Computed tomography road map of the paranasal sinuses

for treatment planning

Poster No.: C-2607

Congress: ECR 2013
Type: Educational Exhibit
Authors: N. Schembri, A. S. Gatt, D. Ellul, J. Brunton; Dundee/UK
Keywords: Ear / Nose / Throat, CT, Normal variants, Diagnostic procedure,
Structured reporting, Education and training
DOI: 10.1594/ecr2013/C-2607

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 21
Learning objectives

Computed tomography (CT) has superseded plain radiography in delineating bony

anatomy. The role of CT in preoperative planning prior to functional endoscopic sinus
surgery (FESS) has been well established. Complex anatomy and congenital anatomical
variants of the paranasal sinuses impose an interpretation challenge to radiologists and
intraoperative technical challenges to the surgeon.

This poster aims to present a systematic approach utilising reformat CT reconstructions

to discuss

i. anatomy

ii. clinically significant anatomical variants

iii. terminology used in FESS

with a view to encourage more accurate preoperative interpretation of normal and

aberrant anatomy that plays a key role in the diagnosis and safe surgical management
of these patients.

Background

What is FESS?

Devised by Messerklinger & Stammberger in the 1980s & 1990s, FESS is a minimally
invasive surgical procedure that offers access to nasal and sinus cavities facilitating
the use of different instruments to identify & restore the proper drainage & ventilation
relationships between the nose and sinus cavities. It relies on preservation and
restoration of normal flow of mucosal secretions.

Advantage Disadvantage
Minimally invasive technique Proximity of the sinuses to the eyes, optic
nerves, brain and internal carotid arteries

Access to nasal cavity via nostrils

Page 2 of 21
Indications for FESS

Chronic sinusitis refractory to medical treatment is the main clinical indication, which
includes:

• recurrent acute sinusitis

• nasal polyposis
• antrochoanal polyps
• sinus mucoceles

Other uses include excision of selected tumours, CSF leak closure, orbital
decompression (e.g. in Graves' ophthalmoplegia, optic nerve decompression),
dacryocystorhinostomy, choanal atresia repair.

What does the surgeon want to know?

The surgeon relies on expert radiologist interpretation of CT of the paranasal sinuses

such that imaging acts as a road-map of anatomy, highlighting normal variants, in
particular hazardous ones, in order to prevent catastrophic complications.

The radiologist's goal is to report on five key points:

1. the extent of sinus opacification/disease

2. opacification of sinus drainage pathways
3. anatomical variants
4. critical variants
5. condition of surrounding soft tissues of the neck, brain and orbits

Imaging findings OR Procedure details

The following is a stepwise approach, starting at the external nares, to viewing the
nasal cavity with cross-sectional imaging using 3D multiplanar reformats (MPR) of the
paranasal sinuses acquired using a 64-slice multidetector CT scanner.

st
STEP 1 - NASAL SEPTUM - 1 structure encountered

Normal Variant - Septal deviation may cause nasal cavity obstruction limiting endoscopic
visualisation and access.

Page 3 of 21
Implication - Patients may need pre-operative counselling for the need of septoplasty
during FESS procedure.

STEP 2 - FRONTAL/KUHN'S AIR CELLS

The frontal air cells constitute the most complex of all the paranasal sinus drainage
pathways. The frontal sinus drainage pathway (FSDP) has 2 compartments: superior and
inferior. The latter is a narrow passageway formed by either the ethmoid infundibulum
or the middle meatus depending on variable anatomical attachment of the uncinate
process to the lamina papyracea or skull base. The frontal air cells constitute the
superior compartment. They are divided into types I - IV according to their pattern of
pneumatisation as per Bent et al (Figure 1).

• Type I - single cell above the agger nasi and inferior to frontal sinus floor
• Type II - this is a stack of air cells above the agger nasi, extending to inferior
frontal sinus; it is the multiplicity of cells that distinguishes it from the Type I
• Type III - usually large, above agger nasi extending into frontal sinus
• Type IV - infrequent; isolated cells located within the frontal sinus

Implication - They interfere with frontal recess drainage pathway if large.

STEP 3 - BASAL LAMELLA of the MIDDLE TURBINATE

This divides the anterior from the posterior ethmoid air cells and serves as a landmark
for access to the posterior ethmoidal air cells.

Normal Variants of the Middle Turbinate

• Concha bullosa (Figure 2) - common (15 - 45%) usually of little clinical

significance.
• Paradoxical middle turbinate (Figure 3) - paradoxical lateral convexity may
lead to obstruction of middle meatus.

Implication - This has a critical attachment to the base of skull at the cribriform plate. It
must also be preserved since it serves as a landmark for revision surgery.

