Chapter (1): Anatomy and physiology of the frontal sinus

Surgical Anatomy of frontal sinus

As with any surgical procedure, a thorough knowledge of anatomy is the one most important factors in minimizing complications and maximizing ones chances of a good surgical outcome. This is particularly important for otolaryngologists performing frontal sinus surgery, as each and every one of the paranasal sinuses are in close proximity to critical orbital and skull base structures. A good knowledge of anatomy will enable the surgeon to operate with more confidence(Mosher,1904). The frontal sinus is contained within the frontal bone. The frontal bone makes a major contribution to the floor of the anterior cranial fossa and, in doing so, forms the roof of the orbits. The frontal bone articulates with the ethmoid, sphenoid, parietal, and nasal bones, as well as with the zygoma and the maxilla(Clemente,2005). Posteriorly, each sinus borders on the anterior cranial fossa. The lateral portion of the sinus floor overlies the orbital roof, whereas its medial portion is directly over the anterior ethmoid air cells. The bones of the posterior wall and the orbital roof portion of the sinus floor are relatively thin. The anterior sinus wall, especially the part overlying the root of the nose (the nasofrontal beak), is frequently the strongest (Stammberger and Kennedy,1995). At birth, the frontal sinus is rudimentary and has little clinical significance. After the age of 6 to 8 years, the sinus becomes more pronounced as a result of its higher rate of growth. Growth is usually completed by ages 12- to 14 years in women and 16 to 18 years in men(Kountakis,2005).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.1Sagittal and coronal views of the frontal sinus noting its progressive secondary pneumatization between the ages of 3 and 18 years of age. Between 1 and 4 years of age (1), the frontal sinus starts its secondary pneumatization. After 4 years of age, the frontal sinus may be seen as a small, but definable, cavity (2) .When a child reaches8 years of age (3), the frontal sinus becomes more pneumatized. Significant frontal pneumatization is generally not seen until early adolescence (4), and continues until the child reaches18 years of age (5). The agger nasi air cell (AN), type III frontal infundibular cell (III), ethmoid bulla (B), suprabullar cell (SB),middle turbinate (MT), and orbit (O) (Kountakis,2005). The anterior wall of the frontal sinus begins at the nasofrontal suture line and ends below the frontal bone protuberance, along the vertical portion of the frontal bone. The height of the cavity at its anterior wall ranges from 1 to 6 cm, depending on the degree of pneumatization (Peynegre and Rouvier, 1996). The anterior wall of the sinus forms the forehead and is by far the thickest of all sinus walls, measuring up to 12 mm. There is a definite trilayered bony structure identical to the rest of the calvaria with anterior and posterior tables and a middle diploe in all of the walls of the sinus. The posterior wall is a plate of thin, compact bone (1-2 mm) whose upper part is vertical. It gradually curves downward and posteriorly until it is almost horizontal (depending on the level of pneumatization of the orbital roofs that has occurred). The posterior wall of the frontal sinus is also the anterior wall of the anterior cranial fossa and can extend as far posteriorly as to the lesser wing of the sphenoid bone(Kountakis,2005).
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Chapter (1): Anatomy and physiology of the frontal sinus

The inferior wall of the frontal sinus is formed by the orbital roof on the lateral side and the nasoethmoid floor on the medial side. The most anterior area of the sinus floor is directly above the roof of the nose. It consists of a very thick bony mass of the nasal spinous process of the frontal bone, or internal nasal spine (spina nasalis interna) passing through the inferior border of the angle of the mandible inferiorly (Clemente ,2005). It has a superior vertical, and a smaller inferior horizontal, portion. The horizontal portion will form part of the orbital roof. Both posterior walls join inferiorly to form the internal frontal crest, to which the falx cerebri inserts (Fig. 3.6). The posterior table of the frontal sinus can also be inherently thin (Cryer ,1907).

Figure 1.2:View of the anterior cranial fossa and orbital roof. The posterior table and extent of the f s (F) are identified. The crista galli (CG) and superior saggital sinus (SS). The cribriform plate (C) is seen on either side of the crista galli. Branches of the anterior ethmoid artery (EA) are seen reentering intracranially. The optic nerve(ON) is seen entering the optic canal medial to the anterior clinoid process (AC)(Clemente, 2005).
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Chapter (1): Anatomy and physiology of the frontal sinus

At the frontal sinus floor close to the anteromedial aspect of the intersinus septum rests the frontal sinus ostium. The frontal sinus ostium marks the site where pneumatization of the sinus began. The frontal sinus drainage pathway has an hourglass shape composed of three distinct segments: The top part of the hourglass is the frontal infundibulum, which is the inferior portion of the frontal sinus cavity narrowing like an upright funnel toward the second segment, the frontal ostium.The third segment is the inferior air chamber'named the frontal recess. This functional unit for frontal sinus drainage has been referred to as the frontal sinus outflow tract. (Clemente , 2005).

Figure 1.3:Sagittal section through the agger nasi (A), ethmoid bulla (B), suprabullar cells (SB), posterior ethmoid (PE), andlateral sphenoid (S). The frontal sinus (F) outflow tract is noted by the dotted arrow, The uncinate process has been removed to expose the maxillary ostium (M). The tail of the middle turbinate (MT)(Clemente ,2005). The frontal sinus infundibulum is formed by the most inferior aspect of the frontal sinus. It has the form of a funnel that points towards the ethmoid in a posteromedial direction. The angulation (posteromedially)and maximum diameter of this funnel may vary greatly between patients(Kountakis,2005).
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Chapter (1): Anatomy and physiology of the frontal sinus

A triangular-shaped intersinus septum separates the frontal sinuses into separately draining sinus cavities. It is the continuation, anteriorly, of the fused and ossified embryologic sagittal suture line. Although the intersinus septum may vary in direction and thickness as it proceeds superiorly, the base of the intersinus septum will almost always be close to the midline at the level of the infundibulum. At this level, the intersinus septum is continuous with the crista galli posteriorly, the perpendicular plate of the ethmoid inferiorly(Lang,1989). The frontal sinus infundibulum is bounded by the following structures: 12345The lamina papyracea laterally in its superior portion. The middle turbinate anteriorly. The vertical lamella medially. The agger nasi anteroinferiorly. The ethmoid suprabullar air cells posteriorly.

It is important to know that these cells might be present in any given patient, an endoscopic surgeon not aware of these cells might confuse them with the frontal sinus(Bolgeret al,1991).

Agger Nasi Cell:

The term agger nasi means nasal eminence. This area is found just anterior to the middle turbinate insertion . It arises from the superior aspect of the infundibulum or the frontal recess. It is bounded anteriorly by the frontal process of the maxilla, anterolateral by the nasal bones, superiorly by the frontal recess, inferomedially by the uncinate process, and inferolaterally by the lacrimal bone. The superior aspect of the cell serves mainly as the anterior border of the frontal recess ( Bent et al ,1994). Figure 1.4:endoscopic view of Agger nasi cell (Agn), septum (s)(Mclaughlin et al,2001).

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Chapter (1): Anatomy and physiology of the frontal sinus

Ethmoid Bulla:
The ethmoid bulla is one of the most constant and largest of the anterior ethmoid air cells. It is located within the middle meatus directly posterior to the uncinate process and anterior to the basal lamella of the middle turbinate. The cell is based on the lamina papyracea and projects medially into the middle meatus. The cell has the appearance of a bulla, that is, a hollow, thin-walled, rounded, bony prominence(Sethi ,2006). Superiorly, the anterior wall of the ethmoid bulla can extend to the skull base and form the posterior limit of the frontal recess. Posteriorly, the bulla can blend with the basal lamella (Bolger ,2001). The term bulla indicates that this part of the bone is pneumatized. Where the bulla is not pneumatized, it is referred to as the lateral torus. The ethmoid bulla is about 18 (9-23) mm long and 5.4 (2-13) mm high (Sethi ,2006).

Figure 1.5:View of the outer wall of the nose. The turbinated bones having been removed. Labels: 1, vestibule, 2, hiatus semilunaris; 3, opening of antrum of highmore; 4, bulla ethmoidalis; 5, agger nasi; 6, opening of anterior ethmoidal cells; 7, cut edge of superior turbinated bone; 8, cut edge of middle turbinated bone; 9, pharyngeal orfice of Eustachian tube(Cunningham,1903).
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Chapter (1): Anatomy and physiology of the frontal sinus

