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849 Review Article The Ostiomeatal Unit and Endoscopic Surgery: Anatomy, Variations, and Imaging Findings in
849
Review
Article
The
Ostiomeatal
Unit
and
Endoscopic
Surgery:
Anatomy,
Variations,
and
Imaging
Findings
in Inflammatory
Diseases
Fred
J. Lame1
and
Wendy
R.
K. Smoker
Recent
and
ongoing
advances
made
in endoscopic
surgical
Normal
Anatomy
techniques
require
the
radiologist
to understand
the anatomy
and
pathophysiology
of
the
paranasal
sinuses
and
nasal
passage.
The
relationships
between
important
bony
and
soft-tissue
Endoscopy
and
CT are
complementary
procedures,
and,
as such,
structures
and
sinus
ostia
can
be
more
easily
understood
and
the
normal
anatomic
relationships
and
their
CT appearances
need
interpreted
on
CT
scans
by first
reviewing
the
anatomy
of
the
to
be
well
understood
in
order
for
radiologists
to
offer
continued
lateral
nasal
wall
and
nasal
septum.
support
as
consultants
to
their
clinical
colleagues.
In
this
article,
Projecting
from
the
lateral
nasal
wall
are the
inferior,
middle,
we
review
the
pertinent
anatomy
of
the
lateral
nasal
wall
and
and
superior
turbinate
bones
(or
conchae)
(Fig.
1 A).
Occa-
paranasal
sinuses,
discuss
the
most
frequently
encountered
nor-
sionally,
a supreme
turbinate
bone
can
be
identified.
Beneath
mal
variations
that
may
predispose
a
patient
to
inflammatory
each
turbinate
bone
lies
a respectively
named
meatus
into
sinus
disease,
outline
imaging
protocols
for
evaluation
of
this
region,
and
introduce
the
reader
to current
endoscopic
surgical
which
the
various
ostia
drain
(Fig.
i
B).
techniques.
Last,
the
imaging
findings
in
various
inflammatory
The
inferior
turbinate
bone
is
the
largest
of
the
three,
under
processes
involving
the
sinuses,
as well
as
the
local
and
regional
which
lies
the
inferior
meatus.
The
inferior
meatus
receives
complications
associated
with
paranasal
sinus
inflammatory
dis-
drainage
from
the
nasolacrimal
duct,
which
is typically
seen
eases,
are presented.
only
segmentally
on
axial
scans.
Occasionally,
the
duct
can
be
followed
from
its
origin
in
the
inferomedial
aspect
of
the
In our
role
as consultants,
radiologists
must
keep
abreast
orbit
to
its
ostium
in
the
anteroinfenior
aspect
of
the
meatus,
of clinical advances
and
be able
to adapt
imaging
procedures
adjacent
to
the
attachment
of
the
inferior
concha.
as necessary
to
meet
changing
clinical
demands.
Advances
Under
the
superior
turbinate
bone,
the
smallest
of
the
three,
in
the
understanding
of mucociliary
drainage
patterns
and the
lies
the
superior
meatus,
through
which
posterior
ethmoidal
pathophysiology
of
paranasal
sinus
inflammatory
disease,
air
cells
drain
via
multiple
ostia.
This
turbinate
bone
is identi-
coupled
with
the
availability
of
high-resolution
CT
and
im-
fled
on
coronal
images
as
a
slender
structure,
suspended
provements
in endoscopic
instrumentation,
have
led
to major
from
the
dome
of
the
posterior
aspect
of
the
nose
[i
].
The
changes
in
the
surgical
management
of sinusitis.
As
a result,
sphenoethmoidal
recess,
draining
the
sphenoidal
sinus
the
radiologist
must
relearn
the
anatomy
of nasal
and
para-
through
the
sphenoidal
ostium,
lies
posterosupenior
to
the
nasal
structures,
as
well
as
the
pathologic
changes
caused
superior
turbinate
bone,
between
the
anterior
wall
of
the
by
diseases
that
affect
this
region,
in order
to correlate
CT
sphenoidal
sinus
and
the
posterior
wall
of
the
ethmoidal
sinus
and
endoscopic
findings.
(Fig.
2).
Lateral
to
the
recess,
the
most
posterior
ethmoidal
Received
November
8,
1 991
; accepted
after
revision
April
1 6,
1992.
1 Both
authors:
Department
of Radiology,
Medical
College
of Virginia
Hospitals,
MCV
Station,
Box
61 5, Richmond,
VA
23298.
Address
reprint
requests
to
F.
J.
Lame.
AJR
159:849-857,
October
1992
0361
-803x/92/1
594-0849
© American
Roentgen
Ray
Society
850 LAINE AND SMOKER AJR:i59, October 1992 Fig. 1.-A, Line diagram of lateral nasal wall
850
LAINE
AND
SMOKER
AJR:i59,
October
1992
Fig.
1.-A,
Line
diagram
of
lateral
nasal
wall
with
intact
turbinate
bones.
Arrowheads
agger
=
nasi
cells,
IT
inferior
turbinate
bone,
MT
=
=
middle
turbinate
bone,
ST
superior
turbinate
=
bone.
B, Line diagram
of lateral
nasal
wall
with
tur-
binate
bones
removed.
Arrows
ostia
and
mu-
=
cous
flow
patterns,
I
drainage
from
frontal
=
sinus,
2
drainage
from
maxillary
sinus,
3
=
=
drainage
from
anterior
and
middle
ethmoidal
si-
nuses,
4
drainage
from
posterior
ethmoidal
=
sinuses,
5 =
drainage
from
sphenoidal
sinus.
1,
2,
and
3 drain
to
the
middle
meatus,
whereas
4
and
5 drain
through
sphenoethmoidal
recess
to
superior
meatus.
A
B
air
cell
(cell
of
Onodi)
and
the
sphenoidal
sinus
share
a
The
hiatus
semilunaris
is
bounded
superiorly
by
the
bulla
common
wall,
the
sphenoethmoidal
plate
[2]
(Fig.
2).
ethmoidalis,
laterally
by the
bony
orbit,
inferiorly
by
the
uncin-
The
middle
turbinate
bone
covers
the
middle
meatus,
the
ate
process,
and
medially
by
the
middle
meatus.
It accom-
most
complex
region
of
the
lateral
nasal
wall.
Near
the
su-
modates
multiple
anterior
ethmoidal
ostia,
and
the
single
perior
attachment
of the turbinate
bone,
a prominence
of
the
maxillary
sinus
ostium,
to form
the final
segment
of drainage
lateral
wall
is produced
by
the
agger
nasi
cells,
the
most
from
these
sinuses.
A superior
extension
of
the
hiatus
semi-
anterior
ethmoidal
air cells
(Fig.
1). Above
these
cells
lies the
lunaris
communicates
with
the
sinus
lateralis,
the
space
be-
frontal
recess.
The
frontal
sinus
drains,
via
the
frontonasal
tween
the
posterior
wall
of
the
ethmoidal
bulla
and
the
basal
duct,
agger
nasi
cells,
and
frontal
recess,
into
the
anterior
lamella,
providing
drainage
of
this
area
and
the
middle
eth-
aspect
of the middle
meatus,
medial
to the uncinate
process,
moidal
air cells.
or
directly
into
the
ethmoidal
infundibulum
(Fig.
1 B).
The
The bulla
ethmoidalis,
usually
consisting
of
a single
variable
ethmoidal
infundibulum
is often
continuous
with
the
fronto-
air cell,
projects
inferomedially
over
the
hiatus
semilunaris
in
nasal
duct.
a
rounded
fashion.
The
relationships
of
these
three
lateral
The middle
turbinate
bone
attaches
to two
areas
of delicate
wall
structures
are
such
that
a channel
is formed,
linking
the
bone,
which
can
pose
potential
problems
during
endoscopic
frontal,
anterior
and
middle
ethmoidal,
and
maxillary
sinuses
manipulation:
the
superior
attachment
to
the
delicate
lateral
to the
middle
meatus.
This
connecting
channel is collectively
aspect
of the cribriform
plate,
and the
lateral,
intraethmoidal
referred
to as the ostiomeatal
unit
(OMU)
(Figs.
3
and
4).
In
attachment,
basal
(or
ground)
lamella,
to
the
thin
lamina
summary,
mucociliary
drainage
of
the
sinuses
eventually
papyracea
of
the
lateral
ethmoidal
wall
(Fig.
3).
Posteriorly,
merges
into
two
common
pathways,
allowing
division
into
the
basal
lamella
curves
superiorly
and
becomes
oriented
in
two
anatomic
and
functional
groups
[2].
The
first
group
the
coronal
plane,
behind
the ethmoidal
bulla,
thereby
sepa-
(frontal,
anterior
ethmoidal,
middle
ethmoidal,
and
maxillary
rating
the anterior
and posterior
ethmoidal
air cells.
Ethmoidal
sinuses)
drains
into the middle
meatus,
around
the ethmoidal
air cells
located
anterior
to
the
basal
lamella
will
drain
into
the
bulla
(the
OMU)
(Fig.
i B).
This
region
is frequently
involved
middle meatus,
whereas
those
cells
located
posterior
to
the
by inflammatory
disease.
The
second
group
(posterior
eth-
basal
lamella
will drain
into
the superior
meatus
[2].
moidal
and sphenoidal
sinuses),
draining
into the sphenoeth-
If
the
middle
turbinate
bone
is removed,
three
prominent
moidal
recess
and superior
meatus
(Fig.
i B),
is less
frequently
underlying
structures
are
seen:
the
uncinate
process
affected
by inflammatory
processes.
anteriorly,
the
hiatus
semilunaris,
and
the
bulla
ethmoidalis
The nasal
septum,
easily identified
on both
axial and coronal
posteriorly.
The
uncinate
process,
a thin,
hook-shaped,
mu-
CT, extends
the entire
length
of
the
nasal
cavity
(Figs.
2 and
cosa-covered
bony
prominence,
originates
anteriorly
from
the
4). The anterior
portion
is composed
of cartilage,
whereas
the
posteromedial
border
of the nasolacrimal
duct.
Almost
parallel
posterior
portion
is osseous,
formed
mainly
by the vomer
and
to
the
middle
turbinate
bone,
it
forms
a
free
border
that
the
perpendicular
plate
of
the
ethmoid
bone.
The
interfrontal
defines
the
anterior
boundary
of
the
hiatus
semilunaris.
On
septum
anteriorly
and
the
intersphenoidal
septum
posteriorly
coronal
CT,
the
uncinate
process
is easily
detected
as
a
do not always
lie in the
same
plane
as the
nasal
septum.
This
superior
extension
of the medial
maxillary
sinus
wall,
forming
is
an
important
anatomic
consideration
for
endoscopic
sur-
the
lateral
wall
of
the
middle
meatus
(Figs.
3
and
4). Lateral
geons.
to the uncinate
process
lies the infundibulum,
connecting
the
Two
important
anatomic
relationships
between
the
para-
ostia
of
the
maxillary
and
ethmoidal
sinuses
to
the
hiatus
nasal
sinuses
and
adjacent
structures
must
be mentioned.
semilunaris
(Figs.
3
and
4).
Mucociliary
drainage
from
the
Awareness
of
the
intimate
relationship
between
the
internal
maxillary
sinuses
courses
superiorly,
through
the
ostia
and
carotid
artery
and
the
sphenoidal
sinus
is important
for
un-
posterior infundibulum
to
the
hiatus
semilunaris,
and eventu-
derstanding
the
potentially
devastating
complications
of
in-
ally into
the middle
meatus.
flammatory
disease
or
endoscopy
(Fig.
2).
Bulging
of
the
AJR:159, October 1992 OSTIOMEATAL UNIT AND ENDOSCOPIC SURGERY 85i - *: #{149}#{149} -; : #{149}
AJR:159,
October
1992
OSTIOMEATAL
UNIT
AND
ENDOSCOPIC
SURGERY
85i
- *: #{149}#{149} -; :
#{149}
I,, .
r
Fig.
2.-Axial
CT
scan
obtained
with
inter-
Fig.
3.-Line
diagram
of
normal
ostiomeatal
Fig. 4.-Coronal
CT scan shows
normal ostlo-
mediate
windows
shows
sphenoethmoidal
re-
unit
Small
arrowheads
basal
lamella,
large
ar-
meatal
unit.
Curved
arrows
maxillary
ostium,
=
=
cesses
(white
dots)
and proximity
of carotid
ca-
rowhead
cribriform
plate,
dots
uncinate
proc-
dots
infundibulum,
straight
arrows
middle
=
=
=
=
nals
(C) to lateral
wall of sphenoidal
sinus (5).
ess.
meatus,
arrowheads
nasal
septum.
=
Note also proximity
of optic nerve
terior ethmoidal (E) and sphenoldal
(ON) to pos-
sinuses. NS
= nasal septum, arrowheads = sphenoethmoidal
plate.
carotid
artery
into
the
sphenoidal
sinus
is seen
in 65-72%
of
air
cells,
the
air
cell
created
is referred
to
as
concha
bullosa
patients
[3-5].
The
thin
bone
separating
the
artery
from
the
[9]
(Fig.
5A).
The
reported
prevalence
of
concha
bullosa
sinus
is less
than
1 mm
in 66%
of patients,
less than
0.5 mm
ranges
from
4%
to 80%,
depending
on criteria
for pneumati-
in 88%
of patients,
and
completely
absent
in 4-8%
of cases
zation
and
differences
in study
populations.
“True”
concha
[4,
5].
bullosa
(pneumatization
of
both
the
vertical
lamellar
and
infe-
The
location
of
the
optic
canal
and
nerve
is an additional
nor
bulbous
portions)
is reported
in
4-i
5.7%
ofthe
population
important
anatomic
consideration.
Because
of
the
location
of
[9,
i 0].
If the
definition
is broadened
to include
any
degree
of
the
distal
canal
opening,
in 75%
of
cases
the
nerve
will
be
middle
turbinate
pneumatization,
the
prevalence
increases
to
close
to both
the
sphenoidal
and ethmoidal
sinuses
[6]
(Fig.
34%
[1 1].
The
highest
prevalence
(80%)
is found
in patients
2). During
its course,
the optic
nerve
bulges
into the
supero-
with
chronic
sinusitis
[1 2].
For
this
reason,
some
suggest
that
lateral
sphenoidal
sinus
wall,
forming
the
optic
eminence.
A
concha
bullosa
may
be a contributing
factor
in
the
pathogen-
thin
bony
partition
is present
in 70-78%
of
patients
[5,
7],
esis
of
sinus
inflammatory
disease,
although
others
do
not
and complete
bony
dehiscence
is present
in 3.6-4%
of cases
share
this
view
[9].
Stammberger
and
Wolf
[1 3]
and
Lidov
[5,8].
and
Som
[i
4]
reported
that
concha
bullosa
can,
when
suffi-
ciently
large,
produce
signs
and
symptoms
by
encroaching
on the infundibulum.
Concha
bullosa
may also contain
polyps,
Anatomic
Variations
cysts,
pyoceles,
or
mucoceles.
Paradoxically
curved
middle
turbinate
bone.-Normally,
the
The
middle
meatus
and
lateral
nasal
wall
are
subject
to
wide
normal
variations
that
must
be distinguished
from
path-
convexity
of
the
middle
turbinate
bone
is directed
medially,
toward
the
nasal
septum.
When
paradoxically
curved,
the
ologic
changes.
These
variations
may,
themselves,
be
the
convexity
is directed
laterally,
toward
the
lateral
sinus
wall
underlying
cause
of recurrent
sinus
disease.
However,
there
(Fig.
SB).
A 26.i
% prevalence
of paradoxically
curved
middle
is
a lack
of consensus
among
investigators
with
respect
to
the prevalence
and clinical
significance
of these
variations,
as
turbinates
has
been
reported
[9]. Although
it is a presumed
no
studies
relate
this
variation
to sinus
disease,
etiologic
factor
they
have
been
encountered
with
similar
frequency
in patients
because
of
the
deformity
and
obstruction
or
alteration
of
being
scanned
for
sinus-related
problems,
as well
as those
nasal
passage
air flow
dynamics,
especially
when
associated
undergoing
evaluation
for
problems
[9].
The more
common
variations
non-sinus-related
can be divided
into four
groups,
with
other
variations
[i3].
depending
on the structures
involved:
middle
turbinate
bone,
uncinate
process,
ethmoidal
bulla,
and
nasal
septum.
Uncinate
Variations
Deviation
of
the
uncinate
tip.-The
superior
aspect
of
the
Middle
Turbinate
Variations
uncinate
tip
may
deviate
laterally,
medially,
or
anteriorly
out
Concha
bullosa.-The
middle
turbinate
bone
is usually
a
of the meatus,
appearing
as a second
middle
turbinate
bone
thin
plate
of bone.
When
this plate
becomes
pneumatized
by
[i
3,
iS].
When
deviated
medially,
it comes
into
contact
with
extension
of the anterior
(55%)
or posterior
(45%)
ethmoidal
and
compromises
the
middle
meatus.
When
deviated
laterally,
852 LAINE AND SMOKER AJR:159, October 1992 Fig. 5.-A, Coronal CT scan shows pneumatl- zation
852
LAINE
AND
SMOKER
AJR:159,
October
1992
Fig.
5.-A,
Coronal
CT scan
shows
pneumatl-
zation
of
middle
turbinate
bones
bilaterally
(con-
cha
bullosa),
much
greater
on
left
(asterisk)
than
on
right.
Also
note
nasal
septal
deviation,
which
narrows
right middle
meatus.
B,
Coronal
CT
scan
reveals
paradoxically
lat-
erally
curved
middle
turbinate
bones
bilaterally
(dots).
Also
note
pneumatization
of
right
uncinate
tip (arrow).
C, Coronal
CT
scan
shows
large
Halle
cells
(H)
projecting
downward
along
roofs
of
maxillary
si-
nuses.
Concha
bullosa
is seen
bilaterally
(aster-
lsks).
Sinuses,
at this
time,
are
clear.
D,
Coronal
CT
scan
shows
evidence
of
eth-
moidal bullae (asterisks)
bilaterally
without
cvi-
dence of associated sinus disease. Normal rela-
tionship
to ostiomeatal
unit (dots)
is well
visualized
bilaterally.
it
may
encroach
on
the
hiatus
semilunaris
and
infundibulum,
prevalence
of Halle
cells
between
patients
scanned
for
chronic
impeding
drainage
and
ventilation
of
the
anterior
ethmoidal,
sinus
disease
and
patients
scanned
for
nonsinus
reasons,
frontal,
and maxillary
sinuses.
The exact
prevalence
of these
Stammberger
and
Wolf
[1 3]
consider
the
presence
of
these
variations
and
their
relation
to sinus
disease
have
not
been
cells
as
another
predisposing
factor
for
recurrent
maxillary
determined.
sinusitis.
Pneumatized
uncinate
tip
(uncinate
bulla).-The
exact
Large
ethmoidal
bulla.-The
ethmoidal
bulla
can
be
so
mechanism
by
which
uncinate
pneumatization
(Fig.
SB)
oc-
extensively
pneumatized
that
it
completely
fills
the
sinus
of
curs
is
not
known.
It
has
been
proposed
that
this
process
is
the
middle
turbinate
bone
(Fig.
SD).
Stammberger
and
Wolf
due to growth
of agger
nasi cells
into
the most
anterosuperior
[1 3] reported
that
an enlarged
ethmoidal
bulla
may
contribute
region
of the uncinate
process
[9]. Studies
reveal
a prevalence
to
sinus
disease
by
obstructing
the
infundibulum
or
middle
of 0.4-2.5%
[9].
This
variation
has been
implicated
in narrow-
meatus
or
by
being
primarily
diseased
and
filled
with
pus,
ing
of
the
infundibulum,
producing
impaired
sinus
ventilation
cysts,
or
polyps.
The
exact
prevalence
of
an
enlarged
eth-
[16].
moidal
bulla
is
not
known.
Agger
nasi
cells.-Agger
nasi
cells,
the
most
constant
ethmoidal
air
cells,
lie below
the
frontal
sinus,
inferolateral
to
the
lacrimal
sinus,
and
represent
pneumatization
of
the
lacri-
Ethmoidal
Variations
mal
bone
by
extension
of
the
anterior
ethmoidal
cells
[i
0].
Halle
cells-According
to Kennedy
and
Zinreich
[i
7],
Halle
They
are
located
anterior
and
superior
to
the
insertion
of
the
cells,
ethmoidal
air cells that
project
inferiorly
to the ethmoidal
middle
turbinate
bone,
along
the
lateral
nasal
wall
[1 3]
(Fig.
bulla
into
the
floor
of
the
orbit
in
the
region
of
the
maxillary
iA).
In anatomic
dissection,
the prevalence
of
the
agger
nasi
sinus
ostium,
are
encountered
in
1 0%
of
the
population
(Fig.
cell
varies
from
1 0%
[18]
to
89%
[1 9].
Because
of
their
SC).
However,
Bolger
et
al.
[9]
defined
Halle
cells
as any
air
location
near
the
lacrimal
sac,
involvement
of
these
cells
by
cells
located
beneath
the
ethmoidal
bulla,
lamina
papyracea,
sinus
disease
can
lead
to ocular
symptoms.
These
cells
may
or
orbital
floor.
Using
this
criteria,
they
reported
a prevalence
provide
access
to
the
frontal
sinus
and
recess
during
endos-
of
45%.
Although
they
found
no
significant
difference
in
the
copy.
AJR:159, October 1992 OSTIOMEATAL UNIT AND ENDOSCOPIC SURGERY 853 Nasal Septum Variations of endoscopic
AJR:159,
October
1992
OSTIOMEATAL
UNIT
AND
ENDOSCOPIC
SURGERY
853
Nasal
Septum
Variations
of
endoscopic
techniques
is
necessary
for
meticulous
CT
evaluation.
