“STAY CURIOUS”

Cadaveric dissection course

UZ Leuven - edition 3, 2024

Manual for functional endoscopic sinus surgery

Cristobal Langdon - Juan Carlos Ceballos

Laura Van Gerven - Saartje Uyttebroek
Introduction

Applied anatomical knowledge is the surgeon's main tool to maximize benefits and avoid
complica�ons. It is essen�al to keep the orienta�on and the correct visualiza�on of anatomical
landmarks while advancing during dissec�on. The authors do not intend to impose a surgical style or
the "correct" way to perform surgery, they want to communicate their way of applying current
knowledge.

During the review of various materials for the prepara�on of this manual, we found great variability
in the nomenclature of the anatomical structures described. For this reason, we decided to use the
Interna�onal Anatomical Nomenclature (1) to standardize as much as possible the anatomical terms.
In case of doubt, or when no English name was found, the original La�n anatomical term was used.
If more than one name is accepted, both are included when they first appear.

“STAY CURIOUS” 1
 I. Anatomy

Conceptual theory of sinonasal surgery

We have approached the nasal and sinonasal anatomy as a great labyrinth. In pathological condi�ons
we need to break down bony walls to restore the physiological func�on or ease the delivery of
intranasal drugs or nasal lavage to restore and create a “healthy” sinonasal system. It is based on this
concept that we will develop our anatomical and surgical dissec�on philosophy.

Concept of lamellae or “maze walls”

In the descrip�on of the anatomy of the lateral wall of the nose, the embryonic origin of the ethmoid
is important. Embryologically, the so-called "lamellas" are formed between the ninth and tenth week
of gesta�on as folds in the lateral wall of the nose. Subsequently, they fuse during the following
weeks into three or four ridges (18), each with an anterior (ascending) and a posterior (descending)
por�on, ul�mately forming the following structures (Fig. 1.):

Uncinate process

Ethmoidal Basal
bulla lamella
Sphenoid
sinus

Figure 1: Schematic illustration of the arrangement of the ethmoidal lamellae

“STAY CURIOUS” 2
 ● First lamella: agger nasi and uncinate process
● Second lamella: ethmoidal bulla
● Third lamella: basal lamina of the middle turbinate
● Fourth lamella: part of the superior turbinate (and supreme turbinate, when there is one)

The agger nasi is the most anterior cell of the ethmoid; it is located anterosuperior to the axilla of
the middle turbinate (19). Its name comes from the La�n agger, which means eminence or mound,
and nasi, which means nose. That is why some authors use the term nasal eminence. It is a constant
structure in 98% (20) of people, so it is a key reference, especially in frontal sinus surgery. Strong
pneuma�za�on in this structure can obstruct the frontal recess or narrow the nasolacrimal duct (21).

The limits of the agger nasi are:

● Anterior: frontal process or ascending ramus of the maxilla
● Superior: frontal recess, frontal sinus, or both
● Inferomedial: con�nuous with the uncinate process
● Inferolateral: lacrimal bone
This close rela�onship to bone and lacrimal sac explains why inflamma�on of the anterior ethmoid
can cause epiphora.

Immediately behind the agger nasi, we find the middle turbinate. It consists of various segments: In
its anterosuperior por�on (ver�cal or sagi�al plane) it inserts into the region of the agger nasi in the
por�on known as the axilla and in the lateral plate of the cribriform plate. The posterior por�on
(horizontal or in the axial plane) a�aches to the ethmoid crest of the perpendicular lamina of the
pala�ne bone. In 24-55% of the popula�on, pneuma�za�on of the middle turbinate could be found,
this is called a “concha bullosa” (22).

“STAY CURIOUS” 3
 The uncinate process is a sickle-shaped bony structure that inserts from anterosuperior to
posteroinferior in the sagi�al plane. It is a�ached anteriorly to the lacrimal bone and fu ses
posteriorly with the medial wall of the agger nasi. For this reason, in a coronal sec�on of computed
tomography (CT), it is up to the posterior half of the agger nasi where we begin to see the uncinate
process, while its posterior segment is inserted into the perpendicular por�on of the pala�ne bone
and the ethmoid process of the inferior turbinate.
The uncinate process has a concave free edge that, together with the anterior face of the bulla
ethmoidalis, forms a space called the inferior semilunar hiatus, a three-dimensional space that
cons�tutes the drainage pathway of the ethmoidal infundibulum.

There are three types of inser�on of the uncinate process:

1) Lamina papyracea (lateral inser�on) which is the most common type of inser�on, in
52% of the cases (23). (Fig. 2A) In this case, a lateral cul-de-sac is formed called
recesses terminals, which cons�tutes the upper limit of the ethmoid infundibulum,
and causes the frontal sinus to drain directly to the middle meatus; that is, the
drainage is medial to the uncinate process (24).
2) Middle turbinate (medial inser�on) (Fig. 2B)
3) Skull base (upper a�achment) (Fig. 2C)

A B C

Figure 2: Insertion of the uncinate process to the A. lamina papyracea, B. middle turbinate, C. skull base

“STAY CURIOUS” 4
 In the la�er 2, the frontal recess drains through the ethmoid infundibulum. Other variants of the
uncinate process that we can find are medialized, paradoxical, bullous, or pneuma�zed processes
(1%). A case of special importance is that of the lateralized apophysis since it can cause atelectasis of
the ethmoid infundibulum and silent maxillary sinus syndrome.
It is important to analyze the inser�ons of the uncinate process on CT before the start of the surgery.

The middle meatus corresponds to the area of the lateral wall of the nose where the maxillary,
anterior ethmoidal and frontal sinuses drain. It is bounded superiorly and medially by the middle
turbinate, laterally by the uncinate process, and bulla ethmoidalis. It is in this space where we can
find purulent rhinorrhea in cases of acute or chronic sinusi�s of maxillary, frontal, or anterior
ethmoidal origin since it is here where the drainages of these sinuses converge to a space called the
os�omeatal complex (some�mes erroneously wri�en "osteomeatal", It refers to the La�n word
os�um which means door or hole).

If we con�nue advancing in the middle meatus and without the need to medialize the middle
turbinate, we find just behind the free edge of the uncinate process the ethmoidal bulla (or bulla
ethmoidalis) which is the most prominent cell of the anterior ethmoidal complex. Its limits are as
follows:

● Antero-superior: frontal recess

● Anteroinferior: ethmoid infundibulum and uncinate process
● Posterior: basal lamina of the middle turbinate or retrobullar recess if present
● Lateral: lamina papyracea
● Medial: middle turbinate
● Superior: skull base or suprabullar recess if present

Occasionally, the ethmoidal bulla has as its posterior limit the basal lamina of the middle turbinate.
However, in most cases (90%) (25) there is a space between the posterior wall and the basal lamina
called the retrobullar recess, where the ethmoidal bulla drains in 68% of cases (26). (Image 2)

“STAY CURIOUS” 5
 FR

UP EB
Middle
Ethmoid turbinate
infundibulum
EI
Ethmoidal MM
bulla
Uncinate OM
process MT
Retrobullar
recess
Ethmoidal
bulla

Basal lamella

Image 2: Ostiomeatal complex. UP, Uncinate pro-

cess; EI, Ethmoidal infundibulum; OM, ostium of
the maxillary sinus; FR, frontal recess; EB, ethm-
Image 1: Computed tomography, axial slices. oidal bulla; MM, middle meatus; MT, middle turb-
Ethmoidal bulla is seen on the right side and inate
retrobullar recess on the left side.

The retrobullar recess communicates with the middle meatus through the superior hiatus
semilunaris, a cle� bounded by the posterior wall of the bulla ethmoidalis and the basal lamina of
the middle turbinate for drainage.
The anatomic limits of the retrobullar recess are:
• Anterior: bulla ethmoidalis
• Posterior: basal lamina of the middle turbinate
• Lateral: lamina papyracea
• Medial: middle turbinate
• Superior: skull base or suprabullar recess if any

“STAY CURIOUS” 6
 The suprabullar recess is the space between the ethmoid bulla and the ethmoid roof (base of the
skull). When the bulla ethmoidalis is pneuma�zed to the ethmoidal roof, this space does not exist.

The anatomic limits of the suprabullar recess are:

● Anterior: frontal recess
● Posterior: retrobullar space or basal lamina of the middle turbinate
● Lateral: lamina papyracea
● Medial: middle turbinate
● Superior: ethmoid roof

Before con�nuing posteriorly, we will talk about the (ethmoid) infundibulum (27), a funnel-shaped
three-dimensional space. It is limited by the uncinate process, the lamina papyracea, and the
ethmoidal bulla, where the anterior ethmoidal cells, the maxillary sinus, and in some cases the frontal
sinus (according to the inser�on of the uncinate process, as already men�oned) drain, and it
communicates with the meatus through the inferior hiatus semilunaris.

While exploring the infundibulum, we search for the natural orifice (os�um) of the maxillary sinus,
which is ellip�cal, measures around 5 millimeters (3 to 10 millimeters in diameter), and drains to the
lower third of the infundibulum in 65% of people (28)(29). In contrast, accessory holes (os�a) are
round. For this reason, if we explore with a 0º endoscope, we will not see the natural os�um of the
maxillary sinus unless we perform the uncinectomy. If we see a drainage hole of the maxillary sinus,
with a 0° endoscope, it will be an accessory one.

Fontanelles are areas of weakness in the medial wall of the maxillary sinus, above the inferior
turbinate, where the mucosa lacks bone. They are formed by mucosa, connec�ve �ssue, and the
periosteum of the maxillary sinus. Two fontanels, one anterior and one posterior, are described with
respect to the free edge of the uncinate process.

“STAY CURIOUS” 7
 Some�mes the fontanelles can be found permeable, forming accessory holes (os�a) observed in 5%
of the healthy popula�on and up to 25% in pa�ents with chronic rhinosinusi�s (30).

It is of great importance to understand the func�onal anatomical concept of the os�omeatal

complex (OMC), since it represents the area where the structures and pathways for drainage and
ven�la�on of the maxillary, anterior ethmoidal, and frontal sinuses are found. Therefore, medical,
and surgical strategies are focused on resolving the obstruc�on of this complex when there is
pathology in these sinuses.

