Sinonasal Anatomy

Embryology
• Embryo’s head
• Structure with two distinct
nasal cavities.
• Lateral nasal walls
• Create complex folds
• Turbinates & sinuses.
• 4-8th weeks ：
– As frontonasal & maxillary
processes join.
– Develops separate nasal
cavities
 Embryology
• Upper maxilla & philtrum of the upper lip.
– Fusion of medial prominence with the maxillary
process
• Septum:
– Posterior midline growth of the frontonasal process
– mesoderm from the maxillary processes.
 Embryology
• Primary & secondary palatal shelves
– Nasal cavity and nasopharynx  oral cavity and
oropharynx.
• Descending septum merges with the fused
palate
– Two nasal cavities .
• Fusion failure
– Cleft lip or palate deformity.
– Extend into the nose
• Technically difficult.
 Embryology
• 6th week ： mesenchyme forms a simple lateral
nasal wall
• 7th week ： three axial furrows form,
– 3 turbinates
• 10th week ：
– Development of the maxillary sinus begins with the
invagination of the middle meatus.
– Uncinate process & the bulla ethmoidalis form a
narrow groove : hiatus semilunaris
 Embryology
• 14th week ：
– Ant. ethmoidal cells from the upper middle meatus
– Post. ethmoidal cells from the floor of the superior
meatus.
• 36th week ：
– Well developed lateral nasal wall
– Turbinates at adult proportions.
• Fully develop ：
– Ethmoid -> Maxillary -> Sphenoid
-> Frontal sinuses.
Anatomy
 Ethmoidal sinuses and lateral
nasal wall
• Central structures
of nose with
complex anatomy

• Box-like structure
with open anterior
& inferior faces.
 Ethmoidal sinuses and lateral
nasal wall
• Lateral ： Lamina papyracea
– the medial walls of the orbits
• Posterior ： sphenoid
• Superior ：
– Skull base of ant. cranial fossa

Skull base of the ant. cranial fossa

Lamina papyracea
 Ethmoidal sinuses and lateral
nasal wall
• Midline vertical plate
– In the anterior cranial fossa
• Crista galli
– In the nasal cavity
• Perpendicular plate of the ethmoid
– Nasal septum

• Horizontal plate
– Medial cribriform plate :
• Medial
– Ethmoid roof.
• Thicker, more lateral
– Anterior cranial fossa
ethmoid
 Ethmoidal sinuses and lateral
nasal wall
• Lateral lamella of the
cribriform plate,
– Thinnest bone in the skull
base.
– Length
• Position of the cribriform plate
 ethmoid roof.
 Ethmoidal sinuses and lateral
nasal wall
• Keros type skull base
– Type 1 ：
• Cribriform plate 1 ~ 3 mm below
fovea ethmoidalis,
• Making the lateral lamella short or
nonexistent.
– Type 2 ： 4-7mm
– Type 3 ： 8-16mm
• Lower cribriform
– Greatest risk for CSF leak during
FESS
 Ethmoidal sinuses and lateral
nasal wall
• From anterior to posterior
– Uncinate process
– Bulla ethmoidalis
– Basal / (Ground) lamella
– Superior turbinate
– Supreme turbinate
• The aeration projects anterior
to the attachment of the
middie T.
– Agger nasi cells
 2

1
 Ethmoidal sinuses and lateral
nasal wall
• Uncinate process ：
– L-shaped bone
– AS to PI direction.
– Posterosuperior margin ：
• Paralle to the inferior border of the
bulla ethmoidalis
– Posterior
• Palatine bone and the Inf. T.
– Superior ：
• Lamina papyracea : most
commonly
• Also attach to agger nasi cell, the
skull base, or the middle T.
 Ethmoidal sinuses and lateral
nasal wall
• Bulla ethmoidalis
– Largest ant. ethmoid air cell
– Lat. ： lamina papyracea
– Post. ： basal lamella
– Sup. ： roof of the ethmoid
• Form the posterior wall of frontal
recess.
• Minimal or absent
pneumatization of the
ethmoid bulla
– 8% of individuals
 Ethmoidal sinuses and lateral
nasal wall
• Basal lamella
– Dividing line :
• Ant.  post. ethmoid sinus.
– Inf. ： connects the middle
T. to the lateral wall 
stabilize
 Ethmoidal sinuses and lateral
nasal wall
• Posterior ethmoid cell
– Larger
– Onodi cell : developmental variant
• 9% to 12%
• Exposure the optic nerve within the ethmoid sinus
lumen.
 Four recesses
• Frontal recess ：
– Drains the frontal sinus
• Infundibulum ：
– 3D space lateral to the
unicate process
– Hiatus semilunaris ： door
– The ostium of maxillary
sinus lies deep within.
• Sinus lateralis ：
– retrobullar recess
– Exists if the post. wall of
the bulla ethmoidalis
doesn’t contact basal
lamella.
• Spheno-ethmoidal recess
– Post. end of superior
meatus.
– Draining the posterior
ethmoid & sphenoid
sinuses separately,
 Ethmoidal sinuses and lateral
nasal wall
• Ant. ethmoid sinus, maxillary sinus, & frontal
sinus
– Drain into or near the infundibulum and ostiomeatal
complex (OMC).
• Post. Ethmoid & sphenoid sinuses
– Into the spheno-ethmoidal recess.
 Ethmoidal sinuses and lateral
nasal wall
• Ant. ethmoid artery
– The weakest portion :
• Enters the anterior cranial fossa through the lateral lamella .
– 1/10 as strong as the roof.