Nasalseptaldeviation.-Normally,
the
structures
that
make
For
diagnostic
endoscopy,
a 4.0-mm,
0#{176}and
30#{176}illumi-
up
the
nasal
septum
are
aligned
to
form
a
straight
wall,
nated
endoscope
or
a 2.7-mm,
30#{176}and
70#{176}illuminated
en-
extending
from
the
cribriform
plate
superiorly
to
the
hard
doscope
is
used
[24].
The
endoscope
is passed
along
the
palate
inferiorly
(Fig.
4).
At
the junction
of
the
nasal
cartilage
floor
of
the
nose
while
the
septum,
inferior
meatus
and
and
vomer,
acute
bowing
and deviation
of the septum
occur
turbinate
bone,
middle
turbinate
bone,
and
nasopharynx
are
in
20%
of
the
population
[20].
When
severe,
the
deviated
evaluated.
The
instrument
is
then
rolled
over
the
inferior
septum
may
compress
the
middle
turbinate
bone
laterally,
turbinate
bone
into
the
posterior
aspect
of
the
middle
meatus
narrowing
the
middle
meatus
and
causing
obstruction,
sec-
and
drawn
anteriorly
as
the
ethmoidal
bulla,
hiatus
semilu-
ondary
inflammation,
and
infection
(Fig.
SA). When
it
is asso-
naris,
and
OMU
are
evaluated
[24].
Cultures
and
mucosal
ciated
with
swollen
membranes,
there
is additional
obstruc-
biopsy specimens
can
be
obtained,
or
antibiotics
can
be
tion
to the normal
flow
of mucus
from
the sinuses.
administered,
if indicated.
Currently,
two
functional
endoscopic
surgical
approaches
are
used
[1 8,
25].
Both
are
based
on
the
conjecture
that
once
Imaging
Techniques
aeration
of
the
sinuses
is reestablished
and
normal
drainage
Radiologic
evaluation
is directed
toward
assessing
the
pa-
is
restored,
the
mucosa
will
return
to
its
prediseased
state.
tency
of
the
maxillary
sinus
ostium,
ethmoidal
infundibulum,
The
Wigand
procedure,
the
more
extensive
and
less
com-
hiatus
semilunaris,
and
middle
meatus.
Plain
radiographs,
monly
used
of
the
two,
begins
posteriorly
with
a sphenoido-
widely
available
and
inexpensive,
provide
insufficient
detail
to
tomy
and proceeds
anteriorly
to the frontal
recess.
It involves
allow
surgical
planning.
MR,
with
its
excellent
soft-tissue
a total
sphenoethmoidectomy
and
a supramiddle
turbinate
detail,
does
not
adequately
depict
the
osseous
sinus
walls
antrostomy
to
create
surgical
drainage
of
the
ipsilateral
si-
and
ostia.
CT,
because
of
its
superb
soft-tissue
and
bone
nuses
into
the nose.
The
Messerklinger
procedure
begins
at
detail,
remains
the
best
technique
for
evaluating
the
presence
the
ethmoidal
bulla
and
moves
anteriorly
to
the
frontal
recess
and extent
of sinonasal
disease
before
endoscopy.
or
posteriorly
to
the
posterior
ethmoidal
and
sphenoidal
si-
The
coronal
plane
provides
the
best
demonstration
of
the
nuses,
depending
on the location
of disease.
This
procedure,
OMU
and
simulates
the
plane
seen
by the endoscopist.
For
considered
the true functional
endoscopic
surgical approach,
scanning,
the
patient
is prone
with
the
head
hyperextended
relieves
obstruction
to
the
normal
pathway
of
mucociliary
to
ensure
that
free
fluid
layers
along
the
maxillary
sinus
floor
drainage.
and
does
not
“falsely”
obliterate
the
OMU.
Unenhanced
3-
to
Advantages
of
functional
endoscopic
surgery
over
more
S-mm-thick
contiguous
slices
are
obtained.
Although
originally
conventional
surgical
techniques
include
(1 ) absence
of skin
obtained with soft-tissue
algorithms
but filmed
with soft-tissue
or mucous
membrane
incisions
and
accompanying
removal
and
bone
windows,
our
recent
experience,
as well
as that
of
of
intervening
bone,
(2) unparalleled
visualization
of
the
si-
others
[21 ], suggests
that
a single
set
of
images
obtained
in
nuses
of
the
lateral
nasal
wall,
(3) more
accurate
diagnosis
of
bone
algorithm
and filmed
with
intermediate
windows
is suf-
malformations
or
obstructing
masses
producing
refractory
ficient
in most
instances.
Contrast
material,
administered
via
sinusitis,
and
(4) precise
localization
and
removal
of
the
site
a
bolus
drip
technique,
is
used
only
when
assessing
for
of
disease
with
mucosal
preservation
and
restoration
of nor-
complications
of inflammatory
disease.
Occasionally,
exten-
mal
mucociliary
drainage
[1 8].
Endoscopy
is
limited
in
its
sive dental
amalgams
may
require
thin-section
axial
scanning
ability
to show
frontal
sinuses
and recesses,
maxillary
sinuses
with
reformation
in the coronal
plane.
Uncooperative
patients
and
ostia,
ethmoidal
bullae,
and
posterior
ethmoidal
and
and
those
who
are
unable
to
maintain
their
head
in hyperex-
sphenoidal
sinuses.
CT
is, therefore,
a complementary
pro-
tension
can
also
be examined
in
the
axial
plane.
Imaging
is
cedure
that
ensures
complete
evaluation
of
changes
caused
best
performed
after
treatment
of
an
acute
process,
so
that
by inflammatory
paranasal
sinus
disease.
areas
of residual
disease,
most
likely
responsible
for recurring
problems,
can
be fully
assessed
[22,
23].
Inflammatory
Sinus
Diseases
Endoscopic
Surgery
Techniques
Acute
Sinusitis
Anterior
rhinoscopy
and
indirect
nasopharyngoscopy
yield
Although
occasionally
due
to
a
pure
viral
infection,
acute
little
information
regarding
the
middle
meatus
and
the
OMU
sinusitis
usually
results
from
a bacterial
superinfection,
most
[24].
Paranasal
sinus
endoscopy
now
permits
accurate,
direct
commonly
Streptococcus
pneumoniae,
Haemophllus
influen-
visualization
of
the
entire
nasal
cavity,
middle
meatus,
OMU,
zae,
and
Staphylococcus
aureus.
A single
sinus
is typically
and sphenoethmoidal
recess.
It can be performed
as a purely
involved,
usually
a maxillary
sinus.
When
the
frontal,
eth-
diagnostic
procedure
or
as
a
therapeutic
procedure
(func-
moidal,
or
sphenoidal
sinuses
are
independently
or
addi-
tional)
to clear
obstructed
sinus
ostia.
“Functional”
endoscopic
tionally
acutely
involved,
risk
of
regional
complications
is
sinus surgery
is usually
reserved
for patients
in whom
medical
increased,
and
aggressive
treatment
is required.
The
radio-
management
fails and
who
have
OMU
disease
shown
by
CT
logic
hallmark
of acute
sinusitis
is the
air-fluid
level.
Alterna-
and/or diagnostic
endoscopy
[23].
A fundamental
knowledge
tively,
CT
findings
may
be limited
to nonspecific,
smooth
or
854 LAINE AND SMOKER AJR:159, October 1992 polypoid mucosal thickening. If the sinus ostium becomes
854
LAINE
AND
SMOKER
AJR:159,
October
1992
polypoid
mucosal
thickening.
If
the
sinus
ostium
becomes
the
normal
respiratory
flora,
are
the
pathogens
most
com-
obstructed,
complete
opacification
may
result.
monly
encountered.
Although
radiologically
similar,
they
can
frequently
be
differentiated
clinically.
Mucormycosis,
an
ag-
gressive,
highly
invasive
disease,
occurs
mainly
in
an
immu-
Chronic
Sinusitis
nocompromised
or diabetic
(50-75%)
host.
Aspergillus,
how-
Chronic
sinusitis
is diagnosed
clinically
when
the
patient
ever,
can
produce
infection
in otherwise
healthy
persons
by
has
either
persistent
inflammation
or repeated
bouts
of acute
colonization
of a paranasal
sinus.
An allergic
form
of asper-
inflammation.
Anaerobes
are
more
frequently
implicated
in
gillosis
has also
been
described,
associated
with
asthma
and
chronic
than
in acute
sinusitis
[26].
CT may
show
mucosal
recurrent
nasal
polyps.
Invasive
aspergillosis
occurs
primarily
thickening
or opacification,
but
the
hallmark
of chronic
sinus-
in immunocompromised
persons
and
progresses,
like
mucor-
itis
is
osseous
thickening
of
the
sinus
wall,
representing
mycosis,
to
produce
necrosis,
vascular
thrombosis,
and
intra-
remodeling
and new bone formation
in response
to persistent
cranial
extension.
Initially,
both
cause
nodular
mucoperiosteal
inflammation
[26]
(Fig.
6).
The
prevalence
of
complications
thickening,
which
eventually
coalesces
to opacity
an entire
with
chronic
sinusitis
is increased,
including
mucous
retention
sinus
(Fig.
8).
Multiple
focal
areas
of
bone
destruction,
occur-
cysts,
polyps,
and
mucoceles.
Although
CT
permits
evalua-
ring
in later
stages,
may
mimic
an aggressive
tumor.
However,
tion of the complications
of chronic
sinusitis,
more
importantly
in contrast
to tumors,
areas
of bone
thickening
and
sclerosis
it shows
the
pathologic
changes
responsible
for
the
chronic
may
also
be detected
(Fig.
8).
Regions
of
high
density
within
disease
(e.g.,
obstructed
ostium,
apical
tooth
abscess).
In
the
opacified
sinus
on
CT
are
highly
suggestive
of
fungal
addition
to inflammatory
disease,
occasionally
tumors
may
be
infection
[30-33]
(Fig.
8A).
These
dense
concretions
may
be
responsible
for
recurrent
disease.
MR
evaluation
has
been
the
result
of
the
combination
of
metal
ions
and
calcium
salts
shown
to
be useful
in this
regard.
Most
sinus
tumors,
except
known
to
occur
in fungal
mycetomas.
Recent
studies
[32]
neuromas
and minor
salivary
gland
tumors,
are homogeneous
suggest
that
MR may
be more
specific
than
CT for diagnosing
and
have
intermediate
signal
intensity
on
T2-weighted
im-
fungal
sinusitis.
The
presence
of ferromagnetic
metallic
ions
ages,
as compared
with
the inhomogeneous
high signal
inten-
produces
a
hypointensity
on
Ti-
and
T2-weighted
images
sity
of
most
inflammatory
tissue
[27].
(Fig.
8C).
In addition,
MR
more
effectively
shows
the
multiple
intracranial complications
of fungal
diseases
such
as cavern-
ous
sinus
thrombosis,
arterial
involvement,
and
skull
base
Allergic
Sinusitis
infection
[34,
35].
Allergic
disease,
a systemic
process
with
a tendency
for
symmetric
sinus
involvement
and
pansinusitis
[28],
affects
10% of the population.
CT often
shows
bilateral
mucoperios-
Granulomatous
Sinusitis
teal polypoid
thickening
of the sinus
and turbinate
membranes
(Fig.
7). Air-fluid
levels
are typically
absent unless associated
A variety
of diseases
can produce
granulomatous
changes
acute
bacterial
superinfection
occurs.
Polypoid
thickening
is
in the
sinonasal
cavities.
Actinomycosis,
syphilis,
tuberculosis,
more
often
seen
with
allergic
disease
than
with
bacterial
and
sarcoidosis
have
all been
reported
[29],
but
Wegener’s
infection
[29],
resulting
from
persistent
membrane
hyperpla-
granulomatosis
and
midline
granuloma
are
most
familiar.
We-
sia.
gener’s
granulomatosis,
a small-vessel
necrotizing
vasculitis,
includes
involvement
of
the
sinuses,
tracheobronchial
tree,
and
kidneys.
Midline
granuloma,
thought
to
be
a lymphore-
Fungal
Sinusitis
ticular
disease,
has
recently
been
described,
and
is
being
Although
uncommon,
a variety
of fungal
diseases
involve
reported
with
increasing
frequency
in cocaine
users
[36].
the
sinonasal
cavities.
Mucor
and
Aspergillus,
both
part
of
Granulomatous
diseases
initially
involve
the
nasal
cavity
and
Fig. 6.-Chronic
sinusitis.
Axial
CT scan
shows
total
opacification
of
left
maxillary
sinus
with
marked
thickening
of
lamina
dura
(arrowheads)
compared
with
normal
right
sinus
wall.
Fig.
7.-Polypoid
disease.
Coronal
unenhanced
CT
scan
shows
complete
opacificatlon
of
right
maxillary
sinus with nearly complete
opacification
of
left
maxillary
sinus.
Mucosal
thickening
of tur-
binate
bone
and
nasal
passage
(dots)
contributes
to
obstruction.
Biopsy
revealed
polypoid
muco-
periosteal
thickening.
AJR:159, October1992 OSTIOMEATAL UNIT AND ENDOSCOPIC SURGERY 855 Fig. 8.-Fungal sinusitis. A and B, Axial
AJR:159,
October1992
OSTIOMEATAL
UNIT
AND
ENDOSCOPIC
SURGERY
855
Fig.
8.-Fungal
sinusitis.
A
and
B, Axial
CT scans
show soft tissue
filling right maxillary,
ethmoidal,
and sphenoidal
sinuses.
“Lesion”
is heterogeneous;
increased
density
is
suggestive
of fungal
infection
with
calcium
and/or
metals
contained
within mycetoma.
Lamina
dura of right maxillary
sinus is slightiy thickened
compared
with
left, indicative
of chronic
disease
(arrowheads,
A).
However,
at higher
level,
there
is evidence
of sinus expansion
and osseous
destruction
involving
both
right
lateral
ethmoidal
wall
and
right
posterolateral
sphenoidal
sinus
wall
(arrowheads,
B).
C,
Coronal
contrast-enhanced
Ti-weighted
MR
image
reveals
heterogeneous
enhancement
of
lesion.
Areas
of
marked
hypolntensity
(asterisks)
represent
signal
void effects
of calcium
and metals
contained
within mycetoma.
This appearance
on MR images
is highly suggestive
of fungal
disease.
Fig.
9.-Mucocele.
SagittalTi-weighted
MR
im-
age
shows
a mass
within
frontal
sinus
that
has
expanded
the sinus and is isointense
with mucosal
membranes.
Fig.
iO.-Mucocele.
Coronal
Ti-weighted
MR
image
shows
mass
occupying
ethmoidal
sinus
with bony expansion
of lateral
walls.
Mass
is
hy-
perintense relative to mucosal membranes
and,
when compared
with mass
seen
in
Fig.
9,
exem-
plifies
variable
appearance
of
mucoceles
on
MR
imaging.
septum
primarily
and the paranasal
sinuses
secondarily
[37].
spissated
secretions
and
expansion
of
sinus
walls.
At
this
Although
Wegener’s
granulomatosis
may
cause
extensive
point,
they
may
resemble
tumors,
and
distinction
on
CT
bone
loss,
without
an
associated
mass
[38],
CT
generally
becomes
difficult.
As mentioned,
MR has
been
shown
to
aid
shows
bulky,
bilateral
soft-tissue
nodules
lining
the
mucosa
in this
differential
diagnosis
[27].
of
the
nasal
cavity
and
septum.
Advanced
cases
involve
Mucous
retention
cyst-Mucous
retention
cyst,
a benign
destruction
of
the
cartilaginous
nasal
septum
and
osseous
lesion
commonly
occurring
in
the
maxillary
sinus
floor,
repre-
structures.
sents
inflammatory
obstruction
of
a seromucinous
gland
of
the
sinus
mucosal
lining.
CT
typically
shows
a homogeneous,
dome-shaped,
non-gravity-dependent
soft-tissue
mass
with
sharply
defined
margins.
Local
Complications
of Sinusitis
Mucocele.-Mucoceles
result
from
obstruction
or septated
Inflammatory
polyp-Mucous
membrane
hyperplasia
from
sequestration
of
a portion
of
a sinus
cavity.
These
collections
chronic
inflammation
is thought
to
be
the
underlying
cause
of
result
not
only
from
inflammation
but
also
from
posttraumatic
inflammatory
polyps.
The
hyperplasia
is
usually
allergic
in
or neoplastic
obstruction.
The
sinus
fills with
secretions,
and
origin,
most
commonly
located
in
the
nasal
cavity
or maxillary
eventually
benign
expansion
occurs.
Sixty
percent
of muco-
sinus.
CT typically
shows
a homogeneous
soft-tissue
mass.
celes
occur
in the
frontal
sinus,
30%
in
the
ethmoidal
sinus,
When
severe,
polyps
may
cause
obstruction,
leading
to
in-
and
10%
in
the
maxillary
sinus
[37].
Sphenoidal
mucoceles
856 LAINE AND SMOKER AJR:159, October 1992 are rare. CT shows a low-density, nonenhancing mass
856
LAINE
AND
SMOKER
AJR:159,
October
1992
are
rare.
CT shows
a low-density,
nonenhancing
mass
that
of
the
intraconal
space
(orbital
phlegmon)
typically
is mani-
fills
or
expands
the
sinus.
On
both
Ti - and T2-weighted
MR
fested
as
an
increased
density
of
the
retrobulbar
fat
(“dirty
images
the
signal
varies
considerably,
from
hypointense
to
fat”).
hyperintense
depending
on
the
concentration
of water,
pro-
An
additional
complication
of
sinus
inflammation
is regional
tein,
and
mucus
[39,
40]
(Figs.
9
and
10).
An enhancing
rim
osteomyelitis,
most
commonly
involving
the
frontal
bone
with
heterogeneous
density
suggests
a
mucopyocele,
an
[26].
Infection
can
spread
hematogenously,
via diploic
veins,
infected
mucocele
[38,
41].
or
by
direct
extension.
Extensive
therapy
is required.
Frontal
osteomyelitis,
termed
Potts
puffy
tumor,
causes
lytic
destruc-
tion
of
the
frontal
bone
associated
with
an
extracranial
soft-
Regional
Complications
of Sinusitis
tissue
mass
[43].
Regional
complications
may
result
from
frontal,
ethmoidal,
or
sphenoidal
sinusitis.
In particular,
in
one
study,
ethmoidal
sinusitis
was
the
cause
of
acute
orbital
inflammation
in 75%
Intracranial
Complications
of Sinusitis
of patients
[42].
These
infections
may
travel
system
of valveless
veins
through
the
thin,
via an extensive
occasionally de-
Intracranial
complications
of
sinusitis,
commonly
due
to
hiscent
lamina
papyracea.
Orbital
cellulitis,
subperiosteal
ab-
extension
of frontal,
ethmoidal,
or sphenoidal
disease,
include
scess,
retrobulbar
abscess,
or
optic
neuritis
may
result.
Dis-
meningitis,
subdural
and
epidural
empyema,
brain
abscess,
tinction
between
postseptal
abscess
and
cellulitis,
usually
and
venous
sinus
thrombosis.
Spread
of
infection
can
occur
possible
on
CT
scans,
is important,
as treatment
protocols
along
several
routes:
(1 ) hematogenous,
(2)
perineural,
(3)
will differ
(Fig. 1 1). Cellulitis
is characterized
on
CT
by diffuse,
retrograde
thrombophlebitis,
or
(4)
direct
inoculation
(trauma
homogeneously
increased
density
and
treated
medically.
On
through
an
infected
sinus)
[26].
Complete
head
CT
with
the
other
hand,
abscesses
characteristically
have
a central
contrast
enhancement
or
MR
examination
is required
when
low-density
area
on
CT
and
usually
require
both
external
intracranial
complications
are
suspected,
as
the
infection
may
ethmoidectomy
and prolonged
antibiotic
therapy.
Involvement
localize
in areas
distant
from
the
primary
infection.
Fig.
1 1.-Orbital
complications
of
inflammatory
sinus
disease.
A,
Axial
contrast-enhanced
CT
scan
shows
a
hypointense
postseptal
collection
containing
air
adjacent
to
opacified
left
ethmoidal
air
cells.
This
subperiosteal
abscess
required
surgical
interven-
tion.
Note
marked
edema
of
left
medial
rectus
muscle
(dots).
Preseptal
cellulitis
(asterisk)
and
slight
proptosis
are
also
apparent.
B, Axial contrast-enhanced
CT scan
in
a differ-
ent
patient
shows
homogeneously
increased
den-
sity
involving
both
pro-
and
postseptal
space
of
right
orbit.
There
is
also
a
suggestion
of
slight
proptosis
and
cellulitis.
This
case
resolved
with
medical
management
alone.
Fig.
i2.-Cystic
fibrosis.
A
and
B,
Axial
(A )
and
coronal
(B)
CT
scans
show
heterogeneous,
polypoid
opacification
of
paranasal
sinuses
and
nasal
cavity.
Thickening
of
maxillary
sinus
lamina
dura
indicates
chronic,
long-standing
disease
(arrowheads,
A ).
There
is
pressure
erosion
of
medial
wall
of
left
maxillary
sinus
and expansion
of left
nasal
cavity.
Ethmoidal
sinuses
are
expanded
bilaterally,
left
greater
than
right.
Note
pressure
erosion
of
lamina
paparycea
in several
areas
bilaterally.
AJR:159, October 1992 OSTIOMEATAL UNIT AND ENDOSCOPIC SURGERY 857 Syndromes 14. Lidov M, Som PM.
AJR:159,
October
1992
OSTIOMEATAL
UNIT
AND
ENDOSCOPIC
SURGERY
857
Syndromes
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M,
Som
PM.
Inflammatory
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(en-
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CT appearance.
AJNR
Systemic
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is a component
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i990;1 1:999-1001
1
5.
Messerklinger
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infrequent
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The
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berg,
i978:6-18
encountered
are
Kartagener’s
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syn-
16.
Zinreich
SJ,
Kennedy
DW,
Rosenbaum
AE,
Gayler
BW,
Kumar
AJ,
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The
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Zinreich
SJ.
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Am
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Am
i989;22:291-306
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