The role of the ostiomeatal unit anatomic variations in inflammatory disease of the maxillary sinuses

Evaluation of osteomeatal complex by cone-beam computed tomography in patients with maxillary sinus pathology and nasal septum deviation

BACKGROUND

This study aimed to determine if there is a relationship between the presence of maxillary sinus pathology, nasal septum deviation and various lengths of the osteomeatal complex.

METHODS

A total of 223 CBCT images were included in the study. The lengths of the osteomeatal complex (maxillary sinus ostium width, infundibulum length, maxillary sinus ostium height) were analyzed. The presence of maxillary sinus pathology, nasal septum deviation, age, sex, right-left, septum deviation level, and the relationship between pathology level and all variables were evaluated.

RESULTS

The average maxillary sinus ostium width, ostium height and infundibulum length were 3.06 ± 0.70 mm, 30.10 ± 5.43 mm and 8.82 ± 1.86 mm, respectively. Ostium width was significantly higher in the healthy group than in the groups evaluated in the presence of deviation and pathology. A significant difference was found in infundibulum length only between the healthy condition and the condition evaluated in the presence of deviation. No significant difference was observed between the groups in terms of ostium height. In all groups, ostium height and infundibulum length were significantly higher in men than in women. The age group with the highest average ostium height was found in the 35-44 age group (p < 0.001).

CONCLUSION

Identifying normal and abnormal conditions in the osteomeatal complex area is important for diagnosing the cause of a patient's complaint, guiding the surgical procedures to be performed, and preventing possible complications that may arise during surgical procedures.

Prevalence of the anatomical variations of concha bullosa and its relation with sinusitis among Saudi population: a computed tomography scan study

Concha bullosa (CB) is a pneumatic cavitation inside a concha in the nasal cavity. It is one of the most widely recognized nasal variations and is mostly found in the middle concha. CB is divided according to its site into three types; lamellar, bulbous and extensive. The goal of our study was to estimate the prevalence of CB among Saudi adult population and its association with sinusitis by using multidetector computed tomography (MDCT). This was a retrospective study carried out over a three-year period on 879 adult Saudi patients aged 18 years or older, referred for MDCT assessment of paranasal sinuses. Males were 540 and females were 339. Patients with facial congenital anomalies or nasal trauma were excluded from our study. CB was prevalent in both males and females among Saudi population (55.4%, 55.7%) respectively. Bilateral CB (55.5%) was more frequent than unilateral (44.5%). Extensive CB (44.0%) was the most frequent type. Sinusitis was associated more in patients with CB (48.0%) versus those who have no CB (5.9%). In conclusion, CB was prevalent among Saudi population and the most frequently recorded is the extensive type. Furthermore, the most common type associated with sinusitis was extensive CB (49.6%).

Relationship Between the Posterior Superior Alveolar Artery and Maxillary Sinus Pathology: A Cone-Beam Computed Tomography Study

PURPOSE

The purpose of the present study was to assess the relationship between the posterior superior alveolar artery (PSAA), which plays an important role in the maxillary sinus blood supply, and maxillary sinus pathologic entities using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

The CBCT data from 325 patients (650 sinuses), aged 18 to 55 years, who had been referred to the Department of Dentomaxillofacial Radiology from 2015 to 2017 were evaluated retrospectively. For the PSAA examination, the axial, coronal, and sagittal CBCT images were evaluated for detection of an osseous canal in the lateral wall of the maxillary sinus and the prevalence, position, and location of the canal. In addition, the presence of maxillary sinus pathologic features was analyzed, and the relationship with the PSAA was investigated. The relationship among the categorical variables was tested using the χ² test.

RESULTS

The study group consisted of 325 patients, including 155 men (47.7%) and 170 women (52.3%). The PSAA was observed in 80.6% of the patients. Of the detected PSAAs, 79.0% were bilateral and 21.0% were unilateral and 56.3% were intraosseous and 40.7% were submembranous. A significant positive correlation was detected between the presence of a PSAA and patient age (P < .05). The prevalence of sinus pathologic entities was 73.2% of all patients. The most common sinus pathologic finding was localized mucosal thickening (53.5%). A significant relationship was found between the presence of PSAA and maxillary sinus pathologic entities (P < .001).

CONCLUSIONS

The presence of a PSAA might be a predisposing factor that increases the susceptibility to maxillary sinus pathologic entities. CBCT is an effective imaging method in the evaluation of the maxillary sinuses.

Anatomic Variations of the Lateral Nasal Wall in the Computed Tomography Scans of Patients with Chronic Rhinosinusitis

The development of computed tomography (CT) technique results in the advance in visualization of the anatomic structures of the lateral nasal wall. It allows the anatomic variations of this region to be identified precisely, which is important in surgical treatment of chronic rhinosinusitis. The aim of this study was to determine the incidence of anatomic variations of the lateral nasal wall in a group of patients with chronic rhinosinusitis. The preoperative, frontal plane CT scans of the study group were evaluated using the method of the four-zone interpretation. The incidence of the anatomic variations of the lateral nasal wall was consistent with the results reported by other authors.

Is endoscopic endonasal transsphenoidal surgery increases the susceptibility to rhinosinusitis

The aim of the study was to analyze whether the measurement of changes in the anatomical position and volume of middle concha, the volume changes in the area between the middle concha and lamina papyracea, the evaluation of opacification in major paranasal sinuses, and osteomeatal complex occlusion in cases with middle concha by out-fracture technique during endoscopic endonasal transsphenoidal approach is a minimally invasive surgery, and also to find out whether these changes lead to the development of tendency to rhinosinusitis. It was a retrospective clinical study. Forty-five cases, between 2013 and 2015, planned for endoscopic endonasal transsphenoidal surgery due to hypophyseal pathology at the Neurosurgery Departments of Marmara University Hospital were evaluated retrospectively. The patients were evaluated for the changes in the anatomy of the middle concha and the effects of these changes to paranasal sinuses by paranasal computed tomographies were studied at the preoperative second week and postoperative 12 month. The Lund-Mackay scoring system was used for the evaluation of opacification in the five major paranasal sinuses and occlusion of the osteomeatal complex in the pre- and postoperative period. The Lund-Mackay scoring system was used to analyze the paranasal computed tomography of the patients at the preoperative 2 weeks and postoperative first year. According to the Lund-Mackay scoring system, no significant difference was detected between the preoperative and postoperative opacification of paranasal sinuses (p > 0.05). Besides, there was also no significant difference between the preoperative and postoperative osteomeatal complex occlusion (p > 0.05). Considering the distance between middle concha and lamina papyracea following the out-fracture of the middle concha, a significant lateralization of 0.5 mm between the preoperative and postoperative period was observed (p < 0.05). In addition, a significant change was also detected in the volume of middle concha (p < 0.05). The volume of the area between the middle concha and lamina papyracea was decreased with a statistical significance (p < 0.05). The endoscopic endonasal transsphenoidal surgery causes some variations in the structures of the middle concha, paranasal sinuses, and OMC, but these changes do not lead to significant rhinologic pathologies.

The Effect of Nasal Septal Deviation on Frontal and Maxillary Sinus Volumes and Development of Sinusitis

The purpose of this study was to determine the possible role of nasal septal deviation on volume of maxillary and frontal sinuses. Between February 2011 and October 2013, paranasal sinus computed tomography (CT) findings of 732 patients (410 males, 322 females) who were admitted to Ear Nose and Throat Department of Kayseri Research and Training Hospital were retrospectively analyzed. By excluding the other coexistent sinonasal pathologies, 83 consecutive patients with nasal septal deviations were included in the study. The volume of each maxillary and frontal sinus (ipsi- and contralateral to the deviation side) was also calculated using the computer program. There was no statistically significant difference between ipsilateral and contralateral maxillary sinus volumes in group 1 and group 3 (P > 0.05). There was a statistically significant difference between ipsilateral and contralateral maxillary sinus volumes in group 2 (P < 0.05). There was no statistically significant difference between ipsilateral and contralateral frontal sinus volumes in group 1, group 2, and group 3 (P > 0.05). Moderate septal deviation significantly affects the volume of maxillary sinus. Mild and severe septal deviation does not significantly affect the volume of maxillary sinus. Effect of septal deviation on frontal sinus volume was not detected. The probability to encounter maxillary and frontal sinusitis ipsilateral to the all septum deviation groups was significantly increased in both right- and left-sided subjects.

Sinonasal anatomical variations: their relationship with chronic rhinosinusitis and effect on the severity of disease-a computerized tomography assisted anatomical and clinical study

ABSTRACT

The anatomy of the sinonasal area has a very wide rage of anatomical variations. The significance of these anatomical variations in pathogenesis of rhinosinusitis, which is the commonest disease in the region, is still unclear. The aims of the study were to compare the rate of sinonasal anatomical variations with development and severity of chronic rhinosinusitis patients. CT scan of paranasal sinuses images of 99 individuals were retrospectively reviewed. 65 cases of chronic rhinosinusitis (study group) who had undergone endoscopic sinus surgery were compared with 34 cases without chronic rhinosinusitis (control group). Also in study group Lund-Mackay score of the sinus disease were calculated and compared to the rate of related anatomical variations. There were 74 (74.7 %) males and 25 (25.2 %) females with ages ranging from 13 to 70 years (mean 32.2 years). The anatomical variations recorded were: Septal deviation 47 (72.3) in study and 25 (73.5 %) in control group, concha bullosa 27 (41.5 %) in study and 18 (52.9 %) in control group, overpneumatized ethmoid bulla 17 (26.1 %) in study and 14 (41.1 %) in control group, pneumatized uncinate 3 (4.6 %) in study and 3 (8.8 %) in control group, agger nasi 42 (64.6 %) in study and 19 (55.8 %) in control group, paradoxical middle turbinates 9 (13.8 %) in study and 4 (11.7 %) in control group, Onodi cell 6 (9.2 %) in study and 2 (5.8 %) in control group, Haller's cells (infraorbital ethmoid cell) 9 (13.8 %) in study and 7 (20.5 %) in control group. None of these results were statistically significant between study and control group (p > 0.05). Lund-Mackay score (which was assumed to show the severity of the disease) of the maxillary, ethmoid and frontal sinus were calculated and compared to rate of septal deviation, concha bullosa, agger nasi cells. No significant correlation was conducted (p > 0.05). The results of study showed no statistically significant correlation between sinonasal anatomical variations and pathologies of the paranasal sinus. Also these anatomical variations did not increase the severity of pre-existing sinusitis significantly.

LEVEL OF EVIDENCE

This is a retrospective cohort study (2b).

A patient presenting with concha bullosa in another concha bullosa: a case report

Introduction

Anatomic variations of the paranasal sinuses are very common. The paranasal sinus anatomy should be carefully examined prior to performing endoscopic sinus surgery in terms of both existent pathologies and anatomic variations. The anatomy of the paranasal sinuses and its variations have gained importance, along with advances in coronal paranasal sinus computed tomography and extensive use of endoscopic sinus surgery.

Case presentation

A 53-year-old Caucasian woman was admitted to our clinic with complaints of nasal breathing difficulties and headache persisting for a long time. Another concha bullosa was detected in the middle concha bullosa on preoperative paranasal computed tomography examination. It is known that the paranasal sinuses have a number of anatomical variations.

Conclusion

Herein we report a rare case, along with a review of the literature, to emphasize that a concha bullosa inside another concha bullosa should not be ignored.

Role of surgery in isolated concha bullosa

Objective:

To study the benefit of surgery in different types of isolated concha bullosa.

Design:

Prospective case series.

Setting:

Academic Medical Center.

Patients:

Forty seven symptomatic patients complaining of nasal congestion and block, headache and facial pain having concha bullosa without any other sinonasal finding. Their conchae bullosa were classified as lamellar, bulbous and extensive concha bullosa. They were subjected to endoscopic operation.

Main outcome measures:

Subjective evaluation of postoperative improvement of sinonasal symptoms and objective pre- and postoperative measurement of total nasal resistance by rhinomanometry.

Results:

Two patients (25%) of lamellar type showed complete improvement, 5 patients (62.5%) showed partial improvement and 1 patient (12.5%) showed no improvement. Regarding bulbous type, 16 patients (72.72%) showed complete improvement, 6 patients (27.28%) showed partial improvement and no patient (0%) showed no improvement. Regarding extensive type, 15 (88.24%) patients showed complete improvement, 2 patients (11.76%) showed partial improvement and no patient (0%) showed no improvement. The total nasal resistance was 0.25 Pa/cm³ per second postoperatively compared with 0.37 Pa/cm³ per second preoperatively in patients having lamellar type; 0.28 Pa/cm³ per second postoperatively compared with 0.71 Pa/cm³ per second preoperatively in patients having bulbous type; and 0.27 Pa/cm³ per second postoperatively compared with 0.67 Pa/cm³ per second preoperatively in patients having extensive type.

Conclusions:

With proper patient selection, the operative management is of great value in relieving the sinonasal symptoms in patients having isolated Concha bullosa. This will be more obvious in certain types as bulbous and extensive types especially of large sizes.

Mucocele of a pneumatised uncinate process: first reported case

OBJECTIVE

We report a unique case of a mucocele of a pneumatised uncinate process.

METHOD

Clinical, radiological and intra-operative findings are presented.

RESULTS

A 43-year-old woman was referred to our ENT department suffering from persistent symptoms of left-sided sinusitis. Although an initial computed tomography scan suggested a lacrimal duct mass, dacrocystography showed free flow through the nasolacrimal duct. The patient underwent surgery, revealing a mucocele within a pneumatised uncinate process.

CONCLUSION

This patient's clinical, radiological and intra-operative findings illustrate how variations in sinus anatomy can pose a diagnostic challenge.

Anatomical variations of nasal turbinates

After the widespread use of endoscopic sinus surgery and paranasal sinus computed tomography, many variations of nasal turbinates have been described. In addition to the most common one-middle turbinate pneumatization (concha bullosa)-superior and inferior turbinate pneumatizations have also been described. Secondary and accessory middle turbinates that can mimic real middle turbinate are anomalies described in recent years. Paradoxical middle turbinate and bifid inferior turbinate are very rarely encountered anomalies and can be easily recognized in paranasal tomography but can be overlooked by endoscopical examination. In the present study, the computed tomography images of 384 patients were evaluated for nasal turbinate variations, as well as their relations to mucosal pathologies. The most frequent variation was found to be concha bullosa; the least frequent one was found to be bifid inferior turbinate. In 1 of our patients, 5 of the 6 turbinates were found to have pneumatization, which is extremely rarely encountered in the literature. In this study, the prevalence of the variations of the turbinates and their association with chronic rhinosinusitis were investigated.

Variações anatômicas do complexo ostiomeatal: achados tomográficos em 200 pacientes

OBJETIVO: O objetivo deste trabalho foi verificar a freqüência e os tipos de variações anatômicas do complexo ostiomeatal. MATERIAIS E MÉTODOS: Foram revisadas 200 tomografias computadorizadas de pacientes com suspeita clínica de sinusopatia. RESULTADOS: Observamos um ou mais tipos de variações anatômicas em 83,5% dos pacientes, as mais freqüentes envolvendo o corneto médio (84%) e o septo nasal (34%). Outras variantes anatômicas comuns encontradas foram a presença de aeração do agger nasi e células etmoidais infra-orbitárias (células de Haller). CONCLUSÃO: As variações anatômicas do complexo ostiomeatal anterior são muito corriqueiras. As mais freqüentes envolvem o corneto médio e o septo nasal.

Are maxillary mucosal cysts a manifestation of inflammatory sinus disease?

BACKGROUND

The aetiology of maxillary mucosal cysts is uncertain. Chronic rhinosinusitis has been proposed as a probable aetiological explanation for their formation.

METHOD

We recruited 500 consecutive patients who had undergone computed tomography scanning of the paranasal sinuses for possible chronic sinus disease. We identified 110 (22 per cent) cases of maxillary mucosal cysts.

RESULTS

Patients' mean age was 42.65 years, with a female to male ratio of 0.69:1 (45:65). The mean cyst size was 14.27 mm, and most were located on the inferior surface of the antrum. Only in two cases did the cyst obstruct the sinus ostium. Of patients with antral cysts, 52.7 per cent had computed tomography evidence of sinus disease, whereas only 41.3 per cent of noncyst (control) patients had sinus pathology. The total Lund-Mackay score was significantly greater in the cyst group (n=390) compared with the noncyst group (Mann-Whitney; p<0.05).

CONCLUSION

Chronic rhinosinusitis plays an important role in the aetiology of maxillary mucosal cysts.

Radiological imaging of inflammatory lesions in the nasal cavity and paranasal sinuses

Paranasal sinus development and pneumatisation variants are described, and rhinosinusitis and different patterns of inflammatory sinonasal diseases are reviewed. Other inflammatory sinonasal diseases, e.g., fungal sinusitis, mucocele, pyocele and sinonasal manifestations in systemic diseases, are briefly described. Computed tomography (CT) is the primary modality in diagnosing and mapping suspected inflammatory sinonasal disease. Magnetic resonance (MR) imaging is complementary to CT if fungal sinusitis, pyocele or malignancy are suspected.

Pathogenesis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a multifactorial disease. Predisposing factors can be divided into environmental and non-host factors, such as pollution, viral infections, smoking, fungus, and bacteria; general host factors, including genetic factors and immune deficiency; and local host factors, including persistent focal inflammation within the ostiomeatal complex. Evidence suggests that the underlying bone in the ostiomeatal complex is actively involved in the disease process of CRS. The evidence concerning a broad range of predisposing factors for CRS is reviewed.

Variações anatômicas e sinusopatias: estudo por tomografia computadorizada

Introdução: A tomografia computadorizada tem sido cada vez mais utilizada para a identificação e avaliação das variações anatômicas das cavidades nasais que podem levar às sinusites. Objetivo: Avaliar, por meio da tomografia computadorizada, a incidência de espessamento mucoso nos seios paranasais de pacientes com sintomas de sinusite e a correlação entre sinusopatias e presença de célula de Haller, concha média bolhosa e desvio de septo nasal localizado no meato médio. Forma de Estudo: Clínico retrospectivo. Material e Método: Foram avaliadas retrospectivamente 150 tomografias computadorizadas de seios paranasais de pacientes com idade igual ou superior a 13 anos, realizadas no Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo - Escola Paulista de Medicina, no período de julho de 1999 a outubro de 2001. Foram excluídos os exames de pacientes com pós-operatório de cirurgias de seios paranasais e de base de crânio, além dos portadores de lesões tumorais envolvendo estas regiões. Resultados: 70% dos pacientes apresentavam espessamento mucoso em pelo menos um dos seios paranasais. Observou-se a freqüência de 52,7% de sinusopatia maxilar, 28,0% de etmoidal, 13,0% de esfenoidal e 8,3% de frontal. Concha média bolhosa foi encontrada em 33,3% das cavidades nasais, desvio de septo nasal localizado no meato médio em 23,3% e célula de Haller em 9,3%. Conclusões: Os seios paranasais mais freqüentemente acometidos foram, em ordem decrescente: maxilar, etmoidal, esfenoidal e frontal. Não foi observado correlação entre sinusopatias e presença de célula de Haller, concha média bolhosa e desvio de septo nasal localizado no meato médio.

Aplasia of bilateral uncinate processes with a bilateral nasomaxillary cavity

Aplasia or hypoplasia of the uncinate process is associated with maxillary sinus aplasia or hypoplasia. It is of particular clinical importance to recognize the presence of normal or abnormal uncinate processes in patients who will undergo surgical procedures for paranasal sinus diseases. In this report, we present a case of aplasia of bilateral uncinate processes, discuss the variations of uncinate processes, and review related literature.

Sinonasal inflammatory disease: pathophysiology, imaging, and surgery

The body of literature regarding imaging inflammatory diseases of the sinonasal cavity is extensive. This article will not recapitulate standard imaging protocols, osteomeatal complex (OMC) anatomy, or drainage pathways to any significant extent. Clinical and radiographic topics that create confusion for radiologists will be covered in some depth to include the pathophysiology of rhinosinusitis and bone response to inflammation. Fungal sinusitis is covered elsewhere in this issue. Clinical imaging issues will be followed by a discussion of common surgical procedures, their complications, and postoperative recurrent disease. The role of MRI as a problem-solving modality will be emphasized.

Complicated acute sinusitis and the computed tomography anatomy of the ostiomeatal unit in childhood

The ostiomeatal unit is postulated to be a critical area in the pathogenesis of sinus disease and accurate assessment of this anatomical area has made possible by the coronal computed tomography (CT) scan. Data from the CT scans of 24 patients with complications of acute sinusitis were retrospectively reviewed and compared with a set of normative data of the infundibular length, and width and the uncinate angle in 196 scans of healthy children. In the patients with complicated sinusitis the infundibular length was found to be less and the infundibular width greater than the normative data. No difference in the mean uncinate angle of the two groups was shown. One, therefore, has to assume that the pathological process at the ostiomeatal unit is more likely to be mucosal than bony.