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Paranasal Sinuses Anatomy &

Variants-
A Systematic Approach To
Imaging Before FESS


Dr Priyanka Vishwakarma
Four Paired Sinuses

Ethmoid
Maxillary
Frontal
Sphenoid

The sinuses develop as outgrowths from
the nasal cavity; hence they all drain
directly or indirectly into the nose


Meati
superior meatus drains the posterior ethmoid
air cells and the sphenoid sinus via the
sphenoethmoidal recess
middle meatus drains the frontal sinus via the
nasofrontal duct/frontal recess, the maxillary
sinus via the maxillary ostium, and the anterior
ethmoid air cells via the ethmoid cell ostia.
The nasolacrimal duct drains into the inferior
meatus
spheno-ethmoidal recess, above and posterior
to the superior concha, receives the opening of
the sphenoidal sinus


Osteomeatal unit
Common Drainage Pathway Of The Ant.
Group of Sinuses.-Coronal scan
The osteomeatal unit (OMU) includes the
uncinate process
Ethmoid infundibulum
Ethmoid Bulla
Middle Meatus
Hiatus Semilunaris
Most common site of inflammatory disease

Nasal Septum
Commonest Variation-DNS
Pneumatization

Inferior Turbinate-Hypertrophy
Maxillary sinus
Largest and most constant pns.
Pyramidal in shape- base is usually
medial, with its apex in the zygomatic
process of the maxilla
Base -lat nasal wall-ostium
Posterior wall/Temporal- pterygomaxillary
fossa
Roof -Formed by roof of the orbit- infra
orbital foramen containing the infra orbital
vessels and nerves
Ant-maxilla facial surface
Variants Related To the maxillary Sinus

Concha bullosa
Paradoxical curvature of MT
Haller Cell
Septae
Dehiscent floor-1
st
,2
nd
Molar Infn
Concha Bullosa
pneumatization of
the bulbous portion
of the middle
turbinate
An enlarged
concha bullosa may
impede drainage
from the middle
meatus
Haller cells

Ethmoidal air cells belonging to the
anterior ethmoidal group.
Also known as the infra orbital cells
Adhere to roof of maxillary sinus forming
the lat wall of infundibulum
Enlargement of these cells can impede the
maxillary sinus drainage
Paradoxical curvature- can potentially narrow or
obstruct the infundibulum or middle meatus.
bony septum in the maxillary
sinuses (MS)
Ethmoidal sinus
basal lamellae of the middle turbinate
separates the ethmoid into anterior and
posterior groups with different drainage
patterns
Ant cells form 1st followed by the posterior
cells.They are not seen on radiographs
until age one
Lateral wall-Formed by the orbital plate of
the ethmoid,known as the lamina
papyracea.this wall could be dehiscent-
route of spread of infection

. The transition of thick fovea to the thin
portion of roof of ethmoid medially is very
weak-injuries during surgery leading on to
CSF leak.
Ethmoids-ant and post
vertical attachment of basal
lamellae to anterior skull base
Related Variants
A cell above the orbit is called a
supraorbital cell.found in 15% of pt
Invasion of an ethmoid cell into the floor of
the frontal sinus is called a frontal cell(type
1-4)
Agger Nasi Cell
term Agger in Latin - Mound/Eminence.
anterior to the antero superior attachment
of the middle turbinate and borders the
frontal recess.
its size may directly influence the patency
of the frontal recess. These agger nasi
cells are commonly involved in the
pathogenesis of the formation of frontal
mucocele.
It is the 1st prominent anatomical
landmark encountered in FESS

ethmoid bulla
superior to uncinate processes.
Ethmoid bulla air cells are part of the
anterior ethmoid sinuses and make up the
superior border of the hiatus semilunaris.
variable pneumatization.
Onodi Cells
posterior ethmoidal cells extending supero
lateral to the sphenoid sinus & can either
abut to or impinging upon the optic nerve.
When these Onodi cells abut or surround
the optic nerve, the nerve is at risk when
surgical excision of these cells is
performed.
It is also a potential cause of incomplete
sphenoidectomy.

Olfactory fossa
The depth of the olfactory fossa is determined by
the height of the lateral lamella of the cribriform
plate, which is part of the ethmoid bone. In 1962,
Keros had classified the depth of the olfactory
fossa into three types, that is,
Keros type I: <3 mm,
type II: 4-7 mm , and
type III: 8-16 mm.-Kero type III is most
vulnerable to iatrogenic injury.
Keros type I-< 3 mm

Keros type II- 4 to 7 mm

Keros type III-6-18 mm

Frontal sinus
different sizes, are separated by a bony
septum that is usually deviated to one side
Asymmetry btw the two sinuses frequent
It may be absent in 5% of cases
Best seen on Saggital images
Among the para nasal sinuses this sinus
shows the maximum variations.


