Anatomy and relevant

anatomical variants in nasal

and paranasal sinuses CT scan
CERTIFICATE
OF
MERIT
RSNA 2003

P. Loubeyre1 MD & J.S Lacroix2 MD, PhD

1 Radiology Department,
2 Rhinology-Olfactology Unit

Hôpitaux Universitaires de Genève

CH- 1211 Genève 14
Switzerland
 Sinusitis – Imaging technique (3-10) Anatomic variants
Septal deviation (dia 40)
Anatomy Septal spurs (dia 41)
Paranasal sinuses (dia 11-12) Middle turbinate (dia 42-44)
Ostiomeatal unit (dia 13-16) Superior turbinate (dia 45)
Uncinate process (dia 17-19) Uncinate process (dia 46)
Ethmoid bulla (dia 20-22) Frontal bulla cell (dia 47)
Middle turbinate (dia 23,24) Frontal sinus extension (dia 48)
Ethmoid infundibulum (dia 25) Agger nasi cell (dia 49)
Frontal recess (dia 26-28) Maxillary sinus recesses (dia 50)
Sphenoethmoidal recess (dia 29,30) Sphenoid sinus recesses (dia 51-53)
Posterior nasal fontanel (dia 31) Intersinus sphenoid septation (dia 54)
Posterior choana (dia 32)
Nasal septum (dia 33) Surgical risks
Nasolacrymal duct (dia 34) Vulnerability of the carotid canal (dia 55-57)
Anterior skull base (dia 35-38) Vulnerability of the optic nerve (dia 58-61)
Vulnerability of the orbit (dia 62-65)
Vulnerability of the nasolacrymal duct (dia 66)
Vulnerability of anterior skull base (dia 67)

Some articles to read

Mafee MF. Endoscopic sinus surgery: role of the radiologist. AJNR1991;157:855-60
Earwaker J. Anatomic variants in sinonasal CT. Radiographics 1993;13:381-415
Rao VM, El-Noueam KI. Sinonasal imaging. Radiologic Clinics of North America 1998;36(5):921-39
Zeifer B. Update on sinonasal imaging. Neuroimaging Clinics of North America 1998;8(3):607-30
 Mucociliary clearance
impairment

Mucous accumulation
increases the risk of infection or
chronic inflammation
 Mucociliary transport : anatomy of the drainage pathway of
the paranasal sinuses

Ostio-meatal
complex
 Obstruction
Normal
mucociliary
clearance

or

Normal mucosal
thickening during Contact of two opposing Mucous accumulation
nasal cycle mucosal surfaces
increases risk of infection
(ex: anatomic variants)
 Chronic rhinosinusitis unresponsive to
medical management
The aim of nasal and paranasal sinuses imaging is to provide a
surgical road map delineating the anatomy, defining the obstructive
lesions, and noting the anatomical factors that may predispose
impaired mucociliary clearance and per operative complications

CT High spatial resolution

Minute bony details and adjacent soft tissue
structures

Pre-operative investigation for

patients undergoing
endoscopic sinus surgery
Rhinosinusitis is a medical
diagnosis,
not a radiologic diagnosis
 Supine position Confortable position

console

Coronal, sagittal or oblique reformations

Real time image-guided anatomic localization
1-mm-thick overlapping during endoscopic surgery
axial slices
 Medical treatment should be
performed before CT scan
To reduce transient acute inflammatory or
infectious mucosal changes

Nasal lavages
Topical corticosteroids
Antibiotics
Mucolytic agents CT scan should be
scheduled after
completion of medical
treatment
 Contrast-enhanced CT ?

