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Felippu AWD, Morsch TP, Felippu AWD, Cascio F, Oliveira CRGCMD, Felippu A, Voegels RL. Endoscopic Study of Ethmoidal Canals in Cadavers, Including a Histological Analysis of Their Contents. Int Arch Otorhinolaryngol 2024; 28:e70-e75. [PMID: 38322450 PMCID: PMC10843925 DOI: 10.1055/s-0043-1767805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/29/2022] [Indexed: 02/08/2024] Open
Abstract
Introduction The advent of the endoscope has enabled the use of the endonasal approach for a variety of diseases. Studying the ethmoidal canals is important for surgeries of the paranasal sinuses and the anterior base of the skull. Objective To investigate the ethmoidal canals and evaluate their structure, the presence of vessels and nerves, their location, and to perform an anatomopathological study of their contents. Methods We evaluated 20 cadavers (20 left and 20 right nasal cavities) through endoscopic dissection of the anterior base of the skull and exposure of the medial periorbita and dura mater; then, the ethmoidal canals were located and measured in relation to the anterior wall of the sphenoid sinus and between the ethmoidal canals, followed by removal of their content for histological analysis. Results Vessels were present in 75% of the left anterior ethmoidal canals, 70% of the left posterior ethmoidal canals, 75% of the left middle ethmoidal canals, 85% of the right anterior ethmoid canals, and 64.5% of the right posterior ethmoid canals; 50% of the right middle ethmoidal canals contained one vessel. Conclusion The ethmoidal canal does not necessarily contain an ethmoidal artery. Studies with a larger sample should be performed to quantify the correct proportion of arteries and ethmoidal canals.
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Affiliation(s)
- Alexandre Wady Debes Felippu
- Department of Otorhinolaryngology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | | | - Filippo Cascio
- Department of Otorhinolaryngology, Azienda Ospedaliera Papardo, Messina, Italy
| | | | | | - Richard Louis Voegels
- Department of Otorhinolaryngology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Kilinc MC, Basak H, Çoruh AG, Mutlu M, Guler TM, Beton S, Comert A, Kahilogullari G. Endoscopic Anatomy and a Safe Surgical Corridor to the Anterior Skull Base. World Neurosurg 2020; 145:e83-e89. [PMID: 32980565 DOI: 10.1016/j.wneu.2020.09.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/19/2020] [Accepted: 09/20/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We describe the possibility to create precise preoperative planning for endonasal endoscopic approaches to the anterior skull base by overlapping endoscopic and radiologic anatomy. The important anatomic structures were marked. Morphometric measurements between these anatomic landmarks were performed endoscopically and compared with radiologic measurements of the same areas to ensure result compatibility. METHODS Seven cadaver heads injected intravascularly with colored silicone were used for this study. Thin-section brain and paranasal sinus computed tomography scans were obtained on all cadavers. Using 0-degree rigid endoscopes and endonasal endoscopic surgical instruments, the anterior skull base was examined binostrally in all cadavers. Bilateral middle turbinates were identified and preserved. Next, an inferior uncinectomy and middle meatal antrostomy were performed. After performing a frontal antrostomy, bilateral anterior and posterior ethmoidal cells were opened and the skull base was identified and followed to the posterior wall of the frontal sinus. A transnasal transethmoidal sphenoidotomy was done with full exposure to the entire anterior skull base. RESULTS The anatomic landmarks for endonasal endoscopic skull base approaches were distinguished and measurements were made. The anterior skull base was divided into 3 compartments: anterior (area between the posterior inferior border of the frontal sinus and the course of anterior ethmoidal artery), middle (area between the course of the anterior ethmoidal artery and that of the posterior ethmoidal artery [PEA]), and posterior (area between the course of the PEA and the attachment point of the anterior border of the sphenoid sinus to the skull base) compartments. The distances between important anatomic markers and endoscopic depth measurements of this area were measured. CONCLUSION During endonasal endoscopic anterior skull base surgery, the area between the anterior border of the sphenoid sinus and PEA artery was safe as the first dissection zone. Preoperative radiologic width and depth measurements facilitate orientation to the endoscopic anatomy during surgery and help predict the endonasal surgical corridor anatomy preoperatively.
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Affiliation(s)
- Mustafa Cemil Kilinc
- Department of Neurosurgery, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Hazan Basak
- Department of Otolaryngology, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Ayşegul Gürsoy Çoruh
- Department of Radiology, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Merve Mutlu
- Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Tugba Morali Guler
- Karabuk University, School of Medicine, Department of Neurosurgery, Karabuk, Turkey
| | - Suha Beton
- Department of Otolaryngology, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Ayhan Comert
- Department of Anatomy, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey
| | - Gokmen Kahilogullari
- Department of Neurosurgery, Ankara University, School of Medicine, Sihhiye, Ankara, Turkey.
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Endoscopic Transcaruncular Medial Orbitotomy as an Alternative Approach to Anterior Ethmoidal Artery Coagulation. J Craniofac Surg 2019; 30:911-913. [PMID: 30845092 DOI: 10.1097/scs.0000000000005207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The authors present a series of 5 patients with anterior epistaxis in which a transcaruncular endoscopic approach was used for the anterior ethmoidal artery coagulation (AEA). METHODS Six AEA coagulations (5 unilateral, 1 bilateral) using the transcaruncular endoscopic approach were performed in 5 patients with anterior epistaxis resistant to conservative measures. An incision was made between the plica semilunaris of conjunctiva and the lacrimal caruncle. Using a rigid endoscope, tissues were dissected lateral to the lacrimal sac, to the posterior lacrimal crest. The periorbit was incised and pulled aside. Hereafter, the technique was the same as that involving a frontoethmoidal incision. After bipolar coagulation of the AEA, the conjunctiva was sutured. RESULTS Bleeding was resolved in all patients. One patient experienced early postoperative temporary diplopia. CONCLUSIONS The transcaruncular endoscopic approach is a promising technique with no outer scarring. It is convenient in patients with difficult orientation in the nasal cavity, relatively safe, and faster than the transnasal endoscopic approach.
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Surgical and interventional radiological management of adult epistaxis: systematic review. The Journal of Laryngology & Otology 2018; 131:1108-1130. [PMID: 29280696 DOI: 10.1017/s0022215117002079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery. METHOD A systematic review of the literature was performed using a standardised published methodology and custom database search strategy. RESULTS Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73-100 per cent and 75-92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1-1.5 per cent). No articles directly compared the two techniques. CONCLUSION Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.
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Ferrari M, Pianta L, Borghesi A, Schreiber A, Ravanelli M, Mattavelli D, Rampinelli V, Belotti F, Rodella LF, Maroldi R, Nicolai P. The ethmoidal arteries: a cadaveric study based on cone beam computed tomography and endoscopic dissection. Surg Radiol Anat 2017; 39:991-998. [PMID: 28299444 DOI: 10.1007/s00276-017-1839-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/27/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the anatomical variability of the ethmoidal arteries (EAs). To evaluate the reliability of cone beam computed tomography (CBCT) in preoperative assessment of EAs. METHODS Fourteen cadaver heads underwent CBCT and endoscopic dissection. The following anatomical features were evaluated for anterior (AEA), middle (MEA), and posterior (PEA) EAs: presence, cranio-caudal position, antero-posterior position, and dehiscence of the bony canal. Accuracy of radiological assessment was calculated. RESULTS AEA, MEA, and PEA were identified in 100, 28.6, and 100% of sides. They were caudal to the skull base in 60.7, 25, and 17.9%, respectively. CBCT showed a high accuracy in identifying these features. The antero-posterior position of EAs, which was highly variable, was correctly assessed by CBCT. A dehiscent bony canal of AEA, MEA, and PEA was found in 46.4, 12.5, and 28.6% of sides, respectively. Accuracy of CBCT in picking up this feature was poor but negative predictive value was high. CONCLUSIONS CBCT was adequate in identifying and localizing EAs. In addition, it can be used to exclude the presence of MEA and dehiscence of ethmoidal canals, whereas the accuracy in detecting these anatomic variants was low.
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Affiliation(s)
- Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy.
| | - Luca Pianta
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Andrea Borghesi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
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Bortoli VT, Martins RF, Negri KC. Study of Anthropometric Measurements of the Anterior Ethmoidal Artery using Three-dimensional Scanning on 300 Patients. Int Arch Otorhinolaryngol 2017; 21:115-121. [PMID: 28382116 PMCID: PMC5375950 DOI: 10.1055/s-0037-1598598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/03/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction The anterior ethmoidal artery (AEA) is one of the main arteries that supply both the nasal mucosa and the ethmoid sinuses. The AEA shows variability regarding its distance from adjacent structures. Several studies have developed techniques to identify the AEA. Objective This study aimed to compare the measurements from the AEA to the ethmoid bulla and to the frontal beak by using computed tomography of the face, while identifying their intraindividual and interindividual variations. Methods We analyzed 300 CT scans of the face performed at the CT scan Center at Hospital. The average age of subjects was 36 ± 15.1 years (range 4–84). Results We found that the average distance from the AEA to the ethmoid bulla was 17.2 ± 1.8 mm and the distance from the AEA to the frontal beak was 15.1 ± 2.2 mm. Regarding the average distance from the AEA to the frontal beak (AEA-frontal beak), there was a difference between the right and left sides, with the former being 0.4 mm higher on average than the latter. Among the age groups, there was a significant difference of distances between the AEA and the ethmoid bulla (AEA-ethmoid bulla), which were shorter in the ≤ 12 years group. There was a positive and significant correlation between both measurements analyzed, with low values (high) of AEA-ethmoid bulla distance corresponding to low values (high) of AEA-frontal beak distance. Conclusion The measurements obtained adds anatomical knowledge that can serve as a parameter in frontal and ethmoid sinus surgery.
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Affiliation(s)
- Vinicius Tomadon Bortoli
- IPO - Hospital Paranaense de Otorrinolaringologia LTDA - Núcleo de Ensino e Pesquisa, Curitiba, Paraná, Brazil
| | - Rafael Ferri Martins
- IPO - Hospital Paranaense de Otorrinolaringologia LTDA - Núcleo de Ensino e Pesquisa, Curitiba, Paraná, Brazil
| | - Krystal Calmeto Negri
- IPO - Hospital Paranaense de Otorrinolaringologia LTDA - Núcleo de Ensino e Pesquisa, Curitiba, Paraná, Brazil
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Cornelis MMK, Lubbe DE. Pre-caruncular approach to the medial orbit and landmarks for anterior ethmoidal artery ligation: a cadaveric study. Clin Otolaryngol 2016; 41:777-781. [PMID: 26987555 DOI: 10.1111/coa.12648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In epistaxis and skull base surgery, the anterior ethmoidal artery sometimes needs to be ligated. We describe a novel, quick and scar-free surgical technique to ligate this artery with salient landmarks allowing rapid identification. PATIENTS AND METHODS Twenty medial orbital walls from 10 randomly selected fresh-frozen, non-formalinised cadaver heads were examined. Dissection was performed by a pre-caruncular external approach to expose the AEA in all cases. RESULTS The Horner's muscle and nasion, two salient landmarks, have been identified for use during the pre-caruncular approach. DISCUSSION/CONCLUSION The pre-caruncular approach is a novel combined open and endoscopic surgical approach to the anterior ethmoidal artery. It is a simple, quick and scar-free technique. The identification of the artery is easy when using the two anatomic landmarks we describe in our study, that is Horner's muscle and the nasion.
