Preoperative CT scanning for endoscopic sinus surgery: a rational approach.

Recent research on inflammatory sinus disease has implicated a central role for the ethmoid labyrinth, which may influence changes in the maxillary and frontal sinuses. CT can provide excellent definition of the paranasal sinuses and particularly the ethmoids, which is a prerequisite for endoscopic surgery. We describe a prospective series of 110 coronal CT scans performed on patients with a clinical diagnosis of sinusitis who had undergone diagnostic nasal endoscopies and medical treatment prior to surgery. 86% of the scans showed abnormal mucosal thickening. The ethmoids were affected in 73% and the maxillary sinus in 64%. Pneumatization of the middle turbinate was a common variant and when present was associated with anterior ethmoid disease in 60% of patients. Anterior ethmoid inflammatory changes were demonstrable in 95% of patients with maxillary sinus disease. Direct coronal CT can readily demonstrate disease in the infundibulum, frontal recess and posterior ethmoids in the same orientation confronting the endoscopist, and helps in the planning of ethmoidal surgery. Following surgery the sinuses can be directly inspected in outpatients which reduces the need for any further plain radiographs. It is important that the diagnosis of sinusitis is not based on CT findings alone as isolated areas of mucosal thickening are common in the normal population.     

鼻鼻窦解剖变异与慢性鼻窦炎的关系

量化研究鼻鼻窦解剖变异与慢性鼻炎的发病的关系。用自行开发计算机图像分析系统定量分析９１例慢性鼻窦炎患者的冠状位鼻窦ＣＴ，观测指标包括：骨性解剖结构变异，筛漏钹突角度，筛泡等，测量相应结构的冠状位截面积，角度，长度。     

鼻窦炎患者鼻窦骨结构变异和鼻窦粘膜异常的CT扫描分析

对109例临床疑为鼻窦炎患者的CT冠状扫描结果进行了分析,鼻窦粘膜异常改变者93例(85.3％),16例粘膜呈正常影像(14.7％),93例鼻窦粘膜异常改变者中,发现鼻窦骨结构变异60例(64.5％)。通过对鼻窦骨结构变异和鼻窦炎情况的观察分析,认为鼻窦骨结构变异可能是鼻窦炎致病因素之一。鼻窦粘膜异常以前组筛窦和上颌窦发生率最高,同时伴有窦口鼻道复合体粘膜异常,支持了鼻窦口引流障碍可以继发鼻窦炎的观点。作者认为采用鼻窦CT冠状扫描对判断鼻窦炎的病因和临床诊断具有重要意义。     

窦口鼻道复合体区解剖变异影像分析及与鼻-鼻窦炎的关系

目的 用高分辨率CT对鼻腔鼻窦炎进行影像学分析,探讨窦口鼻道复合体(OMC)区的解剖变异与儿童鼻窦炎、成人慢性鼻-鼻窦炎的关系。 方法 回顾性分析有明显临床表现且经CT扫描确诊为慢性鼻-鼻窦炎167例的临床资料,年龄4~74岁,并将其影像学资料分为儿童组和成人组,并对其分析结果进行比较。 结果 (1)儿童组和成人组的窦腔炎症最常累及上颌窦、前组筛窦和额窦;(2)儿童组的窦口鼻道复合体区解剖变异与慢性鼻-鼻窦炎的发生没有明显关系,而成人组的窦口鼻道复合体区解剖变异与慢性鼻-鼻窦炎的发生关系显著(P<0.05)。 结论 窦口鼻道复合体区的解剖变异对儿童慢性鼻-鼻窦炎的发生不如对成人的影响大,儿童慢性鼻-鼻窦炎的诊断和手术指征不能单凭异常的鼻窦CT扫描图作为惟一依据,应该切实联系临床症状。     

CT检查在真菌性鼻窦炎术前诊断的意义

目的 探讨CT检查在真菌性鼻窦炎术前诊断中的意义。方法 对67例真菌性鼻窦炎患者CT改变、临床表现和术中所见进行回顾性对比分析。结果 CT表现为：鼻窦充填密度不均软组织影29例,术前明确诊断为真菌性鼻窦炎12例;窦内充填软组织影伴散在不规则钙化灶34例,术前均明确诊断为真菌性鼻窦炎;上颌窦内壁吸收破坏21例,术前明确诊断为真菌性鼻窦炎14例：筛顶骨壁吸收破坏2例,术前均明确诊断为真菌性鼻窦炎：上颌窦骨壁出现增生硬化19例,术前明确诊断为真菌性鼻窦炎14例。67例中CT诊断鼻窦炎症60例,其中46例术前临床初诊为真菌性鼻窦炎,7例为上颔窦／筛窦肿物或占位性变。结论 窦腔内散在斑块状钙化的软组织充填是真菌性鼻窦炎CT诊断的主要征象,其它的CT表现常会导致术前误诊。虽然真菌性鼻窦炎的确诊有赖于病理学检查,但CT在其诊断中仍具有重要参考价值,并且是显示鼻窦解剖结构和病变范围的较好方法。     

Unilateral pathological lesions of paranasal sinuses removed by endoscopic surgery

Introduction

The aim of this study was to analyze the incidence and nature of unilateral pathological lesions of paranasal sinuses in patients who had endoscopic sinus surgery performed in ENT. Materials and methods: In the years 2006–2011 endoscopic sinus surgery for unilateral pathological lesions of paranasal sinuses was performed in 1847 patients (838 women and 1009 men). The enrollment of patients was based on the findings of otolaryngological clinical and subjective examinations, assessment of the paranasal sinuses on three-dimensional CT scans, and laboratory examinations. Based on the analysis of medical history data, including gender, age, the type of surgical procedure performed, and histopathological findings the cases were finally analyzed.

Results

Pathological lesions of the paranasal sinuses were localized on the left side in 132 (57%) patients, and on the right side in 100 (43%) patients. Of the 232 patients with unilateral pathological changes, 41.8% subjects underwent endoscopic sinus surgery for polypotic changes in the ethmoid and maxillary sinuses; 28.4% for the maxillary sinus; 10.8% for the ethmoid, maxillary and frontal sinuses; and 8.6% patients for all paranasal sinuses on one side. The number of operations of only one sinus was considerably lower: sphenoid sinus, 4.7%; ethmoid sinus, 2.2%; and frontal sinus, 1.7% patients. The histopathological analysis of unilateral pathological lesions removed by endoscopic surgery showed chronic paranasal sinusitis with polyps in 56.5% patients; chronic paranasal sinusitis in 22.8% patients; and maxillary sinus cyst was confirmed in 11.6% patients. In 5.1% patients inverted papilloma was diagnosed and in 2.2% patients the presence of osteoma was found.

Conclusions

Unilateral paranasal pathological lesions, leaving aside rather typical maxillary sinus cysts, require a particularly thorough pre-operative diagnosis and a precise histopathological assessment.     

Computed tomography evidence of dental restoration as aetiological factor for maxillary sinusitis

Maxillary sinusitis due to dental causes is usually secondary to periodontal disease or periapical infection and is commonly associated with mucosal thickening of the floor of the maxillary antrum. Computed tomography (CT) is currently the modality of choice for evaluating the extent of disease and any predisposing factors in patients with symptoms of chronic maxillary sinusitis, but it is unable to diagnose dental disease reliably. The presence of restorative dentistry is, however, easily seen at CT and is associated with both periapical and periodontal disease. We aimed to determine whether its presence at CT may predispose to maxillary sinusitis, and in particular to focal mucosal thickening of the sinus floor characteristic of dental origin. Three hundred and thirty maxillary sinus CT images in 165 patients were reviewed for the presence of restorative dentistry in the adjacent teeth, focal maxillary sinus floor mucosal thickening, any maxillary sinus disease (including complete opacification, air fluid levels, diffuse mucosal thickening, focal mucosal thickening) and evidence of a rhinogenic aetiology (osteomeatal complex pathology, mucosal thickening in other sinuses). One hundred and ninety two sinuses adjacent to restorative dentistry and 178 sinuses not adjacent to restorative dentistry were analysed. Focal floor thickening both with, and without, evidence of a rhinogenic aetiology, was significantly more common adjacent to restorative dentistry. Maxillary sinus disease overall was no more common adjacent to restorative dentistry. This work demonstrated that the presence of restorative dentistry predisposes to focal mucosal thickening in the floor of the maxillary sinus and its presence should prompt clinical and radiographical assessment to exclude dental disease as a source of chronic maxillary sinusitis.     

Anatomic risk factors for sinus disease: fact or fiction?

BACKGROUND: Sinonasal anatomic variants have been postulated as a risk factor for sinus disease. Therefore, a study was conducted to examine the correlation of sinus disease to septal deviation, concha bullosa, and infraorbital ethmoid cells. METHODS: Two hundred fifty consecutive sinus and orbital computed tomography scans were examined at the University of Virginia over a 2-year period. Coronal, sagittal, and axial views were examined for the presence and size of concha bullosa and infraorbital ethmoid cells. Septal deviations were measured by examining the width of the nasal cavity at the level of the maxillary sinus ostium. The severity of mucosal thickening in the maxillary, ethmoid, and frontal sinuses was recorded. The correlation between mucosal disease of the sinuses to the anatomic variants was then compared. RESULTS: Computed tomography images were reviewed in 250 consecutive studies (500 sides). Of the 500 sides, 67.2% of sides had some level of mucosal thickening. Concha bullosa and infraorbital ethmoid cells were both present in 27% of the sides. Concha bullosa was associated with maxillary sinus disease (p < 0.01). Infraorbital ethmoid cells were associated with both ethmoid (p < 0.05) and maxillary (p < 0.01) mucosal disease. Frontal sinus disease had no significant correlation with these anatomic variants (p > 0.05). For sinuses with infraorbital ethmoid cells or concha bullosa, there were a higher number of diseased sinuses with larger anatomic variants (p < 0.01). Narrow nasal cavities were associated with maxillary sinus disease (p < 0.01). CONCLUSION: Septal deviations, concha bullosa, and infraorbital ethmoid cells, which contribute to the narrowing of the osteomeatal complex, are associated with mucosal disease.     

Coronal CT scan abnormalities in children with chronic sinusitis

Coronal computed tomography (CT) scans are currently the optimal study to display the normal and abnormal anatomy in children with chronic and recurrent acute sinusitis after failure of medical therapy. To assess the extent and distribution of disease as well as associated anatomic abnormalities in this pediatric population, 74 coronal CT scans of children with continued symptoms of sinusitis after failure of extensive medical therapy were reviewed retrospectively. Twelve children with cystic fibrosis showed the characteristic features of medial displacement of the lateral nasal wall in the middle meatus and uncinate process demineralization, creating the appearance of a maxillary sinus mucocele. Nine of these 12 children had increased attenuation in the maxillary sinus on soft-tissue windows. In the remaining 62 children, a significantly greater frequency of disease, when compared with that reported for adults, was seen in the maxillary, anterior ethmoid, posterior ethmoid, and frontal sinuses. Children with asthma (n = 33) had more extensive disease. Bony anatomic abnormalities were similar to those reported for adults, except for a lower incidence of septal deformity.     

Correlation between bacteriology and computed tomography staging for chronic sinusitis

In this study we report on the correlation between bacteriology and disease severity staging by computed tomography (CT) for chronic sinusitis. When patients with chronic sinusitis underwent functional endoscopic sinus surgery (FESS), swab specimens were taken from the ipsilateral middle meati and ethmoid sinuses under endoscope guidance. The severity of chronic sinusitis was evaluated by pre-operative CT scans. The CT scans were staged by the Lund and Mackay system. The scores for the frontal, anterior ethmoid and maxillary sinuses and for the ostiomeatal complex were added.The culture rates were correlated with the added scores. Between November 1998 and January 2003, 79 pairs of specimens were collected from 79 patients whose CT scans were done within a day before FESS. The culture rates of middle-meatus specimens were moderately correlated with the scores, but those of ethmoid sinus specimens were negatively correlated with the scores. If Staphylococcus epidermidis and corynebacteria were considered normal flora, the bacteriology of the middle meatus was highly correlated with the CT scores. This study shows that culture rates of middle-meatal specimens tended to increase with the severity of chronic sinusitis.     

眶上筛房在CT和鼻内镜下的临床特征

目的通过分析眶上筛房在CT和鼻内镜下的临床特征，进一步阐明眶上筛房和额窦引流通道的关系。方法通过术前评估冠状位和水平位CT和术中鼻内镜所见，确诊眶上筛房5侧（男4例，女1例，每例1侧）。结果①眶上筛房在冠状位CT上表现为额窦区域最外侧的气房；②眶上筛房在水平位CT上表现为额窦后外方的气房；③鼻内镜下见额窦和眶上筛房均引流至前筛顶部，眶上筛房的引流通道位于额窦引流口的后外方，眶上筛房向外上方气化，从后方进入额窦。结论CT和鼻内镜观察证实眶上筛房是位于筛泡上方的气房向上、向外延展过程中，超过了筛骨眶板和筛顶的范围，导致额骨眶板气化而成。     

Bony abnormalities of the paranasal sinuses in patients with Wegener's granulomatosis

Wegener's granulomatosis is a systemic vasculitis that can affect any organ system, but primarily involves the upper and lower respiratory tracts and the kidneys. Chronic sinusitis is a well-known clinical feature of the disease. Mucosal abnormalities of the nose and paranasal sinuses have been well-characterized and range from granulomatous lesions to diffuse mucosal thickening. In contrast, abnormalities of the underlying bone of the paranasal sinuses in this disease have not been well-described, and reports have been limited. To characterize bony abnormalities of the nose and paranasal sinuses in patients with Wegener's granulomatosis, we performed a retrospective review of all patients with Wegener's granulomatosis who underwent a sinus CT scan at our institution between 1989 and 1999. Nine patients were identified. A total of 22 distinct bony abnormalities were identified in 5 patients. Specific bony findings included bony erosion and destruction of the septum and turbinates; erosion of the ethmoid sinuses; neo-osteogenesis of the maxillary, frontal, and sphenoid sinuses; and complete bony obliteration of the maxillary, frontal, and sphenoid sinuses. Although these findings are suggestive of Wegener's granulomatosis, they are not pathognomonic. Bony changes on sinus CT scan may provide radiologic evidence of underlying Wegener's granulomatosis when clinical suspicion is high.     

Utility of sagittal reformatted computerized tomographic images in the evaluation of the frontal sinus outflow tract

BACKGROUND: Anatomic and mucosal obstruction of the frontal sinus outflow tract (FSOT) can result in frontal sinusitis often associated with frontal headache. Thorough evaluation of symptomatic patients requires axial and coronal computerized tomographic (CT) scans of the paranasal sinuses (PNS). With the advent of multichannel multidetector CT scanning, the availability of high-quality sagittal images has become increasingly widespread. However, the utility of these images in the assessment of FSOT patency has not yet been established. METHODS: A retrospective review of coronal and sagittal images from 25 PNS CT scans (50 sides) were randomized, blinded, and independently evaluated by two neuroradiologists. FSOT obstruction by agger nasi cells, the ethmoid bulla, and mucosal disease was assessed. A degree of confidence was rendered for each of these findings. The results were then compared against a consensus diagnosis, which was rendered based upon simultaneous reading of the coronal and sagittal images. Generalized estimating equations were used to assess the difference between sagittal and coronal images in terms of reader confidence and diagnostic concordance with the consensus. RESULTS: Review of sagittal images had a higher degree of concordance with the consensus than did coronal images, and was highest for mucosal disease. Both readers were more confident in rendering a diagnosis based upon the sagittal images. CONCLUSION: Sagittal reformatted CT images of the PNS are helpful in the radiologic evaluation of the FSOT. Experienced neuroradiologists had a higher degree of confidence in the diagnosis of the obstruction of the FSOT using sagittal reformatted images.     

Is there a correlation between radiographic and histologic findings in chronic sinusitis?

OBJECTIVE: To determine if the degree of radiologic changes noted on computed tomography (CT) scan correlate with the severity of histologic changes. DESIGN: Retrospective analysis. SETTING: Academic tertiary care centre. METHODS: Sixty consecutive patients undergoing endoscopic sinus surgery for chronic sinusitis, with complete data obtained for 131 sinuses. MAIN OUTCOME MEASURES: Paranasal sinus CT scans and pathologic reports were examined. Respective findings were graded as mild, moderate, or severe, and the results were analyzed for agreement. CT scan grading was based on the extent of sinus opacification and pathologic grading was determined by the number of inflammatory cells found in the sinus mucosa. RESULTS: Of the 51 ethmoid sinuses, agreement between the radiographic and histologic grading occurred in 32 or 62.7%. In the maxillary group, a 57.1% (24 of 42) correlation was noted. Of the 20 frontal sinuses, agreement occurred in 8 or 40%, whereas a 22.2% (4 of 18) correlation was present in the sphenoid group. CONCLUSION: This study suggests that the severity of sinus disease based on preoperative CT scan does not correlate with the histologic degree of disease.     

Ethmomaxillary sinus

Ethmomaxillary sinus is a variation of the posterior ethmoid cells. It is formed by the extension of the posterior ethmoid cells into the maxillary sinus and drains into superior nasal meatus. It is incidentally seen on paranasal sinus computerized tomography (CT) scans. Its prevalence has been reported as 0.7 and 2% in two studies. In this study, paranasal CT scans of 466 patients were investigated for the presence of ethmomaxillary sinus. The patients had paranasal CT with the preliminary diagnoses of septal deviation, chronic inflammatory paranasal sinus disease and nasal turbinate disorders. The ethmomaxillary sinus was present in nine of those patients (1.93%). It was septated in one of them. The CTs were further investigated for other anatomical variations and co-existent mucosal disease of the paranasal sinuses.     

A comparative study of the ciliary area of the maxillary sinus mucosa and computed tomographic images

The ciliary area of the maxillary sinus mucosa and coronal sinus computed tomographic (CT) scans were studied in 36 maxillary sinuses of 28 patients with chronic sinusitis. Tissue specimens allowed ciliary surfaces to be observed under scanning electron microscopy, allowing surfaces to be expressed in terms of ciliary area (CA) as the percentage of mucosal surface occupied by cilia. The opacity produced by mucosal swelling and secretion in the maxillary sinus on CT was assessed by two methods: Min’s and modified van der Veken’s methods. Both techniques indicated an inverse correlation between opacity of the maxillary sinus and CA. Our findings suggest that the opacity of maxillary sinus on CT could be a significant parameter for predicting the surface conditions of ciliated maxillary mucosa prior to sinus surgery. Received: 3 February 1997 / Accepted: 19 June 1997     

MRI of the paranasal sinuses: incidental abnormalities and their relationship to symptoms

Magnetic resonance imaging is able to demonstrate a wide range of sinus abnormalities. Incidental findings in patients referred for neuroradiology because of suspected intracranial pathology are surprisingly common and were present in 37.5 per cent of 483 images examined. The maxillary and ethmoid sinuses were most commonly affected with 27 and 26 per cent of images abnormal whereas the frontal and sphenoid sinuses were less commonly affected with 5 per cent of each abnormal. If minor changes were excluded then 17 per cent of patients had either fluid, a polyp or marked mucosal thickening in at least one sinus. Nasal symptoms, other than the presence of a cold, showed no statistically significant relationship to abnormal findings. Many people with inflammatory changes in their sinuses demonstrated on MRI do not have symptoms classically attributed to sinusitis.     

Comparison of Histopathological and CT Findings in Experimental Rabbit Sinusitis

The aim of this study was to investigate and compare histopathological and computerized tomographic (CT) findings of experimental acute sinusitis in an animal model. The noses of five healthy rabbits were inoculated with a gelatin sponge impregnated with a solution containing Staphylococcus aureus, and one healthy rabbit acted as the control. The animals were sacrificed on the tenth day, following the acquisition of paranasal CT scans. Specimens were obtained from the lateral nasal walls, and the ethmoid and maxillary sinuses of the animals for histopathological examination. Histopathological and CT findings were compared. Various degrees of epithelial disorganization, foci of ruptured epithelial cells, and inflammatory cell infiltration in the lamina propria were seen in the histopathological examinations of the five study rabbits, and mucosal thickening and soft tissue density were noted in their CTs. There was no correlation between the histopathological and CT findings. It was shown that CT did not reflect the acute changes in the sinus mucosa. Patients with chronic sinusitis must be evaluated for a chronic process. Computerized tomographic scans should not be obtained in acute sinusitis cases. In this way, both unnecessary radiation exposure and economic waste can be avoided.     

Surgical treatment of chronic recurrent sinusitis--the Caldwell-Luc versus a functional endoscopic technic

More than 50 patients who underwent intranasal or radical (Caldwell-Luc) antrostomy for chronic recurring sinusitis and who had still the same symptoms as before the operation, were examined by endoscopy and polytomography/CT. More than 50% still had polypoid changes of the maxillary sinus mucosa. No correlation was found between the degree of the patient's symptoms and the degree of the maxillary sinus pathology or the patency of the naso-antral window. CT demonstrated anterior ethmoid disease in all of the patients, correlating well with the endoscopic findings and the patient's symptoms. This again proves that the anterior ethmoid holds the key position for re-infection or cure of the larger dependent sinuses. Functional endoscopic sinus surgery therefore aims at the primary infective foci in the anterior ethmoid and usually cures disease in the larger sinuses without an attack upon the latter sinuses.     

A-mode ultrasound in the diagnosis of chronic polypous sinusitis

A-mode ultrasound (A-US) is a simple, non-invasive and non-ionizing method for detecting fluid or even mucosal swelling in inflamed maxillary and frontal sinuses. A-US has been shown to be a quite reliable tool in the diagnosis of acute maxillary sinusitis. However, controversy still exists over the reliability of A-US in detecting fluid retention or mucosal swelling in patients suffering from chronic polypous rhinosinusitis or in transantrally operated maxillary sinuses. We have compared the results of maxillary sinus A-US with computed tomography (CT) images in a selected series of chronic polypous rhinosinusitis comprising 40 patients. Fluid retention was seen in 20 of 79 maxillary sinuses on CT scanning. Only 6 of these 20 retentions were detected with A-US. There were 11 false positive findings. In six of these cases a back-wall echo was received through polypoid masses in the sinus. Mucosal swelling was also difficult to diagnose. The results of A-US were not easily reproduced; only in 50% of cases were identical results obtained by two investigators. We do not recommend the use of A-US to diagnose fluid retention or mucosal swelling in a patient with chronic mucosal changes in the maxillary sinus or if surgery has been performed on the anterior wall of the maxillary sinus.