Anatomy of Nasal Cavity & Paranasal Sinuses

Nasal Cavity:

The nares lead into the vestibule, the skin-lined part of the nasal cavity that contains the vibrissae (nasal hairs), the hair follicles, and the sebaceous glands.

The vestibule is limited above and behind by a curved ridge, the limen nasi. The union of the skin-lined nasal vestibule with the mucosa-lined chamber of the nasal cavity has the shape of a triangular aperture.

The nasal valve constitutes the narrowest area of the normal nasal airway. Its superior and lateral limits are formed by the upper lateral cartilage; its medial wall is the nasal septum.

The mucosa of the nasal cavity has a pseudostratified ciliated columnar epithelium .

It communicates with the adjoining paranasal sinus and with the nasopharynx via the posterior choana.

ROOF (Olfactory Cleft):

Sloping anterior portion is formed by nasal bones and nasal spine of frontal bone.

Central segment (olfactory area) is formed by cribriform plate of the ethmoid bone.

Descending posterior part is formed by face of the sphenoid sinus.

FLOOR:

Formed by the premaxilla, the maxilla (palatine plate), and the horizontal plate of the palatine bone in the posterior portion.

Bony floor is about 4.5 cm long and continues posteriorly into the soft palate.

MEDIAL WALL (Nasal Septum):

Cartilaginous segment: (Quadrilateral cartilage). Superiorly, is connected to the the inter-nasal suture and to the upper lateral cartilages.

Inferiorly, it rests on the maxillary crest, its anterior extension the anterior nasal spine, and vomer.

Cranially, is related to the perpendicular plate of ethmoid bone. Caudally, cartilage is related to the medial crura of the lower lateral cartilages.

Bony segment: Perpendicular plate of ethmoid bone: Continuous superiorly with the cribriform plate. Continuous postero-inferiorly with vomer. The long anterior border of the vomer articulates Vomer: Continuous antero-superiorly with the perpendicular plate, and septal cartilage. Continuous inferiorly with bony floor.

LATERAL NASAL WALL:

Bones forming the lateral wall:

Superior Turbinate:

Belongs to the ethmoid bone. Measures 1.5 cm in length. Attached laterally to the lamina papyracea of the ethmoid bone. It is usually pneumatized, forming part of the posterior ethmoidal cells. Supreme turbinate sometimes visible above the superior turbinate.

Superior meatus:

Lies between the middle and superior turbinates and contains the ostia of the posterior ethmoidal cells.

Immediately behind the superior meatus is situated the sphenopalatine foramen.

Middle turbinate:

a portion of the ethmoid bone. 4 cm in length. Attachments: Anterior end inserts into the ascending process of the maxilla. Superior attachment (in the para-sagittal plane) to the lateral edge of cribriform plate of ethmoid.

Lateral attachment:
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Anteriorly: (in the coronal plane) into the lamina papyracea of the ethmoid bone through the vertical part of basal (ground ) lamella.

Posteriorly: (in the horizontal = axial plane) into perpendicular plate of the palatine bone through the horizontal part of basal lamella.

Pneumatization of the middle turbinate (concha bullosa) is present in one-third of the population.

Middle meatus:

Ostiomeatal complex describe a group of anatomical structures belonging to the nasal lateral wall that are contributing to the final common drainage pathways of the anterior ethmoid, maxillary, and frontal sinuses. It includes the middle meatus, the uncinate process, the hiatus semilunaris, the ethmoid infundibulum, the ethmoid bulla, the maxillary sinus ostia, and the frontal recess.

Uncinate Process:

Thin, sagittally oriented lamella, latin uncinatus, meaninghooked.

Attachment antero-superiorly: (variable)

1. May attach to the roof of the ethmoid bone. 2. May turn medially and fuse with the middle turbinate. Frontal recess and, consequently, the frontal sinus open directly into ethmoid infundibulum (Fronto-nasal communication Type II). 3. May insert laterally on the lamina papyracea (85% of cadavers), where the ethmoid infundibulum is closed superiorly by a blind pouch named the recessus terminalis (cap of the egg). In this situation, the ethmoid infundibulum and the frontal recess are separated from each other, and so the frontal sinus drains into the middle meatus medial to the infundibulum (Fronto-nasal communication Type I).

Type I

Type II Attaches postero-inferiorly to the perpendicular plate of the palatine bone. The bony posterior end of the uncinate process may be absent. This allows the mucosa of the maxillary sinus to contact the mucosa of the lateral nasal wall. This area is called the posterior fontanelle.

Inferiorly, it articulates with the ethmoid process of the inferior turbinate. A dehiscence at this articulation with the inferiorn turbinate is termed the anterior fontanelle, and it is located anterior to the natural ostium of the maxillary sinus.

Perforation of these membranes (fontanellae) leads to openings accessory ostia of the maxillary sinus. Free postero-superior edge, 2 cm in length, is hidden by middle turbinate.

It may itself become pneumatized causing narrowing of the ethmoid infundibulum. Its pneumatization can expand anteriorly and superiorly as far as the lacrimal bone, thereby creating the ethmo-lacrimal cells.

Uncinate process can occasionally be absent and be replaced by a fibrous band, which is laterally pent.

Hiatus Semilunaris:

Two-dimensional space between the posterior edge of the uncinate process and the anterior wall of the ethmoid bulla.

It is the doorway that leads to the ethmoid infundibulum.

Ethmoid Infundibulum:

Three-dimensional space bounded by the uncinate process medially, the ethmoid bulla posteriorly, and the lamina papyracea laterally.

Length of the ethmoid infundibulum may reach 4 cm, depending on the shape of the uncinate process.

The greatest width (free margin of the uncinate process to the lamina papyracea) is 5 mm. It is wider antero-superiorly and narrower at its posterior end. It may be atelectatic according to anatomical variations of other structures such as paradoxical bending of the middle turbinate, a concha bullosa, or a hypoplastic maxillary sinus.

The lateral surface of the ethmoid infundibulum leads to ostium of the maxillary sinus. Its size is variable, with a diameter of 1 to 4 mm, and it can be round or elliptical or formed of two or three openings. An accessory maxillary opening is often found posterior to the true ostium.

Depending on the anatomical configuration of the uncinate process, the superior side of the infundibular space can communicate or not with the frontal recess.

Frontal Recess:

The funnel-shaped lower part of the hourglass-shaped space above the level of the ethmoid infundibulum that gives access to the frontal sinus.

Frontal sinus opens into the frontal recess through frontal ostium, a channel that is 3 mm long, usually found in the most anterosuperior part of the frontal recess.

Agger nasi cells mark the anterior limit of the frontal recess. If there is marked pneumatization of these cells, the frontal recess may be reduced in volume and limited to a small tubular lumen.

BOUNDARIES: Medial: Superior attachment of the middle turbinate Lateral: Lamina papyracea Superior: Internal os of the frontal sinus Anterior: nasofrontal "beak" Inferior: ethmoid infundibulum or middle meatus Posterior: variable, depending on ethmoid bulla.
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If the ethmoid bulla and inserts into the roof of the ethmoid bone, it will form the posterior wall of the frontal sinus.

Frontal recess to communicate with the space above the ethmoid bulla, termed the supra-bullar recess. If the bulla is well pneumatized and extends far forward, the frontal recess will be narrowed.

Ethmoid Bulla: (Bulla Ethmoidalis)

A hollow bony protuberance situated in the lateral wall of the middle meatus behind the uncinate process.

It is the most constant and largest of the anterior ethmoid air cells. There may be up to four cells pneumatizing the bulla, with the most common one being located supero-posteriorly.

It is pneumatized in 70% of all individuals, but, occasionally, the ethmoid bulla may not be pneumatized (Torus protuberance 30%).

Laterally, the bulla is attached to the lamina papyracea.

Superiorly, if the bulla does not reach the roof of the ethmoid bone, a suprabullar recess is formed.

Posteriorly, if it not expand to the vertical portion of the basal lamella of the middle turbinate, the formed space is named the lateral sinus. (recessus terminalis)

A very large bulla may obliterate the space for the lateral sinus. On the contrary, a small bulla allows communication between the suprabullar ethmoid infundibulum and the sinus itself.

Agger Nasi:

A smooth bony swelling in the frontal process of the maxilla situated in front of the anterior insertion of the middle turbinate.

The lateral wall can extend to the lacrimal bone and/or the orbital wall. Anterolateral to the agger nasi and running parallel to it is the nasolacrimal duct. It drains into the anterior middle meatus and into the ethmoid infundibulum.

