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Year : 2001  |  Volume : 3  |  Issue : 1  |  Page : 6-10

CT scan of the nose and paransasl sinuses: Anatomical and Pathological findings

Department of Oto-Rhino-Laryngology, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication9-Jul-2020

Correspondence Address:
FRCSEd Kamal J Daghistani
P.O. Box 11217, Jeddah 21453
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289362

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Objectives: To find out the occurrence of anatomical anomalies and pathological changes in patients subjected to CT scanning.
Materials and Methods: The CT of 584 patients were studied. Age,sex, anatomical nomalies and pathological changes were recorded .
Results: Eighty seven patients had anatomical anomalies and 177 had pathological changes with 296 having combined anatomical and pathological findings. Of the anatomical anomalies, deviated septum was the most common and Haller’s cells were the least common. Pathological changes included mucosal thickening, nasal polypi and hypertrophy of the turbinates.
Conclusion: CT scan is a useful diagnostic method in the diagnosis of sinus disease. Deviated nasal septum and mucosal thickening were the common findings seen by this modality of imaging in this series.

Keywords: Deviated nasal septum, concha bullosa, Haller’s cell, paradoxical middle turbinate, mucosal thickening, hypertrophied turbinate, chronic sinusitis, CT scan

How to cite this article:
Daghistani KJ, Jamal TS, Mandura MM. CT scan of the nose and paransasl sinuses: Anatomical and Pathological findings. Saudi J Otorhinolaryngol Head Neck Surg 2001;3:6-10

How to cite this URL:
Daghistani KJ, Jamal TS, Mandura MM. CT scan of the nose and paransasl sinuses: Anatomical and Pathological findings. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2001 [cited 2021 May 5];3:6-10. Available from: https://www.sjohns.org/text.asp?2001/3/1/6/289362

  Introduction Top

Currently we have four main diagnostic examination methods to assess the paranasal sinuses. These are : plain x-rays, computing tomography (CT), magnetic resonance imaging (MRI) and ultrasound. CT offers a better definition and less radiation exposure than polytomography. The tremendous advances seen in mucociliary transport activity and pathophysiology of the nose and paranasal sinuses has revolutionized the management of sinus diseases. Nasal endoscopy coupled with meticulous radiological identification of the structures of the region provides detailed information that helps in the surgical management of these tissues. The ostiomeatal complex ( OMC) has come to be identified as a vital area that affects the health of sinuses. Chronic inflammation, nasal polyposis, mucosal hypertrophy or anatomical variants may block the area leading to chronic sinus disease.

The anatomical complexity of the nasal passages and paranasal sinus system makes direct examination of this area not a very satisfactory procedure. Although nasal endoscopy can be used to define the nasal cavity and middle meatal structures it can not directly visualized all the OMC or deeper ethmoidal labyrinth.

It is now agreed that plain x-rays are of little use in the imaging of the paranasal sinuses. Pfleiderer et al [1] demonstrated only 44% correlation between plain maxillary sinus x-ray and subsequent sinoscopic findings. Discrepancies are sometimes noted between a sinus series and a CT scan.[2] The CT examination in the coronal plane is the optimal imaging modality to evaluate the nasal cavity and the paranasal sinuses specially for evaluating chronic inflammatory disease. [3] However, axial views may be necessary at times to visualize the relationship of the optic nerve to the posterior ethmoid cells.

The role of CT scan is to provide information about mucosal changes and anatomical variants not readily evaluated endoscopically. No information is available about anatomical variants and pathological changes in the nose and sinuses in Saudi Arabia. Hence, this study aims to find out the occurrence of anatomical anomalies and pathological changes seen in patients subjected to CT scanning.

  Materials and Methods Top

The CT scans of 584 patients scanned for various sinus diseases were examined for the period 1997- 1999. This data was collected from King Abudlaziz University Hospital and Erfan & Bagedo General Hospital in Jeddah, Saudi Arabia. All CT scans were taken in the coronal plane with 3mm thickness cuts. Age and sex of patient was entered. The data related to abnormalities was divided into:

Anatomical variants.

Pathological changes.

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!The anatomical anomalies recorded consisted of deviated nasal septum, anomalies of the uncinate process, concha bullosa, paradoxical middle turbinte, Haller’s cells, Onodi cells, and hypoplsia or atresia of sinuses.

The pathological changes recorded consisted of hypertrophy of the inferior and middle turbinates, occlusion of the OMC, mucosal thickening, fluid levels, polypi, mucoceles and miscellaneous findings.

  Results Top

During the period 1997-1999 five hundred and eighty four consecutive coronal CT scans of the paranasal sinuses performed in King Abdulaziz University Hospital and Erfan & Bagedo General Hospital for various condition were included in this study. CT scans were done in the coronal plane with 3mm thickness cuts. There were 354 males and 230 females. The age range was between 4 and 84 years with a mean age of 32.5 years. Eighty seven (14% ) patients had anatomical anomalies with no pathological changes and 177 ( 30.3% ) had pathological changes while 296 ( 50.7% ) had a combined anatomical variants and pathological changes. Five per cent of the CT scans showed no anomalies or changes. The results were divided into anatomical anomalies and pathological changes.

