The Laryngoscope

© 2020 The American Laryngological,

Rhinological and Otological Society, Inc.

Anatomical Factors that Can Predict the Structure of Lamina

Papyracea for Endoscopic Sinus Surgery

Shinya Ohira, MD ; Kentaro Matsuura, MD; Hidehito Matsui, MD; Mitsuto Nakamura, MD;
Kazuhisa Kamiyama, MD; Riko Kajiwara, MD; Akiko Inoue, MD; Kota Wada, MD

Objectives: This study investigated morphological variations of lamina papyracea, the structure that should be carefully
considered when opening posterior ethmoid sinus during endoscopic sinus surgery, to avoid injury.
Study design: This study employed axial, coronal, and sagittal computed tomography.
Methods: Using computed tomography images of 228 face-sides, various anatomical parameters were determined: dis-
tances of the anterior and posterior ethmoid arteries from the skull base, and from the third lamella; changes in the angles of the
lamina papyracea at the anterior and posterior ethmoid sinuses; and presence or absence of supraorbital ethmoid cell (SECs),
Onodi cell, and Haller cell. The relationship between the distances which indicate the point of maximum projection by the lamina
papyracea among third lamina and posterior ethmoid artery into the posterior ethmoid sinus and these anatomical factors were
analyzed statistically.
Results: The projection distance of lamina papyracea into the posterior ethmoid sinus was −2.6 mm to 3.4 mm, and in
41.2% of cases, projection in the direction of the nasal cavity was greater than that of the lamina papyracea at the anterior ethmoid
sinus. This distance increased with increasing distance of the maximum projection point from the skull base and increasing floating
distances of the anterior and posterior ethmoid arteries. The number of subjects with large projection distances was increased
among those with floating posterior ethmoid arteries. In addition, subjects with SECs had significantly greater projection distances.
Conclusions: Particular care should be taken to avoid injury to the lamina papyracea when opening the posterior ethmoid
sinus in subjects with floating anterior or posterior ethmoid arteries, and/or SEC.
Key Words: anterior ethmoid artery, posterior ethmoid artery, supraorbital ethmoid cell.
Level of Evidence: 4
Laryngoscope, 131:E19–E25, 2021

INTRODUCTION and other serious complications.7,8 Consequently, numer-

Injury to the lamina papyracea is a potential
complication of endoscopic sinus surgery1 (ESS), but this
injury can lead to serious sequelae, such as permanent
ocular motility disorder and visual impairment.2 As the
lamina papyracea is thinner and more closely positioned to
the extraocular muscles and optic nerve at the back than
at the front,3–5 particular care to avoid injury is needed
when manipulating the posterior ethmoid sinus. Moreover,
when transitioning to posterior ethmoid sinus manipula-
tion during ESS, it is recommended that the integrity of
the lamina papyracea be checked while performing
anterior ethmoid sinus manipulation.
On the other hand, injury to the anterior ethmoid
artery (AEA) can lead to intraorbital hematoma, and com-
pression by the hematoma can cause ischemia of the oph-
thalmic and retinocentral arteries,6 leading to blindness
From the Department of Otorhinolaryngology, Omori Medical
Center, Toho University, Tokyo, Japan.
Editor’s Note: This Manuscript was accepted for publication on
February 24, 2020.
We would like to thank Editage (www.editage.com) for English lan-
guage editing.
The authors have no funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Shinya Ohira, MD, 6-11-1, Omorinishi, Ota-ku,
Tokyo, 143-8541 Japan. E-mail: shinya.oohira@med.toho-u.ac.jp
DOI: 10.1002/lary.28644
ous anatomic studies have been performed, but there have
been few investigations of the posterior ethmoid artery
(PEA), and, with respect to ESS in particular, there have
been no reports to date of the relationships of the PEA
with morphological variations in the lamina papyracea
between the anterior and posterior ethmoid sinuses, which
are separated by the third basal lamella.
In the present study, the relationships between
morphological variations in the lamina papyracea and var-
ious anatomical factors were investigated with a view to
preventing injury to the lamina papyracea when opening
the posterior ethmoid sinus.
METHODS
Among patients who underwent ESS by the author at the
Department of Otorhinolaryngology, Omori Medical Center, Toho
University, between April 2016 and December 2019, this retrospec-
tive study enrolled those in whom ESS involved opening the sinus
up to the posterior ethmoid cells, and in whom the condition of the
lamina papyracea was ascertained. Patients were excluded if they
were of non–East Asian ethnicity, were under 18 years of age, had
undergone nasal surgery at least once previously, had obsolete
orbital fractures, and/or had a history of Basedow’s disease. The
patients provided informed consent, and the study protocol was
reviewed and approved by the relevant institutional review board.
In total, 138 patients were included, and preoperative
computed tomography (CT) images of 228 face-sides of these

