International Journal of Otorhinolaryngology and Head and Neck Surgery

Handi PS et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):898-903

http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20174204
Original Research Article

Evaluation of nose and paranasal sinus disease, anatomical variations

by computerized tomography
Prakash S. Handi1*, Mallikarjun N. Patil2

Department of ENT, 1ESIC Medical College and PGIMSR, Bengaluru, 2SN Medical College, Bagalkot, Karnataka,
India

Received: 21 August 2017

Accepted: 14 September 2017

*Correspondence:
Dr. Prakash S. Handi,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The anatomy of paranasal sinuses is very complicated. Evaluation of the location, extent of sino nasal
diseases and anatomical variations by preoperative radiologic evaluation of the paranasal sinuses is essential in
planning surgical intervention. Meticulous radiographic delineation of the small structures in this region, coupled with
endoscopic evaluation, provides detailed preoperative information regarding morphology and pathology.
Methods: Patients with sinonasal symptoms indicating requirement of CT scan evaluation and aged more than 10
years were included in the study. Each CT scan was interpreted by an otolaryngologist and a radiologist and
interpretation was by consensus. The data collected was evaluated and results are reported as rates and proportions.
Results: Sinusitis (single or multiple sinus involvement), nasal polyposis, frontal mucocele and ethmoidal carcinoma
with destruction of medial wall of maxilla were the pathologies observed in these CT scans with sinusitis [22
(43.1%)] being the most common pathology observed. Deviated nasal septum [21 (41.2%)] was the most common
anatomical variation observed. All patients who had concha bullosa [5 (9.8%)] were observed to have sinusitis
involving multiple bilateral PNS. Based on Keros’ classification, olfactory fossa depth type I was most commonly
observed followed by type II and type III.
Conclusions: CT scan is important in patients undergoing endoscopic sinus surgery for sinonasal diseases where it
acts as a road map in identifying the presence, extent of disease and any anatomical variations. This pre-operative CT
scan evaluation improves planning and helps in significantly reducing morbidity and possible complications during
surgery.

Keywords: CT scan, Paranasal sinus, Sinusitis, Anatomical variations

INTRODUCTION Computed tomography is considered the radiologic

method of choice in completely delineating the normal
The paranasal sinuses are a group of air filled spaces anatomy and anatomical variants of the paranasal sinuses
surrounding the nasal cavity; which start developing from and it is extremely useful in the pre-operative planning of
the primitive choana at 25–28 weeks of gestation.1 The endonasal surgeries.1 Coronal images can be directly
anatomy of paranasal sinuses is very complicated.2 acquired, preferentially with the patient in prone position,
Evaluation of the location, extent of sino nasal diseases or otherwise being reconstructed from axial images.
by radiologic evaluation of the paranasal sinuses is Multislice spiral CT allow multiplanar image
essential in planning surgical intervention. Plain reconstruction with a quality similar to the images
radiography, computed tomography and magnetic directly acquired in the coronal plane, while eliminating
resonance imaging are applied in evaluating the sinuses. artifacts originated by eventual dental restorations.

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 Handi PS et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):898-903

Sagittal reconstructions supplement the anatomical indicating requirement of CT scan evaluation and aged
detailing of paranasal cavities provided by coronal more than 10 years were included in the study. Patients
images, especially of frontal sinuses and frontal recess. who were previously operated and patients with facial
The advantage of this approach for endoscopic sinus anomalies were excluded.
surgery is, it can provide anatomical and pathological
image with the same perspective to the surgeon.3 CT scan was performed with a Philips CT scanner. Direct
axial sections were done in all the patients with the
Sinonasal region that possess frequently anatomic patients in supine position; with coronal reconstruction.
variations, plays an important role in the pathogenesis of Axial and coronal views in bone and soft tissue windows
paranasal sinus diseases.2 Earlier studies have of all the CT scan films were reviewed using Philips
demonstrated the very high rate of anatomical variations Dicom Viewer software. All the CT scans evaluated in
in the sinonasal area especially the osteomeatal complex- this study were performed without contrast. The study
a small area located in the region between the middle parameters evaluated were age, sex, and radiographic
turbinate and lateral nasal wall in the middle meatus findings of disease and anatomical variations. Each CT
representing the area of drainage of anterior ethmoid, scan was interpreted by an otolaryngologist and a
maxillary and frontal sinuses and the importance of radiologist and interpretation was by consensus. Each
careful assessment of CT scan in patients with chronic scan was reviewed for the presence of haller cell, onodi
rhinosinusitis, especially in the pre-operative planning cell, concha bullosa, paradoxically curved middle
prior to endoscopic surgery.4-7 Meticulous radiographic turbinate, deviated nasal septum (DNS), pneumatisation
delineation of the small structures in this region, coupled in the nasal septum, superior and middle turbinate,
with endoscopic evaluation, provides detailed uncinate process, osteomeatal complex, type of olfactory
preoperative information regarding morphology and fossa, lamina papyracea, the presence of frontal sinus,
pathology. This information has led to more focused sinonasal soft tissue and site of sinus infection. The data
endoscopic surgical procedures, which have dramatically on concha bullosa and Haller’s cell were also analyzed
reduced patient morbidity.4 In view of this, the aim of this for their contribution to maxillary sinusitis. If the septum
study was to evaluate the anatomy of the nose and was obstructing at least half of the nasal cavity, it was
paranasal sinuses as delineated by computed tomography termed as deviated nasal septum. The data collected was
and to describe the clinical significance of the observed evaluated and results are reported as rates and proportions
anatomical variants, nasal and paranasal sinus pathology. (%).

METHODS RESULTS

The CT scan of fifty one patients attending the outpatient The study evaluated CT scan of 51 patients of which 34
department of otorhinolaryngology in a tertiary care were male patients and 17 were female patients with age
centre between April 2015 to September 2016 were ranging from 15 years to 65 years. Most [15 (29.4%)] of
evaluated in this study. Patients with sinonasal symptoms these patients belonged to the 21-30 age group (Table 1).

Table 1: Distribution of cases based on age and sex.

Age group (years) Males Females Total number (%)

11-20 3 4 7 (13.7)
21-30 10 5 15 (29.4)
31-40 10 1 11 (21.6)
41-50 5 4 9 (17.6)
51-60 5 2 7 (13.7)
61-70 1 1 2 (3.9)
TOTAL 34 17 51

Table 2: Classification of cases based on sites of paranasal sinus (PNS) disease.

Number n (%) Pattern of involvement

Site of PNS disease
N=51 Unilateral Bilateral
Frontal sinus 26 (51.0) 4 22
Maxillary sinus 38 (74.5) 9 29
Ethmoid sinus 32 (62.7) 5 27
Sphenoid sinus 22 (43.1) 5 17
N= total number evaluated; n= number in each group; % = n/N×100.

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Table 3: Classification of cases based on types of olfactory fossa (Keros’ classification).

Type of olfactory fossa Number evaluated, n (%) N=51

Type I (1-3 mm in depth) 29 (56.9)
Type II (4-7 mm in depth) 20 (39.2)
Type III (> 8 mm in depth) 2 (3.9)
N= total number evaluated; n= number in each group.

Sinusitis (single or multiple sinus involvement), nasal Based on Keros’ classification, olfactory fossa depth type
polyposis, frontal mucocele and ethmoidal carcinoma I was most common followed by type II and type III
with destruction of medial wall of maxilla were the (Table 3).
pathologies observed in these CT scans with sinusitis [22
(43.1%)] being the most common pathology observed.
Orbital wall erosion was observed in 2 cases: one lamina
papyracea erosion and one with erosion of floor of orbit.

Figure 3: Concha bullosa with maxillary sinusitis.

Figure 1: Classification of cases based on anatomical

variations observed.

Deviated nasal septum [21 (41.2%)] was the most

common anatomical variation observed (Figure 1). All
patients who had concha bullosa [5 (9.8%)] were
observed to have sinusitis involving multiple bilateral
PNS. Maxillary sinus [38 (74.5%)] was the most common
site of paranasal sinus disease (Table 2).

Figure 4: Destruction of medial wall of maxillary

Sinus.

Figure 2: Bilateral maxillary ethmoid sinusitis with

polyposis with OMC block. Figure 5: DNS With OMC Block With Maxillary and
Ethmoid Sinusitis.

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 Handi PS et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):898-903

DISCUSSION

The knowledge of the sinonasal anatomical variations by

the radiologist and otorhinolaryngologist is essential,
considering their possible involvement in the genesis of
sinusitis, changing the anatomy of the region and
increasing the risk for eventual iatrogenic complications
from endonasal procedure.3 While there are many studies
which indicate that anatomical variations of paranasal
sinus structures may predispose patients to recurrent
sinusitis, the relative importance of anatomical variations
is still a matter of discussion with some authors
considering local, systemic and environmental factors or
intrinsic mucosal abnormalities as significant contributors
to the pathogenesis of rhinosinusitis.8-12

In this study, patients with sinonasal symptoms

Figure 6: Erosion of floor of orbit. undergoing CT scan were found to be more commonly in
the 21-30 age group which is consistent with the
observations by Verma et al, Kanwar et al.13,14 There were
more male patients (66.7%) than female patients (33.3%)
with CT scan for sinonasal symptoms which is consistent
with literature reported by Fadda GL et al, Kushwah APS
et al.8,15

Sinusitis (single or multiple sinus involvement) was the

most common pathology observed (43.1%) and maxillary
sinus [38 (74.5%)] was the most common site of
paranasal sinus disease (Table 2). This is in line with
studies by Verma, Kanwar, Khushwa et al.13-15

Among the CT scans evaluated, anatomical variations

were observed in 31 cases (60.8%). Variation in the nasal
septum results in morphological variations such as
deviated nasal septum, chondro-vomeral junction
deformity, pneumatisation of nasal septum and nasal
bone spur1. Deviated nasal septum (41.2%) was the most
common anatomical variation observed (Figure 1) in this
Figure 7: Gross DNS causing narrowing of
study with similar prevalence reported in studies by
infundibulum.
Verma et al, Asruddin et al.13,16

Concha bullosa was observed in 9.8% of the cases in this

study. This incidence is lower than that reported by
Zinreich et al (34%).4 The wide reported incidence (14–
53%) of concha bullosa in CT scan evaluation may be
explained by varied definition of a concha bullosa among
studies. Some reports defined a concha as any aeration of
the middle turbinate, even if the aeration is restricted to
the upper nonbulbous portion of the turbinate while
others as aeration of the middle turbinate that caudally
into the bulbous portion of the middle turbinate.12 In this
study all patients who had concha bullosa [5 (9.8%)]
were observed to have sinusitis involving multiple,
bilateral PNS while in literature, the relationship of
concha bullosa to paranasal sinus disease continues to be
debated.12

Abnormal curvature of the middle turbinate towards the

midline (convexity is lateral instead of medial) is called
Figure 8: Type I olfactory fossa. the paradoxical middle turbinate. Compression of the

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 Handi PS et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):898-903

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