Endoscopic Anatomy Of Nose And

Paranasal sinuses

Presenter : Maj S Raina

Moderator: Lt Col R Datta
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Outline
 Evolution and historical background
 Brief Gross anatomy
 Endoscopic Anatomy
 Diagnostic
 Surgical
 Fly through
 Anatomy, relations, variations, applied
and surgical aspects

2
Scope
 Important applied and surgical
endoscopic anatomy
 How it looks through the endoscope !
 Omitting radiological, embryological
and external anatomy

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Evolution
 Endo’ – within ; ‘skopeein’– to see
 Optical device with lighting
 Used to look inside a body cavity, organ

4
Evolution
 1806 Philip Bozzini, Frankfurt made a
"Lichtleiter" (light conductor) illuminated by
a candle
 1853 Desormeaux added
burning gas flame to it
- “father of endoscopy”
modified by Cruise and Andrews
light source and mirror attached to
the instrument.
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Evolution
 Lang Ebert's uretheroscope 1868
 Wales endoscope 1868
 Bruntons otoscope
 Endoscope and mirror combined,
light source separate

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Bruntons otoscope Wales endoscope

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Modern endoscopes
 Nitze-Leiter 1879, marks the second stage of
development
 German urologist ; developed Cystoscope
 ‘to light up a room one must carry the lamp
inside’. Used platinum wire light for
illumination

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 1945 – Karl Storz est his company
 1951-1965 Harold Hopkins, fundamental
improvements made
 Solid glass rods with lenses in between,
providing excellent resolution with good
contrast, a large visual field and perfect
fidelity of colour

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Gross anatomy
 External Nose
 Nasal Septum
 Lateral Wall of Nose
 Paranasal Sinuses

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Septum

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 Lateral wall
 INFERIOR TURBINATE
& MEATUS
 MIDDLE TURBINATE
& MEATUS
 SUPERIOR TURBINATE
& MEATUS
 SPHENOETHMOIDAL
RECESS

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Paranasal sinuses

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Paranasal sinuses
 Late 19th century Emil Zukerkandl published
first detailed anatomic & pathologic
description of PNS. “Father of modern sinus
anatomy”.
 Related to the regional anatomy of cranio-
oro-facial region.
 Varies from person to person and even side
to side
 “All but sphenoids develop from
invagination from lateral nasal wall”
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Paranasal sinuses
 Air-filled pockets within the cranium which
communicate with the nasal cavity & lined
with the same type of ciliated mucous
membrane
 Anterior Group:
 Frontal

 Maxillary

 Anterior ethmoid

 Posterior Group:
 Posterior ethmoid

 Sphenoid
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Frontal sinus
 Pyramidal shaped air
cells
 Can be considered as
an ant ethmoidal air
cell
 Rudimentary at birth,
first becomes distinct
at 6-8 yrs.
 Continuing
pneumatisation
into the frontal bone
forms
the frontal sinus

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 Fully developed b/w 12 & 14 yrs in female
and 16-18 yrs male
 Separated by bony septum, develop
independently and asymmetry between
them is rule than exception.
 Frontal recess-superior ascending part of
first primary furrow
 The roots of the confusing anatomy in the
area of frontal recess (frontonasal duct) go
back all the way to its embryonic
development
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Maxillary sinus
 Largest and most
constant PNS
 First sinus to develop
 Appears slit like –In
fetal life
 Shape(round or
elongated to gradually
pyramidal)
 Further growth follows
development of
maxilla
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Ethmoid sinus
 Complex group of small cells(3-14) located
within the Ethmoid bone
 At birth Ethmoid sinus fluid filled
 During primary pneumatisation ethmoids
develop from dimple like depression on nasal
mucosa. Deepen and become air cells
 Other structures i.e turbinates/uncinate/ bulla
are medial extension from lat nasal wall.

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 Complex anatomy & intersubject
variation
 For simplification divided into
series of parallel lamella
 First: Uncinate
 Second: Ethmoid bulla
 Third: Basal/Ground lamella
of MT
 Fourth : lamella of superior
Turbinate
 The lamellae are relatively
constant features between human
subjects, making intraoperative
recognition important
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Sphenoid sinus

 Develops as an
evagination from the
sphenoethmoidal
recess
 Small cavity at birth
 Extensive variation in
Pneumatisation,
asymmetry very
common

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Outline
 Evolution and historical background
 Brief Gross anatomy
 Endoscopic Anatomy
 Diagnostic
 Surgical
 Fly through
 Anatomy, relations, variations, applied
and surgical aspects

22
 Diagnostic nasal endoscopy
 A careful and methodical diagnostic
endoscopy is the key.

 Equipment

 Procedure

 Normal endoscopic findings

 Anatomical variations
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Equipment
 Light source
 Cable
 Endoscope [0 - 30
degree] , [wide
angle] , [2.7 - 4
mm]
 Suction tubes
[straight - curved]
 Forceps [forward -
upward]
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Position
Endoscopist Patient

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Passes in nasal endoscopy
S No Scott Stammberg AP Singh Bradoo
Brown er
First Pass Floor – Nasopharynx – Inf meatus

Second Spheno Spheno Spheno Spheno

pass ethmoid ethmoid ethmoid ethmoid
recess recess, sup recess, sup recess,
meatus meatus sup
meatus

Third Pass Return into Ant to post Ant to Post Both ways
middle direction into middle
meatus meatus 26
1st Pass
 0 or 30 degree scope passed gently along
the floor of nasal cavity b/w inf turbinate and
septum without touching them.
 Inferior meatus :NLD opening
 Floor of the nose, nasal septum
 Post nasal space, Roof of nasopharynx
 ET opening
 Mucus channels

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Endoscopic view

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Inferior turbinate
 Separate bone, inf
concha
 Irregular surface
with grooves for vs
 Maxillary process
articulates with
inf margin of
maxillary hiatus.
 Forms the med wall
of NLD
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Nasal septum & Floor
 Nasal septum and
the adjoining floor
can be visualized
while advancing
the scope
 Look for spurs,
mucosal anomalies

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Nasopharynx
 Eustachian tube
opening can be
visualised.The
cartilaginous end
protrudes in the
nasopharynx. Torus
tubaris and the fossa
of Rosenmuller is seen
 Dynamic study

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Inferior meatus
 Largest meatus
extending almost
entire length,
lateral to inf
turbinate
 Highest at jn of ant
and mid 1/3
 NLD opens just ant
to highest point

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2nd Pass
 Careful and gentle
handling
 Scope advanced b/w
septum & post part of MT
 Moved upwards medial to
MT along roof of post
choana & ant surface of
sphenoid
 ST and meatus seen
 Sphenoethmoidal recess
visualised,ostia 1-1.5cm
above the roof of post
choana 33
Sphenoid Sinus ostia
 Ostia 1-1.5 cm above the
post end of choana,
opens into the
Sphenoethmoid recess
 Least invasive access to
sphenoid
 Preferred route for Biopsy
/ sampling

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Middle turbinate
 3 Parts
 Anterior third : saggital plane attached
superiorly to lateral lamella of cribriform plate
 Basal Lamella : coronal plane attached to lamina
papyracea (separates the ethmoids)
 Related to ethmoid bulla intimately or

seperated by lateral sinus

 Posterior third: attached to lamina papyracea or
lateral wall of nose (roof of middle meatus)

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Anatomic variations
 Concha bullosa:ballooned air cell enclosed
within, pneumatised
 Interlamellar cell of Grunwald: pneumatised
vertical lamella
 Paradoxically curved turbinate
 Bifid turbinate: ground lamella attached to
lat wall of maxillary sinus instead of lamina
papyracea.

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Paradoxically curved MT, Bifid MT

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Concha bullosa

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Concha bullosa

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Spheno-ethmoid recess
 The recess lies med to sup turbinate and lat to
septum
 Bounded above by skull base, inf continuous
with post part of nasal cavity
 The ostia of sphenoid sinus opens 1-1.5cm
above roof of post choana
 Often hidden by view of sup turbinate
 Ostium shows variations in size and shape, being
circular, oval and sometimes pinpoint.
 Below the ostia is the mesh of bld vs forming the
Woodruff’s plexus. Septal br of sphenopalatine
artery runs across the ant wall of sphenoid. 40
41
Accessory Ostia
 Accessory ostia may be seen in the region
of ant fontanelle i.e. ant inf to ant end of
uncinate process or in the region of post
fontanelle i.e. above and behind the post
end of uncinate process (most common)
 Circular and easily seen unlike the natural
ostia which is often hidden.
 Incidence varies from 15-45 % with an
average of 25%.

