 Ladies and gentlemen, thank you very much for being here. I would like to start with the anatomy of the nasal cavity and the peronasal sinuses, which give access to that where you are going to the cellar. So basically just one idea when you look on the peronasal sinuses, where do we have them for? They were not constructed by nature during the millions of years of evolution in order to make happy our ENT colleagues, in order to provide them with work. They were also not introduced only to give a resonance cavity. They were not only used for making some light-white construction of the skull, because otherwise if you had a solid bone, if you didn't have that, then the back musculature would be used much more for keeping the head in a balance by these excavations of the peronasal sinuses, by the ventilation of the peronasal sinuses. We have a better light-white construction, so the head is more in equilibrium. But there's one more reason why we have these peronasal sinuses, and that reason lies in the development of the peronasal sinuses and the nose itself. They were used mainly to shift the nose and the eye and the eye cavity towards the midline, because initially the eyes were positioned just lateral on the head. Then what you see here are not the eyes. The eyes are on this embryo on the sixth week, located somewhere here far lateral. Then what we see here is the lateral and the medial nasal process, and this lateral and medial nasal process are pushed together by the force of the development of the peronasal sinuses. So they come to a midline, there's an insertion of an intermaxillary process, and after that insertion of the intermaxillary process, the medial and lateral nasal processes come together and they start forming then in the midline the nose and the nasal septum after that insertion of the intermaxillary process. Well, basically the positioning of the orbiter towards the front is only made possible by that shift that we find from the lateral side or from the lateral part to the medial part, otherwise it wouldn't be possible at all. So when we look on the nasal cavity, we realize that we have some means for increasing the surface, the inner surface of the nose. On the lateral side we find these turbinates, the inferior turbinates, the middle turbinate and the superior turbinate, and these turbinates are covered with the mucosal surface, that's why it's looking so wet, a mucosal surface that guarantees that the air that we breath in is moisture and also warmed up because with an ambient temperature of 20 degrees, well, it's not always like in India in summer, that you don't need the warming, that you need only the moistering of the air, we need that in order to make the gas exchange possible in the alveoli. With an humidity like we have here in this room now today, perhaps 55-60%, it wouldn't be possible to make a gas exchange. And the distance that we have from the trachea down to the alveoli is too little when there's a flow with each breath, 15 breaths a minute, there's a flow of 600-700 millimeters, that's why we need to increase the surface where we can exchange and moisturize the air in order to make possible the gas exchange in the alveoli. In the alveoli we have a humidity of around 99%, it's nearly foggy there. Nobody ever looked into one individual alveolus, I never realized that before. When we look at the scanning electron microscope in alveolus, it's looking quite nicely, but we are always looking at an artifact, no man, well we have been on the moon everywhere, but nobody has ever looked into an individual alveolus. But that's what we know from physiology, so we have to moisturize, so we start from that area from the lima nazi, that's the area we can go up with a little finger easily, but we will never reach the germinates and especially we will never reach the area on the roof of the nose where the olfactory nerve is coming down and getting the phila terminalis or the phila olfactory phila down there. Two landmarks that we need to recall is one is the phenyl ethmoidal recess just behind the superior nasal conchia that has a distance from the lima nazi of around 45 mm. Usually we do not, it's very variable in size and maybe variable in the extension. However, what is a constant feature is this phenyl palatine foramen is that we find just behind the middle a turbinate. The phenyl palatine foramen is of utmost importance insofar as this foramen gives the access to the pterigopalatine fossa and through this pterigopalatine fossa we find the origin of the vessels, namely of the arteries of the phenyl palatine artery that is nourishing the majority of the vascular plexus here in the mucosa. And then it's also the entrance point or the exit point from the skull palatine nasal nerves, the superior and the superior nasal nerves. They all emerge here through the phenyl palatine foramen behind there. So the basis, the bone basis for these turbinates are the superior and middle conchia. These belong to the ethmoid bone. It's a part of the ethmoid bone. However, the inferior turbinate, the biggest turbinate is a bone by itself. It's an original, that's why in American literature it's called the osteosturbinale. In nominal anatomica, in the official anatomical nomenclature there is no name for it, it's only called inferior turbinate and that's it. So basically it's an own bone that is then fusing together with the ethmoid bone in the front, with the palatine bone in the posterior and in the basal part and with the maxillor in the anterior and basal part. These turbinate bones are very thin bones. So from the turbinate itself the majority is only the vascular plexus and the mucosa. The bony tissue is very fragile, it's a very thin bone. It can be easily cracked. Sometimes even the turbinates may be also pneumatized, just like the paranasal sinus. Maybe these are small bulae, it's called the conchia bullosa or such a big bulae in the middle turbinate which is significantly bigger. You see that there are some connections and that's the same etiology to the cells, to the bulae cells that we find more superior located. So all this makes indeed an enlargement of the surface leaving little space for the inferior meatus, the middle meatus and the superior meatus where the air comes through. Here in that section, in that frontal section you also see the maxillary sinus. Maxillary sinus cut off here, as we said, light-white construction of that. The conchia only form when we get the right fusion of the lateral and medial nasal processes from each side. If you don't have that correct fusion, then also a retarded fusion, then we get also retarding in the development of these surface structures. And that is visible then in hypoplastic. In hypoplastic sinuses like here in the maxillary sinus you see it is very small, a very shallow sinus so there is no big excavation and just corresponding to that also the turbinates are formed very little. If we have a complete aplagia of the turbinates then it looks like that on the lateral surface of the nose and you can easily detect that also the nose itself is indeed malformated and not formated in a normal fashion. So coming back to the construction site, here is the septum nasi, which is also covered by that plexus. We see indeed that we have a venous cavernous tissue that's way thicker than the bone itself. The monolaminar bone is very thin, plate easily crackable. The majority of that is a vascular plexus that is used for increasing the fluidity transfer to the surface in order to moisturize the stuff correctly. This is in that case a real venous cavernous tissue. It's not like in the genitals an arterial cavernous tissue. It's a venous cavernous tissue. We don't need a high pressure here. But we need a pretty much fluid transport. You realize that that also most when we lie on the side during sleep only one nostril is open, the other is obstructed and blocked, usually the one that is down there. It's obstructed because there's a swelling of this cavernous tissue. When you turn around, go flip from the right side to the left side, you realize, oh, it's blocked, the nose is blocked, it takes only two minutes and then this venous swelling will decrease and the other takes over. So this is indeed a highly reactive stuff that we need always. Indeed we see on the surface of the structure then of course a respiratory epithelium, typically respiratory epithelium, and we see lots of vessels originating from these already called phenopalatine artery that's nourishing the majority of the vessels here of the surface. This phenopalatine artery belongs to the external carotid artery. It's one of the terminal branches of the maxillary artery. The last branch it's given off is the meningeal, the middle meningeal artery. So the phenopalatine artery crosses in the phenopalatine foramen together with the nasal nerves and then making also some anastomosis with branches from the ophthalmic artery that give off the anterior and posterior ethmoidal arteries. Then we have also some branches that are interconnecting down here to the palatine artery. That's a descending palatine artery that also goes then to the foramen palatinomaeo and that's connecting then upside down. On the medial side we find the same branches. There are also some external carotid artery branches that go onto the septum and then nourish the surface of the septum. Septum itself is a composite of three different structures. It contains on the one hand on the basal part the vomary bone, the vomary bone and then it's accomplished from the laminar perpendicular of the edmary bone coming down from the top. Here's the aria crevosa with the feel of the terminal olfactory branches and this composite of these two bones is accomplished by the cartilage of the septum hyalinus cartilage that's growing in from the front. So if you have two structures, one growing down, one growing up and one coming from the front, then it's evident it will never be straight. It's not an exemption but a rule that we have a septum deviation mostly in the area where the vomary bone comes together with a perpendicular esmary bone process. So it's more or less a rule and not an exemption. But of course for you for the axis it would be easier if it was just straight but the advantage of a deviation is that at least one nostril is a little bit bigger