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Purpose To perform endoscopic sinus surgery safely and effectively, surgeons need to visualize the complex anatomy of the anterior ethmoid and frontal sinus region. Because this anatomy is so variable and individualized, the foundation of understanding lies in identifying, following, and visualizing the drainage pathway patterns and anticipating possible variations. Methods We studied 100 sides (50 cases: 22 male, 28 female, aged 12–86, average age 46.5 years, ± 19.5) using computed tomography (CT) and multiplanar reconstruction (MPR) to identify and classify the drainage pathways leading to the frontal sinus and anterior ethmoidal cells. Results Analysis revealed five patterns of drainage pathways defined by their bony walls: between the uncinate process and the lamina papyracea [UP–LP]; between the uncinate process and the middle turbinate [UP–MT]; between the uncinate process and the accessory uncinate process [UP–UPa]; between the uncinate process and the basal lamella of the ethmoidal bulla [UP–BLEB]; and between the basal lamella of the ethmoidal bulla and the basal lamella of the middle turbinate [BLEB–BLMT]. In most cases, BLEB formed the posterior wall of the drainage pathway of the frontal sinus, indicating BLEB could be one of the most important landmarks for approaching the frontal sinus. Conclusions As endoscopic sinus surgery depends on an understanding of this anatomy, this study may help surgeons to identify and follow the drainage pathways more accurately and safely through the anterior ethmoid to the frontal sinus.

Purpose The anterior ethmoidal artery (AEA) is an important risk area in endoscopic sinus surgery. This study aimed to evaluate the course of AEA according to the Keros classification and the presence of supraorbital ethmoid cell (SOEC) and to prevent possible complications by emphasizing the importance of preoperative paranasal computed tomography (CT) imaging. This approach will increase the effectiveness of endoscopic sinus surgery and improve patient safety. Methods The paranasal CT scan images of patients aged > 18 years between October 2020 and November 2021 from our center were retrospectively analyzed. The images were primarily evaluated in the coronal plane, and the sagittal and axial planes were utilized to evaluate variations in AEA regarding the skull base. Furthermore, the relation of AEA course with Keros classification and SOEC was evaluated. The study included 1000 patients aged 18–80 years (right and left, a total of 2000 samples). Results Grade 3 AEA was the most common regarding the skull base. Keros Type 2 was the most common classification. Overall, 48.7% patients had SOEC. The incidence of Grade 3 AEA was higher among patients with SOEC and a higher Keros classification compared with those without SOEC and a lower Keros classification. Furthermore, Keros Type 3 was the most associated with SOEC presence. Conclusion Consistent with the literature, the probability of Grade 3 AEA in patients with high Keros classification and SOEC was significantly higher in our study. Therefore, we consider that preoperative imaging according to Keros classification and SOEC presence can predict AEA course and guide surgery.

Fibrous dysplasia is an uncommon bone disorder affecting various parts of the skeleton, often affecting facial and cranial bones. In this case, a 10-year-old patient was diagnosed with fibrous dysplasia of the ethmoid sinus at an early age. The patient has experienced nasal congestion, snores, and worsening nasal patency since 2019. A CT scan revealed an expansive proliferative lesion, likely from the frontal or ethmoid bone, protruding into the nasal cavity, ethmoid sinus, and right orbit. The tumor causes bone defects in the area of the nasal bone, leading to fluid retention in the peripheral parts of the right maxillary sinus. The patient’s parents decided not to undergo surgery to remove the diseased tissue and reconstruct the area, as it would be very extensive, risky, and disfiguring. The patient is being treated conservatively with an MRI, with a contrast performed approximately every six months and infusions of bisphosphonates. Despite the lesion’s size, the patient does not experience pain characteristic of dysplasia, and functions typically. Fibrous dysplasia of bone is a rare condition that presents with the most visually apparent manifestations, often mistaken for other bone conditions. Advanced diagnostic tools, like CT and MRI, are used to identify conditions affecting the ethmoid sinus more frequently. However, diagnostic errors often occur in imaging studies, leading to confusion. The most common period for clinical manifestations and diagnosis is around 10 years of age. The preferred approach in managing fibrous dysplasia involves symptomatic treatment, which can alleviate airway obstruction, restore normal globe position and visual function, and address physical deformities. Surgical intervention is recommended only for patients with severe functional impairment, progressive deformities, or malignant transformation.

