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Anatomic variation in the pterygopalatine angle of the maxillary sinus and the maxillary bulla

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Abstract

Bulges of the most posterior ethmoid air cells into the maxillary sinus were termed maxillary bullæ by Onodi. With few exceptions, they have since been ignored by anatomists through time. Likewise, Sieur cells—the spheno-ethmoido-maxillary air cells—are uncommonly found in anatomical texts. We therefore aimed to perform a retrospective cone beam computed tomography study on 50 patients to document the possibilities of anatomic variation in the situs of the orbital process of palatine bone—a variation related anatomically with the pterygopalatine fossa (PPF) and the respective angle of the maxillary sinus. Commonly occurring pneumatizations in this situs were the Sieur cell (58 %/64 % right/left side), and the maxillary recess of the sphenoidal sinus (20 %/22 % right/left side). Alone or in combination, these determined, but not exclusively, the maxillary bullæ. Uncommon pneumatizations in the anterior wall of the PPF were also found, such as a sphenoidal recess of the maxillary sinus, and lateral (maxillary, or pterygopalatine) recesses of the middle and superior, respectively, nasal meatuses. In two different cases, non-Haller, and non-Sieur posterior ethmoid air cells were found extruded posterior to the maxillary sinus. Significant statistical association indicated bilateral symmetry of Sieur’s cell and of the maxillary recess of the sphenoidal sinus. It is important to identify such variant pneumatizations on a case-by-case basis in different surgical procedures and endoscopic corridors.

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Acknowledgments

The work presented in this paper was partly supported (author #5) by the Sectorial Operational Programme Human Resources Development (SOPHRD), Financed by the European Social Fund and by the Romanian Government under the Contract Number POSDRU/159/1.5/S/141531.

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Authors and Affiliations

  1. Division of Anatomy, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 8 Bd. Eroilor Sanitari, 050474, Bucharest, Romania

    C. Craiu, M. C. Rusu & A. I. Derjac-Aramă

  2. Department of Legal Medicine and Bioethics, Department 2 Morphological Sciences, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

    S. Hostiuc

  3. Division of Oral Implantology, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

    M. Săndulescu

  4. INTERMEDICA HIGH CARE RO Clinic, Bucharest, Romania

    A. I. Derjac-Aramă

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  1. C. Craiu
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  2. M. C. Rusu
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  3. S. Hostiuc
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  4. M. Săndulescu
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  5. A. I. Derjac-Aramă
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Correspondence to M. C. Rusu.

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12565_2015_320_MOESM1_ESM.tif

Fig. S1 Bi-dimensional multiplanar reconstructions (MPR: a axial, b coronal) identifying the orbital process of the palatine bone. 1 Maxillary sinus, 2 orbital process of the palatine bone (OPPB), 3 sphenopalatine foramen, 4 maxillary nerve canal, 5 sphenoidal tubercle, 6 pterygopalatine fossa (PPF), 7 sphenoidal sinus, 8 orbital apex, 9 ethmoidal crest of the palatine bone (TIFF 1224 kb)

12565_2015_320_MOESM2_ESM.tif

Fig. S2 Bi-dimensional reconstructions (a oblique axial, b oblique sagittal), identifying on the left side of composite maxillary bulla (MB). Bilateral asymmetry of sphenoidal and posterior ethmoidal pneumatizations. 1 Maxillary recess of right sphenoidal sinus; 2 right SC, intercalated between the sphenoidal and maxillary sinuses; 3 left SC; 4 maxillary recess of left sphenoidal sinus; 5 left maxillary sinus; 6 MB (TIFF 1065 kb)

12565_2015_320_MOESM3_ESM.tif

Fig. S3 Bi-dimensional MPRs depicting anatomic variations related to the pterygopalatine angle of maxillary sinuses: right sagittal (a), axial (b) and left oblique sagittal (c). 1 Lateral (maxillary, or pterygopalatine) recess of right superior nasal meatus; 2 maxillary nerve canal (foramen rotundum); 3 right maxillary sinus; 4 right PPF; 5 greater palatine canal; 6 maxillary recess of right sphenoidal sinus; 7 left maxillary sinus; 8 inferior (Sieur) part of a left posterior ethmoid air cell; 9 superior (Onodi) part of a left posterior ethmoid air cell; 10 left sphenoidal sinus (TIFF 1474 kb)

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Fig. S4a–d Study of a left composite MB. a Oblique axial MPR; b oblique sagittal MPR; c three-dimensional volume rendering (3DVR) (filter: Sinus/Bone), left side, lateral view; d 3DVR (filter: Sinus/Bone), left side, medial view. 1 Sphenoidal recess of the right maxillary sinus; 2 posterior ethmoid air cell, placed inferiorly to a Sieur cell (SC); 3 SC; 4 left maxillary sinus; 5 MB; 6 left PPF; 7 pterygoid recess of the sphenoidal sinus. (TIFF 3041 kb)

12565_2015_320_MOESM5_ESM.tif

Fig. S5a–h Case study depicting large bilateral posterior ethmoid air cells located beneath SCs and determining MB. a Axial MPR. b Coronal MPR. c Left sagittal MPR. d, e 3DVRs with variable transparencies (Filter: Transparent Skin), lateral views of the medial wall of the left maxillary sinus. f Right sagittal MPR. g, h 3DVRs with variable transparencies (Filter: Transparent Skin), lateral views of the medial wall of the right maxillary sinus. On each side are indicated (right side black marks, left side white marks): i large posterior ethmoid air cell (arrow) determining MB and draining into the upper nasal meatus (bullet in b) and ii the Sieur cell (arrowhead). On the left side the sphenoidal sinus is projecting a small maxillary recess (c–e, double-headed arrow). There are also indicated the right (*) and left (**) maxillary sinuses (TIFF 2975 kb)

12565_2015_320_MOESM6_ESM.tif

Fig. S6a–f Study of a lateral (maxillary) recess of the middle nasal meatus projected in the pterygopalatine angle of right maxillary sinus. Bi-dimensional multiplanar reconstructions: a axial, at the level of foramen rotundum; b axial, at the level of vidian canal; c sagittal, through the right pterygopalatine fossa and foramen rotundum; d coronal, in front of the right pterygopalatine fossa. 3DVRs (Filter: Sinus/Bone), antero-posterior views: e in front of right pterygopalatine fossa; f through the right PFF. 1 Right maxillary sinus; 2 right middle nasal meatus; 2’ lateral (maxillary) recess of right middle nasal meatus; 3 middle nasal turbinate; 4 upper nasal turbinate; 5 left sphenoidal sinus, of conchal type of pneumatization; 6 right upper nasal meatus; 7 right foramen rotundum; 8 right pterygopalatine fossa; 9 right vidian canal (TIFF 3949 kb)

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Fig. S7a–c Bilateral asymmetry of pneumatizations producing MB. a Oblique/axial multiplanar reconstruction; b 3DVR (Filter: Sinus/Bone), lateral view of the medial wall of right maxillary sinus; c 3DVR (Filter: Sinus/Bone), lateral view of the medial wall of left maxillary sinus. 1 Right maxillary bulla produced by a SC, 2 left maxillary bulla produced by the maxillary recess of the sphenoidal sinus; 3 right PPF (TIFF 3366 kb)

12565_2015_320_MOESM8_ESM.tif

Fig. S8 Case study on multiplanar reconstructions (MPRs), coronal (in posterior-to-anterior series a–g), and left sagittal (in lateral-to-medial series h–j). Additional details result from Fig. 7 and Figs. S9 and S10. On coronal MPRs the posterior chamber within the left maxillary bone appears to be a huge extruded posterior ethmoid air cell, while the anterior chamber is a hypoplastic maxillary sinus. a Left greater palatine canal (7) that opens superiorly into a wide PPF determined by the left maxillary atrophy. b Right maxillary sinus (3) and the ethmoido-maxillary air cell (2), which produces a MB and drains above the middle nasal turbinate (arrowhead); on the left side the canal of the infraorbital nerve (8) courses on the lateral side of the posterior maxillary pneumatization (chamber) (5). c Opening (*) by which the ethmoido-maxillary cell communicates with a suprajacent posterior ethmoid cell; on the left side the canal of the infraorbital nerve (8) courses on the lateral side of the posterior maxillary pneumatization (5), which drains above the middle turbinate (arrowhead), thus being validated as a huge posterior ethmoid cell displaced within the maxillary bone. d Right infraorbital canal (9) in normal anatomical position; the ethmoid cell displaced within the left maxillary bone appears as the lower, maxillary part of a complex pneumatization, continued superiorly by a neck (arrowhead) that links it with a proper posterior ethmoid cell. On the left side the canal of the infraorbital nerve keeps its lateral position to the maxillary pneumatization (8). e Right infraorbital canal (9) lies in the roof of the maxillary sinus but on the left side is in a lateroantral position (8) as referred to the anterior chamber (hypoplastic left maxillary sinus) of the maxillary bone (4). The slice in f depicts the same anatomic structures as in e. g Left hypoplastic maxillary sinus (4) draining in the ethmoidal infundibulum (10). On sagittal MPRs the course of the canal of left infraorbital nerve (white arrows) is observed lateral to the maxillary bone pneumatizations: posterior/ethmoidal (5) and anterior/ hypoplastic maxillary (4) (TIFF 2625 kb)

12565_2015_320_MOESM9_ESM.tif

Fig. S9 Drainage pattern of the posterior/ethmoidal left maxillary pneumatization in the case presented in Fig. 10 on a sagittal and b–d axial MPRs. 1 Left sphenoidal sinus; 2 inferior, maxillary chamber of a complex ethmoid air cell that is united by a narrow neck with a superior, proper ethmoidal cell (5); 3 left hypoplastic maxillary sinus; 4 posterior, sphenoethmoidal air cell. Corresponding pneumatizations are indicated with connectors. b Neck of the complex ethmoid pneumatization draining (white arrow) in (4). c Drainage pattern of (5) into (white arrow) a middle ethmoid air cell observed on a successive slice in (d), draining into the middle nasal meatus (white arrow) (TIFF 1519 kb)

12565_2015_320_MOESM10_ESM.tif

Fig. S10 Diagram of the complex morphology and drainage pattern in the case presented in Fig. 9 and Fig. S1. The infraorbital canal is replaced by a canal (*) coursing laterally to the chambers within the maxillary bone (TIFF 563 kb)

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Craiu, C., Rusu, M.C., Hostiuc, S. et al. Anatomic variation in the pterygopalatine angle of the maxillary sinus and the maxillary bulla. Anat Sci Int 92, 98–106 (2017). https://doi.org/10.1007/s12565-015-0320-z

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