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Introduction: Vestibular migraine is the most common cause of spontaneous episodic vertigo in adult patients and the second most common cause of vertigo in patients of all ages. Objective: To assess the effectiveness of oral medication type (propranolol, flunarizine, and amitriptyline) and botulinum toxin A application on vestibular symptoms, headache severity and attack frequency for vestibular migraine patients. Methods: Sixty patients with vestibular migraine were enrolled. Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B− group). Headache severity was evaluated with Migraine Disability Assessment Scale and vertigo severity was evaluated with Dizziness Handicap Inventory scale. Vestibular migraine attack frequencies in the last three months were also evaluated. Results: There was a statistically significant decrement in mean Dizziness Handicap Inventory scores, Migraine Disability Assessment Scale scores and vertigo attack frequencies after treatment for all patients, B+ and B− group patients (p < 0.001 for all). The mean Migraine Disability Assessment Scale score gains (p < 0.001) and vertigo attack frequency gains (p = 0.003) were significantly higher in the B+ patients than B− patients. Conclusions: Both B+ and B− group patients exhibited significant improvement in vestibular migraine attack frequencies, Dizziness Handicap Inventory score and Migraine Disability Assessment Scale score values. However, botulinum toxin A application had a more pronounced effect for Migraine Disability Assessment Scale score gain and vestibular migraine attack frequency values, but not for Dizziness Handicap Inventory score gain values. Thus, botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. The oral medication type (propranolol, flunarizine or amitriptyline) did not differ in influencing the vestibular migraine attack frequency, Dizziness Handicap Inventory score gain and Migraine Disability Assessment Scale score gain values.

OBJECTIVES The study aimed to display the growth pattern of the tympanic ring in fetal cadavers of 20-30 weeks of gestation. METHODS In the study, 32 temporal bones of 16 fetuses (8 males, 8 females) of 24.62 ± 3.44 weeks of gestation were dissected to measure the height (TRH), width (TRW), and perimeter (TRP) of the annulus, and the width (TNW) of the opening part of the annulus at the level of the tympanic notch. RESULTS The TRH, TRW, TRP, and TNW were measured as 8.25 ± 1.04 mm, 7.64 ± 1.08 mm, 24.93 ± 3.40 mm, and 4.01 ± 0.91 mm, respectively. The parameters were similar at the seventh and eighth months of gestation; therefore, there was no variation from the seventh month. Linear function was calculated as y = 1.328 + 0.281 x weeks (P < .001) for the TRH, y = 1.284 + 0.258 x weeks (P < .001) for the TRW, y = 3.367 + 0.876 x weeks (P < .001) for the TRP, and y = -0.603 + 0.188 x weeks (P < .001) for the TNW. CONCLUSION The parameters (TRH, TRW, TRP, and TNW) did not alter from the seventh month in utero. The linear functions (which represent the growth pattern of the parameters) of the tympanic ring may be useful for ear professionals to guess the annulus diameters, and to diagnose growth retardation and probable congenital anomalies in utero during sonographic imaging.

Objective To evaluate the facial nerve function and audiological results of delayed (by at least one month after the insult) transmastoid facial nerve decompression (FND) in traumatic facial nerve paralysis (FNP). Methods Medical records of 57 patients with traumatic FNP were reviewed and surgical results of 13 patients (mean age 28.0 ± 17.67, range 3-67) undergoing transmastoid FND were analyzed. Preoperative and postoperative mean hearing thresholds were compared using 0.5, 1, 2, and 3 kHz. Facial nerve function was graded according to the House-Brackmann scale (HB) before and after surgery. HB scale results of grade III or better were accepted as good results postoperatively. Results Preoperative HB grades were V in 5 and VI in 8 patients. Twelve of 13 patients had good recovery of facial nerve function regardless of the operation timing. When mean preoperative and postoperative air-bone gap (ABG) values were compared (except the patients with total sensorineural hearing loss), the mean preoperative ABG was 33 ± 15.9 dB, and mean postoperative ABG was 17.2 ± 8.68 dB. There was a mean hearing gain of 15.8 dB after transmastoid facial nerve decompression surgery. Surgery and anesthesia-related complications were not seen in any patients. Conclusion The transmastoid route can be used safely and effectively with elimination of the risks of craniotomy and middle fossa surgery for patients with traumatic FNP. Hearing improvement can be achieved by performing ossicular chain reconstruction during decompression surgery for patients with conductive or mixed hearing loss (HL).

This cadaveric work aimed to test the effectiveness of a modified surgical corridor (ExpTSA: expanded transcanal supracochlear approach) developed for anatomic cochlear preservation in selected vestibular schwannoma patients necessitating to perform cochlear implantation for appropriate cases to achieve the best outcome. The ears of 10 cadavers (at mean age 75.70 ± 13.75 years, range 45–92 years) were dissected from the external auditory canal (EAC) to the internal auditory canal by ExpTSA under the guidance of a microscope and endoscope. All stages of the surgical process were recorded step by step and evaluated morphometrically. The vestibular base was successfully reached in all ears without damaging the cochlear morphology and facial nerve. The vestibular base was 23.33 ± 2.02 mm away from the entrance (external orifice) and 10.26 ± 1.33 mm from the exit (internal orifice) of EAC. The oval window and vestibular base were measured to be 2.94 ± 1.05 mm and 5.87 ± 1.24 mm deep from the facial nerve, respectively. The normal areas of the oval window, the exit and entrance of EAC were found as 2.90 ± 0.81 mm2, 42.52 ± 13.66 mm2, and 110.73 ± 25.32 mm2, respectively. After ExpTSA procedure, the areas of the oval window (11.04 ± 2.83 mm2), the exit (122.45 ± 20.41 mm2) and entrance (167.49 ± 30.94 mm2) of EAC were expanded approximately 280%, 188%, and 50%, respectively. The ExpTSA may be performed for accessing to the vestibule and fundus of IAC for tumor removal of intravestibular schwannoma patients (with or without fundus involvement) with unserviceable hearing, preserving the cochlear morphology.

The study aimed to examine morphometric properties of the round window (RW) and oval window (OW) and to show their relation with the tympanic nerve (the Jacobson’s nerve, JN) in human fetuses from the otologic surgeon’s perspective. Thirty temporal bones of 15 fetal cadavers (8 males, 7 females) aged with 24.40 ± 3.71 weeks were included in the study. The height, width and surface area of the RW and OW and also distance from the JN to the OW and RW were measured. The height, width and surface area of the RW in this work were measured as 1.48 ± 0.25 mm, 1.57 ± 0.37 mm, and 2.05 ± 0.69 mm2, respectively. The RW was detected as round-shaped (8 cases, 26.7%), oval-shaped (15 cases, 50%), and dome-shaped (7 cases, 23.3%). The height, width and surface area of the OW were measured as 1.42 ± 0.26 mm, 2.90 ± 0.44 mm, and 3.63 ± 0.74 mm2, respectively. The OW was observed as oval-shaped (15 cases, 50%), kidney-shaped (10 cases, 33.3%), D-shaped (4 cases, 13.3%), and trapezoid-shaped (1 case, 3.3%). The JN was found 1.21 ± 0.60 and 1.18 ± 0.54 mm away from the RW and OW, respectively. This study containing morphological data about the shapes, diameters and area of the RW and OW may be useful to predict surgical difficulty, and to select implants of suitable size preoperatively for the windows. Knowing the relationship between the JN and the windows can be helpful to avoid iatrogenic injuries of the nerve.

Objective The main objective of the study was to show the morphologic features of optic strut (OS) and prechiasmatic sulcus (PS) in the fetal skull base with a surgical anatomical perspective. Methods Twenty-three fetal cadavers (9 female, 14 male) with an average age of 21.70 ± 3.12 (range: 16–28) weeks of gestation in the inventory of the Anatomy Department were included in the study. Measurements were made with a digital image analysis software and goniometer. Results The sulcal length, interoptic distance, planum length, and sulcal angle were detected as follows: 3.91 ± 0.74 mm, 6.88 ± 1.04 mm, 6.55 ± 1.51 mm, and 24.52 ± 9.51°, respectively. Considering the location of the posteromedial margin of OS according to PS, OS was identified as the sulcal in 56.5% (13 cases), postsulcal in 30.4% (7 cases), and asymmetric in 13% (3 cases). According to the sulcal length and angle, PS was identified as type 1 in 26.1% (6 cases), type 2 in 21.7% (5 cases), type 3 in 30.4% (7 cases), and type 4 in 21.7% (5 cases). Conclusions Our findings suggest that the sulcal length and angle reach adult size in utero. Taking into account the fetal and the gathered adult measurements, the high percentage of steep angle compared to flat angle show that after birth, PS become more flat, probably depending on the variations of the sphenoid sinus pneumatization. Thus, more studies conducted on the alterations in PS and OS types relative to the pneumatization are needed in terms of patient positioning, selection of appropriate surgical approach, and intraoperative decision-making.

Petrous apex effusions are rare disorders and usually occur in the petrous apex (PA) having well-aerated cells and it may present with several symptoms or can be diagnosed incidentally on imaging methods obtained for another reason. If there are persistent symptoms despite the conservative treatment in symptomatic patients, a surgical attempt can be considered. In patients with favorable hearing levels and with the well-pneumatized petrous bone, PA cells may be effectively drained through subcochlear or supracochlear approaches by preserving patient's hearing levels. In this case report, the authors presented a severe symptomatic patient with petrous apex effusion who did not respond to conservative treatment and petrous apex drainage was performed via the subcochlear approach.

OBJECTIVE: To assess the effectiveness of paper patch closure of tympanic membrane perforation in patients with otomycosis and tympanic membrane perforation. METHODS: Fifty-six otomycosis patients with central tympanic membrane perforations were included in the study. Patients were randomized into two groups as patched (PG) and non-patched (NPG) groups. In both groups, Castellani’s solution was applied to the external auditory canal. In PG patients, the perforated tympanic membrane was covered with carbon paper patch soaked in Castellani’s solution to reduce ear canal humidity and to prevent fungi from passing from the ear canal to the middle ear mucosa. Paper patch was not used in NPG patients. RESULTS: There were statistically significant differences between the two groups in terms of severity scores in the first, second, third, fourth and sixth weeks of admission (p=0.004, p=0.018, p=0.001, p=0.009, and p

Objectives Skull base is an important and a challenging area for surgeons. Success in skull base surgery depends on various factors such as pre-operative evaluation, appropriate surgical technique, anesthesia duration, intraoperative neuromonitorization and wound care. Materials and methods This study was performed in the Anatomy dissection laboratory of M.U. Medical Faculty (Ethical committee approval number 2010-103). Twelve fetuses between 17-33 gestational weeks fixed with formaldehyde were enrolled to the study. Results This study was planned to investigate the cross sectional areas of the sigmoid sinus in three levels to compare the right-left sides and the probable relationship among the levels in fetuses to further delineate the developmental factors on jugular foramen asymmetry. The cross-sectional measurements of sigmoid sinus lumen were done on 3 levels which are described as A1 level; sinodural angle, A2 level; the midpoint between the sinodural angle and endocranial orifice and A3 level as the entrance (endo-cranial orifice) of the jugular foramen. There is a strong positive correlation between left (L) A1 and L A2 and also the same for L A1 and right (R) A2. These strong and positive correlations are all valid between L A2-L A3, L A2-R A2, L A2-R A3, L A3-R A3, R A1-R A2. Conclusion Multicenter studies would be beneficial to investigate the topic with greater number of fetuses also on the different regions for genetic differences.

Amaç: Bu çalışmanın amacı, insan fetüslerinde septum veya çift hipoglossal kanal insidansını tespit etmektir. Yöntem: Tıp Fakültesi Anatomi Anabilim Dalı envanterinde bulunan ortalama 23.36±2.63 haftalık 25 fetüs (14 erkek, 11 kız) çalışmaya dahil edildi. Bulgular: Fetüslerin 9’unda (%36) septum vardı. Fetüslerin 2’sinde (%8) bilateral, 3’ünde (%12) sağ ve 4’ünde (%16) sol tarafta çift hipoglossal kanal tespit edildi. Gestasyonal yaş, cinsiyet ve taraflar ile septum varlığı arasında bir ilişki görülmedi. Sonuç: Hipoglossal kanalın bölümlenme paterni özellikle hipoglossal kanal schwannoma’ları gibi posterior kraniyal fossa operasyonları açısından önem taşıdığından nörocerrahlar ve radyololar için büyük önem taşımaktadır. Ayrıca çalışmamızdaki veriler, kafa tabanının gelişiminin anlaşılması açısından anatomistler ve antropologlar için kıymetli olabilir.

