APPLIED ANATOMY OF PARA NASAL SINUSES BY DR. SAIMA

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.APPLIED ANATOMY OF PARA NASAL SINUSES

• .MICRO ANATOMY WITH FUNCTION

• PRESENTOR- DR. SAIMA TABASSUM SAROORI
• RESIDENT Ist year,
• DEPARTMENT OF ENT-MMIMSR

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APPLIED ANATOMY OF MAXILLARY SINUS
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• FLOOR
• OROANTRAL FISTULA-MAXILLARY TEETH ARE IN
  DIRECT RELATION TO MAXILLARY SINUS FLOOR. TH E
  DISTANCE BETWEEN THE APICAL END OF MAXILLARY POST
  TOOTH WITH THE FLOOR OF MAXILLARY SINUS IS
  1-1.5CM IN ADULTS. THIS DISTANCE IS MAX IN
  PAEDIATRIC GROUP lt 15 YEARS OF AGE SO CHANCE OF
  ORO ANTRAL FISTULA IS LESS COMMOM IN THEM

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• CALDWELL LUC SURGERY WALL OF MAXILLARY
  SINUS IS VERY THIN IN CANINE FOSSA REGION SO THIS
  IS AN IDEAL SITE FOR CALD WELL LUC SURGERY USED
  IN
• 1. CHRONIC MAXILLARY SINUSITIS WITH
  IRREVERSIBLE CHANGES IN SINUS MUCOSA
• 2.SUSPECTED NEOPLASM IN THE ANTRUM ITS
  BIOPSY
• 3. REMOVAL OF FOREIGN BODY OR ROOT OF TOOTH
• 4. ORO ANTRAL FISTULA DENTAL CYST
• 5. RECURRENT A.C POLYP
• 6. OF MAXILLA OR BLOW OUT OF ORBIT
• 7. LIGATION OF MAXILLARY ARTERY

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OROANTRAL FISTULA
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• MAXILLARY SINUSITIS
• DENTAL CARIES , HALLUTOSIS, GUM BLEEDING MUST
  BE EXAMINED PROPERLY IN THE PATIENT HAVING
  MAXILLARY SINUSITIS AS DENTAL CARRIES OF
  MAXILLARY MOLARS MAY CAUSE ASCENDING INFECTION IN
  THE MAXILLARY SINUS
• MAXILLARY TENDERNESS
• IS ELICITED BY PUTTING GENTLE PRESSURE
  OVER MAXILLARY CANINES.

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• ROOF
• TRAUMA/ BLOW OUT FRACTURE ?
• ORBITAL WALL OF M.S IS VERY FRAGILE SO ITS
  VULNENARABLE TO TRAUMA. IN SUCH CASES ORBITAL
  FAT MAY PROLAPSE IN SIDE THE MAXILLARY SINUS
  CAVITY CAUSE ENOPTHALOUS,RESTRICTED EYE
  MOVEMENTS,LOSS OF SENSATION OVER I.O REGION,
  PERIORBITAL ECHYMOSIS DIPLOPIA GLAUCOMA
• EROSION MAXILLARY SINUS TUMOR MAY ENLARGE
  IN SIZE ERODE THE ORBITAL WALL LEADING TO
  EXOPTHALMOUS, CHEMOSIS MAY HAMPER THE VISION

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BLOW OUT OF LEFT ORBIT
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• INFRA ORBITAL NERVE BLOCK? INFRAORBITAL
  FORAMEN TRANSMITIING I.O NERVE VESSELS LIES IN
  THE ORBITAL WALL/ ROOF OF MAXILLARY SINUS. BEING
  VERY FRAGILE IS VULNERABLE TO GET INJURED IN
  ANY ORBITAL/MAXILLARY TRAUMA
• I.O NERVE IS USED TO ACCOMPALISH REGIONAL
  ANAESTHESIA FOR FACE

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INFRA ORBITAL NERVE BLOCK
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ANTERIOR WALL

