Practical Rhinology - 1st Edition
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Contents
Preface vii
Contributors ix
1. Applied surgical anatomy of the nasal cavity and paranasal sinuses 1
Dharmbir S Sethi
2. Making sense of symptoms 15
Nicholas Jones
3. Medical management of rhinosinusitis 28
Jeffrey D Suh, James N Palmer
4. Technical advances and the endoscopically assisted bimanual technique 38
Daniel B Simmen
5. Preoperative work-up and assessment 46
Peter-John Wormald, Marc A Tewfik
6. Complications of sinus surgery 55
Scott M Graham
7. Orbital and lacrimal surgery 61
Vijay R Ramakrishnan, James N Palmer
8. Endonasal surgery of the anterior skull base 73
Daniel B Simmen
9. Pituitary and parasellar surgery 83
Aldo C Stamm, João F Nogueira Jr
10. Endoscopic management of nasal tumours 89
Aldo C Stamm, João F Nogueira Jr, Maria L S Silva
11. Cerebrospinal fluid leaks 98
Scott M Graham
12. The frontal sinus 105
Peter-John Wormald
13. The posterior ethmoid cells and sphenoid sinus 112
Dharmbir S Sethi, Boaz Forer
14. Management of recalcitrant sinusitis, including allergic fungal sinusitis and Samter’s triad 127
Marc A Tewfik, Erik K Weitzel, Peter-John Wormald
15. What is new in managing the maxillary sinus? 136
Scott M Graham
16. Paediatric issues in sinus surgery 141
Nicholas Jones
17. Sinus surgery and olfaction in chronic rhinosinusitis 150
Daniel B Simmen
18. Postoperative management 159
Vijay R Ramakrishnan, James N Palmer
19. Helping patients 166
Nicholas Jones
20. Case studies 170
Presented by Dharmbir S Sethi and Nicholas Jones
Index 185
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Preface
This book is not meant to be an all encompassing conservative therapy, the latest technology open the book
encyclopaedia of rhinological conditions. It is meant to be and are very well illustrated.
practical and relevant to most doctors treating rhinological The following chapters deal with all the surgery in and
conditions. around the nose and the paranasal sinuses.
In all honesty it was my intention to compile a book that Surgery of the orbit, skull base, sella and of skull base
addressed the difficulties which are posed by the variety of tumors is discussed in detail.
ways patients present with different nasal symptoms, and The frontal sinus is addressed with a special chapter
give guidance on how to arrive at a correct diagnosis. It that looks at good long term results.
is thanks to Scott Graham that this proposal was, in part, Importantly, complications are presented in detail as
jettisoned as he convinced me that few surgeons would be everybody faces these accidents sooner or later.
interested in such a text. He suggested that I approached Paediatric rhinology, the sense of smell, postoperative
some of the world’s leading rhinologists and put together management and guidance for patients, which is not
a text that incorporates most of the current relevant always in the center of the surgeon’s attention, provide an
problems that rhinologists face and present this in, what important finale.
we hope is, a digestible format. So please forgive omissions Excellent figures and photographs make this book a
of some of the less common conditions and the absence of wonderful resource for the beginner and the advanced
a structured evidence based approach, although we have surgeon, and a good practical resource before surgery with
tried to include the evidence base where it exists. We hope answers for many specific questions.
you will find this of use in your day to day work. I am sure it will be a very successful publication because
of its practical qualities in a time when political influences
Nicholas Jones make it difficult for us to have enough time for our patients.
