The lateral nasal wall

I N FER I OR M EATUS
The inferior meatus is that part of the lateral wall of the nose lateral to the inferior turbinate.
It is the largest meatus, extending almost the entire length of the nasal cavity. The meatus is highest
at the junction of the anterior and middle third. In adults, this ranges from 1.6 to 2.3 cm ( mean 1
.9 cm) at 1.6 cm along the bony lateral wall. The nasolacrimal duct opens into the inferior meatus
usually just anterior to its highest point. There is no true valve, the opening being covered by small
folds of mucosa. It can be endoscopically identified in life by gentle massage of the lacrimal sac
at the medial canthus.
INFER I O R TU RBI NATE
This structure is composed of a separate bone, the inferior concha which has an irregular
surface, perforated and grooved by vascular channels to which the mucoperiosteum is firmly
attached (Figures 104.26 and 1 04.27) . The bone has a maxillary process which articulates with
the inferior margin of the maxillary hiatus. It also articulates with the ethmoid, palatine and
lacrimal bones, completing the medial wall of the nasolacrimal duct. The inferior concha has its
own ossification centre which appears around the fifth intrauterine month. The turbinate possesses
an impressive submucosal cavernous plexus with large sinusoids under autonomic control which
provides the major contribution to nasal resistance. The turbinate is covered by respiratory
epithelium, with a high number of goblet cells (approximately 8/mm2 ) which decrease in density
towards the posterior end.
M IDDLE M EATUS
The middle meatus is that portion of the lateral nasal wall lying lateral to the middle
turbinate (Figures 104.28 and104.29 ) . It receives drainage from the frontal, maxillaryand anterior
ethmoidal sinuses. Considerable confusion has arisen with regard to terminology in this area, as
many terms originally defined in the last century by the German and French have been used
interchangeably. In the past, when radical sinus surgery was predominantly used for most
pathology, this was of less significance. The advent of endoscopic smgery has led to an increased
interest in the detailed anatomy of the region and a need for consensus in terminology. The
configuration of the structures of the middle meatus are complex and variable, but can more readily
be understood when the embryological development of the area is considered. If the topographical
anatomy is considered in the sagittal plane, a number of structures are apparent, covered by the
middle turbinate. In a disarticulated skull, the maxillary bone has a large opening in its medial
wall, the maxillary hiatus. In the articulated skull this is filled in by adjacent bones:
inferior: the maxillary process of the inferior turbinate bone;
posterior: the perpendicular plate of the pala tine bone;
anterosuperior: a small portion of the lacrimal bone;
superior: the uncinate process and bulla of the ethmoid.
A portion of the maxillary hiatus is nevertheless left open by these osseous attachments,
which in life is filled by the mucous membrane of the middle meatus, the mucous membrane of
the maxillary sinus and the intervening connective tissue - the membranous portion of the lateral
wall. This membranous area can be defined as lying anterior or posterior to the uncinate process,
constituting the anterior and posterior fontanelles, respectively. It is in the fontanelles that
accessory ostia are found, their formation probably arising as a consequence of infection and,
consequently, they have been compared to perforations in the tympanic membrane. It is difficult
to ascertain a 'natural' incidence for accessory ostia but it is probably of the order of 4-5 percent in
the general adult population, increasing to 25 percent in patients with chronic rhinosinusitis.

Accessory ostia are found most frequently in the posterior fontanelle which is generally larger than
its anterior counterpart.
ETH M O I DAL I I\l FU I\l D I B U L U M
The ethmoidal infundibulum is a cleft-like, three dimensional space in the lateral wall of
the nose that belongs to the anterior ethmoid. The medial wall of the space is provided by the entire
extent of the uncinate process and its mucosal covering. The major part of the lateral wall of the
ethmoidal infundibulum is provided by the lamina papyracea of the orbit, with the frontal process
of the maxilla and, in rare cases, the lacrimal bone providing the remainder anterior and superiorly.
