Advances in surgical and uro-radiological techniques dictate a reappraisal and definition of renal arterial variations. This retrospective study aimed at establishing the incidence of additional renal arteries. Two subsets were analysed viz.: a) Clinical series--130 renal angiograms performed on renal transplant donors, 32 cadaver kidneys used in renal transplantation b) Cadaveric series--74 en-bloc morphologically normal kidney pairs. The sex and race distribution was: males 140, females 96; African 84, Indian 91, White 43 and "Coloured" 18, respectively. Incidence of first and second additional arteries were respectively, 23.2% (R: 18.6%; L: 27.6%) and 4.5% (R: 4.7%; L: 4.4%). Additional arteries occurred more frequently on the left (L: 32.0%; R: 23.3%). The incidence bilaterally was 10.2% (first additional arteries, only). The sex and race incidence (first and second additional) was: males, 28.0%, 5.1%; females, 16.4%, 3.8% and African 31.1%, 5.4%; Indian 13.5%, 4.5%; White 30.9%, 4.4% and "Coloured" 18.5%, 0%; respectively. Significant differences in the incidence of first additional arteries were noted between sex and race. The morphometry of additional renal arteries were lengths (cm) of first and second additional renal arteries: 4.5 and 3.8 (right), 4.9 and 3.7 (left); diameters: 0.4 and 0.3 (right), 0.3 and 0.3 (left). Detailed morphometry of sex and race were also recorded. No statistically significant differences were noted. Our results of the incidence of additional renal arteries of 27.7% compared favourably to that reported in the literature (weighted mean 28.1%). The study is unique in recording detailed morphometry of these vessels. Careful techniques in the identification of this anatomical variation is important since it impacts on renal transplantation surgery, vascular operations for renal artery stenosis, reno-vascular hypertension, Takayasu's disease, renal trauma and uro-radiological procedures.

No abstract

Two hundred and nineteen patients, with intracranial complications of sinusitis, are presented. Sinusitis is still a life-threatening condition and if neglected, or mismanaged, can lead to intracranial complications that result in a high mortality and morbidity.Twenty-two patients had meningitis, 127 subdural empyema, 38 brain abscess, 15 combined brain abscess and subdural empyema and 17 extradural empyema. The diagnosis of intracranial abscess and sinusitis was made with the aid of a CT scan, and that of meningitis on cerebrospinal fluid microscopy, chemistry and culture. The most frequent presenting signs were fever (68 per cent) and headache (54 per cent). The most common localizing neurological sign was hemiparesis (35.5 per cent). Orbital inflammation was present in 41.5 per cent of patients.Treatment entailed immediate, appropriate, intravenous antibiotic therapy and prompt surgery, performed within 12 hours of admission. In patients with meningitis, the surgery entailed surgery of the sinus disease only. In patients with subdural empyema, brain abscess and extradural empyema, evacuation of the primary source of infection by the radical frontoethmoidectomy approach, immediately after drainage of the intracranial collection of pus, was carried out.There were 35 deaths (16 per cent). The highest mortality rate was recorded in patients with meningitis (45 per cent) followed by brain abscess (19 per cent) and subdural empyema (11 per cent). Despite advances in medicine, i.e. antibiotics and CT scan for early and accurate diagnosis, the mortality from sinogenic intracranial complications has remained significant. This can only be eliminated through education. This paper emphasizes to younger generations of otolaryngologists and primary care physicians that sinusitis is a serious disease and there is no place for delay or complacency when managing such patients.

Standard recommended treatment for patients with intracranial complications from otitis media, has been radical mastoidectomy, whether cholesteatoma is present or not. This was established in the pre-antibiotic era to improve survival. Over a six-year period, from January 1985 to December 1990, 268 patients were admitted with intracranial and extracranial complications of otitis media. The prospective treatment consisted of antibiotics and surgery. Surgery entailed mastoidectomy and drainage of intracranial collections of pus in all patients.However, prospectively in these patients the ear pathology and not the complication dictated the type of mastoidectomy performed. Cortical mastoidectomy was performed in non-cholesteatomatous ears and radical mastoidectomy in cholesteatomatous ears.Recurrence of intracranial complications occurred in only four patients (two per cent), a temporal lobe cerebritis in the non-cholesteatomatous ear group, and, a temporal lobe abscess, posterior fossa abscess and subdural empyema in the cholesteatomatous ear group. The temporal lobe cerebritis settled on intravenous antibiotics whilst the temporal lobe abscess, posterior fossa abscess and subdural empyema required redrainage. In none of these was the ear surgery revised.There were 15 deaths (eight per cent), all occurring in patients with intracranial complications, 12 associated with brain abscess, two with subdural empyema and one with meningitis. Eight were from the non-cholesteatomatous group and seven from the cholesteatomatous group. The mortality was directly related to the patients consciousness level on admission and not to the type of ear pathology.It can therefore be concluded that radical mastoidectomy is unwarranted in the non-cholesteatomatous ear, even with an otogenic intracranial complication.

A study was undertaken in 43 patients to determine the role of surgery in tuberculous mastoiditis. Cortical mastoidectomy was performed on five patients (Group I). Incision and drainage of a post-auricular abscess, removal of sequestrum and meatoplasty in eight (Group II). Thirty patients had no ear surgery (Group III). Of the 17 patients with facial palsy, three were in Group I, two in Group II, 12 in Group III. The patients in all three groups were treated with anti-tuberculous drugs for a period of no less than six months. The average time taken for the otorrhoea to subside and granulation tissue to resolve completely was two months in all three groups. The facial nerve recovery in the non-operated ears (Group III) was 92 per cent and in the operated ears (Group I and II) 80 per cent. The conclusion is that chemotherapy is the management of choice in tuberculous mastoiditis. The only role of surgery is incision and drainage of a post-auricular abscess and removal of sequestrum if present.

The highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2-30%; retro-aortic vein 0.8-7.1%; additional renal vein 0.8-6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.

No abstract

Lesions of the cervicothoracic ganglion (CTG) result in interruption of sympathetic fibers to the head, neck, upper limb, and thoracic viscera. The accurate understanding of the anatomy of the CTG is relevant to sympathectomy procedures that may be prescribed in cases where conventional intervention has failed. This study documents the incidence and distribution of the CTG to avoid potential complications such as Horner's syndrome and cardiac arrhythmias. This study utilized 48 cadavers, in which a total of 89 sympathetic chains were dissected. The inferior cervical ganglion (ICG) and the first thoracic ganglion was fused in 75 cases (84.3%) to form the CTG. It was present bilaterally in 48 of these specimens (65.3%). Three different shapes of CTG were differentiated, viz. spindle, dumbbell, and an inverted "L" shape. The dumbbell and inverted "L" shapes demonstrated a definite "waist" (i.e., a macroscopically visible union of the ICG and T1 components of the CTG). Rami from the CTG was distributed to the brachial plexus, the subclavian and vertebral arteries, the brachiocephalic trunk, and the cardiac plexus. This study demonstrates a high incidence of a double cardiac sympathetic nerve arising from CTG. It is therefore imperative that in the technique of sympathectomy, for intractable anginal pain, the surgeon excises both these rami but does not destroy the ganglion itself. The ever-improving technology in endoscopic surgery has made investigations into the nuances of the anatomy of the sympathetic chain essential.