2010
Professor Wolfgang Draf FRCS
Director of the Department of Ear, Nose and
Throat Diseases
This new practical book has been keenly anticipated as Head and Neck Surgery
the list of contributors reads like a “Who’s Who” in International Neuroscience Institute at the
Rhinology. University of Magdeburg (INI)
Practical applied anatomy, clinical examination, Hanover, Germany
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Contributors
Boaz Forer MD Daniel B Simmen
Department of Otolaryngology, Singapore General Hospital, ORL Zentrum, Centre for Rhinology, Skull Base Surgery and Facial
Singapore Plastic Surgery, Hirslanden Clinic, Zurich, Switzerland
Scott M Graham MD Aldo C Stamm MD
Professor, Department of Otolaryngology, Head and Neck Surgery, Director of São Paulo ENT Center, Hospital Professor Edmundo
University of Iowa, Iowa City, and Director, Division of Rhinology, Vasconcelos, and Associate Professor, Federal University of São
University of Iowa Hospitals and Clinics, Iowa, USA Paulo, São Paulo, Brazil
Nicholas Jones BDS MD FRCS FRCS (ORL) Jeffrey D Suh MD
Special Professor, University of Nottingham, Queens Medical Assistant Professor, Department of Surgery, Division of
Centre, University Hospital, Nottingham, UK Otolaryngology–Head and Neck Surgery, UCLA School of
João F Nogueira Jr MD Medicine, Los Angeles, California, USA
Resident, Sao Paulo ENT Center, Hospital Professor Edmundo Marc A Tewfik MD, MSc, FRCSC
Vasconcelos, Sao Paulo, Brazil Assistant Professor, Department of Otolaryngology – Head and
James N Palmer MD Neck Surgery, McGill University, Montreal, Canada
Associate Professor and Director, Division of Rhinology, Erik K Weitzel MD MC USAF
Department of Otorhinolaryngology, Head and Neck Surgery, San Antonio Military Medical Center, Department of
University of Pennsylvania, Philadelphia, USA Otolaryngology – Head and Neck Surgery, Ste 1 Lackland AFB,
Vijay R Ramakrishnan MD Texas, USA
Assistant Professor, Department of Otolaryngology, University of Peter-John Wormald MD FRCS FRACS FCS(SA)
Colorado, Denver, Colorado, USA Professor and Chair, Department of Otolaryngology – Head
Dharmbir S Sethi FRCSEd FAMS and Neck Surgery, Adelaide and Flinders Universities, Adelaide,
Clinical Associate Professor, National University of Singapore, and Australia
Senior Consultant, Singapore General Hospital, Singapore
Maria L S Silva MD
ENT resident, São Paulo ENT Center, Hospital Professor Edmundo
Vasconcelos, São Paulo, Brazil
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1
Applied surgical anatomy of the nasal cavity and
paranasal sinuses
Dharmbir S Sethi
General considerations 1 The ethmoid complex 4
Paranasal sinuses 1 Maxillary sinus ostium 8
Nasal turbinates 1 Maxillary wall fontanelle 8
Agger nasi cell 3 Frontal recess 9
Nasolacrimal duct 3 Sphenoid sinus 13
Uncinate process 3 Reference 14
GENERAL CONSIDERATIONS
A thorough understanding of the anatomy of the paranasal
sinuses and an awareness of the variations in these complex
structures are essential in order to perform safe and
effective sinonasal surgery. In recent years, endoscopic
sinus surgery has gained worldwide acceptance. Although
this modality of treating sinonasal pathology is minimally
invasive, it has a steep learning curve and is not necessarily
safer than headlight or external approaches. Catastrophic
complications may occur in the hands of the inexperienced
with an inadequate understanding of the anatomy. It is,
therefore, essential to have a good grasp of the endoscopic
anatomy of the nasal cavity and the paranasal sinuses. As
anatomy viewed through the lens of an endoscope can
be distorted, it is also essential to understand the gross
Figure 1.1 Sagittal section of a fresh cadaver head showing the
anatomy. Excellent textbooks on detailed anatomy of the
intact nasal septum (s), right frontal sinus (f) and the sphenoid
paranasal sinus are available but they cannot replace the need
sinus (sp).
for training in wet cadaver laboratories. Performing these
dissections first hand under supervision before embarking
on endoscopic surgery is the key to understanding the posterior systems that are anatomically separated by the
anatomy. Surgeons in training are encouraged to attend basal lamella of the middle turbinate (see page 2). The
workshops offering cadaver dissections (Fig. 1.1). This anterior drainage system drains the frontal, maxillary
chapter describes the gross and endoscopic sinus anatomy and anterior ethmoids, and the posterior system drains
that is relevant to the endoscopic sinus surgeon. the posterior ethmoids and the sphenoid. Pathology may
involve one or more of these drainage systems.
PARANASAL SINUSES
NASAL TURBINATES
The paranasal sinuses comprise the frontal, maxillary,
ethmoid and the sphenoid sinuses. The sinus drainage The lateral nasal wall has three prominent projections
pathways divide the paranasal sinuses into anterior and called turbinates (Fig. 1.2). The inferior turbinate is an
2 Applied surgical anatomy of the nasal cavity and paranasal sinuses
3
5
S
2
4
Figure 1.2 The nasal septum (S) has been separated from its
attachments and retracted medially and posteriorly to reveal the
right lateral nasal wall. Note the turbinates: the inferior turbinate
(1), the middle turbinate (2) and the superior turbinate (3). Other
anatomical structures of note are the agger nasi (5) and the Figure 1.3 Endoscopic view of the left nasal cavity. Note the
uncinate process (4). The right frontal sinus (f) is also visible. middle turbinate (1), uncinate process (2), prominence of the
nasolacrimal duct (3), agger nasi (4), nasal septum (5), superior
turbinate (6) and the olfactory cleft (7). Note the groove between
independent bone, whereas the middle and the superior
the uncinate process and the nasolacrimal duct. This corresponds
turbinates are part of the ethmoid complex. Occasionally,
to the attachment of the uncinate to the nasolacrimal bone. The
a fourth turbinate termed the supreme nasal turbinate is
arrowhead is pointing to the sphenoid ostium.
present. The recesses between these turbinates and the
nasal wall are the called the meati, termed the inferior
meatus, the middle meatus and the superior meatus,
respectively.
Inferior turbinate
This structure is attached to the lateral nasal wall. Only one
structure drains into the inferior meatus, the nasolacrimal
duct (NLD).
Middle turbinate
The middle turbinate is approximately 4 cm long and
it is about 14.5 mm, 12.5 mm and 7 mm high in its
Figure 1.4 The arrowheads are pointing to the basal lamella,
anterior, middle and posterior segments, respectively. The
which separates the anterior group of the paranasal sinuses from
attachment of the middle turbinate is divided into three
the posterior group. p, palatine bone.
segments: the anterior third is attached sagittally to the skull
base (Fig. 1.3) and inside the cranial cavity it continues as
the lateral lamella of the cribriform plate (a vertical flange accounts for its stability and an understanding of this
of variable length that is attached to the fovea ethmoidalis structure will help prevent destabilization of the turbinate
– part of the frontal bone – and is often quite thin). As the by excessive resection.
attachment of the middle turbinate continues posteriorly The middle meatus is the final common drainage pathway
it turns laterally towards the lamina papyracea (see below) for the frontal, anterior ethmoid and maxillary sinuses.
and then goes on to form a coronally oriented middle
third of the basal lamella (Fig. 1.4). The posterior third
of the middle turbinate attaches to the lamina papyracea Superior turbinate
as far as the perpendicular plate of the palatine bone; this
part of the attachment is almost horizontal. The varying This structure is sagittally oriented and attached to the skull
orientation of the attachment of the middle turbinate base. The natural sphenoid ostium is located posterior to
Uncinate process 3
the inferior half of the superior turbinate within the anterior fontanelle. Any attempt to extend the middle
sphenoethmoid recess. meatal antrostomy anteriorly into the anterior fontanelle
places the NLD at risk.
AGGER NASI CELL
UNCINATE PROCESS
Derived from the Latin word agger for ‘nasal mound’, this
cell, which is pneumatized in 98 per cent of patients, is the The uncinate process is a thin, almost sagittally oriented,
most anterior and consistent of all ethmoid cells (Fig. 1.5). boomerang-shaped bony leaflet. It forms part of the lateral
Endoscopically, an eminence on the lateral nasal wall nasal wall between the middle and the inferior turbinates
anterosuperior to the origin of the middle turbinate in an anterosuperior to posteroinferior orientation. It is
defines the location of the agger nasi. The agger nasi is attached anteriorly to the posterior edge of the lacrimal bone
bounded laterally by the lacrimal bone, anteriorly by the and inferiorly (by several bony pedicles) to the superior
frontal process of the maxilla and medially by the uncinate edge of the inferior turbinate. It has a free posterosuperior
process (see below); posteriorly it is related to the ethmoid border (Fig. 1.10). Its superior attachment is variable:
infundibulum. Superiorly it forms the anterior boundary
of the frontal recess and serves as an important landmark
in the intraoperative identification of the frontal recess.
