Anterior Superior Portion Research Articles

Trans-Nasion-Complex Approach for Endoscopic Modified Lothrop Procedure: Conception, Anatomy, and Technique

BackgroundThe endoscopic modified Lothrop procedure (EMLP) is an important procedure used to address frontal and anterior skull-base lesions. Two techniques were established, namely, the inside-out approach and the outside-in approach. The former technique take the frontal recess and the first olfactory filament (FOF) as key landmarks while the latter use the FOF as posterior boundary. In some cases, however, these two landmarks are not available. Therefore, we supplement the outside-in approach and named it trans-nasion-complex approach (TNCA) for EMLP that can be performed without locating these two landmarks.MethodsTwo dry human skulls were used to observe the bony nasion complex. Then, five colored silicon-injected human head specimens were dissected via TNCA for EMLP. Finally, the outcomes of patients who underwent TNCA were reviewed.ResultsThe nasion complex is an osseous complex that consists of the nasion and its adjacent structures, including the bilateral root of nasal bones, nasal process of frontal bones, anterior portion of the perpendicular plate of the ethmoid bone that connects with the inferior aspect of the nasal bones, and portions of the bilateral frontal process of the maxillary bones. Surgical landmarks for TNCA include the anterior superior portion of the nasal septum, anterior margin and axilla of the middle turbinate, frontal process of the maxilla bone, nasal process of the frontal bone and upper part of the nasal bone. These structures form a “mushroom sign” during cadaveric dissection and surgery. Twenty-one patients underwent TNCA, of whom 9 had tumors and 12 had chronic rhinosinusitis with nasal polyps (CRSwNP). None of them had major complications.ConclusionTNCA is expected to be a safe, and direct route for EMLP. Adequate understanding of the nasion complex and “mushroom sign” will be helpful to complete TNCA.

30. Large Uterine Leiomyoma in Premenarchal 11-year-old Patient: A Case Report

<h3>Background</h3> Uterine leiomyomas, solid benign monoclonal tumors, are the most common pelvic tumor in women. Steroid hormones are thought to play a role in pathogenesis and they are known to increase with age in premenopausal women. These lesions are exceedingly rare in the pediatric and adolescent population and even more so in premenarchal females. <h3>Case</h3> An 11-year-old female presented with a firm abdominal mass, increasing in size over one year. She had mild cramping with intense physical activity. She denied urinary or gastrointestinal symptoms, except occasional sensation of urge without ability to void. She had no anorexia, fatigue, weight loss, or fevers. She was pre-menarchal with pubarche, adrenarche, and thelarche progressing in the preceding year. She was not sexually active. Her mother's menarche was age 12. Negative family history of cancer. On exam, she had a firm mass, measuring 23 cm from pubic bone. MRI confirmed a solid, circumscribed 8.5 × 16.5 × 15.9 cm mass with scattered areas of heterogeneity, small volume of pelvic free fluid, no lympadenopathy (figure 1). Due to concern for sarcoma, pediatric surgery performed an open biopsy. Pathology was consistent with leiomyoma. The mass was subsequently resected via a vertical midline incision. Intraoperatively, there was a firm mass originating from the anterior superior portion of the uterus, and small omental adhesion to the mass at the prior biopsy site (figure 2). A Penrose drain was tied around the base of the uterus and dilute vasopression was injected in the serosa. The mass was completely resected without entry into the endometrium. The uterus was closed from cornua to cornua in three layers. Pathology showed monomorphic proliferation of myoid cells, staining consistent leiomyoma, without coagulative necrosis or increased mitotic activity to suggest a higher grade process. Genetic testing was negative for hereditary leiomyomatosis, renal cell cancer (FH), multiple endocrine neoplasia (MEN1) and PTEN. <h3>Comments</h3> Despite the high incidence of uterine leiomyomas in women of a reproductive age, few cases have been documented in a premenarchal patient. This premenarchal status, along with the absence of any typical genetic markers for uterine leiomyomas, suggests that there may be additional factors that contribute to the development of leiomyomas.

