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By 
Dr.K.PRASANNA 
Radiology Resident 
RMMCH
NOSE AND NASAL FOSSA 
PARA NASAL SINUSES 
OSTEOMEATAL COMPLEX 
ANATOMICAL VARIATIONS 
IMAGING MODALITIES 
CT PROCEDURE & SECTIONS 
CONCLUSION
NOSE AND NASAL FOSSA
 Bony part & cartilaginous part covered by muscle & skin 
 Cartilaginous part – upper & lower lateral cartilages, lesser alar 
cartilages & septal cartilage 
 Nasal skin 
 Internal nose divided into the 
Right and left by the nasal 
septum
 NASAL CAVITY PROPER 
 Roof – Nasal bone, 
sphenoid & ethmoid bone 
 Floor - Palatine process of 
the maxilla & Palatine bone 
 Medial wall 
 Lateral wall
CT ANATOMY OF PARA NASAL SINUSES
 Mainly by both Internal & 
external carotid, both on the 
septum & lateral walls 
 Anterior & posterior ethmoidal 
artery 
 Sphenopalatine artery 
 Septal branch of greater 
palatine 
 Septal branch of superior labial 
artery
 Formed by bony, soft tissue & 
cartilage 
 Bony – 
 Ethmoid infundibulum & uncinate 
 Perpendicular plate of palatine 
bone 
 Medial plate of pterygoid process 
of sphenoid bone 
 Medial surfaces of lacrimal bones 
and maxillae 
 Inferior conchae
 Cartilage – In external nose, 
the lateral wall of cavity is 
supported by cartilage 
(lateral process of septal 
cartilage & major, minor 
alar cartilage)
 Marked by three bony projections, they extend medially across the 
nasal cavity separating the nasal cavity into for air channels – the 
turbinates or conchae 
 Superior ,middle & inferior tubinates or conchae. The conchae do not 
extend forwards into the external nose 
 The air space below and lateral to each turbinate is called as meatus 
 Superior, middle & inferior meatus & sphenoethmoidal 
recess 
 Middle Meatus – much significant
CT ANATOMY OF PARA NASAL SINUSES
Superior Meatus – Limited only to posterior one third of lateral 
wall. Posterior ethmoidal sinus opens into it. 
Middle Meatus 
Inferior Meatus – Runs along the whole length of lateral wall. 
Nasolacrimal duct opens in its anterior part. Largest of all meatus 
Sphenoethmoidal recess – Above the superior turbinate. It 
receives the opening of sphenoid sinus
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
 Infundibulum – Air passage 
connecting the maxillary sinus 
ostium to middle meatus 
 Hiatus Semilunaris – Gap 
between the uncinate process 
and bulla ethmoidalis. 
Medially it communicates with 
middle meatus. Laterally & inf 
it communicates with 
infundibulum
 Frontal sinus – Opens into the 
anterior part of hiatus 
semilunaris 
 Maxillary sinus – Opens into the 
posterior part of hiatus 
semilunaris 
 Anterior and middle ethmoidal 
cells – Opens into the upper 
margin bulla ethmoidalis
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
SINUSES
 Air containing cavity in certain skull bones 
 Develop as a diverticula/outpouching from the lat wall of nose 
& extend into Maxilla, Ethmoid, sphenoid and frontal bones 
 Four sinuses – Maxillary, Frontal, Ethmoid (Ant & Post) & 
Sphenoid 
 Some sinuses are well developed & asymmetrical
Each sinuses have 
orifices that open into 
the meatus, covered by 
turbinates
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
Clinically - 
two groups 
Anterior – 
Frontal, 
Maxillary, 
Ant.Ethmoidal 
Posterior – Post 
Ethmoidal, 
Sphenoid
 Significance 
 Lighten the skull & facial bones 
 Contributes to vocal resonance 
 Collapsible framework that helps the brain to protect from blunt 
trauma 
 EPITHELIUM 
 They are lined by mucosa similar to that of the nasal cavity – pseudo 
stratified ciliated columnar epithelium 
 Epithelium contains – Mucinous & serous glands 
 Mucoperiosteum
CT ANATOMY OF PARA NASAL SINUSES
Sinuses Status at 
Birth 
First 
Radiological 
evidence 
Reaches 
Adult size 
by 
Maxillary sinus Present at birth 4-5 months after 
birth 
15 years 
Ethmoid sinus Present at birth 1 year 12 years 
Sphenoid sinus Not Present 4 years 15 years – 
adult age 
Frontal Sinus Not Present 6 years Size increases 
until teens
CT ANATOMY OF PARA NASAL SINUSES
 Largest paranasal sinus 
 Pyramidal in shape 
 Base - towards lateral wall of nose 
 Apex – towards zygomatic process of maxilla
 Present at birth as a rudimentary sinus 
 First radiological evidence is at 4-5 months after birth 
 Reaches adult size by 15 years 
 On average, 
it has capacity 
of 14.75 ml (14-15)
• Facial surface of maxilla and cheek Ant wall 
• Infra temporal & pterygopalatine 
fossa Post wall 
• Middle & inferior meatuses (this 
wall is thin & membranous) Med wall 
• Floor of orbits Roof 
• Alveolar part of maxilla Floor
CT ANATOMY OF PARA NASAL SINUSES
 DRAINAGE – OSTIUM 
 Seen high up in the medial wall 
 Does not open directly into the nasal cavity, but opens into post. 
part of ethmoidal infundibulum, via hiatus semilunaris into middle 
meatus. 
