Diagnostic imaging and

Image-guided Interventions

Sinus Surgery
RAMON SANTOS-OCAMPO, MD

Fovea ethmoidalis or
Ethmoid roof

Crista gali spear

Nasal septum

Cribriform plates

Middle turbinates

Lateral lamella
Olfactory grooves

Fovea ethmoidalis

Crista gali
Cribriform plates

Middle turbinates
Lateral lamella

The Middle Turbinate

It is the key in understanding the relationship of the nasal

structures

Basal lamella or ground lamella

Vertical anteriorly

Horizontal posteriorly

Demarcates the anterior and posterior ethmoid air cells

Middle turbinate (sagittal)

Middle turbinate

Sphenoid sinus

Anterior ethmoid air cells

Posterior ethmoid air cells

Middle turbinate

Anterior ethmoid air cells

Middle turbinate

Posterior ethmoid air cells

Sinus drainage pathway

All the parasinuses drain into

the middle meatus, EXCEPT
for the posterior ethmoid and
sphenoid sinuses

Diagnostic Imaging
Multislice CT still the mainstay imaging modality. Cone Beam CT

PURPOSE

Characterize the disease

Describe extent of disease

Locate surgically relevant anatomic structures

Certain structures may predispose to sinus disease

Identify critical anatomic variations

FESS

Preserve or restore normal flow of mucosal secretions

Chronic rhinosinusitis refractory to medical treatment

main clinical indication

Others
excision of selected tumors
CSF leak closure
orbital decompression
in Graves ophthalmoplegia
optic nerve decompression

dacryocystorhinostomy
choanal atresia repair

Expected findings after FESS

Basic components of FESS include

septoplasty, which is performed in about 10% of patients

uncinectomy

unroofing of the face of the ethmoidal bulla

If maxillary sinus mucosal disease is severe, a maxillary

antrostomy can be performed where the natural ostium is widened

Other components to widen the anterior drainage pathway

middle turbinate resection

ethmoidectomies

Postoperative changes

Status post
septoplasty, right
uncinectomy and
unroofing of
ethmoidal bulla

Complications of FESS
Minor (5%)

Major (5%)

Lamina papyracea violation with

CSF leak

Anterior ethmoidal artery

injury, orbital hematoma

Mucosal hemorrhage

Optic nerve injury, diploplia

Scarring and lateralization of the

middle turbinate

Anosmia / hyposmia

Other nerve injuries

Atrophic rhinitis empty nose

syndrome

Lacrimal duct injury

Meningitis
Intracranial hemorrhage

Relevant Anatomic Structures

Nasal Septum

Describe and measure any

septal deviation and spur
formation

Measure deviation from a line

connecting the crista galli
and base of septum of the
hard palate and report

Some patients may have to

be told ahead of time that a
septoplasty may be required
as the initial part of the FESS
procedure

Osteomeatal complex
Common
drainage
pathway for
the frontal,
maxillary
and anterior
ethmoid
sinuses

E
U

Middle turbinate
Concha bullosa - pneumatized
middle turbinate. if LARGE

or INFLAMED, can
contribute to obstruction

Paradoxical turn of the middle

turbinate

the folding of the concha is

reversed from normal

This can cause uncinate

deviation and infundibular
narrowing

Uncinate process insertion

Lamina papyracea

Skull base

Middle turbinate

The anterior portion of the uncinate process

usually inserts laterally onto the lamina papyracea
or medial wall of an agger nasi cell, so the frontal
sinus drainage is medially directed into the middle

Haller cell

Infraorbital air cell can contribute to

narrowing of the ethmoid
infundibulum or ostium, especially if
diseased

Maxillary sinus

Accessory ostium of the right

maxillary sinus, usually located
posterior to the normal ostium
in 10% of patients

Frontoethmoidal cells

Important if surgeon is
planning to widen the frontal
recess

Agger nasi cell

most anterior ethmoid air

cell
lies just anterior to frontal
recess
if large, may cause medial
displacement of the
middle turbinate
causing
narrowing of the
frontal
recess

A
A

Frontoethmoidal cells

Important if surgeon is
planning to widen the frontal
recess

Agger nasi cell

most anterior ethmoid air

cell
lies just anterior to frontal
recess
if large, may cause medial
displacement of the
middle turbinate
causing
narrowing of the
frontal
recess

Kuhn Classification Scheme

Type I: Single air cell
superior to the agger nasi cell.
Does not protrude into the
frontal sinus.

Type

II: More than one air

cell superior to the agger nasi

cell. None protrudes into the
frontal sinus

Type

III: Single air cell

superior to the agger nasi that

protrudes past the frontal
ostium or frontal beak into the
sinus proper

Type

IV: Isolated air cell

completely within the sinus

proper.

Type III

Type IV

Ethmoidal bulla

Largest and
most constant
anterior ethmoid
air cell

bound
superiorly by
the floor of the
anterior cranial
fossa and
laterally by the
lamina
papyracea

Drains into the

infundibulum

Critical Anatomic Variants

CLOSE

Cribriform plate (how low or how tall are the lateral lamellae?)

Lamina papyracea (any dehiscence)

Onodi or Posterior ethmoid cell (present or absent)

Sphenoid sinus (symmetric, extent of pneumatization, optic nerve

or internal carotid artery bony coverings dehiscent)

Ethmoid artery (Is anterior ethmoid artery present on a mesentery

or embedded in bone)

Wormald, Endoscopic Sinus Surgery Third ed.

2013

CLOSE:

Cribriform

Keros Classification:
based on the depth of the olfactory
fossa

determined by measuring the

greatest height of the lateral
lamella in the coronal plane.

The lateral lamella and cribriform

plate are thin and prone to injury
during endoscopic surgery

the greater the height of the

lamella, the greater the chance of
injury

Keros Type 1
1-3 mm

26%

CLOSE:

Cribriform

Keros Classification:
based on the depth of the olfactory
fossa

determined by measuring the

greatest height of the lateral
lamella in the coronal plane.

The lateral lamella and cribriform

plate are thin and prone to injury
during endoscopic surgery

the greater the height of the

lamella, the greater the chance of
injury

Keros Type 2
4-7 mm
73%

CLOSE:

Cribriform

Keros Classification:
based on the depth of the olfactory
fossa

determined by measuring the

greatest height of the lateral
lamella in the coronal plane.

The lateral lamella and cribriform

plate are thin and prone to injury
during endoscopic surgery

the greater the height of the

lamella, the greater the chance of
injury

Keros Type 3
8-16 mm
1%

Asymmetry

Asymmetry in the heights of

the fovea ethmoidalis or
ethmoid sinus roof can
predispose to penetration of
the anterior skull base if the
sinus surgeon is not aware

may be asymmetric so
measurements should be
made for each side

Asymmetry

Asymmetry in the slopes of the fovea

ethmoidalis or ethmoid sinus roof can
predispose to penetration of the
anterior skull base if the sinus surgeon
is not aware

the operator could mistake the low,

downsloping side for an unopened,
diseased ethmoid air cell

CLOSE:

Lamina papyracea

Penetration into the

orbit may occur if the
surgeon is not aware of
any dehiscence in the
lamina papyracea.

Microdebriders, which
suction and remove
tissue rapidly, may lead
to medial rectus injury
in less experienced
hands

CLOSE:

Onodi cell

Must be mentioned if present

extends to the sphenoid sinus

lying medial to the optic nerve
and displaces the sphenoid sinus
medially and inferiorly

Potential damage to the optic

nerve (in 5%), and less
commonly, the internal carotid
artery when attempts are made
at endoscopy to enter the
sphenoid sinus via what is
thought to be the most posterior
ethmoid cell rather than an
Onodi cell

risk of leaving behind mucosal

disease if the cell is not opened

CLOSE:

Sphenoid sinus

Divided by an intersinus septum which may be complete or

incomplete. Asymmetry between the right and left sinus and
insertion of the septum on the carotid canal should be reported.
Twisting may hurt the vessel

CLOSE:

Sphenoid sinus

Carotid canal dehiscence

May lead to increased risk of

injury

CLOSE:

Sphenoid sinus

Vidian canal

Right vidian canal is

exposed as it traverses the
floor of the sphenoid sinus,
the vidian nerve and artery
are at risk

anterior Ethmoidal
artery
CLOSE:

The ethmoidal arteries are embedded

in the bone of the anterior skull base.
Cone-shaped divot at the
superomedial aspect of the orbital
wall represents the anterior
ethmoidal foramen.

In this case, the artery traverses the

air-filled sinuses below the skull base
on a thin mesentery, which increases
the risk of injury during FESS.
Transection and retraction of the
anterior ethmoidal artery can quickly
result in significant orbital
hemorrhage.

Preoperative CT

Sinus pneumatization and symmetry:

Drainage pathway of frontal sinuses: Insertion of the uncinated

process

Description of frontoethmoidal cells: Kuhn classification

Nasal septum: deviated, quantify

Extent and pattern of sinus disease: greatest measurement of
mucosal thickening, air fluid levels or frothy / bubbly secretions

CLOSE
Osseous sclerosis or areas of dehiscence
Extrasinus findings: dental disease, orbital abnormalities,
intracranial mass lesions and other pathology