EMBRYOLOGY AND

ANATOMY OF NOSE AND

PNS
 Embryology of nose

1. Frontonasal process

2. Brachial arches(1st)
i) maxillary process

ii)mandibular process
Frontonasal process
It is a downward projection of mesoderm
covering the developing brain, cranial to
stomatodaeum
Ectoderm of Frontonasal process Thickened
to form nasal placode(4th week IUL or 5.6
mm embryo) and soon sink to form nasal
pits.
Mesoderm on the edge of each pits develop
into medial and lateral nasal folds.
Proliferating mesoderm of medial and lateral
nasal fold ultimately resulting to form nasal
sac(5th week IUL)
Maxillary process
It grows anteriorly, medially, fuse with
Median nasal fold & frontonasal process
and forms
Primitive nasal cavity.
Premaxilla
Medial crus of alar cartilage
Upper lips
The primitive nasal cavity & mouth, initially
separated by bucconasal membrane
which thin out as a nasal sac, and forms
primitive choanae on breakdown
bucconasal membrane.
Mandibular process joins the lateral nasal fold around
nasomaxillary groove & ectoderm of it canalize to
form nasolacrimal duct.

Lateral nasal fold also forms

Nasal bones
Upper lateral cartilage
Lateral crus of lower lateral cartilage.
 PALATE AND NASAL SEPTUM
• Primitve palate : Fusion of maxillary and
frontonasal processes.
• Midline ridge develops from posterior edge of
frontonasal process in roof of oral cavity and
extends posteriorly to opening of Rathke’s pouch.
• This ridge becomes the nasal septum which is
continuous anteriorly with the partition between
the primitive nasal cavities.
• Palatal processes, derived from the lateral maxillary
mesoderm, grow medially towards each other and
the septum.
• Initially they lie lateral to the tongue, but as this
moves ventrally with further growth the palatal
processes swing medially and fuse horizontally
Fusion begins along the posterior margin of the primitive palate and is
complete except for a midline dehiscence at the future site of the incisive
canal.
• The primitive septum is initially
made entirely of cartilage.
• Superior part ossifies to form the
perpendicular plate of the ethmoid;
• Posteroinferior portion : Vomer
(From 2 ossification centres in 8th
week);
• Anteroinferior : Quadrilateral
cartilaginous plate.
• 10th and 11th week : Nasal bones
arise.
MAXILLA
• 6th and 7th week : Maxilla arise from five ossification centre.
• Fuse at 4th month to form the alveolar, palatine, zygomatic and frontal
processes and the floor of the orbit.
• A further centre appears in the medial floor of the pyriform aperture,
forming the premaxilla in which the upper incisor teeth develop.
• Premaxilla forms the anterior nasal spine and fuses with the
vomeronasal cartilages laterally and septal cartilage superiorly.
MAXILLARY SINUS
• First sinus to appear (7-10 weeks)
• As a shallow groove expanding from the primitive ethmoidal
infundibulum into the mass of maxilla.
• Absorption and expansion resuIts in a small cavity at birth (7*4*4 mm)
• Continues to grow during childhood at an estimated annual rate of 2
mm vertically and 3 mm anteroposteriorly.
• Slows down around the seventh year of life, followed by a second
growth phase
• Final size in the seventeenth to eighteenth year of life
ETHMOID BONE
• 4th or 5th intrauterine month : Ossification from three centres (One for
each labyrinth and one for perpendicular plate)
• Partially ossified at birth.
• Perpendicular plate and crista galli develop from one centre during
the first year after birth
• Fuse with the labyrinths at the beginning of the second year.
• Both this centre and that for the labyrinth contribute to the cribriform
plate.
ETHMOID SINUS
• Evaginations of the lateral nasal wall at the third month of fetal life
• Anterior ethmoid cells develop anterior to the second ethmoturbinal
• Posterior ethmoid cells develop posterior to the second
ethmoturbinal
• The ethmoid cells are present at birth and pneumatize further
between years 0 to 3 and 7 to 12
FRONTAL BONE
• 8th week : Ossifies from two centres, one in each superciliary ridge.
• At birth : Bone is composed of two halves separated by
frontal(metopic) suture.
• Begins to fuse from : 2nd year
• Completes by : 8th year
FRONTAL SINUS
• It is most variable in size.
• 3rd month of gestation : Small frontal recess is recognizable.
• Pneumatization begins from anteriosuperior segment of anterior