The OMC is the func�onal unit that encompasses the following three-dimensional structures and
spaces:
● Uncinate process
● Ethmoid infundibulum
● Hiatus semilunaris
● Maxillary sinus os�um
● Front recess
● Ethmoidal bulla
● Middle meatus

The frontal recess, this term has been variously defined for many decades and remains controversial.
It is generally accepted to be the most anterior-superior part of the ethmoid, inferior to the opening
of the frontal sinus (defined below). The term is o�en used as a synonym for "frontal sinus drainage
pathway," but drainage of the frontal sinus through the frontal recess is complex, altered by the
mul�ple cell configura�ons in this region coupled with the different inser�ons of the uncinate
process. The terms "frontal recess" and "frontal sinus drainage pathway" generally refer to two
separate en��es. The frontal sinus opening is best defined in the sagi�al sec�on of CT; here the
contours of the sinus and frontal recess have been described as forming an hourglass, the narrowest
part of which is taken to be the opening of the frontal sinus. The frontal recess is bounded posteriorly
by the anterior wall of the ethmoid bulla (if it reaches the base of the skull), anteroinferior by the
agger nasi, and laterally by the lamina papyracea, and inferiorly by the terminal recess of the ethmoid
infundibulum, if present. If the uncinate process adheres to the base of the skull or rotates medially,
the frontal recess opens directly into the ethmoid infundibulum.

“STAY CURIOUS” 8
 In general, there are many classifica�ons for those cells pneuma�zed towards the frontal recess
related to the agger nasi, the ethmoidal bulla, or the orbit. The classifica�on proposed by Wormald
et al. at the Interna�onal Forum of Rhinology in 2016 (31), classifies them according to the structure
to which they are associated: supra-agger, supra-bullous or supra-orbital cells, and if they enter the
frontal sinus, we call them supra fronto-agger, supra fronto-bulla or frontals.

Previously, the Kuhn classifica�on was used, who divided them into four groups:
● Type 1. Single-cell above the agger nasi.
● Type 2. Two or more cells above the agger nasi.
● Type 3. Single-cell within the frontal sinus but occupying less than 50% of the height of the sinus.
● Type 4. Single-cell that occupies more than 50%.

According to our philosophy, it is of vital importance to iden�fy these cells in the pre-surgical CT
scans, what is not important is the classifica�on or name that we give them. This importance lies in
the fact that during surgery we can confuse these cells with the frontal sinus, which would lead to
incomplete surgery.

The frontal sinus is the most variable of the paranasal sinuses. It drains into the frontal recess and is
usually bisected by the interfrontal septum. The frontal bone not only forms the roof of the orbit but
also the roof of the ethmoid labyrinth. It is at this suture between the ethmoid and frontal that the
anterior ethmoid arteries emerge.

“STAY CURIOUS” 9
Before discussing the posterior por�on of the ethmoid, we will discuss the vasculature of the
anatomical area we are reviewing.

The anterior ethmoidal artery is a branch of the ophthalmic artery (branch of the internal caro�d
artery). It begins its course in the orbit, passing between the internal rectus and superior oblique
muscles, before leaving the orbit and emerging on the lateral wall of the nose, through the anterior
ethmoid foramen, to enter the anterior ethmoid complex at the level of the roof of suprabullar
recess. On its way through the ethmoidal roof, it runs in an oblique direc�on from posterolateral to
anteromedial. It can be covered by a thin bone layer or be dehiscent in up to 40% of cases (32). It
then courses medially to the anterior cranial fossa, where it enters through the lateral plate of the
cribriform plate, or at the ar�cula�on of the cribriform plate with the frontal bone, depending on the
depth of the olfactory fossa. See below for the Keros classifica�on.
Once in the cranial fossa, it acquires an anterior direc�on and carves out the anterior ethmoid groove
of variable length (3 to 16mm) on the lateral plate, finally emerging again to the nasal cavity through
the most anterior por�on of the cribriform plate (33). Along its course, it gives off different branches:
an anterior meningeal branch and others that supply the upper por�on of the nasal septum and the
middle turbinate.

The average distance from the frontal recess to the anterior ethmoid artery is 11 mm (6 to 15 mm)
(34). It is important to consider that the trajectory of the anterior ethmoid artery depends on the
degree of pneuma�za�on of the anterior ethmoid, so it should not be taken as an anatomical
reference during the dissec�on.

The posterior ethmoidal artery emerges from the posterior ethmoidal foramen, 12mm posterior to
the anterior ethmoidal artery, in the most superior por�on of the anterior wall of the sphenoid sinus.
In its emergence, it gives two branches, a medial one that nourishes the posterior nasal septum and
a lateral one for the lateral wall of the nose. There is a rule for loca�ng the neurovascular bundles of
the ethmoid known as 24-12-6. This means that from the lacrimal crest (junc�on of the frontal
process of the maxilla with the lacrimal bone), we find 24 mm from the anterior lacrimal crest and
above the level of the frontotemoidal suture, the anterior ethmoid artery, 12 mm behind it we find
the posterior ethmoidal artery and 6 mm further back, the op�c nerve (Figure 3A-B).

“STAY CURIOUS” 10
 AST
SOA

PEA AEA PEA

AEA

IOA

Figure 3A-B: Course of the anterior ethmoid artery. A Intraorbital distribution and its branches. B, Ethmoidal distribution
and its branches. 24-12-6 rule used to identify the anterior ethmoid artery, posterior ethmoid artery, and optical nerve.
AEA, anterior ethmoidal artery; PEA, posterior ethmoidal artery; SOA, supraorbital artery; AST, supratrochlear artery;
IOA, infraorbital artery

Con�nuing with vascular structures of importance, we cannot ignore the sphenopala�ne foramen.

The anatomic limits of the sphenopala�ne foramen are:

● Superior: Body of the sphenoid.
● Anterior: Orbital process of the pala�ne bone. We usually find a projec�on of the pala�ne bone
called the ethmoid crest (or crest for the ethmoid), an important anatomical landmark.
● Posterior: Sphenoid process of the pala�ne bone.
● Inferior: Perpendicular por�on of the pala�ne bone.
● Lateral: Pterygomaxillary fossa.

The sphenopala�ne artery, a terminal branch of the internal maxillary artery (IMA), crosses this
region, accompanied by nasopala�ne nerve branches.

To our knowledge and based on our own dissec�ons, we give the name of the sphenopala�ne artery
to that arterial por�on found in the sphenopala�ne junc�on. To locate the sphenopala�ne artery and
foramen, the posterior (horizontal) inser�on of the middle turbinate serves as a reference.

“STAY CURIOUS” 11
 To facilitate the understanding of the posterior nasal vasculature, we consider 5 terminal branches
of the posterior maxillary artery. Three run intraforaminal (sphenopala�ne foramen) and two are
extraforaminal. The three intraforaminal arteries are the vidian, palatovaginal, and descending
pala�ne arteries. The ‘extraforaminal’ are the posterior nasal artery and the posterolateronasal
artery. The posterior nasal artery generally divides into two branches (up to 3 branches have been
described) that cross the sphenoid rostrum to the nasal septum. The posterolateral nasal artery gives
off a small branch (branch to the fontanelles), a branch to the middle turbinate, and a large branch
that supplies the inferior turbinate as it enters the inferior turbinate where it divides into an
inferolateral and a superomedial branch. (Fig.4)

PEA
AEA AEA
PEA

SPA
SPA
PLNA

ALN
DPA
SLA
GPA

Figure 4: Vasculature of the nasal septum (A) and the lateral nasal wall (B); AEA, anterior ethmoid artery; PEA,
posterior ethmoid artery; SPA, sphenopalatine artery; SLA, superior labial artery; GPA, greater palatine artery;
PLNA: posterolatero-nasal artery; DPA, descending palatine artery; ALN, alar branch of the lateral nasal artery

The maxillary bone is made up of a body and four processes: zygoma�c, frontal, alveolar, and
pala�ne. It ar�culates with the ethmoid, pala�ne, frontal, zygoma�c, lacrimal, inferior turbinate, and
vomer bones, as well as the contralateral maxillary bone (Fig. 5).

“STAY CURIOUS” 12
 The maxillary sinus is in the body of the maxillary bone. It has a pyramidal shape, its apex is where
the zygoma�c process is born and its base is the lateral nasal wall where we find the natural os�um,
where the transi�on from the ver�cal to the horizontal region of the uncinate process occurs. The
maxillary sinus drains as previously men�oned to the lower third of the ethmoid infundibulum.

The roof of the maxillary sinus forms the floor of the orbit through which the infraorbital canal passes,
leading to the infraorbital nerve (branch of the 2nd trigeminal branch), together with the infraorbital
vessels. The infraorbital nerve may run hanging from a mesentery separate from the maxillary roof.
Its path should always be iden�fied on CT to avoid damaging it. Some�mes we find ethmoidal cells
that pneuma�ze within the maxillary sinus, called Haller's cells. We must look for them on CT,
because the infraorbital nerve can run inside them. These cells can also obstruct the drainage os�um
of the maxillary sinus.

Figure 5: Configuration of the nasal lateral wall. A. Maxillary bone. B. Lacrimal bone in blue, palatine bone in pink
and sphenoid bone in yellow. C. The inferior turbinal bone in purple and the ethmoid bone in green with middle
and superior turbinates (CM and CS).

“STAY CURIOUS” 13
 In the medial maxillary wall, there is a wide natural opening called the maxillary hiatus, which is
par�ally occluded by various mucosa-covered bones: the uncinate process, ethmoidal bulla, inferior
turbinate, pala�ne bone, and lacrimal bone. The natural os�um is the only physiological opening of
the maxillary sinus.
As already men�oned, the holes present in the fontanels are considered accessories to the natural
drainage os�um.
The maxillary floor is formed by the pala�ne processes on each side. In adults, it can be found up to
one cen�meter below the nasal floor (29)(35). The blood supply comes from the maxillary artery
through the infraorbital, descending pala�ne, and posterosuperior and anterosuperior alveolar
arteries.

The inferior turbinate is a separate bone that ar�culates with the maxillary and ethmoid bones in a
region known as Webster's triangle; together with the pala�ne bone and the lacrimal bone, it
completes the medial wall of the nasolacrimal duct (36). This bone is irregular because of impressions
from the vasculature of the inferior turbinate.
Below the inferior turbinate we find the inferior meatus, a space limited by the nasal lateral wall and
the inferior turbinate. Here drains the nasolacrimal duct through the Hasner valve.

