SINUS ANATOMY AND FUNCTION

LITERATURE READING

Dept of Otorhinolaryngology HNS Hasan Sadikin General Hospital Bandung

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INTRODUCTION

Paranasal sinus anatomy is quite variable Differences structure can two sides in the same person There are eight paranasal sinuses Each sinus is lined with a mucous membrane Under normal anatomic and physiologic conditions, the sinuses are filled with air Deviations normal anatomic structure or changes in mucous membrane function predispose a sinus disease
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PARANASAL SINUSES

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PARANASAL SINUSES VIDEO

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THE TOPICS
The The

embryology and development anatomy of each sinus The physiology of the paranasal sinuses Function of the paranasal sinuses

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EMBRYOLOGY AND DEVELOPMENT

During the 4th week in utero : The frontonasal process can be identified with the maxillary and mandibular processes The frontonasal process, which arises over the developing forebrain Ectodermally Sixth week lateral nasal wall Seventh week the three turbinates Tenth week maxillary sinus, uncinate process and bulla ethmoidalis
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Fourteenth week the anterior ethmoidal and posterior ethmoidal cells The ethmoid sinuses are the first to fully develop, followed in order by maxillary, sphenoid, and frontal sinuses

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DEVELOPMENT OF THE SINUSES

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DEVELOPMENT OF THE SINUSES

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Adapted from : Netter Atlas

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THE ETHMOIDAL SINUS

3rd fetal month : The anterior ethmoidal cells form first as evaginations of the lateral nasal wall in the middle meatus 4th fetal month : The posterior ethmoidal cells develop from outgrowths in the superior meatus At birth : These cells enlarge gradually in utero of 2 x 4 x 2 mm anterior group, 4 x 5 x 2 posterior group at birth Are fluid-filled and difficult to visualize radiography
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THE ETHMOIDAL SINUS

Can be visualized on x-ray film at 1 year of age enlarge rapidly to reach adult dimensions by 12 years of age The anterior group 20 x 22 x 10 mm The posterior group 20 x 20 x 10 mm

During adolescence, ethmoidal cell pneumatization may extend to several of the adjacent bones such as the frontal or lacrimal bone
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ETHMOIDAL SINUS

The ethmoidal cells are divided

an

anterior group that drains into the ethmoid infundibulum of the middle meatus a posterior group that drains into the superior meatus Consist 4-17 cells per side , average 9 cells

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coronal view

Adapted from : Stammberger, Functional Endoscopic Sinus Surgery. 2003

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Sagital view

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2006

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ETHMOIDAL SINUS
The horizontal plate of the ethmoid bone variable depend on the position of the cribriform plate with respect to the fovea ethmoidalis KEROS Type 1-3 The Keros type vital importance to remember during intranasal dissection

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Blood supply of the ethmoidal sinus : Receive blood from the nasal branches of sphenopalatine artery, anterior and posterior ethmoidal artery, internal and external carotid vessels Venous drainage, two routes : - Into the nose via nasal veins that are tributaries of the maxillary - via ethmoidal veins that drain into the opthalmic vein, which are tributaries of the cavernous sinus
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Innervation of the ethmoidal sinus : Both the opthalmic and the maxillary divisions of the trigeminal nerve supply sensation to the mucosa of the ethmoid complex

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SURGICAL IMPLICATION
The ethmoidal fovea is easyly penetrated during surgery, which may result in injury to the contents of the anterior cranial fossa Dissection along the fovea from posterior to anterior provides a surgical landmark for locating the frontal sinus during endoscopic sinus surgery. The fovea appears more opaque than surrounding bone and has yellowish
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SURGICAL IMPLICATION
Maxillary bone : completes the inferior ethmoidal cells adjacent to the roof of the maxillary sinus This relationship has been used to perform ethmoidectomy via the maxillary sinus The lacrimal bone : provides a surgical landmark for locating the anterior ethmoidal cells during external ethmoidectomy