ethmoidal complex
• Upward expansion does not take place until birth.
• At birth : Small, poorly pneumatized
• At 5th year : Pneumatization visible in CT scan
• At 12th year : Well developed
 SPHENOID
BONE
• Sphenoid divided into two parts :
• Presphenoidal portion anterior to tuberculum
sellae continuous with lesser wings. Derived from
six ossification centres.
• Postsphenoidal part : Composed of the sella turcica
and dorsum sellae associate with the greater wings
and pterygoid processes. Derived from eight
centres.
• Two parts fuse around 8th intrauterine month.
• At birth : Bone consists of 3 pieces : Central portion
(body, lesser wings) and two lateral parts (each
consists of greater wing and pterygoid process)
• Begins to fuse at 1 year after birth.
SPHENOID SINUS
• Seen at third intrauterine month as evagination from the sphenoethmoidal
recess
• At birth : 2 x 2 x 1.5 mm
• 7 years : Pneumatization reach the floor of the sella
• Internal carotid artery, optic nerve, V2 and the vidian nerve can be exposed
in the walls of the sphenoid sinus
 TURBINATES
• 6th fetal week : Series of elevations
appear on the lateral wall of nose
which will ultimately form turbinates.
• Inferior turbinate : Forms from
maxilloturbinal
• Middle, superior and supreme
turbinates : From ethmoturbinal
system.
• Agger nasi region and uncinate
process of ethmoid : Primitive
nasoturbinal
 DEVELOPMENTAL
MALFORMATIONS OF
NOSE
CHOANAL ATRESIA
• Choana : Greek word : Funnel
• More common congenital abnormality of nose
• May be bony (90%) or membranous
• Just in front of posterior end of nasal septum.
• In bony type, thin and easily perforated.
• Associated with asymmetry of facial skeleton and high arched palate
• EMBRYOLOGY :
• Many theories :
• Failure of the bucconasal
membrane to undergo
involution
• Persistent of the epithelial
cells which proliferate
within the nasal cavities.
SEPTAL DEVIATION
• Found in 58% of all newborn, 4% newborn with associated external
nasal deformity.
• Two mechanisms:
• Differences in rate of growth of septum as compared to other
midfacial structures, resulting in septum which is too big for the space
it has to occupy.
• Trauma to the nose, either as result of prolonged contact with uterine
wall or during parturition.
• C/F s : Resulting nasal obstruction, presents as difficult or slow
feeding, colic due to air swallowing.
• If nasal infection supervenes, child breathes noisily through nose.
• In some cases, nasal blockage mimics choanal atresia.
• Both external pyramidal and internal septal deformities are corrected
within first few days of life using neonatal nasal septum forceps.
• By 6 years : Septoplasty can be performed but minimal tissue removal
to retain growth and development of nose.
CONGENITAL NASAL
MASSES
NASAL DERMOIDS
• Solid tumors, cysts or sinuses.
• Position : Anywhere in midline of nose from glabella to columella
• Walls contain skin adnexae
• In nasopharynx, take form of ‘hairy polyp’
• Formed as a result of sequestration of epithelial elements during fusion of median nasal processes.
• May only manifest if infection occurs.
• Contrast sinography : Determines
both extent and configuration of
sinus tract.
• T/T : Complete excision facilitated by
prior cannulation of external
punctum and instillation of
methylene blue.
• Also by external rhinoplasty
approach.
• Combined intracranial and
extracranial approach for intracranial
extension
NASAL GLIOMAS
• Account for approx. 5% of all congenital
nasal swellings.
• Males > Females
• May occur : Outside the nasal cavity (60%)
Within the nasal cavity (30%)
Combination of both sites (10%)
• Origin : Due to faulty neuropore
• Become detached from intracranial cavity by closure of skull sutures.
However, fibrous tract may connect glioma to skull base.
• Tend to enlarge slowly with age but rapid expansion can occur.
• Macroscopic : Smooth and rubbery with a grey, yellow or purple
surface.
• Histology : Aggregation of mature glial cells, predominantly astrocytes
interspersed with fibrous tissue.
• Diagnosis : Soon at or after birth
Either as subcutaneous lump to one side of nasal bridge or as
obstructing intranasal mass
• CT scan : To rule out intracranial communication.
• T/T : Excision
• Laser excision
• Intranasal masses : Lateral rhinotomy approach
ENCEPHALOCELE GLIOMA WITH DURAL
CONNECTION

DERMOID CYST WITH SINUS

NASAL MENINGOENCEPHALOCELES
• Local herniation of glial tissue and meninges through defect in skull
• May occur at any site
• Due to faulty closure of anterior neuropore
• Retain communication with subarachnoid space.
• Cranioschisis : Very large bony defects in skull
• Frontoethmoidal / Basal : Most common
• Origin depends on local developmental abnormalities
• Sac-like protrusion of meninges contains brain tissue and sub
arachnoid space, filled with CSF, communicates freely with cranial
cavity
• Injury is likely to cause CSF rhinorrhea and meningitis
• Presents as either a soft cystic mass overlying root of nose
(frontoethmoid) or pedunculated intranasal swelling (basal).
• Crying or straining increase size and tension of mass
• Investigations :
• Radiological examination, including plain films, CT to determine
extent, exact size and site of cranial defect.
• MRI to distinguish between brain parenchyma and inflamed nasal
mucosa.
• In cases where skull defect is small and readily accessible : Local
external excision with plugging of cranial opening.
• T/T : Craniotomy with removal of herniated brain tissue, followed by
closure of bony defect using tantalum mesh and repair of meninges
with fascia.
HAEMANGIOMA
• Vascular hamartoma
• Common in childhood
• Primary involvement of nose is rare.
• Almost all will regress spontaneously with little or no residual
deformity.
• If not regress, associated with increasing numbers of AV fistula.
• Histology : Identified as capillary, cavernous, mixed or hypertrophic.
• Monitored with serial Doppler examinations.
• Active interventions in cases where tumor growth continues.
PROBOSCIS LATERALIS
• Due to imperfect fusion of lateral nasal and maxillary
processes.
• Consists of tube of skin and soft tissue, arising at
inner canthus at eye.
• Nasal cavity : May be normal, may be
maldevelopment of varying degree or total agenesis.
• Also in association with other congenital nasal
defects.
• Repair : Incorporation of some of extraneous tissue
of tube in reconstruction. Dacryocystorhinostomy
will also be required.
AGENESIS OF NOSE
• Rare abnormality
• In 5th week: nasal placode fails to canalize to form nasal passages
• Associated absence of nasopharynx and no nasal development.
• Child may learn to mouth breathe.
• Presents with acute respiratory distress (>feeding), hyposmia
• Physical examination: Absence of the external nose and nasal airways,
hypoplasia of the maxilla, a high arched palate, and hypertelorism
• T/T : Surgery to establish nasal airway or nasal prosthesis.
 POLYRHINIA
• Presents with anterior (septal duplication, duplicated nasal passageways)
and posterior (choanal atresia) nasal defects.
• Major priority : choanal atresia.
• Nasal deformity : removing the medial portions of each nasal cavity and
anastomosing the lateral portions in the midline.
• Gives rise to a broad flat nose with a depression in the midline.
• Incomplete development of the frontonasal process
• Separation of the developing lateral portions of the nose
• Medial nasal process and nasal septum follows the development and are
thereby duplicated causing a double nose
SUPERNUMERARY NOSTRIL
• Small accessory nasal orifices
• Orifices : seen lateral, medial or superior
to the already existing nose
• When true fistulous tract is present then
discharge from these orifices are
common.
• Treatment : excision of the
supernumerary nostril and primary
closure of the defect or closure with local
flaps
CLEFT NOSE
• Rare
• Varies from minor notching of nasal tip to total midline division of nose into widely separated
nasal cavities
• Associated median cleft of upper lip and palate or notching of alar margins.
• Strong association between separation of eyes, hypertelorism, cephalic anomalies and mental
deficiency.
• In more severe cases, multiple procedures.
• If bony elements are involved, delay repair until growth of nose and face has ceased.
ANATOMY OF NOSE
• External Nose : Pyramidal projection of face, presents a free tip and a
root at its junction with forehead
• Vestibule : Dilated passageway leading from the external nares into
the nasal fossae, demarcated by the limen nasi, at the superior
margin of the lower lateral cartilage. Lined by skin bearing coarse
hairs or vibrissae, sebaceous and sweat glands.
• It becomes thicker and more adherent over the tip and alar cartilages
where it contains numerous large sebaceous glands.
• Columella : Part of the septum running between the tip of the nose
and philtrum. Bounds anterior nares medially.
MUSCLES OF EXTERNAL NOSE
• Nerve supply : Facial Nerve

• Depressor nasi septi : Attaches between the alveolus and the medial crus of the lower
lateral cartilage. Function : Depress the septum and tip, expanding the external nares
during forced inspiration.
• Nasalis : Composed of an alar and a transverse part.
• Transverse fibres : Run from the pyriform aperture onto the dorsum of the nose into a
thin aponeurosis attached to the transverse muscle fibres of the opposite side.
Function : Contracts the nasal aperture.
• The alar component : Arises beneath the nasomaxillary suture and runs inferiorly,
laterally and anteriorly, attaching by a short thin tendon to the skin of the nasal ala.
Function : Produces shortening and dilatation of the nostril.
• Procerus (Depressor glabelli): Continuation of frontalis. Function :
shortens the nose when contracted but also produces facial
movement of the area between the eyebrows. This muscle and
associated fat pad gives shape of root of nose.
• Levator labii superioris alaequae nasi : Arises from the frontal process
of the maxilla and blends with the perichondrium of the lateral crus of
the lower lateral cartilage. Function : Pulls lower lateral cartilage
superiorly, dilating the nostril and also elevates the upper lip.
NASAL BONES
• The nasal bones : Unite with each other in
the midline.
• With the frontal bone superiorly at the
nasofrontal suture and
• Laterally with the frontal process of the
maxilla at the nasomaxillary suture.
• Between one and four (average 2.3) minor
sesamoid cartilages are found between the
upper and lower lateral cartilages.
• BLOOD SUPPLY :
• Alar region : Branches of the facial artery
• Dorsum and lateral walls of the external nose : Dorsal branch of the ophthalmic artery
and the infraorbital branch of the maxillary.

