AJR 2001; 176:241-245
© American Roentgen Ray Society
Three-Dimensional Volumetric Display of the Nasal Ostiomeatal Channels and Paranasal Sinuses
T. F. Gotwald1,
S. J. Zinreich2,
F. Corl3 and
E. K. Fishman3
1
Radiology II, University Clinic of Innsbruck, Anichstra. 35, 6020 Innsbruck,
Austria.
2
Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical
Institutions, Phipps B-100, 600 N. Wolfe St., Baltimore, MD 21287.
3
Department of Radiology, Johns Hopkins Medical Institutions, 601 N. Caroline
St., Baltimore, MD 21287.
Received February 14, 2000;
accepted after revision June 1, 2000.
Address correspondence to S. J. Zinreich.
Introduction
The premise behind functional endoscopic sinus surgery is the reduction of
sinus disease through improved ventilation and mucociliary clearance within
the paranasal sinuses [1]. The
surgical procedure is guided by endoscopy and, therefore, requires a precise
understanding of the highly individualized anatomy of this area. CT in the
coronal plane provides the closest imaging correlation to the endoscopist's
view and has been used since the introduction of functional endoscopic sinus
surgery to guide the surgeon performing this procedure
[2]. Nevertheless, since the
introduction of this technique, the radiologist's aim and the
otolaryngologist's wish have been to view this area three-dimensionally. Given
the three-dimensional (3D) reconstruction programs available over the past 15
years, an accurate 3D reconstruction of the underlying anatomy has been
virtually impossible. The newly available volumetric 3D display made possible
by the Virtuoso 3D workstation (Siemens Medical, Iselin, NJ) is, for the first
time, able to provide reliable and realistic 3D images in an interactive,
real-time display [3,
4]. The objective of this
presentation is to show the 3D anatomy of the nasal cavity and paranasal
sinuses with the Virtuoso 3D imaging workstation.
The Role of Imaging in Functional Endoscopic Sinus Surgery
The wide individual variability of the anatomy of the nasal cavity and
paranasal sinuses; the proximity to the orbit, optic canal, and intracranial
compartments; and the hidden nature of superimposed layers of cells
necessitate an accurate and dependable anatomic road map to guide the surgical
procedure. CT excellently displays the bony architecture and its mucosal
covering as well as the narrow air channels of the ostiomeatal complex.
Furthermore, CT accurately depicts the boundaries between the paranasal
sinuses, the orbit, and the intracranial compartment and the relationship
between the optic nerve, the cavernous carotid artery, and the fifth cranial
and vidian nerves to the sphenoidal sinus
[5,6,7].
Subjects and Methods
Patients were scanned in the axial plane (2-mm slice thickness, 1-mm
reconstruction interval) on a conventional helical CT scanner (Somatom Plus 4;
Siemens Medical). The imaging data were subsequently transferred to the
Virtuoso 3D workstation for imaging.
The Anterior Ostiomeatal Channels
The frontal recess (Figs. 1A
and 1B) is an hourglass-shaped
channel affording communication between the frontal sinus and the anterior
ethmoidal sinus. The frontal recess is not a tubular structure, as the former
term "nasofrontal duct" implies; therefore, this term has been
replaced with the term "frontal recess." The agger nasi cells
(Fig. 1C), frontal cells, and
suprabullar recess cells are in contiguity with the frontal recess, and the
various shapes and sizes of these cells influence the patency of the frontal
recess. The agger nasi cells (Fig.
2A,2B)
are situated below the frontal sinus; these cells are the most anterior cells
in the anterior ethmoidal sinus complex and are aerated to various degrees in
virtually everyone. The agger nasi cells border the nasal bone anteriorly and
the middle turbinate medially, and the uncinate process adheres to their
lateral border. Supraorbital ethmoidal cells develop as an extension from the
frontal or suprabullar recess. They can pneumatize the orbital plate of the
frontal bone. The number and shape of cells that may be present between the
agger nasi cells and the frontal sinus vary. Some frontal cells will indent
and some will actually be within the perimeter of the frontal sinus. Schaeffer
[8] and Van Alyea
[9] describe four types of
frontal cells that may encroach on the frontal sinus or frontal recess. The
frontal recess affords mucociliary drainage of the frontal and anterior
ethmoidal sinuses to the middle meatus and ethmoidal infundibulum. From the
frontal recess, mucous may flow directly into the middle meatus medial to the
uncinate process, into the ethmoidal infundibulum more laterally, or above the
ethmoid bulla more posteriorly (Fig.
3A,3B).
The middle meatus is an air space lateral to the middle turbinate and medial
to the uncinate process and ethmoid bulla. The uncinate process is a superior
extension of the medial maxillary sinus wall. Anteriorly, the uncinate process
fuses with the agger nasi cells and the posterior wall of the nasal lacrimal
duct. The uncinate process may adhere to the middle turbinate and to the
ethmoid bulla (Fig.
4A,4B).
Superoposteriorly, it has a free edge that is separated from the ethmoid bulla
by a crevice termed the "inferior hiatus semilunaris." Inferiorly
and laterally, this crevice communicates with the ethmoidal infundibulum, an
air space bordered medially by the uncinate process and laterally by the
lamina papyracea.
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Fig. 1A. —Three-dimensional volume-rendered images illustrate anatomy
of frontal sinus and frontal recess region. 21-year-old woman with chronic
sinus pain. Axial image from helical CT data reveals frontal sinus ostia
(arrows).
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Fig. 1B. —Three-dimensional volume-rendered images illustrate anatomy
of frontal sinus and frontal recess region. 33-year-old man with facial pain.
Coronal image shows frontal recess (solid white arrow), ethmoid bulla
(asterisk), uncinate process (black arrows), and concha
bullosa (open arrow).
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Fig. 1C. —Three-dimensional volume-rendered images illustrate anatomy
of frontal sinus and frontal recess region. 21-year-old woman with chronic
sinus pain. Sagittal image shows frontal recess (long solid arrow),
ethmoid bulla (asterisk), uncinate process (short solid
arrow), retrobullar recess (open white arrow), and agger nasi
cell (open black arrow).
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Fig. 2A. —Three-dimensional volume-rendered images illustrate anatomy
of anterior ethmoidal sinus region. 21-year-old woman with sinus pain.
Sagittal image reveals location of frontal recess (long arrow),
ethmoid bulla (asterisk), and uncinate process (short
arrows).
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Fig. 2B. —Three-dimensional volume-rendered images illustrate anatomy
of anterior ethmoidal sinus region. 17-year-old boy with chronic sinus pain.
Sagittal image shows middle meatus, ethmoidal infundibulum (white
arrow), and agger nasi cell (black arrow).
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Fig. 3A. —44-year-old man with chronic sinus pain. Axial and sagittal
three-dimensional volume-rendered image shows frontal recess (arrow),
anterior middle meatus (M), and suprabullar recess (asterisk).
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Fig. 3B. —44-year-old man with chronic sinus pain. Conventional
endoscopic image shows structures similar to those seen in A: frontal
recess (arrow), anterior middle meatus (M), and suprabullar recess
(asterisk).
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Fig. 4A. —Three-dimensional volume-rendered images illustrate anatomy
of uncinate process region. 27-year-old man with facial pain. Coronal image
reveals uncinate process (solid arrow) adhering to middle turbinate
(open arrow).
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Fig. 4B. —Three-dimensional volume-rendered images illustrate anatomy
of uncinate process region. 18-year-old woman with sinus pain. Oblique axial
image shows uncinate process (arrow) adhering to medial wall of
ethmoid bulla.
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The ethmoidal infundibulum (Fig.
5) is an extension of the primary ostium of the maxillary sinus.
Thus, ventilation and physiologic mucociliary clearance occur through the
primary ostium of the maxillary sinus, into the ethmoidal infundibulum through
the hiatus semilunaris inferior into the middle meatus. The ethmoid bulla is
usually the largest aerated cell in the anterior ethmoidal sinus complex.
Laterally, the wall of the ethmoid bulla is the lamina papyracea. In most
patients, the ethmoid bulla is totally enclosed with only a small ostium
present; however, occasionally the posterior wall of the ethmoid bulla is
absent whereby the ethmoid bulla and retrobullar recess (sinus lateralis) are
a single air space. The retrobullar recess is the most posterior air space in
the anterior ethmoidal sinus complex.
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Fig. 5. —32-year-old man with sinus pain. Oblique coronal
three-dimensional volume-rendered image reveals primary ostium of maxillary
sinus (arrow), uncinate process (u), ethmoidal infundibulum
(dotted line), and infraorbital recess cell (h).
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The middle turbinate adheres anteriorly and superiorly to the skull base
just lateral to the cribriform plate. It fuses together anteriorly with the
uncinate process and the medial wall of the agger nasi cell. As the middle
turbinate projects posteriorly, it is located medial to the structures
mentioned earlier and provides the medial border for the middle meatus.
Approximately in its mid course, "leaflets" begin to fan out,
attaching laterally to the lamina papyracea and posteriorly to the roof of the
ethmoidal sinus. The first lateral attachment is the basal lamella, which
forms the boundary between the anterior and posterior ethmoidal sinus complex
(Fig.
6A,6B).
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Fig. 6A. —21-year-old woman with chronic sinus pain. Axial
three-dimensional volume-rendered images obtained from helical CT data reveal
anatomy of region of the basal lamella. Image reveals location of uncinate
process (arrows) and ethmoidal infundibulum (dotted
line).
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Fig. 6B. —21-year-old woman with chronic sinus pain. Axial
three-dimensional volume-rendered images obtained from helical CT data reveal
anatomy of region of the basal lamella. Image reveals location and orientation
of retrobullar recess (s) situated between ethmoid bulla (asterisk)
and basal lamella (arrowheads).
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The Posterior Ostiomeatal Channels
The relationship between the aerated portion of the sphenoidal sinus and
the posterior ethmoidal sinus needs to be accurately perceived by the surgeon
to avoid complications during surgery. This morphology is best displayed in
the axial plane with 3D imaging (Fig.
7A,7B)
of the sphenoidal sinus.
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Fig. 7A. —Sagittal three-dimensional volume-rendered images illustrate
sphenoethmoidal recess region. 53-year-old woman with facial pain. Image
obtained from helical CT data reveals sphenoethmoidal recess (solid
arrow), sphenoidal sinus (S), posterior ethmoidal sinus (P), and superior
turbinate (open arrow).
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Fig. 7B. —Sagittal three-dimensional volume-rendered images illustrate
sphenoethmoidal recess region. 37-year-old man with sinus pain. Image shows
sphenoethmoidal recess (arrow), sphenoidal sinus (S), and posterior
ethmoidal sinus (P).
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Usually in the paramedian sagittal plane, the sphenoidal sinus is the most
superior and posterior air space. In the more lateral plane, the sphenoidal
sinus is situated more inferiorly, and the most posterosuperior air space is
the posterior ethmoidal sinus. The sphenoidal sinus is usually embedded in the
clivus and bordered superoposteriorly by the sella turcica. The ostium of the
sphenoidal sinus lies in its anterosuperior region (Fig.
8A,8B).
The sphenoidal sinus and the posterior ethmoid air cells drain into the
superior meatus via the sphenothmoidal recess or into the supreme meatus
through tiny ostia located just under the superior turbinate. The
sphenoethmoidal recess lies between the anterior wall of the sphenoidal sinus
and the posterior ethmoidal sinus cells. The posterior nasal septum is
frequently pneumatized and always in communication with the sphenoidal sinus.
These air spaces can be infected, and a mucocele may evolve. Horizontally
situated "septations" in the sphenoidal sinus are actually bony
separations between the posterior ethmoidal sinus and the sphenoidal sinus.
These separations indicate a posterior extension of the posterior ethmoidal
sinus above the aerated sphenoidal sinus. Septations in the sphenoidal sinus
assume a vertical orientation. It is important to note whether these bony
structures adhere to the carotid canal and optic canal. The surgeon operating
in the sphenoidal sinus must be extremely careful not to infringe on this
relationship (Fig.
9A,9B).
Doing so could result in a carotid artery puncture or optic nerve injury
[8].
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Fig. 8A. —Three-dimensional volume-rendered images illustrate anatomy
in the region of the sphenoidal sinus ostium. 37-year-old man with sinus pain.
Coronal image shows location of sphenoidal sinus ostium (arrowhead).
Note dehiscence in medial maxillary sinus wall (arrow).
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Fig. 8B. —Three-dimensional volume-rendered images illustrate anatomy
in the region of the sphenoidal sinus ostium. 43-year-old woman with sinus
pain. Axial image shows sphenoidal sinus ostia (arrowheads).
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Fig. 9A. —Three-dimensional volume-rendered images illustrate
relationship of optic canal and carotid artery to sphenoidal sinus.
37-year-old man with sinus pain. Axial image shows indentation of optic canal
into sphenoidal sinus (arrows).
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Fig. 9B. —Three-dimensional volume-rendered images illustrate
relationship of optic canal and carotid artery to sphenoidal sinus.
32-year-old man with sinus pain. Oblique coronal image shows pneumatized
anterior clinoid process (asterisk) and optic canal
(arrow).
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Introduction
The Role of Imaging...