The post wall separates the frontal sinus
from the anterior cranial fossa and is
much thinner.
Floor is formed by the upper part of the
orbits
Frontal sinus appear very late in life. Infact
they are not seen in skull films before the
age of 6.
Nasofrontal duct-misnomer
Frontal Recess


the frontal recess can be conceptualized as an
inverted funnel within the anterior ethmoid complex
through which the frontal sinus drains.
The tip or apex of the funnel lies at the frontal sinus
ostium, -sagittal CT images as a waist located at
the level of the nasofrontal process.
The frontal recess typically flares out inferiorly and
posteriorly to form the wider opening of the funnel.
inferior portion of the frontal sinus (commonly
referred to as the frontal infundibulum)
+
the frontal ostium
+
frontal recess = frontal sinus outflow tract
the right frontal
recess (dotted
red line), which
is bounded
anteriorly and
laterally by an
agger nasi cell
(white arrow)
and a type 1
frontal cell (black
arrow), medially
by the middle
turbinate

posteriorly by
the ethmoid
bulla and bulla
lamella.
The nasofrontal
process
(arrowhead in b)
forms the floor of
the frontal sinus
and demarcates
the level of the
frontal sinus
ostium
superior compartment of the FSDP
Frontal outflow tract shows conglomeratization of
air cells.
Types of frontal sinus air cells include:
I Type I frontal cell (a single air cell above
agger nasi)
II Type II frontal cell (a series of air cells above
agger nasi but below the orbital roof)
III Type III frontal cell (this cell extends into the
frontal sinus but is contiguous with agger nasi
cell)
IV Type IV frontal cell lies completely within
the frontal sinus
Type 2 frontal cells

Type 3 frontal cell
Type 4 frontal cell
situated entirely
within the right
frontal sinus &
bordered by the
anterior frontal
sinus wall. The
type 4 cell does
not abut the
agger nasi cell.
Variants obstruct FSDP
Agger nasi
Supraorbital cells
Frontal recess is bounded anteriorly by agger
nasi cell and posteriorly by suprabullar air cell-
can compromise frontal sinus drainage pathway.
Supraorbital/suprabullar ethmoid cell
Pneumatized
crista galli
may
communicate
with the
frontal recess
and can
potentially
obstruct the
frontal sinus
ostium
Interfrontal sinus septal cell
arises from the frontal sinus septum
Fess Failure
Frontal sinusitis after FESS
The uncinate process may be attached to:
Lamina papyracea or agger nasi (lamina
terminalis). The frontal recess opens
directly into middle meatus,medial to UP
The lamina terminalis is the blind pouch
between the UP and lamina papyracea
Skull base or middle turbinate. The frontal
recess drains into the ethmoid
infundibulum lateral to UP
Orbital floor or inferior aspect of the lamina
papyracea (silent sinus syndrome,
atelectatic uncinate process). This variant
is associated with hypoplastic, ipsilateral
maxillary sinus secondary to closure of the
infundibulum.

Sphenoidal sinus
They remain undeveloped until age
three.By age seven the pneumatisation
has reached the sell turcica.By age 18 the
sinuses have reached full size
Optic nerve and internal carotid arteries
traverse its lateral wall.
Pneumatisation can extend as far as the
clivus,the sphenoid wings and the foramen
magmum

sphenoid sinus
(SpS) and the
sphenoethmoidal
recess marked by
the (*).

(AE: anterior ethmoid, PE:
posterior ethmoid, CC: carotid
canal, NS: nasal septum)
(FR: foramen
rotundum,
VC: vidian
canal,
OC: optic
canal,
AC: anterior
clinoid,
PtP: pterygoid
plate)
sphenoethmoidal recess
variations of intersinus septum

1.A single midline intersinus septum
extending on to the anterior wall of sella.
2. Multiple incomplete septae may be seen
3. Accessory septa may be present. These
could be seen terminating on to the carotid
canal or optic
3 types

Concal-children-5%
presellar-23%
Sellar-67%
Pneumatized
lateral
recesses of
sphenoid
sinus (SpS)
and foramen
rotundum
(FR) bulging
into the sinus
pneumatized pterygoid plates
FESS-a roadmap to the otorhinolaryngologist prior to
surgery.
There are two main questions that the radiologist should
address:
1. Are there anatomic features on the computed
tomography (CT) scan that predispose the patient to
impaired mucociliary clearance?
2. Are there anatomic features that pose a surgical
hazard?
Checklist-Systematic
the extent of sinus opacification,
patency of sinus drainage pathways,
anatomic variants(obstruct drainage
pathways &limit Surgical access),
critical variants, (CP,LP,SphS
dehiscence)and
condition of soft tissues of the brain, neck,
and orbits.-extrasinus extent of the
disease




References
http://www.ajronline.org/doi/full/10.2214/AJ
R.09.3584
http://dx.doi.org/10.1148/rg.291085118

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