Purpose This study aimed to validate a method for successful frontal sinus surgery. The method classifies the frontal sinus drainage pathway (FSDP) into five categories based on three bony walls of the anterior ethmoid sinus, including the uncinate process (UP), accessory uncinate process (UPa), and basal lamella of the ethmoid bulla (BLEB), which was tested in actual surgical procedures. Methods This study analyzed 53 sides of 48 patients who underwent frontal sinus surgery between October 2022 and March 2023. We classified the FSDPs using preoperative computed tomography (CT) and multiplanar reconstruction (MPR). During surgeries for FSDPs located anterior to the BLEB, we used a two-step method involving resection of the turbinal UP, followed by upward resection from the lower edge of the ethmoidal UP. For FSDPs located posterior to the BLEB, we resected the BLEB at the superior semilunar recess. Results We confirmed the origin of each of the five types of FSDP during surgery. These origins, which were located at the lowest part of the anterior ethmoid, could be identified in the early stages of ethmoid sinus surgery before proceeding to the frontal recess area. Conclusion The origins of the five types of FSDP, classified based on the bony walls, can be clearly and accurately identified during surgery. This provides a reliable method for preoperatively predicting and locating the inferior end of the FSDP (origin), without extensive manipulation of the cells formed in the frontal fossa.

Aims of this study are to analyze the association of the anterior ethmoidal artery’s (AEA) visualization with variations in its adjacent structures in coronal, axial, and sagittal CT images, to assess its relation with the ethmoid roof, and, based on this relation, to introduce a new classification for the ethmoid roof. A retrospective, cross-sectional study was performed in a tertiary referral center. In this retrospective, cross-sectional study, the coronal, axial, and sagittal CTs of 184 patients have been surveyed and the AEA canal, the ethmoid roof, and their relations with surrounding structures have been assessed. The Keros classification used to measure the depth of the lateral lamella of the cribriform plate (LLCP) in the ethmoid roof has been modified to include anterior–posterior length of the LLCP. It was shown that the visualization of the AEA canal increases in a statistically significant manner with an increase in the superior–inferior depth and the anterior–posterior length of the LLCP bilaterally. In the presence of supraorbital pneumatization, AEA visualization was shown to increase bilaterally significantly. This study demonstrated a positive correlation between the AEA canal, the LLCP superior–inferior depth, and the anterior–posterior length. It was shown that with the increased depth and length of the LLCP and in the presence of supraorbital pneumatization, the visualization of the artery and hence the injury risks are increased. The LLCP anterior–posterior length is as clinically relevant as is its depth, and a radiologic classification has been defined according to the anterior–posterior length of the LLCP.

Purpose To compare two types of CT acquisition parameters: CT scan of the facial bone and CT scan of the sinuses, for studying the ethmoidal slit and its relationship with the frontal sinus and anterior ethmoidal artery. Materials and methods Retrospective study of 145 scans of the sinuses and 79 of the facial bones performed between 2012 and 2016. On each scan, the visibility of the ethmoidal slits, their length, their distance from the ethmoidal artery, and their relationship with the anterior and posterior wall of the frontal sinus were studied. Results The ethmoidal slit was better visualized on CT scans of the facial bone (58.2%) than on those of the sinuses (43.1%) ( p  = 0.02). The distance between the anterior ethmoidal artery and the anterior part of the cribriform plate was 9.3 mm for CT scans of the facial bone and 8.4 mm for CT scans of the sinuses. The theoretical risk of damaging the glabellar soft tissue and that of damaging the meninges during a frontal sinusotomy was evaluated, respectively, at 9.6% and 26.1% for CT scans of the facial bone, and at 6.2% and 21.5% for sinus scans. Conclusions CT scans of the facial bone are better than CT scans of the sinuses for identifying ethmoidal slits and their distance from the canal of the anterior ethmoidal artery. The identification of these elements is relevant for the surgeon during frontal sinus surgery and makes it possible to assess the risk of damaging the glabellar soft tissue or meninges. Performing a CT scan of the facial bone seems preferable to that of a CT scan of the sinuses in certain pathological situations, such as cerebrospinal rhinorrhea or revision surgeries of the frontal sinus.

A patient in his 20s presented with a change in the appearance of his left eye with evidence of relative afferent pupillary defect. Imaging revealed a giant frontoethmoidal osteoma, a benign sinonasal tumour, invading three-quarters of the orbit. Multidisciplinary discussion involving opthalmology, maxillofacial surgery, neurosurgery and otolaryngology resulted in the decision to attempt entirely endoscopic excision of this lesion, which was performed with successful outcomes. This case demonstrates how a sinonasal osteoma should be considered in the differential diagnosis for a patient presenting with proptosis or other eye signs suggestive of compression of the orbital compartment. This case report and literature review highlights the possibility of managing giant sinonasal osteomas with orbital extension through a completely endoscopic approach.

Woakes’ syndrome (WS) is a rare entity, defined as severe recalcitrant nasal polyposis with consecutive deformity of the nasal pyramid. WS occurs mainly in childhood and its aetiology remains unclear. We report a case of a 68-year old woman, with aspirin-exacerbated respiratory disease, who presented with recurrent nasal polyposis and progressive broadening of the nasal dorsum. CT scan revealed extensive bilateral nasal polyposis and diffuse osteitis, with anterior ethmoidal calcified lesions. The patient underwent revision endoscopic sinus surgery and nasal pyramid deformity was successfully managed without osteotomies.

Purpose The study aimed to evaluate the prevalence of extramural expansion of posterior ethmoid cells using Cone beam computed tomography (CBCT), as well as to propose anatomical criteria and a classification system for Onodi cells based on their spatial relationship with the sphenoid sinus. Methods Cone beam computed tomography (CBCT) scans of 513 ENT (Ear, Nose, and Throat) and dental patients of outpatient clinics, 199 men and 314 women, mean age 36 ± 13 years (range: 18–84 years). Results Several extramural variants of posterior ethmoid (PE) cells were examined, such as sphenoethmoidal cells (where PE cells extend into the sphenoid sinus) and posterior ethmomaxillary cells (characterized by extension into the maxillary sinus). Among sphenoethmoidal cells, the following subtypes were identified: Onodi cells (PE cell extension toward the optic canal), inferolateral sphenoethmoidal cells (inferolateral expansion of PE cells relative to the sphenoid sinus without reaching the optic canal), and supraseptal posterior ethmoid cells (migration of PE cells into the region between the nasal septum and the cribriform plate). Among 513 patients examined, sphenoethmoidal cells were identified in 66 cases (89 cells), demonstrating considerable anatomical diversity. We observed a spectrum of variants that included predominant Onodi cell types (superior [48.2%], superolateral [19.2%], and lateral [18%]), less frequent Onodi forms (superoposterior [11.3%] and intersphenoidal [1.1%]), as well as other sphenoethmoidal variants such as supraseptal and inferolateral cells. Conclusion Based on the data obtained, we introduce an updated classification of Onodi cells that accounts for their spatial relationship with surrounding structures. Posterior extramural ethmoid cells may pneumatize the sphenoid bone to such an extent that they can be radiologically mistaken for the sphenoid sinus. Accurate differentiation between these structures is crucial, as inflammatory processes may develop independently within either the sphenoid sinus or the sphenoethmoidal cells. Misidentification may lead to inappropriate treatment strategies. Therefore, precise radiological assessment is essential to determine the true origin of inflammation and ensure targeted, effective clinical management.

Background Deviation and asymmetry relapse after secondary unilateral cleft rhinoplasty with septal extension graft is a common yet serious problem especially among Asian patients. Therefore, finding an effective approach to reduce deformity relapse remains a great challenge to plastic surgeons. Methods In this study, authors established finite element models to simulate different nasal cartilage-corrected options and different reinforcing strategies in secondary unilateral cleft rhinoplasty. A load of 0.01N was given to the nasal tip to simulate the soft tissue pressure, while two loads of 0.5N were separately given to the anterior and posterior part of the septal extension graft to simulate the rhinoplasty condition. Maximum deformations were evaluated to make stability judgments. Results The maximum deformation of different cartilage correction models in ascending order was: UCL deformity with septum correction, normal nasal cartilage, UCL nasal deformity, and UCL nasal deformity with lower lateral cartilage correction. When applied L-strut reinforcement graft was harvested from the perpendicular plate of the ethmoid bone, the maximum deformation of the models decreased significantly, and strong fixation of the septum could further enhance this decreasing effect. Conclusions Correcting the septum and lower lateral cartilage together could improve the structural stability and symmetry in secondary unilateral cleft rhinoplasty. To keep the corrected septum stable and thus reduce deformity relapse, reinforcing the L-strut with perpendicular plate of ethmoid graft while strongly anchoring the septal cartilage to the anterior nasal spine was proved to be effective in both finite element analysis and clinical observation. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .