Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal and Endoscopic-Assisted Transmaxillary Transpterygoid Approaches.

Introduction The endoscopic endonasal transpterygoid approach (EETPA) with or without the addition of the endoscopic-assisted sublabial anterior transmaxillary approach (ESTA) has become increasingly utilized for lesions posterior to the pterygopalatine fossa (PPF), including infratemporal fossa (ITF), lateral recess of the sphenoid sinus, Meckel's cave, petrous apex, and parapharyngeal space. The main goal of this study is to develop an educational resource to learn the steps of the EETPA for trainees. Methods EETPA and ESTA were performed in 12 specimens by neurosurgery trainees, under supervision from the senior authors. One EETPA and one ESTA were performed on each specimen on opposite sides. Dissections were supplemented with representative cases. Results After a wide unilateral sphenoidotomy, ethmoidectomy, and partial medial maxillectomy, the anteromedial bone limits of the PPF were identified and drilled out. The pterygoid progress was modularly removed. By enlarging the opening of the posterior and lateral walls of the maxillary sinus through EETPA and ESTA, respectively, the neurovascular and muscular compartments of the PPF and ITF were better identified. The EETPA opens direct corridors to the PPF, medial ITF, middle cranial fossa, cavernous sinus, Meckel's cave, petrous apex, and internal carotid artery. If a more lateral exposure of the ITF is needed, the ESTA is an appropriate addition. Conclusion Despite the steep learning curve of the EETPA, granular knowledge of its surgical anatomy and basic surgical steps are vital for those advancing their learning in complex endoscopic approaches to the ventral skull base when expanding the approach laterally in the coronal plane.

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.

The Lingual Process of the Sphenoid Bone and the Petrolingual Ligament: Surgical Anatomy, Landmarks, and Clinical Relevance.

BACKGROUND: The lingual process of the sphenoid bone (LP) and the petrolingual ligament (PLL) surround laterally the internal carotid artery within the middle cranial fossa (MCF). OBJECTIVE: To study the LP and the PLL and anatomical variations considering their relationships with different structures and landmarks within the MCF, especially oriented toward the endoscopic endonasal approaches. METHODS: Seventy-two sides of dry skulls and 20 sides of embalmed specimens were studied. The measurements of the LP and the PLL were obtained, considering important landmarks in the MCF. RESULTS: The LP had a mean length and height of 5 mm and 3 mm, respectively. Its distance from the foramen lacerum was 6 mm, from the foramen ovale 10 mm, foramen rotundum 15 mm, and petrous apex 9 mm. In 44 sides (61.11%), the LP partially closed the lateral aspect of the carotid sulcus; in 17 sides (23.61%), it was found as a near-ring; and in 11 sides (15.2%), it was considered rudimentary. Considering the PLL, its length and height were, respectively, 9 mm, and 4 mm. CONCLUSION: The LP and PLL separate the carotid artery at the inferior aspect of Meckel's cave and constitute important landmarks for endoscopic endonasal approaches to Meckel's cave and MCF, and their identification and removal is essential for internal carotid artery mobilization in this area.

Three-hundred and sixty degrees of surgical approaches to the maxillary sinus.

Objectives: To demonstrate three-hundred and sixty degrees of maxillary sinus (MS) surgical approaches using cadaveric dissections, highlighting the step-by-step anatomy of each procedure. Methods: Two latex-injected cadaveric specimens were utilized to perform surgical dissections to demonstrate different approaches to the MS. The procedures were documented with macroscopic images and endoscopic pictures. Results: Dissections were performed to approach the MS medially (endoscopic maxillary antrostomy and ethmoidectomy), anteriorly (Caldwell-Luc), superiorly (transconjunctival/transorbital approach), inferiorly (transpalatal approach), and posterolaterally (preauricular hemicoronal approach). Conclusion: A number of approaches have been described to address pathology in the MS. Surgeons should be familiar with indications, limitations, and surgical anatomy from different perspectives to approach the MS. This paper illustrates anatomic approaches to the MS with detailed step-by-step cadaveric dissections and case examples.

Aerosol-Printed MoS2 Ink as a High Sensitivity Humidity Sensor.