Objectives:This study aims to reveal morphometric properties of the clivus including length, width and angle to the base of the skull from the perspective of skull base procedures.Materials and Methods:Twenty-four human dry skulls were included in the inventory of Mersin University Medical Faculty Anatomy Department. Direct anatomic measurements (DAM) were performed using digital caliper and digital image analysis software. Radiological analysis was performed using computed tomography (CT).Results:The length and inner surface area of the clivus for DAM and CT were 25.17±3.98/24.83±3.91 mm and 546.51±66.44/523.37±87.48 mm2, respectively. Clival angle (Welcher angle) for DAM and CT was 126.12±9.51°/124.37±10.86°. No statistically significant difference was found between the numerical data obtained by DAM and CT (p>0.05).Conclusion:Considering that clivus anomalies are associated with diseases such as platybasia, basilar invagination, CHARGE syndrome or Chiari type I, the data of the present study can be used for the detection of clivus anomalies as well as choosing the type of approach to the skull base.

Mucoepidermoid carcinoma arising in Warthin tumor of the parotid gland is an extremely rare entity. This is so far described only in the adult age group, and only one patient has been reported in the pediatric age group until today. Herein, we describe our patient and review the literature. This was a case of a 9-year-old girl admitted with a painless swelling in the left side of her face for at least 2 weeks. Histopathologic examination of total parotidectomy specimens revealed mucoepidermoid carcinoma arising in the Warthin tumor. This case is the youngest patient reported to date.

To investigate the factors affecting disease specific mortality (DSM) in patients with mucormycosis. This retrospective study included 24 patients diagnosed with mucormycosis and who had undergone surgical and medical treatment between 2010 and 2020. There were 14 male and 10 female patients whose mean age was 53.70 ± 16.87 years, range 18–83. We reviewed the factors affecting DSM, including the extent of disease (paranasal sinus, palatal, orbital or intracranial involvement) and blood parameters (BP) that are serum glucose level (SGL), white blood cell, neutrophil, lymphocyte counts, C-reactive protein and hemoglobulin levels. Also, the effect of SGL in diabetes mellitus and BP in hematological malignancies on DSM was additionally evaluated. Orbital (p = 0.001) and intracranial (p

The purpose of this study was to assess the effectiveness of sialendoscopy (SE) on the symptom severity of chronic obstructive sialadenitis (COS) and patient satisfaction by using the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire and the Patient Satisfaction Scores (PSS).COSS questionnaire was employed to 51 Turkish patients with COS before and three months after SE. Patients' satisfaction with SE was evaluated by analyzing the PSS.Gland preservation rate of the SE operation was 96.2%. The sialolith extraction rate was 74.2%. A significant decrease in the COSS scores of all of the patients in the study sub-groups was observed (p 0.05). The effectiveness of SE was more pronounced for patients with sialolithiasis and submandibular gland (SG) involvement (p 0.001, p = 0.03, respectively). Totally extracted stone and symptom duration were the only independent factors that significantly affected the COSS score gain values in patients with and without sialolithiasis, respectively (p 0.001). There was a statistically significant correlation between COSS score gain values and PSS values. (r = 0.786) CONCLUSION: The benefit of SE was more pronounced in patients with sialolithiasis and SG involvement. Successful stone extraction and symptom duration were two independent factors that influenced both clinical improvement and patient satisfaction for patients with and without sialolithiasis, respectively. COSS questionnaire results correlated with the PSS values; thus, this questionnaire can also be used to evaluate the patients' satisfaction with SE.

Introduction: A cadaveric experimental investigation aimed to show the rupture pressure of the tympanic membrane (TM) for otologists to evaluate its tensile strength. Methods: Twenty adult ears in 10 fresh frozen whole cadaveric heads (four males, six females) mean age 72.8 (SD 13.8) years (range 40–86) were studied. The tensile strength of the TM was evaluated with bursting pressure of the membrane. The dimensions of the membranes and perforations were measured with digital imaging software. Results: The mean bursting pressure of the TM was 97.71 (SD 36.20) kPa. The mean area, vertical and horizontal diameters of the TM were 57.46 (16.23) mm2, 9.54 (1.27) mm, 7.99 (1.08) mm respectively. The mean area, length and width of the perforations were 0.55 (0.25) mm2, 1.37 (0.50) mm, and 0.52 (0.22) mm, respectively. Comparisons of TM dimension, bursting pressure, and perforation size by laterality and gender showed no significant differences. The bursting pressure did not correlate (positively or negatively) with the TM or perforation sizes. Conclusions: The TM can rupture during activities such as freediving or scuba diving, potentially leading to serious problems including brain injuries. Studying such events via cadaveric studies and data from case studies is of fundamental importance. The minimum experimental bursting pressures might better be taken into consideration rather than average values as the danger threshold for prevention of TM damage (and complications thereof) by barotrauma.

BACKGROUND Evaluation of cranial nerve morphology through measuring cross-sectional area (CSA) on magnetic resonance imaging (MRI) is increasing day-by-day in clinical diseases. In Bell's palsy (BP), the manifestation of the enlarged CSA of the facial nerve (FN) may be used for diagnosis. This study aims to evaluate whether there is an enlargement of the cisternal FN in BP. METHODS This retrospective study included 43 patients diagnosed with BP. In the reconstructed MRI, the long (LD) and short (SD) diameters of the paralytic and normal sides of the FNs located in the cerebellopontine angle were measured, and the CSA was calculated using the Radinsky formula. Before the radiologic measurement, a preliminary experiment was carried out on the rat sciatic nerve to be able to determine the actual nerve boundary on MRI. FINDINGS There was a statistically significant relationship between paralytic and normal sides in the measurements of LD, SD, and CSA. The paralytic side was larger than the normal side in the cisternal FN. According to the Receiver Operating Characteristic (ROC) curve, BP can be estimated with 60% sensitivity and 70% specificity by the CSA of the FN more than 1.04 mm2 . As a result of the preliminary experiment, it was found that the actual nerve boundary was at approximately 50% intensity between the minimum and maximum values. CONCLUSION Although entrapment of FN in the labyrinthine segment in BP was known, this study showed that the cisternal FN, which could be evaluated more conveniently, enlarged in the paralytic side compared with the normal side, and revealed the necessity of performing the comparison amongst the MRI studies on BP patients by a standardised measurement method. This study will also help clinicians to make a decision in the diagnosis of BP by giving a cut-off value for the CSA.

