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“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
I
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 M.S. (ENT) in partial
fulfillment of the regulations for the award of M. S.
(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
supervision of Dr. N. D. Zingade M.S.(ENT) 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
C O P Y R I G H T
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
V
A C K N O W L E D G E M E N T S 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, M.S., Associate
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.
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.S’s 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 Introduction Page No. 1
2. Objectives Page No. 3
3. Review of Literature Page No. 4
4. Methodology Page No. 22
5. Results Page No. 27
6. Discussion Page No. 40
7. Conclusion Page No. 59
8. Summary Page No. 60
9. Bibliography Page No. 61
10. Annexures
I. Endoscopic and CT pictures Page No. 69
II. Proforma Page No. 75
III. Master Chart Page No. 79
IX
LIST OF TABLES
Table 1. Age distribution Page No. 27
Table 2. Sex distribution Page No. 28
Table 3. Skull base types Page No. 29
Table 4. Septal variations Page No. 30
Table 5. Middle turbinate variations Page No. 32
Table 6. Types of middle turbinate pneumatization Page No. 32
Table 7. Uncinate variations Page No. 33
Table 8. Uncinate superior attachment Page No. 34
Table 9. Ethmoidal bulla variations Page No. 35
Table 10. Sphenoid sinus ostium variations Page No. 37
Table 11. Intrasphenoidal projections Page No. 38
Table 12. Prevalence of septal deviations Page No. 42
Table 13. Prevalence of agger nasi Page No. 44
Table 14. Prevalence of pneumatized middle turbinate Page No. 47
Table 15. Prevalence of paradoxical middle turbinate Page No. 48
Table 16. Prevalence of large ethmoidal bulla Page No. 49
Table 17. Differences between natural and accessory ostia Page No. 51
Table 18. Prevalence of Onodi cell Page No. 53
Table 19. Prevalence of Haller cell Page No. 55
X
LIST OF FIGURES
Fig1. Left medialized uncinate process Page No. 69
Fig 2. Septal spur impinging on right middle turbinate Page No. 69
Fig 3. Rathke’s pouch remnant Page No. 69
Fig 4. Accessory maxillary sinus ostium Page No. 70
Fig 5. Right agger nasi Page No. 70
Fig 6. Polyp in sphenoethmoidal recess Page No. 70
Fig 7. Anteriorly turned uncinate Page No. 71
Fig 8. Septal pneumatization Page No. 71
Fig 9. Septal tubercle Page No. 71
Fig 10. Bilateral superior turbinate pneumatization Page No. 72
Fig 11. Pneumatized crista galli Page No. 72
Fig 12. Bilateral agger nasi pneumatization Page No. 72
Fig 13. Left concha bullosa Page No. 73
Fig 14. Bilateral frontal sinus agenesis Page No. 73
Fig 15. Bilateral nonpneumatized sphenoid Page No. 73
Fig 16. Right uncinate attaching to lamina papyracea
and left to middle turbinate Page No. 74
XI
1
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
1
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.
2
3
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.
3
4
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.
4
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
5
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 Nitze’s 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
6
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
7
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
8
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%.
9
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%.
10
11
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:
12
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 found-
1) 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 following-
Recess 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, 30-
degree, 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 into-
i. 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 No of cases
11-20 7
21-30 7
31-40 7
41-50 9
51-60 5
61-70 3
71-80 1
Age distribution
7, 18%
7, 18%
7, 18%9, 22%
5, 13%
3, 8%
1, 3% 11to2021to3031to4041to5051to6061to7071to80
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 25
Female 15
Sex distribution
Male, 25, 62%
Female, 15, 38% Male
Female
Variations:
Skull base types: The following was the incidence of various skull base types-
1) 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 Number Percentage
I 10 12.5%
II 50 62.5%
III 20 25%
Keros skull base types
10, 13%
50, 62%
20, 25%IIIIII
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%).
29
30
Table 4. Septal variations
Variation Number Prevalence
Deviation 26 65%
Spur 19 47.5%
Thick 12 30%
Pneumatized 10 25%
Septal variations
65% 47.50% 30% 25%0%20%40%60%80%
Dev
iatio
n
Spu
r
Thic
k
Pne
umat
ized
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%).
30
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.
31
32
Table 5. Middle turbinate variations
Variation Number Percentage
Typical 32 40%
Paradoxically curved 7 8.75%
Pneumatized 24 30%
Large non pneumatized 3 3.75%
Middle turbinate variations
32, 48%
7, 11%
24, 36%3, 5%
Typical
ParadoxicallycurvedPneumatized
Large nonpneumatized
Table 6. Types of middle turbinate pneumatization
Type Number Percentage
Lamellar 10 41.6%
Bulbous 1 4.2%
Complete 13 54.2%
32
33
Types of Middle Turbinate Pneumatization
10, 42%
1, 4%13, 54%
LamellarBulbousComplete
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 Number Percentage
Typical 39 48.75%
Medialized 29 36.25%
Anteriorly turned 2 2.5%
Hypertrophied 8 10%
Pneumatized 2 2.5%
33
34
Uncinate variations
39, 48%
29, 36%
2, 3%
8, 10%
2, 3%Typical
Medialized
AnteriorlyturnedHypertrophied
Pneumatized
Table 8. Uncinate superior attachment
Attachment Number Percentage
Middle turbinate 31 38.75%
Lamina papyracea 28 35%
Skull base 21 26.25%
Superior attachment of uncinate process
31, 39%
28, 35%
21, 26%Middle turbinate
LaminapapyraceaSkull base
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 Number Percentage
Typical 50 62.5%
Large 17 21.25%
Hypoplastic 13 16.25%
Ethmoidal bulla variations
50, 63%17, 21%
13, 16% TypicalLargeHypoplastic
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.
35
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.
36
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 Number Percentage
Circular 19 30.6%
Oval 28 45.2%
Slit 15 24.2%
Shape of sphenoid ostium
19, 31%
28, 45%
15, 24%CircularOvalSlit
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 Number Prevalence
Optic nerve 22 27.5%
Maxillary nerve 23 28.7%
Vidian nerve 24 30%
Intrasphenoidal projections
26.00%27.00%28.00%29.00%30.00%31.00%
Optic nerve Maxillarynerve
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.
Rathke’s pouch remnant:
This was seen in 1 (2.5%) case.
39
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
40
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) Rathke’s 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 Prevalence
Zinreich 21%
Jones NS 24%
Yadav SPS 38%
Bolger 40%
Jareoncharsri P 72%
Our study 65%
Prevalence of Septal Deviations
21% 24% 38% 40%72% 65%
0%20%40%60%80%
Zinr
eich
Jone
s N
S
Yad
avS
PS
Bol
ger
Jare
onch
ars
ri P
Our
stu
dy
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
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.
43
44
Table 13. Prevalence of agger
nasi cells
Author Prevalence
Messerklinger 10 to 15%
Lloyd 14%
Davis 65%
Van Alyea 89%
Kennedy and
Zinreich
100%
Our study 72.5%
44
45
Prevalence of agger nasi cells
14%
65%
89%100%
72.50%
0%
20%
40%
60%
80%
100%
120%
Lloyd
Davis
Van A
lyea
Kenne
dy an
d Zinr
eich
Our stu
dy
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%.
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 Prevalence
Joe JK 15%
Liu X 34.85%
Basic N 42%
Lothrop 9%
Davis 8%
Shaeffer 11%
Our study 30%
47
48
Prevalence of pneumatized middle turbinate
15%
34.85%42%
9% 8% 11%
30%
0%5%
10%15%20%25%30%35%40%45%
Joe J
KLiu
X
Basic
N
Lothr
opDav
is
Shaeff
er
Our stu
dy
Table 15. Prevalence of
paradoxical middle turbinate
Author Prevalence
Calhoun 7.9%
Lusk 8.5%
Our study 8.75%
48
49
Prevalence of paradoxical middle turbinate
7.90%8.50% 8.75%
7.00%7.50%8.00%8.50%9.00%
Calhoun 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 Prevalence
Lloyd 17%
Lund VJ 18%
Our study 21.25%
49
50
Prevalence of large ethmoidal bulla
17% 18% 21.25%
0%5%
10%15%20%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 Accessory
Always present Present in 10% to 40%
Difficult to see clinically Easily seen on endoscopy
Lies deep in infundibulum Lies in the sagittal plane in fontanelle
Oval shaped Round or punched out appearance
Always single Could be multiple
Small in diameter Could be large (upto 1 cm)
51
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.
52
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 Prevalence
Aibara 7%
Basic 10%
Earwaker 24%
Our study 22.5%
53
54
Prevalence of Onodi cells
7% 10%24% 22.50%
0%
10%
20%
30%
Aibara Basic Earwaker Our study
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 Prevalence
Bolger 45.1%
Stackpole and
Edelstein
34%
Yadav 28%
Lloyd 15%
Zinreich 10%
Shroff 6%
Jones 6%
Liu X 1%
Our study 3.75%
55
56
Prevalence of Haller cells
45.10%34%28%
15%10% 6% 6% 1%3.75%0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%
Bolger
Stackp
ole an
d Ede
lstein
Yadav
Lloyd
Zinreic
hShro
ff
Jone
sLiu
X
Our stu
dy
-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.
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.
Rathke’s pouch remnant:
Rathke’s 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 Rathke’s pocket occasionally a drop of viscous
secretion can be seen.2
58
59
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
60
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.
60
61
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ANNEXURE I ENDOSCOPIC AND CT PICTURES
Fig 1. Left medialized uncinate process
Fig 2. Septal spur impinging on right middle turbinate
Fig 3. Rathke’s pouch remnant
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70
Fig 4. Accessory maxillary sinus ostium
Fig 5. Right agger nasi
Fig 6. Polyp in sphenoethmoidal recess
70
71
Fig 7. Anteriorly turned uncinate (double middle turbinate)
Fig 8. Septal pneumatization
Fig 9. Septal tubercle
71
72
Fig 10. Bilateral superior turbinate pneumatization
Fig 11. Pneumatized crista galli
Fig. 12 Bilateral agger nasi pneumatization
72
73
Fig 13. Left concha bullosa
Fig 14. Bilateral agenesis of frontal sinus
FJig 15. Bilateral nonpneumatized sphenoid
73
74
Fig 16. Right uncinate attaching to lamina papyracea and left to middle turbinate
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75
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
76
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
77
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:
78
79
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
79
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
80
Bulla Ethmoidalis
Rig
ht
Left
Bila
tera
l
Rig
ht
Left
Rig
ht
Left
Bila
tera
l
Rig
ht
Left
Rig
ht
Left
Rig
ht
Left
Rig
ht
Left
Rig
ht
Left
Atta
chm
ent
Type
Atta
chm
ent
Type
Type
Whe
n pn
eum
atis
ed, p
atte
rn
Type
Whe
n pn
eum
atis
ed, p
atte
rn
Ant
erio
r fon
tane
lle
Post
erio
r fon
tane
lle
Ant
erio
r fon
tane
lle
Post
erio
r fon
tane
lle
S. N
o
Nam
eFul
l
2 3 4 5 6 7
1 1 Sabind Rodrigues SR 35 M 114044 P P Y T T SB H SB M PN lm PN A A A A A A A A A A A A A A A A
2 2 Vandana Marve VM 52 F 113163 A A T T SB M SB T T T A A A A A A A A A A A A A A A A
3 3 Sushil Kumar SK 27 M 112344 P P Y T L MT H MT M T T A A A A A A A A A A A A A A A A
4 4 Ramachandra RC 15 M 114967 A A T T LP T LP T M T A A A A A A A A A A A A A A P P
5 5 Mohammed Farooq MF 45 M 113737 P P Y T T SB H SB H M M A A A A A A A A A A A A A A A A
6 6 Mangala Jadhav MJ 33 F 110635 P P Y T T LP T MT T PN lm PN lm P P Y A A A A A A A A A A A A A A
7 7 Koshiram Dahi KD 65 M 109499 P P Y L T SB H SB M T PN cb P P Y A A A A A A A A A A A A P P
8 8 Jagannath Karachi JK 55 M 110853 P P Y T T LP M LP M PA PA A A A A A A A A A A A A A A A A
9 9 Darshan Govani DG 20 M 110739 P P Y T L MT M MT M T PN cb P A A A A A A A A A A A A A P P
10 10 Vanita Patil VP 53 F 109085 P P S S MT T SB T LB T A A P A P A A A A A A A A A A A
11 11 Uma Chikmath UC 25 F 108927 P P Y T T MT T MT P PN lm PN lm A A P A P A A A A A A P A A P A
12 12 Raosabab Pujari RP 36 M 108233 P P Y S S MT T MT T PN lm PN lm A A A A A A P P A A A A A A P P
13 13 Geeta Patil GP 25 F 108853 P P Y T T SB M MT M PA PA A A A P A A A P A A P P A A A A
14 14 Chetan Durn CD 24 M 112970 P P Y T T MT T MT T T LB A A A A A A A A A A A A A A A A
15 15 Chandrakant Kankolkar CK 32 M 114519 P P Y L L LP M LP M T T A A P A A A A A P A A A A A P A
16 16 Basawwa Gulannavar BG 72 F 113351 A A S S LP T LP T T T A A A A A A A A A A A A A A A A
17 17 Basappa Pujari BP 50 M 107075 P P Y L L LP M SB T T LB P P Y A A A P A A A A A A A A A A
18 18 Arjun Koppad AK 33 M 112969 P P Y T T LP T LP T T T A A A A A A A A P A A A A A A A
19 19 Preeti Gaonkar PG 16 F 117520 P P Y L L SB M MT M PA PN cb P P Y A A A A A A A A P A A A A A
20 20 Bhagyashree Latti BL 19 F 135698 P P Y L L MT T SB AT PA PN cb A A A A A A A A A A A A A A A A
21 21 Basayya Hiremath BH 52 M 116011 P P Y T S LP T LP T PN cb PN cb P P Y A A A A A A A A A A A A A A
22 22 Bahubali Najagavi BN 43 M 108987 A A S S LP T MT T L T A A A A A A A A A A A A A A A A
23 23 Sajjan Gaonkar SG 13 M 117186 P P Y L L MT M MT M T PN lm A A A A A A A A A A A A A A A A
24 24 Sajeed Ali SA 29 M 116131 P P Y T T SB M MT M T T A A A A P P A A A A A A A A A A
25 25 Lazar Shirguri LS 42 M 115943 P P Y T T LP H LP H L L A A A A A A A A A A A A A A A A
26 26 Venkappa Devaraddi VD 55 M 115576 P P Y T T MT M MT M PN lm PN cb A A A A A A A A A A A A A A A A
27 27 Savithri Kumbar SK 20 F 139717 A A T T SB T SB T T T A A A A A A A A A A A A A A A A
28 28 Padmashri Chougule PC 19 F 139411 A A L L MT T MT T LB LB A A A A P A A A A A A A A A A A
29 29 Murtuza Elival ME 34 F 127040 A A T T SB M MT M LB PN cb A A A A A A A A A A P A A A A A
30 30 Chandrashekar Tippareddy CT 23 M 115345 P P Y T T LP H LP M LB PN cb P P Y A A A A A A A P A A A A P P
31 31 Suresh Patil SP 50 M 124714 A A T T LP T LP T T T P P Y A A A A A A A A A A A A A A
32 32 Sulochana Desai SD 61 F 126414 P P Y T T LP T LP M LB T A A A A A A A A A A A A A A A A
33 33 Rekha Bagewadi RB 40 F 124439 P P Y L L SB P MT T T PN cb A A P P A A A A A A A A A A A A
34 34 Kavitha Sawant KS 39 F 133968 P P Y L L MT T MT T PN cb PN cb A A A A A A A A A A A A A A A A
35 35 Kallappa Dombale KD 50 M 129905 P P Y T T LP M SB M LB L A A A A A A A A A A A A A A P P
36 36 Jayanth Bhogan JB 27 M 126541 P P Y S S MT M MT M LB PN cb A A A A A A A A A A A A A A A A
37 37 Iqbal Asti IA 46 M 125107 A A T T LP T LP T PA PN cb A A A A A A A A A A A A A A P P
38 38 VS Patil VP 69 M 125012 P P Y T T SB T SB T T T P P Y A A A A A P A A A A A A A A
39 39 Basavaraj Hiremath BH 43 M 131506 A A T T MT T MT T T T A P A A A A A A A A A A A A P P
Age
Nam
e In
itial
s
S. N
o
IP N
o.
Sex
Agger Nasi
Rig
ht
Left
Rig
ht
Left
Supraorbital cell Accessory ostia
Rig
ht
Left
Onodi cellMiddle TurbinateANNEXURE III MAST
Uncinate Process Maxillary sinus septation Haller cell Pneumatised superior turbinate Supreme turbinate