Paranasal sinus

Note that there is very wide range of possible anatomical variation between different people & even between the 2
sides of the same individual's nose
All three turbinates and all the paranasal sinuses arise from the cartilaginous nasal capsule.
Embryology:
THE TURBINATE BONES
 A series of elevations arise from the lateral aspect of the nasal capsule (the lateral wall of the nose) from the
6th foetal week which will ultimately form the turbinates.
 The most inferior or maxilloturbinal forms the inferior turbinate.
 The middle, superior and supreme turbinates result from reduction of the complex ethmoturbinal system.
 Primitive nasoturbinal is represented by the agger nasi region and uncinate process of the ethmoid.
 Ethmoturbinal:
 series of lateral wall ridges, appear during the 8th wk (5-6 in number)
 ultimately form 3-4 ridges through the process of fusion & regression
Name of ethmoturbinal Derivative
st
1 ethmoturbinal Ascending part: agger Nasi (nasoturbinal); Decending part: uncinate process
2nd Middle turbinate
rd
3 Superior turbinate
4th +5th fuse Supreme turbinate (Note: 60% of population has supereme nasal concha)

Maxilloturbinal Inferior turbinate (Note: the inferior turbinate is not ethmoid derivative)
 The inferior turbinate is a separate bone, while the superior and middle turbinates are parts of ethmoid bone
 The middle turbinate forms an important landmark from the point of view of FESS and should be preserved.
 Concha Bullosa: an aerated middle/superior turbinate, may result in nasal obstruction
Furrows form between the ethmoturbinals & ultimately establish the primodal meati & recesses:
 1st furrow (between the 1st & 2nd ethmoturbinals):
a. Descending aspect forms:
1) Ethmoidal infundibulum
2) Hiatus semilunaris
3) Middle meatus
b. Ascending aspect forms: Frontal recess
 2nd furrow (between the 2nd & 3rd ethmoturbinals): Superior meatus
 3rd furrow (between the 3rd & 4th ethmoturbinals): Supereme meatus
5 basal/ground lamellae of the paranasal sinus:
These lamellae are obliquely oriented and lie parallel to each other. They are helpful in maintaining orientation in ethmoid
procedures.
1) Uncinate process
2) Bulla lamella: (usually results in the largest and most constant cell of anterior ethmoid complex)
 If pneumonized it is called bulla ethmoidalis
 If not pneumonized it is called: torus ethmoidalis/lateralis)
3) Basal lamella of the middle turbinate- divides anterior and posterior ethmoid complexes.
4) Lamella of superior turbinate
5) Lamella of supreme turbinate ( if present)
Note: The ethmoid sinus is commonly referred to as “the labyrinth” due to its complexity and intersubject variability
The ethmoid bone:
 The ethmoid bone ossifies in the cartilaginous nasal capsule from 3 centers:
 One for each labyrinth; one for the perpendicular plate.
a) Labyrinth:
 Labyrinth centers are present from 4th/5th intrauterine month; and are partially ossified at birth.
b) Perpendicular plate and crista galli:
 Develop from 1 centre during the 1st Yr of birth; Fuse with the labyrinths at the beginning of the 2nd year.
c) Cribriform plate:
 Both perpendicular plate centre and those for the labyrinth contribute to the cribiform plate.
 Cribriform plate ossification occurs at the age of 3 years
 Ossification of the cribriform plate stabilizes the whole ethmoid complex
Note: The nasal cavity grows rapidly in the 1st 6 years; the external nasal dimensions are generally mature at the age
of 13 in females, 15 in males
Note: Normal nasal flora: Strep. Pneumonia, H.influenza, Morexella catarralis, Staph
Nasolacrimal duct:
 Each maxillary process is separated from the lateral nasal processes by
the nasolacrimal groove.
 This groove invaginates, and the epithelium within it is reabsorbed to
form the nasolacrimal duct.
Frontal bone:
 Ossifies in 2 centers one in each superciliary ridge appearing in 8th
intrauterine week
 At birth the bone has 2 halves begin to fuse in 2nd year of life
The maxilla
Arise from 5 ossification centers these fuse to form:
 Alveolar, palatine, zygomatic, frontal processes and the floor of the orbit.
The premaxilla:
 Forms the anterior nasal spine
Maxillary bone is the 2nd largest Facial bone
The body is described as a quadrilateral pyramid & contains the maxillary sinus
Forming:
 The majority of the roof of the mouth
 Lateral wall and the floor of the nose
 Floor of the orbit
Contributing in the formation of:
 Infratemporal fossa
 Pterygopalatine fossa
 Inferior orbital Fissure
 Pterygomaxillary fissures.
Maxillary Bone processes:
1. frontal process
2. zygmatic process
3. palatine process
4. alveolar process
The zygomatic process divides the lateral
surface of the maxillary bone into anterior &
posterior parts
It articulates with 8 bones:
1) The opposite maxillary bone
2) Palatine bone
3) Zygomatic bone
4) Nasal Bone
5) Frontal Bone
6) Lacrimal Bone
7) Ethmoid Bone (lamina papyracea)
8) Inferior concha
The anterior surface:
 Has the infraorbital foramen transmitting the infraorbital artery and nerve
Nasolacrimal canal:
 Nasolacrimal canal is created by indentation in the following bones:
1- Frontal process of maxilla (Nasolacrimal notch)
2- lacrimal Bone
3- Anterior part of Inferior turbinate
Conchal Crest:
 Anterior to the Nasolacrimal groove
 attachment site for the inferior turbinate
The posterior surface (Infratemporal surface)
Convex
At the center:
1- The surface is pierced and grooved near its centre by the alveolar canals
which transmit the posterior superior alveolar vessels and nerves.
2- At the lower part of this surface:
There is a maxillary tuberosity which is rough for articulation with:
- The tubercle (pyramidal process) of the palatine bone.
- It gives origin to a few fibers of the medial pterygoid muscle
- articulates with the lateral pterygoid plate of the
sphenoid bone (in some cases)
3- The Anterior boundary of the pterygopalatine fossa:
 Above the maxillary tuberosity.
 grooved for the maxillary nerve
Pterygopalatine canal (Greater palatine canal):
 Transmits:
1- descending palatine vessels
2- anterior palatine nerve: branch of the maxillary Nerve
 Pterygoid canal reaching into the foramen lacerum
 Sphenopalatine foramen opening into nasal cavity
 Pharyngeal nerve going through the paharyngeal canal
(palatovaginal canal) - canal between the sphenoid
bone and the palatine bone that connects the
nasopharynx with the pterygopalatine fossa
Ethmoid Crest:
 attachment site for:
1- middle turbinate
2- agger nassi
Inferior aspect of the Maxilla:
 2 articulated maxillae = alveolar arch
 Forms the incisive foramen just posterior to the incisors
 This foramen transmits (in separate canals to each side of
the nose):
1- Nasopalatine Nerve from above
2- Greater palatine Artery from below
 Palatine process of maxilla + horizontal plate of the palatine
bone= hard palate
 The inferior surface of the palatine process is pittied by
sharpey’s fibers from the palatine periosteum, by vascular
foramina and indentations from small salivary gland
Sphenoid bone:
Embryology:
Divided into:
 presphenoidal:
o anterior to tuberculum sellae
o made of 6 ossification centers
o Its anomalous fusion results in hyperteleorism.
 postsphenoidal:
o composed of sella turcica and dorsum sellae
o made of 8 ossification centers
Pre and post fuse around 8th week intrauterine (premature
ossification can produce depression in nasal bridge (seen
achondroplasia)
Anatomy:
 The largest bone in the skull base
 Divides the Anterior & Posterior Cranial fossa By its lesser wings
 Greater wings contributes into the middle cranial fossa
 Lies anterior to the temporal & occipital bone
Sphenoid bone components:
 Body: pneumatized to a variable degree
 2 wings: lesser and greater wings
 2 pterygoid processes: lateral and medial
Forms of pneumatization:
 Conchal 2-3% (rudimentary sinus)
 Presellar 11% (as far as the anterior bony wall of pituitary
fossa)
 Sellar 59% (extends beneath pituitary fossa)
 Mixed 27%
Sinus Divided by paramedian septum, absent in 1%
Surfaces of the body:
A- The superior surface of the body:
1. The ethmoidal spine: articulates with the cribriform plate.
2. Groove for olfactory lobe: smooth surface slightly raised in the middle line and grooved on either side
for the olfactory lobes of the brain.
3. The chiasmatic groove (optic groove):
 the anterior border bound the posterior aspect of the olfactory groove
 above and behind which lies the optic chiasm
 Ends on either side in the optic foramen (which transmits the optic Nerve and ophthalmic Artery
into the orbital cavity). (optic foramen distance from posterior ethmoid artery is 5-10mm)
4. The tuberculum sellæ; elevation behind the chiasmatic groove.
5. The sella turcica:
 deep depression posterior to the tuberculum sellae
 The fossa hypophyseos: The deepest part of sella turcica of which lodges the hypophysis cerebri.
 The anterior boundary: is completed by 2 small eminences called the middle clinoid processes.
 the posterior boundary: is formed by a square-shaped plate of bone, the dorsum sellæ
6. The dorsum sellae:
 ends at its superior angles in 2 tubercles, the posterior clinoid processes
 The size and form of which vary considerably in different individuals.
 The posterior clinoid processes:
1- Deepen the sella turcica.
2- Give attachment to the tentorium cerebelli.
 On either side of the dorsum sellæ is a notch for the passage of the abducent nerve.
 Petrosal process: sharp process below the notch, Articulates with the apex of the petrous portion of
the temporal bone, Forms the medial boundary of the foramen lacerum.
7. clivus:
 Posterior portion of the sphenoid (basisphenoid) articulates with basilar part of the occipital bone
(bisocciput) to form the clivus
 Basiosphenoid + bisocciput = clivus
 Shallow depression posterior to dorsum sellæ
 Slopes obliquely backward
 Continuous with the groove on the basilar portion of the occipital bone
 It supports the upper part of the pons.
 Note: the bone slopes away posterior to dorsum sellae toward the clivus
 Carotid sulcus: groove on the lateral surface of the body made by the internal carotid artery as it
transverses the cavernous sinus (dehiscent in 25%)
B- Anterior surface of the body:
1- crest: articulates with the perpendicular plate of the ethmoid
2- ostia of the sinuses:
 On either side
 Half way up the face
 Large (5-8mm) on macerated skull, but are partially overlapped & closed by sphenoid concha &
mucus membrane
 The sinuses open into the sphenoethmoidal recess superior and medial to the superior turbinate
C- Inferior surface of the body:
 Bears the rostrum which articulates with the vomer
Greater wings:
Contributes to:
 Intra cranially:
1- The middle cranial fossa
2- foramen lacerum
 Orbit:
1- The posterior-lateral orbital wall
2- Lower part of the superior orbital fissure
3- upper part of the inferior orbital fissure
 Lateral aspect of the skull:
1- Medial wall of the Infratemporal fossa: Lateral surface of the greater wings
2- posterior wall of pterygopalatine fossa: anterior surface of pterygoid process
Note: the greater wings and lateral pterygoid plates forms the lateral aspect of the infratemporal fossa
Pterygoid processes
 Perpendicular process
 Arise from the junction of the body & grater wings
 Each pterygoid process is formed of medial & lateral inferior pterygoid plate
 Medial pterygoid plate has inferiorly the pterygoid hamlus around which the tensor palate tendon
hooks
 At the base of Medial pterygoid plate is lacerum foramen:
o Bounded by medial pterygoid plate, petrous part of temporal bone and basilar part of occipital bone
o Internal Carotid artery runs along the cranial aspect of the foramen
o Lateral to the foramen lies the internal auditory meatus
 Between the Lateral pterygoid plate and the posterior aspect of maxilla lies the pterygomaxillary fissure
which leads to the pterygopalatine fossa
 At the base of the lateral pterygoid plate is the foramen ovale & spinosum
 The medial pterygoid plate articulates with vertical plate of the palatine bone
 lateral and medial plate which diverge around the pterygoid canal which transmits the pterygoid nerve
and artery and which may invaginate the floor of the sphenoid sinus
 Anterior and posterior pterygoid plates are fused anteriorly creating pterygoid fossa
 Cranial to the pterygoid fossa is the sphenoid fossa
 Note: between the Greater wings and superior aspect of maxilla lies the inferior orbital fissure
 Inferior meatus & turbinate
Inferior meatus:
 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 (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 (Anterior 1/3)
 There is no true valve, the opening being covered by small folds of mucosa.
 Endoscopically can be identified by gentle massage of lacrimal sac at the medial canthus.
Inferior turbinate:

 composed of a separate bone

 60mm in anterior to posterior direction
 The inferior concha has its own ossification centre which appears around the 5th intrauterine month.
 The inferior concha has an irregular surface, perforated and grooved by vascular channels to which the
mucoperiosteum is firmly attached.
 articulates with:
1) Inferior margin of the maxillary hiatus via maxillary process.
2) lacrimal bones, completing the medial wall of the nasolacrimal duct
3) ethmoid bone
4) palatine bone
 Possess 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.
 Nerve supply: greater palatine nerve (major) + anterior ethmoid nerve
The configuration of the structures of the middle meatus is complex and variable
 inferior: the maxillary process of the inferior turbinate bone
 posterior: the perpendicular plate of the palatine 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 are 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.
 Middle turbinate

In the anterior and superior aspect of the middle turbinate,

it attaches laterally at the agger nasi area specifically at the
crista ethmoidalis of the maxilla
The posterior end is attached to the crista ethmoidalis of
the perpendicular process of the palatine bone (lamina
perpendicularis)

