What is the anatomy in paranasal sinus CT images?

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paranasal sinus CT anatomy coronal axial landmarks

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https://pmc.ncbi.nlm.nih.gov/articles/PMC3698895

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I now have rich, comprehensive content from authoritative otolaryngology textbooks (Cummings, K.J. Lee) with CT anatomy images. I have enough to provide a thorough, well-organized answer. Let me compile the full response.

Here is a comprehensive overview of the anatomy seen on paranasal sinus (PNS) CT imaging, drawn from Cummings Otolaryngology and K.J. Lee's Essential Otolaryngology.

Anatomy on Paranasal Sinus CT

Why CT Is the Standard

Plain radiographs have largely been abandoned for PNS evaluation because of tissue overlap, poor visualization of the posterior ethmoids and osteomeatal complexes, and poor soft tissue resolution. CT is the current imaging gold standard because of its exquisite ability to differentiate hypertrophic mucosa, bone, and air. Modern multislice CT acquires thin transverse slices (<1 mm) that can be reconstructed in coronal, axial, and sagittal planes. Coronal views are best for the ostiomeatal unit and orbit relationships; axial views are critical for posterior ethmoid and sphenoid disease; sagittal views are most useful for the frontal recess and slope of the skull base. - Cummings Otolaryngology, p. 781-783

The Four Paranasal Sinuses

Sinus	Location	Drainage
Maxillary	Body of maxilla; largest sinus	Maxillary ostium → ethmoid infundibulum → hiatus semilunaris → middle meatus
Frontal	Frontal bone above orbits	Frontal recess → superior middle meatus
Ethmoid (anterior)	Ethmoid labyrinth, medial to orbit	Middle meatus via ethmoid cell ostia
Ethmoid (posterior)	Posterior to basal lamella	Superior meatus via sphenoethmoidal recess
Sphenoid	Sphenoid body; most posterior	Sphenoethmoidal recess → superior meatus

The Lateral Nasal Wall - The Key to CT Interpretation

The lateral nasal wall is the central organizing structure. It carries three bony projections called turbinates (conchae): inferior, middle, and superior (a fourth "supreme" turbinate is occasionally present). These divide each nasal cavity into three air passages called meati:

Inferior meatus: drains the nasolacrimal duct
Middle meatus: drains the frontal, anterior ethmoid, and maxillary sinuses (the most important for disease)
Superior meatus: drains the posterior ethmoid cells and sphenoid sinus (via the sphenoethmoidal recess)

The Osteomeatal Complex (OMC) / Unit

This is the most important region on PNS CT - often called the "bottleneck" of normal sinus drainage. It sits within the middle meatus and is bounded by:

Posterior: basal lamella of the middle turbinate
Medial: middle turbinate
Lateral: lamina papyracea
Superior: fovea ethmoidalis

The OMC is the regional confluence of drainage pathways for the maxillary, anterior ethmoid, and frontal sinuses. Obstruction here - by anatomic variations, polyps, or mucosal disease - is the key pathophysiologic mechanism in rhinosinusitis. Coronal CT best demonstrates the OMC and should always be assessed.

The anterior ostiomeatal unit includes: frontal sinus ostium, frontal recess, maxillary sinus ostium, ethmoid infundibulum, and middle meatus.

The posterior ostiomeatal unit consists of: sphenoid sinus ostium, sphenoethmoidal recess, and superior meatus.

Key Structures Seen on CT - Described Anteroposteriorly

1. Agger Nasi Cell

The most anterior ethmoid air cell; an ethmoturbinal remnant present in most people
Seen on coronal CT as a cell anterior and inferior to the frontal recess, just superior to the attachment of the middle turbinate
If enlarged, it narrows the frontal recess and may obstruct frontal sinus drainage

2. Uncinate Process (UP)

A crescent-shaped, mucosa-lined bone of ethmoid origin that shields the natural maxillary ostium
On coronal CT, it appears as a thin bony projection in the middle meatus
Its vertical portion attaches anteriorly to the lacrimal line; its horizontal portion attaches inferiorly to the inferior turbinate
The superior attachment of the UP determines frontal sinus drainage:
- Attaches to lamina papyracea (80%): frontal sinus drains medial to UP, directly into the middle meatus
- Attaches to fovea ethmoidalis or middle turbinate (20%): frontal sinus drains lateral to UP, into the ethmoid infundibulum

3. Ethmoid Infundibulum

A 3D trough bounded by: UP medially, lamina papyracea laterally, ethmoid bulla posterosuperiorly
Opens inferiorly at the maxillary sinus ostium
This is the second "tight spot" for mucus clearance

4. Hiatus Semilunaris

The gap between the free edge of the UP and the anterior face of the ethmoid bulla
Medially communicates with the middle meatus; laterally and inferiorly communicates with the infundibulum

5. Ethmoid Bulla (Bulla Ethmoidalis)

Usually the largest anterior ethmoid air cell
Enclosed laterally by the lamina papyracea
Visible on coronal CT superior to the ethmoid infundibulum
Forms the posterior wall of the frontal recess

6. Middle Turbinate (MT) and Basal Lamella

The MT has three portions:
- Anterior (vertical): attached to cribriform plate, oriented sagittally; separates fovea ethmoidalis from cribriform plate
- Middle (basal/ground lamella): oriented in the coronal plane, fuses laterally with the lamina papyracea - divides anterior from posterior ethmoid cells
- Posterior (horizontal): attached to the palatine bone, oriented in the axial plane
Concha bullosa: pneumatization of the middle turbinate; present in ~1/3 of people; clinically significant if it narrows the OMC

7. Frontal Recess

The first and narrowest "tight spot" in the frontal sinus outflow tract (FSOT)
On coronal CT: a narrow air channel between the agger nasi cell anteriorly and the ethmoid bulla posteriorly, leading superiorly into the frontal sinus ostium
Best evaluated on sagittal CT where the hourglass shape of the FSOT is appreciated
The frontal sinus outflow tract widens superiorly (frontal infundibulum) → narrows at the frontal ostium → widens again at the frontal recess → opens into the middle meatus

Frontal sinus anatomy on coronal CT: agger nasi cell (A), frontal sinus (F), nasal septum (S), ethmoid bulla (B), middle turbinate (T), concha bullosa (C) shown from anterior to posterior

Fig. 38.2 - Coronal CT scans of frontal sinuses from anterior (A) to posterior (D). Note frontal sinus (F), agger nasi (A), ethmoid bulla (B), middle turbinate (T), concha bullosa (C), nasal septum (S), and the frontal recess (arrow).