To present the quantitative development of the geniculate ganglion (GG) in foetal cadavers.This study focused on 60 temporal bones of 30 (15 female and 15 male) foetuses aged 18?30 weeks of gestation (mean age, 22.83 ± 3.49 weeks) to measure the length, width and area of the GG.According to gestational weeks and months, the ganglion length (1.21 ± 0.41 mm), width (1.03 ± 0.28 mm) and area (1.24 ± 0.61 mmsup2/sup) did not change. In terms of sexes or sides, ganglion dimensions were not significantly different. Positive correlation was found between the length and width (p=0.033, r=0.276), between the length and area (p0.001, r=0.762) and between the width and area (p0.001, r=0.622). Linear functions were calculated for the ganglion area (y=0.355 + 0.039 × weeks), length (y=0.636 + 0.025 × weeks) and width (y=0.634 + 0.017 × weeks).The ganglion size did not change in foetal cadavers aged 18?30 weeks of gestation. This finding may be important for anatomists and embryologists in performing morphometric studies and understanding the development of the GG and for neurootologists and neurosurgeons in achieving greater success in skull base surgeries.

Introduction: The effect of the quantity of olfactory neuroepithelium in the middle turbinate on the postoperative olfactory function for middle turbinate concha bullosa patients has not yet been evaluated. Objective: The primary aim of this study was to investigate the olfactory structures in the middle turbinate by immunohistochemical analysis of the olfactory marker protein and to correlate the immunostaining results with the olfaction test results for patients with middle turbinate concha bullosa. Methods: Surgical materials of 18 middle turbinate concha bullosa patients who had undergone lateral marsupialization surgery were immunostained with olfactory marker protein antibodies. Smell diskettes olfaction test was applied to all of the study group patients both preoperatively and three months postoperatively. A visual analog scale was used to quantify the sense of nasal obstruction. Results: It was observed that the postoperative smell scores and the nasal obstruction visual analog scale values were significantly improved as compared to the preoperative values (p < 0.05). In addition, there was a significant correlation between the smell score gain and the visual analog scale gain values (r = 0.682). Results also indicated no significant correlation between the olfactory marker protein staining scores and the smell scores (p > 0.05). Conclusion: This first paper demonstrated that the quantity of the olfactory mucosa in the middle turbinate was not a determining factor for the postoperative smell function degree for middle turbinate concha bullosa patients. The underlying cause of the olfactory deficit for middle turbinate concha bullosa patients seems to be obstruction related rather than the middle turbinate's olfactory mucosa containing status. © 2021 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial Mersin Üniversitesi This study was funded by Academic research unit committee of Mersin University .

This study aimed to peruse anatomic features of the cranial aperture of the optic canal (CAOC) for obtaining an extended morphometric dataset in children. Computed tomography images of 200 children were included in this retrospective work to analyze the shape, location and diameters of the CAOC. The CAOC area, width and height were observed as 17.53 ± 2.80 mm2, 6.12 ± 0.84 mm, and 4.35 ± 0.64 mm, respectively. The angle of the optic canal in axial plane was found as 39.28 ± 5.13°, while in sagittal plane as 16.01 ± 6.76°. The distance between the CAOC and the midsagittal line was 7.17 ± 1.48 mm. The CAOC was measured as 54.04 ± 5.23 mm and 42.55 ± 3.28 mm away from the anterior and lateral boundary of the anterior skull base, respectively. The CAOC shape was described as the tear-drop (186 foramina, 46.5%), triangular (156 foramina, 39%), oval (47 foramina, 11.8%), and round (11 foramina, 2.8%). The depth, angle and diameter measurements belonging to the CAOC were changing according to its shape or demographic data (e.g., sex and age). Therefore, preoperative radiologic evaluation containing the shape, location and size of the CAOC should be considered by multidisciplinary operating teams in terms of surgical interventions such as implant positioning.

To compare the graft success rates and hearing results of single-layered (composite island) grafting (SLG) vs double-layered (composite plus second layer of perichondrium) grafting (DLG) for over-under type 1 tympanoplasty techniques.Retrospective chart review.Tertiary center otorhinolaryngology clinic.Medical charts of the patients who underwent type 1 tympanoplasty via the microscopic technique by a single surgeon between 2015 and 2019 were analyzed.A total of 48 patients were included. The DLG (n = 26) group had higher graft take rates as compared to the SLG group (n = 22) for all patients (DLG tympanoplasty is encouraged, especially for patients with higher MERI scores, to increase the graft success rates. Better hearing outcomes of DLG tympanoplasty were related to the higher graft success status of this technique; DLG had no additional hearing effect for patients with successful grafting. Higher MERI scores and presence of myringosclerosis were related to graft failure.

The work aimed to compare fetal and adult tympanic membrane (TM) sizes for understanding dimensional development from intrauterine life to adulthood. Fifty-six temporal bones (18 fetuses, 10 elderly adults, half male and half female in each group) were included in this study. Using a digital image software, the TM height, width and area were measured. The mean area, height and width of the TM in adults were found as 58.84 ± 22.01 mm2, 9.06 ± 1.33 mm, and 8.10 ± 1.43 mm, respectively. Moreover, the mean area, height and width of the TM in fetuses were measured as 47.62 ± 12.57 mm2, 8.22 ± 1.12 mm, and 7.25 ± 1.15 mm, respectively. The TM dimensions were increasing in fetuses between 20–32 weeks of gestation. However, the TM dimension was statistically similar at the 7th month, the 8th month and adult periods. The TM height was greater than its width in fetuses and adults. The calculated regression equations of the TM parameters in fetuses may be used to estimate its size. The TM size did not change from the 7th gestational month, and thus the membrane reached adult diameter in fetal life. The TM height and width showed a very wide range; therefore, we thought that the 12 mm (the height) × 10 mm (the width) graft might be ideal dimension during the repair of the TM perforations.

This study aimed to establish an extended morphometric dataset regarding the stapedius muscle for anatomists and otologists. The tympanic cavity of ten cadavers (five females, five males) aged with 75.70 ± 13.75 years was bilaterally dissected. Morphometric properties of the stapedius muscle (i.e., its muscular belly and tendon) and its relationship with the neighborhood structures including the facial nerve was evaluated. The length of the entire stapedius muscle was found as 4.80 ± 1.13 mm. The depth between the entrance of the external auditory canal and stapedius muscle was measured as 18.23 ± 2.30 mm. The incudostapedial joint and stapedial tendon were found to be 1.66 ± 0.25 mm and 1.18 ± 0.19 mm away from the facial nerve, respectively. The stapedial tendon length was standardized as five types: Type 1, extremely short tendon (under 0.5 mm), 5% of cases; Type 2, short tendon (between 0.5 and 1 mm), 30% of cases; Type 3, normal tendon (between 1 and 2 mm), 55% of cases; Type 4, long tendon (between 2 and 2.5 mm), 10% of cases; and Type 5, extremely long tendon (above 2.5 mm), no cases. Our findings showed that the stapedius tendon size in adults was quite similar to fetuses. Therefore, probably entire muscle dimension does not alter after birth. Considering the concordance between direct anatomic (our findings) and radiologic measurements (literature findings) of the stapedius muscle, preoperative radiological evaluation may be important for otologists in terms of the choice of surgical tools such as diamond burr sizes. Due to the lack of standardization regarding the evaluation of the stapedius tendon size (i.e., extremely short or extremely long), we defined the tendons below 0.5 mm as extremely short (Type 1) and above 2.5 mm as extremely long (Type 5).

Purpose To investigate the characteristics of the prechiasmatic sulcus in children aged between 1–20 years. Methods Patient files of 200 children admitted to the university hospital on 2019 were analyzed, retrospectively. The computed tomography images of patients were used to obtain anatomical knowledge containing prechiasmatic sulcus types and dimensions. Results The measurements related to the sulcal length (6.94 ± 1.25 mm) and sulcal angle (31.01 ± 18.13°) showed that the sulcal length did not alter in children between 1 and 20 years, whereas the sulcal angle did not vary from infancy to prepubescent period, but it was decreasing in postpubescent period. In 29 patients, the sulcal length was observed to divide into 2 parts with an evident angle. The interoptic distance and planum length were found as follows: 14.70 ± 2.85 mm and 14.84 ± 4.12 mm, respectively. The order of PS types was observed as type 4 (26.5%, 53 cases) > type 2 (26%, 52 cases) > type 1 (24%, 48 cases) > type 3 (23.5%, 47 cases). Conclusions The sulcal length did not vary in children, whereas the sulcal angle decreased with an irregular pattern. The sulcal angle decreased after prepubescent period, possibly due to the sphenoid sinus pneumatization and spheno-occipital synchondrosis. The sulcal length angle mostly in infants and young children may cause surgical orientation difficult during the resection of tumors using transcranial approaches.

This study assessed the adequacy of patient data entry in the context of International Statistical Classification of Diseases and Related Health Problems (ICD-10) in the Hospital Information Administration System. It was also aimed to study the adequacy and functionality of the ICD-10 coding in the current Turkish Otorhinolaryngology (ORL) practice in detail. The medical records of 1216 patients who presented to the ORL outpatient clinic between 2012 and 2013 were reviewed. Eight diagnostic codes used by the ORL department were selected from the patient diagnoses report to form patient lists. The accessibility of the ICD-10 codes was analyzed. The data was transferred into the MEdCalc 12.0 software package in a digital medium. The study data was analyzed using frequency tables, Chi-square test, and the two sided likelihood ratio test. Among the ICD-10 codes included in the study, the larynx malignant neoplasm diagnosis (C32.9) was recorded at a rate of 60% and had the greatest ratio of recorded medical history, followed by malignant disorders (C32.3) of the laryngeal cartilage, vertigo (R42) (12.4%) whereas facial asymmetry (Q67.0) (10.5%) had the lowest recorded medical history ratios. There was a significant difference between the recorded and unrecorded patient groups (p [Med-Science 2018; 7(4.000): 873-7]

Objective There is still ongoing research on the relationship of arcuate eminence (AE) and superior semicircular canal (SSC). We aimed to evaluate the precision of predictability of SSC through the morphology of AE via radiological means. Materials and methods This investigation is performed on 12 dry skulls belonging to Mersin University Medical Faculty department of anatomy. Computed tomography (CT) assessment is performed with 0.5-mm-thin sections temporal bone algorithm on dry skulls which were marked with fixated copper wire by scotch tapes on the most prominent part of the middle fossa floor assuming the location of AE. The data are reformatted on the workstation with vitrea 2.0. The distances of the determined three points including lateral (A), apical (B), and medial (C) of the SSC and the copper wire are measured radiologically. Also, the height between the most apical part of the SSC to the floor of the skullbase (H) is measured. The angles between the placed copper wires and the SSC (E) are calculated. The angle between SSC and the midpoint of the IAC (F) and SSC to the sulcus of the greater GSPN (G) were measured. The nearest distance was measured between the most posterior part of the SSC and the point marked by the perpendicular line drawn from the medial border of the petrous bone to the most posterior part of the internal auditory canal (IAC) (D). Results The right and left A, B, and C distances are 2.54+/- 2.75, 3.67+/-3.16, 5.85+/-3.77; 2.92+/-2.24, 3.68+/-2.93, 6.09+/-3.40, respectively. We could not find any statistical significance when the right A, B, and C distances were compared with the left values. Examination of the values revealed that C distance is greater than the A distance of the same side both for right (p=0.040) and left (p=0.022) measurements. The calculated left and right E angles are 30.313+/-12.838, and 35.558+/-18.437 degrees, respectively. Statistical significance was not found between the right and left angles. The right and left F, G angles were 53.17, 47.25; 93.58, 100.92 degrees; and D distances are 8.01, 8.13 millimeters, respectively. Statistical significance was not found when right and left E, F, G angles and D distances were compared. Among 12 left and 12 right sides, the copper wire was found to be nearly overlapping to SSC in two in the right and only one in the left. Conclusion This study reveals that there is a great variability predicting the exact location of SSC through the prominence of AE. Complementary studies are needed with greater number of dry skulls and cadavers. Comparison of different hypothesis including the effect of temporal lobe sulcus is to be discussed to better enlighten the exact relationship of the aforementioned anatomical structures.

BackgroundAlthough the role of neurotrophins such as nerve growth factor and brain-derived neurotrophic factor in nasal polyps development has been studied, the contribution of neurotrophin-3 has not been evaluated yet. This study aimed to investigate the possible role of neurotrophin-3 in nasal polyps pathogenesis.MethodsThe study group comprised 70 non-allergic nasal polyps patients and the control group consisted of 53 patients with middle turbinate concha bullosa. Specimens were taken, during surgery, from the ethmoid sinus nasal polyps in the nasal polyps group and from the lateral part of the middle turbinate concha bullosa in the control group. Tissue and serum levels of neurotrophin-3 were assessed by immunohistochemistry and enzyme-linked immunosorbent assay, respectively.ResultsNasal polyps patients had higher tissue neurotrophin-3 scores (p< 0.001). There was no statistically significant difference between groups regarding serum neurotrophin-3 levels (p= 0.417). Tissue neurotrophin-3 staining scores in the nasal polyps group had no statistically significant correlation with Lund–Mackay scores (p= 0.792).ConclusionNeurotrophin-3 may have a local effect in nasal polyps pathogenesis, without joining systemic circulation.

This study aims to evaluate the antimicrobial effects of Ecballium Elaterium (E.E) that is topically applied for treatment of rhinosinusitis as a traditional medicine. Pure and extract forms of E.E are applied to the nasal cavity of rats for rhinosinusitis. Nasal mucosa, soft palate and trachea of rats were harvested in the first hour, 3rd day and 3rd week for histopathological evaluation. This experimental study revealed antiinflammatory effects of E.E. It has also been shown that E.E reduced fibrosis. The antiinflammatory effect of all forms of E.E has been found to be at their maximum level in the 3rd day with a decreasing manner to 3rd week. Additionally, pure form of E.E caused severe epithelial loss in hyperacute stage. E.E also reduced fibrosis besides its antiinflammatory effect. The action mechanism of antiinflammatory effect of different levels of extract forms need to be further analysed through related enzymatic pathways by different dose and time studies.

The main objective of the study was to evaluate the probable diversity in the area of the foramen magnum (FM) calculated by different measuring methods.The study was conducted on 24 dry skulls, present in the collection of the Anatomy Department, Faculty of Medicine, Mersin University. The area of FM was calculated by different measurement methods including automatic field setting, Teixeria and Radinsky formulas obtained from anatomic (ASM), photographic (PSM) and radiologic (RSM) skull measurements.The areas of FMs calculated by Teixeria formula in RSM, PSM, and ASM were as follows: 857.96 ± 99.97 mm, 796.68 ± 105.08 mm, and 820.86 ± 96.40 mm, respectively. The areas calculated by Radinsky formula in RSM, PSM, and ASM were as follows: 851.37 ± 99.68 mm, 792.63 ± 104.18 mm, and 814.85 ± 94.99 mm, respectively. Lastly, the areas calculated by the automatic field setting of RSM and PSM software were as follows: 799.75 ± 103.38 mm and 752.83 ± 105.60 mm, respectively.Statistical significance was observed between the areas of FM obtained from RSM, ASM, and PSM when calculated by the automatic field setting, Teixeria formula, and Radinsky formula. The authors think that considering the amorphous shape of FM, the automatic field setting of the software should be used to obtain the most accurate numerical data related to the area of FM.

Amac: Cocukluk doneminde karsilasilan tiroid nodullerinde tanisal yaklasimi ve cerrahi yonetimi degerlendirmek. Yontem: Tiroid nodulu nedeni ile Ocak 2012 ve Ocak 2015 yillari arasinda ameliyat edilen 14 cocuk hastanin dosyalari geriye donuk olarak incelendi. Hastalarin yasi, cinsiyeti, klinik bulgulari, tiroid fonksiyon testleri, ultrasonografi raporlari, sintigrafi raporlari, ince igne aspirasyon biyopsi (IIAB) raporlari, yapilan ameliyatlar, patoloji sonuclari ve postoperatif komplikasyonlar degerlendirildi. Bulgular: Olgularin 12’i kiz ve ikisi erkekti. Ortanca yas 14 (8-17) yil idi. 14 hastada boyunda ele gelen sislik, birer hastada gece terlemesi ve yutma guclugu saptandi. Bir hastada boyuna radyoterapi uygulama oykusu mevcuttu. Tiroid nodulleri USG bulgularina gore degerlendirildiginde dokuz hastada hipoekoik, dort hastada hipo-hiperekoik, bir hastada solid nodul saptandi. Tiroid sintigrafilerinde, 10’unda hipoaktif nodul, ikisinde hiper-hipo aktif nodul saptandi, iki hastada ozellik saptanmadi. IIAB’nde birer hastada benign sitoloji ve onemi belirlenemeyen folikuler neoplazi, uc hastada malignite suphesi, yedi hastada folikuler neoplazi saptandi, iki hastada materyal yetersiz bulundu. Patoloji preparatlarinda 9/14’sinde (%64.2) malignite saptandi. Dokuz hastaya total tiroidektomi (altisina patoloji sonucu tamamlayici tiroidektomi) tiroidektomi, bes hastaya lobektomi yapildi. Yedi hastaya boyun disseksiyonu uygulandi. Sonuc: Cocuklardaki tiroid nodulleri yuksek malignite riski nedeni ile hizla degerlendirilmeli ve guncel kilavuzlar esliginde multidisipliner olarak yaklasilmalidir.

Hydatid disease is a zoonotic disease caused by the parasite Echinococcus granulosus. This infection frequently infects the liver and the lung and even in endemic regions rarely occurs in the head and neck region. This is also true for the parotid gland. The diagnosis relies on imaging techniques and the medical history. Another method that is helpful in the diagnosis is serological tests. Fine-needle aspiration biopsy is usually not recommended due to the potential risk of anaphylactic shock or spreading of daughter cysts. The preferred treatment method of hydatid cysts in the salivary gland is surgical excision. We introduce a rare case of hydatid cyst in the parotid gland diagnosed preoperatively by fine-needle aspiration biopsy and discuss the differential diagnosis.

