AN ENDOSCOPIC STUDY OF SINONASAL ANATOMICAL VARIATIONS IN PATIENTS UNDERGOING ENDOSCOPIC SINUS SURGERY AT KLES HOSPITAL AND MRC, BELGAUM

AND DISTRICT HOSPITAL, BELGAUM. BY

DR SRINIVAS D R

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of M. S. in OTORHINOLARYNGOLOGY

Under the guidance of

DR. N. D. ZINGADE M.S.

DEPARTMENT OF OTORHINOLARYNGOLOGY, JAWAHARLAL NEHRU MEDICAL COLLEGE, BELGAUM, KARNATAKA

MARCH 2006

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

C E R T I F I C A T E BY THE GUIDE
This is to certify that the dissertation entitled AN ENDOSCOPIC STUDY OF SINONASAL ANATOMICAL VARIATIONS IN

PATIENTS UNDERGOING ENDOSCOPIC SINUS SURGERY AT KLES HOSPITAL AND MRC, BELGAUM AND DISTRICT HOSPITAL, BELGAUM is the bonafide work of Dr Srinivas D R which is being submitted to the Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore, in partial fulfillment of the regulations for the award of M. S. (Otorhinolaryngology) degree, examination to be held in March 2006, has been carried out under my direct supervision and guidance in the Department of Otorhinolaryngology, J. N. Medical College, Belgaum. I have great pleasure in forwarding it to the Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore. Place: Belgaum Date: Guide: Dr. N. D. Zingade M.S. (ENT) Professor and HOD, Department of Otorhinolaryngology, J. N. Medical College, Belgaum 590 010, Karnataka

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

ENDORSEMENT BY THE HOD

This is to certify that the dissertation entitled AN ENDOSCOPIC STUDY OF SINONASAL ANATOMICAL VARIATIONS IN

PATIENTS UNDERGOING ENDOSCOPIC SINUS SURGERY AT KLES HOSPITAL AND MRC, BELGAUM AND DISTRICT HOSPITAL, BELGAUM is the bonafide work of Dr Srinivas D R which is being submitted to the Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore, in partial fulfillment of the regulations for the award of M. S. (Otorhinolaryngology) degree, examination to be held in March 2006, has been carried out under the direct supervision and guidance of Dr. N. D. Zingade
M.S. (ENT)

in the Department of

Otorhinolaryngology, J. N. Medical College, Belgaum. As a Professor and Head of the Department, I have immense pleasure in forwarding it to the Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore. Place: Belgaum Date: Dr. N. D. Zingade M.S. (ENT) Professor and Head, Department of Otorhinolaryngology, J. N. Medical College, Belgaum 590 010, Karnataka

II

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

ENDORSEMENT BY THE PRINCIPAL

This is to certify that the dissertation entitled AN ENDOSCOPIC STUDY OF SINONASAL ANATOMICAL VARIATIONS IN

PATIENTS UNDERGOING ENDOSCOPIC SINUS SURGERY AT KLES HOSPITAL AND MRC, BELGAUM AND DISTRICT

HOSPITAL, BELGAUM by Dr Srinivas D R, a post graduate student of M. S. (Otorhinolaryngology), J. N. Medical College, Belgaum under direct guidance and supervision of Dr. N. D. Zingade fulfillment of the regulations for the
M.S. (ENT)

in of

partial M. S.

award

(Otorhinolaryngology) degree, examination to be held in March 2006. I am pleased to forward it to the Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore, as he has undergone the prescribed course in accordance with the university regulations.

Place: Belgaum Date: Dr. V. D. PATIL M.D., D.C.H. Principal, J. N. Medical College, Belgaum 590 010, Karnataka

III

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation AN ENDOSCOPIC STUDY OF SINONASAL ANATOMICAL VARIATIONS IN PATIENTS UNDERGOING ENDOSCOPIC SINUS SURGERY AT KLES

HOSPITAL AND MRC, BELGAUM AND DISTRICT HOSPITAL, BELGAUM has been prepared by me, under the able guidance and
M.S.(ENT)

supervision of Dr. N. D. Zingade

Professor and HOD, Department

of Otorhinolaryngology, J. N. Medical College, Belgaum as a part of my postgraduate study in partial fulfillment of the regulations of Rajiv Gandhi University of Health Sciences - Karnataka, Bangalore, for the award of degree of M. S. (Otorhinolaryngology), examination to be held in March 2006. This has not formed the basis for the award of Degree or Diploma to me previously from any University.

Place: Belgaum Date: Dr Srinivas D R

IV

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.

Place: Belgaum Date: Dr Srinivas D R

Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENTS
At the outset, I would like to express my deep sense of gratitude towards my guide Dr. N. D. Zingade,
M.S.,

Professor and Head, Department of

Otorhinolaryngology, J.N. Medical College, to whom I am indebted in many ways. His clarity of concepts is remarkable. No minute is spent with him without learning something new. He has always been doing things to improve the way the subject of Otorhinolaryngology is taught and under his guidance the department has taken giant leaps forward. His personal interest and enthusiasm towards this study and the subject of Otorhinolaryngology and Head and Neck Surgery is truly remarkable. He has always been very critical and analytical from a wholly constructive viewpoint, always making suggestions to improve not only this study but also my entire approach to the subject and its practice. I express my deep sense of gratitude and sincere thanks for his constant encouragement and invaluable guidance, he has so willingly shown in preparing this dissertation. I am thankful to Dr. R. S. Mudhol,
M.S., D.L.O.,

Professor in the

Department of Otorhinolaryngology, J.N. Medical College for his high ranking advice not only in dissertation work but also in my overall performance in the field of Otorhinolaryngology. I thank Dr. R. N. Patil,
M.S.,

Professor in the Department of

Otorhinolaryngology for his encouragement and guidance. My sincere gratitude to Dr. B. P. Belaldavar,
M.S.,

Associate Professor

for his invaluable support and encouragement that has greatly increased my knowledge base. I express my gratitude to Dr. A. S. Harugop, Professor for his encouragement and support. My sincere appreciation to Dr. S. B. Bagewadi and Dr. Chetana Naik, Assistant Professors, Department of Otorhinolaryngology, J.N. Medical College, for their help and guidance during my tenure.
M.S.,

Associate

VI

I wish to thank Dr. Nitin Ankle, Lecturer, for his especial help and encouragement. I wish to thank Dr. Prashant Patil and Dr. R. B. Metgudmath, Lecturers, Department of Otorhinolaryngology, J.N. Medical College, for their constant encouragement and help. I wish to thank Dr. C. V. Hosapeti Sr. Specialist, Dr. Doddawad, Specialist, and Dr. Umadevi Angadi, Specialist in Otorhinolaryngology, DHB, for their timely help and advice whenever required. I thank most of all, Dr. V. D. Patil, Principal J.N. Medical College, District Surgeon, DHB, MD CEO, K.L.E.Ss Hospital and MRC, Belgaum for their unfailing support and help throughout my course. I appreciate the help rendered by all my colleagues during my postgraduate study. I thank Mr. Shivanand and Mr. Subhas, for their help

and coordination during my course. I thank my parents and brothers who have been a constant source of support throughout.

Dr. Srinivas D R

VII

ABSTRACT
Background and objectives: The presence of several sinonasal anatomical variations is well known and are important in regard to chronic sinusitis pathogenesis and avoidance of complications during surgery. We studied the different variations and their frequency of occurrence.

Methods: A total of 40 patients undergoing endoscopic sinus surgery were studied by nasal endoscopy, CT scanning and at the time of definitive surgery and variations recorded.

Results: The frequency of occurrence of the sinonasal anatomical variations were septal deviation in 65%, septal spurs in 47.5%, thick septum in 30%, septal pneumatization in 25%, agger nasi cells in 72.5%, frontal sinus absent pneumatization in 6.25%, frontal recess obstruction in 18%, paradoxical middle turbinate in 8.75%, pneumatized middle turbinate in 30%, medialized uncinate process in 36.25%, pneumatized uncinate process in 2.5%, supraorbital cells in 22.5%, accessory maxillary ostia in 15%, Haller cells in 3.75%, pneumatized superior turbinate in 6.25% and Onodi cells in 18%.

Interpretation and conclusion: The high incidence of variations emphasises the need for proper preoperative assessment for safe and effective endoscopic sinus surgery. Keywords: Paranasal sinuses; variations; chronic sinusitis.

VIII

TABLE OF CONTENTS

1 2. 3. 4. 5. 6. 7. 8. 9. 10.

Introduction Objectives Review of Literature Methodology Results Discussion Conclusion Summary Bibliography Annexures I. II. III. Endoscopic and CT pictures Proforma Master Chart

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Page No. 69 Page No. 75 Page No. 79

IX

LIST OF TABLES

Table 1. Age distribution Table 2. Sex distribution Table 3. Skull base types Table 4. Septal variations Table 5. Middle turbinate variations Table 6. Types of middle turbinate pneumatization Table 7. Uncinate variations Table 8. Uncinate superior attachment Table 9. Ethmoidal bulla variations Table 10. Sphenoid sinus ostium variations Table 11. Intrasphenoidal projections Table 12. Prevalence of septal deviations Table 13. Prevalence of agger nasi Table 14. Prevalence of pneumatized middle turbinate Table 15. Prevalence of paradoxical middle turbinate Table 16. Prevalence of large ethmoidal bulla

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Table 17. Differences between natural and accessory ostia Page No. 51 Table 18. Prevalence of Onodi cell Table 19. Prevalence of Haller cell Page No. 53 Page No. 55

LIST OF FIGURES

Fig1. Left medialized uncinate process Fig 2. Septal spur impinging on right middle turbinate Fig 3. Rathkes pouch remnant Fig 4. Accessory maxillary sinus ostium Fig 5. Right agger nasi Fig 6. Polyp in sphenoethmoidal recess Fig 7. Anteriorly turned uncinate Fig 8. Septal pneumatization Fig 9. Septal tubercle Fig 10. Bilateral superior turbinate pneumatization Fig 11. Pneumatized crista galli Fig 12. Bilateral agger nasi pneumatization Fig 13. Left concha bullosa Fig 14. Bilateral frontal sinus agenesis Fig 15. Bilateral nonpneumatized sphenoid Fig 16. Right uncinate attaching to lamina papyracea and left to middle turbinate

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INTRODUCTION
If the ethmoids were placed in any other part of the body, it would be an insignificant and harmless collection of bone cells. In the place where nature has put it, it has major relationships so that diseases and surgery of the labyrinth often leads to tragedy. Any surgery in this region should be simple but it has proven one of the easiest ways to kill the patient -Mosher in 1929.