 The infundibulum is the air passage that connects the maxillary 
sinus ostium to the middle meatus. 
 Unfavourable for natural sinus drinage 
 Accessory ostium – 30 % cases
 Arterial supply – Maxillary 
artery, infra orbital, facial & 
greater palatine 
 Venous supply – anteriorly by 
facial vein & post.by maxillary 
vein 
 Nerve supply – infra orbital, 
anterior, middle & posterior 
superior alveolar nerves 
 Lymph nodes – cervical nodes & 
submandibular nodes
CT ANATOMY OF PARA NASAL SINUSES
 Situated between the outer & inner table of frontal bone 
 Funnel shaped 
 Two sinuses on either side 
 Asymmetrical 
 Intervening bony septum which may be thin or deficiency
 Not present at birth 
 First radiological evidence is at 6 years 
 Reaches adult size after puberty 
 The natural frontal sinus ostium is usually located in the 
posteromedial floor of the sinus (most dependent part). 
 It opens into the middle meatus 
 The ethmoidal infundibulum can act as a channel for carrying the 
secretions (and infection) from the frontal sinus to anterior ethmoid 
cells and the maxillary sinus or vice versa.
CT ANATOMY OF PARA NASAL SINUSES
 They develop from a variable site, their drainage will be either 
via an ostium into the frontal recess or via a nasofrontal duct 
into the anterior infundibulum. The opening or duct can be 
distorted by expansion of adjacent ethmoid cells 
 Boundaries 
 Ant wall – Skin over the forehead 
 Post wall - Meninges & the frontal lobe of brain 
 Inferior wall - orbit & its contents
 FRONTAL RECESS 
 The frontal recess is an hourglass 
like narrowing between the 
frontal sinus and the anterior 
middle meatus through which 
the frontal sinus drains. It is not a 
tubular structure, as the term 
nasofrontal duct might imply, 
and therefore the term recess is 
preferred.
 The frontal recesses are the 
narrowest anterior air 
channels and are common 
sites of inflammation. Their 
obstruction subsequently 
results in loss of ventilation 
and mucociliary clearance of 
the frontal sinus
 AGGER NASI CELL 
 Anterior, lateral, and inferior to the frontal recess is the 
agger nasi cell. It is aerated and represents the most anterior 
ethmoid air cell, usually lying deep to the lacrimal bone. 
 It usually borders the primary ostium or floor of the frontal 
sinus, and thus its size may directly influence the patency of 
the frontal recess and the anterior middle meatus.
CT ANATOMY OF PARA NASAL SINUSES
 The frontal sinus can pneumatize both the vertical and the 
horizontal (orbital) plates of the frontal bone. The deepest area 
of the vertical portion of the sinus is near the midline at the 
level of the supraorbital ridge, and the medial sinus floor and 
the caudal anterior sinus wall are thinnest in this area. As a 
result, the sinus is best approached for a trephination at this 
level
 There is a rich sinus venous plexus (Breschet’s canals) that 
communicates with both the diploic veins and the dural 
spaces. 
 Arterial supply – supra orbital & supra trochlear 
 Venous supply – superior opthalmic vein 
 Lymph – Submandibular lymph node 
 Sensory innervation – supra orbital & supra trochlear
 Occupies the body of sphenoid 
 Right & left, seperated by a thin strip 
of bony septum (like frontal sinus) 
 Ostium opens into spheno ethmoidal 
recess 
 Relations of the sinus are very 
important, esp during the surgical 
approach of pituitary gland
CT ANATOMY OF PARA NASAL SINUSES
 Relations – 
 Anterior part – 
 Roof – olfactory tract, optic chiasma & 
frontal lobe 
 Lateral – optic nerve, internal carotid 
artery & maxillary nerve 
 Posterior part 
 Roof – Pituitary gland in sella turcica 
 Lateral – Cavernous sinus,ICA & Cranial 
nerves III, IV, VI & all divisions of V
 Thin strips of bone separate the 
sphenoidal sinuses from the nasal cavities 
below and hypophyseal fossa above 
 The pituitary gland can be surgically 
approached through the roof of the nasal 
cavities by passing first through the 
anteroinferior aspect of the sphenoid 
bone and into the sphenoidal sinuses and 
then through the top of the sphenoid 
bone into the hypophyseal fossa
 Thin walled air cavities in the lateral masses of the ethmoid 
bone 
 Varies from 3 – 18 
 Occupy the space between the upper third of the lateral nasal 
wall and the medial wall of orbit 
 Clinically divided into anterior ethmoidal air cells & posterior 
ethmoidal air cells, by basal lamella (lateral attachment of 
middle turbinate to lamina papyracea)
CT ANATOMY OF PARA NASAL SINUSES
 DRAINAGE: 
Anterior - a recess of hiatus 
semilunaris & middle meatus via 
ehmoid bulla 
Post- sup.meatus & spenethmoidal 
recess. 
 Present at birth 
 Reaches adult size by 12 years 
 First radiological evidence seen at 1 
year
Relations 
 Roof – formed by the anterior cranial fossa 
 Lateral wall - orbit 
 Medial wall – nasal cavity 
 Thin paper like bony part of the ethmoid separating the air cells 
from the orbit, called lamina papyracea, can be easily destroyed 
leading to spread of ethmoidal infections into the orbit 
 Optic nerve forms a close relationship with the posterior ethmoidal 
cells & is at risk during ethmoidal surgery
OSTEOMEATAL COMPLEX
 The osteomeatal complex is the key anatomic area addressed 
by endoscopic sinus surgeons. Blockage of the osteomeatal 
complex prevents effective mucociliary clearance, thus leading 
to a stagnation of secretions and therefore leading to recurrent 
or chronic sinusitis.
 The OMC is bounded 
 medially by the middle 
turbinate, 
 posteriorly and superiorly by 
the basal lamella, and 
 laterally by the lamina 
papyracea. 
 Inferiorly and anteriorly the 
OMC is open.
 This anatomic region therefore 
includes 
 Maxillary sinus ostium 
 ethmoid bulla 
 frontal recess 
 uncinate process 
 infundibulum 
 hiatus semilunaris 
 middle meatus.
CT ANATOMY OF PARA NASAL SINUSES
ANATOMICAL 
VARIANTS
 Paradoxic Curvature 
 Normally, the convexity of the middle 
turbinate bone is directed medially, toward 
the nasal septum. 
 When paradoxically curved, the convexity 
of the bone is directed laterally toward the 
lateral sinus wall. 
 The inferior edge of the middle turbinate 
may assume various shapes, which may 
narrow and/or obstruct the nasal cavity, 
infundibulum, and middle meatus.
 Concha Bullosa 
 It is an aerated turbinate, most often the middle 
turbinate. 
 Less frequently, superior & inferior turbinate 
aeration can occur. 
 When the pneumatization involves the bulbous 
segment of the middle turbinate, the term 
concha bullosa applies. 
 If only the attachment portion of the middle 
turbinate is pneumatized, and the 
pneumatization does not extend into the 
bulbous segment, it is known as a lamellar 
concha.
 Other Variations 
 Additional variations of the middle turbinate can occur, including 
medial & lateral displacement, lateral bending, L shape, and sagittal 
transverse clefts 
 Medial displacement – due to other middle meatal structures (i.e., 
polypoid disease, pneumatized uncinate process) encroaching upon 
the middle turbinate. 
 Lateral displacement - due to the compression of the turbinate 
toward the lateral nasal wall by a septal spur or septal deviation.
 The nasal septum deviation may 
compress the middle turbinate 
laterally, narrowing the middle 
meatus and the presence of 
associated bony spurs may 
further compromise the OMU. 
 Obstruction, secondary 
inflammation, swollen 
membranes, and infection can 
occur
 DEVIATION 
 The course of the free edge of the uncinate process may either 
extend slightly obliquely toward the nasal septum, with the 
free edge surrounding the inferoanterior surface of the ethmoid 
bulla, or it extends more medially to the medial surface of the 
ethmoid bulla. If the free edge of the uncinate is deviated in a 
more lateral direction, it may cause narrowing or obstruction of 
the hiatus semilunaris and infundibulum.
 Attachment 
 Attachment to the lamina papyracea, the lateral surface of the 
middle turbinate, or the fovea ethmoidalis in the floor of the 
anterior cranial fossa may occur. 
 If the uncinate process attaches to the ethmoidal roof or middle 
turbinate, during uncinatectomy, traction could inadvertently 
damage the ethmoid roof and result in CSF rhinorrhea or other 
intracranial complications.
CT ANATOMY OF PARA NASAL SINUSES
 Sometimes the free edge of 
the uncinate process 
adheres to the orbital floor, 
or inferior aspect of the 
lamina papyracea. This is 
referred to as an atelectatic 
uncinate process
 Pneumatization 
 The pneumatization of the uncinate 
process is believed to be due to 
extension of the agger nasi cell within 
the anterosuperior portion of the 
uncinate process. 
 Functionally, the pneumatized 
uncinate process resembles a concha 
bullosa or an enlarged ethmoid bulla.
 Infraorbital ethmoid cells are 
pneumatized ethmoid air cells 
that project along the medial 
roof of the maxillary sinus and 
the most inferior portion of the 
lamina papyracea, below the 
ethmoid bulla and lateral to 
the uncinate process
CT ANATOMY OF PARA NASAL SINUSES
 Two definitions of Onodi cells. 
 The first defines them as the most 
posterior ethmoid cells, being 
superolateral to the sphenoid sinus and 
closely associated with the optic nerve. 
 Another, more general description 
defines Onodi cells as posterior ethmoid 
cells extending into the sphenoid bone, 
situated either adjacent to or impinging 
upon the optic nerve
CT ANATOMY OF PARA NASAL SINUSES
 Its appearance varies considerably, based on the extent of 
pneumatization. 
 Extensive pneumatization may obstruct the ostiomeatal 
complex. 
 Elongated ethmoid bullae are usually in a superior to inferior 
direction rather than in an anterior to posterior direction. 
 So, Relatively unlikely to obstruct the ostiomeatal complex.
 Encountered rarely 
 extends into the lesser wing 
and the anterior and 
posterior clinoid processes 
 Can lead to distortion of 
optic cannal configuration
 May be either congenital or the 
result of prior facial trauma. 
 It occur most often at the site of 
the insertion of the basal 
lamella into the lamina 
papyracea, thus rendering this 
portion of the lamina papyracea 
most delicate 
 Orbit at risk
CT ANATOMY OF PARA NASAL SINUSES
 When aeration of the normally bony crista galli occurs the 
aerated cells may communicate with the frontal recess, and 
obstruction of this ostium. 
 To avoid unnecessary surgical extension into the anterior 
cranial vault, it is important to recognize an aerated crista galli 
and differentiate it from an ethmoid air cell.
 Air cells are commonly found within the posterosuperior 
portion of the nasal septum and, when present, communicate 
with the sphenoid sinus. 
 As a result, any inflammatory disease that occurs within the 
paranasal sinuses may also affect these cells
 It is important to note any asymmetry in the height of the 
ethmoid roof. 
 Intracranial penetration during surgery is more likely to 
occur on the side where the position of the roof is lower
IMAGING MODALITIES
 X RAY 
 CT 
 MRI
 X ray – Water’s view & caldwell view 
 Ct – gold standard. Coronal & axial sections 
 MRI is predominantly used for pre and post operative 
management of naso sinus malignancy 
 The chief disadvantage of MRI is its inability to show the bony 
details of the sinuses, as both air and bone give no signal
CT PROCEDURE & 
SECTIONS
 CT is currently the modality of choice in the evaluation of the 
paranasal sinuses and adjacent structures. 
 Its ability to optimally display bone, soft tissue, and air 
provides an accurate depiction of both the anatomy and the 
extent of disease in and around the paranasal sinuses. 
 In contrast to standard radiographs, CT clearly shows the fine 
bony anatomy of the osteomeatal channels.
 There are few pre requisites in few situations 
 a course of adequate medical therapy to eliminate or 
diminish reversible mucosal inflammation. 
 pretreatment with a sympathomimetic nasal spray 15 
minutes prior to scanning in order to reduce nasal congestion 
(mucosal edema) and thus improve the display of the fine 
bony architecture and any irreversible mucosal disease
 Coronal & axial views 
 The coronal plane best shows the ostiomeatal unit (OMU), 
shows the relationship of the brain to the ethmoid roof. 
 Coronal plane should be the primary imaging orientation for 
evaluation of the sinonasal tract in all patients with 
inflammatory sinus disease who are endoscopic surgical 
candidates
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
 Prone with chin hyperextended 
 Gantry anglutaion- perpendicular 
to hard palate 
 Section thickness-3mm 
contigous 
 Table increment- 3-4 mmeach 
step 
 Kvp-125 
 Mas-80 
 Hanging head technique
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
 HEAD HANGING METHOD 
 Performed in the prone position, so 
that any remaining sinus secretions 
do not obscure the OMU 
 In patients who cannot tolerate 
prone positioning (children, 
patients of advanced age, etc.), the 
hanging head technique can 
sometimes be utilized.
 In this technique, the patient is 
placed in the supine position and the 
neck is maximally extended. 
 A pillow placed under the patient’s 
shoulders facilitates positioning. 
 The CT gantry is then angled to be 
perpendicular to the hard palate. 
 It is not always possible to obtain 
true direct coronal images with this 
technique
 Axial images complement the coronal study, particularly when 
there is severe disease (opacification) of any of the paranasal 
sinuses and surgical treatment is contemplated. 
 The axial studies provide the best CT evaluation of the anterior 
and posterior sinus walls 
 Axial images are particularly important in visualizing the 
frontoethmoid junction and the sphenoethmoid recess.
 CT axial section of PNS 
- image
 Whenever there is total opacification of the frontal, maxillary, or 
sphenoid sinuses, a complete axial and coronal CT examination 
should be performed. 
 And also, if the patient has a suspected neoplasm, a complete 
axial and coronal examination need to be performed to provide 
the most detailed analysis of the sinonasal cavities and the 
adjacent skull base
 IMAGING PLANE : 
REIDS’S LINE – runs b/w infraorbital margin (IOM line) 
& EAM. (parallel - axial) 
ALEXANDER’S LINE – perpendicular to reids line. 
(perpendicular - coronal)
 Contrast is not required for all cases of CT paranasal sinus 
 Used in cases such as vascular lesion, malignancy, mass 
extending intra cranially, acute infections
CT ANATOMY OF PARA NASAL SINUSES
AGE OF THE PATIENT
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
CT ANATOMY OF PARA NASAL SINUSES
X RAY SHOULDER JOINT 
BY 
DR.V.PRIYA 
ON SATURDAY

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CT ANATOMY OF PARA NASAL SINUSES

  • 1. By Dr.K.PRASANNA Radiology Resident RMMCH
  • 2. NOSE AND NASAL FOSSA PARA NASAL SINUSES OSTEOMEATAL COMPLEX ANATOMICAL VARIATIONS IMAGING MODALITIES CT PROCEDURE & SECTIONS CONCLUSION
  • 4.  Bony part & cartilaginous part covered by muscle & skin  Cartilaginous part – upper & lower lateral cartilages, lesser alar cartilages & septal cartilage  Nasal skin  Internal nose divided into the Right and left by the nasal septum
  • 5.  NASAL CAVITY PROPER  Roof – Nasal bone, sphenoid & ethmoid bone  Floor - Palatine process of the maxilla & Palatine bone  Medial wall  Lateral wall
  • 7.  Mainly by both Internal & external carotid, both on the septum & lateral walls  Anterior & posterior ethmoidal artery  Sphenopalatine artery  Septal branch of greater palatine  Septal branch of superior labial artery
  • 8.  Formed by bony, soft tissue & cartilage  Bony –  Ethmoid infundibulum & uncinate  Perpendicular plate of palatine bone  Medial plate of pterygoid process of sphenoid bone  Medial surfaces of lacrimal bones and maxillae  Inferior conchae
  • 9.  Cartilage – In external nose, the lateral wall of cavity is supported by cartilage (lateral process of septal cartilage & major, minor alar cartilage)
  • 10.  Marked by three bony projections, they extend medially across the nasal cavity separating the nasal cavity into for air channels – the turbinates or conchae  Superior ,middle & inferior tubinates or conchae. The conchae do not extend forwards into the external nose  The air space below and lateral to each turbinate is called as meatus  Superior, middle & inferior meatus & sphenoethmoidal recess  Middle Meatus – much significant
  • 12. Superior Meatus – Limited only to posterior one third of lateral wall. Posterior ethmoidal sinus opens into it. Middle Meatus Inferior Meatus – Runs along the whole length of lateral wall. Nasolacrimal duct opens in its anterior part. Largest of all meatus Sphenoethmoidal recess – Above the superior turbinate. It receives the opening of sphenoid sinus
  • 15.  Infundibulum – Air passage connecting the maxillary sinus ostium to middle meatus  Hiatus Semilunaris – Gap between the uncinate process and bulla ethmoidalis. Medially it communicates with middle meatus. Laterally & inf it communicates with infundibulum
  • 16.  Frontal sinus – Opens into the anterior part of hiatus semilunaris  Maxillary sinus – Opens into the posterior part of hiatus semilunaris  Anterior and middle ethmoidal cells – Opens into the upper margin bulla ethmoidalis
  • 20.  Air containing cavity in certain skull bones  Develop as a diverticula/outpouching from the lat wall of nose & extend into Maxilla, Ethmoid, sphenoid and frontal bones  Four sinuses – Maxillary, Frontal, Ethmoid (Ant & Post) & Sphenoid  Some sinuses are well developed & asymmetrical
  • 21. Each sinuses have orifices that open into the meatus, covered by turbinates
  • 24. Clinically - two groups Anterior – Frontal, Maxillary, Ant.Ethmoidal Posterior – Post Ethmoidal, Sphenoid
  • 25.  Significance  Lighten the skull & facial bones  Contributes to vocal resonance  Collapsible framework that helps the brain to protect from blunt trauma  EPITHELIUM  They are lined by mucosa similar to that of the nasal cavity – pseudo stratified ciliated columnar epithelium  Epithelium contains – Mucinous & serous glands  Mucoperiosteum
  • 27. Sinuses Status at Birth First Radiological evidence Reaches Adult size by Maxillary sinus Present at birth 4-5 months after birth 15 years Ethmoid sinus Present at birth 1 year 12 years Sphenoid sinus Not Present 4 years 15 years – adult age Frontal Sinus Not Present 6 years Size increases until teens
  • 29.  Largest paranasal sinus  Pyramidal in shape  Base - towards lateral wall of nose  Apex – towards zygomatic process of maxilla
  • 30.  Present at birth as a rudimentary sinus  First radiological evidence is at 4-5 months after birth  Reaches adult size by 15 years  On average, it has capacity of 14.75 ml (14-15)
  • 31. • Facial surface of maxilla and cheek Ant wall • Infra temporal & pterygopalatine fossa Post wall • Middle & inferior meatuses (this wall is thin & membranous) Med wall • Floor of orbits Roof • Alveolar part of maxilla Floor
  • 33.  DRAINAGE – OSTIUM  Seen high up in the medial wall  Does not open directly into the nasal cavity, but opens into post. part of ethmoidal infundibulum, via hiatus semilunaris into middle meatus.  The infundibulum is the air passage that connects the maxillary sinus ostium to the middle meatus.  Unfavourable for natural sinus drinage  Accessory ostium – 30 % cases
  • 34.  Arterial supply – Maxillary artery, infra orbital, facial & greater palatine  Venous supply – anteriorly by facial vein & post.by maxillary vein  Nerve supply – infra orbital, anterior, middle & posterior superior alveolar nerves  Lymph nodes – cervical nodes & submandibular nodes
  • 36.  Situated between the outer & inner table of frontal bone  Funnel shaped  Two sinuses on either side  Asymmetrical  Intervening bony septum which may be thin or deficiency
  • 37.  Not present at birth  First radiological evidence is at 6 years  Reaches adult size after puberty  The natural frontal sinus ostium is usually located in the posteromedial floor of the sinus (most dependent part).  It opens into the middle meatus  The ethmoidal infundibulum can act as a channel for carrying the secretions (and infection) from the frontal sinus to anterior ethmoid cells and the maxillary sinus or vice versa.
  • 39.  They develop from a variable site, their drainage will be either via an ostium into the frontal recess or via a nasofrontal duct into the anterior infundibulum. The opening or duct can be distorted by expansion of adjacent ethmoid cells  Boundaries  Ant wall – Skin over the forehead  Post wall - Meninges & the frontal lobe of brain  Inferior wall - orbit & its contents
  • 40.  FRONTAL RECESS  The frontal recess is an hourglass like narrowing between the frontal sinus and the anterior middle meatus through which the frontal sinus drains. It is not a tubular structure, as the term nasofrontal duct might imply, and therefore the term recess is preferred.
  • 41.  The frontal recesses are the narrowest anterior air channels and are common sites of inflammation. Their obstruction subsequently results in loss of ventilation and mucociliary clearance of the frontal sinus
  • 42.  AGGER NASI CELL  Anterior, lateral, and inferior to the frontal recess is the agger nasi cell. It is aerated and represents the most anterior ethmoid air cell, usually lying deep to the lacrimal bone.  It usually borders the primary ostium or floor of the frontal sinus, and thus its size may directly influence the patency of the frontal recess and the anterior middle meatus.
  • 44.  The frontal sinus can pneumatize both the vertical and the horizontal (orbital) plates of the frontal bone. The deepest area of the vertical portion of the sinus is near the midline at the level of the supraorbital ridge, and the medial sinus floor and the caudal anterior sinus wall are thinnest in this area. As a result, the sinus is best approached for a trephination at this level
  • 45.  There is a rich sinus venous plexus (Breschet’s canals) that communicates with both the diploic veins and the dural spaces.  Arterial supply – supra orbital & supra trochlear  Venous supply – superior opthalmic vein  Lymph – Submandibular lymph node  Sensory innervation – supra orbital & supra trochlear
  • 46.  Occupies the body of sphenoid  Right & left, seperated by a thin strip of bony septum (like frontal sinus)  Ostium opens into spheno ethmoidal recess  Relations of the sinus are very important, esp during the surgical approach of pituitary gland
  • 48.  Relations –  Anterior part –  Roof – olfactory tract, optic chiasma & frontal lobe  Lateral – optic nerve, internal carotid artery & maxillary nerve  Posterior part  Roof – Pituitary gland in sella turcica  Lateral – Cavernous sinus,ICA & Cranial nerves III, IV, VI & all divisions of V
  • 49.  Thin strips of bone separate the sphenoidal sinuses from the nasal cavities below and hypophyseal fossa above  The pituitary gland can be surgically approached through the roof of the nasal cavities by passing first through the anteroinferior aspect of the sphenoid bone and into the sphenoidal sinuses and then through the top of the sphenoid bone into the hypophyseal fossa
  • 50.  Thin walled air cavities in the lateral masses of the ethmoid bone  Varies from 3 – 18  Occupy the space between the upper third of the lateral nasal wall and the medial wall of orbit  Clinically divided into anterior ethmoidal air cells & posterior ethmoidal air cells, by basal lamella (lateral attachment of middle turbinate to lamina papyracea)
  • 52.  DRAINAGE: Anterior - a recess of hiatus semilunaris & middle meatus via ehmoid bulla Post- sup.meatus & spenethmoidal recess.  Present at birth  Reaches adult size by 12 years  First radiological evidence seen at 1 year
  • 53. Relations  Roof – formed by the anterior cranial fossa  Lateral wall - orbit  Medial wall – nasal cavity  Thin paper like bony part of the ethmoid separating the air cells from the orbit, called lamina papyracea, can be easily destroyed leading to spread of ethmoidal infections into the orbit  Optic nerve forms a close relationship with the posterior ethmoidal cells & is at risk during ethmoidal surgery
  • 55.  The osteomeatal complex is the key anatomic area addressed by endoscopic sinus surgeons. Blockage of the osteomeatal complex prevents effective mucociliary clearance, thus leading to a stagnation of secretions and therefore leading to recurrent or chronic sinusitis.
  • 56.  The OMC is bounded  medially by the middle turbinate,  posteriorly and superiorly by the basal lamella, and  laterally by the lamina papyracea.  Inferiorly and anteriorly the OMC is open.
  • 57.  This anatomic region therefore includes  Maxillary sinus ostium  ethmoid bulla  frontal recess  uncinate process  infundibulum  hiatus semilunaris  middle meatus.
  • 60.  Paradoxic Curvature  Normally, the convexity of the middle turbinate bone is directed medially, toward the nasal septum.  When paradoxically curved, the convexity of the bone is directed laterally toward the lateral sinus wall.  The inferior edge of the middle turbinate may assume various shapes, which may narrow and/or obstruct the nasal cavity, infundibulum, and middle meatus.
  • 61.  Concha Bullosa  It is an aerated turbinate, most often the middle turbinate.  Less frequently, superior & inferior turbinate aeration can occur.  When the pneumatization involves the bulbous segment of the middle turbinate, the term concha bullosa applies.  If only the attachment portion of the middle turbinate is pneumatized, and the pneumatization does not extend into the bulbous segment, it is known as a lamellar concha.
  • 62.  Other Variations  Additional variations of the middle turbinate can occur, including medial & lateral displacement, lateral bending, L shape, and sagittal transverse clefts  Medial displacement – due to other middle meatal structures (i.e., polypoid disease, pneumatized uncinate process) encroaching upon the middle turbinate.  Lateral displacement - due to the compression of the turbinate toward the lateral nasal wall by a septal spur or septal deviation.
  • 63.  The nasal septum deviation may compress the middle turbinate laterally, narrowing the middle meatus and the presence of associated bony spurs may further compromise the OMU.  Obstruction, secondary inflammation, swollen membranes, and infection can occur
  • 64.  DEVIATION  The course of the free edge of the uncinate process may either extend slightly obliquely toward the nasal septum, with the free edge surrounding the inferoanterior surface of the ethmoid bulla, or it extends more medially to the medial surface of the ethmoid bulla. If the free edge of the uncinate is deviated in a more lateral direction, it may cause narrowing or obstruction of the hiatus semilunaris and infundibulum.
  • 65.  Attachment  Attachment to the lamina papyracea, the lateral surface of the middle turbinate, or the fovea ethmoidalis in the floor of the anterior cranial fossa may occur.  If the uncinate process attaches to the ethmoidal roof or middle turbinate, during uncinatectomy, traction could inadvertently damage the ethmoid roof and result in CSF rhinorrhea or other intracranial complications.
  • 67.  Sometimes the free edge of the uncinate process adheres to the orbital floor, or inferior aspect of the lamina papyracea. This is referred to as an atelectatic uncinate process
  • 68.  Pneumatization  The pneumatization of the uncinate process is believed to be due to extension of the agger nasi cell within the anterosuperior portion of the uncinate process.  Functionally, the pneumatized uncinate process resembles a concha bullosa or an enlarged ethmoid bulla.
  • 69.  Infraorbital ethmoid cells are pneumatized ethmoid air cells that project along the medial roof of the maxillary sinus and the most inferior portion of the lamina papyracea, below the ethmoid bulla and lateral to the uncinate process
  • 71.  Two definitions of Onodi cells.  The first defines them as the most posterior ethmoid cells, being superolateral to the sphenoid sinus and closely associated with the optic nerve.  Another, more general description defines Onodi cells as posterior ethmoid cells extending into the sphenoid bone, situated either adjacent to or impinging upon the optic nerve
  • 73.  Its appearance varies considerably, based on the extent of pneumatization.  Extensive pneumatization may obstruct the ostiomeatal complex.  Elongated ethmoid bullae are usually in a superior to inferior direction rather than in an anterior to posterior direction.  So, Relatively unlikely to obstruct the ostiomeatal complex.
  • 74.  Encountered rarely  extends into the lesser wing and the anterior and posterior clinoid processes  Can lead to distortion of optic cannal configuration
  • 75.  May be either congenital or the result of prior facial trauma.  It occur most often at the site of the insertion of the basal lamella into the lamina papyracea, thus rendering this portion of the lamina papyracea most delicate  Orbit at risk
  • 77.  When aeration of the normally bony crista galli occurs the aerated cells may communicate with the frontal recess, and obstruction of this ostium.  To avoid unnecessary surgical extension into the anterior cranial vault, it is important to recognize an aerated crista galli and differentiate it from an ethmoid air cell.
  • 78.  Air cells are commonly found within the posterosuperior portion of the nasal septum and, when present, communicate with the sphenoid sinus.  As a result, any inflammatory disease that occurs within the paranasal sinuses may also affect these cells
  • 79.  It is important to note any asymmetry in the height of the ethmoid roof.  Intracranial penetration during surgery is more likely to occur on the side where the position of the roof is lower
  • 81.  X RAY  CT  MRI
  • 82.  X ray – Water’s view & caldwell view  Ct – gold standard. Coronal & axial sections  MRI is predominantly used for pre and post operative management of naso sinus malignancy  The chief disadvantage of MRI is its inability to show the bony details of the sinuses, as both air and bone give no signal
  • 83. CT PROCEDURE & SECTIONS
  • 84.  CT is currently the modality of choice in the evaluation of the paranasal sinuses and adjacent structures.  Its ability to optimally display bone, soft tissue, and air provides an accurate depiction of both the anatomy and the extent of disease in and around the paranasal sinuses.  In contrast to standard radiographs, CT clearly shows the fine bony anatomy of the osteomeatal channels.
  • 85.  There are few pre requisites in few situations  a course of adequate medical therapy to eliminate or diminish reversible mucosal inflammation.  pretreatment with a sympathomimetic nasal spray 15 minutes prior to scanning in order to reduce nasal congestion (mucosal edema) and thus improve the display of the fine bony architecture and any irreversible mucosal disease
  • 86.  Coronal & axial views  The coronal plane best shows the ostiomeatal unit (OMU), shows the relationship of the brain to the ethmoid roof.  Coronal plane should be the primary imaging orientation for evaluation of the sinonasal tract in all patients with inflammatory sinus disease who are endoscopic surgical candidates
  • 89.  Prone with chin hyperextended  Gantry anglutaion- perpendicular to hard palate  Section thickness-3mm contigous  Table increment- 3-4 mmeach step  Kvp-125  Mas-80  Hanging head technique
  • 92.  HEAD HANGING METHOD  Performed in the prone position, so that any remaining sinus secretions do not obscure the OMU  In patients who cannot tolerate prone positioning (children, patients of advanced age, etc.), the hanging head technique can sometimes be utilized.
  • 93.  In this technique, the patient is placed in the supine position and the neck is maximally extended.  A pillow placed under the patient’s shoulders facilitates positioning.  The CT gantry is then angled to be perpendicular to the hard palate.  It is not always possible to obtain true direct coronal images with this technique
  • 94.  Axial images complement the coronal study, particularly when there is severe disease (opacification) of any of the paranasal sinuses and surgical treatment is contemplated.  The axial studies provide the best CT evaluation of the anterior and posterior sinus walls  Axial images are particularly important in visualizing the frontoethmoid junction and the sphenoethmoid recess.
  • 95.  CT axial section of PNS - image
  • 96.  Whenever there is total opacification of the frontal, maxillary, or sphenoid sinuses, a complete axial and coronal CT examination should be performed.  And also, if the patient has a suspected neoplasm, a complete axial and coronal examination need to be performed to provide the most detailed analysis of the sinonasal cavities and the adjacent skull base
  • 97.  IMAGING PLANE : REIDS’S LINE – runs b/w infraorbital margin (IOM line) & EAM. (parallel - axial) ALEXANDER’S LINE – perpendicular to reids line. (perpendicular - coronal)
  • 98.  Contrast is not required for all cases of CT paranasal sinus  Used in cases such as vascular lesion, malignancy, mass extending intra cranially, acute infections
  • 100. AGE OF THE PATIENT
  • 104. X RAY SHOULDER JOINT BY DR.V.PRIYA ON SATURDAY