You are on page 1of 104

CT PNS

By
Dr.K.PRASANNA
Radiology Resident
RMMCH

CONTENTS
NOSE AND NASAL FOSSA
PARA NASAL SINUSES
OSTEOMEATAL COMPLEX
ANATOMICAL VARIATIONS
IMAGING MODALITIES
CT PROCEDURE & SECTIONS
CONCLUSION

NOSE AND NASAL


FOSSA

NOSE AND THE NASAL FOSSA

Bony part & cartilaginous part covered by


muscle & skin

Cartilaginous part upper & lower lateral


cartilages, lesser alar cartilages & septal
cartilage

Nasal skin

Internal nose divided into the


Right and left by the nasal
septum

NOSE AND THE NASAL FOSSA

NASAL CAVITY PROPER

Roof Nasal bone,


sphenoid & ethmoid
bone

Floor - Palatine
process of the maxilla
& Palatine bone

Medial wall

Lateral wall

Medial Wall - Nasal


Seperates the nasalSeptum
cavity into
two.
Columellar septum
Membranous septum
Septum proper
Perpendicular plate of ethmoid
Vomer
Septal cartilage
Minor contributions crest of
nasal bone, nasal spine of
frontal bone, rostrum of
sphenoid, crest of maxilla &
palatine bone

Blood supply

Mainly by both Internal &


external carotid, both on
the septum & lateral walls

Anterior & posterior


ethmoidal artery

Sphenopalatine artery

Septal branch of greater


palatine

Septal branch of superior


labial artery

LATERAL WALL

Formed by bony, soft tissue


& cartilage

Bony
Ethmoid infundibulum &

uncinate
Perpendicular plate of

palatine bone
Medial plate of pterygoid

process of sphenoid bone


Medial surfaces of lacrimal

bones and maxillae


Inferior conchae

Cartilage In
external nose, the
lateral wall of cavity
is supported by
cartilage (lateral
process of septal
cartilage & major,
minor alar cartilage)

LATERAL WALL

Marked by three bony projections, they extend


medially across the nasal cavity separating the nasal
cavity into for air channels the turbinates or conchae

Superior ,middle & inferior tubinates or conchae. The


conchae do not extend forwards into the external nose

The air space below and lateral to each turbinate is


called as meatus

Superior, middle & inferior meatus & sphenoethmoidal


recess

Middle Meatus much significant

LATERAL WALL
Superior Meatus Limited only to posterior

one third of lateral wall. Posterior ethmoidal sinus


opens into it.

Middle Meatus
Inferior Meatus Runs along the whole length
of lateral wall. Nasolacrimal duct opens in its
anterior part. Largest of all meatus

Sphenoethmoidal recess Above the

superior turbinate. It receives the opening of


sphenoid sinus

MIDDLE MEATUS
Bulla ethmoidalis Bulge
produced by the middle
ethmoidal cells

Uncinate process Superior


extension of lateral nasal wall
(medial wall of maxillary
sinus). Medial and inferior to
bulla ethmoidalis

MIDDLE MEATUS

Infundibulum Air passage


connecting the maxillary
sinus ostium to middle
meatus

Hiatus Semilunaris Gap


between the uncinate
process and bulla
ethmoidalis. Medially it
communicates with middle
meatus. Laterally & inf it
communicates with
infundibulum

MIDDLE MEATUS

Frontal sinus Opens


into the anterior part of
hiatus semilunaris

Maxillary sinus Opens


into the posterior part
of hiatus semilunaris

Anterior and middle


ethmoidal cells Opens
into the upper margin
bulla ethmoidalis

ETHMOID BONE

SINUSES

SINUSES

Air containing cavity in certain skull bones

Develop as a diverticula/outpouching from the


lat wall of nose & extend into Maxilla, Ethmoid,
sphenoid and frontal bones

Four sinuses Maxillary, Frontal, Ethmoid (Ant


& Post) & Sphenoid

Some sinuses are well developed &


asymmetrical

Sinuses

Each sinuses have


orifices that open
into the meatus,
covered by
turbinates

Sinuses
Clinically
- two
groups

Anterior
Frontal,
Maxillary,
Ant.Ethmoid
al

Posterior
Post
Ethmoidal,
Sphenoid

Middle
meatus
Sup. Meatus
&
sphenoethmo
idal recess

SINUSES

Significance
Lighten the skull & facial bones
Contributes to vocal resonance
Collapsible framework that helps the brain to protect

