New data on nasal morphology and morphological structure of paranasal sinuses

The authors summarize the results of investigations of specific anatomical features of paranasal sinuses in more than 12,000 subjects. The patients with suspected cerebral pathology and lesions in the paranasal sinuses were examined using computed tomography. Structural variants of ethmoid bone and ethmoidal labyrinth, nasal septum, maxillary, frontal, and sphenoidal sinuses are described. The morphometric analysis revealed the zonal relationship between different structures of nasal mucosa and the new variants of regulatory structures in the cavernous sinus vessels.     

Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses

A prospective analysis of 666 patients was performed to examine the prevalence of radiologic abnormalities of the paranasal sinuses in asymptomatic adults. The initial sample group included 1000 patients who were referred for cranial computed tomographic scans for conditions such as head injuries and seizures. Patients in whom there was clinical suspicion of sinus disease were excluded from the study. A questionnaire was completed by each patient and cranial computed tomography, including magnetic resonance imaging of the paranasal sinuses, was performed. Abnormality of one or more of the paranasal sinuses was reported in 42.5% of scans. Mucosal thickening in the ethmoid sinus was the abnormality most often identified. The high frequency of reported radiologic abnormalities in asymptomatic patients highlights the importance of correlation with the clinical presentation when interpreting computed tomographic scans of the paranasal sinuses.     

Nasal polyposis (or chronic olfactory rhinitis)

The concept of chronic rhinosinusitis with or without polyps is founded on the structural and functional unicity of the pituitary mucosa and its united response to environmental aggression by allergens, viruses, bacteria, pollution, etc. The present review sets this concept against the evo-devo three-nose theory, in which nasal polyposis is distinguished as specific to the olfactory nose and in particular to the non-olfactory mucosa of the ethmoid, which is considered to be not a sinus but rather the skull-base bone harboring the olfactory mucosa. The evo-devo approach enables simple and precise positive diagnosis of nasal polyposis and its various clinical forms, improves differential diagnosis by distinguishing chronic diseases of the respiratory nose and those of the paranasal sinuses, hypothesizes an autoimmune origin specifically aimed at olfactory system auto-antigens, and supports the surgical concept of nasalization against that of functional sinus and ostiomeatal-complex surgery. The ventilation function of the sinuses seems minor compared to their production, storage and active release of nitric oxide (NO) serving to oxygenate arterial blood in the pulmonary alveoli. This respiratory function of the paranasal sinuses may indeed be their most important. NO trapped in the ethmoidal spaces also accounts for certain radiographic aspects associated with nasal polyposis.     

CT diagnosis of polypous rhinosinusitis

Patients with diseases of the nasal cavity and paranasal sinuses (PNS) were examined with computed tomography (CT) with subsequent estimation of the area of the ethmoid bone sinuses (EBS) using Contour program. CT detected the following changes: total area of EBS in polypous rhinosinusitis (PRS) was 12-26 cm2 versus 42-51 cm2 in healthy subjects. In ostiomeatal complex pathology total cell area was 30-41 cm2 while area of at least one EBS group was subnormal and corresponded to sinus area in PRS. Conduction of PNS CT with subsequent calculation of EBS area detects patients with defective structure of the ostiomeatal complex predisposed to development of PRS and allows early surgical correction of anomalous group of EBS.     

Primary adenocarcinoma of the frontal sinus

When tumor involvement of the frontal sinus occurs, it is usually the result of the direct spread of the mass from the nasal cavity or anterior ethmoid sinuses. Primary frontal sinus tumors are extremely rare. We describe a case of primary adenocarcinoma of the frontal sinus in a 53-year-old man. The patient refused surgery, so he was treated with chemotherapy followed by radiotherapy. At the 1-year follow-up, only a slight reduction of the swelling was noted. Thereafter, he was lost to follow-up. This case represents a typical example of a paranasal cancer extending beyond the bony margins, with a silent onset that simulated benign disease. The best hope for an early diagnosis of such a tumor lies in the greater use of computed tomography to assess chronic rhinosinusitis.     

Anatomic variations of the paranasal sinuses: CT examination for endoscopic sinus surgery

Chronic rhinosinusitis endoscopic surgery requires an accurate evaluation of diseases and paranasal sinus anatomic variations. This study aims to show the main anatomical variations in the ostiomeatal complex and paranasal sinuses which are usually depicted by computed tomography (CT). CT scans obtained 2 mm thickness in axial and coronal plane from a series of 200 patients with chronic sinusitis were examined to determine the prevalence of anatomic variants. Anatomical variations determined were supraorbital recess in 6%, concha bullosa in 30%, sphenomaxillary plate in 17%, infra-orbital ethmoid cells (Haller's cells) in 6%, spheno-ethmoid cells (Onodi's cells) in 12%, pneumatization of the anterior clinoid process in 6%, carotid artery bulging into the sphenoid sinus in 8%, pneumatization of the uncinate process in 2%, paradoxical curvature of the middle turbinate in 3% and septal deviation in 36%. Level difference between the ethmoid roof and nasal vault was an average of 8 mm in right side and 9.5 mm in left side. Awareness of these different variations will help the rhinologic surgeon in his orientation during endoscopic surgical procedures.     

Acute invasive fungal rhinosinusitis--case report

A case report of acute invasive fungal rhinosinusitis in 28 year old woman with acute myeloid leukemia is described in this paper. The diagnosis of the fungal disease was based on clinical presentation, endoscopic evaluation of nasal cavity, computed tomography and magnetic resonance imaging of the paranasal sinuses and histopathological findings. An aggressive treatment including antifungal therapy (amphotericin B), antibiotics and the surgery of paranasal sinuses was implemented. Unfortunately the underlying disease and the fungal invasion progressed rapidly and the patient died on the forth week post-op due to cardiorespiratory failure.     

Endoscopy‐Negative,Computed Tomography‐Negative Facial Pain in a Nasal Clinic

Objectives To establish the etiology of facial pain in individuals attending the nasal clinic of the Department of Otorhinolaryngology, University Hospital, Nottingham, U.K., with normal nasal endoscopy and computed tomography of the paranasal sinuses. Study Design A retrospective analysis of a cohort of 973 patients consecutively presenting to the nasal clinic with symptoms of rhinosinusitis and/or facial pain. Methods We reviewed the case notes of 973 consecutive patients who presented to the nasal clinic with either symptoms of rhinosinusitis or facial pain, and in particular 101 who had facial pain without any objective evidence of nasal disease as detected by nasal endoscopy or computed tomography. The diagnosis was based on the outcome and response to treatment after a mean of 2 years 2 months. Results One hundred one patients had pain as a predominant symptom with normal nasal endoscopy and computed tomography of the paranasal sinuses. None of these patients responded to either medical or surgical treatment for what some workers have hypothesized could be “occult” sinonasal disease. A neurological diagnosis was made in 99 patients. Eighty patients received successful medical treatment for “neurological” diagnoses, 8 patients experienced spontaneous resolution of their symptoms, 7 failed to respond to any treatment modality, 2 were lost to follow‐up, and 2 refused any treatment. Conclusion The majority of patients presenting to a rhinologic clinic with facial pain and no objective evidence of sinus disease, as detected by endoscopy and computed tomography, responded well to neurological treatment and surgical intervention was unnecessary. These patients should receive a trial of medical therapy, such as low‐dose amitriptyline for 6 weeks in the first instance, before any surgical intervention is considered.     

Study of ethmoid sinus involvement in multibacillary leprosy

The nasal mucosal involvement in lepromatous leprosy is well recognized. Currently interest has centred around the involvement of paranasal sinuses in leprosy. They act as a reservoir and constant source of reinfection to the nasal mucosa. In the present prospective study 25 untreated patients with multi-bacillary leprosy were included. Clinical examination, computed tomography (CT) scan of paranasal sinuses, ethmoid sinus endoscopy and biopsy were carried out in all patients, to investigate the involvement of the paranasal sinuses in leprosy. Ethmoid sinus involvement was noted in 20 patients on CT scan. Bilateral involvement was more common (65 per cent). Anterior ethmoids were more commonly affected (65 per cent). On ethmoid sinus endoscopy abnormal mucosa was noted in 17 patients (68 per cent). Ethmoid sinus biopsy was confirmative in 16 patients (64 per cent). Statistically significant correlation was found between CT findings, sinus endoscopy and sinus biopsy findings.     

Radiologic diagnosis of inflammatory and tumorous disorders of the paranasal sinuses

In a retrospective study, 158 patients with therapy resistant symptoms of paranasal sinus affections were investigated with conventional tomography, 39 patients in addition underwent computed tomography (CT) examination. From conventional tomography films, inflammatory affections limited to the paranasal sinuses were clearly diagnosed in 99%, and benign tumours in 76%. The dignity of malignant neoplasms was correctly recognized in 100%. CT provided additional information in 10% with regard to bone destruction, in 28% with regard to brain involvement, and in 17% with regard to tumour extension into the orbita. Considering the precise diagnosis and economical factors, conventional tomography is indicated as the primary investigation procedure in the evaluation of inflammatory and benign disease of the paranasal sinuses. CT gives definite additional information in cases of suspected bone destruction and in affections extending beyond the paranasal sinuses because of its more detailed depiction of the paranasal sinus structures.     

The relationship between anatomical variations of the sino-nasal region and chronic sinusitis extension in children

OBJECTIVE: To report the prevalence of paranasal sinus anatomic variations and their relationship with the extent of chronic sinusitis in pediatric population. METHOD: This is a prospective study of all the cases of persistent pediatric chronic sinusitis despite medical therapy that presented to the otolaryngology clinics of King Abdullah University Hospital in Irbed, Jordan, and had coronal computed tomography examination of the nose and paranasal sinuses as part of their diagnostic or preoperative work up, between the periods of April 2006 and August 2007. Sixty-five cases met inclusion criteria and were analyzed. Cases were further subdivided into three groups according to age. Group 1: with ages from 5 to 7 years; group 2: ages 8-12; and group 3: above 12 years. The scans were analyzed for the presence of anatomical variations, and disease extension. Correlation between anatomical variations and disease extension was the primary outcome measure. RESULTS: There were 30 boys and 35 girls with an average age of 11.4 (age ranges from 5 to 16). The maxillary sinus was the most commonly involved sinus, followed by the ethmoid, sphenoid, and frontal sinuses. Agger nasi cell was the most common anatomical variation, followed by concha bullosa of middle turbinate. The frequency of most of these variants differed widely between groups 1 and 2, groups 1 and 3, but not between groups 2 and 3. No significant correlation was found between these anatomical variants and the extent of chronic sinusitis. CONCLUSION: Anatomical variations in the nose and paranasal sinuses are common in children with chronic sinusitis. Although the prevalence of these variations changes during childhood development they are unlikely to predict the extent and severity of chronic rhinosinusitis in pediatric age group.     

The ethmoid sinus. Plain film and tomographic radiology

Plain films from the routine paranasal sinus examination are used to identify the area occupied by the ethmoid sinuses. Thin-section tomography in coronal and lateral projections illustrates the detailed ethmoid anatomy. These studies are used to illustrate the most common abnormalities of the ethmoid sinuses and demonstrate the basic radiologic signs of disease.     

Effect of a topical vasoconstrictor on computed tomography of paranasal sinus disease

Apparent ethmoid inflammation which resolved with alternation of the nasal cycle or following application of topical vasoconstrictors has been observed with magnetic resonance imaging. A similar phenomenon might occur to a lesser degree with computed tomography (CT), leading to overdiagnosis of limited sinus disease. The degree to which ostiomeatal complex disease is reversible by topical vasoconstrictors was investigated. Ten patients with histories of chronic or recurrent sinusitis underwent coronal CT studies of the paranasal sinuses before and after the application of a topical vasoconstrictor. Mucosal volume or thickness measurements were obtained from the turbinates, infundibulum, ethmoidal cells, and antrum. Vasoconstrictor application markedly reduced turbinate size and appeared to reduce mucosal thickening in the ethmoidal infundibulum. Minimal mucosal changes identified in the paranasal sinuses by computed tomography were not reversed by vasoconstrictors and therefore are likely to be pathologic.     

Paranasal sinus disease could be a reason for unsuccessful immunotherapy of inhalant allergy in children

PurposeThe aim of this study was to evaluate the role of paranasal sinuses condition assessed in computed tomography on inhalant allergen desensitization effects.Materials & methodsRetrospective analysis of medical records of children undergoing allergen immunotherapy in outpatient otolaryngology clinic of University Children Hospital in Lublin was performed. Control group consisted of children who underwent allergen immunotherapy and obtained satisfying effects; study group consisted of children who did not experience significant improvement after desensitization therapy.ResultsComputed tomography of nose cavity and paranasal sinuses exposed numerous pathologic changes affecting both, control and study group. Blockage of ostiomeatal complex was twice more common in children who did not respond adequately to desensitization therapy. In our study group, radiological findings suggesting rhinosinusitis were found in 73% of patients, while retention cysts in maxillary sinuses were discovered in 27% of patients.ConclusionsPathological findings in paranasal sinuses in computed tomography may arise from uncontrolled allergic rhinitis. If chirurgical management is indicated, allergen immunotherapy should be postponed until total recovery from operational procedure and repeated.     

A stereological study on the correlation of inferior turbinate hypertrophy and paranasal sinus disease

The objective of this study is to investigate the correlation between inferior turbinate size and paranasal sinus opacification on computerized tomography (CT) scans. Paranasal sinus CT scans of a total of 185 patients (92 males, 93 females) were examined in terms of sinus opacification. Sizes of the inferior turbinates were measured using stereological method and these sizes in normal and opacified paranasal sinuses are compared using one-way analysis of variance. Scans of 185 patients (93 female, 92 male) aged between 12 and 84 (mean 37.85 ± 16.27) years were examined in this study. Sizes of the inferior turbinates were found to be increased significantly in case of opacification of ipsilateral maxillary and anterior ethmoid sinuses (p = 0.000 and p = 0.4, respectively) on both sides. On the other hand, such a relationship could not be demonstrated for sizes of inferior turbinates with opacified or non-opacified posterior ethmoid, frontal and sphenoid sinuses. In conclusion, the combination of CT and the Cavalieri principle can provide an unbiased, direct, and assumption-free estimate of the regions of interest. The presented method can be efficiently applied without any need for special software, additional equipment, or personnel than that required for routine CT in daily use. Paranasal sinus disease, especially the inflammatory diseases of maxillary and anterior ethmoid sinuses, must be carefully investigated in cases with inferior turbinate hypertrophy.     

Computed tomographic evaluation of multiple mucocoeles of paranasal sinuses

There are some cases in which mucocoeles of the paranasal sinuses are multiple and their structures are complicated. When the mucocoeles are multiple, pre-operative evaluation is especially important for correct surgical management. We describe the usefulness of computed tomography for the evaluation of multiple mucocoeles of the paranasal sinuses.     

鼻腔鼻窦软骨肉瘤9例临床分析

目的：提高对发生于鼻腔鼻窦的软骨肉瘤的诊治水平。方法：回顾性分析9例鼻腔鼻窦软骨肉瘤患者的临床资料。结果：鼻腔鼻窦软骨肉瘤的临床病理特征复杂且差别较大，4例继发性鼻腔鼻窦软骨肉瘤患者比原发性患者病变广泛且接近颅底，预后较差，不规则的斑块状钙化点是本病典型的影像学特点。9例均是经行部分或全部肿块切除后病理确诊，病理学分级以I级多见。结论：结合既往史，临床表现和CT检查，尽早手术探查行部分或全部肿块切除术有助于早期诊断和提高疗效。     

Hemangioma of the sphenoid and ethmoid sinuses: two case reports

Hemangiomas of the paranasal sinuses are rare, particularly those of the sphenoid and ethmoid sinuses. Although imaging of the sinuses is key to determining the extent of involvement, the diagnosis is based on the lesion's histologic appearance. Obtaining an adequate biopsy can be difficult in light of the risk of bleeding and the relative inaccessibility of lesions in this region. These obstacles can make the diagnosis and management of these lesions particularly challenging. We describe two new cases of sinonasal hemangioma--one in the ethmoid sinus and one in the ethmoid and sphenoid sinuses--and we discuss the diagnostic and therapeutic interventions that are needed to manage these lesions.     

Microscope and endoscope-assisted surgery of inflammatory diseases of the paranasal sinuses. Value of the Messerklinger infundibulotomy

Insights into the importance of the infundibulum of the anterior ethmoid bone in the etiology and pathogenesis of chronic paranasal sinusitis, based above all on the studies of Messerklinger, have resulted in a fundamental change in our concept of therapy: the main objective of any treatment must be the restoration of ventilation and drainage of the paranasal sinuses in the region of the semilunar hiatus. Its function in the healing of paranasal sinus diseases parallels the significance of the Eustachian tube for the healing of inflammatory lesions of the middle ear. In many cases, the objective is attained by infundibulotomy, using Messerklinger's technique. Our technique differs from that described by Messerklinger and Wigand: we use the surgical microscope and a self-retaining nasal speculum. It is thus possible to operate with both hands, as in microsurgery of the ear and the larynx. Moreover, the operations can be taught and learned via an observation tube. Since the introduction of this technique which can be extended at any time to complete endonasal surgery of the maxillary, ethmoid and sphenoid sinuses, extranasal operations on the paranasal sinuses have become exceedingly rare. The results have been checked in a newly established paranasal sinus clinic.     

Functional endoscopic sinus surgery

Summary The Messerklinger technique is a primarily diagnostic endoscopic concept demonstrating that the frontal and the maxillary sinuses are subordinate cavities. Disease usually starts in the nose and spreads through the ethmoidal prechambers to the frontal and maxillary sinuses, with infections of these latter sinuses thus usually being of secondary nature. Standard rhinoscopy and sinus X-rays are frequently not sufficient to demonstrate the underlying causes for chronic or recurring acute sinusitis in the clefts of the anterior ethmoidal sinuses. The combination of diagnostic endoscopy of the lateral nasal wall with conventional or computed tomography in the coronal plane has proven to be the ideal method for the examination of inflammatory diseases of the paranasal sinuses. In so doing, diseases and lesions that other-wise might have gone undiagnosed can be identified and consequently treated. Based on this diagnostic approach, an endoscopic surgical concept was developed, aiming for the underlying causes of sinus diseases instead of the secondarily involved larger sinuses. With usually very limited surgical procedures, diseased ethmoid compartments are operated on, stenotic clefts widened and prechambers to the frontal and maxillary sinuses freed from disease. In our experience, there is rarely a need for major manipulations inside the larger sinuses per se. Based on exact diagnosis, the surgical technique used allows a very individualized staging according to the prevailing pathology. In the extreme, a total sphenoethmoidectomy can be performed with this technique, although the true advantage of the technique is that even in cases of massive disease such radical procedures can be avoided. By reestablishing sinus ventilation and drainage via the natural ostia, there is also no need for fenestration of the inferior meatus. The Messerklinger technique can be applied to a wide spectrum of indications, apart from nasal polyposis. The technique has its clear limits as well as its specific problems. Adequate training and experience are required for the surgical approach, as the technique bears all the risks and hazards of all kinds of endonasal ethmoid surgery but has a minimal complication rate in the hands of an experienced surgeon. Results and complications of a series of more than 4500 patients over a period of over 10 years are presented and discussed in detail.Dedicated to Professor W. Messerklinger on the occasion of his 70th birthdayoffprint requests to: H. Stammberger