• VENOUS DRAINAGE :
• Frontomedian area : Drains to the facial vein
• Orbitopalpebral area : To the ophthalmic vein with interconnections to the anterior
ethmoidal system and thence cavernous sinus.
• The facial vein arises by the confluence of the supratrochlear and supraorbital veins at
the inner canthus where it is termed the angular vein in its superior portion.
• Usually a transverse venous anastomosis exists between the right and left
supratrochlear veins.
DANGER AREA OF FACE
• Angular vein – superior ophthalmic vein – cavernous sinus
• Deep facial vein – pterygoid venous plexus – emissiary veins (foramen ovale,
lacerum, spinosum) – cavernous sinus
• NERVE SUPPLY :
• Sensory supply of skin of external nose : Two upper divisions of the
trigeminal nerve; ophthalmic and maxillary.
• The ophthalmic has an infratrochlear branch supplying the lateral
surface of the root of the nose and an external nasal branch supplying
the skin over the root and dorsum as far as the tip of the nose.
• Infraorbital branch of the maxillary nerve : External and internal nasal
branches which supply the nasal alae and skin of the nasal vestibule
respectively.
• LYMPHATIC DRAINAGE :
• Submandibular and submental nodes
NASAL CAVITY
• Extends from the external nares to the posterior choanae, where it
becomes continuous with the nasopharynx
• Narrower anteriorly than posteriorly.
• Anteriorly : External nares
• Posteriorly : Choanae
• Above : Cribriform plate
• Below : Palate
• Divided into two parts by septum.
• Each half has :
• Floor :
Concave from side to side
Anteroposteriorly flat and almost horizontal.
Anterior three-quarters : Palatine process of the maxilla,
Posterior one-quarter : Horizontal process of the palatine bone.
Incisive canal : Slight depression in mucous membrane about 12 mm
behind anterior end. Contains terminal branches of nasopalatine nerve,
the greater palatine artery and a short mucosal canal (Stenson's organ).
Occasionally incisor and canine teeth can protrude into the floor of
nasal cavity.
• Roof :
• Narrow from side to side, except posteriorly
• May be divided into :
• Frontonasal, ethmoidal and sphenoidal parts, related to the respective
bones.
• Highest part of the nasal cavity : Cribriform plate of the ethmoid.
• This area is covered by olfactory epithelium which spreads down a little
distance onto the upper lateral and medial walls of the nasal cavity.
• The rest of the nasal cavity (with the exception of the nasal vestibule) is
lined by respiratory mucous membrane which is continuous with that
of the paranasal sinuses, nasolacrimal duct and nasopharynx.
NASAL SEPTUM
• Surface area : 30-35 cm2 adult
• Composed of :
 Small anterior membranous
portion,
 Quadrangular Septal cartilage,
 Rostrum of Sphenoid,
 Perpendicular plate of ethmoid,
 Vomer and
 Two bony crests of maxilla and
palatine.
Lining membrane of internal nose and glands
• Vestibule : skin containing hair, hair follicles and sebaceous gland.
• Olfactory region:upper one third of lateral wall ( up to superior concha) ,corresponding
part of nasal septum and roof of nasal cavity form the olfactory region
• Respiratory region:lower two third of nasal cavity form respiratory region. Lined by
Ciliated and nonciliated pseudostratified columnar cells, basal pluripotential stem cells
and goblet cells.
• Submucosal glands are found in submucosa. Important in mucus production in nasal
cavity.
• Goblet cells : In sinus.
• In septum, Goblet cells in Posterior > Anterior and Inferior > Superior
Glands : Anterior > Posterior and Superior > Inferior
BLOOD SUPPLY
Nerve supply
• Maxillary division of trigeminal nerve provides
sensory supply to majority of nasal septum
• Nasopalatine nerve supplies the bulk of bony
septum , entering nasal cavity via
sphenopalatine foramen, passing medially
across the roof of upper septum and running
down and forward to incisive canal to reach
hard palate
• Anterosuperior part of septum supplied by
anterior ethmoidal branch of nasocillary nerve
and smaller anterioinferior portion receive a
small supply from nerve to pterygoid canal and
posterior inferior nasal branch of anterior
palatine nerve.
LYMPHATIC DRAINAGE
• Anterior septum : Submandibular nodes
• Posterior septum : Retropharyngeal and anterior deep cervical nodes
Applied anatomy
• Septal cartilage is used for Rhinoplasty
anterior deviation: conservative septoplasty technique
posterior deviation:classic killian SMR operation
• Septal hematoma
collection of bood under perichondrium or periosteum of nasal
septum
trauma/ septal surgery
-B/L nasal obstruction
Small : aspirated with wide bore sterile needle
Large: incised and drained by mucoperichondrial antero-posterior
incision parallel to nasal floor then nasal packing and antibiotics
Thankyou
LATERAL NASAL WALL
• INFERIOR MEATUS :
• The area of the lateral wall of the nose covered medially by the inferior
turbinate, into which the nasolacrimal duct opens.

• INFERIOR TURBINATE :
• Separate bone that articulates with the inferior margin of the maxillary
hiatus via its maxillary process.
• Also articulates with the ethmoid, palatine and lacrimal bones.
• Irregular surface due to the impression of vascular sinusoids, to which the
mucoperiosteum attaches.
• Thickest in the mid-portion.
• MIDDLE TURBINATE :
• Component of the ethmoid bone.
• Anteriorly and posteriorly it attaches to the lateral wall of the nose
• Superiorly : Vertical attachment to the skull base at the lateral border of the
cribriform plate.
• The vertical attachment is in a paramedian sagittal plane, the posterior
attachment is in the horizontal plane and these are connected by a portion of
bone : Basal lamella.
• This rotates to lie in the coronal plane and attaches to the medial orbital wall,
dividing the ethmoidal cells and recesses into an anterior and posterior group
relative to the basal lamella.
• The most anterior part of the middle turbinate fuses with the agger nasi
inferiorly to form Axilla.
• Posterior attachment : Lamina papyracea and/or medial wall of the maxilla
• Superior attachment : Lateral lamella of the cribriform plate.
• MIDDLE MEATUS :
• Area of the lateral wall of the nasal cavity covered medially by the
middle turbinate
• Receives drainage from the anterior ethmoid, frontal and maxillary
sinuses
• UNCINATE PROCESS :
• Thin, sickle shaped structure
• Part of ethmoid bone
• Runs almost in the sagittal plane from anterosuperior to
posteroinferior
• Concave free posterior margin that lies parallel to the anterior surface
of the ethmoidal bulla.
• Posteroinferiorly attaches to the perpendicular process of the palatine
bone and the ethmoidal process of the inferior turbinate.
• Anteriorly, attaches to lacrimal bone.
• Superior attachment is variable, with 6 variations identified:
• Most common superior attachment : To lamina papyracea (up to 52%),
• To skull base or
• To middle turbinate
• May alter the frontal sinus drainage pathway.
• Variations of the uncinate process include: medialised; everted
(paradoxical); occasionally aerated (uncinate bulla); and rarely a
lateralized, concave uncinate may narrow the infundibulum leading to
an atelectatic infundibulum
• AGGER NASI :
• Most anterior part of the ethmoid
• May be seen on intranasal examination
as a small prominence on the lateral
nasal wall just anterior to the attachment
of the middle turbinate.
• Thought to be the most superior
remnant of the first ethmoturbinal
(nasoturbinal).
• Still debated whether the agger nasi cell
drain into the ethmoid infundibulum or
into the frontal recess or elsewhere
• OSTIOMEATAL COMPLEX:
• In 1965, Naumann coined the
term.
• Refers to functional unit and
physiological concept
comprising the clefts and
drainage pathways of the
middle meatus together with
the anterior ethmoid complex,
frontal and suprabullar
recesses, and ethmoidal
infundibulum.
• HIATUS SEMILUNARIS :
• Crescent-shaped cleft between the concave posterior free edge of the
uncinate process and the convex anterior face of the ethmoidal bulla,
forming the entrance to the ethmoidal infundibulum.
• Originally described as the “inferior semilunar hiatus”; the “superior
semilunar hiatus” is a second crescent-shaped cleft between the
posterior wall of ethmoidal bulla and the basal lamella of the middle
turbinate, through which the retrobullar recess, if present, may be
accessed.
Schematic drawing in the axial plane through the frontal
portion of the basal lamella of the middle turbinate1 = hiatus
semilunaris (inferior), 2 = ethmoidal infundibulum, 3 = hiatus
semilunaris superior, 4 = retrobullar recess. be = ethmoidal
bulla.
• ETHMOIDAL INFUNDIBULUM :
• Three-dimensional space in the ethmoidal labyrinth of the lateral nasal wall.
• Boundaries
• Anterior and lateral wall : Frontal process of the maxilla and the lamina papyracea
• Medial wall : Uncinate process
• Posterior wall : Ethmoid bulla
• Superior configuration of the infundibulum depends on the superior attachment of
the uncinate process.
• If uncinate process attaches to the skull base or the middle turbinate: Infundibulum
will be continuous with the frontal recess superiorly.
• If the uncinate process attaches to the lamina papyracea, the infundibulum will end
blindly in the terminal recess.
• The maxillary sinus opens into the ethmoidal infundibulum, usually inferiorly into
the third quarter of the infundibulum.
If the uncinate process (blue line, right side)
attaches to the skull base, the infundibulum
will be continuous with the frontal recess
superiorly (yellow line). If the uncinate
process (blue line, left side) attaches to the
lamina papyracea, the infundibulum will end
blindly in the terminal recess.
If the uncinate process attaches to the middle
turbinate, the infundibulum will be continuous
with the frontal recess superiorly, the frontal
drainage pathway thus being lateral to the
uncinate process
• FRONTAL RECESS :
• Most anterosuperior part of the ethmoid,
inferior to the frontal sinus opening.
• Delimited posteriorly by the anterior wall
of the ethmoidal bulla (if reaches the skull base), anteroinferiorly by
the agger nasi, laterally by the lamina papyracea and inferiorly by
the terminal recess of the ethmoidal infundibulum.
• If the uncinate process attaches to the skull base or turns medially,
the frontal recess opens directly into the ethmoidal infundibulum.
• On endoscopic examination, the access to the frontal sinus is medial
to the attachment of the uncinate process in the majority of cases.
• ETHMOIDAL BULLA :
• The largest anterior ethmoid cell but is occasionally undeveloped (in 8% of cases)
• A number of ethmoidal configurations have been described : Commonest -
Single cell opening into the superior semilunar hiatus or retrobullar recess (68%).
• Rarely - May open into the ethmoidal infundibulum (3%).
• Otherwise there can be multiple cells with multiple openings, one of which is
almost always into the superior semilunar hiatus (98.4%).
• The anterior face of the bulla forms the posterior border of the inferior
semilunar hiatus, ethmoidal infundibulum and frontal recess.
• If the bulla is poorly or non-pneumatized, medial wall of the orbit is potentially
at risk.
• It is also important that the surgeon appreciates the proximity of the skull base
when the bulla is pneumatised superiorly.
1 = frontal sinus, 2 = frontal recess, 3 = uncinate process over ethmoidal
infundibulum, 4 = hiatus semilunaris, 5 = ethmoidal bulla, 6 = suprabullar recess,
7 = retrobullar recess, 8 = basal lamella of middle turbinate.
• Suprabullar recess : If the ethmoidal bulla reaches the ethmoidal roof, it forms the posterior border of
the frontal recess. If it does not, a suprabullar recess is present between the superior aspect of the
bulla and the ethmoidal roof. Thus, the recess is an air containing space bounded by:
• Inferiorly : Roof of the ethmoidal bulla,
• Medially : Middle turbinate,
• Laterally : Lamina papyracea,
• Superiorly : Roof of the ethmoid.
• Laterally it may give rise to an air-containing cleft extending above the orbit, known as a supraorbital
recess.

