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Endoscopic view of a medial ethmoid drainage pathway into the middle meatus.

A 38-year-old male patient was referred to our office because of recurrent facial discomfort and discomfort between the eyes. He had been treated medically for recurrent sinus infections.

Computed tomography (CT) of the sinuses showed bilateral sinusitis. An unusual finding on the CT scan was what appeared to be an ostium or drainage pathway from the left ethmoid sinus into the superior portion of the left middle meatus (figure, A). The patient elected to undergo endoscopic sinus surgery.

At the time of surgery a well-defined ethmoid bulla was encountered in the left middle meatus (figure, B). Examination of the medial wall of the ethmoid with an angled 70[degrees] telescope revealed an ostium in the area of the posterior bulla opening into the left middle meatus (figure, C). Left endoscopic ethmoidectomy was carried out through the anterior face of the left ethmoid bulla using a microdebrider to open the anterior ethmoid area. Examination of the posterior medial portion of the ethmoid bulla showed a large, well-defined ostium (figure, D) that drained into the middle meatus. Endoscopic sinus surgery was completed and nasal septal reconstruction was carried out. The patients postoperative course was uneventful.

The anterior ethmoid sinus normally drains into the infundibulum of the middle meatus. (1,2) The most consistent drainage pattern of the ethmoid bulla is a path from the posterior medial aspect of the bulla medially into the hiatus semilunaris superior. (3) Yanagisawa and his group also have stated that the ostium of the ethmoid bulla is often found in the hiatus semilunaris superior, but that it can also be found in the anterior or lateral wall of the bulla, the ethmoid infundibulum, the hiatus semilunaris inferior, or the retrobullar recess. (4)

Visualizing an actual ostium from the ethmoid sinus is not a common occurrence. This case illustrates a well-defined ostium through the posterior medial wall of the large ethmoid bulla draining into the superior portion of the left middle meatus.


(1.) Yanagisawa E, Mirante JP, Christmas DA. Endoscopic view of a posterior ostium of the ethmoid bulla. Ear Nose Throat J 2008;87(8):428.

(2.) Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C. Decker; 1991:59.

(3.) Hechl PS, SetliffRC 3rd, Tschabitscher M. Endoscopic anatomy of the paranasal sinuses. New York: Springer; 1997:54.

(4.) Yanagisawa E, Joe JK, Christmas DA. Where is the ostium of the ethmoid bulla? Ear Nose Throat J 1999;78(12):886-7.

Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

From the Section of Otolaryngology, Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); the Florida State University School of Medicine, Daytona Beach (Dr. Mirante); and the Section of Otolaryngology, Yale New Haven-Hospital of Saint Raphael Campus and Yale University School of Medicine, New Haven, Ct. (Dr. Yanagisawa).

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Author:Christmas, Dewey A.; Mirante, Joseph P.; Yanagisawa, Eiji
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Feb 1, 2015
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