Paranasal Sinuses

Computed Tomography Anatomy

Rhinology Division

October – November 2023

Aris-Diar/Delia-Disa/Haryogi

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 NASAL CAVITY
• Elongated wedge-shaped spaces with a
large inferior base and a narrow
superior apex
• Skeletal framework consisting
mainly of bone and cartilage
– Nares – external opening of nose
– Choanae - open into the
nasopharynx
• Each nasal cavity has a
floor, roof, medial wall, and lateral
wall
 NASAL CAVITY
o Roof – Nasal bone, Ethmoid
Bone & sphenoid bone
o Floor - Palatine process of
the maxilla & Palatine bone
o Medial wall
o Lateral wall
MEDIAL NASAL WALL
 LATERAL NASAL WALL

• Inferior turbinates
There are 3 • Middle turbinates
projections: • Superior turbinates

These • Inferior nasal meatus

structures • Middle nasal meatus
divide the nasal • Superior nasal meatus
cavity into four • Spheno-ethmoidal recess
air passages
 How to choose the best
paranasal sinus CT-Scan for
assessment??

 Identity of patient
 Had marker (left or right sight)
 Bone setting SPN CT
 Had 3 slice orientation: coronal, sagittal & axial
 Slice thickness was 3 mm
 Window width 1500-2500
 Window level 250-300

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4

Landmark Division of
3 the Paranasal Sinus

2b

2a

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 “Transitional zone”

Lamella basalis
Frontal beak of concha Roof of choana
media

Frontal  ethmoid anterior sinus Anterior ethmoid  posterior ethmoid Posterior ethmoid  Sphenoid

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 Landmark clue: Frontal beak

1st Division: Frontal

Sinus Area

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 Divided into 2 area:
- (2a) Frontal recess area: responsible for frontal sinus
2nd Division:
Ethmoid Anterior drainage
- (2b) Ethmoid anterior area

What is Frontal recess??

The most anterosuperior part of the ethmoid, inferior to the frontal

sinus opening

Posteriorly by the anterior wall of ethmoid bulla, anteroinferior agger nasi, laterally by
lamina papiracea, inferiorly by terminal recess

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 2a Area: Frontal
Recess

Landmark clue:
 No frontal beak
 Nasolacrimal duct
 Septal tubercle
 No middle turbinate
 No maxillary sinus

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INFERIOR TURBINATES, INFERIOR
MEATAL, NASAL SEPTUM
INFERIOR TURBINATES & NASAL
SEPTUM
INFERIOR TURBINATES & NASAL SEPTUM
LACRIMAL SAC
Nasolacrimal Sac and Duct
2b Division: Ethmoid
Anterior

Landmark Clue:
 Superior attachment of basal lamella middle turbinate
to skull base
 Other Clue:
 Maxillary sinus
 Crista Galli
 Meatus inferior well establish

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 Ethmoid
Anterior Air
Cells Ager nasi cells: the most anterior part of the ethmoid. Part division of frontal recess.
Large agger nasi cell may narrow the frontal recess posteriorly and/or laterally

Ethmoid bulla: largest anterior ethmoid cell.

Anterior face of the bulla forms the posterior border of the inferior semilunar hiatus,
ethmoidal infundibulum and frontal recess

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 Ethmoid Anterior
variation

Haller cell (infraorbital ethmoid cells):

ethmoid aircells located anteriorly to ethmoid bulla, along
the orbital floor, adjacents to the natural ostium of
maxillary sinusobstruction of OMC

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 Ethmoid Bulla

“The largest anterior ethmoid cell”

Haller cell
• Ethmoidal air cell
which extends into
inferomedial orbital
floor
• Large  narrow
antrum/ infundibulum
3rd Division:
Ethmoid
Posterior Landmark Clue:
 Horizontal attachment basal lamella of middle
turbinate to lateral wall
 Other Clue:
 Superior turbinate
 Down slope lamina papiracea

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BASAL LAMELLA

Superior
turbinate

Posterior
ethmoid cell

Basal Lamela
BASAL LAMELLA
Suprabullar Recess, Retrobullar
Recess
Suprabullar recess is formed when
superior aspect of the bulla is
separate from the ethmoidal roof.

Retrobullar recess : a retrobullar

recess is formed when the
posterior wall of the ethmoidal
bulla is separate from the basal
lamella of the middle turbinate
creating a cleft between the two
SUPRAORBITAL
CELL

A lateral extension of
pneumatization from the
suprabullar recess over the orbit
Olfactory Fossa and Lateral lamella
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 Lamellar of the Ethmoid

Uncinate
EthmoidProcess
Bulla
Basal Lamella
Lamella
(Lamella of Superior
of Middle
Turbinate
Turbinate)
 4th Division: Sphenoid
sinus

Landmark Clue:
- Roof of choana
- Posterior part of nasal septum
- Small posterior part of inferior turbinate

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 SPHENOID SINUS

• Roof
Floor of anterior cranial fossa or
margins of sella
• Floor
Root of nasopharynx
• Posterior wall
Clivus
• Anterior wall
Posterior wall of ethmoids

1= optic nerve, 2= pneumatised clinoid process, 3= foramen rotundum,

4= pterygoid/vidian canal
Sphenoid Sinus

• Roof
Floor of anterior cranial fossa or margins of sella
• Floor
Root of nasopharynx
• Posterior wall
Clivus
• Anterior wall
Posterior wall of ethmoids
 Onodi cell

A posterior ethmoidal cell which

develops lateral and / or superiorly to
the sphenoid sinus
Ostiomeatal Complex
Definition:
Functional unit and physiological concept comprising the clefts and
drainage pathways of middle meatus

Consisting of:
Middle meatus, together w/
Anterior ethmoid complex
Frontal and suprabullar recess
Ethmoidal infundibulum
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 OSTIOMEATAL COMPLEX
(OMC)
• Uncinate Process
• Infundibulum
• Hiatus Semilunaris
• Bulla ethmoid
• Maxillary ostium
• Middle turbinate
 Uncinate Process: thin, sickle-shaped structure which is part of the ethmoid
bone and runs almost in the sagittal plane from anterosuperior to
Terminology posteroinferior

Semilunar hiatus (superior&inferior): crescent-shaped cleft between the concave posterior free edge of the uncinate
process and the convex anterior face of the ethmoidal bulla, forming the entrance to the ethmoidal infundibulum

Ethmoid infundibulum: three-dimensional space in the ethmoidal labyrinth

of the lateral nasal wall. Anterior border of bula. opening into the middle
meatus via the inferior semilunar hiatus

Maxillary Hiatus: anatomical term referring to a large natural opening in the medial
wall of the disarticulated maxillary bone
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OMC

EB

up
MT

IT

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 Uncinate process attachment:
Divided into 3 category
- Attachment to lamina papiracea (A)
Anatomical variations
- Attachment to skull base (B)
that may increase the
- Attachment to middle turbinate (C)
risk of OMC narrowing

Attachment to lamina papiracea: uncinate process deflection to lateral create space called
terminal recess. In this condition discharge drainage flow from fontal recess to medial UP

Attachment to middle turbinate: this condition can obstruct the OMC and
as the common etiology of CRS

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 Variations of Uncinate Process

Everted (paradoxical) Lateralized

Medialised
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 Anatomical variation in middle turbinate divided into:
- Bullous middle turbinate
Middle turbinate - Paradoxical middle turbinate

Bullous middle turbinate divided into:

- Lamellar type (pneumatization in lamella/neck of MT)
- Bulbous type (pneumatization in body/inferior part MT)
- Extensive type (pneumatization in lamella into body of MT

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Middle turbinate

Paradoxical middle turbinate: the concave side facing to the nasal septum,
the convex side facing the lateral wall. This variation commonly happened
in bilateral side.

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MIDDLE TURBINATES
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 - The nasal septum formed by cartilaginous and osseus.
Deviated nasal septum - Cartilaginous part was formed by quadrangularis lamina & columella
- Osseus part was formed by: perpendicular lamina of os etmoid, vomer,
nasal crist of os maxilla, & nasal crist of os palatina

Nasal septal deviated can be form of c-shaper or s-

shape. If the deviation angle contact with inferior or
middle turbinaterisk factor CRS.

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Deviated nasal septum

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IFAC (International Frontal Sinus Anatomy
Classification

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 Ethmoid Anterior Cells:
- Agger Nasi Cells (ANC), Supra Agger Cells (SAC), Supra Agger
Frontal Cells (SAFC)
- Ethmoid Bula (EB), Supra bula cells (SBC), Suprabula Frontal Cells
Ethmoid & Sphenoid (SBFC)
- Supra Orbital ethmoid Cells (SOEC)
Bone variation - Haller Cells

Ethmoid Posterior: Sphenoetmoid cells (Onodi Cells), ethmomaxillary sinus (EMS), Retroantral Pneumatization of
Posterior ethmoid cells (RP.PE/RAEC)

Sphenoid: pneumatization (conchal, pre-sellar, sellar, post-sellar), latelar sphenoid recess (LSR)/Lateral pterygoid
pneumatization, Intersinus septum, Optic nerve classification (Delano), anterior clinoid process (related to dehiscence
internal carotid artery)

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IFAC (International
Frontal Sinus
Anatomy
Classification

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Anterior cells pushed
frontal drainage
pathway

Agger Nasi Cells

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Anterior cells pushed
frontal drainage
pathway

Supra Agger Nasi Cells

(SAC) 54
Anterior cells pushed
frontal drainage
pathway

Supra Agger Frontal

Cells (SAFC) 55
Anterior cells pushed
frontal drainage
pathway

Supra Agger Frontal

Cells (SAFC) 56
Posterior Cells pushed
the drainage pathway
anteriorly

Supra Bula Cells (SBC)

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Posterior Cells pushed
the drainage pathway
anteriorly

Supra Bula Frontal Cells

(SBFC) 58
Posterior Cells pushed
the drainage pathway
anteriorly

Supraorbita Ethmoid
Cells (SOEC) 59
Medial Cells Pushes
the medial wall
lateraly

Frontal Septal Cells

(FSC) 60
Frontal Anatomy
Variation (Tonah)

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Frontal Anatomy
Variation (Tonah)

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CLOSE MNEMONIC

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Cribriform Plate
(KEROS)

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 Cribriform Plate
(KEROS)

Classification of varying depth of the olfactory fossa. The depth of the olfactory fossa is determined by the height of the
lateral lamella of the cribriform plate, which can be classified into three categories:
•type 1: has a depth of 1-3 mm (26.3% of population)
•type 2: has a depth of 4-7 mm (73.3% of population)
•type 3: has a depth of 8-16 mm (0.5% of population)

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Lamina Papiracea

Danger variation that can risk for lamina papiracea injury was lateral attachment of uncinate process to lamina
papiracea & Haller Cells

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 Sphenoid

ON, optic nerve; ICA, the cavernous segment of internal carotid artery; FR, foramen rotundum and V2 nerve; VC, vidian canal. In
hyperpneumatized sinus, when pneumatization extends laterally between foramen rotundum and vidian canal, creating a recess known
as the lateral recess (asterisk). When pneumatization extends below the optic canal " between optic canal and internal carotid artery "
resulted in infraoptic " opticocarotid " recess (IOR). CP, anterior clinoid process.
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 Onodi Cells

Sphenoethmoidal cells: variant of posterior ethmoid air cells that pneumatized extend to posterior sphenoid.
Greatly risk for the optic nerve injury

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Ethmoid artery

(a) When the ethmoidal notch abuts the fovea ethmoidalis (arrow) or lateral lamella, it is considered protected.
(b) With supraorbital pneumatization of the ethmoid sinus above the ethmoid notch ( ∗), the anterior ethmoidal
artery is at risk for intraoperative injury.

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Thank you
October 2023

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