• Retrobullar recess: Formed when the posterior wall of the ethmoidal bulla is separate from the basal
lamella of the middle turbinate, creating a cleft between the two. Medial wall : Middle turbinate
Lateral wall : Lamina papyracea. Opens medially into the middle meatus via the superior semilunar
hiatus. The supra- and retrobullar recesses may be contiguous or separated by bony lamellae, referred
to as the “sinus lateralis”.

• Terminal recess : Terminal recess (recessus terminalis) of the ethmoidal infundibulum, is formed if the
superior attachment of the uncinate process is onto the lamina papyracea or the base of an agger nasi
cell, thus forming a blind end to the ethmoidal infundibulum superiorly
TERMINAL RECESS View into frontal sinus
TERMINAL RECESS after resection of left
termnial recess
• SUPERIOR MEATUS :
• Area of the lateral wall of the nose covered medially by the superior
turbinate, receiving drainage from the posterior ethmoid.
• The superior turbinate is an integral part of the ethmoid, lying above
the middle turbinate and bearing olfactory epithelium on its medial
surface.
• There may also be a supreme turbinate.
• SPHENOETHMOIDAL RECESS :
• Lies in front of the anterior wall of the sphenoid and medial to the
superior turbinate of the ethmoid.
• The natural ostium of the sphenoid sinus opens into it at the level of the
superior turbinate in most, but not all, cases.
• The ostium is located medial to the posterior end of the superior
turbinate in 83% and laterally in 17%.
• The sphenoid sinus ostium may be medial to the superior turbinate and
easy to identify, or lateral and more difficult to find, depending on the
lateral extent of the sphenoethmoidal recess.
• It is approximately located at the level of the inferior one third of the
superior turbinate and along a horizontal plane through the floor of the
orbit.
BLOOD SUPPLY OF LATERAL NASAL
WALL
• SPHENOPALATINE FORAMEN:
• Just inferior to the horizontal attachment of the middle turbinate
• Bounded above by the body of the sphenoid,
• In front by the orbital process of the palatine bone,
• Behind by the sphenoidal process and
• Below by the upper border of the perpendicular plate of the palatine
bone.
• Sphenopalatine artery, vein and the nasal palatine nerve (maxillary
division of trigeminal nerve)
• Small bony projection anterior to the foramen in 96 percent of cases
'crista ethmoidalis’
• It usually divides beyond the foramen into two main branches:
• Posterior lateral nasal and Posterior septal.
• However, in 39% it was found to divide before the foramen, presenting 2 or even 3 trunks.
• May pass above and/or below the ethmoidal crest.
• Majority (>97%) of individuals had 2 or more branches medial to the crest,
• 67% had 3 or more branches
• and 35% had 4 or more branches.
• Accessory foramen has been observed in 5-13% of individuals, usually inferior to and
smaller than the sphenopalatine foramen.
• The nasopalatine artery, a branch of the maxillary artery, leaves the pterygopalatine fossa
through a canal inside the palatine bone and runs parallel to the nasopalatine nerve.
• It ends in the incisive canal where it anastomoses with the greater palatine artery.
• Ligation: Incision is made approximately 8 mm anterior to and under cover of the
posterior end of the middle turbinate
NERVE SUPPLY OF LATERAL WALL
LYMPHATIC DRAINAGE
• Submandibular LN
• Lateral pharyngeal LN
• Retropharyngeal LN
• Upper deep cervical LN
ETHMOID SINUSES
• Composed of 5 parts :
• Two ethmoidal labyrinths suspended on either side of a perpendicular
plate which forms the upper portion of the bony nasal septum, with an
intervening cribriform plate and a superior midline extension, the crista
galli.
• The cribriform plate divides the nasal cavity from the anterior cranial
cavity.
• Ethmoidal labyrinth : Collection of cells and clefts.
• Lateral walls : Orbital plates or lamina papyracea.
• Roof : Frontal bone.
• Between these two portions of the turbinate, there is an obliquely disposed plate of
bone, the basal lamella of the middle turbinate, attaching laterally to the lamina
papyracea.
• The basal lamella divides the ethmoidal labyrinth into an anterior and posterior group
of cells.
• Anterior cells : Smaller and more numerous (2-8); Largest and most constant anterior
cells : Bulla ethmoidalis
• Posterior cells : Large and pyramidal in shape, pointing towards the orbital apex.
Closed posteromedially by the sphenoid bone. The most posterior ethmoidal cell can
extend lateral to the sphenoid, up to 1.5 cm posterior to the anterior wall of the
sphenoid.
• Haller cells : Pneumatized ethmoidal cells which can encroach upon the ethmoidal
infundibulum
• May narrow the ethmoid infundibulum and predispose patients to maxillary sinus
obstruction
• May injure orbit during surgery.
HALLER CELL
ETHMOIDAL ARTERIES AND VEINS
Internal Carotid