Then moves superiorly medially at follow:

Part Location Plane Attachment
1st Anterior=medial Sagittal (vertical)
Skull base(between the cribriform plate & lateral
lamella/lateral aspect of lamina cribrosa “cribriform fossa”)
nd
2 (basal lamella) Middle Coronal (obliquely) Lamina papyracea and/or medial wall of the maxillary sinus
3rd Posterior-lateral Horizontal Crista ethmoidalis of Perpendicular plate of the palatine bone
st rd
As we move from the 1 part to the 3 part we moves from medial to lateral
1st part:
 The anterior cranial fossa may invaginate into this attachment with olfactory filae
 Danger area is above + medial+ lateral to The superior /vertical attachment of middle turbinate
nd
2 part (basal lamella):
 An important land mark in FESS
 Separates the anterior from the posterior ethmoid air cells
o The boundaries:
o Superiorly: skull base (fovea ethmoidalis)
o Inferiorly: 3rd part of middle turbinate
o Medially: 1st part of the middle turbinate
o Laterally: lamina papyracea
rd
3 part:
 The attachment of the middle turbinate into the perpendicular
plate is just anterior to sphenoplatine artery

Notes:
 The shape of the middle turbinate is highly variable as it can be
paradoxically curved (medially concave) or pneumatized.
 If the vertical portion or lamella of the middle turbinate is pneumatized,
the cell that is formed is referred to as the intralamellar cell.
 Pneumatization of the head of the middle turbinate is referred to as a concha bullosa.
 Length of 40mm, height anteriorly 14.5mm posteriorly 7mm

Middle turbinate is an important landmark:

 It separates the cribriform plate from the fovea ethmoidalis
 its anterior tip marks the limits of anterior dissection of maxillary antrostomy so you won’t injure the
nasolacrimal duct
 the basal lamella identifies the entrance into the posterior ethmoidal sinuses
 the lower half of the middle turbinate and its insertion into the choana help to identify the entrance into the
sphenoidal sinus
 Ethmoid Sinus
Embryology:
 arise as multiple separate evaginations from the lateral wall of the
nasal capsule around the 5th month of gestation
 3–4 cells at birth (most developed paranasal sinus at birth)
 formed from 5 ethmoid turbinals:
1) agger nasi
2) uncinate
3) ethmoid bulla
4) ground lamella
5) posterior wall of the most posterior ethmoid cell
Volume at Adult:
 10–15 aerated cells, total volume of 2–3 ml (adult size at 12–15 years old)
 they are divided into anterior and posterior ethmoid sinus by basal lamella of the middle turbinates
 anterior ethmoid cells: 2-8
 posterior ethmoid cells: 1-5 (fewer # and larger in size)
Posterior ethmoid air cells relations:
 Anteriorly: basal lamella of the middle turbinate
 Posteriorly: sphenoid sinus
 Superiorly: fovea ethmoidalis
 Inferiorly: the posterior part of the middle turbinate
 Medially: superior meatus & superior turbinate
 Laterally: lamina papyreacia
The posterior ethmoid cells are often found to be the cause of
potential complications during FESS because:
1) Optic nerve is too close to the posterior ethmoid air cells
2) The medial rectus is closer to the posterior ethmoid than to the
anterior ethmoid because of the thinner orbital fat
3) The posterior ethmoid artery lies in the roof of the posterior
ethmoid just anterior to the anterior wall of the sphenoid sinus
Cribriform plate:
 Perforated by the Olphactory nerve fibers
 Attached to:
 medially: crista galli + perpendicular plate of the ethmoid bone (both at same level)
 laterally: lateral lamella + superior attachment of middle turbinate (both at same level)
 superior attachment of the middle turbinate is the land mark of cribriform plate
 meningitis post intranasal surgery occurs due to:
1) penetration of cribriform plate
2) spread via perineural lymphatic of Olphactory nerve
Ethmoid roof:
 In a disarticulated skull, the ethmoid bone is open
superiorly (at least the anterior 2/3) lateral to the
lateral lamella of cribriform plate & insertion of middle
turbinate
 The bony coverage of these open ethmoidal cells is
provided by the frontal bone with its foveolae
ethmoidalis = Ossis frontalis
 so the roof of the ethmoid bone is made by:
1) most medially: lateral lamella of cribriform plate
2) laterally: frontal bone
 the part of the roof which is made of the frontal bone
has different configurations:
a) anterior ethmoid roof: step ladder
b) posterior ethmoid roof: flat
 Foveolae ethmoidalis:
 part of the frontal bone
 joins the lateral lamella of cribriform plate medially
 thicker and denser than the adjacent bony lateral lamella of cribriform plate
 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 )
 The lateral lamella of the cribriform plate, where the anterior ethmoid artery crosses from the medial orbital
wall into the cribriform, is the thinnest bone in the entire anterior skull base
 Foveolae ethmoidalis 0.5mm thickness
 Lateral lamella of the cribriform : 0.2mm thickness
ethmoidal sulcus:
 the thickness of the wall may be reduced to 0.05 mm, and is therefore by a factor 10x 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 10% with the right more often lower than the left.
At the calvarium:
 the dura of the anterior cranial fossa is relatively thin & adherent to the skull base, particularly 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.
The Olphactory fossa:
 The space between midline (crista gali) and the lateral lamella of cribriform plate
 floor of olphactory fossa: The cribriform plate (lamina cribrosa)
 lateral wall of the olphactory fossa: The lateral lamella of cribriform plate
 It contains the Olphactory bulb
Lateral lamella of cribriform plate connections:
 Superior end connects to: The foveolae ethmoidalis (roof of the ethmoid)
 Inferior end connects to: The cribriform plate (floor of the olphactory fossa)
So the length of the lateral lamella of the cribriform plate is:
a) The depth of the olphactory fossa
b) Determines the relationship between the olphactory fossa and the ethmoid roof
c) Configuration of the ethmoid roof
Note: lateral lamella of the cribriform plate is the medial wall of the ethmoid dome
Keros classification of the ethmoid roof configuration
This classification is based on the length of the lateral lamella of the cribriform plate=Depth of the olphactory fossa.
Note: the lateral lamella of the cribriform plate is on the same plane of middle turbinate

Type of Lateral lamella length/depth Description of lateral Relation between the ethmoid roof and
Kero's of Olphactory fossa lamellalength cribriform plate
Type I 1-3mm short (almost nonexistent) The roof and plate are almost in the same plane
Type II 4-7mm Longer The roof lies higher than the cribriform plate
Type III 8-17mm Very long The roof lies significantly above the plate
The clinical significance of the Keros classification:
Keros type III with a long, thin, lateral lamella forming a significant part of the medial part of the ethmoid sinus.
Which means 14-16mm of anterior cranial fossa is medial to where instrumentation may be used. So greatest
concern for the surgeon for inadvertent intracranial injury
Note: The Keros classification does not evaluate the skull base height in the posterior ethmoid. This should be evaluated by
comparing the ratio of the ethmoid height to that of the height of the maxillary sinus.
Lateral wall of ethmoid labyrinth:
It is made of lamina papyracea which is paper thin Perpendicular
plate of the ethmoid bone
Nerve supply of the ethmoid sinus:
1) Anterior + posterior ethmoid nerves
2) Supra-orbital nerve
3) Posterior superior lateral nasal branch
Ethmoid Bulla:
 A hollow bony prominence based on lamina papyrecea
 The largest anterior ethmoid air cell
 The most constant ethmoid air cell + constant features of the middle meatus
 May be completely unpneumatized (8%): alternatively called torus lateralis/ethmoidalis (lateral bulge)
Relations of the ethmoid bulla:
Anteriorly & inferiorly
 The ethmoid infundibulum separates the bulla from
the uncinate process
 So Anterior surface of the bulla forms the posterior
margin of the ethmoid infundibulum + hiatus
semilunaris
Superiorly
 Suprabullar recess (anterior & superior portion of the
lateral sinus) separates the bulla from fovea
ethmoidalis
 may reach the ethmoidal roof, forming the posterior
wall of frontal recess
Posteriorly
 may fuse with the basal lamella of the middle
turbinate
 the retrobullar recess Separates the posterior wall of
the bulla and basal lamella of the middle turbinate
Medially
 middle meatus separates the bulla from the middle
turbinate
 the lumen between the middle turbinate & bulla is
called concha sinus
Laterally: based on lamina papyracea (lamina orbitalis)
Drainage: bulla ethmoidalis drain Posteriorly into the
retrobullbar recess
Lateral sinus
Divided into:
1) suprabullar space:
 located superiorly and anteriorly
 borders:
 superiorly: skull base (fovea ethmoidalis)
 inferiorly: bulla
 laterally: lamina papyracea
 Posteriorly: basal lamella of middle turbinate
 It is separated from the frontal recess by suprabullbar lamella.
o In the absence of this lamella the suprabullbar recess of the lateral sinus is
contagious with the frontal recess of the infundibulum
o if the bulla directly adheres to fovea ethmoidalis there will be no suprabullbar space
2) retrobullbar recess:
 the most posterior aspect of anterior ethmoid, located inferior posterior
 borders:
o anteriorly: ethmoid bulla
o posteriorly: basal lamella
 if the bulla directly adheres to the basal lamella there will be no retrobullbar recess
 in case the bulla did not adhere to the basal lamella the suprabullar recess will extend into the
retrobullbar recess
 Suprabullar and retrobullar space may be contagious or separated by complete/incomplete bony septation
 both Suprabullar and retrobullar space drain into hiatus semilunaris superior, so these recesses can be
approached medially & inferiorly through hiatus semilunaris superior
Uncinate Process:
 hook/sickle/cresentic-shaped thin bone located in sagittal plane
 covered by mucoperiosteum
 part of the ethmoid bone, medial to the ethmoid infundibulum
 forms the anterior border of the hiatus semilunaris
 lateral to the middle turbinate (derived from the second ethmoidal turbinal)
 forms the 1st layer of the middle meatus
Dimensions: 2 cm in length, 3-4 mm in width, sagittally oriented
Attachment:
1. Anterior-superior: ethmoidal crest of the maxilla
 Immediately below this it attach to the posterior edge of the lacrimal bone
 This is why in maxillary antrostomy we remove bone anterior as far at the anterior attachment of the
uncinate process so to avoid injury to lacrimal duct
2. Anterio-inferior: no attachment
3. Posterior: free margin with no bony attachment
4. Posterio-inferior: the superior edge of the inferior turbinate.
5. Laterally: lamina papyracea
6. Superior attachment: is highly variable, may be attached to
1) The lamina papyracea
2) The roof of the ethmoidal sinus
3) Middle turbinate
The superior, middle, inferior part of the uncinate process is related to 3 sinuses:
1) Superior segment of the uncinate process:
 Superior attachment of the uncinate process determines:
o The configuration of the ethmoidal infundibulum
o infundibulum relationship to the frontal recess
Classification of the uncinate process based on its superior
attachment
Type I uncinate (most common type):
 The uncinate process bends laterally in its upper most portion and inserts into
the lamina papyracea.
 So the ethmoidal infundibulum is closed superiorly by a blind pouch called the
recessus terminalis (terminal recess).
 So below the uncinate process lies the recess terminalis of the infundibulum
 superior & medial to this attachment lies the frontal recess
 In this case the ethmoidal infundibulum and the frontal recess are separated
from each other
 The route of drainage and ventilation of the frontal sinus run medial to the
ethmoidal infundibulum.
 So that the frontal recess opens into the middle meatus directly medial to the
ethmoidal infundibulum, between the uncinate process and the middle turbinate
Type II uncinate:
 The uncinate process extends superiorly to the roof of the ethmoid (base of skull).
 The frontal sinus opens directly into the ethmoidal infundibulum.
 In these cases a disease in the frontal recess may spread to involve the ethmoidal
infundibulum and the maxillary sinus secondarily.
 Sometimes the superior end of the uncinate process may get divided into three
branches one getting attached to the roof of the ethmoid, one getting attached to the
lamina papyracea, and the last getting attached to the middle turbinate
Type III uncinate process:
 The superior end of the uncinate process turns medially to get attached to the middle
turbinate.
 Here also the frontal sinus drains directly into the ethmoidal infundibulum.

2) Mid aspect of the uncinate:

 Parallels the ethmoid bulla
 So removal of the uncinate process is one of the 1st steps in Fess to allow
surgical access to the ethmoid bulla
3) Inferior aspect:
 Forms part of the medial wall of the maxillary sinus
 The maxillary sinus ostium lies lateral & superior to it
 This part should be removed to widen the natural ostium
Ethmoid Infundibulum:
 funnel-shaped/hooke like 3D pyramidal space
 In the lateral wall of the nose
 Belongs to the anterior ethmoid.
 houses opening to:
1. the maxillary sinus: at the floor & lateral wall between its
middle & posterior 1/3
2. anterior ethmoid sinuses
 Borders:
o Medial wall: the uncinate process
o Lateral wall: the lamina papyracea (orbitalis)
o Floor: is made by the union of the lamina papyracea &
uncinate process
o Anterior & superior wall: frontal process of maxilla
o superior & lateral: lacrimal bone
o Posterior wall: ethmoidal bulla
 The superior attachment of the uncinate process determines the spatial relationship of frontal sinus drainage
(80% attach to the lamina papyracea resulting in frontal sinus drainage medial to the uncinate, 20% attach to the
skull base or middle turbinate resulting in frontal sinus drainage lateral to the uncinate and into the
infundibulum)
 The location of the opening of the sinuses into the infundibulum:
1. The frontal sinus opens into the superior most aspect of the ethmoidal infundibulum into the fronto-nasal
recess
2. The anterior ethmoidal cells open anteriorly into the infundibulum.
3. The ostium of the maxillary sinus opens postero-inferiorly into the infundibulum and can be located just
above the inferior turbinate.
 Anterior and posterior fontanelles: Defects in the medial wall of the infundibulum covered with dense
connective tissue and periosteum.
 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 so-
called 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 cells.
 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 uncinate process to lamina papyracea 5-6 mm.
 From To
Semilunar Hiatus: Hiatus semilunaris inferior Middle meatus Infundibulum
1-Hiatus semilunaris inferior: Hiatus semilunaris Superior Middle meatus Lateral sinus
 2D crescent shape cleft and depression
 Seen from a median view
 Borders:
o Anteriorly: concave posterior free margin of the ucinate process
o Posteriorly: convex anterior surface of ethmoid bulla
Clinical significance
 From the middle meatus through this 2D cleft ( Hiatus semilunaris) a 3D space of the infundibulum can be
reached (hiatus semilunaris is the doorway from the middle meatus into the infundibulum)
 So the hiatus semilunaris is the door through which we enter the ethmoidal infundibulum room/passage way
2-Hiatus semilunaris superior:
 2D crescent shape cleft and depression
 Seen from a median view
 Borders:
o Superiorly: skull base
o Posteriorly: basal lamella of middle turbinate
o Inferio-anterior: ethmoid bulla
 From the middle meatus through this 2D cleft (Hiatus semilunaris superior) a 3D space of the lateral sinus can be
reached (hiatus semilunaris is the doorway from the middle meatus into the lateral sinus)
Osteomeatal Complex:
The common final way of drainage & ventilation for the, maxillary & anterior ethmoid sinuses +/- frontal sinus
Functional designation (not anatomical structure) that refers to the middle meatal structures which include:
 middle turbinate
 middle meatus
 uncinate process
 ethmoid bulla
 anterior ethmoid air cells
 semilunar hiatus
 ethmoid infundibulum.
 Ostium of : maxilla, anterior ethmoid +/- frontal air cells
So it is the critical area of obstruction resulting in the
pathological disease in these sinuses
1- Agger Nasi cell:
 the most anterior ethmoid air cells
 the most constant frontal recess cell
 intranasal prominence which is pneumonization
in 90% of patients by anterior ethmoid air cells
(superior aspect of the infundibulum) in 98.5 % of
the time
 Drain into semilunar hiatus inferior
 Relations: mound/prominence on the lateral wall just
anterior & superior to the insertion of the middle turbinate
 Borders:
o Anteriorly: frontal process of the maxillary bone
o Anteriolaterally: nasal bone
o Superiorly: frontal sinus
o Posteriorly: frontal recess
o inferiorly:
 inferior-lateral : lacrimal bone
 inferior medial: uncinate process
When the agger nasi is aerated, its increased size may cause
structural blockage of frontal recess.
It composes:
 Anterior wall of the frontal recess: The superior posterior
wall of the agger nasi cell.
 floor of the frontal sinus : The roof of the agger nasi cell is
an important landmark for frontal sinus surgery
The frontal recess may be defined as follows:
 Medially: middle turbinate
 Laterally: lamina papyracea, lacrimal bone
 Superiorly: skull base
 Inferiorly: dependent upon the attachment of the uncinate
process
2- Haller cells:
 ethmoid air cells that extend into maxillary sinus above the
ostium, pneumatize the medial and inferior orbital walls
 Origin:
o anterior ethmoid air cells 88%
o posterior ethmoid air cells 12%
 Location
o below the orbit
o in the medial part of the maxillary sinus roof.(i.e., in the orbital floor)
 It occurs in 10% of people.
As it is closely related to maxillary ostium/ ethmoidal infundibulum:
Enlarged Haller cells may contribute to narrowing of the maxillary ostium/ ethmoidal infundibulum and variation of
the infundibulum & recurrent sinus disease.
do not confuse these terms:
Ethmoid bulla: located along the lateral wall of the orbit
Haller cells :located along the medial floor of the orbit
supraorbital air cells: located in the orbital roof.
3- Onodi cells/sphenoethmoidal cell
 Definition:
Lateral and posterior pneumatization of the most
posterior superior ethmoid cells along the lamina
papyracea over the superolateral sphenoid sinus.
 12% of the patients have Onodi cells
 Note:
o Sphenoid sinus is located inferior & medial to the most posterior ethmoid air cell
o Carotid artery & optic nerve are located at the lateral aspect of the sphenoid sinus
 Clinical significance:
o commonly mistaken as a sphenoid cell
o radiographically, it appears as a septate sphenoid sinus with the superior compartment being onodi cells
o Because the Onodi cells are posterior ethmoid cells that are positioned superolateral to the sphenoid
sinus, the optic nerve & carotid artery may often course through the lateral aspect of onodi cell instead
of sphenoid sinus proper.
o Optic nerve relation is more important than internal carotid artery
o Optic nerve may indent into the lateral wall
So the presence of Onodi cells increases the chance that the optic nerve and/or carotid artery would be exposed (or
nearly exposed) in the pneumatized cell.
The optic nerve, and more rarely, the internal carotid artery, may be exposed within or lie immediately adjacent to
such an air cell
So the sphenoid sinus is entered through the most inferior and medial portion of the posterior ethmoid sinus
Summary:
During endoscopic sinus surgery attempts to localize the sphenoidal sinus via instrumentation through the posterior
most ethmoidal air cells can lead to optic nerve, and even, internal carotid artery, injury
Drainage:
o anterior cells drain into the ethmoid infundibulum
o posterior cells drain into the spheno-ethmoid recess (superior meatus)

So:
o the Onodi cell are the most posterior part of
the ethmoid air cells
o the agger nassi are the most anterior part of
the ethmoid air cells
4- Frontal cells: (frontoethmoidal cells)
 rare anatomical variant of the anterior ethmoid cells
 impinge upon the frontal recess
 extends within the lumen of the frontal ostium
 above the agger nasi
 they become clinically evident if:
o if they become primarily infected
o cause obstruction of the frontal sinus drainage system
Types of frontal cells: (Kuhn classification)
1. type 1: single frontal recess cell above the agger nasi cell
2. type 2: tier of frontal cells within the frontal recess above the agger nasi
3. type 3: single massive cell, arising above the agger nasi
 pneumanitize cephaled extending into the frontal sinus, but not >50% of the sinus height
4. type 4: single isolated frontal cell entirely in the frontal sinus (sinus within sinus), away from agger nasi cell
 bordered by the anterior wall of the frontal sinus

Note: difference between type III frontal cell and frontal bulla is that frontal cell is
along the agar nasi while the frontal bulla is along the skull base, and these can be
distinguished on CT using the sagittal and axial cuts, not coronal.
5- supraorbital vs frontal bulbar ethmoid cells:
Both frontal bulbar cell & supraorbital cell are:
o ethmoid air cells that reside above the frontal bulla
o can cause significant compromise from the posterior portion of the frontal recess
o pneumatizes along the skull base in the posterior frontal recess
Difference:
o frontal bulbar cells: pneumatization extends into the frontal sinus suprorbital ethmoid air cell
o suprabullbar cells: does not pneumatize into the frontal cells
Further details on the suprabullbar recess:
o Extends out over the orbit by pneumatizing the orbital plate of the frontal bone
o Septate frontal sinus is the hallmark of extensive pneumatized suprabullbar cell
o Its ostium is posteriolateral to the frontal sinus
o its opening is closely related to the canal for the anterior ethmoid artery
o This cell is commonly mistaken for frontal sinus septation in the frontal sinus
Missed supra-orbital cell is a common cause for iatrogenic frontal sinusitis.
Vasculature of ethmoid air cells:
Artery: Netter p323+ 327 + tutorial p25, 27
A. Anterior and posterior ethmoid arteries (from ophthalmic artery)
 originate from the ophthalmic artery in the orbit
 anterior ethmoid artery Pass between superior oblique and medial rectus muscle
 posterior ethmoid artery pass above the superior oblique muscle
 Through the anterior and posterior ethmoid foramen at the
fronto-ethmoidal suture into the anterior ethmoid complex
 It crosses the anterior ethmoid either at the level of the
ethmoidal roof or as much as 5mm below this level, running
in a mucous membrane fold or a thin bony mesentery in the
roof of the anterior ethmoidal sinuses
 The artery may be surrounded by only a thin-walled bony
channel, which can be dehiscent in over 20- 40 % inferiorly.
 After this passage through the anterior ethmoid, the artery
enters the olfactory fossa (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 -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.
o The posterior ethmoid artery lies in the roof of the posterior ethmoid just anterior to the anterior wall of
the sphenoid sinus
o After intracranial entry, the artery turns anteriorly forming a groove in the lateral lamella, the called
ethmoidal sulcus. Here, it gives off anterior meningeal branches and finally reaches the nasal cavity again
through the cribroethmoidal foramen and the cribriform plate.
o Here 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.
o Intranasal location is:
 Below: skull base
 Posterior to: frontal recess & ethmoid bulla
 anterior to: vertical attachment of the middle turbinate
Note:
 The anterior & posterior ethmoid foramen are situated in the frontal bone between the lower margin of the
foveolae ethmoidalis & upper edge of the lamina papyrecia
 Cranial cavityorbital cavitycranial cavitynasal cavity
 The artery can be the source of significant intraoperative bleeding when injured
 The anterior ethmoidal artery has been estimated to be unilaterally absent in 14 %, bilaterally absent in 2 %
and multiple in 30 %.
 If the anterior ethmoidal artery is absent, it is replaced by a branch of the posterior ethmoidal artery.
The ethmoidal foraminae (situated at the frontoethmoidal suture) that transmit the anterior and posterior
ethmoidal arteries mark the roof of the ethmoidal sinuses, above which lie the anterior cranial base and brain
B. Posterior lateral nasal artery (sphenopalatine artery)

Vein:
o Maxillary and ethmoid veins (cavernous sinus)
o Unique feature of the venous supply of the ethmoidal sinuses is the intracranial pathways

Innervation: netter 324

o Anterior ethmoid air cell: nasociliary branch of V1
o Posterior ethmoid air cell: posteriolateral orbital branches of pterygopalatine ganglion
General notes about the ethmoid bone:
 Lamina papyracea is Part of the lateral wall of the ethmoid
 Lateral lamella is in the medial wall of the ethmoid sinus
 Middle and superior turbinate are part of the ethmoid
 Uncinate process is part of the ethmoid, lateral of the middle turbinate
 crista gali and perpendicular plate are on the same level
 lateral lamella of the cribriform plate and insertion of middle turbinate
are on the same level
 Layers from mediallateral: Middle
turbinateuncinateinfundibulumbullalamina papyrecia
 Frontal Sinus
Embryology:
o not present at birth, starts to develop after the 4th years
o Adult Volume: 4–7 ml by 18 years old
o Dimensions: 28 mm length, 24 mm width, 20 mm depth
o Intersinus septum is usually present but dehiscent in 9%
o % of agenesis: Unilateral: 4% ; bilateral: 5%; Underdeveloped: 5-10%
o The frontal sinus is pyramid in shape, originates from pneumatization of the frontal
recess in an antero-superior direction, into the vertical part of the frontal bone.
Natural Ostium: posterio-inferio-medial
Drainage into Frontal recess: middle meatus directly/infundibulum then into the middle meatus
o 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.
o The natural ostium of the frontal sinus is somewhat variable in its configuration but most frequently it
presents as an hourglass narrowing opening (rather than a duct).
o Its narrowest part is at the level of the frontal ostium
Funnel ( superior part of the hour glass) Frontal sinus
Narrowed part of the hour glass Frontal sinus ostium
Inverted funnel ( inferior part of the hour glass) Frontal recess
o In 10 % 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
o Pott’s puffy tumour is a frontal infection which can lead to meningitis, brain abscess, orbital cellulitis, or
osteomylitis of the frontal bone.
Frontal recess:
o 3D Cavity; the term 'frontonasal duct' has been generally abandoned as: no true duct exists, either
histologically or topographically, in most people.
o It is not an independent bony tubular structure but simply the potential space which other independent
bony structures leave between them
o found in the most anterosuperior portion of the middle meatus/anterior ethmoid complex
 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
 Anterior: superior posterior surface of agger nasi cell (when present) + frontal cells
 Posterior: anterior wall of ethmoid bulla/skull base (depends on the presence of suprabulbar recess)
 The agger nasi cell is the most constant frontal recess cell
 The frontal recess tapers as it approaches the superiorly located internal os of the frontal sinus
 frontal recess in anterior middle meatus either medial (more frequent)or lateral to the uncinate (posterior and
medial to agger nasi cells)
 The entrance to frontal recess is just above the superior border of the bulla. If the bulla is entered first, one
should preserve its superior border as a landmark for entrance to the frontal recess.
 Best landmark of frontal sinus ostium is to follow the uncinate process remnant up to its superior attachment
 The limits, shape and width of the frontal recess are largely determined by its neighboring structures (these
structure can narrow the frontal recess):
1. The shape of the ethmoidal bulla: if it extends far forward in the case of a well-developed bulla, the frontal
recess will be narrowed from posteriorly.
2. Significant pneumatization of the agger nasi may cause Narrowing.
 Note that frontal recess is pneumatized by variety of anterior ethmoid cells
 Anterior ethmoid artery is identified in the posterior part of the frontal recess, anterior to the vertical part of
the basal lamella, immediately below skull base
 Vasculature:
 supraorbital and supratrochlear arteries
 ophthalmic (cavernous sinus) and supraorbital (anterior facial) veins
 Innervation:
 supraorbital and supratrochlear nerves (V1)
 Foramina of Breschet: small venules that drain the sinus mucosa into the dural veins
 Maxillary Sinus