from blunt trauma

EPITHELIUM

They are lined by mucosa similar to that of the nasal


cavity pseudo stratified ciliated columnar epithelium

Epithelium contains Mucinous & serous glands

Mucoperiosteum

Physiology
Approx 1.5 - 2
lit/day
Mucous produced
from the glands are
removed by two
mechanisms
Ciliary action
Slime trails

Sinuses Status at
First
Reache
Birth
Radiologi s Adult
cal
size by
evidence
Maxillary
sinus

Present at
birth

4-5 months
after birth

15 years

Ethmoid
sinus

Present at
birth

1 year

12 years

Sphenoid
sinus

Not Present

4 years

15 years
adult age

Frontal
Sinus

Not Present

6 years

Size
increases
until teens

Maxillary Sinus - (Antrum of


Highmore )

Largest paranasal sinus

Pyramidal in shape

Base - towards lateral wall of nose

Apex towards zygomatic process of maxilla

Maxillary Sinus - (Antrum of


Highmore )

Present at birth as a rudimentary sinus

First radiological evidence is at 4-5 months


after birth

Reaches adult size by 15 years

On average,
it has capacity
of 14.75 ml (14-15)

Maxillary Sinus - (Antrum of


Highmore )
Ant wall
Post wall
Med wall
Roof
Floor

Facial surface of maxilla


and cheek
Infra temporal &
pterygopalatine fossa
Middle & inferior meatuses
(this wall is thin &
membranous)
Floor of orbits
Alveolar part of maxilla

Maxillary Sinus - (Antrum of


Highmore )

Maxillary Sinus - (Antrum of


Highmore )

DRAINAGE OSTIUM

Seen high up in the medial wall


Does not open directly into the nasal cavity, but

opens into post. part of ethmoidal infundibulum, via


hiatus semilunaris into middle meatus.
The infundibulum is the air passage that connects

the maxillary sinus ostium to the middle meatus.


Unfavourable for natural sinus drinage
Accessory ostium 30 % cases

Maxillary Sinus - (Antrum of


Highmore )

Arterial supply Maxillary


artery, infra orbital, facial
& greater palatine

Venous supply anteriorly


by facial vein & post.by
maxillary vein

Nerve supply infra orbital,


anterior, middle & posterior
superior alveolar nerves

Lymph nodes cervical nodes


& submandibular nodes

Maxillary Sinus - (Antrum of


Highmore )

FRONTAL SINUS

Situated between the outer & inner table of frontal


bone

Funnel shaped

Two sinuses on either side

Asymmetrical

Intervening bony septum which may be thin or


deficiency

Frontal Sinus

Not present at birth

First radiological evidence is at 6 years

Reaches adult size after puberty

The natural frontal sinus ostium is usually located in the


posteromedial floor of the sinus (most dependent part).

It opens into the middle meatus

The ethmoidal infundibulum can act as a channel for


carrying the secretions (and infection) from the frontal sinus
to anterior ethmoid cells and the maxillary sinus or vice
versa.

Frontal Sinus

They develop from a variable site, their drainage


will be either via an ostium into the frontal
recess or via a nasofrontal duct into the anterior
infundibulum. The opening or duct can be
distorted by expansion of adjacent ethmoid cells

Boundaries

Ant wall Skin over the forehead

Post wall - Meninges & the frontal lobe of brain

Inferior wall - orbit & its contents

Frontal Sinus

FRONTAL RECESS

The frontal recess is an


hourglass like narrowing
between the frontal
sinus and the anterior
middle meatus through
which the frontal sinus
drains. It is not a tubular
structure, as the term
nasofrontal duct might
imply, and therefore the

The frontal recesses


are the narrowest
anterior air channels
and are common sites
of inflammation. Their
obstruction
subsequently results in
loss of ventilation and
mucociliary clearance
of the frontal sinus

AGGER NASI CELL

Anterior, lateral, and inferior to the frontal


recess is the agger nasi cell. It is aerated and
represents the most anterior ethmoid air cell,
usually lying deep to the lacrimal bone.

