FESS: The Required Imaging Anatomy - Alexorlalexorl.edu.eg/alexorlfiles/alexorl2013-presentations/001001.pdf · 4/10/2013 1 FESS: The Required Imaging Anatomy Vincent Chong, MD MBA

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FESS:The Required Imaging

AnatomyAnatomy

Vincent Chong, MD MBA FRCR

Professor

Department of Diagnostic Imaging

National University Heath System

Singapore

• Kennedy DW. Functional endoscopic sinus surgery: technique. Arch Otolaryngol Head Neck Surg 1985; 111:643-649

• Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol. 1990;247(2):63-76.

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Overview

Normal anatomy General concepts

Specific anatomic structures

Variants

Pathological anatomy Stress normal anatomy Stress normal anatomy

Appropriate imaging modality

Basal Lamella &Drainage System

Middle turbinate

Middle turbinate

Basal lamella

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Anterior system Ostiomeatal unit

Ethmoid infundibulum

Middle meatusB


Posterior system Posterior ethmoid cells

& sphenoid sinus

Sphenoethmoidal recess

Superior meatus SphenoidPE

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Anterior Drainage System: Ostiomeatal Complex

Middle turbinate

Posterior Drainage System:Spheno-ethmoidal Recess

PE

S Sphenoethmoidal recess

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Spheno-ethmoidal Recess

PE Superiorturbinate Nasal

septum

Identifying the spheno-ethmoidal recess

S

Frontal Recess

Relationships Anterior Agger nasi cell

Posterior Anterior wall of

ethmoid bulla

A

Ethmoid bulla

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Frontal Recess

RelationshipsA

Lamina papyracea

MT

Medial Middle turbinate

Lateral Lamina papyracea

Frontal RecessA

Lamina papyracea

MT

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Frontal Bulla CellsFronto-ethmoid Cells

AA

Kuhn Type 1: single cell above agger nasi

Fronto-ethmoid Cells

Kuhn Type 2: Two or more cells above agger nasi

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Frontal Bulla

Frontal bulla cell

Difficult to differentiate frontal-ethmoidal cells from frontal bulla cells on coronal sections alone

Frontal bulla cells

Frontal Bulla versus K3 Cells

K3Frontal bulla cell

Leunig A et al. Surgical anatomy of the frontal recess – is there a benefit in multiplanar CT-reconstruction? Rhinology, 46, 188-194, 2008

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Middle Turbinate

Insertion

Anterior ethmoidal artery

Concha bullosa

Orientation

Insertion of MT

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A

P

A

P

Attached to lamina papyracean

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A

P

Attached to medial wall of maxillary sinus

Skull Base Insertion of MT:Critical Anatomy

Cribriform plate “sieve-like”

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Keros (1962): Type I, II, III


Keros (1962): Type I, II, III

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Anterior Ethmoidal Artery

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MT Variant:Concha Bullosa


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Endoscopic Diagnosis

Versus

CT Diagnosis


How should we treated the

inflammation?

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My Journey (through time….)

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Uncinate Process Insertion Anteriorly nasolacrimal Anteriorly nasolacrimal

apparatus Inferiorly inferior turbinate



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Uncinate ProcessHiatus semilunaris



B

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Uncinate Process

Ethmoid infundibulum Lamina papyracea

Ethmoid bulla

Uncinate Process

Insertion in lamina papyracea Recessus terminalis

Ethmoid infundibulum sealed off from frontal recess

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Uncinate Process

Uncinate Process

Insertion in skull base

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Uncinate Process

Uncinate Process

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Uncinate Process: Variants

Maxillary Sinus Ostia Accessory Ostia & Nasal Fontanelle

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Ethmoid Cell Anatomy

Ethmoid Absent - torus

ethmoidalis

Small

Giant

Infraorbital ethmoid (Haller Cell)

Sphenoethmoid (Onodi Cell)

Haller Cell

Albrecht von Haller (19th century Swiss anatomist)

Location Below ethmoid bulla, along orbital floor

Significance Infection Infection

Imaging (not surgical) diagnosis

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Haller Cell

Haller Cell

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Haller Cell Infection

Sphenoethmoid (Onodi) Cell

What is a Onodi (1908) What is a Onodi (1908) cell? Post ethmoid cell

Superior to & lateral to sphenoid sinus

Optic nerve contact

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Posterior Ethmoid:Critical Anatomy

Optic nerve relations Optic nerve relations Posterior ethmoid cell

Sphenoid sinus

Onodi cell

PEPE

SPE

S

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Posterior Ethmoid: Critical Anatomy

Sphenoid Sinus: Critical Anatomy

Optic nerve Optic nerve

Maxillary nerve

Carotid artery

Optic N

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Man with headache, post-endoscopy, sudden blindness

SS


S

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Trigeminal Nerve (V2) Neuralgia

CN V2

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Carotid Artery

More “dangerous”? Less “dangerous”?

This is dangerous!

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Mucosal Variant:Nasal Cycle (Lillie, 1923)

Normal

Affects Turbinates

Nasal septum

Ethmoid cells

Suprachiasmatic nucleus of hypothalamusnucleus of hypothalamus

Age

Mucosal Variant:Nasal Cycle (Lillie, 1923)

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Reminders

Meningocoeles

Meningomyelocoeles

Tumours Pituitary

Macroadenoma

Nasal Meningocoeles

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Nasal Meningocoeles

Nasal MeningocoelePituitary Macroadenoma

Macroadenoma

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Conclusion:Drainage System

Middle turbinate

Middle turbinate

Basal lamella

Conclusion:

Anterior Ostiomeatal complex

Middle meatus

Posterior Sphenoethmoidal

Superior meatus Superior meatus

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Conclusion: Frontal Recess

A

Ethmoid bulla

Conclusion: Frontal RecessFrontal Bulla versus K3 Cells

K3Frontal bulla cell

Leunig A et al. Surgical anatomy of the frontal recess – is there a benefit in multiplanar CT-reconstruction? Rhinology, 46, 188-194, 2008

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Conclusion: AEA

Conclusion: Ethmoid Cell

Infraorbital ethmoid (Haller Cell)

Sphenoethmoid (Onodi Cell)

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Conclusion: Posterior EthmoidCritical Anatomy

PEPE

S

Conclusion: Critical Sphenoid Sinus Anatomy

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Conclusion: Reminders

EncephalocoelePituitary macroadenoma

Conclusion: RemindersCarotid Aneurysm

Documents

FESS: The Required Imaging Anatomy - Alexorlalexorl.edu.eg/alexorlfiles/alexorl2013-presentations/001001.pdf · 4/10/2013 1 FESS: The Required Imaging Anatomy Vincent Chong, MD MBA