Frontal Cell:

Originates from the anterior ethmoid sinus above the agger nasi cell and may obstruct the frontal recess or the frontal sinus itself.

Bent - Kuhn Classification: Type I: Single frontal cell above agger nasi cell, but below frontal sinus. Type II: More than one cell in frontal recess above agger nasi cell, but below frontal sinus.

Type III: Large single cell pneumatizing cephalad into frontal sinus. Type IV: Single isolated cell within the frontal sinus.

Inferior Turbinate:

An independent anatomical structure composed of the inferior conchal bone, mucoperiosteum, a submucosal cavernous plexus, and respiratory mucous membrane.

Attached to the conchal ridge of the medial process of the maxilla and the palatine bone.

It articulates with the lacrimal bone by its lacrimal process and covers the lacrimal groove to form the bony canal for the nasolacrimal duct.

Inferior meatus lies inferolateral to the inferior urbinate. Nasolacrimal duct is the only structure that opens in this meatus. The duct opens close to the angle between the two attachment limbs of the inferior turbinate, between its anterior and middle thirds through a semi-valve (Hasner`s valve).

Maxillary Sinus:

A quadrilateral pyramidal-shaped cavity within the body of maxillary bone with its apex directed into the zygomatic process.

Average adult dimensions of the sinuses are 35 to 45 mm in height, 35 to 45 mm in length, and 25 to 35 mm in width. The mean volume is 15 cc.

Maxillary bone consists of: 1. body 2. frontal process is articulated with the frontal bone and the nasal bone; 3. zygomatic process is connected with the zygomatic bone;

4. alveolar process is fused with the contralateral alveolar process, forming an alveolar arch containing the dentition; 5. palatine process is linked with the palatine bone to constitute the roof of the mouth.

Medial wall: (base of the pyramid) Can be divided into thirds; the superior third lies lateral to middle meatus, the middle third lies lateral to inferior meatus, and the inferior third is the alveolar process.

Natural ostium is located in the supero-posterior aspect of the medial sinus wall, it opens in the posterior third of the ethmoid infundibulum.

Ostium varies widely in size and shape, but the mean size is 3 mm. There are one to three accessory ostia usually found within antero-inferior fontanelle. They are located below and in front of natural ostium and sometimes behind it.

Anterior wall:

It extends from the pyriform aperture medially to the maxillo-zygomatic suture laterally, and from the infraorbital rim superiorly to the alveolus inferiorly.

Anterior surface contains several elevations on its inferior area over the roots of the teeth. Above the elevations are slight depressions, including canine fossa, the thinnest region of bone, which lies above the canine tooth. (Lateral and central incisors are not part of the maxilla, and therefore the maxillary sinus does not relate to their dental roots).

Above the canine fossa there is infraorbital foramen through which pass the infraorbital vessels and nerve. It lies 5 mm below the inferior orbital ridge.

Lateral & Posterior walls: Formed by the zygomatic bone and the greater wing of the sphenoid bone. They form the anterior boundary of the pterygo-palatine fossa.

Pterygopalatine fossa:

Entrance into the pterygopalatine fossa is gained through the pterygo-maxillary fissure, which transmits the internal maxillary vessels. This fissure is situated on the medial wall of the infra-temporal fossa and is represented by the space between the pterygoid process of the sphenoid bone and posterior surface of the maxilla.

Fossa is pyramidal in shape (inverted cone), it apex pointing inferiorly to the palatine canal.

It is formed by three bones: the maxilla, the palatine bone, and the pterygoid process of the sphenoid bone.

It communicates with:

1. Middle cranial fossa through foramen rotundum, which transmits the maxillary division of the trigeminal nerve (V2). 2. Orbit via the inferior orbital fissure containing the infraorbital artery (a continuation of the maxillary artery), and zygomatic branch of V2. 3. Nasal cavity by the sphenopalatine foramen, which carries the sphenopalatine artery and sphenopalatine nerve of V2.

Extending posteriorly from this fossa is the pterygoid (vidian) canal, which is crossed by the nerve of the pterygoid canal (vidian nerve) formed of deep petrosal nerve and the greater petrosal nerve the former carrying sympathetic fibres and the latter parasympathetic fibres of the autonomic nervous system to lacrimal gland and mucosal glands of the nose, palate, and pharynx. 1. . Vidian nerve then passes through foramen lacerum, together with; artery of the ptyregoid canal, terminal branch of ascending pharyngeal artery, emmissary veins. 2. Inferiorly, the fossa ends in the pterygo-palatine canal, which conducts the Greater palatine vessels (of internal maxillary A) and Palatine nerve (of sphenopalatine ganglion), which emerge from the greater palatine foramen.

It contains: Pterygo-palatine ganglion, Located high in the fossa. Postsynaptic parasympathetic fibers leave this ganglion and distribute with branches of the maxillary division of the trigeminal nerve (V2).

These fibers are secretomotor in function and provide parasympathetic innervation to the lacrimal gland and the mucosal glands of the nose, palate, and pharynx.

Acts as a

peripheral regulatory center for the innervation of the vessels of the nasal mucosa. Stimulation of this ganglion may produce redness, swelling, increased secretions from the nasal mucosa. Thus ganglion block were applied in cases with severe mucosal reactivity.

Superior wall (Roof): Represents the majority of the floor of the orbit, which also includes the orbital process of the palatine bone posteromedially and the zygomatic bone anterolaterally.

This wall is very thin, Extending postero-laterally to the infraorbital fissure (between maxilla and greater wing of sphenoid bone).

Infra-orbital canal is a groove in the roof of the maxillary sinus containing the infraorbital vessels and nerve. Near its midpoint this canal gives off a small canal for dental vessels and nerve.

Inferior wall (floor): Formed by the alveolar process of maxilla. Each maxilla contains 5 deciduous or 8 permanent teeth.

The projecting roots are usually separated from the maxillary sinus by bone of variable thickness, but sometimes by mucosa alone. Periapical or periodontal inflammation of upper premolars and molars may therefore spread to the sinus, and endodontic treatment or extraction of these teeth may penetrate into the sinus.

Ethmoid Sinus:

Group of small cavities within the ethmoid bone, 3.3 cm 3. 2 cm 3 1. cm in size and contains 3 to 15 cells.

5 parts of the ethmoid bone:

Bilateral labyrinths (containing air cells). Crista galli. Cribriform plate. Perpendicular plate.

Cribriform plate:

Perforated by olfactory nerve fibers, dura, and ethmoid vessels and nerves. Lies at a lower level than the roof of the ajdacent ethmoid labyrinth. Slope downward as it passes posteriorly. Divided into 3 parts:

1. Horizontal medial portion, thick, contains 20 or more foramina for the olfactory fibers. 2. Lateral lamellae; that arises from the horizontal segment at an angle to join the orbital plate of the frontal bone. It is usually thin. The angle at which it rises determines the height of the olfactory groove. A more horizontal lateral cribriform plate produces a shallow olfactory groove. Ethmoidal Arteries then enter olfactory fosssa through an openings in lateral lamella of cribriform plate (this points are considered the areas of least resistance because the lateral lamella is only one-tenth as strong as the roof of the ethmoid) 3. The junction of the horizontal and lateral parts, which is the attachment point of the middle turbinate and superior turbinate to the ethmoid roof.

Keros Classification of the Depth of Olfactory Fossa:

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Roof of the ethmoid labyrinth (Fovea ethmoidalis): formed by the strong bony plate of the frontal bone. Anterior part of the fovea ethmoidalis lies more superiorly than the posterior one because the floor of the anterior cranial fossa descends 15 degrees as it passes posteriorly.

The junction of this structure with the lateral lamella of the cribriform plate defines the fronto-cribriform suture. This suture is situated in the medial wall of the ethmoid labyrinth above the level of the olfactory groove.

Lateral surface of the ethmoid labyrinth (Lamina papyracea):

Thin, flat, smooth, rectangular bony plate. Articulates with;

1. Lacrimal bone anteriorly, 2. Maxilla inferiorly 3. Lesser wing of the sphenoid bone posteriorly. 4. Frontal bone superiorly, to form the fronto-ethmoid suture, along this suture lie: a. Anterior ethmoid foramen:

Crossed by the anterior ethmoid artery, a terminal branch of the ophthalmic artery.

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Located 25 mm posterior to the anterior rim of the lacrimal fossa. Anterior ethmoid artery and the accompanying nerve course medially between the superior oblique and medial rectus muscles and exit the orbit through the anterior ethmoid foramen. They enter the anterior ethmoid canal which passes in an anterior and medial direction within the roof of the ethmoid labyrinth, cross the ethmoid cells. The anterior ethmoid canal may be absent, and the artery and the nerve are then exposed to the ethmoid air cells.

