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![• Cribriform plate shows a horizontal medial
lamella & oblique / vertical lateral lamella.
• Lateral lamella articulates with the frontal bone
forms - Ethmoid fovea
[medially by the lateral lamella of the
cribriform plate & laterally by the frontal bone]
• Frontal bone - ethmoid fovea - 0.5 mm thick
lateral lamella of the cribriform plate -0 .2 mm.
• The region where the anterior ethmoidal artery
pierces the dura medially is the thinnest area in
the base skull -0.05 mm thick.](https://image.slidesharecdn.com/anatomyofnose-250410181913-056aba62/75/ANATOMY-of-NOSE-power-point-presentation-15-2048.jpg)
![Kennedy’s Nipple [Ant Ethmoidal Foramen]](https://image.slidesharecdn.com/anatomyofnose-250410181913-056aba62/75/ANATOMY-of-NOSE-power-point-presentation-74-2048.jpg)
ANATOMY of NOSE power point presentation
- 1. ANATOMY OF NOSE- FESS PRESENTOR- Dr SMITHA D MODERATOR-Dr ANIL REDDY
- 2. CONTENTS • Embryology • Osteology •Lateral wall of nose proper Gross Anatomy Blood supply Nerve supply Lymphatic Drainage Transport of Secretion • Surgical Anatomy • Endoscopic Anatomy
- 3. EMBRYOLOGY • Facial developmenttakes place between 4 – 8 weeks of intra uterine life • Face develops from 5 facial swellings that surround the Primitive mouth by the end of 4th week Central unpaired frontonasal process Pair of maxillary process Pair of mandibular process
- 4. At 5th week thickeningappear in fronto nasal process called nasal placodes At 6th week nasal placode invaginates to form nasal pits 38- 40 days - Maxilloturbinal appear as swelling- Inferior Turbinate 40- 43 days - Ethmoturbinals appear at junction of nasal septum and nasal roof Space btw MT & ET – Middle Meatus 6th and 7th week maxillary process increase in size to grow medially
- 5. Maxillary process fuseswith the lateral nasal process The junction is marked by a groove called nasolacrimal/ naso-optic groove By 7th week groove invaginates into mesenchyme to form nasolacrimal duct
- 6. 9th & 10th wk -6major furrows develops 60 Days – Nasoturbinal appear (ant to ET)- Agger Nasi 65 Days – 1st Ethmoturbinal - uncinate process is identifiable 1st &2nd ET – Ethmoidal infundibulum 2nd ET- Middle turbinate 3rd ET – Superior turbinate 4th & 5th ET – Supreme turbinate 1st Furrow (ascending)- Frontal recess descending – Middle meatus & hiatus semilunaris 2nd Furrow – Superior meatus 3rd Furrow- Uppermost meatus
- 7. • 65/70 days– pouch into floor of infundibulam- maxillar sinus • 105 days – frontal recess cells develop medial to uncinate • Fetal frontal recess cells- lateral to ant attachment of middle turbinate, medial to uncinate • frontal sinus opens medial to uncinate into middle meatus • Ant aspect of infundibulam- Ant infundibular cells Near roof of ethmoid Most ant- may expand – frontal sinus Frontal sinus opens into infundibulam (lat to UP) Frontal bulla – ant ethmoidal cell, when frontal recess cells form frontal sinus Pneumatise agger nasi, uncinate, lacrimal bone
- 8. • Suprabulbar cells– sup to bulla, infundibulam expands into 3 – 4 furrows. Ethmoid bulla is pneumatised supraorbital cells One of the source for frontal sinus source of concha bullosa • lateral sinus forms following the development of ethmoidal bulla • Infrabulbar cells- Infundibulaam expands inf to bulla Inconstant space Pnematise the bulla invade ethmomaxillary plate - Ethmomaxillary cells- Haller cells (post medial sup aspect of maxilla)
- 9. • 110 days– Ant end of sup meatus divide to Inf & Sup arm Inf arm: two tracts of cell 1.Expand ant into lamella of middle turbinate as M/C origin of concha bullosa 2.Expand laterally, space btw lat ethmoidal wall & maxilla & ascending / orbital process of palate as M/C origin of Haller cell • Post ethmoidal cells Origin from sup & supreme meatus Supraorbital cells Ant to frontal bone & post upto sphenoid
- 10. OSTEOLOGY OF LATERALNASAL WALL
- 11. Maxillary Bone • Centrally-Maxillary hiatus • Anterior to maxillary hiatus, a process extends superiorily-Frontonasal process of the maxilla • Upper border- frontal bone, Ant border- nasal bone • Medial surface- Contains two crests: • The upper - Ethmoidal crest. Most anterior part of the middle turbinate is attached. Agger nasi cells also overlie this crest . Pneumatization of this part of the frontonasal process along with the adjacent lacrimal bone contributes to the formation of the agger nasi cells. • The lower - Conchal crest - Inferior turbinate is attached • Posterior to frontonasal process is a groove which is closed by the lacrimal bone and the lacrimal process of the inferior turbinate to form:nasolacrimal duct
- 12. • Roughened areaposterior to the hiatus at the junction of the medial and the posterior wall of the maxilla: maxillary tuberosity. This area has an oblique groove which when completed by the perpendicular plate of the palatine bone forms the canal for the greater palatine vessels and nerve. • roof of maxillary sinus- orbital surface of the maxilla -marked by the infraorbital canal - dehiscent to expose its contents, namely, the infraorbital vessels and nerve.
