Supreme nasal turbinate as a landmark during endoscopic sphenoid sinus surgery.

A 45-year-old man came to us with nasal congestion, difficulty smelling, and intermittent sinus infections. Clinical evaluation revealed scattered polyps in the right superior nasal cavity. Computed tomography of the sinuses showed right ethmoid and sphenoid sinusitis.

Right powered endoscopic sinus surgery was performed. Nasal endoscopy revealed polyps in the right superior meatus and in the right nasal roof between the superior turbinate and the nasal septum (figure, A). The polyps were removed with a microdebrider (figure, B). Following complete removal of the polyps, the superior turbinate was well visualized; a supreme turbinate and supreme meatus were seen posterior to the superior turbinate (figure, C). In the middle of the shallow supreme meatus, an ostium of a posterior ethmoid cell was seen (figure, C). On the medial side of the inferior insertion of the supreme turbinate, a slit-like ostium of the sphenoid sinus in the right sphenoethmoid recess was seen. On closer examination, the supreme turbinate and the ostium of the posterior ethmoid cell were clearly visualized (figure, D). Right sphenoidotomy was carried out, using the supreme turbinate as a landmark. The sphenoid sinus ostium was located just medial to the inferior portion of the supreme turbinate. Dissection was performed medial to the inferior portion of the supreme turbinate (figure, D) and was completed with the use of the microdebrider.

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On the lateral nasal wall, there are usually three nasal turbinates: inferior, middle, and superior. In some cases, a supreme turbinate is also present. Supreme turbinates are the smallest of all turbinates. They are found unilaterally or bilaterally. The shallow groove inferolateral to the supreme turbinate is the supreme meatus, and it may contain the ostium of a posterior ethmoid cell (figure, C and D). (1)

The appearance of supreme turbinates was described by Stammberger. (2) The use of a supreme turbinate as a landmark during endoscopic sphenoid sinus surgery has not been described as often as has the use of the superior turbinate. (3-5) Both turbinates are consistent anatomic landmarks that allow for safe entrance into the sphenoid sinus. The supreme turbinate's inferior insertion is lateral to the ostium of the sphenoid sinus. The sphenoid sinus ostium usually lies between the inferior attachment of the supreme turbinate (when present) laterally and the nasal septum medially (figure, C and D). The opening may be slit-like, oval, or round. The opening may be hidden by the medially bent lower portion of the supreme turbinate. It is important to remember that the sphenoid sinus ostium is situated in the anterosuperior portion of the sphenoid sinus (usually about 1.5 cm from the floor of the sinus) and that the optic nerve and the internal carotid artery are often exposed in the lateral portion of the sphenoid sinus. (3) Endoscopic sphenoidotomy can be safely performed by enlarging the sphenoid sinus ostium, first inferiorly and medially, then laterally using a Stammberger mushroom punch and/or a microdebrider. (3)

References

(1.) Hollinshead WH. Anatomy for Surgeons. New York: Harper and Row, 1968.

(2.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(3.) Yanagisawa E, Yanagisawa K, Christmas DA. Endoscopic localization of the sphenoid sinus ostium. Ear Nose Throat J 1998;77: 88-9.

(4.) Bolger WE, Keyes AS, Lanza DC. Use of the superior meatus and superior turbinate in the endoscopic approach to the sphenoid sinus. Otolaryngol Head Neck Surg 1999;120:308-13.

(5.) Kim HU, Kim SS, Kang SS, et al. Surgical anatomy of the natural ostium of the sphenoid sinus. Laryngoscope 2001;111:1599 1602.

From the Department of Otolaryagology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach. Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn.; the Section of Otolaryngology, Hospital of St. Raphael, New Haven; and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa).