Paranasal Sinus Imaging

for FESS
WHAT THE SURGEON NEEDS TO KNOW

Paranasal
sinuses
•Frontal sinus
•Ethmoid sinus
• Anterior ethmoid air cells
• Posterior ethmoid air
cells
• Maxillary sinus
• Sphenoid sinus

Frontal Sinus
Ethmoid Sinus

frontal recess
sphenoid

middle turbinate

Ethmoid Sinus

Ethmoid Sinus
Maxillary Sinus

Sphenoid Sinus

Sinus drainage pathways

Frontal sinus  frontal sinus ostium and recess  direct to middle meatus  nasal cavity  nasopharynx
ethmoid infundibulum to middle meatus

Maxillary sinus  maxillary sinus ostium  ethmoid infundibulum  middle meatus  nasal cavity  nasopharynx

Anterior ethmoid air cells/ethmoid bulla  middle meatus  nasal cavity  nasopharynx

Posterior ethmoid air cells  superior/supreme meatus  sphenoethmoid recess  nasal cavity  nasopharynx

Sphenoid sinus  sphenoid sinus ostium  sphenoethmoid recess  nasal cavity  nasopharynx
 Ostiomeatal Unit (OMU)
• Maxillary sinus ostium
• Ethmoid infundibulum
• Hiatus semilunaris
• Uncinate process
• Ethmoid bulla
• Frontal recess
• Ostia of anterior ethmoid air
cells
• Middle meatus

Sphenoethmoidal drainage
• Sphenoid sinus ostium
• Ostia of posterior ethmoid
sinuses
• Sphenoethmoidal recess

Nasal septum
• (Supreme turbinate)

• Superior turbinate

• Middle turbinate

• Inferior turbinate

• (Supreme meatus)

• Superior meatus

• Middle meatus

• Inferior meatus

Middle turbinate
• 2 attachments
• Medial lamella or the
vertical attachment
 Middle turbinate
• 2 attachments
• Medial lamella or the
vertical attachment
• Basal (ground) lamella or
the lateral attachment
• Divides ethmoid air
cells into anterior and
posterior air cells

Basal lamella of the middle turbinate

Preoperative imaging
• Evaluation of the extent of disease
• Identification of the anatomic variants that
narrow or obstruct sinus outflow tracts
• Evaluation of the anatomic variants that
predispose patients to surgical complications
• Most importantly, the preoperative imaging
examination affords the radiologist an
opportunity to identify danger areas for the
otolaryngologist prospectively

O’Brien Sr WT, Hamelin S, Weitzel EK. Radiology. 2016 Sep 19;281(1):10-21.

Anatomic
variants of the
OMU:
Infraorbital ethmoid air cell (Haller cell)

Concha bullosa

Paradoxical turn of the middle

turbinate

Nasal septal deviation

Anatomic
variants of the
frontal recess:
Superior uncinate process insertion
Agger nasi cell
Frontal cells (Kuhn cells)
Type 1
Type 2
Type 3
Type 4
Supraorbital ethmoid air cell
Suprabullar cell
Frontal bullar cell
Inter-frontal sinus septal cell

Superior uncinate process insertion

Flint PW and Cummings CW. Cummings Otolaryngology Head & Neck Surgery. 2010. Internet resource.
 Agger nasi cell
Huang, BY, et al. Radiographics 29.1 (2009): 177-195.

Type 1 frontal cell

Huang, BY, et al. Radiographics 29.1 (2009): 177-195.

Type 2 frontal cell

Huang, BY, et al. Radiographics 29.1 (2009): 177-195.
 Type 3 frontal cell
Huang, BY, et al. Radiographics 29.1 (2009): 177-195.

Type 4 frontal cell

Huang, BY, et al. Radiographics 29.1 (2009): 177-195.

Frontal bullar cell Suprabullar cell

Huang, BY, et al. Radiographics 29.1 (2009): 177-195.
Preoperative Imaging Report
• description of paranasal sinus
development, with a focus on
under- or overpneumatization
• sinus hypoplasia

Eggesbø HB, et al. Acta Radiologica. 2001 Sep 1;42(5):482-93.

Preoperative Imaging Report

• Sinus drainage pathways and patterns of
inflammatory sinus disease
• OMC and frontal recess patency along with
anatomic variants
• Haller cells, frontal recess cells, superior attachment
of the uncinate process
• sphenoethmoidal recess patency
•Patterns of inflammatory disease:
• polypoid or nonpolypoid mucosal thickening
• frothy attenuation and air-fluid levels
• intrasinus contents, such as mucous retention
cysts, suspected fungal colonization, and
sinoliths
• central increased attenuation (inspissated
secretions and/or fungal colonization), osteitis,
bony demineralization, or bony dehiscence

Preoperative Imaging Report

• Nasal cavity is then evaluated for pathologic or variant anatomic lesions that may affect surgical
access during endoscopy
• Nasal septal deviation and spur, configuration of the middle turbinates, concha bullosa
• Nasal polyps or mass

• CLOSE criteria or the critical FESS points

 CLOSE Criteria
• C – Cribriform plate
• L – Lamina papyracea
• O – Onodi cells
• S – Sphenoid sinus pneumatization
• E – (Anterior) Ethmoidal artery canals

Cribriform plate

Asymmetry in height of ethmoid roof

 Keros classification
O’Brien Sr WT, Hamelin S, Weitzel EK. Radiology. 2016 Sep 19;281(1):10-21.

Lamina
papyracea
Dehiscence

Fracture

Onodi cell

Onodi Cell
 sphenoid

Onodi Cell

Sphenoid bone
pneumatization
Pneumatized anterior clinoid
process

Optic nerve types

Type 1
Type 2
Type 3
Type 4

Pneumatized pterygoid process

Dehiscent carotid canal

Relationship of the optic nerve to the

posterior paranasal sinus
• Type 1 optic nerves (bilateral) –
nerves course adjacent to the
sphenoid sinus without indentation
of the wall
• Type 2 optic nerve (right) – nerve
courses adjacent to the sphenoid
sinus, causing indentation of the
sinus wall
 OC
Relationship of the optic nerve to the
posterior paranasal sinus
• Type 1 optic nerve
• Type 2 optic nerve
• Type 3 optic nerve (left) – nerve
courses through the sphenoid sinus
• Type 4 optic nerve (right) - nerve
courses immediately adjacent to
the sphenoidal sinus and the
posterior ethmoidal air cell or
Onodi cell

Anterior
ethmoidal
artery canals