Uncinate process :
A description of these structures is crucial to the understanding surgical approaches. Many surgeons analyzing coronal CT scans of paranasal sinuses focus on the easily identified posteroinferior segment of the uncinate process. The superior attachment of the uncinate process is often ignored or misnamed as anterior ethmoid cells, anterior ethmoid complex, or agger nasi cells. Intimate knowledge of this area shows that even though the anatomy is variable, it is also highly predictable(Landsberg and Friedman,2001). Stammberger and Kennedy experience led to view the uncinate process superior attachment as the most important anatomical landmark in frontal sinus surgery. The inferior portion of the uncinate process is well recognized and clearly visible. The uppermost segment of the uncinate process is no longer visible behind the insertion of the middle turbinate(Mclaughlin et al,2001). In Landsberg study with image-guided surgery software, surgon identified 6 types of superior attachment of the uncinate process: Type 1 (52%) is the most frequent. The uncinate process bends laterally in its upper-most portion and inserts into lamina papyracea .Type 2 (18.5%), the uncinate process confluences with the posteriormedial wall of the agger nasi.In this case, the floor of the agger nasi closes the infundibulum superiorly.Type 3 (17.5%) has 2 insertions; one forms the terminal recess and a second runs to the junction of the middle turbinate with the cribriform plate(Landsberg and Friedman,2001). These 3 types include the vast majority of cases (88%) and from a surgical standpoint mandate the same approach (ie, the frontal recess can be reached by dissecting medial or posteromedial to the uncinate process, because the frontal ostium outflow opens medial to the superior attachment of the uncinate process and directly into the meatus of medial turbinate)(Landsberg and Friedman,2001).
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Chapter (1): Anatomy and physiology of the frontal sinus

Types 4 to 6 include only 12% of cases and mandate a different approach; ie, the frontal recess can be reached by dissecting lateral to the superior attachment of the uncinate process because the frontal ostium outflow opens lateral to the superior attachment of the uncinate process and directly into the ethmoid infundibulum (Landsberg and Friedman,2001).

Figure 1.6:Schematic drawings of uncinate process superior attachment variations. (A) Insertion to the lamina papyracea. (B) Insertion to the posterior medial wall of the agger nasi cell. (C) Insertion to both the lamina paprycea (D) Insertion to the junction of the middle turbinate with cribriform plate. (E) Insertion to the skull base. (F) Insertion to the middle turbinate(Landsberg and Friedman,2001).

Hiatus Semilunaris:
The hiatus semilunaris is a sagittal cleft between the posterior border of the uncinate process and the anterior surface of the ethmoid bulla. The middle meatus communicates with the infundibulum through this area, designated as the hiatus semilunaris inferioris. The hiatus semilunaris superioris is the cleft formed between

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Chapter (1): Anatomy and physiology of the frontal sinus

the posterior wall of the ethmoid bulla and the basal lamellae of the middle turbinate(Polavarani et al,2004).

Figure 1.7: the relation between frontal recess to hitaus Semilunaris, SS, sphenoid sinus,ST superior turbinate ,BE Bulla ethmoidali(Polavarani et al,2004).

Sinus Lateralis:
The sinus lateralis is a variable air space that lies behind and above the ethmoid bulla, This space can be highly developed, and in such cases, it is bordered by the ethmoid roof superiorly, the lamina papyracea laterally, the ethmoid bulla roof and posterior wall inferiorly and anteriorly, and the basal lamella of the middle turbinate posteriorly. If the ethmoid bulla does not reach the skull base, the suprabullar recess is continuous anteriorly with the frontal recess at that site(Hoseman and Fanghanel,2005).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.8:sagittal CT image showing a large frontal bullar cell (asterisk), suprabullar in location (B, bulla ethmoidalis), with an anterior margin related to the frontal sinus (arrows) and posterior margin formed by the anterior skull base (arrowheads)(Hoseman and Fanghanel ,2005).

Ethmoidal Infundibulum:
The ethmoidal infundibulum is the passage through which the secretions from various anterior ethmoid cells, the maxillary sinus, and, in some cases, the frontal sinus are transported. The ethmoidal infundibulum is a three-dimensional space located in the anterior ethmoid region, bordered medially by the mucosacovered uncinate process, laterally by the lamina papyracea, and anteriorly and superiorly by the frontal process of the maxilla and lacrimal bone superolaterally. The anterior wall of the ethmoid bulla forms the posterior border of the ethmoidal infundibulum(Loury,1993).

Ostiomeatal Unit:
The ostiomeatal unit is not a discrete anatomic structure but refers collectively to several middle meatal' structures: the uncinate process, the ethmoid infundibulum, anterior ethmoid cells, and ostia of the anterior ethmoid, maxillary, and frontal sinuses. The ostiomeatal unit is a functional rather than an anatomic designation(Lang ,1989).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.9:Ostiomeatal Unit(green).1 frontal sinus;2 ethmoid sinus;3 middle turbinate;4 inf turbinate;5 maxillary s;6 orbit;9a infundibium;9b frontal recess;10 ethmoid cells ;11 natural ostium;12 hiatus semilunaries (Kountakis,2005).

Frontal Recess:
The frontal recess is initially a smooth mucosal pocket that appears in the anterosuperoir middle meatus during the third or fourth month. In late fetal life, folds and furrows lined by mucosa develop within this recess; the number is inconstant varying from none to four or five. Further development finds mucosal lined air cells advancing into and absorbing cancellous bone(Daniels et al , 2003). The frontal recess is the most anterosuperior aspect of the anterior ethmoid sinus that forms the connection with the frontal sinus. The boundaries of the frontal recess are the lamina papyracea laterally, the middle turbinate medially, the posterosuperior wall of the agger nasi cell (when present) anteriorly, and the anterior wall of the ethmoid bulla posteriorly. If the anterior wall of the ethmoid bulla does not reach the skull base and form a complete posterior wall, the frontal recess may communicate with the suprabullar recess. The frontal recess tapers as it approaches the superiorly located internal os of the frontal sinus; above the os, it again widens. An hourglass-like appearance is evident, with the narrowest portion being the frontal ostium(Cuilty-Silver et al,1994).
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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.10:The frontal recess is a potential inverted funnel-shaped space with the most narrow portion being the internal ostium(Daniels et al , 2003). An intimate relationship therefore exists between the agger nasi cell and the frontal recess. Secretions from the frontal sinus destined for the nasal cavity usually follow a path through the frontal recess and over the posterior and medial surface of the agger nasi ceil. If the agger nasi cell is extensively pneumatized, the frontal recess can be relatively narrowed, and hence the patient may be predisposed to frontal sinusitis. In surgery, an extensively pneumatized agger nasi can be mistaken for the frontal recess or sinus. If a large agger nasi cell is opened and mistaken for a frontal sinus, the residual superoposterior wall of the agger nasi cell can scar posteriorly to the ethmoid roof, and iatrogenic stenosis or obstruction of the nasofrontal connection can occur(Owen et al,1997). Endoscopically: they appear as a prominence just anterior to the attachment of the middle turbinate to the lateral nasal wall. They are bounded anteriorly by the frontal process of the maxilla, posteriorly by the infundibulum, superiorly by the frontal sinus and its recess, and inferomedially by the uncinate process(Kuhn et al, 1999).

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Chapter (1): Anatomy and physiology of the frontal sinus

Cells of the Frontal Recess:

Frontal cells are divided into four variants always in conjunction with an agger nasi cell Cell Type Type 1 Type 2 Anatomical Location Single frontal cell above agger nasi cell, but not extending above frontal beak Tier of cells in frontal recess above agger nasi cell, but not extending above frontal beak Type 3 Type 4 Single massive cell pneumatizing cephalid into frontal sinus Isolated cell in the frontal sinus

Table1.1: frontal cells Category and Their Anatomical Locations(Bent et al,1994). The frontal cells arise somewhat more posteriorly than the agger nasi cell and pneumatize further into the frontal sinus. (Bent et al,1994). Several discrete anterior ethmoid cells could potentially obstruct the frontal recess contributing to or causing frontal sinusitis. They clearly influence frontal sinus drainage and cautioned that their inadequate removal could lead to surgical failure and recurrent disease or create iatrogenic frontal sinus disease ( Van Alyea,1941).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.11: Sagittal CT images showing types 1,2 &3 frontal cells (arrows). (d) Coronal CT image shows an isolated right type 4 frontal cell (arrow) surrounded by an opacified frontal sinus. Frontal beak (asterisk); agger nasi (an)(McLaughlin et al, 2001).

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Chapter (1): Anatomy and physiology of the frontal sinus

All variants of this cell, including tiers of cells in the frontal recess, may occlude frontal sinus drainage. The smaller isolated type IV frontal cell within the frontal sinus may completely close off the internal frontal ostium and appear as an air bubble in an otherwise opaque frontal sinus (McLaughlinet al, 2001).

Figure 1.12:Bent and Kuhns classification offrontal infundibular air cells basedon its proximity to the agger nasi (A)and orbital roof. Types I, II, III, and IV are shown. In addition, one or more intersinus septal cell (IS) may also exist

