II.

13-Paranasal fossa
The paranasal air sinuses are air-containing cavities in the bones around the nasal cavity. The
paranasal air sinuses develop as mucosal diverticula of the main nasal cavity invading the adjacent
bones. They are lined by a pseudostratified ciliated columnar epithelium as in the nasal cavity
(Fig. 17.14).

There are four paranasal air sinuses on each side and are named after the bones containing them,
viz.
1. Frontal air sinuses present in the frontal bone.
2. Ethmoidal air sinuses present in the ethmoid bone.
3. Maxillary air sinuses present in the maxilla.
4. Sphenoidal air sinuses present in the sphenoid bone.

The paranasal air sinuses are arranged in pairs except the ethmoidal air sinuses, which are
arranged in three groups, viz. anterior, middle, and posterior on each side.

The orbit of eye serves as a landmark to appreciate the location of various paranasal air sinuses.

The relationship of the paranasal sinuses to the orbit is as follows:

_ the frontal air sinus above,
_ the maxillary air sinus below,
_ the ethmoidal air sinus medial to, and
_ the sphenoidal air sinus behind the orbit.
The sinuses exhibit two spurts of growth, viz:
1. First around 7–8 years (during the eruption of the teeth).
2. Second at puberty.

N.B. All the paranasal air sinuses are present in rudimentary form at birth except the frontal air
sinuses, which start developing 2 or 3 years after birth.
FUNCTIONS
Paranasal air sinuses perform the following functions:
1. Make the skull lighter.
2. Add resonance to the voice.
3. Act as air conditioning chambers by adding humidity and temperature to the inspired air.
4. Aid in the growth of facial skeleton after birth.

Clinical correlation

Sinusitis: The infection of a paranasal air sinus is called sinusitis. Clinically it presents as:
headache and persistent thick purulent discharge from the nose.
In standard radiological images, the normal paranasal air sinuses are radiolucent, whereas
diseased paranasal sinuses show varying degree of opacity. The newer imaging techniques, viz. CT
scan provide very clear images of the sinuses, which significantly aid in diagnosis .

CLASSIFICATION

Clinically the sinuses are divided into the following two main groups:

1. Anterior group: It includes those sinuses, which drain into the middle meatus, viz. frontal,
anterior and middle ethmoidal, and maxillary sinuses.
2. Posterior group: It includes those sinuses, which do not drain into the middle meatus, viz.
posterior ethmoidal and sphenoidal air sinuses.

FRONTAL AIR SINUSES

The frontal air sinus (two in number) lies between the inner and outer tables of the frontal bone
deep to medial part of the superciliary arch. They are triangular in shape. The right and left sinuses
are usually unequal in size and rarely symmetrical. The right is frequently larger than the left and
separated from it by a septum.
Each sinus drains into the anterior part of the hiatus semilunaris of the middle meatus through
frontonasal duct.

Measurements
Vertical: 3 cm.
Transverse: 2.5 mm.
Anteroposterior: 1.8 cm.

Relations
Anterior wall is related to: superciliary arch of forehead.
Posterior wall is related to: meninges and frontal lobe of the brain.
Inferior wall is related to: roof of nose, roof of orbit (medial part), and ethmoidal air cells.

Nerve Supply
It is by supraorbital nerve.
Clinical correlation
Frontal sinusitis: Infection of frontal air sinus may spread posteriorly into the anterior cranial
fossa causing frontal
lobe abscess or downwards into the orbit leading to orbital cellulitis.
The pain of frontal sinusitis is usually severe and localized over the affected sinus (frontal
headache). It shows
characteristic periodicity, i.e., it starts on waking, gradually increases and reaches its peak by about
midday and then
starts subsiding. It is also referred to as 'office headache' because of its presence during office hours.

MAXILLARY SINUS (ANTRUM OF HIGHMORE)

It is the largest of paranasal air sinuses and is present in the body of maxilla.
It drains into the hiatus semilunaris (posterior part) of the middle meatus.

Development
The maxillary sinus is first to develop. It appears about the 4th month of intrauterine life as an out-
pouching from the mucous membrane lining the lateral wall of the nasal cavity. It is rudimentary at
birth, enlarges rapidly during 6–7 years and becomes fully developed at puberty after the eruption
of
permanent teeth.

Measurements
Vertical: 3.5 cm.
Transverse: 2.5 cm.
Anteroposterior: 3.25 cm.

Shape
It is pyramidal in shape with the base directed medially towards the lateral wall of the nose and
its apex laterally towards the zygomatic bone.

Relations
Roof is formed by the floor of the orbit. The infraorbital nerve and artery traverse the roof in a
bony canal.
Floor (very small) is formed by the alveolar process of maxilla and lies about 1.25 cm below the
floor of the nasal cavity. The level of the floor corresponds to the level of the ala of nose. Normally
the roots of the first and second molar teeth project into the floor producing elevations but
sometimes roots of the first and second premolars, third molar, and rarely even that of canine may
project into the floor.
Sometimes roots of teeth are separated from the sinus only by a thin layer of mucous lining.
Base is formed by the lateral wall of the nose. It possesses the opening or ostium of the sinus in
its upper part, i.e., close to the roof, a disadvantageous position for natural drainage.
In the disarticulated skull, the base of maxillary sinus (medial surface of the body of maxilla)
presents a large opening—the maxillary hiatus, which is reduced in size by the following bones :
1. Uncinate process of ethmoid, from above.
2. Descending process of lacrimal, from in front.
3. Ethmoidal process of inferior nasal concha, from below.
4. Perpendicular plate of palatine from behind.

N.B. The nasolacrimal duct lies in the osseous canal formed by the maxilla, the lacrimal bone and
inferior nasal concha. It opens into the inferior meatus beneath the inferior nasal concha.
Apex extends into the zygomatic process of maxilla.

Anterior wall is formed by the anterior surface of the body of maxilla and is related to infraorbital
plexus of nerves. Within this wall runs the anterior superior alveolar nerve in a curved bony canal
called canalis sinuosus.

Posterior wall is formed by the infratemporal surface of the maxilla, separating the sinus from the
infratemporal and pterygopalatine fossae. It is pierced by the posterior superior alveolar nerves and
vessels.

Opening
Maxillary sinuses open in the hiatus semilunaris of middle meatus near the roof of the sinus.

Arterial Supply
It is by the anterior, middle, and posterior superior alveolar arteries from maxillary and infraorbital
arteries.

Lymphatic Drainage
The sinus drains into submandibular lymph nodes.

Nerve Supply
Maxillary sinuses are supplied by the anterior, middle, and posterior superior alveolar nerves from
the maxillary and infraorbital nerves.

Clinical correlation
• Maxillary sinusitis: Maxillary sinus is most commonly infected of all the sinuses due to following
reasons:
 Infection can reach into this sinus from infected nose (viral rhinitis), carious upper
premolar and molar teeth, especially molars, and infected frontal and anterior ethmoidal
sinuses.
 Being most dependent part, it acts as a secondary reservoir for pus from frontal air sinus
through frontonasal duct and hiatus semilunaris.
 Pain of maxillary sinusitis is referred to the upper teeth and infraorbital skin due to
common innervation by the maxillary nerve.
• Drainage of maxillary sinus: The opening of this sinus is unfortunately located in the upper part
of the lateral wall of nose, which is a disadvantageous site for adequate natural drainage. Surgically,
maxillary sinus is drained in the following two ways:
 Antral puncture (antrostomy) by using trocar and cannula, which are passed below the
inferior nasal concha in an outward and backward direction.
 Fenestrating the antrum through canine fossa in the gingivolabial sulcus (Caldwell–Luc
operation).
• Carcinoma of maxillary sinus: It arises from the mucous lining of the sinus. The signs and
symptoms produced by the invasion of the carcinoma can be easily remembered anatomically:
 The upward invasion into the orbit displaces the eyeball causing proptosis (protrusion of
eyeball) and diplopia (double vision).
 Involvement of infraorbital nerve produces pain and anesthesia in the skin over the face
below the orbit.
 The downward invasion into the floor produces visible bulge or even ulceration of palatal
roof of the oral cavity.
  The medial invasion encroaches the nasal cavity causing obstruction and epistaxis. The
obstruction of nasolacrimal duct in this wall produces epiphora (overflow of tears).
 The lateral invasion produces swelling on the face and palpable mass in the gingivolabial
fold (groove).
 Backward (posterior) invasion may involve the palatine nerves leading to severe referred
pain to the upper teeth.

ETHMOIDAL SINUSES
The ethmoidal air sinuses are made up of a number of air cells present within the labyrinth of
ethmoidal bone, thus they are located between the upper part of the lateral nasal wall and the orbit.

They are divided into the following three groups:

1. Anterior, consisting of up to 11 cells.
2. Middle, consisting of 1–3, usually three cells.
3. Posterior, consisting of 1–7 cells.
The first two groups—anterior and middle—drain into the middle meatus (anterior opens in the
hiatus semilunaris and middle on the surface of bull ethmoidalis) and the posterior into posterior
part of superior meatus.

Clinical Correlation

Ethmoidal sinusitis: It is often associated with infection of other sinuses. The pain is localized over
the bridge of nose medial to the eye.
The ethmoidal sinuses are separated from the medial wall of the orbit only by a very thin plate of
bone called
lamina papyracea, therefore the infection from these sinuses can easily spread into the orbit
producing orbital
cellulitis.

SPHENOIDAL SINUSES
The right and left sphenoidal sinuses lie within the body of the sphenoid bone above and behind the
nasal cavity. They are separated from each other by a bony septum. The two sinuses are usually
asymmetrical. Each sinus drains into the sphenoethmoidal recess of the nasal cavity.

Measurements
Vertical: 2 cm.
Transverse: 1.5 cm.
Anteroposterior: 2 cm.

Relations
Above: Pituitary gland and optic chiasma.
Below: Roof of the nasopharynx.
Lateral: Cavernous sinus and internal carotid artery (on each side).
Behind: Pons and medulla oblongata.
In front: Sphenoethmoidal recess.
Clinical correlation

Sphenoidal sinusitis: Isolated sphenoidal sinusitis is rare. It is usually a part of pansinusitis or is

associated with the
infection of posterior ethmoidal sinuses.
The infection of sphenoidal air sinuses spreading upwards may affect the pituitary gland and optic
chiasma.