NASOLACRIMAL DUCT
The lacrimal sac is closely related to the agger nasi cell,
being located slightly lateral and anterior to it. The lacrimal
sac is usually 15 mm in height and 5–8 mm of this extends
superior to the anterior insertion of the middle turbinate
on the lateral wall (Figs 1.6–1.9). The NLD courses from
the lacrimal sac down to its opening in the inferior meatus.
The eminence anterior to the uncinate process is formed
by the NLD. The intraosseous portion of the NLD is
approximately 12 mm in length. The opening of the NLD
in the inferior meatus is located about 15 mm above the Figure 1.6 The anterior end of the inferior turbinate has been
nasal floor and approximately 1 cm behind the anterior truncated and retracted superiorly to expose the inferior meatus.
end of the inferior turbinate. As the NLD descends it The arrowhead is pointing to the opening of the nasolacrimal
curves slightly posteriorly and is closely related to the duct in the inferior meatus.
Figure 1.5 The nasal septum has been completely detached
to reveal the lateral nasal wall. Note the agger nasi cell (1), Figure 1.7 Endoscopic view of the opening of the nasolacrimal
nasolacrimal duct (2), uncinate process (3), bulla ethmoidalis (4) duct (arrowheads) in the left inferior meatus. Also seen are the
and the posterior fontanelle (5). inferior turbinate (1) and the lateral nasal wall (2).
4 Applied surgical anatomy of the nasal cavity and paranasal sinuses
Figure 1.10 The middle turbinate (m) has been reflected
medially and superiorly, upon its lateral attachment called the
Figure 1.8 The overlying mucosa and the bone have been basal lamella, to reveal the middle meatus. Note the uncinate
removed to expose the nasolacrimal duct (arrowheads). process (1) and the bulla ethmoidalis (2). The cleft between the
posterior free border of the uncinate process and the anterior wall
of the bulla is called the hiatus semilunaris anterioris (asterisk).
THE ETHMOID COMPLEX
Bulla ethmoidalis
The bulla ethmoidalis is the most prominent of the anterior
ethmoid air cells and is readily identified posterior to the
uncinate process (Figs 1.11 and 1.12). The bulla is variable
in size and is pneumatized in 60–70 per cent of cases (thus
Figure 1.9 The lacrimal sac and nasolacrimal duct have been
incised open. The blue probe is showing the nasolacrimal duct
and its opening. The white probe is showing the location of the
common canaliculus on the lateral wall of the lacrimal sac.
it may be attached to the lamina papyracea, the roof of
the ethmoid sinus or the middle turbinate. Often there
is more than one attachment. The superior attachment
of the uncinate process determines the drainage of the
frontal recess. The uncinate process may also present
with many anatomical variations, including medial and
lateral rotations. Occasionally, it may be rotated anteriorly,
mimicking the middle turbinate to give the impression of Figure 1.11 Endoscopic view of the left middle meatus showing
a double middle turbinate. Together with the agger nasi, the hiatus semilunaris superioris (white arrowheads) and the
the uncinate process forms the first of the four lamellae on hiatus semilunaris inferioris (black arrowheads). Also seen are the
the lateral wall. uncinate process (1), bulla ethmoidalis (2) and the basal lamella (3).
The ethmoid complex 5
to three recesses: the ethmoid infundibulum, the retrobullar
recess and the frontal recess (see below). The anterior wall
of the bulla ethmoidalis forms the posterior limit of the
ethmoid infundibulum and its posterior wall forms the
anterior wall of the retrobullar recess. The anterior and
posterior walls of the bulla ethmoidalis merge superiorly
to first form the bulla lamella, which can be attached to the
skull base immediately anterior to the anterior ethmoid
artery, and then continue as the posterior limit of the
frontal recess (Fig. 1.13). It is important to remember that
the lateral wall of the bulla ethmoidalis is formed by the
lamina papyracea (Fig. 1.14). Inferiorly and posteriorly the
bulla ethmoidalis may fuse with the basal lamella, in which
case the retrobullar recess may be obliterated or is absent.
