Orbit The International Journal on Orbital Disorders, Oculoplastic and Lacrimal Surgery

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Two Types of the Sinus of Maier: An Anatomic Study Hirohiko Kakizaki, Yasuhiro Takahashi, Hyera Kang, Takashi Nakano, Ken Asamoto & Hiroshi Ikeda To cite this article: Hirohiko Kakizaki, Yasuhiro Takahashi, Hyera Kang, Takashi Nakano, Ken Asamoto & Hiroshi Ikeda (2015) Two Types of the Sinus of Maier: An Anatomic Study, Orbit, 34:5, 253-256 To link to this article: http://dx.doi.org/10.3109/01676830.2015.1056309

Published online: 17 Jul 2015.

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Orbit, 2015; 34(5): 253–256 ! Taylor & Francis ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2015.1056309

ORIGINAL ARTICLE

Two Types of the Sinus of Maier: An Anatomic Study Hirohiko Kakizaki1, Yasuhiro Takahashi1, Hyera Kang1,2, Takashi Nakano3, Ken Asamoto3, and Hiroshi Ikeda4 Department of Ophthalmology, Aichi Medical University, Nagakute, Japan, 2Department of Ophthalmology, University of Seonam College of Medicine, Presbyterian Medical Center, Jeonju, Korea, 3Department of Anatomy, Aichi Medical University, Nagakute, Japan, and 4Department of Pathology, Aichi Medical University, Nagakute, Japan

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ABSTRACT Purpose: To show the morphological characteristics of two different types of the sinus of Maier, one with a lacrimal sac diverticulum supplied by separate canalicular openings, and the other with a terminal dilatation of the common lacrimal canaliculus. Methods: Twelve coronal specimens (6 right and 6 left) from 6 Japanese cadavers (age range, 70–90 years at death) and 15 axial specimens of 11 Japanese cadavers (8 right, 7 left; age range, 45–89 years at death), fixed in 10% buffered formalin, were used. All specimens were stained with Masson’s trichrome. Results: The sinus of Maier, with a lacrimal sac diverticulum supplied by separate canalicular openings, was shown in one coronally sectioned group, with a diameter of 1.29 mm. The mucosa between both openings (0.282 mm length) comprised stratified squamous epithelia, which was characteristic of the lacrimal canaliculi. The diverticular mucosa was lined by a stratified columnar epithelium, which corresponded to the lacrimal sac. The sinus of Maier, with a terminal dilatation of the common lacrimal canaliculus and with a diameter of 0.51 mm, was demonstrated in one axially sectioned group. Conclusions: The morphological characteristics of two types of the sinus of Maier were described in this study. One type was the lacrimal sac diverticulum supplied by separate canalicular openings, and the other was the terminal dilatation of the common lacrimal canaliculus. Keywords: Common lacrimal canaliculus, lacrimal sac diverticulum, morphological, Sinus of Maier, terminal dilatation

INTRODUCTION

however, its anatomy has thus far not been described in detail. Type 2, a terminal dilatation of the common lacrimal canaliculus, is also poorly described and understood. We therefore examined the morphological characteristics of the types 2 and 3 sinus of Maier. This study did not include type 1 sinus of Maier, because this type is a simple common lacrimal canaliculus and we had previously described its detailed morphological characteristics.10,11

The sinus of Maier is a small dilatation occasionally presenting at the opening of the common internal ostium.1,2 However, the use of this term is confusing. The ‘‘sinus of Maier’’ has been used to describe three different structural types:3 (1) the common lacrimal canaliculus itself;4,5 (2) a terminal dilatation of the common lacrimal canaliculus; and, (3) a lacrimal sac diverticulum into which the upper and lower canaliculi open separately.3,6 Some studies showed type 1 as the most common anatomy of the sinus of Maier.7–9 On the contrary, others claimed that type 3 is the most common;3,6

METHODS Coronal sections of 12 specimens (6 right and 6 left) fixed in 10% buffered formalin, were harvested from

Received 10 September 2014; Revised 16 April 2015; Accepted 12 May 2015; Published online 15 July 2015 Correspondence: Hirohiko Kakizaki, Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi 480-1195, Japan. Tel: +81-56162-3311 (ext. 22181). Fax: +81-561-63-7255. E-mail: [email protected]