The lacrimal sac receives drainage from the common canaliculus formed by the inferior and superior
canaliculi. It is in the lacrimal fossa, in the medial por�on of the orbital wall. To be more precise, the
anterior wall of the lacrimal fossa is formed by the frontal process of the upper maxilla and the
posterior wall by the lacrimal bone, thus leaving two lacrimal crests, one anterior and one posterior,
where the superficial and deep ligaments of the maxilla are inserted. inner edge, respec�vely. From
the lower por�on of the lacrimal sac begins the nasolacrimal duct that drains into the inferior meatus,
10 to 15 mm posterior to the head of the inferior turbinate.

The lacrimal bone is a thin bone that is closely related to the uncinate process, the agger nasi, and,
of course, the lacrimal sac. An important anatomical landmark that we look for whenever we perform
a dacryocystorhinostomy (DCR) is the maxillary line (Image 3), formed by the union of the lacrimal
bone with the frontal ramus of the maxilla, 10 to 15 mm anterior to the axilla of the middle turbinate
(37).

“STAY CURIOUS” 14
 Maxillary
line

Image 3: Maxillary line. Important anatomical landmark for the identification of the lacrimal duct and sac.

Returning to our anatomical study of the lateral nasal wall, advancing posteriorly and once the
ethmoid bulla has been resected, we find the basal lamina of the middle turbinate or third lamella, a
structure that divides the anterior from the posterior ethmoidal cells (38). Due to their embryonic
origin, the anterior ethmoidal cells, in addi�on to the frontal and maxillary sinuses, drain to the
middle meatus, while the posterior cells drain to the superior meatus. Usually, there are two to three
posterior ethmoid cells.

The sphenoid sinus (Image 4) is the most posterior of the paranasal sinuses. Its natural os�um opens
into the spheno-ethmoidal recess; we found it superomedial to the tail of the superior turbinate,
about 11 to 13 mm from the choanal frame, or 7 cm from the anterior nasal spine at an angle of 30°
with respect to the horizontal plane of the bony palate.

The natural os�um of the sphenoid must be precisely located to enter the sphenoid sinus safely, since
the internal caro�d artery ascends through its lateral wall and the cavernous sinus is found, and the
op�c nerve runs through its uppermost por�on.

The sphenoid sinus is very inconstant, it results from the pneuma�za�on of the sphenoid body, and
depending on its pneuma�za�on we can use Hamberger's classifica�on and divide it into (39):
● Agenesis: occurs in up to 0.7% of individuals.
● Conchal type: it is a rudimentary pneuma�za�on and represents less than 5% of subjects.
● Presellar type: It does not exceed the anterior wall of the sella turcica, which occurs in
approximately 20% of cases.
● Sellar type: when it exceeds the Turkish chair, which is observed in up to 80% of people.

“STAY CURIOUS” 15
 The maxillary trigeminal branch (V2) and the vidian nerve also cross the lateral wall of the sphenoid
sinus. The internal caro�d artery presents dehiscence in up to 25% of pa�ents (40). However, the
overlying bone thins with age, so caro�d dehiscence is seen in 80% of those older than 85 years. In
the floor of the sinus, we can see the indenta�on of the vidian nerve, which runs through the
pterygoid or vidian canal (Image 5). The greater the pneuma�za�on, the more exposed these
structures will be, especially the caro�d op�c recess, located between the caro�d artery and the
op�c nerve. The roof is formed by the sphenoid plane, and the floor forms the roof of the
nasopharynx.

On CT we must iden�fy superolateral ethmoidal cells, previously called Onodi cells, since both the
internal caro�d artery and the op�c nerve can be found inside.

PS
ON

LOCR
MOCR MOCR
PsCA LOCR
PsCA

ST

PcCA
C PcCa
IS

Image 4: Sphenoid sinus. ON, optic nerve; PS, planum sfenoidale; LOCR, lateral optico-carotid recess; MOCR,
medial optico-carotid recess; PsCA, parasellar internal carotid artery; ST, sella turcica; PcCA; paraclival internal
carotid artery; C, clivus; IS, intersinus septum

“STAY CURIOUS” 16
 When pneuma�za�on passes the trigeminal (V2) and vidian nerves laterally, we call that space the
lateral recess, which can predispose to a type of defect associated with CSF fistula called Sternberg
canal or craniopharyngeal canal fistula (41). (42), generally associated with meningoceles or
meningo-encephaloceles.

The skull base is composed of the frontal, ethmoid, sphenoid, temporal, and occipital bones; It can
be divided into three segments: anterior fossa, middle fossa, and posterior fossa.
The anterior fossa, located above the nasal cavity and orbits, is composed of the frontal and ethmoid
bones, the cribriform plate, and the lesser wings of the sphenoid. Its posterior boundary is the
tubercle of the sella turcica.
The middle fossa is formed by the temporal rock and the body of the sphenoid, where we find the
sella turcica and its greater wings.
The posterior fossa comprises the space from the posterior border of the sella turcica to the posterior
por�on of the occipital bone.

