2015

Carlos Pinheiro-Neto

THE ALBANY MANUAL OF DISSECTION

OF THE NOSE AND SINUSES
 THE ALBANY MANUAL OF DISSECTION
OF THE NOSE AND SINUSES

Carlos D. Pinheiro-Neto MD PhD

Assistant Professor
Co-Director Cranial Base Surgery Program
Department of Surgery / Division of Otolaryngology
Albany Medical Center
Albany, New York



Contributors

Maria Peris-Celda MD PhD
Department of Neurosurgery
Albany Medical Center
Albany, New York

Tiago Fernando Scopel MD
Department of Otolaryngology
Federal University of Mato Grosso do Sul
Campo Grande, Mato Grosso do Sul, Brazil.

Marcelo Charles Pereira MD
Department of Surgery / Division of Otolaryngology
Albany Medical Center
Albany, New York

ALL RIGHTS RESERVED. NONE OF THE CONTENTS OF THIS MANUAL MAY BE REPRODUCED IN A RETRIEVAL SYSTEM OR TRANSMITTED IN
ANY FORM OR BY ANY MEANS (ELECTRONIC, MECHANICAL, PHOTOCOPYING, RECORDING OR OTHERWISE) WITHOUT PRIOR WRITTEN
PERMISSION OF THE AUTHOR
INTRODUCTION

This manual is a guidance for sinonasal anatomy study and dissecRon with focus on the

endoscopic surgical anatomy. First a review of the endoscopic anatomy of the nasal cavity is

provided. Then, funcRonal endoscopic sinus surgery is demonstrated step-by-step. Finally,

dissecRons of the infraorbital area and pterygopalaRne fossa are showed.

All images were taken from the right nasal cavity. The 0o endoscope was used in most of

the photos. Pictures taken with a 45o endoscope are highlighted in the legends.

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 Nasal Cavity and Nasopharynx
Middle turbinate

Inferior turbinate

Inferior meatus

Nasal septum

Horizontal porRon
middle turbinate

Choana

Tail of the inferior turbinate

Nasopharynx

Fossa of Rosenmller

Salpingopharyngeal fold
of the torus tubarius

SalpingopalaRne fold
Eustachian tube
of the torus tubarius

Nasopharyngeal osRum
of the Eustachian tube

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 Inferior Meatus

Middle turbinate

Inferior turbinate

Inferior meatus

Nasal septum

Inferior meatus

Nasolacrimal duct
opening in the inferior
meatus
(Hasner`s valve)

45o endoscope looking up to the roof of

the inferior meatus.

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Sphenoethmoidal Recess

Middle turbinate

Inferior turbinate

Nasal septum

Supreme turbinate

Superior turbinate

Middle turbinate

Sphenoid sinus
osRum

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 Middle Meatus
VerRcal porRon
middle turbinate

Uncinate process

Ethmoid bulla

Nasal septum

Retrobullar recess and

Superior semilunar hiatus
(groove that communicates
the retrobullar recess and
the middle meatus)

Ethmoid bulla

Uncinate process

Ethmoidal infundibulum and

Inferior semilunar hiatus
(crescent shape groove that
communicates the ethmoidal
infundibulum to the middle
meatus)

Uncinate process

Ethmoid bulla

45o endoscope looking up to the frontal

sinus recess

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 Uncinectomy

Uncinate process

Middle turbinate

Uncinate process incision

Ethmoid bulla

Observe the uncinectomy opens the

ethmoidal infundibulum

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Uncinectomy

Superior cut
uncinate process

Middle turbinate

Uncinate process incision

Ethmoid bulla

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 Maxillary Antrostomy

Uncinate process

Middle turbinate

Maxillary sinus

Lamina papyracea

Diagnonal porRon
Middle turbinate
or
Basal lamella
(It divides the anterior
and posterior ethmoid)

Ethmoid bulla

Maxillary sinus

LateralizaLon of the ethmoid bulla to

expose the retrobullar recess and the
diagonal porLon of the middle turbinate

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Frontal Sinusotomy (Draf I)

Superior a`achment
of uncinate process

Middle turbinate

Ethmoid bulla

Superior a`achment
of uncinate process

Draf I: Removal of the superior aPachment

of the uncinate process

Frontal sinus

All pictures: 45o endoscope looking to

the frontal sinus

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Frontal Sinusotomy (Draf IIA)
Frontal sinus

Orbit

Middle turbinate

Draf IIA: Exposure from the orbit to the

middle turbinate

Frontal Sinusotomy (Draf IIB)

Frontal sinus

Orbit

Posterior table frontal sinus

Superior nasal septum

Draf IIB: Exposure from the orbit to the

superior nasal septum

Frontal Sinusotomy (Draf III)

Anterior table frontal sinus

Frontal sinus

Posterior table frontal sinus

Draf III: Drill out of the frontal beak,

interfrontal septum and superior nasal
septum.

Olfactory clea

All pictures: 45o endoscope

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 Ethmoid Bulla Removal

Lamina papyracea

Ethmoid bulla

Maxillary sinus

Middle turbinate

Ethmoid bulla removal

Diagnonal porRon
Middle turbinate
or
Basal lamella
(It divides the anterior
and posterior ethmoid)

VerRcal porRon
Middle turbinate

Horizontal porRon
Middle turbinate

ASer complete removal of the anterior

ethmoid

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Posterior Ethmoidectomy

Basal lamella

VerRcal porRon
Middle turbinate

Horizontal porRon
Middle turbinate
Maxillary sinus

Basal lamella should be opened inferior

and medial (circle)

Posterior ethmoid

Further opening of the posterior ethmoid

should be carried inferior and medial

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Posterior Ethmoidectomy

Superior turbinate

Further opening of the posterior ethmoid

should be carried inferior and medial

Orbit

Posterior ethmoid

Superior turbinate

Anterior ethmoidal artery

Anterior skull base

Orbit

Anterior wall of the sphenoid sinus

Horizontal porRon
Middle turbinate
Maxillary sinus
ASer complete removal of the posterior
ethmoid cells

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Transethmoidal Sphenoidotomy

Skull base

Orbit

Anterior wall of the sphenoid sinus

The transethmoidal opening of the sphenoid

sinus should be performed inferior and medial

Posterior ethmoidal artery

OpRc nerve

Internal caroRd artery

Sella

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 Transnasal sphenoidotomy

Natural osRum sphenoid sinus

Superior turbinate

Nasal septum

Planum sphenoidale

OpRc nerve

Paraclinoid internal caroRd artery

Sella

Paraclival internal caroRd artery

Clival recess

Unilateral sphenoidotomy

Planum sphenoidale
OpRc nerve
OpRcocaroRd recess (OCR)
Paraclinoid internal caroRd artery

Intersphenoid septum

Paraclival internal caroRd artery

Clival recess

Bilateral sphenoidotomy for transphenoidal

approaches to pituitary tumors

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Endoscopic Approach to the
Infraorbital Nerve

Orbital oor

Infraorbital groove

Posterior wall maxillary sinus

Orbital oor

Infraorbital artery

Infraorbital nerve

Infraorbital artery

Infraorbital nerve

All pictures: 45o endoscope looking to the

maxillary sinus

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 PterygopalaLne Fossa

Orbital process palaRne bone

SphenopalaRne artery

Posterior maxillary sinus wall

SphenopalaRne artery

ASer removal of the posterior maxillary sinus

wall and incision of the periosteum of the
pterygopalaLne fossa

Maxillary nerve (V2) at

foramen rotundum

SphenopalaRne artery

Descending palaRne artery

Maxillary artery

PterygopalaRne ganglion
Greater palaRne nerve
Neurovascular structures of the
pterygopalaLne fossa

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