Artery then enter olfactory fosssa through an opening in lateral lamella of cribriform plate (this point is considered the area of least resistance because the lateral lamella is only one-tenth as strong as the roof of the ethmoid) to the olfactory fossa.

b. Posterior ethmoid foramen:

Located 7 mm anterior to the anterior rim of the optic canal. This foramen is the begining of the posterior ethmoid canal, which courses almost directly medial to its foramen. The smaller posterior ethmoid artery runs through the canal in the medial orbital wall to supply the posterior ethmoid cells..

Classification of the ethmoid cell groups:

A. Anterior ethmoid cells: (Anterior to ground lamella) comprise three cellular systems: 1. Bullar system:

between the basal lamella of the bulla anteriorly and the basal lamella of the middle turbinate posteriorly.

consists of one to four intrabullar cells + suprabullar cells.

all drain into the bullar groove.

2. Uncinate system:

lies laterally to uncinate process, and its posterior limit is bulla. drain into the ethmoid infundibulum, above and behind maxillary ostium. 1. Superior cell (Frontal cell = Boyers cell): may project superiorly and contributes to the formation of the frontal sinus (Bent-Kuhn classification). 2. Anterior cell (agger nasi cell): is not a constant finding, but when well pneumatized it produces a smooth bony swelling on the lateral nasal wall in front of the anterior insertion of the middle turbinate. 3. Posterior cell: lies in front of the bulla. 4. Inferior cell (Hallers cells = infra-orbital): expand into roof of the maxillary sinus (orbital floor). (15% of cases). 1. Meatal system:

Two cells (ant & post), located medially to uncinate process, both may grow upward into the frontal sinus.

B. Posterior ethmoid cells: 1. Central cells: bounded by the basal lamella of the middle turbinate and the basal lamella of the superior turbinate posteriorly. 2. Supreme cells: located behind the basal lamella of the superior turbinate. 3. Spheno-ethmoid (Onodi) cell: 12%

Large posterior ethmoid cell that invades the superior aspect of the sphenoid sinus, sometimes mistaken for the sphenoid cells itself, but there are sphenoid sinus cells below it.

May extend postero-laterally to embrace or even surround the optic nerve. The internal carotid artery may also project on its lateral wall. May migrate to the body of the sphenoid and even reach the anterior wall of the sella turcica.

Present in

12% of individuals.

Frontal Sinus:

Pyramid-shaped cavity extending between the anterior and posterior tables of the ascending portion of the frontal bone. The apex of the pyramid is superior, and the base lies inferiorly.

The two frontal sinuses separated completely by a bony septum, which is located approximately in the midline. Bilateral asymmetry is a frequent anatomical finding, and the inter-sinus septum may be deviated as a result.

Each sinus is further divided into incomplete chambers by a bony intra-sinus septation.

Average frontal sinus measures 3 cm in height, 2.5 cm in width, and 2 cm in depth.

Mean volume of 10 cc. Walls: Anterior wall: forms the forehead and is the thickest of all sinus walls, measuring up to 10 mm. Posterior wall: is a plate of thin, compact bone (12 mm) whose upper part is vertical. It gradually curves downward and posteriorly until it is almost horizontal. It is also the anterior wall of the anterior cranial fossa, it is attached to its dura.

Medial wall: inter-sinus septum. Inferior wall: formed by orbital roofs on the lateral side and the frontal recess cells on the medial side.

Frontal sinus ostium: located antero-medially on the floor.

has an hourglass shape composed of three distinct segments: The top part of the hourglass is the frontal infundibulum, which is the inferior portion of the frontal sinus cavity, the frontal ostium. The third segment is the frontal recess.

Depends on insertion of uncinate process, fronto-nasal pathway is classified into Type I, II, III.

Sphenoid Sinus:
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Sphenoid bone:
Largest single bone in the skull base. Contributes to the floor of the middle cranial fossa, together with petrous and squamous parts of the temporal bone.

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Composed of: body (containing the sinus), lesser wings, greater wings, pterygoid plates, and upper part of clivus.

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Lesser wing: Forms the posterior lip of the anterior cranial fossa, part of the orbital wall that includes the optic canal and the anterior clinoid processes.

