Surgical Radk)logtc Anatomy
Surg Radiol Anat (1992) 14 : 335-339
Journal of Clinical Anatomy
© Springer-Verlag 1992
Radiological anatomy
Radiologic anatomy of the paranasal sinuses in the child A Weiglein 1, W Anderhuber 2 and G Wolf 2 1Anatonfisches Institut, Karl-Franzens-Universit~it Graz, Harrachgasse 21, A-8010 Graz, Austria 2Universitfitsklinik for Hals-Nasen-Ohren-Kxankheiten, Auenbmggerplatz 20, A-8036 Graz, Austria
S u m m a r y . The development of the paranasal or accessory sinuses begins very early in utero. In the newborn the ethmoidal sinus, which gives rise to all the other sinuses, as well as the maxillary sinus, can ah'eady be identified on x-rays. The frontal sinus appears as a triangle at the age of four and oversteps the supraorbital margin at the age of six. The sphenoidal sinus begins to excavate the concha sphenoidalis at the age of four and can be seen on x-rays at the age of eight, when it extends to the hypophyseal fossa. In the twelveyear-old child all sinuses almost reach their final sizes. However, the size and shape of all sinuses, particularly of the frontal and the sphenoidaI sinuses are very different.
Offprint requests : A Weiglein
Anatomic radiologique des sinus para-nasaux chez l'enfant R 6 s u m 6 . Le d 6 v e l o p p e m e n t des sinus para-nasaux ou sinus accessoires commence trbs prdcocement darts la vie in-ut6ro. Chez le nouveau-n6 le sinus ethmoidal, qui contr61e l ' a p p a r i t i o n de t o u s l e s autres sinus, et le sinus maxillaire peuvent d6j~ ~tre identifi6s ~tla radio. Le sinus frontal a la forme d'un triangle a l'fige de 4 arts et fi'anchit la ligne supra-orbitaire ~ 6 ans. Le sinus sph6no)'dal commence fi creuser le comet sph6noi'dal dbs l'~ge de 4 ans et devient visible ~ la radio 5 8 arts lorsqu'il s'gtend j u s q u ' ~ la fosse hypophysaire. Chez l'enfant de 12 arts tousles sinus ont pratiquement atteint leur taille adulte. Cependant la taille et la tbrme de ces sinus et spdcialement les sinus ffontaux et sph6no'idaux sont trbs diff&entes.
Key words: Paranasal sinuses - Postnatal development - - Radiology
The paranasal or accessory sinuses of the nose begin their development as e v a g i n a t i o n s of the m u c o s a during the third and fourth fetal months, but undergo their m a j o r expansion after birth according to the development of the facial cranium and the teeth [8, 9, 12, 16, 17]. The anatomical features of each age are snapshots of the development of the paranasal sinuses. It has to be emphasized that the child's nose is not a reduced copy of the adult's nose. An exact knowledge of the a n a t o m y of each stage of life is necessary to understand the clinical symptoms, the radiographs, and the complications of this region.
Material and methods We examined 134 human skulls. The total number consisted of 38 dried skulls of newborns, 8 heads of newborns, 32 dried skulls of children aged one month up to one year, 20 dried skulls of children at the age of
336
A Weiglein et al : Paranasal sinuses
Fig. la-c Occipito-nasal radiographs, a 4 year old child: three-cornered frontal sinus, maxillary sinus extends laterally to the infraorbital canal, b 8-year-old child: frontal sinus, maxillary sinus extends beyond the infraorbital canal, c 12- year-old child: frontal and maxillary sinus fully developed Radiographie occipito-nasale, a Enfant de 4 arts : sinus frontal ~ trois angles, le sinus maxillaire s'6tend lat6ralement jusqu'au canal infra-orbitaire. b Enfant de 8 ans: sinus frontal, ie sinus maxillaire s'6tend sous le canal infra-orbitaire, e Enfant de 12 arts : sinus frontal et maxillaire compl~tement d~veloppds
Table 1. MaxilIary sinus
Fig. 2 Frontal section, newborn. 1 Ethmoid cells 2 maxillary sinus with long infnndibulum ethmoidale, 3 developing tooth Coupe frontale, nouveau-n6. 1 Cellules ethmo'l'dales 2 sinus maxillaire avec un long infundibulum ethmo~dal 3 dent en formation
four, 23 dried skulls of children at the age of eight, and 13 dried skulls of children at the age of twelve. The skulls were x-rayed in following
Table 2. Ethmoidal sinus
Age (years)
Height (mm)
Length (ram)
Width (mm)
Age (years)
Height (ram)
Length (mm)
Width (mm)
0 4 8 t2
3-4 12-18 22-26 22-28
8-13 21-30 34-38 35-40
3-5 10-18 18-24 20-29
