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Association Between Superior Attachment of Uncinate 
Process and Frontal Sinusitis

Journal of College of Medical Sciences-Nepal, Vol-18, No 4, Oct-Dec 2022
ISSN: 2091-0657 (Print); 2091-0673 (Online) Open Access 

DOI: 10.3126/jcmsn.v18i3.42487

1Department of Otorhinolaryngology, 2Department of Radiology, Nepal Medical College and Teaching Hospital, 
Kathmandu University, Nepal.

Original Research Article

 

ABSTRACT

Introduction

 

Methods

A cross sectional study was conducted in the Otorhinolaryngology out-patient department. Patients 
were diagnosed as chronic rhinosinusitis according to the American Academy of Otolaryngology–
Head and Neck Surgery Rhinosinusitis Task Force criteria. Patients then underwent a non-contrast 
CT scan of paranasal sinuses. Superior attachment of the UP was noted from the CT, and the 
association between the superior attachment of the UP and chronic frontal sinusitis was recorded. 

Results

Conclusions 

Among the superior attachments of the uncinate process, attachment into the lamina papyracea 
was the commonest. It was noted that chronic frontal sinusitis was significantly associated with 
the superior attachment of the uncinate process.

Keywords: Chronic frontal sinusitis; lamina papyracea; superior attachment; uncinate process.

Anupama Shah Rijal, 1Abhushan Siddhi Tuladhar, 2Rupesh Raj Joshi, 1Kundan Kumar Shrestha, 
1Anup Dhungana1

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Correspondence: Dr. Anupama Shah Rijal, Department of Otorhinolaryngology Nepal Medical College and Teaching 
Hospital, Kathmandu University, Nepal. Email: asrijal@gmail.com. Phone: +977-9841906215



JCMS | Vol-18 | No 3 | Jul-Sep 2022186

INTRODUCTION

The uncinate process (UP) is a sickle shaped 
bone, which attaches inferiorly to the 
inferior turbinate and palatine bone and 
anterosuperiorly to the lacrimal bone.1 The 
superior attachment of uncinate process can be 
into the lamina papyracea (Type I), the skull 
base (Type II) and the middle turbinate (Type 
III).2,3 Drainage of the frontal sinus depends on 
the superior attachment of the uncinate process 
and alteration in the drainage predisposes 
to frontal sinus diseases. Chronic frontal 
rhinosinusitis (CRS) is encountered frequently 
in Otorhinolaryngology. CRS can be diagnosed 
by using the rhinosinusitis task force criteria of 
American Academy of Otolaryngology–Head 
and Neck Surgery (AAOHNS).4 Computed 
tomography (CT) currently is the gold standard 
imaging method to show the anatomy and 
pathology of paranasal sinuses.5,6 This study 
was conducted with an aim to determine an 
association between the superior attachment of 
uncinate process and chronic frontal sinusitis. 

METHODS

A cross sectional study was conducted at Nepal 
Medical College Teaching Hospital (NMCTH), 
Otorhinolaryngology out-patient department 
(OPD). The study duration was from April to 
September 2022. All consecutive OPD patients 
with nasal obstruction and discharge for more 
than 12 weeks, above 20 years of age and 
who consented were included in the study. 
Patients with past history of sinonasal surgery, 
craniofacial malformations, fractures, malignant 
neoplasm, fungal sinusitis, mucocele were 
excluded. Other variations of uncinate processes 
namely, pneumatised, hypertrophied, medially 
bent, laterally bent and unclear or multiple 
superior attachments were also excluded. 
Ethical approval was obtained from the research 
and institutional review committee of NMCTH 

 

RESULTS

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

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;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-18 | No 3 | Jul-Sep 2022 187

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

males and 10 (13.9%) females. In the other two 
groups of 30 to 39 years and 40 to 49 years there 
were 18 (25%) patients in each. In the 30 to 39 
years age group there were 7 (9.7%) males and 
11 (15.3%) females and in the 40 to 49 years age 
group there were 12 (16.7%) males and 6 (8.3%) 
females. The 50 to 59 years age group consisted 
of 8 (11.1%) patients out of which 2 (2.8%) were 
males and 6 (8.3%) were females. There were 6 
(8.3%) patients above sixty years of age with 5 
(6.9%) females and 1 male (Figure 1).

