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Surgical Anatomy of
the Paranasal Sinus
M. PAIS CLEMENTE
The paranasal sinus region is one of the most complex This chapter is divided into three sections: develop-
areas of the human body and is consequently very diffi- mental anatomy, macroscopic anatomy, and endoscopic
cult to study. The surgical anatomy of the nose and anatomy. A basic understanding of the embryogenesis of
paranasal sinuses is published with great detail in most the nose and the paranasal sinuses facilitates compre-
standard textbooks, but it is the purpose of this chapter hension of the complex and variable adult anatomy. In
to describe those structures in a very clear and systematic addition, this comprehension is quite useful for an accu-
presentation focused for the endoscopic sinus surgeon. rate evaluation of the various potential pathologies and
A thorough knowledge of all anatomical structures their managements. Macroscopic description of the
and variations combined with cadaveric dissections using nose and paranasal sinuses is presented through a dis-
paranasal blocks is of utmost importance to perform cussion of the important structures of this complicated
proper sinus surgery and to avoid complications. The region. A correlation with intricate endoscopic topo-
complications seen with this surgery are commonly due graphical anatomy is discussed for a clear understanding
to nonfamiliarity with the anatomical landmarks of the of the nasal cavity and its relationship to adjoining si-
paranasal sinus during surgical dissection, which is con- nuses and danger areas. A three-dimensional anatomy is
sequently performed beyond the safe limits of the sinus. complemented with schematic diagrams.
The sinus surgeon must be able to orientate himself or
herself while looking through optical instruments that
Developmental Anatomy
provide better illumination and a greater view of the del-
icate structures of the nose and paranasal sinus. The sur-
Nose Development
geon must also develop a mental three-dimensional ana-
tomical image, allowing himself or herself to know the The embryogenesis of the nose and paranasal sinuses is
precise location, the relationships with vital structures, related to the regional embryology of the cranial-oral-
and especially where the danger points lie. facial region. These primary events occur between the
Besides clinical judgment and technical skills, a com- fourth and eighth weeks of fetal life. The first nasal
petent surgeon must also be a good anatomist. To structures are initially identifiable in the 5 mm, 4-week-
achieve these goals, it is wise to perform a reasonable old embryo.1,2 At this point, there are three developing
number of surgical dissections on cadaveric specimens, facial projections that contribute to the formation of the
attend several dissection courses, and participate in nose: the frontonasal process, the maxillary process, and
many meetings. During the past years the author has or- the mandibular process.
ganized international dissection courses on paranasal The frontonasal process is ectodermally derived, and
sinus surgery with limited numbers of participants. This it develops independently over the forebrain giving rise
is the best way to improve medical teaching, hospital to the forehead and the nasal olfactory placodes. A
practice, and patient care. thickened plaque of ectoderm develops during the
1
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Maxillary Buccopharyngeal
process membrane
Mandibular
process
Hyoid 1st
arch pharyngeal
groove
3rd Arch
Cardiac
bulge
A
Auditory vesicle
Cardiac prominence
B
FIGURE 1–1 Embryo at 4 to 5 weeks. (A) Frontal view: Observe the branchial arch formation and the ruptured
buccopharyngeal membrane. (B) Lateral view.
fourth intrauterine week on each side of the ventral sur- of the nasal placode and the lateral nasal swelling at the
face of this frontonasal elevation. Within a few days lateral side of the nasal placode.3
these thickenings become paired lateral nasal placodes Meanwhile, other outgrowths of mesenchymal origin
(Fig. 1–1). Initially the placodes have a convex external called the maxillary processes grow ventrally from the
surface, but the unequal forward growth of the fron- dorsal ends of the mandibular processes (first visceral)
tonasal swelling (particularly the medial and lateral arch. These maxillary swellings are located at the infero-
sides of the nasal placodes) will transform these surfaces lateral border of the placodes. These three swellings are
into concave nasal grooves. These grooves are well devel- separated from each other by shallow depressions and
oped when the embryo is 32 to 34 days old. They are sur- continue to grow forward and downward. As they do so,
rounded by the medial nasal swelling at the medial side the epithelial linings of the medial and lateral nasal
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swellings fuse inferiorly, and the nasal grooves become pit. As the nasal pit deepens, it becomes the nasal sac. As
blind-ending tubes or pits, called the nasal pits, that will the cavity enlarges, the posterior limiting membrane
ultimately become the nares. The epithelium within the (initially the nasal fin) becomes the oronasal membrane.
