The sphenoid sinus natural ostium is consistently medial to the superior turbinate

BACKGROUND: This study was performed to determine the location of the natural ostium of the sphenoid sinus relative to the intact superior turbinate. METHODS: Forty-seven cadaveric specimens were examined. Mucosa over the sphenoethmoidal recess, superior turbinate, and posterior ethmoid was left intact. The position of the sphenoid sinus natural ostium relative to the superior turbinate was identified. RESULTS: The sphenoid ostium was identified in all specimens. In all specimens, the sphenoid ostium was found to be medial to the intact superior turbinate, notwithstanding lateral deflection of the posterior few millimeters of the superior turbinate in some cases. CONCLUSION: The superior turbinate is an excellent landmark for the sphenoid sinus natural ostium. Previous observations of the ostium positioned lateral to the superior turbinate may have been caused by stripping of the superior turbinate mucosa before measurements were taken. In the intact specimen, the sphenoid ostium is reliably found medial to the superior turbinate.     

筛窦基板层次气化分析及其在鼻内镜鼻窦手术中的应用

目的探讨应用筛窦基板层次性分析方法，指导内镜下筛窦层次性开放的可行性。方法通过鼻窦CT扫描的薄层DICOM数据，层厚层距均为0.65 mm，ImageViewer软件三维重建分析筛窦的基板（III V）层次及其气化情况。结果获得100例（200侧）患者鼻窦CT原始薄层数据，通过三维重建分析发现筛骨结构包含5个基板（I V）：①基板V的出现率为60.0%，相邻基板间存在潜在的层次间隙；②Haller气房出现率为28.0%，与中鼻甲、上鼻甲基板结构气化相关者分别占19.5%、8.5%；③上鼻甲及基板气化发生率为91.5%，其中19.1%气化为Onodi气房。最上鼻甲及基板出现率60.0%，气化发生率为76.7%，其中15.8%气化为Onodi气房。Onodi气房出现率为33.0%，来源于上鼻甲基板、最上鼻甲基板的分别占17.5%，9.5%，来源于二者共同气化的占6.0%。各基板及其气化结构组成相对独立的通气引流系统，可单独出现引流障碍。手术中筛窦的开放（III V基板）过程，以上鼻甲、最上鼻甲为标志结构，结合CT提示的气化变异，可在其前方分别充分地开放III基板、IV基板气化结构构成的筛窦迷路（包括变异气房，如Haller气房），而根据CT提示V基板的气化状况和方向，可进一步实现V基板及其气化结构（包括Onodi气房）的开放。结论通过分析筛窦基板的层次性结构，对指引内镜下筛窦开放过程实现层次性、标准化有重要指导价值。     

Surgical anatomy of the natural ostium of the sphenoid sinus

OBJECTIVES: This study was undertaken to measure the distance and the angle between the anterior part of nasal cavity and the natural ostium of the sphenoid sinus. The anatomical location of the natural ostium according to the direction of surgeon's operating view toward the anterior wall of the sphenoid sinus was also analyzed. STUDY DESIGN: This study used careful cadaver dissection under a surgical microscope. METHODS: One hundred sagittally sectioned adult cadaveric heads were used. We measured the distances and angles for identifying the natural ostium of the sphenoid sinus using several reference points such as the limen nasi, the sill, and the posteroinferior end of the superior turbinate. In addition, we tried to identify whether the location of the natural ostium is medial or lateral to the posterior end of the superior turbinate. RESULTS: The natural ostium of the sphenoid sinus was located at an angle of 35.9 degrees with a distance of 56.5 mm from limen nasi and at an angle of 34.3 degrees with a distance of 62.7 mm from nasal sill. It was located approximately 1 cm above the posteroinferior end of the superior turbinate and at a medial aspect to the posterior end of the superior turbinate in 83% of specimens. CONCLUSIONS: We speculate that the posteroinferior end of the superior turbinate is the best landmark for identifying the natural ostium of the sphenoid sinus. Furthermore, the natural ostium should ideally be searched from a superior and medial aspect in relation to the posteroinferior end of the superior turbinate.     

