Ecr2017 C-2117

CT anatomy of paranasal sinuses.
Poster No.: C-2117

Congress: ECR 2017
Type: Educational Exhibit
Authors: 1 2 1 1
O. Dib , H. Chahinez , B. Asma , C. abdelouahab , M. Ourrad El ,
3
1 1 2 3
B. Nacereddine ; Algiers/DZ, 16000/DZ, Alger/DZ
Keywords: Anatomy, Ear / Nose / Throat, CT, Education, eLearning,
Education and training
DOI: 10.1594/ecr2017/C-2117
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Page 1 of 66
Learning objectives
•To recall the normal anatomy of paranasal sinuses.
•To know anatomic variations of paranasal sinuses.
•To have a systematic way in looking for these variations in a CT scan.
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Background
1.The paranasal sinuses are the frontal, ethmoid, sphenoid and maxillary sinuses,
housed within the bones of the skull (figure 1).
All sinuses open into the lateral wall of the nasal cavity through their corresponding ostia
(figure 2).
The lateral wall of nasal cavity has three projections of bone called superior, middle and
inferior nasal conchae.
The space below each concha is called a meatus.
• Inferior meatus: receives opening of lower end of nasolacrimal duct.

• Middle meatus: Lies below the middle concha, It has a rounded swelling
called bulla ethmoidalis, which open on its upper border. Hiatus semilunaris
is a curved opening lying just below the bulla and receives opening of
maxillary sinus. Infundibulum is a funnel-shaped channel at anterior end of
hiatus.
• Superior meatus receives openings of posterior ethmoid sinuses.
• Sphenoethmoidal recess: is a small area above superior concha and
receives the opening of sphenoid air sinus.
2.The aim of nasal and paranasal sinuses imaging is to provide a surgical road map
describing the anatomy, defining the obstructive lesions, and noting the anatomical
factors that may predispose impaired mucociliary clearance and per operative
complications.
3.The CT scan is the gold standard investigation in all sinus diseases, when performed
it allows to identify:
• Obstruction of the drainage pathways or anatomic variants that may

compromise already narrow drainage pathways.
• Identification of critical anatomic areas where anatomic variants pose special
risks during sinus surgery.
• Local extension of disease.
• Complications.
4.How to perform a CT imaging?
• Medical treatment should be given before CT scan to reduce transient acute

inflammatory or infectious mucosal changes.
• Anatomy is adequately assessed without the use of IV injected ionated
contrast material.
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• The acquisition is accomplished in supine position with 1mm thick
overlapping axial slices (figure 3).
• Coronal, sagittal or oblique reformations are helpful for a good interpretation
(figure 4).
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Images for this section:
Fig. 1: Figure 1. Anatomic representation of paranasal sinuses
© RADIOLOGY, AIN NADJA HOSPITAL - Algiers/DZ
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Fig. 2: Figure 2. Coronal and sagittal CT slices showing the paranasal sinuses drainage
pathways.
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Fig. 3: Figure 3. CT scan acquisition in supine position from the top of the frontal sinuses
to bottom of the alveolar process of the maxillary sinus ( red arrow), with a 1mm thick
axial slices.
Fig. 4: Figure 4. Axial, coronal and sagittal planes are helpful for a good interpretation
of a paranasal sinuses CT scan.
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Findings and procedure details
A/ CT anatomy:
1. Ostiomeatal unit:
• It is a complex anatomic region at crossroads of mucociliary drainage from

frontal, anterior ethmoid sinuses and maxillary sinuses.
• Components of anterior osteomeatal unit are (figures 5, 6):
Maxillary ostium: drainage channel of maxillary sinus.
Infundibulum: common channel that drains the ostia of maxillary and
ethmoid sinuses to the hiatus semilunaris.
Uncinate process: hook like process that arises from posteromedial aspect
of nasolacrimal duct and forms the anterior boundary for hiatus semilunaris.
Ethmoid bulla: usually a single air that projects inferomedially over hiatus semilunaris.
Hiatus semilunaris: final drainage passage, region that between ethmoid bulla superiorly
and free edge of uncinate process.
• Uncinate process (UP):
The uncinate process, is the most important structure of the ostiomeatal unit.
The UP prevents the direct contact of the inspired air with the maxillary sinus, acting like
a shield, and plays a role in mucociliary activity.
The UP is a thin, semi-circular bony process of variable length and covered with the
mucosa.
It is a thin curved bony lamina of variable height from the lateral side of the ethmoid
labyrinth, that forms a portion of the lateral nasal wall.
It has different attachments (figure 8):
Inferior attachment to the neck of the inferior turbinate.
Supero-anterior attachement to lamina papyracea in 50%.
Postero-lateral attachment to the roof of the maxillary sinus.
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Anterior attachment of the uncinate process.
• Ethmoid bulla:
Ethmoid bulla is the most posterior of all anterior ethmoid air cells.
It is the roof of the hiatus semilunaris and posterior ethmoid infundibulum.
The relationship of ethmoid bulla with lamina paprisea in lateral, and the relationship of
frontal cranial fossa in superior with base should be clarified in preoperative CT (figure 9).
The degree of pneumatization may be highly variable (figure 10), from a giant ethmoid
bulla that pushes the UP medially to torus ethmoidalis without pneumatization.
• Middle turbinate
It attaches superiorly to the cribriform plate (medial lamella).
It attaches posteriorly and laterally to the lamina papyracea: basal(ground) lamella (figure
11).
It lies inferomedially to the anterior ethmoidal air cells.
Anterior: oriented in sagittal plate and it is vertically attached to the cribriform plate.
Middle: oriented in frontal plate and it is attached to the lamina papyracea or basal lamella
laterally; it separates anterior and posterior ethmoids (figure 12).
Posterior: oriented in horizontal plate and it's attached to the perpendicular plate of palate.
Different sizes of middle turbinate may be seen (figure 13).
• Frontal recess
It's bordering anatomical structure forming the walls of the passage from frontal sinus to
the middle meatus.
It is not strictly a duct but a channel located between anterior ethmoid cells.
It is the space posterior to the frontal beak (nasal process of the frontal bone), between
the lamina papyracea and the vertical lamella of the middle turbinate continuing on to
the lateral wall of the olfactory fossa and is anterior to the basal lamella of the middle
turbinate (figure 14).
• Frontal sinus ostium
The frontal ostium is defined as the narrowest area of the transition zone from the frontal
sinus to the frontal recess with its anterior edge formed by the frontal sinus beak and
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the posterior edge formed by the skull base (best seen on the parasagittal computed
tomography [CT] scan) (figure 13).
The lateral boundary of the frontal ostium is the lamina papyracea and the medial
boundary, the upward extension of the vertical lamella of the middle turbinate and lateral
wall of the olfactory fossa.
• Sphenoethmoidal recess
The sphenoethmoidal recess, also called the posterior ostiomeatal unit, drains the
posterior sinuses (posterior ethmoidal and sphenoid) (figure 15).
• Olfactory fossa:
It is a variable depression seen in cribriform plate that medially bounded by perpendicular

plate and laterally by lateral lamella.
Lateral lamella is the point of structural weakness in the anterior skull base.
The fovea ethmoidalis is a part of the frontal bone that separates the ethmoidal cells from
the anterior cranial fossa.
The fovea ethmoidalis also medially connects with the lateral lamella of the cribriform
plate (Figure 18).
• Anterior ethmoid foramen:
It is a small opening in the ethmoid bone and transmits the anterior ethmoid artery and
nerve.
It is the anatomical border for anterior and posterior ethmoid air cells in coronal plate
(figure 19).
B/ Anatomic variants:
• Anatomical variations are which damage the normal functional drainage

pathways and increase the risk of surgeries.
• Identification of these anatomic variants of paranasal sinus helps the
surgeons to access sites of diseases which are extremely difficult.
• Deviated nasal septum:
The nasal septum may be focally deviated inferiorly at the chondro-vomeral junction or
have a more broad based curvature.
It is most of the time associated with asymmetry of the adjacent turbinates (figure 20).
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Septal spurs is a generally asymptomatic bone deformity that may cause restriction of the
nasal air flow, it may be associated with septal deviation, which makes surgical access
difficult and narrow the middle meatus or ethmoid infundibulum (figure 21).
Septal spurs are frequently encountered at the junction of the perpendicular plate of the
ethmoid and the vomer.
• Middle turbinate:
Concha bullosa is a variation originated from pneumatization of the bone plate by

extension of ethmoid sinus cells.
Such variation may be either uni- or bilateral (figure 22).
Varied degrees of pneumatization of the concha may be observed, possibly causing