 Embryology:
 1st to develop in utero (7-10 weeks)
 Arise from the inferior aspect of the ethmoid infundibulum
 Formed as a lateral evagination between the middle & inferior
turbinates at 3 months gestation
 Has biphasic growth, consides with teeth growth at 3 and 7–12 years
 Size at birth 7*4*4 mm3, can be seen on CT at age of 4-5 months
 Adult size (18 years) 15 cm3 (largest paranasal sinus)
 Has a Triangular/pyramidal shape with the base being the lateral
nasal wall and the apex towards the zygomatic precess
 Dimensions: AnterioPosterior: 3.5cm, Transverse: 2.5cm, Height: 3.3 cm
 Floor of the maxillary sinus:
 At birth: superior to the nasal floor
 8-9 yr: at the same level as the nasal floor
 Adult hood: below the level of the nasal floor
Average: 0.5cm, Max: 1.25cm
 relatively symmetrical; rarely absent
 Borders:
 Anteriorly: facial surface of the maxilla
 Posteriorly: infratemporal surface of the maxilla
o contains pterygopalatine fossa housing the: maxillary
artery, pterygopalatine ganglion, and branches of the
trigeminal nerve)
 roof: orbital floor
 inferior: alveolar process of maxilla (contains second
bicuspid and 1st & 2nd molars)
 Drainage:
o At the floor and lateral aspect of the infundibulum between
its middle & posterior 1/3
o 10–30% have accessory ostium located anterior/posterior
to the uncinate
o Infra-orbital Haller cells can be in close approximity to the
infundibulum and Maxillary ostium
o the exact site ,size & orientation of the maxillary sinus
ostium is subjected to great variation
 General features:
o Indented anterio-medially by the lacrimal notch which is
related to the lacrimal sac
o posterior edge contributes to the inferior orbital fissure
o traversed by the infra-orbital canal which may be dehiscent
o inferiorly the floor of the sinus is thicker but can encroach
around the roots of the teeth
o the majority of the maxillary sinus is in the body of the
maxillary bone but not entirely
o Its medial wall is made by the ethmoid, inferior tuebinates. vertical plate of palatine bone

maxillary hiatus
In a disarticulated skull, the maxillary bone has a large opening in its medial wall (the maxillary hiatus) whose size is reduced
by the overlapping bones
 The posterior aspect is overlapped by the Perpendicular Plate of palatine bone
 The Inferior is overlapped with maxillary process of the inferior concha
 anterosuperior: a small portion of the lacrimal bone
 The Superior aspect is overlapped with the ethmoid (mainly the bulla + uncinate process)
 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 will leave the maxillary ostium at the base (posterior inferior part) of ethmoid infundibulum
Nasolacrimal duct:
 The orifice lies 3-3.5 mm behind the posterior margin of the nostril
 Maxillary sinus ostium is 3-6 mm away from the posterior end of the
Nasolacrimal duct, nasolacrimal duct is around 12 mm long
 So it can be injured during maxillary antrostomy
 The anterior lateral part of the uncinate is attached to the posterior part of the
NasoLacrimal Duct
 This is why in maxillary antrostomy, remove bone as far at the anterior
attachment of the uncinate process to avoid injury to lacrimal duct
 Nasolacrimal duct is contained within the Nasolacrimal canal (Canal > Duct)
 Nasolacrimal duct passes into the anterior part of the inferior turbinate
 Antral wash out should be done through incision in the posterior part of the
inferior meatus were the bone is thinner and to avoid injury to nasolacrimal duct,
it is hazardous in children with unirrupted teeth
 Agger nasi cells (the most anterior ethmoid air cells ) are used as land mark for
the nasolacrimal duct
 Can be visualized on CT dacrocystogram
Fontanelle area:
 Bony dehiscence of the lateral nasal wall usually above the insertion of
the inferior turbinate where the nasal mucosa approximate the
mucoperiostium of the maxillary sinus area (membranous-mucosal
components)
 The inferior aspect of the uncinate process separate the fontanelle
area into anterior & posterior fontanelles
 Posterior fontanelle is larger & more distinct
 The natural maxillary sinus is located in the posterior fontanelle
 The frontanelles (especially the posterior) may be perforated creating
an accessory ostium into the maxillary sinus (20-25%)
 Accessory ostium may be an indicator of chronic infection
 Note: that both the anterior + posterior fontanelle areas are located
in the middle meatus above the inferior turbinates
Innervation:
 infraorbital nerve (V2) with middle + anterior superior alveolar+ Posterior superior alveolar
 greater palatine nerve
 posterior inferior lateral nasal branch
Vasculature:
 Branches from facial artery; branches from maxillary artery (Infra-orbital branch, Greater palatine branch)
 Sphenoid sinus
 Embryology:
th
 Recognizable at around the 4 intrauterine month as an evagination from the posterior aspect of nasal
capsule (sphenoethmoidal recess)/(cartilaginous cupolar recess ossified to become ossiculum Bertini then
becomes part of the sphenoid body)
 Minimal in size at birth
 Pneumonization occurs at the middle childhood (6 year) completed by 9-12 years
 Adult Volume: 0.5–8 ml (adult size at 12–18 years old), asymmetry is the rule
rather than the exception
 Located:
 anterior & lateral to the sphenoid bone
 superiorly: anterior cranial fossa (frontal lobe) + pituitary gland
 laterally: cavernous sinus+ middle cranial fossa
 medially: sphenoid septum which differ in location, direction, #, thickness
 anteriorlly: superior turbinate + sphenoethmoidal recess + posterior ethmoid
(anterior + inferior to sphenoid sinus)
 posteriorly: posterior cranial fossa (pons) + basillary artery + basi-
sphenoid/clivus
 inferiorly: nasopharynx
So in transethmoidal approach we enter the sphenoid sinus via the most inferior & medial part of ethmoid (to avoid
injury to the posterior ethmoid artery superiorly, optic nerve laterally)
Septum of the sphenoid sinus:
 The sinuses are divided by a septum
 Asymmetry is the rule rather than the exception
 Often paramedian
 There may be diverticula and incomplete septa.
 It is completely absent in approximately 1 % of the population
 The septum may attach laterally to one side in the region of internal carotid
artery/optic nerve , an important consideration if the septum is being
removed
 sphenoid sinus pneumonization:
o The sinus cavities are variable in size and shape.
o Pneumatization can extend:
 laterally: into the greater wing forming lateral recess
 inferiorly: into pterygoid processes and rostrum
 Posteriorly: may extends for variable distance inferior to sella tursica
Hamberger sphenoid sinus classified based on pneuminzation:
1. Conchal pneumatization: The sinus is entirely filled with cancellous bone (rudimentary sinus) (0-5 %)
2. Presellar pneumatization: extends to anterior bony wall of the pituitary fossa (cancellous bone extends under
the sella to the anterior aspect of the floor (23-25 %).
3. Sellar pneumatization: extends back beneath the pituitary fossa (sella bulges into well developed sinus (67-76%))
4. Mixed (27%)