Molybdenum disulfide (MoS2) is attractive for use in next-generation nanoelectronic devices and exhibits great potential for humidity sensing applications. Herein, MoS2 ink was successfully prepared via a simple exfoliation method by sonication. The structural and surface morphology of a deposited ink film was analyzed by scanning electron microscopy (SEM), Raman spectroscopy, and atomic force microscopy (AFM). The aerosol-printed MoS2 ink sensor has high sensitivity, with a conductivity increase by 6 orders of magnitude upon relative humidity increase from 10 to 95% at room temperature. The sensor also has fast response/recovery times and excellent repeatability. Possible mechanisms for the water-induced conductivity increase are discussed. An analytical model that encompasses two ionic conduction regimes, with a percolation transition to an insulating state below a low humidity threshold, describes the sensor response successfully. In conclusion, our work provides a low-cost and straightforward strategy for fabricating a high-performance humidity sensor and fundamental insights into the sensing mechanism.

The Posterior Septal Nasal Floor Mucosal Flap for Cranial Base Reconstruction.

OBJECTIVE: While pedicled intranasal flaps, such as the nasoseptal flap (NSF), successfully reduce postoperative CSF leaks following endoscopic endonasal approaches (EEA) to the skull base, morbidity remains prevalent. This study describes the first cadaveric description and radiographic analysis of the posterior septal nasal floor mucosal flap (PSNF) designed to reduce pedicled nasal flap morbidity. A case series is also detailed. STUDY DESIGN: Cadaveric dissection, radiographic analysis, and case series. METHODS: Seven cadaver specimens underwent harvest of the PSNF. PSNF flap dimensions were measured on the thirty deidentified sinus computed tomography (CT) scans. A retrospective case series was performed on the first set of patients who received the PSNF for reconstruction of a sellar base defect. Information concerning complications, symptoms, and the appearance of the flap was recorded from records of the patient's postoperative inpatient stay, 1-week postop visit, and 1-month postop visit. RESULTS: Cadaver dissection of the PSNF flap demonstrated good arc rotation along its pedicle with ability to cover both sellar and planum defects. Cadaveric flap measurements and CT-derived measurements estimated a mean surface area of 16.7 and 18.3 cm2 , respectively. 15 patients underwent reconstruction of a sellar or planum defect using the PSNF technique. Only one CSF leak was encountered postoperatively. Minimal crusting of the flap and donor site was seen 1 month postoperatively. CONCLUSION: The PSNF flap provides a sizeable pedicled region for reconstruction comparable to other pedicled nasal flaps. Our case series demonstrated good postoperative outcomes without reduced donor site morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1561-1568, 2022.

The posterior ligament of the incus ("white dot"): A reliable surgical landmark for the facial recess.

OBJECTIVE: There is a void in the literature describing reliable surgical landmarks that aid in the dissection of the facial recess in the absence of skeletonizing the mastoid segment of the facial nerve. The posterior ligament of the incus is a readily distinguishable "white dot" along the incus buttress that has been used to guide dissection in a safe and efficient manner. The goal of our study is to describe a surgical approach that utilizes this surgical landmark to drill the facial recess and to take anatomical measurements demonstrating the safety and reliability of this approach. MATERIALS AND METHODS: After cortical mastoidectomies were performed in 10 cadaveric temporal bones, the white dot was identified at the junction of short process of the incus and the incus buttress. Using the white dot for anatomical reference, a 2 mm diamond drill bit was used to open the facial recess without first identifying the facial nerve or chorda tympani nerve. After photographs were taken, the facial and chorda tympani nerves were definitively identified and skeletonized to delineate the confines of the facial recess. Photographs were once again acquired in a consistent manner for comparison. Finally, calibrated anatomic measurements were acquired from the 10 distinct image sets. RESULTS: The facial recess was successfully drilled in 10 temporal bones using the posterior ligament as a surgical landmark without injury to the chorda tympani or facial nerve. The median angle taken from the axis of the short process of the incus to the facial nerve - chorda tympani junction was 139.2° (IQR 136.8-141). At the widest point in the facial recess, median distances anterior and posterior to an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.6 mm (IQR 1.5-1.7) and 1.6 mm (IQR 1.6-1.7; p = 0.57), indicating at this point, the white dot reference reliably bisects the facial recess width. Similarly, at the level of the round window niche, median anterior and posterior distances from an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.1 mm (IQR 1.1-1.3) and 1.3 mm (IQR 1.1-1.7; p = 0.07), respectively, once again demonstrating the white dot reliably bisecting the facial recess. CONCLUSIONS: The white dot, representing the posterior ligament of the incus, is a reliable surgical landmark that aids in safe and efficient drilling of the facial recess without first skeletonizing the facial nerve.

