Panayiotis Skandalakis

The Pterygopalatine Ganglion and its Role in Various Pain Syndromes: From Anatomy to Clinical Practice

Abstract  The postsynaptic fibers of the pterygopalatine or sphenopalatine ganglion (PPG or SPG) supply the lacrimal and nasal glands. The PPG appears to play an important role in various pain syndromes including headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection. Clinical trials have shown that these pain disorders can be managed effectively with sphenopalatine ganglion blockade (SPGB). In addition, regional anesthesia of the distribution area of the SPG sensory fibers for nasal and dental surgery can be provided by SPGB via a transnasal, transoral, or lateral infratemporal approach. To arouse the interest of the modern‐day clinicians in the use of the SPGB, the advantages, disadvantages, and modifications of the available methods for blockade are discussed.▪

Functional anatomy of the mandibular nerve: consequences of nerve injury and entrapment.

Various anatomic structures including bone, muscle, or fibrous bands may entrap and potentially compress branches of the mandibular nerve (MN). The infratemporal fossa is a common location for MN compression and one of the most difficult regions of the skull to access surgically. Other potential sites for entrapment of the MN and its branches include, a totally or partially ossified pterygospinous or pterygoalar ligament, a large lamina of the lateral plate of the pterygoid process, the medial fibers of the lower belly of the lateral pterygoid muscle and the inner fibers of the medial pterygoid muscle. The clinical consequences of MN entrapment are dependent upon which branches are compressed. Compression of the MN motor branches can lead to paresis or weakness in the innervated muscles, whereas compression of the sensory branches can provoke neuralgia or paresthesia. Compression of one of the major branches of the MN, the lingual nerve (LN), is associated with numbness, hypoesthesia, or even anesthesia of the tongue, loss of taste in the anterior two thirds of the tongue, anesthesia of the lingual gums, pain, and speech articulation disorders. The aim of this article is to review, the anatomy of the MN and its major branches with relation to their vulnerability to entrapment. Because the LN expresses an increased vulnerability to entrapment neuropathies as a result of its anatomical location, frequent variations, as well as from irregular osseous, fibrous, or muscular irregularities in the region of the infratemporal fossa, particular emphasis is placed on the LN. Clin. Anat. 24:143–150, 2011.

New distal embolic protection device the FiberNet® 3 dimensional filter: First carotid human study

Objective: Evaluate the performance and safety of the FiberNet® Embolic Protection System during carotid artery intervention. Background: Carotid Angioplasty and Stenting (CAS) can be proposed to treat the majority of carotid stenoses. Brain embolization takes place and routine use of Embolic Protection Devices (EPD) is warranted. Many EPDs have significant limitations, which may be addressed by a new EPD, the FiberNet® (Lumen Biomedical, Plymouth, MN). Methods: The system consists of a 3‐dimensional expandable filter made of fibers, which expand radially, mounted onto a 0.014″ wire and retrieval catheter. FiberNet can capture particles as small as 40 μm without compromising flow. Results: 35 lesions treated in 34 patients. Male 67.6%. Age: 71.4 ± 8.8 (50–85). Average stenosis 84.5% ± 7.9 (70–99). 29.4% were symptomatic. Technical success: 34/35 (97%). No stroke or death within 30 days. Neurological events: two permanent amaurosis, one amaurosis fugax. All samples visually contained significant amounts of emboli. The mean surface area of debris caught was 63.8 mm2 (37.7–107.5). Comparisons were made with other EPDs. The mean surface area of debris caught was 12.2 mm2 (2.7–34.3). No changes were noted in CT/MRI at 30‐day post procedure. Conclusion: The first human use of this new novel EPD in carotid artery stenting is encouraging. The FiberNet was easy to use and confirmed the ability to capture particles less than 100 μm. The feasibility of the FiberNet has been demonstrated. Additional patients will demonstrate the overall safety and efficacy of this new EPD device.

Anatomical variation and morphology in the position of the palatine foramina in adult human skulls from Greece

OBJECTIVE To investigate the anatomical variability of the palatine structures in Greek population. MATERIAL AND METHODS 71 Greek adult dry human skulls were examined to detect the position of the greater palatine (GPF) and lesser palatine foramina (LPF) related to adjacent anatomical landmarks. RESULTS The perpendicular distance of the GPF to the midline sagittal suture was 1.53 cm and 0.3 cm from the inner border of the alveolar ridge. The mean distance from the posterior palatal border was consistent 0.46 cm on the right and 0.47 cm on the left side of the skulls. In the greater majority of the skulls (76.2%), the GPF were between proximal-distal surfaces of the 3rd maxillary molar. A single LPF was observed in 53.45% of the skulls, two LPF were observed in 31% of the skulls bilaterally and five LPF were rare (2.1%). The commonest position of LPF was at the junction of the palatine bone and the inner lamella of the pterygoid plate (71.9%). CONCLUSION Our results can help clinicians localize the palatine foramina in patients with and without maxillary molars and to predict the depth of a needle to anaesthetise the maxillary nerve with greater success when performing surgical procedures in the hard and soft palate.

