The Arterial Pattern of the Upper Nasal Septum (S-Point) and Potential Role in Severe Epistaxis.

OBJECTIVES: The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The objective is to define the anatomical patterns of vascularization of the S-point area that could explain its clinical relevance. METHODS: Thirty-three nasal septums of latex-injected formalin-embalmed and fresh human cadaveric heads were dissected to analyze the arterial arrangement of the S-point area. Measurements and patterns of vascularization were described. RESULTS: The S-point area, was consistently surrounded by a single or multiple arterial anastomotic arches consistently formed superiorly by the anterior ethmoidal and posterior ethmoidal artery branches, and inferiorly by the posterior septal artery. The caliber of the arterial arches was typically larger than the caliber of the arterial branches supplying them. A single arch was present in 36.3% of septums, and multiple arches in 63.6%. The mean distance from the S-point to the anterior limit of the arch was 9 mm, to the posterior arch when the present was 3 mm, to the superior limit 6 mm, to the inferior limit 6 mm, and to the nasal roof was 10 mm. CONCLUSION: This study demonstrates the dense arterial configuration of the S point area, which is characterized by a single or multiple vascular arches of greater caliber than the branches of origin. This finding could explain why the S-point area is a frequent source of epistaxis, and guide its surgical cauterization when an obvious vascular ectasia is not visualized. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2075-2080, 2023.

Pneumatization of the Sphenoidal Sinus May Affect Endonasal Cranial Base Reconstruction.

OBJECTIVE: The aim of this study is to verify if the length of the nasoseptal flap is sufficient to cover the tuberculum sellae and planum sphenoidale of sphenoidal sinuses with varied degrees of pneumatization. METHODS: Retrospective study of paranasal sinus computed tomography comparing the potential length of the nasoseptal flap and the length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches in conchal, presellar, sellar, incomplete postsellar, and complete postsellar sphenoidal sinuses. RESULTS: The length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches was directly related to the degree of pneumatization of the sphenoidal sinus. The nasoseptal flap length was adequate to cover the cranial base after transtuberculum approaches of all cases from the conchal, presellar, and sellar groups and the majority of cases from postsellar pneumatization. For transplanum approaches, the nasosseptal flap was sufficient to reconstruct defects in most cases from conchal, pre-sellar, and sellar type sinuses and in 54,9% and 19,2% in incomplete and complete postsellar, respectively. CONCLUSIONS: In well pneumatized sphenoidal sinus, the nasoseptal flap may not be sufficient to cover the cranial base after transtuberculum and transplanum approaches.

Foundations of Advanced Neuroanatomy: Technical Guidelines for Specimen Preparation, Dissection, and 3D-Photodocumentation in a Surgical Anatomy Laboratory.

Objective This study was aimed to provide a key update to the seminal works of Prof. Albert L. Rhoton Jr., MD, with particular attention to previously unpublished insights from the oral tradition of his fellows, recent technological advances including endoscopy, and high-dynamic range (HDR) photodocumentation, and, local improvements in technique, we have developed to optimize efficient neuroanatomic study. Methods Two formaldehyde-fixed cadaveric heads were injected with colored latex to demonstrate step-by-step specimen preparation for microscopic or endoscopic dissection. One formaldehyde-fixed brain was utilized to demonstrate optimal three-dimensional (3D) photodocumentation techniques. Results Key steps of specimen preparation include vessel cannulation and securing, serial tap water flushing, specimen drainage, vessel injection with optimized and color-augmented latex material, and storage in 70% ethanol. Optimizations for photodocumentation included the incorporation of dry black drop cloth and covering materials, an imaging-oriented approach to specimen positioning and illumination, and single-camera stereoscopic capture techniques, emphasizing the three-exposure-times-per-eye approach to generating images for HDR postprocessing. Recommended tools, materials, and technical nuances were emphasized throughout. Relative advantages and limitations of major 3D projection systems were comparatively assessed, with sensitivity to audience size and purpose specific recommendations. Conclusion We describe the first consolidated step-by-step approach to advanced neuroanatomy, including specimen preparation, dissection, and 3D photodocumentation, supplemented by previously unpublished insights from the Rhoton fellowship experience and lessons learned in our laboratories in the past years such that Prof. Rhoton's model can be realized, reproduced, and expanded upon in surgical neuroanatomy laboratories worldwide.

