Inferomedially projecting pneumatised secondary middle turbinate

Secondary middle turbinate (SMT), a rare variation of the nasal cavity, is a bony projection covered by soft tissue that arises from the lateral nasal wall. It is almost always bilateral and usually projects superomedially without any ostiomeatal unit obstruction. Herein, we report a case of bilateral inferomedially projecting secondary middle turbinates, one of which is pneumatised and hypertrophied, resembling a large ethmoid bulla extending into the middle meatus. The recognition of this variation is important since it may predispose to inflammatory sinus disease, by narrowing the ostiomeatal unit.     

Concha bullosa: CT evaluation

Aeration of the middle turbinate, termed "concha bullosa," is a common anatomical variant of intranasal anatomy. Of 320 patients evaluated for sinus disease with coronal CT, 34% had concha bullosa on at least one side. The overall incidence of inflammatory disease in the ostiomeatal complex in these symptomatic patients was not different between those with and without concha bullosa. However, there were many cases in which an abnormally large middle turbinate appeared to obstruct the ostiomeatal complex causing secondary infection of the ethmoid, frontal, and maxillary sinuses. Obstruction of drainage of the concha bullosa itself can lead to mucocele formation. Furthermore, the presence of a concha bullosa has important implications for the technique of endoscopic surgery used in the management of the sinus disease. The anatomy, pathophysiology, and CT findings in patients with concha bullosa are reviewed.     

Partial resection of the middle turbinate at functional endoscopic sinus surgery

The middle turbinate is often carefully preserved at Functional Endoscopic Sinus Surgery (FESS). However there is no clear understanding of its importance and its presence may prevent good access to the middle meatus to the detriment of the surgical result. In addition its bulk may cause symptoms of nasal obstruction and prevent paranasal sinus drainage. Adhesions and stenosis have been reported at the middle meatus following its preservation. We undertook a prospective study of 50 consecutive patients all of whom underwent resection of the anterior half of the middle turbinate at the time of Functional Endoscopic Sinus Surgery. The patients were asked to complete a symptom score sheet before and ten weeks after surgery. The parameters considered were nasal obstruction, nasal congestion, discharge, facial pain and headache. Non parametric analysis of the results indicated a significant improvement in all patient symptom scores and no postoperative complications were noted. We conclude that partial resection of the middle turbinate is a useful modification of accepted endoscopic sinus surgery techniques.     

飞行人员鼻科疾病谱研究（摘要）

目的总结飞行人员鼻科疾病谱的变化规律。方法对1966～2007年闾住院的320名373例次飞行人员的鼻科疾病谱进行对比分析。结果排鼻科疾病谱前位的为慢性鼻窦炎、鼻息肉、鼻窦气压伤、鼻中隔偏曲、变应性鼻炎、慢性鼻炎、鼻窦囊肿、急性鼻窦炎、鼻腔鼻窦肿瘤、鼻外伤等。飞行合格283人,暂时飞行不合格12人,永久停飞25人。     

CT demonstration of accessory nasal turbinates: secondary middle turbinate and bifid inferior turbinate

Normally, there are three pairs of nasal turbinates in the nasal cavity. Coronal computed tomographies of 253 cases of sinusitis were examined for the presence of additional turbinates and bilateral secondary middle turbinates were detected in two cases. Also, we describe another accessory turbinate, 'bifid inferior turbinate', in one of these cases. Existence of these accessory turbinates may occur during embryologic development of lateral nasal wall.     

Bilateral accessory inferior turbinates and secondary middle turbinates

Bifid inferior nasal turbinates-two inferior turbinates with a single root observed in the nasal cavity-are an extremely rare anatomical variation, especially when they are observed bilaterally and exist with other variations. We report a case of bilateral bifid inferior nasal turbinates with bilateral secondary middle turbinates. We discuss the findings of this rare condition and suggest an appropriate term-accessory inferior turbinate-to replace bilateral inferior turbinate by reason of its embryology.     

Topographic anatomy of the ethmoid labyrinth in x-ray computed tomography

These last years the surgical treatment of inflammatory ethmoid disease has been completely modified, with new endoscopic conservative procedures. In a preoperative phase it is mandatory to provide optimal CT imaging of the ethmoid labyrinth, and for this purpose sections perpendicular and parallel to the nasofrontal duct axis are better than axial and coronal slices. The anatomy of the ethmoid is fairly complex; however certain constant anatomic landmarks allow a systematic analysis of the ethmoid labyrinth: the unciform process, the bulla, the middle turbinate, the superior turbinate and their respective basal lamellae.     

Another CT sign of sinonasal polyposis: truncation of the bony middle turbinate

In order to study the features of sinonasal polyposis (SNP) on CT, 100 consecutive coronasal sinus CT examinations done for chronic inflamamtory sinonasal disease were reviewed. The CT findings of the 27 fully documented SNPs were analyzed. All our SNPs were bilateral. There was a strong tendency for extensive involvement. Nasal polyps were seen in 22 of 27 (81%); bony trabecular deossification in 23 of 27 (85%); widening of infundibulum in 26 of 27(96%). We discovered a new sign truncation of the bony middle turbinate, where the bulbous part of bony middle turbinate was missing, in 51 of 26 (58 %) of SNP patients without a previous history of middle turbinectomy, 12 of 15(80%) were bilateral. The one SNP patient (1 of 27) with previous middle turbinectomy was not regarded to be real truncation. Truncation of the bony middle turbinate is a characteristic and easily recognizable ancillary sign, and is not seen in other patterns of sinusitis. Together with other features on coronal sinus CT, this adds diagnostic confidence in diagnosing sinonasal polyposis. Correspondence to: E. Y. Liang     

Multiplanar reconstructions in the study of ethmoid anatomy

Summary Multiplanar and surface reconstructions are useful tools in anatomical studies. Details of ethmoid architecture which are hard to image in axial and coronal scans are well displayed by means of oblique sections. This paper addresses reformatted images of a) the nasal lateral wall; b) the middle meatus lateral wall; c) the lamina basilaris of the middle turbinate and d) the frontonasal duct.     

Concha bullosa and the nasal middle meatus obstructive syndrome

BACKGROUND: Concha bullosa (CB) is pneumatization of the middle turbinate and one of the most common anatomic variation of the sinonasal region. It is found in about 25% of the population. Middle meatus obstructive syndrome (MMOS) is, usually connected with CB. The main symptoms of this syndrome are headaches, impaired nasal breathing and hyposmia. Headache is the most common symptom and it may occur due to contact between a CB and other structures of the nasal cavity. CASE REPORT: We presented a case of 32 year-old-woman with headaches, located in the orbital and the left frontal region. The headaches were intermittent and corresponding to the nasal cycle. After neurologic and allergic examination, endoscopic nasal examination demonstrated a septal deviation to the right side and a large middle turbinate in the left side of the nasal cavity. Coronal computerized tomography (CT) of the paranasal sinuses demonstrated the septal deformation and pneumatization of the left middle turbinate. Diagnosis was confirmed by lidocaine test. In the functional endoscopic surgery (FESS), the lateral lamela of the anterior CB was removed. At the same time, the septoplasty was done. At the control examination, the patient was without symptoms. CONCLUSION: Although CB is the common anatomic variation of the nasal cavity, MMOS is rare. Headache (rhinogenic origin) is the most important symptom. Surgical treatment is the lateral resection of the CB in the FESS technique and the septoplasty.     

功能性鼻内窥镜鼻腔鼻窦手术27例临床观察

鼻内窥镜下的鼻腔鼻窦手术在彻底切除病变组织基础上尽可能不损伤鼻控及鼻窦的解剖结构，最大限度地保留鼻腔和鼻窦的基本功能。方法；采用功能性鼻内窥镜进行鼻腔，鼻窥手术２７例。结果；术后随访，１３例鼻息肉并鼻窦炎，５例慢性肥厚性鼻炎全部恢复正常通气功能。     

Aberrant middle turbinate masquerading as a nasopharyngeal mass

We present a unique variant of the middle turbinate that extends posteriorly through the choana to wrap around the posterior free edge of the nasal septum. The embryology and anatomy of the lateral nasal wall and the nasal septum are reviewed.     

窦口-鼻道复合体解剖变异与慢性副鼻窦炎(附70例分析)

目的 探讨窦口鼻道复合体发育不良、解剖变异对慢性副鼻窦炎的影响程度。方法 收集经ＣＴ冠状面扫描发现的慢性另鼻窦炎７０例。重点观察钩突、中鼻甲、鼻中隔的发育形态、位置。测量钩突的内偏角及外偏角度,测量鼻中隔偏曲的突出度与偏曲角度,行统计处理分析解剖变异与慢怀鼻窦炎的关系。结果 ７０例慢性副鼻窦炎与窦口－鼻道复合体的发育不良、解剖变异有明显的相关性。钩突、中鼻甲及鼻中镉的解剖结构变异为主要的影响因素。     

The Impact of Middle Turbinate Concha Bullosa on the Severity of Inferior Turbinate Hypertrophy in Patients with a Deviated Nasal Septum

BACKGROUND AND PURPOSE:Inferior turbinate hypertrophy and concha bullosa often occur opposite the direction of nasal septal deviation. The objective of this retrospective study was to determine whether a concha bullosa impacts inferior turbinate hypertrophy in patients who have nasal septal deviation.MATERIALS AND METHODS:The electronic medical record was used to identify sinus CT scans exhibiting nasal septal deviation for 100 adult subjects without and 100 subjects with unilateral middle turbinate concha bullosa. Exclusion criteria included previous sinonasal surgery, tumor, sinusitis, septal perforation, and craniofacial trauma. Nasal septal deviation was characterized in the coronal plane by distance from the midline (severity) and height from the nasal floor. Measurement differences between sides for inferior turbinate width (overall and bone), medial mucosa, and distance to the lateral nasal wall were calculated as inferior turbinate hypertrophy indicators.RESULTS:The cohorts with and without concha bullosa were similarly matched for age, sex, and nasal septal deviation severity, though nasal septal deviation height was greater in the cohort with concha bullosa than in the cohort without concha bullosa (19.1 ± 4.3 mm versus 13.5 ± 4.1 mm, P < .001). Compensatory inferior turbinate hypertrophy was significantly greater in the cohort without concha bullosa than in the cohort with it as measured by side-to-side differences in turbinate overall width, bone width, and distance to the lateral nasal wall (P < .01), but not the medial mucosa. Multiple linear regression analyses found nasal septal deviation severity and height to be significant predictors of inferior turbinate hypertrophy with positive and negative relationships, respectively (P < .001).CONCLUSIONS:Inferior turbinate hypertrophy is directly proportional to nasal septal deviation severity and inversely proportional to nasal septal deviation height. The effect of a concha bullosa on inferior turbinate hypertrophy is primarily mediated through influence on septal morphology, because the nasal septal deviation apex tends to be positioned more superior from the nasal floor in these patients.

Nasal airway obstruction is a challenging problem that can arise from multiple etiologies, which include structural abnormalities such as nasal septal deformity and turbinate hypertrophy. Inferior turbinate hypertrophy (ITH) has received much attention in the literature in the debate over optimal surgical management of nasal obstruction.¹ Although the term “hypertrophy” is most accurately reserved for the overall enlargement of an organ because of increasing cell size, its use is widely accepted in the setting of turbinate enlargement secondary to greater thickness of soft-tissue and/or bone components.^2–5 Although limited normative data has been published on inferior turbinate size by using CT, ITH remains a clinical diagnosis.⁶ITH has been commonly described as occurring contralateral to the direction of nasal septal deviation (NSD) or, alternatively phrased, along the concave side of the septum.^2,3,7–14 Because of this association, it has been speculated that ITH is compensatory, to create physiologically favorable nasal airflow turbulence and to protect the mucosa from excessive drying and crusting with increased air flow. In other words, the inferior turbinate may have progressively enlarged to fill the void in the nasal cavity created by the shifted midline with the undesirable result of a smaller-than-expected cross-sectional area for air passage.² Using septoplasty to correct NSD without addressing the ITH may have the unintended consequence of worsening symptomatic nasal obstruction.⁷Concha bullosa is an anatomic variant of ethmoid air cell development in which pneumatization most commonly extends into the middle turbinate. This can be limited to the vertical lamella, extend into the bulbous portion, or extensively involve the vertical lamella and bulbous segment of the middle turbinate.¹⁵ If one allowed some outlier data, the prevalence is likely in the range of 21%–53%.^15–27 Some of the reported variability can be attributed to differences in the populations being evaluated, the type of evaluation (ie, CT versus surgery), and the definition of concha bullosa (ie, whether to include small lamellar types). Similar to ITH, a preponderance of published reports support a strong association between the presence of concha bullosa and NSD, in which the nasal septum typically bows toward the contralateral side and may increasingly do so when middle turbinate pneumatization is greatest.^{23,24,27–30} Moreover, in bilateral cases, the nasal septum is usually near midline when the conchae bullosa are balanced in size but usually deviates away from an asymmetrically enlarged dominant concha bullosa.When one controls for the shape and severity of a deviated nasal septum, it has yet to be determined whether a concha bullosa significantly influences the presence of ipsilateral ITH. Logically, an interaction may exist between the structures because the concha bullosa and ITH both commonly develop along the concave side of a deviated nasal septum within a secondarily widened nasal cavity. The objective of this study was to assess patients with NSD on CT in an attempt to identify whether the presence or absence of a concha bullosa influences ipsilateral ITH.     

鼻中隔偏曲与单侧上颌窦炎性病变的临床观察与CT图像处理

目的通过临床和CT图像观察了解鼻中隔偏曲与单侧上颌窦炎性病变的关系，探讨鼻中隔偏曲在慢性鼻窦炎发病中的作用。方法前瞻性、连续收集经鼻窦冠状位CT扫描证实的鼻中隔偏曲伴单侧上颌窦炎性病变（包括慢性上颌窦炎、上颌窦浆液性囊肿、上颌窦后鼻孔息肉和霉菌性上颌窦炎）患者56例，观察单侧上颌窦炎性病变与鼻中隔偏曲的关系。随机抽取10例患者的鼻窦冠状位CT图像，按Uygur法计算钩突所在平面两侧下鼻甲、钩突和中鼻甲的横断面积（以坐标纸格数表示）在各自鼻腔所占的百分数，并与10例正常对照（鼻中隔正直、无鼻窦病变）进行比较。结果56例患者中，单侧慢性上颌窦炎25例，上颌窦后鼻孔息肉9例，上颌窦浆液性囊肿5例，霉菌性上颌窦炎17例；病变位于鼻中隔偏曲鼻腔宽大侧35例（62．5％），狭窄侧21例（37．5％）。10例鼻中隔偏曲伴单侧上颌窦炎性病变患者下鼻甲、钩突和中鼻甲的横断面积在各自鼻腔所占的百分数在鼻腔宽侧为48．8％，窄侧为44．1％，两侧无显著性差异（P〉0．05）。10例正常对照下鼻甲、钩突和中鼻甲的横断面积在各自鼻腔所占的百分数为右侧40．1％，左侧39．8％，两侧无显著性差异（P〉0．05）。结论鼻中隔偏曲使鼻腔宽大侧发生单侧上颌窦炎性病变的机会大于鼻腔狭窄侧；临床处理上颌窦炎性病变的同时应矫正偏曲的鼻中隔，恢复鼻腔鼻窦正常的结构和功能，阻断鼻中隔偏曲造成的代偿失调。     

Coronal imaging of the osteomeatal unit: anatomy of 24 variants.

The purpose of this paper is to present a user-friendly reference for 24 of the most common normal variants of the osteomeatal unit. A five image set of consecutive normal coronal hanging head computed tomography (CT) images was obtained. Half of each image was duplicated enough times to allow superimposition of the variants. For organizational purposes, each variant was sorted into six color-coded regions: middle turbinate (five variants), inferior turbinate (three variants), maxillary sinus (three variants), nasal septum (three variants), ethmoid sinuses (five variants), and uncinate process (five variants). This reference can be used to rapidly identify a CT scan level and obtain an overview of common variants in that level. In addition, the color-coded system can be used to find any variant on all appropriate CT levels quickly by locating its colored column.     

Primary extracranial meningioma of the sinonasal tract

Meningiomas occurring outside the cerebrospinal axis can be primary at an extracranial site (nasal cavity, paranasal sinuses, and nasopharynx) or secondary extending from an intracranial lesion. Magnetic resonance imaging findings of an 8-year-old child with primary meningioma before and after surgery have been reviewed and compared to computed tomography and histological evaluation. The child had difficulty breathing through the left nostril and tearing of the left eye. After physical and radiological examination, a tumor comprising the left lower, middle turbinate, and ethmoidal cells was found and radically extirpated. On histological examination, the tumor was identified as meningothelial meningioma. On the basis of the clinical, radiological, and histological features, the tumor was diagnosed as extracranial meningioma of the sinonasal tract. A follow-up examination 6 months later revealed no evidence of recurrence of the tumor.     

Classification of the inferior turbinate bones: a computed tomography study

BACKGROUND: There are only few reports describing the texture of the inferior turbinate bone in normal and pathologic conditions. In this study, different types of human inferior turbinate bones were classified and radiological features of each type were defined. METHODS: The shape, structure and density of the inferior turbinate bones were evaluated using paranasal sinus computed tomography images of 283 patients. The cross-sectional areas of the bony part of the inferior turbinate were measured in bone windows. RESULTS: Human inferior turbinate bones were classified into four groups on the basis of different shape and structure as: Type I, lamellar; Type II, compact; Type III, combined type (compact with spongious component); Type IV, bullous. The distribution was as follows: 352 (62.19%) lamellar, 50 (8.83%) compact, 162 (28.63%) combined, and 2(0.35%) bullous type. CONCLUSION: Inferior turbinate bone is not in a uniform shape and structure. These diversities should be taken into consideration in radiological and clinical evaluation.     

Fungal ball in concha bullosa as incidentaloma: A case report and the review of the literature

Concha bullosa is an anatomic variant consisting in an enlargement and pneumatization of the middle nasal turbinate. A fungal ball (FB) localized in this structure is an extremely rare disease. This article describes the unusual case of a young patient with an asymptomatic fungal mass in the concha bullosa, incidentally discovered at computed tomography (CT) scan of the head, which was performed after trauma.