The two cardinal factors in the maintenance of normal physiology of the paranasal sinuses and their mucous membranes are drainage and ventilation. Normal drainage of the paranasal sinuses depends on effective mucociliary clearance; this is dependant, among other things, on the condition of the sinus ostia.1

Mucus transport from the sinuses into the nose is greatly enhanced by unimpeded nasal airflow creating negative pressure within the nasal cavity during inspiration.1

The secretions of the various sinuses do not reach their respective ostia randomly but by definite pathways which seem genetically determined.2

The two of the largest sinuses, the frontal and maxillary, communicate with the middle meatus via narrow and delicate prechambers. In each of these prechambers, the mucosal surfaces are closely apposed such that mucus can be more readily cleared by an effective ciliary action on two or more sides. However, when surfaces become more closely

2 apposed due to mucosal swelling, the ciliary action is immobilized. This impairs the ventilation and drainage of larger sinuses, result in mucus stasis, predispose to further infection and establish a vicious cycle causing chronic sinusitis.2

The key region for these changes is that part of the lateral nasal wall that encloses the sinus ostia and their adjacent mucosa and prechambers. There is considerable anatomical variation in this area that may interfere with normal nasal function and predispose to recurrent or chronic sinusitis.3

Functional endoscopic sinus surgery restores normalcy by working on the key regions rather than on the larger sinuses. The safe and effective performance of any surgery is dependent on a sound knowledge of anatomy. This is most true during endoscopic sinus surgery because of the intimate association with such vital structures as the orbit, optic nerve, anterior and posterior ethmoidal vessels, skull base and internal carotid artery. The difficulty is compounded by the occurrence of variations in sinonasal anatomy.

The incidence with which these variations are seen in a normal population is less frequent than in those individuals with chronic sinusitis.4 The incidence of the sinonasal anatomical variation reported in literature shows considerable variation between populations. This study aims to study the various sinonasal anatomical variations in our population and their frequency of occurrence in patients with chronic sinusitis.

OBJECTIVES

1. To study the various anatomical variations that are present in patients with chronic sinusitis undergoing endoscopic sinus surgery.

2. To determine the frequency of occurrence of these variations.

REVIEW OF LITERATURE

The endoscopic management of chronic rhinosinusitis is the result of a culmination of (1)changing views of the pathological and regenerative processes of respiratory mucosa, (2)development of intranasal (rather than open) procedures in the late nineteenth and early twentieth century, (3)introduction and development of endoscopes with high quality straight and angled vision and (4)expanding knowledge of sinonasal anatomy.5

CHANGING VIEWS OF PATHOLOGICAL AND REGENERATIVE PROCESSES The mucociliary transport system of paranasal sinuses was discovered in the 1930s by Anderson C. Hilding6 and endoscopically illustrated by Messerklinger and colleagues.7 The work of Wigand and Messerklinger has shown that limited procedures established ventilation and drainage and led to healing of severe mucosal changes.8

These facts prove that the established surgical principle of where there is pus, let it out does not aptly apply to the paranasal sinuses that have a complex but highly organized self-cleaning system.

DEVELOPMENT OF INTRANASAL PROCEDURES The late nineteenth century and early twentieth century saw the development of intranasal (rather than open) approaches to sinus problems, though without the advantage of endoscopic visualization.

5 In 1886, von Mikulicz performed the first opening of maxillary antral cavity through the middle meatus.9

Zuckerkadl in 1882 had observed that unlike inferior meatal antrostomy, the middle meatal antrostomy window generally remained fully patent.10

Dahmer, in 1900, resected anterior third of middle turbinate and created a wide opening from nasal floor to middle meatus through which he removed chronic hyperplastic mucosa from the maxillary antrum.11

In 1900, Killian described a technique of resection of the uncinate process using scissors with widening of neighbouring ostium.12

Halle, in his work published in 1906 described intranasal ethmoidectomy and frontal and sphenoidal sinusotomy. He mentioned important points such as prevention of blind dissection, use of topical adrenaline for bleeding control and the use of special curved instruments.13

In 1912, Mosher initiated intranasal ethmoidectomy in the English speaking world. He resected middle turbinate widely to improve the view of sphenoid and posterior ethmoid sinuses and to make the operation safer.14

6 INTRODUCTION AND DEVELOPMENT OF ENDOSCOPES The earliest endoscopes in rhinology were used for endoscopic diagnosis and for tissue removal for histopathology.

Hirshmann was the first to use a reflector, a speculum and a true endoscope which was a modification of Nitzes cystoscope.15 Endoscopy of the nose received impetus with the improvements by Hopkins between 1951 and 1956. These included a light source that was separate from the instrument, excellent resolution with high contrast, wide angle of vision and true fidelity of colour.

In 1981, Wigand reported on the use of a suction-irrigation surgical endoscope with a rotary and interchangeable angled telescope that could be used in situ for a longer time without lens getting fogged or stained with blood. Around the same time, Stammberger and several other workers started reporting on the use of angled vision endoscopes.

Yamashita16 in 1984 and Lancer and Jones17 in 1986 have reported the role of flexible rhinolaryngoscope with 3.4 mm diameter, 85 degree angle vision and 230 degree arc of visual field mainly for diagnostic purposes. Their role for therapeutic purposes is not established.

EXPANDING KNOWLEDGE OF SINONASAL ANATOMY The introduction of endoscopic intranasal procedures gave a new impetus to the study of sinonasal anatomy. Together with the availability of high quality CT scanning, the

7 knowledge of sinonasal anatomy continues to grow. The following is a presentation of the (a)various anatomical variations and their frequency of occurrence with emphasis on recent work as reported by various authors and (b) various CT scanning protocols for study of sinonasal anatomy.

THE ANATOMICAL VARIATIONS This review presents the sinonasal anatomical variations as studied by various workers in relation to their relevance to endoscopic sinus surgery.

Cribriform plate depth: Keros18 has described three types of skull base conformations: Type 1: Olfactory sulcus is 1 to 3 mm deep Type 2: Olfactory sulcus is 4 to 7 mm deep Type 3: Olfactory sulcus is 8 to 16 mm deep. Erdem G found that the greater the depth of cribriform plate, the shorter was the middle turbinate and higher was the nasal cavity as measured from nasal floor to roof.19 Arslan H et al in a computed tomographic evaluation of 200 patients found that the average depth of olfactory sulcus was 8 mm on right and 9.5 mm on left.20

Septal variations: The nasal septum can be deviated, thick, pneumatized and have spurs. Danese M et al showed septal ridges or spurs in 33% patients with chronic or recurrent sinusitis.21

8 Jareoncharsri P et al22 found septal deviations in 72.3% and spur in 25.3% subjects. Chao TK23 in a computed tomography study of 100 patients reported septal pneumatization in 2%.

Uncinate process: Normally, the uncinate process extends from its sickle-shaped attachment on the lateral wall of the nose and the inferior turbinate posteriorly and medially to its posterior free margin, so that only a 1 to 3 millimeter wide fissure, the hiatus semilunaris, remains between the uncinate process and the anterior surface of the ethmoidal bulla.

The uncinate attaches superiorly in a variety of ways. It may curve laterally to reach the lamina papyracea, it may attach superiorly to the skull base or occasionally it may fuse with the insertion of the middle turbinate. In the first situation, the ethmoidal infundibulum leads superiorly into a blind pouch, the terminal recess.

Yang QT et al24 studied eighty patients using computed tomography with image reconstruction and found that the superior attachment of uncinate process was as follows: lamina papyracea in 41%, posteromedial wall of agger nasi cell in 11%, middle turbinate in 19%, anterior skull base in 16% and superior bifurcation in 13%. Landsberg R and Friedman M25 in a study of 144 patients found that the superior attachment of uncinate process was to lamina papyracea in 52%, to posteromedial wall of agger nasi cell in 18.5%, to both lamina papyracea and junction of middle turbinate to

9 cribriform plate in 17.5%, to junction of middle turbinate to cribriform plate in 7%, to ethmoid roof in 3.6% and to middle turbinate in 1.4%.

Isobe M et al26 classified uncinate process into various forms: Type I: The infero-posterior tip of uncinate process articulates with inferior concha (turbinate). Subtype Ib: The uncinate process adhered to inferior concha along anterior inferior margin closing anterior nasal fontanelle. Type N: The tip of the uncinate process has no articulation and has a free edge. Type S: The tip of the uncinate process is articulated to superior structures such as bulla, medial orbital wall. Type P: The tip articulated with the perpendicular plate of palatine bone. Combinations: IS, IP, SP, ISP- As indicated by the alphabets, these denote combinations of above.

Liu X et al27 found uncinate hyperplasia in 19.36% and deviation in 45.27%. Joe JK et al28 reported typical uncinate in 85% and medially rotated uncinate in 15%. Jareoncharsri P22 reported abnormal uncinate process in 9.6%. Danese M21 reported unusual deflections of the uncinate process in 31%.

Chao TK23 reported bilateral pneumatization of uncinate process in 1% and large uncinate process that mimics the middle turbinate in 1%.

10 Wang R et al29 demonstrated four variations of the uncinate process: 1) Medially deviated, 2) Laterally deviated, 3) Pneumatized and 4) Hypertrophied.

Middle turbinate: The middle turbinate is said to have paradoxical curvature when its concavity is towards the nasal septum and convexity towards the lateral nasal wall. Concha bullosa is a pneumatized middle turbinate. It can be of three types as made out by computed tomographic evaluation: 1) Lamellar: Only the vertical lamella is pneumatized. This occurs from the superior meatus and is called interlamellar cell. 2) Bulbous: When only the bulb is pneumatized. 3) True concha bullosa: When the whole turbinate is pneumatized.

Liu X et al27 reported paradoxical curvature of the middle turbinate in 13.97% and pneumatized middle turbinate in 34.85%. Joe JK et al28 reported the presence of the following types of middle turbinate: Typical in 63%, Conchal bullosa in 15%, Sagittal cleft in 6%, Laterally displaced in 4%, L shaped in 3%, Medially bent in 3%, Laterally bent in 3%, Medially displaced in 2% and Transverse cleft in 0.5%.

Basic N et al30 found paradoxical curvature of middle turbinate in 24.2%, pneumatized middle turbinate in 42.%, true concha bullosa in 8.3% and bilateral concha bullosa in 1.7%.

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Kayalioglu G et al31 compared incidence of variations in sinusitis and non-sinusitis subjects. In subjects with sinusitis, concha bullosa was found in 28.88% and paradoxical curvature in 12.22%. In non-sinusitis subjects, concha bullosa was found in 26.83% and paradoxical curvature in 7.31%.

The infundibulum: According to Van Alyea, 32, 33 the wall of the uncinate process is 2 mm high in 70% of cases at the maxillary sinus ostium. The infundibulum is considered to be deep when this is more than 4 mm high. The infundibulum may be made narrow because of a lateralized uncinate or uncinate hugging a large bulla or Haller cell.

According to Mayerson, 34 the maxillary ostium is situated obliquely in 3.4%, horizontally in 40% and vertically in 57.6% in the infundibulum.

The ethmoidal bulla: This represents the largest anterior ethmoidal air cell. It is poorly aerated or completely unpneumatized in 8% of patients in which case it is called torus lateralis.

In order to determine whether the bulla ethmoidalis was a true cell or a lamella that is pneumatized, Wright ED and Bolger WE35 studied 14 sinonasal complexes by gross anatomy. They found that the ethmoid bulla contained a distinct lamella in all cases. The degree of pneumatization varied ranging from a rudimentary torus to a relatively well

11

12 pneumatized bulla like structure. A pneumatization tract originating from retrobullar recess was present in all specimens. This pneumatization excavated into the lamella, creating the bulla-like appearance as viewed from the middle meatus. The lack of a distinct posterior wall made them to conclude that the bulla ethmoidalis was a bony lamella with an air space behind it and not a separate cell.

On endoscopy, the bulla may vary considerably with balloon shaped in 45%, sausage shaped in 34% and flat in 21% according to Joe JK et al.28 According to Stammberger,2 the bulla may be excessively pneumatized to the extent of blocking the hiatus semilunaris, extending beyond the uncinate or sometimes extending out of the middle meatus between uncinate and middle turbinate.

The fontanelles and accessory maxillary sinus ostia The posteroinferior end of the uncinate process attaching to the inferior turbinate divides the fontanelle into anterior and posterior portions. Accessory sinus ostia may be present in the fontanelles, the natural incidence being 4 to 5% increasing to 25% in patients with chronic rhinosinusitis.

The shape of the ostia vary from round in 50% to oval in 46% to kidney shaped in 4% of patients.

Frontal sinus, ostium and recess:

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13 The frontal sinus commonly has two chambers, one on each side, almost always asymmetrical. There may be three or more chambers in 1.5% to 21% of individuals.

The natural ostium of frontal sinus most frequently presents as an hourglass narrowing opening directly into the recess, a space into which frontal sinus opens. The size and shape of the recess depends on the pneumatization of agger cells.

Landsberg R and Friedman M25 found that the average dimension of frontal sinus ostium was 7.22 mm anteroposteriorly and 8.92 mm transversely. They concluded that the naturally wide dimensions of the frontal ostium explains why postoperative patency can be achieved merely by exposing it without need to enlarge it.

Shi JB et al36 studied the frontal recess and ostium in 96 nasal cavities and found1) Obstruction by swollen mucosa, polypoid mucosa or polyps with no cell obstruction in 38 out of 96 nasal cavities studied. 2) Constriction by over development of agger nasi cells, ethmoidal bulla or terminal recess at frontal recess in 34 of 96. 3) Obstruction by overdevelopment of ethmoid cells in 15 of 96. 4) Osteal stenosis at sinus orifice in 9 of 96.

Yang QT et al24 studied the incidence of obstruction of frontal recess by cells and reported the followingRecess obstruction by cells:

13

14 Terminal recess in 38.8% Anterior ethmoidal cell in 27.6% Agger nasi cells in 24.5% Recess obstruction by accessory cells: Perifrontal cells in 32.7% Supraorbital cells in 38.8% Intersinus septal cells in 32%

The ethmoidal cells which project into the frontal sinus cavity are called frontal cells. Zuckerkandl called them frontal bullae. In such cases, the frontal sinus drains into the sinus lateralis. Meyer TK et al37 reported a 20.4% incidence of frontal cells. They also studied the incidence of frontal mucosal thickening in individuals with and without frontal cells. In individuals with frontal cells, mucosal thickening was found in 69% compared to just 17.1% in those without frontal cells.

Jareoncharsri P et al22 found narrowing of the frontal recess in 30.1% and obstruction of entrance to frontal recess in 19.3%.

Agger nasi: The agger nasi cell presents as a smooth elevation anterior and superior to the junction of the middle turbinate with lateral nasal wall. It is a product of pneumatization of the

14

15 lacrimal bone and contains 1 to 3 cells. The posterosuperior wall of the cell forms the inferior wall of the frontal recess.

Landsberg R and Friedman M25 reported agger cells in 78% of patients. Liu X et al27 found large agger nasi in 0.70%. Jareoncharsri P22 reported enlargement of agger nasi cells in 2.4%. Kayalioglu et al31 demonstrated agger nasi cells in 7.77% of patients with sinusitis and in 4.88% subjects without sinusitis.

Wang N et al38 studied one hundred patients and reported the presence of agger nasi cells in 99% of these cases. The morphology of agger nasi cells varied widely but their relationship to anterior border of middle turbinate, bulla ethmoidalis and nasolacrimal canal was stable. The upward pneumatization was closely related to the development of frontal sinus.

Supraorbital ethmoidal cells: These represent extramural invasion of the supraorbital plate of the frontal bone by air cells of the ethmoid sinus and is said to be present in 15% to 21% according to Bhatt NJ.39 Arslan H et al20 in a CT study of 200 patients showed supraorbital recess in 6%.

Haller cell:

15

16 Also called infraorbital ethmoid cell, this is present in the roof of maxillary sinus (orbital floor), distinct from bulla and maxillary sinus.

Stackpole SA and Edelstein DR40 reported an incidence of 34% of patients. Liu X et al27 found Haller cells in only 1% of patients. Arslan H et al20 reported an incidence of 6%.

Sinus Lateralis: Also called the suprabullar or retrobullar recess, this is a cleft between the roof of the ethmoid, ground lamella and bulla.

Picerno NA and Bent JP41 in their anatomic study of 33 cadaver heads used 0-degree, 30degree, and 70-degree endoscopes; and dissected anterior ethmoids. The findings were correlated with findings on gross anatomic dissection of the same specimens. They classified sinus lateralis into four types: Type I: Posterosuperior extension to skull base seen in 44% Type II: Posterior extension to sphenoid face seen in 30% Type III: Abrupt termination posterior to ethmoid bulla seen in 16% Type IV: Extension to posterior ethmoid through dehiscent basal lamella seen in 5%. They concluded that sinus lateralis is a consistent feature of the anterior ethmoid. In types I and II, they suggested a method of using the sinus lateralis as a critical landmark and removal of air cells in a posterior to anterior direction for complete anterior ethmoid

16

17 clearance. They have confirmed the utility of this approach by operating using the above principle and found it to be safe.

Sphenoid sinus and ostium: The sphenoid sinus is a bilateral pneumatization of the sphenoid bone. Variations in size, shape, pneumatization and number of septa are so common that Van Alyea33 regards variability as typical of the anatomy of the sphenoid sinus.

Types of pneumatization seen are 1) Conchal: Limited pneumatization not extending to sella turcica. 2) Presellar: Pneumatization extends upto to anterior part of sella turcica. 3) Sellar and post sellar: Pneumatization extending beyond the sell turcica.

Batra PS et al42 studied 64 cadaver heads and found the following incidence of sphenoidal pneumatization: conchal in 4.7%, presellar in 4.7%, sellar in 25% and postsellar in 65%. When pneumatization extends into the lesser wing of sphenoid, supraoptic and infraoptic recesses are prominent. Agenesis of sphenoid sinus is seen in 1% of cases.

Lang43 has reported the following incidence of intrasphenoidal projections- internal carotid artery in 85.7%, optic nerve in 19%, maxillary nerve in 28.6%, Vidian nerve in 14.3% and abducent nerve in 4.8%.

17

18 Joe JK et al28 studied the shape of sphenoid sinus ostium and reported oval shaped ostium in 42%, slit shaped in 32% and round in 26%. Kim HU et al44 reported that the sphenoid sinus ostium is located 1 cm above the posteroinferior end of superior turbinate. It was at a medial aspect to the postero-inferior end of superior turbinate in 83% of cases. Onodi cell: Postero-lateral pneumatization of posterior ethmoid cells is reported to occur in 10% of patients according to Basic et al.30

Pneumatized inferior turbinate: This is best made out on computed tomography. Braun H and Stammberger H45 reviewed literature and found only 10 cases of pneumatized inferior turbinate.

Pneumatized superior turbinate: For clinical purposes, this can be made out on computed tomography. Ariyurek OM et al46 reported the presence of superior turbinate pneumatization in 48% of patients. In 40% of these patients the pneumatization was minimal; unilateral in 25% and bilateral in 15%. Marked pneumatization was present in 8%; unilateral in 2% and bilateral in 6%.

Supreme turbinate: Kim SS et al47 in a cadaveric study found that the basal lamella of the supreme turbinate could be made out in 15% of cases.

18

19 Arredondo et al48 reported that 23% of fetuses show presence of supreme turbinate, but do not grow beyond average length of 5 mm.

The various anatomical variations can be summarized as follows: 1) Ethmoid roof and depth of cribriform plate: Keros types I to III. 2) Septal variations: Deviations, spurs, thick septum and pneumatization. 3) Turbinates: a. Middle: Paradoxical, pneumatized, hyperplastic, lateralized. b. Superior: Pneumatized. c. Inferior: Hypertrophied and pneumatized. d. Supreme: Presence or absence.

4) Uncinate: Medialized, lateralized, anteriorly curved, hyperplastic and pneumatized. 5) Infundibulum: a. Shallow or deep b. Narrow or wide 6) Ethmoidal bulla: Absent, hypoplastic, typical and enlarged. 7) Extramural ethmoidal cells: a. Agger nasi cells (lacrimal bone) b. Supraorbital cells c. Middle turbinal cells (concha bullosa) d. Uncinate process cells

19

20 e. Superior turbinal cells f. Haller cell (orbital plate of maxilla) 8) Sphenoid sinus: a. Septations b. Patterns of pneumatization: Conchal, presellar and sellar. c. Lateral extensions: Lesser wing, greater wing and pterygoid. d. Midline extensions: Rostral, septal, inferior clival and superior clival e. Dehiscences of optic nerve and internal carotid artery. 9) Frontal sinus a. Aplastic, hypoplastic and hyperplastic b. Presence of more than two chambers c. Extensions intoi. Orbital plate ii. Crista galli iii. Anterior ethmoid 10) Maxillary sinus a. Sinus septa b. Accessory ostia c. Extensions i. Infraorbital recess ii. Alveolar recess iii. Zygomatic recess.

20

21

CT SCANNING PROTOCOLS Stammberger2 recommends the following parameter. Imaging should be in the coronal plane perpendicular to infra-orbito-meatal line. Slice thickness should be set at 4 mm and when extra detail is required at 2 mm. When no sagittal or axial reconstruction is contemplated, contiguous 4 mm thickness scans should be taken. When reconstruction is planned, thinner or overlapping slices should be chosen. The position of the patient should be prone with head hyperextended. The scan time should be 5 to 7 seconds, window width of +1500 to 2000 HU centered at a level of -150 HU.

Bhatt NJ39 recommends the following protocol for imaging. Axial and coronal images of the sinuses should be obtained using 1.5 mm collimation and 4 mm spacing. Detail scan technique should be used with display field of view of 16 cm for adults and 14 cm for children. The axial plane scans should be from a little below the level of the hard palate up to the top of frontal sinuses. The coronal scans should be perpendicular to hard palate and extending from nasion to posterior aspect of sphenoid sinus. Contrast is not required for uncomplicated chronic sinusitis and is to be used only in case of suspected pyocele, mucocele and malignancy.

Wigand5 recommends quasi-frontal coronal sections with high resolution bone window and slice thickness of 2 mm and slice interval of 5 mm.

21

22

METHODOLOGY

The present study entitled an endoscopic study of sinonasal anatomical variations and their frequency of occurrence in patients undergoing endoscopic sinus surgery was conducted in the Department of ENT of Jawaharlal Nehru Medical College, Belgaum at KLES Hospital and Medical Research Center, Belgaum and District Hospital, Belgaum between July 2003 and June 2004.

Source of data: All the patients attending the ENT outpatient department with proven history of sinusitis of three months duration not responding to medical treatment with full course of antibiotics, analgesics and decongestants and who were willing to undergo endoscopic sinus surgery and CT scanning of paranasal sinuses.

Sample size: 40.

Sampling procedure: Cross sectional study.

Inclusion criteria: All the patients with chronic sinusitis not responding to medical treatment and willing to undergo endoscopic sinus surgery and CT scanning of paranasal sinuses.

22

23

Exclusion criteria: 1) Patients who have had previous endoscopic sinus surgery and hence undergoing revision procedure. 2) Patients who have undergone previous septal or turbinate surgery. 3) Patients with chronic sinusitis responding to medical management. 4) Patients not consenting to participating in the study.

Method of collection of data: 1) The cases selected for the study were subjected to detailed history and evaluation. 2) Routine investigations like hemogram, bleeding and clotting time and routine urine evaluation were done for the patients. 3) Those patients in active stage of the disease were treated with a course of antibiotics, analgesics and decongestants. However, steroids were not given either topically or systemically for any patient. 4) The patients underwent a diagnostic nasal endoscopy using the standard 3-pass technique. 5) The patients underwent CT scanning of paranasal sinuses. 6) Finally, the patients underwent endoscopic sinus surgery, the extent of which was as dictated by the disease extent by the above two procedures.

Equipments used: 1) Nasal endoscopes: 0 degree, 30 degree and 45 degree Hopkins rod endoscopes.

23

24 2) Cold light source. 3) Fiber optic light cord. 4) Karl Storz single chip camera. 5) Sony 14 inch colour monitor. 6) Savlon as antifog solution. 7) Standard endoscopic sinus surgery instruments.

The method of diagnostic nasal endoscopy used: After testing the patient for lignocaine sensitivity, diagnostic endoscopy was performed. Position: The examination was done with the patient in supine position and head turned towards the examiner standing/sitting on the right side of the patient. Anesthesia: Topical decongestant anesthetic 4% lignocaine with 1:100000 adrenaline. This was first used as a spray and then applied intranasally as wet cottonoid strips. Procedure: Endoscopy was performed using the standard three pass technique. During the first pass, the endoscope was passed along the floor of the nasal cavity noting the status of the inferior turbinate, septum, Eustachian tube orifice, fossa of Rosenmuller, nasopharyngeal mucosa and nasolacrimal duct orifice. During the second pass, the scope was introduced along the superior surface of the inferior turbinate and directed into the sphenoethmoidal recess. While withdrawing the scope, the sphenoid ostium, sphenoethmoidal recess and superior turbinate were visualized and any variations noted.

24

25 During the third pass, the agger nasi area, uncinate, middle meatus and frontal recess area were visualized and variations noted. Technique of CT scanning performed: Before undergoing CT scanning, the patients were instructed to clean their noses by blowing out any secretions. Xylometazoline 0.1% drops were instilled to both nasal cavities 30 minutes before scanning. The scanning was done on Somatom Spiral CT Scanner. Patient position: Supine with head extension. In patients in whom head extension was contraindicated due to cervical spondylosis, gantry tilt was suitably adjusted. Angulation: Perpendicular to hard palate. Extent: From the nasion to posterior extent of sphenoid. Thickness: 5 mm thickness with 5 mm shift to get contiguous sections. Exposures: 120 kV, 4.5 sec scan time, 300 mA, window width of 2500 to 3000 HU and window level of 250 to 300 HU. The images were recorded onto compact disc and photographic plates. The photographic plates were displayed in the operation theater at the time of surgery.

Technique of endoscopic sinus surgery: The patients underwent endoscopic sinus surgery after obtaining written informed consent for the same. Position: Supine with head slightly elevated and turned towards the surgeon, who stands/sits at the right side of the patient.

25

26 Premedication: Intramuscular injection of 0.6 mg atropine, 25 mg promethazine and 30 mg pentazocine was given to the patients 30 minutes before procedure. Anesthesia: All patients in this study underwent the procedure under local anesthesia. Lignocaine 4% soaked cotton strips were used for topical anesthesia. Lignocaine 2% with 1:200000 adrenaline was used for infiltration. Lignocaine 4% with 1:30000 adrenaline was used topically for bleeding control intraoperatively. Procedure: The extent of the procedure was dictated by the extent of disease as determined by nasal endoscopy, CT scanning and intraoperatively. A typical complete procedure included the following: 1) Infundibulotomy 2) Middle meatal antrostomy 3) Clearance of frontal recess 4) Opening bulla and exenteration of anterior ethmoids 5) Posterior ethmoid exenteration 6) Sphenoid exenteration. The surgical technique used was the Messerklinger technique as described by Stammberger.

Following the above procedures, the findings were recorded in the proforma as shown in Annexure II. The results were tabulated. The various variations were analysed as a percentage of the total and reported.

26

27

RESULTS

Age distribution: The age of the patients varied from 15 years to 72 years. The majority of the patients i.e. 9 (22.5%) were in the fifth decade of life.

Table 1. Age distribution Age group 11-20 21-30 31-40 41-50 51-60 61-70 71-80 No of cases 7 7 7 9 5 3 1

Age distribution
1, 3% 3, 8% 5, 13% 7, 18% 9, 22% 7, 18% 7, 18% 11to20 21to30 31to40 41to50 51to60 61to70 71to80

27

28 Sex distribution: The sex distribution showed a slight male preponderance with 25 (62.5%) males and 15 (37.5%) females.

Table 2. Sex distribution Sex Number of patients Male Female 25 15

Sex distribution

Female, 15, 38% Male, 25, 62%

Male Female

Variations: Skull base types: The following was the incidence of various skull base types1) Keros Type I: 10 (12.5%) 2) Keros Type II: 50 (62.5%) 3) Keros Type III: 20 (25%)

28

29

Table 3. Skull base types Keros type I II III Number 10 50 20

Keros skull base types

Percentage 12.5% 62.5% 25%

20, 25%

10, 13% I II III 50, 62%

Septum: Septal deviations were seen in 26 (65%). Of these 10 (38.4%) were to right and 16 (61.6%) were to the left. Septal spurs were seen in 19 (47.5%). Of these 9 were to right and 10 were to the left. Among them, 11 (57.8% of spurs) had contact area with the turbinates. Thick septum was found in 12 (30%). Pneumatization of the septum was found in 10 (25%).

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30

Table 4. Septal variations Variation Deviation Spur Thick Pneumatized Number 26 19 12 10 Prevalence 65% 47.5% 30% 25%

Septal variations
80% 60% 40% 20% 0%

65%
Deviation

47.50%
Spur

30%
Thick

25%
Pneumatiz ed

Agger nasi: Pneumatization of agger nasi was seen in 58 (72.5%) nasal cavities. When present, the agger cells were always bilateral.

Frontal sinus: The frontal sinus was present in 75 (93.5%) sides, absent in 5 (6.25%) sides, and hyperpneumatized in 22 (27.5%). The sinus was larger on the right in 19 subjects and on the left in 21 subjects. Interfrontal cells were seen in 8 (10%).

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31

Frontal recess: The frontal recess was found to be obstructed in 14 of 75 (18%). Of these 8 (57%) were on the right and 6 (43%) were on the left. The obstruction was caused by agger nasi cells in 6 (43%), ethmoidal bulla or accessory cells in 4 (28.5%) and polyps in 4 (28.5%).

Middle turbinate: The middle turbinate was typical in 32 (40%). Of these 17 (53.1%) were on the right and 15 (46.9%) were on the left. It was paradoxically curved in 7 (8.75%). Of these 5 (71.4%) were on the right and 2 (28.6%) were on the left. In 2 patients, it was bilateral. Hyperplastic non-pneumatized middle turbinate was seen in 3 (3.75%). Of these 2 (66.6%) were on the right and 1 (33.3%) was on the left. In 1 (2.5%) patient, it was bilateral. Pneumatized middle turbinate was seen in 24 (30%). Of these 7 (29.1%) were on the right and 17 (70.8%) were on the left. In 7 (29.1%) patients, it was bilateral. Of the pneumatized turbinates, 10 (41.6%) showed lamellar pattern, 1 (4.2%) showed bulbous pattern and 13 (54.2%) were true concha bullosae.

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32

Table 5. Middle turbinate variations Variation Typical Paradoxically curved Pneumatized Large non pneumatized Number 32 7 24 3 Percentage 40% 8.75% 30% 3.75%

Middle turbinate variations

Typical 3, 5% 24, 36% 7, 11% Large non pneumatized 32, 48% Paradoxically curved Pneumatized

Table 6. Types of middle turbinate pneumatization Type Lamellar Bulbous Complete Number 10 1 13 Percentage 41.6% 4.2% 54.2%

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33

Types of Middle Turbinate Pneumatization

10, 42% 13, 54% 1, 4%

Lamellar Bulbous Complete

Uncinate process: The superior attachment of the uncinate process was as follows: middle turbinate in 31 (38.75%), lamina papyracea in 28 (35%) and skull base in 21 (26.25%). The uncinate was typical in 39 (48.75%), medialized in 29 (36.25%), anteriorly turned in 2 (2.5%), hypertrophied in 8 (10%) and pneumatized in 2 (2.5%).

Table 7. Uncinate variations Variation Typical Medialized Anteriorly turned Hypertrophied Pneumatized Number 39 29 2 8 2 Percentage 48.75% 36.25% 2.5% 10% 2.5%

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34

Uncinate variations
Typical 2, 3% 8, 10% 2, 3% 29, 36% 39, 48% Medialized Anteriorly turned Hypertrophied Pneumatized

Table 8. Uncinate superior attachment Attachment Middle turbinate Lamina papyracea Skull base Number 31 28 21 Percentage 38.75% 35% 26.25%

Superior attachment of uncinate process

Middle turbinate 21, 26% 31, 39% Lamina papyracea Skull base

28, 35%

34

35

Ethmoidal bulla: The bulla was typical in 50 (62.5%), large in 17 (21.25%) and hypoplastic in 13 (16.25%).

Table 9. Ethmoidal Bulla variations Type Typical Large Hypoplastic Number 50 17 13 Percentage 62.5% 21.25% 16.25%

Ethmoidal bulla variations

13, 16% 17, 21% 50, 63%

Typical Large Hypoplastic

Supra-orbital cells: Supra-orbital ethmoid pneumatization was seen in 18 (22.5%). Of these 10 (55.5%) were on the right and 8 (44.5%) were on the left. In 8 (20%) patients, it was bilateral.

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36

Accessory ostia: Accessory maxillary sinus ostia were seen in 12 (15%). Of these, 8 (66.6%) nasal cavities showed accessory ostia in anterior fontanelle and 4 (33.3%) in the posterior fontanelle. In 2 (2.5%) of patients, there were multiple accessory ostia.

Maxillary sinus septations: Septations were found in 4 (5%) maxillary sinuses. Of these 1 (25%) was on the right and 3 (75%) were on the left. In 1 (2.5%), it was bilateral.

Haller cell: Haller cell was seen in 3 (3.75%).

Pneumatized superior turbinate: Superior turbinate pneumatization was seen in 5 (6.25%). Of these 3 (60%) were on the right and 2 (40%) were on the left. In 1 (2.5%) patient, it was bilateral.

Supreme turbinate: The presence of supreme turbinate could not be discerned in any of the subject examined.

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37

Sphenoid sinus: The sphenoid sinus ostium could be visualized in 62 (77.5%). The ostium was circular in 19 (30.6%), oval in 28 (45.2%) and slit in 15 (24.2%). In the 18 (22.5%) in which it could not be visualized, 12 (66.6%) were due to narrow sphenoethmoidal recess and 6 (33.3%) were due to polyps.

Table 10. Sphenoid sinus ostium variations Shape Circular Oval Slit Number 19 28 15 Percentage 30.6% 45.2% 24.2%

Shape of sphenoid ostium

15, 24%

19, 31%

Circular Oval Slit

28, 45%

The various patterns of pneumatization seen were: absent in 1 (2.5%), conchal in 1 (2.5%), presellar in 9 (22.5%) and sellar in 29 (72.5%).

The various intrasphenoidal projections seen were:

37

38 1) Optic nerve in 22 (27.5%). 2) Maxillary nerve in 23 (28.7%). 3) Vidian nerve in 24 (30%).

Table 11. Intrasphenoidal projections Structure Optic nerve Maxillary nerve Vidian nerve Number 22 23 24 Prevalence 27.5% 28.7% 30%

Intrasphenoidal projections
31.00% 30.00% 29.00% 28.00% 27.00% 26.00% Optic nerve Maxillary nerve Vidian nerve

Onodi cell: Onodi cells were seen in 18 (22.5%). Of these 10 (55%) were on the right and 8 (45%) were on the left. In 7 (17.5%) of patients, it was bilateral.

Large inferior turbinate:

38

39 A large inferior turbinate was found in 29 (36.2%). Of these 14 (48.2%) were on the right and 15 (51.8%) were on the left. In 8 (20%) of patients, it was bilateral. In 22 (75.8%), the large inferior turbinate was associated with pathology in ipsilateral maxillary sinus and in 7 (24.2%) there was no ipsilateral maxillary sinus pathology.

Rathkes pouch remnant: This was seen in 1 (2.5%) case.

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40

DISCUSSION
The present study was conducted from July 2003 to June 2004 in the Department of ENT, Jawaharlal Nehru Medical College, Belgaum at KLES Hospital and MRC, Belgaum and District Hospital, Belgaum. The study included 40 patients of chronic sinusitis who were undergoing endoscopic sinus surgery. Thus, a total of 80 nasal cavities were examined by diagnostic nasal endoscopy, CT scanning and at the time of definitive surgery. CT scan was used in addition to endoscopic assessment to increase the accuracy of recording of the findings. The various anatomical variations of each patient were noted and their frequency of occurrence determined.

The discussion is presented along the following headings: 1) Age and sex distribution 2) Septal variations 3) Agger nasi cells 4) Frontal sinus 5) Frontal recess 6) Middle turbinate 7) Bulla ethmoidalis 8) Uncinate process 9) Maxillary intrasinus septa 10) Accessory ostia 11) Inferior turbinate hypertrophy

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41 12) Pneumatized superior turbinate 13) Supreme turbinate 14) Onodi cell 15) Haller cell 16) Supraorbital ethmoidal cells 17) Intrasphenoidal projections 18) Sphenoid sinus pneumatization 19) Skull base configuration 20) Rathkes pouch remnant.

Age and sex distribution: The age of the patients varied from 15 years to 72 years. The sex distribution showed a slight male preponderance with 62.5% males and 37.5% females.

Septal variations: We found septal deviations in 65% of cases. In our study, there was slight preponderance of deviation to the left (61.6%) compared to deviation to the right (38.4%). The reported incidence of septal deviations in literature ranges from 40% (Calhoun et al49) to 96.9% (Takanishi et al50). The prevalence of septal spurs in our study was 47.5%. Among these, over half (57.8%) had contact area with the turbinates. The prevalence of deviations of nasal septum as reported by various workers is 21% (Zinreich51), 24% (Jones NS52), 38% (Yadav SPS53), 40% (Bolger54) and 72% (Jareoncharsri P22). Our results are comparable to the higher ranges reported. The prevalence of septal ridges or

41

42 spurs is reported as 33% (Danese M et al21) and 25.3% (Jareoncharsri P et al22). The results in our study are slightly higher than this.

Table 12. Prevalence of septal deviations Author Zinreich Jones NS Yadav SPS Bolger Jareoncharsri P Our study Prevalence 21% 24% 38% 40% 72% 65%

Prevalence of Septal Deviations

80% 60% 40% 20% 0%

21%

24%

38%

40%

72%

65%

The mere presence of a septal deviation does not suggest pathology. However, a marked deviation can force the middle turbinate laterally, thus narrowing the entrance to the

Jareoncha rsri P

Jones NS

Our study

Zinreich

Yadav SPS

Bolger

42

43 middle meatus. Also, ridges and spurs coming into contact with turbinates or other areas of the lateral wall can predispose to recurrent sinusitis.

We found septal pneumatization in 25%. This correlates well with that of Wang RG et al55 who reported an incidence of septal pneumatization in 18%. Attention can be drawn to the importance of this variation by the first reported case of septal mucocele by Wang RG.

Agger nasi cells: We found pneumatization of the agger nasi cells in 72.5%. In all patients, the pneumatization when present was bilateral. The prevalence of agger nasi cells varies widely as reported by various workers: 10-15% (Messerklinger56); 14% (Lloyd et al57); 65% (Davis58); 89% (Van Alyea33) and 100% (Kennedy and Zinreich59). Depending on the degree of pneumatization, agger nasi cells may reach laterally to the lacrimal fossa and superiorly to cause narrowing of frontal recess.

On coronal CT, these cells appear inferior to frontal recess and lateral to the middle turbinate. Because of this intimate relationship these cells form excellent surgical landmarks. Opening the agger nasi cells usually provides a good view of the frontal recess. Therefore, identification of this variation is important in diagnosis and treatment of recurrent or chronic frontal sinusitis.

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44

Table 13. Prevalence of agger nasi cells Author Messerklinger Lloyd Davis Van Alyea Kennedy and Zinreich Our study 72.5% Prevalence 10 to 15% 14% 65% 89% 100%

44

45

Prevalence of agger nasi cells

120%

100%

80%

60% 100% 89% 40% 65% 20% 14% 0% 72.50%

ch re i Zi n O ur

Al ye

Ll oy

av i

Va

Frontal sinus: We found the prevalence of nonpneumatization of frontal sinus in 6.25%. This correlates with the study by Natsis K60 who reported a prevalence of 5%.

In all our patients, frontal sinuses on either side were always asymmetrical with right being large in 47.5% and the left sinus being large in 52.5%.

Ke

nn e

dy

an d

st

ud y

45

46

Frontal recess: As the axis of the frontal recess is tilted approximately 50 degrees to the canthomeatal line, this drainage pathway cannot be included entirely within a single coronal section. Therefore, coronal oblique views are required for complete information.

In our study, we found that the frontal recess was obstructed in 18%. Of these, in 43% the obstruction was by agger nasi cells, in 28.5% by ethmoid bulla or accessory cells and in 28.5% by polyps. As the natural ostium of the frontal sinus is very wide with average anteroposterior diameter of 7.22 mm and transverse diameter of 8.92 mm, the obstruction to the frontal sinus drainage and ventilation most often lies in the frontal recess rather than the ostium as is evident from our results. Therefore merely clearing the recess is sufficient to achieve patency of frontal sinus ostium in most cases.25

Middle turbinate: Typically, the middle turbinate is said to have convex medial and concave lateral surfaces with smooth uniform curvature with no obstruction to middle meatus and adequate space between the turbinate and septum. However, the middle turbinate in known for several variations. Pneumatized middle turbinate: We found pneumatized middle turbinate in 30%. Of these, 41.6% showed lamellar pattern, 4.2% showed bulbous pattern and 54.2% showed true concha bullosae. The origin of the pneumatization can sometimes be seen as depressions on the lateral surface. Literature reports a wide variation in the incidence of middle turbinate pneumatization and is a follows: Joe JK28 et al -15%; Liu X27 et al 34.85%, Basic N30 et al -42%, Lothrop61 -9%, Davis58 -8%, Shaeffer62 -11%. Our results are close to that reported by Lie X et al.

Presence of a concha bullosa does not suggest a pathological finding. However, in the setting of chronic sinus disease, resection of the concha bullosa should be considered to

46

47 improve paranasal sinus access. Further, the concha bullosa interior may be affected by disease in other sinuses.

Paradoxically bent middle turbinate: A middle turbinate which is distorted such that the convex surface faces towards the meatus is in itself not pathologic but can contribute to severe narrowing of the middle meatus if other mucosal derangements are present.

We found paradoxical curvature of middle turbinate in 8.75%. This correlates well with that reported by Calhoun49 (7.9%) and Lusk63 (8.5%).

Table 14. Prevalence of pneumatized middle turbinate Author Joe JK Liu X Basic N Lothrop Davis Shaeffer Our study Prevalence 15% 34.85% 42% 9% 8% 11% 30%

47

48

Prevalence of pneumatized middle turbinate

45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

42% 34.85% 15% 30% 9% 8% 11%

th ro p

Li u

sic

Jo

Ba

Lo

ae f

Table 15. Prevalence of paradoxical middle turbinate Author Calhoun Lusk Our study Prevalence 7.9% 8.5% 8.75%

O ur

Sh

st ud y

JK

av i

fe r

48

49

Prevalence of paradoxical middle turbinate

9.00% 8.50% 8.00% 7.50% 7.00%

7.90% Calhoun

8.50%

8.75%

Lusk

Our study

Bulla ethmoidalis: We defined a hypoplastic bulla as one in which the distance between the lateral surface of middle turbinate and summit of bulla was more than 4 to 5 millimeters. An enlarged bulla ethmoidalis was defined as one that contacts or extends beyond the free margin of the uncinate and middle turbinate. This can result in a narrow hiatus semilunaris. We found large ethmoidal bulla in 21.25%. This correlates with the reported frequency by Lloyd57 (17%) and Lund VJ64 (18%).

Table 16. Prevalence of large ethmoidal bulla Author Lloyd Lund VJ Our study Prevalence 17% 18% 21.25%

49

50

Prevalence of large ethmoidal bulla

25% 20% 15% 10% 5% 0%

17%

18%

21.25%

Lloyd

Lund VJ

Our study

Uncinate process: The superior attachment: The superior attachment of uncinate process is important for the following reasons. When the uncinate process is attached to the skull base or middle turbinate, the frontal recess opens into the ethmoidal infundibulum and can be involved in infundibular disease. When the superior attachment is to the lamina papyracea, the frontal sinus opens into the middle meatus directly and can be spared from infundibular disease. Further, during surgery, this attachment needs to be cleared before gaining access to frontal recess. In our study, we found that the superior attachment was to middle turbinate in 38.75%, lamina papyracea in 35% and skull base in 26.20%.

Deviated uncinate process: In our study, we found medially turned uncinate process in 36.25% and anteriorly turned uncinate process in 2.5%. This correlates well with 45.27% deviations reported by Liu X et al and 31% deflection reported by Danese M.21

Normally, the uncinate is a sagitally-oriented structure with adequate space between it and bulla ethmoidalis, middle turbinate and lamina papyracea. The medial deflection may contact the middle turbinate or can narrow the middle meatus. A lateral deflection of the uncinate process will make the infundibulum narrow. Because of the reduced distance between the lateralized uncinate process and lamina papyracea, care needs to be

50

51 taken while performing uncinectomy to prevent orbital injury. An anteriorly bent uncinate process gives the impression of double middle turbinate on endoscopy.

Pneumatized uncinate process: We found this variation in 2.5%. This correlates with the prevalence reported by Kennedy(0 to 4%) and Bolger et al (2.5%).54 The pneumatized uncinate is called uncinate bulla and can narrow the infundibulum, frontal recess and middle meatus.

Maxillary intrasinus septa: An intrasinus maxillary septum can convert the maxillary sinus into two chambers. According to Prahlada NB, 65 this is present is 1% to 6% of the population. Earwaker reported a prevalence of 2.38% in his study. In our study, we found maxillary sinus septation in 5% which is consistent with that reported by Prahlada NB. All the intrasinus septae were running obliquely along the longest diameter. This finding is important in that a part of the maxillary sinus can have impaired drainage while the rest of it is normal.

Accessory ostia:

Table 17. Differences between natural and accessory ostia Natural Always present Difficult to see clinically Accessory Present in 10% to 40% Easily seen on endoscopy

Lies deep in infundibulum Lies in the sagittal plane in fontanelle Oval shaped Always single Small in diameter Round or punched out appearance Could be multiple Could be large (upto 1 cm)

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52 The accessory ostia of the maxillary sinus are present in the anterior and posterior nasal fontanelles, the bone deficient areas in lateral nasal wall behind and below uncinate process. The differences between the natural and accessory ostia of maxillary sinus is given in table 17. In our study, accessory ostia were present in 15% of nasal cavities. Earwaker has reported an incidence of 13.75%. Our results are very close to that of Earwaker.

Inferior turbinate hypertrophy: We found inferior turbinate enlargement in 36.2%. Of these, in 75.8%, the large inferior turbinate was associated with ipsilateral maxillary sinus pathology. While the incidence of inferior turbinate enlargement in patients with nasal obstruction and with septal deviations is reported widely in literature, we did not find any studies reporting its prevalence in patients with chronic sinusitis. However, Stammberger2 stated that in a vast majority of their cases of inferior turbinate enlargement, there was inflammatory disease in other parts of the nose. In almost all their cases, inferior turbinate enlargement resolved after sinusitis was treated. Grevers G et al66 found significant increase in inflammatory cells in inferior turbinates in patients with chronic sinusitis. The high incidence of ipsilateral maxillary sinus pathology associated with inferior turbinate enlargement in our study could be related to the above phenomenon.

Pneumatized superior turbinate: Pneumatization of superior turbinate can occur from posterior ethmoid cells. Of the 48% incidence reported by Ariyurek OM et al46 in their study, 40% of cases showed pneumatization in the form a small air cell minimally expanding the superior concha-he called this as grade I pneumatization. In the remaining 8%, there was marked pneumatization which he called as grade II pneumatization. In our study, we found a prevalence of superior turbinate pneumatization of 6.25% which correlates to the prevalence of marked pneumatization reported by Ariyurek OM et al.

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53

Markedly pneumatized superior turbinates can narrow the nasal cavity predisposing the patient to chronic sinusitis. A pneumatized superior turbinate may also contain polyps, cysts, mucoceles and pyoceles.

Supreme turbinate: We could not discern the presence of supreme turbinate in any of our cases. However, a study by Kim SS47 which was based on cadaver dissections found evidence of basal lamella of supreme turbinate in 15%.

Onodi cell: This is a posterolateral pneumatization of posterior ethmoidal cell coming into intimate relationship with optic nerve. On coronal CT, an Onodi cell is seen above the sphenoid sinus. Endoscopically, these cells appear as outgrowths of posterior ethmoids posteriorly and superiorly. They have a pyramidal configuration with the tip of the pyramid pointing away from the endoscopist. It is said to have a higher incidence is Asians. In our study, the prevalence of Onodi cells was 22.5%. The prevalence of Onodi cells according to various workers are: Earwaker67 -24%, Aibara68 -7%, Basic30 -10%. Our results are comparable to that of Earwaker.

Table 18. Prevalence of Onodi cell Author Aibara Basic Earwaker Our study Prevalence 7% 10% 24% 22.5%

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54

Prevalence of Onodi cells

30% 20% 10% 0% 7% Aibara 10% Basic Earwaker Our study 24% 22.50%

Haller cells:

Also called infraorbital ethmoidal cells, these are anterior ethmoidal cells pneumatizing the floor of the orbit or the roof of the maxillary sinus. In view of their location precisely above the region of the maxillary sinus ostium and infundibulum, they can cause narrowing of maxillary sinus ostium or infundibulum, thus predisposing to recurrent maxillary sinusitis.

In our study, Haller cells were present in 3.75%. The frequency with which these cells are encountered varies in literature from 1% to 45.1% and is as follows. Liu X- 1%; Jones52- 6%; Shroff69- 6%; Zinreich51- 10%; Lloyd57- 15%; Yadav53- 28%; Stackpole and Edelstein40- 34%; Bolger54- 45.1%.

The wide discrepancy noted in literature in the prevalence of these cells may be related to the differences in the interpretation of these cells:

-Ethmoidal labyrinth cells which outwardly excavate the os planum and os maxillae: Albert Van Haller.

54

55

Table 19. Prevalence of Haller cell Author Bolger Stackpole and Edelstein Yadav Lloyd Zinreich Shroff Jones Liu X Our study 28% 15% 10% 6% 6% 1% 3.75% Prevalence 45.1% 34%

55

56

Prevalence of Haller cells

50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 45.10% 20.00% 34% 15.00% 28% 10.00% 15% 10% 6% 6% 5.00% 1%3.75% 0.00%

-Cell inferior to the ethmoid bulla adhering to the roof of the maxillary sinus, in continuity with the proximal infundibulum which formed part of the lateral wall of the infundibulum: Zinreich and Kennedy.

-In addition to the above description, cells precisely in the region of the maxillary sinus ostium: Stammberger.

-A large cell representing a point of access between the inferior part of the ethmoid base and the posterosuperior part of the nasal surface of the maxilla behind and above the hiatus semilunaris: Kimpoti, Nemanic, et al.

-Ethmoid bulla occupying a lower position than normal, whereby the outer wall of the lowest cell is formed by the orbital wall of the superior maxilla instead of the lamina papyracea: Skillern.

St ac kp

ol e

an B d olg Ed e el r st e Ya i n da v Ll o Z i yd nr ei c Sh h ro Jo ff ne s Li u O ur X st ud y

56

57

-Air cells located below the ethmoid bulla, along the maxillary sinus roof and most inferior portion of lamina papyracea, including air cells located within the infundibulum: Bolger et al.54

Supraorbital ethmoidal cells: The ethmoid air cells can extend supraorbitally and is said to be present in 15% to 21% according to Bhatt NJ.39 In our study, we found a prevalence of 22.5% which corresponds to that reported by Bhatt NJ.

Intrasphenoidal projections: Due to extensive pneumatization, certain vital structure that are normally in the neighborhood of sphenoid, actually project inwards. We found the following prevalence of intrasphenoid projections: Optic nerve in 27.5%, maxillary nerve in 28.7% and vidian nerve in 30%. The true prevalence of internal carotid artery projections or dehiscence could not be ascertained as axial CT sections were not obtained in our patients. The prevalence of intrasphenoid projections according to Van Alyea33 is optic nerve in 40%, maxillary nerve in 40% and vidian nerve in 36%. According to Lang,43 they are as follows: Optic nerve in 19%, maxillary nerve in 28.6%, vidian nerve in 14.3%. Our results are closer to that reported by Lang than to Van Alyea. The high incidence of these projections means that in addition to optic nerve and carotid artery, even maxillary nerve and vidian nerve are at risk during sphenoid surgery.

Sphenoid sinus pneumatization: The pneumatization of the sphenoid sinus can vary from total nonpneumatization to hyperpneumatization including clinoid processes, sphenoid wings and pterygoid plates.

57

58 In our study, we found absent pneumatization 2.5%, conchal type in 2.5%, presellar type in 22.5% and sellar in 72.5%. These findings compare well with that reported by Lang43 (conchal 0%, presellar 23.8%, sellar 76.2%) and by Congdon (conchal 5%, presellar 28%, sellar 67%).

Skull base configuration: The roof of the ethmoid bone is formed by the fovea ethmoidalis laterally and the cribriform plate medially. The lateral lamella of the cribriform plate is thin and may be of substantial height making it vulnerable to injury.

The anatomy of the anterior ethmoid is critical for two reasons. First, this area is most vulnerable to iatrogenic cerebrospinal fluid leaks. Second, the anterior ethmoid artery is vulnerable to injury which can cause devastating bleeding into the orbit.

In our study, we found Keros type I (1 to 3 mm deep) olfactory fossa in 12.5%, type II (4 to 7 mm) in 62.5% and type III (8 to 16 mm) in 25%. Though several authors draw attention to the importance of deep skull base conformation, we did not find any studies reporting the incidence of various types of conformations. Arslan et al20 reported that average depth was 8 mm on right side and 9.5 mm on the left side.

Rathkes pouch remnant: Rathkes pouch remnant was seen on endoscopy in 2.5% of cases. This is a small slit or round opening seen in nasopharynx that enters into a small depression or even into a superiorly directed passage. In such a Rathkes pocket occasionally a drop of viscous secretion can be seen.2

58

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CONCLUSION

-All the variations of sinonasal anatomy described in literature except the presence of supreme turbinate were encountered in our study.

-The medialised uncinate process was most common uncinate process variation and pneumatized middle turbinate was the most common middle turbinate variation.

-Extramural pneumatization like septal, supraorbital, sphenoid wing and pterygoid plates was quite common.

-Inferior turbinate enlargement in association with ipsilateral maxillary sinusitis was common.

-The depth of olfactory fossa was of Keros Type II in majority of patients.

-There was also a high prevalence of optic nerve, maxillary nerve and vidian nerve lying bare in the sphenoid sinus.

-In view of the presence of these significant variations, we reemphasize the need for proper preoperative assessment in every patient in order to accomplish a safe and effective endoscopic sinus surgery.

59

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SUMMARY

This study titled An endoscopic study of sinonasal anatomical variations in patients undergoing endoscopic sinus surgery was conducted in the Department of ENT, Jawaharlal Nehru Medical College, Belgaum at KLES Hospital and MRC, Belgaum and District Hospital, Belgaum. The study was conducted from July 2003 to June 2004. The objective of the study was to study the various sinonasal anatomical variations in patients with chronic sinusitis and to determine their frequency of occurrence. The study included 40 patients undergoing endoscopic sinus surgery for chronic sinusitis. The various sinonasal anatomical variations were noted during diagnostic nasal endoscopy, CT scanning of paranasal sinuses and during surgery.

The various anatomical variations encountered with their clinical significance is described. The prevalence of the various anatomical variations as detemined by our study correlated well with that of other authors studying similar patient groups.

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62 10. Zuckerkandl E. Normale und pathologische Anatomie der Nasenhohle und ihrer pneumatischen Anhange. W. Braumuller, Wein, Leipzig; 1882. 11. Dahmer R. Die breite Eroffnung der Oberkieferhohle vor der Nase mit Schleimhautplastik und persistierender Offnung. Arch. Laryngol. Rhinol. 1909; 21:325333. 12. Killian G. Die Krankheiten der Kieferhohle. In Handbuch der Laryngologie und Rhinologie. Band Wein; 1990. 13. Halle M. Externe oder interne Operation der Nebenhohleneiterungen. Berl. Klin. Wschr. 1906; 43:1369-1372. 14. Mosher HP. The applied anatomy and the intra-nasal surgery of ethmoidal labyrinth. Trans. Amer. Laryngol. Ass. 1912; 34:25-39. 15. Hirshmann A. Uber Endoskopie der Nase und deren Nebenhohlen. Eine neue Untersuchungsmethode. Arch. Laryngol. Rhinol. 1903; 14:195-202. 16. Yamashita K, J Mertens, H Rudert. Die flexible Fiberendoskopie in der HNOHeilkunde. H.N.O. 1984; 32:378-384. 17. Lancer JM, AS Jones. The flexible fiberoptic rhinolaryngoscope. Brit. Med. J. 1986; 293:712-713. 18. Keros P. Uber die praktische beteudung der Niveau-Unterschiede der lamina cribrosa des ethmoids. In Naumann HH, editor. Head and Neck Surgery, vol. 1. Face and facial skull. WB Saunders; 1980. 19. Erdem G, Erdem T, Miman MC, Ozturan O. A radiological anatomic study of the cribriform plate compared with constant structures. Rhinology. 2004 Dec;42(4):225-9.

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63 20. Arslan H, Aydinlioglu A, Bozkurt M, Egeli E. Anatomic variations of the paranasal sinuses: CT examination for endoscopic sinus surgery. Auris Nasus Larynx 1999 Jan; 26(1);39-48. 21. Danese M, Duvoisin B, Agrifoglio A, Cherpillod J, Krayenbuhl M. Influence of naso-sinusal anatomic variants on recurrent, persistent or chronic sinusitis. X-ray computed tomographic evaluation in 112 patients. J Radiol. 1997 Sep;78(9):651-7. 22. Jareoncharsri P, Thitadilok V, Bunnag C, Ungkanont K, Voraprayoon S, Tansuriyawong P. Nasal endoscopic findings in patients with perennial allergic rhinitis. Asian Pac J Allergy Immunol. 1999 Dec;17(4):261-7. 23. Chao TK. Uncommon anatomic variations in patients with chronic paranasal sinusitis. Otolaryngol Head Neck Surg. 2005 Feb; 132(2):221-5. 24. Yang QT, Shi JB, Kang Z, Chen HX, Wang T, Lu JT, et al. Computer-assisted anatomical study of nasofrontal region. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2004 Jun; 39(6):349-52. 25. Landsberg R, Friedman M. A computer-assisted anatomical study of the nasofrontal region. Laryngoscope. 2001 Dec; 111(12):2125-30. 26. Isobe M, Murakami G, Kataura A. Variations of the uncinate process of the lateral nasal wall with clinical implications. Clin Anat. 1998; 11(5):295-303. 27. Liu X, Zhang G, Xu G. Anatomic variations of the ostiomeatal complex and their correlation with chronic sinusitis: CT evaluation. Zhonghua Er Bi Yan Hou Ke Za Zhi. 1999 Jun; 34(3):143-6. 28. Joe JK, Ho SY, Yanagisawa E. Documentation of variations in sinonasal anatomy by intra-operative nasal endoscopy. Laryngoscope 2000 Feb; 110(2 Pt 1):229-35.

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64 29. Wang R, Sun J, Sun Z. The uncinate process: ultrastructural and CT studies. Zhonghua Er Bi Yan Hou Ke Za Zhi. 1997 Dec;32(6):363-5. 30. Basic N, Basic V, Jukic T, Basic M, Jelic M, Hat J. Computed tomographic imaging to determine the frequency of anatomical variations in pneumatization of the ethmoid bone. Eur Arch Otorhinolaryngol. 1999; 256(2):69-71. 31. Kayalioglu G, Oyar O, Govsa F. Nasal cavity and paranasal sinus bony variations: a computed tomographic study. Rhinology 2000 Sep; 38(3):108-13 32. Van Alyea. Ethmoid Labyrinth: anatomic study with consideration of clinical significance of its structural characteristics. Arch Otolaryngol. 1939; 29:881. 33. Van Alyea OE. Nasal sinuses: an anatomic and clinical consideration. 2nd Ed. Williams and Wilkins. Baltimore; 1951. 34. Myerson MC. The natural orifice of the maxillary sinus. Arch Otolaryngol 1932;15. 35. Wright ED, Bolger WE. The bulla ethmoidalis: lamella or a true cell? J Otolaryngol. 2001 Jun; 30(3): 162-6. 36. Shi JB, Xu G, Yang QT, Wang T, Chen HX, Wen WP. Transnasal endoscopic frontal surgery for chronic frontal sinusitis. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2004 Feb;39(2):108-11. 37. Meyer TK, Kocak M, Smith MM Smith TL. Coronal computed tomography analysis of frontal cells. Am J Rhinol. 2003 May-Jun;17(3):163-8. 38. Wang N, Fan W, Zhang H. The CT scan of the agger nasi cell and its adjacent structure in endoscopic paranasal sinus surgery. Zhonghua Er Bi Yan Hou Ke Za Zhi. 1999 Feb; 34(1):27-9.

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65 39. Bhatt NJ. Endoscopic Sinus Surgery. New Horizons. Singular Publishing Group, Inc. San Diego; 1997. 40. Stackpole SA, Edelstein DR The anatomic relevance of the Haller cell in sinusitis. Am J Rhinol. 1997 May-Jun;11(3):219-23. 41. Picerno NA, Bent JP. Sinus lateralis in endoscopic ethmoidectomy. Laryngoscope. 1998 Sep; 108(9):1314-9 42. Batra PS, Citardi MJ, Gallivan RP, Roh HJ, Lanza DC. Software-enabled computed tomography analysis of the carotid artery and sphenoid sinus pneumatization patterns. Am J Rhinol. 2004 Jul-Aug; 18(4):203-8. 43. Lang J. Clinical anatomy of the nose, nasal cavity and paranasal sinuses. Thieme Medical Publishers. New York; 1989. 44. Kim HU, Kim SS, Kang SS, Chung IH, Lee JG, Yoon JH. Surgical anatomy of the natural ostium of the sphenoid sinus. Laryngoscope. 2001 Sep;111(9):1599-602. 45. Braun H, Stammberger H. Pneumatization of turbinates. Laryngoscope. 2003 Apr; 113(4):668-72. 46. Ariyurek OM, Balkanci F, Aydingoz U, Onerci M. Pneumatised superior turbinate: a common anatomic variation? Surg Radiol Anat. 1996;18(2):137-9. 47. Kim SS, Lee JG, Kim KS, Kim HU, Chung IH, Yoon JH. Computed tomographic and anatomical analysis of the basal lamellas in the ethmoid sinus. Laryngoscope. 2001 Mar;111(3):424-9. 48. Arredondo de Arreola G, Lopez Serna N, de Hoyos Parra R, Arreola Salinas MA.Morphogenesis of the lateral nasal wall from 6 to 36 weeks. Otolaryngol Head Neck Surg. 1996 Jan;114(1):54-60.

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66 49. Calhoun KH, Waggenspack GA, Simpson CB, Hokanson JA, Bailey BJ. CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg. 1991 Apr;104(4):480-3. 50. Takanishi R. The formation of the nasal septum and the etiology of septal deformity. Acta Otolaryngol. Suppl. Stockh 1987; 443:1-154. 51. Zinreich SJ, Kennedy DW, Rosenbaum AE, Gayler BW, Kumar AJ, Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology. 1987 Jun;163(3):769-75. 52. Jones NS, Strobl A, Holland I. A study of the CT findings in 100 patients with rhinosinusitis and 100 controls. Clin Otolaryngol Allied Sci. 1997 Feb;22(1):47-51. 53. Yadav SPS, Asruddin, Yadav RK, Singh J. Low dose CT in chronic sinusitis. Indian Journal of Otolaryngology 2000; 52(1):17-22. 54. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope. 1991 Jan;101(1 Pt 1):56-64. 55. Wang RG, Zou YH, Han DY, Zhang W. Pneumatization of perpendicular plate of the ethmoid bone and mucocele. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2003 Aug; 38(4):279-81. 56. Messerklinger W. On the drainage of the normal frontal sinus of man. Acta Otolaryngol 1967; 63:176-181. 57. Lloyd GA, Lund VJ, Scadding GK. CT of the paranasal sinuses and functional endoscopic surgery: a critical analysis of 100 symptomatic patients. J Laryngol Otol. 1991 Mar;105(3):181-5.

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67 58. Davis WE. Anatomy of the paranasal sinuses. OCNA 1996; 29:57-73. 59. Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Functional endoscopic sinus surgery. Theory and diagnostic evaluation. Arch Otolaryngol. 1985 Sep;111(9):576-82. 60. Natsis K, Karabatakis V, Tsikaras P, Chatzibalis T, Stangos A, Stangos N. Frontal sinsus anatomical variations with potential consequences for the orbit. Study on cadavers. Morphologie. 2004 Apr; 88(280):35-8. 61. Lothrop HA. The anatomy of the inferior ethmoidal turbinate bone with particular reference to cell formation. Surgical importance of such ethmoid cell. Ann. Surgery. 1903; 38:233-255. 62. Shaeffer SD. An anatomic approach to endoscopic intranasal ethmoidectomy. Laryngoscope. 1998 Nov;108(11 Pt 1):1628-34. 63. Lusk RP. Anatomic variations in pediatric chronic sinusitis- a CT study. OCNA 1996; 29:75-91. 64. Lund VJ, Holmstrom M, Scadding GK. Functional endoscopic sinus surgery in the management of chronic rhinosinusitis. An objective assessment. J Laryngol Otol. 1991 Oct;105(10):832-5. 65. Prahlada NB. Imaging for FESS. Thulasi Research Foundation; 1999. 66. Grevers G, Klemens A, Menauer F, Sturm C. Involvement of inferior turbinate mucosa in chromic sinusitis-localization of T-cell subset. Allergy. 2000 Dec; 55(12):1155-62. 67. Earwaker J. Anatomic variants in sinonasal CT. Radiographics. 1993 Mar;13(2):381-415.

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68 68. Aibara R, Kawakita S, Yumoto E, Yanagihara N. Relationship of Onodi cell to optic neuritis--radiological anatomy on coronal CT scanning. Nippon Jibiinkoka Gakkai Kaiho. 1997 Jun;100(6):663-70. 69. Shroff MM, Shetty PG, Kirtane MV. Coronal screening sinus CT in inflammatory sino-nasal disease. Indian J of Radiol and Imaging. 1996; 6:3-17.

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69 ANNEXURE I ENDOSCOPIC AND CT PICTURES Fig 1. Left medialized uncinate process

Fig 2. Septal spur impinging on right middle turbinate

Fig 3. Rathkes pouch remnant

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70 Fig 4. Accessory maxillary sinus ostium

Fig 5. Right agger nasi

Fig 6. Polyp in sphenoethmoidal recess

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Fig 7. Anteriorly turned uncinate (double middle turbinate)

Fig 8. Septal pneumatization

Fig 9. Septal tubercle

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Fig 10. Bilateral superior turbinate pneumatization

Fig 11. Pneumatized crista galli

Fig. 12 Bilateral agger nasi pneumatization

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Fig 13. Left concha bullosa

Fig 14. Bilateral agenesis of frontal sinus

FJig 15. Bilateral nonpneumatized sphenoid

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Fig 16. Right uncinate attaching to lamina papyracea and left to middle turbinate

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ANNEXURE II PROFORMA
Patient Name: Age: Sex: IP No. Date of Admission: Date of Discharge: Address:

Right 1. Septum: Deviation: Yes / No Spur: Yes / No 2. Inferior turbinate enlargement: Yes / No If so, is there associated ipsilateral maxillary pathology? 3. Agger nasi pneumatized: Yes / No 4. Bulla Ethmoidalis: Large/ Typical/ Small 5. Uncinate process: Superior attachment: Skull base/ Middle turbinate/ Lamina papyracea

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76 Type: Typical/ Medialized/ Lateralized/ Anteriorly turned/ Pneumatized 6. Middle turbinate: Typical/ Paradoxical/ Medialised/ Lateralised/ Pneumatized. If pneumatized: Lamellar/ Bulbous/ Complete 7. Accessory ostia: Present / Absent If present: Anterior fontanelle/ posterior fontanelle 8. Maxillary sinus septation: Present/ Absent 9. Supraorbital cell: Present/ Absent 10. Haller cell: Present/ Absent 11. Pneumatized superior turbinate: Present/ Absent 12. Supreme turbinate: Present/ Absent 13. Onodi cell: Present/ Absent 14. Skull base: Depth: mm. Keros Type I/ II/ III 15. Frontal sinus: Present/ Absent 16. Frontal recess obstruction: Present/ Absent If so by what? 17. Sphenoid ostium: Shape: Circular/ Oval/ Slit If not seen why? Narrow sphenoethmoidal recess/ Polyps 18. Sphenoid pneumatization pattern: Conchal/ Presellar/ Sellar 19. Extramural sphenoid pneumatization: Greater wing of sphenoid/ Lesser wing of sphenoid/ Pterygoid plate

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77 20. Intrasphenoid projection: Maxillary nerve/ Vidian canal/ Optic nerve

Left
21. Septum: Deviation: Yes / No Spur: Yes / No 22. Inferior turbinate enlargement: Yes / No If so, is there associated ipsilateral maxillary pathology? 23. Agger nasi pneumatized: Yes / No 24. Bulla Ethmoidalis: Large/ Typical/ Small 25. Uncinate process: Superior attachment: Skull base/ Middle turbinate/ Lamina papyracea Type: Typical/ Medialized/ Lateralized/ Anteriorly turned/ Pneumatized 26. Middle turbinate: Typical/ Paradoxical/ Medialised/ Lateralised/ Pneumatized. If pneumatized: Lamellar/ Bulbous/ Complete 27. Accessory ostia: Present / Absent If present: Anterior fontanelle/ posterior fontanelle 28. Maxillary sinus septation: Present/ Absent 29. Supraorbital cell: Present/ Absent 30. Haller cell: Present/ Absent 31. Pneumatized superior turbinate: Present/ Absent

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78 32. Supreme turbinate: Present/ Absent 33. Onodi cell: Present/ Absent 34. Skull base: Depth: mm. Keros Type I/ II/ III 35. Frontal sinus: Present/ Absent 36. Frontal recess obstruction: Present/ Absent If so by what? 37. Sphenoid ostium: Shape: Circular/ Oval/ Slit If not seen why? Narrow sphenoethmoidal recess/ Polyps 38. Sphenoid pneumatization pattern: Conchal/ Presellar/ Sellar 39. Extramural sphenoid pneumatization: Greater wing of sphenoid/ Lesser wing of sphenoid/ Pterygoid plate 40. Intrasphenoid projection: Maxillary nerve/ Vidian canal/ Optic nerve

Recorded by: Date:

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ANNEXURE III MASTER CHART

KEY TO MASTER CHART A- Absent P- Present Y- Yes N- No T- Typical L- Large S- Small SB- Skull base MT- Middle turbinate LP- Lamina papyracea M- Medialized PN- Pneumatized Lm- Lamellar Cb- Concha bullosa AT- Anteriorly turned PA- Paradoxical DL, DR- Deviation of septum to left, right SL, SR- Spur to left, right BE- Bulla ethmoidalis AG- Agger cell

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80 PO- Polyp C- Circular P- Oval S- Slit NR- Narrow sphenoethmoidal recess CP- Conchal pattern PP- Presellar pattern SP- Sellar pattern PtP- Pterygoid plate GrW- Greater wing of sphenoid LsW- Lesser wing of sphenoid VN- Maxillary nerve VC- Vidian canal OC- Optic canal

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Agger Nasi Bilateral

Bulla Ethmoidalis

Uncinate Process

Middle Turbinate

Supraorbital cell Bilateral

Accessory ostia

Maxillary sinus septation

Haller cell

Pneumatised superior turbinate

Supreme turbinate

ANNEXURE III MAST Onodi cell

Right

Right

Right

Right

Right

Right

Right

Right

Right

Right

Right

Left

Left

Left

Left

Left

Left

Left

Left

Left

Left

When pneumatised, pattern

When pneumatised, pattern

Posterior fontanelle

Name Initials

S. No

Nam eFull

2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 1 2 3 4 5 6 7 8 9

3 Sabind Rodrigues Vandana Marve Sushil Kumar Ramachandra Mohammed Farooq Mangala Jadhav Koshiram Dahi Jagannath Karachi Darshan Govani

4 SR VM SK RC MF MJ KD JK DG VP UC RP GP CD CK BG BP AK PG BL BH BN SG SA LS VD SK PC ME CT SP SD RB KS KD JB IA VP BH

5
35 52 27 15 45 33 65 55 20 53 25 36 25 24 32 72 50 33 16 19 52 43 13 29 42 55 20 19 34 23 50 61 40 39 50 27 46 69 43

6 M F M M M F M M M F F M F M M F M M F F M M M M M M F F F M M F F F M M M M M

114044 113163 112344 114967 113737 110635 109499 110853 110739 109085 108927 108233 108853 112970 114519 113351 107075 112969 117520 135698 116011 108987 117186 116131 115943 115576 139717

IP No.

S. No

Age

Sex

7 P A P A P P P P P P P P P P P A P P P P P A P P P P A P A P A P P P P P P P P P P P A P P P P P A P P P P A A A P A P P P P P A P A Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y T T T T T T L T T S T S T T L S L T L L T S L T T T T L T T T T L L T S T T T T T L T T T T T L S T S T T L S L T L L S S L T T T T L T T T T L L T S T T T SB H SB M MT H LP T SB M SB T MT M LP T SB H MT T SB M LP M MT M SB T MT P MT T MT M MT T LP M LP T SB T LP T MT M PN lm T T M M PN lm T PA T LB PN lm PN lm PA T T T T T PA PN T T T M PN lm PN cb PA PN cb T PN lm PN lm PA LB T T LB T PN cb PN cb PN cb T PN lm T L PN cb T LB PN cb PN cb T T PN cb PN cb L PN cb PN cb T T A A A A A P P A P A A A A A A A P A P A P A A A A A A A A P P A A A A A A P A A A A A A P P A A A A A A A A A P A P A P A A A A A A A A P P A A A A A A P P Y Y Y Y Y Y Y Y A A A A A A A A A P P A A A P A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A P P A A A A A A A A A A A A P A A A P A A A A A A A A A A A A A A A A A A A A A A A A A A A P A A A A A A P A A A A A A A A A A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A P P A A A A A A A A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A P A A P A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A P A A A A A A A A A A A A A A A A A A A A A P A A A A A P A A A A A A A A A P A A A A A A A A A A A A A A A A A A A A P A P A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A P A A P A P A P P A A P A A A A A A A A A A A A A A P A A A A P A P A P A A A P A A P A P A A P A A A A A A A A A A A A A A A A A P A A A A P A P A P

SB H LP T

SB H LP M

MT M MT T MT T MT T SB M MT T LP LP LP LP M T M T

10 Vanita Patil 11 Uma Chikmath 12 Raosabab Pujari 13 Geeta Patil 14 Chetan Durn 15 Chandrakant Kankolkar 16 Basawwa Gulannavar 17 Basappa Pujari 18 Arjun Koppad 19 Preeti Gaonkar 20 Bhagyashree Latti 21 Basayya Hiremath 22 Bahubali Najagavi 23 Sajjan Gaonkar 24 Sajeed Ali 25 Lazar Shirguri 26 Venkappa Devaraddi 27 Savithri Kumbar 28 Padmashri Chougule 29 Murtuza Elival 30 Chandrashekar Tippareddy 31 Suresh Patil 32 Sulochana Desai 33 Rekha Bagewadi 34 Kavitha Sawant 35 Kallappa Dombale 36 Jayanth Bhogan 37 Iqbal Asti 38 VS Patil 39 Basavaraj Hiremath

SB M MT T LP LP T T

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139411 A 127040 A 115345 P 124714 A 126414 P 124439 P 133968 P 129905 P 126541 P 125107 A 125012 P 131506 A

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