Sternberg's Canal and Defect: Is the Lateral Craniopharyngeal Canal a Source of Spontaneous Cerebrospinal Fluid Leak? Anatomic and Radiological Analysis in Pediatric and Adult Populations.

BACKGROUND: The lateral craniopharyngeal or Sternberg's canal (SC) originates from superior orbital fissure (SOF) and traverses the sphenoid body into the nasopharynx. A remnant of the canal, Sternberg's defect (SD), has been debated as a source of cerebrospinal fluid (CSF) leak. The canal was described in 1888, and there is limited accurate visual illustration in the literature. OBJECTIVE: To provide a detailed anatomic and radiological illustration of the canal in pediatric and adult population including the mechanism undermining the incidence of the canal, and the possibility of the canal as a source of CSF leak. METHODS: A total of 195 high-resolution computed tomographies (CT) of patients (50 3-yr-old, 20 5-yr-old, and 125 adults) and 43 dry adult skulls (86 sides) were analyzed for a canal matching the description of the SC. RESULTS: A SC was identified in 86% of the 3-yr-old and 40% of 5-yr-old patients. The diameter and length were 2.12 mm and 12 mm, respectively. The incidence of the canal decreased with age as sinus pneumatization extended into the sphenoid sinus. Only 0.8% of the adult skull on CT had the canal. The canal was not present on the dry adult skulls examination, but SD was found in 4.65%. CONCLUSION: SC exists with high incidence in the pediatric group. Sinus pneumatization obliterates the canal in the adult population, leaving a defect in 4.65% of cases, which given the location and related anatomic structures, is unlikely to be a source of CSF leak.

Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus

Abstract Introduction The endoscopic access has reduced the morbidity associated with external approaches in diseases of themaxillary sinus. A reversible endoscopic medialmaxillectomy (REMM) is presented as an alternative for treatment of benign maxillary diseases. Objective To describe the REMM technique and report four cases of patients with benign maxillary sinus conditions treated through this approach. Methods The present study was divided into two parts: anatomical and case series. Two cadaveric dissections confirmed the feasibility of the REMMapproach. The same technique was performed on four consecutive patients with benign maxillary sinus disease. Results The cadaveric dissections confirmed wide exposure to the maxillary cavity, preserving the anatomy of the maxillary sinus. In the patient series, one patient presented with an antrochoanal polyp, one had a silent sinus syndrome, one had a chronic maxillary sinusitis secondary to a gunshot, and the last one had an inverted papilloma in the maxillary sinus. In all of the cases, the REMM approach provided excellent access and adequate resection, as well as preservation of the inferior turbinate, nasolacrimal duct, and lateral wall of the nose (including its osteomucosal component). Finally, all of the patients had an uneventful postoperative course. Conclusion The REMM technique is an excellent surgical approach to benign conditions of the maxillary sinus. It has few limitations and appears to be associated with less morbidity than conventional techniques.

Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus.

Introduction The endoscopic access has reduced the morbidity associated with external approaches in diseases of the maxillary sinus. A reversible endoscopic medial maxillectomy (REMM) is presented as an alternative for treatment of benign maxillary diseases. Objective To describe the REMM technique and report four cases of patients with benign maxillary sinus conditions treated through this approach. Methods The present study was divided into two parts: anatomical and case series. Two cadaveric dissections confirmed the feasibility of the REMM approach. The same technique was performed on four consecutive patients with benign maxillary sinus disease. Results The cadaveric dissections confirmed wide exposure to the maxillary cavity, preserving the anatomy of the maxillary sinus. In the patient series, one patient presented with an antrochoanal polyp, one had a silent sinus syndrome, one had a chronic maxillary sinusitis secondary to a gunshot, and the last one had an inverted papilloma in the maxillary sinus. In all of the cases, the REMM approach provided excellent access and adequate resection, as well as preservation of the inferior turbinate, nasolacrimal duct, and lateral wall of the nose (including its osteomucosal component). Finally, all of the patients had an uneventful postoperative course. Conclusion The REMM technique is an excellent surgical approach to benign conditions of the maxillary sinus. It has few limitations and appears to be associated with less morbidity than conventional techniques.

Chicken wing training model for endoscopic microsurgery.

Objectives To present and validate a chicken wing model for endoscopic endonasal microsurgical skill development. Setting A surgical environment was constructed using a Styrofoam box and measurements from radiological studies. Endoscopic visualization and instrumentation were utilized in a manner to mimic operative setting. Design Five participants were instructed to complete four sequential tasks: (1) opening the skin, (2) exposing the main artery in its neurovascular sheath, (3) opening the neurovascular sheath, and (4) separating the nerve from the artery. Time to completion of each task was recorded. Participants Three junior attendings, one senior resident, and one medical student were recruited internally. Main Outcome Measures Time to perform the surgical tasks measured in seconds. Results The average time of the first training session was 48.8 minutes; by the 10th training session, the average time was 22.4 minutes. The range of improvement was 25.7 minutes to 72.4 minutes. All five participants exhibited statistically significant decrease in time after 10 trials. Kaplan-Meier analysis revealed that an improvement of 50% was achieved by an average of five attempts at the 95% confidence interval. Conclusions The ex vivo chicken wing model is an inexpensive and relatively realistic model to train endoscopic dissection using microsurgical techniques.

The extended nasoseptal flap for skull base reconstruction of the clival region: an anatomical and radiological study.

Objective Reconstruction of large clival defects after an endoscopic endonasal procedure is challenging. The objective is to analyze the morphology, indications, and limitations of the extended nasoseptal flap, which adds the nasal floor and inferior meatus mucosa, compared with the standard nasoseptal flap, for clival reconstruction. Design Twenty-seven sides of formalin-fixed anatomical specimens and 13 computed tomography (CT) scans were used. Under 0-degree endoscopic visualization, a standard flap on one side and an extended flap on the other side were performed, as well as exposure of the sella, cavernous sinus, and clival dura mater. Coverage of both flaps was assessed, and they were incised and extracted for measurements. Results The extended flap has two parts: septal and inferior meatal. The extended flaps are 20 mm longer and add 774 mm(2) of mucosal area. They cover a clival defect from tuberculum to foramen magnum in 66.6% cases and from below the sella in 91.6%. They cover both parasellar and paraclival segments of the internal carotid arteries. The lateral inferior limits are the medial aspect of the hypoglossal canals and Eustachian tubes. CT scans can predict the need or limitation of an extended nasoseptal flap. Conclusions The nasal floor and inferior meatus mucosa adds a significant area for reconstruction of the clivus. A defect laterally beyond the hypoglossal canals is not likely covered with this variation of the flap. Preoperative CT scans are useful to guide the reconstruction techniques.

Endoscopic anatomy of the approaches to the sellar area and planum sphenoidale.

UNLABELLED: The productive work between otolaryngologists and neurosurgeons has resulted in the emergence of endoscopic endonasal skull base surgery. The goal of the present study is to describe the endoscopic anatomy of the endonasal approach to the sellar region and planum sphenoidale, highlighting the key points of the surgical approach and the neurovascular landmarks. METHOD: Descriptive study of the endoscopic endonasal dissection of 9 fresh cadavers with exposure of the anatomic structures. RESULTS: The endoscopic endonasal ethmoidectomy and sphenoidotomy allows an expanded access to the sellar area and planum sphenoidale. The surface anatomy of the sphenoid sinus is easily identifiable and provides safe landmarks, guiding the intracranial dissection. CONCLUSION: The endoscopic endonasal approach to the skull base by the ENT and neurosurgeon is feasible, but it requires adequate anatomical knowledge and endoscopic skills for its realization, which can be obtained by practicing in cadavers.

Current outlook of ethics in research with human subjects.

UNLABELLED: In the last decades, medical care has been increasingly permeated by the concept of evidence-based-medicine, in which clinical research plays a crucial role in establishing diagnostic and treatment. Following the improvements in clinical research, we have a growing concern and understanding that some ethical issues must be respected when the subjects are human beings. Research with human subjects relies on the principles of autonomy, beneficence, no maleficence and justice. Ordinance 196/96 from the National Health Board adds to the Brazilian legislation such renowned bioethical principles. AIM: Discuss the main ethical aspects involved in research with human subjects. MATERIALS AND METHODS: Critical analysis of Ordinance 196/96 and related literature. CONCLUSION: Ordinance 196/96 rules research with human subjects; nevertheless, it requires more in-depth discussions regarding the informed consent, use of placebo, research with vulnerable populations and research in developing countries.