The UP was attached into the lamina papyracea 
in 54 (75.0%) on the right side and 53 (73.6%) on 
the left side. Attachment into the skull base was 
seen in 13 (18.1%) on the right and 11 (15.3%) on 

the left side. On the right side 5 (6.9%) and on 
the left 8 (11.1%) were attached into the middle 
turbinate.The  various attachments of superior 
part of UP in our study are shown in the CT 
scans below. (Figure 2), (Table1)  

Overall total chronic frontal sinusitis was seen in 
39 (54.2%) frontal sinuses on the right side out of 
which 23 (31.9%) frontal sinusitis had attachment 
to the lamina papyracea. Twelve (16.7.%) out 

of 39 showed chronic frontal sinusitis with the 
attachment to skull base, whereas 4 (5.6%) had 
sinusitis with attachment to middle turbinate. In 
our study on the right side there was significant 
association seen between the superior attachment 
of the UP and chronic frontal sinusitis (P=0.001). 

Figure 1. Distribution of age and gender.

Table 1. Distribution of superior attachment of UP

 Superior attachment of UP                                       
            Right side              Left side 

Frequency Percentage (%) Frequency Percentage (%)

Lamina papyracea 54 75.0% 53 73.6%

Skull base 13 18.1% 11 15.3%

Middle turbinate 5 6.9% 8 11.1%

Total 72 100% 72 100%

Figure 2. CT scan coronal view showing superior 
attachment of UP.
a. insertion into the lamina papyracea on the right 

side and skull base on the left side
b. insertion into the middle turbinate bilaterally

a b

(Table 2)



JCMS | Vol-18 | No 3 | Jul-Sep 2022188

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

We also looked at the total number of chronic 
frontal sinusitis in relation to the total number 
of sides studied. As documented in the previous 
tables the total number of chronic frontal 
sinusitis was 77 out of 144 sides, out of which 

52 (67.5%) had the superior attachment of the 
uncinate process into the lamina papyracea. 
Seventeen (22.2%) had the attachment of the 
uncinate process into the skull base and 8 (10.3%) 
had attachment into the middle turbinate. This is 
documented in Table 4.

DISCUSSION

Chronic frontal rhinosinusitis is a common 
condition frequently encountered in the ENT 
outpatient, which can lead to considerable 
morbidity for the patient. Among the various 

factors leading to this condition, we looked at the 
association between the superior attachment of 
the uncinate process and chronic frontal sinusitis. 
Our demographics showed younger age groups 
were more affected, with 30.6% between 20 to 29 

Table 2. Association of right superior attachment of UP and chronic frontal sinusitis

Superior attachment of UP
Not developed

No (%)
Normal 
No (%)

Frontal sinusitis 
No (%)

Total sides 
No (%)

Lamina papyracea 1 (1.4%) 30 (41.6%) 23 (31.9%) 54 (75%)

Skull base 0 (0.0%) 1 (1.4%) 12 (16.7%) 13 (18.1%)

Middle turbinate 1 (1.4%) 0 (0.0%) 4 (5.6%) 5 (6.9%)

Total 2 (2.8%) 31 (43%) 39 (54.2%) 72 (100%)

Table 3. Association of left superior attachment of UP and chronic frontal sinusitis

Superior attachment of UP
Not developed
       No (%)

     Normal 
      No (%)

Frontal sinusitis
        No (%)

Total sides
   No (%)

Lamina papyracea 0 (0.0%) 24 (33.3%) 29 (40.3%) 53 (73.6%)

Skull base 0 (0.0%) 6 (8.3%) 5 (6.9%) 11 (15.3%)

Middle turbinate 2 (2.8%) 2 (2.8%) 4 (5.6%) 8 (11.1%)

Total 2 (2.8%) 32 (44.4%) 38 (52.8%) 72 (100%)

Table 4. Superior attachment of UP and chronic frontal sinusitis

Superior attachment of UP
Frontal Sinusitis present

No. (%) 
Total sides
  No. (%)

Lamina papyracea 52 (67.5%) 107 (74.3 %)

Skull base 17 (22.2%) 24 (16.7 %)

Middle turbinate 8 (10.3 %) 13 (9.0 %)

Total 77 (100%) 144 (100 %)

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;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-18 | No 3 | Jul-Sep 2022 189

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

years followed by 25% in both 30 to 39 and 40 to 
49 age groups. This was similar to a study done 
by Singh I., who also showed that in his study 
two third of the cases were below 35 years with 
40% of the cases between18 to 25 years.7 Tuli et 
al. also demonstrated that 30% patients in their 
study were between the ages of 21-35 years with 
chronic sinusitis.8 One plausible reason for this 
is that younger patients are more active and are 
involved in more outdoor activities. Likewise 
younger patients are also more concerned about 
their health and tend to seek medical care earlier 
compared to other age groups. Similarly, female 
patients with chronic rhinosinusitis were seen to 
be higher in numbers than males, which again is 
similar to the study done by Singh I. This could 
be because females in our country are more 
involved in household chores, agriculture and 
are generally more exposed to various allergens.

It is imperative to understand the anatomy 
of the frontal sinuses along with its drainage 
to comprehend the factors responsible for the 
development of sinusitis. In this respect we 
need to understand the osteomeatal complex, 
which is the small compartment located in 
the area between the middle turbinate and 
the lateral nasal wall in the middle meatus 
and this represents the region for drainage of 
anterior ethmoid, maxillary and frontal sinuses. 
Variations in any one of the components of 
the ostiomeatal complex (OMC) can lead to 
improper drainage of these sinuses causing 
chronic frontal sinusitis.9

The uncinate process is a key structure of the 
anterior OMC, which is important for drainage 
and ventilation. The OMC consists of the hiatus 
semilunaris, a two-dimensional crescent-
shaped region located between the free edge 
of the UP and the anterior surface of the bulla 
ethmoidalis, extending laterally into the ethmoid 
infundibulum.10,11 The superior attachment of the 
uncinate process will determine the direction of 

frontal sinus outflow that finally drains into the 
middle meatus and ethmoidal infundibulum, 
either medial or lateral to UP.12 This drainage 
mechanism is considered as one of the important 
factors in the development of chronic frontal 
sinusitis. 

 

 

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JCMS | Vol-18 | No 3 | Jul-Sep 2022190

REFERENCES

1. Dalgorf D M, Harvy R J. Anatomy 
of Nose and Paranasal Sinuses. In: 
Watkinson JC, Clarke RW, edit ors. Scott-
Brown’s Otorhinolaryngology Head and 
Neck Surgery. 8th ed. Vol. I, London: 
CRC Press; 2019:961-76.

2. Stammberger HR, Kennedy DW. Anatomic 
Terminology Group. Paranasal sinuses: 
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Ann Otol Rhinol Laryngol Suppl. 1995 
Oct;167(6):7-16. PMID: 7574267

3. Stammberger H, Posawetz W. Functional 
endoscopic sinus surgery. European 

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

Considering the attachments of the UP and 
their relation it was seen that there was 
significant association on both sides with 
superior attachment of the uncinate process and 
chronic frontal sinusitis (p=0.001 and p=0.002 
respectively). This was similar to studies done 
by Gnanavelraja C et al.17 Taking into account 
both sides, 67.5% of superior attachment of the 
uncinate process into the lamina papyracea was 
seen to give rise to chronic frontal sinusitis that 
was similar to other studies.8,9,13,14  

The pathophysiology explaining this 
phenomenon seems to be unclear, however, it 
has been speculated the superior attachment 
of uncinate process changes the pattern of 
drainage of frontal sinus, which may be one 
factor determining the development of frontal 
sinusitis.Theoretically, attachment into lamina 
papyracea is likely to have less frontal sinusitis 
because the frontal sinus drains directly into the 
middle meatus. However, in our study, frontal 
sinusitis was more frequent than in this type. 
Similar findings have been reported in literature 
as well.8,9,13,14 This finding suggests that several 
other factors, such as airflow of the nasal cavity 
and the status of nasal mucosa other than simple 
anatomic narrowing of the OMC may play 
an important role in functional and anatomic 
disturbance of OMC. The cause of frontal 
sinusitis in patients with lamina papyracea 
attachments may be attributed to infundibular 
disease displacing the uncinate process medially 

and obstructing the frontal sinus drainage 
between the uncinate and middle turbinate.15 
Several other factors have also been previously 
discussed regarding the pathophysiologic 
process of chronic frontal sinusitis. Kuhn 
classified a number of cells that can lead to 
obstruction of the frontal recess and cause frontal 
sinusitis. These are namely frontal recess cells 
including agger nasi, supraorbital ethmoid cells, 
frontal cells, frontal bulla cells, suprabullar cells, 
and interfrontal sinus septal cells.18 In addition 
to anatomical obstruction, mucosal obstruction 
of the frontal recess plays an important role in 
chronic frontal sinusitis.19 There are also different 
factors such as hypoxia, dehydration, infection, 
foreign bodies, environmental irritants, trauma, 
tumor, and allergens that can affect the frontal 
sinus physiologic functions by disrupting 
the mucociliary clearance.20   Further studies 
regarding the superior attachment of the UP in 
larger sample may identify attachment to lamina 
papyracea as an independent major contributing 
factor to chronic frontal sinusitis.

CONCLUSIONS

Chronic frontal rhinosinusitis was more common 
in the younger age group and among female 
patients. Among the superior attachments of 
the uncinate process, attachment into the lamina 
papyracea was the commonest. It was noted that 
frontal sinusitis was significantly associated with 
the superior attachment of the uncinate process.



;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-18 | No 3 | Jul-Sep 2022 191

Rijal et al. Association Between Superior Attachment of Uncinate Process and Frontal Sinusitis

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BF00183169

4. Benninger MS, Ferguson BJ, Hadley JA, 
Hamilos DL, Jacobs M, Kennedy DW, 
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Stankiewicz JA, Anon J. Adult chronic 
rhinosinusitis: definitions, diagnosis, 
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5. Mancuso AA, Hanafee WN: Computed 
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1985; 1–42.

6. Cashman EC, MacMahon PJ, Smyth 
D. Computed tomography scans of 
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endoscopic sinus surgery. World journal 
of radiology. 2011 Aug 8;3(8):199. 
DOI: 10.4329/wjr.v3.i8.199

7. Singh I, Sherstha A, Gautam D. Chronic 
rinosinusitis and nasal polyposis in 
Nepal. An International Journal Clinical 
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DOI: 10.1016/j.jaip.2016.04.012

8. Tuli IP, Sengupta S, Munjal S, Kesari 
SP, Chakraborty S. Anatomical 
variations of uncinate process observed 
in chronic sinusitis. Indian Journal 
of Otolaryngology and Head & 
Neck Surgery. 2013 Apr;65(2):157-61. 
DOI: 10.1007/s12070-012-0612-8

9. Srivastava M, Tyagi S. Role of 
anatomic variations of uncinate 
process in frontal sinusitis. Indian 

Journal of Otolaryngology and Head 
& Neck Surgery. 2016 Dec;68(4):441-4. 
DOI: 10.1007/s12070-015-0932-6

10. Stammberger H, Hawke M. Essentials 
of endoscopic sinus surgery. St. Louis: 
Mosby Inc. 1 st Edition. 1993:01-108.

11. Güngör G, Okur N, Okur E. Uncinate 
process variations and their relationship 
with ostiomeatal Complex: a pictorial 
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