pits eventually develops neural processes that extend to- During the forward and downward growth of the vari-
ward the brain to become the olfactory nerves. Thus, the ous facial swellings, each swelling also increases its di-
development of the nasal pits is part of the cranial and mensions in a mediolateral direction. Thus, during the
neural tube formation. transformation of the nasal groove into the primary
The floor of each nasal pit is constituted by the fused nasal cavity, the furrows between maxillary and lateral
medial and lateral nasal swellings and further anteriorly nasal swellings are increased, both on the external sur-
by the fused medial nasal and maxillary swellings. The face and on the internal surface of the lateral wall of the
epithelial lining in the contact plane is called the nasal primary nasal cavity. The early structures responsible for
fin and is disrupted anteriorly by the outgrowth of the the development of the eyes are visible at 28 days. Ini-
surrounding tissues. Posteriorly, this epithelial band per- tially, the early eyes are oriented laterally (80 degrees to
sists for a short period of time in the floor of the nasal the neural axis), but during the next weeks the growth
A B C
2
D E
FIGURE 1–2 Developing face. (A) Fourth week. (B) Fourth eyes forward and toward the midline, the nose development,
to fifth week. (C) Fifth to sixth week. (D) Sixth to seventh the sealing of the nasolacrimal groove (1), and the formation
week. (E) Eighth to tenth week. Note the orientation of the of the upper lip (2) and the philtrum (3).
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of the mesenchyme posterior to the eyes reorients the TABLE 1–1 Derivatives of Facial Components
eyes forward toward the midline. The groove on the ex-
ternal surface is transformed into the nasolacrimal duct Embryonic Part Facial Derivatives Skeletal Derivatives
by the interposition of surface epithelium between the
Frontonasal process Nasal bridge Nasal bones
maxillary and lateral nasal swellings and by the loss of Median nasal Columella of nose Perpendicular plate
contact between this epithelium and the surface epithe- process of the ethmoid bone
lium. It is like an infolded epithelial transformation. Philtrum Vomer
Lateral nasal process Sides and ala of
The groove on the inside surface will develop into the nose
inferior meatus of the nasal cavity. The nasolacrimal Maxillary process Major portion of Maxilla, zygoma,
duct connects the eye to the internal nasal cavity inferior upper lip secondary palate
Upper cheek
to the attachment of the inferior turbinate. As the eye Mandibular process Lower lip, Mandible
migrates from a lateral orientation relative to the devel- Lower cheek
oping nose, the nasolacrimal duct assumes a more
oblique rather than horizontal direction (Fig. 1–2).
The rupture of the oronasal membrane in the 15 mm choana is the premaxilla (primitive palate). The external
embryo takes place between days 42 and 44 in the poste- nares are widely separated by the remaining median
rior floor of the nasal pit, transforming this blind- frontonasal process, which gradually reduces, bringing
ending cavity into a primary nasal cavity that communi- the openings close together.
cates with the primary oral cavity through the newly Simultaneously, other facial structures develop rapidly.
formed opening, or primitive choana.1–3 Lack of disinte- The digestive tube is formed, and the cephalic opening
gration of the oronasal membrane results in choanal of this tube, called the oral stoma, is found just caudal to
atresia. The part of the roof of the mouth in front of the the level of the nasal pits. The branchial clefts and
A B C
D E F
FIGURE 1–3 Development of the nose, mouth, and palate. (A–C) Formation of the nose, upper lip, and philtrum. (D–F) Differ-
ent stages of palate formation and the separation of the nasal and oral cavities.