Sinus lateralis in endoscopic ethmoidectomy

Objective: To characterize the anatomy of the sinus lateralis and enable a more accurate and safe approach to endoscopic ethmoidectomy. Study Design: An anatomic study of 33 cadaver heads providing a prospective evaluation of 50 ethmoid sinuses. The sinus lateralis, in particular, was thoroughly examined and typical variations were classified into four categories. A technique using the sinus lateralis as a critical landmark is described which allows calculated removal of anterior ethmoid cells in a posterior-to-anterior direction, avoiding inadvertent entry into the posterior ethmoid. Prospective evaluation of this technique in 12 pediatric patients found it to be safe and particularly useful for neophyte endoscopic surgeons. Methods: Endoscopic examination of 50 cadaver sinuses using 0?, 30?, and 70-degree, 4-mm telescopes to dissect the anterior ethmoid. The characteristics of each sinus lateralis were documented. To confirm the endoscopic findings, we grossly examined each specimen. Results: Four different categories of sinus lateralis formation were identified: type I (n = 22), posterosuperior extension to skull base; type II (n =15), posterior extension to sphenoid face; type III (n = 8), abrupt termination posterior to ethmoid bulla; and type IV (n = 5), extension into posterior ethmoid through dehiscent basal lamella. Conclusions: The sinus lateralis is a consistent feature of the anterior ethmoid. Type I and II patterns are most conducive to the aforementioned technique. Type III is the most difficult to identify endoscopically, whereas type IV is most apt to encourage an unplanned posterior ethmoidectomy. Regardless of the chosen ethmoidectomy technique, careful assessment of the sinus lateralis should enable more accurate and safe removal of ethmoid disease with reduced complications.     

Surgical technique of endonasal micro-endoscopic operation in patients with massive and recurrence nasal polyposis--own experience

The author presents modification of the well-known surgical techniques used in endonasal optically aided operations in the patients with massive and recurrent nasal polyposis. After septal correction the attachment of the middle turbinate and lower turbinate is identified. It helps to find an appropriate place to open a maxillary sinus through uncinectomy. Opened maxillary sinus makes possible to find orbital lamella. The posterior maxillary sinus wall as the anatomic point helps to find the anterior wall of sphenoid sinus through posterior ethmoidectomy. After finding choane it is possible to open sphenoid sinus without cutting the posterior part of the middle turbinate. From this part it is possible to continue the operation like in the posterior-to-anterior technique, because it is well known where is the ethmoid roof. The operation is finished after opening frontal recess and correction of the middle turbinate. I did 110 total endonasal sphenoethmoidectomies using this technique in the patients with massive and recurrent nasal polyposis without any serious complications. I didn't have any problems with orientation in operative field even in very complicated cases.     

Anatomic findings in patients undergoing revision endoscopic sinus surgery

OBJECTIVE: To report the anatomic findings that contribute to persistent sinusitis in patients requiring revision functional endoscopic sinus surgery (FESS). METHODS: Data were collected prospectively on consecutive patients requiring revision FESS at a tertiary institution over a 2-year period. Patients were evaluated with endoscopic examination of the sinonasal cavities, and computed tomography of the sinuses was performed after patients failed prolonged medical therapy for sinusitis. Information was also collected during the revision surgery. RESULTS: The most common anatomic factor associated with primary surgery failure was lateralization of the middle turbinate (78%) followed by incomplete anterior ethmoidectomy (64%), scarred frontal recess (50%), incomplete posterior ethmoidectomy (41%), and middle meatal antrostomy stenosis (39%). In addition, retained agger nasi and retained uncinate process were identified in 49% and 37% of the patients, respectively. Recurrent polyposis was seen in 37% of the patients. Other factors such as persistent sphenoid disease and sphenoid ostium stenosis were less frequent. CONCLUSION: Failure of primary FESS is most often associated with anatomic obstruction in the area of the ostiomeatal complex. Meticulous attention in this area during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary FESS.     