Connected to the frontal bone along the posterior border of the anterior cranial fossa and to the cribriform plate of the ethmoid bone in the midline.

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Greater wing: Form part of the floor of the middle cranial fossa.

More anteriorly, forms the posterior wall of the orbit, including the inferior lip of the superior orbital fissure.

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Posteriorly, it creates the lateral side of the carotid canal. At its junction with the body medially, lie foramen ovale posteriorly ((accessory meningeal artery and the mandibular division of the trigeminal nerve), and foramen rotundum anteriorly ((maxillary branch of trigeminal nerve).

Projecting off its inferior and most posterior portion the spine of the sphenoid bone, an important landmark for identification of foramen spinosum ((middle meningeal vessels and the recurrent meningeal branch of the mandibular division of the trigeminal nerve)).

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Medial and lateral pterygoid plates: Extend inferiorly from the body of the sphenoid and are attached to the posterior wall of the maxillary sinus.

Medial pterygoid plate forms the lateral wall of the nasopharynx superior to the Eustachian tube.

Between the base of medial pterygoid plate and vertical segment of the palatine bone lies spheno-palatine foramen, located 10mm above the posterior end of the middle turbinate and in front of the choanae ((sphenopalatine artery and the posterosuperior nasal branches of the maxillary nerve)).

Clivus:

The inferior projection of the body of the sphenoid which forms the posterior wall of the nasopharynx and part of the anterior wall of the foramen magnum.

Walls of sphenoid sinus:

Superior wall (Roof): Planum sphenoidale: in direct contact, from front to back, with the olfactory nerves, optic chiasm, and sella turcica. It lies in continuity with the roof of the ethmoid sinus, and this provides a useful landmark for surgical dissection.

Lateral wall: Composed of two areas: orbital area in front and cranial area behind.

Related structures: optic nerve (postero-superiorly), internal carotid artery (postero-inferiorly), with carotido-optic recess in-between, and, more posteroinferiorly, cavernous sinus and its contents (ICA, CN III, IV, VI, V2 of CN V). In addition, bulging of maxillary nerve (V2) may be seen on the lateral wall of the sinus.

Normally, a thin layer of bone covers these structures. However, optic nerve may be dehiscent (6% of patients).

Internal carotid artery ascends from the carotid canal and courses vertically to cross posterior and lateral to the optic nerve. In approximately 25% of patients, there is dehiscence of bone over the artery.

Posterior wall: Forms the floor of the sella turcica, which can be divided into three parts: an olive-shaped swelling called the tuberculum sellae, a saddle-like depression (hypophysial fossa), and posteriorly the dorsum sellae.

Sella turcica producing a pulge into the sinus, and containing the pituitary gland.

Anterior wall:

Faces the upper region of the nasal cavity, and is connected to the perpendicular plate of the ethmoid and vomer in the midline through the rostrum, and to the lateral masses of the ethmoid bone on each side. Between these attachments remains a free vertical surface (face of sphenoid).

Can be displaced by well-developed Onodi cells. In this situation, the optic nerve is surrounded by the Onodi cells.

Spheno-ethmoid recess is located within this wall, above the choana and between the superior or supreme turbinates and the septum.

Inferior wall (Floor): Forms dome of choanae and the nasopharynx. Junction of the anterior and inferior walls makes an obtuse, rounded angle called the choanal arch.

Vidian canal may bulge on the floor of the sphenoid sinus.

Size (Pneumatization): Average adult sphenoid sinus measures H 25 mm W 20 mm D 15 mm. Depending on degree of pneumatization, sphenoid sinus can be described as conchal (fetal),presellar (juvenile), or sellar (adult).

When the pneumatization of the sphenoid sinus is well developed, the surrounding vessels and nerves are in contact with the lateral wall of the sinus.
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Inter-sinus septum: May be deviated, causing asymmetry. Minor incomplete septations of the sphenoid sinus are common.

Removal of any sphenoid septations should be undertaken with great care, as the septations and the intersinus septum are sometimes attached on the bony canal of optic nerve and/ internal carotid artery.

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Ostium: Located in the spheno-ethmoid recess, medial to the superior or supreme turbinates and close to the nasal septum.

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1 cm above choana, and 5 mm lateral to the nasal septum. Shape varies widely. It may be elliptical, oval, or round. 2 to 3 mm in diameter. There may be two or more ostia on one side.