Blood supply:
The frontal sinus obtains its vascular supply from terminal vessels of the sphenopalatine artery and internal carotid artery (via the anterior and posterior ethmoid arteries). Terminal branches of the sphenopalatine artery make their way towards the frontal sinus by way of the nasofrontal recess and infundibulum. The anterior ethmoid artery (and more rarely the posterior ethmoid artery) also gives off some branches to supply the posterior aspect of the frontal sinus cavity(Han,2008).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.13:Vasculature of the nasal cavity.1,Kiesselbach area 2,int carotid art 3,sphenopalatine art 4,ophthalmic art 5,anterior &post ethemoid artery(McLaughlin et al , 2001). The anterior ethmoidal artery arises from the ophthalmic artery within the orbit and travels medially to perforate the lamina papyracea and traverse the anterior ethmoid cells. It courses through the roof of anterior ethmoid running a curvilinear, course from a postero-lateral to an antero-medial direction. In the ethmoid roof the artery is enveloped by only a thin bony canal (anterior ethmoid canal). The canal can be attached to the roof of the ethmoid by a bony septation of variable length (up to 5 mm), as if it were hanging by a mesentery(Simmen,2006). During frontal sinus surgery the anterior ethmoid artery may be identified by opening the suprabullar space after the bulla has been removed. The artery can be identified traversing roof of the ethmoid 2 to 4 mm from attachment of the bulla ethmoidalis onto the skull base (Simmen,2006). The mean distance from the axilla to the anterior ethmoid artery was measured as 17.5 mm. The mean distance from the posterior ethmoid artery to the anterior ethmoid artery was 14.9 mm. The mean distance from the posterior ethmoid artery to the anterior wall of the sphenoid sinus was 8.1 mm.The anterior ethmoid artery was located immediately anterior to the superior attachment of the basal lamella(33%) (Han,2008).

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Chapter (1): Anatomy and physiology of the frontal sinus

Most of the frontal sinus venous blood supply consists of a compact system of valveless diploic veins, which communicate intracranially, intraorbitally, and with the midfacial and forehead skin. The posterior wall drains into the superior sagittal sinus, intracranially (Duque and Casiano,2005). Lymphatic supply: Microscopic channels provide lymphatic drainage to the frontal sinus through the upper nasal (midfacial) lymphatic plexus, for most of the anterior and inferior part of the sinus. The remaining portion of the frontal sinus drains into the subarachnoid space(Sadler ,2004). Innervation :

Figure 1.14 :nerve suplly of the nasal mucosa&paranasal sinuses(Simmen,2006). Branches of the ethmoidal, nasal, supraorbital, and supratrochlear nerves provide the frontal sinuscavity with an extensive array of sensory innervation. Autonomic innervation of mucosal glands accompanies the neurovascular bundle supplying the frontal sinus(Sadler ,2004).

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Chapter (1): Anatomy and physiology of the frontal sinus

Radiological Anatomy of the Frontal Sinus

Plain films: In 1984, when endoscopic surgery was first introduced in the United States, two principal surgical procedures were being performed to treat chronic sinusitis: the Caldwell -Luc procedure and surgical procedures aimed at the frontal sinus. Plain films were used to display the morphology and pathology of the frontal and maxillary sinuses as well as the nasal cavity and sinuses in general (Ay gun et al,2005). The standard radiographic sinus series consists of 4 views:

1. lateral view:
shows the bony perimeter of the f rontal, maxillary, and sphenoid sinuses.

Figure 1.15:Adult Sinuses - Lateral(Som and Curtin ,1996).

2. Caldwell's view:
shows the bony perimeter of the frontal sinus.
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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.16: The modified Caldwell view ( Som and Curtin ,1996).

3. Waters' view:
shows the outlines of the maxillary sinuses,some of anterior ethmoid air cells, and the orbital floors.

Figure 1.17: The modified Waters view. with Positioning diagram Sample closed-mouthradiograph (Som and Curtin ,1996).

4. submentovertex (base view)

evaluates the sphenoid sinus and the anterior and posterior walls of the frontal sinuses.

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Chapter (1): Anatomy and physiology of the frontal sinus

Standard radiography may be accurate in showing air and fluid levels in the frontal, maxillary, and sphenoid sinuses, but it

significantly underestimates the degree of chronic inflammatory disease present, particularly in the ethmoid sinuses. Furthermore, the superimposition of fine bony structures on standard radiography precludes the accurate evaluation of the anatomy of the ostiomeatal channels (Zinreich et al,1996).

Polytomography:
In the early 18 and 20 century polytomography was used to display better the anatomic detail needed to guide the surgeon in performing a safe endoscopically guided surgical procedure. This imaging technology (in use 20-30 years ago) provided a finer display of bone morphology and was used to delineate better the skull-base and temporal bone morphology. It also was employed to visualize bone changes better. The benefits of this technology were offset by several disadvantages: a higher radiation dose, increased examination time, and a moderately blurry display without soft tissue resolution (Ay gun et al,2005).

Computed X-ray tomography:

The utility of computed tomographic (CT) scanning in the preoperative is evaluation of patients undergoing endoscopic surgery has been well established. Coronal images are obtained perpendicular to the hard palate while the patient lies prone on the gantry table with the head hyperextended.The coronal view is excellent in determining the presence of the following Remaining agger nasi. Frontal recess. Superior uncinate process ( Ghiu and Kennedy,2005).
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Chapter (1): Anatomy and physiology of the frontal sinus

Axial images are obtained parallel to the hard palate while the patient lies supine on the gantry table with the head in a neutral position (Holliday and Shpizner,1995). Sagittal Images reformatted images should never be used for assessing osseous integrity within the sinonasal cavity. Manipulation of axial or coronal images to create sagittal images can also create apparent dehiscences in the sinus walls (Daniels et al,2003) . Neither the axial nor the coronal projections provide a complete evaluation of the complex anatomy of the ostiomeatal unit and

sphenoethmoid recess. For example, the relationship between the four primary lamellas of the sinonasal cavity (uncinate process, anterior wall of the bulla, basal lamella, and anterior wall of the sphenoid) a re best appreciated in a sagittal projection. Unfortunately, direct sagittal CT imaging of the sinonasal cavity is precluded by patient intolerance of the position necessary to achieve these images. CT images in a sagittal projection may be produced by manipulation of the data obtained from either coronal or axial images, a process commonly termed

reformatting (Holliday and Shpizner,1995). Sagittal and axial views are important in determining the following: Anterior to posterior dimension of the frontal recess. The identification of a supraorbital ethmoid cell. Frontal recess. Interseptal frontal sinus cell. Window Setting The correct window settings are of critical importance for the examination and evaluation of the delicate mucosal and bony structures of the sinuses (Kopp and Stammberger,1991) .

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Chapter (1): Anatomy and physiology of the frontal sinus

Sinus Imaging Evaluation

- Frontal Sinus Ostium : The frontal sinus narrows down inferiorly and medially into a funnel shaped transition point , extendingbetween the anterior and posterior frontal sinuswalls at the skull base level. Th is point is typicallydemarcated along its anterior wall by the variablyshaped bone ridge of the nasofrontal buttress, frequentlycalled the nasal beak (Senior and Das,2007) .

Fig. 1.18:sagittal image illustrate The frontal sinus ostium(FS) .Asterisks ethmoid infundibulum,AN agger nasi cells,BL basal lamella of the middle turbinate (MT), IT inferior turbinate,NB nasal beak,SS sphenoid sinus(Senior and Das,2007).

-Frontal Recess, Agger Nasiand Uncinate Process:

The frontal recess can be narrowed from anterior-inferior direction by hyper pneumatized agger nasi cells. Furthermore, the frontal recess inferior drainage is dictated by the insertion of the vertical attachment of the uncinate process, a sagittally oriented hooklike bony leaflet,the uncinate process attaches to the skull base or the superior-anterior portion of the middle turbinate, the frontal recess will drain directly into the superior end of the ethmoid infundibulum (Senior and Das,2007) .
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Chapter (1): Anatomy and physiology of the frontal sinus

Fig. 1.19:Th e frontal recess. a Sagittal image at the frontal recess showing the frontal sinus ostium as a funnel shaped outfl ow tract (dashed line). b Coronal image showingthe right anterior ethmoid artery (AEA) coursing through its bony canal (long arrow). The left anterior ethmoid artery is dehiscent (short arrow) just below the frontal recess(Senior and Das,2007).

Figure 1.20:In the sagittal image (a) the uncinate process (asterisks) is shown as a curved bony projection that extends towards the frontal recess.The bulla ethmoidalis (BE).the lamina papyracea (arrow), with the frontal recess (FR) opening directly to the middle meatus, and the left ethmoid infundibulum ending in a blind end or terminal recess (TR)(Senior and Das,2007).

-Ethmoid Infundibulum :
true three-dimensional space.It opens medially into the middle meatus across the hiatus semilunaris inferioris, a cleft like opening between the free posterior margin of the uncinate process and the corresponding anterior face of the bulla ethmoidalis.
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Chapter (1): Anatomy and physiology of the frontal sinus

Fig. 1.21: Th e ostiomeatal complex. Notice on the sagittal image (a) the cleft like ethmoid infundibulum (dotted line), bordered anteriorly by a pneumatized agger nasi cell (AN) and posteriorly by the bulla ethmoidalis (BE). Th e middle turbinate (MT) is seen below. In the coronal image (b) the ethmoid infundibulum (dotted line) lies between the uncinate process(UP) and the bulla ethmoidalis (BE), opening into the middle meatus across the hiatus semilunaris inferior (asterisks)(Senior and Das,2007).

Frontal Cells
The frontal cells are uncommon anatomic variants of anterior ethmoid pneumatization that impinge upon the frontal recess and typically extend within the lumen of the frontal sinus ostium above the level of the agger nasi cells .The different types of frontal cells as described by Bent,All frontal cells can be clinically significant if they become primarily infected or if they stenose the frontal sinus ostium, leading to mucus recirculation and secondary frontal sinusitis see Figure1.11(Ghiu and Kennedy,2005)

MRI:
Although CT affords an excellent display of bony morphology and has proved to be an excellent surgical guide, MRI offers a better soft tissue resolution to show pathologic boundaries when inflammatory sinus diseaseextended beyond the limits of the nasal cavity and paranasal sinuses into theorbits and brain ( Ay gun et al,2005) .
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Chapter (1): Anatomy and physiology of the frontal sinus

Values of MRI in imaging of paranasal sinuses 1. MRI has proved superior to CT in demonstrating the extent of inflammatory disease and in the characterization of fungal concretions. The presence of calcium and paramagnetic elements within the fungal concretion results in a very low to absent signal on T2-weighted image sequences. This image is distinctly different from the high-signal intensity on T2-weighted images demonstrated by bacterial and viral inflammatory processes :( Stultz and Modie ,2005) . 2. MRI excels in distinguishing because between neoplasia neoplasms displays and an

inflammatory

disease,

intermediate rise in T2 signal intensity, whereas bacterial and viral inflammatory disease produce very high T2 signal. 3. MRI is necessary in presence of opacification in contrast with defect of skull base to exclude meningoencephalocele. 4. Detection of mucoceles : Magnetic resonance imaging is necessary to differentiate between different types of soft tissues within the sinonasal cavities, especially if the mucocele formed secondary to a neoplasm. Additionally, when the mucocele extends intracranially, MRI offers superior imaging of the surrounding brain. The usual signal characteristics for a mucocele are low T1 and high T2, but variations commonly occur depending on the presence of blood and the water content of the mucoceles) (Palmer and Schipor,2005).

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Chapter (1): Anatomy and physiology of the frontal sinus

Figure 1.22: MRI T 2 coronal image of paranasal sinus & brain (Palmer and Schipor,2005). Three-dimensional imaging: Currently, CT scanners afford images of submillimeter thickness that can be easily magnified to provide significantly better data for easily achievable 3-D display of the sinuses. 3-D display technology now affords an endoscopic like display of the regional morphology through virtual 3-D endoscopy( Ay gun et al,2005) . Imaging technology used to stage sinusitis: Lund-Mackay staging system: Perhaps the mostly widely accepted CT scan classification system in chronic rhinosinusitis is the Lund-Mackay system (Table 1-2), the system is reduced to a simplistic form that minimizes individual variation in the interpretation of the degrees of opacification. It requires no formal radiologic training, only the ability to identify the major sinuses and to distinguish between zero, partial or total sinus opacification( Ogston ,1885).

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Chapter (1): Anatomy and physiology of the frontal sinus

According to this system, each sinus group is graded with a score between 0 (no abnormality) and 2 (total opacification). Left and right sides are rated separately, with a maximum possible score of 24 (Lund and Mackay,1993) .

0 Points 1 points 2 points

No abnormality Partial opacification Total opacification

Table 1.2 :Lund-Mackay staging system for chronic rhinosinusitis(Lund and Mackay,1993) . Score 0, 1, or 2 points for left and right side of each of the following regions and calculate total for each side:Maxillary ,Anterior ethmoid,Posterior ethmoid, Sphenoid ,Frontal & Ostiomeatal complex (scored only with a 0 or 2) (Perez et al,2005) . Proposals for improving currently available staging systems: The Lund-Mackay system is the most popular staging systems. It is the most objective and most reproducible. Its major drawback is its inability to "subgrade" the volume of inflammatory disease .When considering the use of a specific medical therapeutic agent, if grade I with 10% disease is cured it is reduced to grade 0. If grade 1 with 90% disease is reduced to 30%, however a substantial improvement the stage is still grade I (no change). These issues can be easily addressed by further stratifying gradeI into A (l%-33%), B (34%-66%), and C (67%-99%) subgrades (Perez et al,2005) .

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Chapter (1): Anatomy and physiology of the frontal sinus

Physiological Considerations of Frontal Sinus

The physiological role of the paranasal sinuses is a contiriuation of the respiratory cavity and are lined by a respiratory mucosa. They share certain features with the nose but the responses are much less marked due to relatively poorly developed vasculature and nerve supply (Lee,2008).

Mucosa:
The frontal sinus mucosa resembles the rest of the upper respiratory mucosa with its ciliated columnar respiratory epithelium, along with numerous glands and goblet cells that produce serous and mucinous secretions. The frontal sinus mucosa is constantly producing secretions in order to ensure that the cavity is at all times cleared of particulate matter, and that proper humidification is achieved (Kuhn,2001).

Respiratory Cilia:
the respiratory cilia are found throughout the respiratory tract except for the nasal vestibule, the posterior oropharyngeal wall, portions of the larynx, and terminal ramifications of the bronchial tree. They are found in the eustachian tube, much of the middle ear, and the paranasal sinuses. Cilia in a modified form also occur in the maculae and cristae in the inner ear and in the eye as retinal rods (Ballenger, 2003) .

Figure 1.23:histology of the respiratory epithelium ( Ballenger, 2003) .

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Chapter (1): Anatomy and physiology of the frontal sinus

Ciliary Beat:
The to-and-fro movement of the cilium is termed the ciliary beat. The forward beat is the more forceful, effective stroke in which the cilium is fully extended, and the claws at the tip penetrate the top layer of mucus bordering on the luminal surface and propel the mucus forward. The recovery stroke is less forceful and slower, and the shaft curls back on itself so that it does not reach the overlying flakes of mucus.- Beating occurs 1,000 or more times per minute (Messerklinger,1976). In health, particles resting on the mucous blanket are moved by active cilia at 3 to 25 mm per minute, with an average of about 6 mm per minute. Dryness of the mucosa is quickly detrimental to ciliary activity. Other factors known to influence clearance speeds are the relativ e humidity and the pH of the fluids, B2- Adrenergic agonists accelerate the wave frequency, whereas X2- adrenergic activity retards the movement ( Probst et al,2006) .

Figure 1.24 : Diagram of the normal ciliary cycle ( Ballenger, 2003).

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Chapter (1): Anatomy and physiology of the frontal sinus

Drainage:
Mucociliary Clearance: Nitric oxide (NO), a substance with many important physiologic functions, including bactereostasis and stimulating ciliary beat rate, is produced in remarkably large quantities from epithelial cells in the maxillary sinuses. NO is reported to be locally increased in allergic rhinitis but decreased in chronic sinusitis and Kartagener's syndrome, indicating an important role as a regulator of mucociliary function. Ciliary beat frequency is also altered by many inflammatory substances causing acceleration or retardation, the net effect being difficult to predict in the clinical situation (Bolger et al,2001).

Figure 1.25 : Diagram Cilia on the respiratory epithelium beat in a coordinated, metachronous pattern in the periciliary fluid (deeper sol layer), which transports the superficial gel layer toward the nasopharynx (arrow) (Lee,2008).

Oxygen tension:
The P02 is lower in the maxillary sinuses than in the nose and it is lower still in the frontal sinuses. If the ostium becomes blocked, the oxygen tension drops further. Ciliary motion remains normal if the blood supply is adequate. If the blood supply is impaired, ciliary activity is reduced and. stasis of secretions results. Blockage of the natural sinus ostium results in areduction of ventilation and stasis of secretions. An ostium below2.5 mm presposes to disease ( Aust et al,1976).
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Chapter (1): Anatomy and physiology of the frontal sinus

Physiological functions of the sinuses : diminution of auditory feedback. air conditioning. pressure damper. reduction of skull weight. flotation of skull in water. mechanical rigidity. heat insulation. (Ballenger ,2003)

Most ImportantPhysiological Concepts:

1. Contrary to long-held popular concepts, the drainage pathway, not the frontal sinus, is the primary cause of chronic frontal sinusitis. 2. Frontal sinus ciliary beat pattern and therefore mucus flow is up the interfrontal sinus septum, lateral across the frontal sinus roof, and then medial over the frontal sinus floor to the ostium .

Figure 1.26: Frontal sinus mucociliary flow (Mullol et al,2000). 3. Mucus clearance out of the sinus is active by ciliary action down the lateral aspect of the frontal recess, whether it is directly down the medial orbital wall, or over the medial or posterior aspect of a frontal recess cell, such as an agger nasi cell. 4. If this mucus membrane is damaged or removed, the sinus may not function properly after healing. As columnar epithelium does not regenerate well after being stripped off of bone (Moriyama et al,1996).
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