We call the olfactory rhyme (Fig. 6) the region limited superiorly by the cribriform plate, medially by
the highest por�on of the nasal septum, and laterally by the middle and superior turbinates, and it is
in these structures that most of the olfactory neuroepithelium is located. Above the cribriform plate,
in the intracranial portion where the olfactory bulbs are, the olfactory fossa is located, limited
laterally by the lateral plate of the cribriform plate and medially by the crista Galli, which is
pneuma�zed in 13% of the specimens. (43). The greater the depth of the olfactory fossa, the greater
the length of the lateral lamina (which is the thinnest structure of the skull base) and therefore is
more likely to cause CSF leak if the lateral lamina is damaged by surgical manipula�on. of the middle
turbinate.
OB OB ON OB

ST
ST
MT MT Sep
Sep
IT

IT

Figure 6: Location of the olfactory neuroepithelium and its relationship with the olfactory bulb. ST, superior
turbinate; MT, middle turbinate; IT, inferior turbinate; Sep, septum; OB, olfactory bulb; ON, olfactory nerve

“STAY CURIOUS” 17
 II. Endoscopic surgery of the paranasal sinuses

Explanatory videos: www.youtube.com/c/BarcelonaRhinologySchool

“You can know the anatomy and its variants back to front, but if you don't know how to manipulate
the endoscope and the instruments you will get lost in the dark”.
What we want to convey with this phrase is that it is extremely important to get used to various
angled endoscopes and instruments. You must, at all �mes, remain oriented in �me and space, keep
the op�cs clean and well-focused. Once endoscopic management has been perfected, we
recommend being methodical in all approaches, regardless of the type of approach or dissec�on
preferred (anteroposterior, postero-anterior, or combined). This in order to ensure good results,
reduce accidents and, above all, proceed safely during surgery.

Instruments
In addi�on to the 0, 30, 45 or 70 degree lenses, depending on the surgeon's preference, the basic
instruments are:

A. Freer's dissector
B. Seeker
C. Co�le's dissector
D. Sickle knife
E. Straight and angled Blakesley forceps
F. Straight and angled cu�ng forceps (Thru cut)
G. Retrograde forceps (Backbi�ng forceps)
H. Kerrison forceps
I. Straight and curved suc�on.

Microdebriders, mushroom forceps, powered equipment (burrs, piezo, and debriders), equipment
with different angles to work in the frontal recess and sinus can also be used.

“STAY CURIOUS” 18
 Arrangement in the operating room
The surgeon should stand to the right of the pa�ent if he is right-handed or to the le� if he is le�-
handed, regarding the ladder the idea is to be as comfortable as possible in order to work properly
as a team and for long hours. You can work si�ng or standing. It is important to be comfortable,
upright and with the screen at eye level to avoid uncomfortable cervical postures. The pa�ent's head
should be slightly angled toward the surgeon and elevated 20° to 30° in the semi-Fowler posi�on to
reduce intracranial pressure and thus reduce bleeding.

The superior border of the inferior turbinate is our ini�al reference. Once the drainage os�um of the
maxillary antrum has been enlarged, the floor of the orbit and the axilla of the middle turbinate will
be our main references.

The endoscope rests on the nasal valve to give stability to the image, always introducing the material
below the endoscope. When we work looking towards the nasal a�c, we can rest the scope on the
floor of the nose and introduce the instruments above it.

Pre-surgical endoscopic examination

Adequate visualiza�on of the anatomical structures is essen�al to successfully and safely perform
endoscopic sinus surgery on the pa�ent. For this, first use topical vasoconstric�on (the mixture you
like). Then fracture and lateraliza�on of the inferior turbinate’s is helpful if the space is not enough,
if the situa�on warrants it a septoplasty can be performed (Image 6). A bad visualiza�on can be the
cause of accidents.
Once this is done, we proceed to an endoscopic reconnaissance, although we already have a previous
mental map, since we have already performed an endoscopy in the office and have also thoroughly
reviewed the CT.
We recommend inten�onally looking for the following structures:
● Nasal septum
● Maxillary line
● Inferior and middle turbinates (from head to tails)
● Uncinate process
● Ethmoidal bulla
● Olfactory cle�
● Choanal framework

“STAY CURIOUS” 19
 SS S MT

IT
IT

Image 6: Pre-surgical endoscopic examination with visualisation of: S, septum; MT, middle turbinate; IT, inferior
turbinate; SS, septal spur

Uncinectomy
The main goal of uncinectomy is to enlarge the drainage site of the os�omeatal complex and allow
access to the maxillary sinus. This is the ini�al step of our dissec�on.
The middle turbinate should be gently medialized to enlarge the middle meatus, subsequently
loca�ng the uncinate process, the hiatus semilunaris and the ethmoid bulla.
An uncinectomy is then performed. There are several techniques to perform it, in all of them the
uncinate process must be located with the palpator and gently pulled to medialize it. We will describe
only two techniques:
1. Retrograde: With the backbite forceps, a window is created at the junc�on of the middle
third with the superior third of the uncinate process. Two or three cuts are usually required,
and then the remnant can be removed with an angled Blakesley forceps or a microdebrider,
avoiding tearing the mucosa.
2. Anterograde: Another way to remove the uncinate process is to cut it through its en�re
thickness from top to bo�om with the sickle knife or the co�le dissector (Image 7). The upper
and lower ends are separated with a Blakesley clamp.

Injuring the lamina papyracea should always be avoided. To do this, begin the dissec�on in the middle
third of the uncinate or in the transi�on between its ver�cal and horizontal por�ons. It should also
be men�oned that the uncinate extends all the ways to the pala�ne bone, so it is important to
con�nue its resec�on un�l that structure, generally with straight cu�ng forceps.