Pancreas divisum as a cause of recurrent pancreatitis

Presenter: Paula Morgade MD | Hospital Central de las Fuerzas Armadas Background: The pancreas develops from two separate intestinal outlines, one dorsal and one ventral. Main pancreatic duct arises from the tail of the pancreas and crosses the gland. Throughout its journey, smaller ducts flow into it. Accessory pancreatic duct drains the anterior superior portion of the head of the pancreas directly into the duodenum through the lesser papilla or into the duct of Wirsung. Pancreas divisum is the most common anatomical variant of the pancreas and is associated with recurrent acute pancreatitis. Pathological mechanism would be a disproportion between the amount of pancreatic secretion and the caliber of the duct (smaller), which could generate stasis, ductal distention and increase the risk of acute pancreatitis, which could be considered a predisposing factor for pancreatitis. Treatment goals consist in otpimizing pancreatic drainage. Modalities are endoscopic and surgical. The efficacy of endoscopic and surgical treatment is controversial. Endoscopic retrograde cholangiopancreatography (ERCP) is done for minor papila sphincterotomy, balloon dilation and eventual stent placement. Succes rates of vary between 31% to 96%. Surgery should be considered when endoscopic treatment fails. Even though surgery has more complications, it has better success rates improving symptoms and avoiding pancreatitis. Methods: 50yo female. Laparoscopic cholecystectomy 3 years ago after acute pancreatitis. Since then 10 more episodes of mild acute pancreatitis. No associated cholestasis. MRCP showed a dilated pancreatic duct (7mm) ending in the lesser papila (white arrow figure). Compatible with pancreas divisum as a probable cause of recurrent pancreatitis. Bile duct ends in major papila (grey arrow in figure) separatedly from pancreatic duct. ERCP was performed for stent placement in the minor papila, procedure failed because minor papila was not recognized. Endoscopic ultrasound was not available. Given recurrence of episodes impairing quality of life, surgery was proposed. Results: A classic Whipple procedure with Child-Tredeé reconstruction was performed. No intraoperative incidents. No postoperative complications. Discharge was at day 7. Histopatological analysis of the specimen was consistent with chronic pancreatitis. After 18 months patient is asymptomatic, no new episodes of pancreatitis. Conclusion: Pancreas divisum is an infrequent cause of pancreatitis, it must be considered as cause in recurrent non biliary pancreatitis. Surgery may be an option when endoscopic treatment fails.

The morphology of ligamentous sacroiliac lesions - challenge to the antero-posterior compression mechanism.

This paper evaluates computer tomographic morphology of partial ligamentous lesions of the sacroiliac joint. We hypothesised that in antero-posterior compression (APC) injuries the anterior superior portion of the sacroiliac joint (SIJ) should open up the most as suggested by the vector forces outlined in the Young and Burgess classification. All patients who underwent operative fixation of a ligamentous APC pelvic injury between July 2009 and December 2015 in a single Level-1 trauma centre were included. Patients were case matched (1:1) to controls without pelvic injury. SIJ width was measured by two independent reviewers at the anterior superior and anterior inferior part of the SIJ. Wilcoxon ranged test was applied for analysis. 70 patients (35 cases, 35 controls) were evaluated. Median inferior and superior SI joint widths were 5.27 (IQR 3.68-7.80) and 4.05 (IQR 3.13-5.31) mm in cases versus 2.24 (IQR 1.83-2.50) and 2.44 (IQR 2.14-2.65) mm in controls, respectively. The difference between the inferior and superior SI width in cases was larger than in controls (p-value < 0.01, median of -0.22 mm in the control group versus 1.51 mm in the cases). Our data suggests that the inferior part of the SIJ opens up after injury more, relative to its superior portion. The vector of the force involved in rotationally unstable pelvic injuries is unlikely to be antero-posterior if the force causes the SI joint to widen up inferiorly first. This should be considered in SIJ fixation and challenges the APC mechanism in pure ligamentous rotationally unstable pelvic ring injuries.

Can preoperative magnetic resonance arthrography accurately predict intraoperative hip labral thickness?

ObjectiveThere is limited literature investigating the reliability of magnetic resonance-based assessments of labral size. The goal of this study was to validate the reliability of magnetic resonance arthrography-based labral size measurements with intra-operative arthroscopic measurements. MethodsPatients undergoing hip arthroscopy for femoroacetabular impingement and labral tears were prospectively enrolled. Preoperative magnetic resonance arthrograms were used to determine labral size at the anterior-superior portion (zone 2), mid-superior portion (zone 3), and posterior-superior portion (zone 4). Intra-operative labral widths were measured at the same anatomical zones of the acetabulum using an arthroscopic probe. Mean labral size was determined for each location and a Pearson correlation was used to determine the correlation between imaging-based measurements and intra-operative measurements. Results117 patients were enrolled with 70% being female, an average age of 39.1 ± 13.3, and an average body mass index was 26.5 ± 5.4. The average labral sizes based on intraoperative measurements were 6.85 mm in zone 2, 7.45 mm in zone 3, and 7.29 mm in zone 4. The average labral sizes based on MRA were 6.95 mm in zone 2, 7.24 mm in zone 3, and 6.71 mm in zone 4. There was a poor correlation between MRA and intraoperative measurements in zones 2 and 3 (zone 2: R = 0.171, p = 0.065; zone 3: R = 0.335, p = 0.00022) and no correlation in zone 4 (R = −0.22, p = 0.82). ConclusionThis study demonstrates a poor correlation in labral measurements between magnetic resonance arthrogram imaging and intraoperative measurements, suggesting that this imaging modality may be insufficient in providing accurate measurements of labral size.

Spontaneous Temporomandibular Joint Herniation into the External Auditory Canal through a Persistent Foramen Tympanicum (Huschke): Otologic Features

A persistent foramen tympanicum (Huschke) is an anatomic variation located in the anterior inferior portion of the bony external ear canal. We present a case of symptomatic temporomandibular joint (TMJ) herniation into the right external auditory canal though an enlarged osseous defect. The herniated retrodiscal temporo-mandibular joint (TMJ) tissue moved backward when the patient’s mouth was closed, and forward, when opened. Imaging findings were useful for differentiating TMJ herniation from salivary fistula or a true granuloma of the anterior bony canal wall near the tympanic membrane. The purpose of this presentation is to alert otologists that a large granuloma near the anterior inferior or anterior superior portion of the bony ear canal adjacent to the anterior superior tympanic membrane can be a herniation of either the parotid gland or in this case, the temporomandibular joint capsule. Several attempts at removal of this through the ear canal failed because of the initially incorrect diagnosis of a primary lesion of the ear canal. Only after considerable thought was it realized that this was a rare herniation of the temporomandibular joint capsule through a patent foramen of Huschke.

SU-GG-I-123: Volumetric Reduction of the Corpus Callosum in Alzheimer”s Disease

Purpose: This study investigated correlations between regional corpus callosum (CC) atrophy and cognitive measurements in AD subjects at mild disease stages with volumetry. Our aims were to replicate ROI-based findings of reduced volumes of the CC in AD patients relative to mild cognitive impairment (MCI) and to investigate, on a voxel-by-voxel basis, the presence of significant correlations between CC atrophy and cognitive test scores in AD subjects. Method and Materials: We used the VBM and cross-sectional ROI-based volumetry approach to conduct a detailed assessment of CC volumetric reductions in a probable AD patients (n=40) in comparison to MCI (n=40) and subjective memory impairment (SMI) (n=12) matched for age. Results: The volumetric reduction of the posterior portion of the CC body, which inter-connects cortical regions that are also early affected in AD (mean area at mid intersection, AD=510.7mm2, MCI=515.6mm2, SMI=603.9mm2, relative%ratio: AD=0.27, MCI=0.3, SMI=0.4) such as the superior temporal lobes, is also consistent with results of previous ROI-based morphometric MRI studies. Significant CC atrophy was detected in the anterior-superior portion of the splenium, the isthmus, the anterior and posterior portions of the CC body. Structural abnormalities of the CC splenium may be secondary to an early primary neuronal loss in AD involving parieto-temporal neocortical regions, which are inter-hemispherically connected by this callosal portion. Conclusions: Our results confirm of diffuse volumetric CC reductions in the AD, and warrant further evaluation of the relevance of atrophic changes in anterior CC portions to the cognitive impairments that characterize the disorder. A cluster of significant positive correlation with MMSE scores was seen on the left anterior CC body. The VBM results reported showed that in predominantly AD subjects, foci of atrophy are present in several portions of the CC, involving the anterior-superior portion of the splenium and the isthmus.

Endoscopic endonasal reduction surgery for diplopia caused by orbital roof fractures

Orbital roof fractures (ORF) frequently occur together with frontal bone fractures, and can cause diplopia as a sequela. However, ORF have never been treated using endoscopic endonasal reduction surgery. A 22-year-old woman was injured in a traffic accident and diagnosed with right ORF along with frontal bone fractures. She was referred to us for diplopia 2 weeks after the initial trauma. No facial deformation was seen. Endoscopic endonasal reduction surgery was performed under general anaesthesia. Ethmoidectomy was performed and, subsequently, the anterior superior portion of the medial orbital bone was removed. During the procedure, an ophthalmologist performed eye traction tests until definitive ocular motility improvement was observed. Postoperatively, diplopia disappeared and no enophthalmos was seen. From both a functional and an aesthetic point of view, the endoscopic endonasal reduction surgery resulted in a satisfactory outcome without having to use any extranasal approaches in this case.

Technical Considerations of Transsphenoidal Removal of Fibrous Pituitary Adenomas and Evaluation of Collagen Content and Subtype in the Adenomas.

Pituitary adenomas are usually soft, but 5-13.5% are fibrous adenomas which are difficult to remove. Magnetic resonance (MR) imaging and operative findings were evaluated in eight patients (12.1%) with fibrous pituitary adenoma among 66 patients. Tumor specimens were examined histologically and immunohistochemically for collagen content and subtypes. Seven patients had clinically inactive non-functioning pituitary adenomas and one patient growth hormone-secreting adenoma. All patients underwent transsphenoidal surgery. Four cases were giant adenomas with suprasellar extension of more than 2 cm. T1- and T2-weighted MR imaging showed the tumors as nearly isointense to the surrounding brain, except in one case where the tumor was high intense on T2-weighted MR imaging. All tumors required piecemeal resection using a micro-dissector and tumor forceps. Four tumors of maximum size more than 3 cm needed a second operation. The interface between the thinned normal pituitary gland and fibrous adenoma was intended to identify at the anterior-superior portion in recent four cases, which was helpful to remove the tumors and preserve pituitary functions. Histological examination revealed prominent deposition of collagen in the perivascular area. The percentage of collagen content in fibrous adenomas was more than 5% and significantly higher than that in soft adenomas and normal pituitary glands. Immunohistochemical examination showed positive staining for collagen types I and III in the fibrous adenomas, but only for type V collagen in the normal pituitary glands. Large fibrous adenomas can be resected by transsphenoidal surgery which may require two-stage operations. Identification of the interface between the normal pituitary gland and adenoma is helpful to remove fibrous adenomas and to preserve pituitary functions. We propose that firm adenomas containing more than 5% collagen are "fibrous" adenomas.

Microanatomical variations in the cerebellopontine angle associated with vestibular schwannomas (acoustic neuromas): a retrospective study of 1006 consecutive cases

Great advances in neuroimaging, intraoperative cranial nerve monitoring, and microsurgical technique have shifted the focus of acoustic neuroma surgery from prolonging life to preserving cranial nerve function in patients. An appreciation of the vascular and cranial nerve microanatomy and the intimate relationship between neurovascular structures and the tumor is essential to achieve optimum results. In this paper the authors analyze the microanatomical variations in location of the facial and cochlear nerves in the cerebellopontine angle (CPA) associated with acoustic neuromas and, additionally, describe the frequency of involvement of surrounding neural and vascular structures with acoustic tumors of varying size. The authors base these findings on their experience with 1006 consecutive patients who underwent surgery via a retrosigmoid or translabyrinthine approach. Between July 1969 and January 1998, the senior author (D.M.L.) performed surgery in 1022 patients for acoustic neuroma: 705 (69%) via the retrosigmoid (suboccipital); 301 (29%) via the translabyrinthine; and 16 (2%) via the middle fossa approach. Patients undergoing the middle fossa approach were excluded from the study. The remaining 1006 patients were subdivided into three groups based on tumor size: Group I tumors (609 patients [61%]) were smaller than 2.5 cm; Group II tumors (244 patients [24%]) were between 2.5 and 4 cm; and Group III tumors (153 patients [15%]) were larger than 4 cm. The senior author's operative notes were analyzed for each patient. Relevant cranial nerve and vascular "involvement" as well as anatomical location with respect to the tumor in the CPA were noted. "Involvement" was defined as adherence between neurovascular structure and tumor (or capsule), for which surgical dissection was required to free the structure. Seventh and eighth cranial nerve involvement was divided into anterior, posterior, and polar (around the upper or lower pole) locations. Anterior and posterior locations were further subdivided into upper, middle, or lower thirds of the tumor. The most common location of the seventh cranial nerve (facial) was the anterior middle third of the tumor for all groups, although a significant number were found on the anterior superior portion. The posterior location was exceedingly rare (< 1%). Interestingly, patients with smaller tumors (Group I) had an incidence (3.4%) of the seventh cranial nerve passing through the tumor itself, equal to that of patients with larger tumors. The most common location of the eighth cranial nerve complex was the anterior inferior portion of the tumor. Not surprisingly, larger tumors (Group III) had a higher incidence of involvement of fourth cranial nerve (41%), fifth cranial nerve (100%), ninth-11th cranial nerve complex (99%), and 12th cranial nerve (31%), as well as superior cerebellar artery (79%), anterior inferior cerebellar artery (AICA) trunk (91.5%), AICA branches (100%), posterior inferior cerebellar artery (PICA) trunk (59.5%), PICA branches (79%), and the vertebral artery (VA) (93.5%). A small number of patients in Group III also had AICA (3.3%), PICA (3.3%), or VA (1.3%) vessels within the tumor itself. In this study, the authors show the great variation in anatomical location and involvement of neurovascular structures in the CPA. With this knowledge, they present certain technical lessons that may be useful in preserving nerve function during surgery and, in doing so, hope to provide neurosurgeons and neurootologists with valuable information that may help to achieve optimum outcomes in patients.

