Sinus Anatomy

Amy Anstead, MD
Director, Rhinology and Endoscopic Skull Base
Surgery
Virginia Mason Medical Center
Seattle, WA
Location of the sinuses
 Sinus anatomy
pictorial representation

F - Frontal sinuses, E - Ethmoid sinuses, M - Maxillary sinuses, O - Maxillary sinus ostium, ST-
Superior turbinate, T - Middle turbinate, IT- Inferior turbinate, SM- Superior meatus, MM- Middle
meatus, S-Septum
Hypoplastic Frontal Sinus

Nasal
Valve
 Vertical
Lamella MT

Infraorbital nerve
Orbital Apex

Inferior Orbital
Fissure
 Optic N. Canal

Carotid

Anterior Clinoid Foramen

Rotundum
 Sinus anatomy
CT scan

+ - border of maxillary sinus, * - maxillary sinus ostium, U - uncinate process, E -

ethmoid sinuses, IT- inferior turbinate, MT- middle turbinate, S - septum, C - concha
bullosa.
 CT scans of normal and
infected sinuses

Normal Infected
*/O - maxillary sinus ostium, U - uncinate process, E - ethmoid sinuses, IT-
inferior turbinate, MT- middle turbinate, S - septum, C - concha bullosa, P -
polyp
Axial Cuts
1 Incisive Foramen
 1 Greater Palatine Foramen

2 Lateral Pterygoid Muscle

5 3 Medial Pterygoid Muscle

Torus Tubarius
4
Fossa of Rosenmuller
 1 Infraorbital Nerve (V2)

2 Nasolacrimal Duct

4 3
Coronoid Pterygopalatine
Process Fossa
 1 Nasal Bone
Middle Turbinate (head) 2

3 Nasolacrimal Duct

Natural Os – maxillary 4
(leads to OMC)

5 Sphenopalatine Foramen

6 Foramen Ovale (V3)

7 Foramen Spinosum

8 ICA
Inferior Orbital Fissure 1

4 9 cm (distance
ICA 2 to columella)

3
Clivus
 Cribriform Plate 1

Planum Sphenoidale 3 2 Optic Nerve (in optic canal)

Pituitary Gland in Sella Turcica

4
(hypophyseal fossa)
6 Opticocarotid Recess
Posterior Clinoid Process 5
Coronal Cuts
 Superior
1 Sagittal
Sinus

Intersinus Septum
2
(frontal sinus)

3 Columella
 Superior Oblique
1
Muscle

Internal Valve 2
Lacrimal Gland 1

Agger Nasi 2

Nasal Spine 3
 Crista Galli
1

Middle Turbinate 2 3 Lacrimal Sac

4 Inferior Oblique Muscle

5 Nasal Crest
 1 Fovea Ethmoidalis

Olfactory Fossa &

2
Cribriform Plate

3 Lamina Papyracea

4 Uncinate Process

5 Infraorbital Nerve (V2)

6 Hasner’s Valve

7 Incisive Foramen

8 Olfactory Cleft
 Anterior
Ethmoid
Artery
1 2 Levator Palpebrae Superioris

3 Superior Rectus

Ethmoid Bulla 6 4 Medial Rectus

5 Inferior Rectus

Natural Os – maxillary 7
(leads to OMC)
 2 Posterior Ethmoids
Optic Nerve 1
Basal Lamella of the
3
Middle Turbinate
 1 Optic Nerve
Superior
Orbital 2 3 Sphenopalatine Foramen
Fissure

4
Greater Palatine Canal
(pterygopalatine canal)
1 Optic Nerve / Chiasm

2 7 cm
 1 Anterior Clinoid Process

Foramen
3
Rotundum (V2)
2 Intersinus Septum (sphenoid)

