This presentatoin useul for pgs

1. DR.ASHOK KUMAR.,
MS ENT PG,
ENDOSCOPIC
NASAL
ANATOMY

2. EMBRIYOLOGY
 7th&8th wk lat.wall of nasal capsule begins to
form series of ridges of mesenchchymal tissue
 1st ridge the Ethmotubinal-INFERIOR TUBINATE
 Ramus ascendens-anterior ascending parts
 Ramus decendens-post,inf,more horizontal part
 ET-1-5(maxillo tubinal/nasotubinals)
 S1-s6 –major furrows

4.  ET1-regress during later development
 ET-1 desending portion (UP)
 ascending portion(aggar nasi)
 ET1/ET2-bet furrows(ethmoid infundibulam)
 ET2-permanent MT
 ET3-permanent ST
 Fusion of ET4/ET5-supreme turbinate

5.  Frontal,maxillary,&ethmoid sinus arises from
evagination of LNW
 sphenoid sinus arises from post. evagination of
nasal capsule
 Maxillary sinus –develop from ethmoidal
infundibulam
 HS-from desending portion of 1st primary furrow
 SM-develop from S2
 Upper most meatus from-S3
 BERTINI OSSICLES-unpneumatized sphenoid

6. Tubinates
 Tubinates are ends of
the bony lamella
 Tubinates has a
visible/invisible
part(ground lamella)
 Passage bet tubinate
are meati

7. GROUND LAMELLA
 1ST- uncinate process
 2nd- bulla ethmoidalis
 3rd- middle tubinate
 4th- superior tubinate
 5th- supereme turbinate

8. LATERAL WALL OF NOSE
 BONES-from before backwards
1.nasal bones
2.frontal pr.of maxilla
3.lacrimal bone
4.sup& middle nasal conchae of ethmoid labrinth
5.inf. Nasal concha
6.perpendicular plate of palatine bone(orbital
sphenoid pr.)
7.medial pterygoid plate
 Cartilages-ULC,LLC(alar cartilage)
 Fibrofatty tissue-covering with skin in lower part

11. INFERIOR TURBINATE&MEATUS
 Largest tubinate and lagest meatus
 Highest at the jn of mid 1/3rd
 Separate bone covered by thick mucus memb.
irregular surface with vascular channels
 NLD opening in ant portion of lat wall of IM
 slit like openig protected by fold of mucus
memb.plica lacrimalis or valve of hasner
 maxillary pr. articulate with inf. marigin of
maxillary hitus

12. Nasolacrimal duct

13. Middle tubinate & meatus
 Portion of ethmoid bone
 It receive drainage from the frontal maxillary
&ant.ethmoidal cells
MM- Atrium ,aggar nasi,limen nasi,
Maxillary hiatus
uncinate pr.,bulla ethmoidalis,
hiatus semilunaris,
ethmoidal infundibulum
recess terminalis
Opening –frontal sinus in ethmoidal inf.
Through FND,AEC

14. Superior turbinate &meatus
 Is approx. ½ length of MT
 starts from middle of lower turbinate
 ST-projects from medial surface of the
ethmoidal labyrinth,below &infront of SER
 SUPREMETURBINATE
 u/l or b/l in 60 % of individuals
 Ostia of PEC opens into supreme
meatus[75%]

15. Blood supply

16. Nerve supply

17. Aggar nasi
 Most ant. Part of ethmoid bone
 Represented by small crest or mound on the
lateral wall just ant.To the attachment
middle tubinate
 It may be pneumatised [5-80%]

18. Aggar nasi cell
E BOSS 18-08-2011

19. Aggar nasi cell
 Aggar means- mound/eminence
 Nasi means-nose
 Pneumaticed from FR
 Just above & ant to MT insertion
 Ant. –frontal pr. Of maxilla
 Superiorly- FR/FS
 Anterolaterally –nasal bone
 Inferomedial-UP
 Inferolaterally –lacrimal bone

20. Middle turbinate(3RD LAMELLA)
 Ethmoid bone(fromET2)
 Divides into segments-
ant1/ 3rd –horizontal seg.sagittaly
oriented attaches to
skull base
mid 1/3rd – vertical portion ,
oriended to coronal
plane att.to LP
post.1/3rd – inferior horizontal
portion
 Basal lamella of MT divides
ethmoid labrynth into AEC/PEC
 Shape of the MT is highly
variable[paradoxical MT,CB]

21. MT attachments-
 1.ant-aggar nasi region at crista
ethmoidalis(ethmoidal eminence of maxilla)
 2.superioriy/medially-vertically lateral aspect
of lamina cribrosa(CP)
 3.inferiorly – lamina papyracea[medial wall of
the MS]
 4.most post.aspect of MT-lat wall at crista
ethmoidalis of pp of palatine bone just ant to
SPF

22. SBR
RBR
Sinus Lateralis
Middle turbinate: Horizontal
and vertical basal lamella
E BOSS 18-08-2011

23. paradoxical MT CONCHA
BULLOSA]

24. Uncinate process
 Sagittaly oriented after
reflecting MT
 3 layered structure
 3 to 4mm wide,/1.5 to2cm
length
 Normally anterosuperiorly
attach to ethmoidal crest of
maxilla just inf.To lat attach
.of MT fuses with
post.aspect of lacrimal bone

25. UP-ATTACHMENTS
 Posteroinfriorly
attach.to ethmoidal pr.
Of IT
 Anteromedial
boundary of EI
 Posterior marigin is
free-no bony attach.

26. Superior attachment -LP
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27. Superior attachment-MT
E BOSS 18-08-2011

28. Superior attachment –skull
base
E BOSS 18-08-2011

29. Medialized uncinate
[double MT]
uncinate
uncinateuncinate
E BOSS 18-08-2011

30. LATERALISED UNCINATE
[MAXILLARY SINUS HYPOPLASIA]

31. Ethmiodal bulla
 Most constant ant.ethmoid air cell
 Largest anterior ethmoidal cell
 Anterior to basal lamella of MT
 Post.to uncinate process
 Superiorly ant.wall of the BE extend to skull base
 Form post. Limit of
the frontal recess
 Pneumatised ET2
 Type-simple,compound,
complex

32. Ethmoidal bulla
[anatomical variants]
 Highly pneumatised [retrobullar
recess,suprabullar recess]
 Low lying bulla- potentially narrow ethmoid
infundibulam l/t impaire mucocilliary
transport
 unpneumatised[8%] –torus lateralis[bony
projection fron LP]

33. Hiatus semilunaries
 Hiatus means-gap,cleft,passage way
 Semilumaris means-cresent shaped
 Sickle shaped[moon ]-2D sagittal ceft
 Between post.free marigin of UP and ant.
Wall of bulla ethmoidalis
 Forms the doorway that lead to ethmoidal
infundibulum
 Inferior HS of grunwald[MI]
 Superior HS –bet.EB/MT[EI]

34. Osteomeatal unit
 Not discrete
anatomic structure
 Collectivelly
several MM
struc.[UP,EI,AEC]

35. SINUS LATERALIS
 When the posterior wall of the BE is not in contact with BL
of MT
 Suprabullar recess[space sup.to bulla]
 Retro bullar recess[space behind thhe BE]-forms lateral
sinus of grunwald
 Sinus lateralis lise
P- basal lamella of MT
A- roof &posterior wall of BE
S - roof ofethmoid
L-lamina papyracea

36. Ethmoidal infundibulum
 Cleft like 3D space in lateral
wall of nose
 Funnel shaped passage
 Boundaries:
Ant.-lacrimal bone
Post. –ant.surface of the
ethmoidal bulla
Superior –frontal recess
Med. -entire extend of
UP &mucosal covering
Lat.wall - LP

37.  Ethmoidal infundibulum ends anteriorly in acute
angle-v shaped in axial cut
 If UP attaches with LP –EI closed superiorly by
blind pouch called TERMINAL RECESS
 Frontal recess opens medial to EI
 Posteriorly EI tapers parallel to tappering of UP
 entire length of EI -4cm
 Greatest width-approx.5-6mm[free marigin of
UP]
 Maxillary ostium –mid3rd lower part of EI
 FND –drain into ant sup.to upper end of EI

39. Zones of ethmoid box
 ZONE A
anterior OMC[anterosuperior
attachment of MT to
posterolateral att. Of MT]
 ZONE B
posterior OMC [posterolat.
MT to face of sphenoid sinus ]
 ZONE C
sphenoid sinus [SS to
neighbouring structure]

40. ANTERIOR ETHMOIDAL ARTERY
 canal for AEA is over superio
medial aspect of orbit –
pyramidal sign
 Anatomy is highly variable
 Commonly injured during
attempts to asscess
frontal sinus outlet tract
 Bony covering is very thin

41. Posterior ethmoidal artery
anterior nasal crest to anterior
ethmoidal foramina 22 -24 mm
ant. to post. ethmoidal artery 12 –
15 mm
post.ethmoidal artery to optic
canal 3 – 7mm
importance

43. Hellar cells
 inferomadial aspect
of the orbital rim
 variation-10%
 Also called -
maxilo orbital cell
maxilloethmoidal cell
orbitoethoidal cell
Infero orbital
ethmoidal cell

44. Ethmoidal cells
 Anterior ethmoidal cell:[6-14/smaller in size]
 1.frontal recess cell
 2.infundibular cell
 3.bullar cells
 4.Cochal cell
 5.exramural cell[cell outside the ethmoid]
 -supra orbital cell
 -aggar nasi cell
 -haller cell

45.  Posterior ethmoid cell:[1-5/larger insize ]
intramural post. Ethmoid cell
extramural post. Ethmoid cell
-onodi cell

46. Post ethmoid sinus
 Derived from 2nd /3rd primary furrow
 Boundaries
 ant –BL of MT
 post.-anterior wall of SS
 Lat- LP
 Medially by –ST/supreme turbinate
 Superiorly – ethmoid roof
 Specific sugical signi.-d/t proximity to skull
base/optic N

