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Advanced anatomy of lateral nasal wall Ent Scholar

Advanced anatomy of lateral nasal wall

For the endoscopic sinus surgeon
September 19, 2012 Rhinology

Authors
BalasubramanianThiagarajan

Anatomy of lateral nasal wall

Introduction: Anatomyofthelateralnasalwallishighlycomplexandvariable.Withthepopularityofendoscopic sinussurgeryathroughknowledgeofthiscomplexanatomyisveryvital.Highlyvariableanatomyand paucityofstandardlandmarkmakesthisregionvulnerableforcomplicationsduringendoscopicsinus surgery.Thelearningcurveforendoscopicsinussurgeryismaderathersteepbythishighlyvariable anatomy1.StudyofanatomyoflateralnasalwalldatesbacktoGalen(AD130201).Hedescribed theporosityofbonesinthehead.Davinciinhisclassicalanatomicaldrawingshasillustratedmaxillary sinusantrum.Healsodescribedmaxillarysinusascavitiesinthebonethatsupportsthecheek2. Highmore(1651)describedmaxillarysinusanatomy.HenceitisalsoknownasantrumofHighmore3. Itwasduringthe19thcenturythatZuckerkandlcameoutwiththefirstdetaileddescriptionof maxillarysinusanditssurroundinganatomy.Paranasalsinusesarefourairfilledcavitiessituatedat theentranceoftheupperairway.Eachofthesesinusesarenamedaftertheskullboneinwhichitis located4. Nasalturbinates: Theturbinatesarethemostprominentfeatureofthelateralnasalwall5.Theyareusuallythreeor sometimesfourinnumber.Theseturbinatesappearasscrollsofbone,delicate,coveredbyciliated columnarepithelium.Theseturbinatessometimesmaycontainanaircell,inwhichcaseitistermed asaconcha.

Fig.1:Figureshowingturbinatesinthelateral nasalwall

Theseturbinatesprojectfromthelateralwallofthenose.Outoftheseturbinatesthefollowingare presentinallindividuals:

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Thesuperior,middleandinferiorturbinates.Asmallsupremeturbinatemaybepresentinsome individuals.Amongtheseturbinatesthesuperiorandthemiddleturbinatesarecomponentsofthe ethmodialcomplexwhereastheinferiorturbinateisaseparatebone.Commonlyaprominencemay beseenattheattachmentofthemiddleturbinate.

lateralwallofnoseafterremovalofturbinates

Thisprominenceisknownastheaggernasicell.Thisprominencevariesinsizeindifferent individuals.Theseaggernasicellsoverliethelacrimalsac,separatedfromitjustbyathinlayerof bone.Infactthisaggernasicellisconsideredtobearemnantofnasoturbinalbonesseeninanimals. Whentheanteriorattachmentoftheinferiorandmiddleturbinatesareremoved,thelacrimal drainagesystemandsinusdrainagesystemcanbeclearlyseen. Theinferiorturbinateisaseparatebonedevelopedembryologicallyfromthemaxilloturbinalbone. Theinferiormeatusispresentbetweentheinferiorturbianateandthelateralnasalwall.Thenasal openingofthenasolacrimalductopensintheanteriorthirdoftheinferiormeatus.Thisopeningis coveredbyamucosalvalveknownastheHassnersvalve.Thecourseofthenasolacrimalductfrom thelacrimalsaclieundertheaggernasicell. Themiddlemeatusliebetweenthemiddleturbinateandthelateralnasalwall.Themiddleturbinateis partoftheethmoidalcomplex.Thesinuseshavebeendividedintotheanteriorandposteriorgroups. Theanteriorgroupofsinusesarefrontal,maxillaryandanteriorethmoidalsinuses.Thesesinuses drainintothemiddlemeatus,i.e.underthemiddleturbinate.Themiddlemeatushostsfromanterior toposteriorthefollowingstructures: 1.Aggernasi 2.Uncinateprocess 3.Hiatussemilunaris 4.Ethmoidalbulla 5.Sinuslateralis 6.Posteriorfontanelle Uncinateprocess:actuallyformsthefirstlayerorlamellaofthemiddlemeatus.Thisisthemost stablelandmarkinthelateralnasalwall.Itisawingorboomerangshapedpieceofbone.Itattaches