middle meatus or infundibulum obstruction, besides being related to deviation of the nasal
septum to the contralateral side (figure 23).
Paradoxical turbinates occur as the convexity of the middle turbinate is directed towards
the medial wall of the maxillary sinus (figure 24).
Depending on the degree of curvature of the paradoxical turbinate; compression of the

infundibulum and sinusal obstruction may be observed.
Pneumatized superior turbinate;In some cases the pneumatization may happen in the
superior turbinate (figure 25) .
• Uncinate Process (UP) variations
Variations of the superior attachment of the uncinate process :
Landsberg and Friedman described six different types related to the position of the
superior attachment of UP and presented more detailed information relating to the
superior attachment, by an imaging technique (Figures 26, 27).
The variability of the UP's anterosuperior attachment affects the drainage of the frontal
recess.
The most common superior attachment of uncinate process is to the lamina papyraceae
followed by the attachement to the agger nasi air cell anteriorly, in these two cases the
frontal recess is drained into the middle meatus.
UP can be attached to the middle concha, this causes the frontal recess to move toward
the agger nasi posteriorly.
Rarely the skull base can be reached and the frontal recess can be drained Into the
ethmoid infundibulum.
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Uncinate bulla
The aeration of UP is called uncinate bulla (figure 28) .
This variation increases the wideness of the uncinate, so it constitutes to be potentially

dangerous for the infundibulum.
It can act like a concha bullosa or a widened ethmoid bulla.
Deviation of the tip of the uncinate
The UP can show lateral deviation, obstructing infundibulum and/or semilunar hiatus or
medial deviation, affecting the middle meatus (figure 29).
According to John Earwaker, six (06)Types of ostiomeatal complex abnormalities can