.Anatomy is adequately assessed without the use

no of IV injected iodinated contrast material
.Iodine injection does not allow for discriminating
an inflammatory disease from a tumoral process

Initial images or clinical symptoms suggest

yes intracranial complications of a chronic
inflammatory sinus disease MRI
 CT imaging
1. Obstruction of the drainage pathways or anatomic
variants that may compromise already narrow drainage
pathways
2. Identification of critical anatomic areas where anatomic
variants pose special risks during sinus surgery

3. Local extension of disease

4. Complications

1+2 : Preoperative CT scan as a

road map for endoscopic sinus
surgery
Coronal CT

Maxillary sinuses
Ethmoid sinus
Nasal cavity
Sagittal CT

Frontal sinuses
Ethmoid sinus
Sphenoid sinus
Nasal cavity
 Ostio-meatal unit
Coronal CT

Sagittal CT

Middle nasal meatus

(air channel medial to uncinate process
and lateral to the middle turbinate)
 Ostio-méatal unit
Drainage from frontal, maxillary
and anterior ethmoid sinuses

Obstruction
Frontal sinusitis
Maxillary sinusitis
Anterior ethmoid sinusitis

Sagittal view
 Ostio-meatal unit

Coronal CT
Ethmoid
bulla (EB)
Orbit

EB
Middle
turbinate

Middle
meatus
Uncinate
process

Axial CT
Ostio-meatal unit
Maxillary ostium
Ethmoid infundibulum (posterior)
Hiatus semilunaris
Middle meatus

Coronal CT
 Uncinate process
Thin-curved bony lamina of variable height from the lateral side of the
ethmoid labyrinth, that forms a portion of the lateral nasal wall.

Coronal CT

EB Lamina
papyracea

Inferior attachment to the Supero-anterior

neck of the inferior turbinate attachment to lamina
papyracea in 50%
 Uncinate process

Coronal CT
Sagittal CT

Postero-lateral attachment to the roof of the maxillary sinus

 Uncinate process
Sagittal CT Coronal CT

Anterior-most ethmoid cell: EB

agger nasi cell

Lacrymal bone

Anterior attachment
of the uncinate process
Ethmoid bulla (EB)
Most posterior of all anterior ethmoid air cells, roof of the
hiatus semilunaris and posterior ethmoid infundibulum
Coronal CT
Sagittal CT

EB

Anterior ethmoid drainage

Middle meatus

Anterior ethmoid cells can drain into the middle meatus via the ethmoid bulla
 Ethmoid bulla

Orbit
EB

Uncinate
process

Normal-sized bullae Large bullae Hypoplasic bullae

Acording to John Earwaker. Anatomic variants in sinonasal CT.Radiographics 1993;13:381-415

 Coronal CT

Different
ethmoid
bullae
 Middle turbinate
Coronal CT Coronal CT

Posterior
ethmoid
cell
EB

Bulb

It attaches superiorly to the It attaches posteriorly and

cribriform plate: laterally to the lamina papyracea:
Medial lamella Basal (ground) lamella
Coronal CT

Middle turbinate

Sagittal CT

Anterior Posterior Anterior Posterior

ethmoid ethmoid ethmoid ethmoid
EB air cells air cells

Basal lamella
 Ethmoid infundibulum
Anterior ethmoid cells drainage
Frontal sinus drainage (25%)
Anterior ethmoid cells can directly drain into middle meatus

Coronal CT
 Frontal recess
Communication between frontal sinus and nasal cavity.
It is not strictly a duct but a channel located between
anterior ethmoid cells. Variety of configurations.

Sagittal CT Coronal CT
Frontal
sinus Frontal ostium

Agger nasi cell

Anterior middle meatus

 Coronal CT Frontal sinus drainage pathways
according to supero-anterior attachment
of the uncinate plate

50% Attachment to the lamina papyracea

Frontal drainage in the medial meatus

25%
Attachment to the skull base
Frontal drainage into the ethmoid infundibulum

25%
Attachment to the neck of the middle turbinate
Frontal drainage into the ethmoid infundibulum
or into an anterior ethmoid cell
Frontal sinus outflow obstruction

Frontal sinusitis

Sagittal view
Sphenoethmoidal recess
Posterior ethmoid and sphenoid sinus drainages

Axial CT Sagittal CT

Sphenoid
sinus

Sphenoid sinus
ostium

Superior nasal meatus

Sphenoethmoidal recess obstruction

Posterior ethmoid sinusitis

Sphenoid sinus sinusitis
 Posterior nasal fontanel
Coronal CT
coronal

Axial CT

Area of the lateral wall of the nose immediately behind the posterior
attachment of the uncinate plate. Consists of mucous membrane only,
without bony support.

