CT and MR Anatomy of Paranasal Sinuses: Key Elements 9 2 CT and MR Anatomy of Paranasal Sinuses: Key Elements Roberto Maroldi, Andrea Borghesi, Patrizia Maculotti CONTENTS 2.1.1 Nasal Cavity and Lateral Nasal Wall 2.1 Introduction 9 2.1.1 Nasal Cavity and Lateral Nasal Wall 9 2.1.2 Ethmoid Bone 10 Nasal cavities are located in the midface, separated 2.1.3 Frontal Sinus and Frontal Recess 12 by a median septum; they communicate posteriorly 2.1.4 Maxillary Sinus, Uncinate Process with the nasopharynx through the choanae. The fl oor and Ethmoidal Infundibulum 17 of nasal fossae is the hard palate, the cribriform plate 2.1.5 Sphenoid Sinus 18 and the planum ethmoidalis compose its roof, that 2.2 Development of Nasosinusal Cavities 18 2.3 Surgical Anatomy 18 separate nasal cavities from the anterior cranial fossa. 2.4 Anatomic Variants 19 The nasal septum is made of a “hard” portion (per- 2.4.1 Nasal Septum and Middle Turbinate 19 pendicular lamina of the ethmoid, vomer), and of a 2.4.2 Uncinate Process 20 “soft” part (septal cartilage). 2.4.3 Anterior Ethmoid Cells 20 The lateral nasal wall has a more diffi cult anatomy, 2.4.4 Onodi Cells and Sphenoid Sinus 21 2.4.5 Asymmetry of Ethmoid Roof 22 an understanding of it being critical for endonasal 2.5 Pterygopalatine Fossa and Pterygoid Process 23 surgery planning. 2.6 Nasal Septum 26 The complex anatomical arrangement of the lateral References 26 nasal wall can be more easily understood if related to the embryologic development of turbinates and eth- moid (Wolf et al. 1993). The ethmoid turbinates originate from ridges in the 2.1 lateral nasal wall of the fetus. Each of the fi ve ridges Introduction (ethmoidoturbinals) has an ascending (more verti- cal) and descending (more horizontal) portion, be- A conceptual understanding of the anatomic and ing – therefore – similar to the turbinate in the adult. functional relationships between the nasal cavity Between the fetal ridges are six grooves. Some ridges and paranasal sinuses is of the utmost importance, and grooves will fuse or disappear – partially or to- particularly when dealing with chronic infl ammatory tally – during fetal development to ultimately result in diseases. the nasal turbinates of the adult. Key points are: According to their drainage pathway, the sinusal The fi rst ethmoidoturbinal regresses, i.e. will not cavities may be functionally classifi ed into two sub- develop into a turbinate. The agger nasi is considered groups. The fi rst one includes the anterior ethmoid a residual of the ascending portion, while the uncinate cells, the frontal sinus, and the maxillary sinus; all process is presumably a remnant of the descending these cavities drain mucus into the middle meatus. portion. The second group encompasses the posterior eth- The descending part of the fi rst groove (located moid cells and the sphenoid sinus, both draining into between the fi rst and second ethmoidoturbinals) be- the superior meatus. comes the ethmoidal infundibulum and middle me- atus, whereas the ascending part becomes the frontal recess. R. Maroldi, MD The second ethmoidoturbinal gives rise to the bulla Professor, Department of Radiology, University of Brescia, lamella, a lamina attached to the lateral nasal wall, a Piazzale Spedali Civili 1, Brescia, BS, 25123, Italy A. Borghesi, MD; P. Maculotti, MD structure that can be observed in few patients because Department of Radiology, University of Brescia, Piazzale it is usually pneumatized, therefore appearing as the Spedali Civili 1, Brescia, BS, 25123, Italy bulla ethmoidalis. 10 R. Maroldi et al. The third and fourth ethmoidoturbinals develop, The inferior meatus, although the largest, has a less respectively, into the permanent middle and superior relevant functional role: in this space only the distal turbinates; and the fi fth ethmoidoturbinals become opening of the nasolacrimal duct is found. the supreme (uppermost) turbinate. The superior and uppermost meatus develop from third and fourth fetal grooves. 2.1.2 As a result, ridges fully develop into thin laminae Ethmoid Bone crossing the entire ethmoid to project into the nasal cav- ity (turbinates) or give rise to incomplete laminae, like From a practical standpoint, the ethmoid bone can the uncinate process. Each bony lamina has a constant be divided into four structures: two lateral masses, portion inserting into the lateral nasal wall (ground a sagittal midline lamina, and a horizontal plate lamella) and additional attachments to the lamina (Fig. 2.1). The latter (cribriform plate) is the central cribrosa or to the fovea ethmoidalis (superiorly). part of the fl oor of the anterior cranial fossa. Several In most subjects, four ground lamellae are usually microscopic foramina perforate its thin structure, present, almost each one obliquely oriented, somewhat through which course the olfactory nerve fi laments parallel to one another. The uncinate process – an in- with their perineural investment. completely developed lamella – is the fi rst one, followed by the bulla lamella. If the latter extends vertically up to the ethmoid roof, the frontal recess becomes separated from the rest of the ethmoid. Pneumatization of this la- mella results in the development of the ethmoidal bulla. The third, more constant and complete ground lamella consists of the lateral insertion of the middle turbinate on the lamina papyracea. This lamella separates ante- rior from posterior ethmoidal cells. A fourth lamella is made by the lateral attachment of the superior turbinate. Occasionally, a fi fth lamella may be observed when the supreme turbinate does not regress (KIM et al. 2001). The spaces among the ground lamellae (interturbi- nal meatus) are further subdivided by transverse bony septa, resulting in several cells that communicate with the interturbinal meatus only through a small ostium. Rarely these septa are absent. In this latter condition, Fig. 2.1. The ethmoid plates and fovea ethmoidalis. A midline the original framework of the labyrinth organized (perpendicular plate, PP) and two lateral vertical laminae: the into single large cells – corresponding to the intertur- medial one made by the vertical lamella of the middle turbi- binal meatus – can be observed. nate (vlMT) on the top of which is the vertical lamella of the Variations or anomalies in the development of cribriform plate (vlCP), the lateral one is the lamina papyracea (LP). Horizontal lamella of the cribriform plate (hlCP), hori- ground lamellae and septa will result in a great vari- zontal (hGL) and vertical (vGL) – ascending part – of ground ability of number, size and morphology of the single lamella of the middle turbinate, crista galli (CG), fovea eth- ethmoid cells and may additionally refl ect on the ratio madalis (FE) between the volume of anterior versus posterior cells. As mentioned above, the superior meatus is the drainage pathway of posterior ethmoid cells and On the upper part of the sagittal midline lamina sphenoid sinus (the latter through the sphenoeth- (crista galli) – located just above the cribriform moid recess). plate – inserts the cerebral falx; the inferior part, The middle meatus plays a crucial functional role, below the cribriform plate, being referred to as the as in this area the secretions of several sinuses are col- perpendicular lamina, a component of the nasal lected, namely: septum (Fig. 2.2–2.4). ¼ The ethmoid bulla (roof of the meatus) The lateral masses (ethmoid labyrinth) are made ¼ The anterior ethmoid cells and maxillary sinus, of a variable number (3–18) of pneumatized cells both through the hiatus semilunaris, a subtle fi s- separated by thin bony walls. sure located in front and below the ethmoid bulla Each ethmoid labyrinth is closed by bony mar- ¼ The frontal sinus, through the frontal recess gins on its external and internal surfaces only. The CT and MR Anatomy of Paranasal Sinuses: Key Elements 11 external surface is made by the lamina papyracea the labyrinth is bordered by two constant laminae that separates the cells from the orbit. Dehiscences hanging from the horizontal plate: the middle and may be present. As a result, the periosteum of the superior turbinates. An uppermost small third eth- ethmoid cell comes in contact with the periosteum moid turbinate (supreme turbinate) can seldom be investing the orbital wall (periorbita). Medially, observed. a b c Fig. 2.2a–c. CT coronal reconstructions through the ethmoid labyrinth. a Anterior nasal fossa, level of the uppermost insertion of both uncinate processes on the vertical lamellae of the middle turbinates – type 4 according to Landsberg and Friedman (2001) (white arrows on left side). b Bilateral pneumatization of the horizontal (non-attached) free portion of the uncinate pro- cesses (white arrows on left side). c The horizontal portion of the uncinate process (white arrows on left side) and the inferior surface of the ethmoid bulla (B) limit the oblique and narrow ethmoid infundibulum. The maxillary sinus ostium is detectable at the bottom of the infundibulum (white ellipse). Curved white arrows show the path along the ostium and the infundibulum a b c Fig. 2.3a–c. CT coronal reconstructions through the ethmoid labyrinth. a Middle nasal fossa at the level of the short horizontal portion of the uncinate process posterior to the ethmoid infundibulum (white arrowheads on left side). A large ethmoid bulla (B) impinges the left middle turbinate on left side. b The CT section cuts the posterior part of the bulla (B). The horizontal portion of the cribriform plates (arrowheads) appears thinner than the bone of the fovea ethmoidalis (FE). Bilateral pneumatization of the superior turbinate (ST) is present. c Lateral attachment of the middle turbinate – the ground lamella (opposite arrows) – onto the lateral nasal wall. Posterior ethmoid cells (PEC) extend between the lamina papyracea and the supreme turbinate (SuT) 12 R.