Ophthalmic artery

Ethmoidal arteries

• Anterior artery accompanies nerve and supplies anterior ethmoidal

cells and frontal sinus.
• Passes through the anterior ethmoidal canal in the
medial wall of the orbit, usually at the junction of the
frontal bone and lamina papyracea
• Traverses the roof of the ethmoid
• Passes through the vertical attachment of the middle
turbinate
• Abuts the base of skull
• Reaches the superior surface of the cribriform plate
• Gives off a meningeal branch
• Passes down to supply the upper nasal septum and
lateral wall of the nose
• Terminal branch to the nasal dorsum between the
nasal bone and upper lateral cartilages.
• The artery crosses the roof of the ethmoids just
posterior to the frontal recess and may run in a
dehiscent canal or in a fold of mucosa.
• The smaller posterior ethmoidal artery runs through the canal in the
medial wall to supply the posterior ethmoidal cells
• Also gives a meningeal branch
• Terminates in nasal branches to the septum and lateral wall,
anastomosing with the sphenopalatine artery
• The anterior ethmoidal artery is unilaterally absent in 14%,
• Bilaterally absent in 2% and
• Multiple in 30%
• If the anterior ethmoidal artery is absent, it is replaced by a branch of
the posterior ethmoidal
• BLOOD SUPPLY OF ETHMOID SINUS: Sphenopalatine and ethmoidal
(anterior and posterior) arteries
• Sphenopalatine and ethmoidal (anterior and posterior) veins
• NERVE SUPPLY : Anterior and posterior ethmoidal nerves and orbital
branches of pterygopalatine ganglion.
• LYMPHATIC DRAINAGE : Submandibular nodes anteriorly and
retropharyngeal nodes posteriorly.
KEROS CLASSIFICATION
• For anatomic variation of ethmoid
roof and olfactory fossa

• Type I : Shallow olfactory fossa of 1-3

mm depth in relation to medial end
of ethmoid roof, Short lateral lamella

• Type II : Olfactory fossa depth of 4-7

mm, Longer lateral lamella
• Type III : Much longer lateral
lamella of 8-16mm depth,
cribiform plate projecting
deep within nasal cavity well
below the roof of ethmoid
labyrinth
SPHENOID BONE AND SINUSES
• The sphenoid bone is the largest in the skull base and divides the
anterior and middle cranial fossa.
• Composed of : Body, two wings (greater and lesser) and two inferior
plates (lateral and medial pterygoid plates).
• The jugum on the anterior superior surface of the body articulates
with the cribriform plate.
• BODY :
• Lies at centre, cubical in shape
• Contains sphenoid sinus
• Superior surface contains :
• Sella turcica : Surrounded by anterior and posterior clinoid processes. Which has 3 parts:
Tuberculum sellae
Hypophyseal fossa
Dorsum sellae
• Anterior clinoid process : Arise from sphenoidal lesser wings. Posterior process : Superolateral
projection of dorsum sellae. Serve as attachment for tentorium cerebelli which divides the
brain.
• Chiasmatic groove (formed by optic chiasm)
• GREATER WING :
• Extends from sphenoid body in lateral, superior and posterior direction.
Contributes for
• Floor of middle cranial fossa
• Lateral wall of skull
• Posterolateral wall of orbit
• 3 foramina are present :
• Foramen rotundum : Maxillary nerve
• Foramen ovale : Mandibular nerve
• Foramen spinosum : Middle meningeal vessels
• LESSER WING :
• Arises from anterior aspect of sphenoid body in superolateral direction
• Forms lateral border of optic canal. Medial border is formed by body of
sphenoid.
• Slit like gap between lesser and greater wings : Superior orbital fissure
which transmits :
 Superior and inferior division of oculomotor nerve
Trochlear nerve
Lacrimal, frontal and nasociliary branches of ophthalmic
Abducens nerve
Superior and inferior division of ophthalmic vein
Sympathetic fibres from cavernous plexus
• PTERYGOID PROCESS:
• Descends inferiorly from point of junction between sphenoid body
and greater wing.
• 2 parts :
• Medial Pterygoid plate : Supports posterior opening of nasal cavity
• Lateral Pterygoid plate : Site of origin of medial and lateral pterygoid
muscles (muscles of mastication).
• Clinical Significance of Sphenoid Bone :
• Endoscopic trans-sphenoidal surgery : Pituitary gland can be assessed
by passing instruments through sphenoid bone and sinus. Thus,
treatment of choice for pituitary adenoma and does not require
extensive craniotomy.
Four general forms of pneumatization of sphenoid sinus are described :
Conchal pneumatization, with only a rudimentary sinus (2-3%)
Presellar, in which the sinus is pneumatized as far as the anterior
bony wall of the pituitary fossa
Sellar, in which pneumatization extends back beneath the pituitary
fossa (59%).
Mixed (27%).
• The optic nerve and internal carotid artery produce variable prominences in the
lateral and posterior walls of the sinus, with an intervening cleft.

