Unilateral inferior turbinate agenesis: a case report

Many common anatomic variations in the nasal cavity have been observed, including paradoxical turbinates and pneumatization of the inferior, middle, and superior turbinates. We describe a case of a rare anomaly-unilateral inferior turbinate agenesis-in a 65-year-old man who had presented with epistaxis. During evaluation, anterior rhinoscopic examination revealed the absence of the right inferior turbinate; this finding was confirmed on computed tomography. The patient had never undergone nasal or sinus surgery, and he denied ever having expelled anything of significance from his nasal cavity. This case merits attention because of the rarity of reports on turbinate agenesis.     

Superior turbinate pneumatization in patients with chronic rhinosinusitis: prevalence on paranasal sinus CT

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)-bilaterally in 17 (17%) and unilaterally in 10 (10%).     

Isolated turbinitis and pneumatization of the concha inferior in a child

Concha bullosa of the inferior turbinate is an extremely rare anatomic malformation with 11 reports of this condition in the literature. The inferior turbinate is an independent bone originating from the lateral nasal wall. Although inferior concha bullosa is generally asymptomatic and diagnosed incidentally by computed tomography, nasal obstruction, headache, and epiphora are some of the possible symptoms. Isolated turbinitis with no additional paranasal infection is also very rare. Although there is only 1 reported case of pediatric inferior concha bullosa before, this case is the first pneumatized inferior concha with associated isolated turbinitis.     

Infected inferior turbinate pneumatization

With the widespread utilization of endoscopic nasal surgery, the interest in nasal structures has increased. Inferior turbinate pneumatization is among the most rare causes of nasal obstruction. In the current literature, there are only ten reported cases of inferior turbinate pneumatization. A 52-year-old male patient presented with nasal obstruction, purulent nasal discharge, facial pain and headache. Anterior rhinoscopic examination showed bilateral middle and inferior turbinate hypertrophy and edema of the nasal mucosa. Computed tomography (CT) revealed bilateral frontal, anterior and posterior ethmoidal and maxillary sinusitis with bilateral concha media bullosa and right infected inferior turbinate pneumatization. In this report, infection of this rare anatomical abnormality is presented for the first time and documented with acoustic rhinometry, CT and peroperative photography.     

Middle turbinate osteoma

Osteoma is the most common benign tumor of the paranasal sinuses. Turbinate osteomas are very rare and only four middle turbinate, one superior turbinate and one inferior turbinate osteoma cases have been reported. We present a rare case of osteoma of the left middle turbinate in a patient presented with unilateral nasal obstruction and epiphora that was removed endoscopically, and conduct a literature review on turbinate osteomas arising from different turbinates, their symptoms and management.     

Trifurcate middle turbinate; an unusual anatomical variation

Anatomical variations of supernumerary middle turbinates include a secondary middle turbinate, which is a bony projection arising from the lateral nasal wall and covered by soft tissue, and an accessory middle turbinate, which is a medially bent uncinate process. Although pneumatization of the middle turbinate is common, inferior turbinate pneumatization is very rare. We report what we believe is the first case of a middle turbinate split into three divisions, i.e. trifurcated. This co-existed with a pneumatized inferior turbinate.     

A unique case of multiple sites of pneumatization of the sinonasal bony framework in a pediatric patient

Anatomic variations of the sinonasal bony framework in the pediatric population are quite common. In children with such variations, however, bony pneumatization is uncommon. Moreover, pneumatization of the inferior turbinate in children is extremely rare; to the best of our knowledge, only 3 cases have been previously reported in the literature-none of which involved additional pneumatization variations of the sinonasal skeleton. Herein we present a new pediatric case that was unique in that an inferior concha bullosa coexisted with rarely seen pneumatized anatomic structures.     

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.     

A massive superior concha bullosa: case report and literature review

The superior turbinate was the most neglected of the turbinates in the past. With the advent of functional endoscopic sinus surgery and coronal computed tomography imaging, considerable attention has been concentrated exclusively on the lateral nasal wall anatomy, including the hidden turbinate, whose symptomatic concha bullosa is extremely rare. Only a very few cases have been reported to date. This seemingly interesting as well as rare case report is concerned with unilateral hyperpneumatization of the superior turbinate, which contacts the septum and leads to headache, associated with bilateral massive concha bullosa of the middle turbinate.     

Giant concha bullosa containing another concha bullosa inside: unique anatomic variation of the middle turbinate

Detailed knowledge of the anatomical variations of the lateral nasal wall is crucial for both the surgeon who is performing endoscopic sinus surgery and the radiologist who is involved in the preoperative work-up. Preoperative recognition of these variations will avoid possible complications during the surgery. In this report, we present a unique anatomical variant of the middle turbinate, a large concha bullosa inside a giant concha bullosa, which has never been reported before. Furthermore, we comment on the differential diagnosis of the variations of the middle turbinate and on the embryology of the nasal turbinates. This report also supplies additional aspects to rhinologists in the scope of middle turbinate pneumatization.     

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.     

Pneumatization of the inferior turbinate

Pneumatization of the inferior turbinate is an extremely rare intranasal anatomical variation. Only a few cases have been reported yet. In this paper we present two cases, one unilateral and one bilateral case with pneumatization of the inferior turbinate.     

The relationship between pneumatized middle turbinate and the anterior ethmoid roof dimensions: a radiologic study

The development of pneumatized middle turbinate may affect anterior ethmoid roof formation. The aim of this study was to investigate the relationship between the pneumatized middle turbinate and the dimensions of the anterior skull base structures using computed tomography scans. The coronal reconstructed images of the computed tomography scans were evaluated retrospectively. The lateral and medial ethmoid roof points, the width of the cribriform plate (CP), and the anterior ethmoid roof were identified at the first coronal cut, which was determined by the infraorbital nerve. The pneumatized middle turbinates were measured on the axial, vertical, and sagittal planes. The images of 101 patients were evaluated. The mean axial diameters of the pneumatized middle turbinate on the right and left sides were between 6.93 and 4.95 mm, respectively. The correlation between the axial diameters of the pneumatized middle turbinate and the width of the anterior ethmoid roof (termed AER width) was significant for both sides and gender (p < 0.05). There was a higher correlation on the right side where the pneumatized middle turbinate was observed more frequently (r = 0.357). The relationship between CP width and the diameters of the pneumatized middle turbinate was not significant (p > 0.05) for both sides. Iatrogenic lesions of the skull base occur predominantly in the lateral lamella of the CP. The risk of this complication may decrease with increasing of the AER width. Pneumatized middle turbinate may cause an increase in the width of the anterior ethmoid roof and provide more reliable endoscopic intervention of the anterior skull base and frontal sinus.     

筛窦基板层次气化分析及其在鼻内镜鼻窦手术中的应用

目的探讨应用筛窦基板层次性分析方法，指导内镜下筛窦层次性开放的可行性。方法通过鼻窦CT扫描的薄层DICOM数据，层厚层距均为0.65 mm，ImageViewer软件三维重建分析筛窦的基板（III V）层次及其气化情况。结果获得100例（200侧）患者鼻窦CT原始薄层数据，通过三维重建分析发现筛骨结构包含5个基板（I V）：①基板V的出现率为60.0%，相邻基板间存在潜在的层次间隙；②Haller气房出现率为28.0%，与中鼻甲、上鼻甲基板结构气化相关者分别占19.5%、8.5%；③上鼻甲及基板气化发生率为91.5%，其中19.1%气化为Onodi气房。最上鼻甲及基板出现率60.0%，气化发生率为76.7%，其中15.8%气化为Onodi气房。Onodi气房出现率为33.0%，来源于上鼻甲基板、最上鼻甲基板的分别占17.5%，9.5%，来源于二者共同气化的占6.0%。各基板及其气化结构组成相对独立的通气引流系统，可单独出现引流障碍。手术中筛窦的开放（III V基板）过程，以上鼻甲、最上鼻甲为标志结构，结合CT提示的气化变异，可在其前方分别充分地开放III基板、IV基板气化结构构成的筛窦迷路（包括变异气房，如Haller气房），而根据CT提示V基板的气化状况和方向，可进一步实现V基板及其气化结构（包括Onodi气房）的开放。结论通过分析筛窦基板的层次性结构，对指引内镜下筛窦开放过程实现层次性、标准化有重要指导价值。     

Pneumatization of the concha inferior as a cause of nasal obstruction

Chronic nasal obstruction is a common disorder. Hypertrophy of the inferior turbinates is responsible for nasal obstruction more frequently than it is commonly thought. A pneumatized inferior turbinate has recently been described as a cause for nasal obstruction and only two cases have been reported until now. Inferior nasal turbinate develops by endochondral ossification of components of the mesethmoid and ectethmoid. The chondral framework of the inferior turbinate consists of a double lamella and two separate ossification centers that develop between the fifth and seventh month of fetal life. The separate ossification centers meet by the eighth fetal month. During ossification, the inferior turbinate detaches from the ectethmoid and becomes an independent bony structure. During that time the epithelium may misinvaginate into double lamellas and such double lamellas formed by the inferior turbinate may become persistent. A patient was referred to our clinic with headaches and nasal obstruction. A CT scan was performed which showed that the right lower concha was pneumatized. The headache of the patient disappeared after partial resection of the lower and middle turbinate.     

Two cases of malignant melanoma in turbinate and maxillary sinus

Malignant melanomas develop from malignant transformation of melanocytes that are present in the skin and mucosal linings throughout the body. The overall rate of mucosal melanoma is rare and malignant melanomas developing from turbinates or maxillary sinuses are extremely rare. Symptoms of nasal melanoma are generally nonspecific, and patients often fail to seek prompt medical attention. Diagnosis can be confirmed by the immunochemical profile of staining with anti-S100 and HMB-45 antibodies, even in the case of melanin-free pigment melanoma. The present study reports two cases of primary malignant melanoma in the turbinate and maxillary sinus.     

Acoustic rhinometry in healthy humans: accuracy of area estimates and ability to quantify certain anatomic structures in the nasal cavity

OBJECTIVES: We evaluated the accuracy of acoustic rhinometry (AR) measurements in healthy humans and assessed the ability of AR in quantifying the dimensions of the paranasal sinuses and certain anatomic structures in the nasal cavity. METHODS: Twenty nasal passages of 10 healthy adults were examined by AR and computed tomography (CT) before and after decongestion. Actual cross-sectional areas of the nasal cavity and actual locations of the nasal valve, the head of the inferior turbinate, the head of the middle turbinate, the ostia of the frontal and maxillary sinuses, and the choana were determined from CT sections perpendicular to the curved acoustic axis of the nasal passage. RESULTS: The AR-measured cross-sectional areas in the anterior nasal cavity were in reasonable agreement with the corresponding areas determined from CT, whereas AR consistently overestimated the passage areas at locations posterior to the paranasal sinus ostia. The nasal valve was identified as a pronounced minimum on the AR area-distance curve. However, AR did not discretely identify the head of the inferior turbinate, the head of the middle turbinate, or the choana. CONCLUSIONS: The local minima on the AR area-distance curve beyond the nasal valve are caused by acoustic resonances in the nasal cavity, and do not correspond to any anatomic structure. The AR area overestimation beyond the paranasal sinus ostia is due to the interaction between the nasal cavity and the paranasal sinuses, rather than to sound loss into the sinuses. Acoustic rhinometry provides no quantitative information on ostium size or sinus volume in either non-decongested or decongested nasal cavities.     

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.     

Transnasal endoscopic medial maxillectomy as the initial oncologic approach to sinonasal neoplasms: the anatomic basis

OBJECTIVE: To demonstrate an anatomic basis for endoscopic medial maxillectomy with excision of the lateral nasal wall to the nasal floor, including the inferior turbinate, and nasolacrimal duct. Transnasal endoscopic medial maxillectomy involves complete resection of the lateral nasal wall with boundaries that are inferior to the nasal floor; superior to the cribriform plate and fovea ethmoidalis; anterior to the anterior maxillary wall, including the nasolacrimal duct; and posterior to within 5 mm of the eustachian tube. Transnasal endoscopic medial maxillectomy provides exposure for endoscopic resection of the orbital wall, pterygopalatine fossa, pterygoid plates, nasopharynx, and anterior skull base when indicated. DESIGN: Volumetric analysis of the maxillary sinus was performed on axial and coronal computed tomographic scans of 19 adult patients for a total of 38 maxillary sinuses. SETTING: Tertiary care medical center. PATIENTS: Nineteen adult patients with tumors of the head (but outside the sinonasal region). INTERVENTIONS: Radiographic analysis. MAIN OUTCOME MEASURES: The total volume of the maxillary sinus, volume above and below the superior attachment of the inferior turbinate, and volume anterior to the nasolacrimal duct were measured. RESULTS: The mean (SD) total volume of the maxillary sinus was 20.1 (4.2) cm(3), whereas its volume inferior to the superior attachment of the inferior turbinate was 12.9 (3.7) cm(3) and anterior to the nasolacrimal duct was 1.1 (0.6) cm(3). The mean (SD) volume of the maxillary sinus inferior to the superior attachment of the inferior turbinate was 64% (12%), whereas the nasolacrimal duct obscured the transnasal anterior exposure of the maxillary sinus. CONCLUSION: Without excision of the lateral nasal wall inferiorly to the nasal floor and anteriorly, including the nasolacrimal duct, over half of the maxillary sinus would be inaccessible for procedures directed at neoplasms within the maxillary sinus.     

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.