THE PARANASAL SINUSES

A HANDBOOK OF APPLIED SURGICAL ANATOMY

 THE PARANASAL SINUSES
A HANDBOOK OF APPLIED SURGICAL ANATOMY

Robin Youngs MD FRCS

Consultant Otolaryngologist
Gloucestershire Royal Hospital
Great Western Road
Gloucester, UK

Kate Evans MB BS FRCS

Consultant Otolaryngologist
Gloucestershire Royal Hospital
Great Western Road
Gloucester, UK

Martin Watson
Chief Dissecting Room Technician
Department of Anatomy
University of Cambridge
Downing Street
Cambridge, UK
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Contents

1. Introduction and anatomical terminology 1

Robin Youngs

2. Radiology of the paranasal sinuses 9

Kate Evans

3. Nasal cavity 27
Robin Youngs

4. Anterior ethmoid and frontal sinuses 43

Derek Skinner and Paul White

5. Maxillary sinus 71
Stephen Wood

6. Posterior ethmoid and sphenoid sinuses 91

David Gatland and Duncan McRae

7. Orbit and lacrimal system 119

Matthew Yung

8. Arterial supply of the nasal cavity 135

Paul Montgomery and Asad Qayyum
Contributors

Kate Evans Martin Watson

Consultant Otolaryngologist Anatomy Department Technician
Gloucestershire Royal Hospital University of Cambridge
Gloucester, UK Cambridge, UK

David Gatland Paul White

Consultant Otolaryngologist Consultant Otolaryngologist
Southend General Hospital Ninewells Hospital and Medical
Westcliff on Sea, Essex, UK School, Dundee, UK

Duncan McRae Stephen Wood

Consultant Otolaryngologist Consultant Otolaryngologist
Essex County Hospital, Colchester Wexham Park Hospital, Slough, UK
Essex, UK
Robin Youngs
Paul Montgomery Consultant Otolaryngologist
Consultant Otolaryngologist Gloucestershire Royal Hospital
Norfolk and Norwich Hospital Gloucester, UK
Norwich, UK
Matthew Yung
Asad Qayyum Consultant Otolaryngologist
Specialist Registrar The Ipswich Hospital
East Anglian Training Scheme, UK Ipswich, UK

Derek Skinner
Consultant Otolaryngologist
Royal Shrewsbury Hospital
Shrewsbury, UK
Preface

This book aims to provide the trainee surgeon with the anatomical knowledge
required to perform safe endoscopic sinus surgery by providing a stepwise
approach to the understanding of sinus anatomy. The content is loosely based
around the curriculum of the Cambridge Endoscopic Sinus Anatomy Course, with
contributions from faculty members. The book is ideal for otolaryngology trainees
of all levels, both for use in the operating theatre and as a dissection guide for
cadaver endoscopic sinus anatomy courses. The authors, with extensive experi-
ence in running such courses, add useful clinical and surgical information as
relevant.
High quality images are derived from cadaver sections with direct coronal CT
scan radiological correlates. Prosected specimens are also used to illustrate key
anatomical points. Endoscopic photographs demonstrate normal anatomical
variation as well as steps in endoscopic surgical dissection. The book sets out to
simplify the complex anatomy of this region, with particular attention given to
those areas of prime surgical importance. A contemporary approach is adopted
with individual sinuses grouped along functional lines. In addition to the
paranasal sinuses there are chapters on the vascular supply and lacrimal system,
areas of increasing importance to the modern endoscopic nasal surgeon.

Robin Youngs
Kate Evans
Martin Watson
1. INTRODUCTION AND ANATOMICAL
TERMINOLOGY
ROBIN YOUNGS
• INTRODUCTION
• ACQUISITION OF IMAGES

• HISTORICAL CONTEXT OF PARANASAL SINUS ANATOMY

• ANATOMICAL TERMINOLOGY

‘There are many difficulties in the way of acquiring a practical knowl-

edge of nasal anatomy, and a correct idea of the topographical relations
of the nasal fossae can only be obtained by the study of sections’

ST CLAIR THOMSON, 18941

INTRODUCTION

The purpose of this book is to provide an accessible guide to the complex

anatomy of the nasal cavity and paranasal sinuses. The book is particularly aimed
at surgeons training in the techniques of endoscopic nasal and sinus surgery. The
principal teaching materials are photographic illustrations of gross anatomical
cross-sectional images, with their radiological correlates obtained through
computed tomography (CT). Use is also made of anatomical prosections, and
endoscopic images obtained, with permission, from patients. The anatomical
images have been obtained from the Department of Anatomy at the University
of Cambridge, UK, where the authors have conducted an annual Endoscopic
Sinus Anatomy Course since 1995.
We have intentionally concentrated on the gross anatomy directly relevant to
modern endoscopic sinus surgery. Areas not covered in detail include nasal
embryology, anatomy of the external nose, nasal physiology and nasal
histopathology. These areas, although important, are covered in detail in other
textbooks.2–4 In addition, detailed measurements of anatomical parameters have
not been undertaken. The osteology of the paranasal sinuses is presented largely
by the study of CT radiological images, although some of the fine bony anatomy
will be illustrated by skull specimens and diagrams. A separate chapter on the
vascular supply of the nasal cavity and paranasal sinuses is included. A detailed
THE PARANASAL SINUSES

understanding of nasal blood supply is becoming particularly important with

the advent of endoscopic techniques of epistaxis management, particularly
endoscopic interruption of the sphenopalatine artery.
Although aimed at endoscopic sinus surgeons, this is not a textbook of surgical
technique. Anatomical points of particular surgical importance will be emphasised,
however, with reference to common surgical steps in what has become widely
termed ‘functional endoscopic sinus surgery’ (FESS). The anatomy of the sinuses
bordering the orbit and anterior skull base will be covered in detail, as these are
the areas in which major complications of endoscopic sinus surgery can occur.
The importance of simulation in surgical training is well recognised. In
endoscopic sinus surgery, the mainstay of surgical simulation has been the use of
cadaver material. Computerised surgical simulators have been developed,5
although the complexity of reproducing the detailed anatomy of the sinuses and
the haptic tactile feedback required to simulate surgical manoeuvres have prohib-
ited the common use of these systems.
In the UK, the use of cadaver material in surgical training is strictly regulated
by the Anatomy Act 1988.6 This act limits the availability of cadaver material
in anatomy departments to the study of anatomy. The teaching of surgical
manoeuvres is prohibited, although anatomical dissection using surgical instru-
ments, including endoscopes, is allowed. At the time of writing, changes in the
law governing the use of cadaver material in the UK have been proposed, some
of which will enhance the availability of material for surgical training. In addition,
the opportunity to simulate surgical procedures in hospital postmortem pathol-
ogy departments no longer exists, owing to concerns over contamination of
instruments and informed consent from relatives. These issues seem likely to limit
the practical study of sinus surgical anatomy to recognised courses with cadaver
dissection. It is hoped that this book will be used as a companion to such courses,
and also as a reference to the surgical trainee undertaking supervised endoscopic
sinus surgery on live patients.

ACQUISITION OF IMAGES

The sectional images presented in this book were acquired as follows. Three
cadaver heads were selected. Each head had been preserved by embalming with
a solution containing ethanol (83.6%), formalin (3.16%), polyethylene glycol
(7.5%) and citricidal (1%). Diagnostic endoscopy of approximately 60 heads had
been undertaken in order to select the most suitable specimens for anatomical
study. Each of the heads was then sectioned using a bandsaw at approximately
3 mm intervals. The first head was sectioned in the axial plane, the second in the
coronal plane and the third in the sagittal plane. The head sectioned in the
coronal plane had previously undergone coronal CT scanning.

2
 INTRODUCTION AND ANATOMICAL TERMINOLOGY

Figure 1.1 Cleaning the section prior to photography

After each section had been taken, the remaining specimen was cleaned of
debris (Figure 1.1) and photographed using a Nikon D1 digital SLR camera on
a gantry. Specimens were also photographed using a Nikon Coolpix 995 digital
camera. Images were saved as TIFF and JPEG files for subsequent use.
Where endoscopic images are presented, the majority of these were obtained
using a 4 mm zero-degree Karl Storz Hopkins rod endoscope connected to a Karl
Storz flash generator (Figure 1.2). Images were captured using a Ricoh SLR
camera and Kodak Ektachrome 400 ISO 35 mm film. Some of the more recent
endoscopic images have been captured by the use of an Olympus or Karl Storz
three-chip endoscopic camera system connected to a digital video recorder with
image capture software.

3
THE PARANASAL SINUSES

Figure 1.2 Karl Storz flash generator used for endoscopic photography

HISTORICAL CONTEXT OF PARANASAL SINUS ANATOMY

Although descriptions of gross paranasal sinus anatomy can be found going back
many centuries, it is only in the 19th and 20th centuries that detailed accounts
of ethmoidal structure were presented. Most anatomists in the 18th century
4
 INTRODUCTION AND ANATOMICAL TERMINOLOGY

Figure 1.3 A section from the Onodi Collection showing the relationship between the
optic nerves and posterior ethmoid sinuses. (Reproduced with permission from the Journal
of Laryngology and Otology)

(Rysch, Valsalva and Morgagni) fail to mention the ethmoid sinuses at all. The
two individuals contributing most to our modern understanding of paranasal
sinus anatomy are Zuckerkandl and Onodi.
In 1882, Zuckerkandl7 published his ‘anatomy of the nose and its pneumatic
attachments, which became a standard reference work. Zuckerkandl emphasised
the functional distinction between the anterior and posterior ethmoid sinuses
stating ‘the only certain point of reference for the topographical orientation of
an ethmoidal cell is its ostium. Cells that open into the middle meatus belong
to the anterior ethmoidal labyrinth and those that open into the superior meatus
belong to the posterior ethmoidal labyrinth’. He also introduced the term ‘hiatus
semilunaris’.
Onodi undertook the preparation of numerous anatomical specimens, demon-
strating through detailed study of sections the complex paranasal sinus anatomy
(Figure 1.3).1,8 In particular, he studied the relationships between the sinuses and
the optic nerve, having observed orbital complications of sinus disease.9 He
pointed out that the optic nerves often involved the posterior ethmoid sinuses
and that ‘we must relinquish the rigid acceptation of the relationship of the optic
nerves to the sphenoid sinus’. This observation remains key today to the under-
standing of posterior ethmoid anatomy, with the Onodi or spheno-ethmoid cell

5
THE PARANASAL SINUSES

being one of the few structures in the sinuses to be named after an individual.
Onodi actually described 38 different ways in which the optic nerve could be
related to the sinuses, falling into 12 main groups.

ANATOMICAL TERMINOLOGY

With the advent of endoscopic sinus surgery and sinus CT, rhinologists sought
to clarify anatomical terminology in order to provide clear communication among
surgeons, radiologists and anatomists. To this end, the Anatomic Terminology
Group of the International Conference on Sinus Disease: Terminology, Staging
and Therapy met in 1993. A consensus paper on sinus anatomy nomenclature
was published,10 to which this book adheres. The prime importance of the
ethmoid sinuses was recognised, with a key concept being the division of the
ethmoid sinuses into anterior and posterior by the basal lamella of the middle
turbinate.
There have been two controversial terms in sinus anatomy that require clari-
fication at the outset. The term ‘infundibulum’ has been used to describe a
number of anatomical structures and spaces. In addition, the term ‘infundibular
disease’ has also been used by some rhinologists to describe limited disease in the
anterior ethmoid. In this book, we will only use the term ‘ethmoid infundibu-
lum’ to describe the three-dimensional space formed by the uncinate process
medially, the ethmoid bulla posteriorly, and the lamina papyracea laterally. The
term ‘hiatus semilunaris’ introduced by Zuckerkandl will refer to the two-dimen-
sional space between the posterior edge of the uncinate process and the anterior
aspect of the ethmoid bulla, which leads into the ethmoid infundibulum.
One important feature in sinus anatomy is the degree of anatomical variation.
Reference will be made to this variation and the ways in which it can influence
both the functional organisation of and the surgical approach to the sinuses.

REFERENCES

1. Onodi A. The Anatomy of the Nasal Cavity and its Accessory Sinuses. An Atlas for
Practitioners and Students (transl St Clair Thomson). London: HK Lewis, 1895
2. Lang J. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. Stuttgart:
Georg Thieme Verlag, 1989
3. Navarro JAC. The Nasal Cavity and Paranasal Sinuses – Surgical Anatomy. Berlin:
Springer-Verlag, 2001
4. Stammberger H. Functional Endoscopic Sinus Surgery. The Messerklinger
Technique. Philadelphia: Decker, 1991

6
 INTRODUCTION AND ANATOMICAL TERMINOLOGY

5. Rudman DT, Stredney D, Sessanna D et al. Functional endoscopic sinus surgery

training simulator. Laryngoscope 1998; 108: 1643–7
6. The Anatomy Regulations 1988. London: HMSO, 1988
7. Zuckerkandl E. Normale und Pathologische Anatomie der Nasenhohle und ihrer
Pneumatischen Anhange (Normal and Pathological Anatomy of the Nose and its
Pneumatic Attachments). Vienna: W Braumuller, 1882
8. Layton TB. Catalogue of the Onodi Collection in the Museum of the Royal College
of Surgeons of England. London: Headley Brothers, 1934
9. Onodi A. The Optic Nerve and the Accessory Sinuses of the Nose (A Contribution
to the Study of Canalicular Neuritis and Atrophy of the Optic Nerve of Nasal
Origin) (transl J Luckhoff). London: Baillière, Tindall and Cox, 1910
10. Stammberger H, Kennedy D. Paranasal sinuses: anatomic terminology and nomen-
clature. The Anatomic Terminology Group. Ann Otol Rhinol Laryngol 1995;
104(Suppl 167): 7–16

7
2. RADIOLOGY OF THE PARANASAL
SINUSES
KATE EVANS
• PLAIN RADIOGRAPHY
• COMPUTED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• RELATIVE ADVANTAGES OF CT AND MRI
• ANATOMICAL VARIANTS
Cribriform plate
Defects in the orbital wall
The middle turbinate
Anterior and posterior ethmoid arteries
The optic nerve

PLAIN RADIOGRAPHY

The development of endoscopic sinus surgery occurred concurrently with the

development of high-resolution radiological imaging. Historically, the mainstay
of imaging was the plain radiograph. These were conducted in four different
planes:

• The Waters view, otherwise known as the occipitomental view, demonstrates

the maxillary antra, the anterior ethmoid air cells and the orbital floor (Figure
2.1).
• The Caldwell view, otherwise named the occipitofrontal view, provides images
of the posterior ethmoid air cells and the frontal sinuses. Magnification of
the frontal sinus is reduced by taking the X-ray with the patient’s head in
contact with the radiographic film. This view is particularly useful for making
the template used when planning an osteoplastic flap.
• The lateral view shows the sphenoid sinus, and clearly demonstrates air–fluid
levels. The maxillary antra and the frontal sinuses are demonstrated, but the
left and right paired sinuses overlie each other, leading to some difficulty in
interpretation.
• The basal or submento-vertical view demonstrates the individual sphenoid
sinuses.
THE PARANASAL SINUSES

1 2 3 4 5

Figure 2.1 A plain radiograph showing Waters view (occipitomental view). 1, anterior
ethmoid air cells; 2, nasal septum; 3, sphenoid sinus; 4, medial orbital wall; 5, maxillary
antrum with a fluid level

These plain radiographs were used routinely for diagnostic and preoperative
assessment. However, current clinical practice only occasionally requires their use.
The main use of plain films today is in the assessment of patients who have
suffered facial trauma or in identifying radio-opaque foreign bodies. Plain
radiographs were superseded by polytomography. This technique has the disad-
vantage that there was an increased dose of radiation delivered to the lens of the
eye.

COMPUTED TOMOGRAPHY

The development of computed tomography (CT) scanning in the late 1970s and
early 1980s has led to a greater understanding of both the radiological anatomy

10
 RADIOLOGY OF THE PARANASAL SINUSES

and pathology of the paranasal sinuses. This technique requires a well-focused or

collimated, slit-like beam to be produced from the X-ray tube. The detector unit
is housed in a circular gantry, which moves 1° at a time while X-rays are contin-
uously produced. Some of the X-rays are absorbed as they pass through the
patient and some remain unchanged. The detectors convert the received X-ray
photons to electrical signals that are subsequently translated into digital infor-
mation before being analysed by computer software. The computer reprocesses
the information, producing an image, which is then stored on disc, magnetic tape
or X-ray film. The early CT scanners took images as single slices. These were
time-consuming and relied on the patient’s ability to remain very still. They were
superseded by dual-slice and then multislice (or spiral) scanners. Current CT
scanners use multiple rows of detectors and are able to image a greater volume
of tissue in a much shorter time. An additional benefit is the reduction in the
dose of radiation administered to the patient, in particular to the lens of the eye.
Developments in software support allow good-quality multiplanar reconstruction
or image reformatting from a stack of contiguous transverse axial scans.
Reformatted images can enable visualisation of specific anatomical sites and can
help to determine the true extent of specific lesions.
The quality of CT images depends on various physical factors. The computer
will reconstruct sequences of picture elements, known as pixels. This is usually
on a 256 × 256 or a 512 × 512 matrix. By recording the scan slice thickness,
the volume of each picture element can be calculated and stored as a voxel. The
absorption of X-ray photons in a known voxel is related to the average absorp-
tion coefficient of that volume of tissue. The distribution of tissues of different
densities is detected by the computer and reproduced as a high-quality image.
There are over 4000 different tissue densities between air and metal. The unit of
measurement is a Houndsfield unit (HU), with a range from –1000 to +3000.
Godfrey Houndsfield was a scientist with expertise in both electronics and electri-
cal and mechanical engineering. His work led to the development of the first
clinically useful CT scanner used for scanning the brain. He was awarded the
Nobel Prize in 1979 for his work. Houndsfield units are represented by thousands
of different shades of grey (Figure 2.2). The human eye is less able to differen-
tiate the shades than the computer and is limited to approximately 40 shades of
grey. Following a single exposure to X-rays, the raw data obtained can be manip-
ulated by the computer within different ‘window’ settings. In each window
setting, different tissue densities within the window will be shown as a range of
greys. Outside the window setting, higher densities, such as bone, will appear
white and lower densities, such as air, will appear black. Each window can be
centred on a specific Houndsfield unit. This action decides which shade of grey
will be the middle tone. Imaging the paranasal sinuses in a patient with benign
inflammatory disease is best conducted with a wide window setting, usually
between 2000 and 3000 HU. This is centred at –250 HU. If imaging of the soft

11
 THE PARANASAL SINUSES

1 11

2
10
3

4
5
6

7 8 9

Figure 2.2 An example of a coronal CT scan with the Houndsfield unit scale to the
right and degradation of the picture by dental amalgam. 1, medial wall of orbit; 2,
uncinate process; 3, middle turbinate; 4, medial wall maxillary sinus; 5, inferior turbinate;
6, lateral wall of maxillary sinus; 7, artefact secondary to scatter from dental amalgam;
8, cribriform plate; 9, floor of orbit; 10, Houndsfield unit scale; 11, lateral wall of orbit

tissue is important, such as in assessing invasion by tumour or distortion of tissue

planes, a narrow window setting of 300 HU is selected, centred at about
+65 HU.
The quality of the image is influenced by many factors, including the dose of
radiation, the matrix size (pixel size), the milliamperes per second (MAS), the
kilovoltage (kVP), the slice thickness and the influence of the algorithm in the
computer software. There is a linear relationship between the dose of radiation
and the MAS. If there is a greater ‘noise’ level during data accumulation, increas-
ing the MAS will increase the quality of the images. For imaging the paranasal