Anteriorly, the uncinated process attaches to the bones of the lateral nasal wall at a sharp angle
and inferiorly, provides the bony connection with the inferior turbinate. Bony defects in this area
are covered by connective tissue and the continuation of the periosteum as well as mucous
membrane, and are thus closed in the area of the anterior nasal fontanelle. Through the attachment
of the anterior margin of the uncinate process to the lateral nasal wall, the ethmoidal infundibulum
ends blindly anteriorly in an acute angle. Further inferiorly and posteriorly, the lateral wall of the
ethmoidal infundibulum is formed by the mucosa-covered connective tissue components of the
posterior nasal fontanelle. The posterior border of the ethmoidal infundibulum is composed largely
of the anterior surface of the ethmoidal bulla, in front of which the infundibulum opens into the
middle meatus through the inferior hiatus semilunaris.
Superiorly, configuration of the ethmoidal infundibulum depends largely on the uncinate
process: if this turns laterally thus attaching to the orbit, the ethmoidal infundibulum ends in a
superior blind alley, the terminal recess (recessus terminalis) . If the uncinate process reaches the
skull base superiorly or turns medially to attach to the middle turbinate, the ethmoidal
infundibulum is contiguous with the frontal recess superiorly (Figure 1 04.30) . In these situations,
portions of the lacrimal bone may contribute to the lateral wall of the
ethmoidal infundibulum.
If a terminal recess of the ethmoidal infundibulum is present, the ethmoidal infundibulum
and frontal recess are separated from each other in this region. The frontal recess then opens in!o
the middle meatus medial to the ethmoidal infundibulum between the uncinate process and the
middle turbinate. Ventilation and drainage of the frontal sinus then run medial to the ethmoidal
infundibulum. If the uncinate process reaches the skull base or turns medially, the frontal recess
and consequently the frontal sinus open directly into the superior part of the ethmoidal
infundibulum. Numerous configurations of these principal uncinate variants can occur. The
superior bony end of the process may become divided into several branches that insert into the
base of the skull, the lamina papyracea and the middle turbinate. Depending on the development
of these branches, various septations and recesses may be formed. The mucosal membrane may
produce partial or complete septations and form additional blind bulges near the skull base or the
middle turbinate. These can expand anteriorly in varying numbers and sizes and evolve into socalled infundibular cells. If such a cell develops anteriorly and superiorly, it can extend as far as
the lacrimal bone and may be called an ethmolacrimal cell. No universally accepted terminology
and nomenclature exist in this regard as of today. Posteriorly, the ethmoidal infundibulum tapers
parallel to the tapering of the uncinate process. Depending on the form of the uncinate process, the
anterior length of the ethmoidal infundibulum may reach 4-5 cm. Its greatest depth (measured from
the free posterior margin of the uncinate process) may be as much as 12 mm, and its greatest width
from the free margin of the uncinated process to lamina papyracea) 5-6 mm. The maxillary sinus
ostium is located in the medial wall of the ethmoidal infundibulum, at the transition of its middle
to posterior third.

The ethmoidal infundibulum may be almost atelectatic, when anatomic variations such as
a paradoxically curved middle turbinate, concha bullosa or hypoplastic maxillary sinus are present.
Occasionally, the uncinated process may be pneumatized, i.e. an ethmoid air cell has developed
into the structure.
Kaufmann has coined the term 'doubled middle turbinate' for an uncinate process, which is
bent medially like the brim of a hat and thus may protrude significantly out of the middle meatus,
giving the aspect of an additional middle turbinate. This is interpreted by some as the closest the
uncinate process can get to its primary determination, to form an ethmo-turbinal.
CLEFTS A N D SPACES OF TH E LATERAL NASAL WALL
The mucosal lining of the primary nasal cavity and the paranasal sinuses not only serves a
physiological function but also contributes to the shape of these areas. It is only after they are
covered by mucous membrane that the spaces and clefts of the lateral nasal wall assume their
definitive shape and relationship to each other. Thus, the nasal fontanelles become membranousmucosal components of the lateral nasal wall only after the maxillary sinus and the nasal passages
are covered by mucosa; and the natural ostium of the maxillary sinus assumes its definitive form
only after it is lined by mucosa.
H IATUS SEM I LU NARIS
The term 'hiatus semilunaris' (inferior hiatus semilunaris according to Grunwald) was
coined who gave this name to both the cleft and the depression that are seen from a medial view
lying between the free posterior margin of the uncinate process and the anterior surface of the
ethmoidal bulla; The sickle-shaped hiatus semilunaris can be considered a strictly two-dimensional
formation, i.e. the sagittal cleft between the concave free posterior border of the uncinate process
and the convex anterior surface of the ethmoidal bulla. From the middle meatus, through this 'twodimensional' cleft, the three-dimensional space of the ethmoidal infundibulum can be approached.
The hiatus semilunaris thus is the 'door' through which we can reach the ethmoidal infundibulum.
Grunwald described a second hiatus semilunaris, the superior hiatus semilunaris. This cleft
between the ethmoidal bulla and the middle nasal meatus exists, when there is a marked recess
posterior to the ethmoidal bulla, i.e. between this and the frontal portion of the basal lamella of the
middle turbinate. The hiatus semilunaris superior is also a 'sickle-shaped' cleft, which leads into
the retrobullar recess (Figure 104.31 ) .
TH E AGG ER NASI
This area has caused considerable confusion but constitutes, together with the uncinate
process, the remnants of the nasoturbinal in lower mammals and is the most anterior part of the
ethmoid. It is represented by a small crest or mound on the lateral wall just anterior to the
attachment of the middle turbinate. It may be pneumatized, though the incidence in the normal
population is considered to be between 5 and 80 percent. Pneumatization of the agger nasi region
may encroach upon the nasolacrimal duct.
THE FRONTAL RECESS
The frontal recess is found in the most anterosuperior portion of the middle meatus. The
term 'frontonasal duct' has been generally abandoned as no true duct exists, either histologically or
topographically, in most people. The natural ostium of the frontal sinus is somewhat variable in its
configuration but most frequently it presents as an hourglass narrowing opening directly into the

recess. Rarely, a longer narrowed region is found. In 10 percent of patients, multiple ostia are
found, though these openings should not be confused with a more laterally placed suprabullar
(superior anterior ethmoidal) cell running into the orbital roof.
The frontal recess may be defined as follows:
medial: middle turbinate;
lateral: lamina papyracea, lacrimal bone;
superior: skull base;
inferior: dependent upon the attachment of the uncinate process;
pneumatization of agger nasi cells.
From a developmental point of view, this space is the superior continuation of the ascending branch
of the first primary interturbinal furrow, i.e. the groove between the first and second ethmoturbinal
crests. The descending branch of this first groove becomes the ethmoidal infundibulum, thus
indicating the close topographic relationship between these two spaces. The frontal sinus originates
from pneumatization of the frontal recess in an antero-superior direction, into the frontal bone. In
a sagittal section through the transition of the floor of the frontal sinus (frontal sinus infundibulum)
to the frontal recess, an hourglass-shaped structure is present. Its narrowest part is at the level of
the frontal ostium. Whereas the superior portio n of the hourglass is the frontal sinus infundibulum,
the inferior portion (the 'inverted funnel' ) is the frontal recess. The limits, shape and width of the
latter are largely determined by its neighbouring structures. The posterior wall of the frontal recess
is only well defined if the bulla lamella ascends in continuity to the roof of the ethmoid. The ground
lamella of the bulla then separates the frontal recess from the suprabullar recess. As the ethmoidal
bulla lamella is frequently inco mplete and does not reach the roof of the ethmoid over the entire
width of the latter, the frontal recess may communicate widely posteriorly with the space above
(and occasionally behind) the ethmoidal bulla, namely, supra- and retrobullar recess. The shape of
the ethmoidal bulla can significantly affect the configuration of the frontal recess: if it extends far
forward in the case of a well-developed bulla, the frontal recess will be narrowed from posteriorly.