It usually borders the primary ostium or floor


of the frontal sinus, and thus its size may
directly influence the patency of the frontal
recess and the anterior middle meatus.

Frontal Sinus

The frontal sinus can pneumatize both the


vertical and the horizontal (orbital) plates of
the frontal bone. The deepest area of the
vertical portion of the sinus is near the midline
at the level of the supraorbital ridge, and the
medial sinus floor and the caudal anterior sinus
wall are thinnest in this area. As a result, the
sinus is best approached for a trephination at
this level

Frontal Sinus

There is a rich sinus venous plexus (Breschets


canals) that communicates with both the
diploic veins and the dural spaces.

Arterial supply supra orbital & supra


trochlear

Venous supply superior opthalmic vein

Lymph Submandibular lymph node

Sensory innervation supra orbital & supra


trochlear

Sphenoid sinus

Occupies the body of


sphenoid

Right & left, seperated by a


thin strip of bony septum
(like frontal sinus)

Ostium opens into spheno


ethmoidal recess

Relations of the sinus are


very important, esp during
the surgical approach of

Sphenoid sinus

Sphenoid sinus

Relations

Anterior part
Roof olfactory tract, optic chiasma

& frontal lobe


Lateral optic nerve, internal

carotid artery & maxillary nerve

Posterior part
Roof Pituitary gland in sella turcica
Lateral Cavernous sinus,ICA &

Cranial nerves III, IV, VI & all


divisions of V

Sphenoid sinus

Thin strips of bone separate the


sphenoidal sinuses from the
nasal cavities below and
hypophyseal fossa above

The pituitary gland can be


surgically approached through
the roof of the nasal cavities by
passing first through the
anteroinferior aspect of the
sphenoid bone and into the
sphenoidal sinuses and then

ETHMOID SINUS

Thin walled air cavities in the lateral masses of


the ethmoid bone

Varies from 3 18

Occupy the space between the upper third of the


lateral nasal wall and the medial wall of orbit

Clinically divided into anterior ethmoidal air cells


& posterior ethmoidal air cells, by basal lamella
(lateral attachment of middle turbinate to
lamina papyracea)

ETHMOID SINUS

ETHMOID SINUS

DRAINAGE:

Anterior - a recess of hiatus


semilunaris & middle meatus
via ehmoid bulla
Post- sup.meatus &
spenethmoidal recess.

Present at birth

Reaches adult size by 12 years

First radiological evidence seen


at 1 year

ETHMOID SINUS
Relations

Roof formed by the anterior cranial fossa

Lateral wall - orbit

Medial wall nasal cavity

Thin paper like bony part of the ethmoid separating


the air cells from the orbit, called lamina
papyracea, can be easily destroyed leading to
spread of ethmoidal infections into the orbit

Optic nerve forms a close relationship with the


posterior ethmoidal cells & is at risk during

OSTEOMEATAL
COMPLEX

OSTEO MEATAL
COMPLEX

The osteomeatal complex is the key anatomic


area addressed by endoscopic sinus surgeons.
Blockage of the osteomeatal complex prevents
effective mucociliary clearance, thus leading to
a stagnation of secretions and therefore leading
to recurrent or chronic sinusitis.

OSTEO MEATAL
COMPLEX

The OMC is bounded


medially by the middle

turbinate,
posteriorly and

superiorly by the basal


lamella, and
laterally by the lamina

papyracea.
Inferiorly and anteriorly

the OMC is open.

This anatomic region


therefore includes
Maxillary sinus ostium

ethmoid bulla

frontal recess
uncinate process

infundibulum

hiatus semilunaris
middle meatus.

OSTEO MEATAL
COMPLEX

ANATOMICAL
VARIANTS

Variations of Middle
turbinate
Paradoxic

Curvature

Normally, the convexity of the middle


turbinate bone is directed medially,
toward the nasal septum.

When paradoxically curved, the


convexity of the bone is directed
laterally toward the lateral sinus wall.

The inferior edge of the middle turbinate


may assume various shapes, which may
narrow and/or obstruct the nasal cavity,
infundibulum, and middle meatus.

Variations of Middle
turbinate
Concha Bullosa

It

is an aerated turbinate, most often the

middle turbinate.
Less

frequently, superior & inferior

turbinate aeration can occur.


When

the pneumatization involves the

bulbous segment of the middle turbinate,


the term concha bullosa applies.
If

only the attachment portion of the

middle turbinate is pneumatized, and the


pneumatization does not extend into the
bulbous segment, it is known as a lamellar
concha.

Variations of Middle
turbinate

Other Variations

Additional variations of the middle turbinate can occur,


including medial & lateral displacement, lateral
bending, L shape, and sagittal transverse clefts

Medial displacement due to other middle meatal


structures (i.e., polypoid disease, pneumatized uncinate
process) encroaching upon the middle turbinate.

Lateral displacement - due to the compression of the


turbinate toward the lateral nasal wall by a septal spur
or septal deviation.

Nasal septal deviation

The nasal septum


deviation may compress
the middle turbinate
laterally, narrowing the
middle meatus and the
presence of associated
bony spurs may further
compromise the OMU.

Obstruction, secondary
inflammation, swollen
membranes, and

VARIATIONS OF UNCINATE
PROCESS

DEVIATION

The course of the free edge of the uncinate


process may either extend slightly obliquely
toward the nasal septum, with the free edge
surrounding the inferoanterior surface of the
ethmoid bulla, or it extends more medially to
the medial surface of the ethmoid bulla. If the
free edge of the uncinate is deviated in a more
lateral direction, it may cause narrowing or
obstruction of the hiatus semilunaris and

Attachment

Attachment to the lamina papyracea, the lateral


surface of the middle turbinate, or the fovea
ethmoidalis in the floor of the anterior cranial fossa
may occur.

If the uncinate process attaches to the ethmoidal


roof or middle turbinate, during uncinatectomy,
traction could inadvertently damage the ethmoid
roof and result in CSF rhinorrhea or other
intracranial complications.

Sometimes the free


edge of the uncinate
process adheres to
the orbital floor, or
inferior aspect of the
lamina papyracea.
This is referred to as
an atelectatic
uncinate process

Pneumatization

The pneumatization of the


uncinate process is believed
to be due to extension of the
agger nasi cell within the
anterosuperior portion of the
uncinate process.

Functionally, the pneumatized


uncinate process resembles a
concha bullosa or an enlarged
ethmoid bulla.

Infraorbital Ethmoid Cells


(Hallers Cells)

Infraorbital ethmoid cells


are pneumatized ethmoid
air cells that project
along the medial roof of
the maxillary sinus and
the most inferior portion
of the lamina papyracea,
below the ethmoid bulla
and lateral to the
uncinate process

Onodi Cells

Two definitions of Onodi cells.


The first defines them as the most
posterior ethmoid cells, being
superolateral to the sphenoid sinus
and closely associated with the optic
nerve.

Another, more general description


defines Onodi cells as posterior
ethmoid cells extending into the
sphenoid bone, situated either
adjacent to or impinging upon the
optic nerve

Ethmoid Bulla Variations

Its appearance varies considerably, based on


the extent of pneumatization.

Extensive pneumatization may obstruct the


ostiomeatal complex.

Elongated ethmoid bullae are usually in a


superior to inferior direction rather than in an
anterior to posterior direction.

So, Relatively unlikely to obstruct the


ostiomeatal complex.

Extensive Pneumatization of the Sphenoid


Sinus

Encountered rarely

extends into the


lesser wing and the
anterior and
posterior clinoid
processes

Can lead to
distortion of optic
cannal configuration

Medial Deviation or Dehiscence of the


Lamina Papyracea

May be either congenital


or the result of prior
facial trauma.

It occur most often at the


site of the insertion of the
basal lamella into the
lamina papyracea, thus
rendering this portion of
the lamina papyracea
most delicate

Orbit at risk

Aerated Crista Galli

When aeration of the normally bony crista galli


occurs the aerated cells may communicate with
the frontal recess, and obstruction of this
ostium.

To avoid unnecessary surgical extension into


the anterior cranial vault, it is important to
recognize an aerated crista galli and
differentiate it from an ethmoid air cell.