- 13. Frontal Bone • Center- Hiatus- cribriform plate of ethmoid • anterior and posterior ethmoidal air cells on either side. • Roof of air cells: skull base or Ethmoidal fovea-higher level • Laterally, lamina papyracea of ethmoid bone • Junction of the suture lines between the lamina and the frontal bone, is the anterior and posterior ethmoidal foramina transmitting their respective arteries. • Lateral to the lamina papyracea- Orbit. • Anteriorly and in the midline - Nasal spine. This spine articulates with the nasal bones, which help in forming the anterior most portion of the lateral nasal wall
- 14. Ethmoidal Bone • Itconsists of four parts: Horizontal or Cribriform plate, forming part of the base of the cranium Perpendicular plate, constituting part of the nasal septum Two lateral masses or labyrinths • Cribriform plate (lamina cribrosa) : Attach to ethmoidal notch of the frontal bone and roofs in the nasal cavities Projecting from the middle line of this plate : Crista galli
- 15. • Cribriform plateshows a horizontal medial lamella & oblique / vertical lateral lamella. • Lateral lamella articulates with the frontal bone forms - Ethmoid fovea [medially by the lateral lamella of the cribriform plate & laterally by the frontal bone] • Frontal bone - ethmoid fovea - 0.5 mm thick lateral lamella of the cribriform plate -0 .2 mm. • The region where the anterior ethmoidal artery pierces the dura medially is the thinnest area in the base skull -0.05 mm thick.
- 16. Anatomical variations • Thelength of the lateral lamella and the depth of the olfactory fossa are classified by Keros into 3 types: • Type I — 1-3 mm • Type II — 4-7 mm • Type III — 8-17 mm • Deeper the olfactory fossa, longer is the vertical lamella of the cribriform plate. • Prone to injury • shallow olfactory fossa - placed in a more horizontal or axial plane – liable to injury by the advancing tip of the forceps.
- 17. • Perpendicular Plate(lamina perpendicularis; vertical plate) Anterior border articulates with the spine of the frontal bone & crest of the nasal bones. Posterior border articulates by its upper half with the sphenoidal crest, by its lower with the vomer. Inferior border is thicker than the posterior, & serves for the attachment of the septal cartilage of the nose A- post view B- ant view
- 18. • Labyrinth orLateral Mass (labyrinthus ethmoidalis) consists of a number of thin walled cellular cavities, the ethmoidal cells, arranged in three groups, anterior, middle, & posterior Upper surface : Completed by the edges of ethmoidal notch of the frontal bone. Crossing this surface are two grooves, converted into canals by articulation with the frontal bone: anterior & posterior ethmoidal canals & open on the inner wall of the orbit
- 19. Posterior surface :Presents large irregular cellular cavities, which are closed in by articulation with the sphenoidal concha and orbital process of the palatine Lateral surface : Formed of a thin, smooth, oblong plate, the lamina papyracea (os planum), which covers middle and posterior ethmoidal cells C-sup view D- inf view
- 20. • Forms alarge part of the medial wall of the orbit; • Articulates : Above - orbital plate of frontal bone, Below - maxilla and orbital process of the palatine, Front – lacrimal bone & Frontal process of maxilla Behind – sphenoid bone Uncinate process, projects downward and backward from this part of the labyrinth; it forms a small part of the medial wall of the maxillary sinus & articulates with the ethmoidal process of the inferior nasal concha Medial surface : Forms part of the lateral wall Middle Turbinate Superior Turbinate
- 21. Palatine Bone • Formsthe posterior part of the lateral nasal wall and the floor of the nasal cavity • 2 plates→ perpendicular plate, which forms the posterior part of the lateral nasal wall & horizontal plate, which forms the posterior part of the nasal floor • 2 crest in medial surface of perpendicular plate divide into 3 sections
- 22. Lower crest -Conchal crest – attach to inf turbinate Upper crest - Ethmoidal crest - attach to middle turbinate Area below the conchal crest – Inferior meatus. Area btw the two crests - Posterior part of the Middle Meatus Above the ethmoidal crest is a narrow groove - Part of the superior meatus • Sphenopalatine foramen opens into the nose just above the post. attachment of the middle turbinate 3 processes • anterior -orbital process- small portion of the orbital floor • posterior -sphenoidal process -body of the sphenoid. • Bet these sphenopalatine notch- sphenopalatine foramen lies bet sphenoid and palatine bone. • pyramidal process extends posterolaterally from junction of the perpendicular and horizontal plates. • It does not take part with the formation of the nasal cavity.