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anteriorlytotheposterioredgeofthelacrimalbone,andinferiorlytothesuperioredgeoftheinferior turbinate6.Superiorattachmentoftheuncinateprocessishighlyvariable,maybeattachedtothe laminapalyracea,ortheroofoftheethmoidsinus,orsometimestothemiddleturbinate.The configurationoftheethmoidalinfundibulumanditsrelationshiptothefrontalrecessdependslargely onthebehavioroftheuncinateprocess.TheUncinateprocesscanbeclassifiedinto3types dependingonitssuperiorattachment. Theanteriorinsertionoftheuncinateprocesscannotbeidentifiedclearlybecauseitiscoveredwith mucosawhichiscontinuouswiththatofthelateralnasalwall.Sometimesasmallgrooveisvisible overtheareawheretheuncinateattachesitselftothelateralnasalwall.Theanteriorconvexpart formstheanteriorboundaryoftheostiomeatalcomplex.Itisherethemaxillary,anteriorethmoidal andfrontalsinusesdrain.Uncinateprocesscanbedisplacedmediallybythepresenceofpolypoidal tissue,orlaterallyagainsttheorbitin individualswithmaxillarysinushypoplasia7.Removingofthispieceofboneisthemostimportant stepinEndoscopicsinussurgery. TypeIuncinate:Heretheuncinateprocessbendslaterallyinitsuppermostportionandinsertsinto thelaminapapyracea.Heretheethmoidalinfundibulumisclosedsuperiorlybyablindpouchcalled therecessusterminalis(terminalrecess).Inthiscasetheethmoidalinfundibulumandthefrontal recessareseparatedfromeachothersothatthefrontalrecessopensintothemiddlemeatusmedial totheethmoidalinfundibulum,betweentheuncinateprocessandthemiddleturbinate.Therouteof drainageandventilationofthefrontalsinusrunmedialtotheethmoidalinfundibulum.

TypeIuncinateinsertion

TypeIIuncinate:Heretheuncinateprocessextendssuperiorlytotheroofoftheethmoid.Thefrontal sinusopensdirectlyintotheethmoidalinfundibulum.Inthesecasesadiseaseinthefrontalrecess mayspreadtoinvolvetheethmoidalinfundibulumandthemaxillarysinussecondarily.Sometimesthe superiorendoftheuncinateprocessmaygetdividedintothreebranchesonegettingattachedtothe roofoftheethmoid,onegettingattachedtothelaminapapyracea,andthelastgettingattachedtothe middleturbinate.

TypeIIuncinateinsertion

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TypeIIIuncinateprocess:Herethesuperiorendoftheuncinateprocessturnsmediallytoget attachedtothemiddleturbinate.Herealsothefrontalsinusdrainsdirectlyintotheethmoidal infundibulum. Rarelytheuncinateprocessitselfmaybeheavilypneumatisedcausingobstructiontothe infundibulum.

TypeIIIuncinateinsertion

Polypseenpushingtheuncinatemedially

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Hypoplasiaofmaxillarysinusseenpushingtheuncinatelaterally

Imageshowinguncinateprocess

Removalofuncinateprocessrevealsthenaturalostiumofthemaxillarysinus.Thisisanothervital landmarkinthelateralnasalcavity.Thesuperiorwallofthenaturalostiumofthemaxillarysinusisat thelevelofflooroftheorbit.Aggernasi:ThisisalatinwordforMound.Thisareareferstothemost superiorremnantofthefirstethmoturbinalwhichpresentsasamoundanteriorandsuperiortothe insertionofmiddleturbinate.Dependingonthepneumatizationofthisareamayreachuptothelevel oflacrimalfossatherebycausingnarrowingoffrontalsinusoutflowtract.Ethmoidalinfundibulum:isa cleftlikespace,whichisthreedimensionalinthelateralwallofthenose.Thisstructurebelongstothe anteriorethmoid.Thisspaceisboundedmediallybytheuncinateprocessandthemucosacovering it.Majorportionofitslateralwallisboundedbythelaminapapyracea,andthefrontalprocessof maxillatoalesserextent.Defectsinthemedialwalloftheinfundibulumiscoveredwithdense connectivetissueandperiosteum.Thesedefectsareknownasanteriorandpoteriorfontanelles. Anteriorlytheethmoidalinfundibulumendsblindlyinanacuteangle.

Figureshowinglargeaggernasiaircell

Bullaethmoidalis:ThisisderivedfromLatin.Bullameansahollowthinwalledbonyprominence.This isanotherlandmarksinceitisthelargestandnonvariantoftheaircellsbelongingtotheanterior