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patients were evaluated. Preoperative, multi-slice sinus CT data
were obtained through multiplanar reconstruction of CT data,
which were scanned parallel to Reid’s base line from the bottom
of the maxillary sinus to the top of the frontal sinus. The slice
range was 0.5 mm, and the scanning powers were 125 mA and
120 kV. The imaging data were stored in Digital Imaging and
Communications in Medicine (DICOM) files. And these files were
processed with DV-R Version 1.91.00 (Toshiba Medical System
Corp, Tokyo, Japan) for coronal, sagittal, and axial sections, to
measure the anatomical lengths.
The point of maximum projection of the lamina papyracea
into the nasal cavity at the midpoint between the third lamellae
and the PEA in the posterior ethmoid sinus was set as point P. Its
spatial relationships with parameters such as the distances of the
AEA and PEA from the skull base and third basal lamella, the
angles of the lamina papyracea at the anterior and posterior eth-
moid sinuses, and the changes in the angle of the orbital internal
wall were measured as detailed below. Firstly, the position of the
third basal lamella was ascertained in sagittal sections, and the
sinuses in front and behind this lamella were taken to be the ante-
rior and posterior ethmoid sinuses, respectively. Next, coronal
slices, from anterior to posterior, were studied. The structure
projecting from the orbit into the nasal cavity at the anterior
ethmoid sinus, including the third basal lamella, was judged to be
the AEA, and the structure projecting from the orbit into the nasal
cavity at the posterior ethmoid sinus, after the third basal lamella,
was judged to be the PEA. Then, in sagittal slice 1 in which both
the AEA and PEA could be ascertained, perpendicular slices at
intermediate points between the perpendicular line most closely
approaching the third basal lamella, and the nasal beak (sagittal
slice 2) and PEA (sagittal slice 3), respectively, were judged to be
slices at the anterior and posterior ethmoid sinuses, respectively
(Fig. 1, sagittal slice 1). Using sagittal slice 1, the distances of the
AEA and PEA from the skull base were calculated to be A and B,
respectively, and the distances from the third basal lamella at the
heights of the AEA and PEA were calculated to be C (added to the
anterior direction) and D (added to the posterior direction), respec-
tively (Fig. 1, sagittal slice 1). Lines with the widest ranges of con-
tact with the orbital internal lower wall were drawn in the coronal
section for sagittal slices 2 and 3, and the angles between these
lines and a line perpendicular to the coronal slice were taken to be,
respectively, the angle E of the lamina papyracea at the anterior
ethmoid sinus, and the angle F of the lamina papyracea at the
posterior ethmoid sinus (Fig. 1, coronal slices 2 and 3). Addition-
ally, the angle change rate, F/E, for the lamina papyracea at the
anterior and posterior ethmoid sinuses was calculated.
Next, the point of maximum internal projection of the lamina
papyracea at coronal slice 3, that is, the posterior ethmoid sinus,

Fig. 1. Anatomical distances measured by paranasal sinus computed tomography. A: Distance of anterior ethmoid artery (AEA) from skull
base. B: Distance of posterior ethmoid artery (PEA) from skull base. C: Distance of AEA from third basal lamella. D: Distance of PEA from third
basal lamella. E: Angle of lamina papyracea at anterior ethmoid sinus. F: Angle of lamina papyracea at posterior ethmoid sinus. G: Distance of
maximum projection point t, P, of lamina papyracea at midpoint between 3rd lamellae and PEA in posterior ethmoid sinus from skull base.
H: Distance of maximum projection point, P, of lamina papyracea at midpoint between 3rd lamellae and PEA in posterior ethmoid sinus from
third basal lamella. I: Distance of maximum projection point, P, of lamina papyracea at midpoint between 3rd lamellae and PEA in posterior
ethmoid sinus from lamina papyracea at anterior ethmoid sinus (projection distance into posterior ethmoid sinus). J: Angle of optic nerve at
maximum projection point, P, of lamina papyracea at midpoint between 3rd lamellae and PEA in posterior ethmoid sinus.

Laryngoscope 131: January 2021 Ohira et al.: Predictable Factors of Lamina Papyracea
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 TABLE I. point P in sagittal slice,1 and the distance, H (added to the posterior
Patients’ Characteristics and Anatomical Distances. direction), of the third basal lamella from point P in sagittal slice
1, were measured (Fig. 1, sagittal slice 1). Finally, in order to inves-
Mean  SD N (%) tigate the degree of projection of point P into the nasal cavity, in
comparison with the position of the lamina papyracea at the ante-
Age (y) 56.8  15.5 rior ethmoid sinus, this distance was defined as the projection
Male age (y) 55.6 151 sides (66.2%) distance, I, into the posterior ethmoid sinus. Using the axial slice
Female age (y) 59.1 77 sides (33.8%) passing through point P (axial slice 4), the distance, I (internal
AEA floating distance (A; mm) 2.03  1.95 148 sides (64.9%) direction added), was calculated as the distance of point P from a
line perpendicular to axial slice 4 at the point of contact between
PEA floating distance (B; mm) 0.34  0.80 44 sides (19.3%)
the anterior ethmoid sinus slice (sagittal slice 2) and the lamina
Orbital internal wall angle at anterior 9.17  5.09 papyracea (Fig. 1, axial slice 4). In addition, the angle between the
ethmoid sinus (cor; E)
optic nerve in axial slice 4 and the perpendicular line was taken to
Orbital internal wall angle at posterior 27.15  6.85 be J (Fig. 1, axial slice 4). Finally, given their relationship with eth-
ethmoid sinus (cor; F)
moid cells, the presence or absence of supraorbital ethmoid cells
Anterior–posterior ethmoid sinus 4.25  3.90 (SECs), which extend upwards from the orbit,9 Onodi cells (OCs),
angle ratio at orbital internal wall
(F/E ratio) which extend upwards or laterally from the ethmoid and sphenoid
sinuses,10,11 and Haller cells (HCs), which extend into the internal
Distance from skull base of projection 0.61  1.18
point P in posterior ethmoid sinus part of the suborbital wall,12 was confirmed.
(G; mm)
Distance from lamina papyracea at 0.376  1.08
anterior ethmoid sinus to projection
point P in posterior ethmoid sinus
(I; mm)
Statistical Analysis
For statistical analysis, R software (version 3.6.1; R
Angle of optic nerve at projection 22.67  4.19
point
Foundation for Statistical Computing, Vienna, Austria) was
used, and statistical significance was considered at P < .05.
SECs 60 (26.3%)
Continuous variables were expressed as mean  standard devi-
OCs 77 (33.8%) ation. The correlation of the distance, G, from the skull base,
HCs 75 (32.9%) which shows the spatial relationships of the maximum projec-
tion point, P, of the lamina papyracea in the posterior ethmoid
AEA = anterior ethmoid artery; HC = Haller cells; OCs = Onodi cells; sinus, projection distance, I, into the posterior ethmoid sinus
PEA = posterior ethmoid artery; SECs = superior ethmoid cells.
with anatomical parameters were evaluated using multivariate
linear regression analysis. Spearman’s rank correlation coeffi-
cient was used to determine these correlations. In addition,
was taken to be the maximum projection point, P, at the posterior each factor that correlate point P was compared between the
ethmoid sinus (Fig. 1, coronal slice 3). In order to measure the spa- groups with and without the presence of the factors, using the
tial relationships of point P, the distance, G, from the skull base of Mann–Whitney U-test.

TABLE II.
Multivariate Linear Regression Analysis of Factors Associated With Point P.
Distance From Lamina Papyracea at Anterior
Distance From Skull Base of Projection Point P in Ethmoid Sinus to Projection Point
Posterior Ethmoid Sinus (G) P in Posterior Ethmoid Sinus (I)
Coef P 95% CI Coef P 95% CI

−3 −3
Age 0.01 .12 −3.1 × 10 0.01 5.8 × 10 3.1 × 10−3 to 0.02
to 0.03
Gender 0.24 .34 −0.26 to 0.73 0.02 .87 −0.23 to 0.27
Distance of AEA from skull base (A) 0.25 2.7 × 10−3 0.09 to 0.42 0.09 .04 0.01 to 0.17
Distance of PEA from skull base (B) 0.90 8.1 × 10−7 0.55 to 1.25 0.46 6.4 × 10−7 0.28 to 0.63
Distance of AEA from third basal lamella (C) −0.01 .86 −0.11 to 0.10 −0.05 .05 −0.11 to −1.0 × 10−3
−3
Distance of PEA from third basal lamella (D) −3.7 × 10 .82 −0.04 to 0.03 −0.01 .35 −0.02 to 0.01
Anterior–posterior ethmoid sinus angle ratio −4.0 × 10−3 .89 −0.06 to 0.05 −0.01 .66 −0.03 to 0.02
at orbital internal wall (F/E ratio)
Angle of optic nerve at projection point (J) 0.05 .09 −7.1 × 10−3 −0.01 .62 −0.03 to 0.02
to 0.10
HC −0.17 .50 −0.64 to 0.31 0.07 .59 −0.17 to 0.31
OC 0.39 .12 −0.09 to 0.87 0.26 .04 0.02 to 0.50
SEC 0.35 .30 −0.32 to 1.01 0.47 .01 0.14 to 0.81

The distance A of AEA from skull base and the distance B of PEA from skull base were associated with the distance G of the maximum projection point, P,
from the skull base. Age, the distance A of the AEA from skull base, the distance B of PEA from skull base, the distance C of AEA from 3rd lamellae, presence of
OC and presence of SEC were associated with projection distance I into the posterior ethmoid sinus.
AEA = anterior ethmoid artery; CI = confidence interval; Coef = regression coefficient; HC = Haller cells; OCs = Onodi cells; PEA = posterior ethmoid artery;
SEC = superior ethmoid cells.

Laryngoscope 131: January 2021 Ohira et al.: Predictable Factors of Lamina Papyracea
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Fig. 2. Correlations relating to I (Spearman’s rank correlation coefficient) G: the distance of the maximum projection point, P, from the skull base.
(a) A positive correlation was found between the projection distance, I, into the posterior ethmoid sinus and the distance, A, of the anterior eth-
moid artery (AEA) from the skull base. (b) A positive correlation was found between the projection distance, I, into the posterior ethmoid sinus
and the distance, B, of the posterior ethmoid artery (PEA) from the skull base. (c) A positive correlation was found between the projection
distance, I, into the posterior ethmoid sinus and the distance, G, of the maximum projection point, P, from the skull base. The correlation between
distance B of the PEA from the skull base and projection distance I into the posterior ethmoid sinus was stronger than the correlation between
distance A of the AEA from the skull base and projection distance I into the posterior ethmoid sinus.

