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Surgical Anatomy and Embryology of the Frontal Sinus Chapter 3 23 Chapter 3 Surgical Anatomy and Embryology 3 of the Frontal Sinus Carlos S. Duque, Roy R. Casiano Core Messages Introduction í (Overview) A thorough knowledge of fron- As with any surgical procedure, a thorough knowl- tal sinus anatomy is critical when perfor- edge of anatomy is the one most important factors in ming even basic endoscopic sinus surgical minimizing complications and maximizing one’s procedures. Every endoscopic sinus surge- chances of a good surgical outcome. This is particu- on must be aware of all the normal, as well larly important for otolaryngologists performing en- as the abnormal, variants that may exist doscopic sinus surgery, as each and every one of the paranasal sinuses are in close proximity to critical í The number and size of the paranasal sinu- orbital and skull base structures. A good knowledge ses are determined early during embryolo- of anatomy will enable the surgeon to operate with gic development. Disease processes during more confidence, by improving one’s ability to cor- childhood or early adulthood may modify rectly interpret normal variants from abnormal or this anatomy or its relationship to neighbo- pathological conditions, and determine an appropri- ring structures ate surgical treatment plan to reestablish mucociliary flow to the sinus. This is even more critical for dis- í The close relationship between the frontal torted anatomy, due to previous surgery or neo- sinus and neighboring orbit or anterior plasms. Furthermore, CT imaging has become an in- skull base makes it particularly vulnerable tegral part of the diagnostic armamentarium for si- to complications from disease or surgery nus surgeons. Technological advancements such as intraoperative navigational devices depend on the surgeon’s proper identification of normal or abnor- mal structures on CT or MRI scans. However, despite this technology’s intent of reducing complications, failure to know the sinus anatomy or properly identi- Contents fy critical structures on the scan may still result in Introduction . 21 disastrous consequences. The frontal sinus hides in the anterior cranial Embryology of the Frontal Sinus . 22 vault surrounded by two thick layers of cortical bone. Surgical Anatomy of the Frontal Sinuses . 25 Its naturally draining “ostium”, or frontal infundibu- Conclusions . 30 lum, remains immersed in an intricate complex area covered by ethmoid cells and other anatomical struc- References . 30 tures that may not be so easy to find. In order to bet- ter understand frontal sinus anatomy, one must be- gin with its embryological development. 22 Carlos S. Duque, Roy R. Casiano Embryology of the Frontal Sinus limited superiorly by the frontonasal prominence and inferiorly by the mandibular arch [10, 15, 16]. The frontonasal prominence differentiates inferi- It is important to know that all of the development of orly with two nasal projections, or nasal placodes, the head and neck, along with the face, nose, and par- that will be invaded by the growing ectoderm and anasal sinuses, takes place simultaneously in a very mesenchyme. These structures later fuse and form 3 short period of time. Frontal sinus development be- the nasal cavity and primitive choana, separated gins around the fourth or fifth week of gestation, and from the stomodeum by the oronasal membrane.The continues not only during the intrauterine growth primitive choana will be the point of development period, but also in the postnatal period through pu- for the posterior pharyngeal wall as well as the differ- berty and even early adulthood. ent sinuses. The oronasal membrane will be fully By the end of the fourth week of development, one formed by the end of the fifth week of development, begins to see the development of the branchial arch- to form the floor of the nose (palate). As the embryo es,along with the appearance of the branchial pouch- grows, the maxillary processes and the nasal pla- es and the primitive gut. This gives the embryo its codes come together in the midline, to form the max- first appearance of an identifiable head and face,with illary bone and the beginning of the external nose. an orifice in its middle, called the stomodeum The frontonasal prominence will also develop a cau- (Fig. 3.1). This structure is surrounded by the man- dal mesodermic projection that will form the nasal dibular and maxillary arches or prominences, bilat- septum, diving the nose into two chambers [15–17]. erally. Both of these prominences are derivatives of Simultaneously, while all these changes are start- the first branchial arch. This arch will ultimately give ing to take place, the cranial and facial bones are rise to all of the vascular and neural structures sup- forming as well. The skeletal system develops from plying this area. The newly developed stomodeum is the mesoderm, from which mesenchyme develops, forming the connective tissue (fibroblasts, chondro- blasts, osteoblasts) that eventually differentiates into the various support structures of the nose and para- nasal sinuses. The neural crest cells and mesenchyme migrate to the occipital area and the future site of the cranial cavity, and disperse in order to form the hya- line cartilage matrix that will later become ossified. Each cranial bone is formed by a series of bone spic- ules that grow from the center towards the periphery, to occupy its place.At birth, all cranial bones are sep- arated by layers of connective tissue that later be- come fused and ossified in the postnatal period. Al- though all of these cranial structures are made out of cartilage and eventually will become ossified, they can still be invaded by neighboring epithelial cells (from the nasal cavity), eventually giving rise to the future paranasal sinuses [16, 17]. Around the 25th to 28th week of development, three medially directed projections arise from the lateral wall of the nose. This begins the process of de- fining the anatomical structures of the paranasal si- Fig. 3.1. Ventral view of a 5-week-old embryo, showing the sto- nuses. Between these projections small lateral diver- modeum (S),mandibular arch (MA),2nd branchial arch (2nd), ticula will invaginate into the lateral wall of the prim- 3rd branchial arch (3rd), frontonasal prominence (FP), nasal placode (NP), maxillary prominences (MP), and cardiac bulge itive choana to eventually form the nasal meati (C) (Fig. 3.2) [15–17]. Surgical Anatomy and Embryology of the Frontal Sinus Chapter 3 23 form process. During the 13th week of development the infundibulum continues expanding superiorly, giving rise to the frontonasal recess. It has been pro- posed that the frontal sinus might develop during the 16th week simply as a direct elongation of the infun- dibulum and frontonasal recess, or as an upwards epithelial migration of the anterior ethmoidal cells that penetrate the most inferior aspect of the frontal bone between its two tables.Primary pneumatization of the frontal bone occurs as a slow process up to the end of the first year of life. Up to this moment, the frontal sinus remains as a small, smooth, blind pock- et, and will remain this way until the infant reaches approximately 2 years of life,when the process of sec- ondary pneumatization begins. From 2 years of age until adolescence, the frontal sinus will progressively grow and become fully pneumatized (see Fig. 3.3) [14, 15, 17]. Between 1 and 4 years of age, the frontal sinus starts its secondary pneumatization, forming a cavity no bigger than 4–8 mm long, 6–12 mm high, and Fig.3.2. Between the 25th and 28th week of gestation,lateral di- 11–19 mm wide. After 3 years of age, the frontal sinus verticula will invaginate into the lateral wall of the primitive may be seen in some CT scans. When a child reaches choana to eventually form the nasal meati. Between these in- vaginations lie the prominences that later form the middle tur- 8 years of age, the frontal sinus becomes more pneu- binate (MT), inferior turbinate (IT), and uncinate process (U). matized, and will be seen by most radiological stud- The infundibulum (I), maxillary sinus (M), and frontal recess ies. Significant frontal pneumatization is generally (FR) are seen as small blind recesses or pockets within the not seen until early adolescence, and continues until middle meatus (MM). The inferior meatus (IM) is also noted the child reaches 18 years of age. Frontal sinus development may be variable. On ca- daveric and radiological (CT) studies, the frontal si- The medial projections of ectodermal tissue form the nus is only identifiable in less than 1.5% of infants following structures: less than one year of age [6, 8, 9]. During this period, the frontal sinus remains as a potential pocket and í The anterior projection forms the agger nasi has been referred to as a “cellulae ethmoidalis”, since í The inferior projection (the maxillo-turbi- the findings point clearly to its close embryological nate) forms the inferior turbinate and maxil- and anatomical relationship with anterior ethmoid lary sinus [16, 17] air cells [19, 20, 25]. í The superior projection, known as the eth- The frontal sinuses develop within the frontal moido-turbinate, forms the middle and super- bones. Each bone remains separated by a vertical ior turbinate as well as the small ethmoidal (sagittal) suture line that becomes ossified. This will cells, with their corresponding draining meati, eventually form the frontal sinus intersinus septum. between the septum and the lateral wall of the It is not clear which factors trigger the formation of nose. Between the already formed inferior tur- the frontal sinuses. Some authors have speculated binate and the middle turbinate, the middle that the adolescent growth phase may be stimulated meatus will develop [14–16] by the different hormonal changes or even by the process of mastication itself [13, 19, 20, 25].
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