- 23. • Perpendicular plate •Anterior border of the perpendicular plate has a prolongation - maxillary process - articulates - maxillary process of inferior turbinate • Posteriorly - medial pterygoid plates to form the lateral wall of the posterior choana. • Inferiorly - continuous with the horizontal plate. • Superiorly- maxilla by its orbital process and sphenoid by its sphenoidal process. • Horizontal plate • Anteriorly- horizontal process of the maxilla to form the nasal floor. • Posteriorly- free border, which is the posterior end of the hard palate
- 24. Lacrimal Bone • anteriorly- frontonasal process of maxilla, • posteriorly - uncinate process, • superiorly - frontal bone • inferiorly - descending process of lacrimal bone-lacrimal process of the inferior turbinate - medial wall of the nasolacrimal canal. • orbital surface - posterior lacrimal crest ( anterior lacrimal crest is on the frontonasal process of maxilla). • Bet two crests is lacrimal fossa contains lacrimal sac. • posterior lacrimal crest forms a hook inferiorly called the lacrimal hamulus- upper opening of the nasolacrimal duct. • Nasal surface of lacrimal bone is pneumatized by an anteriorly migrated ethmoidal cell, i.e. agger nasi cell.
- 25. GROUND LAMELLA OFETHMOTURBINALS Lateral wall is partitioned by lamella • 1st Lamella- lateral extension of Uncinate process • 2nd Lamella - lateral extension of Ethmoidal Bulla • 3rd Ground Lamella – Middle Turbinate attachment • 4th Ground Lamella – Sup. Turbinate attachment • 5th Lamella – Supreme Turbinate (if present) • Interturbinal Meatus- Passage btw lamella
- 26. Anatomical variations ofGround Lamella(GL) GL of MT, separates ant & post ethmoid cells, is not always in a coronal plane • May bulge into ant ethmoids & have a convexity anteriorly • May bulge into post ethmoids with a concavity anteriorly • May show dehiscences or be partially deficient - infection can pass from ant to post ethmoids. • May itself be pneumatized & split into multiple septae • Usually attaches to lamina papyracea, may, rarely, turn inferiorly in which case it “misses” lamina papyracea & attaches to lateral wall of maxillary sinus • Maxillary sinus is thus divided into two parts. The post part behaves like a post ethmoidal cell in terms of drainage and involvement by disease
- 27. LATERAL WALL OFNOSE Gross Anatomy • Anteriorly in the area of the nostril, the lateral nasal wall is lined by skin and has hair : vestibule. • Behind this is a plain structureless area lined by nasal mucosa: atrium. • Atrium shows a bulge anterior to the middle turbinate formed by the underlying Agger nasi cell. • Very often a ridge can be discerned extending from the agger nasi cell to an apex on the superior border of the inferior turbinate, this ridge overlies the nasolacrimal duct
- 28. • Behind theatrium are the three scrolls of the inferior, middle & superior turbinates, overlying the respective meatii. • Occasionally, supreme turbinate. • Above the superior turbinate is the sphenoethmoidal recess, which gets its name from the fact that this area forms a niche between the posterior ethmoid cells and the sphenoid sinus.