Ant. ethmoidal foramen

Very near skull base at the

junction of ethmoid roof &
posterior border of frontal
recess.
 Maxillary Sinus
• Within maxillary bone
• Largest
– Ant ： facial surface
– Post ： infratemporal fossa
– Medial ： lateral wall of nasal cavity
– Floor ： the alveolar process
– Superior ： Orbital floor
 Maxillary Sinus

• Natural ostium
– Into the ethmoidal infundibulum
– Superior & posterior to the
uncinate process : Most
commonly
– Accessory ostia : 15% ~ 40%
• Haller cell ：
– Pneumatizes laterally
– Between maxillary sinus & floor of
the orbital
– Potentially impairing sinus
drainage.
 Maxillary Sinus
• Infraorbital nerve
– Cross orbital floor
– Infraorbital foramen: exit maxilla
• Dehiscent into the maxillary sinus ：
14%
• First & second molars
– Dehiscent into maxillary sinus ：
2%
– Oroantral fistula following dental
extraction
 Frontal Sinus
• Size varies
– Completely absent (5%)
• Divided by intersinus spetum
• Anterior wall : twice as thick as the
posterior wall
• Floor ： as the supraorbital roof
 Frontal Sinus
• Drainage ostium ： posteromedial sinus floor
– Hourglass-shaped
– Frontal ostium : narrowest
– Agger nasi cell or ethmoidal bulla obstruct frontal sinus drainage
• Narrowing the frontal recess.
– Pattern
• Depends on penumatization of the surrounding ethmoid air cells &
position of unicate process
• The attachment of the superior portion of
the unicate process
– To lamina papyrace
• Middle meatus :88%
– To ethmoid roof
– To middle T.
• Ethmoidal infundibulum
 Sphenoid sinus
• ICA ： lateral to sphenoid sinus
– Cavernous sinus ： prominence in the lateral
wall :65%
• Optic n.
– prominence ： 40%
– Dehiscent ： 6%
 Sphenoid sinus
• 20 years old: reaching completion
• Pneumatization
– Sellar type ： 86%
– Presellar type ： 11%, children
– Conchal type ： 3%, children
• The posterior wall is the thickest wall.
 Sphenoid sinus
• Opens into the sphenoethmoidal recess
– Posteroinferior end of the superior T. as the
best landmark
• In the same horizontal plane as the floor of the
sphenoid sinus
– Medial to superior T. : 83%
– Lateral ： 17%
• Sphenoid septum
– Posteriorly from midline
 Inferior turbinate
• Bilateral outgrowths from the lateral wall
• Central bony skeleton + mucosa layer
• Articulates with the perpendicular plate of the
palatine bone and nasal surface of the maxilla
• Regulates nasal temperature & humidification
 Nasal Septum
• Cartilage & bone covered by
respiratory mucosa
– Structure support & Influences
airflow
• Structure:
– Membranous septum ： connects
the columnella to the cartilage
– Quadrangular cartilage ： ant.
Septum (1)
– Perpendicular plate ： upper 1/3
bony (2)
– Vomer ： bony posteroinferior (3)
 Nasal Valve
• The mobile, airflow-
regulating part of nose.
• Narrowest part of the nasal
airway
– Superolaterior ： caudal edge
of the upper lateral cartilage.
– Inf. ： nasal floor
– Post. ： head of inferior T.
– An angle of 10-15 degrees
• Change: Airflow turbulence and
N-O