Clinical Anatomy 12:1619 (1999)

Anatomical Variability of the Frontal Sinuses and Their

Application in Forensic Identification
PHRABHAKARAN NAMBIAR,1 MURALI D.K. NAIDU,2
1Department

AND

KRISHNAN SUBRAMANIAM2*

of Oral Biology, Faculty of Dentistry, University of Malaya, Malaysia

of Anatomy, Faculty of Medicine, University of Malaya, Malaysia

2Department

The uniqueness of anatomical structures and their variations provides the basis for forensic
identification of unknown deceased persons. Similar to fingerprints, each frontal sinus is so
distinctive and unique that the chances of two individuals having the same morphology of the
frontal sinuses is extremely remote. Radiographs, especially the occipitomental view
commonly used in the assessment of paranasal pathology, provide excellent records of these
sinuses. The case illustrated here is an application of the frontal sinus identification of a victim
in a mass disaster. Clin. Anat. 12:1619, 1999. r 1999 Wiley-Liss, Inc.
Key words: frontal sinus; radiography; forensic identification

INTRODUCTION
Among the four major sinuses present in the human
skull, namely, the maxillary, frontal, sphenoidal, and
ethmoidal, considerable forensic interest in identification has been shown in the frontal sinus (Harris et al.,
1987a,b; Kullman et al., 1990; Reichs, 1993). Comparison of the frontal sinus, which is considered unique to
every individual, has significant value to establish
identification. The significance of these sinuses in
positive identification has been emphasized by anatomists, radiologists, and anthropologists who have stated
that the frontal sinuses of no two persons are alike.
One such case whereby a person was killed in an
aircrash was positively identified by configuration of
the frontal sinuses is discussed in this article. The
developmental anatomy of the frontal sinuses is also
briefly reviewed.

DEVELOPMENTAL ANATOMY
OF THE FRONTAL SINUS
The paranasal sinuses begin development early in
fetal life. They develop as pockets of nasal epithelium,
which expand into concavities of the cartilaginous
nasal capsule. These epithelial pouches expand into
the skeletal components of the nasal frame. With the
exception of the ethmoidal sinus, much of their
enlargement takes place only after birth (Sandler,
1990; Blitzer et al., 1991). The functions of these
sinuses are not fully understood, but most anatomical

r 1999 Wiley-Liss, Inc.

literature suggests that that they lighten the skull and

add resonance to the voice (Hollinshead, 1966; Williams et al., 1989; Moore, 1992; McMinn, 1994; Snell,
1995).
The frontal sinuses develop as diverticula from the
lateral nasal wall around the fourth fetal month following the development of the frontal recess. They may
also rise from the laterally placed anterior ethmoidal
cells, anterior part of the frontal recess, or from the
frontal furrow (Donald et al., 1994). They are rudimentary or absent at birth but noticeable by the end of the
first year. By the sixth year, they can be demonstrated
radiographically and grow larger in size after puberty,
attaining almost full size by late adolescence (Harris et
al., 1987b).
The definitive frontal sinuses are paired, irregular
shaped, air-containing chambers, lined by mucoperiosteum and are located between the outer and inner
tables of the frontal bone, posterior to the superciliary
arches and at the root of the nose (Hollinshead, 1966;
Williams, 1989; and Moore, 1992). These triangularshape pneumatic spaces are usually separated by a
bony septum, which frequently deviates from the
median plane. Each frontal sinus drains into the
middle meatus of the nose through the infundibulum.
*Correspondence to: Professor Krishnan Subramaniam, Department of Anatomy, Faculty of Medicine, University of Malaya,
50603 Kuala Lumpur, Malaysia.
Received 24 August 1997; Revised 23 January 1998

Frontal Sinuses

Because right and left frontal sinuses develop independently, it is common to find one larger than the
other, and the larger sinus may cross the midline and
even overlap the other. A review by Donald et al.
(1994) reported that in 4-15% of the population, one
sinus may be totally absent and the absence may be
attributed to an extremely deviated septum. Aplasia of
the left frontal sinus occurred 3.6% in men and 2.8% in
women. Complete aplasia is found in 15% of Caucasians, 52% in Eskimos, and 35% in other races. Studies
by Harris et al. (1987a) showed frontal sinuses were
absent in 6.7% of blacks and 1.7% of the Cape
Coloureds. It is suggested that the frontal sinuses are
generally larger in males except for the Canadian
Eskimo population (Yoshino et al., 1987). In females
the frontal sinuses are smaller and their upper borders
are more scalloped (Krogman and Iscan, 1986).
Sizes of the frontal sinuses are also highly variable,
ranging from a few cubic centimeters in volume to
occupying most of the frontal bone. The height of the
frontal sinus varies from 5-66 mm with an average
height of 24.3 mm. They extend laterally from the
midline with an average distance of 29 mm (variation
17-49 mm) (Donald et al., 1994). Three or more frontal

Fig. 1.

17

sinuses are rare, but incomplete septations of various

lengths extending from the roof are not uncommon.
These septations give the sinus its scalloped configuration, which can be appreciated in radiographs. As a rule
the frontal sinuses of both sides are asymmetrical in
configuration.
Yoshino et al. (1987) proposed a system of classifying the frontal sinuses utilizing the following criteria:
area size, degree of bilateral asymmetry, form of
scalloping, number of septa and complete cells. Each
parameter is given a class according to its variation.
When the above parameters are taken into consideration, a frontal sinus can represent one of the 20,000
possible combinations.

CASE REPORT
The male victim described in this report died in an
aircrash in which his body was badly burned, presenting police and forensic pathologists the urgent problem of identifying him and other victims. Tentative
identification was made on the basis of photographs
provided by the family, which show presence of prominent supracilliary ridges, and he was the only male

Antemortem radiograph displaying the frontal sinus (arrows).

18

Nambiar et al.

caucasion listed on the passenger manifest. Three

antemortem radiographs were received: (1) lateral view
of the skull, (2) postero-anterior view, and (3) occipitomental view. The body in question was subsequently
transported from the mortuary to the radiological unit
where matching radiographs of the skull were taken.
Of the three radiographs, the occipitomental view is
best for determining the morphology of the frontal
sinus. To obtain this view, the head faces the film and
the orbito-meatal line is 45 to the floor with the
sagittal plane of the head being vertical (Mason, 1982).
In view of the fact that the body was in an advanced
state of decomposition, several views with different
angulations and densities were required to obtain a
proper comparison. Comparison of the ante- and
postmortem morphology of the sinuses showed exact
match resulting in the positive identification of the
deceased (see Figs. 1, 2).

DISCUSSION
The need for identification of a deceased is mandatory because a death certificate is required for legal
matters such as: (1) inheritance and succession to

property, (2) collection of insurance policies and pensions and settlement of business matters, (3) possible
remarriage of the spouse, and (4) accident reconstruction. Further, identification following the mysterious
disappearance or sudden death of an individual brings
to an end the emotional strain on the next of kin.
Additionally, relief may be afforded to a family who
learns that an unknown body does not represent the
remains of a missing relative. Burial problems may also
result when multiple bodies are of persons of different
religious faiths. In addition, evidence in a criminal case
may be dependent upon positive identification of the
victim and the establishment of the victims relationship to a suspect (Cotton, 1982; Vale et al., 1991).
Like fingerprints, sinus patterns are unique for a
person. Identification by comparison of radiographs of
the antemortem and postmortem frontal sinuses is
scientifically valid because frontal sinus configurations
of no two person are alike. Apart from radiographs
from normal traditional projection methods, CT scans
of frontal sinuses have also been used for identification
(Reichs, 1993). However, caution must be expressed
as there are possibilities that the frontal sinus being
absent altogether. In old age, the walls of the frontal

Fig. 2. Postmortem radiograph showing the same morphology of the frontal sinus (arrows).

Frontal Sinuses

sinuses become thinner and the sinuses look larger.

Furthermore, unlike fingerprints, frontal sinuses are
affected by pathology such as acute or chronic inflammations, some endocrine dysplasias, osteotitis, and
trauma (Krogman and Iscan, 1986; Harris et al., 1987a).
In addition, the use of this above mentioned method
of comparison for identification must be restricted to
persons over the age of 20 years when definite morphology is established after a rapid development during puberty (Harris et al., 1987a; Yoshino et al., 1987).

ACKNOWLEDGMENTS
Our sincere gratitude and heartfelt thanks to the
radiographers at the Radiological Unit of the Tawau
Hospital, Sabah, Malaysia.

REFERENCES
Blitzer A, Lawson W, Friedman WH. 1991. Surgery of paranasal
sinuses, 2nd Ed. Philadelphia: W.B. Saunders. p 124.
Cottone JA, Standish SM. (eds.) 1982. Outline of forensic
dentistry. Year Book Medical Publisher, p 7387.
Donald PJ, Gluckmann JL, Rice DH. 1994. The sinuses. New
York: Raven Press, p 1548.
Harris AMP, Wood RE, Nortje CJ, Thomas CJ. 1987a. The
frontal sinus: Forensic fingerprint?-A pilot study. J Forensic
Odontostomatol. 5:1,915.
Harris AMP, Wood RE, Nortje CJ, Thomas CJ. 1987b. Gender
and ethnic differences of the radiographic image of the
frontal region. J Forensic Odontostomatol 5:5157.

19

Hollinshead WH. 1966. Anatomy for surgeons: Volume 1, 1st

Ed. New York: Harper & Row and Weatherhill. p 229281.
Krogman WM, Iscan MY. 1986. The human skeleton in forensic
medicine, 2nd Ed. Springfield, IL: Charles C. Thomas. p
125126, 466471.
Kullman L, Eklund E, Grundin R. 1990. The value of frontal
sinus in identification of unknown persons. J Forensic
Odonstostomatol 8:310.
McMinn RMH. (ed.) 1994. Lasts anatomy, regional and applied, 9th Ed. London: Churchill Livingstone, p 469476.
Mason RA. 1982. A guide to dental radiography. 2nd Ed.
London: Wright. p 108114.
Moore KL. 1992. Clinically oriented anatomy, 3rd Ed. Baltimore: Williams & Wilkins. p 760762.
Reichs KJ. 1993. Quantified comparison of frontal sinus patterns by means of computed tomography. Forensic Sci Int
61:141168.
Sadler TW. (ed.) 1990. Langmans medical embryology, 6th Ed.
Baltimore: Williams & Wilkins. p 321.
Snell RS. 1995. Clinical anatomy for medical students, 5th Ed.
Boston: Little, Brown and Company. p 746747.
Vale GL, Cogan JL, Suchey JM. 1991. Forensic dentistry:
Investigation of the Los Angeles Airport disaster. Cal Dent
Assoc J 19:2026.
Williams PL, Warwick R, Dyson M, Bannister LH. (eds.) 1989.
Grays anatomy, 37th Ed. London: Churchill Livingstone. p
11771180.
Yoshino M, Miyasaka S, Sato H, Seta S. 1987. Classification
system of frontal sinus patterns by radiography: Its application to identification of unknown skeletal remains. Forensic
Sci Int 34:289299.