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254 H. Kakizaki et al. 6 Japanese cadavers (age range, 70–90 years at death) for the possibility of including both upper and lower canaliculi in the same slice. Fifteen postmortem specimens of 11 Japanese individuals (8 right, 7 left; age range, 45–89 years at death) fixed in 10% buffered formalin, were axially sliced at 1-mm intervals parallel to the lower eyelid margin to include a longer canalicular portion. None of the cadavers had any history or clinical evidence of a previous eyelid, lacrimal, or orbital trauma, surgery, tumor, or any other periocular pathology. The cadavers were used after having obtained appropriate consent and approval before death. All cadavers were registered with the cadaveric service of Aichi Medical University. All methods for securing human tissue were humane and adhered to the tenets of the Declaration of Helsinki. We removed specimens of the medial eyelids and orbits. After performing a full-thickness circumferential incision to the periosteum around the orbit, the periosteum was detached close to the orbital apex. Nerves, blood vessels, and the nasolacrimal duct extending out of the orbital wall were cut. The lateral orbital wall was then removed to about 3 cm from the orbital rim, and the retrobulbar content was incised with a sharp scalpel, in the coronal plane. The removed orbital content was incised perpendicular to the upper and lower eyelid margins around their center, and the medial half was used for analysis. All sliced specimens were dehydrated and embedded in paraffin, cut into 7-mm-thick sections, and stained with Masson’s trichrome. Micrographs were taken with a digital camera system attached to a microscope (Moticam 2000; Shimadzu, Tokyo, Japan) and merged with Adobe Photoshop CS5 Extended (Adobe Systems Inc., San Jose, CA, USA). The diameters of the sinuses were measured on the merged figures. A micro-millimeter ruler was photographed on the same magnifying power with each photographed

tissue specimen. They were merged together on the same plane, with the same contraction scale. Then, using the measurement tool of the same software, a certain length of the micro-millimeter ruler was adjusted to the corresponding pixel length, and each diameter of the sinuses was determined. Some of the upper and lower canaliculi reached the lacrimal sac separately without forming a common canaliculus.3,8,12 However, for convenience, we termed the canaliculus just before entering the sac the ‘‘common lacrimal canaliculus.’’

RESULTS One coronal specimen demonstrated the type 3 sinus of Maier with a lacrimal sac diverticulum into which the upper and lower canaliculi opened separately (Figure 1A). The specimen was from the right orbit of a female cadaver who died at 79 years of age. The diameter of the diverticulum emptying into the sac was 1.29 mm (Figure 1A, yellow dimension bar). Although independent openings were found in the diverticulum, the mucosa between both openings (0.282 mm length) comprised a stratified squamous epithelium, which was characteristic of the lacrimal canaliculus (Figure 1B). The diverticular mucosa was lined by a stratified columnar epithelium, which corresponded to the lacrimal sac (Figure 1B). The type 2 sinus of Maier with a terminal dilatation of the common lacrimal canaliculus, lined by a stratified squamous epithelium, was demonstrated in one axial specimen (Figure 2). The specimen was from the right orbit of a female cadaver who died at 89 years of age. The diameter of this sinus at its point of emptying into the sac was 0.51 mm. In both specimens, the contralateral sides did not demonstrate the sinus of Maier.

FIGURE 1. (A) Overview of the type 3 sinus of Maier stained with Masson’s trichrome. Yellow dimension bar, measured length of the diverticulum. (B) Magnified square area from (A). Yellow asterisk, the area between the upper and lower canaliculi. Orbit

Two Types of the Sinus of Maier 255

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DISCUSSION This study described the morphological characteristics of the type 3 sinus of Maier with a lacrimal sac diverticulum supplied by separate canalicular openings, and that of the type 2 sinus of Maier with a terminal dilatation of the common lacrimal canaliculus. The anatomical origin of the sinus of Maier, namely whether it is derived from a sac or a canaliculus, is controversial. Whitnall2 referred to this sinus as part of the lacrimal sac. However, Schaeffer12 stated that it was likely derived from a wide common duct of the lacrimal ducts. The present study disclosed both types of sinuses, depending on the type of epithelium. The sinus lined by a stratified columnar epithelium was considered to be derived from the lacrimal sac. The other sinus lined by a stratified squamous epithelium was considered to have a canalicular origin. The type 3 sinus of Maier had an epithelium between both openings which was a stratified squamous epithelium, typical for the canalicular epithelium. As the distance was very short (0.282 mm), and these openings continued to the sinus, this type of canalicular opening may be considered to be a common opening. If an interpositioning epithelium comprised a stratified columnar epithelium, which is typical for the lacrimal sac epithelium, the openings would be identified as completely separate connections. Although the diameter at the point of emptying into the lacrimal sac in the type 2 sinus of Maier was 0.51 mm, this value, as well as the value of the type 3 sinus of Maier (1.29 mm), was much larger than that of a simple common canaliculus (0.24–0.4 mm).10 As the common canaliculus is not encircled by the Horner muscle, this area likely shows less contractility than the other parts of the canaliculus. If the