If, in addition, significant pneumatization of the agger nasi exist and additional ethmoidal
infundibular ceils, the frontal recess may be narrowed to a small passage or even have a tubular
lumen. It is this configuration that probably gave rise to the term 'nasofrontal duct'. Even if such a
tubular configuration is present, this is not an independent bony tubular structure but simply the
space wruch other independent bony structures leave between them..
The anatomic situation can be further complicated in that the most anterior ethmoidal cells
may develop from the frontal recess. Thus, pneumatization of the- agger nasi may begin here. The
middle turbinate may also become pneumatized from the frontal recess. From here, cells not
uncommonly develop into the frontal bone, alongside the frontal sinus proper. These cells have
been called bulla frontalis This variation may range from a bare suggestion of a bulge of the frontal
recess into the floor of the frontal sin us to the format;ion of two or more approximately equally
large cells on one side of the frontal bone. As all of these cells open into the frontal recess, it may
become impossible in some cases to determine which of those cells is the true frontal sinus and
which a bulla frontalis.
TH E ETH M O I DAL B U LLA
This is one of the most constant features in the middle meatus containing the largest
anterior ethmoidal cell, but it may be poorly aerated or completely unpneu matized in 8 percent of
patients, hence its alternative nomenclature of torus lateralis (lateral bulge ) .The anterior face
forms the posterior margin of the hiatus semilunaris and ethmoidal infundibulum. Posteriorly) the

bulla may fuse with the basal lamella of the middle turbinate and superiorly it may reach the roof
of the ethmoids forming the posterior wall of the frontal recess. Sometimes a cleft is encountered
between the posterior wall of the bulla and the basal lamella of the middle turbinate, the retrobullar
recess. The space between it and the ethmoidal roof is called the suprabullar recess) which may
connect anteriorly with the frontal recess if the bulla does not reach the skull base. Suprabullar and
retrobullar recess may be continguous or may be separated by complete or incomplete bony
septations. Contiguous) supra- and retrobullar recess may be defined as follows:
medial: middle turbinate;
lateral: lamina papyracea;
superior: roof of ethmoid;
inferior and anterior: unicate process;
posterior: basal Lamella of the middle turbinate.
ANATOM ICAL VARIATI ONS
There is a considerable range of anatomical variation in this area which has been implicated
in the aetiology of sinus infection (Figures 104.32, 104.33 and 104.34) Table 104. 1 ) . This
includes pneumatization of the middle turbinate) enlargement of the ethmoidal bulla) a
paradoxically bent middle turbinate) everted uncinate processand the presence of infraorbital
(Haller cells) or a septaldeflection. The incidence with which these are seen in a'normal) population
may appear to be less frequent than in those individuals with chronic rhino sinusitis, but on closer
inspection it is clear that it is narrowing of the ostiomeatal complex rather than the existence of
the variant which is the important factor.
ROOF OF ETH M O I D COM PLEX A N D ANTE R I O R ETH M O I DAL ARTERY
In a disarticulated dry skull, the ethmoid bone is open superiorly, at Least over its anterior
two-thirds (Figure 104.35). The bony cover for these open clefts and cells of the ethmoid is
provided by the frontal bone, which covers these open spaces with its foveolae ethmoidales (ossis
frontalis) . In this area, the frontal bone is both thicker and denser than the adjacent bony ethmoidal
structures. This difference is greatest medially, in the transition from the thicker bony lamellae of
the frontal bone to the much thinner lateral lamella of the cribriform plate. This lateral lamella
constitutes the lateral border of the olfactory fossa) with the lamina cribrosa providing its floor.
The lateral 'lamella of the lamina cribrosa is also the medial wall of the dome of the ethmoid) the
height -and shape of which varies considerably from case to case. Keros and Kainz have assigned
a classification I-III to this surgically very important and critical area. It is here too) where the
topographic relationships of the anterior ethmoidal artery are especially important. The artery, in
its course from the orbit to the olfactory fossa and back into the nasal cavity) traverses thret
compartments of the head: the orbit, the ethmoidal Labyrinth) the anterior cranial fossa and finally
down into the nose again. The artery can be the source of significant intraoperative bleeding when
injured. At the point where the artery enters the anterior cranial fossa through the lateral lamella
of the lamina cribrosa, the thinnest bony structures of the entire anterior skull base can be
encountered. It is here where the very thin lateral lamella of the lamina cribrosa presents the least
resistance to any instrument, with a bony thickness frequently only 10 percent as strong as the roof
of the ethmoid.
After its origin from the ophthalmic artery in the orbit, the anterior ethmoidal artery passes
between superior oblique and medial rectus muscles, through the anterior ethmoidal foramen into
the anterior ethmoid complex. It crosses the anterior ethmoid either at the level of the ethmoidal

roof or as much as 5 mm below this level, running in a mucous membrane fold or a thin bony
mesentery in the roof of the anterior etlunoidal sinuses. The artery may be surrounded by only a
thin-walled bony channel, which can be dehiscent in over 40 percent inferiorly. After this
occasionally oblique passage through the anterior ethmoid, the artery enters the olfactory fossa,
i.e. intracranially through either the lateral lamella of the lamina cribrosa or where this attaches to
the frontal bone of the ethmoidal roof. The longer the lateral lamella of the cribriform plate, i.e.
the deeper the olfactory fossa and with that, the higher the ethmoidal roof above the level of the
cribriform plate - the more likely the ethmoidal artery is to be found travelling freely through the
ethmoid cavity and penetrating through the lateral lamella of the cribriform plate. After intracranial
entry, the artery turns anteriorly forming a groove in the lateral lamella, the so- called ethmoidal
sulcus. Here, it gives off anterior meningeat branches and finally reaches the nasal cavity again
through the cribroethmoidal foramen and the cribriform plate. It is here where it divides into the
anterior nasal artery with superior, lateral and medial nasal branches, as well as a posterior branch.
This division may take place before or after its passage through the lamina cribrosa. The anterior
ethmoidal artery has been estimated to be unilaterally absent in 14 percent, bilaterally absent in 2
percent and multiple in 30 percent. If the anterior ethmoidal artery is absent, it is replaced by a
branch of the posterior ethmoidal artery.
The bony structures in the immediate vicinity of the anterior ethmoidal artery may show
remarkable variation in thickness. Those parts of the roof of the ethmoid that are formed by the
frontal bone are much thicker and stronger than the lateral wall of the olfactory fossa, which is
formed by the lateral lamella of the cribriform plate. The frontal bone at the roof of the ethmoid
has a mean thickness of 0.5 mm, whereas the lateral lamella of the cribriform plate averages only
0.2 mm. In the ethmoidal sulcus, the thickness of the wall may be reduced to 0.05 mm, and is
therefore by a factor of ten thinner than the roof of the ethmoid The length of the ethmoidal sulcus
can vary between 3 and 16 mm. The height of the lateral lamella of the cribriform plate is also
variable (1-17 mm) and the ethmoid roofs themselves are often asymmetric ( 1 0 percent) with the
right more often lower than the left.
At the calvarium, the dura mater is only loosely attached to skull In the region of the
olfactory fossa, however, the dura is not only thinner, but is firmly attached to the bone, partially
where anterior ethmoidal artery and the olfactory filaments pass through the cribriform plate. In
the majority of cases, the anterior ethmoidal artery is intradural on its way through the olfactory
fossa. Trauma in this region, therefore, may easily lead to dural tears with subsequent CSF leakage
and, possibly, even intracranial bleeding from branches of the anterior ethmoidal artery.
SU PER I O R M EATUS
This meatus is again defined by its relationship to the superior turbinate. The posterior
ethmoidal cells open into this region.
A supreme turbinate is discernible above the superior meatus in 60--67 percent of subjects,
though is well developed in less than 20 percent. Drainage to the corresponding supreme meatus
from the posterior ethmoidal system can take place under these circumstances.
POSTERI O R ETH MO I D CO M PLEX
The ground lamella of the middle turbinate is the border between anterior and posterior
ethmoidal sinuses. All clefts and cells opening posterior to the basal lamella belong to the posterior
ethmoid in the superior (and occasionally supreme) meatus. The sphenoid sinus ostium opens into
the sphenoethmoidal recess medial to the superior turbinate.