Purpose The main objective of this study was to display the morphologic properties of the anterior clinoid process (ACP) in human fetuses in term of early childhood surgeries. Methods Twenty-four (10 females and 14 males) fetal cadavers aged from 16th to 28th weeks of gestation (at mean, 21.54 ± 3.11 weeks) were included in the present study. The dimensions of ACP were measured with a digital image analysis software. Results Taking into account the length, width, and angle of ACP, it was classified as Type 1 in 20.83% (10 cases), Type 2 in 10.42% (5 cases), Type 3 in 10.42% (5 cases), Type 4 in 2.08% (1 case), Type 5 in 8.33% (4 cases), Type 6 in 16.67% (8 cases), Type 7 in 8.33% (4 cases), and Type 8 in 22.92% (11 cases). According to the attachment site of the optic strut (OS) relative to ACP, OS was identified as the anterior 3/5 in 16.67% (8 cases), anterior 4/5 in 68.75% (33 cases), and posterior 1/5 in 14.58% (7 cases). Neither right-left nor male-female significant differences were observed between the quantitative values belonging to ACP and OS. Conclusion The percentage of the most complex and challenging type of ACP (the long, narrow, and narrow-angled ACP) in fetuses was found to be close to adults. Thus, routine adult surgical procedures such as anterior clinoidectomy might be successfully used in young children and infants. The attachment site of OS relative to ACP in adults was more anterior according to fetuses probably due to postnatal development such as the pneumatization of the sphenoid bone. In this regard, for pediatric neurosurgeons to avoid iatrogenic injuries and to select appropriate surgical approaches, further studies conducted on the attachment of OS relative to ACP in children are needed.

To compare the right and left sides and the endo?exocranial orifices of the jugular foramen (JF) considering the vascular compartment (VC) and the neural compartment (NC).A total of 20 human dry skulls belonging to the inventory of Medical Faculty, Department of Anatomy, were included in this study. Numerical values were obtained using direct anatomical and also computed tomography measurements.The endocranial and exocranial VC occupied wider areas on the right side than on the left side (p0.05). However, there was no statistically significant difference between the surface area of the endocranial and exocranial NC in terms of the sides (p0.05). The length of the endocranial VC was greater on the right than on the left side. The right exocranial VC was wider than the left exocranial VC. However, the widths and lengths of the endocranial and exocranial NC showed no statistically significant difference between the sides (p0.05).The right-sided dominance of JF observed in this study was attributed to the length of endocranial VC and the width of exocranial VC.

Antrochoanal polyp (ACP) is a benign soft tissue lesion arising from the inner wall of the maxillary sinus that extends into the nasal cavity and choana. Although it was first explained by Killian in 1906, the underlying pathogenesis has not been yet fully understood. Neurotrophins have been demonstrated to have a possible role in the pathogenesis of allergic rhinitis, idiopathic rhinitis and nasal polyps. To date any study has not investigated the function of neuronal inflammation and neurotrophins in the development of ACP. The objective of this study was to investigate the possible effect of neurotrophin-3 (NT-3) in ACP pathogenesis.Twenty adult patients with ACP who underwent endoscopic sinus surgery in our department were included in the study group. The control group included 15 patients with concha bullosa of middle concha who underwent lateral excisional surgery. Nasal tissue NT-3 staining scores were evaluated using immunohistochemical methods. Blood NT-3 levels of both groups were evaluated by enzyme-linked immunosorbent assay (ELISA).There were no statistically significant differences between these two groups regarding tissue NT-3 staining scores (p=0.843) and blood NT-3 levels (p=0.463). In addition, no statistically significant correlation has been observed between tissue NT-3 staining scores and blood NT-3 levels in both ACP (p=0.578) and control (p=0.359) group patients.NT-3-related neuronal inflammation does not seem to have any role in ACP pathogenesis.Antrokoanal polip (AP), maksiller sinüs iç duvarından kaynaklanan, nazal kavite ve koanaya uzanan benign yumuşak doku lezyonudur. İlk kez 1906’da Killian tarafından açıklanmasına rağmen, altta yatan patogenezi halen tam olarak anlaşılamamıştır. Nörotropinlerin alerjik rinit, idiyopatik rinit ve nazal polip patogenezinde rolü olabileceği gösterilmiştir. Bugüne kadar nöronal inflamasyon ve nörotropinlerin AP oluşumundaki fonksiyonunu araştıran çalışma bulunmamaktadır. Bu çalışmanın amacı, Nörotropin 3 (NT-3)’ün AP patogenezinde olası etkisini araştırmaktır.Çalışmaya kliniğimizde endoskopik sinüs cerrahisi yapılan AP’li 20 erişkin hasta alınmıştır. Kontrol grubu, lateral eksizyon yapılan 15 orta konka büllozalı hastayı içermektedir. Nazal dokuda NT-3 boyanma skorları immünohistokimya ile değerlendirilmiştir. Her iki grubun kan NT-3 seviyeleri Enzyme linked immunosorbent assay (ELISA) ile değerlendirilmiştir.İki grup arasında doku NT-3 boyanma skorları (p=0,843) ve kan NT-3 seviyeleri (p=0,463) bakımından anlamlı fark yoktur. Ek olarak doku NT-3 boyanma skorları ile kan NT-3 seviyeleri arasında hem AP (p=0,578) hem de kontrol (p=0,359) grubunda istatistiksel olarak anlamlı korelasyon yoktu.NT-3 bağımlı nöronal enflamasyonun, AP patogenezinde rol oynamadığı düşünülmüştür.

This retrospective computed tomography (CT) study was aimed to assess the growth dynamic of the external aperture of the carotid canal (EACC) in children aged between 1 and 20 years. Two hundred patients (sex 100 females/100 males, average age 10.50 ± 5.77 years) with good head CT image quality were included in this study. CT images of the patients were used to obtain data related to the location, shape and dimension of EACC. EACC shapes were identified as oval shaped, round shaped, and tear-drop shaped in 58.3% (233 sides), 24% (96 sides) and 17.8% (71 sides), respectively. EACC length, disEACC–MSP (distance between EACC and midsagittal plane), and EACC width did not change from the prepubescence period; while, the disEACC–SC (distance between EACC and supramastoid crest) seemed to reach adult size in the postpubescence period. Linear functions for EACC length and width were calculated as: y = 5.453 + 0.091 × years, and y = 5.398 + 0.059 × years, respectively. The regression equations of the measured parameters representing the growth dynamic of EACC in children can be helpful to estimate its size, location and angulation, which suggest that the dimension and distances to certain anatomical landmarks seemed to reach adult size in different developmental periods. In this context, the findings of this study may seem to emphasize the importance of preoperative radiological evaluation on skull base, related to EACC, for multidisciplinary surgeon teams during childhood surgeries in terms of patients’ positioning, and the selection of appropriate surgical approach.