“STAY CURIOUS” 20
 We will know that we have completed the uncinectomy when we can see the complete os�um of the
maxillary sinus, which we dis�nguish by being oval and having a sagi�al orienta�on, unlike an
accessory os�um which will be round and slightly rotated.
One of the main causes of failure of endoscopic antrostomy is incomplete removal of the uncinate
process.

Image 7: Sickle knife uncinectomy (0º endoscopy). CM,

middle turbinate; MM, middle meatus; U, Uncinate process;
OM, natural ostium of maxillary sinus

Middle meatal antrostomy

To create a func�onal antrostomy, we must unite the natural drainage os�um of the maxillary sinus
and the posterior fontanel with the straight cu�ng forceps. If the natural os�um is not located, an
alterna�ve to enter the maxillary sinus is to look for the posterior fontanel, a structure located above
the posterior third of the inferior turbinate, which ensures the surgeon safer access to the maxillary
sinus, to enlarge it anteriorly.

Once the os�um of the maxillary sinus has been enlarged, we arrive at one of the main anatomical
landmarks, the union of the lamina papyracea with the edge of the orbit. This reference not only
keeps us oriented, but also marks the lateral limit of our dissec�on, which is the lamina papyracea,
and delimits the height of the sphenoid sinus backwards.
If the pathology is limited to the anterior por�on of the os�omeatal complex, uncinectomy and
antrostomy will suffice to resolve the disease.

“STAY CURIOUS” 21
 Anterior ethmoidectomy

There are usually four to five ethmoidal cells on each side. The anterior ethmoidal cells will be found
medial to the lamina papyracea and above our upper limit of the antrostomy (lower edge of the
orbit). The ethmoidal bulla is opened in its inferior-medial por�on, away from the skull base and the
lamina papyracea. We start by removing the anterior and inferior wall of the bulla. Remember that
the lateral limit of our dissec�on is the lamina papyracea, and the posterior wall can be formed by
the basal lamella of the middle turbinate or be separated from it by the retrobullar space, and the
roof can be the skull base or the suprabullar space (Image 8). A maneuver that allows us to work
safely is to gently press the orbit and endoscopically observe the movement of the lamina papyracea
to avoid injuring it.

Image 8. Resection of the ethmoidal bulla (0º endoscopy). BE, ethmoidal bulla; CM, middle turbinate; SM, maxillary sinus.

Posterior ethmoidectomy

The next step is the posterior ethmoidectomy. To start, we first locate the basal lamella of the middle
turbinate and enter the posterior ethmoid through its inferomedial por�on. The dissec�on begins in
the lower cells, in a posterior direc�on, and con�nues with the upper cells un�l reaching the anterior
wall of the sphenoid sinus. The lateral limit of the dissec�on is the lamina papyracea, and the medial
limit is the middle and superior turbinates. At this point, the superior meatus is iden�fied, which can
also approach from the olfactory corridor, which is the site where the posterior ethmoid cells drain.

“STAY CURIOUS” 22
 Sphenodotomy
The choanal framework, the superior turbinate, and the anterior nasal spine are key landmarks for
reaching the sphenoid sinus. Its os�um is located between 12 and 15 mm from the upper border of
the choanal frame, superomedial to the tail of the superior turbinate, or 7 cm from the anterior nasal
spine, at an angle of 30º with respect to the horizontal plane of the bony palate.

Transnasal sphenidotomy can be performed by entering the sphenoid sinus through the olfactory
corridor and through the sphenoethmoidal recess. The sphenoid can also be approached
transethmoidally a�er performing the anterior and posterior ethmoidectomy. We always enter the
sphenoid sinus in the medial por�on of the natural os�um, away from essen�al structures such as
the internal caro�d artery or the op�c nerve, located in the most lateral por�on. Once the os�um
has been widened inferomedially, it can be widened laterally as far as possible. The instruments used
should be seen through transparency to ensure we are not invading other structures. If visualiza�on
is inadequate, the tail of the superior turbinate can be resected.

If we draw a horizontal line with the inferior border of the orbit as a reference, we will see that much
of the sphenoid sinus lies below this line. It is essen�al to keep this in mind since the tendency is to
go in a superior direc�on and confuse the sphenoid sinus with an Onodi cell.

Frontal recess and sinus

The objec�ve of frontal sinus surgery is to remove the cells in the lower part of the frontal recess
(Draf I) or remove all the anterior ethmoidal cells (Draf IIa). There are more aggressive procedures
since that require removing the ver�cal lamina of the middle turbinate (Draf IIb) and even the nasal
septum and the septum of the frontal sinus (Draf III).

Pneuma�za�on of the frontal sinus is highly variable, and it is aplas�c in 10% of cases. We know that
the frontal sinus drainage pathway is shaped like a bo�leneck, and we call it frontal recess (Image 9).
It is limited forward by the "frontal beak" and the agger nasi; posteriorly by the posterior wall of the
sinus and the ethmoidal bulla suprabullar space, laterally by the lamina papyracea and medially by
the ver�cal lamina of the middle turbinate.

