Surgical Anatomy of Paranasal Sinuses

-Radiological Correlations

Dr Satish Jain
Jain ENT Hospital
Jaipur

CT IMAGING OF THE
PARANASAL SINUSES
Sometimes useful in:
Diagnosis of disease

Usually useful in:

Clarifying the extent of disease

Always useful in:

Planning surgery and minimising
complications

Nasopharynx

ITF muscles

Osteo-meatal Complex

Orbit

Septal deviation

Onodi cell axial section

Skull Base Slope

Sella Sphenoid relationship

Frontal recess configuration

Onodi cell

CT CHECKLIST
Anterior Skull Base

Keros Classification
Anterior Ethmoid arteries

Osteomeatal Complex

Nasal structures

Nasal septum, bony and cartilaginous components,

including deviations
Inferior turbinates

Frontal Recess Cells

Agger nasi cell

Kuhn cells
Suprabullar cell/ frontal bullar cell/ supraorbital ethmoid
cell
Intersinus septal cell

Frontal sinus

Frontal sinus cells and septum

Identify drainage pathway of the frontal sinus on 3planar views

Orbital Wall

Lamina papyracea and the presence of dehiscence

Nasolacrimal duct

Maxillary Sinus

Presence of disease, including hypoplasia or Silent sinus

syndrome
Disease of the maxillary teeth

Boundaries:
1. Middle turbinate, and the basal lamella
2. Middle meatus
3. Lateral nasal wall
4. Uncinate process, and the presence of
medialization
5. Ethmoid bulla and other anterior ethmoid air cells
The presence of disease

Posterior Ethmoid Region

.
.
.
.
.

Superior turbinate
Superior meatus
Posterior ethmoid air cells
Supreme turbinate and posterior ethmoid artery, when
visible
Onodi (sphenoethmoidal) cell, when present, and its
relation to the orbital nerve

Sphenoid Region
.
.
.
.
.

Sphenoid air cells, and septum

Orbital nerve and the presence of dehiscence
Internal carotid artery and the presence of dehiscence
Sella Turcica
Foramen rotundum and vidian canal

Nasolacrimal duct

CRIBRIFORM PLATE KEROS

CLASSIFICATION

KEROS I
1-3mm

KEROS II
4-7mm

KEROS III
8-16mm

Measurement refers to the height of the lateral lamella

CRIBRIFORM PLATECONFIGURATION MAY VARY

CRIBRIFORM PLATECONFIGURATION MAY VARY

Lateral
LateralNasal
NasalWall
Wall(Osteology)
(Osteology)
Ethmoid
labyrinth
Ethmoid labyrinth
Lateral lamella
Crista galli
Horizontal lamella
Ant. Ethmoidal artery

CSF leak

SKULL BASE
Skull base slopes
downward from
anterior to posterior
Components are:
Ethmoid roof
(Foveolae
ethmoidales)
Lateral lamella of the
cribiform plate
Lamina cribrosa

Anterior ethmoidal skull base

Posterior ethmoidal skull base

ANTERIOR ETHMOID ARTERY

ANTERIOR ETHMOID ARTERY

Posterior ethmoidal artery

Septal spur

Septal pneumatization

Hypertrophied inferior turbinate

OSTIOMEATAL COMPLEX
Boundries

Medial: MT
Lateral: Lamina
Papyracea

Ostium
Infundibulum,
leading to the hiatus
semilunaris
Uncinate process
Middle meatus
Anterior Ethmoid
cells

ETHMOID INFUNDIBULUM
3D space draining into
the middle meatus
through the hiatus
semilunaris
Boundries

Medial: uncinate process

and hiatus semilunaris
Lateral: lamina papyracea &
maxillary sinus
Posterior and Superior:
ethmoid bulla
Anterior: medial and lateral
walls meet at the frontal
process of the maxilla

Ethmoid Infundibulum

Ethmoid Infundibulum

Large bulla & concha bullosa

narrowing infundibulum

MAXILLARY SINUS- HALLER CELLS

Haller Cell

Haller cells

multiple

Large & flat

Haller Cell

SUPERIOR INSERTION OF THE

UNCINATE PROCESS

RT

Pneumatized uncinate process

ETHMOID BULLA
Largest and most
consistent
Ethmoid Air cell
Located posterior
to the uncinate
and anterior to
the basal lamella
of the MT