12
 RADIOLOGY OF THE PARANASAL SINUSES

Figure 2.3 A lateral topogram or scout image, which identifies the position of the
sequential images

sinuses, the kVP is usually set at 125 and the MAS at 450, although this remains
at the discretion of the radiologist.
Image quality may be degraded by variations in output and detection in the
scanner or by the presence of dental amalgam causing a rapid change in tissue
density (Figure 2.2). These can be overcome by changing the MAS or the scan
thickness or by altering the patient’s position.
Images can be produced in coronal or axial planes. The plane in which the
image is acquired is demonstrated on a lateral topogram or scout image (Figure
2.3). This also demonstrates the thickness of the slice of the image and the limits

13
THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 2.4 An axial CT scan at the level of the maxillary sinus. 1, posterior wall of the
maxillary sinus; 2, anterior wall of the maxillary sinus; 3, inferior meatus; 4, inferior
turbinate; 5, the nasal septum; 6, medial pterygoid plate; 7, lateral pterygoid plate

of the scan. For CT imaging of the paranasal sinuses, the slice thickness is usually
between 4 and 5 mm, with the table moving at 3–4 mm increments. The overlap
is helpful if reformatting of images in a different plane, including the sagittal
plane, is required.
Imaging in the coronal plane remains the mainstay of preoperative radiologi-
cal assessment for benign inflammatory disease of the paranasal sinuses. This
orientation has the advantage that it demonstrates the anatomy and pathology
in the same perspective as it is approached in the endoscopic surgeon. Coronal
scans are conducted perpendicular to the infraorbitomeatal line (also known as
Alexander’s line) in a direction known as Reid’s line. To achieve this, the patient
is positioned either prone or supine with their neck extended. The gantry of the
scanner can be adjusted to accommodate any limitation of neck extension. The
coronal images of the paranasal sinuses are acquired between the anterior margins

14
 RADIOLOGY OF THE PARANASAL SINUSES

Figure 2.5 An axial CT scan reconstructed in the coronal plane

of the frontal sinus and the posterior margin of the sphenoid sinus. Anatomical
structures that are clearly demonstrated in this plane include the medial wall of
the maxillary sinus, the floor of the orbit, the floor of the frontal sinus, the lateral
aspect and the floor of the sphenoid sinus, the ostiomeatal complex, the superior
orbital fissure, the optic nerve, the cribriform plate, and the three paired
turbinates (Figure 2.2).
Imaging in the axial plane is indicated if the patient is unable to extend their
neck sufficiently to achieve scans in the coronal plane. These views are particu-
larly useful when assessing the surgical anatomy of the posterior ethmoid or
sphenoid sinuses or when malignancy is being staged. To acquire axial images,
the patient lies supine. The images are taken parallel to the infraorbitomeatal
line. The images extend from the alveolar ridge to the superior aspect of the
frontal sinus.
Imaging in the axial plane provides essential information about the relation-
ship of the optic nerve to the posterior ethmoid and sphenoid sinuses. Other
anatomical features that are clearly seen in this plane include the anterior and

15
THE PARANASAL SINUSES

1 2 3 4 5

Figure 2.6 An axial CT scan reconstructed into the sagittal plane demonstrating the
inferior and middle turbinates. Note the slope of the skull base. 1, frontal sinus; 2, inferior
turbinate; 3, middle turbinate; 4, skull base; 5, sphenoid sinus

posterior walls of the maxillary sinus, the anterior and posterior walls of the
frontal sinus, the anterior and posterior walls of the sphenoid sinus, the lateral
wall of the ethmoid sinuses, and the pterygopalatine fossa (Figure 2.4).
Axial images can be reconstructed to provide coronal images, although some
definition may be lost (Figure 2.5).
Images reconstructed in the sagittal plane can be difficult to interpret and do
not often provide information that cannot be gleaned from good-quality axial
and coronal images. Useful information can, however, be gained about the config-
uration of the skull base and the frontal recess (Figure 2.6).
The reconstruction of three-dimensional (3D) images, although not routinely
available, has been possible since the early 1980s. In ideal circumstances, the
image is reconstructed from a series of adjacent scans that do not overlap or have
gaps between them. Individual voxels of similar densities are then segmented to

16
 RADIOLOGY OF THE PARANASAL SINUSES

Figure 2.7 A 3D reconstruction from an axial CT scan, demonstrating a bony defect in

the anterior table of the frontal bone. This was caused by osteomyelitis of the frontal
bone (Pott’s puffy tumour). 1, bony defect

allow 3D reconstruction. Thinner slices lead to better-quality images, with 3 mm

slices being ideal. Current uses include medical education, assessing the extent of
trauma or malignant disease, and preoperative planning for complex resections
or reconstructions (Figure 2.7).
Intravenous contrast is rarely required in routine imaging of the paranasal
sinuses for benign inflammatory disease. Lesions that have increased blood flow
and large blood vessels enhance following the administration of intravenous
contrast. The use of contrast helps to distinguish between acute and chronic
inflammatory disease, with mucosal enhancement being more obvious in the
presence of acute inflammation. Intravenous contrast provides a diagnostic benefit
when assessing complications of inflammatory sinus disease, such as orbital
abscess, or if intracranial thrombosis or intracranial abscess is suspected.

17
THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 2.8 An axial T1-weighted MRI scan. Note that the static fluid in the globe is
dark and the fat is bright. 1, orbital fat; 2, ethmoid labyrinth; 3, dermoid cyst; 4, medial
rectus; 5, optic nerve; 6, eyeball; 7, lateral rectus

Disadvantages of intravenous contrast include the risk of an anaphylactic reaction

to the contrast agent and the cost.
Several systems for reporting scans have been published in the literature.1 Most
surgeons will have an individual preference, which must encompass systematic
examination of the images to evaluate variations in the anatomy of individual
sinuses and the extent of pathology.

MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging (MRI) has become an important imaging modality

since its inception in the late 1980s. It has the major advantage of not involv-
ing ionising radiation. In brief, MRI is a complex process involving magnets,
radiofrequency coils and a computer processing system. The process is dependent

18
 RADIOLOGY OF THE PARANASAL SINUSES

1 2 3

Figure 2.9 A T2-weighted MRI scan. Note that the fluid in the eyeball has a bright
signal and fat appears dark. 1, temporal lobe; 2, optic nerve; 3, eyeball

on the abundance of hydrogen that is present in water and fat. In the absence
of a magnetic field, unpaired hydrogen nuclei (protons) are randomly orientated.
When the protons are placed in a magnetic field, they undergo a rotation that
aligns them in the direction of the applied field. This equilibrium is upset by the
application of radiofrequency pulses, which change the alignment of the protons.
This results in the emission of radiofrequency energy, which represents the MR
signal and is detected by the receiver coils in the scanner. This information is
analysed by the computer software and recorded as an image. There are two
sequences that are commonly used in the head and neck: T1-weighted and T2-
weighted. T1-weighted images demonstrate static fluids, oedema and tumour as
dark images. Fat, haemorrhage, proteinaceous cysts and gadolinium contrast
agents are revealed by a bright signal (Figure 2.8). T2-weighted images demon-
strate tendons, muscle and cartilage as dark images. Fluid, oedema and tumour
are revealed by a bright signal (Figure 2.9).

19
THE PARANASAL SINUSES

RELATIVE ADVANTAGES OF CT AND MRI

Both CT scans and MRI have their own distinct advantages. The advantages of
CT scanning are related to bony detail, which is not seen on MRI. CT is better
at identifying the extent of pneumatisation of the anterior and posterior ethmoid
air cells, the proximity of the maxillary sinus ostium to the orbital floor, the
degree of pneumatisation of the frontal sinus, the position of the internal carotid
artery and its relationship to the variable septations in the sphenoid sinus.
Currently in the UK, it is easier to access CT imaging than MRI and the scan
times are shorter. The scan environment is more patient-friendly, being quieter
and less claustrophobic. CT scanning, unlike MRI, is not contraindicated for
patients with cardiac pacemakers, metallic orbital foreign bodies or intracranial
metal surgical clips.
The advantages of MRI include much better discrimination of different soft
tissues without the administration of intravenous contrast. This is particularly
useful in assessing the spread of malignant tumours through soft tissue planes or
through dura. The ability to reconstruct images in any plane is extremely useful
and does not involve uncomfortable postures for the patient. Vascular structures
are clearly seen as voids. Artefacts from dental amalgam are not a significant
problem as with CT imaging.

ANATOMICAL VARIANTS

Some anatomical variants can be identified more easily on CT images than on

endoscopic examination of the nasal cavity. It is useful to study the following
anatomical sites preoperatively and thereby predict challenges to surgical diagno-
sis and technique. Although this book does not set out to provide a compre-
hensive radiological review, the essential learning points are addressed to help
understand anatomy and reduce surgical risk.

Cribriform plate
It is well described that the cribriform plate may lie at different levels in relation
to the skull base. This has been classified well by Keros.2 It is also recognised
that the skull base can be asymmetrical. Recognising this on the CT images
preoperatively is important in order to avoid unnecessary morbidity (Figure 2.10).

Defects in the orbital wall

It can be difficult to identify deficiencies in the lamina papyracea because the
bone is very thin. Defects commonly occur following surgery, especially when the
uncinate process is resected. Defects may be congenital or can follow trauma. If
20
 RADIOLOGY OF THE PARANASAL SINUSES

1 2 3

Figure 2.10 A coronal CT scan demonstrating asymmetry of the cribriform plate. 1,

crista galli; 2, cribriform plate; 3, skull base

in doubt, the surgeon should ballot the eye while observing the lateral wall of
the nose in the region of the lamina papyracea with the endoscope. Movement
of the soft tissue suggests that the bone is deficient.

The middle turbinate

Endoscopic examination of the middle turbinate will reveal any sagittal or axial
clefting. The middle turbinate may have a paradoxical curve that reduces the
volume of the middle meatus (Figure 2.11). It is not always clear whether a
bulbous middle turbinate represents solid bone or an additional air cell termed
a concha bullosa. CT images give great clarity regarding the bony anatomy and
the extent of any concha bullosa (Figure 2.12). The ethmoid infundibulum can

21
THE PARANASAL SINUSES

1 2 3 4

Figure 2.11 A cadaveric coronal CT scan demonstrating paradoxically bent middle

turbinates. 1, inferior turbinate; 2, uncinate process; 3, middle turbinate; 4, nasolacrimal
duct

be reduced in volume by the presence of additional air cells on the inferomedial

aspect of the orbit, known as Haller cells (Figure 2.13).

Anterior and posterior ethmoid arteries

It is not possible to identify the anterior or posterior arteries on endoscopic
examination of the unoperated nose. It is important for the surgeon to be aware
of any low-lying arteries that may hang on a mesentery and be at risk during
surgical dissection. It is often possible to identify the point at which the vessels

22
 RADIOLOGY OF THE PARANASAL SINUSES

1 2 3

Figure 2.12 A coronal CT scan demonstrating two generous concha bullosa. 1, inferior
turbinate; 2, medial plate of concha bullosa; 3, lateral plate of concha bullosa

1 2 3 4 5

Figure 2.13 A coronal CT scan demonstrating a right-sided Haller cell that is compro-
mising the maxillary sinus ostium. 1, inferomedial wall of orbit; 2, Haller cell; 3, uncinate
process; 4, middle turbinate; 5, inferior turbinate
23
THE PARANASAL SINUSES

1 2 34

Figure 2.14 A coronal CT scan demonstrating the characteristic tenting of the bony
channel for the anterior ethmoid artery. This patient also has gross polypoid change in
the sinonasal cavity. 1, maxillary antrum; 2, middle turbinate; 3, nasal septum; 4, cribri-
form plate; 5, channel for anterior ethmoid artery

traverse the nasal cavity by looking for ‘tenting’ of the bone. Sometimes, depend-
ing on the position of the CT image, it is also possible to see the bony channel
through which the artery passes (Figure 2.14).

The optic nerve

The proximity of the optic nerve to the posterior ethmoid sinus and any lateral
extension, known as an Onodi cell, is easily identified on axial CT scans (Figure
2.15). It is easy for the endoscopic surgeon to continue dissecting laterally as the
posterior aspect of the posterior ethmoid sinus is approached, placing the optic

24
 RADIOLOGY OF THE PARANASAL SINUSES

1 2 3 4 5

Figure 2.15 An axial CT scan showing the optic nerve passing through an Onodi cell.
1, eyeball; 2, optic nerve (left); 3, gyrus rectus of frontal lobe of the brain; 4, posterior
ethmoid sinus; 5, optic nerve (right)

nerve at great risk. The surgeon needs to make a conscious decision to move
medially and inferiorly when entering the sphenoid sinuses from the posterior
ethmoid sinuses.

FURTHER READING

Shankar L, Evans KL, Hawke M, Stammberger H. An Atlas of Imaging of the Paranasal

Sinuses. London: Martin Dunitz, 1994

25
THE PARANASAL SINUSES

Rao VM, Flanders AE, Tom BM. MRI and CT Atlas of Correlative Imaging in
Otolaryngology. London: Martin Dunitz, 1992
Seeram E. Computed Tomography – Physical Principles, Clinical Applications and
Quality Control. Philadelphia: WB Saunders, 2001

REFERENCES

1. Metson R, Glicklich RE, Stankiewicz JA et al. Comparison of sinus computed tomog-

raphy staging systems. Otolaryngol Head Neck Surg 1997; 117: 372–9
2. Keros P. Über die praktische Bedeutung der Niveauunterschiede der lamina cribrosa
des ethmoids. Z Laryngol Rhinol Otol 1962; 41: 808–13

26
3. NASAL CAVITY
ROBIN YOUNGS
• ANTERIOR APERTURE
• NASAL VALVE
• NASAL SEPTUM
• LATERAL NASAL WALL
• INFERIOR TURBINATE AND MEATUS
• MIDDLE TURBINATE
• MIDDLE MEATUS
• SUPERIOR TURBINATE AND SPHENO-ETHMOID RECESS
• POSTERIOR CHOANAE AND NASOPHARYNX

ANTERIOR APERTURE (Figure 3.1)

The nasal cavity itself is limited by the lateral nasal wall, the nasal septum and
the nasal floor. There are openings anteriorly and posteriorly known as apertures.
The anterior or piriform aperture of the skull forms the bony surrounds to which
the structures of the external nose and underlying nasal cavity are attached. The
margins of the piriform aperture are formed by the nasal bones superiorly and
the maxillae laterally and inferiorly. The inferior junction of the left and right
maxillae is in the midline sagittal plane, where anteriorly the anterior nasal spine
is found. The spine is closely related to the anterior end of the cartilagenous nasal
septum, from which it is separated by perichondrium and periostium. From its
inferior aspect, the piriform aperture curves upwards to be formed by the frontal
process of the maxilla in its lateral border. The junction between the two nasal
bones forms the superior limit. The piriform aperture is divided into two by the
nasal septum.

NASAL VALVE (Figure 3.2)

This area corresponds to the main site of airway resistance in the normal nasal
cavity. The nasal valve complex is limited by the angle between the upper lateral
cartilage and nasal septum superiorly, the anterior end of the inferior turbinate
posteriorly, the piriform aperture laterally and the floor of the nose inferiorly.
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8

Figure 3.1 The bony anterior aperture of the nasal cavity. 1, right lacrimal fossa; 2,
right inferior turbinate; 3, right nasal bone; 4, anterior nasal spine; 5, perpendicular plate
of ethmoid; 6, left middle turbinate; 7, left maxilla; 8, left infraorbital foramen

Superiorly, the junction of the nasal septum and upper lateral cartilage form an
angle of 10–15° in Caucasians. In African-Americans and Asians, this angle is
more obtuse. The airflow through this narrow part of the nose is governed by
Poiseuille’s law, with flow being proportional to the fourth power of the radius.
Small changes in airway dimensions will therefore have exponential effects on
flow. Nasal valve obstruction can occur with distortion of the anterior septal
cartilage, and upper and lower lateral cartilages. These fixed obstructions can be
greatly augmented by the influence of mucosal swelling in the region of the
inferior turbinate. Obstruction of the nasal valve is estimated to be a factor in
13% of adults complaining of nasal blockage.

28
 NASAL CAVITY

1 2 3 45

Figure 3.2 Coronal section through the nasal valve. 1, right inferior turbinate; 2, right
middle turbinate; 3, quadrilateral nasal septal cartilage; 4, left upper lateral nasal carti-
lage; 5, left nasal vestibule

NASAL SEPTUM (Figures 3.3 and 3.4)

The nasal septum separates the two sides of the nasal cavity. It is composed of
bone and cartilage with a mucosal covering. The bony constituents are the
perpendicular plate of the ethmoid bone and the vomer. The cartilagenous
constituent is the nasal septal or quadrilateral cartilage. Superiorly, the septum is
formed by the perpendicular plate of the ethmoid bone, which passes backwards
from under the nasal bones to reach the vomer. The vomer itself attaches poste-
riorly to the rostrum of the sphenoid, and inferiorly to the palate. The vomer
also has a posterior free edge forming part of the posterior choana. The septal

29
THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 3.3 Sagittal view of the nasal septum. 1, quadrilateral nasal septal cartilage; 2,
nasal bone; 3, perpendicular plate of ethmoid; 4, olfactory filaments; 5, vomer; 6, rostrum
of sphenoid; 7, sphenoid sinus

cartilage is anchored to the perpendicular plate and vomer by collagenous connec-

tive tissue. Inferiorly, the septal cartilage rests on the premaxilla anteriorly, where
it widens significantly. More posteriorly, the septal cartilage rests on the nasal
crest of the palatine process of the maxilla. The antero-inferior border of the nasal
septum becomes membranous in an area otherwise known as the collumella.
Most of the nasal septum is covered with ciliated respiratory mucosa. The
thickness of this mucosa is variable and dependent on the vascularity of the
submucosal tissues. The septum is particularly thick at the vomero-cartilagenous
junction, where there is a submucosal arteriovenous plexus first described by
Zuckerkandl. The superior part of the nasal septum over the perpendicular plate

30
 NASAL CAVITY

1 2 3 4 5 6 7

Figure 3.4 Coronal section through the anterior nasal cavity. 1, right frontal process of
maxilla; 2, right inferior turbinate; 3, nasal bone; 4, vomero-cartilagenous junction; 5,
bony septal spur; 6, left middle turbinate; 7, left inferior meatus

is covered by specialised olfactory epithelium, with olfactory fibres often visible

in postmortem specimens. This epithelium also extends over the lateral wall of
the nasal cavity in the area of the superior turbinate and superior part of the
middle turbinate.
The nasal septum is frequently deviated. This deviation can be either bony or
cartilagenous, with combinations of both types being frequent. Bony deviations
often take the form of septal ‘spurs’, usually affecting the vomer. Cartilagenous
deviation can occur with dislocation of the cartilage out of the nasal crest. Most
septal deviation occurs developmentally with unequal facial growth. Trauma can
also be a factor in some cases.

31
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9 10 11 12

Figure 3.5 Bony lateral nasal wall (left side). 1, lateral pterygoid plate; 2, medial ptery-
goid plate; 3, sphenoid sinus; 4, sphenopalatine foramen; 5, spheno-ethmoid recess; 6,
attachment of inferior turbinate; 7, superior turbinate; 8, middle turbinate; 9, bony hiatus
into maxillary sinus; 10, palatine process of maxilla; 11, nasolacrimal canal; 12, frontal
process of maxilla

LATERAL NASAL WALL (Figures 3.5 and 3.6)

The lateral nasal wall is a complex and functionally important component of the
nasal anatomy. Anteriorly, the lateral nasal wall can be visualised through the
bony piriform aperture. The bony lateral nasal wall is formed by parts of the
maxilla, ethmoid, palatine, sphenoid (medial pterygoid plate), lacrimal, nasal and
inferior turbinate bones. Three and occasionally four turbinates or conchae project
into the nasal cavity from the bony lateral wall. The spaces underneath the
turbinates are known as meatuses. The inferior turbinate is a separate bone
largely attached to the maxilla, but with a delicate attachment superiorly to the

32
 NASAL CAVITY

1 2 3 4 5 6 7 8

Figure 3.6 Sagittal section through the lateral nasal wall (right side). 1, agger nasi; 2,
uncinate process; 3, inferior turbinate; 4, middle turbinate; 5, superior turbinate; 6,
supreme turbinate; 7, sphenoid sinus; 8, nasopharyngeal opening of Eustachian tube

ethmoid adjacent to the natural ostium of the maxillary sinus. Under the inferior
turbinate, the inferior meatus is walled off laterally by a concavity of maxillary
bone. The middle and superior turbinates project from the ethmoid bone.
Occasionally, a supreme turbinate is present. In the middle meatus, there are
lateral bony dehiscences known as the anterior and posterior fontanelles.
More posteriorly a further dehiscence is bordered by the medial pterygoid plate
and body of the sphenoid, the vertical plate of the palatine bone (orbital and
sphenoidal processes) and the ethmoid. This is the sphenopalatine foramen,
through which nerves and vessels pass to the nasal cavity from the pterygopala-
tine fossa. The lateral wall of the middle meatus is formed by very thin bone

33
THE PARANASAL SINUSES

attached inferiorly to the top of the inferior turbinate. This bone has components
from the ethmoid (uncinate process), maxilla and lacrimal bones. In life, the
anterior and posterior fontanelles are normally covered by mucosa. Occasionally,
this mucosa may be deficient, producing an accessory maxillary sinus ostium. The
structures of the lateral nasal wall are subject to considerable anatomical varia-
tion, both in the underlying bony framework and in the covering mucosa.
Mucosal variation occurs as a physiological response to such factors as changes
in temperature and posture, as well as in response to pathological factors such as
infection and allergy.

INFERIOR TURBINATE AND MEATUS (Figure 3.7)

The inferior turbinate occupies most of the length of the lateral nasal wall, lying
12–23 mm above the nasal floor. Anteriorly, the bony inferior turbinate is attached
to the conchal crest of the maxilla. The mucosa over the inferior turbinate is partic-
ularly prone to variation in thickness, having a rich submucosal blood supply. The
physiological variation in nasal mucosa, known as the nasal cycle, is commonly
seen on clinical examination. Longitudinal furrows increasing the surface area of
the mucosa are often seen. Just behind the posterior end of the inferior turbinate
is found the pharyngeal opening of the Eustachian tube. The inferior meatus
contains the inferior ostium of the nasolacrimal duct. This ostium normally lies in
the roof of the meatus, although it can exit as far as the midpoint of the inferior
meatus. The opening of the duct, with its membranous valve, lies close to (within
15 mm) of the anterior attachment of the inferior turbinate bone.

MIDDLE TURBINATE (Figures 3.8 and 3.9)

The middle turbinate is the foremost surgical landmark in the nasal cavity. As
an integral part of the ethmoid bone, it has a complex attachment to the roof
of the ethmoid and the lateral nasal wall. At its most anterior, the middle
turbinate has a superior attachment, where it forms the medial relation of the
frontal recess. This superior attachment continues posterior to the frontal recess,
with a close relationship to the anterior skull base at the junction between the
relatively thick orbital plate of the frontal bone and the thin lateral lamella of
the cribriform plate. It is in this area that accidental surgical penetration of the
skull base with cerebrospinal fluid leakage is most likely to occur. More posteri-
orly, the middle turbinate attaches laterally to the lamina papyracea. This part
of the turbinate is the basal or ground lamella, corresponding to the embryo-
logical third basal lamella. The basal lamella is an important surgical landmark,
being the boundary between the anterior and posterior ethmoidal air cells.

34
 NASAL CAVITY

1 2 3 4 5 6 7 8 9

Figure 3.7 Axial section through the inferior nasal cavity (from above). 1, nasal septal
cartilage; 2, left inferior meatus; 3, right inferior turbinate; 4, left maxillary sinus; 5,
vomer; 6, maxillary vessels; 7, choana; 8, right Eustachian tube; 9, fossa of Rosenmüller

When viewed endoscopically, the middle turbinate occupies a dominant

position in the nasal cavity. Just anterior to the middle turbinate is a prominence
created by the most anterior ethmoidal air cell – the agger nasi. Also, a distinct
‘maxillary line’ can be seen anterior to the turbinate, marking the junction
between the thick bone of the frontal process of the maxilla and the thin uncinate
process of the ethmoid. In its superior part, the maxillary line also lies over the
lacrimal bone and lacrimal sac – a landmark used in endonasal lacrimal surgery.
The middle turbinate is subject to variations in size and shape. The turbinate
is frequently pneumatised – the so-called ‘concha bullosa’. This pneumatisation

35
THE PARANASAL SINUSES

1 2 3 4 5

Figure 3.8 Coronal CT scan through the anterior nasal cavity. 1, right middle turbinate;
2, crista galli; 3, cribriform plate; 4, left inferior turbinate; 5, foveola ethmoidalis of
frontal bone

36
 NASAL CAVITY

1 2 3 4 5 6

Figure 3.9 An endoscopic view into the right nasal cavity. 1, frontal process of maxilla;
2, maxillary line (surface marking of suture line); 3, uncinate process; 4, inferior turbinate;
5, middle turbinate; 6, nasal septum

can be in anterior or posterior segments, or both. In addition, deep longitudinal

furrows and clefts, embryological remnants, can give the impression of a double
turbinate. A convex curve of the middle turbinate laterally, narrowing the middle
meatus, has been termed a paradoxical curve, thought to be of no pathological
importance.

37
THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 3.10 Sagittal section with middle and inferior turbinates partially removed (right
side). 1, agger nasi cell; 2, opening of nasolacrimal duct in inferior meatus; 3, uncinate
process; 4, hiatus semilunaris; 5, bulla ethmoidalis; 6, middle turbinate (cut edge); 7,
sphenoid sinus

MIDDLE MEATUS (Figure 3.10)

When viewed endoscopically from an anterior perspective, the principal structure

seen in the middle meatus is the uncinate process. Behind the posterior free
border of the uncinate process lies the ethmoidal bulla. In a cadaver specimen
with the middle turbinate removed or deflected, the relationship between the
structures of the middle meatus can be seen in more detail. The bone of the
uncinate process is very thin, and in sagittal section it appears as a J-shaped struc-
ture. It has a variable attachment to adjacent bones, including inferiorly to the
inferior turbinate and anteriorly to the frontal process of the maxilla. Where the
bone of the uncinate process is deficient, the anterior and posterior fontanelles

38
 NASAL CAVITY

1 2 3 4 5

Figure 3.11 Coronal section through the superior nasal cavity. 1, posterior ethmoid cells;
2, right superior turbinate; 3, olfactory nerve; 4, left middle turbinate; 5, left maxillary
sinus

separate the middle meatus from the maxillary sinus. Accessory ostia are more
commonly found in the posterior fontanelle. The superior attachment is variable
and is key to the pneumatisation of the frontal recess. Between the uncinate
process and the ethmoidal bulla lies the two-dimensional hiatus semilunaris.
Medial to the uncinate process lies the ethmoidal infundibulum.

SUPERIOR TURBINATE AND SPHENO-ETHMOID RECESS (Figure 3.11)

The superior turbinate is a variable structure that, in a similar fashion to the

middle turbinate, has an anterior attachment to the cribriform plate, with a

39
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8

Figure 3.12 Axial section through the nasopharynx. 1, right maxillary artery; 2, right
inferior turbinate; 3, pharyngeal opening of Eustachian tube; 4, vomer; 5, soft palate; 6,
posterior wall of nasopharynx; 7, fossa of Rosenmüller; 8, Eustachian tube

lateral posterior attachment. The superior meatus contains the ostia of posterior
ethmoidal cells. In about one-third of cases, when the superior turbinate is small
a supreme turbinate and meatus also exist. The posterior part of the superior
meatus leads into the spheno-ethmoid recess. The latter is well developed in
about half of cases and lies just anterior to the sphenoid sinus. From a functional
standpoint, the spheno-ethmoid recess is important in that it receives the
mucociliary flow from the sphenoid and posterior ethmoid sinuses. This flow joins
that from the anterior nasal cavity and the anterior ethmoid, frontal and maxil-
lary sinuses to converge on the nasopharynx. Endoscopically, the posterior end of
the middle turbinate, superior turbinate and nasal septum are key to the locali-
sation of the sphenoid sinus ostium through the nasal cavity.

40
 NASAL CAVITY

POSTERIOR CHOANAE AND NASOPHARYNX (Figure 3.12)

The posterior choana is the most posterior part of each nasal cavity. The poste-
rior free edge of the vomer forms the medial boundary of the choanae. Inferiorly
lies the horizontal plate of the palatine bone. Superiorly, the alar of the vomer
inserts into the rostrum of the sphenoid. Laterally, the choanae are bordered by
the perpendicular plate of the palatine bone. With the posterior edge of the
vomer being in the midline in over 90% of cases, choanal asymmetry is uncom-
mon. The posterior choanae lead into the cavity of the nasopharynx. In the
nasopharynx, the most prominent structure is the pharyngeal opening of the
Eustachian tube. Just behind the tubal opening lies the Eustachian cushion or
tubal eminence. Between the tubal eminence and posterior nasopharyngeal wall
lies a fossa (of Rosenmüller) of varying dimension – this is an important site clini-
cally in the pathogenesis of nasopharyngeal carcinoma. The posterior wall of the
nasopharynx contains the adenoidal lymphoid tissue, which is most prominent in
childhood.

41
4. ANTERIOR ETHMOID AND FRONTAL
SINUSES
DEREK SKINNER, PAUL WHITE
• INTRODUCTION
• OSTEO-MEATAL COMPLEX
• UNCINATE PROCESS
• ETHMOID BULLA
• RETROBULLAR AND SUPRABULLAR RECESSES
• HIATUS SEMILUNARIS SUPERIOR AND INFERIOR

• ETHMOID INFUNDIBULUM
• MIDDLE TURBINATE
• FRONTAL BONE AND FRONTAL SINUS
Anatomical origin
Encroachment or invasion
Complexity
Communicating cells

INTRODUCTION

The anatomy of the anterior ethmoid and frontal sinuses is complex. Proctor and
Messerklinger introduced the concept that chronic or recurrent bacterial sinusitis
is most commonly caused by unappreciated and untreated disease of the anterior
ethmoid sinuses. This chapter defines the anatomy and outlines the drainage of
the anterior ethmoid sinuses through the ostio-meatal complex and its role in
secondary infection of the maxillary and frontal sinuses. It is essential that surgeons
understand the key anatomical features of the anterior ethmoid region, including
the ostio-meatal complex area, when undertaking endoscopic sinus surgery.
The key anatomical sites are as follows:

• ostio-meatal complex
• uncinate process
• ethmoid bulla
• variable recesses
– suprabullar recess
– retrobullar recess
THE PARANASAL SINUSES

1 2 3 4

Figure 4.1 Coronal CT scan through the anterior ethmoid sinuses. 1, uncinate process;
2, frontal recess; 3, middle turbinate; 4, maxillary sinus ostium

• hiatus semilunaris superior and inferior

• ethmoid infundibulum
• maxillary sinus ostium
• middle turbinate
• frontal sinus
• frontal recess
• the influence of additional air cells and recesses

OSTIO-MEATAL COMPLEX (Figure 4.1)

The infundibulum along with the frontal recess and the maxillary sinus ostium
is referred to as the ‘ostio-meatal complex’ or ‘ostio-meatal unit’ by Messerklinger.

44
 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4

Figure 4.2 Sagittal view of lateral nasal wall (left side). 1, elevated middle turbinate; 2,
ethmoid bulla; 3, uncinate process; 4, inferior turbinate

Stammberger and Kennedy1 describe this region as a functional entity, with the
anterior ethmoid complex representing the final common pathway for drainage
and ventilation of the frontal, maxillary and anterior ethmoid air cells. There is
no consensus with respect to a precise anatomical definition, but importantly it
is the cells, clefts and ostia within this region of the lateral wall of the nose that,
when diseased, contribute to the symptoms and pathophysiology of sinusitis.

UNCINATE PROCESS (Figure 4.2)

The uncinate process is a sickle-shaped bone, which is normally very thin (Latin
processus uncinatus, meaning hooked outgrowth). This bone descends from an
anterosuperior attachment on the lateral nasal wall to its postero-inferior attach-
ment to the inferior turbinate. The uncinate process extends posteromedially to
its concave free margin, which normally lies parallel to the anterior surface of the
ethmoid bulla. The uncinate process is attached to the perpendicular process of

45
THE PARANASAL SINUSES

1 2 3 4 5

Figure 4.3 Lateral wall of the nose: osteology. 1, lacrimal bone (shaded blue); 2, superior
attachment of uncinate process; 3, anterior fontanelle; 4, inferior attachment of uncinate
process; 5, posterior fontanelle; 6, hiatus semilunaris

46
 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4 5

Figure 4.4 Coronal CT scan demonstrating two of the variants of the superior insertion
of the uncinate process. 1, inferior turbinate; 2, ethmoid bulla; 3, uncinate process insert-
ing to skull base; 4, middle turbinate; 5, uncinate process inserting to middle turbinate

the palatine bone and the ethmoid process of the inferior turbinate by bony inter-
digitations.
The convex anterior margin of the uncinate process ascends to the lacrimal
bone while remaining in contact with the bony lateral nasal wall (Figure 4.3).
The superior attachment of the uncinate bone is variable: (a) it can attach to the
middle turbinate when it is curved medially in its most superior segment or (b)
pass vertically to the skull base or (c) curve laterally to join the lamina papyracea
(Figure 4.4). In some patients, the free edge is rolled anteromedially and the free
margin can protrude into the middle meatus, lateral to the middle turbinate.
Nasal polyposis frequently causes eversion of the posterior aspect of the uncinate
process, with the free edge of the uncinate appearing within the middle meatus.

47
THE PARANASAL SINUSES

The uncinate bone is a constant structure, despite the variations in its attach-
ment to the lateral nasal wall. The hiatus semilunaris is a two-dimensional slit
situated between the free edge of the uncinate process and the ethmoid bulla
and leading into a narrow passage, the ethmoid infundibulum, which commu-
nicates directly with the maxillary sinus ostium. Mucus from the maxillary
antrum and the anterior ethmoid sinuses is channelled through the ethmoid
infundibulum.
It is possible to identify the uncinate process in the 10th week in utero. It is
seen arising from the medial surface of the lateral cartilaginous capsule. The
infundibulum is evident within a further 2 weeks, representing the descending
portion of the first of the five ethmoturbinals.
The function of the uncinate bone is poorly understood, but it has been
suggested that it has a protective function whereby inspired air is deflected away
from the sinuses, and expired, and possibly cleaner air, is diverted towards the
sinuses for ventilation. This would help to prevent the deposition of allergens into
the anterior group of sinuses.
There are many different techniques used to remove the uncinate process. Its
intimate attachment to the lateral nasal wall sometimes compromises excision
and there is always a risk that the orbit may be accidentally entered because of
the proximity of the uncinate process to the lamina papyracea.

ETHMOID BULLA (Figure 4.5)

The ethmoid bulla is the largest and least variable air cell in the anterior ethmoid
complex, arising from pneumatisation of the bulla lamella (second ethmoid basal
lamella) and lying medial to and attached to the lamina papyracea.
Setliff et al2 have described the development of three specific types of ethmoid
bullae: simple, compound and complex. The ‘simple bulla’ is a single large cavity
with one medial ostium opening either anterior to the basal lamella or (less often)
anteriorly through a discrete opening in the face of the bulla into the ethmoidal
infundibulum. The ‘compound ethmoid bulla’ usually has two (occasionally three)
separate compartments, each of which opens medially, anterior to the basal
lamella and communicates with the hiatus semilunaris superior. There is no
communication with the other compartments. The ‘complex ethmoid bulla’ has
two or three compartments, one of which usually communicates with the hiatus
semilunaris superior. The other compartments communicate anteriorly to the
ethmoid infundibulum and/or posteriorly to the superior meatus. Again there is
no communication between the individual compartments.
Setliff et al2 reported that 47% of patients had a simple bulla, 27% had a
complex bulla with multiple cells and mixed patterns of communication, and
26% had a compound bulla. Interestingly, bilaterally symmetrical ethmoid

48
 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4 5 6

Figure 4.5 Cadaver axial section through the paranasal sinuses. 1, nasal septum; 2,
middle turbinate; 3, uncinate process; 4, hiatus semilunaris; 5, compound ethmoid bulla;
6, maxillary antrum

anatomy was present in 58% of patients, and this was most commonly seen with
a simple bulla configuration.

RETROBULLAR AND SUPRABULLAR RECESSES (Figures 4.6 and 4.7)

Until recently, these structures and spaces were not well appreciated by sinus
surgeons; however, following the introduction of sinus endoscopy, these structures
and spaces have taken on more significance with respect to understanding the
variations of anatomy in this region. In the past, the retrobullar and suprabullar

49
THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 4.6 Endoscopic surgical view into the anterior ethmoid following partial removal
of the uncinate process (left side). 1, uncinate process remnant; 2, middle turbinate; 3,
skull base; 4, suprabullar recess; 5, ethmoid bulla; 6, frontal recess

recesses were known as the sinus lateralis of Grunwald and the susbullar cell of
Mouret, respectively.3 Understanding these recesses allows an approach to the
frontal sinus to be more anatomically sound.
The retrobullar recess or lateral sinus, when present, lies posterior to the
ethmoid bulla and anterior to the basal lamella. The superior boundary is
the roof of the ethmoid and the anterior boundary is the posterior aspect of the
ethmoid bulla if it extends to the skull base. If the ethmoid bulla does not extend

50
 ANTERIOR ETHMOID AND FRONTAL SINUSES

Figure 4.7 Coronal CT demonstrating inflammatory disease in the suprabullar space. 1,

diseased suprabullar space; 2, lamina papyracea; 3, ethmoid bulla; 4, concha bullosa; 5,
inferior turbinate

to the skull base, the retrobullar recess may extend anteriorly into the supra-
bullar recess.
Stammberger and Kennedy1 describe the suprabullar recess as a space bordered
superiorly by the ethmoid roof, laterally by the lamina papyracea and inferiorly
by the roof of the ethmoid bulla. The basal lamella of the middle turbinate forms
its posterior boundary. Anteriorly, it is separated from the frontal recess only when
the bulla lamella reaches the skull base. Otherwise, the suprabullar recess opens
into the frontal recess.
The suprabullar and retrobullar recesses can be approached from medially and
inferiorly through the hiatus semilunaris superior. The suprabullar recess may join

51
THE PARANASAL SINUSES

with the retrobullar recess when the posterior wall of the ethmoid bulla is not
in contact with the basal lamella of the middle turbinate.
Bolger and Mawn,4 in their analysis of cadaveric dissections and CT scans,
found the suprabullar and retrobullar recesses to be separate entities, each having
a corresponding pneumatisation that did not connect with neighbouring cells or
structures. The two recesses were separated by a small but consistent tissue
bridge, projecting from the basal lamella to the superior aspect of the ethmoid
bulla and lamina papyracea.
Two anatomical variants occur within the suprabullar and retrobullar recesses:
(a) a rudimentary suprabullar recess with a dominant retrobullar recess and (b)
a dominant suprabullar recess that progresses to become the frontal recess and
to pneumatise the frontal bone or sinus.

HIATUS SEMILUNARIS SUPERIOR AND INFERIOR (Figure 4.8)

The hiatus semilunaris inferior is a two-dimensional slit that represents the short-
est distance between the free posterior margin of the uncinate process and the
anterior face of the ethmoid bulla. Frequently, this lies in the sagittal plane. The
hiatus semilunaris inferior is a crescent-shaped cleft, through which one must pass
to reach the ethmoid infundibulum.
The hiatus semilunaris superior is a crescent-shaped cleft between the ethmoid
bulla and the middle turbinate when there is a marked lateral sinus. It is less
well defined than the hiatus semilunaris inferior. The suprabullar and retrobullar
recesses can be entered medially and inferiorly between the middle turbinate
through the hiatus semilunaris superior.

ETHMOID INFUNDIBULUM (Figure 4.9)

The ethmoid infundibulum is a funnel-shaped space that is bordered medially by

the uncinate process and laterally by the lamina papyracea. The frontal process
of the maxilla and the lacrimal bone may constitute parts of the lateral wall
anterosuperiorly. Anteriorly, the ethmoid infundibulum has a blind ending that
forms an acute angle, sometimes seen as a V-shaped structure in the axial sections
of CT scans. Posteriorly, the ethmoid infundibulum extends to the anterior face
of the ethmoid bulla and opens into the middle meatus through the hiatus
semilunaris inferior. The maxillary sinus ostium usually opens into the inferolat-
eral aspect of the ethmoid infundibulum in the middle or posterior third. It is
important to note that the natural ostium of the maxillary sinus remains hidden
lateral to the uncinate process in the ethmoid infundibulum in the unoperated
nose. Any obvious ostium in the unoperated nose must represent an accessory
ostium in either the anterior or the posterior fontanelle.

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4 5 6 7 8

Figure 4.8 Cadaver axial section through the nasal cavity, ethmoid and sphenoid sinuses.
1, nasal septum; 2, middle turbinate; 3, uncinate process; 4, ethmoid bulla; 5, maxillary
antrum; 6, posterior ethmoid sinus; 7, sphenoid sinus; 8, internal carotid artery

The relationship of the ethmoid infundibulum to the skull base depends upon
the attachment of the uncinate process and its possible variations as previously
described.
The maxillary sinus ostium is an integral part of the anatomy of the anterior
ethmoid. Its detailed relationships are discussed in Chapter 5.

MIDDLE TURBINATE (Figures 4.10 and 4.11)

The middle turbinate has three parts: the anterior third, the basal lamella and
the posterior third.

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THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 4.9 Coronal section through the nasal cavity and the anterior ethmoid and maxil-
lary sinuses. 1, maxillary sinus ostium; 2, ethmoid infundibulum; 3, uncinate process; 4,
superior turbinate; 5, septal spur; 6, ethmoid bulla

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4 5 6 7

Figure 4.10 Sagittal view of lateral nasal wall and sphenoid sinus (left side). 1, sphenoid
sinus; 2, superior turbinate; 3, superior meatus; 4, inferior meatus; 5, middle meatus; 6,
inferior turbinate; 7, middle turbinate–anterior third–vertical attachment

The anterior third of the middle turbinate lies in the sagittal plane and attaches
superiorly to the lateral lamella of the cribriform plate. The body of the middle
turbinate usually presents a convex aspect to the nasal septum. In some, there is
a paradoxical curvature, which may reduce ventilation of the middle meatus. The
complex embryological development of the lateral wall of the nose leads to the
finding of both sagittal and horizontal clefts of the middle turbinate. These rarely
have any functional significance.
The basal lamella of the middle turbinate lies in the coronal plane and
separates the anterior ethmoid sinuses from the posterior ethmoid sinuses. It lies

55
THE PARANASAL SINUSES

1 2 3 4 5

Figure 4.11 Coronal CT scan demonstrating the posterior ethmoid sinuses and nasal
cavity. 1, posterior ethmoid sinus; 2, horizontal insertion of middle turbinate; 3, superior
turbinate; 4, middle turbinate; 5, inferior turbinate

between the posterior margin of the vertical, anterior third of the middle
turbinate and the lamina papyracea. It either lies in intimate contact with the
posterior boundary of the ethmoid bulla or is separated from the ethmoid bulla
by the lateral sinus. The face of the basal lamella has a variable anatomy and is
frequently convoluted and has variable communications with the posterior
ethmoid sinuses.
The posterior third of the middle turbinate lies in the horizontal plane and
attaches to the lamina papyracea or the lateral wall of the nose. Its superior
surface is separated from the posterior ethmoid sinuses by a narrow cleft. The
posterior end of the middle turbinate lies anterior to the posterior choana.

56
 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4

Figure 4.12 Inferior view of the frontal bone. 1, fovea ethmoidalis; 2, slot for ethmoid
bone; 3, vertical plate of frontal bone; 4, roof of orbit

FRONTAL BONE AND FRONTAL SINUS (Figures 4.12–4.15)

The frontal bone consists of two portions: a vertical or squamous plate, which
forms the forehead, and a horizontal or orbital plate, which serves as the floor of
the anterior cranial fossa and the roof of the orbit. The frontal sinuses are
pyramid-shaped air cells expanded between the anterior and posterior tables of
the vertical plate. The base of the sinus extends for a variable extent over the
medial orbital rim, and the apex is located superiorly. The sinuses are usually
paired, although variants include a single unilateral sinus, a third intersinus cell
and complete hypoplasia. The frontal sinus develops as an extension of one or
more anterior, superior ethmoid cells. It is rudimentary at birth and first becomes
a distinct entity between the ages of 6 and 8 years. The frontal sinus is fully
developed between the ages of 12 and 14 years in females and 16 and 18 years
in males. The average frontal sinus in an adult is 3 cm high, 2.5 cm wide and
1.9 cm deep. The volume ranges up to 37 ml, with an average value of 10.02 ml.
The frontal sinus is frequently divided by incomplete septae. The final pathway
of mucociliary clearance from the frontal sinus into the middle meatus of the nose

57
 THE PARANASAL SINUSES

1 2 3 4

Figure 4.13 Sagittal section through the lateral wall of the nose (right side). 1, frontal
sinus; 2, uncinate process; 3, middle turbinate; 4, ethmoid bulla; 5, frontal cell; 6, frontal
recess; 7, retrobullar space

is via the frontal recess. This is bordered by the middle turbinate medially, the
ethmoid bulla posteriorly, the lamina papyracea laterally and the frontal process
of the maxilla anteriorly. The angulation of the frontal recess is affected by the
configuration of the uncinate process and the variable pneumatisation of the
surrounding bony partitions.
The final drainage pathway of the frontal sinus through the frontal recess is
unpredictable. It has either a convoluted pathway via the labyrinth of the anterior
ethmoid cells into the ethmoid infundibulum, lateral to the uncinate process, or
a direct pathway into the middle meatus passing medial to the uncinate process.

58
 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3 4 5

Figure 4.14 Coronal section through the anterior ethmoid sinuses. 1, uncinate process;
2, frontal recess; 3, superior turbinate; 4, intersinus cell; 5, middle turbinate

The key structure in understanding the anatomical variations of the frontal recess
is the ethmoid infundibulum. The frontal sinus develops, with rare exceptions,
either as a direct extension of the middle meatus lying medial to the uncinate
process (55%) or as an anterosuperior extension of the ethmoid infundibulum
lying lateral to the uncinate process. The frontal sinus is absent or remains a
vestigial frontal ethmoid cell in up to 5% of individuals.
The frontal recess is the pathway of drainage from the main lumen of the
frontal sinus into the middle meatus and is not synonymous with the frontonasal
duct. The medial wall of the frontal recess is formed by the medial surface of the

59
THE PARANASAL SINUSES

1 2 3

Figure 4.15 Axial section demonstrating the frontal sinus and frontal recess. 1, anterior
table frontal sinus; 2, frontal recess; 3, posterior table frontal sinus

most anterosuperior part of the middle turbinate. The superior insertion of the
uncinate process is variable and contributes to the medial wall of the frontal recess
when it inserts into the skull base or the middle turbinate. The lateral wall of
the frontal recess is formed by the lamina papyracea. The anterior boundary of
the frontal recess is the agger nasi. The posterior wall is usually incomplete, but
is formed by the bulla and any suprabullar cells or recesses anterior to the basal
lamella of the middle turbinate, reaching superiorly as far as the skull base in
relation to the anterior ethmoidal artery. The skull base forms the posterior wall
just distal to the frontal sinus ostium. Extensive pneumatisation of the supra-

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2

Figure 4.16 Coronal CT demonstrating a prominent agger nasi cell. 1, nasal septum;
2, prominent agger nasi cell; 3, pneumatised crista galli

bullar cells and/or of the ethmoid bulla will give rise to a narrowing of the frontal
recess from posteriorly. When viewed in sagittal section, the frontal recess and
frontal sinus resemble an hourglass shape with the axis sloping in a posterior
direction. The most constricted portion is the natural ostium of the frontal sinus,
which may be narrow and has a variable length.
When the frontal bone becomes pneumatised, the anterior ethmoid cells tend
to occupy the space of its drainage pathway – these are known as frontal recess
cells. The description of these cells and of cells developing within the frontal sinus
itself has been associated with significant confusion in the literature.

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THE PARANASAL SINUSES

1 2

Figure 4.17 Coronal section demonstrating the frontal recess and the nasal cavity. 1,
frontal sinus; 2, frontal recess; 3, uncinate process; 4, lamina papyracea

The variation between individuals is sufficiently wide that the patterns of sinus
pneumatisation may be used for forensic purposes. It is therefore necessary to
have a broad understanding of the anatomical variation of the frontal recess cells.
As such, it is useful to consider not just their anatomical origin (e.g. agger nasi),
but also the degree of complexity (single versus multiple cells) and the degree
with which they encroach onto the frontal recess and frontal sinus lumen.

Anatomical origin (Figures 4.16 and 4.17)

It is useful to classify these cells by anatomical origin, bearing in mind that very
often the so-called cell is a recess-type extension of the frontal recess rather than
an individual cell (Table 4.1). The Anatomic Terminology Group1 recommends
62
 Table 4.1 Cell types as decribed by Lang5

Cell type Origin

Agger nasi (77%) Frontal process of maxilla

Lacrimal (33%) Lacrimal bone

Nasal (39%) Nasal process of frontal bone

Supraorbital Orbital plate of frontal bone

Uncinate Uncinate process

Frontal bullar (19%) Frontal bone

Suprabullar Anterior ethmoid

that because the formation of additional cells in the frontal recess and the
infundibulum (apart from agger nasi cells) is highly individual, these cells should
be described according to their anatomical orientation. For example, if they reach
the lacrimal sac and pneumatise into the lacrimal bone, they would be described
as lacrimal cells of the ethmoid infundibulum or lacrimal cells of the frontal
recess.
A cell that pneumatises into the frontal bone itself is a frontal cell of the
anterior ethmoid or a bulla frontalis. A supraorbital cell is an anatomical variant
that develops as an extension, from the posterior aspect, of the frontal or supra-
bullar recess and pnuematises into the orbital plate of the frontal bone.

Encroachment or invasion (Figure 4.18)

Van Alyea6 studied 112 cadaver sinus specimens. His work has been widely
quoted. He described cells that encroach into sinuses as invading cells (Table 4.2).
The frequency distribution of the cell types varies. Van Alyea found that invad-
ing cells occur in 63% of specimens and non-invading cells in 56%, while 19%

Table 4.2

Degree of invasion Grade

Non-invading 0

Invading <50% of lumen 1

Invading >50% of lumen 2

Lumen closed 3

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THE PARANASAL SINUSES

1 2 3 4

Figure 4.18 Endoscopic view of the frontal recess (right side). It is impossible to identify
the pathway to the frontal sinus without correlating the endoscopic view with the coronal
CT scan. 1, middle turbinate; 2, frontal recess; 3, uncinate process (cut edge); 4, ethmoid
bulla

had both types. A common location of an invading cell was the agger nasi.
Invading cells commonly encroach directly on the frontal sinus lumen, by extend-
ing upwards to pneumatise the frontal bone into the frontal sinus or arrive at a
point between the sinuses to become an intersinus cell. The latter usually
encroach on the medial wall of one or both frontal sinuses. The location of any
invading frontal cell may assume significant clinical importance when the cell

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3

Figure 4.19 Coronal section demonstrating the frontal recess and anterior ethmoid
sinuses. 1, uncinate process; 2, frontal recess (1); 3, middle meatus; 4, frontal sinus; 5,
communicating cell; 6, frontal recess (2)

invades the frontal sinus or anywhere in the pathway of the frontal recess. The
degree of invasion can be assessed using preoperative CT scanning.

Complexity
Bent et al7 have provided a useful functional means of classifying the complex-
ity and degree of invasion of these cells. Their classification describes four variants
of frontal recess cells that pneumatise anterosuperior to the agger nasi as identi-
fied on coronal CT scans (Table 4.3).

65
 Table 4.3 Classification of invading cells according to Bent et al7

Type I Single cell located above the agger nasi

Type II A tier of two or more cells above the agger nasi

Type III A single large cell that pneumatises into the frontal sinus lumen

Type IV A cell contained entirely within the frontal sinus

Communicating cells (Figure 4.19)

Not infrequently, frontal recess cells communicate directly with the frontal sinus
as well as the frontal recess. Up to 10% of frontal sinuses have a communicat-
ing cell. The communicating link has at times been large and may take up the

1 2 3

Figure 4.20 Coronal CT demonstrating frontal sinus anatomy. 1, lacrimal fossa; 2, agger
nasi cell; 3, type I frontal cell

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

1 2 3

Figure 4.21 Coronal CT scan demonstrating type II frontal cells. 1, nasolacrimal duct;
2, agger nasi; 3, type II frontal cells

1 2 3 4

Figure 4.22 Coronal section demonstrating a type III frontal cell. 1, frontal sinus; 2,
nasal septum; 3, type III frontal cell; 4, uncinate process

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THE PARANASAL SINUSES

1 2

Figure 4.23 Coronal CT demonstrating a type IV frontal cell. 1, type IV frontal cell;
2, frontal sinus

entire width of the cell. Although the two cavities may be connected by an
opening, each usually has a separate drainage outlet into the middle meatus.
The complicated and variable development of the fronto-ethmoid region has
a profound effect on the function and structure of the frontal recess (Figures
4.20–4.23).

REFERENCES

1. Stammberger HR, Kennedy DW. Paranasal sinuses: anatomic terminology and

nomenclature. The Anatomic Terminology Group. Ann Otol Rhinol Laryngol 1995;
104(Suppl 167): 7–16

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 ANTERIOR ETHMOID AND FRONTAL SINUSES

2. Setliff RC, Catalano PJ, Catalano LA, Francis C. An anatomic classification of the
ethmoidal bulla. Otlaryngol Head Neck Surg 2001; 125: 598–602
3. Mouret J. Anatomie des cellules ethmoidales. Rev Hebdo de Laryngol Otol Rhinol
1889; 3 Juillet No. 31: 913–24S
4. Bolger WE, Mawn CB. Analysis of the suprabullar and retrobullar recesses for
endoscopic sinus surgery. Ann Otol Rhinol Laryngol 2001; 110: 3–14
5. Lang J. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. New
York: Thieme Medical, 1989
6. Van Alyea OE. Frontal cells: an anatomic study of these cells with consideration of
their clinical significance. Arch Otolaryngol 1941; 34: 11–22
7. Bent JP, Cuilty-Siller C, Kuhn FA. The frontal cell as a cause of frontal sinus
obstruction. Am J Rhinol 1994; 8: 185–91

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5. MAXILLARY SINUS
STEPHEN WOOD
• INTRODUCTION
• PNEUMATISATION AND GROWTH
• ANATOMICAL RELATIONS
• MAXILLARY OSTEUM
• ANTERIOR WALL
• POSTEROLATERAL WALL
• SUPERIOR WALL
• INFERIOR WALL
• ANATOMICAL VARIATION

INTRODUCTION

The maxillary sinus is the largest of the paranasal sinuses and lies lateral to the
middle meatus, into which it drains. It is also commonly referred to as the antrum
(Greek antron, meaning ‘cave’) and was first described by Highmore in 1651. It
forms a large pyramid-shaped single chamber, with its limits being the orbital
floor superiorly, the hard palate and alveolus inferiorly, the zygomatic process
laterally, a thin plate of bone separating the cavity from the infratemporal and
pterygopalatine fossa posteriorly, and the uncinate process, fontanelles and
inferior turbinate medially. The apex of the sinus points laterally and extends into
the zygomatic process, sometimes into the zygomatic bone. The base of the sinus
faces medially and forms the lateral wall of the nasal cavity.
The maxillary sinus is located within the maxillary bone, which is the second
largest of the facial bones, the mandible being the largest. The paired bones form
the majority of the facial structure, including the whole upper jaw, the orbital
floors and a large part of the roof of the mouth and the lateral wall of the nasal
cavity. The maxillary bone contributes to the infratemporal and pterygopalatine
fossae and the infraorbital and pterygomaxillary fissures. Each bone consists of a
body and four processes that articulate with surrounding structures. These
processes are the frontal process, which articulates with the frontal bone and the
nasal bones; the zygomatic process, which articulates with the zygomatic bone;
the alveolar process, which contains the dentition; and the palatine process, which
articulates with the palatine bone to form the roof of the mouth.
THE PARANASAL SINUSES

1 2 3 4 5

Figure 5.1 Anterior view of the bony maxilla. 1, maxillary crest; 2, piriform aperture;
3, frontal process of maxilla; 4, infraorbital foramen; 5, zygomatic process of maxilla

PNEUMATISATION AND GROWTH

The degree of pneumatisation of the maxillary sinus varies with age, ranging from
agenesis to hyperpneumatisation. The shape of the sinus also changes with age.
At birth, the maxillary sinus has a round or elongated shape and gradually
becomes pyramidal with the appearance of the permanent teeth. By the 13th
year, the maxillary sinus reaches its definitive shape, and by the 18th year, its
proportions are stable. During the growth phase, the spatial relationship between
the orbit, the nasal cavity, the maxillary sinus, and the teeth varies.
The rate of growth of the sinus is not constant throughout childhood. Until
age 8 years, the maxillary sinus grows 2 mm a year vertically and 3 mm a year

72
 MAXILLARY SINUS

1 2 3 4 5

Figure 5.2 Coronal CT scan showing a hypoplastic maxillary antrum. 1, hypoplastic

right maxillary antrum; 2, lateralised right nasal wall; 3, right inferior turbinate; 4, right
middle turbinate; 5, nasal septum

in an anterior–posterior direction. There are accelerated periods of maxillary sinus

growth from birth to 2 years, from 71⁄2 to 10 years, and from 10 to 12 years.
Thereafter, there is slower steady growth until 14–18 years of age. From 7
months (prenatal) to birth, the sinus averages 7–16 mm anterior–posterior and
2–13 mm superior–inferior. Onödi studied the maxillary sinus in the newborn
and found it to measure 7 mm from anterior to posterior, 4 mm vertically and
3 mm wide. The average volume of the adult maxillary sinus is 9.5–20 ml, with
a mean of 14.8 ml.

