ANATOMY OF THE

LATERAL NASAL WALL

DR. HAZEM JADALLAH

Nasal turbinates

3 bony projections from the lateral nasal wall.

From below upwards they are inferior, middle, and
superior turbinates.
Appear as scrolls of bone, delicate, covered by ciliated
columnar epithelium.
It sometimes may contain an air cell, in which case it is
termed as a concha.
The inferior turbinate is a separate bone, while rest of
the turbinates are a part of ethmoidal labyrinth.
Below and lateral to each turbinate is the corresponding
meatus.

Nasal turbinates

Superior Concha
Ethmoid.

Middle Concha
Ethmoid.

Inferior Concha
separate bone.

Nasal turbinates

Commonly a prominence may be seen at the

attachment of the middle turbinate.
This prominence is known as the agger nasi cell .
This prominence varies in size in different
individuals.
These agger nasi cells overlie the lacrimal sac,
separated from it just by a thin layer of bone .
In fact this agger nasi cell is considered to be a
remnant of naso turbinal bones seen in animals .

Inferior Turbinate
A separate bone developed

embryologically from the maxilloturbinal

bone.
Has an irregular surface, perforated and
grooved by vascular channels to which the
mucoperiosteum is firmly attached.
Articulates with the ethmoid, palatine and
lacrimal bones, completing the medial wall
of the nasolacrimal duct.

Inferior Meatus
It is the largest meatus.
Its highest point is the junction of anterior

and middle third.

Nasolacrimal duct opens in the inferior
meatus, just anterior to its highest point, (it
is closed by a mucosal flap called
Hansers valve).
The course of the naso lacrimal duct from
the lacrimal sac lie under the agger nasi
cell.

Middle Meatus

lies between the middle turbinate and the lateral nasal

wall.
The middle turbinate is part of the ethmoidal complex.
Frontal, maxillary and anterior ethmoidal sinuses drain
into the middle meatus, i.e. under the middle turbinate.
The middle meatus hosts from anterior to posterior the
following structures:

Agger nasi
Uncinate process
Hiatus semilunaris
Ethmoidal bulla
Sinus lateralis
Posterior fontanelle

Middle Meatus cont.

Uncinate process

Thin, bony structure.

Forms the first layer or lamella of the middle
meatus. This is the most stable landmark in the
lateral nasal wall.
It attaches anteriorly to the posterior edge of the
lacrimal bone, and inferiorly to the superior edge
of the inferior turbinate.
Superior attachment of the uncinate process is
highly variable, may be attached to the lamina
palyracea, or the roof of the ethmoid sinus, or
sometimes to the middle turbinate.

Middle Meatus cont.

Uncinate process
The

configuration of the ethmoidal

infundibulum and its relationship to the
frontal recess depends largely on the
behavior of the uncinate process.
The Uncinate process can be classified
into 3 types depending on its superior
attachment.

Middle Meatus cont.

Uncinate process
Type I uncinate:

Here the uncinate process bends laterally in its upper

most portion and inserts into the lamina papyracea.
Here the ethmoidal infundibulum is closed superiorly
by a blind pouch called the recessus terminalis
(terminal recess).
In this case the ethmoidal infundibulum and the
frontal recess are separated from each other so that
the frontal recess opens into the middle meatus
medial to the ethmoidal infundibulum, between the
uncinate process and the middle turbinate.
The route of drainage and ventilation of the frontal
sinus run medial to the ethmoidal infundibulum.

Middle Meatus cont.

Uncinate process

Middle Meatus cont.

Uncinate process

Type II uncinate:

Here the uncinate process extends superiorly to the

roof of the ethmoid.
The frontal sinus opens directly into the ethmoidal
infundibulum.
In these cases a disease in the frontal recess may
spread to involve the ethmoidal infundibulum and the
maxillary sinus secondarily.
Sometimes the superior end of the uncinate process
may get divided into three branches one getting
attached to the roof of the ethmoid, one getting
attached to the lamina papyracea, and the last getting
attached to the middle turbinate.

Middle Meatus cont.

Uncinate process

Middle Meatus cont.

Uncinate process

Type III uncinate process:

Here the superior end of the uncinate process
turns medially to get attached to the middle
turbinate.
Here also the frontal sinus drains directly into
the ethmoidal infundibulum.
Rarely the uncinate process itself may be
heavily pneumatised causing obstruction to
the infundibulum.

Middle Meatus cont.

Uncinate process

Middle Meatus cont.

Uncinate process

Middle Meatus cont.

Agger Nasi
The most anterior part of the ethmoid.
The most superior remnant of the first

ethmoturbinal which presents as a mound

anterior and superior to the insertion of
middle turbinate.
Depending on the pneumatization of this
area may reach up to the level of lacrimal
fossa thereby causing narrowing of frontal
sinus outflow tract.

Middle Meatus cont.

Ethmoidal infundibulum

A cleft like space, which is three dimensional in the

lateral wall of the nose.
Belongs to the anterior ethmoid.
This space is bounded medially by the uncinate process
and the mucosa covering it. Major portion of its lateral
wall is bounded by the lamina papyracea, and the frontal
process of maxilla to a lesser extent. Defects in the
medial wall of the infundibulum is covered with dense
connective tissue and periosteum. These defects are
known as anterior and poterior fontanelles.
Anteriorly the ethmoidal infundibulum ends blindly in an
acute angle.

1: inferior hiatus semilunaris.

2: ethmoidal infundibulum.
3: superior hiatus
semilunaris.
4: retrobullar recess.
BE: bulla ethmoidalis.
CM: concha media.
DNL: nasolacrimal duct.
GLM: ground lamella of
middle turbinate.
LP: lamina papyracea.
PU: uncinate process.
S: nasal septum.

Middle Meatus cont.

Bulla
ethmoidalis
It is one of the most constant features of the

middle meatus.
It is the largest and non variant of the air cells
belonging to the anterior ethmoidal complex.
This air cell is formed by pneumatization of bulla
lamella (second ethmoid basal lamella).
The anterior face forms the posterior margin of
the hiatus semilunaris and ethmoidal
infundibulum.

Middle Meatus cont.

Bulla ethmoidalis

Posteriorly the bulla may fuse with the basal

lamella of the middle turbinate and superiorly it
may reach the roof of the ethmoids forming the
posterior wall of the frontal recess.
Sometimes a cleft is encountered between the
posterior wall of the bulla and the basal lamella
of the middle turbinate, the retrobullar recess.
The space between it and the ethmoidal roof is
called the suprabullar recess which may connect
anteriorly with the frontal recess if the bulla does
not reach the skull base.

1: inferior hiatus semilunaris.

2: ethmoidal infundibulum.
3: superior hiatus
semilunaris.
4: retrobullar recess.
BE: bulla ethmoidalis.
CM: concha media.
DNL: nasolacrimal duct.
GLM: ground lamella of
middle turbinate.
LP: lamina papyracea.
PU: uncinate process.
S: nasal septum.

Middle Meatus cont.

Bulla ethmoidalis
Supra-

and retrobullar recess may be

defined as follows:

medial: middle turbinate.

lateral: lamina papyracea.
superior: roof of ethmoid.
inferior and anterior: unicate process.
posterior: basal Lamella of the middle
turbinate.

Middle Meatus cont.

Osteomeatal complex

This term is used by the surgeon to indicate the

area bounded by the middle turbinate medially,
the lamina papyracea laterally, and the basal
lamella superiorly and posteriorly.
The inferior and anterior borders of the
osteomeatal complex are open.
The contents of this space are the agger nasi,
nasofrontal recess (frontal recess),
infundibulum, bulla ethmoidalis and the anterior
group of ethmoidal air cells.

Middle Meatus cont.

Osteomeatal complex
This

is in fact a narrow anatomical region

consisting of :
1.

2.

3.

Multiple bony structures (Middle turbinate,

uncinate process, Bulla ethmoidalis)
Air spaces (Frontal recess, ethmoidal
infundibulum, middle meatus)
Ostia of anterior ethmoidal, maxillary and
frontal sinuses.

1: inferior hiatus semilunaris.

2: ethmoidal infundibulum.
3: superior hiatus
semilunaris.
4: retrobullar recess.
BE: bulla ethmoidalis.
CM: concha media.
DNL: nasolacrimal duct.
GLM: ground lamella of
middle turbinate.
LP: lamina papyracea.
PU: uncinate process.
S: nasal septum.

Middle Meatus cont.

Hiatus semilunaris

The term means inferior hiatus semilunaris.

It is lying between the free posterior margin of
the uncinate process and the anterior surface of
the ethmoidal bulla.
The hiatus semilunaris is the 'door' through
which we can reach the ethmoidal infundibulum.
There is a second hiatus semilunaris, the
superior hiatus semilunaris. This cleft between
the ethmoidal bulla and the middle nasal
meatus.
The hiatus semilunaris superior leads into the
retrobullar recess.

Concha bullosa

Sometimes middle turbinate may become

pneumatized. This pneumatization is known as
concha bullosa.
This process of pneumatization starts either
from frontal recess or agger nasi air cells.
This is usually considered to be a normal
variant.
Sometimes this pneumatization may become so
extensive that it could cause obstruction in
osteomeatal complex

Superior meatus
The

posterior ethmoidal cells open into it.

A supreme turbinate is recognizable above
the superior meatus in 60-67 %.

Posterior ethmoid complex

The ground lamella of the middle turbinate

is the border between anterior and

posterior ethmoidal sinuses.
The sphenoid sinus ostium opens into the
sphenoethmoidal recess medial to the
superior turbinate.
The number of cells that make it varies
between one and more than five.

SPHENOETHMOIDAL RECESS
Lies medial to the superior turbinate.
It is the location of the ostium of the

sphenoid sinus.

Histology
The majority of the lateral wall is covered

by respiratory ciliated columnar

epithelium.
Areas of squamous metaplasia are often
found on the lateral wall, particularly in
areas subject to greatest airflow, such as
the anterior inferior turbinate.

Blood supply of the lateral wall

The

external and internal carotid arteries

supply the lateral wall.
The sphenopalatine artery contributes the
majority of the supply to the turbinates and
meatus.
The sphenopalatine artery branches enter
posteriorly to the respective turbinates.

Blood supply of the lateral wall cont

Internal carotid artery

Opthalmic artery
Anterior ethmoidal artery

Posterior ethmoidal artery

Blood supply of the lateral wall cont

External carotid artery

Facial artery
Superior labial A

Maxillary artery
Greater palatine A
Sphenoplatine A

Blood supply of the lateral wall cont

Blood supply of the lateral wall cont

Venous drainage of the lateral

nasal wall
It

is to the sphenopalatine veins via facial

and ophthalmic vessels.
Intracranially via the ethmoidal veins to
veins on the dura.
And to the superior sagittal sinus via the
foramen caecum.

Venous drainage of the lateral

.nasal wall cont

Nerve supply of the lateral nasal

wall
Olfactory supply on the superior concha.
Ordinary sensation is recieved from

the

anterior ethmoidal nerve

anterosuperiorly and from branches of the
pterygopalatine ganglion and anterior
palatine nerves posteriorly.

Lymphatic drainage of the lateral

nasal wall
The lateral wall drains with the external

nose to the submandibular nodes

anteriorly.
And to the lateral pharyngeal,
retropharyngeal and upper deep cervical
nodes posteriorly.

Thank You