ETHMOID BULLA

Sinus Lateralis

Frontal Recess

FRONTAL RECESS HOURGLASS

APPAERANCE

Frontal Ostium
Frontal beak

FRONTAL RECESS CELLS

ANTERIOR TO
NASOFRONTAL
DRAINAGE

POSTERIOR TO
NASOFRONTAL
DRAINAGE

KUHN CELLS

SUPRABULLAR(SB)
FRONTAL
BULLAR(FB)
SUPRA ORBITAL
ETHMOIDAL
CELL(SOEC)
INTERSINUS
SEPTAL(ISS)

Types 1-4

AGGER NASI CELL

Present in 90-95%

AGGER NASI

Agger Nasi

FRONTAL RECESS: KUHN TYPE

1 (K1)

K1 SINGLE AIR CELL SUPERIOR TO AN

FRONTAL RECESS: KUHN TYPE

2 (K2)

K2 TWO OR MORE AIR CELLS SUPERIOR TO AN

FRONTAL RECESS: KUHN TYPE

3 (K3)

K3 AIR CELL SUPERIOR TO AN EXTENDING INTO FRONTAL SINUS

FRONTAL RECESS: KUHN

TYPE 4

Originally described
as isolated cell in
frontal sinus
Best seen on Sagittal
and Coronal imaging
In patients with
frontal sinus disease
an isolated aerated
cell that abuts the
anterior sinus wall in
an otherwise
opacified sinus

FRONTAL RECESS CELLS:

SUPRABULLAR CELLS

A
BE

FRONTAL
RECESS CELLS:
FRONTAL
BULLAR CELL

Frontal beak

FRONTAL RECESS CELLS:

SUPRA-ORBITAL ETHMOIDAL
CELL

FRONTAL RECESS CELLS:

SUPRA-ORBITAL ETHMOIDAL
CELL

FRONTAL RECESS CELLS:

INTERSINUS SEPTAL CELL

MAY PNEUMATISE THE CRISTA GALLI

FRONTAL RECESS - CORONAL

RECONSTRUCTIONS
RIGHT K3

K3

LEFT FB

K3

FB

FRONTAL RECESS - SAGITTAL

RECONSTRUCTIONS
RIGHT K3
RIGHT

K3

LEFT FB
FB

LEFT

Interlamellar cell

Hypoplastic
maxillary
sinus

Dehiscent infra-orbital nerve

Infra-orbital canal

MIDDLE TURBINATE
Important landmark for the sinus
surgeon
Guides us to the structures of the
Osteomeatal complex
Divides the ethmoid air cells into an
anterior and posterior compartment

Anatomical variants may

contribute to diseases of the sinus
Instability of the MT from surgery
may contribute to
narrowing/adhesions and hence
sinus disease

Middle Turbinate Part 1

Middle Turbinate Part 2

Middle Turbinate Part 3

MIDDLE TURBINATE VARIANTS

paradoxical curvature

Middle
Middle Turbinate
Turbinate

Paradoxically curved M.T

Paradoxically curved M.T

Variants
Variants

MIDDLE TURBINATE VARIANTS

Turbinate sinus

Pterygopalatine fossa

SUPERIOR TURBINATES
Posterior to the
basal lamella of the
Middle turbinate
Situated anterior to
the sphenoid
ostium (and
slightly lateral)
Landmark for the
sphenoid ostium

Onodi cell

Onodi cell

Onodi cells

Trans sphenoidal approach

Sphenoid Osteum

Sphenoid Sinus

Sphenoid Bone

Sphenoid bone

Sphenoid anatomy

Sphenoid anatomy

Sphenoid sinus pneumatization

POSTERIOR ETHMOID AND

SPHENOID
V2 AND VIDIAN NERVE

V2

V2

Vidian
nerve

V2

V2

SPHENOID SINUS RIGHT OPTIC

NERVE DEHISCENCE
!!!!

POSTERIOR ETHMOID AND

SPHENOID OPTIC NERVE

Prolapsed
optic
nerve

POSTERIOR ETHMOID AND

SPHENOID INTERNAL CAROTID
ARTERY

Approaches to sphenoid

Orbit

Superior orbital fissure & optic foramen

Optic foramen

SOF

CT Scans - Pitfalls
Do not show minimal disease
Frequently show asymptomatic changes
Poor correlation between CT scans and symptoms

A CT is a snapshot in time

Thank you