Revision sphenoidethmoidectomy

In 1981, a series of 236 intranasal ethmoidectomy (INE) procedures was reported with a complication rate of 1.8%. Special attention has subsequently been directed to the surgical failures; namely, recurrent nasal polyposis which accounted for approximately 17%. The reason for recurrence in most instances was felt due to failure to do a more thorough posterior ethmoidectomy and enter and clean out the sphenoid sinuses. Subsequently, in all revision cases where a more thorough sphenoidethmoidectomy (RSE) was performed, the overall long-term success rate raised to better than 90%. Attention to skeletonizing the middle turbinate by stripping mucosa and leaving a thin bony shell is an important technical factor. An attempt is made to leave some of this bony skeletonized medial wall of the middle turbinate as it represents the most crucial landmark in doing the surgery via the intranasal route. There still remains approximately 8% to 10% of this patient population with nasal polyposis and sinusitis of such severity that surgery has offered only a temporary measure of relief. In dealing with this group it may be necessary to see these patients postoperatively at four to six-week intervals, carefully suctioning the ethmoid labyrinth and occasionally doing minor office "touch-up" ethmoidectomy-polypectomy procedures to clean off redundant mucosa or early polyposis. This paper is written to offer a compromise to the two schools of intranasal ethmoidectomy surgery as to the necessity of removing the middle turbinate in its entirety.     

内镜下经中鼻甲基板开放后筛加鼻中隔入路经蝶垂体瘤手术观察

目的观察经中鼻甲基板水平部开放后筛加鼻中隔入路经蝶窦垂体瘤手术的效果。方法50例垂体瘤患者内镜下经一侧或双侧中鼻甲基板开放后筛后加鼻中隔后段切除暴露蝶窦前壁，继之充分开放蝶窦前壁，显露鞍底切除垂体瘤。记录手术时间、出血量、住院时间、并发症（脑脊液漏、尿崩、颅内感染、神经功能损伤），术后鼻腔功能以及肿瘤全切和死亡情况。结果本组患者平均手术时间2.2 h，出血量245 ml，术后平均住院时间6.2 d，术中12例患者出现脑脊液漏，即时修补后无持续脑脊液漏发生；尿崩3例；嗅觉减退/丧失12例；术后垂体功能低下4例；无视神经损伤及颅内感染。因肿瘤压迫或卒中导致的视力下降术后均有改善。肿瘤全切率86%(43/50)，无死亡病例。结论内镜下经中鼻甲基板水平部开放后组筛窦加鼻中隔后段部分切除后充分开放蝶窦前壁显露鞍底及蝶窦内解剖结构，继而切除垂体瘤的方法，视野清晰、肿瘤全切率高、微创安全、对鼻腔鼻窦功能保护好。值得临床推广应用。     

The superior turbinectomy approach to isolated sphenoid sinus disease and to the sella turcica

Sphenoidotomy or sphenoidectomy are most commonly performed as part of a more extensive pansinus procedure. However, rhinologists may find themselves occasionally in a need to surgically treat an isolated sphenoid sinus disease. With the introduction of endoscopic sinus techniques and instrumentation, intranasal sphenoidotomy has become increasingly popular. The most common approach used is the intranasal, transethmoid sphenoidectomy. Alternatively, many surgeons perform middle turbinectomy to approach the sphenoid sinus transnasally. We describe our direct transnasal, nontransethmoid, nontransseptal approach to the sphenoid sinus. Superior tubinectomy is performed to enhance the exposure of the anterior sphenoid wall. Seventy patients underwent sphenoid sinus exploration for isolation sphenoid sinus disease or for pituitary lesions. Surgical goals were achieved in all patients and there were no complications related to the technique. The superior turbinectomy approach to isolated sphenoid sinus disease provides excellent exposure and avoids the sequelae of total ethmoidectomy or middle turbinectomy.     

Computed tomographic and anatomical analysis of the basal lamellas in the ethmoid sinus

OBJECTIVES: To investigate the exact anatomical structure of the lamellas in the ethmoid sinus by computed tomography (CT) and anatomical analysis. STUDY DESIGN: Cadaver dissections and CT scans were used to compare lamellar structures and their radiological images. METHODS: Anatomical microdissection of 100 midsagittal sections from adult cadaver head specimens were examined and compared with those of sagittal CT scans at 1-mm intervals. RESULTS: The posteroinferior end of the uncinate process attaching to the inferior turbinate divided the fontanelle into the anterior and posterior portions in the majority of cases. The basal lamellas of the bulla ethmoidalis were subdivided into three major types. The posteroinferior portion of its basal lamella was connected to the lower horizontal portion of the third basal lamella in all cases. The anterior indentation of the third lamella was identified in nine cases, but there was no indentation in the posterior direction. The basal lamella of the superior turbinate was attached to the skull base superiorly either separately or fused to the third lamella, and its posteroinferior portion was attached to the lowest portion of the anterior wall of the sphenoid sinus. The supreme turbinate existed in 50 cases; however, its basal lamella was identified in only 15 cases. CONCLUSIONS: Our results indicate that the lamellas of the ethmoid sinus have relatively uniform patterns, although there is variability in shape. It is hoped that this study will provide surgeons with a more detailed structure of the basal lamellas for better surgical results and lower complication rates.     

The Superior Turbinate as a Source of Functional Human Olfactory Receptor Neurons

Objectives The function of human olfactory receptor neurons (ORNs) remains incompletely understood, in part because of the difficulty of obtaining viable olfactory tissue for study. During endoscopic sphenoidotomy, a portion of the superior turbinate is often removed to achieve wide and safe access to the sphenoid sinus. The purpose of this study was to determine whether functional olfactory mucosa could be obtained from such superior turbinate tissue. Study Design/Methods Superior turbinate tissue was resected from 4 patients undergoing transnasal endoscopic approaches to the sphenoid sinus. The gross appearance of the turbinate mucosa was normal at the time of surgery. The specimens were placed directly into cold cell culture media and transferred to the laboratory. A portion of the mucosa was fixed and embedded for histology and immunohistochemistry. The remaining tissue was enzymatically dissociated, and the resulting cell suspension was either prepared for immediate calcium imaging or placed into cell culture. Cultured ORNs underwent calcium imaging after several weeks to assess their ability to respond to odorants. Results Histologic analysis of superior turbinate tissue revealed the presence of patchy olfactory neuroepithelium staining positive for olfactory marker protein. Acutely dissociated ORNs were capable of generating calcium responses to odorant mixtures. ORNs could be maintained in mixed culture and retained their ability to respond to odorants. Conclusions Superior turbinate tissue removed during endoscopic sphenoidotomy can provide a valuable source of human olfactory neuroepithelium for functional or histologic study. Superior turbinate tissue yields stem cells and immature neurons capable of differentiating into ORNs that retain many of their functional characteristics even after growth in culture.     

鼻内镜手术治疗额窦病变

目的 探讨经鼻内镜手术治疗额窦病变的方法及疗效。方法 经CT明确诊断的额窦病变33例(56侧),以CT扫描成像为基础在鼻内镜下以鼻丘气房、钩突附着上缘及筛泡前上缘为标记开放额隐窝及额窦。结果 所有手术最终找到并开放额窦,无严重并发症发生。术后鼻内镜检查,随访3～18个月。27侧痊愈,额窦口开放引流良好,炎症全部消失;21侧有效,症状明显改善;8侧无效。结论 经鼻内镜手术治疗额窦病变应密切参考CT扫描影像,准确定位额窦口。去除额隐窝处病变,充分开放额窦口引流是治疗额窦病变的关键。     

鼻内镜下经鼻中隔后蝶窦入路切除累及鞍外的鞍区肿瘤

目的总结内镜下经鼻蝶扩大手术入路切除侵犯鞍外的鞍区肿瘤的临床经验,并对术后疗效及并发症进行评估。方法选择侵犯鞍外的鞍区肿瘤13例,在鼻内镜下经鼻腔切除鼻中隔后端,进入蝶窦,再磨去鞍底及周围骨质,进入鞍区及鞍外,行肿瘤切除术。结果术后病理检查结果显示,13例患者中垂体腺瘤8例,颅咽管瘤4例,脑膜瘤1例;8例肿瘤完全切除（61.5%）,4例部分切除（30.7%）,1例死亡。术后发生的主要并发症有尿崩症、脑脊液鼻漏、脑膜炎、下丘脑衰竭等。结论侵犯鞍外的鞍区肿瘤可以经鼻内镜下手术切除,但具有一定风险,需要谨慎选择。     

筛泡基板前上端在鼻内镜额窦手术中的定位作用

目的寻找适合鼻内镜手术下开放额窦的解剖学标志,以降低手术并发症的发生率。方法对30例(60侧)慢性鼻窦炎病人行鼻窦CT扫描,根据CT扫描中筛泡基板前上端向上附着的部位与纸样板/筛顶的关系,术中以筛泡基板前上端为标志,寻找额窦开口,进行鼻内镜额窦手术。并与同期40例(75侧)依据前筛顶额突为标志进行鼻内镜额窦开放术的手术并发症的发生率进行比较。结果30例(60侧)病人在以筛泡基板前上端为解剖标志进行鼻内镜额窦开放术中,手术并发症的发生率为3.3%(1/30),与同期40例(75侧)病人依照颅底额突作解剖标志进行鼻内镜额窦开放术的手术并发症的发生率20%(8/40)进行比较有统计学意义(P<0.05)。结论在鼻内镜额窦手术中以筛泡基板前上端为解剖标志,能有效地帮助寻找额窦开口,降低手术并发症的发生率。     

Laterally attached superior turbinate is associated with opacification of the sphenoid sinus

Objective

The sphenoid sinus is situated at the most posterior part of the nasal cavity and opens at the sphenoethmoidal recess located between the nasal septum and the superior turbinate. The correlation between anatomical structures surrounding the sphenoid sinus and sphenoid sinusitis is poorly understood. This study investigated possible factors that correlate to opacification of the sphenoid sinus on computed tomography.

Methods

Review of computed tomography images of 200 patients who underwent endoscopic sinus surgery and/or septoplasty. The total lengths of the anterior sphenoid wall and the part medial to the superior turbinate were measured. The correlations were analyzed between the occurrence of sphenoiditis and these values, as well as age, sex, presence or absence of Onodi cell, opacification of the paranasal sinuses other than the sphenoid sinus, and shadow at the olfactory cleft.

Results

The length of the part medial to the superior turbinate was significantly (odds ratio = 1.36, P = 0.001) associated with sphenoiditis, but the total length of the anterior wall of the sphenoid was not. Advanced age and disease of the olfactory cleft, posterior ethmoid cells, and frontal sinus were also correlated with sphenoiditis.

Conclusions

Certain characteristics of the anatomical structures surrounding the sphenoid sinus are associated with sphenoiditis.     

The intranasal ethmoidectomy procedure: historical, technical and clinical considerations

The intranasal ethmoidectomy procedure is in questionable repute at this time. The reasoning behind its waning popularity is historical and primarily due to the poor results obtained in the pre-antibiotic era. Two schools of thought regarding the procedure were present in this earlier era: one dedicated to the preservation of the middle turbinate and the other concerned with its entire removal. ^5,6,7 Shortly before the emergence of antibiotics, a third school developed, led by some of the leaders of the more destructive procedure, showing preference for an external approach. ¹⁰ Descendants of the more conservative school, namely those dedicated to the preservation of the middle turbinate, are the only ones still actively and enthusiastically endorsing the intranasal method. ^1,2 An intranasal approach is described which attempts to leave intact the medial wall of the middle turbinate. It is this structure that is felt to be the crucial landmark necessary to perform a safe and effective procedure. Several steps that are felt to be essential to this technique are outlined in detail. Avoiding the sphenoid sinus, especially in reference to opening up the ostium of the sphenoid sinus, is advocated. It is felt that the normal nasal anatomy can be restored by the proper application of this technique. The need for more effective and intensive measures, corticosteroids, antibiotics, and antihistamine-decongestant medication, is stressed, especially in the postoperative state. It is recognized that it is impossible to treat an underlying allergy with a knife or forceps. The indications for utilization of this procedure are many and are listed. When a space expanding lesion, such as a neoplasm, mucocele, mucopyocele, or osteoma is encountered, then a primary external approach is advocated; likewise, when an isolated sphenoid sinus problem is suspected, then external, a transantral, or a transseptal approach is preferred. In the remaining problems, especially in the more difficult ones, involving the paranasal sinuses, either in the acute or chronic state, with or without complications, the intranasal ethmoidectomy technique is felt to be the key procedure in the initial approach to these problems. If this method of approach appears to be ineffective, then one can resort to the more elaborate external techniques that are commonly being performed. Five cases are reported in detail, illustrating some of the areas where this procedure is effective. The most common utilization is for the alleviation of obstructive nasal polyposis, with or without concommitant sinusitis. Radiographic improvement in many of these cases may prove to be an objective perimeter to gauge the type of surgery. This procedure also supplies an important link in the development of a more standardized or uniform approach to the more difficult problems involving the paranasal sinuses.     

改良Wigand术在修正性鼻内镜手术中的应用

目的探讨改良Wigand修正性鼻内镜术在复发性慢性鼻窦炎、鼻息肉Ⅲ型中的疗效.方法对113例复发性慢性鼻窦炎、鼻息肉Ⅲ型患者行"由前→后→前"的改良Wigand修正性鼻内镜手术,将后鼻孔,上颌窦口,中鼻甲残端和蝶窦的顶、侧壁作为4大固定的解剖标志,所有患者双侧同时行全筛窦切除.结果治愈76例(67.3%),好转31例(27.4%),无效6例(5.3%),总有效率为94.7%.术中平均出血165 ml,平均手术时间小于1 h,无严重并发症发生.结论改良Wigand术是一种"由前→后→前"的安全、快速、有效的修正性鼻内镜手术方法.4个固定解剖标志的运用对彻底切除筛窦,防止严重并发症的发生有重要作用.     

Radiologic anatomy of the sphenoid sinus for intranasal surgery.

Endoscopic surgery of the sphenoid sinus can present the operator with a considerable challenge. The relationship of the sphenoid sinuses, in particular on the lateral wall, to the carotid artery, optic nerve, as well as the other anatomic structures, is of utmost importance. Surgical complications can occur because of a lack of orientation during dissection. To avoid the complications or lessen, somehow, the rate of complications, some described the technique consisting of the opening of the sphenoid sinus ostium medially. We studied 69 axial high resolution computed tomography (HRCT) of temporal bones to reveal the relationship of sphenoid sinus to the vital structures and to get some measurements in the sphenoid sinus. The lateral distance from the sphenoid ostium revealed that the lateral distance was about the distance between both ostea. We consider that in selected cases the dissection might be carried out laterally from the sphenoid ostium for safe enlargement of the ostium and approaching the sinus.     

Resection of the inferior superior turbinate: does it affect olfactory ability or contain olfactory neuronal tissue?

BACKGROUND: One approach to the sphenoid sinus involves resection of the inferior portion of the superior turbinate. There is general agreement from anatomic investigations that this area contains olfactory mucosa. This study will determine if olfactory tissue can be found in the superior turbinate mucosa of patients with chronic sphenoiditis and what effect its removal has on a patient's olfactory ability. METHODS: The inferior one-third of the superior turbinate removed during endoscopic sphenoidotomy was stained with olfactory marker protein antibody, a marker for mature olfactory tissue. The specimens were graded for content of olfactory neuronal elements. All patients underwent uninasal 12-item smell identification testing before surgery and at least 3 weeks after surgery. RESULTS: Fifty-five superior turbinate samples were taken from 31 patients. Nine (16%) of 55 samples contained olfactory neuronal elements that stained with olfactory marker protein. When comparing the pre- and postoperative smell test results, 52% of the nostrils had no more than a one-item change, 35% of the nostrils had a more than one-item improvement, and only 12% had more than a one-item loss. None of the nostrils with a loss of olfactory ability after the surgery showed olfactory neuronal elements in their superior turbinate specimens. CONCLUSION: There is olfactory mucosa in approximately one-sixth of the superior turbinate specimens removed during the endoscopic transethmoidal sphenoidotomy procedure. Although 12% of the patients had a loss of olfactory ability in this study, none of the loss could be attributed to excision of olfactory tissue.