Anatomy Of Paranasal Sinuses Research Articles

Cross-Sectional Study of Nasal Cavity, Nasal Septum and Paranasal Sinus Anatomy in Children

Cross-Sectional Study of Nasal Cavity, Nasal Septum and Paranasal Sinus Anatomy in Children

Acute and chronic rhinosinusitis age characteristics

Children's and adults' rhinosinusitis are two diseases that have both similarities and differences in anatomy, epidemiology, causes, pathogenesis, diagnosis and treatment. At the same rhinosinusitis is one of the most common in otorhinolaryngology's practice, both in children and adults. The of adults paranasal sinuses (PNS) anatomy differs from children's PNS anatomy. Although ostiomeatal complex occlusion is recognized as a major cause of poor ventilation and drainage of the adult paranasal sinuses, it does not have a strong effect on pediatric rhinosinusitis, but adenoids play a key role. Adenoids are bacteria and biofilms reservoirs that cause chronic refractory rhinosinusitis regardless of pharyngeal tonsil size. The prevalence of chronic rhinosinusitis (CRS) is lower in children than in adults. Diagnosis of children's rhinosinusitis is more difficult because nasal cavity endoscopic examination is performed rarely due to the occasional need of general anesthesia during the procedure. Moreover, it's necessary to take into account prevailing etiological role of viruses in ARS at children's age and chronic adenoiditis often accompanies pediatric CRS, which requires attention prescribing medical therapy as the basis of rhinosinusitis treatment. The DysheLORz based on Pelargonium sidoides roots is highly effective and safe for children's and adults ARS and CRS treatment, both as monotherapy and in combination with topical steroids and antibiotics. This herbal medicine immunomodulatory effect is mediated mainly by stimulating the production of TNF-α, IL-1, IL-12 and IFN-γ. It activates macrophages and improves their phagocytic activity. IL-12, together with TNF-α, enhances NK and cytotoxic CD8+ lymphocytes' activity against infected cells. IL-12 effect on Th1 lymphocytes maturation provides a link between innate and adaptive immunity. This is also increasing MCP-1, IP-10 and MIP-1β chemokines synthesis and decreasing MIP-1α, ENA-78, GROα and IL-8 production in PNS and nasal mucosa. This leads to decrease of neutrophils chemotaxis to the inflammation site, and decline of serine proteases concentration (neutrophils main enzymes), that increases mucous membrane epithelial barrier permeability, reducing bacterial infections risk. Additionally, Pelargonium sidoides increases epithelial cells beating cilia frequency and inhibits hemagglutinin and neuraminidase present on influenza virus surface. The drug increases antimicrobial peptides production as defensins, human neutrophil peptides (HNP) and bactericidal permeability-increasing protein (BPI), which is also important for rapid inflammation regression in rhinosinusitis. It causes bacterial adhesion to epithelial cells inhibition, phagocytosis stimulation, nitric oxide (NO) release and oxidative burst. The medicine had a direct effect on Streptococcus pneumoniae, Staphylococcus aureus, Neisseria, Moraxella catarrhalis and Haemophilus influenza. Based on these data, it is possible to explain the high effectiveness and safety of the drugs based on Pelargonium sidoides in ENT organs inflammation treatment, for both adults and children over 1 year old.

Anatomical variations of the Paranasal sinuses in Javanese patients with Chronic Rhinosinuitis

Variations in paranasal sinuses anatomy are common and vary among populations. Having clear picture of paranasal sinuses anatomy of a chronic rhinosinusitis patients is essential in surgical planning. This study was done to know paranasal sinuses anatomical variations of chronic rhinosinusitis in Javanese patients by Ct-scan. Retrospective chart survey from medical record of the ORL-HNS outpatient unit at Dr. Soetomo hospital Surabaya during the period January 2019 to December 2020. The data of age, gender, anatomical variations of paranasal sinuses and Keros classification of 55 patients who met the inclusion and exclusion criteria were obtained and recorded. The most common paranasal sinuses anatomical variations were deviated nasal septum (71%), concha bullosa (27%) and ager nasi (22%). Genderwise, anatomical variations were seen more in males. Based on Keros classification, type II(47%) is the most frequently found. The high incidence of paranasal sinuses anatomical variations, emphasize the need for proper preoperative assessment for safe and effective endoscopic sinus surgery.

Infectious and Inflammatory Sinonasal Diseases.

Rhinosinusitis is a commonly encountered disease. Imaging is not typically required in acute uncomplicated rhinosinusitis; however, it is integral in the evaluation of patients who present with prolonged or atypical symptoms or when acute intracranial complications or alternate diagnoses are suspected. Knowledge of the paranasal sinus anatomy is important to understand patterns of sinonasal opacification. Bacterial, viral, and fungal pathogens are responsible culprits and, with duration of symptoms, serve to categorize infectious sinonasal disease. Several systemic inflammatory and vasculitic processes have a predilection for the sinonasal region. Imaging, along with laboratory and histopathologic analysis, assist in arriving at these diagnoses.

Comparison of Low-Dose Non-contrast CT in Detecting Anatomical and Surgically Important Variants of Paranasal Sinuses to Standard Dose Non-contrast CT: Experience from a Tertiary Care Hospitalin Sub-Himalayan Region of Northern India.

Computed tomography (CT) is the gold standard for diagnosing sinusitis and anatomical variations and a guide for paranasal sinus (PNS) surgeries. High doses of radiation lead to increased risk of head and neck malignancies, radiation-induced cataracts, hypothyroidism, and hyperthyroidism. The purpose of this study was to assess the effectiveness of low-dose CT as compared to standard-dose CT in the identification of anatomical variants of paranasal sinus and rhinosinusitis. This was a prospective cross-sectional study consisting of 72 patients who were divided equally into cases (underwent low-dose CT for PNS) and controls (underwent CT for PNS using standard dose protocols). Prevalence of anatomical variants and sinusitis were compared. Image quality was assessed using volume CT dose index (CTDIvol), dose length product (DLP), scan length, and noise. Subjective assessment was done by two radiologists, and scores were given. The comparison and analysis of the quantitative and qualitative variables were done. Anatomical variants were comparable among cases and controls, with post-sellar sphenoid being most common and paradoxical middle turbinate being least common surgically important variant. The difference in meanSD of CTDIvol (mGy), DLP (mGy-cm), effective dose (mSv), globe, and air noise between low and standard doses was statistically significant. A moderate agreement (with kappa 0.50) in cases and substantial agreement (with kappa 0.69) in controls was observed between both observers. Low-dose CT PNS and standard-dose CT PNS are comparable in delineating the paranasal sinus anatomy, with a 3.53× reduction of effective radiation dose to patients.

Radiological Evaluation of Uncinate Process Variations using Multidetector Computed Tomography

Introduction: Functional endoscopic sinus surgery has emerged as a superior technique in sinus surgery with a lower incidence of associated complications as compared to traditional surgeries; however, it still carries risks of possible complications, some of which could be attributable to the variations that exist in the nose and paranasal sinus anatomy. Variations in the uncinate process, one of the important structural landmarks in functional endoscopic sinus surgery can have implications during sinus surgery. Therefore, identifying the variations in the uncinate process becomes a very important consideration. The objective of this study was to identify the variations of the uncinate process on Multidetector Computed Tomography of paranasal sinuses
 Methods: This cross-sectional study was conducted in the Department of Radiodiagnosis, Birat Medical College and Teaching from December 2021 to June 2022 after obtaining ethical clearance from IRC. A total of 240 participants referred to the Department of Radiodiagnosis for CT of paranasal sinuses were included in the study.
 Results: The most frequent superior attachment of uncinate was found to be Type I and the least common was Type IV. The least frequent variation was UP pneumatisation. Most of the cases showed typical angulation followed by medial orientation and lateral orientation.
 Conclusion: Variations in the uncinate process exist and Multidetector CT is a commendable tool for identifying these variations.

Ubiquity and attribution of Haller cells – A CBCT study

With the increasing popularity of sinus surgeries and the prolific advances in imaging technology, there is a major inclination towards the in-depth study of the anatomy of paranasal sinuses and the osteomeatal complex. Anatomical variations like deviation of nasal septum, paradoxical middle turbinate, double middle turbinate, and concha bullosa are seen in routine clinical examinations, but variations like Haller cells and Onodi cells require explicit radiological support. CBCT has the unique advantage of obtaining isometric images in all three planes with 3-Dimensional viewing and circumvent the obscurity of images due to superimposition. CBCT enables detection of even miniscule Haller cells along with discernment into the disease process and is a crucial preoperative planning tool. There has been a dearth of studies in the literature in this regard, and our study is a promising attempt to elucidate the significance of Haller cells with respect to surgical aspects

Endoscopic Sinus Surgery- Surgical Steps with Implications in Intraoperative Complications

Objective: Endoscopic sinus surgery is a worldwide performed operation which has gained acceptance as the primary treatment modality in paranasal sinus diseases. Any surgeon performing this surgery needs a valid treatment algorithm. Inappropriate surgical techniques may lead to failure and complications. Proximity of the surgical field to the critical structures poses difficulties to the surgeon. Too much removal of the normal structures and too little removal of the diseased tissues can have undesirable consequences. Although several techniques have been defined for each step, highlight ing critical points in a concise manner will be beneficial.Methods: This review article aimed to enlight the complex paranasal sinus and relevant anatomy, define the intraoperative maneuvers to achieve a successful sinus surgery while avoiding surgeon-related complications. Books and journals were reviewed comprehensively. Classic techniques and contemporary aspects of the endoscopic sinus surgery were assembled.Results: Paranasal sinus surgical anatomy and diseases show great variations. Endoscopic sinus surgery is performed in ameliorating paranasal sinus diseases. Improving the efficiency and safety of this surgery remains an important matter. There is a narrow border between suggested surgical steps and perilous complications. A thorough surgical anatomy knowledge and meticulous surgical methods needs to be defined.Conclusion: Sinus surgeon must carefully evaluate the underlying disease process, apply a precise surgical method, avoid possible complications, and should take necessary measures in case of a complication. A systematic surgical technique is mandatory for success.

GENDER DETERMINATION USING MAXILLARY SINUS DIMENSIONS - A DIGITAL RADIOGRAPHIC STUDY

Background and Objectives: Paranasal sinus anatomy is complex and rather variable from person to person. Gender determination is an important step in human identication in forensic medicine. Radiographs are used in forensic medicine for the identication of humans especially in cases where the body is decomposed, fragmented, or burned. The maxillary sinus is the largest of the four paranasal sinuses and its measurements are valuable in studying sexual dimorphism. Maxillary sinuses remain intact, although the skull and other bones may be badly disgured in victims who are incinerated. Therefore, this study was undertaken to examine and measure dimensions of maxillary sinus as observed on maxillary sinus radiographs and propose the use of the same, as an aid in gender determination. Materials and Methods: Maxillary sinus views of 50 healthy patients (25 males and 25 females) were taken using Kodak 8000 C Digital and Panoramic and Cephalometric system (73 Kvp. 12mA, 10.7s) and measurements made using Master View 3.0 software. Results: The total studied sample composed of 50 patients; the results were based on two study groups: the male group (composed of 25 patients) and female group (composed of 25patients). In the current study, the size of the maxillary sinuses of the female was found to be smaller than those of men. The width of right maxillary sinus, the height of right maxillary sinus and left maxillary sinus and the total width across right and left maxillary sinus showed statistically signicant differences at a p value of .007, .020, .008 and .005 respectively. The present study showed that the accuracy rate for identication of males was 76% and for females was 60%. From the observations of our study, we found signicant differences in dimensionsConclusion: of maxillary sinuses between males and females. We therefore conclude that maxillary sinus dimensions are useful and can be used as an aid in gender determination.

Evaluation of a 3D Computer Model of the Equine Paranasal Sinuses as a Tool for Veterinary Anatomy Education.

Detailed knowledge of anatomical systems is vital for clinical veterinary practice. However, students often find it difficult to transfer skills learned from textbooks to real-life practice. In this study, a three-dimensional computer model representing equine paranasal sinus anatomy (3D-ESM) was created and evaluated for its contribution to student understanding of the 3D dynamic nature of the system. Veterinary students and equine professionals at the University of Bristol were randomly allocated into experimental (3D model) and control (2D lecture) groups. A pre-/post-study design was used to evaluate the efficacy of the 3D model through a pre-/post-multiple-choice question (MCQ) anatomical knowledge exam and a pre-/post-questionnaire gathering information on participant demographics, confidence, and satisfaction. No statistically significant difference was found between 3D and 2D groups' post-MCQ exam scores (t39 = 1.289, p = .205). 3D group participant feedback was more positive than 2D group feedback, and 3D group satisfaction scores on Likert questions were significantly higher (t118 = -5.196, p < .001). Additionally, confidence scores were significantly higher in the 3D group than in the 2D group immediately following the study (p < .05). Participants' open-text responses indicated they found the 3D model helpful in learning the complex anatomy of the equine paranasal sinuses. Findings suggest the 3D-ESM is an effective educational tool that aids in confidence, enjoyment, and knowledge acquisition. Though it was not better than traditional methods in terms of anatomy knowledge exam scores, the model is a valuable inclusion into the veterinary anatomy curriculum.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit.

Introduction Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Use of Computed Tomography (CT scan) for delineating anatomy and variation of frontal Sinus before Functional Endoscopic Sinus Surgery

Abstract Introduction: For Functional Endoscopic Sinus Surgery (FESS), the surgeon needs an accurate depiction of the anatomy of paranasal sinuses and their variations. Computed tomography (CT Scan) fulfills this requirement by providing detailed anatomy, the anatomical variants, and the extent of the disease in and around the Para nasal sinuses. The aim of this study is to show the anatomy of the Frontal sinus as delineated by the computed tomography. Materials and Methods: STUDY DESIGN: Cross section Descriptive Study. Out of 337 patients above 12 years of age who were referred for computed tomography of paranasal sinuses in the Dept. of Radio- Diagnosis, Govt. Medical College and Hospital from December 2015 till October 2017, 200 adults(males and females) were randomly selected.Of the 200 subjects studied 37(18.5%) subjects had hypoplastic/ non or poorly pneumatised frontal sinuses of which 31 (15.5%) were bilateral and 6 (3%) were unilateral i.e. on right side. Observations and results: Intra frontal cell were seen in about 64 (32%) subjects of which 26 (13%) on right side, 24 (12%) were on left side and 14 (7%) were bilateral. Extension of pneumatisation into crista galli was seen in 16 (8%) subjects and into orbital roof was seen in 6 (3%) subjects. Conclusion: The findings in this study show that anatomical variations in the Para nasal sinuses and nasal cavity are common. Computed tomography is fundamental radiologic investigation for diagnosis of the Sino nasal lesions or pre and post-surgical assessment.

Using Virtual Reality to Teach Sinus Anatomy

AbstractAnatomy education is a crucial part of the curriculum for medical students, and it is essential for surgeons to perform safe surgery. The anatomy of the sinus cavity is complicated and cannot be easily understood through cadaver dissection practice and reading of surgical anatomy textbooks. Therefore, the development of methods to effectively teach the anatomy of such complex structures is essential for performing safe medical procedures. This study aimed to investigate whether the use of virtual reality (VR) in an educational course on paranasal sinus anatomy could contribute to the understanding and learning efficiency of dissection of the complex sinus anatomy. We devised a system to observe the paranasal sinuses in the VR space by polygonizing the shape of the sinus cavity using computed tomography images of the sinuses. Medical students moved around the VR space and viewed the sinuses from different angles using the VR system; notably, this is impossible in a conventional anatomy laboratory. A questionnaire was administered to 27 medical students (15 men and 12 women; mean age, 24.9 years) to evaluate their understanding of the sinus anatomy and the number of times they had experienced VR and used VR systems. We found that more than 70% of the students had never used VR before, but they could easily use it even if they were unfamiliar with the operation of the VR system, and the learning process was enjoyable and efficient. Thus, the VR application could be a useful tool for educating medical students.

Variations in Paranasal Sinus Anatomy in Children With Apert Syndrome: A Radiological Analysis.

Apert syndrome is a genetic disorder characterized by craniofacial abnormalities and premature closure of the coronal sutures. The restriction of cranial development may have a subsequent effect on paranasal anatomy development. The aim of the study was to gain an understanding of paranasal sinus anatomical variations seen in children with Apert syndrome. This was a retrospective review of computed tomography and magnetic resonance images of children with Apert syndrome from 2000 to 2020. Images were reviewed to identify anatomical variations in paranasal sinus anatomy. Twenty-one patients were included in the study. The most commonly seen variation was septal deviation in 86% of cases, with 60% of patients having a septal defect. The presence of protrusion or dehiscence of the infraorbital nerve, carotid canal and Vidian nerve, and presence of a concha bullosa were not observed in any patients. Keros type I was the most commonly observed olfactory fossa depth in 79% of patients, and type I Kuhn cells were observed in 83% of patients. To our knowledge, this is the first study which describes the prevalence of variations in paranasal sinus anatomy found in children with Apert syndrome. Septal deviation, type I Kuhn cells and Keros type I olfactory fossa depth were observed in a higher prevalence in our cohort than in the general population. As such, assessment for the presence of chronic rhinosinusitis and nasal obstruction should be evaluated as part of the multidisciplinary assessment.

Rhinological factors predisposing to headaches: our experience.

Background This study aimed to present the correlation between headaches and anatomical changes within the nasal cavity and paranasal sinuses. Material and methods: This study includes a literature search and our observations of 24 patients regarding the correlation of headaches with the nasal cavity and paranasal sinus anatomy.

Paranasal sinus development and implications for imaging.

Because the paranasal sinuses continue to develop throughout childhood, radiologists encounter significant anatomical variation when confronted with pediatric imaging studies. Knowledge of the stages of sinus growth is vital to differentiate normal development from abnormally large, hypoplastic or malformed sinuses. Understanding how the paranasal sinuses develop and their expected appearance at different patient ages is important for accurate interpretation of diagnostic imaging. To that end, we provide a brief review of paranasal sinus anatomy and discuss the mechanisms by which each paranasal sinus develops, as well as the implications for imaging. We also provide a practical guide for assessing normal paranasal sinuses in children based on the relationship of the sinuses to anatomical landmarks at various stages of development in order to help pediatric radiologists provide accurate interpretation of diagnostic imaging.

Computer Tomographic study of Anatomic Variations of Paranasal Sinuses in Libyan Population and their Clinical Correlation

Introduction: In the era of Functional Endoscopic Sinus Surgery, precise knowledge of paranasal sinus anatomy and variations are essential for the surgeon. The multi-slice computed tomography is the imaging modality of choice provides accurate evictions of the anatomy, the anatomical variants and the extent of the disease in paranasal sinuses, such a method allowing their accurate identification with high anatomical details. Some of these variants may predispose to sinus diseases or become of high risk for injuries and complication during surgical procedure, therefore, the study of anatomic variants of paranasal sinuses is important in the preoperative endoscopic surgery. Objectives: The purpose of this study is to assess the frequency of anatomic variants and their clinical importance. Materials and methods: This retrospective study was conducted at the Department of Radiology, Benghazi Medical Center, Benghazi, Libya. Data comprised the paranasal sinus computed images of 112 patients (46 males and 66 females) analyzed for the presence of anatomic variants and associated sinus pathology. Results: Our results showed that the most common anatomical variants was deviated nasal septum (60.7%) with slight higher incidence on left side, followed by concha bullosa (22.3%), other variants found were absent frontal sinus (18.8%), Nasal spur (14.3%) , Agger nasi cell (16.1%), Haller cell (5.4%), Onodi cell (2.7%), accessory ostia of maxillary sinuses (10.7%), accessory middle nasal concha (1.8%), paradoxical middle turbinate (1.8%), nasal septum pneumatization (5.4%), Crista galli pneumatization (2.7%), pneumatization of hard palate (1.8%) and pneumatization of clinoid process (6.3%). (53.6%) patients suffered from sinusitis, the results showed that the most common sinus involved was maxillary sinus. Conclusion: Anatomical variations of PNS are quite common. Analysis of every paranasal CT scan obtained for sinusitis for the presence of different anatomic variants is of questionable value unless endoscopic surgery is planned to reduce the risk of intraoperative complications.

Normal anatomic variants of paranasal sinus region studied by computed tomography

Background and objective: Variation in paranasal sinus anatomy, as shown on computed tomographic scans, is of potential significance as it may pose risks during surgery or predispose to certain pathologic conditions. This study aimed to investigate the frequency of anatomic variants of the nasal cavity and paranasal sinuses in our population and determine their relationship with gender and find out the association of these variants with mucosal abnormalities. Methods: This was a cross-sectional study conducted at the College of Medicine, Hawler Medical University from October 2017 to January 2019. A review of computed tomography scans of the paranasal sinuses of 300 patients was done; special attention was directed toward identifying bony anatomic variants and mucosal abnormalities. Results: Frequent variants were: Agger nasi cells (72%), nasal septal deviation (71.7%), Haller cells (70.7%), concha bullosa (61%), elongation of uncinate process (69.7%) and different variants of the sphenoidal sinus (78.8%). The frequency of variants did not differ significantly with respect to gender, except for sphenoidal variants along with Keros types and asymmetry of the ethmoidal roof. A significant association was found between middle concha variants and inferior turbinate enlargement (P <0.001). Conclusion: Anatomic variants of the paranasal sinus region were common in our population; the most frequent ones were those involving the nasal septum, ethmoid air cells, sphenoid sinuses, and middle turbinates. The study of these variants is important for the management of paranasal sinus region disease.

Chronic rhinosinusitis and its correlation with endoscopic anatomy of nose and paranasal sinuses: a cross-sectional study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Chronic rhinosinusitis (CRS) is a common condition characterized by inflammation of nose and paranasal sinuses and is associated with significant morbidity and healthcare expenditure. The study was undertaken to evaluate the endoscopic findings in different cases of CRS and correlating those findings with the clinical features and severity of symptoms.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A cross-sectional study was carried out at the outpatient Department of Otorhinolaryngology, R. G Kar Medical College and Hospital, Kolkata in a span of 18 months. A total of 56 patients who attended the outpatient department during the study period and met the inclusion criteria as well gave consent for participating in the study were taken as the sample size. The data was collected using history taking proforma. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of 56 patients, 51.8% were female, the most commonly affected age group was 31-40 years with 28.57% of patients. Majority of the patients 30.40% presented within one year of onset of symptoms, all the variables of clinical symptoms shows positive correlation statistically with the endoscopic findings, the most common anatomical variation was deviated nasal septum (DNS) present in 51.78% patients.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; A more extensive and detailed study needs to be done to determine conclusively whether the severity of symptoms can be used to predict the severity of disease in patients diagnosed as having chronic rhinosinusitis&lt;/p&gt;

Anatomy of Nasal Cavity and Paranasal Sinuses; Surgical Perspective

Endoscopic sinus surgery is a treatment method for chronic rhinosinusitis not controlled with medical treatment. It had started with functional endoscopic sinus surgery and the concept of reboot approach was introduced recently. For safe surgical treatment, understanding the anatomy especially personal variations between well-known structures is important. The practical points of surgical concept during endoscopic sinus surgery was suggested.