Lamina papyracea
Figure 1.12 Close-up view of the left middle meatus showing As stated above, the lateral wall of the ethmoid complex is
the middle turbinate (1), uncinate process (2) and the bulla formed by the lamina papyracea, which is literally paper
ethmoidalis (3). thin so that the orbital fat imparts a yellowish colour to
it. The medial rectus muscle may, occasionally, be located
in close contact with the lamina (Figs 1.15 and 1.16).
termed bulla). When it is not pneumatized, it is termed
The lamina thickens towards the orbital apex to form the
the lateral torus. The bulla measures about 18 mm (range
optic tubercle protecting the optic nerve. The optic nerve
9–23 mm) in length and is 5.4 mm (range 2–13 mm) high.
courses in close proximity to the medial orbital wall in this
Not infrequently the bulla may be highly pneumatized,
location.
extending to the skull base superiorly and the ground
lamella posteriorly. The bulla ethmoidalis is closely related
Hiatus semilunaris inferioris
The two-dimensional cleft between the posterior free
border of the uncinate process and the anterior wall
of the bulla ethmoidalis is called the hiatus semilunaris
Figure 1.13 The middle turbinate has been trimmed from
its attachments. The anterior third of the middle turbinate is
attached to the skull base (black arrowheads) and the middle
third and the posterior third curve laterally to form the basal
lamella, which inserts onto the lamina papyracea (white
arrowheads). Note the five lamellae: uncinate process (1), bulla Figure 1.14 The bulla ethmoidalis has been removed, with the
ethmoidalis (2), basal lamella of the middle turbinate (3), lamella dotted line indicating the line of attachment of the anterior wall
of the superior turbinate (4) and the anterior wall of the sphenoid of the bulla ethmoidalis (asterisk) to the lamina papyracea, which
(5). The white asterisk indicates the hiatus semilunaris superioris also forms the lateral wall of the bulla ethmoidalis. The superior
and the black asterisk the hiatus semilunaris inferioris. turbinate (st) is still intact.
6 Applied surgical anatomy of the nasal cavity and paranasal sinuses
Figure 1.15 The lamina papyracea has been removed and Figure 1.16 A complete sphenoethmoidectomy has been done
the periorbita incised to expose the orbital contents related to delineating the lamina papyracea (Lp) laterally and the skull base
the lateral wall. Note the orbital fat and the medial rectus (m) (sb) superiorly. Note the location of the anterior ethmoid artery
in close proximity to the lateral wall posteriorly. The asterisk (a), the posterior ethmoid artery (white asterisk), the optic nerve
indicates the anatomical location of the orbital apex. The (on), the orbital apex (black asterisk) and the carotid artery (ca).
medial wall of the cavernous sinus has been opened to expose
the contents of the cavernous sinus. The cavernous portion of
the internal carotid artery (ca) is the most medial structure in
the cavernous sinus. The pituitary gland (p) has been retracted
medially and superiorly to show the third (arrowhead) cranial
nerve, which is lateral to the carotid artery. Note the optic nerve
(on) anterosuperiorly on the lateral wall of the sphenoid sinus.
inferioris. Its dimensions are variable and it can measure
14–22 mm in length and 0.5–3 mm mediolaterally. The
hiatus semilunaris inferioris is located from 1–10 mm (43
per cent) to 11–20 mm (47 per cent) behind the anterior
attachment of the middle turbinate. This two-dimensional
cleft leads laterally into a three-dimensional space called
the ethmoid infundibulum (see Fig. 1.10).
Hiatus semilunaris superioris Figure 1.17 The ball probe has been placed in a recess lateral
to the uncinate process. This three-dimensional recess bounded
A cleft may be identified between the posterior aspect of laterally by the lamina papyracea and limited superiorly by the
the bulla ethmoidalis and the basal lamella, termed hiatus terminal recess is called the ethmoid infundibulum.
semilunaris superioris (see Fig. 1.13). It leads laterally
into a very variable three-dimensional space called the
retrobullar recess. present, the frontal recess drainage pathway will be medial
to the uncinate process. In about 14 per cent of cases, in
which the terminal recess is absent, the infundibulum
Ethmoid infundibulum continues anteriorly and superiorly into the frontal recess,
which drains directly into the ethmoid infundibulum.
