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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 15
| Issue : 3 | Page : 243-250 |
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Prevalence of normal anatomical variations in the region of paranasal sinuses in patients with chronic rhinosinusitis
Hasanein Hamid Hadi1, Hasanein Ahmed Al-Bayati1, Safaa Sahib Naji Al-Gazali2
1 Department of Diagnostic Radiology, College of Medicine, Babylon University, Hilla, Iraq
2 Department of ENT/Head and Neck Surgery, College of Medicine, Babylon University, Hilla, Iraq
| Date of Web Publication | 24-Sep-2018 |
Correspondence Address:
Hasanein Hamid Hadi
Department of Diagnostic Radiology, College of Medicine, Babylon University, Hilla
Iraq
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/MJBL.MJBL_71_18
Background: Knowledge of the anatomical relationships and the anatomical variations in paranasal sinus region is critical for surgeons performing endoscopic sinus surgery. It helps surgeons to avoid the potential complications of sinus surgery and to improve success of management strategies. Objective: The objective of this study was to show how prevalent are the anatomic variations in the region of the paranasal sinuses and nasal cavity in patients with chronic rhinosinusitis. Materials and Methods: A cross-sectional study was conducted from January 2018 to July 2018 at Al-Hilla general teaching hospital. We collected data of 75 patients (who have met the clinical criteria of chronic rhinosinusitis) subjected to computed tomography (CT) of the paranasal sinuses. CT was performed using SIEMENS SOMATOM Definition AS and Philips machines. Direct coronal scans (1 mm in thickness) were made, from the anterior wall of the frontal sinus to the posterior wall of the sphenoid sinus with axial and sagittal reconstruction images. Results: Anatomical variations found in 69 patients of a total 75 patients with age range from 18 to 60 years with 92%. Among these, nasal septal deviation was the most common (seen in 54/75 patients = 72%) followed by the Agger nasi cells in 52 patients (69%), concha bullosa in 31 patients (41.3%), Haller cells in 28 patients (37%), and Onodi cells in 18 patients (24%). Conclusion: Sinonasal anatomical variations are common findings in patients with chronic rhinosinusitis. Providing information on these anatomical variations will improve the success of endoscopic sinus surgery.
Keywords: Anatomical variations, chronic rhinosinusitis, concha bullosa, nasal septal deviation
How to cite this article:
Hadi HH, Al-Bayati HA, Naji Al-Gazali SS. Prevalence of normal anatomical variations in the region of paranasal sinuses in patients with chronic rhinosinusitis. Med J Babylon 2018;15:243-50 |
How to cite this URL:
Hadi HH, Al-Bayati HA, Naji Al-Gazali SS. Prevalence of normal anatomical variations in the region of paranasal sinuses in patients with chronic rhinosinusitis. Med J Babylon [serial online] 2018 [cited 2019 May 23];15:243-50. Available from: http://www.medjbabylon.org/text.asp?2018/15/3/243/242071 |
| Introduction | |  |
The paranasal sinuses are air-filled spaces. They are named for the bones in which they are located: maxillary sinus, sphenoid sinus, ethmoid sinus, and frontal sinus.
The paranasal sinuses have several functions such as they reduce the weight of the head, air humidification, and aiding in voice resonance so that when they become filled with fluid, the quality of the voice is markedly changed.[1]
The region of the paranasal sinuses is subject to marked variation between individuals and between the two sides in the same individual. Some variations may cause recurrent disease.[2]
It is important to recognize the so-called “critical” variations that may cause complications during surgery, for example, damage to the optic nerve or internal carotid artery, or leakage of cerebrospinal fluid.
| Materials and Methods | | |
Study design
This cross-sectional study was reviewed and approved by the Ethical Committee in Babil Health Directorate-Iraq and verbal consents were obtained from all patients. The study conducted from January 2018 to July 2018 in Al-Hilla general teaching hospital, Babylon province, Iraq, at the computed tomography (CT) unit of the diagnostic radiology department. We collected data of 75 patients referred for Al-Hilla teaching hospital for CT evaluation of paranasal sinuses.
Inclusion criteria
Those patients have met the clinical criteria of chronic rhinosinusitis and their results of CT scan consistent with rhinosinusitis were included in our study with a verbal consent taken from patients to be included in the study.
These criteria are two or more of the following symptoms for >12 weeks: facial pain or fullness, nasal obstruction, nasal discharge (anterior and/or posterior), and abnormal sense of smell (hyposmia or anosmia).
The following groups were excluded from the study:
- Patients with rhinosinusitis symptoms of <12 weeks duration
- Patients <18 years of age due to the development stages of the paranasal sinuses
- Patients with an altered normal nasal anatomy.
- Patients having facial trauma
- Patients with previous sinonasal surgery
- Patients with sinonasal neoplasm.
CT was performed using SIEMENS SOMATOM Definition AS and Philips machines.
Direct coronal scans (1 mm in thickness) were made [Figure 1], from the anterior wall of the frontal sinus to the posterior wall of the sphenoid sinus with axial and sagittal reconstruction images. | Figure 1: Positioning of a patient in computed tomography. Device for coronal imaging of paranasal sinuses
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Radiological investigation of anatomical variations was performed using both a soft-tissue window and a bone-window. Selected scans were chosen for photographic presentation.
There were 75 patients (45 males and 30 females).
Interpretation of CT images is done by academic radiologists during reporting of outpatients in our CT unit.
Patients' age and sex in addition to the normal anatomical variants were recorded in a data collection form and the patients grouped according to the pattern of chronic rhinosinusitis.
- Infundibular pattern (Type I): characterized by obstruction of the maxillary infundibulum resulting in isolated maxillary sinusitis
- Ostiomeatal unit (OMU) pattern (Type II): characterized by middle meatus obstruction resulting in ipsilateral sinusitis affecting the fraontal, anterior ethmoid, and the maxillary antrum
- Sphenoethmoidal recess pattern (Type III): obstruction results in posterior ethmoid and sphenoid sinusitis
- Sinonasal polyposis pattern (Type IV): sinonasal polyps are evident, with opacification of various sinuses
- Sporadic or unclassifiable pattern (Type V): this pattern includes: retention cysts, mucoceles, or mild mucosal thickening without obstruction.[3]
Frequency distributions of collected data were calculated. The relationship of the patient characteristic with finding is analyzed using Chi-square test. A value of P < 0.05 was considered to detect statistical significance.
| Results | | |
A total sample size of this study was 75 patients with chronic rhinosinusitis attending the CT unit for evaluation of paranasal sinuses.
Regarding the age of patients, the range was from 18 to 60 years. Of a total of 75 patients, males formed 45/75 patients with 60%, whereas female number was 30/75 patients with 40%; M:F =1.5:1 [Figure 2]. | Figure 2: Diagram shows the distribution of patients according to age and gender
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Anatomical variations found in 69 patients out of a total 75 patients with a percentage of 92%. Among these, nasal septal deviation was the most common (seen in 54/75 patients = 72%) followed by the Agger nasi cells in 52 patients (69%), concha bullosa in 31 patients (41.3%), Haller cells in 28 patients (37%), and Onodi cells in 18 patients (24%).
Distribution of patients according to the pattern of chronic rhinosinusitis
A total of 23 patients in our study have OMU pattern of chronic rhinosinusitis and this represents 30.66% of the total patients.
Totally 19 patients (25.3%) have unclassified pattern, 11 patients (14.66%) have infundibular pattern, 9 patients (12%) have sinonasal polyposis pattern, 6 patients (8%) have sphenoethmoidal pattern, and 7 patients (9.3%) have a combined pattern [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]. | Figure 3: Diagram shows the distribution of patients according to pattern of chronic rhinosinusitis and sex
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 | Figure 4: Coronal computed tomography image of paranasal sinuses of 18-year-old female with obstruction of the ostium of maxillary sinus and inflammatory mucosal thickening of right. Maxillary sinus and nasal cavity (infundibular pattern of chronic rhinosinusitis)
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 | Figure 5: Coronal computed tomography images of two sections of 32-year-old male with ostiomeatal unit pattern of chronic rhinosinusitis with opacification of the maxillary, frontal, and anterior ethmoid sinuse
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 | Figure 6: Coronal computed tomography image of paranasal sinuses of 26-year-old male with sphenoethmoidal pattern of chronic rhinosinusitis. Inflammatory process involving the sphenoid and posterior ethmoid cell
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 | Figure 7: Coronal computed tomography image of paranasal sinuses. Soft tissue window . 60-year-old male with sinonasal polyposis
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 | Figure 8: Coronal computed tomography image of paranasal sinuses: 54-year-old male with Sporadic pattern of chronic rhinosinusitis. Focal inflammatory process involving the right. Maxillary sinus with no obstruction of the sinus ostium or ostiomeatal unit
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The prevalence of each anatomical variation
The most common AV observed was deviated nasal septum, 54 patients (72%), followed by the Agger nasi cells, 52 (69%), concha bullosa 31 patients (41.3%), Haller cells, 28 (37%), and Onodi cells, 18 (24%).
Anatomical variation related to Nasal Septum
Nasal septal deviations (NSDs) present in 54 patients in our study (72% of total patients with chronic rhinosinusitis). Of these 54 patients, 32 males and 22 females [Figure 9].
In 24 patients (44.5%), the nasal septum is deviated to the right side and in 26 patients (48%), it is deviated to the left side. Bilateral deviation was observed in 4 patients (7.5%).
Septal spurs observed in 24 patients (32% of total patients); in 16 patients of these (64%), the septal spur is right sided and in 8 patients (36%) it is left sided.
Of these 24 patients, 15 were male and 9 were female.
Anatomical variants related to nasal turbinates
In this study, pneumatization of MT observed in 46 patients out of a total of 75 (61.3%) including pneumatization of the lamellar and/or the bulbous parts.
In 12 patients, out of 46 with pneumatization (26%), it was right sided and in 13 patients (28%), it was on the left side and was bilateral in 21 patients (46%).
Concha Bullosa present in 31 patients (19 males and 12 females). About 41% of total patients with chronic rhinosinusitis including 7 patients in whom both bulbous and lamellar parts of middle turbinate are pneumatized.
Paradoxical curve of middle turbinate
Middle turbinates with paradoxical curve presented in 11 patients (15% of total patients with chronic rhinosinusitis). In 2 patients (18%), it is right sided and in 5 patients (46%), it is on the left side and was bilateral in 4 patients (36%). Of these 11 patients, 7 were male and 4 female.
Anatomical variants related to ethmoid air cells
The reported prevalence of the Agger nasi cell in the previous literature varies from 10% to 98.5%. In this study, the prevalence of Agger nasi cells was 69% being seen in 52 patients out of a total of 75. In most of the cases (46 patients), AN cells were bilateral (88%), Of these 52 patients, 30 were male and 22 were female.
Regarding Haller cells, the prevalence of Haller cells is remarkably variable, ranging from 2% to 70.3%. In our study, Haller cells observed in 28 patients out of a total of 75 and this represents 37% of chronic rhinosinusitis (CRS) patients.
They were observed on the right side in 6 of the cases (21%), on the left side in 10 of the cases (36%) and were bilateral in 12 of the cases (43%).
In most of our cases (in 25 cases), a single Haller cell seen and only in 3 cases, 2 cells observed on the same side. Of these 28 patients, 18 were male and 10 were female.
Regarding Onodi cells, these air cells were observed in 18 patients out of a total of 75 with CRS (24%). Right side Onodi cells seen in four cases (22%), left sided Onodi cells seen in 10 cases (46%) and bilateral Onodi cells seen in 4 cases (22%). Of these 18 patients with Onodi cells, 11 were male and 7 females.
| Discussion | | |
In our study, anatomical variants observed in most of CRS patients (69 out of a total of 75 patients = 92%) [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]. Paranasal variants were found in 99.8% of the patients in a study conducted by DasarandGokce.[4] and in 89% of patients in a study conducted by Jagannathan et al.[5] | Table 3: Distribution of cases according to the pattern of chronic rhinosinusitis
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 | Table 4: Distribution of cases in males and females according to the pattern of chronic rhinosinusitis
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Regarding NSD, we considered deviation as any asymmetric curvature of septum [Figure 10] and [Figure 11]. In our study, NSD observed in 54/75 patients (72%) [Table 6]. | Figure 10: Coronal computed tomography image of paranasal sinuses. of 31-year-old male with nasal septal deviation to the right side with sinonasal polyposis
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 | Figure 11: Coronal computed tomography image of paranasal sinuses of 50-year-old female with nasal septal deviation to the left side associated with inflammatory process involving the ipsilateral maxillary and anterior ethmoid sinuses (ostiomeatal unit pattern of chronic rhinosinusitis)
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 | Table 6: Distribution of cases according to the presence of nasal septal deviation
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Deviation of nasal septum was reported in other studies at different rates as the following: 80% of patients as reported by Perez et al.[6], and 38% as reported by Asruddin et al.[7] Dissimilar rates of nasal septum deviation were also reported worldwide by several authors.[8],[9],[10],[11] Low figures in some studies may be related to the fact that they followed the strict criteria of definition of DNS >4 mm.
Regarding septal spurs [Figure 12], they observed in 24 patients (32% of total patients) [Table 7] and reported in 13.6% by Pérez-Piñas et al.[6] | Figure 12: Coronal computed tomography image of paranasal sinuses. of 38-year-old male with septal spur directed to the right side
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 | Table 7: Distribution of cases according to the presence of nasal septal spurs
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Concha bullosa [Figure 13] (pneumatized middle turbinate) has been implicated as a possible etiological factor in the causation of recurrent chronic sinusitis. It is due to its negative influence on paranasal sinus ventilation and mucociliary clearance in the middle meatus region as quoted by Tonai and Baba.[12] In our study, Concha bullosa was observed in 31 patients (41%) [Table 8] which is slightly less as compared to the reported incidence of 53.6% by Bolger et al.,[8] but is almost equal to the reported incidence of 42.6% by Maru and Gupta,[11] and it is higher than the reported incidence of 28% by Asruddin et al.,[7] 24% by Lloyd et al.[10] | Figure 13: Coronal computed tomography image of paranasal sinuses of 54-year-old female with left. Concha Bullosa involved by inflammatory process
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 | Table 8: Distribution of cases of middle turbinate pneumatization according to side and type
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The middle turbinate may be paradoxically curved [Figure 14], that is, bent in the reverse direction. This may lead to impingement of the middle meatus and thus to sinusitis (36). It was found in 11 patients (15%) [Table 9]. The incidence is almost similar to that of 12% by Asruddin et al.[7] and 15% by Lloyd et al.[10] It is less than that reported by Bolger et al.(27%).[8] | Figure 14: Coronal computed tomography image of paranasal Sinuses of 30-year-old male with bilateral paradoxical curve of middle turbinate
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Regarding Agger Nasi cells [Figure 15] and [Figure 16], they were observed in 52 patients (69%) [Table 10]. This is less as compared to 98.5% reported by Bolger et al.[8] and 88.5% by Maru and Gupta,[11] but Asruddin et al.[7] reported a result of 48% and by Dua et al. a result of 40%.[9] In anatomic dissections, Messerklinger encountered the Agger nasi cells in 10%–15% of the specimens, Davis in 65% of specimens and Mosher in 40% of specimens as quoted by Bolger et al.[8] | Figure 15: Coronal computed tomography image of paranasal sinuses of 27-year-old male with bilateral Agger nasi cells. These cells have a close relation to the frontal recess
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 | Figure 16: Sagittal reconstruction computed tomography image of paranasal sinuses of 19-year-old female with Agger nasi cell causing narrowing of frontal recess and inflammatory process involving the frontal sinus
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Haller's cells [Figure 17] are ethmoid air cells grow into the floor of orbit and (if large) may narrow the adjacent ostium of the maxillary sinus, especially if they become infected.[9] In our study, Haller's cells were seen in 28/75 (37%) [Table 11]. This is almost equal to the result of 36% reported by Maru and Gupta [11] and it is slightly less than the result of 45.9% reported by Bolger et al.[8] By Asruddin et al., it was reported as 28%,[7] and by Lloyd et al. as 15%.[10] | Figure 17: Coronal computed tomography image of paranasal sinuses of 35-year-old male. Bilateral Haller cells with inflammatory process involving the right. One causing obstruction of the right infundibulum and inflammatory process of right maxillary sinus
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Results of this study revealed that Onodi cells [Figure 18] were found in 18 patients in our study (24%) [Table 12]. In the series of Earwaker (1993), this type of posterior ethmoidal cells is present in 24% of cases. It is higher than that reported by Shpilberg et al. (12%).[2] Onodi cell was observed in 38% by Nandita et al.[13] | Figure 18: Coronal computed tomography image of paranasal sinuses of 40-year-old female with right Onodi cell
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| Conclusion | | |
Sinonasal anatomical variations are common findings in patients with chronic rhinosinusitis and the radiologist should be familiar with these variations No statistically significant difference was found between males and females and between age groups regarding the prevalence of these variations providing information on these anatomical variations will improve the success of endoscopic sinus surgery. Sinonasal anatomical variations should be looked for and mentioned in the CT report of CRS patients (many of which will have endoscopic sinus surgery) to give an idea for the ENT surgeon to avoid the unwanted complications like injury to optic nerve or ICA or to avoid recurrence of symptoms if certain anatomical variations are not treated adequately.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]
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