Positron emission tomography/computed tomography (PET/CT) is frequently used for diagnosing, staging, and following-up various malignancy types because it provides information on the site and metabolic activity of the tumor. Fluorodeoxyglucose (FDG) uptake by the normal laryngeal tissue is symmetric and low, whereas that under some non-malignant conditions of the larynx, such as vocal cord paralysis and Teflon granuloma, is asymmetrically increased. We reported the first case of histologically proven Reinke’s edema causing false-positive laryngeal FDG uptake on PET/CT imaging. A clinician must be aware of these rare benign lesions in the case of increased FDG uptake, and histopathological investigation is mandatory to rule out malignancy for suspicious cases.

Objective The main aim of this study placed on cadavers was to compare the data related to geniculate ganglion (GG) dehiscence and dimension obtained from computed tomography (CT) with dissection values. Methods This study was conducted on 20 temporal bones obtained from 10 cadavers (4 female, 6 male) aged between 45 and 92 (71.50 ± 15.98) years. All the measurements related to GG dimension were performed with a CT scanner and microdissection. Results The size of GG including its area, length, and width did not show statistically significant differences in terms of sex, side, and assessment method (CT and cadaveric dissections). The dehiscent GG was observed in 6 (30%) and 5 (25%) out of 20 temporal bones in CT and cadaveric dissections, respectively. The presence and absence of GG dehiscence in CT and dissection were similar in 75%. Conclusions Our findings based on dissection data suggest that radiologic evaluation of dehiscent GG detection might be erroneous by 25%, which highlights that surgeons should be careful when lifting the dura to prevent GG injury during middle cranial fossa surgical approaches. On the other hand, there was no statistical difference between CT and dissection measurements related to GG dimension.

OBJECTIVES: This study aimed to compare the right and left sides of the carotid foramen (CF) to determine its precise location according to certain anatomical landmarks. MATERIALS AND METHODS: Twenty human dry skulls were included in the study. A digital caliper and a digital image analysis software were used to obtain direct anatomical numerical values. Then, the same parameters on dry skulls were assessed with computed tomography (CT). RESULTS: CF was found to be round shaped (62.5%), oval shaped (32.5%), and tear-drop shaped (5%). In all cases, the position of CF was seen as just postero-laterally of the foramen lacerum. According to the jugular foramen, CF was seen to be anterior in 85% and antero-medial in 15% of the cases. Regarding the morphometric values of the surface area, the length and width of CF were observed to be 37.86±11.24 mm(2), 8.02±1.09 mm, and 6.86±0.90 mm at direct anatomical measurements and 39.69±10.07 mm(2), 7.89±1.14 mm, and 6.41±0.90 mm at CT, respectively. The angles between the supramastoid crest-CF-zygoma root and the supramastoid crest-CF-mastoid process were determined as 37.11±6.87° and 42.22±6.40° at direct anatomical measurements and 36.59±4.94° and 43.71±4.55° at CT, respectively. CONCLUSION: A significant difference in sides was not observed in relation with the numerical data of CF obtained from CT or from direct anatomical measurements of dry skulls. Moreover, a significant difference was not found between radiological and direct anatomical measurements. Therefore, precise radiological assessment of this region by an experienced neuroradiologist may be assumed as a fundamental need for successful surgeries of the skull base, in addition to thorough anatomical knowledge of neurootologists and neurosurgeons.

The main aim of this retrospective computed tomography (CT) study was to examine the morphometric development of the geniculate ganglion (GG) in children aged between 1 and 18 years for surgical approaches. This study was placed on 41 patients (20 females and 21 males) including cochlear implantation cases aged from one to 18 (at mean, 6.44 ± 5.79) years. All the measurements belonging to the length, width and area of GG were performed with a CT scanner. The morphometric values of GG were not different in terms of sex or side, statistically (p > 0.05). The length (p = 0.155) of GG was not correlated with the increasing ages from one to 18 years; however, its area (p

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and it can cause cystic metastasis to the neck region. Branchial cleft cysts (BCCs) are among the most commonly encountered congenital cystic neck masses. PTC metastasis into BCC has been rarely reported in the literature. In this case report we report a patient presenting with a cystic neck mass for which fine needle aspiration biopsy was reported as benign cytology and eventually was diagnosed as PTC metastasis to the BCC. The importance of investigating the thyroglobulin levels in fine needle aspiration materials of cystic neck masses for early diagnosis of possible PTC metastasis is specifically emphasized.

Background: Deep neck infections are important otolaryngologic emergencies due to serious complications and the risk of airway compromise, which can lead to mortality. Although the most common causes among pediatric patients are tonsillitis and pharyngeal infections, odontogenic infections are an important cause in adults. Case Report: We present three patients with multiple deep neck space abscess formation due to odontogenic infection. Two of them required tracheotomy due to airway compromise, and one had mediastinitis. Conclusion: An underestimated tooth infection can cause hazardous complications such as mediastinitis and respiratory distress requiring tracheotomy.

Mechanical esophageal closure with stapler during total laryngectomy has been used by various authors to decrease the surgical time and pharyngocutaneous fistula (PCF) rates. In a few of the studies, surgical site infection (SSI) rates are mentioned and none of the studies emphasize the effect of decreased surgical time on postoperative cardiovascular and cerebrovascular complications. In this study, the authors compared the PCF rates, SSI rates, operation times between 30 mechanical stapler and 40 manual esophageal closure during total laryngectomy for laryngeal cancer patients. National Nasocomial Infections Surveillance system (NNISS) scores were recorded and compared between groups. Total laryngectomy and total operation times were lower in the stapler group patients (P 0.001 for total laryngectomy time, P = 0.024 for total operation time). There were lower rates of pharyngocutaneous fistula (P = 0.032), surgical site infection (P = 0.019), and NNISS scores (P = 0.009) in the stapler group. There was no statistically significant difference between groups regarding postoperative systemic complications (P = 0.451). In conclusion, stapler esophageal closure decreases operation time, PCF, SSI rates, and NNISS scores but not the systemic complication rates. Comorbid illnesses and prolonged surgical time are risk factors for postoperative systemic complications in total laryngectomy patients, but patients with additional illnesses must not encourage the surgeon to use stapler for decreasing postoperative systemic complications.