CT Scan Pre Operative

Pembimbing: dr. Iriana Maharani, Sp.T.H.T.K.L.(K), FICS

CT - SCAN

Position : coronal, axial, sagital,

slice : 1 - 3 mm
KEROS :
• The lateral lamella the thinnest
and most vulnerable bony portion
of the skull base in terms of
intraoperative injury
• LL is confounded by the
attachment of the middle turbinate
along the lateral margin of the
cribriform plate.
• As the depth of the olfactory fossa
increases, the LL becomes more
vulnerable to intraoperative
injury, either directly or through
manipulation during turbinectomy
or ethmoidectomy.
 KEROS TYPE 1 : the vertical
lamella of the cribriform
plate is very short,
 the olfactory fossa is
almost flat,
 or if the height of the
ethmoid roof from the
cribriform plate is 1-3 mm,

KEROS TYPE 2 : the vertical

lamella is longer and the
height of ethmoid roof from
the cribriform plate is 4-7
mm

KEROS TYPE 3: if the height

of ethmoid roof is 8-16 mm.
The deeply located olfactory
(30%) (49%) (21%) fossa places the thin vertical
lamella at risk of penetration
during endonasal surgery
• The lamina papyracea is a thin layer of the ethmoid bone that comprises
the medial orbital wall.
• It is best evaluated in the coronal and axial planes.
• When dehiscent from a prior injury, the bony margin of the lamina
papyracea is displaced medially into the ethmoid sinus, along with
intraorbital fat and occasionally portions of the medial rectus muscle (Fig
10).
• Deviation into the ethmoid sinus places the lamina papyracea and orbital
structures at risk for intraoperative penetration, as the lamina papyracea
can be mistaken for an ethmoid sinus septation during ethmoidectomy.
• The lamina papyracea may also be at risk for injury–
even when intact– during uncinectomy in the setting of
an underpneumatized or atelectatic maxillary sinus,
with lateral deviation and apposition of the
uncinate process with the medial orbital wall (Fig
11).
• Excessive or aggressive manipulation of the uncinate
process may result in disruption of the medial orbital
wall.
• Manipulation or resection of a Haller cell may also
cause inadvertent disruption of the lamina papyracea
due to its location along the orbital wall.
• Although not specifically evaluated on the preoperative CT examination,
manipulation of the basal lamella of the middle turbinate, which
represents the demarcation of the anterior and posterior ethmoid air
cells, may cause inadvertent breach of the lamina papyracea.

• The most worrisome complication of orbital violation is an intraorbital

hematoma. Hematomas cause increased intraorbital pressures and may
result in temporary or permanent visual loss, depending on the size of
the hematoma and rate of expansion. When substantial, immediate
ophthalmologic intervention may be necessary

• Direct injury to intraorbital structures, particularly the medial rectus

musculature, is less common but disastrous due to its irreparability.

• Rectus muscle injuries range from intramuscular hematomas with focal

muscle enlargement to complete transection, which is fortunately rare.

• In addition, penetration of the lamina papyracea establishes a direct

communication between the orbit and a potentially infected sinus,
which may lead to development of orbital emphysema and cellulitis.
• The Onodi cell, or sphenoethmoidal air cell, is a variant posterior
ethmoid air cell that extends posteriorly along the superior and
lateral aspect of the sphenoid sinus. It is best evaluated in the
coronal plane.

• Onodi cell is an important variant to identify, as the optic nerve

commonly courses through the Onodi cell, with a thin margin of
bone separating the optic nerve from the underlying air cell (Fig 12).

• This greatly increases the risk of optic nerve injury during posterior
ethmoidectomy, especially when surgeons are unaware that they
are in a sphenoethmoidal air cell.

• An Onodi cell is best visualized on coronal sequences by first

locating an air cell above the sphenoid sinus and identifying its
continuity with a posterior ethmoid air cell.
The Sphenoid

• As soon as, we
could identify a
solid bone of
choanae, the cell
directly above the
post solid bony
choanae is the
sphenoid.
• Sphenoid sinus pneumatization with
respect to the clivus and sella may be
characterized as conchal, presellar, or
sellar and is best evaluated in the sagittal
plane (Fig 13).

• The conchal variant refers to

underpneumatization, with a thick bony
margin between the sphenoid sinus
anteriorly and the sella posteriorly.
• The presellar variant refers to
pneumatization extending posteriorly to
the anterior margin of the sella.

• The sellar variant is most common and

refers to pneumatization that extends
inferior and posterior to the sella, resulting
is a thin posterior bony margin of the clivus.

• The sellar variant is important to identify

preoperatively, since it places the thin
posterior clival margin at risk for
inadvertent perforation due to supine
positioning of the patient, with the force of
gravity directed posteriorly.
• Excessive pneumatization of the
sphenoid sinus into the skull base
and anterior clinoid processes
may result in dehiscence of the
bony margins of the carotid and
optic nerve canals, rendering them
susceptible to injury during FESS
(Figs 14, 15).

• This is best evaluated in both the

coronal and axial planes.
• It is also important to identify a sphenoid septation attachment along a thin bony margin
of the carotid canal, as resection of the septation may expose or damage the underlying
carotid artery.

• Fortunately, injuries to the carotid artery are rare; however, when present, they may be
catastrophic, depending on the degree of injury and ability to control the hemorrhage.

• Emergent treatment–either surgical or endovascular– to obtain hemostasis is essential.

1= optic nerve, 2= pneumatised clinoid process, 3= foramen rotundum,
4= pterygoid/vidian canal
In this scan we can see complex sphenoid
anatomy with extensive pneumatization:
• Optic nerve dehiscence may occur in the
1=(bulge of) optic nerve,
setting of excessive pneumatization of the
2= pneumatised clinoid process,
sphenoid sinuses into the anterior clinoids or
3= foramen rotundum,
in the presence of an Onodi
4=pterygoid (vidian) nerve
(sphenoethmoidal) cell.
Tipe lokasi anatomi N. optic
• The artery can be located on coronal CT images
by identifying the anterior ethmoidal notch
along the medial orbital wall at the level of the
anterior ethmoid sinus.

• Prior studies have demonstrated that the anterior

ethmoidal notch can be reliably identified on
coronal CT images bilaterally in
approximately 95%–100% of cases and
unilaterally in the remaining cases.
• If the notch abuts the fovea ethmoidalis or
lateral lamella, then the artery is considered
relatively protected during FESS (Fig 16a).

• The presence of supraorbital pneumatization

of ethmoid air cells above the anterior
ethmoidal notch, however, places the artery at
increased risk of injury during FESS, since the
artery travels freely within the ethmoid sinus
The anterior ethmoidal artery is a branch of the ophthalmic artery that supplies portions of the paranasal sinuses and nasal
cavity to include the ethmoid and frontal sinuses, anterior portion of the nasal septum, and portions of the lateral
nasal wall
 • Supraorbital pneumatization is a
common and often overlooked
critical variant, occurring in
approximately 26%–35% of
patients

• Inadvertent injury of the anterior

ethmoidal artery can result in a
rapidly enlarging retro-orbital
SF hematoma due to retraction of
the transected vessel into the
orbit.
SOEC • A severed anterior ethmoidal
artery should be prophylactically
cauterized when this complication
AEA
occurs to prevent further
complications.
 CT – SCAN : SYSTEMATIC READING
• FRONTAL SINUS: Frontal
recess,frontal cells, Supraorbital
ethmoid cell
• MAXILLARY SINUS: infundibulum,
UP, Haller cell, nasolacrimal duct,
infraorbital nerve, hiatus semilunaris
• ANTERIOR ETHMOID:
bula,lamina papiracea, ant.etm.
artery,basal lamella
• POSTERIOR ETMOID :
post.ethm.artery,Onodi Cell
• SPHENOID SINUS: Optic nerve,
carotid artery
Frontal sinus
Frontal recess
 • When we start moving from the frontal sinus to
frontal recess
Sagittal plane the line no 1 cross through the beak
& no 2 behind the beak in the frontal recess.

1 2

• Coronal Ct scan: This beak perform a continuity

of the bone across that ct scan,
if you note a continuity of the bone and it will be
frontal sinus above & frontal recess below.
If you don’t notice a continuity of the bone it
means you are behind the beak and you are in
frontal recess.
Why is it important? Its crucial if you want to
distinguish cell in the frontal recess whether the
cell is actually pushing it to the frontal sinus like
SAFC or SBFC.
Recessus
Frontalis
IFAC

SBFC
SAFC
SBC
SAC

BE ANC
ANC (Agger Nasi Cell)

• Sagittal plane : ANC (Agger Nasi

Cell) sits above the insertion of the
anterior middle turbinate into the
lateral nasal wall.

• It pneumatizes into the frontal

process of the maxilla and lacrimal
ANC bone area and also below the
beak.

• Coronal : This cell attach to the

lamina papiracea
• Axial scan this cell anterior from
bulla ethmoidalis
 SAC (Supra Agger Cell)

Supra agger
ANC

ANC

• SAC is usually laterally based as can be seen on the axial scan.

• SAC may be a single cell or consist of a number of cells sitting above the ANC
and may affect the frontal drainage pathway depending as to whether it is
situated medially or laterally.
 SAFC (Supra Agger Frontal Cell)
Supra agger
frontal

SAC

ANC

ANC

SAFC: The cell extent into the frontal sinus and occupies a portion of the floor of the frontal
sinus.
• At axial scan The cell is laterally based and pneumatizing through the frontal ostium into the
frontal sinus and pushing the drainage pathway of the frontal sinus medially.
BULLA BE: the largest anterior ethmoid cell but is

ETHMOIDALIS occasionally under or undeveloped in 8% of

cases. The commonest comprises a single cell
opening to the retrobullar recess, otherwise
there can be multiple cells with multiple
opening.

In the coronal ct scan we can see how the bulla

ethmoidalis sits above the horizontal portion of
the UP, in sagital and axial scan behind the agger
nasi cell.

Bulla ethmoidalis
 SBC : the cell sitting directly above the bulla
SUPRA BULLA CELL ethmoidalis and the anterior wall of SBC almost
continuity with the anterior face of the bulla
ethmoidalis.

In sagital and coronal scan we can see this cell

sits above the BE and attach to ethmoidal roof.
In axial scan we can see these cell pushed the
drainage pathway from frontal to medial and
anteriorly.

Supra Bulla Cell

BE
 SBFC : the cell sitting directly above the bulla
SUPRA BULLA FRONTAL CELL ethmoidalis, and the skull base forming the
posterior wall of the cell and the cell
pneumatizing through the frontal ostium into
the frontal sinus.

Axial: the SBFC pushes the frontal sinus

drainage pathway anteriorly

Supra Bulla Frontal Cell

BE
SUPRA ORBITAL ETHMOID CELL

• This cell looks similar to an SBFC as

SF
it migrates up toward the frontal
sinus; howefer on the coronal and
parasagital CT scans the cell is seen
SOEC
to pneumatize over the orbit.
• Another landmark this cell sits
AEA above and around the anterior
ethmoid artery.
Frontal Septal Cell (FSC)

Frontal Septal Cell

• Origin: interfrontal sinus septum

• Occupying a significant part of the frontal
drainage pathwaylaterally posteriorly
• The bony septation can be quite thick
Processus Uncinatus
Konka Media
 Maxillary Sinus
Maxillary ostium
Ethmoid infundibulum (posterior)
Hiatus semilunaris
Middle meatus

Coronal CT
THE ACCESSORY OSTIUM OF MAXILLARY
SINUS
• site : anterior & posterior UP
• Secretion moves in a circle
TERIMAKASIH