than the other. So let's go back to the lateral side to the lateral side of the nasal cavity. If we cut off the inferior turbinate, here's the inferior turbinate, here's the middle turbinate cut off then we see it can expose the naso-electromole duct. You will never see that in your techniques in your axis route because you go straight to the sphenoid sinus and you try to leave away, leave apart the inferior turbinate and the middle turbinate but just for orientation. And then if we go up between the inferior and the middle turbinate we find the processes uncinatus and the process uncinatus gives an access to the opening of the hiatus seminalis to the axis of the maxillary sinus. So more cranially and more occipitaly we find the ethmoid bule, ethmoid bule and then here some ethmoid bule open and then if we go backwards we get into the sphenoidal sinus. The ethmoid bule are highly variable. The ethmoid and cellular bule are discerned for the ENT by posterior and anterior bule. The anterior bule are then categorized through superior, middle and inferior bule. The rest ones are the posterior bule and they come very close to the sphenoid sinus. So this sphenoid sinus is usually found when we go from the limonasi in the distance of about 5 to 6 centimeters. This is a typical type of a cellular type of a sphenoid sinus. It may also be that we have more or less a conchal type where we find only a very little opening of the sphenoid sinus but this is then of course a little bit more difficult to access but in the normal case more than 85% in the cellular type we find that typical correlation that we have the zeloturkika just above on the roof of the sphenoid sinus. The cleavus sphenoidalis forms the back part and the anterior part is then the wall that is then separating from the nasal part. We shouldn't forget that this sphenoid sinus is a paired structure. It's from left and right it was also shifted in the midline so this is only a part of the sinus. We see it from lateral. We look from the medial side towards the lateral side so it doesn't take into account that there's a septum originating from the roof going down to the floor of the cellar. One more thing that may happen is that we have sphenoid sinus frequently also visible the optical nerve in a separate channel there can be some ethmoid bullet around that or it can be into direct connection to the sphenoid sinus. If we have some bullet around it then we call it onodicel inserting just like the ethmoid bullet inserting the optical nerve but that's an exemption more or less. So we have a super optical recess here in that case it's also visible in that specimen optical nerve channel runs down here so we have a super optical large recess that goes up here. It is found about a quarter of the cases. So we have severe left-right differences caused by the septum just like in the nozzle septum it's not said that it's symmetrical. Here we see that the right optical nerve is placed way downwards compared to the left one which is way upwards. So these left-right differences are quite normal for that. This is a type of a conchal sphenoidal sinus you see that the distance and the wall of the bone from this sphenoidal sinus towards the floor of the cellar is way thicker than we saw in the typical case. Good news is that with age usually the bony tissue here is resolved that it's thin but we are way apart here in that case from such a situation in an elderly person where we see that the whole floor of the cellar is a very thin membrane it's a very thin bony structure. It's hardly impossible to discern between the capsule of the pituitary and the dura and the bony tissue itself. Okay now orientation here's the tongue, the mouth cavity and here's the nose the nasal septum is still exposed, ah we can flip this open nasal septum is flipped open so this is the access route we go through the nostril we go through the nostril upwards here's the middle terminate the inferior terminate is not completely exposed and we can see from the sinus only apart I wanted to show something else you can see here only the septum see the septum is really coming up from the roof, it's coming up from the roof down to the floor this is a very small sphenoid sinus I wouldn't call this typical sphenoid sinus because we have only a very small opening and the pituitary is just above here so the cavity is empty perhaps we can crack that open when we crack in here and open that it doesn't become much larger this is a very small one perhaps we look on this one because what I wanted to show you are the recesses that you can find in this sphenoidal sinus so here again the nose we go up, here the middle terminate is only left the mucosal surface and here we get an excess into the sphenoidal sinus the pituitary has been here is it still there? no, it's removed here's the ligamentum zele that is still intact up here here's the cavity for the pituitary and we see that here the sphenoidal sinus is way bigger than we had in the other case and here we have a large recess, a lateral recess that goes down into the depth here's a smaller lateral recess and we find even down here pretty big one so this would give