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Endoscopic views of ostia of the anterior wall of the ethmoid bulla.

[FIGURE 1 OMITTED]

The ostium of the ethmoid bulla is usually difficult to locate even with the use of a telescope. (1) We present here 6 patients in whom the ostia of the ethmoid bulla were found in the anterior wall of the bulla.

Patient 1 was a 54-year-old man who was evaluated because of recurring chronic sinusitis with poor response to medications. Sinus computed tomography (CT) showed chronic findings of mucosal thickening, especially in the right ethmoid sinus. Therefore he elected to undergo functional endoscopic sinus surgery for drainage and ventilation. At the time of surgery, an endoscopic examination of the right ethmoid bulla showed a large ostium in the anterior wall of the bulla opening into the middle meatus (figure, A). An examination through the ostium showed polypoid mucosa in the ethmoid bulla. Endoscopic ethmoidectomy with a microdebrider confirmed that the ostium indeed opened into the ethmoid bulla (figure, B).

Patient 2 was a 47-year-old woman seen for recurring sinus symptoms and discomfort between the eyes, especially on the right side. She was found to have chronic findings of mucosal thickening on sinus CT, particularly in the right ethmoid area. Endoscopic examination at the time of surgery revealed multiple ostia of the right ethmoid bulla (figure, C). Surgical opening of the right ethmoid sinus confirmed that the openings seen in the anterior bulla actually were draining the ethmoid bulla into the middle meatus anteriorly (figure, D).

Patient 3 was a 42-year-old woman who had findings of chronic right ethmoid sinusitis on CT with recurring sinus problems over a number of years. The patient was taken to surgery, where examination of the right ethmoid bulla after removal of the uncinate process showed an ostium in the anterior wall of the ethmoid bulla (figure, E and F). This opening was also confirmed as an anterior ostium of the bulla when the ethmoid bulla was opened with the microdebrider.

Patient 4 was a 31-year-old man who presented with left recurrent sinus problems, particularly in the left ethmoid area. The patient was taken to surgery, where--after removal of the uncinate process on the left side--a well-defined opening was found in the anterior wall of the ethmoid bulla leading into the ethmoid sinus (figure, G). Opening of the ethmoid bulla in this area with a microdebrider confirmed that this was a true ostium of the left ethmoid bulla.

Patient 5 was a 22-year-old woman who at the time of surgery was found to have an ostium in the anterior wall of the left ethmoid bulla (figure, H).

Patient 6 was a 61-year-old man who had been having frequent discomfort medial to the left eye. This caused him to seek evaluation; his nose and sinuses were evaluated. Sinus CT revealed mucosal thickening in the left ethmoid sinus, with an almost totally opacifled ethmoid labyrinth. At the time of left endoscopic sinus surgery, an ostium was found in the anterior face of the left ethmoid bulla (figure, I). Anterior ethmoid surgery confirmed this opening to be the true ostium of the left ethmoid bulla.

The ethmoid sinus is made up of an anterior and posterior cell network. The ethmoid bulla, the largest cell of the anterior ethmoid sinus, usually drains into the ethmoid infundibulum. (2) Visible ostia on the anterior surface of the ethmoid bulla are not frequently seen on endoscopic exam as in the 6 cases presented in this article. The most consistent drainage pattern of the ethmoid bulla is usually from the posterior and medial aspect of the bulla medially into the hiatus semilunaris superior. (3)

According to Yanagisawa et al, the ostium of the ethmoid bulla is often found in the hiatus semilunaris superior, but it can also be found in the anterior or lateral wall of the ethmoid bulla, the ethmoid infundibulum, the hiatus semilunaris inferior, and the retrobullar recess. (1)

This article presents 6 patients in whom the ostium of the ethmoid bulla was visualized in the anterior wall of the bulla at the time of functional endoscopic sinus surgery.

References

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

(2.) Stammberger H. Functional endoscopic sinus surgery: The Messerklinger technique. Philadelphia: BC Decker; 1991.

(3.) Hechl PS, Setliff RC, Tschabitscher M. Endocscopic Anatomy of the Paranasal Sinuses. New York: Springer; 1997.

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

From Southern New England Ear, Nose, Throat and Facial Plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Raphael; and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Ct. (Dr. Yanagisawa); the Section of Otolaryngology, the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and Florida State University School of Medicine, Daytona Beach, Fla. (Dr. Mirante)
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Title Annotation:RHINOSCOPIC CLINIC
Author:Yanagisawa, Eiji; Christmas, Dewey A.; Mirante, Joseph P.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Oct 1, 2011
Words:801
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