Anatomy of Nasal Sinuses

Paranasal sinuses are air-containing

cavities in certain bones of skull, and
they are four on each side. Clinically,
paranasal sinuses have been divided
into two groups:
Anterior group. This includes maxillary,
frontal and anterior ethmoidal. They all
open in the middle meatus.
Posterior group. This includes posterior
ethmoidal sinuses which open in the
superior meatus, and the sphenoid
sinus which open in sphenoethmoidal
recess.
1. Maxillary Sinus
It is the largest of
paranasal sinuses and
occupies the body of maxilla.
It is pyramidal in shape with
base towards lateral wall of
nose and apex directed
laterally into the zygomatic
process. On an average,
maxillary sinus has a capacity
of 15 ml in an adult.
 Ostium of maxillary sinus is situated high up in medial wall and opens
in the posterior part of ethmoidal infundibulum into the middle
meatus. Roof of the maxillary sinus is formed by the floor of orbit. It is
traversed by infraobital nerve and vessels.
2. Frontal Sinus
Each frontal sinus is situated between the inner and outer tables of
frontal bone, above and deep to the supraorbital margin. The two
frontal sinuses are often asymmetric and the intervening bony septum is
thin and often obliquely placed or may even be deficient. Frontal sinus
may be absent on one or both sides or it may be very large.
Ø Anterior wall: the sinus is
related to the skin over the
forehead;
Ø Inferior wall: the orbit and its
contents;
Ø Posterior wall: the meninges
and frontal lobe of the brain.
Ø Opening of frontal sinus is
situated in its floor and through
a canal called frontonasal duct
drains into frontal recess, and in
the anterior of middle meatus.
3. Ethmoidal Sinuses
Thin-walled air cavities in the lateral masses of ethmoid bone, from
3 to 18. They occupy the space between upper third of lateral nasal
wall and the medial wall of orbit. Clinically, ethmoidal cells are divided
into which opens into the middle meatus, and
which opens into the superior meatus and
sphenoethmoidal recess.
4. Sphenoid Sinus It occupies the body of sphenoid. The
two, right and left sinuses, are rarely symmetrical and are
separated by a thin bony septum. Ostium of the sphenoid
sinus is situated in the upper part of its anterior wall and
drains into sphenoethmoidal recess.
drainage of sinus
DISEASES OF PARANASAL SINUES
 According to the duration of the disease, sinusitis is
divided into two categories: acute and chronic.
Acute rhinosinusitis (ARS) is defined as the sudden onset
of symptoms lasting less than 12 weeks ( with sypmtom free
intervals complete resolution of symptoms, if the problem is
recurrent). ARS can occur once or more than once in a
defined time period. This is usually expressed as
episodes/year, but there must be complete resolution of
symptoms between episodes for it to constitute recurrent
ARS.
 Nasal sinuses are divided into two groups:
Ø Anterior group. This includes maxillary, frontal and anterior
ethmoidal. They all open in the middle meatus.
Ø Posterior groups. This includes posterior ethmoidal sinuses which
open in the superior meatus, and the sphenoid sinus which open in
sphenoethmoidal recess.
 Acute inflammation of sinus mucosa is called acute sinusitis. The sinus
most commonly involved is the maxillary followed in turn by ethmoid,
frontal and sphenoid. Very often, more than one sinus is infected
(multisinusitis ). Sometimes, all the sinuses of one or both sides are
involved simultaneously (pansinusitis unilateral or bilateral).
 (a) Exciting Causes
Ø Nasal infections. Sinus mucosa is a continuation of nasal mucosa and
infections from nose can travel directly by continuity or by way of
submucosal lymphatics.
Ø Swimming and diving. Infected water can enter the sinuses through
their ostia.
Ø Trauma. Compound fractures or penetrating injuries of sinuses (frontal,
maxillary and ethmoid) may permit direct infection of sinus mucosa.
Ø Dental infections. This applies to maxillary sinus. Infection from the
molar or premolar teeth or their extraction may be followed by acute
sinusitis.
(b) Predisposing Local Causes:
Ø Obstruction to sinus ventilation and
drainage. Normally, sinuses are well-
ventilated. They also secrete small
amount of mucus, which by ciliary
movement, is directed towards the sinus
ostia from where it drains into the nasal
cavity. Any factors which interfere with
this function can cause sinusitis due to
stasis of secretions in the sinus.
 Factors which interfere with sinus ventilation and drainage
Ø Nasal packing
Ø Deviated septum
Ø Hypertrophic turbinates
Ø Oedema of sinus ostia due to allergy rhinitis
Ø Nasal polypi
Ø Structural abnormality of ethmoidal air cells
Ø Benign or malignant neoplasm.
(c) General causes
Ø Environment. Sinusitis is common in cold and wet climate. Pollution,
smoke, dust and over-crowding also predispose to sinus infection.
Ø Poor general health. Recent attack of exanthematous fever
(measles, chickenpox, whooping cough), nutritional deficiencies,
systemic disorders (diabetes, immune deficiency syndromes).
（d） Bacteriology
u Most cases of acute sinusitis start as viral
infections followed soon by bacterial invasion.
u The bacteria most often responsible for acute
suppurative sinusitis are Strept. pneumoniae, H.
influenzae, Moraxella catarrhalis, Strept.
pyogenes, Staph. aureus and Kleb. pneumoniae.
Anaerobic organisms and mixed infections are
seen in sinusitis of dental origin.
 B. Pathology Acute inflammation of
sinus mucosa causes hyperaemia, exudation
of fluid and increased activity of serous and
mucous glands. Depending on the virulence
of organisms, defences of the host and
capability of the sinus ostium to drain the
exudates, the disease may be mild (non-
suppurative) or severe (suppurative). Initially,
the exudate is serous; later it may become
mucopurulent or purulent. Severe infections
cause destruction of mucosal lining. Failure of
ostium to drain results in empyema of the
sinus and destruction of its bony walls leading
to complications.
C. Clinical features
ü Headache
ü Pain
Different areas in the nasal
cavity may cause referred
pain in various regions of the
head.
ü Tenderness
ü Redness and oedema of cheek
ü Nasal discharge
ü Postural test
 A sinusitis may be 'open~ or 'closed' type depending on
whether the inflammatory products of sinus cavity can drain
freely into the nasal cavity through the natural ostia or not. A
'closed' sinusitis causes more severe symptoms and is also
likely to cause complications.
 D. Diagnose
ü Headache
ü Pain
ü Tenderness
ü Redness and oedema of cheek
ü Nasal discharge
ü Postural test
üEndoscopy

mucopurulent serous nasal

discharge

purulent
 Waters view showing right acute maxillary
sinusitis. There is an air–fluid level in the right
maxillary sinus

Coronal CT shows bilateral maxillary sinusitis

üAffected sinus will be found opaque by X-rays

 E. Complications
Ø Acute maxillary sinusitis may change to chronic sinusitis.
Ø Frontal sinusitis. Frontonasal duct which opens in middle meatus is
obstructed due to inflammatory oedema. Pott’s puffy tumor.
ØOsteitis or osteomyelitis of
the maxilla
Ø Orbital cellulitis or abscess.
Infection spreads to the orbit
either directly, from the roof of
maxillary sinus or indirectly, after
involvement of ethmoid sinuses.
 F. Treatment
l Antimicrobial drugs. Ampicillin and amoxicillin are quite effective
and cover a wide range of organisms. Erythromycin or doxycycline or
cotrimoxazole are equally effective. The use of amoxicillin/clavulanic
acid or cefuroxime axetil is good. Sparfloxacin is also effective, and
has the advantage of single daily dose.
l Nasal decongestant drops. 1% ephedrine or 0.1% oxymetazoline are
used as nasal drops or sprays to decongest sinus ostium and
encourage drainage.
l Steam inhalation. Steam alone or medicated with menthol or Tr.
Benzoin Co. provides symptomatic relief and encourages sinus
drainage.
l Analgesics. Paracetamol or any other suitable analgesic.
l Hot fomentation. Local heat is effective.
 (2) Chronic Diseases of Sinuses
Chronic rhinosinusitis (CRS) is defined as disease lasting
more than 12 weeks without complete resolution of symptoms.
CRS may also be subject to exacerbations.
 Acute infection destroys
normal ciliated epithelium
impairing drainage from the
sinus. Pooling and stagnation
of secretions in the sinus
invites infection. Persistence of
infection causes mucosal
changes, such as loss of cilia,
oedema and polyp formation,
thus continuing the vicious
cycle.
A. Pathology
In chronic infections, process of destruction
and attempts at healing proceed together.
a) Sinus mucosa becomes thick and polypoidal
(hypertrophic sinusitis) or undergoes atrophy
(atrophic sinusitis).
b) Surface epithelium may show desquamation,
regeneration or metaplasia.
c) Submucosa is infiltrated with lymphocytes and
plasma cells and may show microabscesses,
granulations, fibrosis or polyp formation.
 B. Clinical features
a) Clinical features are often vague and
similar to those of acute sinusitis but
of lesser severity. Purulent nasal
discharge is the commonest
complaint. Foul smelling.
b) Discharge suggests anaerobic
infection. Local pain and headache
are often not marked except in acute
exacerbations. Some patients
complain of nasal stuffiness and
anosmia.
C. Diagnosis
a) Clinical features: purulent nasal
discharge, nasal stuffiness and
anosmia lasting more than 12
weeks
b) perform nasal endoscopy
c) CT scan is particularly useful in
ethmoid and sphenoid sinus
infections and has replaced studies
with contrast materials.
d) Aspiration and irrigation: Finding of
pus in the sinus is confirmatory
D. Treatment
a) It is essential to search for underlying aetiological factors
which obstruct sinus drainage and ventilation. Culture and
sensitivity of sinus discharge helps in the proper selection
of an antibiotic.
b) Initial treatment of chronic sinusitis is conservative,
including antibiotics, decongestants, antihistaminics and
sinus irrigations.
c) Recently, endoscopic sinus surgery is replacing radical
operations on the sinuses, provides good drainage and
ventilation. It also avoids external incisions.
 Maxillary sinus irrigation. An opening is created via the
inferior meatus or middle meatus in the nasal cavity,
maxillary sinus or via canine fossa
 2. Nasal polyps
Nasal Polypi are non-neoplastic masses
of oedematous nasal or sinus mucosa.
A. Aetiology
Complex and not well-understood.
They may arise in inflammatory
conditions of nasal mucosa
(rhinosinusitis), disorders of ciliary
motility or abnormal composition of
nasal mucus (cystic fibrosis).
a) Chronic rhinosinusitis. Polypi are seen in chronic rhinosinusitis
of both allergic and nonallergic origin. Nonallergic rhinitis with
eosinophilia syndrome (NARES) is a form of chronic rhinitis
as'sociated with polypi.
b) Asthma. 7% of the patients with asthma of atopic or nonatopic
origin show nasal polypi.
c) Aspirin intolerance. 36% of the patients with aspirin
intolerance may show polypi. Sampter's triad consists of nasal
polypi, asthma and aspirin intolerance.
d) Cystic fibrosis. 20% patients with cystic fibrosis form polypi,
due to abnormal mucus.
e) Allergic fungal sinusitis. Almost all cases of fungal sinusitis form
nasal polypi.
B. Pathogenesis.
• Nasal mucosa, particularly in the
region of middle meatus and
turbinate becomes oedematous
due to collection of extracellular
fluid causing polypoidal change.
Polypi which are sessile in the
beginning become pedunculated
due to gravity and the excessive
sneezing.
C. Pathology.
In early stages, surface of nasal polypi is covered by ciliated columnar
epithelium(B) like that of normal nasal mucosa but later it undergoes a
metaplastic change to transitional and squamous type(A) on exposure
to atmospheric irritation.
