1973

MAY,

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ROENTGEN

EVALUATION
SINUSES
IN

By

CHAS.

E.

SHOP1NER,

comprehensive
pananasal
sinuses
makes
Mucosal

examination
because
their

and

pathologic
thickening,
bone

changes
opacity,

destruction

described

as

ALABAMA

examination
as an important

any

the

AND

has
of

pant

readil
fluid,

pathology

gen

results

cllanges

are

cause

every

sibility

for

realizes

be

various

the

to

tion but may

roentgenognams
unrelated

(Fig. ).
Caffey
graphic

ing
done
ing

and

and

sinuses

that

after

the

variations

development

children
from
more,
Maresh
gen

pathology

a Presented

t
:

Professor
Research
Radiology,

at

rendered
(Fig.

2z1).
ofwork

of

size,

of

the

the

Seventy-third

disease

of

the

ptinpose
of

of this

such

is to

paper

study

report

which

ill

the

mucosal

disease

pananasal
and

chil-

relatively
opacit\-.
that
the

by

shape,

11G.

attributed

ness,

Meeting

swelling

has

The
has
left

aeration

examination

over

the

was

right

left maxillary

mucosal
ethmoid

sinus

thickening.
and the

negative

posterior

except

parietal

is opaque

Opacity
minimally

for

area.

and

the right

also involves
the
developed
frontal

sinuses.

in normal

This patient
has
cal findings
relative
did have
a cold,

infec-

of the

Eight
year old Negro
female
who was hit in
head with a brick.
She did not lose consciousbut complained
of being
unable
to see well.

Physical

stress-

to

I.

the

dun-

Manesh3

sinuses

Annual

p.

birth
to maturity.
Furtherand Washburn4
found
roentusually

not

opaque

piece

crying

for

roentgen

roentgeno-

the

in infants

a monumental

specific

condi-

sinus

of

are

the

inflammatory

---.

may

dren
than
in adults
because
of
redundant
mucosa
which
causes
He also mentions
the probability
pananasal

The

situations

primary

accurate

experience
need

tile

nespon-

clinical

cautioned

is less

clinical

without
disease

examination
changes

examination

sinuses

of

found
in patients
having
for trauma
and other
conto

has

features

and
ofsinus

indicate

in

ilealthv

average,

intervals
or signs

evaluate

tile

of infection

on

Therefore,

con-

be-

the

immediate

be

incidence

literature

an\-

between

findings
sinus

required

medical

roentgen

the

the

A-C).
to

prove

if they

assigned

noentgenologic

in
that

is

to

relation

Si n uses.

roentgen

clinical
to primary

provision

the

related

ditions

the

physician

patients

the

diagnostic,

with
attention

This

infection.

words,

considered

are compatible
which
direct

of

other

able

at regular
to symptoms
the

study

In

and

2,

and

of

M.I)4

roentgenogranls

( Fig.

are

intl ammatorv
sinus
disease.
,67
All authors
insist
on
the
closest
possible
cooperation
between
the radiologist
and the clinician
to
ensure
accurate
interpretation
of the roentchanges.

being
definite

or

children
regard

manifestations

ROSSI,

ARGENTINA

without

sinus

PARANASAL

OMAR

JUSrO,

tioll

visible.
pol\ps

sclerosis

JORGE

SAN

sistent

of
the
content

air

and/or
roentgen

and

M.l).,f

BIRMINGHAM,

OENTGENOLOGIC
been
accepted

OF THE
CHILI)REN*

months

American

of Radiology,
University
of Alabama
in Birmingham,
Fellow,
Department
of Radiology,
Childrens
Mercy
San Justo
Childrens
Hospital,
San Justo,
Providence

Roentgen
University
Hospital,
of Buenos

76

never
had symptoms
or physito the paranasal
sinuses.
She
sore
throat
and
earache
6

earlier.

Ray

Society,

Washington,

Station,
Birmingham,
Alabama.
Kansas
City,
Missouri;
Currently,
Aires,
Republic
of Argentina.

D.

C.,

October

Head,

3-6,

Department

1972.

of

ii8,

VOL.

Paranasal

No.

GROUPS

in Children

177

TABLE
AGE

Sinuses

III

TABLE

FOR

PATIENTS

INDICATIONS

FOR

CHEST

ROENTGENOGRAMS

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OF PATIENTS

Group
NoURI*or

AgeGroup

(104

Groupli
URI
Only

Sinusitis

Groupill
Sinusitis

2 Years

orLess

23

16

2-6Years

30

45

12

6-I4Years

52

43

101

Total
No.
ofPatients1
4

UR1

105

Upper

104

Respiratory

120

Suspected
Fever
Cough

in

opacity,
and bone

children

sinus

with

No.

Pneumonia

fluid,
sclerosis

polyps,
bone
are evaluated

without

75

52

50

38

\\Theezing

32

ChestPain

Asthma

AND

METHOD

Roentgenognams
of the paranasal
sinuses
were obtained
in 3 groups
of patients.
Group I had suspected
primary
sinusitis,
whereas
the other
2
were
control
groups
with
no clinical
evidence
of sinusitis.
Age
categorization
for the groups
is shown
in
Table
I. Group
i contains
105
patients
who
were
referred
solely
for skull
roentgenograms
with
no symptoms
on physical
findings ofsinus
disease.
Table
II shows
simple
trauma
as the most
common
indication
for
the skull roentgenognams.
It is emphasized
that
no patient
had trauma
to the face on

which

area

laceration

be

I)noduce

SKULL

Group

In
cause

of

They

had

findings

mon
sent

for

104

Trauma
Suspected

Neurologic

Disease

incidence

onesisshownin
the manifestations
infection

described
had proven

in
in

were

referred

pananasal

sinus

suspected

Table
of
infants

lO

Symptoms
Per

Cent

I7

.I

9.6

EndocrineProblem

2.9

Craniostenosis

1.9

Total

Retardation

105

cilildren

for

IN

as

and
none
disease
of

record
pnimar
120

corn-

neprenespina-

who
for

patients

and

solely
because

of

symptoms

this

group

and
are

listed

IV

PATIENTS

OF

GROUP

III

Patients)

7.7
5.7

Mental

They

upper
and

The

findings

I)hsica1
most

noentgenognams

sinusitis.

physical

III.

sinuses.
consists
of
specifically

III

were
be-

and
of the

the medical
on suspected

paranasal
Group

who
infection.

ssmptoms

the

(I2o

55.1

I8

sinus

roentgenognams
respiratory

varying

SYMPTOMS

or Proven

Convulsions
Hydrocephalus

with

patients

chest

upper

but

tory

the

are

II

only

EXAMINATION

No.

on

edema

confused

pathology.

II

OF PATIENTS
IN GROUP
(Io5
Patients)

Indication

30

could

and

TABLE

FOR

87

referred

INDICATIONS

Cent

9I
78

NasalDischarge

suspected

disease.

TABLE

Per

Infection.

and

MATERIAL

II

Patients)

Indication

sinus

thickening,
destruction

IN GROUt

100.0

No.

Headache
Postnasal Drip
Nasal
Obstruction
Rhi norrhea
Chronic
Cough
Pain over Sinus
Fever

Allergic
Chronic
Si nobronchi
Epistaxis
Asthma

Rhinitis
Tonsillitis
tis

54

Per

Cent

32

45
26.7

29

24.

27

22.5

13.3

12.5

4
II

11.6
9.1

6.6

5
4
4

4.

.1

.1

.1

.1

Chas.

178

IHYSICAL

TABLE

IN

PATIENTS

FINDINGS

OF GROUP

and

Jorge

Omar

findings
Physical

Findings

No.

Edematous
Nasal
Turbinates
Postnasal I)ischarge
Orbital
and Facial
Edema

21

20

Decreased

I4

Tenderness

38

Transillumination
over

Per

Sinus

i i

Cent

later

and

MAY,

identification

17.5

i6.6

groups.

Roentgen

11.6

mucosal
and
bone

They

to pa-

correlated

physical

findings

findings

thickening,
destruction

were

according

and

and

conditions
physical

grouping.

code

with
of

the

evaluated

opacity,
and/on

fluid,
polyps*
sclerosis.

in

and

objective

evidence

ofpnimany

and
but

the

following

postulates

must

mouth),

upright

Waters,

and

lateral

pro-

jections.
Routine
skull
roentgenognams
in
the
patients
of Group
i were
taken
in
Caldwells
and
lateral
projections
of the
pananasal
sinuses,
to which
was added
a
supi ne Waters
noentgenogram.
Upright
roentgenognams
were
obtained
only
when
the findings
in the other
roentgenognams
indicated
the likelihood
of fluid in a sinus.
The
sinuses
of patients
in Group
ii
were
surveyed
with a single
supine
Waters
projection
roentgenogram
. Additional
views
were added
when
indicated
by the findings
in

the

preliminary

Waters

radiologists,

one

of

whom

The
most

2.

Sinusitis

3.

with
the roentgen
Specific
treatment

4.

roentgen
patients

cause

the

appear

in

The

exist

most

roentgen
who

in

occur

most

in

patients

findings.
for sinusitis

roentgen

significantly

groups

sinusitis,

be met:

findings
must
with sinusitis.

must

on
valid

should

findings

to

dis-

patients.

findings

must

in patients

of

do not

not occur
the control
sinusitis.

have

RESULTS

Patients
were first simply
separated
into
those
having
normal
and abnormal
noentgenognams
(Table
vi).
A noentgenognam
was classified
as abnormal,
if it contained
one or more
of the roentgen
features
being
p Polyp is a descriptive
rounded
densit
within
true polyps,
submucous

roentgen
term referring
to a localized
a sinus
and includes
all lesions
such
as
cyst and
localized
mucosal
hyperplasia.

TABLE
COMPARISON

OF

VI

ROENTGENOGRAMS

BY

Nor mal

GR0U1S

Abnormal

projection

roentgenogram.
This
method
of roentgen
examination
provided
an adequate
evaluation ofthe
paranasal
sinuses
for all patients
in each
group.
The
noentgenognams
were
evaluated
by
3

I.

were

The roentgen
findings
were evaluated
the premise
that
if they
were
to be
Tables
iv and v. Most
of the symptoms
physical
findings
did not occur
alone,
were
associated
with
the others
listed
in each
table.
There
were
only 6 patients
who had acute
sinusitis
established
by the
specific
association
of fever,
enytherna,
swelling,
pain
and tenderness
oven the involved
sinus and/on
sinuses.
The remainder
of the patients
simply
had
sinusitis
suspected
as a cause
for random
association
of
the symptoms
and physical
findings.
All patients
in Group
iii
had
routine
views
of the pananasal
sinuses
consisting
of Caldwells,
Waters
(open
and
closed

1973

roentgeno-

controlled
of the history,

by

history

9.1

the

viewed

patient

categorized

tient

31.6

Rossi

other
2 radiologists
grams
under
blind,
with no knowledge

III

Patients)

(120

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E. Shopfnen

provided

the

clinical
care and dictated
the consultation
report
with
full knowledge
of the history
and physical
findings.
However,
he was tinaware
ofhis
participation
in this study.
The

Group

Group
I (105
patients)
No URI
or Sinusitis
Group
II (104 patients)
Upper
Respiratory
Infection-Only
Group
III (120
patients)
Suspected
Sinus
Pathology

No.

Per
Cent

45

43

6o

57

26

25

78

75

59

49

6i

\o.

Per
Cent

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#{232}:.
:

logical
pharynx,

that

the

sinuses

since

the

would

he involved

by

an

tipper

respirators

the

infection,

as the

flOSC

and

sinusitis

larger
grams
thought

/1 and

B).

When

the

point

of

statistical

percentage
of abnormal
noentgenoTilose
patients
ill
Group
I, who
ilad
upper
respiratory
infection
non

often

evaluated.
Those
upper
respiratory

graphic

part of the upper

respiratory
tract.
(C) A i
at age S months
and at age 1 2 months.
The mother

same

month
old white
female
with history
ofnasal
discharge
is not sure ifthe
infant
has had fever.
Physical
examination
revealed
temperature
of 10101.,
minimal
serous nasal discharge
and
mild pharyngeal
i nfection.
Paranasal
sinus
roentgenograms
were
requested
because
of suspected
sinusi
tis. The
maxillary
and ethmoid
sinuses
are opaque.
The patient
was given
penicillin
and the symptoms
disappeared
in 3 days.
The roentgen
findings
are identical
in these ; infants
with totally
different
clinical
backgrounds
and similar to the observations
of Maresh
and Washburn.4

highest
grams.
neither

are

at

the

in Group

time

examination,
proportion
than
those
to

have

ii

of
in
primary

who

had

only

exhibited

illfectiOn

of the
showed
abnormal
Group

iii,

sinusitis

as

patients

(
abnormal
ofGroup

Mucosal

noentgeno-

findings

for

slightly
was
not

more
found

(Fig.

were
3,

per

cent)

ones

(51

the

were

all

tile

view-

normal

er

occurred
cent)

as

in

III.

and

thickening

sinuses

from

significance,

roentgenograms

roentgenoa slightly

who

considered

most
groups,

frequent
in any

opacity

common
with

(Table
patient

of

the

roentgen

opacity

being

vii).
Fluid
of Group

Chas.

i8o

Shopfner

E.

and

Jorge

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lu;.

Oman

Rossi

MAY,

1973

.
Comparison
of sinus
rontgenograms
in patients ofGroup
i and iii.
(A) An I I year
old Negro
female
of Group
,
who has noticed
bilateral
breast
development
for 3

months.

Skull

roentgenograms

were

requested

for

possible
to explain
maxillary

intracranial
and/or
sellar
abnormality
primary
breast
hyperplasia.
The left
sinus
is opaque
and
the right
shows
mucosal
thickening.
The
frontal
and
right
ethmoid
sinuses
are not developed.
There
were
no
signs of sinus
disease
and the last upper
respiratory
infection
was when
she had the flu 9 months
The patient
proved
to be a normal,
healthy
other
than for the roentgen
findings
in the
sinuses.
(B) A 12 year old Negro
female
of Group
III who
has had periorbital
edema
in the morning
for
week.
There
was slight
tenderness
over the
frontal
sinus.
She was referred
to
the radiologic
earlier.
female

department

because

of

suspected

frontal

sinu-

sitis.
There
tenderness

was no periorbital
edema
or frontal
when
seen
by the radiologist.
The
maxillary,
ethmoid
and frontal
sinuses
are opaque.
No cause
for the periorbital
edema
was found
and the patient
received
no treatment
for sinusitis.

and
in

occurred
those

distinctly

they

Bone
occur

TABLE

INCIDENCE

also

---

________________

------

Per Cent

No.

Per

and

sclerosis

significant
4,

did

not

Pathology

__________
Bone l)estruction
and/or
Sclerosis

Fluid
Cent

a
(Fig.

------

Opacity
No.

to

groups

sus-

speak-

PATHOLOGY

Group

were
with

VII

OF ROENTGEN

incidence

Polyps

comparatively

destruction
in any patient.

low

iii.

in patients

occurred
other

Roentgen
Mucosal
Thickening

common
but,

in the

but
and

ii

sinusitis

degree

equal

Groups

more

pected
ing,

with

of

No.

Per

Polyps
Cent

No.

Per

Cent

No.

Per

Cent

Group!
(io#{231}patients)
(;rotll)
(104

Group

II
patients)

29

27

36

.8

35

33

50

48

1.8

1.8

33

28

45

38

i.6

III

(I2opatients)

14

II

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The
roentgen
pathology
involved
the
maxillary
sinus
almost
exclusively
(Table
viii).
Ethmoid
and frontal
sinus
involvement
was uncommon
and usually
associated
with
changes
in the maxillary
sinus.
The ethmoids
were solitarily
involved
in
patients

of

Group

i,

2 in

Group

ii

and

none

Group
m.
Abnormal
changes
were found
in the frontal
sinus
alone
in i patient
of
Group
i,
in Group
ii and
none
in Group
iii.
A possible
explanation
for the rarity
of
involvement
of the frontal
sinuses
is the
normal
variance
and lack of their development
and
aeration
prior
to the age of 6
in

years.
larger

ages

However,
proportion

of

frontal

oped

6-14
sinuses

alld

greaten

Group
of children

aerated,

Correlation
with
the age

years

of

age

silowed
the

no

ones

in

of abnormal
roentgenogranls
brackets
of Table
i reveals

than

distinctly
higher
incidence
changes
in the younger
patients
The
largest
number
of patients

pathologic

the
devel-

they

and

a
the

when

years
(Table
i),
are more
consistently

involvement
I and
u.

Groups

contained
between

iii

and

findings

the

highest

were

of

pathologic
(Table
ix).
less tilan
incidence

in Group

of
where

Chas.

I 82

E. Shopfner

and
TABLE

INDIVIDUAL

SINUS

Jorge

Rossi

1973

MAY,

VIII

INVOLVEMENT

Maxillary

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Omar

BY

GROUPS

Ethmoid

Frontal

Group

No.
Group

Per

Cent

No.

Per

Cent

No.

Per

Cent

(io

58

patients)

#{231}

0.9

2.8

II

Group
(104

patients)

74

i8

-i

patients)

6,

51

i6

13

Grouplil
(120

there

was

clinical

respiratory

evidence

infection

whereas

the

less

2 Teans

of neither

non

sinusitis

upper

(Fig.

21),

number
of patients
and the lowest
mcidence
of pathologic
findings
were in Group
III
where
primary
sinusitis
was
the
suspected
diagnosis
(Fig.
2 C; and
). A higher
than

incidence

of

for

smallest

the

problem,

sinusitis

was

and

roentgenognams

2-6
ii

year

where

than
primarily

age

brackets

for

was

Group

III

ben

968

and

May

of

969

which

high

mciin pain Group

Novempeak
TABLE

COMPARISON

OF

pen
al

than

upper

respiratory

cent)
of them.
roentgenognams

cantly

lower

percentage

those

ofeithen

Group

ciated
ogy

with
in

the

Group

respiratory

were

No.

of pathology
i

or

infection

within

Group

than
III.

Asso-

of patholan upper
months
of the

GROUPS

Group

2-6 Years

Cent

No. in
Group

Abnormal
No.

Years

6-14

Per

Cent

No. in
Group

Abnormal
______________
No.
Per

Cent

Group
I (io
patients)
(No URI or Sinusitis)

20

90

#{149}o

25

52

15

27

Group
(URI

i6

I4

87

45

35

77

43

22

57

86

12

47

46

Group
(Sinusitis)

II (io.
only)
III

(120

patients)

patients)
6

ifi-

lower
incidence
is the
fact that

BY AGE

Years

Per

sign

IX

ROENTGENOGRAMS

Abnormal

passages

the roentgenobe documented

Group
No. in
Group

There
and an

season.

category

preceding
could

candy
reduced
for the 6-14 year age bnackets ofGnoups
I and
ii, but
Group
H patients
still
had
a slightly
higher
percentage
of
pathology
than those
in Group
1,1.
Group
I
patients
olden
than
6 years
had a signifi-

Age
Less

the

months
examination

(8

Abnonm

where

is the

of
2

38

in

suspected.

A possible
explanation
for the
dence
of abnormal
noentgenognams
tients
younger
than 6 years ofage
I is that
all were examined
between

in this

graphic

of
not

infection

45 patients

infection

also

sinusitis

respiratory

where
within

age

abnormal

existed
Groups
clinical

of

upper

50

101

ii8,

VOL.

No.

Paranasal

roentgenognaphic

documented

in only

noentgenognams

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An

examination
the

19

was

than

years
roentgenognanls
upper

old.

All

and

(Fig.

5).

opposite

side.

in

I 2

noen

6 months
of tile

the
Therefore,

tis.

peaned
tients,
acute

the

involved

had

at

Group

who
roentgen

intervals

of

had
acute
findings
did

the

sinusidisap-

in 6 of

of 8 who

roentgen

but

treatment
in

tile

were
made
abnormal

The

iii.

in 6,

following
but only
sinusitis.

and
on

tgenograms

patients

side

opacity

thickening

disappeared
in

an

symptoms

after
treatment
6i
patients
with
ill

pathology

and

also

mucosal

roentgenograms
were

on
2

ilad

Follow-up
to

signs

sinuses

less

abnormal
with

ilad abnormal
roentgenohad
opacity
of the maxillary

However,

another

of2

from

5 of

were

with
those

i 2

with

eacll

ethmoid

in

who

i 11 fection.

sinusitis

and

in

were

6 patients

ofacute
grams

documented

All

nespiraton

infection

roentgenographic

Group

of

the

also

patients

in 8 of these,

respirator

of

be

Abnormal

present

upper

months

could

i 2 patients.

were

however.
within

i nation

exam

Sinu

pa-

12

not

have

DI S C U S S I 0 N

AllalySiS

mises
gen

reveals

are

findings
that

having

the

of

which

data

patients

with

pected

of

pain

diagnosis

and
in only

of

tender6 of tile

roentgenograms
of

iii

would
if the

tile

with

be
acclinical

pathology

findings

sinusitis

in

Group

roentgen

of

noras

pathology

sinusitis
pilvsical

had

association

roentgen

correlating

history,

of
cent

sinusitis

occurred

indicating

of

have

per

51

WilO

noentgenograms
as

not

significant

abnormal

#{231}6
patients

remaining

pre-

noent-

incidence

in

cent
Acute

edema,

The

III.

An

specific

5111135

did

III

er

tile

witil

in Group

dictum

49

tile

of sinusitis,
suspected

noentgenognams.
roentgen
findings
is Ilot
statistically

indicated
by
fever,
enythema,
ness over
the

abnormal
cepted

Group

ill

compared
to tile
mal
noentgenograrns.

62

to

if the

fulfilled,

are valid
evidence
most
patients

sinusitis

abnormal
pathologic
of patients

ap)lied

to be

and

is

sus-

followed.

Chas.

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184

E. Shopfnen

and

and
effect
relationship
is established
between
the
roentgen
findings
and
simple
upper
respiratory
infection.
The
roentgen
findings
were most
common
in patients
of
Group
II with
upper
respiratory
infection.
No patient
of Group
ii had
either
a diagnosis

of

on

Symptoms

specific

pinatory

treatment

the

in

infection

for

patients

with

who

abnormal

had

sinusitis.

tipper

resroent-

genognams
subsided
with treatment
for the
upper
respiratory
i nfection.
Eighty_five
pen cent of the patients
who were 6 years on
younger

in

genognams
tion within
genognaphic
in

the

Group

with

abnormal

an upper
respiratory
infecmonths
preceding
the roentexamination.
Finally,
a drop

incidence

of

infection

in

abnormal

noentgeno-

older
than 6 years
paralincidence
ofupper
nespinachildren

of

this

age.

The

sinusitis.
of

sinus

polyps

is

given

Table

Rossi

x. Three

toms

ofonly

had

symptoms

by

treatment

MAY,

of the patients
had
week or less in duration.
associated
with
and
of

tooth

abscess.

in

1973

sympOne
cured

Four

me-

were given
penicillin,
i had
antihistamines
and i had treatment
for
asthma.
No
patient
had specific
treatment
for the polyp
and none returned
with either
specific
problems
related
to the
polyp
on for follow-up
roentgenognaphic
examination.
Therefore,
the detection
of
ceived

no

polyps

treatment,

in

and

opacity

age

(Table

as

incidence
of roentgen
pathology
comesponds
identically
with
the
incidence
of
roentgen
pathology
in asymptomatic
adult
patients
studied
by Fascenelli.2
It seems
only
logical
that
most
upper
respiratory
infections
which
involve
the
nasal,
nasophanyngeal
and phanyngeal
mucosa will also involve
the paranasal
sinus
mucosa
by virtue
of the fact that
the sinuses
are part
of the upper
respiratory
tract.
Mucosal
thickening,
opacity
and
rarely
fluid
are the manifestations
of the
upper
respiratory
infection,
but not of pnimary
sinusitis.
Even
in those
patients
who
have acute
signs and symptoms
of sinusitis,
the possibility
exists
that
the
abnormal
roentgen
findings
may
be unrelated
(Fig.
). A glance
at Tables
iv
and v shows
that
many
patients
had isolated
edema,
pain,
swelling
and tenderness
over
the sinuses.
However,
it was only when
these
findings
were associated
with fever that there
was a
positive
correlation
with
abnormal
roentgen findings.
Fever
itself
and
the other
symptoms
and physical
findings
occurring
alone
or in various
patterns
without
fever
had no positive
association
with
roentgen
findings
presumed
to
be
indicative
of
Analysis

Omar

the

paranasal

sinuses

have
no significance
relative
toms,
physical
findings
and
these
patients.
The high incidence
ofmucosal

roent-

had

grams
in children
lels a drop in the
tony

Jorge

signs

in children

ix)
of

completely

sinus

says,

that

crying

causes

the

6 years
it

is,

mucosa
opacity.

of

them

Perhaps

redundant
sinus

to

thickening
than

invalidates

disease.

Caffey
planation
thickening

less

seems

to the symptreatment
of

as

and

This

ex-

prevalence

does
not
account
for mucosal
which
occurs
almost
as freas opacity.
It seems
that
the high
ofuppen
respiratory
infection
in

this

group

quently
age

is a more

important

factor.

Further
support
for the role ofupper
respiratory
infection
in the etiology
of the roentgen pathology
is the drop
in incidence
of
abnormal
roentgen
findings
in children
older
than 6 years,
when
there is also a drop
in the
incidence
of upper
respiratory
infection.

Allergic

concept
cosal

sinusitis

and

the

is a common

roentgen

thickening,

opacity

clinical

findings
and

of mupolyps

are

of it. There
were
7 patients
in Group
ii (Table
iii)
and
4 in Group
III (Table
iv) with
asthma.
An
additional
I i
patients
of Group
iii
had
allergic
rhinitis.
There
was no difference
considered

in

these

the

as

incidence

allergic

manifestations

of

roentgen

children

pathology

and

the

of

others

without
signs
of allergic
disease.
A word
about
the clinical
concept
of
sinobnonchitis
for which
5 patients
in
Group
III
were
referred.
All patients
in
Group
ii and
many
of the others
in Groups
I and
iii
had
chest
roentgenograms.
No
significant
cause
and
effect
relationship

VOL.

118,

Paranasal

No.

Sinuses

in Children
X

TABLE

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ANALYSES

Symptoms

and

I.

Frontal

2.

Nasal
charge

Physical

Findings

headaches;

stuffy

nose

obstruction
and diswith a nasal polyp

Age

(yr.)
Sex

I 8

OF

POLYPS

Location
of Polyp

Treatment

i I

Left
lary

maxil-

None

12

Left
lary

maxil-

Nasal
polyp
antibiotics;

Follow-up
No

removed;
anti-

return

Nasal
symptoms
improved;
no

histamines

recurrence

in

I year

3. Frontal

headaches;

and colds

epistaxis

times

in past

and

rhinorrhea

II

Right

and

left

Nose

drops

No

return

None

No

return

None

No

return

maxillary

penicillin

and

year
10

Left
larv

10

Right
and
maxillary

Right
lary

maxil-

Aspirin

No

return

io

Right
larv

maxil-

Bronchodilators
periodically

No

return

per-

i I

sI

Right
larv

maxil-

Penicillin

No

return

9. Pain,
swelling
and tenderness
over left maxillary
sinus;
has

12

Left
lary

Right
lary

maxil-

None

No

return

Right
lary

maxil-

Penicillin

No

return

4.

Nasal
plugging
for i year

5. Frontal

headaches
for I year

tently
6. URI
for
7.

intermit-

and frontal
week

headaches

Frontal

headaches;

asthma

8. Recurrent

otitis

foration
slight

ofleft
hearing

an infected
1St

of4

molar

media;

ear drum;

maxil-

left

loss
maxil-

Tooth

Symptoms

extracted

cured

left maxillary
tooth;

days

symptoms

duration

10.

Frontal
and
for i year

occipital

II.

Stuffynose;irregularbreathing
and cough
for 3 days

headache

exists
between
pulmonary
and sinus disease
in any of them
except
as related
to acute
respiratory
infection.
Therefore,
it seems
that
the relation
of sinus
infection
to disease of the chest
has been erroneously
ovenemphasized.4
The purpose
of this paper
is not, and was
not, to abolish
sinus roentgenograms
in the
evaluation
of suspected
sinus
disease.
To
the contrary,
it was intended
to establish

the

findings
when
utilized.
Patients
without
acute
sinusitis
constitute
the majority
in Group
m (114
of
the 120
total)
and sinus
disease
was suspected
only
because
of the
nonspecific
symptoms
and
physical
findings
listed
in Tables
iv
and v.
If the sinus
roentgenograms
are to be utilized in patients
with similar
symptoms
and
physical
findings
in general
pediatric
pracsinus

validity

of the

roentgenography

roentgen
is

Chas.

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i86

E. Shopfner

and

tice, it is imperative
to recognize
the omnipresence
ofmucosal
thickening
and opacity
in children
without
sinus
disease.
Furthermore,
the
true
relationship
between
the
common
upper
respiratory
infection
and
the roentgen
findings
must
be recognized
before
applying
the clinical
dictum
of arbitranily
assuming
them
to be manifestations
ofsinusitis
ifthis
disease
is suspected.
Sinus

opacity

was

found

in all 6 patients

by

hardly

because

roentgenography,

needed

to

and its presence

tients
does not

establish

on
affect

the

absence
treatment.

in

it

and

polyps

cance
relative
associated
with
in most patients.
6. If sinus
utilized
in the
children,
the

I.

Fifty_one

suspected
genograms
combination
ity,

University
619

2.

per

Similar

South

abnormal

noentgenograms

with
noenton a
opac-

2.

3.

4.

are

3. Only
6 of 120 patients
sinusitis
had acute
sinusitis,
gen finding
had no diagnostic
significance.

6.

4.

Specific

roentgen

pen

cent

treatment

findings

of

for

with suspected
but the noenton therapeu
tic
sinusitis

to disappear

caused

in 4 of 6

opacity,

fluid

diagnostic

roentgenograms
evaluation
omnipresence

of Alabama
i9th

signifi-

are
to be
of the sinuses
in
and
relation-

pathology
must
be

to upper
recognized.

Radiology

Hospitals

and

Clinics

Street

Alabama

7.

J. Pediatric
Year
p. 100.

35233

Book

X-Ray
Publishers,

Diagnosis.
Inc.,

Fifth

edi-

Chicago,

F. Maxillary
sinus
abnormalities.
Arch.
Otolaryng.,
1969,
90,
190-193.
MARESH,
M. M. Paranasal
sinuses
from birth
to
late adolescence.
Am.
7. Dis. Child.,
1940,
#{243}o,
55-78.
MARESH,
M. M., and WASHBURN,
A. H. Paranasal
sinuses
from
birth
to late
adolescence.
Am. 7. Dis. Child., 1940, 60, 841-861.
SAMUEL,
E. The
Radiology
of the
Paranasal
Sinuses.
A Textbook
of X-Ray
Diagnosis.
By
S. C. Shanks
and P. Kerley.
Volume
I. Fourth
edition.
W. B. Saunders
Company,
Philadelphia, 1969, . 579.
WELIN,
C. S. Roentgen
diagnosis
of paranasal
sinuses.
Minnesota
Med., 1960,
43, 325-338.
WELIN,
C. S. H. Paranasal
Sinuses
In Roentgen
Diagnosis.
By H. R. Schinz,
W. E. Baensch,
W. Frommhold,
R. Glauner,
E. Uehlinger,
and
J. Wellauer.
Volume
II. Grune
& Stratton,
Inc., New York,
1969, p. 518.
FASCENELLI,

A.M.A.

S.

57
and

in only

to sinusitis
and appear
to be
upper
respiratory
infection

M.D.
of Diagnostic

CAFFEY,
1967,

patients

and

1973

REFERENCES

children
without
sinusitis
in 75 per cent of children
who
have
an tipper
respiratory
infection,
but
without
sinusitis.

the

in

of

little

roentgen
infection

pa-

CONCLUSIONS
cent

the

Birmingham,

I.

sinusitis
have
abnormal
consisting
of one
alone
of mucosal
thickening,
and polyps.

fluid

found

AND

MAY,

E. Shopfner,

tion.
SUMMARY

have

Department

is

Rossi

patients
with
acute
sinusitis
of 8 with
suspected
sinusitis.
5. Mucosal
thickening,

Chas.

diagnosis,

these

Omar

ship
of
respiratory

who had fever,

erythema,
edema,
pain and
tenderness
over
the
sinus
in association
with
each
other.
This
is the clinical
syndrome
of acute
sinusitis,
but it is of questionable
value
to demonstrate
the sinus
opacity

Jorge