Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese

Introduction Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the “European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses”, aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language. Objective Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the “European Anatomical Terminology of the Internal Nose and Paranasal Sinuses” to Portuguese. Methods A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith. Results The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms “inferior turbinate”, “nasal septum”, “(bone/cartilaginous) part of the nasal septum”, “(middle/inferior) nasal meatus”, “frontal sinus drainage pathway”, “frontal recess” and “uncinate process” be standardized. Conclusion We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.


Introduction
Endoscopic surgery and sinonasal computed tomography stimulated rhinology in the early 1980s into the revival of research in the fields of anatomy and physiology of the nose and paranasal sinuses. 1 In 1994, the International Conference on Sinus Disease took place aiming to describe the newly identified structures in detail, since Anatomical Terminology had few descriptors of the sinonasal anatomy. 2,3 In 2014, the European Society of Rhinology published the ''European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses'' to unify the sinonasal anatomical terminology through the review of anatomical terms and analysis of the official ''Anatomical Terminology''. 1 They sought to respect the embryological development of structures, avoid terminology in Latin, remove eponyms, and simplify the anatomical terms. Lund et al. summarized in the English language all structures that could be found during a routine sinonasal endoscopic surgery. At that time, there were several publications on clinical anatomy and much discussion about the exact names and definitions for structures of surgical relevance. 2 It is clearly necessary to unify this terminology in all other languages and, that in the process of cross-cultural adaptation, the defined terms find correspondence in English. This publication in other languages would facilitate technical information, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal cavities.
The purpose of this study is the cross-cultural adaptation of the anatomical terms of the nose and paranasal cavities to the Portuguese language of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses and the proposition of a Sinonasal Anatomical Terminology in Portuguese.

Methods
This is a prospective study of cross-cultural adaptation, carried out in Brazil, from 2015 to 2016. Forty-four acknowledged rhinologists from all over Brazil were invited to participate (Fig. 1). We followed an adapted version of the method used by Rudmik and Smith. 4 The entire study process was carried out at distance with the aid of a platform, which allowed the unification and analysis of the results.

Inclusion criteria for the group of rhinologists
-Voluntary interest in participating in the study; -Otorhinolaryngologists with proven experience in sinonasal endoscopic surgery through publications on the subject and/or working in referral centers in rhinology.

Exclusion criteria for the group of rhinologists
-No interest in participating after the invitation; -No experience in sinonasal endoscopic surgery through publications on the subject and/or not working in referral centers in rhinology.

Phase 1. Term suggestion phase
The final list of the 126 terms of Supplement 24 (1) was divided into 8 blocks (Table 1) and each block was randomly assigned to a group of 4---5 authors. All authors received a copy of the original supplement by e-mail 1 and were invited to suggest three or more known terms in Portuguese for each English term of the block assigned to them. All authors were also encouraged to suggest more terms for other blocks. The most voted names will be submitted to a review process, so the three most relevant ones can be chosen.
The three most relevant names for each term will be put to a vote by all authors.
The final version of the text will be sent to the authors and, after approval, will be sent for publication.

Phase 2. Iterative assessment
The most often suggested terms were reviewed by the authors under the supervision of authors with experience in anatomy (G.J. and H.Z.L.). A final list was created with up to three most relevant terms for each term.

Phase 3. Final voting
An electronic survey was sent to each rhinologist through an online platform. The survey included multiple-choice options for each of the 126 terms, divided into the same eight previously defined blocks. All the rhinologists could choose only one term option in Portuguese for each term in English. The most voted term in Portuguese was chosen for each term in English. In cases of tie votes or when there was divergence of names for similar structures, these were discussed and decided by consensus.

Phase 4. Writing of this article
A summarized list of terms in Portuguese was created together with this article for final approval by the authors.

Results
All of the rhinologists accepted the invitation to participate. The final list of terms that were suggested and the voting frequency of the three terms voted on later are shown in Table 1. The proposed terms are underlined.

Discussion
This study proposes a unified sinonasal anatomical terminology through the process of cross-cultural adaptation of the anatomical terms defined for the English language related to the nose and the paranasal cavities. The presence of researchers with experience in anatomical terms (G.J. and H.Z.L.) was important for the project adequacy.
The history of controversy regarding sinonasal anatomical terminology has existed for many years and can be exemplified by the use of the term infundibulum and semilunar hiatus to designate several lateral wall structures to the point that the abandonment of this terminology has been suggested in the past. In this terminology, we propose the use of terms that help to differentiate the anatomical structures so that eponyms are not utilized. 5 We believe this favors the learning and the correct naming of the structures.
The vast majority of the results, as chosen by the rhinologists invited to participate in the study, were maintained. However, the results for some of the terms had to be better discussed to result in a uniform terminology for structures with similar names and a nomenclature adequacy with focus on surgical practice.
The nasal septum is a structure commonly divided into two parts, called bony and membranous parts. The uniformization of the term proposed by most authors for the membranous portion (of the nasal septum) was ''Membranous part of the nasal septum'', by 53 ''Nasal meatus'' was also chosen instead of the term ''meatus'', since there are other anatomical structures      It was suggested that the site should be added to the term ''accessory ostium'', 87.8% (36/41), since there are other accessory ostia in the body, and the term ''accessory ostium of maxillary sinus'' was suggested.
The term ''frontal sinus drainage pathway'' was also rediscussed consensually and we chose ''Via da drenagem do Seio frontal'' (26.8%; 11/41). Although it has been suggested that we use the term ''frontal recess'' (63.4%, 26/41) to designate this structure, the chosen term emphasizes that it is a different entity from the ''frontal recess'', the proposed term of which is ''Recesso frontal'' (97.6%; 40/41). Although controversial, the terms ''frontal recess'' and ''frontal sinus drainage pathway'' are generally distinct entities. The frontal recess is generally defined as the most anterosuperior part of the ethmoid, inferior to the sinus opening. 1 Its use as a synonym of ''frontal sinus drainage pathway'' is not appropriate, since the drainage pathway of the frontal sinus through the frontal recess is a complex one, altered by the configuration of the air cells within it and by the different connections of the uncinate process. 1 It commonly includes the frontal recess, but is not constituted exclusively by it. Usually, the frontal recess is posteriorly delimited by the anterior wall of the ethmoidal bulla (if that is fixed at the base of the skull), antero-inferiorly by the agger nasi, laterally by the lamina papyracea and inferiorly by the terminal recess of the ethmoidal infundibulum, if present. The term ''ducto nasofrontal'' (from the anatomical terminology, ''Ductus nasofrontalis'') was abandoned because the frontal sinus drainage pathway is not a true duct. The term ''maxillary crest'' (from the term ''Lacrimal buldge'' in English) was defined for this important structure as a point of reference for endoscopic dacryocystorhinostomy and is formed by the frontal process of the maxilla.

Final consideration
We propose an adapted version in Portuguese of the ''European Anatomical Terminology of the Internal Nose and Paranasal Sinuses'', that will help with the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.