contractility of the common canaliculi were large, the lacrimal fluid might stagnate, causing stenosis. However, with less contractility, stenosis would not occur so easily, irrespective of lacrimal fluid stagnation. Although common canalicular stenosis was often seen in patients with epiphora5 or failed dacryocystorhinostomy,13 a larger diameter with less contractility of the sinus of Maier provided countermeasures to the occurrences of common canalicular stenosis. The two specimens in the present study showed that the sinus of Maier was not present on the contralateral side. This may suggest that the sinus of Maier was formed by chance in the samples from the cadavers. Our previous study14 showed, under nasal endoscopy, that the internal canalicular orifices were pulled temporally and expanded during eye closing. This expanded status is the sinus of Maier. The differences between type 2 and type 3 sinus of Maier may be because of the lacrimal sac or the canaliculus being pulled to be expanded. In general, muscle tone was lost soon after death, but postmortem rigidity occurred later.12 Although tissues are again relaxed after the rigidity,15some tissues might continue to have the same shape at postmortem rigidity. This may be one reason that the present cadaver study illustrated the sinus of Maier only with a small percentage of the specimens, in contrast to the previous study14 reporting that all the patients demonstrated the sinus of Maier in eye closing. The diameters of the sinuses were measured using the measurement tool of Adobe Photoshop CS5 Extended in this study. However, the diameters can be measured using ImageJ software in the same manner.16 This study was limited by several factors. Examination of only aged Japanese cadavers was a drawback. The results of the present study may not be applicable to younger individuals and other ethnic groups or races. The small sample size was another limitation of this study. With a larger number of samples, this study may provide more informative data. In conclusion, the present study demonstrated the morphological characteristics of the type 3 sinus of Maier with a lacrimal sac diverticulum supplied by separate canalicular openings, and that of the type 2 sinus of Maier, with a terminal dilatation of the common lacrimal canaliculus. We suggest that these findings may contribute to a more complete definition of a particular structures of the sinus of Maier.

DECLARATION OF INTEREST

FIGURE 2. Overview of the type 2 sinus of Maier stained with Masson’s trichrome. !

2015 Taylor & Francis

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

256 H. Kakizaki et al. This study was supported by the Ministry of Education, Culture, Sports, Science, and Technology in Japan.

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8. Zoumalan CI, Joseph JM, Lelli Jr GJ, et al. Evaluation of the canalicular entrance into the lacrimal sac: an anatomical study. Ophthal Plast Reconstr Surg 2011;27: 298–303. 9. Orhan M, Govsa F, Saylam C. Anatomical detailes used in the surgical reconstruction of the lacrimal canaliculus: cadaveric study. Surg Radiol Anat 2009;31:745–753. 10. Kakizaki H, Asamoto K, Nakano T, et al. Lacrimal canaliculus. Ophthalmology 2010;117:644. 11. Kakizaki H, Takahashi Y, Miyazaki H, et al. Intrasac portion of the lacrimal canaliculus. Orbit 2013;32: 294–297. 12. Schaeffer JP. Variations in the anatomy of the nasolachrymal passages. Ann Surg 1911;54:148–152. 13. McLachlan DL, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of the reoperations. Ophthalmic Surg 1980;11:427–430. 14. Kakizaki H, Takahashi Y, Miyazaki H, Nakamura Y. Movement of internal canalicular orifice in association with blinking: direct observation after dacryocystorhinostomy. Am J Ophthalmol 2013;156: 1051–1055. 15. Saukko P, Knight B. The pathophysiology of death. In: Saukko P, Knight B, eds. Knight’s Forensic Pathology, 3rd edition. Boca Raton, FL: CRC Press, 2004:60. 16. Rasband WS, ImageJ, U.S. National Institutes of Health. Available at: http://imagej.nih.gov/ij/. [last accessed 6 Apr 2015].

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Two Types of the Sinus of Maier: An Anatomic Study.

To show the morphological characteristics of two different types of the sinus of Maier, one with a lacrimal sac diverticulum supplied by separate cana...
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