0 4 8 12
5-7 11-12 14-16 15-20
8-12 12-21 18-24 24-30
2-3 3-6 4-10 8-10
manner: occipito-frontal (Caldwell), occipito-nasal (Waters), lateral, with a focus film distance of one meter. All skulls were also examined by diaphanoscopy. One half of the newborns' heads was cut frontally and the other half was cut sagittally and p r e p a r e d under the preparationmicroscope. Measurements were taken directly from the skulls. Results Sinus maxillaris (Figs. 1, 2, Table 1)
In the newborn the maxillary sinus already is of appreciable size. A lot of bony and connective tissue separates the lateral wall of the maxillary sinus from the developing teeth. Its bottom is far from the hard palate and its roof does not reach the
orbital floor. The cavity of Highmore c o m m u n i c a t e s with the nasal cavity through a long infundibulum e t h m o i d a l e . This i n f u n d i b u l u m leads to the hiatus s e m i l u n a r i s below the middle nasal concha. Posteriorly it reaches the developing first molar. The maxilla forms one third of the lateral wall of the nasal cavity while the upper part is represented by the ethmoid bone. The maxillary sinus is filled with air and can be identified on Caldwetl's view in most of the newborns (Fig. 3a). At the latest at five months it can be seen on radiographs. In the four-year-old child the maxillary sinus is well developed according to the first dentition. Laterally it reaches the infraorbital canal. The floor extends to the level of the appendage of the inferior
A Weiglein et al : Paranasat sinuses concha. P o s t e r i o r l y it reaches the t o o t h b u d o f the first p e r m a n e n t molar. The maxilla represents almost half the lateral wall of the nasal cavity. In the eight- year-old c h i l d the m a x i l l a r y sinus has the shape of a f o u r - s i d e d p y r a m i d . It laterally passes the infraorbital c a n a l a n d its b o t t o m r e a c h e s the level of the m i d d l e o f the inferior concha. The roof reaches the floor of the orbit. Its posterior wall totally excavates the tuber maxillae. A c c o r d i n g to the second dentition the cavity of Highmore o f the twelve-year-old child reaches almost the size o f the adult. Its b o t t o m now reaches the level of the floor o f the nasal cavity. The sinus extends late-
337 rally to or b e y o n d the innominate line o f Stenvers. The maxilla forms two thirds of the lateral wall of the nose.
i d e n t i f i e d in x - r a y s b e t w e e n the nasal cavity and the orbit.
Sinus ethmoidal& (Fig. 1, Table 2)
The frontal sinus does not exist in the newborn. At the age of four the sinus appears as a triangle between the upper part o f the medial orbital w a l l and the n a s a l c a v i t y . In the
The full complement of the ethmoidal cells, i.e. 6-10, is present in the newborn. The cells are small and spherical and separated from each other by soft and bony tissue. The e t h m o i d a l cells e x p a n d m o r e and more and at the age of twelve, they h a v e e x c a v a t e d all the a v a i l a b l e room. That is why they are flattened and edged, and separated only b y thin bony lamellae. Beginning from birth the ethmoidal labyrinth can be
Sinusfi'ontalis (Fig. 1, Table 3)
Table 3. Frontal sinus
Age (years)
Height (mm)
4 8 12
4-9 5-25 12-26
Length (mm) 7-13 10-15 t3-21
Width (ram) 4-I0 8-I9 15-22
Fig. 3a-d Diaphanoscopies and x-rays of the same skulls, a, b Newborn: ethmoid labyrinth, maxillary sinus (1). c, d 4 year old child: the upper ethmoid cells (2) begin to excavate the frontal bone
Diaphanoscopies et radios de ces mOmes cr~nes, a, b Nouveau-n& labyrinthe ethmoidal et sinus maxillaire (1). e, d Enfant de 4 ans : Ies cellules ethmd/dales sup6rieures (2) commencent ~ creuser ros frontal
A Weiglein et al : Paranasalsinuses
338
TaMe 4. Sphenoidal sinus
Fig. 4
Lateral radiograph of an 8 year-old-child. Sphenoidal sinus reaches the hypophyseal fossa Radio de profil d'un enfant de 8 ans. Le sinus sphdnoi'dalatteint la fossehypophysaire
e i g h t - y e a r - o l d child it e x t e n d s beyond the orbital roof and is on average as big as a pea. At the age of twelve the sinus has expanded into the frontal squama. However, the size as well as the shape of the frontal sinus is very varied.
Sinus sphenoidalis (Fig. 4, Table 4) The s p h e n o i d a l sinus does not appear before the age of four. At the age of eight it extends to the h y p o p h y s e a l fossa and expands beyond the fossa at the age of twelve. Here again there is a great variety in size and shape. Discussion
The accessory sinuses of the nose appear very early in development. First of all there is the ethmoidal labyrinth, which begins as an evagination of the mucosa in the third month in-utero. The ethmoidal labyrinth forms two recesses; the ethmoido-frontat and the ethmoidomaxillary. These recesses expand to
the frontal bone and to the maxilla. Then they subsequently excavate these bones and by this way give rise to the frontal and maxillary sinuses [12]. Moreover, the most posterior ethmoidal cell infiltrates the Ossiculum Bertini and forms the sphenoidal sinus [3, 4, 10-12, 16]. The ethmoidal cells t h e m s e l v e s excavate the orbital plate of the ethmoid bone and they even pass the borders of the ethmoid [2]. They invade: posteriorly the sphenoid bone (the so-called Onodi-cells), laterally the orbital floor (the so-called Hailer-cells), anteriorly the nasal bone (the so-called cellulae ethmolacrimales of Grunwald), and superiorly the orbital roof [t0, 11, 15]. As opposed to the views of Wasson [19] and Williams [21] the maxilla13~ sinus is already filled with air in the newborn [4] (Fig. 3a). Furthermore it is incorrect to state that the maxillary sinus does not exist in the newborn [5, 13]. The reason why the maxillary sinus cannot be identified on x-rays of all newborns might be that the sinus is surrounded by
Age (years)
Height (ram)
Length (nkrn)
Width (ram)
4 8 12
3-5 7-13 9-16
4-6 11-14 12-20
6-8 9-11 10-18
the developing teeth and the osseous structures of the maxilla. The maxillary sinus forms two recesses, the zygomatic and the alveolar recess [9]. The zygomatic recess extends towards the zygomatic bone and reaches the innominate line of Stenvers at the age of eight. In the twelv e - y e a r - o l d child the z y g o m a t i c recess exceeds this line and forms the so-called paratemporal segment of the m a x i l l a r y sinus [1]. The alveolar recess begins to develop only in the twelve-year-old child. Pneumatization of the frontal bone begins later in life at about the age of four [2, 4, 15]. In the fouryear-old child the upper ethmoidal cells begin to overstep the ethmoid bone (Fig. 3b). The most anterior cell excavates the frontal squama more and more, whereas the other cells stop growing when they reach the orbital part of the frontal bone. The beginning frontal sinus can be seen on x-rays in the four-year-old child. Of course, if on the one hand the frontal squama is limited caudally by a horizontal line through the u p p e r m o s t points of both supraorbital margins, and on the other hand only the cavity going beyond this line is called the frontal sinus, then the sinus does not exist before six years [12]. However, the pneumatization of the frontal squama is very variable [4, 7, 11, 14] and continues until the age of twenty [8], forty [18], and even after forty years [6] (Fig. 5). Pneumatization of the body of the sphenoid bone starts last [3, 4, 7, 20]. It can be clearly identified on lateral x-rays of eight-year-old children,
A Weiglein et al : Paranasal sinuses
339
9,
I0~
11.
12.
t3.
Fig. $a, b Variations in frontal bone pneumatization. a Big frontal sinus in an 8-year-old child, b Small frontal sinus in a 12-year-old child
t4.
15. Variation darts la pneumatisation de l'os frontal, a G r a n d sinus frontal chez un enfant de 8 ans. b Petit sinus frontal chez un enfant de 12 ans
16.
17.
when the cavity reaches the hypophyseal fossa, as shown in figure 4. Changes in the size of the sphenoidal sinus last a whole life-time [3, 9]. The paranasal sinuses are present very early in life and so they may be the sites of infantile rhinosinusitis. Furthermore infections of these sinuses can lead to complications by spreading out to their neighbouring structures, e.g. the frequent orbital complications during infantile ethmoidal sinusitis [22]. Moreover chronical sinusitis in the child may influence pneumatization and this perhaps is one reason for the variability of sinus d e v e l o p m e n t [19].
2. 3. 4.
5.
6.
7.
References 8. 1.
Ali QM, Baxaka ME, Hassan AY (i990) The paratemporal segment of the maxil-
lary sinus: a new sign for assessment of size. Surg Radiol A n a t 12 : 65-67 van Aiyea OE (1939) Ethmoid labyrinth. Arch Ototaryngo129 : 881-902 van Alyea OE (1941) Spheno]d sinus. Arch Otolaryngol 34 : 225-253 A n d e r h u b e r W, Weiglein A, W o l f G (1992) Cavitas nasi und Sinus paranasales im Neugeborenen- und Kindesalter. Acta Anat 144 : 120-126 Duncker HR (1985) Der Atemapparat. In: Fleischhauer K, Staubesand J, Zenker W (eds) Benninghoff Anatomie. Urban & Schwarzenberg, Mfinchen Wien Baltimore Finby N, Kraft E (t972) The aging skull: comparative roentgen study 25 to 34 year interval. Clin Radiol 23 : 410-414 G r u n w a l d L (1925) Deskriptive und topographische Anatomie der Nase und ihrer Nebenhohlen. In: Denker A, Kahler O (eds) H a n d b u c h der Hals- NasenOhrenheilkunde, VoI 1. Springer Bergmann, Berlin Mtinchen, pp 1-94 Koch J (1930) Kfitisches Obersichtsreferat aber die normale und pathologische Pneumatisation der N e b e n h 6 h l e n der
18.
19.
20.
21.
22.
Nase. Arch Ohrenheilkd 125 : 174-218 Krmpotic-Nemanic J (1977) Entwicklungsgeschichte und Anatomie der Nase und der Nasennebenh6hlen. In: Berendes J, Link R, Zollner F (eds) HNO-Heitkunde in Praxis und Klinik, Vol 1. Thieme Stuttgart, pp 1.1-1.35 Krmpotic-Nemanic J, Draf W, Helms J (1985) Chirurgische Anatomie des KopfHals-Bereiches. Springer, Berlin tteidelberg New York Lang J (1988) Klinische Anatomie der Nase, N a s e n h 6 h l e und Nebenh6hlen. Thieme, Stuttgart New York Libersa C, Laude M, Libersa JC (1981) The pneumatization of the accessory cavities of the nasal fossae during growth. Anat Clin 2 : 265-273 Lippert H (1990) Lehrbuch Anatomie. Urban & Schwarzenberg, Miinchen Wien Baltimore Maresh MM (1940) Paranasal sinuses from birth to late adolescence. Am J Dis Child 60 : 55-78 Mundnich K (1938) Zum Pneumatisationsproblem der Nasennebenh6hlen. Z ONK Heilkd 43 : 5-20 Peter K (t938) Die Nase des Kindes. In: Peter K, Wetzel G, tteiderich F (eds) Handbuch der Anatomie des Kindes, Vol 2. B e r g m a n n , Mtinchen, pp 184-221 PIenk H, Tsehabitscher M (1986) Eatwicklung, Makro- und Mikromorphotogie der K i e f e r h 6 h l e . In: W a t z e k G, Matejka M (eds) Erkrankungen der Kieferh6hte. Springer, Wien New York, pp 1-12 Stern L (1939) R 6 n t g e n o l o g i s c h e Betrachtung der Entwicklung und Ausdehnung der Nasennebenh6hlen. HatsNasen Ohrenarzt 30 : 169-199 Wasson W (1933) Changes in the nasal accessory sinuses after birth. Arch Otolaryng 17 : 197-211 Weiglein A, A n d e r h u b e r W, W o l f G (t991) C a v u m nasi und Sinus paranasales des S~iuglings. Verh Anat Ges 172 : 339 W i l l i a m s H L (1954) T h e p a r a n a s a l sinuses. In: Hollinshead WH (ed) Anatomy for Surgeons, Vot 1, Hoeber-Harper, New York, pp 258-276 Wolf G (1991) Die chronisch rezidivierende Sinusitis im Kindesalter. Therapiewoche 0 6 : 320-326
Received April 16, 1992 / Accepted in final form September 30, 1992
Surg Radiol Anat (1992) 14 : 335-339
Journal of Clinical Anatomy
© Springer-Verlag 1992
Radiological anatomy
Radiologic anatomy of the paranasal sinuses in the child A Weiglein 1, W Anderhuber 2 and G Wolf 2 1Anatonfisches Institut, Karl-Franzens-Universit~it Graz, Harrachgasse 21, A-8010 Graz, Austria 2Universitfitsklinik for Hals-Nasen-Ohren-Kxankheiten, Auenbmggerplatz 20, A-8036 Graz, Austria
S u m m a r y . The development of the paranasal or accessory sinuses begins very early in utero. In the newborn the ethmoidal sinus, which gives rise to all the other sinuses, as well as the maxillary sinus, can ah'eady be identified on x-rays. The frontal sinus appears as a triangle at the age of four and oversteps the supraorbital margin at the age of six. The sphenoidal sinus begins to excavate the concha sphenoidalis at the age of four and can be seen on x-rays at the age of eight, when it extends to the hypophyseal fossa. In the twelveyear-old child all sinuses almost reach their final sizes. However, the size and shape of all sinuses, particularly of the frontal and the sphenoidaI sinuses are very different.
