CT PNS

By
Dr.K.PRASANNA
Radiology Resident
RMMCH

CONTENTS
NOSE AND NASAL FOSSA
PARA NASAL SINUSES
OSTEOMEATAL COMPLEX
ANATOMICAL VARIATIONS
IMAGING MODALITIES
CT PROCEDURE & SECTIONS
CONCLUSION

NOSE AND NASAL

FOSSA

NOSE AND THE NASAL FOSSA

Bony part & cartilaginous part covered by

muscle & skin

Cartilaginous part upper & lower lateral

cartilages, lesser alar cartilages & septal
cartilage

Nasal skin

Internal nose divided into the

Right and left by the nasal
septum

NOSE AND THE NASAL FOSSA

NASAL CAVITY PROPER

Roof Nasal bone,

sphenoid & ethmoid
bone

Floor - Palatine
process of the maxilla
& Palatine bone

Medial wall

Lateral wall

Medial Wall - Nasal

Seperates the nasalSeptum
cavity into
two.
Columellar septum
Membranous septum
Septum proper
Perpendicular plate of ethmoid
Vomer
Septal cartilage
Minor contributions crest of
nasal bone, nasal spine of
frontal bone, rostrum of
sphenoid, crest of maxilla &
palatine bone

Blood supply

Mainly by both Internal &

external carotid, both on
the septum & lateral walls

Anterior & posterior

ethmoidal artery

Sphenopalatine artery

Septal branch of greater

palatine

Septal branch of superior

labial artery

LATERAL WALL

Formed by bony, soft tissue

& cartilage

Bony
Ethmoid infundibulum &

uncinate
Perpendicular plate of

palatine bone
Medial plate of pterygoid

process of sphenoid bone

Medial surfaces of lacrimal

bones and maxillae

Inferior conchae

Cartilage In
external nose, the
lateral wall of cavity
is supported by
cartilage (lateral
process of septal
cartilage & major,
minor alar cartilage)

LATERAL WALL

Marked by three bony projections, they extend

medially across the nasal cavity separating the nasal
cavity into for air channels the turbinates or conchae

Superior ,middle & inferior tubinates or conchae. The

conchae do not extend forwards into the external nose

The air space below and lateral to each turbinate is

called as meatus

Superior, middle & inferior meatus & sphenoethmoidal

recess

Middle Meatus much significant

LATERAL WALL
Superior Meatus Limited only to posterior

one third of lateral wall. Posterior ethmoidal sinus

opens into it.

Middle Meatus
Inferior Meatus Runs along the whole length
of lateral wall. Nasolacrimal duct opens in its
anterior part. Largest of all meatus

Sphenoethmoidal recess Above the

superior turbinate. It receives the opening of

sphenoid sinus

MIDDLE MEATUS
Bulla ethmoidalis Bulge
produced by the middle
ethmoidal cells

Uncinate process Superior

extension of lateral nasal wall
(medial wall of maxillary
sinus). Medial and inferior to
bulla ethmoidalis

MIDDLE MEATUS

Infundibulum Air passage

connecting the maxillary
sinus ostium to middle
meatus

Hiatus Semilunaris Gap

between the uncinate
process and bulla
ethmoidalis. Medially it
communicates with middle
meatus. Laterally & inf it
communicates with
infundibulum

MIDDLE MEATUS

Frontal sinus Opens

into the anterior part of
hiatus semilunaris

Maxillary sinus Opens

into the posterior part
of hiatus semilunaris

Anterior and middle

ethmoidal cells Opens
into the upper margin
bulla ethmoidalis

ETHMOID BONE

SINUSES

SINUSES

Air containing cavity in certain skull bones

Develop as a diverticula/outpouching from the

lat wall of nose & extend into Maxilla, Ethmoid,
sphenoid and frontal bones

Four sinuses Maxillary, Frontal, Ethmoid (Ant

& Post) & Sphenoid

Some sinuses are well developed &

asymmetrical

Sinuses

Each sinuses have

orifices that open
into the meatus,
covered by
turbinates

Sinuses
Clinically
- two
groups

Anterior
Frontal,
Maxillary,
Ant.Ethmoid
al

Posterior
Post
Ethmoidal,
Sphenoid

Middle
meatus
Sup. Meatus
&
sphenoethmo
idal recess

SINUSES

Significance
Lighten the skull & facial bones
Contributes to vocal resonance
Collapsible framework that helps the brain to protect

from blunt trauma

EPITHELIUM

They are lined by mucosa similar to that of the nasal

cavity pseudo stratified ciliated columnar epithelium

Epithelium contains Mucinous & serous glands

Mucoperiosteum

Physiology
Approx 1.5 - 2
lit/day
Mucous produced
from the glands are
removed by two
mechanisms
Ciliary action
Slime trails

Sinuses Status at
First
Reache
Birth
Radiologi s Adult
cal
size by
evidence
Maxillary
sinus

Present at
birth

4-5 months
after birth

15 years

Ethmoid
sinus

Present at
birth

1 year

12 years

Sphenoid
sinus

Not Present

4 years

15 years
adult age

Frontal
Sinus

Not Present

6 years

Size
increases
until teens

Maxillary Sinus - (Antrum of

Highmore )

Largest paranasal sinus

Pyramidal in shape

Base - towards lateral wall of nose

Apex towards zygomatic process of maxilla

Maxillary Sinus - (Antrum of

Highmore )

Present at birth as a rudimentary sinus

First radiological evidence is at 4-5 months

after birth

Reaches adult size by 15 years

On average,
it has capacity
of 14.75 ml (14-15)

Maxillary Sinus - (Antrum of

Highmore )
Ant wall
Post wall
Med wall
Roof
Floor

Facial surface of maxilla

and cheek
Infra temporal &
pterygopalatine fossa
Middle & inferior meatuses
(this wall is thin &
membranous)
Floor of orbits
Alveolar part of maxilla

Maxillary Sinus - (Antrum of

Highmore )

Maxillary Sinus - (Antrum of

Highmore )

DRAINAGE OSTIUM

Seen high up in the medial wall

Does not open directly into the nasal cavity, but

opens into post. part of ethmoidal infundibulum, via

hiatus semilunaris into middle meatus.
The infundibulum is the air passage that connects

the maxillary sinus ostium to the middle meatus.

Unfavourable for natural sinus drinage
Accessory ostium 30 % cases

Maxillary Sinus - (Antrum of

Highmore )

Arterial supply Maxillary

artery, infra orbital, facial
& greater palatine

Venous supply anteriorly

by facial vein & post.by
maxillary vein

Nerve supply infra orbital,

anterior, middle & posterior
superior alveolar nerves

Lymph nodes cervical nodes

& submandibular nodes

Maxillary Sinus - (Antrum of

Highmore )

FRONTAL SINUS

Situated between the outer & inner table of frontal

bone

Funnel shaped

Two sinuses on either side

Asymmetrical

Intervening bony septum which may be thin or

deficiency

Frontal Sinus

Not present at birth

First radiological evidence is at 6 years

Reaches adult size after puberty

The natural frontal sinus ostium is usually located in the

posteromedial floor of the sinus (most dependent part).

It opens into the middle meatus

The ethmoidal infundibulum can act as a channel for

carrying the secretions (and infection) from the frontal sinus
to anterior ethmoid cells and the maxillary sinus or vice
versa.

Frontal Sinus

They develop from a variable site, their drainage

will be either via an ostium into the frontal
recess or via a nasofrontal duct into the anterior
infundibulum. The opening or duct can be
distorted by expansion of adjacent ethmoid cells

Boundaries

Ant wall Skin over the forehead

Post wall - Meninges & the frontal lobe of brain

Inferior wall - orbit & its contents

Frontal Sinus

FRONTAL RECESS

The frontal recess is an

hourglass like narrowing
between the frontal
sinus and the anterior
middle meatus through
which the frontal sinus
drains. It is not a tubular
structure, as the term
nasofrontal duct might
imply, and therefore the

The frontal recesses

are the narrowest
anterior air channels
and are common sites
of inflammation. Their
obstruction
subsequently results in
loss of ventilation and
mucociliary clearance
of the frontal sinus

AGGER NASI CELL

Anterior, lateral, and inferior to the frontal

recess is the agger nasi cell. It is aerated and
represents the most anterior ethmoid air cell,
usually lying deep to the lacrimal bone.

It usually borders the primary ostium or floor

of the frontal sinus, and thus its size may
directly influence the patency of the frontal
recess and the anterior middle meatus.

Frontal Sinus

The frontal sinus can pneumatize both the

vertical and the horizontal (orbital) plates of
the frontal bone. The deepest area of the
vertical portion of the sinus is near the midline
at the level of the supraorbital ridge, and the
medial sinus floor and the caudal anterior sinus
wall are thinnest in this area. As a result, the
sinus is best approached for a trephination at
this level

Frontal Sinus

There is a rich sinus venous plexus (Breschets

canals) that communicates with both the
diploic veins and the dural spaces.

Arterial supply supra orbital & supra

trochlear

Venous supply superior opthalmic vein

Lymph Submandibular lymph node

Sensory innervation supra orbital & supra

trochlear

Sphenoid sinus

Occupies the body of

sphenoid

Right & left, seperated by a

thin strip of bony septum
(like frontal sinus)

Ostium opens into spheno

ethmoidal recess

Relations of the sinus are

very important, esp during
the surgical approach of

Sphenoid sinus

Sphenoid sinus

Relations

Anterior part
Roof olfactory tract, optic chiasma

& frontal lobe

Lateral optic nerve, internal

carotid artery & maxillary nerve

Posterior part
Roof Pituitary gland in sella turcica
Lateral Cavernous sinus,ICA &

Cranial nerves III, IV, VI & all

divisions of V

Sphenoid sinus

Thin strips of bone separate the

sphenoidal sinuses from the
nasal cavities below and
hypophyseal fossa above

The pituitary gland can be

surgically approached through
the roof of the nasal cavities by
passing first through the
anteroinferior aspect of the
sphenoid bone and into the
sphenoidal sinuses and then

ETHMOID SINUS

Thin walled air cavities in the lateral masses of

the ethmoid bone

Varies from 3 18

Occupy the space between the upper third of the

lateral nasal wall and the medial wall of orbit

Clinically divided into anterior ethmoidal air cells

& posterior ethmoidal air cells, by basal lamella
(lateral attachment of middle turbinate to
lamina papyracea)

ETHMOID SINUS

ETHMOID SINUS

DRAINAGE:

Anterior - a recess of hiatus

semilunaris & middle meatus
via ehmoid bulla
Post- sup.meatus &
spenethmoidal recess.

Present at birth

Reaches adult size by 12 years

First radiological evidence seen

at 1 year

ETHMOID SINUS
Relations

Roof formed by the anterior cranial fossa

Lateral wall - orbit

Medial wall nasal cavity

Thin paper like bony part of the ethmoid separating

the air cells from the orbit, called lamina
papyracea, can be easily destroyed leading to
spread of ethmoidal infections into the orbit

Optic nerve forms a close relationship with the

posterior ethmoidal cells & is at risk during

OSTEOMEATAL
COMPLEX

OSTEO MEATAL
COMPLEX

The osteomeatal complex is the key anatomic

area addressed by endoscopic sinus surgeons.
Blockage of the osteomeatal complex prevents
effective mucociliary clearance, thus leading to
a stagnation of secretions and therefore leading
to recurrent or chronic sinusitis.

OSTEO MEATAL
COMPLEX

The OMC is bounded

medially by the middle

turbinate,
posteriorly and

superiorly by the basal

lamella, and
laterally by the lamina

papyracea.
Inferiorly and anteriorly

the OMC is open.

This anatomic region

therefore includes
Maxillary sinus ostium

ethmoid bulla

frontal recess
uncinate process

infundibulum

hiatus semilunaris
middle meatus.

OSTEO MEATAL
COMPLEX

ANATOMICAL
VARIANTS

Variations of Middle
turbinate
Paradoxic

Curvature

Normally, the convexity of the middle

turbinate bone is directed medially,
toward the nasal septum.

When paradoxically curved, the

convexity of the bone is directed
laterally toward the lateral sinus wall.

The inferior edge of the middle turbinate

may assume various shapes, which may
narrow and/or obstruct the nasal cavity,
infundibulum, and middle meatus.

Variations of Middle
turbinate
Concha Bullosa

It

is an aerated turbinate, most often the

middle turbinate.
Less

frequently, superior & inferior

turbinate aeration can occur.

When

the pneumatization involves the

bulbous segment of the middle turbinate,

the term concha bullosa applies.
If

only the attachment portion of the

middle turbinate is pneumatized, and the

pneumatization does not extend into the
bulbous segment, it is known as a lamellar
concha.

Variations of Middle
turbinate

Other Variations

Additional variations of the middle turbinate can occur,

including medial & lateral displacement, lateral
bending, L shape, and sagittal transverse clefts

Medial displacement due to other middle meatal

structures (i.e., polypoid disease, pneumatized uncinate
process) encroaching upon the middle turbinate.

Lateral displacement - due to the compression of the

turbinate toward the lateral nasal wall by a septal spur
or septal deviation.

Nasal septal deviation

The nasal septum

deviation may compress
the middle turbinate
laterally, narrowing the
middle meatus and the
presence of associated
bony spurs may further
compromise the OMU.

Obstruction, secondary
inflammation, swollen
membranes, and

VARIATIONS OF UNCINATE
PROCESS

DEVIATION

The course of the free edge of the uncinate

process may either extend slightly obliquely
toward the nasal septum, with the free edge
surrounding the inferoanterior surface of the
ethmoid bulla, or it extends more medially to
the medial surface of the ethmoid bulla. If the
free edge of the uncinate is deviated in a more
lateral direction, it may cause narrowing or
obstruction of the hiatus semilunaris and

Attachment

Attachment to the lamina papyracea, the lateral

surface of the middle turbinate, or the fovea
ethmoidalis in the floor of the anterior cranial fossa
may occur.

If the uncinate process attaches to the ethmoidal

roof or middle turbinate, during uncinatectomy,
traction could inadvertently damage the ethmoid
roof and result in CSF rhinorrhea or other
intracranial complications.

Sometimes the free

edge of the uncinate
process adheres to
the orbital floor, or
inferior aspect of the
lamina papyracea.
This is referred to as
an atelectatic
uncinate process

Pneumatization

The pneumatization of the

uncinate process is believed
to be due to extension of the
agger nasi cell within the
anterosuperior portion of the
uncinate process.

Functionally, the pneumatized

uncinate process resembles a
concha bullosa or an enlarged
ethmoid bulla.

Infraorbital Ethmoid Cells

(Hallers Cells)

Infraorbital ethmoid cells

are pneumatized ethmoid
air cells that project
along the medial roof of
the maxillary sinus and
the most inferior portion
of the lamina papyracea,
below the ethmoid bulla
and lateral to the
uncinate process

Onodi Cells

Two definitions of Onodi cells.

The first defines them as the most
posterior ethmoid cells, being
superolateral to the sphenoid sinus
and closely associated with the optic
nerve.

Another, more general description

defines Onodi cells as posterior
ethmoid cells extending into the
sphenoid bone, situated either
adjacent to or impinging upon the
optic nerve

Ethmoid Bulla Variations

Its appearance varies considerably, based on

the extent of pneumatization.

Extensive pneumatization may obstruct the

ostiomeatal complex.

Elongated ethmoid bullae are usually in a

superior to inferior direction rather than in an
anterior to posterior direction.

So, Relatively unlikely to obstruct the

ostiomeatal complex.

Extensive Pneumatization of the Sphenoid

Sinus

Encountered rarely

extends into the

lesser wing and the
anterior and
posterior clinoid
processes

Can lead to
distortion of optic
cannal configuration

Medial Deviation or Dehiscence of the

Lamina Papyracea

May be either congenital

or the result of prior
facial trauma.

It occur most often at the

site of the insertion of the
basal lamella into the
lamina papyracea, thus
rendering this portion of
the lamina papyracea
most delicate

Orbit at risk

Aerated Crista Galli

When aeration of the normally bony crista galli

occurs the aerated cells may communicate with
the frontal recess, and obstruction of this
ostium.

To avoid unnecessary surgical extension into

the anterior cranial vault, it is important to
recognize an aerated crista galli and
differentiate it from an ethmoid air cell.

Posterior Nasal Septal

Air Cell

Air cells are commonly found within the

posterosuperior portion of the nasal septum
and, when present, communicate with the
sphenoid sinus.

As a result, any inflammatory disease that

occurs within the paranasal sinuses may also
affect these cells

Asymmetry in Ethmoid Roof

Height

It is important to note any asymmetry in

the height of the ethmoid roof.

Intracranial penetration during surgery is

more likely to occur on the side where the
position of the roof is lower

IMAGING
MODALITIES

X RAY

CT

MRI

X ray Waters view & caldwell view

Ct gold standard. Coronal & axial sections

MRI is predominantly used for pre and post

operative management of naso sinus malignancy

The chief disadvantage of MRI is its inability to

show the bony details of the sinuses, as both air
and bone give no signal

CT PROCEDURE &
SECTIONS

CT PROCEDURE &
SECTIONS

CT is currently the modality of choice in the

evaluation of the paranasal sinuses and adjacent
structures.

Its ability to optimally display bone, soft tissue, and

air provides an accurate depiction of both the
anatomy and the extent of disease in and around
the paranasal sinuses.

In contrast to standard radiographs, CT clearly

shows the fine bony anatomy of the osteomeatal
channels.

CT PROCEDURE &
SECTIONS

There are few pre requisites in few

situations
a course of adequate medical therapy to eliminate

or diminish reversible mucosal inflammation.

pretreatment with a sympathomimetic nasal spray

15 minutes prior to scanning in order to reduce

nasal congestion (mucosal edema) and thus
improve the display of the fine bony architecture
and any irreversible mucosal disease

CT PROCEDURE &
SECTIONS

Coronal & axial views

The coronal plane best shows the ostiomeatal

unit (OMU), shows the relationship of the brain
to the ethmoid roof.

Coronal plane should be the primary imaging

orientation for evaluation of the sinonasal tract
in all patients with inflammatory sinus disease
who are endoscopic surgical candidates

Coronal section procedure

Prone with chin
hyperextended

Gantry anglutaionperpendicular to hard palate

Section thickness-3mm
contigous

Table increment- 3-4

mmeach step

Kvp-125

Mas-80

Hanging head technique

Coronal section procedure

SCAN LIMITS :

From the ant

margin of frontal
sinus to post
margin of sphenoid
sinus

Coronal section procedure

HEAD HANGING METHOD

Performed in the prone

position, so that any
remaining sinus secretions
do not obscure the OMU

In patients who cannot

tolerate prone positioning
(children, patients of
advanced age, etc.), the
hanging head technique

In this technique, the patient is

placed in the supine position and
the neck is maximally extended.

A pillow placed under the patients

shoulders facilitates positioning.

The CT gantry is then angled to be

perpendicular to the hard palate.

It is not always possible to obtain

true direct coronal images with
this technique

Axial image

Axial images complement the coronal study,

particularly when there is severe disease
(opacification) of any of the paranasal sinuses
and surgical treatment is contemplated.

The axial studies provide the best CT evaluation

of the anterior and posterior sinus walls

Axial images are particularly important in

visualizing the frontoethmoid junction and the
sphenoethmoid recess.

CT axial section of
PNS - image

Axial image

Whenever there is total opacification of the

frontal, maxillary, or sphenoid sinuses, a
complete axial and coronal CT examination
should be performed.

And also, if the patient has a suspected

neoplasm, a complete axial and coronal
examination need to be performed to provide the
most detailed analysis of the sinonasal cavities
and the adjacent skull base

IMAGING PLANE :
REIDSS LINE runs b/w infraorbital margin
(IOM line)
& EAM. (parallel - axial)
ALEXANDERS LINE perpendicular to reids
line. (perpendicular - coronal)

Contrast in CT PNS

Contrast is not required for all cases of CT

paranasal sinus

Used in cases such as vascular lesion,

malignancy, mass extending intra cranially,
acute infections

CHECK LIST
AGE OF THE PATIENT

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