CT Scan of the

Paranasal Sinuses
Updated: Mar 21, 2016
author heading Author: A John Vartanian, MD, MS, FACS; Chief Editor:
Arlen D Meyers, MD, MBA

History

Many historical references to the paranasal sinuses

exist. The earliest such reference can be dated back to
the works of Galen, who described the presence of the
ethmoid air cells. Later descriptions of the maxillary
sinuses by Leonardo da Vinci (1489), the sphenoid
sinuses by Giacomo Berengario da Carpi (1521), and
the frontal sinuses by Coiter (16th century) introduced
early anatomists and scholars to the presence of these
craniofacial air cells.
The first modern and accurate descriptions of the
paranasal sinuses can be traced to the works of the late
19th century Austrian anatomist Emil Zuckerkandl. His
detailed study and illustrations of the paranasal sinuses
set the standard for generations of anatomists and
physicians. Countless 19th and 20th century anatomists,
radiologists, and surgeons have further contributed to
advancing the knowledge of sinus anatomy (see the
image below). The introduction of computed tomography
(CT) and the wider use of it in the last 20 years have
further contributed to the physician's ability to appreciate
nuances of paranasal sinus anatomy and accurate
disease correlation.

Ostiomeatal unit line drawing: inferior turbinate (1), middle

turbinate (2), maxillary sinus (M), uncinate (U), ethmoidal bulla
(B), frontal sinus (F), ethmoidal infundibulum (INF), nasal
septum (NS), and middle meatus (*).

The introduction of head and neck CT imaging and the

current wider use of this modality have undoubtedly
helped the clinician. CT has become a useful diagnostic
modality in the evaluation of the paranasal sinuses and
an integral part of surgical planning. It is also used to
create intraoperative road maps. Today, CT is the
radiologic examination of choice in evaluating the
paranasal sinuses of a patient with sinusitis.

The use of CT scanning combined with functional

endoscopic sinus surgery (FESS) has empowered the
modern sinus surgeon to treat patients more effectively,
facilitating reduced morbidity and complications.
Physicians who are interested in treating patients with
sinus disease must be able to read and interpret sinus
CT scans. Mastery of sinus anatomy and its variant
features forms the basis from which radiologic
interpretation begins. Familiarization with the radiologic
landmarks and cross-sectional anatomy on patient CT
scans, along with clinical correlation, can further
enhance the reader's ability to understand sinus CT
findings.
With experience, CT findings can be accurately
correlated with the anatomic and clinical realities of the
particular patient. As in all radiologic surveys, sinus CT
scans must be read with a systematic approach. In
addition to reviewing the scan to determine the presence
of disease, CT scans of the sinuses can also be
reviewed to evaluate potential areas of occlusion and
variations of the patient's sinus anatomy in the setting of
surgical planning.
For excellent patient education resources, see
eMedicineHealth's patient education article CT Scan.

Basic Concepts

CT scans typically obtained for visualizing the paranasal

sinus should include coronal and axial (3-mm) cross
sections. Soft tissue and bony windows facilitate
evaluation of disease processes and the bony
architecture. The use of intravenous contrast material
just prior to scanning can help define soft tissue lesions
and delineate vascularized structures, such as vascular
tumors. Contrast-enhanced CT is particularly useful in
evaluating neoplastic, chronic, and inflammatory
processes.[1] However, for most patients with sinusitis,
noncontrast CT of the paranasal sinuses generally
suffices. For patients who may not tolerate the prone
position required for coronal cuts, computer-generated
reconstructed coronal views can be generated from thin
axial sections. If sufficiently thin axial sections (1-2 mm)
are available, sagittal reconstructions can also be helpful
for teaching purposes and further delineating anatomic
structures.

Proper positioning of the patient's head is important to

obtain CT images. For axial views, the patient's hard
palate is placed perpendicular to the CT scanner table.
The images must be captured such that the external
auditory canal is in line with the inferior orbital rim. The
coronal images are taken so that the gantry is
perpendicular to the patient's hard palate. Misalignment
or rotation can lead to distortion of the true anatomy on
the films.