47. Poterior ethmoid cells
 GL forms the partition bet.AEC/PEC
 Located post. & sup.To GL
 No.of cell vary 1 to 5
 Drain into the sup & sup .m
 Can develop lat. & sup to SS
 dissection always –inferomedial direction
rather then superolateral direction
 Most vulnerable point jn of rostum with roof
of spenoid

48.  anatomical variation in PEC
 -onodi 38 variations with PEC/optic N[12
major group]
 Distal opening of optic canal:
next to the most PEC[50%]
at jn of PEC/ant.SS[25%]
next to ant. SS [25%]

49. onodi cell
E BOSS 18-08-2011

50. Onodi cell
sphenoethmoidal cell
 Onodi cell supero
ethmoidal cell-extend
posteriorly along the LP
into the ant.Wall of SS
 INCIDENCE-9-12%
 Optic n /med.recti m
lisein close relation with
lat. Wall of this cell-
vulnerable o injury
during sugery

51. Delano clasification
[onodi cell]
 Type 1-optic N courseing adj. to SS without
intentation of wall,contact with PES
 TYPE2-M/C 76% optic N course adj. to SS causing
indentation of sinus wall without making contact
with PES
 TYPE3-optic N course through SS with atleast 50%
surreounded by air
 Type4-nerve course adj. to SS/PES
 TY2,3- 77% as with dehiscent
 85% of optic N as with pneumaticed ant.clinoid pr.[
indication of optic n vulnerability during FESS

52. Frontal recess
[frontal infundibulum]
 FR –funnel shaped narrowing towards the
frontal ostium
 Boundaries:
M- superior attch. Of MT
L –LP
S –internal os of frontal sinus
A –frontal pr. Of maxilla [aggar nasi]
P –superior extention of ethmoidal
bulla/skull base

53. Frontal recess narrowed by
 Anterior-aggar nasi cell,frontoethmoidal
cell[ty 1,2,3], inter frontal cell
 Posterior-superior orbital cell,frontobullar
, suprabullar cell

54. importance
 Considering complexities of FR serial CT scan
required to know the exact anatomy
 Extensively pneumatised aggar nasi can be
mistaken for FR /FS
 residual posteroosuperior wall of aggar nasi
can scar & iatrogenic stenosis of frontonasl
connection can occur

55. Frontal recess

56. Lamina papyracea

57. Frontal beak

58. FRONTAL SINUS
 Theories :
 direct extention of the FR
 By end of 2nd yr one ant. Ethmid cell migrate
upward & forms frontal sinus
 Ethmoid infundibular cell

59. Suprabullar cell

60. Supraorbital cell

-Anatomic variation
in

FR
AEA
FS
SOC
E BOSS 18-08-2011
-Anatomic variation in
FR
-commonly occurs
from Pneumatisation
of orbital plate frontal
bone by ethmoid air
cell
-Ventilation to FS/SOC-
common ostium at FR

61. Supraorbital cell
E BOSS 18-08-2011

62. frontobullar cell
 From FR/AEC can develop into frontal bone
along the side of frontal sius called
“ BULLA FRONTALIS”

63. Frontal ells[bent& kuhn
classification]
 Type 1-single frontal recess cell above aggar
nasi cell but below FS
 Type 2-tier of more then one cell in FR above
the aggar nasicell
 Type 3-large single cell pneumatised into
frontal sinus[<50%hight of FS]
 Type 4-single isolated cell in frontal sinus
 [>50%hight of the FS]

64. Type 1 frontal cell

65. Type 2 frontal cell

66. Type 3 frontal cell

67. E BOSS 18-08-2011
Type 4 frontal cell

68. Interfrontal sinus
septal cell [IFSSC]

70. KEROS CLASSIFICATION
 TYPE I TYPE II TYPE III
 1to 3mm 4 to 7 mm 8 to 16mm
type3-[dangerous type during fess]

71. Sphenoid sinus
 Pneumatize from SER from birth
 Extensive variation
 3 types based on pneumatisation
 cochal[fetal]2%
 presellar[juvenile]10 to 25%
 sellar [adult] 86%
 Superior –
thin bone base of skull
 Lat. –optic N ,ICA

73. Types of sphenoid
peumatisation
Berger classification
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74. ENDOSCOPIC APPEARENCE

75. ANATOMIC VARIATIONS
 variations in course of ICA in relation toSS
 result in different pattern of bulgein wall of
the sinus

76. ICA AND SPHENOID

77. Angle of attack
 The more acute
the angle Less the
chances of
Skull base injury
E BOSS 18-08-2011

78. Stenberg canal

79. Applied aspect
 Optic N extend backwards & disappears
towards posterior wall
 25% ICA partially dehiscent
 6% dehiscent optic N
 Maxillary nerve may be surrounded by
pneumatisation
 Canal for vidian N may bulge on floor of SS

81. Thank you