Note: conchal sphenoid is not an absolute contraindication for transsphenoidal hypophysectomy because the bone
can be drilled out to permit access
 Key structures associated with the sphenoid sinus:
1. Optic Nerve inside optic canal (6% dehiscence) especially in case of fungal
sinusitis, tumor, mucocele
2. ICA in cavernous sinus (22% dehiscence)
3. Vidian nerve in pterygoid canal
4. Sella
5. Maxillary division of the trigeminal nerve (V2) In Foramen rotundum
Note that both V1 +V2 go through the lateral wall of cavernous sinus but only V2
indents on the inferiolateral wall of sphenoid
Structures that intend over the sphenoid sinus wall:
1. Optic nerve: superior part of the lateral +posterior wall
2. Internal carotid artery: inferior part of the lateral + posterior wall
3. Vidian nerve: floor of the sphenoid sinus
Opticocarotid recess/Infra-optic recess:
 Pneumatzation of the posterior-superior lateral wall of the
sphenoid sinus between the ICA & optic nerve
 Its size & depth depends on the degree of anterior clenoid process
 Optic nerve canal lies anterio-lateral aspect of the sphenoid roof
 May be absent in 4 % of people
Location of the ostium:
 The ostium is 2*3mm, slit, oval or round in shape
 Located in the sphenoethmoidal recess
 7 cm from the nostril rim at a 30 degree angle from
the anterior nasal spine
 1 cm above the roof of choana (or 1/3 of the
distance from choana to skull base) & 1-2 mm
medial to the nasal septum
 Medial to the superior turbinate within millimeters
from the its posterior-inferior edge
Drainage:
 Sphenoid ostium drain into sphenoethmoid recess
in the superior meatus
sphenoethmoid recess:
Formed by the space between the superior
turbinate + septum + nasal roof
Borders:
 Laterally: superior (& supereme, if present) turbinate
 Medially: Septum
 Superiorly: skull base
 Posteriorly: anterior surface of the sphenoid sinus
 Inferiolaterally: inferior margin of the superior turbinate
 blood + nerve supply:
 posterior ethmoid Nerve + Artery: roof
 sphenopalatine: floor
 lymphatic drainage:
 retropharyngeal lymph node

Relationship between the sphenoid & ethmoid sinus

 Although the most posterior ethmoidal cell is closed by the
sphenoid concha, the sphenoid sinus does not simply lie behind
it; that portion of the sphenoid is usually quite small with the
most posterior ethmoid cell often running lateral to the
sphenoid sinus
 Clinical application: the sphenoid sinus is entered through the
most inferior and medial portion of the posterior ethmoid sinus
 Sphenopalatine Foramen:
 posterior to inferior attachment of the middle turbinate
 formed by:
1. superior: sphenoid sinus
2. Inferior: palatine bone
3. anterior: ethmoid process of the palatine bone
4. posterior: sphenoid process of the palatine bone
Leads from pterygopalatine fossa into nasal cavity
Contains:
1. sphenopalatine artery and vein supply:
 inferior posterior part of the septum
 inferior anterior part of the sphenoid sinus
 posterior part of inferior + middle turbinate
2. Nasopalatine nerve: sensory nerve fibers, and
secretomotor fibers (parasympathetic fibers from vidian
nerve to pterygopalatine ganglion)

Important points
Summary of para-nasal sinus drainage ( netter p 321)
Frontal sinus Middle meatus directly Or infundibulum then middle meatus (depending on the position of the uncinate)
Maxillary sinus Posterior inferior part of the infundibulum: middle meatus
Anterior ethmoid Infundibulum: middle meatus
Bulla Retrobullbar recess: middle meatus
Posterior ethmoid Superior meatus
Sphenoid Sphenoethmoidal recess
 Frontal ostium located anterior superior to the angle made between the bulla & uncinate (infundibulum)
 Maxillary ostium located posterior inferior to the angle between the bulla & uncinate (infundibulum)
Note (netter page 321):
 The drainage from the sphenoethmoidal recess + superior meatus: above the eustachian tube
 The drainage from the middle meatus: Below the Eustachian tube
 The area above and lateral & medial to the vertical attachment of the middle turbinates is considered the
dangerous area in the FESS
 Sources of meningitis following FESS:
1. via roof of the ethmoid
2. perineural lymphatic of the Olphactory nerve filaments
It does not mean penetration of the cribriform plate
 Summary about paranasal sinus development:
 1st paranasal sinus to develop: maxillary
 Last one to develop: frontal
 The most well developed at birth: ethmoid
 The 1st one to reach full development: ethmoid
 Last one to reach full development: frontal

Summary of the sinus embryology

Maxillary sinus Ethmoid sinus Frontal sphenoid

Onset of development 3rd month of gestation 5th month 4 years 4th month of gestation
Age of full development 18 yr 15 yr 20 yr 18 yr
Adult size 15ml 2ml 4ml .5ml-8ml
Specific features 1st one to develop The most well Last one to full Minimal in size at birth
developed at develop, Pneumonization occurs at the mid
birth absent at birth childhood

Summary of sinuses innervations:

Frontal sinus:
 Ophthalmic: supratrochlear & supraorbital nerve
Maxillary sinus:
 Maxillary Nerve: Roof: infra-orbital nerve; Inferior & posterior: greater palatine; Medial: posterior lateral
nasal nerve
 Lateral: anterior & middle superior alveolar
Sphenoid sinus:
 Ophthalmic: posterior ethmoid
 Maxillary: sphenoplatine
Ethmoid sinus:
 Ophthalmic: anterior & posterior ethmoid
 Maxillary: orbital branch of pterygoid ganglion

Important measurements in the sphenoid sinus

Distance from nasal spine:

 5 cm: bulla ethmoidalis
 6 cm: frontal recess, basal lamella of middle
turbinate.
 6-6.5 cm: nasofrontal duct ostia
 7 cm: anterior ethmoidal artery, posterior ethmoid
base of skull, sphenoidal sinus anterior wall,
choanal bridge
 nasopharyngeal wall approximates posterior
sphenoid wall to within 1 cm
 ostium of sphenoidal sinus:
 adjacent to septum ~1.5 cm above choanal bridge
 1/3 up from choana to base of skull
 2/3 distance from the vaginal process to the top of the anterior sphenoid sinus

The 4 lamella of ethmoid used in Fess: (constant landmarks that used as guide lines in FESS)
1st lamella: uncinate process
2nd lamella: ethmoid bulla
3rd lamella: basal lamella of the middle turbinate
4th lamella: superior turbinate