Offprint requests : A Weiglein
Anatomic radiologique des sinus para-nasaux chez l'enfant R 6 s u m 6 . Le d 6 v e l o p p e m e n t des sinus para-nasaux ou sinus accessoires commence trbs prdcocement darts la vie in-ut6ro. Chez le nouveau-n6 le sinus ethmoidal, qui contr61e l ' a p p a r i t i o n de t o u s l e s autres sinus, et le sinus maxillaire peuvent d6j~ ~tre identifi6s ~tla radio. Le sinus frontal a la forme d'un triangle a l'fige de 4 arts et fi'anchit la ligne supra-orbitaire ~ 6 ans. Le sinus sph6no)'dal commence fi creuser le comet sph6noi'dal dbs l'~ge de 4 ans et devient visible ~ la radio 5 8 arts lorsqu'il s'gtend j u s q u ' ~ la fosse hypophysaire. Chez l'enfant de 12 arts tousles sinus ont pratiquement atteint leur taille adulte. Cependant la taille et la tbrme de ces sinus et spdcialement les sinus ffontaux et sph6no'idaux sont trbs diff&entes.
Key words: Paranasal sinuses - Postnatal development - - Radiology
The paranasal or accessory sinuses of the nose begin their development as e v a g i n a t i o n s of the m u c o s a during the third and fourth fetal months, but undergo their m a j o r expansion after birth according to the development of the facial cranium and the teeth [8, 9, 12, 16, 17]. The anatomical features of each age are snapshots of the development of the paranasal sinuses. It has to be emphasized that the child's nose is not a reduced copy of the adult's nose. An exact knowledge of the a n a t o m y of each stage of life is necessary to understand the clinical symptoms, the radiographs, and the complications of this region.
Material and methods We examined 134 human skulls. The total number consisted of 38 dried skulls of newborns, 8 heads of newborns, 32 dried skulls of children aged one month up to one year, 20 dried skulls of children at the age of
336
A Weiglein et al : Paranasal sinuses
Fig. la-c Occipito-nasal radiographs, a 4 year old child: three-cornered frontal sinus, maxillary sinus extends laterally to the infraorbital canal, b 8-year-old child: frontal sinus, maxillary sinus extends beyond the infraorbital canal, c 12- year-old child: frontal and maxillary sinus fully developed Radiographie occipito-nasale, a Enfant de 4 arts : sinus frontal ~ trois angles, le sinus maxillaire s'6tend lat6ralement jusqu'au canal infra-orbitaire. b Enfant de 8 ans: sinus frontal, ie sinus maxillaire s'6tend sous le canal infra-orbitaire, e Enfant de 12 arts : sinus frontal et maxillaire compl~tement d~veloppds
Table 1. MaxilIary sinus
Fig. 2 Frontal section, newborn. 1 Ethmoid cells 2 maxillary sinus with long infnndibulum ethmoidale, 3 developing tooth Coupe frontale, nouveau-n6. 1 Cellules ethmo'l'dales 2 sinus maxillaire avec un long infundibulum ethmo~dal 3 dent en formation
four, 23 dried skulls of children at the age of eight, and 13 dried skulls of children at the age of twelve. The skulls were x-rayed in following
Table 2. Ethmoidal sinus
Age (years)
Height (mm)
Length (ram)
Width (mm)
Age (years)
Height (ram)
Length (mm)
Width (mm)
0 4 8 t2
3-4 12-18 22-26 22-28
8-13 21-30 34-38 35-40
3-5 10-18 18-24 20-29
0 4 8 12
5-7 11-12 14-16 15-20
8-12 12-21 18-24 24-30
2-3 3-6 4-10 8-10
manner: occipito-frontal (Caldwell), occipito-nasal (Waters), lateral, with a focus film distance of one meter. All skulls were also examined by diaphanoscopy. One half of the newborns' heads was cut frontally and the other half was cut sagittally and p r e p a r e d under the preparationmicroscope. Measurements were taken directly from the skulls. Results Sinus maxillaris (Figs. 1, 2, Table 1)
In the newborn the maxillary sinus already is of appreciable size. A lot of bony and connective tissue separates the lateral wall of the maxillary sinus from the developing teeth. Its bottom is far from the hard palate and its roof does not reach the
orbital floor. The cavity of Highmore c o m m u n i c a t e s with the nasal cavity through a long infundibulum e t h m o i d a l e . This i n f u n d i b u l u m leads to the hiatus s e m i l u n a r i s below the middle nasal concha. Posteriorly it reaches the developing first molar. The maxilla forms one third of the lateral wall of the nasal cavity while the upper part is represented by the ethmoid bone. The maxillary sinus is filled with air and can be identified on Caldwetl's view in most of the newborns (Fig. 3a). At the latest at five months it can be seen on radiographs. In the four-year-old child the maxillary sinus is well developed according to the first dentition. Laterally it reaches the infraorbital canal. The floor extends to the level of the appendage of the inferior
A Weiglein et al : Paranasat sinuses concha. P o s t e r i o r l y it reaches the t o o t h b u d o f the first p e r m a n e n t molar. The maxilla represents almost half the lateral wall of the nasal cavity. In the eight- year-old c h i l d the m a x i l l a r y sinus has the shape of a f o u r - s i d e d p y r a m i d . It laterally passes the infraorbital c a n a l a n d its b o t t o m r e a c h e s the level of the m i d d l e o f the inferior concha. The roof reaches the floor of the orbit. Its posterior wall totally excavates the tuber maxillae. A c c o r d i n g to the second dentition the cavity of Highmore o f the twelve-year-old child reaches almost the size o f the adult. Its b o t t o m now reaches the level of the floor o f the nasal cavity. The sinus extends late-
337 rally to or b e y o n d the innominate line o f Stenvers. The maxilla forms two thirds of the lateral wall of the nose.
i d e n t i f i e d in x - r a y s b e t w e e n the nasal cavity and the orbit.
Sinus ethmoidal& (Fig. 1, Table 2)
The frontal sinus does not exist in the newborn. At the age of four the sinus appears as a triangle between the upper part o f the medial orbital w a l l and the n a s a l c a v i t y . In the
The full complement of the ethmoidal cells, i.e. 6-10, is present in the newborn. The cells are small and spherical and separated from each other by soft and bony tissue. The e t h m o i d a l cells e x p a n d m o r e and more and at the age of twelve, they h a v e e x c a v a t e d all the a v a i l a b l e room. That is why they are flattened and edged, and separated only b y thin bony lamellae. Beginning from birth the ethmoidal labyrinth can be
Sinusfi'ontalis (Fig. 1, Table 3)
Table 3. Frontal sinus
Age (years)
Height (mm)
4 8 12
4-9 5-25 12-26
Length (mm) 7-13 10-15 t3-21
Width (ram) 4-I0 8-I9 15-22
Fig. 3a-d Diaphanoscopies and x-rays of the same skulls, a, b Newborn: ethmoid labyrinth, maxillary sinus (1). c, d 4 year old child: the upper ethmoid cells (2) begin to excavate the frontal bone
Diaphanoscopies et radios de ces mOmes cr~nes, a, b Nouveau-n& labyrinthe ethmoidal et sinus maxillaire (1). e, d Enfant de 4 ans : Ies cellules ethmd/dales sup6rieures (2) commencent ~ creuser ros frontal
A Weiglein et al : Paranasalsinuses
338
TaMe 4. Sphenoidal sinus
Fig. 4
Lateral radiograph of an 8 year-old-child. Sphenoidal sinus reaches the hypophyseal fossa Radio de profil d'un enfant de 8 ans. Le sinus sphdnoi'dalatteint la fossehypophysaire
e i g h t - y e a r - o l d child it e x t e n d s beyond the orbital roof and is on average as big as a pea. At the age of twelve the sinus has expanded into the frontal squama. However, the size as well as the shape of the frontal sinus is very varied.
Sinus sphenoidalis (Fig. 4, Table 4) The s p h e n o i d a l sinus does not appear before the age of four. At the age of eight it extends to the h y p o p h y s e a l fossa and expands beyond the fossa at the age of twelve. Here again there is a great variety in size and shape. Discussion
The accessory sinuses of the nose appear very early in development. First of all there is the ethmoidal labyrinth, which begins as an evagination of the mucosa in the third month in-utero. The ethmoidal labyrinth forms two recesses; the ethmoido-frontat and the ethmoidomaxillary. These recesses expand to
the frontal bone and to the maxilla. Then they subsequently excavate these bones and by this way give rise to the frontal and maxillary sinuses [12]. Moreover, the most posterior ethmoidal cell infiltrates the Ossiculum Bertini and forms the sphenoidal sinus [3, 4, 10-12, 16]. The ethmoidal cells t h e m s e l v e s excavate the orbital plate of the ethmoid bone and they even pass the borders of the ethmoid [2]. They invade: posteriorly the sphenoid bone (the so-called Onodi-cells), laterally the orbital floor (the so-called Hailer-cells), anteriorly the nasal bone (the so-called cellulae ethmolacrimales of Grunwald), and superiorly the orbital roof [t0, 11, 15]. As opposed to the views of Wasson [19] and Williams [21] the maxilla13~ sinus is already filled with air in the newborn [4] (Fig. 3a). Furthermore it is incorrect to state that the maxillary sinus does not exist in the newborn [5, 13]. The reason why the maxillary sinus cannot be identified on x-rays of all newborns might be that the sinus is surrounded by
Age (years)
Height (ram)
Length (nkrn)
Width (ram)
4 8 12
3-5 7-13 9-16
4-6 11-14 12-20
6-8 9-11 10-18
the developing teeth and the osseous structures of the maxilla. The maxillary sinus forms two recesses, the zygomatic and the alveolar recess [9]. The zygomatic recess extends towards the zygomatic bone and reaches the innominate line of Stenvers at the age of eight. In the twelv e - y e a r - o l d child the z y g o m a t i c recess exceeds this line and forms the so-called paratemporal segment of the m a x i l l a r y sinus [1]. The alveolar recess begins to develop only in the twelve-year-old child. Pneumatization of the frontal bone begins later in life at about the age of four [2, 4, 15]. In the fouryear-old child the upper ethmoidal cells begin to overstep the ethmoid bone (Fig. 3b). The most anterior cell excavates the frontal squama more and more, whereas the other cells stop growing when they reach the orbital part of the frontal bone. The beginning frontal sinus can be seen on x-rays in the four-year-old child. Of course, if on the one hand the frontal squama is limited caudally by a horizontal line through the u p p e r m o s t points of both supraorbital margins, and on the other hand only the cavity going beyond this line is called the frontal sinus, then the sinus does not exist before six years [12]. However, the pneumatization of the frontal squama is very variable [4, 7, 11, 14] and continues until the age of twenty [8], forty [18], and even after forty years [6] (Fig. 5). Pneumatization of the body of the sphenoid bone starts last [3, 4, 7, 20]. It can be clearly identified on lateral x-rays of eight-year-old children,
A Weiglein et al : Paranasal sinuses
339
9,
I0~
11.
12.
t3.
Fig. $a, b Variations in frontal bone pneumatization. a Big frontal sinus in an 8-year-old child, b Small frontal sinus in a 12-year-old child
t4.
15. Variation darts la pneumatisation de l'os frontal, a G r a n d sinus frontal chez un enfant de 8 ans. b Petit sinus frontal chez un enfant de 12 ans
16.
17.
when the cavity reaches the hypophyseal fossa, as shown in figure 4. Changes in the size of the sphenoidal sinus last a whole life-time [3, 9]. The paranasal sinuses are present very early in life and so they may be the sites of infantile rhinosinusitis. Furthermore infections of these sinuses can lead to complications by spreading out to their neighbouring structures, e.g. the frequent orbital complications during infantile ethmoidal sinusitis [22]. Moreover chronical sinusitis in the child may influence pneumatization and this perhaps is one reason for the variability of sinus d e v e l o p m e n t [19].
2. 3. 4.
5.
6.
7.
References 8. 1.
Ali QM, Baxaka ME, Hassan AY (i990) The paratemporal segment of the maxil-
lary sinus: a new sign for assessment of size. Surg Radiol A n a t 12 : 65-67 van Aiyea OE (1939) Ethmoid labyrinth. Arch Ototaryngo129 : 881-902 van Alyea OE (1941) Spheno]d sinus. Arch Otolaryngol 34 : 225-253 A n d e r h u b e r W, Weiglein A, W o l f G (1992) Cavitas nasi und Sinus paranasales im Neugeborenen- und Kindesalter. Acta Anat 144 : 120-126 Duncker HR (1985) Der Atemapparat. In: Fleischhauer K, Staubesand J, Zenker W (eds) Benninghoff Anatomie. Urban & Schwarzenberg, Mfinchen Wien Baltimore Finby N, Kraft E (t972) The aging skull: comparative roentgen study 25 to 34 year interval. Clin Radiol 23 : 410-414 G r u n w a l d L (1925) Deskriptive und topographische Anatomie der Nase und ihrer Nebenhohlen. In: Denker A, Kahler O (eds) H a n d b u c h der Hals- NasenOhrenheilkunde, VoI 1. Springer Bergmann, Berlin Mtinchen, pp 1-94 Koch J (1930) Kfitisches Obersichtsreferat aber die normale und pathologische Pneumatisation der N e b e n h 6 h l e n der
18.
19.
20.
21.
22.
Nase. Arch Ohrenheilkd 125 : 174-218 Krmpotic-Nemanic J (1977) Entwicklungsgeschichte und Anatomie der Nase und der Nasennebenh6hlen. In: Berendes J, Link R, Zollner F (eds) HNO-Heitkunde in Praxis und Klinik, Vol 1. Thieme Stuttgart, pp 1.1-1.35 Krmpotic-Nemanic J, Draf W, Helms J (1985) Chirurgische Anatomie des KopfHals-Bereiches. Springer, Berlin tteidelberg New York Lang J (1988) Klinische Anatomie der Nase, N a s e n h 6 h l e und Nebenh6hlen. Thieme, Stuttgart New York Libersa C, Laude M, Libersa JC (1981) The pneumatization of the accessory cavities of the nasal fossae during growth. Anat Clin 2 : 265-273 Lippert H (1990) Lehrbuch Anatomie. Urban & Schwarzenberg, Miinchen Wien Baltimore Maresh MM (1940) Paranasal sinuses from birth to late adolescence. Am J Dis Child 60 : 55-78 Mundnich K (1938) Zum Pneumatisationsproblem der Nasennebenh6hlen. Z ONK Heilkd 43 : 5-20 Peter K (t938) Die Nase des Kindes. In: Peter K, Wetzel G, tteiderich F (eds) Handbuch der Anatomie des Kindes, Vol 2. B e r g m a n n , Mtinchen, pp 184-221 PIenk H, Tsehabitscher M (1986) Eatwicklung, Makro- und Mikromorphotogie der K i e f e r h 6 h l e . In: W a t z e k G, Matejka M (eds) Erkrankungen der Kieferh6hte. Springer, Wien New York, pp 1-12 Stern L (1939) R 6 n t g e n o l o g i s c h e Betrachtung der Entwicklung und Ausdehnung der Nasennebenh6hlen. HatsNasen Ohrenarzt 30 : 169-199 Wasson W (1933) Changes in the nasal accessory sinuses after birth. Arch Otolaryng 17 : 197-211 Weiglein A, A n d e r h u b e r W, W o l f G (t991) C a v u m nasi und Sinus paranasales des S~iuglings. Verh Anat Ges 172 : 339 W i l l i a m s H L (1954) T h e p a r a n a s a l sinuses. In: Hollinshead WH (ed) Anatomy for Surgeons, Vot 1, Hoeber-Harper, New York, pp 258-276 Wolf G (1991) Die chronisch rezidivierende Sinusitis im Kindesalter. Therapiewoche 0 6 : 320-326
Received April 16, 1992 / Accepted in final form September 30, 1992
