applied to the mucosa, muscle, and organs that contain myelinated nerve fibers. In particular, Sihler's technique may be considered the best tool for observing nerve distribution within skeletal muscles. The intramuscular distribution pattern of nerves is difficult to observe through manual manipulation due to the gradual tapering of nerves toward the terminal end of muscles, so it should be accompanied by histological studies to establish the finer branches therein. This method provides useful information not only for anatomists but also for physiologists and clinicians. Advanced knowledge of the nerve distribution patterns will be useful for developing guidelines for clinicians who perform operations such as muscle resection, tendon transplantation, and botulinum toxin injection. Furthermore, it is a useful technique to develop neurosurgical techniques and perform electrophysiological experiments. In this review, Sihler's staining technique is described in detail, covering its history, staining protocol, advantages, disadvantages, and possible applications. The application of this technique for determining the arterial distribution pattern is also described additionally in this study.

Inferior bundle (fourth band) of the buccinator and the incisivus labii inferioris muscle.

The aim of this study was to clarify the morphologic and spatial relationships of the inferior bundle of the buccinator and the incisivus labii inferioris muscle (ILI) and their surrounding structures. The inferior bundle of the buccinator and the ILI were investigated in 40 hemifaces from Korean cadavers. The inferior bundle (or fourth band) of the buccinator muscle was observed in 14 (35%) of the 40 specimen sides. The ILI was found in 39 (97.5%) of the 40 specimen sides. The spatial relationships of the ILI with the buccinator muscle and the orbicularis oris muscle were classified into 4 categories based on the existence of the inferior bundle of the buccinator. These observations indicate that the lower portion of the buccinator including the third and fourth inferior bundles and the ILI could affect the alveolar bone of the mandible or occlusion during these muscular movements.

Topography of the third portion of the maxillary artery via the transantral approach in Asians.

The maxillary artery (MA) passes over the lateral pterygoid muscle in the infratemporal fossa and enters the pterygopalatine fossa through the pterygomaxillary fissure. Refractory epistaxis is managed by ligation of the sphenopalatine artery via a transmaxillary-transantral approach; there is considerable risk of complications associated with such invasive surgical approaches. The aim of this study was to describe the gross anatomy and variations therein of the MA and its branches at the pterygopalatine fossa. One hundred hemifaces of embalmed Korean adult cadavers were dissected to establish the precise course of the MA and its branching patterns. The average thickness of the posterior wall of the maxillary sinus was 0.8 mm, but varied over a wide range from 0.2 to 3.6 mm. We classified the third part of the MA into 3 morphological categories: looped (61%), bifurcated (19%), and straight (18%). Two cases could not be classified into any of these 3 categories. The pattern of the bifurcation between the sphenopalatine and descending palatine arteries was classified into 4 types: Y (19%), intermediate (36%), M (17%), and T (28%). The posterior wall of the maxillary sinus was divided into 9 sections. The branching areas of the sphenopalatine and descending palatine arteries were most frequently (62% of cases) located at the top of the medial partition and at the middle of the medial partition (30% of cases).

Intramuscular communicating branches in the flexor digitorum profundus: dissection and Sihler's staining.

PURPOSE: This study was designed to clarify the anatomy of the intramuscular communicating branch (ICb) between the median and ulnar nerves in the flexor digitorum profundus (FDP), and morphologically demonstrate the location of connection. METHODS: Twenty Korean cadavers were dissected and a further 8 were subjected to modified Sihler's staining to investigate the pattern of innervation of the ICb and the location of its communicating points in muscle. RESULTS: The median and ulnar nerves divided into small branches before entering FDP muscle. Of these small branches, one or two met inside the muscle. This communicating pattern could be classified into three types: type I, communicating branches in both the proximal and distal regions; type II, at least one communicating branch in the proximal region; type III, at least one communicating branch in the distal region. Of 20 dissected specimens, no case of type I was observed, but 3 cases of type II and 15 cases of type III were found. No ICbs at all were found in two of the dissected specimens. In eight stained specimens, one was classified as type I, two as type II, and five as type III. The proximal communicating branches were located at 34.1% from the interepicondylar line, inside the third muscle bundle. The distal communicating branches were located at 66.0% from the interepicondylar line, between third and fourth muscle bundles. CONCLUSIONS: These findings could provide critical anatomical information regarding the nerve distribution of FDP focused on the ICbs.

Clinical implications of the topography of the arteries supplying the medial pterygoid muscle.

The literature contains numerous accounts of the muscular anatomy of the medial pterygoid muscle, but little is known about the detailed vascular supply of the muscle. Numerous surgical procedures, such as mandibular ramus osteotomy, angle reduction, and/or parotidectomy, are performed around the muscle in the absence of this information. This study aimed to clarify the arterial supplies to the medial pterygoid muscle to provide critical information for use during various surgical procedures. Detailed dissections were performed on 20 sides of adult cadaveric head and neck specimens after injecting the carotid artery with red liquid neoprene latex. The medial pterygoid muscle was supplied by the following 5 branches of the external carotid artery: (1) the pterygoid artery of the maxillary artery, (2) a direct muscular branch of the facial artery, (3) the ascending palatine artery, (4) an anterior muscular branch of the facial artery, and (5) a previously undescribed muscular branch of the external carotid artery. This analysis of vascular anatomy has revealed new anatomic information on the blood supplies to the medial pterygoid muscle and will be useful to the development of guidelines for preventing hemorrhage during surgical procedures.

An anatomic study of the bifid zygomaticus major muscle.

The dramatic changes in facial expression are most remarkable in the perioral region. Among the perioral musculatures, the zygomaticus major (ZMj) muscle plays an important role in the facial expression. The aim of this study was to determine the anatomic patterns of the bifid ZMj through a topographic examination at the perioral region. Through 70 dissections of the hemifaces, the insertion area of the ZMj was observed in 70 embalmed cadavers. The bifid ZMj was observed in 28 cases (40%). In most cases of the bifid ZMj, the superior muscle fibers were larger and wider than the inferior fibers. Bilateral bifid ZMj was found in 71.4% of the bifid ZMj specimens. The arrangement and insertion patterns of the ZMj in this study are expected to provide critical information for the surgical planning and procedure for facial reanimation surgery.

An anatomical study of the insertion of the zygomaticus major muscle in humans focused on the muscle arrangement at the corner of the mouth.

BACKGROUND: The aim of this study was to clarify the arrangement of the zygomaticus major muscle by means of topographic examination, and to evaluate the anatomical variations in the insertion of the zygomaticus major at the perioral region. METHODS: After a detailed dissection in the modiolar region, the insertion area of the zygomaticus major was observed in 70 embalmed cadavers. RESULTS: At the perioral region of the dissected specimens, the anatomical aspects of the muscular arrangement and attachment of the zygomaticus major muscle were classified into four categories. In type I, the superficial muscle band of the zygomaticus major is blended and interlaced with the levator anguli oris, whereas the fibers of the deep muscle band blend into the buccinator, passing deeper to the levator anguli oris; this was the situation most commonly encountered (54.3 percent). It was found that the insertion of the zygomaticus major was divided into superficial and deep bands (types I and IV) [42 cases (60 percent)] and into three layers of superficial, middle, and deep fibers (type II) [17 cases (24.3 percent)]. The others were cases where the zygomaticus major was inserted deep into the levator anguli oris as a single muscle band (type III) [11 cases (15.7 percent)]. CONCLUSION: The arrangement and insertion patterns of the zygomaticus major in this study are expected to provide critical information for surgical planning for the procedure of facial reanimation surgery.

Topographic and histologic characteristics of the sural nerve for use in nerve grafting.

The sural nerve (SN) is a sensory nerve supplying the skin of the lateral and posterior parts of the inferior third of the calf and the lateral side of the foot and is easy to harvest because of its location posterior and superior to the tip of the lateral malleolus. Seventy-one lower limbs from 42 Korean cadavers were dissected to describe the joining type and level of perforated the fascia of the SN. The segments of sural nerve were stained and measured. The communication and joining patterns of the SN formed by the medial sural cutaneous nerve and the communicating branch of the lateral sural cutaneous nerve could be divided into five types. The region where the medial sural cutaneous nerve and the communicating branch of the lateral sural cutaneous nerve join together was observed in 52 cases with this found in the lower two fifths of the calf in 28 (53.8%) of the specimens. The mean number of fascicles was 8.1 (range, 2-12) at the lower calf and 5.8 (range, 1-11) at the middle calf before where the medial sural cutaneous nerve and the communicating branch of the lateral sural cutaneous nerve joined. The mean total areas of the fascicles were 0.55 mm and 0.43 mm in the lower and middle calf, respectively. This study demonstrates that the anatomy of the SN affects its harvesting for use in nerve grafts with the reported results providing a useful reference for SN grafting procedures.

Branching patterns of the infraorbital nerve and topography within the infraorbital space.

The infraorbital nerve (ION) is the terminal branch of the maxillary nerve; it supplies the skin and mucous membranes of the middle portion of the face. This nerve is vulnerable to injury during surgical procedures of the middle face. Severe pain and loss of sense are noted in patients whose infraorbital nerve is damaged. In the study presented here, we investigated the branching pattern and topography of the ION, about which little is currently known, by dissecting 43 hemifaces of Korean cadavers. In most cases, the infraorbital artery was located in the middle (73.8%) and superficial to the ION bundle (73.8%) at its exit from the infraorbital canal. The ION produced four main branches, the inferior palpebral, internal nasal, external nasal, and superior labial branches. The superior labial branch was the largest branch of the ION produced the most sub-branches. These sub-branches were divided into the medial and lateral branches depending upon the area that they supplied. We were able to classify four types of branching pattern of the external and internal nasal branch and the medial and lateral sub-branches of the superior labial branch of the ION at the site of their emergence through the infraorbital foramen (types I-IV). Type I, where all four branches are separated occurred the most frequently (42.1%). These findings will help to preserve the ION while performing certain types of maxillofacial surgery, such as removal of a tumor from the upper jaw and fracture of the upper jaw.

Topographic relationship between the muscle bands of the zygomaticus major muscle and the facial artery.

The aim of this study was to clarify the spatial relationship between the facial artery and the insertion of the zygomaticus major muscle in the perioral region. In 30 of 70 dissections (42.9%), the facial artery passed through the separate muscle bands of the zygomaticus major muscle. The mean diameter of the facial artery passing through the zygomaticus major muscle in this region was 1.74 mm (range 0.82-2.86 mm). The relationship between the facial artery and the insertion of the zygomaticus major muscle in the perioral region described in this study is expected to provide critical information for surgical planning and procedures around the perioral region.