“STAY CURIOUS” 23
 Image 9. Frontal recess and sinus (45º endoscopy).
A. Structures that delimit the frontal recess.
BV FS
B. Frontal sinus. MT, middle turbinate; LP, Lamina
LP papyracea; BV, vertical bar; *, via frontal sinus
MT
drainage; FS, frontal sinus; AEA, anterior
ethmoidal artery.
AEA

The frontal beak can have a thickness of 6 to 11mm and a height of 10mm. The frontal drainage
pathways space has typically 12 to 14mm. For frontal sinus approaches, all three CT planes must be
reviewed. The best technique to approach the frontal is to remove the cells that surround it, one by
one.
One way to classify the extension of the dissec�on to the frontal recess and sinus is the classifica�on
proposed by Draf. There are new classifica�ons in this regard, however, for academic terms, we will
explain this widely used classifica�on.

Draf I
A Draf I means ‘expanding the frontal recess’. Therefore, a complete uncinectomy must be
performed. A�erwards, the medial wall of the agger nasi is removed. Some�mes the anterior wall of
the ethmoid bulla can also be removed to enlarge the frontal recess.

Draf IIa
A Draf IIa requires the removal of all the anterior ethmoidal cells to form a corridor between the
ver�cal lamina of the middle turbinate and the lamina papyracea. Some authors refer to this
procedure as frontal sinusotomy. The upper por�on of the uncinate process should be removed with
a Co�le dissector or cure�es. The agger nasi acquires crucial importance in this technique since its
medial wall fused with the most superior por�on of the uncinate process is called the ver�cal bar and
is removed in this procedure since it is usually the lateral limit of the frontal sinus drainage. The order
of cell removal is as follows: the walls of the agger nasi are removed, always downwards and
forwards. When removing the agger nasi, ensure that there are no cells above it; if there are, they
are removed with the same technique. Cells are removed un�l the ver�cal lamina of the middle
turbinate and the lamina papyracea are visualized. A�empt should be made to preserve the mucosa
to prevent stenosis.

“STAY CURIOUS” 24
 Draf IIb
This procedure extends the approach to the medial border to the septum, resec�ng the lamina of
the middle turbinates. Some�mes it is necessary to drill to widen the frontal sinus floor which
thickens as one approaches the septum. Some�mes it is required to thin the lacrimal bone and the
ascending (Frontal) ramus of the maxilla.

Draf III
This procedure is broadly a bilateral Draf IIb with resec�on of the interfrontal septum. It also includes
the removal of the upper por�on of the nasal septum. There are 2 ways to do it: from lateral to medial
or medial to lateral, which is a safer way to do it ini�ally, since we have the posterior wall of the
frontal sinus exposed from the beginning.

Figure 7: Approach to the frontal sinus: A. Draf I; B Draf IIa; C Draf IIb; D Draf III

“STAY CURIOUS” 25
 Bibliography
1. Anatomical Terminology [Internet]. Copyright © 2018 Visión Médica Virtual. All right reserved.
2. Verger-Kuhnke AB, Reuter MA, Beccaria ML. La biografia de Philipp Bozzini (1773-1809) un
idealista de la endoscopia. Actas Urol Esp. 2007;
3. Shah J. Endoscopy through the ages. BJU Int. 2002;
4. Mikulicz J. Zur opera�ven Behandlung des Empyems der Highmorshöhle. Arch klin Chir.
1887;34:626–34.
5. GW C. Diseases of the accessory sinuses of the nose and an improved method of treatment of
suppura�on of the maxillary antrum. New J Med J. 1893;58:526–528.
6. H L. Une nouvelle methode operatoire pur la cure radicle et l’empyeme chronique du sinus
maxillazire. Arch Int Laryngol d’otologie Rhinol. 1897;10:273–85.
7. L, Grünwald, Munich, Leipzig JFL. Die Lehre von den Naseneiterungen mit besonderer
Rücksicht auf die Erkrankungen des Sieb- und Keilbeins und deren chirurgische Behandlung.
1893;2nd ed. En.
8. G K. Die Krankheiten der Kieferhöhle in Heymann P. Handb der Laryngol und Rhinol III Bd, 2
Wien Häl�e Hölder. 1898;III:1004–96.
9. M H. Externe oder interne Opera�on der Nebenhöhleneiterungen. Berl Klin Wocherschr.
1906;43:1404–7.
10. H L. Some historical aspects of the surgical treatment of the infected maxillary sinus. Rhinol ,
Cited by Weir N Otolaryngol an Illus Hist London Butterworts&Co Ltd, 1990. 1897;
11. Mosher HP. LXXII. Symposium on the Ethmoid:The Surgical Anatomy of the Ethmoidal
Labyrinth. Ann Otol Rhinol Laryngol. 1929;
12. Messerklinger W. On the drainage of the normal frontal sinus of man. Acta Otolaryngol. 1967;
13. Stammberger H. [Personal endoscopic opera�ve technic for the lateral nasal wall--an
endoscopic surgery concept in the treatment of inflammatory diseases of the paranasal
sinuses]. Laryngol Rhinol Otol (Stu�g). 1985;
14. Stammberger H. History of rhinology: anatomy of the paranasal sinuses. Rhinology. 1989;
15. Stammberger H, Posawetz W. Func�onal endoscopic sinus surgery - Concept, indica�ons and
results of the Messerklinger technique. Eur Arch Oto-Rhino-Laryngology. 1990;
16. DW K. Func�onal endoscopic sinus surgery: Technique. Arch Otolaryngol. 1985;
17. Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Func�onal Endoscopic Sinus Surgery:
Theory and Diagnos�c Evalua�on. Arch Otolaryngol. 1985;

“STAY CURIOUS” 26