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from periosteal cells without a preceding formation of appears first and is called the maxilloturbinal. It is
cartilage. followed by five other ethmoturbinals and the naso-
The process of ossification of the nasal capsule in- turbinal. However, through reposition and fusion three
cludes both endochondral and membranous bone for- to four ridges ultimately persist4,9,10 (Fig. 1–5).
mation, although it is microscopically impossible to dif- The maxilloturbinal forms the inferior turbinate,
ferentiate the two. There are a great number of centers which is not considered ethmoid in its embryological
of ossification, and it seems that they follow a pre- origin. The first ethmoturbinal originates at either the
dictable pattern. The first center is located at the ante- superior aspect of the septum or the superior junction
rior edge of what will be the sphenoid bone. This area is of the septum and the lateral nasal wall, and it gives rise
very important because it is considered the growth plate to the middle turbinate. The furrow between the maxil-
for the anterior skull base and face. The second center loturbinal and the first ethmoturbinal eventually devel-
of ossification is in the lateral aspect of the nasal cap- ops into the middle nasal meatus. It is at the primitive
sule. Multiple centers develop thereafter, each of the middle meatus that, during about the 13th week of
nasal and facial bones having at least one center of development, an evagination of the lateral nasal wall
ossification. produces a blind diverticulum: the embryonic in-
fundibulum. The infundibulum is formed by a cord of
epithelial cells that is surrounded by the underlying
Paranasal Sinus Development
mesenchyme. On either side of this structure, the mes-
The embryological development of the paranasal sinus enchyme proliferates, deepening the infundibulum.
is a very complex process, and its description varies The second ethmoturbinal develops shortly after the
among different authors. The growth pattern of the first ethmoturbinal and ultimately forms the superior
paranasal sinus is totally unpredictable and extremely turbinate. The furrow between the superior turbinate
variable from one individual to another, or even from and the middle turbinate is the superior meatus. The
side to side in the same person.8 third ethmoturbinal is the precursor of the supreme
The initial development of the nasosinus cavities takes turbinate, which is present in only 26% of adults.11 The
place early in fetal life, occurring at the same time as the supreme meatus is the furrow between the superior and
growth of the palate below, facial structures anteriorly, the supreme turbinates. All of these structures are con-
and the cerebral cranium above. The paranasal sinuses, sidered to be ethmoid in their origin.
with the exception of the sphenoid sinus, arise as evagi- The nasoturbinal is an additional prominence ante-
nations from the lateral nasal wall. rior and superior to the ethmoid furrow or middle nasal
At the begining, the lateral nasal wall is a smooth, meatus and will develop into the agger nasi. At about the
undifferentiated structure, but during the seventh same time it is identified another mesenchymal ridge,
gestational week it starts to develop. A projection into called the uncinate process, develops on the superior
the nasal capsule just superior to the palatal shelves and posterior border of the agger nasi. The uncinate
Frontal
furrows Suprabullar
furrow Ethmoid
bulla
Agger
Supreme
nasi cell
turbinate
Superior
turbinate
TABLE 1–2 Classification of Lamellae The ethmoid sinus is well developed at birth. During
the second year after birth the air cells may grow beyond
First basal lamella Lateral extension of uncinate process the confines of the ethmoid bone into the surrounding
Second basal lamella Lateral extension of ethmoid bulla bones: maxilla, frontal, lacrimal, and sphenoid. The
Third basal lamella Attachment of middle turbinate
Fourth basal lamella Attachment of superior turbinate growth pattern of the ethmoid sinus is completely un-
Fifth basal lamella Attachment of supreme turbinate predictable, and development will continue until the
(when present) ethmoid has reached almost adult size by the age of 12
years. Some further enlargements may take place in
rior turbinate), and fifth basal lamella (attachment of early adulthood.
the supreme turbinate) when present (Fig. 1–7). The The ethmoid sinus cells are divided into anterior and
sinus cells during their development may stretch the posterior groups based on their initial sites of pneumati-
lamellae but do not break through them, thereby retain- zation and the subsequent locations of their ostia
ing the integrity of each of the compartments. (Fig. 1–8). Ethmoid cells may be further characterized
During primary pneumatization, the rudiments of the on the basis of the skeletal structures they pneumatize.
ethmoid sinus consist of dimple-like depressions of the Thus, it is possible to define groups of cells as remaining
nasal mucosa into the nasal capsule. These depressions within the ethmoid and others as lying beyond the
may originate from any of the mucosal furrows in the ethmoid.
middle meatus or along the mucosa of the superior mea- Ethmoid cells that belong to the ethmoid bone in-
tus, which is, itself, no more than a furrow at this time. clude the conchal, bullar, infundibular, and frontal re-
The depressions gradually deepen and become globular cess cells. Among those that extend beyond the ethmoid
air cells. As development progresses and these cells bone are the agger nasi cells (anterior ethmoid cells that
reach maximum growth and encroach on adjacent bony pneumatize the agger nasi on the medial surface of the
cells, they become flattened. frontal process of the maxilla and lacrimal bone),
Lacrimal bone
Lamella of uncinate process
Lamella of bulla
Lamella of middle turbinate
Lamella of superior turbinate
Lamina papyracea
Agger nasi cells
Sphenoid sinus
Uncinate process
Cut edge of
superior turbinate
Ethmoid bulla
Hiatus semilunaris
Uncinate process
Maxillary ostium
Accessory maxillary ostium
Inferior turbinate
Cut edge of middle turbinate
FIGURE 1–8 Bony anatomy of the various drainage systems of the paranasal sinuses.
frontal sinus cells (anterior ethmoid cells that pneuma- which they finally reside. For example, the frontal sinus
tize the frontal bone), orbital cells (anterior ethmoid is, in reality, often formed by displaced anterior eth-
cells that pneumatize the orbital roof), and palatine moid cells.
bone and sphenoid bone cells (posterior ethmoid cells In the superior meatus there is a ridge in the lateral
that pneumatize these bones). wall that is similar to the uncinate process. An acces-
The ethmoid sinus is responsible for cellular colo- sory swelling is also seen there that resembles the eth-
nization into the surrounding structures: anteriorly, the moid bulla of the middle meatus. A variety of struc-
agger nasi; superiorly, the frontal sinus; posteriorly, the tures of the superior nasal meatus are reminiscent of
sphenoid sinus; inferiorly, the uncinate process; later- those that develop more completely in the middle
ally, the orbital bony structures; and medially, the me- meatus. The superior meatus is the origin of most of
dial surface of the middle turbinate to produce a mid- the posterior ethmoid air cells. These cells may also
dle turbinate concha bullosa. This haphazard growth grow laterally into the junction of the nasal capsule and
makes the ethmoid sinus different from one individual orbit posterior to the maxillary sinus cleft. Expansion
to another. The cells that are located within the eth- of these cells into the posterior, lateral, and superior as-
moid bone are termed intramural cells, whereas those pect of the maxilla is the usual origin of the ethmomax-
whose development involves an adjacent bone such as illary cells (Haller’s cells).9,10,12 These cells may be
the maxilla, lacrimal bone, frontal bone, or sphenoid small or even of significant size, and those of maximum
bone are called extramural cells (Fig. 1–9). Regardless development may give the appearance of an accessory
of their origins, the sinuses are named for the bone in maxillary sinus (Fig. 1–10).
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A B C
FIGURE 1–13 Anatomical variations of the sphenoid sinus pneumatization. (A) Conchal or fetal type. (B) Presellar or juvenile
type. (C) Sellar or adult type.
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Macroscopic Anatomy
Nasal Cavity
Crista galli
Frontal bone
and sinus
Cribriform plate
Nasal bone Sphenoid sinus
and bone
Occipital
Greater alar bone
cartilage
Perpendicular plate
Septal cartilage
Vomer
Palatine bone
moid bone and is often referred to as the olfactory area. the lower and upper cartilages. The upper margin of the
The descending posterior part of the roof of the nasal septal cartilage is connected to the posterior border of
cavity is constituted by the anterior wall of the sphenoid the internasal suture and to the upper lateral cartilages.
sinus. The sphenoethmoid recess lies in this posterior Anteriorly, this cartilage is related to the medial crura of
segment. The junction between the vertical anterior wall the lower lateral cartilages at its superior level, and inferi-
and the horizontal floor of the sphenoidal sinus marks orly, it rests on the anterior nasal spine. This spine is an
the end of the nasal cavity and forms the boundary of extension of the maxillary crest, and it is positioned like
the choana. the prow of a sailing ship. Also, inferiorly the quadrilat-
eral cartilage sits in the groove of the maxillary crest. The
FLOOR bony elevation on the floor of the nose on which the en-
The bony floor of the nasal cavity is formed by the pre- tire cartilaginous septum sits is shaped much like the
maxilla, the maxilla, and the horizontal plate of the lines of a railroad track. The bony segment of the nasal
palatine bone in the posterior portion. The floor is ∼4.5 septum includes the perpendicular plate of the ethmoid
cm long and continues posteriorly into the soft palate. It bone and the vomer. The perpendicular plate forms the
extends laterally into the inferior meatus and medially upper and anterior part of the bony septum and is con-
to the nasal septum. tinuous above with the cribriform plate. The vomer is lo-
cated below and behind the perpendicular plate of the
MEDIAL WALL ethmoid bone. The long anterior border of the vomer ar-
The medial wall of the nasal cavity is represented by the ticulates with the perpendicular plate superiorly and
septum, which is composed of cartilaginous and bony with the quadrilateral cartilage inferiorly. The inferior
segments (Fig. 1–15). The cartilaginous segment consists border is related to the nasal crest formed by the maxil-
of the quadrilateral cartilage, with a contribution from lae and the palatine bones.
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A B
C D
Paranasal bones:
Maxilla
Lacrimal
Palatine
Sphenoid
Inferior turbinate
Ethmoid
Frontal
Nasal
E
FIGURE 1–16 Osteology of the right lateral nasal wall (D) Articulation of the maxilla with the inferior turbinate.
(medial view). (A) Articulation of the maxilla with the lacrimal (E) Articulation of the maxilla with the ethmoid labyrinth and
bone. (B) Articulation of the maxilla with the palatine bone. nasal bone.
(C) Articulation of the maxilla with the sphenoid bone.
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These structures of the nasal septum are covered by eral nasal wall covered by ciliated columnar mucous ep-
a mucosal envelope of mucoperichondrium and mu- ithelium. The superior, middle, and inferior turbinates
coperiosteum. are present in almost all individuals, and a very small
supreme turbinate may also occur. The supreme, supe-
LATERAL NASAL WALL rior, and middle turbinates are included in the ethmoid
The lateral nasal wall is a very complex anatomical struc- bone. The inferior turbinate is an independent bone.
ture and a very important area clinically. The lateral wall The air spaces below and lateral to the turbinates are
of the nasal cavity can be divided into three areas: named the superior, middle, and inferior meatus, re-
Anteriorly, the lateral nasal wall consists of the frontal spectively. They communicate with the common nasal
process of the maxilla and the lacrimal bone; the middle cavity at the lower edge of each meatus (Fig. 1–18).
area is formed by the ethmoid labyrinth, the maxilla, The inferior surfaces of the free-hanging portions of
and the inferior turbinate; and the posterior portion of the turbinates are almost parallel to the nasal floor, but
the lateral nasal wall is represented by the perpendicular their supporting attachments usually are oriented diag-
plate of the palatine bone and the medial pterygoid onally from posterior-inferior to anterior-superior.
plate of the sphenoid bone. The osteology of the lateral Each supporting portion is called a primary lamella.
nasal wall is complex and represented by eight bones, There are five lamellae located from anterior to poste-
which are articulated in such a way as to build up a firm rior: the uncinate process, the ethmoid bulla, the basal
bony structure (Fig. 1–16). lamella of the middle turbinate, the basal lamella of
The most important features of the lateral wall of the superior turbinate, and the fifth lamella of the
the nasal cavity are the turbinates (Fig. 1–17). There are supreme turbinates when present (Fig. 1–7). The supe-
usually three (or rarely four), and they appear as deli- rior and supreme turbinate lamellae are relatively
cate shelflike bony structures protruding from the lat- horizontal.
Frontal sinus
Middle turbinate
Superior turbinate
Sphenoid sinus
Pharygeal
tonsil
Vestibule
Inferior turbinate
Opening of auditory tube