be encountered depending on the deviation of the UP and the type of the ethmoid bulla
(figure 30).
Atelectatic UP
Sometimes, UP's free end shows hypoplastic development and attaches to orbit medial
wall or inferior section of lamina paprisea.
This condition is called atelectatic UP.
Generally, it is seen together with an opacified hypoplastic maxillary sinus.
• Frontal sinus
The frontal recess is the space into which the frontal sinus drains.
This space is usually occupied by a number of cells that affect the direction and position
of this drainage pathway.
A consensus classification (IFAC) which allows more precise naming based on the
position of the cells as well as how these cells affect the frontal drainage pathway, has
been established (table 1).
Agger nasi cells (ANC):
The most constant and anterior of ethmoid air cells.
It is located anterior to the vertical attachment of middle turbinate to the skull base.
Forms the floor of the frontal recess.
It reaches the lacrimal fossa inferiolaterally, and is anterolaterally arched by the nasal
bone (figures 31, 32).
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A large agger nasi can impige on and distort the frontal recess.
The posterior-medial wall usually gives rise to the anterior uncinate process.
Supra agger cell (SAC):
SAC sits above the ANC behind the beak of the frontal bone (figure 33).
In this classification a SAC may be a single cell or consists of a number of cells sitting
above the ANC and may affect the frontal drainage pathway depending as to whether it
is situated medially or laterally.
Supra agger frontal cell (SAFC):
This cell does not extend significantly into the frontal sinus but occupies a portion of the
floor of the frontal sinus (figures 34, 35).
Supra bullar cell
Suprabullar cell (SBC) is the cell sitting directly above the bulla ethmoidalis and the
anterior wall of the SBC almost in continuity with the anterior face of the bulla ethmoidalis
(figure 36).
Supra bulla frontal cell
SBFC is a pneumatization through the frontal ostium into the frontal sinus, with the skull
base forming the posterior wall of the cell and the cell the cell pushes the frontal sinus
drainage pathway anteriorly (figure 37).
Supra orbital ethmoid cell (SOEC)
The SOEC takes its origin from around and above the anterior ethmoid artery.
The cell is seen to pneumatize over the orbit, making this an SOEC rather than an SBFC.
Frontal septal cell
The cell can be seen originating from the region of the interfrontal sinus septum and
occupying a significant part of the frontal drainage pathway, pushing this pathway laterally
and often posteriorly (figure 39).
The cell sitting higher in the frontal sinus and narrowing the frontal sinus drainage pathway
as the frontal sinus transitions into the frontal recess.
• Infra orbital cells (Haller cells):
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Haller cell is located inferiorly and anteriorly to the ethmoid bulla, and grow into the floor
of the orbit, adjacent to the natural ostium of the maxillary sinus, which may narrow the
maxillary sinus ostium (figure 40).
• Maxillary sinus:
The anatomic variations of maxillary sinus are common findings in CT.
It can exhibit anatomic variations such as: antral septa, pneumatization, hypoplasia,
exostosis and variations in location of the arteries.
Maxillary sinus septations:
Maxillary sinus septa are thin walls of cortical bone present within the maxillary sinus,
with variable number, thickness and length.
often extends from the infra orbital canal to the lateral wall (figure 41).
The maxillary sinus pneumatization:
Four recesses have been described, as follows (figures 42, 43):
The palatine recess that extends inferomedially to the hard palate towards the midline.
The alveolar recess, closely related to the molar and premolar teeth roots.
The infraorbital recess, projecting anteriorly along the roof of the maxillary sinus.
The zygomatic recess that extends over the malar bone at variable distances.
Protrusion of the ION into the maxillary sinus:
The infraorbital nerve arises from the maxillary branch of the trigeminal nerve and
normally traverses the orbital floor in the infraorbital canal.
Sometimes, however, the infraorbital canal protrudes into the maxillary sinus separate
from the orbital floor (figure 44).
• Onodi cell:
The Onodi cell has been defined by the Anatomic Terminology Group as being the most
posterior ethmoid air cell that pneumatizes superiorly and laterally to the sphenoid sinus
and which is in intimate relation to the optic nerve.
The posterior ethmoid cells were classified into four types depending on their relation to
the optic nerve canal as follows (figures 45, 46, 47 & 48):
· Type A: no contact observed between the wall of the ethmoid cell and optic nerve canal.
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· Type B: the ethmoid cell wall being adjacent to the wall of the optic nerve canal at
a maximum distance of 2 mm (as measured in the axial and sagittal planes), but not
extending laterally or supero-laterally.
· Type C: the ethmoid cell wall being adjacent the optic nerve canal wall at a distance
greater than 2 mm in the axial and/or sagittal planes extending laterally or supero-laterally
without any bulging of the optic nerve canal into the ethmoid bone.
· Type D: the ethmoid cell wall being adjacent the optic nerve canal wall at a distance
greater than 5mm (as measured in the axial or sagittal plane), extending supero-laterally
with optic nerve bulging.
This bulging being defined as a protrusion of the optic nerve into the ethmoid cell
visualized in at least two planes.
• Sphenoid sinus:
Pneumatization of the sphenoid sinus:
The lateral walls are thin bony layers and can be divided into two areas: an anterior orbital
area and the posterior cranial area.
This wall has immediately adjacent to it highly important structures such as the internal
carotid artery, optic nerve and the cavernous sinus.
The relations of the sphenoid sinus with structures around are close when the sinus is
well pneumatized.
When this happens, the surrounding vessels and nerves are seen in the sinus cavity as
irregularities or ridges.
Pneumatization of the sphenoid sinus can extend to further from its body, and into all of
its parts, such as the clinoid processes, greater wings and pterygoid planes (figure 49).
The sphenoid sinus may pneumatize the anterior clinoid processes, which can encroach
the optic nerve (figure 50).
The pneumatization of the pterygoïd processes is an extension of the sinus between the
maxillary nerve and the nerve of the pterygoïd canal (Vidian nerve), this extension could
reach the posterior part of the maxillary sinus (figure 51).
Intersinus septation of sphenoid:
The sphenoid sinuses are asymmetric cavities inside the sphenoid body separated by
a bony septum, this septum is very often deviated laterally to one side or the other, it is