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Affiliation(s)
- M M K Cornelis
- Department of Otorhinolaryngology, Head and Neck surgery, University of Cape Town, Cape Town, South Africa
| | - D E Lubbe
- Department of Otorhinolaryngology, Head and Neck surgery, University of Cape Town, Cape Town, South Africa
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Seidel DU, Remmert S, Brassel F, Schlunz-Hendann M, Meila D. Superselective microcoil embolization in severe intractable epistaxis: an analysis of 12 consecutive cases from an otorhinolaryngologic and an interventional neuroradiologic point of view. Eur Arch Otorhinolaryngol 2014; 272:3317-26. [PMID: 25502741 DOI: 10.1007/s00405-014-3427-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
Abstract
From 2006 to 2013, 12 patients with severe epistaxis refractory to prior conservative and surgical therapy were treated by superselective embolization of nasal arteries. Supersoft platinum microcoils with smallest diameters were used as the sole embolic agent in all cases. Coils were applied far distally in a stretched position for obtaining ideal target vessel superselectivity. The objective of this study is to evaluate efficacy and complications of superselective coil embolization for treatment of severe intractable epistaxis and to discuss results from an otorhinolaryngologic and an interventional neuroradiologic point of view. Retrospectively, all epistaxis inpatients between 2006 and 2013 were identified and subdivided by form of treatment: conservative, surgical and interventional therapy. Medical records of interventionally treated patients were reviewed for demographics, medical history, risk factors, clinical data, complications and short-term success, and patients were followed up for long-term success. Mean follow-up was 37 months. In 12 patients, 14 embolizations were carried out, with short-term success in 9 patients (75%), while early post-interventional rebleeding occurred in 3 patients (25%). Of 9 patients with short-term success, 1 died during stay, 1 was lost to follow-up and 1 had minor re-bleeding after 30 months. Six patients had short-term and long-term success. Before the first embolization, 3 ± 1 conservative and/or surgical procedures had been undertaken. Length of stay was 12.8 ± 3.6 days. 8 patients (67%) received red cell concentrates. Most frequent complications were mucosal damage and nasal pain, but these were related to repeated packing and surgery. Typical embolic complications as neurological or visual impairment or soft tissue necrosis were not observed in any patient. From the otorhinolaryngologic point of view, surgery is the treatment of choice in severe refractory epistaxis, but in case of repeated failure, superselective microcoil embolization is a valuable addition to the therapeutic spectrum. From the interventional neuroradiologic point of view, superselective microcoil embolization is an effective, well tolerable and safe procedure and complications may be reduced in comparison to microparticle embolization. Modern supersoft microcoils with smallest diameters enable ideal superselectivity of the target vessels.
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Affiliation(s)
- D U Seidel
- Department of Otorhinolaryngology and Head and Neck Surgery, Malteser Hospital St. Anna, Albertus-Magnus-Straße 33, 47259, Duisburg, Germany.
| | - S Remmert
- Department of Otorhinolaryngology and Head and Neck Surgery, Malteser Hospital St. Anna, Albertus-Magnus-Straße 33, 47259, Duisburg, Germany
| | - F Brassel
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Zu den Rehwiesen 9, D-47055, Duisburg, Germany
| | - M Schlunz-Hendann
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Zu den Rehwiesen 9, D-47055, Duisburg, Germany
| | - D Meila
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Zu den Rehwiesen 9, D-47055, Duisburg, Germany. .,Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Carl-Neuberg-Str.1, 30625, Hannover, Germany.
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Manjila S, Cox EM, Smith GA, Corriveau M, Chhabra N, Johnson F, Geertman RT. Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques. Neurosurg Focus 2013; 35:E13. [DOI: 10.3171/2013.10.focus13327] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
There are several surgical techniques for reducing blood loss—open surgical and endoscopic—prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors.
Methods
The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio.
Results
The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques.
Conclusions
Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.
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Affiliation(s)
| | | | | | | | - Nipun Chhabra
- 3Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Freedom Johnson
- 2Otolaryngology-Head & Neck Surgery, MetroHealth Hospital, Case Western Reserve University, Cleveland, Ohio; and
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