RESULTS sinus was −2.6 mm to 3.4 mm, and in 41.2% of cases,

CT images of paranasal sinuses on 228 face-sides
(151 from males, and 77 from females) of 138 subjects
were analyzed. Patients’ characteristics (age and sex),
and anatomical measurements are shown in Table I. The
distance of the AEA from the skull base was 0 mm to
7.6 mm, and in 64.9% of face-sides, the AEA was floating
inside the nasal cavity. The distance of the PEA from the
skull base was 0 mm to 3.5 mm, and in 19.3% of cases,
the PEA was floating inside the nasal cavity. With
respect to the maximum projection point, P, in the poste-
rior ethmoid sinus at midpoint between the third lamel-
lae and the PEA, the distance, G, from the skull base was
0 mm to 5.3 mm, and in 27.6% of cases, it was separated
from the skull base. The distance, I, of projection of the
maximum projection point, P, into the posterior ethmoid
projection in the direction of the nasal cavity was
greater than that of the lamina papyracea at the anterior
ethmoid sinus.
Multivariate linear regression analysis of anatomical
parameters associated with point P (distance G of the
maximum projection point, P, from the skull base; projec-
tion distance I into the posterior ethmoid sinus) is shown
in Table II. Distance A of AEA from the skull base and
distance B of PEA from skull base were associated with
distance G of the maximum projection point, P, from the
skull base. Age, distance A of the AEA from the skull
base, distance B of PEA from the skull base, distance C of
AEA from the third lamellae, presence of OCs and pres-
ence of SEC were associated with projection distance I
into the posterior ethmoid sinus.

Fig. 3. Comparison of factors relating to I (Mann–Whitney U-test). The projection distance I into the posterior ethmoid sinus differed significantly
depending on the presence or absence of supraorbital ethmoid cells (SECs).