common that it inserts on the carotid canal or the optic canal.
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More often than not, the sphenoid cavity is divided by more than one septa (figure 52).
According to Fernandez- Miranda JC et al. (2009), at least one of the septa is inserted
on the carotid canal in 87% of cases.
ICA bulges into sphenoid sinus:
The internal carotid artery is the most medial element of the cavernous sinus, and it lies
in direct relation to the lateral wall of the sphenoid sinus.
Depending on the pneumatization of the sphenoid, the impression of the internal carotid
artery may be barely noticeable or highly noticeable (figure 53).
We may have a bulging of the internal carotid artery or in some cases, the thin bone
usually covering the internal carotid artery is dehiscent, leaving the artery exposed to the
sinus cavity (figure 54).
Hypoplasia or aplasia of the sphenoid sinus
• Vulnerability of the anterior skull base:
The thin lateral lamella of cribriform plate and low Ethmoid Skull Base (ESB) are potential
anatomical variants that can lead to iatrogenic injuries in the form of direct penetration
trauma to the Dura, serious intracranial and intra-cerebral complications during ESS.
Keros classified the depth of the olfactory fossa into 3 types based on the height of the
lateral lamella (figure 56).
The depth of the olfactory fossa is 1-3 mm in Type I, 4-7 mm in Type II, and 8-16 mm
in Type III.
According to Keros, the greater the height of the lateral lamella, the higher the risk of its
penetration into the anterior cranial fossa.
The Keros type III is the most vulnerable one, considering the major risk for iatrogenic
lesion of the lateral lamella of the cribriform plate.
• Ethmoidal roof asymmetry
Asymmetry in the anterior of the skull base and especially in the ethmoid roof is important
for ethmoid sinus surgery.
Ethmoid roof asymmetry is a frequent anatomical variation that may occur as a result
of the association of differences in the height of the lateral lamella and/or contour of the
ethmoidal roof, with angulation of the lateral lamella (figure 57).
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Images for this section:
Fig. 5: Figure 5. Coronal and sagittal CT slices showing the ostiomeatal unit ( red circle),
with the middle meatus (yellow line) between the uncinate process laterally and the medal
turbinate medially.
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Fig. 6: Figure 6. Coronal CT slice showing the components of the ostiomeatal unit
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Fig. 7: Figure 7. Coronal CT slice showing the drainage passage components in the
ostiomeatal unit.
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Fig. 8: Figure 8. Coronal and sagittal CT images showing the different attachments of
the uncinate process (in red) A.Inferior attachment to the neck of the inferior turbinate. B.
Supero-anterior attachement to lamina papyracea in 50%. C. Postero-lateral attachment
to the roof of the maxillary sinus (C': sagittal plane). D. Anterior attachment of the uncinate
process (sagittal plane). Orange circle: ethmoid bulla.
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Fig. 9: Figure 9. Coronal and sagittal CT images showing the ethmoid bulla (EB). EB
forms the roof of the hiatus semilunaris (A and B). Anterior ethmoid cells can drain into
the middle meatus via the ethmoid bulla (C and D).
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Fig. 10: Figure 10. Coronal CT images illustrating different types of the bulla ethmoidalis.
Fig. 11: Figure 11. Coronal CT images showing the superior ans posterolateral attaches
of the middle turbinate (in blue). red circle (ethmoid bulla).
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Fig. 12: Figure 12. Sagittal CT image showing the superior attachment of the middle
turbinate (in blue), dividing the ethmoid cells into anterior and posterior ethmoid cells.
Fig. 13: Figure 13. coronal CT images showing the different size variations of middle
turbinate.
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Fig. 14: Figure 14. Sagittal and coronal CT images showing the different parts of the
frontal recess.
Fig. 15: Figure 15. Axial and sagittal slices showing posterior ethmoid (green arrow) and
sphenoid sinus (red arrow) drainages, in superior meatus.
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Fig. 16: Figure 16. Sagittal and coronal images showing the different components of the
nasal septum.
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Fig. 17: Figure 17. Coronal image and three different axial images of the nasolacrymal
duct (yellow circle).
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Fig. 18: Figure 18. Coronal CT image showing the olfactory fossa ( white asterisk) and
the ethmoidal roof components.
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Fig. 19: Figure 19. Coronal image and axial cut in the level of the anterior ethmoidal
artery. This artery exits the orbit through the anterior ethmoidal foramen and enters the
olfactory fossa at the point of attachment of the middle turbinate to the cribriform plate.
Fig. 20: Figure 20. A. Axial and coronal CT images showing nasal septum deviation
towards right side with asymmetry of the middle turbinates .B. most of the time nasal
septum deviation is associated with asymmetry of the adjacent turbinates.
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Fig. 21: Figure 21. A and B. axial and coronal CT images showing nasal septum deviation
towards left side, with septal spur. C. This spur is frequently seen at the junction of the
perpendicular plate of the ethmoid and the vomer (yellow circle).
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Fig. 22: Figure 22. Coronal, axial and sagittal CT images showing bilateral
pneumatization of middle concha.
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Fig. 23: Figure 23. Coronal and axial CT images showing showing right concha bullosa
with deviation of nasal septum towards left side. Notice that a large concha bullosa, may
obstruct the drainage pathway of the antrum by distorting the UP and narrowing the
infundibulum.
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Fig. 24: Figure 24. coronal CT images showing in (A) Normal configuration of the
turbinates ( convex configuration medially "Yellow curve"). In (B) Paradoxical turn of
middle turbinate, associated with septal deviation and septal spur, which may impair
access to the osteomeatal unit.
Fig. 25: Figure 25. Coronal CT image showing enlargement of the superior turbinates
due to pneumatization.
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Fig. 26: UP Classification
Fig. 27: Figure 27. Coronal CT images illustrating different types of the superior
uncinate process insertion according to Landsberg & Friedman classification. Notice that
attachment to the lamina papyracea allows the frontal drainage in the medial meatus,