you in that case here a pretty large operational field, a very nice excess and a very big excess route to the pituitary and to the zelotulcica way better than it was in the other one so but how do we get in here this perforation that was made here by the cut is way bigger than it's usually in real life we have only a small slit like opening the light is missing here's the optical nerve and the carotid protuberance here and here's the optocarotid recess okay the optocarotid recess so and below that is then you can imagine that's the cause of the exactly okay thank you very much the excess that we find into the cavity oh here we have the very same like you pointed out the excess here it's only by the forceps the excess that we find in here is through a slit like or pinnet like opening the opening may be smaller than that that's in this large one four or five millimeter is more or less a big one it is usually obstructed there's only very little from that because the mucosa that is covering that from the nozzle side this is here seen from posterior anteriorly from the synod sinus this will be of course a little bit smaller than this is a typical view that we have after the middle terminate if you deflect the middle terminate then we see it already on the top and here in more detail so it's more or less a roundish or pinnet light structure doesn't matter whether it's small or big this will anyway be opened the whole posterior wall so we don't care for that another feature that should be taken into account we already mentioned that the septum may be shifted towards one side like here and that side so this paired sinus is divided into two cavities it may also be completely or incompletely divided from a transverse septum here's a spur of a transverse septum that originates from the tuberculum cellae from the floor of the cellae then tens and down there may also be some other ridges like we see here on the lateral wall all of this is done in the sphenoid bone all these structures belong like sphenoid sinus to the sphenoid bone by the way it should be kept into mind that this sphenoid bone is a typical misnomer typical example for plagiarism that we find already in the medieval because this sphenoid bone sphenoid doesn't mean much thing only a wedge shaped stuff originally it was called the sphenoid bone or vaspe bone I mean you look on this sphenoid bone from the frontal view or from the frontal of the posterior view you realize it's really looking like a vaspe with the alamayo and alamino but some monks in the medieval evil they copy pasted this stuff and they mistaken the sphenoid bone to the sphenoid bone and ever since then anatomists are writing sphenoid bone so copy place was already used at that time oh what did I mention that there's one more structure that we have to talk about the foram lacerum foram lacerum the tigrid canal or the vidian canal containing the nerves the deep rephrosal nerve and the greater rephrosal nerve on their way from the superior salivatory nucleus they pass through that foram lacerum that is occluded by a fibrous mass it's not a real cartilage it's a fibrous tissue that's around there and that vidian nerve contains of two parts we have on the one hand the deep rephrosal nerve deep rephrosal nerve that contains the pre-ganglionary pre-ganglionary sympathetic fibers that then are crossed over in the pteropalatine ganglion and go to the lacrimoid gland and also the glands of the nose and then the other hand we have the greater rephrosal nerve that contains the pre-ganglionary parasympathetic fibers that originate from the superior salivatory nucleus and go through the pteropalatine foramen and then to the target organs in the nose and the stuff ok let's have a look on endoscopic anatomy this is an image taken from the original paper from one of the first studies of the group of kapapianca when we look into the sphenoid sinus we see here in the top the opening of the sphenoid sinus we see on the top of it the senoidal planum with the the floor of the cellar and we see then laterally the carotid protuberance which I should try to show you already and the optic protuberance and in between the optic protuberance and the carotid protuberance we find the lateral optic carotid recess that may be a pretty deep one medium size lung like we saw here in the original specimen it may also be pretty shallow and then on the medial side we find the medial optic carotid recess below an occipital of the cellar floor the cleavus sphenoidalus is showing up and then we see the carotid artery in the paraclyle segment coming up from the basal from the typical S shape left and right to the sphenoidal cleavus so the next image shows you again that's an image from kapapianca the lateral optic carotid recess the carotid protuberance here the cellar floor again and here the cleavus sphenoidalus you see there's a remarkable distance between left and right carotid artery these carotid arteries may in places come together like we see here with the kissing arteries we are then of course the access route is a little bit limited because they come very close together another feature of what we see here is that the bony structure of the carotid artery may be thinned out significantly the bone is not thick it's a very thin one it can be less than 0.2 mm and sometimes I have the impression that you can even see nicely the pulsation of the artery through the bone itself here again the close up of the lateral optic carotid recess of the medial optic carotid recess you see here also in that case the bone structure is extremely small these structures let's go a little bit further down and laterally we go further down and laterally then we see in the paraclival segment all the nerves that go to the sphenoidal to the fissura orbitalis superior so superior orbital fissure and that's it of course separately in the optic tract goes to the canalis opticus the optical canal whereas all the other nerves the ocular motor nerve the trochlearis nerve and they tend then to the superior fissure the nerves are embedded into a vascular plexus and we see a typical arrangement of the nerves namely the ocular motor nerve is the highest one below the ocular motor nerve comes in the trochlearis nerve whereas the abducent nerve which has the longest subdural or epidural cause it leaves already from the brainstem pretty early it has about one and a half centimetre subdural epidural cause on the cleville segment going below the tentorium going right there that is into intimate contact with the carotid artery it's lying deeper more profound or closer to the wall of the sphenoidalis than the ocular motor nerve or the trochlearis nerve than of course the oftalmic nerve the first branch of the trigeminal nerve that's running up there so it's embedded in the cavernous sinus the cavernous sinus you will see it again in the macroscopic image here is the optical nerve here is the kerotic artery cut down here is the ocular motor nerve and here that's the trochlearis nerve that's in the forceps and below the forceps is the oftalmic nerve and here runs then very deep close to the artery than the abducent nerve all that stuff here are remnants from the cavernous sinus that is embedding the paraclyval or paracellarly running nerves and structures these cavernous sinuses left and right may be interconnected in more than two-thirds of the cases by the intercavernous sinus that's running on the cellar floor and connecting left and right in the profound profondity of the slaturgica and they're also connected by some venous plexuses that are running over the ligamentum cellar so we have intimate correlations between left and right so shifts may occur especially when we have it on the floor of the cellar which you're going to open with your drill in the frontal section it looks like that here you can see again left and right cellar, left and right sorry cavernous sinus interconnected here on the floor of the cellar below the pituitary by an intercavernous sinus so in fact again we see next to the artery, next to the caustic artery runs the abducent nerve very deep whereas the ocular motor nerve, the trochlearvis nerve and the ophthalmic nerve running a little bit more superficially closer to the border of the dura so when we open now that planum of the cellar here we have the planum of the cellar again the optocarotic recess laterally, medially we have the transceiver when we open that then we get the exposure then on the cellar on the pituitary gland and we see then from after the opening above the wall we see here then the superior upper fusial artery that gives off the branches that run down to the pituitary stalk here another image from a cadaver specimen that was not injected here in that case it was injected here in the cranial part pituitary we see cranially then the chiasma the optical olfactory nerve the chiasma and here we look up in more detail of termic artery branching off from the internal carotic artery again the superior hyperfusial artery here above the optical nerve and the pituitary stalk that runs in together with the vessels to the pituitary gland so non-injected specimen again the chiasma the gyros rectus or the rectal gyrus in the upper nerve encircled by the olfactory nerve that is running below it so the immunencia the fenestration of the laminar terminalis so shows then the masa intermedia and we see here the A1 segment and the anterior communicating artery connecting left and right anterior cerebral artery to each other and we look now a little bit more to the side again the pituitary stalk A1 segment of the arteries left and right and the chiasma of the optical nerve and going down towards the floor of the third ventricle see then the typical arrangement again with the third nerve with the ocular modal nerve that passes through the P1 segment of the posterior cerebral artery and the superior cerebellar artery typically then turning to the right coming into connection to the internal carotic artery and heading forwards to it so in a more laterally closer we see it again ocular modal nerve between the P1 segment and the superior cerebellar artery so these are the more or less the lateral aspects of the retrocellar spaces and I hope that we are able to see that also in the cadaver specimens today in that exposition thank you very much