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SURGICAL IMPLICATION
Cerebrospinal fluid leaks from a fracture or surgery are commonly located in the ethmoidal fovea

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KEROS Type : In type 1, the cribriform plate is located 1 to 3 mm below the fovea ethmoidalis, making the lateral lamella short or nonexistent. In type 2, the distance is 4 to 7 mm, In type 3, it is 8 to 16 mm.
Adapted from : Stammberger, H. Essentials of Functional Endoscopic Sinus Surgery. 1993

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Dome of the Ethmoid bone

Adapted from: Reda kamel 2004

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Hiatus Semilunaris

Adapted from : Netter Atlas

Adapted from: Reda kamel 2004

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Posterior Ethmoid Sinus

A collection of 1-7 ethmoid cells Onodi cell a posterior ethmoidal cell that can pneumatize an area of sphenoid bone

Adapted from : Netter Atlas

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Adapted from : Stammberger, Functional Endoscopic Sinus Surgery. 2003

Adapted from: Reda kamel 2004

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THE MAXILLARY SINUS

The 1st begin development 65th day of gestation Slowly enlarge in utero newborn : 7 x 4 x 4 mm Not demonstrated on plain film radiography 4 to 5 months Growth of these sinuses is biphasic :

1st enlargement during the first 3 years of life 2nd acceleration between 7 and 12 years

Finally, slow expansion until 18 years (34 x33 x23 mm) with average capacity of 14.75 mL

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Blood supply of the maxillary sinus : Branches of the maxillary artery Venous drainage : - anteriorly : anterior facial vein jugular vein - posteriorly : tributaries of the maxillary vein superficial temporal vein retromandibular vein jugular sys Region infratemporal fossa : maxillary vein communicates with pterygoid venous plexus anastomose with the dural sinuses through the skull base
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Innervation of the maxillary sinus : - Several branches of the maxillary nerve (greater palatine, posterolateral nasal, and all of the superior alveolar branches of the orbital nerve) - Pterygopalatine fossa : the sphenopalatine ganglion parasympathetic fibers (branch of N. facialis)
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RELATED STRUCTURES
Ostium of the maxillary sinus Nasolacrimal duct Accessory ostium The canine fossa

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Maxillary Sinus

antrum of Highmore occupies the body of the maxilla the largest of the paranasal sinuses. Pyramidal in shape
Opening of Macillary sinus

Infraorbital recess Infra orbita recesus of maxillary

Zigoma recesus
Maxillary sinus of maxillary sinus Alveolar recesus Alveolar recess

Zygomatic recess of maxillary

Alveolar process of maxilla

Adapted from : Netter Atlas

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coronal view

Maxilar sinus

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2006

Adapted from : Stammberger, Functional Endoscopic Sinus Surgery. 2003

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Maxillary Sinus

The first and second molars are the two most commonly dehiscent teeth in the maxillary sinus. Extensive pneumatization, the third molar, bicuspids, and canine teeth may all be exposed in the maxillary sinus.

Adapted from : Bolger, W. Anatomy of the Paranasal Sinuses. In : Kennedy, D. Disease of The Sinuses. 2001

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Maxillary Sinus

The ostium superior aspect of the medial wall, + 9 mm posterior to the nasolacrimal duct. Hiatus semilinaris ant etmoid In 15% to 40% of cases an accessory ostia

Proc. uncinatus

Adapted from : Netter Atlas

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SURGICAL IMPLICATIONS
An oroantral fistula and maxillary sinusitis may develop after molar extraction because the molar roots may be located within the sinus Infection of the maxillary sinus may extend via the infraorbital vein to the cavernous sinus

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WATERS MAXILLARY SINUS

Adapted from : slide lecture series (rinosinusitis), AAOHNS Found.

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Adapted from : slide lecture series (rinosinusitis), AAOHNS Found.

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THE FRONTAL SINUS

4th month of gestation As potentially arising from direct extension of the frontal recess

The frontal sinus is rarely demonstrated radiographically earlier than the 2nd year of life

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THE FRONTAL SINUS

The sinus invades the frontal bone by about 5 years of age and slowly grows to reach an adult size in late adolescence of 17 x 28 x 27 mm with a volume of 6 to 7 mL The pneumatization of the frontal sinus is also variable, and in 4% to 15% of the population, a developmental failure

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Blood supply of the frontal sinus : Supplied by the supra orbital and supratrochlear ateries derived from the opthalmic atrey, a branch of the internal carotid artery Venous drainage is primarily via the superior opthalmic vein posteriorly through the superior orbital fissure into the cavernous sinus Innervation of the frontal sinus : Supraorbital & supratrochlear branches (N V)
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FRONTAL SINUS
Sinus frontal

Frontal Recesus

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2006

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Frontal Sinus
Frontal Sinus

(Adapted from Netter, 1998)

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SURGICAL IMPLICATION
Relationship to the anterior cranial fossa posteriorly and to the orbital cavity inferiorly Infection of the frontal sinus may result in meningitis, epidural abcess, orbital cellulitis, or orbital abscess, most frequently in the lateral orbit The bone separating the frontal sinus from the anterior cranial cavity is thin & can easily be penetrated during surgery

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THE SPHENOIDAL SINUSES

4th month of gestation As paired evaginations of the mucosa in the superoposterior of the nasal cavity also known as the sphenoethmoidal recess Adult size by age 18 of 23 x 20 x 17 mm with a volume of 7.5 mL.

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Blood supply of the sphenoid sinus : - Via branches of both the internal and external carotid arteries - Posterior ethmoidal branch & Sphenopalatine branch Venous drainage into the maxillary vein & pterygoid venous plexus Innervation of the sphenoid sinus : Trigeminal nerve
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SPHENOID SINUS
The sphenoid sinus is usually an asymmetrically paired structure divided by a deviated intersinus septum. Congdon extent of pneumatization of the sinuses :
Type I (5%) conchal, exists when the posterior extent of the sphenoid sinus is well anterior to the sella turcica Type II (23,5%) presellar pneumatization occurs when the posterior wall of the sphenoid sinus reaches the anterior face of the sella turcica Type III (67%) postsellar and is present when the sphenoid sinus extends past the level of the sella turcica to approach the pons posteriorly

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SPHENOIDAL SINUS

Internal carotid .a

n.optic

Sphenoid sinus

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2006

Adapted from : Stammberger, Functional Endoscopic Sinus Surgery. 2003

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SPHENOID SINUS

Each sphenoid sinus empties into the sphenoethmoidal recess through a small ostium This ostium, which measures 0.5 to 4 mm, is located 10 mm above the sinus floor, or 30 degrees above the floor of the nasal cavity

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2nd ed. 1998

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SURGICAL IMPLICATION Sphenoidal sinusitis can lead to meningitis, Nerve VI palsy, and cavernous sinus thrombosis Anatomic variations may blockage drainage of the sphenoidal sinus and predispose to sinusitis: Small ostium : < 2 mm in diameter Ostium located near the roof of the sinus Ostium narrowed by a posterior ethmoidal cell Recesses and septa within the sinus A narrrow sphenoethmoidal recess

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PHYSIOLOGY

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SINUS EPITHELIUM

Mucosal epithelium : ciliated columnar cells, nonciliated columnar cells, goblet cells, and basal cells. Submucosa contains stromal cells, inflammatory cells, nerves, blood vessels, and seromucous glands

The ciliated cells are plentiful within the sinuses, but the concentration of nonciliated cells grows to 50% at the sinus ostium

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SINUS EPITHELIUM

Serous and mucinous glands Parasympathetic produce thick mucus Sympathetic produce thin mucus Concentration goblet cells and submucosal glands lower in sinuses than nasal cavity Maxillary sinus higher goblet cells than other sinuses Density submucosal glands highest at ostia maxillary, sphenoid, and anterior ethmoidal sinuses
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MUCOUS BLANKET

Two layers Sol layer produced by microvilli Gel layer produced by goblet cells and submucosal glands Mucoglycoproteins Other components : Immunoglobulin A (IgA) Immunoglobulin G (IgG) and interferon Lysozyme and lactoferrin
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MUCOUS BLANKET

Foreign particles or bacteria are trapped

3 to 25 mm per minute

The maxillary sinus has a star-shaped drainage pattern from the sinus floor superiorly to the ostium
The mucociliary transport of the frontal sinus sweeps in a circular

Mucus is swallowed and transported to the stomach

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Mucociliary transport routes in maxillary and frontal sinus

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2001

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MUCUS TRANSPORTATION PATHWAYS

Frontal sinus ostium frontal recess ethmoidal infundibulum middle meatus the nasopharynx

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MUCUS TRANSPORTATION PATHWAYS

ANTERIOR & POSTERIOR ETHMOIDAL AND SPHENOIDAL SINUSES Ostium Sphenoid located in its floor : directly toward the ostium Ostium ethmoid located higher in one of the walls : a spiral transportation pattern directed toward the ostium Anterior ethmoid middle meatus Posterior ethmoid superior meatus
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Adapted from : Stammberger, Functional Endoscopic Sinus Surgery. 2003

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Block : below 18C, Excessively acidic or basic Primary ciliary abnormalities Dehydration or humidity less than 50% Immunoglobulin deficiency decreases the infection-fighting capability
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OSTEO MEATAL COMPLEX

OMC Consist of : the air cells of the anterior ethmoid and their ostia, ethmoidal infundibulum, maxillary ostium, frontal ostium, and middle meatus (Reda Kamel)

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OSTEOMEATAL COMPLEX

Severe sinus disease in the maxillary and frontal sinuses can undergo resolution when normal aeration and mucociliary clearance are restored to the anterior ethmoidal cells.

Adapted from : Miller, A.J. Sinus Anatomy and Funstion In : Bailey, B.J. Head & Neck Surgery-Otolaryngology. 2006

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Normal Sinus Drainage

Block Sinus Drainage Resulting in Sinusitis

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FUNCTION OF THE SINUSES

largely unknown Theories paranasal sinuses functions: Humidify and warm inspired air Assist in regulating intranasal pressure Increasing the surface area of the olfactory membranes Lightening the skull Imparting resonance to the voice Absorb applied shock to the head Contribute to facial growth
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HIGHLIGHT

The maxillary sinus is the first paranasal sinus to develop at about the sixty-fifth day of gestation and in the adult represents the largest. The anatomy of the paranasal sinuses is complex and highly variable and this is especially the case with the ethmoid sinus

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HIGHLIGHT

Sphenoid sinus contain several prominent indentations in its superior and lateral walls including the optic nerve, carotid artery, maxillary branch of the trigeminal nerve, and the vidian nerve, all of which may be dehiscent and possibly damaged during dissection. The mucosa composed of ciliated and nonciliated pseudostratified columnar epithelium interspersed with goblet cells,produce thick mucus
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HIGHLIGHT

The mucous blanket and the ciliated epithelium combine to form the mucociliary system, which contains antimicrobial and immunologic properties capable of preventing bacterial superinfection of the sinuses.

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THANK YOU

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 Pertinent anatomy middle meatus important in understanding concept sinusitis Maxillary sinusitis is secondary in most cases to disease within the ostiomeatal complex Mucosal swelling and obstruction disturbances in physiology sinus lead development significant disease and resultant symptoms

ANATOMY AND PHYSIOLOGY

(adapted from Bailey, 2001)

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SURGICAL IMPLICATIONS
Middle meatal antrostomy, popularized by Stammberger (1986), is performed through the endoscopic endonasal approach Inferior meatal lavage : penetrating the lateral wall of the inferior meatus Inferior meatal antrostomy (a part of a Caldwell-Luc procedure) is performed in the lateral wall of the inferior meatus
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