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Accessory ostia

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3rd Pass
 Examine the
contents of middle
meatal region and
osteomeatal
complex
 Scope advanced
from ant to post.
to view middle
meatal contents

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Key anatomical features
 Osteo meatal Complex
 Uncinate Process
 Ethmoid bulla
 Lateral sinus
 Hiatus Semilunaris
 Infundibulum

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Uncinate process
 Thin sagittally oriented
bony leaflet
 Resembles a bent hook
or boomerang
 Convex anteroinf
 Overlies infundibulum
 Most imp surgical
landmark

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Variations in attachment

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Uncinate importance
 Risk of entering orbit due to proximity
to lamina papyracea
 Its medial end is strategical located
near the OMC
 Dynamics are such that any abnormal
growth or excess pneumatization of
uncinate can narrow the outflow of
sinuses

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Ethmoid bulla
 Ethmoid bulla is
largest and least
variable air cell in the
anterior Ethmoid
complex lying medial
to attachment of
lamina Papyracea

 Pneumatised in 70%

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Bulla ethmoidalis

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Attachments
 Lateral :Lamina Papyracea
along entire length
 Posterior :Expand to vertical
portion of basal lamella
 Superiorly :fuse with roof
of ethmoid sinus(forms
post wall of frontal
recess). If it does not
reach Ethmoid sinus
space is lateral sinus
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 When unpneumatized, appears as bony
projection from the lamina papyracea, called
as the torus lateralis.(apprx 8%)
3 variations
 Simple 47% single large cavity
 Compound 26% 2-3 compartments each
opens medially anterior
to basal lamella
 Complex 27% 2-3 compartments, one to
hiatus semilunaris above,
rest ethmoid
infundibulum
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Sinus lateralis
 Space designated by Gurnwald
(haitus semilunaris superior)
 Not constant feature
 Boundaries
 Lateral: Lamina Papyracea
 Superior: Roof of ethmoid
 Posterior: Ground lamella
 Anterior & Inferior: Ethmoidal bulla
 Reached through hiatus semilunaris medially
between Ethmoid bulla & Middle turbinate
 Localised disease may develop without
involving bulla, difficult to diagnose
endoscopically 53
Hiatus semilunaris
(Hiatus: Gap, Semilunaris: Cresent shape)
 2D slit between post
margin of uncinate and
the anterior face of
Ethmoid.
 Hidden by overhanging
middle turbinate
 Forms doorway that
leads to infundibulum

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Hiatus semilunaris

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Ethmoid infundibulum
 3 dimensionsal funnel-shaped passage
through which the secretions from anterior
ethmoid, maxillary sinus, and in some
cases, the frontal sinus are channeled into
the middle meatus.
 Medially: Uncinate process
 Laterally: Lamina Papyracea
 Ethmoid bulla superiorly
 Opens into middle meatus through hiatus
semilunaris

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57
Osteomeatal complex
 The uncinate process,
the ethmoid
infundibulum, anterior
ethmoid cells,and ostia
of the anterior ethmoid,
maxillary, and frontal
sinuses
 Final common drainage
pathway of ant gp of
sinuses
 Small amount of
obstruction here leads
to significant disease in
the larger frontal and
maxillary sinus
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 Functional area
59
OUTLINE
 Evolution and historical background
 Brief Gross anatomy
 Endoscopic Anatomy
 Diagnostic
 Surgical
 Fly through
 Anatomy, relations, variations, applied
and surgical aspects

60
Endoscopic Anatomy - Surgical
 Maxillary sinus ostia
 Agger nasi
 Lamina papyracea
 Ground lamella
 Roof of ethmoid and anterior ethmoid artery
 Posterior ethmoid cells
 Frontal sinus
 Sphenoid sinus
 Skull base

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Maxillary sinus ostium
 Anatomical entity of
utmost importance
 Can be elliptical,
rounded or oval
 Natural ostium is in ant
fontanelle
 Not visualised usually,
seen after uncinectomy
 2-3 Accessory ostia
may open in post
fontanelle

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 Ostium
Location in endoscopy

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 Nasal fontanelles
 Area on the lateral nasal wall above the IT
in which no bone exists
 Max sinus & Middle meatus separated only
by fibrous periosteum
 The anterior fontanelle is inferior and
anterior to the uncinate process
(inferolateral edge)
 the posterior fontanelle is superior and
posterior

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Applied aspects
 Damage to NLD in excessive ant widening

 Ant extenision may damage branches of ant

superior alveolar nerve (Branch of Infraorbital
nerve)…altered dental sensation

 If antrostomy extended too posterior inf meatal

branch of sphenopalatine artrey is encountered
 Main ostia of max sinus is very close to roof of
max sinus so care to be taken in middle meatus
antrostomy to avoid damage to roof of max
sinus, possible penetration into orbit
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Haller cells
 Infraorbital
ethmoid air cells
 Best studied on ant
and post coronal
CT images
 Adhere to roof of
maxillary sinus
forming the lat wall
of infundibulum
 Incidence of 10-
40%
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Agger nasi cells
 Ant most ant ethmoid air cells
 First prominent anatomical landmark
encountered in FESS
 Location: ant sup to insertion of ant 1/3 of MT
and ant to uncinate (sagittaly)
 Endoscopically seen as a ridge, prominence or
mound on lat wall
 Boundaries : ant- frontal process of maxilla
post- ethmoidal infundibulum
sup- frontal recess and sinus
inf med- uncinate process
lat- nasal and lachrymal bones
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Agger cells
 Normal appearence  Pneumatised

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Surgical significance
 When prominent hides view of uncinate
endoscopically
 Can encroach and fill entire frontal recess
which is medial to it and hence obstruct the
frontal sinus
 Incomplete removal common cause of surgical
failure
 If pneumatised removal can cause injury to
lacrimal apparatus.

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Lamina papyracea
 Lateral wall of ethmoid labyrinth
 Smooth, papery thin bone with dehiscences
 Cone shaped, wide ant and narrow post
 Provides attachment to ground lamella of MT
 Endoscopically identified as a medial bulge on
pressing the orbital contents which return to
normal with release of pressure
 Radiologically delineated best on coronal and
axial cuts
 Yellow coloured

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Surgical importance
 Faster spread of infection into orbit from
ethmoids
 Voilation of lamina alone with intact periorbita
rarely causes serious complications
 Can get damaged during
 Uncinectomy

 Widening of ostium

 Removal of bulla

 Dissection of post ethmoid complex

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Ground lamella
 Forms the distinction between the ant and post gp of
sinuses
 It is constant, complete, best developed and strongest of
the lamellas formed by mid 1/3 of MT
 Ant 1/3 of MT is entirely vertical, inserts directly into skull
base
 Mid 1/3,line of insertion changes sharply inferiorly (free
vertical segment seen in frontal plane)
 Post 1/3 of MT ground lamella turns sharply towards
horizontal forming roof of post 1/3 of MT
 The pattern of insertion contributes to stability

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After removing ant ethmoids

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Anatomic variations
 Free vertical segment can be oriented
postsup. by well pneumatised ant
ethmoidal air cells (esp with developed
lateral sinus)
 Cells of post ethmoids can bulge it
anteriorly.

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 Ant lat and post  Indentation by
med view lateral sinus and
post ethmoid cells

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Roof of ethmoid
 Also termed fovea ethmoidalis
 Domes of top most ethmoid cells bulge into
it
 Ant part higher than post, sloping from ant
to post at 15 degrees
 Med wall in sup part formed by frontal bone
and inf part by lamina cribrosa
 Ant ethmoidal artery pierces the lat lamella
of lamina cribrosa

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Surgical importance
 Ant ethmoidal artery
intimately related
 Identification
endoscopically:
 follow ant surface of
Ethmoid bulla in
direction of roof
 If bulla extends to
roof,seen adjacent to
this point 1-2 mm
posteriorly
 If not may be seen
in lateral sinus

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Posterior ethmoid cells
 Ground lamella forms
the partition between
ant and post ethmoid
air cells
 Located post and sup
to ground lamella
 No of cells vary b/w 1
and more than 5
 Drain into the sup or
supreme meati
 Of great importance to
sinus surgeons as they
can develop lat and
sup to sphenoid sinus