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ethmoidalcomplex.Thisaircellisformedbypneumatizationofbullalamella(secondethmoidbasal lamella).Thisaircellappearslikeablebsituatedinthelaminapapyracea.Someauthorsconsider thistobeamiddleethmoidcell.Ifbullaextendsuptotheroofofethmoiditcanformtheposteriorwall offrontalrecess.Ifitdoesnotreachuptothelevelofskullbasethenarecesscanbeformed betweenthebullaandskullbase.Thisrecessisknownassuprabullarrecess.Iftheposteriorwallof bullaisnotincontactwithbasallamellathenarecessisformedbetweenbullaandbasallamella. Thisrecessisknownasretrobullarrecess/sinuslateralis.Thisretrobullarrecessmaycommunicate withthesuprabullarrecess.Osteomeatalcomplex:Thistermisusedbythesurgeontoindicatethe areaboundedbythemiddleturbinatemedially,thelaminapapyracealaterally,andthebasallamella superiorlyandposteriorly.Theinferiorandanteriorbordersoftheosteomeatalcomplexareopen. Thecontentsofthisspacearetheaggernasi,nasofrontalrecess(frontalrecess),infundibulum,bulla ethmoidalisandtheanteriorgroupofethmoidalaircells.Thisisinfactanarrowanatomicalregion consistingof:1.Multiplebonystructures(Middleturbinate,uncinateprocess,Bullaethmoidalis)2.Air spaces(Frontalrecess,ethmoidalinfundibulum,middlemeatus)3.Ostiaofanteriorethmoidal, maxillaryandfrontalsinuses.Inthisarea,themucosalsurfacesareveryclose,sometimesevenin contactcausingsecretionstoaccumulate.Theciliabytheirsweepingmovementspushesthenasal secretions.Ifthemucosaliningthisareabecomesinflamedandswollenthemucociliaryclearanceis inhibited,eventuallyblockingthesinuses.Someauthorsdividethisosteomeatalcomplexintoanterior andposterior.Theclassicosteomeatalcomplexdescribedalreadyhasbeendescribedasthe anteriorosteomeatalcomplex,whilethespacebehindthebasallamellacontainingtheposterior ethmoidalcellsisreferredtoastheposteriorethmoidalcomplex,thusrecognisingtheimportanceof basallamellaasananatomicallandmarktotheposteriorethmoidalsystem.Hencetheanteriorand theposteriorosteomeatalcomplexhasseparatedrainagesystems.Sowhenthediseaseislimitedto theanteriorcompartmentoftheosteomeatalcomplex,theethmoidcellscanbeopenedanddiseased tissueremovedasfarasthebasallamella,leavingthebasallamellaundisturbedminimisingtherisk duringsurgery.Hiatussemilunaris:LiesbetweentheanteriorwalloftheBullaandthefreeposterior marginoftheuncinateprocess.Thisisinfactatwodimensionalspace.Throughthishiatusacleftlike spacecanbeentered.Thisisknownastheehtmoidalinfundibulum.Thisethmoidalinfundibulumis boundedmediallyalongitsentirelengthbytheuncinateprocessanditsliningmucosa.Thelateral wallisformedbythelaminapapyraceaoftheorbit,withparticipationfromthefrontalprocessofthe maxillaandthelacrimalbone.Theanteriorgroupofsinusesdrainintothisarea.Infactthisareaacts asacesspoolforallthesecretionsfromtheanteriorgroupofsinuses.

Osteomeatalcomplex

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Conchabullosa:Sometimesmiddleturbinatemaybecomepneumatized.Thispneumatizationis knownasconchabullosa.Thisprocessofpneumatizationstartseitherfromfrontalrecessoragger nasiaircells.Thisisusuallyconsideredtobeanormalvariant.Sometimesthispneumatizationmay becomesoextensivethatitcouldcauseobstructioninosteomeatalcomplex8.

CoronalCTshowingconchabullosa

References
1. OhnishiT,TachibanaT,KanekoY,etal.Highriskareasinendoscopicsinussurgeryand preventionofcomplications.Laryngoscope.1993103:1815 2. StoneyP,MacKayA,HawkeM.TheantrumofHighmoreorofdaVinci?JOtolaryngol.1991Dec 20(6):4568 3. BlantonPL,BiggsNL(1969)Eighteenhundredyearsofcontroversy:theparanasalsinuses.AmJ Anat124(2):13547. 4. GraneyDO,RiceDH,Paranasalsinusesanatomy.In:CummingsCW,FredricksonJM,HarkerLA etal(1998)OtolaryngologyHeadandNeckSurgery.Mosby,3rdedn. 5. BodinoC,JankowskiR,GrignonBetal(2004)Surgicalanatomyoftheturbinalwallofthe ethmoidallabyrinth.Rhinology42(2):7380. 6. BolgerWE,AnatomyoftheParanasalSinuses.In:KennedyDW,BolgerWE,ZinreichJ(2001) Diseasesofthesinuses,Diagnosisandmanagement.B.C.Decker 7. http://jorl.net/index.php/jorl/article/view/47 8. JoeJK,HoSY,YanagisawaE(2000)Documentationofvariationsinsinonasalanatomyby intraoperativenasalendoscopy.Laryngoscope110(2):22935.

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