Accessory maxillary ostium is frequently found through the

posterior nasal fontanel (15-40%)
Posterior choana

Coronal CT
Sagittal CT

Nasopharynx
 Nasal septum

Coronal CT

Sagittal view

Perpendicular plate
post of the ethmoid ant

Septal
vomer
cartilage
Chondrovomeral
junction
 Nasolacrymal duct
Axial CT 1 2

3 4 Coronal
CT

Inferior
meatus
 Anterior skull base

Coronal CT
Axial CT

Crista galli
Cribriform plates (floor of the olfactive fossa)
Ethmoid roof (fovea ethmoidalis)
 Ethmoid roof

Axial CT
Sagittal CT
Lateral lamella
(point of structural weakness in
the anterior skull base) Point of structural
weakness during
turbinectomy
Coronal CT
Ethmoid roof

Cribriform plate
Medial
lamella

Middle
turbinate

1-16 mm length
Dehiscent in 15% of specimens Anterior ethmoidal artery
 Anterior ethmoidal artery
Coronal CT Coronal CT

Olfactory
fossa
Lateral lamella

Medial lamella of
Middle turbinate

The anterior ethmoidal artery - branch of the ophtalmic artery - exits the
orbit through the anterior ethmoidal foramen and enters the olfactory
fossa at the point of attachment of the middle turbinate to the cribriform
plate
 Anatomic variants

Very frequently noted

The presence of anatomic variants, singly or in
combination, does not represent a disease state per se

Equal prevalence of patients with and without sinus

disease in the presence of the same anatomic variant
 Septal deviation
Coronal CT Coronal CT

Hypoplasic Large
middle middle
turbinate turbinate

Middle meatus
Inferior meatus
 Septal spurs
Axial CT
Coronal CT

Coronal CT

Bridging spur
Frequently encountered at the junction of the perpendicular
plate of the ethmoid and the vomer

May impige on and invaginate the middle or inferior turbinates. When the
turbinate mucosa swells with the normal nasal cycle or inflammation, it is
impaled on the spur, setting up a cycle of facial pain or headache. A septal
spur occasionally produces a complete bridge.
Size variations of middle turbinate
Coronal CT Coronal CT

Ostio-méatal complex compromise?

Turbinate septal contact when the turbinate mucosa
swells with the normal nasal cycle or inflammation
 Pneumatized middle turbinate
Axial CT
Coronal CT

Air cell in the vertical lamella:

concha neck air cell
Air cell in the bulbous segment:
concha bullosa cell
 Paradoxical middle turbinate

Coronal CT

Usually Paradoxical turbinate

Convex configuration medially Concave configuration medially
Concave configuration laterally Convexe configuration laterally
Pneumatized superior turbinate

Coronal CT

A cause of migraine headache?

Enlargement of the superior turbinate due to pneumatization,
with accompanying mucosal contact, acts as a mechanical
stimulus initiating an axon reflex with resultant referred pain?
Uncinate process
Height : 1-4 mm
Length : 14-22 mm
Coronal CT

Coronal CT

Medially rotated uncinate

Pneumatized
 Frontal bulla cell (suprabullar cell)
Anterior ethmoid air cell extending upwards (intramural ethmoid
air cell)

sagittal axial coronal

Frontal recess

May be small and impiges only on the floor of the frontal sinus.
May elevate and narrows the frontal recess
May be prominent and bulges into the frontal sinus
 Frontal sinus extension
Pneumatization of the orbital plate of the frontal bone

ant post
Coronal CT
Frontal sinus

No frontal sinus drainage compromise

Agger nasi (AN) cell Coronal CT

Sagittal CT

Lacrymal AN
fossa

Frontal recess
The most anterior of the ethmoid cells. Forms the floor of the frontal
recess. It reaches the lacrimal fossa inferiolaterally, and is
anterolaterally arched by the nasal bone. A large agger nasi can impige on
and distort the frontal recess.