Vasculature, Lymphtics, and Innervation of Nasal Cavity & PNSs:

Arterial supply: 1. Ophthalmic artery:

Gives off the anterior and then the posterior ethmoid arteries along the medial wall of orbit.

Anterior ethmoid artery supplies much of the blood flow to the nasal septum and anterior portion of the lateral nasal wall.

Posterior ethmoid artery supplies the posterior portion of the nasal septum and parts of the middle and superior turbinates.

1. Internal maxillary artery:

Greater palatine artery, descending palatine artery which leaves the ptyregopalatine fossa via palatine canal, divides into Greater, and Lesser palatine

branches. The later enters nasal cavity via incisive canal and foramen to irrigate the anterior floor.

Spheno-palatine artery, which enters through the sphenopalatine foramen at the posterior end of the middle turbinate. Almost immediately after exiting the foramen, the sphenopalatine artery gives off the posterior nasal artery. This artery supplies branches to the superior turbinate before passing above the posterior bony choana on the anterior face of the sphenoid sinus to the posterior aspect of the septum. This vessel may be cut if the natural ostium of the sphenoid sinus is enlarged inferiorly and can result in an impressive arterial bleeder during surgery.

Posterior pharyngeal artery, anastmoses with sphenopalatine artery is the region under the posterior end of the inferior turbinate, forming another potentially vascular area on the lateral nasal termed Woodruff's area.

4. Facial artery:

Gives off superior labial artery that supplies blood to the columella, nasal vestibule, and anterior lateral nasal wall.

All of these vessels form a plexiform network in the mucosa and contribute to the Kiesselbachs plexus on the anterior septum (Lytles area), the most common site of epistaxis.

Venous drainage: 1. Anterior and posterior ethmoid veins through the ophthalmic vein. 2. Spheno-palatine vein to the pterygoid plexus of veins.
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These veins usually do not have valves, thus; infection may be propagated throughout the entire septum, affecting the dural venous sinuses (especially cavernous sinus).

Sensory innervation:
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Supplied by ophthalmic (V1) and maxillary (V2) branches of trigeminal nerve.

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Ophthalmic nerve (V1): Gives off the nasociliary nerve and its terminal branches, anterior and posterior ethmoid nerves.

Supply anterior part of the nasal septum and lateral wall of the nose.

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Maxillary nerve (V2): Gives off; Naso-palatine N: Innervates posterior and inferior part of septum and lateral wall.

Antero-superior alveolar N: Innervates anterior-inferior portions of septum and lateral nasal wall with floor of the nasal cavities.
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Infra-orbital N:

Innervates nasal vestibule, columella, nasal tip, and alar regions.

Sympathetic innervation:

Relays in the superior cervical sympathetic ganglion. Postganglionic sympathetic fibers course through the carotid plexus and follow the internal and external carotid arteries to their final destination on small arterioles in the mucosa, where they provoke vasoconstriction

Parasympathetic innervation:

Arises from the superior and inferior salivatory nuclei, join the facial nerve. Some fibers branch off facial nerve at geniculate ganglion into greater superficial petrosal nerve, ending at pterygo-palatine ganglion.

Postganglionic fibers follow spheno-palatine nerve through the sphenopalatine foramen into the posterior area of the nose to innervate the nose and the sinuses.

These fibers terminate on blood vessels and mucous glands within the mucosa. Stimulation leads to mucosal congestion due to dilatation of the blood vessels and increased production of mucous.

Olfactory Innervation: see olfaction. Lymphatic drainage:

Anterior part of the nasal cavities follows the vascular channels and joins those of the external nose to reach the submandibular nodes.

Posteriorly, it drains into the retropharyngeal lymph nodes OR passes directly to the deep cervical lymph chain.

In addition, there are connections along the olfactory nerves draining into the subdural and subarachnoid spaces.

Variations of Sinonasal Anatomy

1. Septal deviation and spurs 2. Concha bullosa 3. Paradoxically curved middle turbinate 4. Hypertrophic inferior turbinate 5. Pneumatization of inferior turbinate 6. Pneumatization of superior turbinate or vomer 7. Choanal atresia 8. Prominent ethmoid bulla 9. Torus protuberence 10. Pneumatization of uncinate process 11. Hook-shaped/inverted/duplicated uncinate process 12. Hypoplasia of maxillary sinus 13. Hellar cell 14. Onodi cell