The number of cells that make up the posterior ethmoid varies between one and more than
five. The topography of the most posterior cell of the posterior ethmoid, however, is of great
importance to sinus surgeons, since these cells can develop laterally and even superiorly to the
sphenoid sinus. In these cases, the optic nerve and even internal carotid artery may bulge into these
sphenoethmoidal cells, named previously after the Austro-Hungarian, Onodi. The optic nerve
tubercle may appear very prominently on the lateral wall of such a cell and may, in fact, be
surrounded by such cells.
SPH ENOETH M O I DAL RECESS
The sphenoethmoidal recess lies medial to the superior turbinate and is the location of the
ostium of the sphenoid sinus.
H I STOLOGY OF THE LATERAL WALL
The majority of the lateral wall is covered by respiratory ciliated columnar epithelium
though there is a small variable area superiorly of olfactory epithelium spreading down from the
cribriform plate. Areas of squamous metaplasia are often found on the lateral wall, particularly in
areas subject to greatest airflow, such as the anterior inferior turbinate.
B LOOD SU PPLY OF THE LATERAL WALL
The external and internal carotid arteries supply the lateral wall (Figure 1 04.36) . The
sphenopalatine artery (from the maxillary artery and thus external carotid artery) contributes the
majority of the supply to the turbinates and meatus. It enters through the sphenopalatine foramen
which lies just inferior to the horizontal attachment of the middle turbinate and may be damaged
in excessive enlargement of a middle meatal antrostomy. Its branches to the respective turbinates
and meatus enter posteriorly. On the conchae, the vessels are partially embedded in deep grooves.
In the inferior meatus, the sphenopalatine branch dips below the level of the palate to re-emerge
anteriorly, leaving the central portion of the meatus relatively avascular. An area anteriorly is
supplied by a branch from the facial and part of the lateral wall adjacent to the palate receives
blood from the greater palatine. The internal carotid artery contribution is via the ethmoidal arteries
which supply the superior lateral wall. There is considerable overlap between the internal and
external carotid arterial systems on each side and between the right and left sides which may
complicate attempts at arterial ligation in the management of epistaxis.
The vascular supply to the nose is well-developed and this is enhanced by cavernous plexus
found in the lamina propria, in particular on the inferior and middle turbinates, which is controlled
autonomically. The veins of the plexus are between 0. 1 and 0.5 mm wide and anastomose with
each other. In addition, numerous arteriovenous anastomoses are found in the deep mucosa and
around the glands. Venous drainage is to the sphenopalatine veins via facial and ophthalmic
vessels, intracranially via the ethmoidal veins to veins on the dura and to the superior sagittal sinus
via the foramen caecum.
N ERVE S U PPLY OF THE IJHERAL WALL
Apart from the olfactory supply on the superior concha, the lateral wall receives ordinary
sensation from the anterior ethmoidal nerve anterosuperiorly and from branches of the
pterygopalatine ganglion and anterior palatine nerves posteriorly (Figure 104.37) . There is a small
area innervated by the infraorbital nerve anteriorly and an area of overlap between the ethmoidal

and maxillary nerves. The anterior superior alveolar nerve sends a small branch to the anterior
inferior meatus which may be damaged in inferior meatal surgeryaffecting dental sensation.
LYM PHATIC DRAI NAG E OF TH E LATERAL WALL
The lateral wall drains with the external nose to the submandibular nodes anteriorly and to
the lateral pharyngeal, retropharyngeal and upper deep cervical nodes posteriorly.
B LOOD. N ERVES A N D LYM PHATIC DRAI NAG E O F ETH M O I D S I N U SES
The vascular supply is derived from the sphenopalatine and ethmoidal (anterior and
posterior) arteries and drains by corresponding veins. The ethmoid sinuses are innervated by the
anterior and posterior ethmoidal nerves and orbital branches of pterygopalatine ganglion.
Lymphatics drain to the submandibular nodes anteriorly and retropharyngeal nodes posteriorly.