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Surgical importance
 Most vulnerable point-jn of rostrum with roof of
post ethmoid (can be mistaken for sphenoid –entry
into cranium)
 Dissection in the posterior Ethmoids could result in
trauma to the optic nerve which is adjacent
 Precaution while entering sphenoid
 inferomedial approach in posterior ethmoid

 safest way for sphenoid is to extend from

sphenoethmoid recess
 Lamina papyracea forming lateral wall may show
dehiscence , orbital content may prolapse

80
Onodi’s cell
 ONODI cells( Sphenoethmoidal cell) the most
posterior ethmoid cell, could extend posteriorly
along the lamina Papyracea into the anterior
wall of the sphenoid sinus.
 Incidence-9-12%
 In presence of Onodi’s cell optic nerve and med
rectus ms lie in close relation with lat wall of
these cells- vulnerable to injury during surgery

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Onodi’s cell
 Endoscopic view

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83
Frontal sinus
 Pyramidal shaped air
cells expanded between  Endoscopic view
anterior and posterior
tables of the vertical
plate of frontal bone.
 Theories:
 direct extension of the
frontal recess
 by end of 2nd yr one
ant Ethmoid cell
migrate upward and
forms frontal sinus
 Ethmoid infundibular
cell

84
Frontal recess

 Through which the

final clearance from
frontal sinus takes
place
 Medially is middle
turbinate
 Posteriorly is bulla
 Laterally is lamina
Papyracea
 Anteriorly frontal
process of maxilla

85
Endoscopic appearence

86
Radiological appearence

87
Applied aspect
 Considering complexities of frontal recess serial
CT scans required to know the exact anatomy
 Infections from frontal sinus can spread
through its thin posterior wall resulting into
extradural abscess.
 Extensively pneumatised agger nasi can be
mistaken for the frontal recess or sinus. If
opened and mistaken for a frontal sinus, the
residual posteriosuperior wall of the agger nasi
cell can scar and iatrogenic stenosis of the
frontonasal connection can occur

88
Sphenoid sinus
 Pneumatize from
sphenoethmoidal
recess from birth
 Extensive variation
 3 types based on
pneumatisation
 Conchal(fetal) 2%

 Presellar(juvenile)

10-24%
 Sellar(adult) 86%

89
Relations

 Superior : thin bone, base of skull

 Direct contact with olfactory nerve, optic

nerve & optic chiasma & Hypophysis

 Continues with roof of Ethmoid so landmark

for dissection
 Lateral wall: normally thin layer of bone cover
 optic nerve
 Internal carotid artery

90
Endoscopic appearence
 Post ethmoid cells  Interior of
removed sphenoid sinus

91
Anatomic variations
 Variations in course of ICA in relation
to sphenoid sinus
 Result in different pattern of bulge in
wall of the sinus

92
Applied aspect
 Optic nerve extend backwards and disappears
towards post wall.
 ICA adjacent during passage through cavernous
sinus
 May not have a resistant bony covering
 25% ICA partially dehiscent

 6% dehiscent optic nerve

 Maxillary nerve(V2) may also be seen on lateral

wall as a bulge, may even be surrounded by
pneumatisation
 Canal for vidian nerve may bulge on floor of
sphenoid sinus

93
Endoscopic appearance after
widening of ostia

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Widening the horizon
 Virtual 3-D imaging of sinuses
 Combined radiological, endoscopic and 3-D
assessment pre operatively
 Individual flexible sinoscopes
 3-D CT Aided Surgery
 3-D CT Reconstruction
 Skull Markers
 Sensors on Endoscope and Instruments
 Realtime Visualisation of Location of Instruments
within Sinuses during any procedure

95
Conclusions
 Endoscopic anatomy crucial for any
surgery
 Variations in anatomy is the rule
 Correlation with imaging to interpret
anatomy correctly
 Ever learning experience

96
References
 Functional endoscopic sinus surgery-
Stammberger
 Scott Brown’s otolaryngology, head and
neck surgery, 7th Edition
 Anatomical principles of endoscopic sinus
surgery-Renuka Bradoo
 Comprehensive review of functional
endoscopic sinus surgery-AP Singh
 Endoscopic sinus surgery,a practical
approach-SK Kaluskar
 Various internet search results.

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Thank You for a
patient hearing

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