The ethmoid infundibulum, a three-dimensional space, is Other structures that drain into the ethmoid infundibulum
bounded medially by the uncinate process, posteriorly by are the anterior ethmoid cells including the agger nasi cell,
the anterior wall of the bulla ethmoidalis and laterally by any frontal cells and the maxillary sinus.
the lamina papyracea (Fig. 1.17). In about 86 per cent of Note that the lateral wall of the ethmoid infundibulum
cases the infundibulum ends superiorly in a blind recess, is the lamina papyracea. When the uncinate process is
called the terminal recess (recessus terminalis), formed by removed and the ethmoid infundibulum is opened, the
the superior attachment of the uncinate process lateral to surgeon will encounter the lamina papyracea, which is an
the lamina papyracea. In cases in which a terminal recess is important intraoperative landmark.
The ethmoid complex 7
Retrobullar recess as Onodi cell (Fig. 1.22). The sphenoid sinus is usually
located inferiorly and medially, and not posteriorly, in
A small, variable, space may exist superior and posterior relation to the posterior ethmoids. The size of this cell
to the bulla ethmoidalis separating it from the skull base complex depends on the degree of encroachment by
and the basal lamella: this is referred to as the retrobullar the anterior ethmoid cells anteriorly and the sphenoid
recess. The boundaries of this recess are: the posterior posteriorly. A posterior ethmoid cell may pneumatize
wall of the bulla ethmoidalis anteriorly, the basal lamella posterolaterally and posterosuperiorly in relation to the
posteriorly, the skull base superiorly and the lamina anterior wall of the sphenoid. This is a sphenoethmoid
papyracea laterally (Fig. 1.18). This recess opens medially cell. In this situation, the sphenoid sinus will be located
through the hiatus semilunaris superioris. Removing the
bulla ethmoidalis and keeping the basal lamella intact
opens the retrobullar recess (Fig. 1.19). Three important
landmarks are encountered in this recess: the skull base
superiorly, the anterior ethmoid artery traversing the skull
base and the lamina papyracea laterally.
Posterior ethmoid cells
Located posterior to the basal lamella the posterior
ethmoid cells are larger in size and fewer in number
than the anterior ethmoid cells. The boundaries of the
posterior ethmoid cells are formed by the basal lamella
anteriorly, lamina papyracea laterally, skull base superiorly
and superior turbinate medially (Figs 1.20 and 1.21). The
posterior ethmoid cells drain under the superior turbinate
Figure 1.19 The anterior wall of the bulla ethmoidalis has been
into the superior meatus. The relationship of the posterior
removed but the posterior wall has been retained. A probe has
ethmoid cells with the sphenoid sinus depends on the
been passed through an opening in the posterior wall of the bulla,
presence or absence of a sphenoethmoid cell, also known
which drains into the retrobullar recess. Note the recess (ball
probe) between the posterior wall of the bulla ethmoidalis (1) and
the basal lamella (2).
Figure 1.18 Endoscopic view of the left middle meatus. The Figure 1.20 Endoscopic view of the left posterior ethmoid cells
retrobullar recess is a three-dimensional recess (5) bounded (3) bounded medially by the superior turbinate (2) and superiorly
anteriorly by the posterior wall of the bulla ethmoidalism (3) by the skull base (4). Note the sphenoid ostium (arrowhead)
and posteriorly by the basal lamella (4). Also seen are the middle medial to the superior turbinate in the sphenoethmoid recess.
turbinate (1) and uncinate process (2). Also seen is the middle turbinate (1).
8 Applied surgical anatomy of the nasal cavity and paranasal sinuses
Figure 1.21 The superior turbinate has been lifted revealing
the posterior ethmoid cells (pe). The probe has been placed in the
sphenoid ostium (asterisk). Note the basal lamella (arrowheads).
Figure 1.23 The left posterior ethmoid cells have been removed
to show the skull base superiorly and the lamina papyracea
laterally (6). Note the posterior ethmoid neurovascular bundle
* (3) as it traverses the skull base. Note the lamella (7) of the
superior turbinate (2) traversing laterally from an anteromedial
to a posterolateral direction. This posterior ethmoid cell is a small
sphenoethmoid cell, at the apex of which is seen the optic nerve
(5). The arrowhead is pointing to the sphenoid ostium. Also seen
are the posterior nasal septum (1) and the fovea ethmoidalis (4).
MAXILLARY SINUS OSTIUM
Figure 1.22 The posterior ethmoid cells have been removed.
Normally hidden from view by an intact uncinate process
Note the optic nerve (black asterisk) at the posterior superior
(Fig. 1.24), the maxillary sinus ostium is elliptical in
aspect of the lateral wall of this posterior ethmoid cell. This is
shape and approximately 7–11 mm long and 2–6 mm
likely to be a sphenoethmoid (Onodi) cell.
high. It is located at the junction of the anterosuperior
and posteroinferior aspects of the infundibulum (Figs 1.25
inferiorly and medially to this cell and not posterior to it
and 1.26). Removal of the uncinate process is necessary to
(Fig. 1.22).
visualize the opening (Figs 1.27 and 1.28).
The ostium lies in a slanted plane, almost 90° to the
Ethmoid roof orientation of the hiatus semilunaris and may be as deep as
18–20 mm. It leads into a short canal that runs inferiorly
The ethmoid roof is formed mainly by frontal bone. Its and laterally into the maxillary sinus.
average thickness is 5 mm and it slants posteriorly at an
angle of 15°. The ethmoid roof has several ‘crater-like’
impressions on it created by the ethmoid cells. These MAXILLARY WALL FONTANELLE
impressions are called the foveae. The most anterior fovea
is often referred to as the fovea ethmoidalis. The anterior and posterior fontanelles are membranous
The fovea ethmoidalis has important anatomical areas in the lateral nasal wall, formed by a double layer
relationships. Medially it joins the lateral lamella of the of mucosa that fills in the gaps in the bony lateral nasal
lamina cribrosa to form a very thin, fragile junction, about wall (Figs 1.29 and 1.30). The small anterior fontanelle is
one-tenth the thickness of the lateral skull base (Fig. 1.23). anterosuperior to the hiatus semilunaris inferioris. The
The vertical height between the cribriform fossa and the larger posterior fontanelle is posteroinferior to the hiatus
fovea ethmoidalis is variable, up to 17 mm, and may be semilunaris and forms the medial wall of the antrum
asymmetrical. The medial slope of the roof may also be between the natural ostium and the vertical plate of the
variable. The thin lateral lamella is at risk of penetration palatine bone. Often an accessory ostium is seen in this
during ethmoid dissection. area (10–50 per cent).
Frontal recess 9
Figure 1.24 The left natural maxillary ostium lies in the
Figure 1.26 A wide middle meatal antrostomy has been created
ethmoid infundibulum and cannot be visualized on this
on the left side. The bulla ethmoidalis (2) is still intact. Note
endoscopic view without removing the uncinate process. The
the middle turbinate (1), basal lamella (5), posterior wall of the
black asterisk shows the location of the natural maxillary ostium
maxillary sinus (4) and the lamina papyracea (3).
and the dotted lines indicate the portion of the uncinate process
that has to be removed to visualize the ostium. Also seen are
the middle turbinate (1), bulla ethmoidalis (2) and the uncinate
process (3).
Figure 1.27 A reverse cutting forceps has been engaged in the
ethmoid infundibulum to remove the lower part of the uncinate
process and expose the natural maxillary ostium which opens in
the ethmoid infundibulum.
FRONTAL RECESS
Figure 1.25 Endoscopic view of the left middle meatus. The
uncinate process has been removed to show the maxillary ostium The frontal recess is a complex anatomical area leading
(white asterisk). Note that the natural maxillary ostium is a from the anterior ethmoids superiorly to the frontal ostium
short three-dimensional channel rather than a two-dimensional (Figs 1.31–1.36). Its anatomical boundaries are formed by
structure. Also seen is the bulla ethmoidalis (1). Removal of the the agger nasi cell anteriorly, the anterior ethmoid artery
uncinate process opens the ethmoid infundibulum, the lateral posteriorly, the anterior portion of the middle turbinate
boundary of which is the lamina papyracea (2). medially, and the lamina papyracea laterally.
