CT of the paranasal sinuses: A pictorial review of normal

variants and potential pitfalls

Poster No.: C-1706

Congress: ECR 2010
Type: Educational Exhibit
Topic: Head and Neck
Authors: A. Kraus, S. Wenham, C. Barwick, U. Nair; Bangor/UK
Keywords: paransal sinuses, functional endoscopic sinus surgery, CT
DOI: 10.1594/ecr2010/C-1706

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Learning objectives

We present a spectrum of normal appearances, normal variants and potential pitfalls

encountered in CT of the paranasal sinuses.

Background

The existence of the paranasal sinuses has been known for a very long time. The earliest
reference can be found in the works of Galen (2nd century AD), who described the
presence of the ethmoid cells. Later Leonardo da Vinci (1489) described the maxillary
sinuses, Giacomo Berengario da Carpi (1521) the sphenoid sinuses and Volcher Coiter
(16th century) the frontal sinuses. The first modern, accurate description of the paranasal
sinuses can be found in the works of Emil Zuckerkandl, a 19th century Austrian anatomist.

Today, CT of the paranasal sinuses is a frequently performed examination. Especially if

functional endoscopic sinus surgery (FESS) is planned it is important to recognise normal
variants, so the ENT surgeon can be alerted to their presence.

With a modern, multi-slice CT scanner, the paransal sinuses are usually scanned
axially and coronal images are reconstructed. Soft tissue and bony windows are
used. Intravenous contrast is sometimes given, especially in neoplastic or inflammatory
processes, however in the majority of patients, especially for the evaluation of sinusitis,
only an unenhanced scan is performed.

The purpose of a CT scan in sinusitis is usually to detect irreversible disease processes,

like chronic disease or structural problems, which would benefit from surgical intervention,
rather than acute problems which will resolve with conservative management. It is
therefore important to time the scan appropriately to avoid confusion of acute and
irreversible processes. A CT scan should therefore only be obtained after acute sinusitis
has been appropriately treated. As changes from acute infections can last several weeks
it is recommended to wait at least 6 weeks after an acute episode before obtaining a scan
to determine the patient's baseline disease status.

Imaging findings OR Procedure details

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For correct interpretation of variants and pathologies of the paransal sinuses it is
important to know the normal anatomy.

The image below shows the important anatomical landmarks seen on coronal images.

1 - maxillary sinus

2 - inferior turbinate

3 - middle turbinate

4 - nasal septum

5 - uncinate process

6 - semilunate hiatus

7 - orbit

Page 3 of 23
Page 4 of 23
Fig.: Anatomy of the paransal sinuses.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The nasal septum and the inferior turbinate are the first structures encountered on
entering the nasal cavity with the endoscope during FESS.

The nasal septum forms the medial border of the nasal cavity. It consists of the
quadrangular cartilage anteriorly, extending to the perpendicular plate of the ethmoid
bone posterosuperiorly and the vomer posteroinferiorly. Recognizing deflections of the
nasal septum preoperatively is important because they may significantly contribute
to nasal obstruction and limit endoscopic visualization during surgery. Sometimes
septoplasty is necessary in conjuction with FESS.

Page 5 of 23
Fig.: Nasal septum deviation convex to the right.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The inferior turbinate extends along the inferior lateral nasal wall posteriorly toward
the nasopharynx. In patients with a significant allergic component to their problems,
the inferior turbinates may be edematous. These patients may benefit from a turbinate
reduction at the same time as the endoscopic sinus surgery. The inferior meatus, where
the nasolacrimal duct opens, is located approximately 1 cm beyond the most anterior
edge of the inferior turbinate.

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The next structure encountered in FESS is the middle turbinate. It is a key landmark in
endoscopic sinus surgery and has 3 anatomical parts. The anterior third runs vertically,
lying in the sagittal plane, running from posterior to anterior. Superiorly, the middle
turbinate attaches to the skull base at the lamina cribrosa of the cribriform plate. The
middle third turns coronally and laterally to insert on the lamina papyracea. The coronal
component of the middle turbinate is referred to as the basal lamella, and it represents the
dividing point between the anterior and posterior ethmoid air cells. The posterior portion
of the middle turbinate becomes horizontal and posteroinferiorly attaches to the lateral
nasal wall.

The uncinate process is the next key structure encountered in FESS. It is a hook shaped
bone of the lateral nasal wall and forms the anterior border of the ethmoid infundibulum
or hiatus semilunaris, which is the location of the osteomeatal complex, where the
natural ostium of the maxillary sinus opens. For patients with sinus disease, a patent
osteomeatal complex is critical for an improvement of symptoms. Anteriorly, the uncinate
process attaches to the lacrimal bone, and inferiorly, the uncinate process attaches to
the ethmoidal process of the inferior turbinate. The posterior edge lies in the hiatus
semilunaris inferioris. Superiorly, the uncinate process may attach to the middle turbinate,
the lamina papyracea, and/or the skull base.

The maxillary sinus, approximately 14-15 mL in volume, is bordered superiorly by the

inferior orbital wall, medially by the lateral nasal wall, and inferiorly by the alveolar portion
of the maxillary bone.

The next structure to be encountered in FESS is the ethmoid bulla, which is one of the
most constant anterior ethmoidal air cells. It is just beyond the natural ostium of the
maxillary sinus and forms the posterior border of the hiatus semilunaris. The lateral extent
of the bulla is the lamina papyracea. Superiorly, the ethmoid bulla may extend all the way
to the ethmoid roof (the skull base). Alternatively, a suprabullar recess may exist above
the roof of the bulla. CT is very helpful to clarify this relationship preoperatively.

The ethmoid sinus consists of a variable number (typically 7-15) of air cells. The most
lateral border of these air cells is the lamina papyracea, and the most superior border
of these cells is the skull base. Supraorbital ethmoid cells may be present. A review of
the patient's CT scan alerts the surgeon to these variations. The basal lamella of the
middle turbinate separates the anterior ethmoid cells from the posterior ethmoid cells.
Anterior ethmoid cells drain to the middle meatus, and the posterior cells drain into the
superior meatus.

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Fig.: Supraorbital ethmoid cell seen on an axial image.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

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Fig.: The same supraorbital ethmoid cell as above seen on a coronal section.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The sphenoid sinus is the most posterior of the paranasal sinuses, sitting just superior to
the nasopharynx and just anterior and inferior to the sella turcica. In FESS the sphenoid
sinus is reached by exenteration of the posterior ethmoid cells.

Several important structures are related to the sphenoid sinus. The internal carotid artery
is typically the most posterior and medial impression seen within the sphenoid sinus.
In approximately 7% of cases, the bone is dehiscent. The optic nerve and its bony
encasement produce an anterosuperior indentation within the roof of the sphenoid sinus.

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In 4% of cases, the bone surrounding the optic nerve is dehiscent. It is important to alert
the ENT surgeon in these cases.

Fig.: The roof of the sphenoid sinus is dehiscent here adjacent to the optical nerve.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The location of the natural ostium of the sphenoid sinus is variable; approximately 60%
are located medial to the superior turbinate, and 40% are located lateral to the superior
turbinate.

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The frontal recess, or the frontal outflow tract, is the tortuous tract that leads from the
frontal sinus into the nasal cavity. Often, the ethmoid bulla is the posterior border of the
frontal sinus outflow tract. Anteriorly, the frontal sinus outflow tract is bordered by the
uncinate process or the agger nasi cells (frontal anterior ethmoid air cells). If any of these
cells are enlarged or if scarring is present from a previous surgery, resultant outflow
tract obstruction, leading to frontal sinusitis, may occur. The lateral wall of the frontal
recess is bounded by the lamina papyracea. The medial boundary is the middle turbinate.
Posteriorly, the frontal recess is bordered by the anterior wall of the ethmoid bulla.

A systematic approach is helpful when interpreting CT scans. Reading the CT scan from
anterior to posterior (on coronal views) or from top to bottom (on axial sections) can help
organize one's approach in analyzing structures to be interpreted. For initial orientation,
a number of important paranasal sinus structures are identified, including the frontal
sinuses, the frontal recess, the agger nasi cells, the anterior ethmoidal sinus cells, the
ethmoid roof, the ethmoidal bulla, the uncinate process, the ethmoidal infundibulum, the
maxillary sinus, the middle meatus, the nasal septum, the turbinates, the basal lamella,
the posterior and anterior ethmoid cells, and the sphenoid sinus.

If FESS is planned following the CT scan, other anatomical and structural features also
need to be considered.

The thickness, orientation, and most medial position of the lamina papyracea must be
noted. Any dehiscences or excessive medial bowing of this thin bone should be noted
prior to surgery. Similarly, the depth of the olfactory fossa must be recognized. The
relationship of the sphenoid sinus and posterior ethmoid air cells in relation to the internal
carotid artery and optic nerves should be assessed.

It is also important to alert the surgeon to the presence of normal variants:

Agger nasi cells are the pneumatisation of the bony prominence in the ascending process
of the maxilla. Its location below the frontal sinus also defines the anterior limit of the
frontal recess.

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Fig.: Agger nasi cells.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

A concha bullosa is a pneumatized middle turbinate. An enlarged middle turbinate may

obstruct the middle meatus and the infundibulum causing recurrent disease. It may also
serve as a focal area of sinus disease.

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Fig.: Concha bullosa obstructing the outflow tract of the anterior ethmoid cells on the
right.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The Haller or infraorbital cell is usually situated below the orbit in the roof of the maxillary
sinus. It is a pneumatized ethmoid cell that projects along the medial roof of the maxillary
sinus. Enlarged Haller cells may contribute to narrowing of the ethmoidal infundibulum
and recurrent sinus disease, despite previous (incomplete) surgery.

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Fig.: Right sided Haller cell.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

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Fig.: Right sided Haller cell (red arrow) and bilateral conchae bullosae (yellow arrows).
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

Supraorbital ethmoid cells, together with agger nasi cells and unfavourable varions of the
ethmoid bulla and the uncinate process can influence the shape of the frontal recess and
cause problems with the frontal sinus outflow tract.

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Fig.: The same supraorbital ethmoid cell as above seen on a coronal section.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

A paradoxical middle turbinate means the major curvature of the middle turbinate projects
laterally, leading to narrowing of the middle meatus.

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Fig.: Paradoxical middle turbinate on the left. Also note the antrochoanal polyp and the
mucocele in the maxiallary sinus on the right.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

Onodi cells are the most posterior ethmoid cells that surround the optic canal and optic
nerve.

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Fig.: Right sided Onodi cell surrounding the canal of the optical nerve.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

The following images show further variants that can be found in imaging of the paranasal
sinuses.

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Fig.: Pneumatised Crista galli. This is clinically and in FESS especially important if
tehre is a connection to the ethmoid cells.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

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Fig.: Bony spurs at the floor of the maxillary sinuses bilaterally. This is usually not of
clinical significance, however in FESS a large spur can be mistaken for the lateral sinus
wall.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

Of course CT of the paranasal sinuses not only needs to assess potential variants but
also detect various disease states.

It is particularly useful in assessing acute and chronic sinusitis. Acute sinusitis is

caused by bacterial or fungal infections usually secondary to an obstructed sinus cavity.
Anatomical variations, mucosal oedema due to infection or allergy and compromise of

Page 20 of 23
nasocilliary flow can all contribute to acute as well as chronic sinusitis. CT findings
of acute sinusitis include sinus opacification, air-fluid levels, and thickened localized
mucosa. Thickening of the turbinates is a non-specific finding, which can be due to acute
inflammation as well as allergy or the normal nasal cycle.

In chronic sinusitis, repeated episodes of acute sinusitis or festering infection usually

combined with unfavorable anatomic factors lead to a vicious cycle of infection,
mucociliary incompetence, and chronic mucosal inflammation. CT findings suggestive of
chronic sinusitis include mucosal thickening, opacified air cells, bony remodeling, and
bony thickening due to inflammatory osteitis of the sinus cavity walls. Bony erosion can
occur in severe cases, especially if associated with massive polyps or mucoceles. CT
findings of bony destruction should raise the suspicion of less common diseases, such
as sinonasal tumors or granulomatous disease processes.

Sinonasal polyps can create sinus disease by obstruction or mass effect and by causing
secondary infections. Sinonasal polyps appear on CT scans as nodular or rounded
masses and amorphous opacified blobs of tissue. Bony remodeling can occur, but it is
typically subtle.

Fungal sinusitis can be divided into invasive fungal sinusitis, chronic noninvasive fungal
sinusitis (mycetoma), and allergic fungal sinusitis. Invasive fungal sinusitis due to
mucormycosis or aspergillosis is typically a disease that affects immunocompromised
patients and can have a fulminant course. Early in the disease process, opacification
of sinuses is seen. Disease progression to a more fulminant state accompanies
vascular invasion and localized destruction. Intracranial, cavernous sinus, and orbital
complications may occur with advanced infections. CT findings mirror these processes
with expanding localized destruction of bone.

Mycetomas appear inside the sinus cavity as noninvasive balls of fungus. CT findings
may include a localized sinus opacification, homogenous mass that does not change
shape with head position (gravity), and a mass with presence of calcifications (found in
25% of cases).

Allergic fungal sinusitis (AFS) may occur in atopic patients as a hypersensitivity reaction
to fungal antigens. Many patients with AFS may also have various degrees of nasal
polyposis. On CT scans, heterogeneous opacification can be seen with a typical
pattern of central hyperdense areas of opacification surrounded by less dense areas of
opacification. Calcified areas can sometimes be seen. Bony expansion, remodeling, and
even diffuse bony destruction can be seen in advanced cases.

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Fig.: Calcification within an opacified maxillary sinus. As there is also evidence of
chronic osteitis of the sinus wall this probably represents calcification of insipated
mucus rather than a fugal disease.
References: A. Kraus; X-ray department, Ysbyty Gwynedd, Bangor, UNITED
KINGDOM

Malignant neoplastic processes, like squamous cell carcinoma, are much less common.
A malignant process must be considered especially if there is bony destruction.

Page 22 of 23
Conclusion

It is important to be aware of normal variants of the paranasal sinuses seen in CT,

especially if sinus surgery is planned.

Careful review of the preoperative CT makes the surgeon aware of anatomical variations
and alerts him to potential pitfalls and difficulties.

Personal Information

References

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Bolger WE, Butzin CA, Parsons DS: Paranasal sinus bony anatomic variations and
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Elias R. Melhem et al.,:0ptimal CT Evaluation for Functional Endoscopic Sinus Surgery.

Am J Neuroradiol, 1996;17:181-188

Scuderi A, Harnsberger H, Boyer R: Pneumatisation of the Paranasal Sinuses: Normal

Features of Importance to the Accurate Interpretation of CT Scans and MR Images. AJR
1993; 160:1101-1104

Zinreich SJ et. al.:Concha bullosa: CT evaluation. J Comput Assist Tomogr 1988;

12:778-784

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