attachment to the skull base allows frontal drainage into the ethmoid infundibulum and
attachment to the neck of the middle turbinate allows frontal drainage into the ethmoid
infundibulum or into an anterior ethmoid cell.
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Fig. 28: Figure 28. Coronal CT image showing a right uncinate bulla (red circle),
narrowing the right ethmoid infundibulum.
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Fig. 29: Figure 29. Coronal CT images showing lateral deviation of the right uncinate
processes, which may obstruct the ethmoid infundibulum.
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Fig. 30: Figure 30. Types of ostiomeatal complex abnormalities
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Fig. 31: Figure 31. Coronal and sagittal CT scan demonstrating a single Agger nasi cell
(ANC). This CT scan demonstrates how the ANC sits directly behind the frontal process
of the maxilla. This ANC wih the suprabullar cell narrow the frontal recess.
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Fig. 32: Figure 32. Coronal and sagittal CT scan showing a single ANC.
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Fig. 33: Figure 33. Coronal and sagittal CT scan images demonstrating a supra agger
cell (SAC). Associated in case 'A' with Supra bullar and supraorbital ethmoid cells and
in cases 'B'and 'C' with supra bullar cells
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Fig. 34: Figure 34. Axial and sagittal CT scan images showing an example of a small
SAFC in which the frontal sinus is well pneumatized with a small beak.
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Fig. 35: Figure 35. Coronal and sagittal CT scan images showing bilateral SAFC. These
cells are laterally based and pneumatizing through the frontal ostium into the frontal sinus
and pushing the drainage pathway of the frontal sinus medially.
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Fig. 36: Figure 36. CT scan showing the classical supra bullar cell (SBC), associated en
case 'A' with an agger nasi cell, and in case 'B' with , supra bulla frontal and supraorbital
ethmoid cells
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Fig. 37: Figure 37. Coronal and sagittal CT scan images illustrating the SBFC pushing
the frontal sinus drainage pathway anteriorly until it touches the SAFC. Again the pathway
becomes an anteromedial pathway (Red line).
Fig. 38: Figure 38. Sagittal and coronal CT images showing pneumatization over orbit
seen on the coronal and parasagittal CT scans (supra orbital ethmoid cell (SOEC)).
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Fig. 39: Figure 39. Axial and coronal CT images illustrating a frontal septal cell narrowing
the frontal sinuses drainage pathways.
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Fig. 40: Figure 40. Coronal CT scan image showing bilateral infra orbital cells, which
impair the maxillary sinuses drainage.
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Fig. 41: Figure 41. Axial and coronal CT images demonstrating bony septation within the
maxillary antrum. These septas extend from the infra orbital canal (green arrow).
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Fig. 42: Figure 42. Coronal and axial CT scan images illustrating in 'A' and 'B' maxillary
sinus pneumatization of alveolar recesses ( with protrusion of roots of the premolar and
molar teeth; red circle), in 'C' pneumatization of the infra orbital recesses.
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Fig. 43: Figure 43. Coronal and axial CT scan images, illustrating in red line in 'A' the
palatine recess and in 'B' zygomatic recess.
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Fig. 44: Figure 44. Axial(A), right parasagittal(B), and coronal (C) sinus CT images show
unilateral right-sided protrusion of the ION into the maxillary sinus (green arrow). While
part of the wall of the left IOC protrudes into the sinus.
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Fig. 45: Figure 45. CT scan sagittal image of the optic nerve canal observed for type
A(protrusion of the optic nerve into the sphenoid sinus, no Onodi cell).
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Fig. 46: Figure 46. CT scan sagittal image of the optic nerve canal observed for type B
in sagittal plane.
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Fig. 47: Figure 47. CT scan images of the optic nerve canal observed for type C in
respectively sagittal and coronal planes.
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Fig. 48: Figure 48. CT scan images of the optic nerve observed for type D(protrusion of
the optic nerve into the Onodi cell) in respectively axial, sagittal and coronal planes.
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Fig. 49: Figure 49. Sagittal and coronal CT sections showing pneumatization of the
sphenoid sinus. In 'A' of infraclival and septal, in 'B' pterygoid process, in 'C' infraclival.
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Fig. 50: Figure 50. Coronal CT scan image illustrating a pneumatization of the right
anterior clinoid process encroaching right optic nerve.
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Fig. 51: Figure 51. Axial, sagittal and coronal CT scan images illustrating pneumatisation
of the left pterygoid process and protrusion of the vidian nerve(green line) within the left
sphenoid sinus.
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Fig. 52: Figure 52. Two Axial CT scan images showing multiple septa in a large sphenoid
sinus. Note that one of septa is inserted on the carotid canal (red circle).
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Fig. 53: Figure 53. Axial CT scan image showing a bulging of the internal carotid arteries
in sphenoid sinuses
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Fig. 54: Figure 54. Coronal and sagittal CT scan images showing dehiscence of the
internal carotid arteries into sphenoid sinuses.
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Fig. 55: Figure 55. Effect of hypoplastic or aplastic sphenoid sinus
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Fig. 56: Figure 56. Coronal CT scan images illustrating the depth of the olfactory fossae.
In 'A' not very deep olfactory fossae, where the ethmoidal roofs are almost in the same
plane as the cribriform plate, corresponding to Keros type I. In 'B' olfactory fossae are
deeper and lateral lamellas are longer, corresponding to Keros type II. In 'C' Olfactory
fossae are very deep, lateral lamellas are long and thin, corresponding to Keros III.
Fig. 57: Figure 57. Coronal CT scan image showing an angulation of the ethmoid roof at
right, with an increase in the angle between the lateral lamella and the horizontal portion
of the cribriform plate.
Page 61 of 66
Fig. 58: IFAC 2016
Page 62 of 66
Conclusion
• The paranasal sinuses have many different anatomical variations.

