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Paranasal Sinuses: Anatomy and Function Glen T. Porter, MD Francis B. Quinn, MD, FACS The University of Texas Medical Branch Department of Otolaryngology Galveston, Texas Grand Rounds Presentation January 2002 1 Case Report—1000B.C. 2 Sinus Anatomy Overview 7 bones 4 paired sinuses 4 turbinates 3 meati Drainage system Nervous supply Vascular supply Related structures 3 Embryology Maxilloturbinal Ethmoturbinal Middle turbinate Superior turbinate Supreme turbinate Agger nasi Uncinate process Ethmoid infundibulum Sinuses 4 Maxillary Ethmoid Sinus Development 5 6 Pediatric Sinuses Bony Structure Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate 7 Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear 8 Innervation 9 Neurovascular Supply 10 Sinus Drainage Schema 11 Ethmoid Sinus Development Present at birth Anterior/Posterior Variability Structure Volume/shape Roof Lateral wall 12 Ethmoid Roof •Anterior 2/3 •Posterior 1/3 Keros I Keros II Keros III 13 Ethmoid Cells 14Supraorbital, Frontal Bulla, Concha Bullosa, Haller’s, Onodi Cells Ethmoid Sinus—Related Structures Basal Lamella of the Middle Turbinate Three planes Agger nasi cell Childhood sinus Ethmoid Bulla Hiatus Semiluninaris/Superior Hiatus Semilunaris Suprabullar/retrobullar recesses (Sinus Lateralis) Ethmoid Infundibulum/Uncinate Process Anterior/Posterior Ethmoid Arteries Osteomeatal complex 15 Basal/Ground Lamella 16 Basal/Ground Lamella Of the Middle Turbinate The Agger Nasi Cell 17 Ethmoid Bulla Uncinate Process Hiatus Semilunaris 18 Ethmoid Infundibulum 19 Suprabullar/Retrobullar Recess 20 Ethmoid Arteries 21 Osteomeatal Complex 22 Middle meatus Maxillary Sinus Ostium Anterior Ethmoid Drainage Maxillary Sinus Development Present at birth Biphasic growth Level of the floor Structure Volume & shape Walls, floor, roof 23 Maxillary Sinus 24 Maxillary Sinus 25 Maxillary Sinus Related Structures Fontanelles Natural ostium Haller’s Cells &Sinusitis Osteomeatal complex Accessory Ostium Nasolacrimal duct 26 Fontanelles 27 Natural Ostium -Haller’s cells Accessory Ostium 28 Nasolacrimal Duct 29 Frontal Sinus Development Frontal bone at birth Age 5 Structure Volume and shape Ostium Walls Anterior vs. posterior Related Structures 30 Frontal recess Frontal Sinus Ostium Frontal recess Boundaries Dumbbell shape Sinus Lateralis Frontal Bulla 31 Sphenoidal Sinus Development Arise within the nasal capsule (no pouch) Age 3 begins to pneumatize Structure Volume/variable pneumatization Wall thickness Position within the sphenoid 32 Relation to sella turcica Sellar and postsellar relationships Sphenoid Sinus Pneumatization 33 Sphenoid Sinus Sphenoid Sinus 34 Sphenoid Sinus 35 Sphenoid Sinus Ostium Size (.5-4mm) Location (sinus floor, anterior nasal floor, anterior sinus wall, superior turbinate, cribiform plate) Bony dehiscence Related Structures 36 Sphenoethmoidal recess Sphenoid rostrum Onodi cell Sphenoid Ostium Sphenoethmoid Recess Sphenoid Rostrum 37 The Onodi Cell 38 Microscopic Anatomy Mucosa Cilliated columnar epithelial cells Anatomy Beat frequency Inhibitory effects of contact Noncilliated columnar cells Distribution Function 39 Basal cells Microscopic Anatomy—Cont’d Goblet Cells Glycoproteins—viscosity and elasticity Innervation (para=thick, symp=thin) Basement membrane Submucosal glands 40 Distribution Microscopic Anatomy 41 Mucous Blanket Two layers Superficial layer Sol layer Function Superficial layer traps bacteria and particulate matter. Enzymes, antibodies, immune cells 42 Mucociliary Transport Directional Flow of Mucous Toward the choanae Ostium drainage—a stubborn beast Hilding, MD Contact inhibition Haller’s cells Surgery 43 Mucociliary Transport 44 Function of Paranasal Sinuses Humidifying and warming inspired air Regulation of intranasal pressure Increasing surface area for olfaction Lightening the skull Resonance Absorbing shock Contribute to facial growth 45 New Frontiers Sleep apnea and the sinuses Humidification contributes up to 6.9mm Hg serum pO2 Mouth breathers noted to have decreased end-tital CO2—increased serum CO2—apneas (high baseline) Nitric Oxide (NO) 46 NO produced primarily in sinuses Toxic to bacteria, fungi, viruses Increases cilliary motility Case Report 39 yom with h/o sinus disease c/o headache, rhinorrhea. PMHx of “sinus surgery” years ago ROS reveals h/o two episodes of meningitis in past few years PE: right superior nasal mass. S/p FESS. Clear rhinorrhea. 47 48 References Anon, Jack B., et al, Anatomy of the Paranasal Sinuses, Theime, New York, c1996. Bhatt, Nikhil J., Endoscopic Sinus Surgery: New Horizons, Singular Publishing Group, Inc., San Diego, c1997. Bailey, Byron J., et al, Head & Neck Surgery -- Otolaryngology, Lippincott Williams & Wilkins, Philadelphia, c2001. Lundberg, J., Weitzberg, E. Nasal Nitric Oxide in Man. Thorax 1999; 54(10):947-952. McCaffrey, Thomas V., Rhinologic Diagnosis and Treatment, Thieme, New York, c1997. Marks, Steven C. Nasal and Sinus Surgery, W.B. Saunders Co., Philadelphia, c2000. Navarro, Joao A.C., The Nasal Cavity and Paranasal Sinuses, Springer, Berlin, c2001. Watelet, J.B., Cauwenberge P. Van, Applied Anatomy and Physiology of the Nose and Paranasal Sinuses. Allergy 1999; 54, Supp 57:14-25. 49