Endoscopic anatomy of the approaches to the sellar area and planum sphenoidale / Anatomia endoscópica do acesso à região selar e plano esfenoidal

The productive work between otolaryngologists and neurosurgeons has resulted in the emergence of endoscopic endonasal skull base surgery. The goal of the present study is to describe the endoscopic anatomy of the endonasal approach to the sellar region and planum sphenoidale, highlighting the key points of the surgical approach and the neurovascular landmarks. METHOD: Descriptive study of the endoscopic endonasal dissection of 9 fresh cadavers with exposure of the anatomic structures. RESULTS: The endoscopic endonasal ethmoidectomy and sphenoidotomy allows an expanded access to the sellar area and planum sphenoidale. The surface anatomy of the sphenoid sinus is easily identifiable and provides safe landmarks, guiding the intracranial dissection. CONCLUSION: The endoscopic endonasal approach to the skull base by the ENT and neurosurgeon is feasible, but it requires adequate anatomical knowledge and endoscopic skills for its realization, which can be obtained by practicing in cadavers.

O trabalho cooperativo entre otorrinolaringologistas e neurocirurgiões resultou no aprimoramento das técnicas cirúrgicas e no surgimento da cirurgia endoscópica endonasal da base do crânio. O estudo tem como objetivo descrever a anatomia endoscópica do acesso endonasal da região selar e plano esfenoidal, destacando os pontos fundamentais do acesso cirúrgico e referências neuro-vasculares. MÉTODO: Estudo descritivo da dissecção endoscópica endonasal de 9 cadáveres frescos com exposição das estruturas anatômicas. RESULTADOS: A etmoidectomia e esfenoidotomia endonasal endoscópica permite um acesso estendido à região selar e plano esfenoidal. A anatomia de superfície do seio esfenoidal é facilmente identificada e fornece pontos de referência seguros, guiando a dissecção intracraniana. CONCLUSÃO: O acesso endoscópico endonasal para a base do crânio pelo otorrinolaringologista e neurocirurgião é perfeitamente viável, mas para isso o conhecimento anatômico da região e de seus pontos de referência é essencial, o que pode ser obtido pelo treinamento em cadáveres.

Current outlook of ethics in research with human subjects / Panorama atual da ética em pesquisa em seres humanos

In the last decades, medical care has been increasingly permeated by the concept of evidence-based-medicine, in which clinical research plays a crucial role in establishing diagnostic and treatment. Following the improvements in clinical research, we have a growing concern and understanding that some ethical issues must be respected when the subjects are human beings. Research with human subjects relies on the principles of autonomy, beneficence, no maleficence and justice. Ordinance 196/96 from the National Health Board adds to the Brazilian legislation such renowned bioethical principles. AIM: Discuss the main ethical aspects involved in research with human subjects. MATERIALS AND METHODS: Critical analysis of Ordinance 196/96 and related literature. CONCLUSION: Ordinance 196/96 rules research with human subjects; nevertheless, it requires more in-depth discussions regarding the informed consent, use of placebo, research with vulnerable populations and research in developing countries.

Nas últimas décadas, a medicina tem sido cada vez mais permeada pelo conceito de medicina baseada em evidências, na qual a pesquisa clínica possui papel crucial no estabelecimento de diretrizes diagnósticas e terapêuticas. Com o avanço da pesquisa clínica, surgiu a preocupação e o entendimento que certos padrões éticos devam ser obedecidos quando o objeto de estudo é o ser humano. A pesquisa em seres humanos baseia-se nos princípios da autonomia, beneficência, não maleficência e justiça. A Resolução 196/96 do Conselho Nacional de Saúde incorpora à legislação brasileira tais princípios bioéticos consagrados. OBJETIVO: Discutir os principais aspectos éticos envolvidos na pesquisa em seres humanos. MATERIAL E MÉTODO: Análise crítica da Resolução 196/96 do CNS e literatura correlata. CONCLUSÃO: A Resolução 196/96 do Conselho Nacional de Saúde regulamenta a experimentação em seres humanos, no entanto necessita de discussões mais profundas no que diz respeito ao consentimento livre e esclarecido, ao uso de placebo, à participação de pessoas em situação de vulnerabilidade e à realização de pesquisas em países em desenvolvimento.

[Endoscopic ligation of the anterior ethmoidal artery: a cadaver dissection study]. / Ligadura endoscópica da artéria etmoidal anterior: estudo de dissecção em cadáveres.

UNLABELLED: Anterior ethmoidal artery (AEA) ligation may be necessary in cases of severe epistaxis not controllable with traditional therapy. Endoscopic endonasal ligation of the AEA is not used frequently; there are few studies in the literature for standardization of the endoscopic technique for this vessel. AIM: To demonstrate the feasibility of periorbital AEA ligation in a transethmoidal endoscopic approach. METHODS: A prospective study where 50 nasal cavities were dissected. After anterior ethmoidectomy and partial removal of lamina papyracea, the periorbital area was carefully dissected along a subperiosteal plane to identify the AEA. The vessel was exposed within the orbit and dissected. RESULTS: Data on technical difficulties, complications, the learning curve and anatomical variations were gathered. CONCLUSION: An endonasal endoscopic approach to the AEA within the orbit was shown to be feasible. Identifying the artery is not difficult, and this technique avoids external incisions. This approach appears to be an excellent alternative for approaching the AEA. Further clinical studies are needed to demonstarte the benefits of this technique.

Ligadura endoscópica da artéria etmoidal anterior: estudo de dissecção em cadáveres / Endoscopic ligation of the anterior ethmoidal artery: a cadaver dissection study

Ligadura da artéria etmoidal anterior (AEA) pode ser necessária em casos de epistaxe grave refratária ao tratamento tradicional. O uso da ligadura endoscópica endonasal da AEA ainda é bastante limitado. Existem poucos estudos na literatura sobre a técnica de abordagem endoscópica desta artéria. OBJETIVOS: Demonstrar a aplicabilidade técnica da ligadura periorbitária da AEA por via endoscópica transetmoidal. MATERIAL E MÉTODOS: Estudo prospectivo. 50 fossas nasais de cadáveres foram dissecadas. Após a realização de uma etmoidectomia anterior e remoção parcial da lâmina papirácea, a periórbita foi cuidadosamente dissecada até a identificação da AEA. Após sua identificação, a artéria foi exposta e ligada dentro da órbita. RESULTADOS: Todas as dificuldades inerentes ao procedimento, as complicações associadas, a curva de aprendizado e variações anatômicas foram coletados. CONCLUSÕES: A abordagem endoscópica da AEA na órbita de cadáveres mostrou-se factível. A identificação da artéria é fácil e a técnica evita incisões externas. Este acesso parece ser uma excelente alternativa para a abordagem da AEA. Estudos clínicos futuros são necessários para comprovar os benefícios desta técnica.

Anterior ethmoidal artery (AEA) ligation may be necessary in cases of severe epistaxis not controllable with traditional therapy. Endoscopic endonasal ligation of the AEA is not used frequently; there are few studies in the literature for standardization of the endoscopic technique for this vessel. AIM: To demonstrate the feasibility of periorbital AEA ligation in a transethmoidal endoscopic approach. METHODS: A prospective study where 50 nasal cavities were dissected. After anterior ethmoidectomy and partial removal of lamina papyracea, the periorbital area was carefully dissected along a subperiosteal plane to identify the AEA. The vessel was exposed within the orbit and dissected. RESULTS: Data on technical difficulties, complications, the learning curve and anatomical variations were gathered. CONCLUSION: An endonasal endoscopic approach to the AEA within the orbit was shown to be feasible. Identifying the artery is not difficult, and this technique avoids external incisions. This approach appears to be an excellent alternative for approaching the AEA. Further clinical studies are needed to demonstarte the benefits of this technique.

Estudo do retalho nasosseptal para reconstrução endoscópica da base do crânio anterior / Study of the nasosseptal flap for endoscopic skull base reconstruction of the anterior cranial base

Introdução: O uso do retalho nasosseptal (NS) para a reconstrução endoscópica da base do crânio foi fator fundamental para o avanço dos acessos endonasais expandidos. Objetivos: Aferir as dimensões do retalho NS e do defeito da base do crânio anterior (BCA) após ressecção craniofacial endoscópica e verificar a suficiência do retalho para cobrir o defeito. Estudar a anatomia da artéria septal (AS) e sua relação com o óstio do seio esfenoide. Métodos: Estudo anatômico do retalho NS em 14 cadáveres. Após ressecção craniofacial endoscópica, foi verificado a suficiência do retalho em cobrir o defeito na BCA. A AS foi dissecada e estuda quanto ao número de ramos presentes no pedículo e sua distância em relação ao óstio do seio esfenoide. Estudo radiológico com tomografia computadorizada de 30 pacientes para a comparação entre medidas do retalho NS e as do defeito na BCA. Resultados: O retalho foi suficiente para cobrir o defeito na BCA nas 14 dissecções. Em 71,4% dos casos, dois ramos da AS foram encontrados no pedículo. A distância média entre o primeiro ou único ramo ao óstio do esfenoide foi de 9,3mm. No estudo radiológico, a média da área reconstrutora do retalho (17,12cm2) foi constantemente maior que a média da área do defeito (8,64cm2) (p<0,001). A diferença entre o comprimento superior do retalho e a distância anteroposterior do defeito foi menor ou igual a 5mm em 26,7% dos casos. A comparação entre a largura anterior do retalho e a distância interorbitária anterior revelou que em 33% dos casos a diferença foi 5mm. A incorporação da mucosa do assoalho da fossa nasal ao retalho aumentou essa diferença em mais 10mm em todos os casos. Conclusões: As dimensões do retalho NS são suficientes para cobrir o defeito na BCA. A extremidade anterior do comprimento anteroposterior do defeito apresenta maior risco de falha de cobertura. A incorporação da mucosa do assoalho da fossa nasal ao retalho é importante para diminuir o risco de falha de cobertura anterior...

Introduction: Use of the nasoseptal (NS) flap for endoscopic skull base reconstruction was an essential contribution for the evolution of the expanded endonasal approaches. Objectives: Measure the dimensions of the NS flap and the anterior skull base (ASB) defect after endoscopic craniofacial resection and verify if the flap is sufficient to cover the defect. Study the anatomy of the septal artery (SA) and its relation with the sphenoid ostium. Methods: Anatomical study of the NS flap in 14 cadavers. After endoscopic craniofacial resection, the sufficiency of the flap to cover the ASB defect was assessed. The SA was dissected and studied regarding the number of branches in the pedicle and the distance between the artery and the sphenoid ostium. Radiological study using CT scans of 30 patients for comparison among measurements of the NS flap and the ASB defect. Results: The flap was sufficient to cover the ASB in all 14 dissections. In 71.4% of the cases, 2 branches of the SA were found in the pedicle. The distance between the first or the only single branch of the SA to the sphenoid ostium was 9.3mm. In the radiological study, the reconstruction area of the flap (17.12cm2) was constantly larger than the defect area (8.64cm2) (p<0.001). The difference between the superior length of the flap and the anterior-posterior distance of the defect was 5mm in 26.7% of the cases. Comparison between the flap anterior width and the defect anterior width revealed that in 33% the difference was 5mm. The incorporation of the nasal floor mucosa to the flap increased that difference in more than 10mm in all cases. Conclusions: The dimensions of the NS flap are sufficient to cover completely the ASB defect. The anterior edge of the anterior-posterior length of the defect presents increased risk for failure in coverage. The additional width provided by the incorporation of the nasal floor mucosa to the flap is important to decrease the risk of failure in coverage of the...

Modelo anatômico para dissecção em cadáveres da vascularização do palato / Anatomical model for dissection in corpses of the palate vascularization

Introdução: A principal artéria que supre o mucoperiósteo do palato duro é a artéria palatina maior. O conhecimento detalhado da anatomia vascular do palato e, em especial, da região do forame palatino maior é importante para prevenção de lesões vasculares durante procedimentos nesta região. Dentre estes procedimentos, inclui-se a confecção de retalhos para correção de falhas no palato duro, palato mole e base do crânio. Objetivo: Desenvolver um modelo anatômico que possa ilustrar a anatomia endoscópica do forame palatino maior e analisar se a técnica de injeção intravascular de silicone colorido é suficiente para preencher os ramos arteriais menores que irrigam o palato duro. Método: A forma de estudo foi experimental através da dissecção endoscópica de 10 artérias palatinas maiores em cinco cabeças de cadáveres preparadas com injeção intravascular de silicone colorido Resultados: Do total de 10 artérias dissecadas, 8 foram devidamente coradas pela técnica de injeção empregada. O que corresponde a uma eficácia de 80%. Conclusão: O modelo anatômico demonstrou ser um método factível para o estudo endoscópico do forame palatino maior, sendo a injeção de silicone eficiente na coloração de vasos terminais em 80% dos casos.