 H&E staining of a sporadic nasal polyp with strong
infiltration of eosinophils (A); and a PJS(Peutz-Jeghers's
syndrome) related nasal polyp lacking eosinophilia (B).
D. Site of origin.
Multiple nasal polypi always arise from the lateral wall of nose,
usually from the middle meatus. Common sites are uncinate
process, bulla ethmoidalis, ostia of sinuses, medial surface and
edge of middle turbinate.
 E. Symptoms
a) Multiple polypi can occur at any age
but are mostly seen in adults.
b) Nasal stuffiness leading to total
nasal obstruction may be the
presenting symptom.
c) Partial or total loss of sense of smell.
d) Headache due to associated sinusitis.
e) Sneezing and watery nasal discharge
due to associated allergy.
f) Mass protruding from the nostril.
F. Diagnosis
a) On anterior rhinoscopy, polypi appear as
smooth, glistening, grapelike masses often
pale in colour. They may be sessile or
pedunculated, insensitive to probing and do
not bleed on touch.
b) Often they are multiple and bilateral. Long-
standing cases present with broadening of
nose and increased intercanthal distance. A
polyp may protrude from the nostril and
appear pink and vascular simulating
neoplasm . Nasal cavity may show purulent
discharge due to associated sinusitis.
c) CT scan of paranasal sinuses is essential to exclude the bony
erosion and expansion suggestive of neoplasia.
G. Treatment
(a) Conservative
• Early Polypoidal changes with oedematous mucosa may
revert to normal with antihistaminics and control of allergy.
• A short course of steroids may prove useful in case of people
who cannot tolerate antihistaminics and/or in those with
asthma and Polypoidal nasal mucosa. They may also be used
to prevent recurrence after surgery. Contraindications to use
of steroids, e.g. hypertension, peptic ulcer, diabetes,
pregnancy and tuberculosis should be excluded.
(b) Surgical
• Endoscopic sinus surgery. These
days, ethmoidal polypi are
removed by endoscopic sinus
surgery more popularly called FESS
(functional endoscopic sinus
surgery). Polypi can be removed
more accurately when ethmoid
cells are removed, and drainage
and ventilation provided to the
other involved sinuses such as
maxillary, sphenoidal or frontal.
 Nose is richly supplied by both the
external and internal carotid systems, both
on the septum and the lateral walls.Bleeding
from inside the nose is called epistaxis. It is
common and is seen in all age groups:
children, adults and older people. It often
presents as an emergency. Epistaxis is a sign
and not a disease per se and an attempt
should always be made to find any local or
constitutional cause.
(1) ANATOMY
A. nasal septum
a) Internal Carotid System
Ø Anterior ethmoidal and Posterior
ethmoidal artery: Both are branches of
ophthalmic artery.
b) External Carotid System
Ø Sphenopalatine artery (branch of
maxillary artery) gives nasopalatine and
posterior medial nasal branches.
Ø Septal branch of greater palatine artery
(Br. of maxillary artery).
Ø Septal branch of superior labial artery (Br.
of facial artery).
B. Lateral Wall
a) Internal Carotid System
Ø Anterior ethmoidal
Ø Posterior ethmoidal
b) External Carotid System
Ø Posterior lateral nasal ➞ From
Sphenopalatine artery branches
Ø Greater palatine artery ➞ From Maxillary
artery
Ø Nasal branch of anterior superior dental –
From Infraorbital, branch of maxillary artery.
Ø Branches of facial artery to nasal vestibule.
C. Kiesselbach’s plexus (Little’s area).
It is localized at the anterior
portion of the septum.
Approximately 90% of bleeding
occurs from this area. The anterior
and posterior ethmoid arteries from
the internal carotid artery system
and the superior labial artery,
greater palatine artery, and
sphenopalatine artery from the
external carotid artery system form a
vascular plexus.
D. Woodruff's Area
This vascular area is
situated under the
posterior end of inferior
turbinate where
sphenopalatine artery
anastomoses with
posterior pharyngeal
artery. Posterior epistaxis
may occur in this area.
A. Local：Trauma（16%），Infection
（15%）， Postoperative（6%），Nasal
and paranasal sinus neoplastic（3%）,
Hereditary hemorrhagic，Foreign body，
telangiectasia(遗传性出血性毛细血管扩张)，
Atrophic rhinitis
B. Systemic：Hypertension（13%），
High venous pressure (mitral stenosis),
Blood dyscrasias （11%，leukemia，
hemophilia(血友病)，vitamin K
deficiency），Anticoagulant drugs
C. Idiopathic (unknown)：30%
A. In any case of epistaxis, it is important to know:
a) Mode of onset. Spontaneous or finger nail trauma.
b) Duration and frequency of bleeding.
c) Amount of blood loss.
d) Side of nose from where bleeding is occurring.
e) Whether bleeding is of anterior or posterior type.
f) Any known bleeding tendency in the patient or family.
g) History of known medical ailment (hypertension,
leukaemias, mitral valve disease, cirrhosis, nephritis).
h) History of drug intake (analgesics, anticoagulants, etc.).
B. First Aid
Most of the time, bleeding
occurs from the Little's area and
can be easily controlled by
pinching the nose with thumb
and index finger for about 5
minutes. This compresses the
vessels of the Little's area. In
Trotter's method patient is made
to sit, leaning a little forward over
a basin to spit any blood, and
breathe quietly from the mouth.
C. Cauterization
This is useful in anterior epistaxis when bleeding point
has been located. The area is first anaesthetised and the
bleeding point cauterised with a bead of silver nitrate or
coagulated with electrocautery.
(a) Anterior nasal packing
Anterior epistaxis, nose is cleared
of blood clots by suction and
attempt is made to localise the
bleeding site. In minor bleeds, from
the accessible sites, cauterization of
the bleeding area can be done. If
bleeding is profuse and/or the site
of bleeding is difficult to localise,
anterior packing should be done.
 Anterior nasal packing with Vaseline-impregnated gauze. After
cleaning the clots, the packing is done in layers. Pack can be
removed after 24 hours if bleeding has stopped. Sometimes, it has
to be kept for 2 to 3 days; in that case, systemic antibiotics should
be given to prevent sinus infection and toxic shock syndrome.
 It is required for patients
bleeding posteriorly into the throat.
A postnasal pack is first prepared
by tying three silk ties to a piece of
gauze rolled into the shape of a
cone. A rubber catheter is passed
through the nose and its end
brought out from the mouth . Ends
of the silk threads are tied to it and
catheter withdrawn from nose.
 Pack, which follows the silk thread,
is now guided into the nasopharynx
with the index finger. Anterior nasal
cavity is now packed and silk threads
tied over a dental roll.
The third silk thread is cut short
and allowed to hang in the
oropharynx. It helps in easy removal
of the pack later. Patients requiring
postnasal pack should always be
hospitalised.
(1) BENIGN
A. Inverted papilloma
Microscopically neoplastic epithlium
is seem to grow towards underly
stroma rather than on the surface.
Mostly seem between 40-70 yeas with
male preponderance（5∶1）. It arise
from the lateral nasal wall. They are
unilateral masses. Histological picture
of the inverted papilloma. Epithelium
shows invaginations into the tissue.
a) Diagnose
ü rhinoscopy
ü CT scan
ü MR scan
ü Biospy

rhinoscopy CT scan MR scan

b) treatment
In 15% of cases there may be malignant transformation. The tumor
should be excised completely and sent for histological examination to
check for malignant transformation. Endoscopic removal is the
treatment of choice.
 The exact cause is unknown. As the tumour is prodominantly
seen in adolescent males in the second decade of life, it
usually arises superior and posterior to the sphenopalatine
foramen. These patients present with the complaint of nasal
obstruction and bleeding.
a) diagnosis
ü It is based on clinical features: age & sex, recurent epistaxis,
progressive nasal obstruction, mass in the nasopharynx.
ü On coronal MR & CT scan. widening of pterygomaxillary fissures is
diagnostic
ü Biospy of the tumour is attended with profuse bleeding,avoided.
Endoscopic view
üAngiography shows the hypervascularity of the tumor(L).
Embolization helps the surgeon to operate in a less bloody
field. No vascularity after embolization isseen(R).
 b) Treatment
Ø Surgical excision is now the traetment of
choice, and various surgical approaches
to angiofibroma, depending on its origin
and extensions. Most otolaryngologists
choose nasal endoscopic surgery.
Ø Before embolization helps the surgeon
to operate in a less bloody field.
Ø Specimen after total removal of the
tumor, we can see the tumor is made up
of vascular and fibrous.
 Osteomas are common benign tumors of the sinuses. They occur most
frequently in the frontoethmoid region. Coronal CT showing osteoma in
the right ethmoid area and the specimen after removal
a) Diagnosis: They may remain
asympomatic, being discovered
incidentally by X-rays.
b)Treatment: It is indicated
when become symptomatic,
causing obstruction to the sinus
ostium, formation of mucocele,
pressure symptoms due to their
growth in the orbit, nose or
cranium.
 Primary nasal cavity
carcinoma is rare. It may be an
extension of maxillary or
ethmoid carcinoma. Squamous
cell variety is the most common,
seen in about 80% of cases. Rest
may be adenoid cystic carcinoma
or an adenocarcinoma.
• Squamous cell carcinoma. It may
arise from the vestibule, anterior
part of nasal septum or the lateral
wall of nasal cavity. Most of them
are seen in men past 50 years of age.
• Adenocarcinoma and adenoid
cystic carcinoma. They arise from
the glands of mucous membrane or
minor salivary glands and mostly
involve upper part of the lateral wall
of nasal cavity.
 It arises from the sinus lining and may remain
silent for a long time giving only vague symptoms of
"sinusitis". It then spreads to destroy the bony
confines 'of the maxillary sinus and invades the
surrounding structures. Disease is common in 40-60
age group with preponderance in males.
• Early features of maxillary
sinus malignancy are nasal
stuffiness, blood-stained nasal
discharge, facial paraesthesias
or pain and epiphora. These
symptoms may be missed or
simply treated as sinusitis.
• Late features will depend on
the direction of spread and
extent of growth.
• Medial spread to nasal cavity
gives rise to nasal obstruction,
discharge and epistaxis. It may
also spread into anterior and
posterior ethmoid sinuses and
that is why most antral
malignancies are antroethmoidal
in nature.
• Anterior spread causes swelling
of the cheek and later invasion of
the facial skin.
Inferior spread causes
expansion of alveolus with
dental pain, loosening of
teeth, poor fitting of
dentures, ulceration of
gingiva and swelling in the
hard palate.
Superior spread invades the
orbit causing proptosis,
diplopia, ocular pain and
epiphora.
• Intracranial spread can occur
through ethmoids, cribriform plate
or foramen lacerum.
• Lymphatic spread. Nodal
metastases are uncommon and
occur only in the late stages of
disease. Submandibular and upper
jugular nodes are enlarged.
• Systemic metastases are rare.
May be seen in the lungs (most
commonly)
• Radiograph of sinuses. A unilateral
mass in the nose that bleeds
spontaneously should arouse the
suspicion of malignancy. Opacity of the
involved sinus with expansion and
destruction of the bony walls. CT & MR
scan. If available, this is the best non-
invasive method to find the extent of
disease. CT scan should be done both in
axial and coronal planes. It also helps in
the staging of disease.
Biopsy. If growth
presents in the
nose or mouth,
biopsy can be
easily taken. In
early cases, with
suspicion of
malignancy, sinus
should be explored
by Caldwell-Luc
operation.
• Histologically, nature of malignancy is
important in deciding the line of
treatment as is the location and extent of
disease.
• For squamous cell carcinoma, a
combination of radiotherapy and surgery
gives better results than either alone.
Radiotherapy can be given before or after
surgery. 4-6 weeks later by surgical
excision of the growth by total or
extended maxillectomy.
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