• OSTEOMYLIETIS ANTERIOR WALL OF MAXILLARY
  SINUS IS VULNERABLE TO DEVELOP OSTEOMYELITIS
  IS MORE OFTEN SEEN IN INFANTS CHILDREN THAN
  ADULTS COZ OF PRESENCE OF SPONGY BONE IN ANTERIOR
  WALL OF SINUS. INFECTION ASCENDS FROM THE DENTAL
  SAC AND LESS OFTEN ITS PRIMARY INFECTION

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• THEN SPREADS TO SUBPERIOSTEAL
  REGION?FISTLA(I.O REGION,ALVEOLUS, PALATE OR IN
  ZYGOMA?SEQUESTERISATION BONE DEFORMITY

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• TO ELICIT THE TENDERNESS OF MAXILLARY SINUS?
• BY TAPPING OVER THE LATERAL ASPECT OF
  ANTERIOR WALL I,e PROMINANCE OF CHEECK BONE
  AND INTRA ORAL PALPATION BETWEEN CANNINE FOSSA
  ZYGOMATIC BUTTRESS.

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PALPATION OF MAX SINUS
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• POSTERIOR WALL
• LIGATION OF MAXILLARY ARTERY ?
• IN CASE OF EPISTAXIS WHENCONSERVATIVE
  PROCEDURES ARE NOT HELPFUL ,LIGATION OF MAXILLARY
  ARTERY IS REQUIRED. WHICH CAN BE APPROCHED
  THROUGH INTRA NASAL PATH INTO THE MAXILLARY SINUS
  WHERE WE CREATE A WINDOW IN ITS POSTERIOR WALL TO
  REACH MAXILLARY ARTERY
• TUMOR OF INFRATEMPORAL SPACE ?
• MAY ERODE POSTERIOR WALL OF MAXILLARY SINUS
  INFILTERATE PARASYMPATHETIC GANGLION (S.P
  GANGLION)

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• PT MAY PRESENT WITH DEEP FACIAL PAIN, HARD
  PALATE INSENSITIVITY DECREASED LACRIMATIOM

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LIGATION OF MAXILLARY ARTERY
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• MAXILLARY CAVITY
• 1.PROOF PUNCTURE
• 2. HALLER CELLS
• 3. KARTAGENERS SYNDROME

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KARTAGENERS SYNDROME
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ANTRAL LAVAGE
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HALLER CELLS
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APPLIED ANATOMY OF FRONTAL SINUS

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• DOMINANCE OF ONE SINUS
• SINUS IS RELATED TO ANT ETHMOIDAL CELLS BOTH
  EMBRYOLOGICALLY ITS ANATOMY. RT LT FRONTAL
  SINUS DEVELOPS INDEPENDENTLY ARE MORE OFTEN
  ASYMETRICAL LEADING TO DOMINANCE OF ONE SINUS.
• EROSION OF POST WALL
• FRONTAL SINUS LIES BETWEEN THE ANTERIOR AND
  POSTERIOR FRONTAL TABLE. ANTERIOR WALL IS THICK
  AS COMPARED TO POST WALL SO EROSION OF POSTERIOR
  WALL IS MORE COMMON.

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• INTERSINUS CELL
• THE INTERVENING INTERSINUS SEPTUM CAN
  SOMETIME GET PNEUMATISED FORMING INTERSINUS CELL.
• MUCOCELE
• FLOOR OF FRONTAL SINUS CORRESPONDS TO THE ANT
  ROOF OF ORBIT WHICH IS A THIN BONE CAN BE EASILY
  ERODED BY MUCOCELE

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• FRONTAL OSTIUM
• FRONTAL SINUS DRAINAGE PATHWAY HAS AN
  HOURGLASS SHAPE OPENS IN NOSE AT THE LEVEL OF
  FRONTAL RECESS. NARROWEST PART OF THIS TRACT IS
  FRONTAL INFUNDIBULUM OR OSTIA WHICH IS LOCATED AT
  MOST I.M ASPECT OF SINUS AND IS BOUNDED BY
  VARIOUS IMP STRUCTURES. BESIDE DIFF ANT ETH CELL
  GROUPS FRONTAL OSTIUM IS MOST CHALLENGING TO
  ACCESS( SMALL DIA,ANT LOCATION,RELATION WD ORBIT)

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• UNCAPPING OF EGG
• DEPENDING ON THE SUPERIOR ATTACHEMENT OF
  U.P, F.R WILL DRAIN MEDIAL OR LATERAL TO THE
  U.P? RECESSES TERMINALIS?UNCAPPING OF EGG
• SUPRAORBITAL CELLS
• SOMETIMES THE SUPRAORBITAL CELLS ARE PRESENT
  IN FRONTAL RECESS? CAN BE SEEN AS TWO OPENINGS.
  F.S OPENING LIES MEDIOALLY LATERAL OPENING IS
  FOR S.O CELLS

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• FRONTAL RECESS FRONTAL SINUS?
• WHILE DISSECTING FRONTAL RECESS SURGEON MAY
  THINK HAS ENTERED F.S BUT HE MAY BE WITH IN THE
  FRONTAL CELL
• OSTEOMYELITIS/POTTS PUFFY TUMOR?
• OF F.B NOT VERY UNCOMMON. THE MUCOSAL LINING
  OF F.S, MARROW CAVITY FRONTAL BONE SHARE COMMON
  VENOUS DRAINAGE THROUGH VALVELESS DIPLOEIC VEINS.
  THIS VENOUS DRAINGAE PERMITS SPREAD OF INFECTION
  FROM F.S INTO F.BONE.

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POTTS PUFFY TUMOUR
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• LOCAL SUPPORATION OF FRONTAL BONE PROPOGATES
  TO HAVERSIAN SYSTEM OF INNER OUTER TABLE OF
  SKULL
• DEMINERALISATION,NECROSIS
• PERFORATION OF ANT TABLE OF F.S
• SUBPERIOSTEAL COLLECTION OF PUS
• GRANULATION TISSUE FORMATION
• POTTS PUFFY TUMOR PT MAY PRESENT WITH
  ANT WALL BULGE FLUCTUANT TENDER
  ERYTHEMATOUS SWELLING OF F.S IS PATHOGNOMIC

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• OSTEOPLASTIC BONE FLAP?
• MOST OF THE FRONTAL SINUS SURGERY IS CARRIED
  OUT THROUGH INTRA NASAL APPROACH . ONLY 5 OF
  ALL FRONTAL SINUS OPERATIONS ARE EXTERNAL. THIS
  APPROACH IS CONSIDERED AS PREFFERED ONE IN
  PROBLEM F.S WHERE COMPLETE MICRO ENDOSCOPIC
  REMOVAL OF MUCOSA IS DONE OBLITERATION OF SINUS
  IS DONE WITH ABDOMINAL FAT

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• THUMB TEST ?FRONTAL TENDERNESS IS EXAMINED BY
  THUMB TEST? PR ON F.S FLOOR CLEARLY BEHIND
  SUPRA ORBITAL RIM
• PATIENT MAY PRESENT WITH PAINFUL PERCUSSION OVER
  F.B ?ACUTE FRONTAL SINUSITIS,PYOCELE
• PAINLESS PERCUSSION WITH BULGING OF ANT WALL?
  MUCOCELE, TUMOR , PNEMATOSINOUS DILATANS OF F.S

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THUMB TEST
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APPLIED ANATOMY OF SPHENOID SINUS

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• DOMINANCE OF S.S?
• RT LT SPHENOID SINUSES ARE SO ASYMETRICAL
  THAT IT LEADS TO DOMINANCE OF 1 SPHENOID COZ OF
  THIS ASYMETRY, THE INTERSINUS SEPTUM GOES OFF THE
  MIDLINE CAN HAVE A POSTERIOR INSERTION ON BONY
  CAROTID CANAL IN THE LAT WALL OF SPHENOID?BRISK
  AVULSION?CAROTID RUPTURE
• RELATION WITH PITUTARY GLAND?
• SUPERIOR WALL OF S.S USUALLY REPRESENT THE
  FLOOR OF SELLA TURCICA. DEPENDING ON EXTENT OF
  PNEMATISATION IS CLASSIFIED IN 3 TYPES. SELLAR
  TYPE IS IN CLOSE RELATION WITH FLOOR OF PITUTARY
  FOSSA, MAKING PITUARY GLAND MORE VULNERABLE TO
  INJURY WHILE APPROACHING S.SIS

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• LATERAL WALL OF S.S?
• SHOWS VARIOUS PROMINANCE, MOST IMP BEING
  CAROTID OPTIC CANAL. ICA IS MOST MEDIAL ST IN
  CAVERNOUS SINUS RESTS AGAINST LATERAL SURFACE
  OF SPHENOID BONE. ITS PROMINANCE VARIES FROM A
  FOCAL BULGE TO SERPENTIGIOUS ELEVATION MAKING
  THE FULL COURSE OF INTRACAVERNOUS PART OF CAROTID
  ARTERY WD AN INTERVENING CLEFT . BONE OVER THESE
  ST ARE VERY THIN LEADING TO DEHISCENCE .

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STRUCTURES IN RELATION TO S.S
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• WHILE APPROACHING S.S, SURGEON MAY GET CONFUSED
  BETWEEN THE P.E.C THE SPHENOID SINUS, WHICH CAN
  BE DIFFERENTIATED ON THE BASIS OF?SHAPE, OPENING
  OF SINUS IN RELATION TO MAXILLARY RIDGE POST
  CHOANA POST END OF NASAL SEPTUM

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• IMP. LANDMARK OF SP. OSTIUM?
• S.S DRAINS THROUGH A SINGLE OSTIUM INTO SER. THIS
  OS IS CLASICALLY LOCATED 7cm FROM COLUMEELA AT
  AN ANGLE OF 30 DEGREE WITH THE FLOOR OF NOSE IN
  PARA SAGITAL PLANE THIS CORRESPONDS TO A
  LOCATION HALF WAY UP THE ANT WALL OF S.S
• ENDOSCOPICALLY THE POSTEROSUPERIOR END OF SUP
  TURBINATE POINTS SUPERIORLY MEDIALLY TOWARDS
  THE OSTIUM THUS REPRESENTS A VERY IMP LANDMARK
  OF IT.

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APPLIED ANATOMY OF ETHMOID SINUS

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CSF RHINORRHOEA

• THE REGION WHERE ANT ETHMOIDAL ARTERY PERFORATES
  THE LATERAL LAMELLA OF CRIBRIFORM PLATE IS
  THINNEST OF ANT PART OF BASE OF SKULL MEASURES
  0.05mm WITH THE UNDERLYING DURA ADHERANT TO IT SO
  THIS REGION IS HIGHLY VULNERABLE TO TRAUMA
  LEADING TO C.S.F LEAKAGE.
• PATIENT WITH DEEP OLFACTORY FOSSA(KEROS TYPE 3)
  ARE AT HIGH RISK

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APPROACH TO ETHMOIDAL AIR CELLS

• FOR AN APPROACH TO ETHMOID AIR CELLS,SURGEON
  SHOULD MAKE A PERFORATION IN GROUND LAMELLA TO
  ENTER THE POST ETHMOIDAL CELLS, ONCE HE REACHES
  THE POST ETHMOID CELLS, HE MUST CHANGE THE
  DIRECTION OF PROBE INFEROMEDIALLY TO ACCESS S.S.
  IF HE CONTINUES TO MOVE POSTERIORL HE LL ENTER
  THE CRANIAL CAVITY

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CHANGES IN ETHMOIDAL POLYP

• IN CASE OF ETHMOIDAL POLYP WHICH IS USUALLY
  BILATERAL ,IT MAY DISTORT THE NORMAL ANATOMY OF
  SINUS THE ETHMOID SINUS WILL EXPAND WHICH LEAD
  TO INCREASE IN INTER CANTHUS DISTANCE MIMICKING
  OCULAR FEATURE OF DOWNS SYNDROME

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MICROANATOMY OF PNS
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• HISTOLOGICAL FEATURES?
• CONISISTS OF 3 LAYERS-
• 1.SUPERFICIAL LAYER
• .EPITHELIAL
  LININIG
• .MUCUS BLANKET
• 2.LAMINA PROPRIA
• .SEROUS GLAND
• .BLOOD
  VESSELS NERV
• 3. CARTILAGENOUS LAYER

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HISTOLOGICAL FEATURE OF PNS
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• EPITHELIAL LINING OF PNS?
• PSUEDOSTRAITIFIED CILIATED COLUMNAR
  EPITHELIUM
• OTHER CELLS IN SUP LAYER?GOBLET CELLS,
  BASAL CELL, NON CILIATEDCELLS
• MUCUS LAYER?
• 1.INNER AQ/SOL/SEROUS LAYER (CONT,LESS
  VISCOUS,SURROUNDS SHAFT OF CILIA)
• 2.OUTER GEL/SUP. LAYER (DISCONT,HIGH
  VISCOSITY,ALONG TIP OF CILIA,CONTAINS AB,ENZYM)

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• CILIARY MOVEMENT OF PNS?
• CILIA OF PNS BEATS IN A SPIRAL MANNER TO PROPEL
  THE MUCUS OUT OF SINUS IN TO THERE RESPECTIVE
  OSTIUM..
• BEAT FREQUENCY OF CILIA IS BETWEEN 10-20 Hz AT
  BODY TEMP WD A MAX OF AROUND 14Hz . IT REMAINS
  FAIRLY CONSTANT BTW 32-40 DEG CELSIUS

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• EACH BEAT CONSISTS OF A RAPID PROPULSIVE STROKE
  FOLLOWED BY A SLOW RECOVERY PHASE
• DURING PROPULSION PHASE CILIA IS STRAIGHT THE
  TIP ENGAGES IN VISCOUS LAYER OF MUCUS BLANKET
  WHERE AS DURING RECOVERY PHASE THE CILIA BENT
  OVER LIES IN AQ LAYER.

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PATTERN OF CILIARY BEAT
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• COMPOSITION OF MUCUS?
• WATER IONS FROM TRANSUDATION
• GLYCOPROTEINSIALO.SULPHO FUCOMUCINS
• ENZYMESLYSOZYME,LACTOFFERIN
• CIRCULATORY PROTEINCOMPLEMENT,ALPHA 2
  MACROGLOBIN, C REACTIVE PROTEIN
• Ig VARIOUS CELLS E.G BASOPHIL EIOSINOPHIL N
  LEUKOCYTES

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• FUNCTIONS OF PARA NASAL SINUSES

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• PLAY ROLE IN CONDITIONING THE INSPIRED AIR
• THEY ADD RESONANCE TO LARYNGEAL VOICE
• LIGHTEN THE SKULL
• REGULATION OF INTRANASAL PRESSURE
• ACTS AS SHOCK TEMP BUFFERS
• CONTRIBUTE TO FACIAL GROWTH
• INCREASES THE SURFACE AREA FOR OLFACTION
• SINUS MUCOSA MAY ACT AS A DONOR SITE FOR
  RECONSTRUCTIVE PROCEDURES E.G SUBGLOTTIC STENOSIS
  IMPLANTATION OF MAX SINUS MUCOSA INTO NASAL
  CAVITY IN ATROPHIC RHINITIS

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