• Computed tomography (CT) scan plays a fundamental role in the diagnosis
of anatomical variations.
• The identification of the anatomical variations helps the endoscopic
surgeons to avoid major risks in approaching the vital anatomical structures.
Page 63 of 66
Personal information
Dr DIB OTHMANE Hopital central de l'armée , Alger, Algérie
Page 64 of 66
References
1/An Analysis of the Anatomic Variations of the Paranasal Sinuses and Ethmoid Roof
Using Computed Tomography ; Hatice Kaplanoglu1, Veysel Kaplanoglu2, Alper Dilli1,
Ugur Toprak2, Baki Hekimo#lu1 , Eurasian J Med 2013; 45: 115-25
2/Radiographic Analysis of the Ethmoid Roof based on KEROS Classification among

Filipinos , Justin Elfred Lan B. Paber, MD1 Michael Salvador D. Cabato, MD2
Romeo L. Villarta, Jr, MD, MPH3 Josefino G. Hernandez, MD3, Philippine Journal of
otolaryngology-head and neck Surgery Vol. 23 no. 1 January - June 2008
3/The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the
Extent of Endoscopic Frontal Sinus Surgery (EFSS), International Forum of Allergy &
Rhinology.
4/Anatomical Variations of Paranasal Sinuses on Coronal CT-Scan in Subjects with