Microanatomical variations in the cerebellopontine angle associated with vestibular schwannomas (acoustic neuromas)

Great advances in neuroimaging, intraoperative cranial nerve monitoring, and microsurgical technique have shifted the focus of acoustic neuroma surgery from prolonging life to preserving cranial nerve function in patients. An appreciation of the vascular and cranial nerve microanatomy and the intimate relationship between neurovascular structures and the tumor is essential to achieve optimum results. In this paper the authors analyze the microanatomical variations in location of the facial and cochlear nerves in the cerebellopontine angle (CPA) associated with acoustic neuromas and, additionally, describe the frequency of involvement of surrounding neural and vascular structures with acoustic tumors of varying size. The authors base their findings on their experience treating 1006 consecutive patients who underwent surgery via a retrosigmoid or translabyrinthine approach. Between July 1969 and January 1998, the senior author (D.M.L.) performed surgery in 1022 patients for acoustic neuroma: 705 (69%) via the retrosigmoid (suboccipital); 301 (29%) via translabyrinthine; and 16 (2%) via middle fossa approach. Patients undergoing the middle fossa approach were excluded from the study. Patients were subdivided into three groups based on tumor size: Group 1 tumors (609 patients [61%]) were smaller than 2.5 cm; Group 2 tumors (244 patients [24%]) were between 2.5 and 4 cm; and Group 3 tumors (153 patients [15%]) were larger than 4 cm. Operative notes were analyzed for each patient. Relevant cranial nerve and vascular “involvement” as well as anatomical location with respect to the tumor in the CPA were noted. “Involvement” was defined as intimate contact between neurovascular structure and tumor (or capsule), where surgical dissection was required to free the structure. Seventh and eighth cranial nerve involvement was divided into anterior, posterior, and polar (around the upper or lower pole) locations. Anterior and posterior locations were further subdivided into upper, middle, or lower thirds of the tumor. The most common location of the seventh cranial nerve (facial) was the anterior middle third of the tumor for Groups 1, 2, and 3, although a significant number were found on the anterior superior portion. The posterior location was exceedingly rare (&lt; 1%). Interestingly, patients with smaller tumors (Group 1) had an incidence (3.4%) of the seventh cranial nerve passing through the tumor itself equal to that of patients with larger tumors. The most common location of the seventh cranial nerve complex was the anterior inferior portion of the tumor. Not surprisingly, larger tumors (Group 3) had a higher incidence of involvement of sixth cranial nerve (41%), fifth cranial nerve (100%), ninth-11th cranial nerve complex (99%), 12th cranial nerve (31%), as well as superior cerebellar artery (79%), anterior inferior cerebellar artery (AICA) trunk (91.5%), AICA branches (100%), posterior inferior cerebellar artery (PICA) trunk (59.5%), PICA branches (79%), and the vertebral artery (93.5%). A small number of patients in Group 3 also had AICA (3.3%), PICA (3.3%), or vertebral artery (1.3%) vessels within the tumor itself. In this study, the authors show the great variation in anatomical location and involvement of neurovascular structures in the CPA. With this knowledge, they present certain technical lessons that may be useful in preserving function during surgery and, in doing so, hope to provide neurosurgeons and neurootologists with valuable information that may help to achieve optimum cranial nerve outcomes in patients.

The inferiorly based superior tympanomeatal flap for removal of congenital cholesteatoma

We believe that the IB-STMF is preferable to the P-TMF for removal of a congenital cholesteatoma from the anterior superior portion of the mesotympanum. Though developing an IB-STMF may require extra time and special care to avoid tearing the flap, the exposure that is achieved affords the best chance for complete removal of the mass, thus decreasing the chance for persistence or recurrence of the lesion.

The Central Nervous System and Carbon Monoxide Poisoning II. Anatomical Study of Brain Lesions following Intoxication with Carbon Monoxide (22 cases)

This chapter presents studies on the brain lesions caused by carbon monoxide intoxication in 22 cases, survival of which varied from 1–139 days. Each of these 22 cases has been described with anatomical findings. Impairment of the globi pallidi is the most frequent lesion. It can be limited to the anterior superior portion of the internal nucleus of the globus pallidus and can only be detected on serial sections of the basal ganglia. Studied under these conditions, this lesion was found in 16 times out of 22 cases: only in one case was this lesion very limited and unilateral. Lesions of Ammon's horn occur less frequently (1 out of 2). They are necrotic and of variable extent, affecting either the entire Ammon's horn or only the sector of Sommer. Lesions of the white matter of the hemispheres occur as frequently as those of the globus pallidus. They can place in 4 groups according to decreasing severity of the lesions of the centrum ovale. The chapter emphasizes the existence of intermediate stages among these groups, all of which constitute a continuum of lesions of which the myelinopathy of Grinker is only one particular aspect.

Preservation of the external ear canal in tympanoplasty

For the purpose of eliminating the troublesome mastoid cavity after tympanoplasty, some surgical procedures have been devised, which consist of preservation of the external ear canal, so that the operative mastoid cavity is primarily closed, with the use of fascia, periost or vein as a tympanic graft. Surgical procedures are as follows : At the first place, mastoidectomy is carried out without sacrifice of bony bridge using Shambaugh's endaural incision. Then, the meatal skin incision is made on the posterior canal skin and on it the window is made to see the drum and to prepare the vascular bed on the undersurface of the drum to receive the graft. Thereafter, the drum is separated from sulcus and elevated, but the anterior superior portion is preserved, which serves for reconstructive pro- cedure of the drum by giving the fixed point. After an adequate tympanoplastic procedure is used in accordance with middle ear condition, the drum is repaired with fascia or other tympanic graft on the undersurface of the drum and recon- structed. Such reconstructive procedures as de- scribed above are easily performed through the meatal window which is made on the early stage in operation. Finally the meatal skin is replaced and the window is closed. With these procedures, it seems that nearly normal ear canal and fully satisfactory results in hearing can he obtained. In Addition, healing process is more rapidly and less postoperative after care is needed than in classical tympanoplasty.

ROENTGENOLOGIC DIAGNOSIS OF THE CANCER IN THE MAXILLARY SINUS

Roentgenograms of 30 cases of the operated maxillary cancer are compared with the histological findings in the large section preparates. Results as follows:1) The maxillary sinus. The dense shadows with the bright portions and discontinuous contours of the sinus walls are the pathogmotical findings. The destruction of the posterior wall and the pterygoid process are visualized by means of the axial views, Rhese's technic and horizontal or sagittal tomography.2) The almost similar findings are found in the ethmoid portion.3) The sphenoidal sinus has to be examined by means of the axial views and the frontal tomography.4) The dense shadows sometimes were found in the frontal sinus, but no invasion of the cancer in this series.5) The nasolacrimal duct was visualized through the injection of 40% moljodol (0.3cc). Its abnormality revealed the invasion of the cancer in the anterior superior portion of the nasal cavity.6) The arteriography of the external carotid reveals the destruction of the bony walls according to the dislocation of the stem and its branches.The existence of the cancer in the maxillary sinus today is easily diagnosed, but the destruction of the bony wall and its grade may be only demonstrated through the adequate technic according to each wall of the sinus, so that the necessary and complete diagnosis will be only successful by means of some films, taken by adequate technics to the cases.