Sinus CT is used in correlation with clinical examination

procedures, including nasal endoscopy. Combined, the
information gathered determines the extent of disease
and forms the basis of the treatment plan. The timing of
CT scanning can have a significant impact on the
correlation of CT findings with actual disease state. The
diagnostic yield of the scan for detecting irreversible
(surgically treatable) disease processes, such as chronic
disease or structural problems, is increased once acute
or reversible problems are treated. As such, CT scans
should be obtained only after acute sinusitis episodes
have been adequately treated. Changes from acute
infections can last several weeks; waiting for at least 6
weeks before obtaining a scan is recommended to
determine the patient's baseline disease status.

Patients with chronic inflammatory disease, such as

strong allergies and/or sinonasal polyposis disease,
should receive maximized medical therapy for a few
weeks before undergoing CT scanning. Depending on
the patient's problems, this therapy may include
antihistamines, nasal steroid sprays, antibiotics, or a
brief course of oral steroids.

Some patients may be referred for evaluation after the

discovery of radiologic disease on a screening CT scan.
These screening sinus CT scans often only include
thicker (5-10 mm) axial cross sections of the paranasal
sinuses. They can help to establish disease diagnosis in
a more cost-effective manner. One may argue against
these so-called screening CT scans because of the
superior diagnostic yield of properly obtained axial and
coronal sections and the eventual need for coronal
sections before surgery in some patients. Moreover,
because the cost of CT scanning today is significantly
reduced compared to that even a decade ago, complete
CT is perhaps a more cost-effective test than screening
CT, with a one-time order of a complete CT scan
providing much more diagnostic and surgical
usefulness.

A study by Aksoy et al indicated that high-pitch, ultra-

low-dose CT scanning can effectively image the
paranasal sinuses. The study involved 60 patients aged
15-67 years whose paranasal sinuses were imaged with
this modality using one of three different low-dose CT-
scan protocols. All anatomic landmarks were found to be
well defined in all three groups, with the exception of the
ethmoid foramen (for identification of the ethmoid
artery), which was indistinct or unidentifiable no matter
which protocol was used. Normal and pathologic
mucosal structures of the paranasal sinuses were also
well defined.

A study by Al Abduwani et al indicated that cone-beam

CT (CBCT) scanning is a good alternative to
conventional and low-dose multidetector CT (MDCT)
scanning in paranasal sinus evaluation, with the
investigators finding the mean effective dose of CBCT
scans in 21 patients to be lower than the dose from
conventional and low-dose MDCT scans by 40% and
30%, respectively. Imaging of high-contrast bone
morphology was comparable between CBCT and
standard sinus CT scanning. However, the visibility of
soft tissue was limited in CBCT imaging, and the study
reported that conventional CT scanning is preferable to
CBCT imaging for more advanced sinus disease.

Anatomy

Nasal structures
The osseocartilaginous septum forms the medial extent
of the nasal cavity, and deviations in its position can be
of clinical significance. The inferior turbinate extends
along the inferior lateral nasal wall posteriorly toward the
nasopharynx. In patients with a significant allergic
component to their symptoms, the inferior turbinates
may be enlarged. Enlarged turbinates may be obscured
on CT scanning and should be correlated with physical
examination findings. The nasolacrimal duct (NLD)
opens into the inferior meatus underneath the inferior
turbinate. The NLD drains the lacrimal sac and runs
within a bony canal formed by the maxilla, lacrimal
apparatus, and inferior turbinate bones. Because of this
location, a large duct can be mistaken for obstruction
within the ostiomeatal unit.

The middle turbinate has 3 anatomic parts and is a key

landmark in endoscopic sinus surgery. The anterior third
courses vertically, lying in the sagittal plane, running
from posterior to anterior. Superiorly, the middle
turbinate attaches to the skull base at the lamina
cribrosa of the cribriform plate. The middle third turns
coronally and laterally to insert on the lamina papyracea.
The coronal component of the middle turbinate is
referred to as the basal lamella, and it represents the
dividing point between the anterior and posterior
ethmoid air cells. The posterior portion of the middle
turbinate becomes horizontal and posteroinferiorly
attaches to the lateral nasal wall.
The uncinate process
This hook-shaped bone of the lateral nasal wall forms
the anterior border of the ethmoid infundibulum, which
leads to the natural ostium of the maxillary sinus.
Anteriorly, the uncinate process attaches to the lacrimal
bone, and inferiorly, the uncinate process attaches to the
ethmoidal process of the inferior turbinate. The posterior
edge lies in the hiatus semilunaris inferioris. Superiorly,
the uncinate process may attach to the middle turbinate,
the lamina papyracea, and/or the skull base. See the
image below.

Coronal view demonstrating the blockage of the ostiomeatal

complex by a large concha bullosa (CB). Important components
of the ostiomeatal complex that can be seen include the
uncinate process (U) and maxillary sinus ostium (MO). The
attachments of the middle turbinate (MT*) to the cribriform plate
(cb) and of the uncinate process (U*) to the skull base can be
appreciated. The fovea ethmoidalis (fv) and crista galli (^) can
also be seen. Image used with permission from A. John
Vartanian, MD.

Ethmoid air cells

The ethmoid sinus consists of approximately 7-15 cells
with a variable pneumatization pattern. The ethmoid
bulla is the most constant landmark and forms the most
anterior ethmoidal air cell. The lateral extent of the bulla
is formed by the lamina papyracea. The basal lamella of
the middle turbinate separates the anterior ethmoid cells
from the posterior ethmoid cells. Anterior ethmoid cells
drain into the middle meatus, while posterior cells drain
into the superior meatus. The anterior ethmoid cells are
an important part of the ostiomeatal unit. Obstruction
here can also affect frontal and maxillary sinus drainage.
Other cells that may originate from the ethmoid cell
development include frontal cells, supraorbital ethmoid
cells, infraorbital cells (ie, Haller cells), and
sphenoethmoid cells (ie, Onodi cells). [4] The suprabullar
recess is a potential air space that can exist between the
ethmoid bulla and the skull base.
Sphenoid sinus
The sphenoid sinus is the most posterior paranasal
sinus. It is found superior to the nasopharynx, just
anterior and inferior to the sella turcica and posterior to
the posterior ethmoid cells. The sphenoid ostium can be
seen medial to the superior turbinate and posterior to the
basal lamella. An intersphenoid septum variably divides
the sphenoid into 2 air cells. Several important
structures are related to the sphenoid sinus. The internal
carotid artery is typically found at the posterolateral wall
of the sphenoid sinus. In up to 22% of cases, this bony
covering may be dehiscent. The optic nerve and its bony
encasement produce an anterosuperior indentation
within the roof of the sphenoid sinus. In 4% of cases, the
bone surrounding the optic nerve is dehiscent. See the
image below.
Close-up coronal view of the sphenoid sinus with dehiscence of
the sellar floor. Image used with permission from A. John
Vartanian, MD.

The frontal sinus outflow tract (frontal recess)

The frontal sinus outflow tract is a tortuous path that
leads from the frontal sinus into the nasal cavity. The
ethmoid bulla often defines and limits the posterior
aspect of the frontal sinus outflow tract. Anteriorly, the
frontal sinus outflow tract is bordered by the agger nasi
cells and, in some cases, the uncinate process. The
lateral wall of the frontal recess is bounded by the
lamina papyracea. The medial boundary is the middle
turbinate. Posteriorly, the frontal recess is bordered by
the anterior wall of the ethmoid bulla. This area is
affected by the development of anterior ethmoid cells,
such as the frontal or supraorbital cells. Enlargement
and/or disease of any of the cells within the frontal sinus
outflow tract may contribute to the blockage of the frontal
sinus.
Disease States
CT scanning can be helpful in the diagnosis of acute
and chronic sinusitis, neoplastic and inflammatory
processes, and other problems (eg, congenital
anomalies).

Acute sinusitis is caused by bacterial or fungal infections

usually secondary to an obstructed sinus cavity.
Structural anatomic variations, acute edema of sinonasal
mucosa in response to infection or allergens, and
compromise of nasociliary flow can all contribute to
acute and chronic sinusitis. CT findings of sinus
opacification, air-fluid levels, and thickened localized
mucosa are all findings of acute sinusitis. Many
nonspecific CT findings, including thickened turbinates
(nasal cycle vs allergic process vs inflammation) or
diffusely thickened sinus mucosa (allergic disease vs
chronic sinusitis), may be associated with several
sinonasal conditions.

In chronic sinusitis, repeated episodes of acute sinusitis

or festering infection usually combined with unfavorable
anatomic factors lead to a vicious cycle of infection,
mucociliary incompetence, and chronic mucosal
inflammation. CT findings suggestive of chronic sinusitis
include mucosal thickening, opacified air cells, bony
remodeling, and bony thickening due to inflammatory
osteitis of the sinus cavity walls. Bony erosion can occur
in severe cases, especially if associated with massive
polyps or mucoceles. CT findings of bony destruction
should alert the clinician to also consider less common
diseases, such as sinonasal tumors or granulomatous
disease processes. See the image below.
Axial image at the level of the inferior turbinates demonstrating
maxillary mucoceles and mucosal thickening, especially in the
right maxillary sinus. Image used with permission from A. John
Vartanian, MD.

Sinonasal polyps can create sinus disease by

obstruction or mass effect and by causing secondary
infections. Sinonasal polyps appear on CT scans as
nodular or rounded masses and amorphous opacified
blobs of tissue. Bony remodeling can occur, but it is
typically subtle, which is expected from the usual slow
growth pattern of sinonasal polyps and benign
processes in general. See the image below
Axial images of the anterior and posterior ethmoid air cells. The
presence of massive sinonasal polyps was confirmed by
intraoperative findings. Image used with permission from A.
John Vartanian, MD.

Fungal sinusitis can be divided into invasive fungal

sinusitis, chronic noninvasive fungal sinusitis
(mycetoma), and allergic fungal sinusitis. Invasive fungal
sinusitis due to mucormycosis or aspergillosis is typically
a disease that affects immunocompromised patients and
can have a fulminant course. Early in the disease
process, opacification of sinuses is seen. Disease
progression to a more fulminant state accompanies
vascular invasion and localized destruction. Intracranial,
cavernous sinus, and orbital complications may occur
with advanced infections. CT findings mirror these
processes with expanding localized destruction of bone.

Mycetomas appear inside the sinus cavity as

noninvasive balls of fungus. CT findings may include a
localized sinus opacification, homogenous mass that
does not change shape with head position (gravity), and
a mass with presence of calcifications (found in 25% of
cases).

Allergic fungal sinusitis (AFS) may occur in atopic

patients as a hypersensitivity reaction to fungal antigens.
Many patients with AFS may also have various degrees
of nasal polyposis. On CT scans, heterogeneous
opacification can be seen with a typical pattern of central
hyperdense areas of opacification surrounded by less
dense areas of opacification. Calcified areas can
sometimes be seen. Bony expansion, remodeling, and
even diffuse bony destruction can be seen in advanced
cases.

With experience, CT findings can be accurately

correlated with anatomic and clinical realities of the
particular patient. As for all radiologic surveys, sinus CT
scans must be read with a systematic approach. After
the primary survey of the CT scan is completed,
including patient name, indications for the CT scan, type
of scan, cross-sectional view being discussed, and
major radiologic findings, particular attention is directed
toward potential "bottle-neck" areas, where normal
passages may be occluded by disease states or variant
anatomy.

A systematic approach is helpful when interpreting CT

scans. Reading the CT scan from anterior to posterior
(on coronal views) or from top to bottom (on axial
sections) can help organize one's approach in analyzing
structures to be interpreted. For initial orientation, a
number of important paranasal sinus structures are
identified, including the frontal sinuses, the frontal
recess, the agger nasi cells, the anterior ethmoidal sinus
cells, the ethmoid roof, the ethmoidal bulla, the uncinate
process, the ethmoidal infundibulum, the maxillary sinus,
the middle meatus, the nasal septum, the turbinates, the
basal lamella, the posterior and anterior ethmoid cells,
and the sphenoid sinus. See the image below.
Coronal view demonstrating well-pneumatized frontal sinuses
(FS), the ethmoid bulla (b), and the lamina papyracea (LP).
Also of interest is the presence of an aerated middle turbinate
or concha bullosa (c) blocking the ostiomeatal complex. The
inferior turbinate is labeled IT. Image used with permission from
A. John Vartanian, MD.

If the CT scan is being read as a prelude to surgery, a

number of additional anatomic and structural features
need to be considered. The thickness, orientation, and
most medial position of the lamina papyracea must be
noted. Any dehiscences or excessive medial bowing of
this thin bone should be noted prior to surgery. Similarly,
 the depth of the olfactory fossa must be recognized. The
relationship of the sphenoid sinus and posterior ethmoid
air cells vis a vis the internal carotid artery and optic
nerves should be noted.

Important Radiologic Anatomic

Landmarks

Landmarks on coronal CT sections

Relationship of cells within the frontal recess and their
relationship to the frontal sinuses
listitem
Depth of the olfactory fossa: The deeper the fossa (ie,
increased distance from the cribriform plate and the
fovea ethmoidalis), the higher the chance for fracture or
perforation with surgical maneuvers.
listitem
Slope, thickness, and asymmetries in the height of the
ethmoid roof itemizedlist
listitem
The prevalence of intracranial penetration during FESS
is higher when this anatomic variation occurs.
listitem
Intracranial penetration is more likely to occur on the
side with the lower roof.

 listitem
Patency of the ostiomeatal complex

Coronal view demonstrating the blockage of the

ostiomeatal complex by a large concha bullosa (CB).
Important components of the ostiomeatal complex that
can be seen include the uncinate process (U) and
maxillary sinus ostium (MO). The attachments of the
middle turbinate (MT*) to the cribriform plate (cb) and of
the uncinate process (U*) to the skull base can be
appreciated. The fovea ethmoidalis (fv) and crista galli
(^) can also be seen. Image used with permission from
A. John Vartanian, MD.
Attachment of the middle turbinate
listitem
 Width of the infundibulum
listitem
Vertical distance from the maxillary sinus to the ethmoid
roof in posterior ethmoid cells
listitem
Degree of pneumatization of the maxillary sinus
listitem
Status of the lamina papyracea itemizedlist
Dehiscence in the lamina papyracea
Shape of the medial orbital wall
Attachment of the uncinate process
listitem
Alignment of the septum
listitem
Size and status of the maxillary sinuses (hypoplastic vs
normal size)
Other variations, such as the presence of a concha
bullosa

Landmarks on axial CT sections

Depth and ratio of the anterior and posterior ethmoid
cells compared to the sphenoid sinus (see the image
below) itemizedlist
Degree of pneumatization of sphenoid sinus
Position of sphenoid intersinus septae
 Axial images of the anterior (ae) and posterior (pe)
ethmoid air cells. The sphenoid sinus (sp) can be seen
with its intersinus septum. Image used with permission
from A. John Vartanian, MD.
Presence or absence of an Onodi cell (sphenoethmoidal
cell)
listitem
Dehiscence in the bony covering of the carotid artery or
optic nerve itemizedlist
Relationship of the optic nerve to the posterior ethmoid
cells
The presence of anterior clinoid process pneumatization

Degree of indentation created by the carotid artery and
optic nerve
listitem
Position of uncinate (medial versus lateral)
Patency of the ostiomeatal complex
Patency of the V-shaped ethmoidal infundibulum
Alignment of the septum

Summary of Basic Sinonasal Anatomic

Terms
Agger nasi: This is a bony prominence that is often
pneumatized in the ascending process of the maxilla. Its
location below the frontal sinus also defines the anterior
limit of the frontal recess.

Concha bullosa: The concha bullosa is a pneumatized

middle turbinate. An enlarged middle turbinate may
obstruct the middle meatus and the infundibulum
causing recurrent disease. It may also serve as a focal
area of sinus disease.

Ethmoidal bulla: This is the largest and most anterior

ethmoid cell system. It is found posterior to the middle
turbinate and posteromedial to the uncinate process.
Ethmoidal infundibulum: This is a space bordered
medially by the uncinate process and laterally by the
lamina papyracea. The maxillary sinus ostium is found
inferiorly and laterally within this space.

Haller cell (infraorbital cell): The Haller cell is usually

situated below the orbit in the roof of the maxillary sinus.
It is a pneumatized ethmoid cell that projects along the
medial roof of the maxillary sinus. Enlarged Haller cells
may contribute to narrowing of the ethmoidal
infundibulum and recurrent sinus disease, despite
previous (incomplete) surgery.

Frontal recess: This is an hourglass-shaped space

between the inferomedial aspect of the frontal sinus and
the anterior middle meatus. Unfavorable variations of the
structures that define its borders may cause problems
with the frontal sinus outflow tract. These structures
include the agger nasi cell, supraorbital ethmoid cells,
the ethmoid bulla, and inferiorly, the uncinate process.

Lamina papyracea: This is a thin, bony wall separating

the orbit from the ethmoid air cells. Dehiscences may
occur for congenital reasons or because of previous
surgery or facial trauma.

Maxillary sinus ostium: This is the opening of the

maxillary sinus to the nasal cavity and a part of the
ostiomeatal complex.

Ostiomeatal complex or unit: This term refers to a

collection of middle meatal structures and is not a
discrete anatomic entity. It consists of the ethmoid
infundibulum, anterior ethmoid cells, and the uncinate
process. It also represents the final common pathway of
drainage for the frontal, maxillary, and anterior ethmoid
cells. A patent ostiomeatal complex is essential for the
improvement of patients with sinus disease.

Paradoxical middle turbinate: The major curvature of the

middle turbinate may project laterally, leading to
narrowing of the middle meatus.

Sphenoethmoid cell (Onodi cell): This is formed by

lateral and posterior pneumatization of the most
posterior ethmoid cells over the sphenoid sinus. The
presence of Onodi cells increases the chance that the
optic nerve and/or carotid artery would be exposed (or
nearly exposed) in the pneumatized cell.

Uncinate process: This is a 3-dimensional sickle-shaped

(also described as a hook- or L-shaped) bone of the
lateral nasal wall. Anteriorly, the uncinate process
attaches to the lacrimal bone; inferiorly, the uncinate
 process attaches to the ethmoidal process of the inferior
turbinate. The posterior edge lies in the hiatus
semilunaris inferioris. Superiorly, the uncinate process
may attach to the middle turbinate, lamina papyracea,
and/or the skull base.

Pearls
In general, the larger the air cells, the thinner the bony
walls become. This may increase the chance for injuring
structures within or adjacent to such bony structures
lining the air cell.
On CT scan, AFS is depicted as a heterogenous
opacification that can be seen with a typical pattern of
central hyperdense areas of opacification surrounded by
less dense areas of opacification.
Unilateral sinonasal polypoid soft tissue masses in the
area of the ethmoid cells may represent a herniated
encephalocele. An MRI may be helpful in its
differentiation.