• RELATIONS :
• Anterior: posterior ethmoid cell and spheno-ethmoidal recess
• Posterior: occipital bone, basilar artery and brainstem
• Lateral: cavernous sinus extending from superior orbital fissure to apex of petrous
temporal bone.
• Internal carotid artery, with associated sympathetic plexus, abducent, oculomotor,
trochlear nerves, and ophthalmic and maxillary divisions of the trigeminal nerve
• Inferior: roof of nasopharynx
• Superior : Olfactory tracts, frontal lobes, optic chiasma, pituitary gland.
• Sphenoethmoidal (Onodi) Cell :
• Posterior ethmoid cell that pneumatizes posteriorly into the region of the
sphenoid sinus
• Optic nerve and carotid artery may often course through the lateral aspect
of the sphenoethmoid cell instead of the sphenoid sinus proper
• Failure to recognize could result in inadvertent damage to the optic nerve
or carotid artery
• BLOOD SUPPLY : Posterior ethmoidal artery
• VENOUS DRAINAGE : Posterior ethmoidal veins
• NERVE SUPPLY : Posterior ethmoidal nerves and orbital branches of
pterygopalatine ganglion
• LYMPHATIC DRAINAGE : Retropharyngeal nodes
FRONTAL BONE AND SINUS
• Frontal bone forms the forehead and orbital roof and is pneumatized to a variable degree.
• 1 % they are absent
• ‘L’ shaped
• Intersinus septum is usually present
• May be paramedian and is partially dehiscent in 9 percent
• Drains into the frontal recess
• Accessory channels in 12 percent population and there may
be accessory connections to the ethmoidal system
• Infections from frontal sinus can spread through its posterior wall, resulting in an
extradural abscess
• Proximity to bone marrow of the frontal bone : Spread of infection from sinus directly
into bloodstream
• RELATIONS :
• Inferior: orbit, ethmoid labyrinths and nasal cavity
• Superior: anterior cranial fossa, olfactory niche, bulbs and tracts .
• Medial: cribriform plate and olfactory niche
• BLOOD SUPPLY : Supraorbital and anterior ethmoidal arteries
• VENOUS DRAINAGE : Supraorbital and anterior ethmoidal veins,
diploic veins draining into the sagittal and sphenoparietal sinuses and
an anastomotic vein in the supraorbital notch connecting the
supraorbital and superior ophthalmic vessels.
• NERVE SUPPLY : Supraorbital nerve
• LYMPHATICS : Submandibular lymph node
TYPES OF FRONTAL CELLS :
• Described by Kuhn:
• Type I : Single frontal recess
cell above agger nasi cell

• Type II : Tier of cells above

agger nasi cell, projecting
within the frontal recess
• Type III Frontal Cell: Single
massive cell arising above
the agger nasi cell,
pneumatizing cephalad into
the frontal sinus

• Type IV Frontal Cell: Single

isolated cell within the
frontal sinus, frequently
difficult to visualize due to
its thin wall
MAXILLARY BONE AND SINUSES
• Second largest facial bone, forming the
majority of the roof of the mouth, the
lateral wall and floor of the nasal cavity and
the floor of the orbit.
• Body : Quadrilateral pyramid and contains
the maxillary sinus.
• Four processes : Zygomatic, frontal, palatine
and alveolar.
• RELATIONS :
• Superior: infraorbital artery and nerve, orbit
• Inferior: Upper dentition and hard palate
• Posterior: pterygopalatine and infratemporal fossae
• Anterior: cheek with skin, fat and facial musculature.
• BLOOD SUPPLY : Small branches of the facial, maxillary, infraorbital and
greater palatine arteries.
• VENOUS DRAINAGE : Anterior facial vein and pterygoid plexus.
• NERVE SUPPLY : The maxillary division of the trigeminal nerve supplies
sensation via the infraorbital, superior alveolar (anterior, middle and
posterior) and greater palatine nerves.
• Near the midpoint of the infraorbital canal, a small branch, the anterior
superior alveolar nerve arises which passes in its own canal, the canalis
sinosus, to the anterior wall of the maxilla.
• It passes anterior to the inferior turbinate and reaches the nasal septum in
front of the incisive foramen.
• It supplies the anterior wall of the maxillary sinus, the pulps of the canine
and incisor teeth, the anteroinferior quadrant of the lateral nasal wall, the
floor of the nose and a small portion of the anterior nasal septum.
• Posterior superior alveolar nerves : Arise from the maxillary nerve in
the pterygopalatine fossa and enter the maxilla through the posterior
wall to supply the adjacent mucosa and molar teeth.
• The middle superior alveolar nerve, when present, arises from the
infraorbital nerve in its canal and supplies the lateral wall of the sinus
and upper premolar teeth.
• The posteromedial wall of the sinus is supplied by the greater palatine
nerve and the roof by perforating branches from the infraorbital
nerve.
• LYMPHATIC DRAINAGE : Predominantly into the pterygopalatine fossa
and to the submandibular nodes.
• The natural ostium of the maxillary sinus is located immediately
posterior to the nasolacrimal duct at the base of the ethmoidal
infundibulum and is covered by the transition of the uncinate process
from its vertical to horizontal parts.
• Usually around 5mm in diameter. However, size can vary from 3mm to
10mm.
ANTERIOR AND POSTERIOR
FONTANELLES
• Fontanelles : Areas of the medial maxillary wall lying just above the inferior
turbinate not filled in by other bones.
• Anterior fontanelle : Lies anterior and/or inferior to the free edge of the uncinate
process;
• Posterior fontanelle : Lies posterior and/or inferior.
• They are closed with mucosa, connective tissue and in continuity with the
maxillary periosteum
• May be sites of accessory ostia, seen in approximately 5% of the normal
population and up to 25% of patients with chronic rhinosinusitis.
• Size of the accessory ostia vary from a pinhole to 1cm in diameter, the majority
occurring in the posterior fontanelle.
• Natural ostium of the maxillary
sinus lies between the anterior
and posterior fontanelles of the
maxillary sinus and cannot
usually be seen with a 0 degree
endoscope without removing
uncinate process.

Accessory ostia in the posterior fontanelle (*) and left

maxillary sinus ostium (**).
THANK YOU