Posterior Nasal Septal


Air Cell

Air cells are commonly found within the


posterosuperior portion of the nasal septum
and, when present, communicate with the
sphenoid sinus.

As a result, any inflammatory disease that


occurs within the paranasal sinuses may also
affect these cells

Asymmetry in Ethmoid Roof


Height

It is important to note any asymmetry in


the height of the ethmoid roof.

Intracranial penetration during surgery is


more likely to occur on the side where the
position of the roof is lower

IMAGING
MODALITIES

X RAY

CT

MRI

X ray Waters view & caldwell view

Ct gold standard. Coronal & axial sections

MRI is predominantly used for pre and post


operative management of naso sinus malignancy

The chief disadvantage of MRI is its inability to


show the bony details of the sinuses, as both air
and bone give no signal

CT PROCEDURE &
SECTIONS

CT PROCEDURE &
SECTIONS

CT is currently the modality of choice in the


evaluation of the paranasal sinuses and adjacent
structures.

Its ability to optimally display bone, soft tissue, and


air provides an accurate depiction of both the
anatomy and the extent of disease in and around
the paranasal sinuses.

In contrast to standard radiographs, CT clearly


shows the fine bony anatomy of the osteomeatal
channels.

CT PROCEDURE &
SECTIONS

There are few pre requisites in few


situations
a course of adequate medical therapy to eliminate

or diminish reversible mucosal inflammation.


pretreatment with a sympathomimetic nasal spray

15 minutes prior to scanning in order to reduce


nasal congestion (mucosal edema) and thus
improve the display of the fine bony architecture
and any irreversible mucosal disease

CT PROCEDURE &
SECTIONS

Coronal & axial views

The coronal plane best shows the ostiomeatal


unit (OMU), shows the relationship of the brain
to the ethmoid roof.

Coronal plane should be the primary imaging


orientation for evaluation of the sinonasal tract
in all patients with inflammatory sinus disease
who are endoscopic surgical candidates

Coronal section procedure


Prone with chin
hyperextended

Gantry anglutaionperpendicular to hard palate

Section thickness-3mm
contigous

Table increment- 3-4


mmeach step

Kvp-125

Mas-80

Hanging head technique

Coronal section procedure

SCAN LIMITS :

From the ant


margin of frontal
sinus to post
margin of sphenoid
sinus

Coronal section procedure

HEAD HANGING METHOD

Performed in the prone


position, so that any
remaining sinus secretions
do not obscure the OMU

In patients who cannot


tolerate prone positioning
(children, patients of
advanced age, etc.), the
hanging head technique

In this technique, the patient is


placed in the supine position and
the neck is maximally extended.

A pillow placed under the patients


shoulders facilitates positioning.

The CT gantry is then angled to be


perpendicular to the hard palate.

It is not always possible to obtain


true direct coronal images with
this technique

Axial image

Axial images complement the coronal study,


particularly when there is severe disease
(opacification) of any of the paranasal sinuses
and surgical treatment is contemplated.

The axial studies provide the best CT evaluation


of the anterior and posterior sinus walls

Axial images are particularly important in


visualizing the frontoethmoid junction and the
sphenoethmoid recess.

CT axial section of
PNS - image

Axial image

Whenever there is total opacification of the


frontal, maxillary, or sphenoid sinuses, a
complete axial and coronal CT examination
should be performed.

And also, if the patient has a suspected


neoplasm, a complete axial and coronal
examination need to be performed to provide the
most detailed analysis of the sinonasal cavities
and the adjacent skull base

IMAGING PLANE :
REIDSS LINE runs b/w infraorbital margin
(IOM line)
& EAM. (parallel - axial)
ALEXANDERS LINE perpendicular to reids
line. (perpendicular - coronal)

Contrast in CT PNS

Contrast is not required for all cases of CT


paranasal sinus

Used in cases such as vascular lesion,


malignancy, mass extending intra cranially,
acute infections

CHECK LIST
AGE OF THE PATIENT

THANK YOU

NEXT
PRESENTATION

X RAY SHOULDER JOINT


BY
DR.V.PRIYA
ON SATURDAY