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Endoscopic view of the drainage pathway of a pneumatized uncinate process.

A 32-year-old man had been having recurring bouts of sinusitis. He was referred to our office following a sinus computed tomography (CT) scan that showed extensive bilateral chronic rhinosinusitis. In addition, the CT scan showed a well-pneumatized uncinate process on the left side that appeared to be obstructing the outflow tract in the left ostiomeatal complex (figure, A). Nasal endoscopy showed a large structure in the left middle meatus between the middle turbinate and lateral wall of the nose (figure, B) The patient was taken for endoscopic sinus surgery for ventilation and drainage.

At the time of surgery the large, pneumatized structure in the middle meatus on the left nasal cavity was found to be the uncinate process (figure, C). The uncinate process was opened with a microdebrider and found to be well pneumatized (figure, D). Further inspection, posteriorly, of the superior lateral portion of the uncinate process revealed what appeared to be a drainage pathway exiting the uncinate process (figure, E) into the ethmoid sinus (figure, F) The remainder of the uncinate process was removed, relieving the obstruction in the middle meatal area. Ethmoidectomy and maxillary antrostomy were carried out.

The patient had an uneventful postoperative course.

Pneumatization of nasal structures is well described. (1) One of the most common pneumatized nasal structures is the middle nasal turbinate, forming a concha bullosa of the middle turbinate. (2) Pneumatization has also been described in the other turbinate structures as well as in the uncinate process. (3) Pneumatized structures of the nose and sinuses have a mucosal lining whose mucociliary clearance will be associated with a drainage pathway into the nose. The drainage pathway, or ostium, of a pneumatized uncinate process may open directly into the middle meatus, the ethmoid infundibulum or, as seen in this patient, into the ethmoid sinus. The drainage pathway of a pneumatized uncinate is rarely seen on endoscopic nasal exam or at the time of surgery.

Pneumatization of these structures is clinically significant when it causes obstruction to airflow or to sinus drainage and ventilation. (4) This case represents a well-developed pneumatized left uncinate process. A well-defined ostium, or drainage pathway, of the pneumatized uncinate process is also well visualized.

References

(1.) Stammberger HR. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: B.C Becker, 1991.

(2.) Braun H, Stammberger H. Pneumatization of turbinates. Laryngoscope 2003; 113(4):668-72.

(3.) Christmas DA, Merrell RA, Mirante JP, Yanagisawa E. Pneumatized inferior turbinate: Report of three cases. Ear Nose Throat J 2004;83(3):152-3.

(4.) Christmas DA, Mirante JP, Yanagisawa E. A pneumatized uncinate process causing obstruction. Ear Nose Throat J 2005;84(12):754.

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

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

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Title Annotation:RHINOSCOPIC CLINIC
Author:Christmas, Dewey A.; Mirante, Joseph E.; Yanagisawa, Eiji
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Aug 1, 2013
Words:503
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