849

Review

Article

..

..

The Ostiomeatal Unit and Endoscopic Surgery: Anatomy, Variations, and Imaging Findings in Inflammatory Diseases
Fred J. Lame1 and Wendy R. K. Smoker

Recent and ongoing advances made in endoscopic surgical techniques require the radiologist to understand the anatomy and pathophysiology of the paranasal sinuses and nasal passage. Endoscopy and CT are complementary procedures, and, as such, the normal anatomic relationships and their CT appearances need
to be well understood in order for radiologists to offer continued

Normal
The structures

Anatomy
relationships and sinus between ostia important can be more bony easily

and soft-tissue
understood and

support as consultants to their clinical colleagues. In this article, we review the pertinent anatomy of the lateral nasal wall and paranasal sinuses, discuss the most frequently encountered normal variations that may predispose a patient to inflammatory sinus disease, outline imaging protocols for evaluation of this region, and introduce the reader to current endoscopic surgical techniques. Last, the imaging findings in various inflammatory processes involving the sinuses, as well as the local and regional complications associated with paranasal sinus inflammatory dis-

interpreted on CT scans by first reviewing the anatomy of the lateral nasal wall and nasal septum. Projecting from the lateral nasal wall are the inferior, middle, and superior turbinate bones (or conchae) (Fig. 1 A). Occasionally, a supreme turbinate ostia inferior drain bone can be identified. Beneath

each
which which

turbinate
the various lies the

bone turbinate

lies a respectively bone

meatus. (Fig. i B). is the largest The inferior

named

meatus

into
under

The inferior

of the three, meatus

receives

eases, are presented.

In our role as consultants, radiologists must keep abreast of clinical advances and be able to adapt imaging procedures as necessary to meet changing clinical demands. Advances in the understanding of mucociliary drainage patterns and the pathophysiology of paranasal sinus inflammatory disease, coupled with the availability of high-resolution CT and improvements in endoscopic instrumentation, have led to major changes in the surgical management of sinusitis. As a result,

the radiologist
nasal structures,

must relearn

the anatomy

of nasal and parachanges caused

drainage from the nasolacrimal duct, which is typically seen only segmentally on axial scans. Occasionally, the duct can be followed from its origin in the inferomedial aspect of the orbit to its ostium in the anteroinfenior aspect of the meatus, adjacent to the attachment of the inferior concha. Under the superior turbinate bone, the smallest of the three, lies the superior meatus, through which posterior ethmoidal air cells drain via multiple ostia. This turbinate bone is identifled on coronal images as a slender structure, suspended from the dome of the posterior aspect of the nose [i ]. The sphenoethmoidal recess, draining the sphenoidal sinus through the sphenoidal ostium, lies posterosupenior to the
superior turbinate bone, between the anterior wall of the

as well as the pathologic

by diseases that affect this region, and endoscopic findings.

Received
1

in order to correlate

CT

sphenoidal sinus and the posterior wall of the ethmoidal sinus (Fig. 2). Lateral to the recess, the most posterior ethmoidal

November

8, 1 991 ; accepted of Radiology,

after revision Medical

April

1 6, 1992. of Virginia Hospitals, MCV Station, Box 61 5, Richmond, VA 23298. Address reprint requests to F. J.

Both

authors:

Department

College

Lame.
AJR 159:849-857, October 1992 0361 -803x/92/1 594-0849 American Roentgen Ray Society

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Line diagram of lateral nasal wall bones. Arrowheads = agger nasi cells, IT = inferior turbinate bone, MT = middle turbinate bone, ST = superior turbinate

Fig. 1.-A,

with intact turbinate bone.

B, Line diagram of lateral nasal wall with turbinate bones removed. Arrows = ostia and mucous flow patterns, I = drainage from frontal sinus, 2 = drainage from maxillary sinus, 3 = drainage from anterior and middle ethmoidal sinuses, 4 = drainage from posterior ethmoidal sinuses, 5 = drainage from sphenoidal sinus. 1, 2, and 3 drain to the middle meatus, whereas 4 and 5 drain through sphenoethmoidal recess to superior meatus.

A
air cell common

B
(cell of Onodi) and the sphenoidal sinus share a wall, the sphenoethmoidal plate [2] (Fig. 2). The middle turbinate bone covers the middle meatus, the

The hiatus semilunaris is bounded superiorly ethmoidalis, laterally by the bony orbit, inferiorly

by the

bulla

by the uncin-

most complex region of the lateral nasal wall. Near the superior attachment of the turbinate bone, a prominence of the lateral wall is produced by the agger nasi cells, the most anterior ethmoidal air cells (Fig. 1). Above these cells lies the frontal recess. The frontal sinus drains, via the frontonasal duct, agger nasi cells, and frontal recess, into the anterior aspect of the middle meatus, medial to the uncinate process, or directly into the ethmoidal infundibulum (Fig. 1 B). The ethmoidal infundibulum is often continuous with the frontonasal duct. The middle turbinate bone attaches to two areas of delicate bone, which can pose potential problems during endoscopic
manipulation: the superior attachment to the delicate lateral aspect of the cribriform plate, and the lateral, intraethmoidal attachment, basal (or ground) lamella, to the thin lamina

ate process, and medially by the middle meatus. It accommodates multiple anterior ethmoidal ostia, and the single maxillary sinus ostium, to form the final segment of drainage
from these sinuses. A superior extension of the hiatus semilunaris communicates with the sinus lateralis, the space between the posterior wall of the ethmoidal bulla and the basal lamella, providing drainage of this area and the middle ethmoidal air cells. The bulla ethmoidalis, usually consisting of a single variable air cell, projects inferomedially over the hiatus semilunaris in a rounded fashion. The relationships of these three lateral wall structures are such that a channel is formed, linking the frontal, anterior and middle ethmoidal, and maxillary sinuses

papyracea of the the basal lamella the coronal plane, rating the anterior
air cells located

lateral ethmoidal wall (Fig. 3). Posteriorly, curves superiorly and becomes oriented in behind the ethmoidal bulla, thereby sepaand posterior ethmoidal air cells. Ethmoidal
to the basal lamella will drain into the

to the middle meatus. This connecting channel is collectively referred to as the ostiomeatal unit (OMU) (Figs. 3 and 4). In summary, mucociliary drainage of the sinuses eventually merges into two common pathways, allowing division into
two anatomic and functional groups [2]. The first group (frontal, anterior ethmoidal, middle ethmoidal, and maxillary

anterior

middle meatus, whereas those cells located posterior to the basal lamella will drain into the superior meatus [2]. If the middle turbinate bone is removed, three prominent
underlying structures are seen: the uncinate process

anteriorly,
posteriorly.
cosa-covered

the hiatus
bony

semilunaris,
process,

The uncinate

and the bulla ethmoidalis a thin, hook-shaped, muoriginates anteriorly from the

prominence,

posteromedial border of the nasolacrimal duct. Almost parallel to the middle turbinate bone, it forms a free border that defines the anterior boundary of the hiatus semilunaris. On coronal CT, the uncinate process is easily detected as a superior extension of the medial maxillary sinus wall, forming the lateral wall of the middle meatus (Figs. 3 and 4). Lateral to the uncinate process lies the infundibulum, connecting the ostia of the maxillary and ethmoidal sinuses to the hiatus
semilunaris
maxillary

sinuses) drains into the middle meatus, around the ethmoidal bulla (the OMU) (Fig. i B). This region is frequently involved by inflammatory disease. The second group (posterior ethmoidal and sphenoidal sinuses), draining into the sphenoethmoidal recess and superior meatus (Fig. i B), is less frequently affected by inflammatory processes. The nasal septum, easily identified on both axial and coronal CT, extends the entire length of the nasal cavity (Figs. 2 and 4). The anterior portion is composed of cartilage, whereas the posterior portion is osseous, formed mainly by the vomer and
the perpendicular septum anteriorly is an important geons. plate of the ethmoid and the intersphenoidal anatomic consideration bone. The interfrontal septum posteriorly

do not always lie in the same plane as the nasal septum.

for endoscopic

This
sur-

(Figs.
sinuses

3 and
courses

4). Mucociliary
superiorly,

drainage
through the

from

the

posterior infundibulum to the hiatus semilunaris, ally into the middle meatus.

ostia and and eventu-

Two important anatomic relationships between the paranasal sinuses and adjacent structures must be mentioned. Awareness of the intimate relationship between the internal carotid artery and the sphenoidal sinus is important for understanding flammatory the potentially devastating complications disease or endoscopy (Fig. 2). Bulging of inof the

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I,,.
Fig. 2.-Axial
mediate

*:#{149}#{149}

-;:

#{149}

CT scan obtained

with inter-

Fig. rowhead

3.-Line
=

diagram
=

of normal dots
=

ostiomeatal uncinate arproc-

cesses nals (C) to lateral wall of sphenoidal sinus (5). Note also proximity of optic nerve (ON) to posterior ethmoidal (E) and sphenoldal sinuses. NS = nasal septum, arrowheads = sphenoethmoidal plate.

windows shows sphenoethmoidal re(white dots) and proximity of carotid ca-

unit Small arrowheads

cribriform

basal lamella, large

plate,

Fig. 4.-Coronal CT scan shows normal ostlomeatal unit. Curved arrows = maxillary ostium, dots = infundibulum, straight arrows = middle
meatus, arrowheads
=

ess.

nasal

septum.

carotid

artery

into

the

sphenoidal

sinus

is seen

in

65-72%
from

of
the

air cells,

the air cell created

is referred

to as concha

bullosa

patients

[3-5].

The thin bone

separating

the artery

sinus is less than 1 mm in 66% of patients, less than 0.5 mm in 88% of patients, and completely absent in 4-8% of cases [4, 5]. The location of the optic canal and nerve is an additional
important anatomic consideration. Because of the location of

[9] (Fig. 5A). The reported prevalence of concha bullosa ranges from 4% to 80%, depending on criteria for pneumatization and differences in study populations. True concha
bullosa the vertical lamellar and infein 4-i 5.7% ofthe population [9, i 0]. If the definition is broadened to include any degree of middle turbinate pneumatization, the prevalence increases to
nor bulbous portions) is reported

(pneumatization

of both

the distal canal opening, in 75% of cases the nerve will be close to both the sphenoidal and ethmoidal sinuses [6] (Fig. 2). During its course, the optic nerve bulges into the superolateral sphenoidal sinus wall, forming the optic eminence. A
thin bony partition is present in 70-78% of patients [5, 7],

34% [1 1]. The highest

prevalence

(80%) is found in patients

with chronic sinusitis [1 2]. For this reason, some suggest that concha bullosa may be a contributing factor in the pathogenesis of sinus inflammatory disease, although others do not

and complete [5,8].

Anatomic The

bony dehiscence

is present

in 3.6-4%

of cases

share this view [9]. Stammberger and Wolf [1 3] and Lidov and Som [i 4] reported that concha bullosa can, when sufficiently large, produce signs and symptoms by encroaching

Variations meatus and lateral nasal wall are subject to

on the infundibulum.

Concha bullosa may also contain

polyps,

middle

wide normal variations that must be distinguished from pathologic changes. These variations may, themselves, be the underlying cause of recurrent sinus disease. However, there is a lack of consensus among investigators with respect to the prevalence and clinical significance of these variations, as
they have been encountered with similar frequency in patients

cysts, pyoceles, or mucoceles. Paradoxically curved middle turbinate bone.-Normally, the convexity of the middle turbinate bone is directed medially, toward the nasal septum. When paradoxically curved, the

convexity is directed laterally, toward the lateral sinus wall (Fig. SB). A 26.i % prevalence of paradoxically curved middle
turbinates has been reported

this variation

to sinus disease,

[9]. Although no studies it is a presumed etiologic

relate factor

being scanned for sinus-related problems, as well as those undergoing evaluation for non-sinus-related problems [9]. The more common variations can be divided into four groups, depending on the structures involved: middle turbinate bone, uncinate process, ethmoidal bulla, and nasal septum.

because of the deformity and obstruction nasal passage air flow dynamics, especially
with other variations [i3].

or alteration of when associated

Uncinate

Variations

Middle

Turbinate

Variations

Deviation of the uncinate tip.-The superior aspect of the uncinate tip may deviate laterally, medially, or anteriorly out

Concha bullosa.-The middle turbinate bone is usually a thin plate of bone. When this plate becomes pneumatized by extension of the anterior (55%) or posterior (45%) ethmoidal

of the meatus, appearing as a second middle turbinate bone [i 3, iS]. When deviated medially, it comes into contact with
and compromises the middle meatus. When deviated laterally,

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Fig. 5.-A,

Coronal

CT scan shows

pneumatl(conthan which

zation of middle turbinate bones bilaterally cha bullosa), much greater on left (asterisk) on right. Also note nasal septal deviation,

narrows right middle meatus.

B, Coronal CT scan reveals paradoxically laterally curved middle turbinate bones bilaterally (dots). Also note pneumatization of right uncinate tip (arrow). C, Coronal CT scan shows large Halle cells (H) projecting downward along roofs of maxillary sinuses. Concha bullosa is seen bilaterally (asterlsks). Sinuses, at this time, are clear. D, Coronal CT scan shows evidence of ethmoidal bullae (asterisks) bilaterally without cvi-

dence of associated
tionship to ostiomeatal bilaterally.

sinus disease.
unit (dots)

Normal rela-

is well visualized

it may encroach
impeding drainage

on the hiatus
and ventilation

semilunaris
of the

and infundibulum,
anterior ethmoidal,

frontal, and maxillary sinuses. The exact prevalence of these variations and their relation to sinus disease have not been
determined. Pneumatized uncinate tip (uncinate bulla).-The exact mechanism by which uncinate pneumatization (Fig. SB) occurs is not known. It has been proposed that this process is

prevalence of Halle cells between patients sinus disease and patients scanned for Stammberger and Wolf [1 3] consider the cells as another predisposing factor for
sinusitis.

scanned for chronic nonsinus reasons, presence of these recurrent maxillary

due to growth of agger nasi cells into the most anterosuperior region of the uncinate process [9]. Studies reveal a prevalence of 0.4-2.5% [9]. This variation has been implicated in narrowing of the infundibulum, producing impaired sinus ventilation

[16].

Ethmoidal

Variations to Kennedy and Zinreich [i 7], Halle

Halle cells-According

cells, ethmoidal

air cells that project

inferiorly

to the ethmoidal

Large ethmoidal bulla.-The ethmoidal bulla can be so extensively pneumatized that it completely fills the sinus of the middle turbinate bone (Fig. SD). Stammberger and Wolf [1 3] reported that an enlarged ethmoidal bulla may contribute to sinus disease by obstructing the infundibulum or middle meatus or by being primarily diseased and filled with pus, cysts, or polyps. The exact prevalence of an enlarged ethmoidal bulla is not known. Agger nasi cells.-Agger nasi cells, the most constant ethmoidal air cells, lie below the frontal sinus, inferolateral to the lacrimal sinus, and represent pneumatization of the lacrimal bone by extension of the anterior ethmoidal cells [i 0]. They are located anterior and superior to the insertion of the middle turbinate bone, along the lateral nasal wall [1 3] (Fig.

bulla into the floor of the orbit in the region of the maxillary sinus ostium, are encountered in 1 0% of the population (Fig.

iA). In anatomic

dissection,

the prevalence

of the agger nasi

SC). However, Bolger et al. [9] defined Halle cells as any air cells located beneath the ethmoidal bulla, lamina papyracea, or orbital floor. Using this criteria, they reported a prevalence
of 45%. Although they found no significant difference in the

cell varies from 1 0% [18] to 89% [1 9]. Because of their location near the lacrimal sac, involvement of these cells by sinus disease can lead to ocular symptoms. These cells may provide access to the frontal sinus and recess during endoscopy.

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Nasal

Septum

Variations the structures that make to form a straight wall,

up

Nasalseptaldeviation.-Normally, the nasal septum are

aligned

extending from the cribriform plate superiorly to the hard palate inferiorly (Fig. 4). At the junction of the nasal cartilage and vomer, acute bowing and deviation of the septum occur
in 20% of the population [20]. When severe, the deviated sec-

of endoscopic techniques is necessary for meticulous CT evaluation. For diagnostic endoscopy, a 4.0-mm, 0#{176} and 30#{176} illuminated endoscope or a 2.7-mm, 30#{176} and 70#{176} illuminated en-

doscope is used [24]. The endoscope floor of the nose while the septum,
turbinate bone, middle turbinate bone,

is passed along the inferior meatus and

and nasopharynx are

septum
narrowing

may compress
the middle

the middle
meatus

turbinate

bone laterally,
obstruction,

evaluated.

The instrument

is then

rolled

over

the inferior

and causing

ondary inflammation, and infection (Fig. SA). When it is associated with swollen membranes, there is additional obstruction to the normal flow of mucus from the sinuses.

turbinate bone into the posterior aspect of the middle meatus and drawn anteriorly as the ethmoidal bulla, hiatus semilunaris, and OMU are evaluated [24]. Cultures and mucosal

biopsy specimens can be obtained, or antibiotics can be administered, if indicated. Currently, two functional endoscopic surgical approaches
are used [1 8, 25]. Both are based on the conjecture that once aeration of the sinuses is reestablished and normal drainage

Imaging

Techniques evaluation is directed toward assessing the pa-

Radiologic

is restored,

the

mucosa

will

return

to its

prediseased

state.

tency of the maxillary sinus ostium, ethmoidal infundibulum, hiatus semilunaris, and middle meatus. Plain radiographs,
widely available and inexpensive, provide insufficient detail to

The Wigand monly used

procedure, of the two,

the more extensive and less combegins posteriorly with a sphenoido-

allow
detail, detail,

surgical
does remains

planning.
not adequately

MR,

with
depict

its excellent
the osseous

soft-tissue
sinus walls

and ostia.

CT, because

of its superb

soft-tissue

and bone
the presence

tomy and proceeds anteriorly to the frontal recess. It involves a total sphenoethmoidectomy and a supramiddle turbinate antrostomy to create surgical drainage of the ipsilateral sinuses into the nose. The Messerklinger procedure begins at
the ethmoidal or posteriorly bulla and moves to the posterior anteriorly ethmoidal to the frontal recess and sphenoidal si-

the best technique

for evaluating

and extent of sinonasal disease before The coronal plane provides the best OMU and simulates the plane seen by scanning, the patient is prone with the
to ensure S-mm-thick that free fluid layers along

endoscopy. demonstration of the the endoscopist. For head hyperextended

sinus floor

nuses, depending on the location of disease. This procedure, considered the true functional endoscopic surgical approach,
relieves obstruction to the normal pathway of mucociliary

the maxillary Although

and does not falsely

contiguous

obliterate

the OMU. Unenhanced

3- to

slices are obtained.

originally

obtained with soft-tissue algorithms but filmed with soft-tissue and bone windows, our recent experience, as well as that of others [21 ], suggests that a single set of images obtained in bone algorithm and filmed with intermediate windows is sufficient in most instances. Contrast material, administered via

a bolus drip technique, is used only when assessing for complications of inflammatory disease. Occasionally, extensive dental amalgams may require thin-section axial scanning with reformation in the coronal plane. Uncooperative patients
and those who are unable to maintain their head in hyperex-

drainage. Advantages of functional endoscopic surgery over more conventional surgical techniques include (1 ) absence of skin or mucous membrane incisions and accompanying removal of intervening bone, (2) unparalleled visualization of the sinuses of the lateral nasal wall, (3) more accurate diagnosis of malformations or obstructing masses producing refractory sinusitis, and (4) precise localization and removal of the site of disease with mucosal preservation and restoration of normal mucociliary drainage [1 8]. Endoscopy is limited in its

ability to show frontal sinuses and recesses, maxillary sinuses and ostia, ethmoidal bullae, and posterior ethmoidal and sphenoidal sinuses. CT is, therefore, a complementary procedure that ensures complete evaluation by inflammatory paranasal sinus disease. of changes caused

tension can also be examined in the axial plane. Imaging is best performed after treatment of an acute process, so that areas of residual disease, most likely responsible for recurring
problems, can be fully assessed [22, 23].

Inflammatory

Sinus

Diseases

Endoscopic Anterior

Surgery rhinoscopy

Techniques and indirect nasopharyngoscopy yield

Acute

Sinusitis due to a pure viral infection, acute from a bacterial superinfection, most pneumoniae, Haemophllus influenaureus. A single sinus is typically

little information regarding the middle meatus and the [24]. Paranasal sinus endoscopy now permits accurate, visualization of the entire nasal cavity, middle meatus, and sphenoethmoidal recess. It can be performed as a

OMU direct OMU, purely

Although occasionally sinusitis usually results commonly Streptococcus zae, and Staphylococcus

involved,
moidal, tionally

usually

a maxillary

sinus.

When

the frontal,

ethaddiis

diagnostic procedure or as a therapeutic procedure (functional) to clear obstructed sinus ostia. Functional endoscopic

or sphenoidal sinuses acutely involved, risk

are independently or of regional complications

sinus surgery is usually reserved for patients in whom medical management fails and who have OMU disease shown by CT and/or diagnostic endoscopy [23]. A fundamental knowledge

increased, and aggressive treatment is required. The radiologic hallmark of acute sinusitis is the air-fluid level. Alternatively, CT findings may be limited to nonspecific, smooth or

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polypoid

mucosal

thickening.

If the

sinus

ostium

becomes

the normal

respiratory

flora,

are the

pathogens

most

com-

obstructed,
Chronic

complete

opacification

may result.

Sinusitis

monly encountered. Although radiologically similar, they can frequently be differentiated clinically. Mucormycosis, an aggressive, highly invasive disease, occurs mainly in an immunocompromised or diabetic (50-75%) host. Aspergillus, how-

Chronic
has either

sinusitis
persistent

is diagnosed
inflammation

clinically

when

the patient
of acute

or repeated

bouts

inflammation. Anaerobes are more frequently implicated in chronic than in acute sinusitis [26]. CT may show mucosal
thickening or opacification, but the hallmark of chronic sinus-

ever, can produce infection in otherwise healthy persons by colonization of a paranasal sinus. An allergic form of aspergillosis has also been described, associated with asthma and recurrent nasal polyps. Invasive aspergillosis occurs primarily
in immunocompromised
mycosis, to produce

persons
necrosis,

and progresses,
vascular thrombosis,

like mucorand intra-

itis is osseous thickening of the sinus wall, remodeling and new bone formation in response
inflammation [26] (Fig. 6). The prevalence

representing to persistent

cranial

extension.

Initially,

both cause

nodular

mucoperiosteal

of complications

thickening,

which

eventually

coalesces

to opacity

an entire

with chronic sinusitis is increased, including mucous retention cysts, polyps, and mucoceles. Although CT permits evaluation of the complications of chronic sinusitis, more importantly it shows the pathologic changes responsible for the chronic disease (e.g., obstructed ostium, apical tooth abscess). In
addition to inflammatory disease, occasionally tumors may be

sinus (Fig. 8). Multiple focal areas of bone destruction, occurring in later stages, may mimic an aggressive tumor. However, in contrast to tumors, areas of bone thickening and sclerosis may also be detected (Fig. 8). Regions of high density within the opacified sinus on CT are highly suggestive of fungal

infection
the result

[30-33]

(Fig. 8A). These dense concretions

of metal ions and calcium

may be
salts

responsible for recurrent disease. MR evaluation has been shown to be useful in this regard. Most sinus tumors, except neuromas and minor salivary gland tumors, are homogeneous and have intermediate signal intensity on T2-weighted images, as compared with the inhomogeneous high signal intensity of most inflammatory tissue [27].
Allergic Allergic symmetric Sinusitis disease, a systemic sinus involvement process with a tendency for and pansinusitis [28], affects

of the combination

known to occur in fungal mycetomas. Recent studies [32] suggest that MR may be more specific than CT for diagnosing fungal sinusitis. The presence of ferromagnetic metallic ions
produces a hypointensity on Ti- and T2-weighted images (Fig. 8C). In addition, MR more effectively shows the multiple

intracranial ous sinus

infection

complications of fungal diseases thrombosis, arterial involvement,

[34, 35].

such as cavernand skull base

10% of the population. CT often shows bilateral mucoperiosteal polypoid thickening of the sinus and turbinate membranes (Fig. 7). Air-fluid levels are typically absent unless associated acute bacterial superinfection occurs. Polypoid thickening is more often seen with allergic disease than with bacterial
infection [29], resulting from persistent membrane hyperpla-

Granulomatous

Sinusitis

A variety of diseases
in the sinonasal cavities.

can produce
Actinomycosis, granuloma

granulomatous
syphilis, are most

changes

tuberculosis, familiar. We-

and sarcoidosis
granulomatosis

have all been reported

and midline

[29], but Wegeners necrotizing vasculitis,

sia.
Fungal Sinusitis

geners

granulomatosis,

a small-vessel

includes involvement and kidneys. Midline

of the sinuses, tracheobronchial tree, granuloma, thought to be a lymphore-

Although uncommon, the sinonasal cavities.

a variety of fungal diseases involve Mucor and Aspergillus, both part of

ticular disease, has recently been described, and is being reported with increasing frequency in cocaine users [36]. Granulomatous diseases initially involve the nasal cavity and

Fig. 6.-Chronic

sinusitis.

Axial CT scan shows

total opacification of left maxillary sinus with marked thickening of lamina dura (arrowheads) compared with normal right sinus wall.

Fig. 7.-Polypoid CT scan shows

disease. Coronal unenhanced complete opacificatlon of right

maxillary sinus with nearly complete opacification

of left maxillary sinus. Mucosal thickening of turbinate bone and nasal passage (dots) contributes to obstruction. Biopsy revealed polypoid muco-

periosteal thickening.

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Fig. 8.-Fungal sinusitis. A and B, Axial CT scans show soft tissue filling right maxillary, ethmoidal, and sphenoidal sinuses. Lesion is heterogeneous; increased density is suggestive of fungal infection with calcium and/or metals contained within mycetoma. Lamina dura of right maxillary sinus is slightiy thickened compared with left, indicative of chronic disease (arrowheads, A). However, at higher level, there is evidence of sinus expansion and osseous destruction involving both right lateral ethmoidal wall and right posterolateral sphenoidal sinus wall (arrowheads, B). C, Coronal contrast-enhanced Ti-weighted MR image reveals heterogeneous enhancement of lesion. Areas of marked hypolntensity (asterisks)

represent signal void effects of calcium and metals contained within mycetoma.

This appearance

on MR images is highly suggestive

of fungal disease.

age

Fig. 9.-Mucocele. shows a mass

SagittalTi-weighted within frontal sinus

MR imthat has

expanded the sinus and is isointense with mucosal membranes.

Fig. iO.-Mucocele. image shows mass

Coronal occupying

Ti-weighted ethmoidal

MR sinus

with bony expansion of lateral walls. Mass is hyperintense relative to mucosal membranes and, when compared with mass seen in Fig. 9, exemplifies variable imaging. appearance of mucoceles on MR

septum
Although

primarily

and the paranasal

granulomatosis

sinuses
may

secondarily
cause

[37].

Wegeners

extensive

bone loss, without an associated mass [38], CT generally shows bulky, bilateral soft-tissue nodules lining the mucosa of the nasal cavity and septum. Advanced cases involve
destruction of the cartilaginous nasal septum and osseous

spissated secretions and expansion of sinus walls. At this point, they may resemble tumors, and distinction on CT becomes difficult. As mentioned, MR has been shown to aid
in this differential diagnosis [27]. Mucous retention cyst-Mucous retention cyst, a benign lesion commonly occurring in the maxillary sinus floor, repre-

structures.

sents inflammatory
the sinus mucosal defined

obstruction
lining.

of a seromucinous
shows

gland of mass with or septated

CT typically

a homogeneous,

dome-shaped,
Local Complications of Sinusitis sharply

non-gravity-dependent
margins.

soft-tissue

Mucocele.-Mucoceles
Inflammatory polyp-Mucous membrane hyperplasia from chronic inflammation is thought to be the underlying cause of inflammatory polyps. The hyperplasia is usually allergic in origin, most commonly located in the nasal cavity or maxillary

result from obstruction

sequestration of a portion of a sinus cavity. These collections result not only from inflammation but also from posttraumatic

sinus. CT typically shows a homogeneous soft-tissue mass. When severe, polyps may cause obstruction, leading to in-

or neoplastic obstruction. The sinus fills with secretions, and eventually benign expansion occurs. Sixty percent of mucoceles occur in the frontal sinus, 30% in the ethmoidal sinus,
and 10% in the maxillary sinus [37]. Sphenoidal mucoceles

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October

1992

nonenhancing mass that and T2-weighted MR images the signal varies considerably, from hypointense to hyperintense depending on the concentration of water, protein, and mucus [39, 40] (Figs. 9 and 10). An enhancing rim
fills or expands the sinus. On both Ti
-

are rare. CT shows

a low-density,

of the intraconal space fested as an increased fat).

An additional complication

(orbital density

phlegmon) typically is maniof the retrobulbar fat (dirty

inflammation is regional

of sinus

osteomyelitis,

most

commonly

involving

the

frontal

bone

with

heterogeneous

density

suggests

a mucopyocele,

an

infected
Regional

mucocele

[38, 41].
of Sinusitis

[26]. Infection can spread hematogenously, via diploic veins, or by direct extension. Extensive therapy is required. Frontal
osteomyelitis, termed Potts puffy tumor, tion of the frontal bone associated with tissue mass [43]. causes lytic destrucan extracranial soft-

Complications

Regional
or sphenoidal sinusitis was

complications
sinusitis. the cause

may result from frontal,

ethmoidal,
Intracranial Intracranial Complications complications of Sinusitis of sinusitis, commonly due to

In particular, in one study, ethmoidal of acute orbital inflammation in 75%

of patients [42]. These infections may travel via an extensive system of valveless veins through the thin, occasionally dehiscent scess, tinction lamina papyracea. Orbital cellulitis, subperiosteal abretrobulbar abscess, or optic neuritis may result. Disbetween postseptal abscess and cellulitis, usually

extension

of frontal,

ethmoidal,

or sphenoidal

disease,

include

possible on CT scans, is important, as treatment protocols will differ (Fig. 1 1). Cellulitis is characterized on CT by diffuse, homogeneously increased density and treated medically. On
the other
low-density

meningitis, subdural and epidural empyema, brain abscess, and venous sinus thrombosis. Spread of infection can occur along several routes: (1 ) hematogenous, (2) perineural, (3) retrograde thrombophlebitis, or (4) direct inoculation (trauma

through
contrast
intracranial

an infected
enhancement
complications

sinus)

[26].

Complete

head
is required

CT with
when
may

hand,
area

abscesses
on CT and

characteristically
usually require

have
both

a central
external

or MR examination
are suspected,

as the infection

ethmoidectomy

and prolonged

antibiotic

therapy.

Involvement

localize

in areas

distant

from

the primary

infection.

Fig. 1 1.-Orbital complications of inflammatory sinus disease. A, Axial contrast-enhanced CT scan shows a hypointense postseptal collection containing air adjacent to opacified left ethmoidal air cells. This subperiosteal abscess required surgical intervention. Note marked edema of left medial rectus muscle (dots). Preseptal cellulitis (asterisk) and slight proptosis are also apparent. B, Axial contrast-enhanced CT scan in a different patient shows homogeneously increased density involving both pro- and postseptal space of right orbit. There is also a suggestion of slight proptosis and cellulitis. This case resolved with medical management alone.

Fig. i2.-Cystic fibrosis. A and B, Axial (A ) and coronal (B) CT scans show heterogeneous, polypoid opacification of paranasal sinuses and nasal cavity. Thickening of

maxillary

sinus lamina

dura indicates

chronic,

long-standing disease (arrowheads, A ). There is pressure erosion of medial wall of left maxillary

sinus and expansion

of left nasal cavity. Ethmoidal

sinuses are expanded bilaterally, left greater than right. Note pressure erosion of lamina paparycea in several areas bilaterally.

AJR:159, October 1992

OSTIOMEATAL

UNIT AND

ENDOSCOPIC

SURGERY

857

Syndromes

14. Lidov

M, Som

PM.

Inflammatory

disease

involving

a concha

bullosa

(enAJNR

Systemic

syndromes

in which sinusitis

is a component

are

infrequent but well described. The syndromes most frequently encountered are Kartageners syndrome (immotile-cilia syndrome) and cystic fibrosis (mucoviscidosis). The primary de-

larged pneumatized middle nasal turbinate): i990;1 1:999-1001 1 5. Messerklinger W. Endoscopy of the nose. 16.

MR and CT appearance. Baltimore: Urban

& Schwarzen-

fect in Kartageners syndrome is a functionally inefficient central core of epithelial cell cilia that leads to inspissated
sinus secretions [44]. Cystic fibrosis, on the other hand, is an inherited disorder involving a fundamental dysfunction of exocrine glands that results in the secretion of thick, tenacious mucus [45]. Although the causes of these syndromes differ, their CT

1 7.

1 8. 19.

appearances are similar. Almost universal opacification of all developed paranasal sinuses occurs. The secretions are frequently dense, reflecting the chronic inspissated state, with variable concentrations of mucoproteins and fluid. When the disease is long-standing or associated with polyps, sinus
enlargement can occur, leading to bone remodeling and facial

20. 21
.

berg, i978:6-18 Zinreich SJ, Kennedy DW, Rosenbaum AE, Gayler BW, Kumar AJ, Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology i987;163:769-775 Kennedy DW, Zinreich SJ. Functional endoscopic approach to inflammatory sinus disease: current perspectives and technique modifications. Am J Rhinol i988;2:89-96 Schaefer SD, Manning 5, Close LG. Endoscopic paranasal sinus surgery: indications and considerations. Laryngoscope i989;99: 1-5 Van Alyea OE. Ethmoid labyrinth: anatomic study, with consideration of the clinical significance of its structural characteristics. Arch Otolaryngol Head Neck Surg i939;29:881-901 Blaugrund SM. The nasal septum and concha bullosa. Otolaryngol Clin North Am i989;22:291-306 Babbel R, Hamsberger HR, Nelson B, Sonkens J, Hunt S. Optimization of techniques in screening CT of the sinuses. AJNR i99i;12:849-854 surgery. Otolaryngol Clin North Am i989;22

22. Rice DH. Basic surgical techniques 23. Kennedy DW. Functional endoscopic
Surg i985;1 11:643-649

and variations of endoscopic :713-722 sinus surgery. OtolaryngolHead

sinus
Neck

deformity

(Fig. 12).

24. Gustafson
Otolaryngol

Summary
Endoscopic paranasal sinus surgery is consistently gaining momentum in the diagnosis and treatment of sinus disease. Otolaryngologists are now capable of visualizing and treating all sinus drainage passages on an outpatient basis. High-

RO, Kem EB. Office endoscopy: when, where, what, and how. Clin North Am i989;22:683-688 25. Schaefer SD. Endoscopic total sphenoethmoidectomy. Otolaryngol Clin North Am 1989:22:727-732
26. Weber AL. Inflammatory disease of the paranasal sinuses and mucoceles. Otolaryngol Clin North Am i988;21 :421-437 27. Som PM, Shapiro MD, Biller HF, Sasaki C, Lawson W. Sinonasal tumors and inflammatory tissues: differentiation with MR imaging. Radiology 1988; 167: 803-808 28. Stahl RH. Allergic disorders of the nose and paranasal sinuses. Otolaryngol Clin North Am i974;7:703-71 8 29. Som PM. Sinonasal cavity. In: Som PM, Bergeron RT, eds. Head and neck imaging, 2nd ed., St. Louis: Mosby-Year Book, 1991 :1 14-1 28 30. Kopp W, Fotter R, Steiner H, Beaufort H, Stammberger H. Aspergillosis of the paranasal sinuses. Radiology i985;1 56:715-716 31 . Kumazawa H, Zehm 5, Nakamura A. CT findings of aspergillosis in the 32. sinuses and anterior paranasal sinuses. Arch Otolaryngol Head Neck Surg 1987:244:77-83 Zinreich SJ, Kennedy DW, Malat J, et al. Fungal sinusitis: diagnosis CT and MR imaging. Radiology i988;169:439-444 with

resolution CT has become an important complementary procedure to sinus endoscopy. The normal anatomy and variations of sinus structure, as well as pathologic appearances and complications of sinus disease, need to be well under-

stood by the radiologist

to provide

optimal

patient

care.

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