Literatur Reading :

Sinonasal Anatomy and Physiology

dr. Tita Puspitasari

Supervisor :
dr. Sinta Sari Ratunanda, MKes., Sp THT KL (K)

Dept of Otorhinolaryngology Head

and Neck Surgery
Hasan Sadikin General Hospital
Bandung
2017
 EMBRIOLOGY
Embryologic development of the nasal cavity
and sinuses can be divided into two ongoing
processes.
- The embryo's head develops into a structure
with two distinct nasal cavities;
- The lateral nasal walls then invaginate to create
complex folds : turbinates, and spaces, known
as sinuses.
Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 The External Nose

http://slideplayer.fr/slide/1142986/
 Nasal Foundation

Bone : Os nasal,
Procc frontalis os
maxila, Procc
nasalis os frontal
Cartilage :
Cartilago nasalis
lateralis superior
inferior, septum
 Medial Nasal Wall
Bone : Lamina
perpendicularis
ossis
ethmoidalis,
Vomer, Crista
nasalis os
maxila, Crista
nasalis os
palatina
Cartilage :
Columella,
Septum/Lamin
a
Quadrangularis
 Lateral Nasal Wall

Ager Nasi
Konka :
Suprema,
Superior,
Middle, Inferior
Meatus :
Superior media,
Inferior
 Nasal Vascular Anatomy

http://slideplayer.fr/slide/1142986/
Osteomeatal Complex
 1. Septum, Middle turbinate, 3. Uncinate process, 4. Ethmoid bulla,
5. Inferior turbinate

Dalgorf. M Justin, Harvey. J Richard. 2015. Sinonasal Anatomy and Function. American Journal of Rhinology & Allergy.
Vol 27: 3
Paranasal Sinuses
 Maxillary Sinus
The largest of the
paranasal sinuses
The anterior wall derives
from the facial surface of
the maxilla
The posterior wall
borders the
ptetygopalatine fossa
The medial wall
constitutes the lateral
wall of the nasal cavity
The floor of the sinus is
the alveolar process
The superior wall serves
as the orbital floor.

14
Frontal sinus
 Frontal Sinus
The size of the frontal sinus varies depending on the degree of
pneumatization, may be completely absent (5%).
The anterior table is twice as thick as the posterior table,
which separates the sinus from the anterior cranial fossa.
The floor of the sinus : Supraorbital roof
The drainage :
Pathway is located in the posteromedial portion of the sinus
floor.
Resembling an hourglassshaped structure in the sagittal plane
The superior portion widens into the frontal sinus and the
inferior portion expands into the frontal recess.

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Anatomical Variation in Superior Attachment of Uncinate Process
and Localization of Frontal Sinus Outflow Tract

G. Arun, P. Moiden Sanum, et. al.2017. Anatomical Variation in Superior Attachment of Uncinate Process and Localization of
Frontal Sinus Outflow Tract : 176
 SPHENOID SINUS
The sphenoid sinus has
many important
neurovascular
relationships.
It relates laterally to the
cavernous sinus, the
internal carotid artery,
and cranial nerves IIVI,
and it is very closely
related to the optic
canal.

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5 th ed, . Lippincott Williams & Wilkins, 2014
18
 Sphenoid Sinus
The internal carotid artery is lateral to the sphenoid sinus as it courses
through the cavernous sinus producing a prominence in the lateral
sphenoid sinus wall in 65% of individuals.
The visibility of all structures related to the walls of the sphenoid sinus
depends on the degree of pneumatization of the sinus. The degree of
pneumatization is classified into three types: sellar type (86%), presellar
(11 %), and concha] type (3%)
The sphenoid sinus ostium opens into the sphenoethmoidal recess
Identified the posteroinferior end of the superior turbinate as the best
landmark.
The ostium was located medial to the superior turbinate in 83% of cases
and lateral to it in 17%. The sphenoid septum usually deviates posteriorly
from the midline dividing the sinus into two asymmetric parts and can
insert onto thebony prominences overlying the optic nerve or carotid
artery.

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Ethmoid Sinuses

Anterior :
Lacrimal Bone
Medial : Lateral
nasal wall
Superior :
Fovea
ethmoidalis
 Ethmoid Sinuses
The ethmoidal sinus comprises numerous small
cavities (ethmoidal cells) in the ethmoidal
labyrinth. The walls of these cavities are completed
by the surrounding bones. Anterior and posterior
groups drain into the middle and superior meatuses.
 Drainage of Paranasal Sinus

Watelet, JB. 2009. Applied Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 57, 14 - 25
 Osteomeatal Unit

1. Inferior turbinate, 2. Middle turbinate, INF. Infundibulum, M. Maxillary sinus, F.

Frontal sinus, U. Uncinate process, B. Bulla ethmoid, O. Maxillary sinus ostium

Chaitanya Sai Chinala, Raviteja Atkuri. 2015.Computed Tomography Evaluation of Disease of Paranasal Sinuses. International Journal of
Recent Scientific Research. Vol 6
 1. Septum, Middle turbinate, 3. Uncinate process, 4. Ethmoid bulla,
5. Inferior turbinate

Dalgorf. M Justin, Harvey. J Richard. 2015. Sinonasal Anatomy and Function. American Journal of Rhinology & Allergy.
Vol 27: 3
 1. Right maxillary
procces 2. Maxillary
sinus ostium 3.
Ethmoidal
Infundibulum 4.
Hiatus semilunaris 5.
Bulla ethmoid 6.
Perpendicular plate
of ethmoid bone 7.
crista galli 8. lamina
papyracea 9. left
uncinate process
attaching medially to
the septum;
10. Middle turbinate
11. Haller cell 12.
maxillary sinus
13.Inferior turbinate.

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Skull base with uncinate process attaching
superiorly to the skull base 14. Uncinate
process attaching superiorly to the skull
base

Skull base with uncinate procces attaching

laterally to the lamina papyracea 15.
Cribriform plate 16, lateral lamella 17.
Ethmoid roof 18. Left uncinate
process attaching laterally to the lamina
papyrac

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Sagital view of the lateral
nasal wall 19. Inferior
turbinate 20. Middle
turbinate 21. Frontal sinus
22. Crista galli 23. Superior
turbinate 24. Sphenoid
sinus

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Axial view
36. Septum
37. Ethmoid cell
38. Ondi cell
39. Optic nerve
40. Carotid
artery
41. sphenoid sinus

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
Prevalence of Various Anatomical Variations

The common anatomical variations found among

the 360 CT scans evaluated were Pneumatized
Agger nasi cells ,
Concha bullosa,
Asymmetry ethmoidal roof,
Haller cells,
Asymmetry of ethmoid fovea,
Anterior ethmoidal artery canal,
Paradoxical bending of middle turbinate,
Suprabullar Cells, Infrabullar Cells, and Onodi cells

Al-Abri Rashid, Bhargava Deepa, Al-Basam Wameedh, et. al. 2014 Clinically Significant
Anatomy Variant of The Paranasal Sinus. Oman Medical Journal. Vol 29
Overview of the
common nasal
meatus
and entry Into the
middle nasal
meatus on
the right
View Into the middle
nasal meatus on the
right. From lateral, the
uncinate process is
clearly recognizable
and behind partially
obscured. the front
surface of the
ethmoidal
bulla. Medially. the
lateral surface of the
middle turbinate .
Hasners valve (orifice
of the nasolacrimal
duct) in the inferior
nasal meatus on the
right.
Right
sphenoethmoldal
Right nose. A very A septal spur
recess. The
large septum ridge protrudes Into the
sphenoidal sinus
In lateral
ostium is clearly
close contact with nasal wall just below
recognize. Laterally
the middle the lell middle
from this
turbinate. turbinate.
rudimentary
supreme turbinate
 Concha Bulosa

Left middle nasal

meatus with
concha bulosa in
a paradoxical
curve, middle
turbinate as a
variant
 Ephitelium

The nasal epithelium lies on a basement membrane and a

lamina propria.
Types of epithelium in the nasal cavity:
o A pseudostratified columnar epithelium
(respiratory epithelium), composed of 4 major types of
cells: ciliated (columnar) cells, nonciliated (columnar)
cells, goblet cells and basal cells.
o A squamous and transitional epithelium (stratified
epithelium containing cuboidal cells with microvilli)
o The epithelium of the paranasal sinuses, the
simple ciliated columnar type with a few goblet cells
and glands

Watelet, JB. 2009. Applied Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 57, 14 - 2 35
 Physiology Sinonasal
Olfaction
Respiration
Protection

Leung RM, Walsh WE, Kern RC : Head & Neck Surgery Otolaryngology, 5th ed, . Lippincott Williams & Wilkins, 2014
 Respiration
The extensive vascular and secretory systems of the
nasal cavity and paranasal sinuses serve to warm and
humidify ambient air in preparation for access to the
lower airways.
Can raise the humidity of inspired air to
approximately 85%
This moisture comes from the water content of the
mucus that is directly transudated from nasal blood
vessels and supplied by nasal glands

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Sympatic vasoconstrictor : Decreasing the
volum of blood venous sinusoid in the mucosa
causing decongestion
Parasympatic : Minor control of nasal blood
volume, but stimulating nasal secretion

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Olfaction

The olfactory neuroepithelium is scattered through the superior

portions of the nasal cavity, located between the septum and
medial surface of the superior turbinate bilaterally.
Extend anteriorly onto the middle turbinate. and inferiorly
below the cribriform plate. This area is known as the olfactory
cleft
Olfactory neuron cell bodies reside superficial to the basal
cells.
Dendrites terminate in knobs at the epithelial surface.
Axons extend through the lamina propria and converge with
other axons to form nerve bundles, or fila olfactoria

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Protection
Normal sinonasal mucosa : Epithelial layer,lamina propria,
submucosa, and periosteum
Epithelial cells are ciliated, pseudo-stratified, columnar cells with
a variable number of goblet cells
Coarse nasal hairs, vibrissae, located at the nasal orifice filter out
large particles entering the nose. Smaller particles impact the
mucosa as a result of turbulent flow and stick to the nasal mucus
Turbulence increases contact between inspired air and the nasal
mucosa enhancing not only the respiratory functions but also
olfaction and protection

Leung M. Randy, Walsh E. Wiliam, Kern. C Roberts. 2014. Baileys Head and Neck Surgery Ottolaryngology.Fifth edition. Baltimore : Lippincott
William & Wilkins: 359-369
 Mucous Blanket
The mucous blanket is composed of two
layers.
o Sol layer exists as a thin, periciliary fluid that allows
the cilia to be mobile between strokes produced
by microvilli
o Gel layer is a thick sheet of mucus that supplies an
insertion point for the tips of the cilia produced
by the goblet cells and submucosal glands.
Primarily composed of mucoglycoproteins
The mucous blanket contains other
components :
o Immunoglobulin A (IgA)
o Immunoglobulin G (IgG) and interferon
o Lysozyme
Watelet, JB. 2009. Appliedand lactoferrin
Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 57, 14 - 2 41
 Ciliary Movement and Mucous Blanket

Watelet, JB. 2009. Applied Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 57, 14 - 25
42
 Mucous Blanket
Once the foreign particles or bacteria are trapped, the sinuses can
effectively drain the mucus through the mucociliary clearance
system
The cilia propel the mucus at a rate of 3 to 25 mm per minute
toward the natural ostium of the ethmoidal cells and sphenoidal
sinus.
The maxillary sinus has a star-shaped drainage pattern from the
sinus floor superiorly to the ostium.

The mucociliary transport of the frontal sinus sweeps in a circular

pattern beginning on the medial wall of the frontal recess,
progressing toward the roof, turning laterally, and finally curving
downward and medially toward the sinus ostium.
Once the sinus drainage has taken place, the mucus is swallowed
and transported to the stomach, destroying any acquired bacteria.

Watelet, JB. 2009. Applied Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 57, 14 - 25 43
 Hightlights
Sinonasal embryology can be divided into two ongoing processes: The

embryo's head develops into a structure with two distinct nasal cavities;
The lateral nasal walls then invaginate to create complex folds, known as
turbinates, and spaces, known as sinuses.

The ethmoidal, maxillary; sphenoid, and frontal sinuses make up the

paranasal sinuses.

The complex and variable anatomy of the lateral nasal wall influences
approaches to endoscopic sinus surgery.

The three major functions of the nose : Olfaction,respiration, and

protection