Its posterior-medial wall usually gives rise to the anterior uncinate process
 Maxillary sinus recesses
Coronal CT Palatine recess Axial CT

Infraorbital recess of
The maxillary sinus

Coronal CT Sagittal CT Axial CT

Alveolar recesses
(roots of the premolar
and molar teeth) Zygomatic recess
 Sphenoid sinus recesses
Sagittal view
Coronal anterior view

ant
post Sphenoid
Sphenoid sinus Temporal Orbital
wall
sinus
bone

Maxillary
bone

Rostrum
Septum, vomer
Sup or inf clivus
Lesser wing
Greater wing
Pterygoid process
Sphenoid sinus recesses

Sagittal CT Sagittal CT

Septal recess Inferior clival recess

 Sphenoid sinus recesses
Coronal CT

Lesser wing

Greater wing

Ptérygoid process Coronal CT

Anterior clinoid process

Foramen rotundum
(maxillairy nerve)

Optic nerve
Intersinus septation of sphenoid

Axial CT
Coronal CT

Presellar segment of the internal carotid artery

 Vulnerability of the carotid canal
Internal carotid artery bulges into sphenoid sinus

Axial CT Axial CT

Sphenoid
sinus
surgery

septum
Vulnerability of the carotid canal
Dehiscent carotid canal

Sphenoid
Axial CT Axial CT sinus
surgery
Vulnerability of the carotid canal

Normal Hypoplasia or aplasia

sphenoid of the sphenoid sinus
sinus Carotid canal impiges on or bulges into
posterior ethmoid
Axial CT
Posterior
ethmoid
surgery

Ethmoid
ETHMOIDE
Normal POST
sphenoid
sinus
 Vulnerability of the optic nerve
1 Onodi cell (bulging of the optic canal into the posterior ethmoid)
2 Pneumatization of the lesser wing of the sphenoid bone
3 Pneumatization of the anterior clinoid process of the sphenoid bone

Coronal CT 2 Coronal CT
3
Sagittal CT 1

Posterior Sphenoid
Sphenoid
ethmoid sinus
sinus
surgery surgery
surgery

Encasement of the optic nerve

Within the sphenoid sinus
Optic nerves
Vulnerability of the optic nerve
Onodi cell Sagittal CT

Axial CT

Sinus
sphénoide
Posterior
ethmoid
surgery Coronal CT

Posterior ethmoid cell, with prominent superior or lateral

pneumatization to the sphenoid sinus, and a bulge of the optic
canal into it.
Vulnerability of the optic nerve

Axial CT

Sphenoid
sinus
surgery

1 2
Coronal CT
2

1. Bulging of the optic nerve

into the sphenoid sinus Sphenoid
2. Dehiscent optic canal sinus
surgery
 Vulnerability of the optic nerve
Hypoplasia or aplasia of the sphenoid sinus
(Optic nerves impinge on or bulge into the posterior ethmoid)

Post Posterior
ethmoid ethmoid
Normal-sized
surgery
sphenoid sinus
mt mt mt

Sagittal view

mt: middle turbinate Optic nerve

 Vulnerability of the orbit
Haller cells

Coronal CT

Anterior
ethmoid
endoscopy

Anterior ethmoid air cells that extend along

the medial floor of the orbit
 Vulnerability of the orbit

Coronal CT
Axial CT

orbite
orbit Uncinectomy

Uncinate process is very close to infero-medial orbit wall.

They can be merged.
 Vulnerability of the orbit

Lamina papyracea localized medial to

the maxillary sinus ostium

Coronal CT Coronal CT

orbit

Fusion of the uncinate process to the

medial orbital wall
(usually associated with ipsilateral hypoplastic
(Ex :maxillary sinus hypoplasia;reduced maxillary sinus)
ethmoid transverse diameter;children)
 Vulnerability of the orbit

Coronal CT Axial CT Axial CT

Anterior
ethmoid
endoscopy

coronal

Dehiscent lamina Thin medial orbital wall Dehiscent lamina

papyracea (lamina papyracea) papyracea
Vulnerability of the nasolacrymal duct
Agger nasi cell can invade the lacrymal bone
and impinge on or encircle the nasolacrymal duct

Coronal CT

Anterior
ethmoid
endoscopy

Axial CT
Vulnerability of the anterior skull base

Low cribriform plate: below the upper third of the vertical

orbital plate
Coronal CT

orbit

Risk of penetration into the

anterior cranial fossa during
Usually associated with ethmoid endoscopic surgery
hypoplastic middle
turbinate(s)