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.

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.

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.