- 29. INFERIOR MEATUS • lateralto the inferior turbinate. • largest meatus, extending almost the entire length of the nasal cavity. • highest at the junction of the anterior and middle third. • In adults,1.6 cm along the bony lateral wall • Nasolacrimal duct – Hasner valve • endoscopically identified by gentle massage of the lacrimal sac at the medial canthus
- 30. INFERIOR TURBINATE • separatescroll-like bone • Superior margin- maxilla anteriorly & palatine bone posteriorly • Inferior margin- free,overhanging its meatus
- 31. 3 PROCESS • Lacrimal-arises anteriorly from its superior margin • Articulates – descending process of lacrimal bone • Forms canal for NLD • Ethmoidal- arises from a little behind lacrimal process from sup margin • Articulates- uncinate process of ethmoid bone • Maxillary- arises from sup border of inf turbinate & curves laterally attaches maxilla
- 32. AGGER NASI • mostanterior part of ethmoid, • most superior remnant of first ET/NT • small prominence on lateral nasal wall • just anterior to attachment of the MT • groove may be seen where the Uncinate process attaches to lateral wall. • This is the junction of the uncinate process to the lacrimal bone. • .Ant. –frontal pr. Of maxilla • Superiorly- FR/FS , • Anterolaterally –nasal bone • Inferomedial-UP, Inferolaterally –lacrimal bone
- 33. • The areaanterior to the uncinate process overlies the lacrimal sac • This area extends downwards in the form of a diffuse ridge to reach a “peak” in the attachment of the inferior turbinate.- • ridge overlies the nasolacrimal duct agger nasi cell (Ag), ridge overlying nasolacrimal duct (
- 34. ANATOMICAL VARIATIONS • usually1-3 in number. • size depends on extent of pneumatization of lacrimal bone & adjacent frontonasal process of maxilla. • may be hypoplastic. • may be well pneumatized • prominent agger nasi cell tends to displace anterior attachment of middle turbinate posterosuperiorly • large agger nasi cell may narrow frontal recess posteriorly and laterally nasolacrimal duct or directly pneumatise lacrimal bone
- 35. MIDDLE TURBINATE (MT) •Origin- ethmoturbinal • Convouted structure,dried leaf • 3 PARTS • Anterior 1/3rd - sagittal (vertical) plane • attachment-skull base – lateral edge of cribriform • plate at junct of medial & lateral lamella & • frontal nasal process of maxilla • This arch like attachment of MT to cribriform plate – Axilla of MT • Olfactory fossa
- 36. • Middle1/3RD – coronal(oblique) plane • Attachment – lamina papyracea by its ground lamella • Separates anterior ethmoidal cells from posterior ethmoidal cells • This lamella stabilizes MT • Posterior 1/3rd - axial (horizontal ) plane • Attachment- ┴r plate of palatine bone, lamina papyracea, -forms roof of posterior choana -roof of most posterior section of middle meatus -forms medial wall of maxillary sinus
- 37. ANATOMICAL VARIATIONS • Maybe pneumatized and ballooned up – Concha Bullosa, which is pneumatized from either frontal recess, agger nasi cell, anterior ethmoid cells or middle meatus • Occasionally Superior Meatus may pneumatize vertical lamella of MT - Interlamellar cell of Grunwald • a sharp bend laterally instead of its usual smooth medial curvature - Paradoxically bent Middle Turbinate
- 38. • interlamellar cellof grunwald • paradoxial middle turbinate
- 39. • Often bilateral& can block infundibulum • Normally curved MT may curl upon itself to produce a concavity within it - Turbinate Sinus
- 40. MIDDLE MEATUS • Lateralto middle turbinate • receives drainage from the anterior ethmoid, frontal and maxillary sinuses • Drainage from frontal, maxilary & ant. ethmoidal sinuses • In disarticulated bone large opening is seen in medial wall of maxillary bone, maxillary hiatus, which is covered normally by adjacent bones making its opening narrow Inf: Maxillary process of Inferor Turbinate Post: Perpendicular plate of Palatine bone Anterosup: Descending process of Lacrimal bone Sup: Uncinate process & Ethmoidal Bulla • Left out hiatus is filled by: mucous memb of middle meatus & maxillary sinus with intervening connective tissue- the membranous portion of lateral wall.
- 41. • Membranous portion: lying ant or post to uncinate process, constituting Ant & Post Fontanelle • Accessory ostia are found here • Most frequantly in post fontanelle
- 42. Natural & AccessoryOstia
- 43. Natural Os • Alwayspresent • Very difficult to see clinically • Lies deep in infundibulum (immdtly post. to NLD) • Usually oval & tunnel like • 3 dimension • Always single • Lies at the level of MT or upper border IT • Small in diameter 3mm to 10mm • Inferiorly - inferior turbinate, • superiorly1 to 2 mm -lamina papyracea and orbit, • posteriorly - posterior fontanelle, • anteriorly 0.5 cm -nasolacrimal duct Accessory Os • Present about 4-5% • Easily seen on endoscopy • Lies in sagittal plane in fontanella • Usually round & punched out. • 2 dimension • Could be multiple • Lies anywhere in MM • Could be large up to ½ to 1 cm
- 44. • A windowis cut in the middle turbinate to view the relationship of structures within the middle meatus • Most anteriorly is a curved ridge called the uncinate process. • Behind this is the well pneumatized and most constant anterior ethmoidal cell, ethmoidal bulla. • These structures are separated by a semilunar groove -hiatus semilunaris. • The hiatus semilunaris is 2- dimensional and leads into a 3-dimensional space called infundibulum
- 45. Osteomeatal Complex • Commonchannel that links frontal sinus, ant & post ethmoidal sinuses & maxillary sinus to middle meatus that allows airflow and mucociliary drainage • OMC- uncinate process bulla ethmoidalis hiatus semilunaris infundibulum maxillary ostium
- 46. • Boundaries: Medial- MiddleTurbinate Lateral - lamina papyracea Sup & post - basal lamella Inf & Ant – open • Space contains: Agger nasi, nasofrontal recess, infundibulam, bulla, ant ethmoidal cells
- 47. UNCINATE PROCESS • Thinbent hook/sickle shaped structure • Parts-vertical, horizontal & intermediate transitional part • Runs in sagittal plane from anteriosuperior to posterioinferior • Margins – Posterosup. - sharp, concave & lies parallel to ant. surface of ethmoidal bulla. • Posteroinf – lamina perpendicularis of palatine bone & ethmoidal process of inf. turbinate. • Anterior– convex, contact with bony lateral wall & can extent upto lacrimal bone • upper end of the uncinate process lies within the frontal recess.
- 48. Anatomical variations Upper endshows great variation • UP attaches laterally to the lamina papyracea- • it’s upper end encloses within it a blind recess called recessus terminalis - commonest mode of drainage of the frontal sinus is medial to the uncinate process • UP attach to the skull base. • In this case the frontal sinus drains into infundibulum and therefore disease from the frontal sinus can spread to the maxillary sinus and vice versa
- 49. • UP maybend medially to attach to the middle turbinate • UP may lie free within the middle meatus and not attach to any adjacent bony structure
- 50. • UP maybe pneumatized /aerated (uncinate bulla) • and compromise the infundibulum • Lateralized/ Hypoplastic concave uncinate - narrow the infundibulum leading to an atelectatic infundibulum - difficult to enter
- 51. • Everted orparadoxical Or Medialised –resembles anterior wall of the bulla- further medial rotation of the UP brings it in contact with the middle turbinate- look like a duplicated middle turbinate.
- 52. Ethmoidal Bulla • Mostconstant & largest air cells in ant. ethmoid cells. • Pnematisation of the bulla lamella. • 8%- poorly aerated/ completely unpneumatised. Torus Lateralis (lateral bony bulge) Ant : Post. margin of hiatus semilunaris & ethmoidal infundibulam. Post : Fuse with basal lamella of middle turbinate. Sup : Reach upto roof of ethmoids (frontally orinted plate) forming the post wall of frontal recess
- 53. Boundaries in PrasagittalSection • Ant: • Lower down: Infundibulum • Higher up: Frontal recess • Post: Basal lamella
- 54. • Cleft btwpost wall of bulla & ground lamella of middle turbinate Retrobulbar Recess • Space btw EB & Ethmoidal roof Suprabulbar Recess : may be connected ant. with frontal recess if bulla doesn’t reach skull base. • These recess may be continuous or seperated • If continuous : Medial : Middle Turbinate Lateral : Lamina Papyracea Sup : Roof of Ethmoid Inf & Ant : Uncinate process Post : Basal lamella of Middle Turbinate
- 55. Suprabulbar Recess If theethmoidal bulla do not reach the ethmoidal roof Btw the superior aspect of the bulla and the ethmoidal roof Air containing space, Boundaries Inf: Roof of the ethmoidal bulla, Medial: Middle turbinate, Lateral: Lamina papyracea Superiorly: Roof of the ethmoid. Laterally it may give rise to an air-containing cleft extending above the orbit – supraorbital recess Suprabullar recess may open into frontal recess
- 56. • Retrobulbar Recess Posteriorwall of the ethmoidal bulla is separate from the basal lamella of the middle turbinate Medial wall : Middle Turbinate Lateral wall : Lamina Papyracea • The supra & retrobullar recesses may be continuous form a semilunar space above and behind the bulla -“sinus lateralis” opens into the middle meatus roof of the sinus lateralis - ethmoid fovea floor- ethmoidal bulla. posteriorly - ground lamella of the middle turbinate anteriorly -opens intofrontal recess. Laterally -lamina papyracea and medially -middle turbinate.
- 57. Hiatus Semilunaris • Semilunargroove bet UP & EB Inf. Hiatus Semilunaris- Grunwald • Saggital cleft btw concave free post. margin of UP & convex ant. surface of EB. • Sickle shaped, 2Dimensional • “Door” to reach ethmoidal infundibulam 2nd Hiatus Semilunaris: Grunwald, Superior Hiatus Semilunaris • saggital cleft btw EB & basal lamella of middle turbinate, when there is marked recess post to EB.This leads to retrobulbar recess • hiatus semilunaris superioris is absent when the bulla is attached either to the base skull superiorly or to the ground lamella posteriorly
- 58. Anatomical Variations Ethmoidal Bulla •May be hypoplastic or rarely even a solid non-pneumatized hillock • More commonly - extensively pneumatized to produce a large bulge, which abuts against UP ant or MT, compromising infundibulum or middle meatus respectively.
- 59. Ethmoid Air Cells •Ant & post ethmoid air cells may pneumatize surrounding bones like lacrimal , maxilla, frontal & sphenoid bone to produce varying patterns of pneumatization - “migrated” air cells
- 60. • Ant ethmoidcells pneumatize lacrimal bone & frontonasal process of maxilla to produce agger nasi cells. Well pneumatized produce a distinct bulge on lateral nasal wall & compromise drainage of frontal recess. • Ant ethmoid cells may pneumatize roof of maxillary sinus - Haller’s cell & it is usually seen in floor of orbit at level btw inferior and medial rectus - compromise the infundibulum
- 61. • Ant ethmoidcells may migrate into frontal recess area -frontal cells, four types: Type I: A single cell above agger nasi cell • Type II: Two or more cells above agger nasi cell
- 62. • Type III:(Frontal bulla) A cell which extends well into frontal sinus & simulates frontal sinus itself on endoscopy • Type IV: An isolated “loner cell” within frontal sinus
- 63. • Pneumatization fromsuprabullar recess may extend laterally over roof of orbit to form supraorbital cell, seen on coronal scans above EB & post to frontal sinus • Ant ethmoid cells may pneumatize MT to give rise to concha bullosa. • Ant ethmoid cells may also pneumatize crista galli
- 64. • Post ethmoidcells may pneumatize sphenoid bone posteriorly to give rise to a cell, which extends superolateral to sphenoid sinus - Onodi cell • Optic nerve & at times internal carotid artery are in close relation with lateral wall of this cell rather than with sphenoid sinus
- 65. Ethmoidal Infundibulam • Cleftlike, 3 dimensional space • Belongs to anterior ethmoid • Lateral wall : Ant & Superiorly : majority by lamina papyracea, frontal process of maxilla & rarely lacrimal bone . Inf & Posteriorly: mucosa covered connective tissue components of posterior nasal fontanelle
- 66. • Posterior Border:Ant. Surface of ethmoidal bulla, in front of which infundibulam opens into middle meatus via hiatus semilunaris. • Medial Wall: Entire extent of uncinate process & its mucosal covering Superiorly depends on uncinate process • UP turns laterally & attach to orbit- EI ends blindly Terminal recess • UP reach skull base or turns medially to attach to middle turbinate EI will be contiguous with frontal sinus
- 67. • If terminalrecess is present : EI & frontal recess are separate, in this case frontal recess opens in the middle meatus medial to EI, btw uncinate process & middle turbinate. Posteriorly, tapers parallel to tapering of UP • Ant length of EI- 4-5 cm • Greatest depth -12cm ( measured from free post margin of UP) • Greatest width – 5-6cm ( measured from free margin of UP to lamina papyracea) • Maxillary sinus ostium- medial wall of EI at middle & post third.
- 68. Frontal Recess • Anterosup.portion of middle meatus. • May be defined as: Ant : Pneumatisation of aggar nasi cells medial : Middle turbinate,UP Lateral : Lamina papyracea, lacrimal bone Sup : Skull base, frontal sinus & ostium Inf : Depend on attachment of UP (open to infundibulam or middle meatus) Post : Bulla, bulla lamella, ant. ethmoidal artery • Natural ostium of frontal sinus - variable Most frequantly- hour glass narrowing Rarely – longer narrowed region 10% - multiple ostia
- 69. • Sagittal section: hourglass shaped structure, narrowest part at frontal ostium, superior portion frontal sinus infundibulam & inferior portion is frontal recess. ` • Post. wall only defined, if bulla lamella aascends in continuity to roof of ethmoid. • Ground lamella of bulla seperates frontal recess from suprabulbar recess.
- 70. • As bullalamella is frequantly incomplete, frontal recess will communicate widely post. with suprabulbar & retrobulbar recess. • Well developed bulla: - frontal recess is narrowed posteriorly • Significant pneumatisation of agger nasi with ethmoidal cells: - frontal recess will further narrowed to a small passage( tubular lumen)- nasofrontal duct • Large agger nasi cells-Displaces the anterior attachment of middle turbinate posterosuperiorly-Narrow down the frontal recess area- Encroach upon nasolacrimal duct
- 71. Anterior Ethmoidal Artery •Course is of clinical significance As in its course from orbit to olfactory fossa, it traverse three cavities : Orbit Ethmoidal labrynth Ant. cranial fossa • Most critical area- were it enters ant cranial fossa through lateral lamella of lamina cribrosa ( thinnest area) • Origin:- opthalmic artery in orbit, passes btw sup oblique & medial rectus muscle • Passes through ant ethmoidal foramen into anterior ethmoid.
- 72. • Cross antethmoidal either: at level of ethmoidal roof, or as much as 5mm below roof ( running in mucous memb fold or thin bony mesentry in the roof) • Artery is surrounded by thin walled bony channel, dehiscent in 40% • Artery enters olfactory fossa, (intracarnial) via lamina cribrosa • Turns anteriorly forming a groove in lateral lamella- ethmoidal sulcus, gives of ant meningeal branches • Reach nasal cavity through cribroethmoidal foramen & cribriform plate, divides into ant nasal artery with sup, lat, medial br, as well as post branch
- 73. • M/C siteto find AEA- Suprabulbar recess (85%) • Unilateral absent ant ethmoidal artery- 14% • Bilateral absent ant ethmoidal artery - 2% • Multiple ant ethmoidal artery – 30% • Absent ant ethmoidal artery- replaced by branch of post ethmoidal artery • CSF leakage- trauma in the area were it enter olfactory foss – dura is not only thin but firmly adherent to bone • Infraorbital hematoma
- 74. Kennedy’s Nipple [AntEthmoidal Foramen]
- 75. Posterior Ethmoidal Complex •Ground lamella of middle turbinate is the border btw ant & post ethmoidal sinuses • All cells opening post to basal lamella • Spenoid sinus opens into sphenoethmoidal recess medial to sup turbinate • Number 1-5 • Most post cells can develop laterally & or superiorly optic nerve & int carotid artery bulge into spheno ethmoidal cells onodi cells
- 77. Superior Meatus • Postethmoid cells open • Related to superior turbinate • 60-67% supreme is seen above superior turbinate • Sphenoethmoidal Recess Medial to sup turbinate Ostium of sphenoid sinus
- 78. Superior/Supreme Turbinate • Superiorturbinate is always present & acts as a guide for sphenoid ostium. • May occasionally be pneumatized or paradoxically curved • Fourth turbinate - supreme turbinate, which represents persistence of an ethmoturbinal may be seen in adult
- 79. Sphenoid Ostium • Medialto posterior sup. turbinate • Located between nasal septum and inferior aspect of sup. turbinate • Located at the same level as the roof of the maxillary sinus • Located 1-1.5 cm above the roof of post choana & approximately 2-3 mm away from the septum. • Drains into sphenoethmoidal recess
- 80. Sphenopalatine Foramen • Boundaries: Above:Body of Sphenoid Front: Orbital process of Palatine bone Below: Upper border of perpendicular plate of palatine bone Ant margin - related to projection in palatine bone - Ethmoidal crest- postinf base of middle turbinate attach • Opens- middle or superior meatus • Transmit: sphenopalatine A & V, Nasopalatine N • Sphenopalatine branches out into post lat nasal & post septal beyond foramen; 39%- divide before foramen
- 81. Blood Supply • INTERNAL& EXTERNAL CAROTID ARTERY • Majority- Sphenopalatine branch of maxillary (ECA), enters through sphenopalatine foramen ( lies just inferior to horizontal attachment of middle turbinate, which is usually damaged due to excessive enlargement of middle meatal antrostomy) Branches enter posteriorly to turbinate & meatus • On concha, vessels are partially embedded in deep groves • Inferior Meatus- sphenopalatine dips below level of palate to re-emerge anteriorly, leaving central portion of meatus avascular. • Lateral wall adjacent to palate – Greater palatine artery • Anteriorly – Facial artery branch (ICA) • Sup. Lateral wall – Ethmoidal artery (ICA) • Overlap btw ICA & ECA, complicate while ligation in case of epistaxis
- 83. Venous Drainage • Cavernousplexus in lamina propria on inf & middle turbinate, controlled autonomically • Veins –btw 0.1 & 0.5 mm wide & anastomose with each other • Venous drainage :- Sphenopalatine veins via facial & opthalmic vessels Vein on dura via ethmoidal veins Sup Sagittal sinus via foramen caecum
- 84. Nerve supply oflateral wall • Sup concha – Olfactory supply • Anterosup – Ant Ethmoidal nerve • Post – Branch of Pterygopalatine ganglion & Ant palatine nerves • Ant small area – Infraorbital nerve • Area of overlap – Ethmoid & Maxillary N • Ant inferior Meatus – small branch from ant sup alveolar nerve
- 85. Lymphatic Drainage • Anteriorly:With external nose to submandibular nodes • Posteriorly : lateral pharyngeal, retropharyngeal & upper deep cervical
- 86.
- 87. Secretion in maxillarysinus • mucous is transported along ant, medial, post & lateral walls as well as roof & finally converge at ostia, which open into ethmoidal infundibulam, which opens into middle meatus via hiatus semilunaris, which is transported over the medial face of inf. Turbinate post. into nasopharynx • Secretions from sinus is always transported via natural ostium.
- 88. Secretion transport infrontal sinus • Along interfrontal septum, then laterally along roof & back medially via floor & inf portions of post & ant wall of sinus • Secretion exit via lateral aspect of ostia • After exit – frontal recess (collect secretion from lateral sinus, agger nasi, pneumatised middle turbinate & ant ethmoidal cells) • Drain either :directly to infundibulam, or medial to infundibulam • Secretion from frontal sinus merge with maxillary sinus secretions & transported to nasopharynx
- 89. Secretion transport fromant & post ethmoidal & sphenoidal sinus cells anteroinf to ground lamella drain to middle meatus cells opening post & sup are post ethmoidal & drain via superior meatus into sphenoethmoidal recess supreme or fourth turbinate – drain into sphenoethmoidal recess Secretion transport in lateral wall of nose Two route : 1st - frontal, maxillary & ant ethmoidal complex,after it reach nasopharynx;secretion pass ant & inf to eustachian tube orifice (active transport upto borderline of ciliated & squamous epithelium in nasopharynx)
- 90. • 2nd route :post ethmoidal cells & sphenoid sinus, meet in sphenoethmoid recess, then to nasopharynx, pass post & sup to eustachian tube
- 92. Reference • Essentials offunctional endoscopic sinus surgery-Heinz Stammberger, Micheal Hawke • Scott-brown’s Otorhinolaryngology, Head and Neck Surgery vol 2 • Anatomical principles of endoscopic sinus surgery: a step by step approach- Renuka Bradoo • Paediatric otolaryngology- Bluestone-vol 2 • Rhinology Journal- supplement 24 • Various Websites
- 93. case presentation-A unit drsantosh kumar moderator- A unit staff Case presentation- B unit Dr Tarakeshwari moderator-B unit staff • Seminar presentation • Topic-ANATOY OF FRONTAL SINUS & ITS DRAINAGE PATHWAY • Presentor-Dr Mohan • Moderator-Dr Abilash Journal presentation-A unit Dr Hiran Moderator- Dr Abilash sir Journal presentation-B unit Dr Snehalatha Moderator – Dr srilaxmi mam