Prevalência de sintomas ansiosos e depressivos em universitários da área da saúde / Prevalence of anxious and depressive symptoms in health students / Prevalencia de síntomas ansiosos y depresivos en estudiantes de salud

Objetivo: analisar a prevalência de sintomas ansiosos e depressivos e suas associações com as características sociodemográficas, acadêmicas e de hábitos de saúde em universitários da área da saúde. Método: estudo transversal, censitário e com abordagem quantitativa, realizado em uma universidade pública de Alagoas. Participaram 140 universitários do último ano teórico de graduação dos cursos de Enfermagem, Fonoaudiologia, Medicina, Fisioterapia e Terapia Ocupacional. Foram aplicados o questionário com aspectos sociodemográficos, acadêmicos e de hábitos de saúde e os inventários de Beck para ansiedade e depressão. Foram utilizados os testes G-Williams e Qui-quadrado com resíduos ajustados, sendo considerados estatisticamente significativos resultados com p<0,05. Resultados: os sintomas ansiosos e depressivos foram evidenciados em 57,9% (n=81) e 34,3% (n=48) dos estudantes, respectivamente. Houve associação entre a depressão e horas de sono (p=0,018) e entre a ansiedade e estado civil (p=0,021). Conclusão: os sintomas ansiosos foram mais prevalentes que os sintomas depressivos. Ambos não apresentaram associação com as características acadêmicas, sugerindo que as condições sociais dos estudantes devem ser melhor investigadas. (AU)

Objective: To analyze the prevalence of anxious and depressive symptoms and their associations with sociodemographic, academic and health habits in university students in the health field. Methods: Cross-sectional, census and quantitative approach, conducted at a public university in Alagoas. 140 university students from the last theoretical year of undergraduate courses in Nursing, Speech Therapy, Medicine, Physiotherapy and Occupational Therapy participated. The questionnaire with sociodemographic, academic and health habits aspects and Beck's inventories for anxiety and depression were applied. The G Williams and Chi-square tests with adjusted residuals were used, and results with p <0.05 were considered statistically significant. Results: Anxious and depressive symptoms were seen in 57.9% (n =81) and 34.3% (n=48) of students, respectively. There was an association between depression and hours of sleep (p=0.018) and between anxiety and marital status (p=0.021). Conclusion: Anxious symptoms were more prevalent than depressive symptoms. Both were not associated with academic characteristics, suggesting that students' social conditions should be further investigated. (AU)

Objetivo: Analizar la prevalencia de síntomas ansiosos y depresivos y sus asociaciones con hábitos sociodemográficos, académicos y de salud en estudiantes universitarios del ámbito de la salud. Métodos: Enfoque transversal, censal y cuantitativo, realizado en una universidad pública de Alagoas. Participaron 140 estudiantes universitarios del último año teórico de las carreras de grado en Enfermería, Logopedia, Medicina, Fisioterapia y Terapia Ocupacional. Se aplicó el cuestionario con aspectos sociodemográficos, académicos y de hábitos de salud y los inventarios de Beck para ansiedad y depresión. Se utilizaron las pruebas de G-Williams y Chi-cuadrado con residuos ajustados, y los resultados con p <0,05 se consideraron estadísticamente significativos. Resultados: Los síntomas de ansiedad y depresión se observaron en el 57,9% (n = 81) y el 34,3% (n =48) de los estudiantes, respectivamente. Hubo asociación entre depresión y horas de sueño (p =0,018) y entre ansiedad y estado civil (p=0,021). Conclusión: Los síntomas de ansiedad fueron más prevalentes que los depresivos. Ambos no se asociaron con características académicas, lo que sugiere que las condiciones sociales de los estudiantes deben investigarse más a fondo. (AU)

Inspiratory muscular training in chronic stroke survivors: a randomized controlled trial.

OBJECTIVE: To assess the effectiveness of inspiratory muscular training (IMT) on measures of strength, resistance, functional performance, and quality of life (QOL) for chronic stroke survivors. DESIGN: Double-blinded randomized controlled trial. SETTING: Research laboratory. PARTICIPANTS: Subjects (N=21) with stroke (11 men, 10 women; maximal inspiratory pressure [MIP] <90% of predicted values) were randomly assigned to the experimental (n=11) and control groups (n=10); 18 participants completed all testing and training. INTERVENTIONS: Interventions were based on home-based training, with resistance adjusted biweekly to 30% of MIP for the experimental group. The control group underwent the same protocol without the threshold resistance valve. Both groups received home training 30 minutes a day 5 times a week for 8 weeks. MAIN OUTCOME MEASURES: MIP, inspiratory muscular endurance (IME), functional performance, and QOL. RESULTS: There were significant between-group differences for the MIP and IME measures. Significant changes were observed for only the experimental group for MIP (67.8±14.6 at baseline to 102.2±26.0cmH(2)O at posttraining) and IME (31.8±19.3 to 49.2±21.1cmH(2)O). No statistically significant differences were observed for measures of functional performance and QOL. CONCLUSIONS: Significant short-term effects of the IMT program for inspiratory strength and endurance were observed in chronic stroke survivors. These findings gave some indications that IMT may benefit people with stroke, and it is feasible to be included in rehabilitation interventions with this population.

Associação de doença tireoideana ao adenoma de paratireóide / Thyroid disease association to parathyroid adenoma

OBJETIVO: avaliar a prevalência de doença incidental de tireóide em tratamento cirúrgico por HPP. MÉTODO: De janeiro de 1998 a dezembro de 2004, 20 pacientes com evidência clínica e laboratorial de HPP foram submetidos à paratiroidectomia. A população de pacientes incluía 15 mulheres e cinco homens, com idade variando de 44 a 83 anos. Os dados utilizados para o diagnóstico de doença tireoidiana: clínico, laboratorial, ultra-sonografia com Doppler, exame citopatológico da punção aspirativa por agulha fina (PAAF) e exame durante a exploração intra-operatória. Todos os pacientes eram portadores de adenoma de paratireóide, sendo dois duplos. RESULTADOS: Ao exame clínico foi detectado alteração à palpação da tireóide em sete pacientes, com cinco indicações cirúrgicas; a avaliação laboratorial mostrou alteração da função tireoidiana em três pacientes; a ultra-sonografia mostrou doença nodular em 15 pacientes, mas não determinou indicação cirúrgica; a PAAF de nódulo tireoidiano foi indicada em nove pacientes, com três pacientes de carcinoma papilífero; a exploração intra-operatória não adicionou achado ao exame ultra-sonográfico. CONCLUSÃO: A associação patológica entre doenças da tireóide e da paratireóide é freqüente. A ultra-sonografia é o método mais sensível de detecção, porém, o exame clínico e a PAAF são os que revelaram impacto na indicação cirúrgica sobre a glândula tireóide no momento da paratireoidectomia.

BACKGROUND: to evaluate the prevalence of incidental thyroid disease in patients with surgical indication due to PH. METHODS: Twenty patients with clinical and laboratorial evidence of HP underwent parathyroidectomy from January, 1998 to December, 2004. The casuistic included 15 women and 5 men, whose ages varied from 44 to 83. The criteria employed for the diagnosis of thyroid disease were clinical, laboratorial, through ultrasound-Doppler, cytopathological analysis of the fine needle aspiration biopsy (FNAB), and intraoperatively. All patients had parathyroid adenoma, with two cases of double adenomas. RESULTS: The clinical examination showed palpation changes in 7 patients, with 5 surgical indications. The laboratorial evaluation presented thyroid function changes in 3 cases. Ultrasound-Doppler indicated thyroid nodular disease in 15 cases, but without impact on the surgical indication. The FNAB of the thyroid nodules was indicated in 9 patients, with 3 cases de papillary carcinoma. Intra-operative exploration did not add any finding to the ultrasound examination. CONCLUSION: The pathological association between thyroid and parathyroid diseases is not rare (75 percent). The ultrasound is the most sensible method. However, clinical examination and FNAB have a higher impact upon the surgical indication on the thyroid gland during the parathyroid approach.