Introduction: The main artery that supplies the mucoperiosteum of the hard palate is the greater palatine artery. The knowledge detailed of the vascular anatomy of the palate and, in special, of the region of the greater palatine foramen is important for prevention of lesions vascular during procedures in this region. Among these procedures, it included the making of shreds for correction of failures in the hard palate, soft palate and cranial base. Objective: To develop an anatomical model that can illustrate the endoscopic anatomy of the greater palatine foramen and analyze the technical of injection intra vascular of colored silicone is sufficient for fill the lower arterial branches than irrigate the hard palate. Method: The form of study was experimental through the endoscopic dissection of 10 greater palatine arteries in five heads of corpses prepared with injection intra vascular of colored silicone. Results: Of the total of 10 arteries dissected, 8 properly were colored by the technique of injection employed. What corresponds to an efficacy of 80%. Conclusion: The anatomical model showed to be a feasible approach for the endoscopic study of the greater palatine foramen, being the injection of efficient silicone in the terminals vessels coloring in 80% of the cases.

Avaliação polissonográfica e de videoendoscopia da deglutição de pacientes portadores da sequência de Pierre-Robin / Polysomnography evaluation and swallowing endoscopy of patients with Pierre Robin sequence

Asequência de Pierre Robin é caracterizada por micrognatia, glossoptose e obstrução das vias aéreas superiores. A gravidade dos sintomas é muito variável, o que torna o tratamento destes pacientes um desafio. Objetivos: Identificar a presença de apneia-hipopneia obstrutiva do sono e avaliar a presença de alterações da deglutição em pacientes portadores da sequência de Pierre-Robin. Material e métodos: Estudo retrospectivo em que foram avaliadas 14 crianças com sequência de Pierre-Robin, sendo oito do sexo feminino. As crianças foram submetidas à videoendoscopia da deglutição e polissonografia. Resultado: Oito pacientes foram incluídos no estudo. Seis apresentaram polissonografia normal e apenas 1 paciente apresentou apneia-hipopneia leve de origem central. A videoendoscopia da deglutição mostrou-se normal em cinco pacientes e disfagia moderada foi detectada em três pacientes sendo submetidos à gastrostomia. A distração da mandíbula foi realizada em quatro pacientes que também foram submetidos à traqueostomia no mesmo tempo cirúrgico. Conclusões: Disfagia foi mais prevalente do que a apneia do sono. A videoendoscopia da deglutição mostrou ser um exame dinâmico e eficaz na detecção de distúrbios alimentares em pacientes com a sequência de Pierre Robin.

The Pierre Robin sequence is characterized by micrognathia, glossoptosis and upper airway obstruction. Symptom severity varies, and this makes the treatment of these patients a true challenge. AIM: to identify the presence of sleep hypopneaapnea in patients with Pierre-Robin sequence. Materials and methods: retrospective study in which we assessed 14 children with Pierre-Robin sequence, eight girls. The children were submitted to swallowing video-endoscopy study and polysomnography. Results: eight patients were included in this study. Six had normal polysomnography and only one patient had mild central hypopnea-apnea. Swallowing video-endoscopy was normal in five patients and moderate dysphagia was detected in three patients, who were then submitted to gastrostomy. Mandible distraction was carried out in four patients who were also submitted to tracheostomy during the same procedure. Conclusions: dysphagia was more prevalent than sleep apnea. Swallowing video-endoscopy proved to be a dynamic test and one able to detect feeding disorders in patients with Pierre Robin sequence.

Rhinosinusitis in HIV-infected children undergoing antiretroviral therapy.

UNLABELLED: The association of protease inhibitors (PI) to antiretroviral therapy has generated sensible changes in morbidity and mortality of HIV-infected patients. AIM: Aims at evaluating the impact of this association on the prevalence of rhinosinusitis (RS) and CD4+ lymphocyte count in HIV-infected children. METHODS: Retrospective cross-sectional study of the medical charts of 471 HIV-infected children. In 1996, protease inhibitors were approved for use as an association drug in antiretroviral therapy. Children were divided into two groups: one which did not receive PI and another which received PI after 1996. The prevalence of RS and CD4+ lymphocyte counts were compared between these groups. RESULTS: 14.4% of HIV-infected children had RS. Chronic RS was more prevalent the its acute counterpart. Children under 6 years old who were taking protease inhibitors presented with a significant higher prevalence of acute RS. The association of PI with the antiretroviral regimen was associated to higher mean CD4+ lymphocyte count and lower prevalence of chronic RS. CONCLUSIONS: The use of protease inhibitors was associated to higher mean CD4+ lymphocyte count. Children under 6 years of age in antiretroviral therapy associated with PI presented a lower likelihood of developing chronic RS.