Endoscopic Sinus Surgery Anatomy and Techniques

Endoscopic sinus surgery (ESS) has become the cornerstone of contemporary management for chronic sinonasal disorders, leveraging detailed endonasal anatomy and minimally invasive techniques to address pathologies of the paranasal sinuses and anterior skull base. Mastery of the complex three-dimensional relationships between the nasal septum, middle turbinate, ethmoid labyrinth and surrounding neurovascular structures is essential to minimise complications such as cerebrospinal fluid leak or orbital injury. Advances in high-resolution imaging, navigation systems and instrument design have refined access to anterior and posterior ethmoid cells, frontal recesses and sphenoid ostia. Precise knowledge of key landmarks—including the cribriform plate, olfactory fossa and anterior ethmoidal artery—guides safe dissection. Moreover, recognition of anatomical variants, such as suprabullar pneumatization or concha bullosa, informs tailored surgical approaches. Continuous integration of radiological classification schemes with intraoperative endoscopy underpins improved outcomes and reduced morbidity across diverse patient populations.

Research from Nature Portfolio

Recent studies have proposed a novel radiological classification to enhance preoperative risk stratification of anterior skull base injury. By using the orbital floor as a stable reference, the Thailand-Malaysia-Singapore (TMS) schema subdivides patients into three types based on measurements to the cribriform plate and ethmoid roof. Analysis of computed tomography images across a large cohort demonstrated strong correlation with established Keros grades, while offering practical intraoperative applicability. This approach provides an additional tool for surgeons to predict the depth of the lateral lamella of the cribriform plate and to adjust dissection strategies accordingly, thereby reducing the likelihood of skull base breach during ethmoidotomy.

Endoscopic Sinus Surgery Anatomy and Techniques publication trend

The graph below shows the total number of articles in endoscopic sinus surgery anatomy and techniques across all publications each year (not limited to Nature Index journals).

Technical terms

Lateral lamella of the cribriform plate: The thinnest vertical segment of the anterior skull base, spanning between the cribriform plate and ethmoid roof, prone to breach during surgery.

Keros classification: A system categorising the depth of the olfactory fossa into three types to assess risk of skull base injury.

Anterior ethmoidal artery (AEA): A small vessel traversing the ethmoid roof that supplies anterior ethmoidal cells and serves as a critical surgical landmark.

Suprabullar pneumatization: Variation in air cell development above the ethmoid bulla that alters the orientation of adjacent neurovascular structures.

Thailand-Malaysia-Singapore (TMS) classification: A radiological scheme measuring distances from the orbital floor to the cribriform plate and ethmoid roof to refine risk assessment of skull base injury.

References

1. A new radiological classification for the risk assessment of anterior skull base injury in endoscopic sinus surgery. Scientific Reports (2020).
2. Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study. Surgical and Radiologic Anatomy (2023).
3. The Complete Anatomy of the Anterior Ethmoidal Artery: A Meta-Analysis with Implications for Sinus and Skull Base Surgery. Journal of Clinical Medicine (2024).
4. Risk Factors for Anterior Skull Base Injury in Endoscopic Sinus Surgery. Cureus (2023).