Nasal cavity and paranasal sinus bony variations: a computed tomographic study

Variations of the nasal cavity are very important for the otolaryngologist in functional endoscopic sinus surgery. To provide data on bony variations of this region, we performed high resolution computed tomography images of paranasal sinuses on 82 adult patients without sinus pathology and on 90 adult patients with sinus disease. We observed paradoxical curvature of the middle concha in 11 (12.22%) sinus patients and 6 (7.31%) in non-sinus patients. Concha bullosa was observed in 26 sinus patients (28.88%) and 22 (26.83%) in non-sinus patients, deviated nasal septum in 20 (22.22%) sinus and 10 (12%) non-sinus, Haller's cell in 5 (5.55%) sinus and in 3 (3.65%) non-sinus, agger nasi cell in 7 (7.77%) sinus and 4 (4.88%) non-sinus patients. Pneumatisation of cristae galli was observed in 8 (8.88%) sinus and 2 (2.44%) non-sinus, of the anterior clinoid process in 5 (5.55%) sinus and 1 (1.22%) non-sinus patients, pneumatisation of the nasal septum in 7 (7.77%) and of the pterygoid recess in 12 (13.33%) sinus patients. We did not find any correlation between age intervals and paranasal sinus variations, and also no statistically significant difference was observed between males and females. These data provide very important information to guide the otolaryngologist and/or radiologist in the evaluation of patients with coronal CT which guides functional endoscopic sinus surgery.     

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     

A computed tomographic study of nasal mucosa: effects of vasoactive substances

Computed tomographic studies of mucosal responses to vasoactive substances (xylometazoline and histamine) in healthy nasal cavities of adult subjects demonstrate the distribution of erectile mucosa. Following artificial congestion of the mucosa by local application of histamine: (1) the middle turbinate and the body of the inferior turbinate limit the main nasal airway as it passes through the middle meatus; (2) an expanded mass of localized erectile tissue in the anterior septal region bars the entrance to middle meatus and intrudes medially into the narrow airway of the piriform aperture and nasal valve; (3) this critical segment of the airway is further limited by forward extension of the anterior tip of the inferior turbinate.     

Melanoma of the nasal and paranasal sinus mucosa

Melanoma involving the nasal and paranasal sinus mucosa is a rare disease that is difficult to treat and generally has a poor prognosis. Data on 17 patients treated at the UCLA Medical Center during the period 1970 to 1985 were reviewed in a retrospective manner. The five-year disease-free survival was 25% (3/12). Surgery, with or without radiation therapy, is the mode of treatment to control disease in most patients. Treatment failures, which include both local recurrence and distant metastases, may occur many years after initial therapy. We found a correlation between the thickness of tumor and the clinical outcome.     

Evaluation of ultrastructural changes in paranasal sinus mucosa after functional endoscopic sinus surgery in patients with chronic rhinosinusitis

The purpose of this study was to compare the preoperative and postoperative ultrastructural changes of paranasal sinus mucosa in patients treated with functional endoscopic sinus surgery for chronic rhinosinusitis. Twelve patients undergoing functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis were involved. The ethmoid sinus mucosa was sampled during the operation and approximately 6 months after the operation. The ciliated epithelium of sinus mucosa was evaluated with transmission electron microscopy. The samples were taken at the Otolaryngology Department of Istanbul University School of Medicine. Electron microscopic study was performed at the Histology and Embryology Department of the same University. Preoperatively, ciliated epithelial cells of the sinus mucosa of the patients showed degenerated ultrastructure with decreased number of cilia, cytoplasmic protrusions, cisternal dilatations of endoplasmic reticulum, and mitochondrial swellings. Remnants of degenerated cells and cellular separations at cell junctions were evident in the diseased epithelium. Goblet cells were frequent along the epithelial lining. Postoperatively, normal architecture and ultrastructure of the ciliated epithelium was restored. These observations showed that unlike other surgical operations, paranasal sinus mucosa can regenerate and the ciliated epithelium can return to normal after functional endoscopic sinus surgergy.     

Inter-observer agreement of paranasal sinus computed tomography scans

Conclusion: The study demonstrated considerable inter-observer variation in certain surgically important structures. This would indicate the significance for consultation when evaluating sinus CT scans of CRS patients for planned advanced sinus surgery.

Objectives: After the failure of medical treatment of chronic rhinosinusitis (CRS), the need for surgery and the pre-operative planning of safe surgery is based on computed tomography (CT) findings. The aim of this prospective study was to compare inter-observer agreement of anatomical and surgical structures of sinus CT scans. The hypothesis was that the agreement between observers is good.

Methods: Of these 57 CRS patients, Lund-Mackay (LM) scores and 43 other structural parameters were analyzed blinded. The reproducibility of the findings between three observers, a radiologist, an Ear, nose and throat (ENT) surgeon, and an ENT resident, were compared.

Results: In general, there was moderate inter-observer agreement of the structures by Cohen’s kappa coefficient. Poor reproducibility was observed in the following structures: optic nerve, insertion of the uncinated process, anterior ethmoidal artery, and Keros class.     

Total IgE levels and peripheral eosinophilia: correlation with mucosal disease based on computed tomographic imaging of the paranasal sinus

OBJECTIVE: To evaluate the relationship among peripheral eosinophilia, total IgE, and paranasal sinus mucosal disease based on computed tomography (CT) of the sinus. DESIGN: Retrospective review of a large medical information database from a tertiary referral medical center. SETTING: Tertiary referral medical center specializing in respiratory disorders. PATIENTS: Consecutive patients having total IgE and peripheral eosinophil levels and sinus CT imaging available for review. Patients 18 years or older were included; subjective or objective evidence of chronic rhinosinusitis was not used as selection criteria. A total of 303 patients were found to have peripheral eosinophil levels and CT imaging for review; 288 patients had total IgE levels and CT imaging. MAIN OUTCOME MEASURES: Linear regression analysis was used to evaluate (1) the correlation between peripheral eosinophil level and CT stage of sinus disease and (2) the correlation between total IgE level and CT stage of sinus disease. The CT scans were graded using the Lund-MacKay scoring system. RESULTS: There was a significant positive correlation between sinus CT stage and peripheral eosinophil levels (r=0.60, P<.05). Eighty-nine percent of the abnormal eosinophil counts (>550 cells/microL) were associated with CT scores higher than 12. Total IgE did not correlate with CT stage of disease (r=0.05, P>.05). CONCLUSIONS: The presence of peripheral eosinophilia indicates a high likelihood of mucosal sinus disease based on CT imaging. No correlation was noted between total IgE levels and CT stage of mucosal disease. These data support a link between eosinophilia and the presence of paranasal sinus mucosal inflammation.     

正常额窦引流通道的三维CT研究

目的 研究正常额窦引流通道的三维CT影像解剖学特征.方法 对51例健康成人（102侧）,采用16排螺旋CT扫描,层距0.300 mm,层厚0.625 mm,使用三维重建技术,观察额窦引流通道毗邻气房分布、钩突附着情况、测量额窦引流通道不同径线.结果 1～4型额气房、1型额气房、眶上筛房、泡状中甲的出现率没有显著性差异（P＞0.05）.额窦中隔气房、终末隐窝的出现率有显著性差异（P＜0.05）.双侧额窦引流通道各径线,除额隐窝左-右径有统计学差异外（P＜0.05）,其余各组间差异均没有显著性（P＞0.05）.钩突顶端同时附着于眶纸板和中鼻甲（垂直板）的为82.35%,同时附着于中鼻甲（垂直板）和颅底的为17.65%.钩突的顶端与中鼻甲之间总有骨性连接,钩突与中鼻甲（垂直板）之间有第二骨性连接的达55.88%.钩突的顶端与眶纸板之间骨性连接有0～4个不等,分别占0.98%、7.84%、68.63%、21.57%、1.96%.当钩突的顶端与眶纸板之间骨性连接的个数≤1个的时候,观察不到鼻丘气房的存在.结论 以三维影像解剖为基础,构建额窦引流通道毗邻空间立体构象,正确的认识额窦引流通道,有助于个性化地选择鼻内镜下额窦开放术式,提高手术的成功率.     

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.     

Endoscopic and computed tomographic findings in ostiomeatal sinus disease

Previously, there has been no organized format for the documentation of the findings of the nasal endoscopy and the coronal computed tomographic sinus scan. The findings from 100 nasal endoscopies and computed tomographic scans were reviewed and summarized. The summarized findings were incorporated into two forms--"the Nasal Endoscopy Exam Form" and the "Computed Tomographic Scan Findings [form]"--utilizing computerized graphics techniques. The forms are presented along with their illustration of pathologic ostiomeatal findings. These forms represent a method of documentation of nasal endoscopic and coronal computed tomographic scan findings. They may be used in the demonstration of disease, treatment, planning, resident training, communication of information, and assisting in a future classification of degrees of severity of sinus disease.     

Rehabilitation of surgically traumatized paranasal sinus mucosa using retinoic acid

BACKGROUND: Paranasal sinus mucosa that regenerates after surgical stripping is characterized by sparse, dysmorphic cilia. Although such dysfunctional mucosal changes are thought to be irreversible, the potential rehabilitation of deciliated mucosa by topical therapies has not been explored. This study evaluated the effect of topical retinoic acid (RA) in rehabilitating deciliated sinus mucosa that has regenerated after surgical stripping. METHODS: Twelve New Zealand rabbits underwent bilateral maxillary sinus mucosal stripping and were allowed to remucosalize for 10 days. In the first treatment arm (n = 6), 0.01% RA was applied to the regenerated mucosa of the left maxillary sinus and an aqueous control was placed contralaterally. In the second treatment arm, the regenerated mucosa was surgically restripped bilaterally before applying RA and control. After 14 additional days, mucosa was harvested and examined by scanning electron microscopy for ciliary density, orientation, and morphology. RESULTS: In the first treatment arm, no significant differences in ciliary density, orientation, or morphology were noted between RA-treated sinuses and controls. In the second arm, RA-treated sinuses showed improved ciliary density, morphology, and orientation compared with controls. CONCLUSION: RA does not appear to significantly enhance ciliogenesis when applied after mucosal regeneration has occurred. However, if deciliated mucosa is restripped and allowed to regenerate in the presence of RA, ciliary ultrastructural features may be enhanced. RA may have therapeutic value in rehabilitating deciliated sinus mucosa when applied before mucociliary differentiation of regenerating mucosa.     

A study of factors regulating ciliary activity using cultured human paranasal sinus mucosa]

Whether temperature, pH, osmotic pressure, Ca2+, Mg2+, and ATP have promotive effects on ciliary activity was investigated by a photo-electric method using cultured human ethmoid sinus mucosa. The results obtained were as follows: 1. Ciliary activity was reversible between 11 and 43 degrees C. It was activated with rising temperature, and inactivated at 40 degrees C. A temperature between 36 and 40 degrees C was optimal for activation of ciliary activity. 2. In the case of brief immersion (30 min.) in solutions between pH 4.5 and 8.5 ciliary activity was reversible, and with prolonged immersion (72 h) between pH 6.5 and 7.5 it was also reversible. with brief immersion within 30 min, pH 8.5 was an activating factor. 3. Ciliary activity was reversible in solutions between 143 and 1,140mOsm/Kg for 30 min. However, the ciliary reaction was different even at the same osmotic pressure according to the substance, NaCl or glucose, used to adjust it. Inhibited beating was reversible after prolonged immersion (72 h) in an osmotic pressure between 285 and 423mOsm/Kg adjusted by NaCl, and between 285 and 570mOsm/Kg adjusted by glucose. Any osmotic pressure of 428mOsm/Kg adjusted by NaCl activated ciliary activity. 4. Neither Ca2+ nor Mg2+, between 10(-2) and 10(-6) Mol, increased ciliary activity. 5. Between 10(-3) and 10(-5) Mol of Na-ATP, given exogenously, slightly activated ciliary movement, while Mg-ATP of 10(-3) Mol also activated it but only slightly. It is important to bear in mind the above results in administering local aerosol therapy for nasal and paranasal sinus diseases.     

Dynamic assessment of paranasal sinus ventilation using xenon-enhanced computed tomography

Disease of the paranasal sinuses is a common and costly condition. Evaluation of the efficacy of either medical or surgical methods of treatment is limited by the lack of quantitative methods to characterize sinus ventilation, which may be an important determinant of the baseline physiological state of the sinuses. Xenon-enhanced computed tomography (Xe-CT) measurement of sinus ventilation provides a noninvasive method of quantifying maxillary sinus ventilation using the nonradioactive, radiodense gas Xe as a tracer. Study subjects breathed a mixture of Xe gas and oxygen through a close-fitting nasal mask during serial CT imaging of a single radiographic plane through the maxillary sinuses--a generally well-tolerated protocol. Analysis of the sinus density-time curves allowed calculation of first-order exponential time constants from which specific ventilation rates could be determined for individual sinuses. Previously developed data analysis techniques were used to assess the statistical significance of the data and determine confidence intervals, allowing examination of the effects of noise in the data, and to demonstrate areas for further study protocol refinement. We conclude that Xe-CT measurement of sinus ventilation is a potentially valuable noninvasive technique for the diagnostic imaging of the human maxillary sinus.     

Na/K-ATPase in rabbit paranasal sinus mucosa during induced sinusitis

Summary Sinusitis was produced in rabbits, after which animals were separated into three groups: allergic sinusitis, induced purulent sinusitis, and spontaneous purulent sinusitis. Mucosal specimens were taken from these animals and normal controls. Na/K-ATPase was localized cytochemically and its activity studied in order to define the energy metabolism of secretion. The Na/K-ATPase reaction was unable to be clearly distinguished in either the allergic sinusitis specimens or the normal mucosa. In both purulent sinusitis groups, an intensive reaction was observed in the subepithelial glands and a weak reaction was found in the goblet cells. The Na/K-ATPase activity in the purulent sinusitis groups was significantly higher than that in the normal control group. The increased Na/K-ATPase activity may be an affect of hyperactivity of the secretory cells. Offprint requests to: M. Miyaguchi, Department of Otolaryngology, Kagawa Medical School, 1750-1 Miki-cho Kita-gun, Kagawa 761-07, Japan     

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.     

Prevalence of the petrified ear: a computed tomographic study

The petrified ear is characterized by calcifications or ossifications of the cartilaginous parts of the outer ear. It is described as a rare finding, but the prevalence of this finding is unclear. In a retrospective analysis of 200 computed tomographic scans of the head, 39 patients showed ossifications/calcifications of the cartilaginous parts of the outer ear (19.5 %). These affected the cartilage of the auricle in 13 patients (6.5 %), the cartilaginous parts of the external auditory channel in 25 (12.5 %) and in one patient both (0.5 %). All ossifications/calcifications were incidental findings in our series. Contrary to most authors, auricular ossifications/calcifications per se seem to be a common finding, but symptoms due to a petrified ear seem to be rare. To establish proper differential diagnosis, radiologists and otorhinolaryngologists should be aware of these findings.     

Local differences in the tissue picture of chronic hyperplastic paranasal sinus mucosa

Five standardised mucosal biopsies were taken on each side during endoscopic sinus surgery from twenty-two patients with severe hyperplastic paranasal sinusitis. The different samples from the ethmoidal and maxillary sinus mucosa were compared with regard to the uniformity of histological changes. Each histological component of the sinus mucosa was involved to a different extent in local pathological changes. These analyses support the view that the character of the chronic inflammatory process is influenced by local pathogenetic factors. Preoperative biopsies do not give information about the general condition of the sinus mucosa.     

Paranasal sinus computed tomographic findings of children with chronic cough

Objective: Chronic cough is a frequent problem in the practice of clinical pediatrics, and sinusitis is a common etiologic factor. In this study, our aim was to determine the prevalence of sinus abnormalities in pediatric patients presenting with chronic cough. Methods: Forty-two patients, ranging from 3 to 16 years of age from both sexes completed the study. Paranasal sinuses were examined by coronal paranasal sinus limited computed tomographic scan. The CT scan findings were categorized as no disease, minimal, moderate and severe sinusitis. Results: The most frequent symptoms after cough were rhinorrhea, sniffling, and halitosis. We found sinus abnormalities in 66.6% and no abnormality in 33.3% of the children. Age and sex were not important factors in sinus disease. There was no correlation between sinus findings and any of symptoms. The most common anatomical abnormalities were concha bullosa, paradoxical middle turbinate, Haller's cells, and deviated nasal septum. These abnormalities were not correlated with sinus disease. Conclusion: Paranasal sinus abnormalities are common among pediatric patients with chronic cough and imaging studies of the sinuses should be considered in these children.     

Efficacy of computed tomographic image--guided endoscopic sinus surgery in residency training programs

OBJECTIVE: To determine the efficacy of computed tomographic image-guided endoscopic surgery in the hands of inexperienced surgeons. STUDY DESIGN: Four second-year otolaryngology residents, with no prior experience performing ethmoidectomies, performed endoscopic sinus surgery (ESS) on formalin-fixed human cadaveric specimens with and without the aid of computer-assisted surgery (CAS). METHODS: Each resident was asked to identify critical sinus, orbital, and skull base structures while performing a total ethmoidectomy and multiple sinusotomies. Their surgical accuracy (percentage of correctly identified structures), total operative time, and incidence of major complications were recorded for each side. A total of 16 sides were evaluated (8 with and 8 without CAS). Statistical significance between groups was determined by means of Pearson's chi2 analysis. RESULTS: Statistical analysis showed a significant difference (P = .001) in the mean accuracy of identifying critical anatomical landmarks between the CAS (97%) and non-CAS (76.8%) groups. Although not statistically significant, operative time appeared to be longer in the group using CAS (average of 67 vs. 80 min). Three major intracranial complications were documented only in the group not using CAS. CONCLUSIONS: Although, unquestionably, a thorough knowledge of the anatomy remains essential for performing ESS, CAS improves surgical accuracy and reduces the risk of major intracranial or intraorbital complications for residents. In additional, our data suggest that this technology may enhance surgical efficiency and improve the learning curve by reducing operative time (below one's normal baseline) while maintaining a greater than 90% accuracy in identifying critical anatomical landmarks.