Download Fronto-ethmoid Cells

4/10/2013
FESS:
The Required Imaging
Anatomy
Vincent Chong, MD MBA FRCR
Professor
Department of Diagnostic Imaging
National University Heath System
Singapore
• Kennedy DW. Functional endoscopic sinus surgery: technique.
Arch Otolaryngol Head Neck Surg 1985; 111:643-649
• Stammberger H, Posawetz W. Functional endoscopic sinus
surgery. Concept, indications and results of the Messerklinger
technique. Eur Arch Otorhinolaryngol. 1990;247(2):63-76.
1
4/10/2013
Overview

Normal anatomy




General concepts
Specific anatomic structures
Variants
Pathological anatomy


Stress normal anatomy
Appropriate imaging modality
Basal Lamella &
Drainage System
Middle
turbinate
Basal lamella
Middle
turbinate
2
4/10/2013
Basal Lamella &
Drainage System

Anterior system



Ostiomeatal unit
Ethmoid infundibulum
Middle meatus
B
Basal Lamella &
Drainage System

Posterior system



Posterior ethmoid cells
& sphenoid sinus
Sphenoethmoidal
recess
Superior meatus
PE
Sphenoid
3
4/10/2013
Anterior Drainage System:
Ostiomeatal Complex
Middle
turbinate
Posterior Drainage System:
Spheno-ethmoidal Recess
PE
S
Sphenoethmoidal
recess
4
4/10/2013
Spheno-ethmoidal Recess
PE
Superior
turbinate
Nasal
septum
S
Identifying the
spheno-ethmoidal recess
Frontal Recess
Relationships

Anterior


Posterior

Ethmoid bulla
Agger nasi cell
A
Anterior wall of
ethmoid bulla
5
4/10/2013
Lamina
papyracea
Frontal Recess
Relationships

A
Medial


MT
Middle turbinate
Lateral

Lamina papyracea
Lamina
papyracea
Frontal Recess
MT
A
6
4/10/2013
Frontal Bulla Cells
Fronto-ethmoid Cells
A
A
Kuhn Type 1: single cell above
agger nasi
Fronto-ethmoid Cells
Kuhn Type 2: Two or more
cells above agger nasi
7
4/10/2013
Fronto-ethmoid Cells
Kuhn Type 2: Two or more
cells above agger nasi
Fronto-ethmoid Cells
Kuhn Type 2: Two or more
cells above agger nasi
8
4/10/2013
Fronto-ethmoid Cells
Kuhn Type 3: Two or more
cells above agger nasi
Fronto-ethmoid Cells
9
4/10/2013
Frontal Bulla
Frontal bulla
cell
Difficult to differentiate frontalethmoidal cells from frontal bulla
cells on coronal sections alone
Frontal
bulla cells
Frontal Bulla versus K3 Cells
Frontal
bulla cell
K3
Leunig A et al. Surgical anatomy of the frontal recess – is there a
benefit in multiplanar CT-reconstruction? Rhinology, 46, 188-194, 2008
10
4/10/2013
Middle Turbinate




Insertion
Anterior ethmoidal
artery
Concha bullosa
Orientation
Insertion of MT
11
4/10/2013
A
P
A
Attached to lamina
papyracean
P
12
4/10/2013
A
Attached to medial wall
of maxillary sinus
P
Skull Base Insertion of MT:
Critical Anatomy
Cribriform plate “sieve-like”
13
4/10/2013
Skull Base Insertion of MT:
Critical Anatomy
Keros (1962): Type I, II, III
Skull Base Insertion of MT:
Critical Anatomy
Keros (1962): Type I, II, III
14
4/10/2013
Skull Base Insertion of MT:
Critical Anatomy
Anterior
Ethmoidal Artery
15
4/10/2013
Anterior
Ethmoidal Artery
Anterior
Ethmoidal Artery
16
4/10/2013
MT Variant:
Concha Bullosa
MT Variant:
Concha Bullosa
17
4/10/2013
MT Variant:
Concha Bullosa
Endoscopic Diagnosis
Versus
CT Diagnosis
MT Variant:
Concha Bullosa
How should we
treated the
inflammation?
18
4/10/2013
MT Variant:
Concha Bullosa
My Journey (through time….)
19
4/10/2013
20
4/10/2013
Uncinate Process

Insertion


Anteriorly nasolacrimal
apparatus
Inferiorly inferior turbinate
Uncinate Process

Insertion


Anteriorly nasolacrimal
apparatus
Inferiorly inferior turbinate
21
4/10/2013
Uncinate Process
Hiatus semilunaris
Uncinate Process

Insertion


Anteriorly nasolacrimal
apparatus
Inferiorly inferior turbinate
B
22
4/10/2013
Uncinate Process

Ethmoid infundibulum


Lamina papyracea
Ethmoid bulla
Uncinate Process

Insertion in lamina
papyracea


Recessus terminalis
Ethmoid infundibulum
sealed off from frontal
recess
23
4/10/2013
Uncinate Process
Uncinate Process

Insertion in skull base
24
4/10/2013
Uncinate Process
Uncinate Process
25
4/10/2013
Uncinate Process: Variants
Maxillary Sinus Ostia
Accessory Ostia &
Nasal Fontanelle
26
4/10/2013
Ethmoid Cell Anatomy

Ethmoid





Absent - torus
ethmoidalis
Small
Giant
Infraorbital ethmoid
(Haller Cell)
Sphenoethmoid
(Onodi Cell)
Haller Cell


Albrecht von Haller (19th century Swiss
anatomist)
Location


Below ethmoid bulla, along orbital floor
Significance


Infection
Imaging (not surgical) diagnosis
27
4/10/2013
Haller Cell
Haller Cell
28
4/10/2013
Haller Cell Infection
Sphenoethmoid (Onodi) Cell

What is a Onodi (1908)
cell?



Post ethmoid cell
Superior to & lateral to
sphenoid sinus
Optic nerve contact
29
4/10/2013
Posterior Ethmoid:
Critical Anatomy

Optic nerve relations



Posterior ethmoid cell
Sphenoid sinus
Onodi cell
PE
S
PE
S
30
4/10/2013
Posterior Ethmoid:
Critical Anatomy
Sphenoid Sinus:
Critical Anatomy



Optic nerve
Maxillary nerve
Carotid artery
Optic N
31
4/10/2013
Man with headache, postendoscopy, sudden blindness
S
S
Man with headache, postendoscopy, sudden blindness
S
32
4/10/2013
Man with headache, postendoscopy, sudden blindness
Trigeminal Nerve (V2)
Neuralgia
CN V2
33
4/10/2013
Trigeminal Nerve (V2)
Neuralgia
Trigeminal Nerve (V2)
Neuralgia
34
4/10/2013
Carotid Artery
More “dangerous”?
Less “dangerous”?
This is dangerous!
35
4/10/2013
Mucosal Variant:
Nasal Cycle (Lillie, 1923)


Normal
Affects





Turbinates
Nasal septum
Ethmoid cells
Suprachiasmatic
nucleus of hypothalamus
Age
Mucosal Variant:
Nasal Cycle (Lillie, 1923)
36
4/10/2013
37
4/10/2013
Reminders



Meningocoeles
Meningomyelocoeles
Tumours


Pituitary
Macroadenoma
Nasal Meningocoeles
38
4/10/2013
Nasal Meningocoeles
Nasal Meningocoele
Pituitary Macroadenoma
Macroadenoma
39
4/10/2013
Conclusion:
Drainage System
Middle
turbinate
Basal lamella
Middle
turbinate
Conclusion:

Anterior



Ostiomeatal complex
Middle meatus
Posterior


Sphenoethmoidal
Superior meatus
40
4/10/2013
Conclusion: Frontal Recess
Ethmoid bulla
A
Conclusion: Frontal Recess
Frontal Bulla versus K3 Cells
Frontal
bulla cell
K3
Leunig A et al. Surgical anatomy of the frontal recess – is there a
benefit in multiplanar CT-reconstruction? Rhinology, 46, 188-194, 2008
41
4/10/2013
Conclusion:
AEA
Conclusion:
Ethmoid Cell


Infraorbital ethmoid
(Haller Cell)
Sphenoethmoid
(Onodi Cell)
42
4/10/2013
Conclusion: Posterior Ethmoid
Critical Anatomy
PE
S
Conclusion: Critical Sphenoid
Sinus Anatomy
43
4/10/2013
Conclusion: Reminders
Encephalocoele
Pituitary
macroadenoma
Conclusion: Reminders
Carotid Aneurysm
44