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 Spearman’s rank correlation coefficients of distance I
of the maximum projection point into the posterior ethmoid
sinus at midpoint between the third lamellae and PEA are
shown in Figure 2. Projection distance I into the posterior
ethmoid sinus was correlated positively with distance A of
the AEA from the skull base, and distance B of the PEA
from the skull base. In addition, there was a positive corre-
lation between distance G of the maximum projection point
P from the skull base and projection distance I into the
posterior ethmoid sinus. The correlation between distance
B of the PEA from the skull base and projection distance I
into the posterior ethmoid sinus is stronger than the corre-
lation between distance A of the AEA from the skull base
and projection distance I into the posterior ethmoid sinus.
In addition, SECs, OCs, and HCs were present in
26.3%, 33.8%, and 32.9% of cases, respectively. The result
of the Mann–Whitney U-tests for distance I of maximum
projection point P into the posterior ethmoid sinus
according to the presence or absence of each of OCs and
SECs is shown in Figure 3. Distance I of maximum projec-
tion point P into the posterior ethmoid sinus is significantly
different between the groups with and without SECs,
whereas no significant difference was found for these
distances according to the presence or absence of OCs.
DISCUSSION
This study investigated variations into parameters
related to the morphology of the lamina papyracea and its
relationship with surrounding structures, with a view to
avoiding injury of this lamina during ESS. The maximum
projection of the lamina papyracea into the nasal cavity at
midpoint between the third lamellae and the PEA mid-
point between the third lamellae and the PEA in the pos-
terior ethmoid sinus ranged from 0 mm to 5.3 mm from
the skull base. The maximum projection distance of the
lamina papyracea at midpoint between the third lamellae
and the PEA into the nasal cavity ranged from −2.6 mm to
3.4 mm, as compared with the lamina papyracea projection
at the anterior ethmoid sinus. In addition, the former dis-
tance increased with increases in the distance by which
the AEA and PEA floated away from the skull base, and
was significantly greater if SECs were present.
ESS aims to establish an excretion route via the par-
anasal sinus, to allow management of diseased mucosa.13
To facilitate long-term improvement in the patient’s
quality of life, access routes to all sinuses must be
established.14 Sinusitis is an inflammatory disease, and it
is essential to avoid complications. In particular, the
probability of serious complications, such as great vessel
injury, orbital injury, and intracranial complications is
1% to 3%.15 The possibility of orbital hematoma is 0.6%,16
and it is sometimes caused by injury to the lamina
papyracea, AEA or PEA. The possibility of injury to the
lamina papyracea is 0.4%,17 but there has been no prior
study addressing the possibility of injury to AEA or PEA.
If orbital hematoma happens by injury to these
structures, we have to decompress intra-orbital pressure
suddenly to avoid loss of sight. In order to avoid these, it
is important to ascertain anatomical landmarks such as
the lamina papyracea, skull base, and middle turbinate
Laryngoscope 131: January 2021
when performing surgery.18 In particular, the lamina
papyracea plays an important role as a signpost for
approaches to the posterior ethmoid sinus and sphenoid
sinus.19 When opening the posterior ethmoid sinus, a safe
method is considered to involve exposing risk areas, such
as the lamina papyracea and skull base, sufficiently when
opening the anterior ethmoid sinus, and to perforate the
third basal lamella in such a manner that the spatial
relationships of the posterior ethmoid sinus to other
structures can be predicted (Fig. 4a). In general, the pos-
terior part of paranasal sinuses is narrower, and thus,
serious secondary injury can be avoided by perforating
and gradually widening the lower internal part, where
opening of the third basal lamella is safest (Fig. 4b,c).
However, we have found that, in a certain proportion
of cases, the lamina papyracea among the third lamellae
and the PEA at the posterior ethmoid sinus projects in
the direction of the nasal cavity (Fig. 4d–f). The third
basal lamella is the defect-free basal lamella, and the
structure of its posterior part is difficult to assess visu-
ally; hence, it is clinically important to predict anatomical
variation prior to surgery. The approach taken at many
medical institutions is to assess the anatomical structure
by paranasal sinus CT before surgery, and then to per-
form surgery on that basis. There have been many stud-
ies investigating anatomical variations using CT for ESS,
but there have been no reports investigating anatomical
risk factors that can predict risk of complications for ESS.
Preoperative paranasal sinus CT in the present study
involved high-frequency CT, with 0.5-mm-thick slices,
and it was used to investigate whether morphological
changes in the lamina papyracea can be predicted preop-
eratively. If the distance of the maximum projection point
of the lamina papyracea at midpoint between the third
lamellae and the PEA in the posterior ethmoid sinus from
the skull base is 0 mm, its maximal projection is present
at the skull base, and it is therefore not difficult to esti-
mate the position of the orbit to the anterior side of the
third basal lamella, as usual, and then open the posterior
ethmoid sinus. In the present study, in 24% of subjects,
the maximum projection point was separated from the
skull base, and the greater the separation distance, the
greater the projection toward the nasal cavity, up to a
maximum of 3.4 mm. In such patients, there is a poten-
tial for injury to the lamina papyracea when opening the
posterior ethmoid sinus, and this should be kept in mind
in order to perform surgery safely.
In the present study, factors favoring development of
cases of this type were investigated using preoperative
CT. We identified the AEA and PEA distances from the
skull base, and the presence of SECs as risk factors for
greater projection of the lamina papyracea into the nasal
cavity at the midpoint between the third lamellae and the
PEA. Numerous anatomical investigations have been per-
formed with the AEA, Simmen et al. have reported that in
35% of cases the AEA was separated from the skull base,
with the mean separation distance being 3.5 mm.7 How-
ever, in the present study, 64.9%, the AEA was separated
from the skull base in a larger proportion of cases, but this
proportion included numerous cases with, for example,
separation by only approximately 1 mm, and only on the
Ohira et al.: Predictable Factors of Lamina Papyracea
E23
Fig. 4. (a) Status after opening anterior ethmoid sinus. The lamina papyracea and skull base are checked, followed by exposure of a wide area
of the third basal lamella. (b) The safe range posterior to the lamina papyracea and skull base is estimated (blue box), and the third basal
lamella is perforated. (c) After perforation, the third lamella is safely expanded, because the posterior structure can be predicted. (d) Subject
showing projection of the lamina papyracea at the posterior ethmoid sinus. (e) Magnification of image shown in D. The red box indicates the
area where there is considered to be risk of injury. (f) The red box indicates the same area on coronal computed tomography, as indicated by
the red box in E. Blue: range considered safe; Red: projection at posterior ethmoid sinus. 3rd = third basal lamella; AEA = anterior ethmoid
artery; LP = lamina papyracea; MT = middle turbinate; OC = optic canal; PEA = posterior ethmoid artery; SB = skull base.