ANATOMICAL RELATIONS

The maxillary sinus has medial (nasal), superior (orbital), anterior, inferior and
posterolateral (infratemporal) walls. With the exception of the posterior and

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THE PARANASAL SINUSES

1 2 3 4 5 6 7 8

Figure 5.3 Coronal section through the maxillary antra at the level of the posterior
ethmoid. 1, right maxillary antrum; 2, right inferior turbinate; 3, nasal septum; 4, left
superior turbinate; 5, left middle turbinate; 6, left lamina papyracea; 7, left medial rectus;
8, left infraorbital canal

lateral walls, which tend to merge into one another, the remaining sinus walls
have clear boundaries.
The medial wall of the maxillary sinus forms a major part of the lateral wall
of the nasal cavity and lies in juxtaposition to the middle meatus and inferior
meatus. The medial aspect of the maxillary bone has a large irregular opening
posterosuperiorly – the maxillary hiatus, which leads into the sinus. Anterior to
the hiatus there is a groove that is continuous above with the lacrimal groove,
which forms part of the circumference of the nasolacrimal canal, the remainder
of the canal being completed by the lacrimal bone and the lacrimal process of
the inferior nasal concha. This canal contains the nasolacrimal duct, which opens

74
 MAXILLARY SINUS

1 2 3 4 5 6

Figure 5.4 Sagittal section through the left maxillary antrum. 1, orbital fat; 2, natural
maxillary ostium; 3, maxillary antrum; 4, orbital floor; 5, accessory maxillary ostium in
posterior fontanelle; 6, maxillary artery

into the inferior meatus at the junction of the inferior turbinate with the medial
wall of the maxillary sinus, approximately 1.5–2.5 cm posterior to the anterior
free edge of the inferior turbinate. The nasolacrimal duct angulates from anterior
to posterior as it passes from the orbit into the nasal cavity, although this can be
variable. The ostium of the nasolacrimal duct is the only opening into the inferior
meatus. The primary maxillary ostium is found close to the bone of the
nasolacrimal duct, and the intervening bone tends to be quite thick as it merges
with the bony duct. Despite this, excessive anterior enlargement of a maxillary
sinus antrostomy can result in injury to the nasolacrimal duct and epiphora. The
anterior projection of the maxillary sinus over the lateral wall of the nasal cavity
varies according to the lacrimal expansion of the maxillary sinus and may be
lateral, anterior or posterior to the nasolacrimal duct. This is an important
anatomical aspect to be considered in the course of a dacrocystorhinostomy using
the endonasal approach.

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THE PARANASAL SINUSES

1 2 3 4

Figure 5.5 Axial section showing the left nasolacrimal duct. 1, nasal septum; 2, left
nasolacrimal duct; 3, left inferior turbinate; 4, left maxillary antrum

MAXILLARY OSTIUM

The hiatal aperture of the maxillary sinus is closed in part by the uncinate process
of the ethmoid and by the descending part of the lacrimal bone above, by the
maxillary process of the inferior nasal concha below, and by the perpendicular plate
of the palatine bone behind. Anterior to the hiatus is the conchal crest for attach-
ment of the inferior nasal conchal bone. These bones reduce the hiatus of the
maxillary sinus to two small holes or fontanelles that open into the middle meatus.
The anterior fontanelle contains the ostium of the sinus, and the posterior
fontanelle is closed by mucous membrane and periosteum. The wall of the middle
meatus is therefore thin, unlike the thick bone of the inferior meatus, and this

76
 MAXILLARY SINUS

1 2 3 4 5 6

Figure 5.6 Coronal section through the left maxillary antrum. 1, middle turbinate; 2,
inferior turbinate; 3, ethmoid bulla; 4, natural maxillary ostium; 5, uncinate process; 6,
left maxillary antrum

77
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8

Figure 5.7 Coronal section through the left maxillary antrum. 1, nasal septum; 2, left
inferior turbinate; 3, left middle turbinate; 4, natural maxillary ostium; 5, posterior
fontanelle; 6, infraorbital canal; 7, orbital fat; 8, left maxillary antrum

allows the creation of a maxillary sinus ostium in this area using delicate micro-
surgical instrumentation.
The anatomical relationship of the roof of the maxillary sinus with the wall of
the middle nasal meatus is variable. The structures of surgical importance found
in this wall are the uncinate process, the ethmoid bulla and the ostia of the
ethmoid and maxillary sinuses. The main ostium of the maxillary sinus is very
close to the roof of the sinus, as seen from a lateral aspect. Hence great care has
to be taken in performing a maxillary sinus antrostomy in order to avoid damage
to the roof of the sinus and possible penetration through the orbital floor into
the orbit. The ostium continues as a small canal only a few millimetres long with

78
 MAXILLARY SINUS

1 2 3

Figure 5.8 Endoscopic view into the right middle meatus. 1, accessory maxillary ostium;
2, posterior fontanelle; 3, right middle turbinate

an inferosuperior and posteroanterior course, to open in the hiatus semilunaris.

The ostium may be found at any point along the course of the ethmoid
infundibulum. In one study, the ostium was identified in the anterior third of the
ethmoid infundibulum in 5.5%, in the middle third in 11% and in the posterior
third in 72% of specimens.1 The ostium varies widely in size and shape. The
mean functional size of the primary maxillary ostium is 2.4 mm. The primary
maxillary sinus ostium may rarely be duplicated.
The primary maxillary sinus ostium is distinct from and should not be confused
with the accessory ostia that are commonly found within the membranous
fontanelle of the lateral nasal wall. There may be between one and three of these

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THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9

Figure 5.9 Coronal CT scan at the level of the anterior ethmoid. 1, right infraorbital
canal; 2, right maxillary antrum; 3, right lamina papyracea; 4, terminal recess; 5, right
inferior turbinate; 6, nasal septum; 7, left middle turbinate; 8, left uncinate process; 9,
left optic nerve

accessory ostia and they are found in 18–45% of cadaver specimens. They range
in size from less than 1 mm diameter to as large as 10.5 mm × 6.5 mm.
The accessory ostia develop after infancy, as they have rarely been described in
infants or in prenatal studies. There is speculation that the secondary ostia may
develop as a result of a pathological process. The primary and accessory ostia may
combine without a separating membranous bridge. Such a union leads to the
formation of an exceptionally large ostium within the ethmoid infundibulum.

ANTERIOR WALL

The anterior wall of the maxilla faces anterolaterally and extends from the
piriform aperture of the nasal cavity medially to the maxillozygomatic suture

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 MAXILLARY SINUS

1 2 3 4 5 6 7 8 9

Figure 5.10 Coronal section through the maxillary sinuses at the level of the posterior
ethmoid. 1, right optic nerve; 2, right inferior rectus; 3, right inferior turbinate; 4, right
middle turbinate; 5, right superior turbinate; 6, left posterior ethmoid sinus; 7, left
ethmoid bulla; 8, left medial rectus; 9, left maxillary antrum

laterally, and from the infraorbital rim superiorly to the alveolus inferiorly. The
thickness of the bone of the anterior wall ranges from 2 mm to 5 mm, with the
bone being thickest at its margins. Inferiorly, the anterior surface has raised areas
where the dental roots bulge into the bone of the inferior part of the anterior
wall. The canine fossa lies above the canine tooth and here the bone is thickest.
The bone over the canine tooth is known as the canine eminence. Medial to this
is a more shallow depression lying above the incisor teeth, known as the incisive
fossa. The infraorbital foramen lies above this area on the anterior wall of the
maxilla. It lies 1 cm below the infraorbital rim, the sharp border between the
anterior and the orbital surfaces, and approximately 1.5 cm above the first and

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THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 5.11 Sagittal section through the left maxillary antrum. 1, orbital fat; 2, natural
maxillary ostium; 3, globe of orbit (bulbus oculi); 4, left maxillary antrum; 5, left maxil-
lary artery; 6, orbital apex

second premolars. This foramen transmits the infraorbital vessels and nerve. The
bone surrounding this foramen is quite thick.

POSTEROLATERAL WALL

The posterolateral or infratemporal surface of the maxilla is convex and forms the
anterior wall of the infratemporal fossa. The zygomatic bone and the greater wing
of the sphenoid bone form the lateral and posterior walls of the maxillary sinus.
The posterior wall is often thin medially but is much thicker laterally. Superiorly,
the medial posterior wall is attached to the pterygoid plates. The posterior ethmoid

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 MAXILLARY SINUS

1 2 3 4 5 6 7

Figure 5.12 Sagittal section through the left maxillary antrum at the level of the lamina
papyracea. 1, lamina papyracea; 2, left frontal sinus; 3, left maxillary antrum; 4, supra-
orbital ethmoid cell; 5, left posterior ethmoid cell; 6, orbital apex; 7, left internal carotid
artery

sinuses are closely related to the posterior–superior and medial aspect of the
maxilla. Depending on the size of the maxillary sinus, the posterior wall may be
immediately adjacent to the sphenoid sinus. The optic canal lies approximately
1 cm above the posterior maxillary wall. The internal maxillary artery runs behind
the posterior wall of the maxillary sinus at the level of its floor within the ptery-
gopalatine fossa. This close association has allowed a transmaxillary approach to
this artery during ligation for epistaxis. The maxillary nerve also passes through
this fossa, where it grooves the bone as it travels laterally and slightly upwards
into the infraorbital groove on the orbital surface. The maxillary tuberosity lies
below this area. In the central area of the posterior wall are apertures of two or

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THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 5.13 Sagittal section through the left maxillary antrum at the level of the
ethmoid sinuses. 1, left inferior turbinate; 2, lamina papyracea; 3, left ethmoid bulla; 4,
left maxillary antrum; 5, left posterior ethmoid cells; 6, sphenoid sinus

three alveolar canals that transmit the posterior superior alveolar vessels and nerves
to the molar teeth. These vessels travel inferiorly, where they join the superior
dental plexus. Ridges may be present on the sinus wall overlying these canals. The
lateral wall is curved and concave and forms the largest projection of the sinus,
termed the zygomatic or pyramidal expansion. Middle superior alveolar vessels and
nerves pass along the lateral wall, reaching the superior dental plexus.

SUPERIOR WALL

The superior wall of the maxillary sinus forms the majority of the floor of the
orbit. It is triangular in shape and extends postero–laterally to the infraorbital

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 MAXILLARY SINUS

1 2 3 4 5 6 7 8 9

Figure 5.14 Axial section through the maxillary sinuses at the level of the nasal floor.
1, right temporalis muscle; 2, right lateral pterygoid muscle; 3, right maxillary antrum;
4, right medial pterygoid muscle; 5, right nasal floor; 6, nasal septum; 7, left maxillary
antrum; 8, fat pad; 9, left masseter muscle

fissure. Anteriorly on its medial border is the lacrimal notch, in which lies the
lacrimal apparatus. Posterior to the notch, the bone fuses with the lacrimal bone,
the orbital plate of the ethmoid bone and the orbital process of the palatine bone
posteriorly. Its posterior border forms the anterior margin of the inferior orbital
fissure, with the inferior orbital groove in the centre. The anterior border forms
part of the orbital rim and blends medially with the lacrimal crest of the frontal
process of the maxilla. The orbital floor contains the infraorbital canal transmit-
ting the infraorbital vessels. This canal often forms a groove that indents the roof
of the maxillary sinus. The bone covering the canal is sometimes dehiscent, with
the nerve and vessels hanging within the sinus. The canal extends anteriorly to
the infraorbital foramen. At the midpoint of the canal as it runs anteriorly, a

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1 2 3 4 5 6 7

Figure 5.15 Coronal CT scan showing bilateral infraorbital ethmoid (Haller) cells in a
patient with bilateral maxillary sinusitis. 1, right maxillary sinus; 2, right infraorbital
ethmoid cell; 3, right ethmoid infundibulum; 4, terminal recess; 5, ethmoid bulla; 6, left
infraorbital ethmoid cell; 7, left maxillary sinus

small lateral branch, the anterior superior alveolar nerve and vessels, are given
off. These pass inferiorly and then medially to reach the lateral margin of the
piriform aperture. Here the vessels turn inferiorly to supply the anterior teeth
and periodontium. As these vessels cross inferomedially along the anterior wall
of the maxillary sinus, they could potentially be damaged in the course of trans-
maxillary surgical procedures. The bone of the orbital floor is thinnest on either
side of the infraorbital canal.

INFERIOR WALL
The inferior surface or floor of the sinus is formed by the alveolar process of the
maxilla, and it may be above, at the level of or below the floor of the nasal cavity,

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 MAXILLARY SINUS

1 2 3 4 5 6 7

Figure 5.16 Axial section through the right maxillary antrum at the level of the
infratemporal fossa. 1, masseter muscle; 2, lateral pterygoid muscle; 3, right maxillary
artery; 4, temporalis muscle; 5, fat pad; 6, right maxillary antrum; 7, right inferior
turbinate

depending on such factors as race, sex, age or function. In adults, the antral floor
is more inferiorly located in 65%, lies in the same plane in 15% and is superior
in 20%. In the majority of adults, the sinus floor lies approximately 1.25 cm
below the floor of the nasal cavity. In children, however, the sinus floor is at a
higher level. Van Alyea studied the position of the floor by age and found that
the sinus floor was approximately 4 mm above the nasal floor in early infancy, at
the same level by age 8 or 9 years, and 4–5 mm below it in early adulthood.
The alveolus in the newborn is less than 1 cm from the infraorbital rim. The
lateral growth of the maxillary sinus extends above the first molar tooth bud
from the age of 11⁄2 years onwards. By the age of 3 years, the maxillary sinus has

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THE PARANASAL SINUSES

become pneumatised in the region near the infraorbital canal. The relationship
of the floor of the maxillary sinus and the teeth depends on the degree of
pneumatisation of the sinus. The contour of the sinus usually follows the roots
of the second premolar and the first and second molar teeth. The canine and first
premolar may project into the cavity of a large maxillary sinus. The thickness of
the bone over these roots is variable and may even be dehiscent. Bony septa often
arise from the sinus floor between adjacent dental roots.

ANATOMICAL VARIATION

The maxillary sinus may be partially or completely divided and have other verti-
cal, oblique or horizontal bony or membranous septa. Karmody et al5 studied
septation of the maxillary sinus and showed that the most common oblique
septum is located in the superior–anterior–medial corner of the sinus, which is
also referred to as the infraorbital recess. This recess may expand anteriorly to
the nasolacrimal duct. It is relatively common for the maxillary sinus to extend
into the alveolar process of the maxilla, and it may also less frequently expand
into the zygomatic, frontal and palatine processes.
The most common anatomical variation in the maxillary sinus region is the
presence of infraorbital ethmoid or Haller cells. These are ethmoid cells that
pneumatise into the floor of the orbit and roof of the maxillary sinus, inferior
and lateral to the ethmoid bulla. The origin of Haller cells is from the anterior
ethmoid in 88% and the posterior ethmoid in 12%.2 Various terms have been
used previously to refer to Haller cells, including maxillo-orbital cells, maxillo-
ethmoid cells and orbitoethmoid cells. Current nomenclature suggests that Haller
cells should be referred to as infraorbital ethmoid cells.3 This term describes the
location of the cells and their origin from the ethmoid. It also distinguishes them
from supraorbital cells arising from the frontal recess or suprabullar recess.
Other variations of the maxillary sinus include a true duplication of the sinus,
which, although reported, is rare. Failure of the maxillary sinus to develop may
occur alone or in association with other anomalies such as choanal atresia, cleft
palate and mandibulofacial dysostosis. Maxillary sinus hypoplasia is reported in
3–10% of patients. The sinus is smaller and the surrounding bone is thicker.
Total aplasia of the maxillary sinus is seen in less than 0.5% of individuals.
Maxillary sinus hypoplasia and aplasia are often associated with abnormalities of
the uncinate process and ethmoid infundibulum. The uncinate process is
hypoplastic and lies against the inferomedial orbit – hence the infundibulum is
also atelectatic.4 The posterior fontanelle of the lateral nasal wall is retracted later-
ally into the maxillary sinus.

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 MAXILLARY SINUS

REFERENCES.

1. Van Alyea OE. The ostium maxillare: anatomic study of its surgical accessibility.
Arch Otolaryngol Head Neck Surg 1936; 24: 552–69
2. Kainz J, Braun H, Genser P. Haller’s cells: morphologic evaluation and clinico-surgi-
cal relevance. Laryngorhinootologie 1993; 72: 599–604
3. Stammberger H, Kennedy D. Paranasal sinuses: anatomic terminology and nomen-
clature. The Anatomic Terminology Group. Ann Otol Rhinol Laryngol 1995;
104(Suppl 167): 7–16
4. Bolger WE, Woodruff WW, Morehead J, Parsons DS. Maxillary sinus hypoplasia:
classification and description of associated uncinate hypoplasia. Otolaryngol Head
Neck Surg 1990; 103: 759–65
5. Karmody CS, Carter B, Vincent ME. Developmental anatomy of the maxillary sinus.
Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1997; 84: 723–80

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6. POSTERIOR ETHMOID AND SPHENOID
SINUSES
DAVID GATLAND, DUNCAN MCRAE
• POSTERIOR ETHMOID SINUSES
Anatomical relations
• SPHENOID SINUS

POSTERIOR ETHMOID SINUSES

The ethmoid (Greek ethmos: sieve) sinuses develop as a number of mucosal clefts
within rudimentary unossified ethmoid cartilage. The most posterior bud within
the cartilage is present at 8 weeks in utero. This posterior bud may sprout several
more buds forming the posterior ethmoid cells. Ossification begins in the eighth
month in utero. The ethmoid air cells continue to expand and pneumatise,
causing the cell walls to progressively thin. By the third year of life, the ethmoid
air cells are already well developed, but the process of air cell expansion and cell
wall thinning continues until the mid-teenage years.
The ethmoid bone comprises a horizontal and vertical bony plate from which
the anterior and posterior ethmoid air cells, the middle turbinate, the superior
turbinate and (if present) the supreme turbinate on each side are suspended. The
vertical plate is the ethmoid portion of the bony nasal septum, and at right-
angles to this superiorly is the horizontal plate comprising the cribriform plate
(lamina cribrosa). Projecting superiorly from the cribriform plate in the midline
is a spur of bone, the crista galli, a superior extension of the vertical plate. The
olfactory fossa lies just lateral to the crista galli on each side. It is limited later-
ally by a further superior bony projection from the cribriform plate, namely the
lateral lamella of the cribriform plate. The olfactory fossa regresses posteriorly as
the roof flattens and thickens over the ethmoid in front of the sphenoid.
Suspended inferiorly from the lateral lamina of the cribriform plate is the
vertical attachment of the anterior one-third of the middle turbinate. This
attachment of the middle turbinate then turns laterally to reach the lamina
papyracea. Just posterior to where the vertical attachment of the middle
turbinate ends, the superior turbinate is suspended from the lateral lamella of
the cribriform plate. Where a supreme turbinate is present, it is attached to the
lateral lamella of the cribriform plate just posterior to where the attachment of
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9

Figure 6.1 Right-side sagittal section from the left. 1, right middle turbinate; 2, right
posterior ethmoid cells; 3, right sphenoid sinus; 4, septum of sphenoid; 5, right optic
nerve; 6, diaphragma sellae; 7, optic chiasma; 8, right oculomotor nerve; 9, basilar artery

the superior turbinate ends, being merely a ridge separated from the superior
turbinate by a shallow gutter. The superior and supreme turbinates are sagitally
orientated and lie in the same plane directly behind the middle turbinate. Their
basal lamellae, numbered four and five, are orientated and attached in a similar
manner to the basal (ground) lamella of the middle turbinate, which is
numbered the third (the first and second are those of the uncinate process and
bulla ethmoidalis, dealt with in Chapter 5). Their lamellae do not, however,
consistently reach the lamina papyracea. The superior and supreme nasal meati
are the spaces between the turbinates and the lateral surface of the posterior
ethmoid complex, whose ostia drain into these meati. The posterior ethmoid

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4 5 6 7 8

Figure 6.2 Left lateral wall of the nose. 1, body of sphenoid; 2, hypophysis cerebri; 3,
optic chiasma; 4, left sphenoid sinus; 5, left superior turbinate; 6, left middle turbinate;
7, cribriform plate; 8, left inferior turbinate

cells are not individually named in the same way as some of the anterior ethmoid
complex cells.
When entering the posterior ethmoid through a surgical perforation of the
coronal part of the middle turbinate basal lamella, the posterior ethmoid basal
lamellae are encountered and extend to the skull base and lamina papyracea in
a variable way. On reaching the lamina papyracea, the attachment of the basal
lamella of the middle third of the middle turbinate turns to run in a postero-
inferior direction across the lamina papyracea. This attachment of the middle
third of the middle turbinate creates a near-vertical face of basal lamella in the
coronal plane. This face may be indented by anterior ethmoid air cells in a

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THE PARANASAL SINUSES

1 2 3 4 56 7 8 9 10 11 12

Figure 6.3 Right-side sagittal section from the left. 1, right middle turbinate; 2, right
inferior tubinate; 3, right superior turbinate; 4, right supreme turbinate; 5, right sphenoid
sinus; 6, cut edge of sphenoid septum; 7, right cavernous sinus; 8, stalk of hypophysis
cerebri; 9, optic chiasma; 10, right oculomotor nerve; 11, clivus; 12, basilar artery

posterior direction or indented by posterior ethmoid air cells pushed anteriorly.

Should this indentation be extensive, it may create a vertical face that is
extremely difficult to locate. The meatus into which a cell in this vicinity drains
is sometimes the only way of determining whether it is an anterior or posterior
ethmoid cell. If such a situation is encountered during endoscopic sinus surgery,
it is particularly important that the surgeon, in dissecting through the ethmoids,
keeps as medial and inferior as possible until an anatomical landmark is identi-
fied. This is in order to avoid breaching the lamina papyracea, which would
cause an orbital injury, or the anterior skull base, which would cause
cerebrospinal fluid rhinorrhoea. The first identifiable landmark in such patients

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4

Figure 6.4 Endoscopic view of the left ethmoid following removal of the uncinate
process and the bulla ethmoidalis (basal lamella). 1, nasal septum; 2, left middle
turbinate; 3, left frontal recess; 4, basal lamella of left middle turbinate

is often the vertical face of the sphenoid sinus, from where the roof can be identi-
fied and followed forward.
In the posterior third of its insertion, the basal lamella of the middle turbinate
turns sharply to run in a horizontal plane, reaching the crista ethmoidalis of the
perpendicular plate of the palatine bone. This creates a horizontal orientation of
the basal lamella of the middle turbinate in the axial plane. The horizontal part
forms the roof of the middle meatus, which runs below the floor of the posterior

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THE PARANASAL SINUSES

1 2 3 4 56 7 8 9 10 11 12 13

Figure 6.5 Left-side sagittal section from the left. 1, left inferior turbinate; 2, left agger
cell; 3, left middle turbinate; 4, left bulla ethmoidalis; 5, left middle meatus; 6, left lateral
sinus; 7, cut edge of middle turbinate basal lamella; 8, cut edge of second part of middle
turbinate basal lamella; 9, nasal septum; 10, left sphenoid sinus ostium; 11, left optic
nerve; 12, lumen of left internal carotid artery; 13, left oculomotor nerve

ethmoid sinuses. The horizontal portion of the basal lamella forms a bridge
between the middle turbinate and the lamina papyracea, which stabilises the
middle turbinate should the ethmoid be otherwise exenterated during sinus
surgery. For this reason, this part of the basal lamella should be preserved during
surgery if possible. Behind and above the coronal and horizontal sections of the
basal lamella of the middle turbinate is the posterior ethmoid sinus. It can there-
fore be seen that to enter the posterior ethmoid sinus from the anterior ethmoid
sinus, one must push through the vertical face of the basal lamella of the middle
turbinate. Of note is that the free vertical medial edge of the middle turbinate
tapers as it runs posteriorly in the sagittal plane.

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4 5 6

Figure 6.6 Right-side sagittal section from the left. 1, sectioned right middle turbinate
and second part of basal lamell; 2, right posterior ethmoid cell ostium; 3, right poste-
rior ethmoid cells; 4, bulge of right pterygoid canal; 5, right sphenoid sinus; 6, bulge of
right maxillary nerve

In summary, the first and third parts of the basal lamella of the middle
turbinate are smooth and regular, while the middle third is indented and not
always easy to identify during surgery. The posterior wall of the bulla ethmoidalis
may be fused with the middle third (vertical face) of the basal lamella, obliter-
ating the lateral sinus at the point of contact (the lateral sinus may still be present
here, but above the point of contact). If such anatomy is encountered during
endoscopic sinus surgery then, when pushing through the posterior wall of the
bulla in order to gain entry to the lateral sinus, the instrument may immediately
enter the posterior ethmoid sinus. This is of no significance provided the surgeon
recognises that such an event has occurred. Because this anatomy may be

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THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9 10

Figure 6.7 Axial section through the sphenoid rostrum. 1, left middle turbinate; 2, left
uncinate process; 3, first part of the left middle turbinate basal lamella; 4, second part
of the left middle turbinate basal lamella; 5, left antral cavity; 6, left superior meatus;
7, left superior turbinate; 8, rostrum of sphenoid; 9, septum of sphenoid; 10, left inter-
nal carotid artery

encountered, it is important that when removing the posterior wall of the bulla
ethmoidalis, an instrument is placed behind the bulla (e.g. posterior blade of a
thru-cutting forceps or a curette). If an instrument cannot get behind the poste-
rior wall then the surgeon should be aware that the bulla may have fused to the
ground lamella, and therefore the bulla should be perforated in its most infero-
medial aspect. It is for the same reason that the vertical face of the ground lamella
is perforated inferomedially, namely to avoid injury to the lamina papyracea and
the anterior skull base.
The anterior and posterior ethmoid air cells are found lateral to the lateral
lamella of the cribriform plate and are open cranially as well as posteriorly. They

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4 5 6 7 8 9 10

Figure 6.8 Right-side sagittal section from the left. 1, sectioned right middle turbinate
basal lamella; 2, second part of right basal lamella middle turbinate; 3, right posterior
ethmoid cell ostium; 4, right posterior ethmoid cells; 5, right sphenoid sinus; 6, right
optic nerve; 7, right internal carotid artery; 8, diaphragma sellae; 9, right oculomotor
nerve; 10, basilar artery

are closed superiorly by the foveolae ethmoidalis of the frontal bone and poste-
riorly by the anterior wall of the sphenoid sinus. The frontal bone of the skull
base is up to ten times thicker than the lateral lamella of the cribriform plate
and is proportionately more resilient to perforation from instrumentation. This
may not be the case, however, where disease such as sinonasal polyposis has
thinned the bone. The bone of the lateral lamella is weakest where it is perfo-
rated by the ethmoid arteries. The dissecting instrument should therefore be
angulated laterally when in the roof to avoid perforating the lateral lamella. The
dura is tightly bound to the lateral lamella and the chance of a cerebrospinal
fluid leak is high should the lateral lamella be perforated.

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THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9 1011 12 13 14

Figure 6.9 Left-side sagittal section from the left. 1, left middle turbinate; 2, left
anterior ethmoid cell; 3, cribriform plate; 4, left posterior ethmoid cell; 5, septum of
sphenoid; 6, left sphenoid sinus; 7, left middle clinoid process adjoining tuberculum
sellae; 8, left optic nerve; 9, hypophysis cerebri; 10, right cavernous sinus, looking at
medial aspect; 11, stalk of hypophysis cerebri; 12, left posterior clinoid process; 13, basilar
artery; 14, left oculomotor nerve

The length of the posterior ethmoid sinuses is the distance between the basal
lamella of the middle turbinate and the posterior wall of the most posterior
ethmoid air cell. There are no data in the literature regarding these two measure-
ments, but there is a wide variation in the size of the posterior ethmoid sinuses.
This is because the anterior extent of the posterior ethmoid sinus depends on
whether there is an anterior or a posterior bulge of the basal lamella, and the
posterior extent depends on whether there is an Onodi cell within the posterior
ethmoid sinus. If it becomes necessary to assess position within the ethmoid sinuses

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4

Figure 6.10 Endoscopic view showing the left posterior ethmoid after perforation of the
basal lamella. 1, left middle turbinate; 2, basal lamella of left middle turbinate; 3, left
posterior ethmoid cell; 4, left lamina papyracea

during surgery, it is best to use the anterior face of the sphenoid as a landmark.
This is achieved by passing an endoscope medial to the middle turbinate. Once
the anterior face of the sphenoid has been reached, the distance to the columella
is measured. This distance has a mean of 7.5 cm with a range of 7.0–8.4 cm in
adults. The distance from the columella to the tip of the instrument within the

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THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 6.11 Coronal section through the posterior ethmoids (this is the same section as
the CT scan in Figure 6.12). 1, right posterior ethmoid cell; 2, right olfactory nerve; 3,
right pneumatised superior tubinate; 4, right sphenoethmoid recess; 5, left cribriform
plate; 6, left superior meatus/skull base

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 234 5 6 7

Figure 6.12 Coronal CT scan through the posterior ethmoids. 1, right posterior ethmoid
cells; 2, right middle turbinate; 3, right superior meatus; 4, pneumatised right superior
turbinate; 5, septal spur; 6, left inferior turbinate; 7, left optic nerve

ethmoid sinus is then measured, allowing the depth within the ethmoid sinus to
be assessed relative to the anterior face of the sphenoid.
The lamina papyracea is the lateral boundary of the posterior ethmoid sinus.
It usually becomes more lateral and thinner as it extends posteriorly. This
thinning as one passes from the anterior to the posterior ethmoid sinus is such
that at times the yellow orbital fat can be seen through the thin lamina
papyracea. The incidence of actual dehiscence in the orbital plate of the ethmoid
bone increases with age. The bone here is easily perforated, with a risk of injury
to the medial rectus muscle, or more posteriorly, the optic nerve. This risk is
greatest if the posterior ethmoid cells extend posterolaterally or posterosuperiorly
beyond the anterior face of the sphenoid sinus. Such sphenoethmoid posterior

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THE PARANASAL SINUSES

ethmoid cells are named Onodi cells after the Director of the Rhinolaryngology
Clinic in the University of Budapest, Hungary in the late 19th century, who
initially described them. Onodi cells are present in about 40% of the Western
population and 60% of South East Asians, and may extend up to 1.5 cm beyond
the anterior face of the sphenoid sinus. In such cases, the anterior clinoid process
can pneumatise from this cell. The term ‘Onodi cell’, however, has also been used
for posterior ethmoid cells in general. During endoscopic surgery, should the
lamina papyracea be inadvertently followed posteriorly in the presence of an
Onodi cell, the optic nerve and occasionally the internal carotid artery may be
encountered, with the risk of injury and catastrophic consequences. The relations
of these structures within an Onodi cell that has extended 1.5 cm posterolater-
ally beyond the anterior face of the sphenoid will be exactly the relations of the
lateral wall of the sphenoid sinus when an extensive Onodi cell is absent. The
optic nerve as it runs in a posteromedial direction will form a superior indenta-
tion on the lateral wall of the Onodi cell. Below this, there may be an indenta-
tion from the internal carotid artery as it runs superiorly and then turns
posteriorly. The optic nerve can still be prominent and subject to injury even
when the posterior cell is not sphenoethmoid in type. When surgically identify-
ing the sphenoid sinus, it is therefore safest to find the sphenoid ostium in the
sphenoethmoid recess and open that laterally rather than following the posterior
ethmoid into the sphenoid sinus. Approaching the sphenoid through the poste-
rior ethmoid sinus, it is essential to angle instruments medially and inferiorly
towards the sphenoid sinus away from the optic nerve. The medial bulge of the
optic nerve canal at the optic foramen is called the optic nerve tubercle and can
be seen in the posterior ethmoid or sphenoid according to the arrangement of
the cells and the degree of pneumatisation. To summarise, the boundaries of the
posterior ethmoid are anteriorly the basal lamella of the middle turbinate, later-
ally the lamina papyracea, medially the superior meatus, inferiorly the horizon-
tal lamella of the middle turbinate and superiorly the open posterior ethmoid air
cells roofed in by the foveolae ethmoidalis of the frontal bone. The posterior
ethmoid cells form the medial roof of the maxillary antrum.
Pneumatisation and septation of the posterior ethmoid sinuses is variable, with
one to four cells each side. The number of cells depends on the degree to which
the basal lamellae of the superior and (if present) the supreme turbinate extend to
the lamina papyracea, together with any further septation. Most commonly, three
cells are present, the ostia draining into the superior meatus. A supreme turbinate
is present in about one-third of cases, and the supreme meatus (if present) is usually
pneumatised backwards into supreme ethmoid cells. Posterior ethmoid cells are
generally larger than anterior cells, reflecting the truncated pyramidal shape of the
ethmoid complex and the lesser degree of septation of the posterior cells.
The surgical approach to the posterior ethmoids should avoid injury to the
lamina papyracea and the anterior skull base. Therefore, during the Messerklinger

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1 2 3 4 5 6 7 8 9

Figure 6.13 Coronal section through the posterior ethmoids (this is the same section as
the CT scan in Figure 6.14). 1, right medial rectus muscle; 2, right lamina papyracea;
3, right inferior turbinate; 4, right middle turbinate; 5, right superior turbinate; 6, left
face of sphenoid (sphenoid concha); 7, choana; 8, left posterior ethmoid cells; 9, left optic
nerve

approach, it is important that the tip of the instrument used to perforate the
basal lamella be angled inferomedially as it perforates the inferomedial aspect of
the coronal portion of the basal lamella. Once within the posterior ethmoid,
dissection should continue in this way until the anterior face of the sphenoid is
reached. Alternatively, the posterior ethmoid sinus can be opened directly lateral
to the landmark of the superior turbinate.
In a well-developed posterior ethmoid air cell system, the root of the ptery-
goid process may be pneumatised. In such cases, there may be extensive supra-
orbital pneumatisation of the posterior ethmoid air cells. The nerve of the

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1 2 3 4

Figure 6.14 Coronal CT scan through the posterior ethmoids. 1, right optic nerve; 2,
right posterior ethmoid cells; 3, right superior turbinate; 4, skull base: frontal bone

pterygoid canal (Vidian nerve), as it runs forward and laterally in the pterygoid
bone in close proximity to the floor of the sphenoid sinus, may also become
surrounded by a posterior ethmoid cell. Similarly, the maxillary nerve in the
foramen rotundum, as it passes forward in close proximity to the lateral wall of
the sphenoid sinus and then anterolaterally to gain the pterygopalatine fossa, may
come into contact with well-pneumatized posterior ethmoid air cells. The roof of
the posterior ethmoid is formed by the foveolae ethmoidalis of the frontal bone,
which is crossed obliquely by the posterior ethmoid vessels and nerve in their
bony canal. At this point, 25% of specimens show rarefaction of the bone of the
adjacent roof and 14% show actual bony defects. The posteror ethmoid artery is

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1 2 3 4 5 6

Figure 6.15 Coronal section through the posterior ethmoids. 1, medial rectus muscle;
2, roof of antrum; 3, right posterior ethmoid cells; 4, right superior meatus; 5, skull base;
6, left optic nerve

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1 2 3 4 5 6

Figure 6.16 Right sagittal section from the left. 1, right posterior ethmoid cells; 2, right
optic nerve; 3, right sphenoid sinus; 4, right internal carotid artery; 5, right oculomotor
nerve; 6, right maxillary nerve

a branch of the ophthalmic artery, and perforates the lamina papyracea to cross
the roof of the posterior ethmoid, usually in a bony canal. The canal is shorter
than the anterior ethmoid canal, with a mean length of 3.5 mm. The artery is
less likely to have a recognisable ‘mesentery’ than the anterior ethmoid artery.
The orbital aperture of the posterior ethmoid canal is not less than 2 mm from
the orbital aperture of the optic nerve. This is an important point when ligating
this artery via an external approach.
The height of the ethmoid labyrinth is less in the posterior ethmoid sinus than
in the anterior. The average height here is 3.2 mm (range 0–10.1 mm), compared
with 4.8 mm in the anterior ethmoid sinus (range 0.6–11.7 mm).

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1 2 3 4 5 6 7 8 9

Figure 6.17 Axial section just below the cribriform plate. 1, first part of left middle
turbinate basal lamella; 2, nasal septum; 3, left bulla ethmoidalis; 4, left lateral sinus; 5,
second part of left middle turbinate basal lamella; 6, left posterior ethmoid cells; 7, optic
nerves; 8, sphenoid sinus septum; 9, internal carotid arteries

Anatomical relations

Laterally, the posterior ethmoid cells are in direct contact with the optic nerve
in 12% of cases, and in half of these the cells envelop the nerve. The optic
nerve passes from the back of the globe posteromedially. This means that the
nerve becomes closer to the bony lateral wall of the posterior ethmoid sinus
(the lamina papyracea) as it becomes more posterior. The average distance from
the optic nerve to the lamina papyracea of the posterior ethmoid is 2.4 mm
anteriorly and just 1.4 mm at the most posterior extent of the posterior
ethmoid.
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THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 6.18 Right-side sagittal section from the left. 1, right posterior ethmoid cells; 2,
bulge of pterygoid canal; 3, bulge of right maxillary nerve; 4, carotid bulge in sphenoid
sinus; 5, right optic nerve; 6, right internal carotid artery; 7, right oculomotor nerve

Laterally, the posterior ethmoid is also related to the ocular muscles: the medial
rectus muscle is the most commonly injured muscle, but the superior oblique
muscle is also related, although there are no reports of injury to this muscle. It
is also possible to injure the inferior ramus of the oculomotor nerve.

SPHENOID SINUS

This sinus was first described by John Riolanus, in an English translation of his
book by Nicholas Culpeper in 1657, according to TB Layton in the Preface to

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1 2 3

Figure 6.19 Endoscopic view into a well-pneumatised right sphenoid sinus. 1, right
optic nerve; 2, carotico-optic recess; 3, bulge of right internal carotid artery

the Catalogue of the Onodi Collection in the Museum of the Royal College of
Surgeons of England.
The sphenoid is a complex bone comprising the body and the greater and lesser
wings together with the pterygoid process, from which project the medial and
lateral pterygoid plates. Ossification is complex because the floors of the middle
and posterior cranial fossae ossify in cartilage while bone above and below this
floor ossify in membrane. Therefore the body, lesser wing and base of the greater
wing ossify in cartilage while the remainder of the greater wing, pterygoid process
and pterygoid plates ossify in membrane. Ossification begins in the third month
in utero.

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THE PARANASAL SINUSES

1 2 3 4 5 6

Figure 6.20 Left-side sagittal section from the left. 1, left posterior ethmoid cell; 2, left
sphenoid sinus; 3, left optic nerve; 4, lumen and vessel of left internal carotid artery; 5,
left foramen rotundum; 5, left maxillary nerve

The sphenoid body forms the roof of the choanae of the nose and nasophar-
ynx. Anteriorly, the wall of the sphenoid sinus closes the posterior ethmoid sinus
and more medially abuts the sphenoethmoid recess. Laterally, the body of the
sphenoid is related to the cavernous sinus (and its contents), the internal carotid
artery and the middle cranial fossa. Superiorly, each optic nerve enters its canal
in the anterior clinoid process from the optic chiasma. The sella turcica bulges
into the roof, the thickness of the bone depending on the degree of pneumatisa-
tion.
The sphenoid bone starts to pneumatise from the sphenoethmoid recess from
birth. The extent of pneumatisation is very variable, so that the sphenoid sinuses

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 23 4 5 6 7 8 910

Figure 6.21 CT scan of the sphenoid: extensive sphenoid pneumatisation. 1, right lateral
pterygoid plate; 2, right maxillary nerve; 3, partially pneumatised right pterygoid process;
4, right internal carotid artery; 5, asymmetric sphenoid septum; 6, septation of left
sphenoid sinus; 7, left optic nerve; 8, left pterygoid canal; 9, left medial pterygoid plate;
10, left anterior clinoid process

may be small and thick-walled or large with extensive pneumatisation.

Pneumatisation may include the anterior clinoid process, when a carotico-optic
recess is seen between the optic nerve and the internal carotid artery. The relation-
ship between these structures and the sinus is variable, as is the degree to which
the internal carotid artery is tortuous. The artery tends to be more tortuous with
increasing age. From the foramen lacerum, the internal carotid artery ascends to
enter the posterior part of the cavernous sinus. The artery then runs upwards and
forwards anterior to the posterior clinoid process, grooving the sphenoid bone
(the carotid groove). The groove extends vertically upwards medial to the anterior
clinoid process before usually looping backwards and upwards at the carotid genu

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THE PARANASAL SINUSES

1 2 3 4 5

Figure 6.22 Coronal section through the posterior ethmoids. 1, right optic nerve; 2,
pneumatised sphenoid rostrum; 3, ostia of the sphenoid sinuses in the sphenoethmoid
recesses; 4, left sphenoid sinus; 5, left optic nerve

to its terminal divisions, namely the anterior and middle cerebral arteries.
Sometimes, in younger patients, the artery may bend forward or be relatively
straight. These bends can often be seen with the endoscope on the lateral wall
of the sphenoid bone and importantly but rarely on the lateral wall of the poste-
rior ethmoid sinus. The bony covering may be very thin or even dehiscent where
the sphenoid is well pneumatised. The bone covering the optic nerve may also
be extremely thin, and more rarely may show areas of complete bony dehiscence.
The maxillary nerve is related to the lateral wall of the sphenoid sinus as it
passes forward from the trigeminal ganglion in the lateral wall of the cavernous
sinus, below the ophthalmic division, to reach the foramen rotundum in the

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 POSTERIOR ETHMOID AND SPHENOID SINUSES

1 2 3 4 5 6 7 8

Figure 6.23 Coronal section through the sphenoid sinuses. This is the same section as
the CT scan in Figure 6.24. Note that this section is anterior to the bulge of the inter-
nal carotid artery. 1, right maxillary nerve; 2, right carotid bulge; 3, right Eustachian
cushion; 4, subseptation right-side sphenoid; 5, intersinus septum; 6, pneumatisation
towards basisphenoid; 7, left Vidian nerve in pterygoid canal; 8, left optic nerve

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THE PARANASAL SINUSES

1 2 3 4 5 6 7 8

Figure 6.24 Coronal CT scan through the sphenoid, a few millimetres posterior to the
coronal section in Figure 6.23. 1, right anterior clinoid process; 2, right maxillary nerve;
3, pterygoid process; 4, right pterygoid canal containing the Vidian nerve; 5, vomer; 6,
intersinus septum; 7, left optic nerve; 8, left internal carotid artery before it turns poste-
riorly

greater wing, where it exits to gain the pterygopalatine fossa. Its canal can be
seeen on CT imaging. Likewise, the pterygoid canal containing the Vidian nerve
(nerve of the pterygoid canal) projecting anteriorly from the foramen lacerum can
be seen on CT scans in the floor of the sphenoid sinus. The pterygoid canal lies
within the pterygoid process of the sphenoid bone.
Extension of pneumatisation into the floor envelops the pterygoid canal and
more inferolaterally the pterygoid plates, possibly as far as the Eustachian tube.
Pneumatisation of the pterygoid process may extend to the posterior wall of the
maxillary antrum. Lateral extension into the greater wing passes under the
cavernous sinuses to envelop the foramen rotundum or further even to the foram-

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ina ovale and lacerum. Anteroinferiorly, the rostrum may pneumatise into the
nasal septum, while posteriorly the sinus may pneumatise the posterior clinoid
process. Rarely, this pneumatisation may extend to the clivus to approach the
basilar surface of the occipital bone as far as the foramen magnum, possibly
exposing the cavernous sinus and the meninges. This variable degree of pneuma-
tisation led to the description of three types of sphenoid sinus: the conchal, the
presaddle and the saddle type, the latter being a descriptive term for the appear-
ance of the sella turcica with increasing pneumatisation. Alternatively, the terms
‘presellar’ and ‘sellar’ may be used, depending on whether the the sinus extends
to the tuberculum sellae or beyond (Latin sella: a seat or saddle).
The site of the sphenoid ostium in the sphenoethmoid recess is, however, more
constant. This recess is the space formed by the superior and (if present) the
supreme turbinate laterally and the nasal septum medially and is roofed in by
the skull base, i.e.the cribriform plate. The posterior limit of the recess is the face
of the sphenoid. The space is much smaller than the middle meatus. The recess
communicates inferiorly and anteriorly with the nasal cavity. The inferior and
anterior extents are the inferior and anterior margins of the superior turbinate.
The volume of this recess is determined by the degree of pneumatisation of the
posterior ethmoid cells, which push medially if extensively pneumatised, render-
ing the space narrow and slit-like, with little space for an endoscope. The mucosal
lining of the superior meatus is largely olfactory epithelium.
The sphenoid ostium can be found by following the superior turbinate poste-
riorly to the face of the sphenoid 5 mm from the midline and 8 mm from the
roof, where it may be seen as a slit-like, round or ovoid foramen, sometimes more
obviously than others. With extensive pneumatisation of the posterior ethmoid,
the sphenoethmoid recess becomes increasingly narrow and the sphenoid ostium
is found closer to the nasal septum but remains at the same vertical level to the
nasal roof. Unusually the ostium may be lower, or very rarely may open into the
posterior sphenoid. In the presence of ethmoid or sphenoid sinus disease, mucosal
oedema may hide the sphenoid ostium, but it can usually be found with a probe.
An important inferior relation of the ostium is a posterior septal ramus of the
sphenopalatine artery as it crosses from the sphenopalatine foramen to the nasal
septum. It is easily damaged, with heavy bleeding, during enlargement of the
sphenoid ostium downward.
Septation of the sinus is also highly variable: a septum may separate the sinus
into equal or unequal halves, vertically or obliquely, and there may be subsepta-
tions. Septations may extend to bone covering the internal carotid artery, with a
surgical risk to this should the septation be fractured or avulsed, since the bony
covering may be very thin at that point. More rarely, a septation may extend to
the optic nerve canal, with a similar surgical risk.

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7. ORBIT AND LACRIMAL SYSTEM
MATTHEW YUNG
• ORBIT
• MEDIAL WALL OF THE ORBIT
• FLOOR OF THE ORBIT
• LATERAL WALL OF THE ORBIT
• ROOF OF THE ORBIT
• ORBITAL SEPTUM
• LACRIMAL SECRETORY SYSTEM
• LACRIMAL DRAINAGE SYSTEM
Puncta and canaliculi
Lacrimal sac, nasolacrimal canal and nasolacrimal duct
Valves and sinuses within the lacrimal drainage system
• BLOOD SUPPLY OF THE ORBIT

ORBIT (Figure 7.1)

The orbit is pyramidal in shape. It has four bony walls which converge posteri-
orly towards the apex. The depth of the orbit is variable, and surgeons cannot
rely on precise measurement as a guide to the exact location of the optic canal.

MEDIAL WALL OF THE ORBIT (Figure 7.2)

The medial orbital wall is formed by four bones, which are (from anterior to
posterior) the maxilla, lacrimal bone, ethmoid and sphenoid. The frontal process
of the maxilla forms the medial orbital rim and contains the anterior lacrimal
crest. It forms the anterior part of the lacrimal fossa. The lacrimal bone is a small
thin bone that forms the posterior part of the lacrimal fossa and raises the poste-
rior lacrimal crest. The suture line between the frontal process of the maxilla and
the lacrimal bone is usually in the middle of the lacrimal fossa, but it may lie
nearer to the posterior lacrimal crest. In such cases, the thicker bone of the frontal
process of the maxilla underlies most of the lacrimal fossa and can make bone
removal in dacryocystorhinostomy more difficult. The anterior and posterior
lacrimal crests are important for the attachment of the superficial and deep
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9 10 11121314 15 16 17

Figure 7.1 Frontal view of the orbital bones. 1, nasal bone; 2, frontal bone; 3, lacrimal
bone; 4, maxilla; 5, infraorbital foramen; 6, maxillary sinus; 7, anterior ethmoid foramen;
8, ethmoid bone; 9, posterior ethmoid foramen; 10, supraorbital foramen; 11, optic canal;
12, optic strut; 13, superior orbital fissure; 14, inferior orbital fissure; 15, sphenoid bone
– lesser wing; 16, zygoma; 17, sphenoid bone – greater wing

components of the medial canthal tendon. The posterior and superior extensions
of the medial canthal tendon are important as they provide the primary support-
ive structures. The anterior extensions are less important for support and are often
sacrificed in external dacryocystorhinostomy.
Posterior to the lacrimal bone is the lamina papyracea of the ethmoid bone. It
is only 0.2–0.4 mm thick. This thin bone is prone to fracture in orbital trauma
and distorts easily with expansile lesions of the ethmoid sinuses. Because the
lamina papyracea is so thin, infection in the ethmoid sinus can spread into the

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 ORBIT AND LACRIMAL SYSTEM

1 2 3 4 5 6 7 8 9 10 11 12

Figure 7.2 The medial wall of the orbit. 1, nasal bone; 2, frontal bone; 3, maxilla; 4,
frontal process of maxilla; 5, anterior lacrimal crest; 6, posterior lacrimal crest; 7, lacrimal
bone; 8, supraorbital foramen; 9, anterior ethmoid foramen; 10, ethmoid bone; 11, poste-
rior ethmoid foramen; 12, sphenoid bone – lesser wing

orbit, resulting in orbital cellulitis or periorbital or orbital abscesses. The lamina

papyracea is at risk during surgery, and injury may lead to surgical emphysema
or infection within the orbit.
Superiorly, the ethmoid bone joins the roof of the orbit at the fronto-ethmoid
suture. The anterior and posterior ethmoid foramina lie within the fronto-
ethmoid suture line and transmit the anterior and posterior ethmoid arteries,
which normally lie in the same horizontal plane. The number of posterior
ethmoid arteries is variable.

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THE PARANASAL SINUSES

Figure 7.3 The floor of the orbit, with the infraorbital canal highlighted with a piece
of string. 1, optic canal; 2, superior orbital fissure; 3, ethmoid bone; 4, maxilla; 5, inferior
orbital fissure; 6, infraorbital canal; 7, zygoma; 8, infraorbital foramen

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 ORBIT AND LACRIMAL SYSTEM

Posterior to the ethmoid bone in the medial orbital wall is the body of the
sphenoid. It lies between the superior and inferior orbital fissures. The optic
foramen is related to the posterior ethmoid cells, but does not lie at the geomet-
ric apex of the orbit. The distance between the posterior ethmoid foramen and
the optic nerve is variable, and may only be a few millimetres. Removal of bone
of the medial orbital wall behind the posterior ethmoid foramen should be
performed with great care.

FLOOR OF THE ORBIT (Figure 7.3)

The orbital floor is composed mainly of the orbital plate of the maxilla. Small
contributions are made from the zygoma anterolaterally and the orbital plate of
the palatine bone posteriorly. The orbital floor undergoes the greatest degree of
deformation with static loading of any of the orbital walls,1 which explains the
high frequency of orbital floor fractures associated with trauma.
The orbital floor is separated from the lateral wall of the orbit by the inferior
orbital fissure. The orbital floor does not extend to the apex of the orbit, but
ends at the pterygopalatine fossa. Access for surgical decompression of the optic
nerve at the apex is limited, and can only be achieved by opening the posterior
ethmoid sinus posterior to the ethmoid–sphenoid suture line along the medial
wall.
The infraorbital sulcus runs in the centre of the orbital floor from posterior to
anterior, carrying the infraorbital nerve and vessels. At the midportion of the
floor, it is bridged by bone to form the infraorbital canal. The latter emerges at
the infraorbital foramen, located 4–10 mm below the midpoint of the inferior
orbital rim. The floor of the orbit is thinnest medial to the infraorbital canal,
where it may be only 0.5 mm thick. This part of the floor is easily removed
during orbital decompression. It is this part of the orbital floor that is commonly
involved in blowout fractures. The inferior rectus and inferior oblique muscles are
more medially located within the orbit, and are likely to be entrapped in such a
fracture. The infraorbital nerve may be damaged by trauma or following surgery,
resulting in paraesthesia of the cheek and upper lip.

LATERAL WALL OF THE ORBIT (Figure 7.4)

The lateral wall of the orbit is the thickest of all the orbital walls. It is composed
of the zygoma and the greater wing of the sphenoid. The superior and inferior
orbital fissures are important features of the lateral wall of the orbit. The superior
orbital fissure lies between the greater and lesser wings of the sphenoid and is
separated from the optic foramen medially by the optic strut. The divisions of

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THE PARANASAL SINUSES

Figure 7.4 The lateral wall of the orbit. 1, frontal bone; 2, sphenoid bone – greater
wing; 3, zygoma; 4, superior orbital fissure; 5, inferior orbital fissure; 6, infraorbital canal;
7, infraorbital foramen; 8, maxilla

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 ORBIT AND LACRIMAL SYSTEM

the ophthalmic division of the trigeminal nerve and blood vessels pass through
the superior orbital fissure. The optic nerve and ophthalmic artery pass through
the optic foramen. The risk of damage to the superior orbital fissure or the optic
nerve in lateral surgical procedures is minimal because of the curved lines of the
lateral orbital wall and the limited access to this area. The inferior orbital fissure
communicates between the orbit and the infratemporal and pterygopalatine
fossae. The contents of this fissure include branches of the maxillary division of
the trigeminal nerve, the infraorbital artery and branches of the sphenopalatine
ganglion.

ROOF OF THE ORBIT

The orbital roof consists of very thin bone formed mainly by the orbital plate of
the frontal bone, with a small contribution from the lesser wing of the sphenoid.
The optic foramen is located in the roof of the orbital apex. The sheath of the
optic nerve is fused to the periosteum of the optic foramen. Blunt trauma may
lead to contusion and immediate loss of vision by compromising the blood supply.
The supraorbital notch, which transmits the supraorbital nerve, is usually
found in the same parasagittal plane as the mental foramen of the mandible and
the infraorbital foramen of the maxilla. The supraorbital nerve and the levator
palpabrae superioris muscle of the upper eyelid are at risk during an eyebrow
incision, although it is possible to avoid the levator palpabrae superioris muscle
by placing the incision as high as possible and dissecting at right angles to the
skin towards the superior orbital rim.

ORBITAL SEPTUM

The orbital septum or palpebral fascia is a thin fibrous diaphragm that stretches
across the entrance to the orbit. It is anterior to the globe and separates the larger
posterior orbit (postseptal compartment) from the skin and subcutaneous tissue
(preseptal compartment). Peripherally, the orbital septum attaches at the orbital
margin, where periosteum becomes periorbitum. It is directly related to the
posterior aspect of the orbicularis muscle. In the upper lid, it unites with the
levator aponeurosis, and in the lower lid, it fuses with the tarsus. In the elderly,
the septum becomes thinner and may allow orbital fat to prolapse anteriorly.
The orbital septum is an important structure that influences the treatment of
complications of sinusitis. Preseptal infections usually respond to treatment with
intravenous antibiotics, but postseptal infections are more serious and may require
both intravenous antibiotics and surgical drainage.

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THE PARANASAL SINUSES

mm
2
mm
8
3–5 mm

10 mm

1 2 3 4 5

Figure 7.5 Schematic drawing of the lacrimal outflow apparatus. 1, lacrimal sac; 2, naso-
lacrimal duct; 3, common cannaliculus; 4, superior cannaliculus; 5, inferior cannaliculus

LACRIMAL SECRETORY SYSTEM

The lacrimal gland has two parts: a larger orbital portion and a smaller palpe-
bral portion. These are separated by the levator aponeurosis and the orbital
septum and are connected to each other by a small isthmus. The orbital portion

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 ORBIT AND LACRIMAL SYSTEM

2
3

Figure 7.6 Dacryocystogram showing the normal anatomy of the lacrimal outflow
apparatus. 1, superior lacrimal canaliculus; 2, inferior lacrimal canaliculus; 3, common
lacrimal canaliculus; 4, lacrimal sac; 5, nasolacrimal duct

lies in the fossa glandulae lacrimalis of the frontal bone under the superolateral
orbital rim. The gland is mainly serous in nature.2 Tear production from the
lacrimal gland is supplemented by the accessory glands in the palpebral conjunc-
tiva.

LACRIMAL DRAINAGE SYSTEM (Figures 7.5–7.10)

The lacrimal drainage system consists of the superior and inferior puncta, the
superior, inferior and common canaliculi, the lacrimal sac, and the nasolacrimal
duct.

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 THE PARANASAL SINUSES

5
1
5
2

Figure 7.7 Dissection of the lacrimal drainage system. 1, lacrimal sac; 2, inferior lacrimal
punctum; 3, superior lacrimal punctum; 5, common lacrimal canaliculus; 4, superior
lacrimal canaliculus; 6, inferior lacrimal canaliculus; 7, nasolacrimal duct; 8, window in
anterior wall of maxillary antrum

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 ORBIT AND LACRIMAL SYSTEM

1 2 3 4 5

Figure 7.8 The lateral nasal wall. The anterior parts of the inferior and middle turbinates
have been removed. 1, frontal process of maxilla; 2, lacrimal bone; 3, uncinate process;
4, middle turbinate; 5, inferior turbinate

Puncta and canaliculi

The eyelids comprise the tarsal plates covered on one side by skin and on the
other by the palpebral conjunctiva. The tarsal plates are made of dense fibrous
tissue, which provides the structural framework of the eyelids. The lacrimal
puncta are present in the medial aspect of both the upper and lower eyelids,
situated lateral to the caruncle. They are slightly elevated above the level of the
lid margin, seated on the lacrimal papilla. The upper punctum lies 8 mm and
the lower punctum 10 mm from the lacrimal sac. The upper punctum lies slightly
medial to the lower punctum, but both meet together on blinking. The part of
the canaliculus that lies beneath the puncta is vertical and 2 mm in length. It

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THE PARANASAL SINUSES

1 2 3

Figure 7.9 The full width of the lacrimal duct is only exposed by removal of the thick
bone at the frontal process of the maxillary bone. 1, maxilla; 2, nasolacrimal duct; 3,
uncinate process

then turns medially, parallel to the free margin of the eyelid. The upper and lower
canaliculi meet medially to form the common canaliculus. The average length of
the common canaliculus is 1.2 mm, but it varies between 0.3 mm and 5 mm. It
enters the lacrimal sac at an acute angle rather than at a right angle. It is thought
by some that the angulated entry of the common canaliculus into the sac prevents
reflux of tears into the common canaliculus when the sac is full. There is a gradual
transition from stratified squamous epithelium in the vertical and the horizontal
parts of the canaliculi to columnar epithelium in the common canaliculus and
the lacrimal sac. Medial and lateral extensions of the tarsal plates give rise to the
medial and lateral canthal tendons. The lateral canthal tendon attaches to the

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 ORBIT AND LACRIMAL SYSTEM

1 2 3 4

Figure 7.10 The lacrimal sac and upper nasolacrimal duct lie immediately anterior to
the uncinate process. 1, maxilla; 2, lacrimal sac; 3, nasolacrimal duct; 4, uncinate process

lateral orbital tubercle, just below the zygomaticomaxillary suture. The medial
canthal tendon attaches to the anterior and posterior lacrimal crests, by way of
anterior and posterior slips. These slips intimately surround the lacrimal canali-
culi and sac and provide structural support.

Lacrimal sac, nasolacrimal canal and nasolacrimal duct

The lacrimal sac is variable in size, being 12–15 mm long and between 4–8 mm
deep. The lacrimal fossa courses posteriorly, inferiorly and laterally to develop into
the nasolacrimal canal. The canal opens into the inferior meatus, beneath the

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inferior turbinate, usually at the junction of the anterior third and posterior two-
thirds. The anterior, posterior and lateral walls of the nasolacrimal canal are
formed by the maxillary bone. The medial wall consists of the lacrimal bone
superiorly and an extension of the inferior turbinate inferiorly. The lacrimal sac
and nasolacrimal duct are anatomically contiguous. There is no demarcation
between them, although some authors have observed a narrowing at the transi-
tion from the lacrimal sac to the nasolacrimal duct within the confines of the
nasolacrimal canal. The nasolacrimal duct is lined by columnar epithelium, similar
to the lacrimal sac. The actual exit point of the nasolacrimal duct underneath the
inferior turbinate is variable, depending on the angulation of the duct. In lacrimal
surgery, the anterior lacrimal crest and the lacrimal fossa are relatively easy to
identify during an external approach. However, the landmark for the lacrimal
fossa using an endonasal approach is less obvious because of the variable nature
of the anatomy in the lateral nasal wall. The most reliable landmark is the
uncinate process. The lacrimal fossa usually lies just anterior to the superior third
of the uncinate process. Some authors suggest using the anterior tip of the middle
turbinate as the landmark. However, the shape and size of the middle turbinate
is too variable and this may not prove reliable. The thickness of the bone of the
lacrimal fossa varies depending on the contribution from the frontal process of
the maxilla.
The average width of the thin lacrimal bone overlying the posteromedial part
of the upper lacrimal duct is 2.5 mm and the average length is 7.2 mm.3 The
average thickness of the lacrimal bone covering the posteromedial portion of the
lacrimal duct and sac is 57 µm, although it can be as thick as 0.3 mm (300 µm).
Surgeons should be aware that the thin bony wall at the posteromedial part of
the lacrimal fossa is easily damaged during endoscopic sinus surgery, especially if
back-biting forceps are used to remove the uncinate process. Injury may result
in epiphora.

Valves and sinuses within the lacrimal drainage system

The vertical portion of the upper and lower canaliculi terminates in a saccular
dilatation called the ‘ampulla’. It is surrounded by muscle that relaxes and
contracts with blinking, hence contributing to the drainage of tears.
Valves within the lacrimal drainage system allow unidirectional flow of tears
from the canaliculi to the inferior meatus. The valve of Rosenmüller is situated
at the internal opening of the common canaliculus within the lacrimal sac. The
valve of Hasner lies at the distal opening of the lacrimal duct at the inferior
meatus. An imperforate valve results in congenital epiphora.

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 ORBIT AND LACRIMAL SYSTEM

BLOOD SUPPLY OF THE ORBIT

The arterial supply to the orbit is primarily from the ophthalmic artery, with
some contribution from the middle meningeal artery. The ophthalmic artery is
the first branch of the internal carotid artery. It enters the orbit through the optic
foramen. Its first branch is the central retinal artery, which pierces the dura and
subarachnoid space around the optic nerve to enter the nerve, and then passes
on to supply the retina.
The ophthalmic artery gives rise to the following branches. The lacrimal artery
supplies most of the structures of the lateral aspect of the orbit. The nasociliary
artery gives rise to a number of short ciliary arteries, as well as the long ciliary
artery. The anterior and posterior ethmoid arteries arise from the nasociliary artery
as it passes their respective foramina. The posterior ethmoid artery varies in that
it may be absent in 15–20% of individuals, or it may be multiple. Having passed
through the posterior ethmoid foramen, it supplies the mucosa of the posterior
ethmoid cells. The anterior ethmoid artery exits the orbit by way of the anterior
ethmoid foramen and courses over the roof of the ethmoid sinus to open beneath
the dura mater on the cribriform plate. At the crista galli, one branch of the
anterior ethmoid artery turns superiorly to supply the meninges, while the other
branch turns inferiorly through the nasal slit to enter the anterior nasal cavity to
supply the upper nasal septum.
The supraorbital artery has a variable origin. It may arise as the frontal branch
of the ophthalmic artery or as a branch of the nasociliary or lacrimal artery. It
exits the orbit at the supraorbital notch.

ACKNOWLEDGEMENT

Acknowledgement goes to Deborah Osborne, Medical Artist, and Marcel Kok,

Medical Photographer, at the Ipswich Hospital NHS Trust for their assistance in
the illustrations.

REFERENCES

1. Rizen AJV, Nikolic V, Banovic BH. The role of orbital wall morphological proper-
ties and their supporting structures in the etiology of ‘blow-out’ fractures. Surg
Radiol Anat 1989; 11: 241–8
2. Orzales N, Riva A, Testa F. Fine structure of the human lacrimal gland. I. The
normal gland. J Submicrosc Cytol 1971; 3: 283
3. Yung MW, Logan BM. The anatomy of the lacrimal bone at the lateral wall of the
nose – its significance to the lacrimal surgeon. Clin Otolaryngol 1999; 24: 262–5

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8. ARTERIAL SUPPLY OF THE NASAL
CAVITY
PAUL MONTGOMERY, ASAD QAYYUM
• SPHENOPALATINE ARTERY AND FORAMEN
Posterior lateral nasal artery
Posterior septal artery
Osteology
Surface anatomy
Surgical application
• ETHMOID ARTERIES AND FORAMINA

The blood supply to the nasal cavity is a confluence of four major arterial systems
(Figure 8.1).

• The sphenopalatine artery: this supplies the majority of the nasal cavity and
nasal septum.
• The anterior and posterior ethmoidal arteries: these supply the roof of the
nasal cavity, the superior turbinate and the adjacent nasal septum.
• The superior labial artery: this supplies the anterior nasal floor and Little’s
area of the nasal septum
• The greater palatine artery: this supplies the posterior nasal floor and Little’s
area of the nasal septum.

The confluence of all the vessels of the nasal cavity, except the posterior ethmoidal
artery, form Kisselbach’s vascular plexus on the antero-inferior part of the nasal
septum (Little’s area)

SPHENOPALATINE ARTERY AND FORAMEN (Figures 8.2 and 8.3)

The sphenopalatine artery originates from the internal maxillary artery, a termi-
nal division of the external carotid artery. The internal maxillary artery (third
part) passes deep to the neck of the mandible, through the infratemporal fossa,
and enters the pterygopalatine fossa, where it divides into its terminal branches:
the posterior–superior alveolar, descending and greater palatine, infraorbital,
pterygoid canal, pharyngeal, and sphenopalatine arteries.
THE PARANASAL SINUSES

1 2 3 4 5 6 7 8 9

Figure 8.1 Sagittal section of the right lateral nasal wall. 1, agger nasi cell; 2, frontal
recess; 3, bulla ethmoidalis; 4, anterior ethmoid artery; 5, middle turbinate; 6, inferior
turbinate; 7, superior turbinate; 8, position of sphenopalatine foramen; 9, sphenoid sinus

The sphenopalatine artery travels through the pterygopalatine fossa and

divides into the posterior lateral nasal artery and the posterior septal artery. In
the majority of cases, the sphenopalatine artery divides within the pterygopala-
tine fossa; if not, it divides into its branches after entering the nasal cavity
through the sphenopalatine foramen. Occasionally, the posterior lateral nasal
branch of the sphenopalatine artery may leave the pterygopalatine fossa by a
separate foramen.

Posterior lateral nasal artery

In the majority of cases, the posterior lateral nasal artery (PLNA) exits from the
superior aspect of the sphenopalatine foramen and is anterior to the posterior

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 ARTERIAL SUPPLY OF THE NASAL CAVITY

1 2 3 4 5 6

Figure 8.2 Endoscopic view of the sphenopalatine artery (cadaver dissection – left side).
1, sphenoid sinus; 2, optic nerve; 3, sphenopalatine artery; 4, crista ethmoidalis; 5, lateral
nasal wall; 6, maxillary antrum

septal artery.1 After leaving the foramen, the PLNA travels inferiorly on the
perpendicular plate of the palatine bone, coursing postero-inferiorly and anteri-
orly along the lateral wall of the nasal cavity.2 Branches are given off anteriorly
to supply the middle turbinate and anterior and posterior fontanelles, the inferior
turbinate and lateral nasal wall, and finally the maxillary, ethmoid and sphenoid
sinuses.

Posterior septal artery

After giving off the posterior lateral nasal branch, the main trunk of the
sphenopalatine artery is now known as the posterior septal artery (PSA). This
artery travels on the antero-inferior surface of the face of the sphenoid sinus,

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THE PARANASAL SINUSES

1 2 3 4 5 6 7

Figure 8.3 Line drawing of divisions of the left sphenopalatine artery. 1, nasal septum;
2, antero-inferior face of sphenoid; 3, posterior septal artery; 4, lateral nasal wall; 5, poste-
rior lateral nasal artery; 6, sphenopalatine foramen; 7, sphenopalatine artery

where it joins the nasal septum before travelling downwards and forwards on the
septum. The PSA divides into three branches. The inferior branch, the nasopala-
tine artery, courses anteriorly on the inferior aspect of the septum and passes
through the incisive foramen, anastamosing with a terminal branch of the greater
palatine artery and reaching the nasal septum through the incisive foramen. The
upper and middle branches arch towards Little’s area. The remainder of the finer
branches course superiorly and anastamose with the septal branches of the
anterior and posterior ethmoidal arteries.

Osteology (Figure 8.4)

The sphenopalatine foramen is formed anteriorly and inferiorly by the
sphenopalatine notch of the perpendicular plate of the palatine bone, and is
completed posterosuperiorly by the front face of the sphenoid. It may occasion-
ally be formed entirely by the palatine bone. The anterior margin of the perpen-

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 ARTERIAL SUPPLY OF THE NASAL CAVITY

1 2 3 4 5 6 7

Figure 8.4 Palatine bone. 1, conchal crest; 2, orbital process; 3, perpendicular plate;
4, sphenopalatine foramen; 5, crista ethmoidalis; 6, sphenoid process; 7, horizontal plate

dicular plate of the palatine bone articulates superiorly with the posterior end of
the middle turbinate, and inferiorly with the posterior fontanelle.
An important landmark in identifying the sphenopalatine foramen is the crista
ethmoidalis. This is a small medial crest projection of the palatine bone found at
the anterior or inferior edge of the sphenopalatine notch.

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THE PARANASAL SINUSES

1 2 3 4 5

Figure 8.5 Left lateral nasal wall. 1, sphenoid sinus; 2, sphenopalatine foramen; 3, poste-
rior free end of middle turbinate; 4, superior turbinate; 5, opening into maxillary sinus

In 95% of cases, the crista ethmoidalis is at the antero-inferior edge of the

sphenopalatine notch; in 5%, it is at the inferior edge.
The relationships of the sphenopalatine foramen to the nasal meati are classi-
fied as follows:

• class I (35%) opens into the superior meatus as a single foramen;

• class II (55%) opens into both superior and middle meati as a single foramen;
• class III (10%) opens into both superior and middle meati as two separate
foramina.

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 ARTERIAL SUPPLY OF THE NASAL CAVITY

1 2

Figure 8.6 Sphenopalatine artery (right side): endoscopic view as it emerges from behind
the crista ethmoidalis at live dissection. 1, crista ethmoidalis; 2, sphenopalatine artery

These variations can, in part, be explained as a consequence of the length of the

middle turbinate, with the class I variation being associated with a short middle
turbinate.

Surface anatomy (Figure 8.5)

The sphenopalatine foramen lies immediately behind the posterior attachment of
the middle turbinate.3,4 It lies approximately 10–15 mm anterior and 5–15 mm
superior to the upper margin of the posterior choana on the lateral wall on the
nasal cavity.

Surgical application (Figure 8.6)

In endoscopic sphenopalatine arterial ligation, the posterior aspect of the middle
meatus is identified and the soft posterior fontanelle is palpated. Moving further

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THE PARANASAL SINUSES

1 2 3 4

Figure 8.7 Osteology of the ethmoid foramina. 1, optic canal; 2, posterior ethmoid
foramen; 3, anterior ethmoid foramen; 4, lacrimal fossa

posteriorly, the fontanelle becomes hard as the perpendicular plate of the palatine
bone is encountered. The mucosa is incised and elevated superiorly towards the
posterior end of the middle turbinate to expose the perpendicular plate of the
palatine bone and the superior meatus. The crista ethmoidalis is encountered; the
SPA and its branches are found superior and posterior to this point. The artery
encountered may be either the sphenopalatine artery or its posterior lateral nasal
branch. The artery is identified and ligated, bipolar diathermy is applied, and the
artery is then divided. Dissection is continued to identify a possible septal branch,
and if present this is ligated, diathermised and divided.

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 ARTERIAL SUPPLY OF THE NASAL CAVITY

1 2 3 4

Figure 8.8 Cadaveric endoscopic view of the anterior and posterior ethmoid arteries
(right side). 1, lamina papyracea; 2, anterior ethmoid artery; 3, posterior ethmoid artery;
4, lateral nasal wall

ETHMOID ARTERIES AND FORAMINA (Figures 8.7 and 8.8)

The anterior and the posterior ethmoid arteries supply the roof of the nasal cavity
and its adjacent superior turbinate and nasal septum. These arteries originate
from the ophthalmic artery within the orbit. The two vessels enter the anterior
and posterior ethmoid sinuses by passing through the anterior and posterior
ethmoid foramina respectively. These foramina are part of the fronto-ethmoid
suture where the lamina papyracea attaches to the frontal bone. The anterior
ethmoid foramen is 18 mm posterior to the anterior lacrimal crest (frontomaxil-

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THE PARANASAL SINUSES

lolacrimal suture), the posterior ethmoid foramen lies a further 12 mm posteri-

orly, with the distance between the posterior ethmoid artery and the optic nerve
being approximately 6 mm.
The anterior ethmoid artery passes through the anterior ethmoid air cell
system, coursing anteriorly at an angle of 45° in an axial plane. It then passes
into the anterior cranial fossa at the junction of the fovea ethmoidalis and the
lateral lamella of the cribriform plate. Its relations are as follows:

• anteriorly, the frontal recess and postfrontal air cell;

• posteriorly, the suprabullar recess (lateral sinus);
• superiorly, the fovea ethmoidalis;
• inferiorly, the anterosuperior face of the bulla ethmoidalis;
• medially, the lateral lamella of the cribriform plate;
• laterally, the lamina papyracea.

Another important relationship is that the true maxillary ostia, the anterior face
of the bulla ethmoidalis and the anterior ethmoid artery lie in the same coronal
plane. Endoscopically, the anterior ethmoid artery can be identified by following
the anterior surface of the bulla ethmoidalis superiorly into the fovea ethmoidalis.
It lies posterior to the frontal recess and postfrontal air cell just anterior to the
suprabullar recess.
The posterior ethmoid artery lies in the posterior ethmoid air cell system
behind the basal lamella. It is 12 mm posterior to the anterior ethmoid artery
and passes medially at 90° to the lamina papyracea. It is endoscopically present
in only 35% of individuals, as it lies at the level of the anterior skull base, in the
roof of the posterior ethmoid, and rarely has a mesentery.

REFERENCES

1. Schwartzbauer H, Shete M, Tami T. Endoscopic anatomy of the sphenopalatine

artery and posterior nasal arteries: Implications for the endoscopic management of
epistaxis. Am J Rhinol 2003; 17: 63–6
2. Lee H, Kim H, Kim S et al. Surgical anatomy of the sphenopalatine artery in lateral
nasal wall. Laryngoscope 2002; 112: 1813–18
3. Lang J. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. Stuttgart:
Georg Thieme Verlag, 1989
4. Wearing M, Padgham N. Osteologic classification of the sphenopalatine foramen.
Laryngoscope 1998; 108: 125–7

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