Mandibular nerve entrapment in the infratemporal fossa

The posterior trunk of the mandibular nerve (V3) comprises of three main branches. Various anatomic structures may entrap and potentially compress the mandibular nerve branches. A usual position of mandibular nerve (MN) compression is the infratemporal fossa (ITF) which is one of the most difficult regions of the skull base to access surgically. The anatomical positions of compression are: the incomplete or complete ossified pterygospinous (LPs) or pterygoalar (LPa) ligament, the large lamina of the lateral plate of the pterygoid process and the medial fibres of the lower belly of the lateral pterygoid (LPt). A contraction of the LPt, due to the connection between nerve and anatomic structures (soft and hard tissues), might lead to MN compression. Any variations of the course of the MN branches can be of practical significance to surgeons and neurologists who are dealing with this region, because of possibly significant complications. The entrapment of the MN motor branches can lead to paresis or weakness in the innervated muscle. Compression of the sensory branches can provoke neuralgia or paraesthesia. Lingual nerve (LN) compression causes numbness, hypoesthesia or even anaesthesia of the mucous of the tongue, anaesthesia and loss of taste in the anterior two-thirds of the tongue, anaesthesia of the lingual gums, as well as pain related to speech articulation disorders. Dentists should be very suspicious of possible signs of neurovascular compression in the region of the ITF.

Intramammary lymph nodes: A question seeking for an answer or an answer seeking for a question?

Intramammary lymph nodes have not received for a long time enough attention from the medical literature and thus many of their characteristics are not sufficiently explored. Their incidence at various studies ranges between 0, 7 and 48%. They may be found in all breast quadrants but usually at the Upper Outer Quadrant (UOQ). Their radiological image at mammography is that of a well circumscribed density with an area of lower density at centre representing the hilum and at ultrasonography of a hypoechoic, circumscribed mass with an echogenic hilum. Their role in lymphatic drainage of breast regions is important although it is not known if they represent true sentinel nodes or if lymphatic drainage to them comes from ectopic, independently developed pathways. Intramammary Lymph Nodes are involved in a variety of clinical situations including benign situations, tumor metastasis, breast lymphoma and breast cancer. Their importance over breast cancer is not fully defined but there is evidence that they worsen prognosis and they may change therapeutic decisions. Breast cancer and Breast lymphoma can coexist and interfere.

Report of an unusual combination of arterial, venous and neural variations in a cadaveric upper limb.

In this study an unusual combination of arterial, venous and neural variations discovered during dissection of cervical, axillary and brachial area of a cadaver is described. Variations are thoroughly described and literature is briefly reviewed. Lateral cord of brachial plexus was not formed; Eight Cervical root divided into anterior and posterior division before uniting with First Thoracic root and Upper Trunk was unusually short. Axillary artery gave origin to a superficial brachial artery and then continued as deep brachial artery. Multiple variations in typical axillary artery branches were present including existence of inferior pectoral artery. Cephalic vein was absent. A variety of interventions, from relative simple as central venous catheter placement to most complicated as brachial plexus injury repair demand thorough knowledge of area’s regional anatomy. Familiarity with anatomic variations allows more precise and careful interventions. Research on these variations is valuable for anatomists and embryologists but also for clinicians because it may provide useful information for non - typical cases but also helps in raising a high level of suspicion.

Bilateral Abnormal Origin of the Anterior Branches of the External Carotid Artery

BACKGROUND Description of a rare variation is provided alongside with a review of the literature with special references to anatomic, embryologic, and clinical issues it may create. METHODS This was a cadaveric dissection conducted during a pregraduate anatomy course that is accompanied by short review of the literature and critical appraisal. RESULTS During dissection of the neck region of a male cadaver, the superior thyroid artery occurred from the common carotid artery bilaterally and the lingual artery occurred from the carotid bifurcation on the left side. CONCLUSIONS Superior thyroid artery originating from common carotid artery or carotid bifurcation is a common variation, but the lingual artery originating from the common carotid artery or carotid bifurcation is very rare (<1%). Its existence can have a significant impact on treatment success and potentially lead to errors during interventions at the neck region. A high level of suspicion is required.

The first Anatomy professors in the Medical School of the University of Athens

The purpose of this historical review is to add new elements to the international literature in relation to the birth and progress of the science of anatomy in modern Greece. Step by step, it outlines the efforts of prominent Greek anatomists to establish the course of the basic science of anatomy in the newly founded Medical School, the laborious effort to collect cadaveric material to compile museum anatomical collections and to gradually build the foundations of modern anatomy science at the Medical School of the Athenian University.

Physiology and Developmental Stages of the Breast

Normal breast development is a complex process extending from the earliest stages of embryogenesis to beyond menopause. This process is driven by intrinsic genetic information, regulated by complex and tightly controlled hormonal mechanisms, and is affected by external events. Schematically, breast development is separated into prenatal, perinatal, peripubertal, adult and postmenopausal stages. Complete breast maturation does not occur until pregnancy and lactation, and thus the breast never evolves completely in nulliparous woman. Many breast diseases, benign and malignant, including breast cancer, can be better examined and explained through the spectrum of normal – or abnormal – breast development. Research is difficult due to the limited availability of human breast tissue. For this, much of our knowledge derives from mouse model studies. This information, while valuable, should be considered with caution since analogy between the mouse and human models is not perfect. Still since understanding of breast development allows better understanding of pathophysiological processes driving diseases of the breast, constant research and education is necessary not only in the sphere of basic science but also for clinicians as it allows better diagnosis and treatment for their patients.