Vidian Canal 4
7 Rostrum Sphenoidale

Pharyngeal Canal 5

6 Choanae
Pituitary Gland in Sella Turcica
(hypophyseal fossa)
1
2 Posterior Clinoid Process

Eustachian
3
tube

Medial & Lateral

4
Pterygoid Plates
1 ICA
Sagittal Cuts
Anterior & Posterior Ethmoid Arteries (12 mm)
1
 1 Anterior Ethmoid Artery
(in roof of most superior subrabullar)

2 Hiatus Semilunaris
 1 Crista Galli

2 Perpendicular Plate of Ethmoid

3 Vomer

Anterior Arch of Atlas (C1) 4

Odontoid Process (Dens) of Axis (C2) 5

Abnormal CT Sinuses
Lateralized Middle Turbinate
Mucus retention cysts
• Prior ESS; Right side clear rhinorrhea . . .
Ethmoid Mucocele
Sinusitis –
Medical Management?
CRS - Maximal Medical Therapy

Survey (N= 308 ARS members)

CRS - Maximal Medical Therapy
• Which CRS therapies must fail before you recommend sinus
surgery? % who use this almost
always
(>90% of time)

1. Oral antibiotics 81%

2. Nasal steroids 74%
3. Nasal saline irrigation 43%
4. Oral steroids 29%
5. Allergy testing 22%
CRS - Maximal Medical Therapy
• Length of oral antibiotic therapy?
▫ 2 – 4 weeks (67% used this length)

• Length of oral steroid therapy?

▫ 6 – 14 days (67% used this length)
▫ High dose (tapered to off)
CRS - Maximal Medical Therapy
• Other therapies SOMETIMES used (10-50%)
▫ Antihistamines
▫ Mucolytics
▫ Leukotriene inhibitors

• Therapies Rarely or Never used (0-10%)

▫ Antifungals
 Oral / spray / nebulizer
▫ Antibiotic
 IV / spray / nebulizers
CRS - Maximal Medical Therapy
• Failure of medical therapy
▫ Persistence of BOTH
Radiographic disease
AND
Symptoms
Sinusitis – Diagnosis & Treatment

31 pages
Review Diagnosis & Treatment of . . .
1. Acute Sinusitis
2. Recurrent Acute Sinusitis
3. Chronic Sinusitis
ACUTE Rhinosinusitis
• Acute = less than 4 weeks
• 3 Cardinal Symptoms of ARS:
▫ Purulent drainage
 ↑ sensitivity
▫ Nasal obstruction
▫ Facial pain-pressure-fullness

• GOAL - Distinguish bacterial from viral/noninfectious

• Bacterial - (if signs/symptoms . . .)
▫ 10 days or more
▫ Initial improvement then worsen w/in 10 days (double
worsening)
Acute Rhinosinusitis
• Only PE finding (to have diagnostic value for
ARS)
▫ Purulence (nasal or posterior pharynx)

• Sputum color is not determined bacteria!

• Sputum color determined by?
▫ Neutrophils (not bacteria)
▫ Generally, allergies and viral ARS have clear
mucus
Acute Bacterial
How to Treat?
• Mild to moderate pain
▫ acetaminophen or NSAIDS (alone or c opioid)
• Symptomatic relief
▫ Topical steroids, PO/topical Decongestants, Saline
irrigation, and Mucolytics (in order of evidence).
• Observation (no antibiotics)
▫ Mild, uncomplictd (mild pain & <101°F) & good f/u
▫ Start Abx if no improve (p 7 days from Diagnosis)
• Antibiotics
▫ Severe, complic sinusitis, immune deficiency, prior
sinus surgery, or coexisting bacterial illness.
▫ CONSIDER age, health, cardiopulmonary / comorbid
Acute Bacterial
• After 7-14 days Placebo = __% improve & __% cure
70% improve & 35% cure !!!!
▫ Abx improve outcomes (rate difference) 15%
▫ PCP setting & exclude severe/persistent Dz
▫ ↑objective dx = ↑ antibiotic benefit
 (+) imaging, (+) culture, Validated algorithm