external side near the orbit. With respect to PEA, on the
other hand, the proportion of cases with separation from
the skull base by ≥2 mm had previously been reported to
be 12%,20 and a similar proportion was found in the pre-
sent study (11.4%). The most common location of the PEA
is the first wall anterior to the optic canal, but in the pre-
sent study, no correlation was found between the distance
of the PEA from the third basal lamella and the projection
distance of the lamina papyracea. In addition, there were
78 of 148 subjects with floating AEA (53%), and 43 of
44 subjects with floating PEA (98%) who had a lamina
papyracea projecting into the nasal cavity at midpoint
between the third lamellae and the PEA in the posterior
ethmoid sinus, and the correlation between distance B of
the PEA from the skull base and projection distance I into
the posterior ethmoid sinus was stronger than the correla-
tion between distance A of the AEA from the skull base
and projection distance I into the posterior ethmoid sinus.
This underscores the need for particular care when
performing ESS in patients with floating PEA.
SECs, OCs, and HCs are cells that support the
development of ethmoid cells along the orbital upper wall,
the upper wall of the sphenoid sinus exterior, and the inter-
nal part of the orbital lower wall, respectively; SECs have
been reported to affect the distance of the AEA from the
skull base.21 In the present investigation, OCs and SECs
were found to affect the projection distance of the maxi-
mum projection point of the lamina papyracea at the mid-
point between the third lamellae and the PEA in the
posterior ethmoid sinus, and the presence of SECs were
correlated more significantly with the projection distance
than the presence of OCs. SECs affect the development of
ethmoid cells in the upper part of the orbit, and, if such cells
exist, it is essential to pay sufficient attention to the poten-
tial for injury not only to the PEA, but also to the lamina
papyracea, when opening the posterior ethmoid sinus.
In this study, the change rate of angles of the lamina
papyracea at the anterior and posterior ethmoid sinuses,
and the angle of the optic nerve were determined, but no
significant findings were made. This suggests that the
angles of the orbital wall and optic nerve are not related
to the projection of the lamina papyracea into the nasal
cavity. Attention should be paid to the potential for
changes in the angle of the lamina papyracea at the
anterior and posterior ethmoid sinuses in all patients.
The study had several limitations. Firstly, the par-
anasal sinus CT used 0.5-mm-thick slices, and measure-
ments of less than 0.5 mm therefore had little reliability.
Secondly, there are known ethnic differences in nasal cavity
and paranasal sinus anatomy,22 and this study was per-
formed only in East Asian (Japanese) individuals; hence, it
is possible that a study of Caucasians, etc., would yield dif-
ferent results. However, projection of the lamina papyracea
toward the nasal cavity is more common in Caucasians than
in Japanese and other East Asians,22 and it is therefore
considered to be important to take even more care when
opening the ethmoid sinuses in Caucasian patients.
CONCLUSIONS
In order to prevent injury to the lamina papyracea
when opening the posterior ethmoid sinus, it is important

Laryngoscope 131: January 2021 Ohira et al.: Predictable Factors of Lamina Papyracea
E24
to monitor the lamina papyracea when opening the
anterior ethmoid sinus, and from this to estimate the
structure of the lamina papyracea at the posterior eth-
moid sinus. On the basis of the results of the present
study, the presence of a floating AEA, a floating PEA, and
SECs are considered to be factors that predispose to pro-
jection of the lamina papyracea into the nasal cavity at
the posterior ethmoid sinus. The frequency of such projec-
tion was particularly high when a floating PEA was
present. When performing ESS in patients with these
risk factors, predicting the potential for expansion of the
lamina papyracea in the posterior direction inside the
nasal cavity based on preoperative CT, and carrying out
the appropriate posterior ethmoid sinus manipulation
accordingly, can reduce the risk of injury to the lamina
papyracea at the posterior ethmoid sinus.
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