Complaints Pertaining to PNS International Journal of Anatomy, Radiology and Surgery.
DOI: 10.7860/IJARS/2016/21554:2192
5/Multiplanar Sinus CT:

A Systematic Approach to Imaging Before Functional Endoscopic Sinus Surgery Jenny
K. Hoang1
James D. Eastwood1 Christopher L. Tebbit2 Christine M. Glastonbury3, AJR 2010;
194:W527-W536
6/CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation
With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning AJR
2015; 204:1255-1260 Katya A. Shpilberg1 Simon C. Daniel1 Amish H. Doshi1 William
Lawson2 Peter M. Som1
7/Protrusion of the Infraorbital Nerve into the Maxillary Sinus on CT: Prevalence,
Proposed Grading Method, and Suggested Clinical Implications X J.E. Lantos, A.N.
Pearlman, X A. Gupta, X J.L. Chazen, R.D. Zimmerman, D.R. Shatzkes, and C.D. Phillips
AJNR Am J Neuroradiol 37:349 -53 Feb 2016
8/The Onodi Cell and Optic Canal as Variations Assessed with Paranasal Sinus CT,
Takahiro Kitamura1), Hironori Takebayashi2), Emi Maeda3), Ryosuke Koike4) and
Takayuki Kawashima5), Pract. Otol. (Kyoto) Suppl. 144:42 ~ 43,2015
9/CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation
With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning, Katya
A. Shpilberg1 Simon C. Daniel1 Amish H. Doshi1 William Lawson2 Peter M. Som1 , AJR
2015; 204:1255-1260.
96 Normal 0 21 false false false FR X-NONE X-NONE
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CT anatomy of paranasal sinuses.

Poster No.: C-2117

•To recall the normal anatomy of paranasal sinuses.

•To know anatomic variations of paranasal sinuses.

•To have a systematic way in looking for these variations in a CT scan.

The space below each concha is called a meatus.

• Inferior meatus: receives opening of lower end of nasolacrimal duct.

• Obstruction of the drainage pathways or anatomic variants that may

4.How to perform a CT imaging?

• Medical treatment should be given before CT scan to reduce transient acute

Fig. 1: Figure 1. Anatomic representation of paranasal sinuses

© RADIOLOGY, AIN NADJA HOSPITAL - Algiers/DZ

© RADIOLOGY, AIN NADJA HOSPITAL - Algiers/DZ

© RADIOLOGY, AIN NADJA HOSPITAL - Algiers/DZ

© RADIOLOGY, AIN NADJA HOSPITAL - Algiers/DZ

• It is a complex anatomic region at crossroads of mucociliary drainage from

Maxillary ostium: drainage channel of maxillary sinus.

Infundibulum: common channel that drains the ostia of maxillary and

ethmoid sinuses to the hiatus semilunaris.

• Uncinate process (UP):

It has different attachments (figure 8):

Inferior attachment to the neck of the inferior turbinate.

Supero-anterior attachement to lamina papyracea in 50%.

Postero-lateral attachment to the roof of the maxillary sinus.

It is the roof of the hiatus semilunaris and posterior ethmoid infundibulum.

It attaches superiorly to the cribriform plate (medial lamella).

It lies inferomedially to the anterior ethmoidal air cells.

Different sizes of middle turbinate may be seen (figure 13).

• Frontal sinus ostium

It is a variable depression seen in cribriform plate that medially bounded by perpendicular

• Anterior ethmoid foramen:

• Anatomical variations are which damage the normal functional drainage

Concha bullosa is a variation originated from pneumatization of the bone plate by

Such variation may be either uni- or bilateral (figure 22).

Varied degrees of pneumatization of the concha may be observed, possibly causing

Depending on the degree of curvature of the paradoxical turbinate; compression of the

• Uncinate Process (UP) variations

Variations of the superior attachment of the uncinate process :

The aeration of UP is called uncinate bulla (figure 28) .

This variation increases the wideness of the uncinate, so it constitutes to be potentially

It can act like a concha bullosa or a widened ethmoid bulla.

Deviation of the tip of the uncinate

According to John Earwaker, six (06)Types of ostiomeatal complex abnormalities can

This condition is called atelectatic UP.

Generally, it is seen together with an opacified hypoplastic maxillary sinus.

Agger nasi cells (ANC):

The most constant and anterior of ethmoid air cells.

Forms the floor of the frontal recess.

Supra agger cell (SAC):

Supra agger frontal cell (SAFC):

Supra bullar cell

Supra bulla frontal cell

Supra orbital ethmoid cell (SOEC)

Frontal septal cell

• Infra orbital cells (Haller cells):

The anatomic variations of maxillary sinus are common findings in CT.

Maxillary sinus septations:

The maxillary sinus pneumatization:

Four recesses have been described, as follows (figures 42, 43):

Protrusion of the ION into the maxillary sinus:

Pneumatization of the sphenoid sinus:

Intersinus septation of sphenoid:

ICA bulges into sphenoid sinus: