THE NOSE &

PARANASAL SINUSES
Surgical Anatomy

Ramon Antonio B. Lopa, MD

Clinical Associate Professor
Department of Otorhinolaryngology
UP-PGH
External Triangles of the Nose
External Nose: Bones and
Cartilages
Valves of the Nose
 Walls of the Nasal Cavity
n Medial: nasal septum (not always in the
midline)
n Lateral wall: turbinates
n Roof: cribriform plate
n Floor: palate
n Anterior: nares
n Posterior: choanae
Nasal Septum
Nasal Septum, Cadaver

Pseudostratified Columnar Ciliated

Nasal septum with mucosa

-Respiratory
epithelium
-Covered with
mucosal blanket
-Ciliary beat of
epithlium is
backwards to
pharynx
-Vascular
Nasal septal arteries
Kiesselbachs
plexus or
Littles area:
common
cause of
bleeding in
children
Nasal septum: cadaver

Sphenopalatine
artery

Nasopalatine
nerve
Kiesselbachs Plexus
Nasal septal nerves
Marked Septal Deviation
Lateral Nasal Wall
Posterior Choanae
3Turbinates & 3 Meati
CT Scan of Turbinates & Meati
LNW, with Mucosa, Cadaver

Erectile Tissues
Supreme Turbinate
 LNW with Turbinates Cut
Hiatus semilunaris

Ethmoidal bulla
Uncinate process

Nasolacrimal duct
Airflow Patterns
Laminar Air Flow by the Turbinates
Nasal Heating & Humidification

Acts Like a Car Radiator

Under the Inferior Turbinate:
Nasolacrimal Duct

O
LNW: turbinates cut, cadaver
Hiatus Semilunaris
Bulla

Uncinate Process

Nasolacrimal Duct
 Uncinate Process

n Sharp ridge of bone, sagittally-oriented

n Boomerang-shaped
n Superior border is concave, parallel to
ethmoidal bulla
n Has varied insertions to LNW which
affects formation of frontal recess
Uncinate Process, Endoscopic View
 Hiatus Semilunaris

n A 2-D cleft between the uncinate

process & ethmoidal bulla
n Sagittally oriented
n Superior HSL leads to lateral sinus
when present
n Inferior HSL serves as door to the
ethmoidal infundibulum
 Hiatus semilunaris

Ethmoidal bulla

Uncinate process
 Ethmoidal Bulla
n The largest &
most consistent
air cell in the gl
anterior ethmoid mt
group b up
n Posterior to hsl
uncinate process
n Part of the ostio-
meatal complex it
of nose
Ethmoidal bulla, endoscopic

b
up s
mt

it
 Ethmoidal Infundibulum
n A 3D space
extending from
HSL antero-
inferiorly & antero-
superiorly to the
LNW, with the
maxillary ostium in
its floor
n Lateral to the
uncinate process
 Ethmoidal Infundibulum
n Boundaries:
Medially:
uncinate process
Laterally: lamina
papyracea
Posteriorly:
anterior surface
of bulla
Four Bony Walls of the LNW
Blood Supply of the LNW
Nasal Cavity, Coronal View
Ostiomeatal Complex
 Significance of OMU

n Blockage of the OMU by secretions,

tumors, foreign bodies or anatomical
defects lead to development of sinusitis
n Treatment: removal of offending
blockers or surgical correction of defect
to facilitate easy drainage of the sinuses
Ostiomeatal Complex
Ostiomeatal Complex, Axial View
1 Hiatus semilunaris (inferior)
2 Infundibulum
3 Superior Hiatus semilunaris
4 Lateral Sinus
Dnl nasolacrimal duct
Cm middle turbinate
Lp lamina papyracea
Glm ground lamella
S -- septum
 Lateral Sinus
n Suprabullar recess and
retrobullar recess, not
constant
n Boundaries:
Inferiorly: roof of the bulla
Superiorly: roof of ethmoid
Laterally: lamina papyracea
Medially: middle turbinate
Retrobullar recess: ground
lamella posteriorly and ethmoid
bulla anteriorly
n Accessed through the
superior HSL
Before & After ESS of the OMC
Ground Lamella, Rt Middle
Turbinate, Lateral View
STABILITY SAGITTAL

CORONAL

AXIAL

Posterior Anterior
Paranasal Sinuses

FRONTAL
ETHMOID
-Anterior
-Middle
-Posterior
MAXILLARY
SPHENOID
The Paranasal Sinuses
 The Paranasal Sinuses

n Maxillary: the largest

n Ethmoid: most complex & frequently
infected, divided into anterior, middle &
posterior groups
n Frontal: between the frontal bones
n Sphenoid: on top of the nasopharynx,
under the sella
 Functions of the Paranasal
Sinuses
n Resonance of voice
n Air reservoir
n Lighten the skull
n Serve as crumple zone for the face in
trauma
n Protects the brain from direct injury
 Openings of the Sinuses

n Maxillary:middle meatus via

infundibulum
n Ethmoids: anterior & middle--middle
meatus; posterior--superior meatus
n Frontal: middle meatus via infundibulum
n Sphenoid: spheno-ethmoidal recess in
the superior meatus
Development of the Sinuses
Maxillary Sinus, Coronal CT
Fluid in the Maxillary Sinus
Maxillary Sinus Drainage
Mucociliary Clearance of Sinuses
Surgery for Maxillary Sinusitis
Caldwell Luc Surgery for
Maxillary Sinus
 ETHMOID SINUS GROUP

Fovea Ethmoidalis
Crista Galli
Cribriform Plate

Septum Lateral Lamina

Ethmoidal Lamina Papyracea

cells Turbinates
ETHMOIDS
ETHMOIDS
 Ethmoidal Labyrinth

n Boundaries:
Lateral wall: lamina papyracea
Medial wall: superior & middle turbinates
Superiorly: walled off by fovea ethmoidalis
of frontal bone
n Open in the other directions
Ethmoidal Air Cells
Ethmoid Air Cells, Axial View
Agger Nasi Cell
Agger Nasi Cell
 Haller Cell
n Infraorbital
ethmoidal cell
n Found inferior
and lateral to
ethmoidal bulla
n Intimately related
to infundibulum
 Onodi Cell
n Spheno-
ethmoidal cell
n Posterior ethmoid
cell lateral &
superior to
sphenoid sinus
n Intimately related
to optic nerve
 Ethmoidal Parts

n Ethmoidal roof
Lateral part is thick, formed by fovea
ethmoidalis of frontal bone, 0.5 mm
Medial part is thin, formed by lateral
lamella of cribriform plate, 0.2 mm
n Olfactory fossa
Lateral is the lateral lamella
Floor is the cribriform plate
Type 1 Cribriform Plate
Type 2 Cribriform Plate
Type 3 Cribriform Plate
Assymetric Cribriform Plate
Course of the Anterior Ethmoid
Artery, Right
1 Orbital
2 Labyrinthine
3 Cranial
4 Nasal

3
2 1

4
Anterior Ethmoidal Artery
AEA at the Dome of the Ethmoid
Frontal Sinus
Frontal Sinus Drainage
Hourglass-shaped Frontal Sinus &
Frontal Recess

Frontal sinus ostium

Drainage
The frontal sinus drains via a small outflow tract into the ethmoid sinus/nasal cavity. The outflow tract
is hour-glass shaped with the true ostium (3-4 mm) at the narrowest portion.
 Frontal Recess

n Lower part of hourglass; upper part is floor of

frontal sinus; narrowest part is frontal sinus
ostium
n Frontonasal duct a misnomer
n May be narrow if bulla is large or agger nasi
is anterior
n Opens into middle meatus or infundibulum
depending attachment of uncinate process
Frontal Recess, CT Scans
Uncinate Process Variation
Sphenoid Sinus
Sphenoid Sinus & Relations
Sphenoid Sinus & Cavernous Sinus
Sphenoid Sinus Ostium
THANK YOU VERY MUCH