STEP 4 - UNCINATE PROCESS

Page 4 of 21
The uncinate process (Figure 4) is part of the ethmoid bone and demonstrates variable
anatomy. It serves as a landmark for the osteomeatal complex (OMC), lying just posterior
to it. The osteomeatal complex is the confluence of the ethmoid bulla, maxiallary ostium
laterally, uncinate process inferolaterally and the middle turbinate medially (Figure 5).
The role of the uncinate process is that of facilitating drainage of the frontal recess. The
uncinate process has a complex attachment:

• Anteriorly - to nasolacrimal apparatus

• Inferiorly - to inferior turbinate
• Posteriorly - it has a free margin
• Superiorly - its attachment is variable

Variant insertion of its superior attachment is classified according to the criteria developed
by Landsberg and Freidman (Figure 6). With usual anatomical configuration, removal of
the uncinate process opens into the ethmoid infundibulum.

Normal Variants - Lateral deviation of the uncinate process may cause narrowing of the
hiatus semilunaris and infundibulum.

Implication - There is a high risk of entry into the orbit if too lateral leading to surgical
emphysema & risk of subsequent loss of vision.

STEP 5 - ETHMOID AIR CELLS

The ethmoid bulla is a reliable surgical landmark - it is the largest and most constant
anterior ethmoid air cell. It is bound superiorly by the floor of the anterior cranial fossa
and laterally by the lamina papyracea (Figure 7).

Implication - (a) laterally - risk of penetration especially of a dehiscent lamina papyracea

with risk of damaging orbital contents, (b) superiorly - penetration into floor of anterior
cranial fossa.

Normal Variants

• AGGER NASI CELL - consistent finding; it is the most anterior ethmoid air
cell lying just anterior to attachment of middle turbinate and frontal recess
(Figure 8).

Implication - if large may cause medial displacement of the middle turbinate causing
narrowing of the frontal recess.

Page 5 of 21
 • HALLER CELL - infraorbital cell extending to floor of orbit (Figure 9).

Implication - may cause narrowing of maxillary sinus ostium/ethmoid infundibulum.

• Posterior ethmoid air cells may have a variable relationship with the
sphenoid sinus and may extend superiorly and laterally to sphenoid sinus.

Implication - It is important to describe their relationship to the sphenoid sinus for

accurate route mapping.

• ONODI CELL - posterior ethmoid air cell (5%) extending to the sphenoid
sinus lying medial to the optic nerve (Figure 10). It displaces the sphenoid
sinus medially and inferiorly.

Implication - Potential damage to (a) the optic nerve (in 5%), and less commonly, (b)
the internal carotid artery when attempts are made at endoscopy to enter the sphenoid
sinus via what is thought to be the most posterior ethmoid cell rather than an Onodi cell.

STEP 6 - SPHENOID SINUS

Hazardous regional structures include:

• Internal carotid artery - most posterolateral structure; may also be dehiscent

(Figure 11).
• Optic nerve- anteroposterior indentation in the roof - may be seen dehiscent
in 4% (Figure 12).

STEP 7 - CRIBRIFORM PLATE

The keros classification describes the position of the cribriform plate relative to the fovea
ethmoidalis (Figure 13):

1. Keros I - 1 - 3mm
2. Keros II - 3 - 7mm
3. Keros III - 7 - 16mm

Implication - There is a higher risk of intracranial penetration with increasing depth and
risk of damaging the anterior and/or posterior ethmoidal artery (Figure 14) as they cross
the ethmoid sinus to enter the anterior cranial fossa via the cribriform plate back into the
nasal cavity especially if dehiscent. Implications are worse in the case of a dehiscent
anterior artery as compared with the posterior.

Page 6 of 21
Images for this section:

Fig. 1: Coronal section CT showing a type III frontal air cell (arrow) - this is usually large,
situated above the agger nasi, extending into the frontal sinus. As depicted by this case,
these cells can cause obstruction to frontal recess drainage.

Page 7 of 21
Fig. 3: Coronal CT reformat of the paranasal sinuses at the level of the middle
turbinate depicting a paradoxical left middle turbinate (dashed arrow). This particular
case also demonstrates left uncinectomy and left maxillary antral polypoid sinus disease.
A paradoxical middle turbinate can cause obstruction to the nasal cavity and middle
meatus.

Page 8 of 21
Fig. 4: Sagittal CT section of the nasal cavity demonstrating the paranasal drainage
pathway.

Page 9 of 21
Fig. 5: Coronal CT section demonstrating the uncinate process (UP) and maxillary antral
ostium (MO), which form part of the osteomeatal complex (OMC).

Page 10 of 21
Fig. 13: This coronal CT image depicts a Keros type II - 6mm descent of the cribriform
plate (CP) from the fovea ethmoidalis (FE). There is a higher risk of intracranial
penetration with increasing depth of the cribriform plate.

Page 11 of 21
Fig. 12: Dehiscent right optic nerve (arrow) as demonstrated by coronal CT section.

Page 12 of 21
Fig. 11: Dehiscent left internal carotid artery (arrow) as demonstrated on axial CT section
of the middle cranial fossa.

Page 13 of 21
Fig. 10: CT Sagittal and coronal CT section in the same patient showing ethmoidal air
cell normal variants - Onodi air cell (arrow).

Fig. 9: CT coronal section showing ethmoidal air cell normal variants - Haller cell.

Page 14 of 21
Fig. 8: CT Sagittal section showing ethmoidal air cell normal variants - agger nasi (arrow).

Page 15 of 21
Fig. 7: Sagittal CT demonstrating an ethmoid bulla (arrow) complicated by sinusitis and
an effusion. The ethmoid bulla is bound superiorly by the floor of the anterior cranial fossa
and laterally by the lamina papyracea.

Page 16 of 21
Fig. 14: Axial CT section demonstrating a dehiscent left posterior ethmoidal artery
(arrow). A low lying cribriform plate puts both the anterior and posterior ethmoidal arteries
at risk as they cross the ethmoid sinus to enter the anterior cranial fossa via the cribriform
plate back into the nasal cavity especially if dehiscent.

Page 17 of 21
Fig. 6: Landsberg aand Friedman classification of superior uncinate process insertion.
a) Type 1 - insertion into lamina papyracea, b) Type 2 - insertion into the posterior wall
of the agger nasi cell, c) insertion into the lamina papyracea and junction of the middle
turbinate with the cribriform plate, e) Type 5 - insertion into the skull base, f) Type 6 -
insertion into the middle turbinate.

Page 18 of 21
Conclusion

• Major complications of FESS can be catastrophic.

• Detailed knowledge of normal and anomalous anatomy is essential for safe,

successful sinus surgery.

• CT is the gold standard imaging modality in the preoperative diagnosis for

FESS.

• Radiologists' familiarity with FESS technique & adopting a systematic

approach is crucial to reviewing CT imaging for normal and variant anatomy
of the paranasal sinuses.

References

1. Bent JP, Cuilty-Siller C, Kuhn FA. The frontal cell as a cause of frontal sinus
obstruction. Am J Rhinol 1994; 8: 185-191.
2. Gonçalves FG, Jovem CL, Moura LO. Computed tomography of intra- and
extramural ethmoid cells: iconographic essay. Radiol Bras. 2011 Set/Out;
44(5): 321-326.
3. Amit ND Dwivedi, Kapil K Singha. CT of the Paranasal Sinuses: Normal
Anatmoy, Variants and Pathology. Journal of Optoelectronics and
Biomedical Materials 2010; 2(4): 281-289.
4. Cashman EC, MacMahon PJ, Smyth D. Computed tomography scans of
paranasal sinuses before functional endoscopic sinus surgery. World J
Radiol. 2011 August 28; 3(8): 199-204.
5. Gotwald TF, Zinreich SJ, Corl F, Fishman EK. Three-Dimensional
Volumetric Display of the Nasal Ostiomeatal Channels and Paranasal
Sinuses. AJR January 2001; 176 (1): 241-245.
6. Daniels D et al. The Frontal Sinus Drainage Pathway and Related
Structures. AJNR 2003; 24: 1618-27.
7. Miranda, Christiana Maia Nobre Rocha de et al. Anatomical variations
of paranasal sinuses at multislice computed tomography: what to look
for.Radiol Bras [online]. 2011; 44 (4): 256-262.
8. Turgut S, Ercan I, Sayin I, et al. The relationship between frontal sinusitis
and localization of the frontal sinus outflow tract: a computer-assisted
anatomical and clinical study. Arch Otolaryngol Head Neck Surg. 2005; 131:
518-22.

Page 19 of 21
Personal Information

N. Schembri (corresponding author)

Specialist Registrar

Clinical Imaging Department

Ninewells Hospital and Medical School

Dundee

DD1 9SY

U.K.

Tel: 00441382-660111 Bleep 3008

Email: nschembri@nhs.net

A.S. Gatt

Specialist Registrar

Clinical Imaging Department

Ninewells Hospital and Medical School

Dundee

DD1 9SY

U.K.

D. Ellul

Specialist Registrar

Department of Otolaryngology

Ninewells Hospital and Medical School

Dundee

DD1 9SY

Page 20 of 21
U.K.

J.N. Brunton

Consultant Radiologist

Clinical Imaging Department

Ninewells Hospital and Medical School

Dundee

DD1 9SY

U.K.

Page 21 of 21