8. Sphenoid Sinus

Most posterior sinus; usually divided by a central septum (sagittal plane)
Its ostium is located medially in the anterosuperior wall and drains into the sphenoethmoidal recess - the third "tight spot"
Septa may adhere to the bony wall covering the internal carotid artery
On axial CT: closely related to optic canals laterally, carotid canals, and sella turcica superoposteriorly
Best seen on axial and sagittal images

Critical Danger Zones on CT (Pre-FESS Review Checklist)

These must be identified before endoscopic sinus surgery: - Cummings Otolaryngology, Table 44.1

Structure	Why It Matters
Lamina papyracea	Thin bony wall between ethmoid cells and orbit; dehiscence → orbital injury
Skull base / cribriform plate	Height asymmetry, low-lying plate = risk of intracranial entry
Anterior ethmoidal artery	Identified on coronal CT at skull base; injury causes orbital hematoma
Posterior ethmoidal artery	Seen at skull base just anterior to the sphenoid sinus
Internal carotid artery	May impinge on/dehisce into the sphenoid sinus; check sphenoid septa
Optic nerve	Onodi cells (sphenoethmoidal cells) may surround the optic nerve
Keros classification	Depth of olfactory fossa: Type I (1-3 mm), Type II (4-7 mm), Type III (8-16 mm) - Type III = high risk of CSF leak

Important Anatomic Variations Seen on CT

Variant	Description
Concha bullosa	Pneumatized middle turbinate (~33%)
Paradoxical middle turbinate	Lateral surface convex rather than concave
Haller cells	Infraorbital ethmoid cells that may narrow the maxillary sinus ostium
Onodi cells	Most posterior ethmoid cells extending laterally/superiorly to the sphenoid; may surround the optic nerve and carotid
Agger nasi cell enlargement	Most common; may obstruct the frontal recess
Uncinate process variations	Medialized, lateralized, or pneumatized
Septal deviation	May narrow OMC and middle meatus
Sphenoid sinus agenesis	Rare; recognized on CT by absence of pneumatization

CT Anatomy at a Glance - Plane by Plane

CT Plane	Best For
Coronal	Osteomeatal complex, infundibulum, uncinate process, turbinates, orbital and skull base relationships
Axial	Posterior ethmoid cells, sphenoid sinus ostia, sphenoethmoidal recess, carotid/optic relationships
Sagittal	Frontal recess, frontal sinus outflow tract, slope of skull base, anteroposterior diameter of frontal recess

Frontal recess anatomy on CT: coronal views showing agger nasi cell, frontal recess, uncinate process, and middle turbinate; plus 3D sagittal views of the hourglass frontal sinus outflow tract

Fig. 38.4 - Frontal recess anatomy on CT. Coronal CT scans (A-D) show the frontal recess (arrow) with agger nasi cell (a), middle turbinate (T), uncinate process (U), and middle meatus (dashed line). 3D sagittal CT reconstructions (E-F) demonstrate the hourglass shape of the frontal sinus outflow tract between the frontal sinus (F) and middle meatus (M).

Summary of the Three "Tight Spots"

Frontal recess - bordered by agger nasi cell anteriorly, ethmoid bulla posteriorly, uncinate inferiorly. Best seen on sagittal CT.
Ethmoid infundibulum - air channel between UP and inferomedial orbit wall, connecting maxillary ostium to middle meatus. Best seen on coronal CT.
Sphenoethmoidal recess - lateral to nasal septum, just anterior to superior meatus. Best seen on axial and sagittal CT.

Sources:

Cummings Otolaryngology Head and Neck Surgery, Chapter 38 (Imaging of the Nose and Paranasal Sinuses), pp. 781-784; Chapter 44 (Preoperative CT Review)
K.J. Lee's Essential Otolaryngology, Nasal Cavity and Paranasal Sinus Anatomy
Pictorial essay on paranasal sinus anatomical variations on CT (PMC open access)

Can you please give me the visualization thing in CT ima-- with the CT images for anatomy of paranasal sinus?

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"cdn.orris.care/cdss_images" in /textbooks/9780323612173

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I now have a comprehensive collection of CT images. Let me compile the full visual anatomy guide.

Here is a full image-based walkthrough of paranasal sinus CT anatomy, organized from anterior to posterior. All images are from Cummings Otolaryngology Head and Neck Surgery.

Paranasal Sinus CT Anatomy - Visual Guide

1. Overview: Coronal CT Series (Anterior → Posterior)

Fig. 38.1 - Thin-section coronal CT through the whole PNS complex (cadaveric specimen):

Coronal CT series A-I showing paranasal sinus anatomy: agger nasi (A), frontal sinus (F), maxillary sinus (M), uncinate process (U), ethmoid bulla (b), inferior turbinate (1), middle turbinate (2); the osteomeatal unit is visible in panels F-I

What you are seeing (panel by panel):

A-C: Most anterior cuts showing the nasal bones, nasal septum, and the agger nasi cells (A) beginning to appear bilaterally
D: Frontal sinuses (F) appear as air-filled spaces in the frontal bone
E: Frontal sinus floor and the start of the maxillary sinuses (M) with the uncinate process (U) coming into view
F-I: The osteomeatal unit (OMU) - the critical middle cuts showing: frontal recess (curved lines), middle meatus (dashed lines), ethmoid infundibulum (small arrows), and the maxillary sinus primary ostium (large arrows). The ethmoid bulla (b) and uncinate process (U) dominate this region.

2. Frontal Sinus - Coronal CT Series

Fig. 38.2 - Coronal CT from anterior to posterior through the frontal sinuses:

Coronal CT panels A-D of frontal sinuses showing frontal sinus (F), agger nasi cell (A), ethmoid bulla (B), middle turbinate (T), concha bullosa (C), nasal septum (S), and the frontal recess (arrow)

What you are seeing:

A & B (leftmost two panels): The frontal sinuses (F) appear as paired air spaces in the frontal bone; the agger nasi cell (A) is visible inferiorly; nasal septum (S) in the midline. A bony strut separates the frontal sinus from the anterior middle meatus - this is lost on more posterior cuts.
C & D (rightmost two panels): The frontal recess (arrow, dotted line) is now visible as the connection between the frontal sinus (F) and the middle meatus. The concha bullosa (C = pneumatized middle turbinate) and ethmoid bulla (B) are labeled. Note how the bulla forms the posterior boundary of the frontal recess.

3. The Osteomeatal Complex (OMC) - Coronal CT + Endoscopy

Fig. 44.1 - The OMC highlighted on coronal CT with endoscopic correlation:

Fig 44.1: Left ostiomeatal complex (blue circle) on coronal CT (A) showing bulla ethmoidalis (BE), uncinate process (U), lamina papyracea (LP), middle turbinate (MT); with endoscopic views (B, C) showing hiatus semilunaris (HS), ethmoid infundibulum (I), and a ball probe passing through the hiatus semilunaris

What you are seeing:

Panel A (coronal CT): The blue oval marks the entire OMC. The lamina papyracea (LP) is the thin bony lateral wall of the ethmoid/medial orbital wall. The bulla ethmoidalis (BE) is the dominant anterior ethmoid air cell. The uncinate process (U) is the crescent-shaped bone medial to the infundibulum. The middle turbinate (MT) is the medial boundary.
Panels B & C (endoscopy): The hiatus semilunaris (HS, white arrows) is the two-dimensional slit between the uncinate (U) and the bulla ethmoidalis (BE). A ball probe enters the infundibulum (I) through the hiatus. This correlates exactly to what the CT shows.

4. Uncinate Process Superior Attachment Variants - Schematic

Fig. 44.2 - Coronal schematic showing 3 variants of uncinate process attachment:

Schematic showing three variants (A, B, C) of uncinate process superior attachment: to lamina papyracea (A), to roof of ethmoid/skull base (B), and to middle turbinate (C); determines whether frontal sinus drains medial or lateral to uncinate

What you are seeing:

A: Uncinate attaches to the lamina papyracea (most common, ~80%) - frontal sinus drains medial to uncinate, directly into the middle meatus
B: Uncinate attaches to the skull base/ethmoid roof - frontal sinus drains into the superior infundibulum
C: Uncinate attaches to the middle turbinate - frontal sinus also drains into the infundibulum
This is a critical variant to identify on preoperative CT before FESS

5. Frontal Recess - Coronal CT + 3D Sagittal Reconstruction

Fig. 38.4 - Multiple CT views of the frontal recess:

Fig 38.4: Coronal CT panels A-D showing frontal recess (arrow) with agger nasi cell (a), middle turbinate (T), uncinate process (U); plus 3D sagittal reconstructions (E-F) showing the hourglass shape of the frontal sinus outflow tract between frontal sinus (F) and middle meatus (M)

What you are seeing:

A-C (coronal CT, top left): Patent frontal recess (arrow) despite a large agger nasi cell (a). The narrow air channel is the frontal recess.
D (coronal CT, bottom left, inverted density): Shows the relationships clearly - middle turbinate (T), uncinate process (U), agger nasi cell (a), and middle meatus (dashed line). The frontal recess arrow points to the narrow isthmus.
E & F (3D sagittal reconstructions, right): The hourglass shape of the entire frontal sinus outflow tract (FSOT) - note the frontal sinus (F) superiorly, the narrow waist of the frontal ostium in the middle, and the frontal recess opening inferiorly into the middle meatus (M). The agger nasi cell (M) sits anteriorly.

6. Frontal Sinus Outflow Tract - 3D Anatomic Diagram

Fig. 44.9 - Sagittal illustration of the frontal recess and frontoethmoidal cells:

Sagittal illustration (A) showing frontal sinus recess (FSR, shaded) as hourglass space with frontal sinus (FS) above and frontal sinus ostium (FSO) at the waist; bounded by agger nasi cell (ANC) and nasal beak (NB) anteriorly, bulla ethmoidalis (BE) and bulla lamella (BL) posteriorly, skull base (SB) superiorly. (B) shows frontoethmoid cells, suprabullar cell, frontal bulla cells, and agger nasi cells around the frontal recess

What you are seeing:

Panel A: The frontal sinus recess (FSR, orange shaded) is the hourglass-shaped space. The frontal sinus ostium (FSO) is the narrowest point/waist. Boundaries: agger nasi cell (ANC) and nasal beak (NB) anteriorly; bulla ethmoidalis (BE) and bulla lamella (BL) posteriorly; skull base (SB) above; cribriform plate/middle turbinate medially; lamina papyracea laterally.
Panel B: Shows how frontoethmoid cells, suprabullar cells, frontal bulla cells, and agger nasi cells fill and narrow the frontal recess - the commonest cause of frontal recess obstruction on CT.

7. Ethmoidal Cells - CT with Endoscopic Correlation

Fig. 44.5 - Three key ethmoidal cell variants on coronal CT:

Fig 44.5 top row CT scans: (A) agger nasi cell (ANC) anterior to middle turbinate (MT); (B) infraorbital ethmoidal cells (IOC / Haller cells) narrowing the infundibulum with maxillary ostium (MO); (C) sphenoethmoidal cell (SEC / Onodi cell) lateral and superior to sphenoid sinus (SS). Bottom row shows corresponding endoscopic views including optic nerve (ON) and internal carotid artery (ICA) in relation to SEC

What you are seeing:

Column A (coronal CT + endoscopy): The agger nasi cell (ANC) - the most anterior ethmoid air cell, seen just anterior to the middle turbinate attachment. Endoscopically it appears as a bulge at the MT attachment.
Column B (coronal CT + endoscopy): Infraorbital ethmoid cells (IOC = Haller cells) - these cells pneumatize into the orbital floor above the maxillary sinus ostium (MO). On CT they narrow the inferior infundibulum. The natural maxillary ostium opens at 45 degrees into the infundibular floor; accessory ostia (AO) are circular and typically in the posterior fontanelle.
Column C (coronal CT + endoscopy): Sphenoethmoidal cell (SEC = Onodi cell) - a posterior ethmoid cell extending lateral and superior to the sphenoid sinus (SS). The sphenoid sinus is displaced inferomedially and appears smaller. The optic nerve (ON) and internal carotid artery (ICA) are visible within the lateral wall of the SEC on the endoscopic view - the critical surgical danger here.

8. Superior Meatus and Sphenoethmoidal Recess (Endoscopy)

Fig. 44.6 - Endoscopic view showing the posterior drainage pathway:

Endoscopic views A-C showing superior turbinate (ST), middle turbinate (MT), superior meatus (arrow), sphenoethmoidal recess (SER), sphenoid ostium (SO), and choana from progressively posterior viewpoints

What you are seeing:

The superior turbinate (ST) runs in a sagittal plane sharing its skull base attachment with the middle turbinate (MT)
The superior meatus (arrow in B) is the air passage receiving posterior ethmoid cell drainage - it lies posterior to the basal lamella of the MT
The sphenoethmoidal recess (SER) is bounded medially by the septum and laterally by the superior turbinate
The sphenoid ostium (SO) opens into the sphenoethmoidal recess; this is the "third tight spot" for mucus clearance
The choana (posterior nasal opening) is visible at the bottom of the final image

Summary: CT Planes and What They Show Best

CT Plane	Best Structures Visualized
Coronal	OMC, uncinate process, infundibulum, ethmoid bulla, turbinates, lamina papyracea, cribriform plate height, orbital floor
Axial	Sphenoid sinus, posterior ethmoids, sphenoethmoidal recess, carotid/optic relationships, Onodi cells
Sagittal	Frontal recess, FSOT hourglass shape, skull base slope, frontoethmoidal cell anatomy

Sources: Cummings Otolaryngology Head and Neck Surgery, Chapters 38 and 44 (Imaging of the Nose and Paranasal Sinuses; Surgical Anatomy of the Paranasal Sinuses)

Create a presentation summarizing paranasal sinus CT anatomy

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Running Command

ls /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/pns-…

Running Command

cd /home/daytona/workspace/pns-ct-anatomy && node /home/daytona/skills/shared/sc…

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  "https://cdn.orris.care/cdss_images/07a320dd24823802dd4189dc2c124e246de07eea937a0c24c056fb7f00d46f87.png", // Fig38.2 frontal sinus
  "https://cdn.orris.care/cdss_images/345c45bf81b9982ae39c8cc17acf9fb7c8d257b4345d49538d0217c3d85d146c.png", // Fig38.4 frontal recess
  "https://cdn.orris.care/cdss_images/0b3570ab8c4696c3c69a413b720f3a6edffd5769be38725455bcd5e7fd04d330.png", // Fig44.1 OMC
  "https://cdn.orris.care/cdss_images/98a40c9842d94b1507e30e3753324c18b88d9712c0b5dea5a8983483918ef1eb.png", // Fig44.2 uncinate variants
  "https://cdn.orris.care/cdss_images/435ba3e4a13784e05f3b12d0df5092ea6333f80bb619c16e1bfb039b414e77ef.png", // Fig44.9 FSOT diagram
  "https://cdn.orris.care/cdss_images/823482d04b9f3f458bd1f31f24a5bda3252a5fd0ab1912297b0ae9c5da931193.png", // Fig44.5 ethmoid cells
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    s.addShape(pres.ShapeType.rect, { x, y, w: 4.5, h: 0.82, fill: { color: WHITE }, line: { color: "D0DCE8", width: 0.5 } });

    s.addShape(pres.ShapeType.rect, { x, y, w: 0.38, h: 0.82, fill: { color: ACCENT1 } });
    s.addText(num, { x, y, w: 0.38, h: 0.82, fontSize: 11, bold: true, color: WHITE, align: "center", valign: "middle" });

    s.addText(title, { x: x + 0.46, y: y + 0.06, w: 3.9, h: 0.3, fontSize: 11, bold: true, color: DARK_BG });
    s.addText(sub, { x: x + 0.46, y: y + 0.38, w: 3.9, h: 0.3, fontSize: 9, color: "5A7A9A", italic: true });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — The Four Sinuses (overview)
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("THE FOUR PARANASAL SINUSES", {
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    fontSize: 9, bold: true, color: ACCENT1, charSpacing: 3, valign: "middle"
  });
  s.addText("Anatomy, Location & Drainage Pathways", {
    x: 0.35, y: 0.82, w: 9.3, h: 0.5,
    fontSize: 20, bold: true, color: DARK_BG, fontFace: "Calibri"
  });

  const sinuses = [
    {
      name: "Maxillary Sinus",
      color: "1565C0",
      accent: "42A5F5",
      loc: "Body of the maxilla; largest sinus bilaterally",
      drain: "Maxillary ostium → ethmoid infundibulum → hiatus semilunaris → middle meatus",
      note: "Most commonly affected in sinusitis; natural ostium on superomedial wall"
    },
    {
      name: "Frontal Sinus",
      color: "2E7D32",
      accent: "66BB6A",
      loc: "Frontal bone above the orbits; paired, often asymmetric",
      drain: "Frontal recess → frontal sinus outflow tract → middle meatus (or infundibulum)",
      note: "Most complex drainage pathway; absent at birth, pneumatizes by age 6–7"
    },
    {
      name: "Ethmoid Sinuses",
      color: "6A1B9A",
      accent: "AB47BC",
      loc: "Labyrinth of 3–18 air cells medial to the orbits",
      drain: "Anterior cells → middle meatus; posterior cells → superior meatus",
      note: "Key anatomic divider: basal lamella of middle turbinate separates anterior from posterior"
    },
    {
      name: "Sphenoid Sinus",
      color: "BF360C",
      accent: "FF7043",
      loc: "Body of sphenoid bone; most posterior sinus",
      drain: "Ostium (anteromedial wall) → sphenoethmoidal recess → superior meatus",
      note: "Intimately related to optic nerve, carotid artery, and cavernous sinus"
    }
  ];

  sinuses.forEach((sinus, i) => {
    const x = (i % 2) === 0 ? 0.35 : 5.2;
    const y = i < 2 ? 1.42 : 3.22;

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    s.addText(sinus.name.toUpperCase(), {
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      fontSize: 10, bold: true, color: WHITE, valign: "middle", charSpacing: 1
    });

    s.addText([
      { text: "Location: ", options: { bold: true, color: "334155" } },
      { text: sinus.loc, options: { color: GRAY_TXT } }
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    s.addText([
      { text: "Drainage: ", options: { bold: true, color: "334155" } },
      { text: sinus.drain, options: { color: GRAY_TXT } }
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    s.addText([
      { text: "★  ", options: { color: sinus.accent, bold: true } },
      { text: sinus.note, options: { color: "5A7A9A", italic: true } }
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  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — CT Planes
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("CT IMAGING PLANES", {
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    fontSize: 9, bold: true, color: ACCENT1, charSpacing: 4
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  s.addText("Why All Three Planes Are Essential", {
    x: 0.4, y: 0.5, w: 9, h: 0.55,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri"
  });

  const planes = [
    {
      name: "CORONAL",
      color: ACCENT1,
      best: "Osteomeatal complex",
      structures: [
        "Uncinate process & infundibulum",
        "Ethmoid bulla & hiatus semilunaris",
        "Turbinates (inf., mid., sup.)",
        "Lamina papyracea",
        "Cribriform plate height (Keros)",
        "Orbital floor / Haller cells"
      ]
    },
    {
      name: "AXIAL",
      color: ACCENT2,
      best: "Posterior sinuses",
      structures: [
        "Sphenoid sinus & its ostium",
        "Sphenoethmoidal recess",
        "Posterior ethmoid cells",
        "Onodi cell / optic nerve",
        "Internal carotid artery",
        "Cavernous sinus relationship"
      ]
    },
    {
      name: "SAGITTAL",
      color: "7EC8E3",
      best: "Frontal sinus drainage",
      structures: [
        "Frontal sinus outflow tract (FSOT)",
        "Hourglass of frontal recess",
        "Agger nasi cell position",
        "Slope of skull base",
        "AP diameter of frontal recess",
        "Frontoethmoidal cell types"
      ]
    }
  ];

  planes.forEach((plane, i) => {
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      x, y: 1.2, w: 3.0, h: 4.0,
      fill: { color: "0D2040" },
      line: { color: plane.color, width: 1.5 }
    });
    s.addShape(pres.ShapeType.rect, {
      x, y: 1.2, w: 3.0, h: 0.45,
      fill: { color: plane.color }
    });
    s.addText(plane.name, {
      x, y: 1.2, w: 3.0, h: 0.45,
      fontSize: 13, bold: true, color: DARK_BG,
      align: "center", valign: "middle", charSpacing: 3
    });

    s.addText("Best for:", {
      x: x + 0.15, y: 1.72, w: 2.7, h: 0.28,
      fontSize: 9, bold: true, color: plane.color, italic: true
    });
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      x: x + 0.15, y: 1.95, w: 2.7, h: 0.32,
      fontSize: 11, bold: true, color: WHITE
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      line: { color: plane.color, width: 0.5, dashType: "dash" }
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    plane.structures.forEach((item, j) => {
      s.addText([
        { text: "▸  ", options: { color: plane.color, bold: true } },
        { text: item, options: { color: "BDD0E8" } }
      ], {
        x: x + 0.15, y: 2.38 + j * 0.42, w: 2.7, h: 0.38,
        fontSize: 9
      });
    });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — Coronal CT Series (Fig 38.1)
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("CORONAL CT SERIES  —  ANTERIOR TO POSTERIOR", {
    x: 0.4, y: 0.0, w: 9, h: 0.68,
    fontSize: 9, bold: true, color: ACCENT1, charSpacing: 3, valign: "middle"
  });

  // Main image
  const img0 = imgData(0);
  if (img0) {
    s.addImage({ data: img0, x: 0.25, y: 0.82, w: 9.5, h: 3.45 });
  }

  // Caption box
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 4.32, w: 9.5, h: 1.2, fill: { color: LABEL_BG } });
  s.addText([
    { text: "Fig 38.1  ", options: { bold: true, color: ACCENT1 } },
    { text: "Thin-section coronal CT cadaver specimen (A→I, anterior to posterior). ", options: { color: WHITE, bold: true } },
    { text: "Panels A–C: anterior cuts, nasal bones and agger nasi (A). Panel D: frontal sinuses (F) appear. Panels E–F: maxillary sinuses (M) and uncinate process (U) emerge. ", options: { color: "BDD0E8" } },
    { text: "Panels G–I (osteomeatal unit): frontal recess (curved lines), middle meatus (dashed), infundibulum (small arrows), maxillary sinus primary ostium (large arrows), ethmoid bulla (b).", options: { color: "BDD0E8" } },
  ], {
    x: 0.4, y: 4.35, w: 9.2, h: 1.14,
    fontSize: 8.5, lineSpacingMultiple: 1.25
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — Osteomeatal Complex (OMC) — CT + endoscopy
// ════════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.68, fill: { color: DARK_BG } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0.68, w: 10, h: 0.05, fill: { color: ACCENT1 } });

  s.addText("OSTEOMEATAL COMPLEX (OMC)", {
    x: 0.4, y: 0.0, w: 9, h: 0.68,
    fontSize: 9, bold: true, color: ACCENT1, charSpacing: 3, valign: "middle"
  });
  s.addText("The Drainage Bottleneck of the Anterior Sinuses", {
    x: 0.4, y: 0.78, w: 9, h: 0.42,
    fontSize: 17, bold: true, color: DARK_BG, fontFace: "Calibri"
  });

  // Image
  const img3 = imgData(3);
  if (img3) {
    s.addImage({ data: img3, x: 0.25, y: 1.28, w: 5.8, h: 3.6 });
  }

  // Key points panel
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  s.addShape(pres.ShapeType.rect, { x: 6.3, y: 1.28, w: 3.45, h: 0.38, fill: { color: ACCENT1 } });
  s.addText("KEY STRUCTURES", {
    x: 6.3, y: 1.28, w: 3.45, h: 0.38,
    fontSize: 9, bold: true, color: DARK_BG, align: "center", valign: "middle", charSpacing: 2
  });

  const omcItems = [
    ["LP", "Lamina papyracea", "Thin bony lateral wall; orbital boundary"],
    ["BE", "Bulla Ethmoidalis", "Largest anterior ethmoid air cell"],
    ["U", "Uncinate Process", "Crescent bone shielding maxillary ostium"],
    ["MT", "Middle Turbinate", "Medial boundary of OMC"],
    ["HS", "Hiatus Semilunaris", "2D slit → entrance to infundibulum"],
    ["I", "Infundibulum", "3D funnel: uncinate ↔ lamina papyracea"],
  ];

  omcItems.forEach(([abbr, name, desc], i) => {
    const y = 1.72 + i * 0.55;
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    s.addText(abbr, { x: 6.45, y, w: 0.38, h: 0.38, fontSize: 8, bold: true, color: DARK_BG, align: "center", valign: "middle" });
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  // Caption
  s.addText("Fig 44.1 — Coronal CT (A) with OMC outlined in blue circle; endoscopic views (B, C) showing ball probe passing through hiatus semilunaris into infundibulum. Source: Cummings Otolaryngology", {
    x: 0.25, y: 4.98, w: 9.5, h: 0.42,
    fontSize: 7.5, color: "5A7A9A", italic: true
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — Uncinate Process & Variants
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("UNCINATE PROCESS", {
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    fontSize: 9, bold: true, color: ACCENT2, charSpacing: 3, valign: "middle"
  });
  s.addText("Superior Attachment Variants — Critical for Frontal Sinus Drainage", {
    x: 0.4, y: 0.78, w: 9, h: 0.42,
    fontSize: 17, bold: true, color: DARK_BG
  });

  // Schematic image
  const img4 = imgData(4);
  if (img4) {
    s.addImage({ data: img4, x: 0.3, y: 1.28, w: 9.4, h: 2.6 });
  }

  // Three variant explanation boxes
  const variants = [
    {
      label: "VARIANT A",
      color: ACCENT1,
      title: "UP → Lamina Papyracea",
      freq: "Most common (~80%)",
      effect: "Frontal sinus drains MEDIAL to uncinate → directly into middle meatus"
    },
    {
      label: "VARIANT B",
      color: ACCENT2,
      title: "UP → Skull Base / Ethmoid Roof",
      freq: "Less common (~10%)",
      effect: "Frontal sinus drains LATERAL → into the superior infundibulum"
    },
    {
      label: "VARIANT C",
      color: "AB47BC",
      title: "UP → Middle Turbinate",
      freq: "Less common (~10%)",
      effect: "Frontal sinus also drains LATERAL → into the superior infundibulum"
    }
  ];

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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — Frontal Sinus & Frontal Recess
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("FRONTAL SINUS  &  FRONTAL RECESS", {
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    fontSize: 9, bold: true, color: "66BB6A", charSpacing: 3, valign: "middle"
  });

  // Left: coronal CT of frontal sinuses
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    s.addImage({ data: img1, x: 0.25, y: 0.82, w: 4.8, h: 2.7 });
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  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 3.56, w: 4.8, h: 0.32, fill: { color: LABEL_BG } });
  s.addText("Fig 38.2 — Coronal CT series: frontal sinuses (F), agger nasi (A), ethmoid bulla (B), concha bullosa (C), frontal recess (arrow)", {
    x: 0.3, y: 3.57, w: 4.7, h: 0.3,
    fontSize: 7, color: "8BA8C8", italic: true
  });

  // Right: frontal recess CT
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    s.addImage({ data: img2, x: 5.2, y: 0.82, w: 4.55, h: 2.7 });
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  s.addText("Fig 38.4 — Coronal CT + 3D sagittal: frontal recess hourglass (E, F). F = frontal sinus, M = middle meatus, U = uncinate, T = middle turbinate", {
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  const facts = [
    ["Agger Nasi Cell", "Most anterior ethmoid cell; present in ~98.5%. Its posterior wall forms the anterior boundary of the frontal recess. Enlargement = most common cause of frontal recess obstruction."],
    ["Frontal Recess", "Narrowest part of FSOT (first \"tight spot\"). Coronal CT shows it as air channel between agger nasi anteriorly and ethmoid bulla posteriorly. Best assessed on sagittal CT."],
    ["FSOT Shape", "Hourglass: widens in frontal sinus above → narrows at frontal ostium (waist) → widens again in frontal recess → opens into middle meatus. The 3D sagittal CT best demonstrates this."],
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    }
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — Frontal Sinus Outflow Tract diagram
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("FRONTAL SINUS OUTFLOW TRACT  —  ANATOMIC DIAGRAM", {
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  const img5 = imgData(5);
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  const diagramNotes = [
    ["FS  — Frontal Sinus", "The pneumatized space within the frontal bone above the orbit"],
    ["FSO — Frontal Sinus Ostium", "The waist of the hourglass; narrowest point of the entire outflow tract"],
    ["FSR — Frontal Sinus Recess", "Inferior portion of the outflow tract (shaded orange in panel A); bounded by ANC anteriorly and BE posteriorly"],
    ["ANC — Agger Nasi Cell", "Most anterior ethmoid cell; forms the anterior boundary of the frontal recess"],
    ["NB  — Nasal Beak", "Bony spur at the junction of the frontal and ethmoid bones; marks the anteroinferior limit of the frontal recess"],
    ["BE  — Bulla Ethmoidalis", "Posterior boundary of the frontal recess"],
    ["BL  — Bulla Lamella", "Posterior attachment of BE to skull base"],
    ["SB  — Skull Base", "Posterosuperior boundary of the frontal recess"],
  ];

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  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — Ethmoidal Cells (Fig 44.5)
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("ETHMOIDAL CELLS  —  CT WITH ENDOSCOPIC CORRELATION", {
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    fontSize: 9, bold: true, color: "AB47BC", charSpacing: 2, valign: "middle"
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  // Three column captions
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      label: "A — Agger Nasi Cell (ANC)",
      color: ACCENT1,
      text: "Most anterior ethmoid cell (98.5%). Located anterior to MT attachment. Large ANC narrows the superior infundibulum and may obstruct the frontal recess. Common cause of iatrogenic frontal sinus obstruction if incompletely removed."
    },
    {
      label: "B — Infraorbital Cell (Haller Cell)",
      color: ACCENT2,
      text: "Ethmoid cell pneumatizing into the orbital floor above the maxillary ostium. Narrows the inferior infundibulum. Natural maxillary ostium opens at 45° into infundibular floor. Accessory ostia (circular) found in posterior fontanelle."
    },
    {
      label: "C — Onodi Cell (SEC)",
      color: "AB47BC",
      text: "Posterior ethmoid cell extending LATERAL & SUPERIOR to the sphenoid sinus (which is displaced inferomedially). Critical danger: optic nerve (ON) and internal carotid artery (ICA) lie within its lateral wall → injury risk during FESS."
    }
  ];

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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — Surgical Danger Zones
// ════════════════════════════════════════════════════════════════════════════
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    fontSize: 16, bold: true, color: DARK_BG
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  const dangers = [
    { structure: "Lamina Papyracea", sinus: "Ethmoid", risk: "Dehiscence → orbital fat herniation, medial rectus injury, blindness", ct: "Coronal", color: "BF360C" },
    { structure: "Skull Base / Cribriform Plate", sinus: "Ethmoid roof", risk: "Penetration → CSF leak, meningitis, intracranial injury. Keros III (deep olfactory fossa) = highest risk", ct: "Coronal", color: "E65100" },
    { structure: "Anterior Ethmoidal Artery", sinus: "Ethmoid", risk: "Transection → retraction into orbit → orbital hematoma → compressive optic neuropathy", ct: "Coronal", color: "F57F17" },
    { structure: "Internal Carotid Artery", sinus: "Sphenoid", risk: "Injury during sphenoid surgery; sphenoid septa may attach directly to carotid canal wall", ct: "Axial", color: "1B5E20" },
    { structure: "Optic Nerve", sinus: "Sphenoid / Onodi cell", risk: "Onodi cells surround the optic canal; injury → permanent visual loss. Seen in ~10–15% of patients", ct: "Axial / Coronal", color: "1A237E" },
    { structure: "Sphenoid Septum Attachments", sinus: "Sphenoid", risk: "Septa may insert directly on the bone over the carotid; fracture = catastrophic hemorrhage", ct: "Axial", color: "4A148C" },
  ];

  dangers.forEach((d, i) => {
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      { text: "Sinus: ", options: { bold: true, color: DARK_BG } },
      { text: d.sinus + "   ", options: { color: GRAY_TXT } },
      { text: "Best seen: ", options: { bold: true, color: DARK_BG } },
      { text: d.ct + " CT", options: { color: GRAY_TXT } }
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — Anatomic Variants on CT
// ════════════════════════════════════════════════════════════════════════════
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    fontSize: 9, bold: true, color: ACCENT2, charSpacing: 3, valign: "middle"
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  s.addText("Common Variants That Affect Drainage and Surgical Planning", {
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    fontSize: 17, bold: true, color: DARK_BG
  });

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    { name: "Concha Bullosa", freq: "~33%", desc: "Pneumatization of the middle turbinate. May narrow the OMC and infundibulum.", impact: "Coronal CT shows air-filled middle turbinate.", color: ACCENT1 },
    { name: "Paradoxical MT", freq: "~5%", desc: "Lateral surface of the middle turbinate is convex instead of concave.", impact: "Narrows the middle meatus; seen on coronal CT.", color: "42A5F5" },
    { name: "Haller Cells", freq: "~20%", desc: "Infraorbital ethmoid cells pneumatizing along the orbital floor above the maxillary ostium.", impact: "Coronal CT: cell at orbital floor bordering maxillary ostium.", color: ACCENT2 },
    { name: "Onodi Cell (SEC)", freq: "10–15%", desc: "Posterior ethmoid cell extending lateral/superior to sphenoid. Contains optic nerve and carotid.", impact: "Axial + coronal CT: posterior cell lateral to sphenoid.", color: "FF7043" },
    { name: "Agger Nasi Enlargement", freq: "~98.5%", desc: "Enlarged agger nasi cell narrows the frontal recess and may obstruct frontal sinus drainage.", impact: "Coronal CT: large cell anterior to middle turbinate.", color: "66BB6A" },
    { name: "Keros Classification", freq: "Varies", desc: "Depth of olfactory fossa: I (1–3 mm), II (4–7 mm), III (8–16 mm). Type III = highest CSF leak risk.", impact: "Coronal CT: measure lateral lamella of cribriform plate.", color: "AB47BC" },
    { name: "Deviated Nasal Septum", freq: "~20–30%", desc: "Significant deviation may narrow the middle meatus and predispose to OMC obstruction.", impact: "Coronal CT: assess contact between septum and turbinate.", color: "78909C" },
    { name: "Sphenoid Septum on Carotid", freq: "~5%", desc: "Sphenoid septum inserts directly on carotid canal wall; fracture = massive hemorrhage.", impact: "Axial CT: trace sphenoid septa carefully to identify this.", color: "EF5350" },
  ];

  variants.forEach((v, i) => {
    const col = i % 2 === 0 ? 0 : 1;
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    s.addText([
      { text: v.name, options: { bold: true, color: DARK_BG } },
      { text: "  (" + v.freq + ")", options: { color: v.color, bold: true } }
    ], { x: x + 0.16, y: y + 0.05, w: 4.3, h: 0.25, fontSize: 9.5 });

    s.addText(v.desc, { x: x + 0.16, y: y + 0.3, w: 4.3, h: 0.3, fontSize: 8, color: GRAY_TXT });
    s.addText([
      { text: "CT: ", options: { bold: true, color: v.color } },
      { text: v.impact, options: { color: "5A7A9A" } }
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  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — Summary Table
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("The Three Tight Spots  ·  Drainage Pathways  ·  CT Plane Guide", {
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  const tightSpots = [
    { num: "1", name: "Frontal Recess", color: ACCENT1, desc: "Narrowest part of FSOT. Between agger nasi (anterior) and ethmoid bulla (posterior), inferior to frontal ostium.", plane: "Sagittal + Coronal" },
    { num: "2", name: "Ethmoid Infundibulum", color: ACCENT2, desc: "3D funnel between uncinate process (medial) and lamina papyracea (lateral). Connects maxillary ostium to middle meatus.", plane: "Coronal" },
    { num: "3", name: "Sphenoethmoidal Recess", color: "AB47BC", desc: "Lateral to nasal septum, medial to superior turbinate. Receives sphenoid ostium drainage → superior meatus.", plane: "Axial + Sagittal" },
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    ["Maxillary", "Maxillary ostium → infundibulum", "Middle meatus", "Coronal"],
    ["Anterior Ethmoid", "Cell ostia → infundibulum", "Middle meatus", "Coronal"],
    ["Posterior Ethmoid", "Cell ostia", "Superior meatus", "Axial + Coronal"],
    ["Sphenoid", "Sphenoid ostium (anteromedial)", "Sphenoethmoidal recess → superior meatus", "Axial + Sagittal"],
  ];
  const colW = [1.4, 2.5, 2.6, 2.4];
  const colX = [0.3, 1.72, 4.24, 6.86];
  const headers = ["Sinus", "Drainage Route", "Destination", "Best CT Plane"];

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// ════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — Closing
// ════════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0.06, w: 10, h: 0.03, fill: { color: ACCENT2 } });

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  const takeaways = [
    "CT is the gold standard for PNS evaluation — best for bone detail, OMC, and surgical planning",
    "The three tight spots (frontal recess, infundibulum, sphenoethmoidal recess) are the key points to assess",
    "The osteomeatal complex is the final common pathway for frontal, maxillary, and anterior ethmoid drainage",
    "Always review all three CT planes: coronal (OMC), axial (sphenoid/posterior), sagittal (frontal recess)",
    "Identify surgical danger zones before FESS: skull base, lamina papyracea, carotid, optic nerve, Keros type",
    "Common variants (concha bullosa, Haller cells, Onodi cells) must be recognized and reported",
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  s.addText("Source: Cummings Otolaryngology Head & Neck Surgery (9780323612173)  ·  K.J. Lee's Essential Otolaryngology (9781260122237)  ·  Compiled by Orris Medical", {
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// ── Write file ────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pns-ct-anatomy/PNS_CT_Anatomy.pptx" })
  .then(() => console.log("✅  Saved: /home/daytona/workspace/pns-ct-anatomy/PNS_CT_Anatomy.pptx"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

Running Command

cd /home/daytona/workspace/pns-ct-anatomy && node build.js 2>&1

Running Command

cd /home/daytona/workspace/pns-ct-anatomy && mkdir -p imgs && \ curl -s "https…

Editing File

~/pns-ct-anatomy/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/pns-ct-anatomy/build.js'

Running Command

cd /home/daytona/workspace/pns-ct-anatomy && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/pns-ct-anatomy/PNS_CT_Anatomy.pptx

Your presentation is ready for download:

PNS CT Anatomy

Presentation · PPTX

Here is what the 14-slide deck contains:

#	Slide	Content
1	Title	Dark navy design with specialty tag and subtitle
2	Outline	8 topic cards with numbered index
3	The Four Sinuses	Maxillary, frontal, ethmoid, sphenoid - location, drainage, clinical notes
4	CT Planes	Dark slide with 3 columns: Coronal / Axial / Sagittal - what each shows best
5	Coronal CT Series	Full Fig 38.1 image (A→I cadaveric thin-section coronal CT) with annotated caption
6	Osteomeatal Complex	Fig 44.1 coronal CT + endoscopy; key structure legend (LP, BE, U, MT, HS, infundibulum)
7	Uncinate Process Variants	Fig 44.2 schematic; 3 variant boxes (A = LP, B = skull base, C = middle turbinate)
8	Frontal Sinus & Frontal Recess	Fig 38.2 + Fig 38.4 side by side; 3 key fact panels (agger nasi, frontal recess, FSOT shape)
9	FSOT Diagram	Fig 44.9 illustration with full annotation of every labeled structure
10	Ethmoidal Cells	Fig 44.5 CT + endoscopy; 3 columns: ANC, Haller cell, Onodi cell
11	Surgical Danger Zones	6 red-coded hazard cards: lamina papyracea, skull base, ethmoidal artery, carotid, optic nerve, sphenoid septum
12	Anatomic Variants	8 variant cards with frequency, description, and CT identification
13	Summary Table	Three tight spots + sinus drainage pathway table
14	Key Takeaways	Dark closing slide with 6 clinical pearls

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Running Command

cp /home/daytona/workspace/pns-ct-anatomy/PNS_CT_Anatomy.pptx /home/daytona/work…

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PNS CT Anatomy

Presentation · PPTX

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