• 1st line therapy = ___(Abx)____

Amoxicillin
▫ Which Abx has been proven to have significant better outcomes?
 NONE (no signif outcome difference among antibiotics!!)
 Amoxicillin, Augmentin, Cephalospn, or Macrolides
▫ Amoxil slightly better than placebo
▫ PCN allergy should use?
 Bactrim (cheap) or macrolide (Z-pak)
Acute Bacterial
• How long to treat with Abx?
▫ No relation btw Abx duration & outcome (8
RCTs!)
▫ Most trials use 10 days
▫ ↑ Abx = ↑ side effects & ↑resistance

• Top 3 organisms?
▫ #1 Strep pneumo, #2 H. flu, #3 M. cat
▫ Amoxil resistance for each?
 25%, 80%, & 30% (respectively)
Acute Bacterial Failure
Define treatment failure
• Worsen or no improve p 7 days from diagnosis
• now, what to do with this patient?
1. Exclude other causes
2. R/o complications
3. Start or change antibiotics
• Why 7days? . . . 73% improve c placebo & 85% Abx
▫ NOT severe, complic sinusitis, immune deficiency,
prior sinus surgery, or coexisting bacterial illness.
▫ CONSIDER age, health, cardiopulmonary /
comorbid
Acute Bacterial Failure
• Cultures (of Abx failure) show ↑resistance to
original Abx (amoxil)
• What are 2nd line Abx?
▫ Augmentin or fluoroquinolone (broad)
▫ Cephalosporins or macrolides (narrower)
Chronic vs Recurrent Acute
Define Chronic
• >12 weeks
• Signs/Sx (at least 2 of 4):
▫ Mucopurulent drainage
▫ Nasal congestion
▫ Facial pain-pressure-fullness
▫ Decreased smell
• AND inflammation (at least 1 of 3)
▫ Purulent mucus or edema (middle meatus)
▫ Polyps
▫ Radiographic imaging c inflammation
Chronic vs Recurrent Acute
Define Recurrent Acute
1.4 or more per year
2.Between episodes no signs/symptoms
• Why 4?
▫ Avg adult has 2 colds/yr (1.4-2.3)
▫ REALITY – hard to meet ABRS criteria 4 times/yr
• (for recurrent acute) When get culture? or CT?
▫ Culture (acute) and CT (between episodes)
CRS Differential Diagnosis
• Allergic rhinitis
• Nonallergic rhinitis
▫ vasomotor rhinitis, eosinophilic nonallergic
rhinitis, etc.
• Septal deviation / turbinate hypertrophy
• Neoplasm
• Neurologic facial pain
▫ Vascular headaches, migraine, trigeminal
neuralgia, etc.
Chronic & Recurrent Acute
• 5 predisposing factors / diseases:
▫ Allergic rhinitis
 Very associated with CRS
▫ Cystic fibrosis
▫ Ciliary dyskinesia
▫ Immunocompromised state
▫ Anatomic variation
 Poor evidence
Chronic & Recurrent Acute
• 3 tests to perform/order:
▫ Nasal endoscopy
 See inflammation, obstruction, masses
 Obtain culture
▫ Radiographic imaging
 See inflammation, obstruction, masses
▫ Allergy/immune testing
Chronic & Recurrent Acute
• Gold standard radiologic test?
▫ CT scan

• How well does CT correlate c symptoms or QOL?

▫ Very poor correlation
Chronic & Recurrent Acute
Immunocompromised state
▫ Examples:
 IgA deficiency, common variable immunodeficiency,
hypogammaglobulinemia, ↓ pneumo vaccine response, or
HIV
▫ Usually have other infections (bronchitis, acute OM)
▫ Labs
 Quantitative IgG, IgA, and IgM
 Specific Ab responses to tetanus & pneumo vaccine
(pre&post)
 T-cell number and function
 Delayed hypersensitivity skin tests
 Flow cytometric enumeration of T cells
Prevention
• Educate patients about control measures
▫ Hand hygiene (prevent viral ARS)
▫ Tobacco use (↓ sinusitis)
▫ Nasal saline
▫ GERD?
If they fail medical treatment?