Mustafa Orhan

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. Clin. Anat. 22:324–330, 2009.

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.

Localization of the marginal mandibular branch of the facial nerve.

The aim of this study was to observe the course of the marginal mandibular branch of the facial nerve (MMBFN) in relation to the inferior border of the mandible and parotid gland and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 50 specimens were dissected. The relationships between the MMBFN and the inferior border of the mandible were recorded and analyzed. We found that posterior to the facial artery, the MMBFN ran above the inferior border of the mandible in 37 (74%) of the specimens. In 11 (22%) specimens, below the inferior border of the mandible it was divided into two branches at the crossing point with the facial artery. In 2 (4%) specimens the MMBFN divided into two branches at the point of emergence from the parotid gland. There were no statistical differences between the left and right sides, and both sexes. The MMBFN is one of the most vulnerable branches to surgical injury because of its location. For this reason, the surgeons who are willing to operate on this area, especially for the rhytidectomies, should have a true knowledge about the anatomy of this branch.

Patterns of motor branching of the musculocutaneous nerve in human fetuses and clinical significance

The purpose of this morphologic study is to investigate the course and the branching pattern of motor branches of musculocutaneous nerve (MCN) in human fetuses. Twenty upper limbs (10 right, 10 left) of spontaneously aborted formalin‐fixed fetuses were dissected under a stereomicroscope to determine motor branches for the biceps brachii and brachialis and the communicating branches between the MCN and median nerve (MN). The MCN entered the proximal and middle part of coracobrachialis in 13/20 and 5/20 of arms, respectively, and the remaining 2/20 did not pierce coracobrachialis. The communication between MCN and MN was observed in 5/20 of the arms and detected only in the distal part of the coracobrachialis. The most frequently observed innervation is the type wherein a single branch to biceps brachii, which bifurcated for supplying the short and long heads (12/20). For the innervation of brachialis, the most frequent type was a single branch from the main trunk of the MCN (15/20). During the dissections, the distance between the acromion and the emerging point of the motor branches was measured. The mean distance between the acromion and the emerging point of the all motor branches for biceps brachii in all types of specimens was 33.8 ± 6.1% of acromion‐lateral epicondyle length and for brachialis was 50.6 ± 11.5% of acromion‐lateral epicondyle length. The data of the MCN variations in the human fetus may be useful for the clinicians and pediatric surgery. Clin. Anat. 24:168–178, 2011.

Anatomic landmarks of the buccal branches of the facial nerve

The aim of this study was to classify the buccal branches of the facial nerve in relation to the parotid duct and its relevance to surgical procedures such as rhytidectomy and parotid gland surgery. In this study, 30 cadaver heads (60 specimens) were dissected. The vertical and horizontal relationships between the buccal branches of the facial nerve and tragus, and parotid duct were recorded and analyzed. The buccal branches of the facial nerve were classified into four types: Type I: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and inferior to the parotid duct. Type II: a single buccal branch of the facial nerve at the point of emergence from the parotid gland and superior to the parotid duct. Type III: buccal and other branches of the facial nerve formed a plexus. Type IV: two branches of buccal branch; one superior and one inferior to the duct at the point of emergence from the parotid gland. The buccal branches of the facial nerve are very vulnerable to surgical injury because of its location in the midface. For this reason, the surgeons who are willing to operate on this area should have a true knowledge about the anatomy of these branches.

Anatomical details used in the surgical reconstruction of the lacrimal canaliculus: cadaveric study.

PurposeThe purpose of this study was to investigate the proximal part of the lacrimal tract.MethodsThe dissection was performed on 20 specimens of adult cadavers under an operating microscope.ResultThe upper lacrimal canaliculus (ULC) and the lower lacrimal canaliculus (LLC) were opened to the lacrimal sac (LS) in three types. In Type A, the ULC and the LLC unite before opening to the LS and form the a common canaliculus (CC). In Type B, the ULC and the LLC unite at the wall of the LS and open to the LS via common hole. In Type C, however, the ULC and the LLC open to the LS separately. Type A, Type B and Type C were observed in 85%, 5% and 10% cases, respectively. Type A and Type B opened to the LS from back to front at an acute angle in 72% of the specimens, and at a right angle in 22%. The opening angles of the CC with lacrimal canaliculus; the ULC with the LS, and the LLC with the LS were realized at an acute angle.ConclusionCrucial parameters, which have not been previously mentioned such as the opening angles of the ULC and the LLC, were investigated as they might be used during the procedure.

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.

Anatomic Guides to Precisely Localize the Zygomatic Branches of the Facial Nerve

Descriptions of superficial anatomic landmarks for the identification of the zygomatic branches of the facial nerve, and their relevance for plastic surgery, are lacking in the literature. This paper provides such a description and discusses its relevance to facial surgery. Materials and Methods:Sixty-six specimens, including the parotid region, from 33 adult cadavers were dissected and studied. All specimens were fixed in formaldehyde, and the superficial tissues were removed and the zygomatic branches of the facial nerve, the parotid gland, the tragus and the lateral palpebral commissure were identified. The vertical and horizontal relationships were recorded and analyzed. Results and Conclusions:A total of 69.7% of the cadavers had two branches, 25.8% had three branches, and 4.5% had a single zygomatic branch. The mean horizontal distance of the zygomatic branch (the most upper one) as it emerged from the anterior border of the parotid gland and the tragus was 30.71 mm, whereas the mean vertical distance of the zygomatic branch from the midpoint between the tragus and the lateral palpebral commissure was 19.29 mm. The branching patterns with the buccal branches were reported. There were no statistical differences between the left and right sides or between the sexes. The zygomatic branches of the facial nerve were always under the oblique line between the tragus and the lateral palpebral commissure and have a close relationship with the buccal branches of the facial nerve under this anatomic landmark. Application of the results in facial surgery is discussed.

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. Clin. Anat. 23:770–776, 2010.

Connection types between the spinal root of the accessory nerve and the posterior roots of the C2–C6 spinal nerves

PurposeThe 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.MethodsThe cranial cervical regions of 49 specimens from 27 human cadavers were used for the present study under an operating microscope.ResultsFive 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.ConclusionsThe 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.