0:00

In addition to the normal neurovascular

0:03

structures that we have to be aware of,

0:06

we also have to recognize that the sinonasal

0:08

cavity has the largest number of anatomic

0:11

variants of any body structure that I know of.

0:15

And I've listed some of these

0:17

here from a study that was done

0:20

by Doug Bigelow back in the 1980s and 1990s.

0:24

You can see that the anatomic

0:27

variants are quite numerous.

0:29

They include concha bullosa, which represents aeration of

0:33

the bulla of the middle turbinate, the rounded

0:36

portion of the middle turbinate, and that

0:39

occurs in 36% of patients, and it is bilateral

0:43

in 44% of the 36%. You have nasal septal deviation

0:49

or deformity to the right or to the left.

0:51

That happens very commonly and sometimes

0:54

is addressed with cosmetic surgery.

0:57

21%. A middle turbinate that turns the wrong

1:01

direction is called a paradoxical turbinate.

1:05

So instead of turning more medially

1:07

inward, it turns laterally inward.

1:09

That's paradoxical.

1:11

We have something called the Haller cell.

1:14

Uh, we are moving away from

1:16

the eponyms.

1:17

So the Haller cell has been called the maxillo-

1:20

ethmoidal cell or the infraorbital ethmoidal cell.

1:25

These are air cells just below the floor of the

1:28

orbit that can encroach upon the osteomeatal unit.

1:32

You can have enlarged ethmoidal bulla.

1:34

You can have laterally deviated uncinate process.

1:37

You can have an inferior turbinate that is aerated,

1:40

which would be called an inferior turbinate bulla.

1:43

And the uncinate process itself can have an air

1:46

cell within it, which is termed an uncinate bulla.

1:49

I'm going to show some of these in just a moment.

1:52

The other normal variant is the degree

1:55

to which you have pneumatization into

1:57

the frontal bone and have air cells that

2:01

herniate or are created into the frontal

2:03

bone, and there are different types here.

2:05

It's not important to understand the different

2:07

types as much as to understand that the agger

2:10

nasi cell is one of these air cells that

2:13

is often associated with the frontal bone.

2:16

So when we look at the frontal sinus,

2:19

you notice that there are some air cells that appear

2:21

to be invaginating into the frontal sinus, and there

2:24

are some air cells that occur anterior to the middle

2:29

turbinate’s attachment to the cribriform plate,

2:33

in which case we might call these agger nasi air cells.

2:37

So these are far anterior ethmoid air cells

2:40

that may invaginate into the frontal sinus.

2:43

Here is an example of a concha bullosa, and some people

2:47

will make the distinction between a concha bullosa, which

2:51

is an aerated portion of the bulla of the ethmoid

2:54

air cell with an aerated extension to the ethmoid

2:59

air cell here.

3:00

So this is a lamellar cell,

3:03

which is aerated with a concha bullosa.

3:06

This is the endoscopic view of a very large

3:08

concha, which as you can see, is dominating

3:11

that side of the nose because it's so

3:13

large as you're looking in endoscopically.

3:16

Here again, you have just an aerated portion of

3:19

the vertical attachment of the middle turbinate.

3:22

Remember I said it has an attachment to the cribriform

3:25

plate and then it has a lateral attachment to

3:28

the orbital wall, that being the ground lamella

3:31

or basal lamella, so different degrees of

3:35

aeration of the middle turbinate, and this is

3:37

the most common turbinate to have that variation.

3:40

But you can see aeration of the inferior

3:43

turbinate, as I mentioned before.

3:46

This is what I referred to as a paradoxical turbinate.

3:50

The turbinate normally turns this direction

3:53

with the vertical portion and then turning

3:55

more lateral in its distal portion.

3:58

In this case, it's turning the opposite direction.

4:01

That's called a paradoxical turbinate.

4:03

It's not necessarily associated with a higher degree

4:08

of sinusitis, but it is a normal variant that

4:12

potentially the endoscopic surgeon would

4:14

run into and has to be aware of that

4:16

that's what it is, as opposed to a polyp, for example.

4:20

And here you can see endoscopically

4:22

the direction of this

4:24

turn, and we're gonna call this the right side.

4:26

And so it's turning this direction more lateral

4:30

than medial, rather than its normal direction,

4:32

which is more medial and then lateral.

4:35

So these are paradoxical turbinates.

4:38

I will say that in my reporting of these studies,

4:42

if I'm just looking for sinusitis in a patient

4:45

who has leukemia and has a fever of unknown

4:48

origin, I don't necessarily mention all the normal

4:52

variants in the anatomy.

4:53

However, if, uh, it's being sent to me by a

4:57

known functional endoscopic sinus surgeon

4:59

who is about to treat the patient for chronic

5:02

rhinosinusitis, then I will mention these normal

5:06

variations in order to help direct that surgery.