The anatomical anomalies are shown in Tables I & II. Deviated nasal septum constituted the majority of findings followed by concha bullosa and paradoxical middle turbinates. Anomalies of the uncinate process were seen in 25 patients ( 4% ) and Haller’s cells in 22 patients ( 3% ). No Onodi cells were seen in this series. Hypoplasia was seen in 20 of the frontal sinuses and 3 of the maxillary sinuses while complete aplasia of the frontal sinus was seen in eight patients.

The pathological changes seen in the different sites are shown in Tables III, IV V, VI & VII. Mucosal thickening took the major share of the pathological changes seen with a total of 724 sites. The maxillary sinus was the most commonly involved sinus. Sixty four per cent of the turbinates were hypertro- phied with the inferior turbinate being the most commonly affected. The majority of fluid levels and polypi were again seen in the maxillary sinuses. One hundred and ninety five (33.3%) middle meati were occluded. Of these 7 were not associated with sinus disease while the remaining 188 ( 32% ) were associated with mucosal thickening or poplypi. Sixty nine ( 11.8% ) of the concha bullosa were associated with sinus disease while 32 ( 5.5%) were associated with disease free sinuses. Ten osteomas were seen in the frontal sinuses, two in the maxillary sinus and one in the ethmoid sinus.

Only one dentigerous cyst was seen. No cases of bony destruction indicating neoplasia were seen in this series. One case of rhinolith was also seen.

  Discussion Top

In 1966 Proctor stated that the ethmoid sinuses are the likely key to infectious sinuses.[4] Messerklinger in 1978 [5] concluded that in the majority of patients infection spreads from the eth- moids to the maxillary antra and frontal sinuses via the middle meatus, infandibulum and frontal recess. Anatomical variations in the middle meatus are said to contribute to middle meatal blockage e.g. concha bollusa. It is now accepted that CT is the optimum imaging method of demonstrating diseases in the sinuses.[6] Pfleiderer et al in 1983 [1] and Laranne et al in 1992 [7] demonstrated poor correlation between plain x-rays and subsequent sinoscopic findings and the high percentage of false positive and negative results. According to Lazar and Younis CT scanning has become the “gold standard” in imaging the paranasal sinuses. [8]. The present study was aimed at finding out the CT scan appearances in a Saudi population attending two general hospitals in Jeddah, Saudi Arabia. This, we believe, is the first such study to come out of Saudi Arabia. Five percent of the scans showed no anatomical variations or pathological changes. Battacharya et al reported a 34% normal scans in their series. [9] Anatomical variations alone were seen in 14% of our patients. Scribeno et al reported 69 ( N=130 ) anatomical variations seen in their series.[10] On the other hand 30.3% of scans in our series showed pathological changes alone while 50% showed a combined anatomical variants and pathological changes. The overall total is 80.3% which is almost similar to other series.[l1] The incidence in our series of DNS was 56%, concha bullosa in 17%, paradoxical middle turbinate in 4%, Haller’s cells in 8% and abnormal uncinate process in 4%. Kennedy and Zinreich [12] reported concha bullosa in 36%, septal deformity in 21% and Haller’s cells in 10% .Bogler et al [13] reported concha bullosa in 17%, Haller’s cells in 46% and paradoxical middle turbinates in 27%. Another study [14] reported septal deformity in 40%, concha bullosa in 29% and paradoxical middle turbinates in 12%. Yet another report gives the incidence as concha bullosa 13%,Haller’s cells 11%,paradoxical turbinates 15%.[15] The following frequency was described by Lloyd [16]: concha bullosa 14%, paradoxical turbinate 17%, bent uncinate process 16% and Haller’s cells 2%. Not a single case of Onodi cell was seen in our series. Gross anatomic studies place the prevalence of Onodi cells at 1-39% [17],[18] while CT scan studies report a prevalence of 1-8%. [17],[19],[20] Hypoplasia of the frontal sinus was seen in 20 (3.4%) of our cases and 3 of the maxillary sinus. Complete aplasia of the frontal sinus was seen in 8 patients.

No dehiscence of the lamina paparyacea was seen in our series. The incidence seems to be between 2% to 32%. [15],[21]

In this series, the maxillary sinuses was the most involved sinus (49.8% ) followed by the ethmoids ( 36.4% ), the frontals ( 30.9% ) and the sphenoids ( 22.2% ). Battacharya et al [9] report the involvement of the maxillary sinus to be 43% while Zinreich et al [22] report the involvement of the maxillary sinus to be 65%, the ethmoids 72%, the frontals 34% and the sphenoids 29%.Others give a similar figures.[23]

Mucosal thickening was the most common pathological finding in our series. The maxillary sinus was the most commonly involved sinus ( 42%) and the sphenoids were the least affected ( 19% ).Tonai and Baba [24] report the mucosal thickening to be 86%. The most common combination was the maxillary and ethmoidal sinuses. It is already known that most sinus disease starts in the middle meatus which may then spread to the adjacent sinuses. In this series the occlusion of the middle meatus occurred in 33.3% of the cases. Out of these only 1.2% were not associated with sinus disease. Kamal [25]demonstrated the presence of anatomical or pathological changes on the ostiomeatal area in all of the 100 patients in his study who were suffering from maxillary sinusitis. Calhoun et al [14] identified a high incidence of disease in the ostiomeatal complex in patients with sinusitis compared with control group.

Sinus disease was also associated with concha bullosa in 11.8% of the cases. Lloyd [16] reported that 11 out of 14 patients showing concha bullosa were associated with CT evidence of sinus infection. East and Annis [23] reported a 30% incidence of concha bullosa. However, they postulate that the extent of pneumatization in the middle turbinate and therefore the size had no correlation with the presence or absence of disease in the anterior ethmoids.


We are grateful to King Abudlaziz University Hospital and Erfan-Bagedo General Hospital for allowing us to use their records.

  References Top

Pfleinderer A,Croft CB.Lloyed GAS. Antroscopy: its place in clinical practice: a comparison of antroscopic findings with radiographic appearances of the maxillary sinus. Clin Otolaryngol 1986; 11:455-461.  Back to cited text no. 1
Stammberger H. Endoscopic endonasal surgery- concepts in treatment of recurring rhinosinusitis. Part ll-Surgical Technique. Otolaryngol Head Neck Surg 1986;94:147-155.  Back to cited text no. 2
Zinreich SJ. Imaging of the nasal cavity and paranasal sinuses. Curr Opin Radiol 1993;2(1):112-116.  Back to cited text no. 3
Proctor DF.The nose,paranasal sinuses and pharynx. In Walters W. ed.Lewi-Walters Practice of Surgery.Vol.4 Hagerstown.MD.Ptior 1966.1-37.  Back to cited text no. 4
Messerklinger W. Endoscopy of the Nose.Urban ans Schwarzenberg:Baltimore,Munich.l978.  Back to cited text no. 5
Lloyd GAS,Lund VJ,Scadding GK. CT of the paranasal sinuses and functional endoscopic surgery: a critical analysis of 100 symptomatic patients J laryngol Otol 1991; 105:181-185  Back to cited text no. 6
LaranneJE,Pentila MA.Paakkata JS, Pukander JS, Karma PH. Diagnostic value of plain radiographs in chronic maxillary sinusitis: a comparison between radiological and endoscopic findings in 75 patients. Rhinology 1992;30:205-215.  Back to cited text no. 7
Lazar RH,Younis RT. Comparison of plain radiographs,CT scans and intraoperative findings in children with chronic/recurrent sinusitis. Otolaryngol Head Neck Surg 1990;103:183-187.  Back to cited text no. 8
Battacharya T,Piccirillo J,Wippold FJ 2nd. Relationship between patient based description of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:l 189-1182.  Back to cited text no. 9
Scribano E.Ascenti G.Cascis F.Racchinsa S.Salamone 1. Computerized tomography in the evaluation of anatomic variations in the evaluation of the ostiomeatal compIex.Radot Med ( Torino ) 1993;86:95-99.  Back to cited text no. 10
Borges Dinis P.Haider H,Gomes A. Rhinomanometry, sinus CT scan and allergy testing in the diagnostic assessment of chronic nasal obstruction. Rhinology 1997;35:158-160.  Back to cited text no. 11
Kennedy DW,Zinreich SJ. The functional endosocpic approach to inflammatory sinus disease. Am J Rhinol 1988;2)89-96.  Back to cited text no. 12
Bolger WE,Butzin CA,Parson DS. Paranasal sinus bony anatomic variations and mucosal abnormalities:CT analysis for endoscopic sinus surgery. Laryngosocpe 1991;101:56-64.  Back to cited text no. 13
Calhoun KH, Waggenspack GA, Simpson CB et al..CT evaluation of the paranasal sinuses in symptomatic and asymptomatic pppulations. Otolaryngol Head Neck Surg 1991;104:480-483.  Back to cited text no. 14
Kaluskar SK,Patil NP.Sharkey AN. The role of CT in functional endoscopic sinus surgery. Rhinology 1993;31:49-52.  Back to cited text no. 15
Lloyd GAS. CT of the paranasal sinuses: Study of a control scries in relation to endoscopic sinus surgery. J Laryngol Otol 1990;104:477-481.  Back to cited text no. 16
Mellinger WJ. The optic nerves and their relations to the sphenoidal region.Tr Pacific Coast Oto-Ophth Soc 1937;22:85-94.  Back to cited text no. 17
Driben JS,Bolger WE.Robles HA,Cable B,Zinreich SJ. The reliability of computerized tomographic detection of the Onodi ( Sphenoethmoid) cell. Am J Rhinol 1998;12:105-111.  Back to cited text no. 18
Kosling S,Wagner F,Schulz HG, Heywang-Kobrunner S.Kocherne variatonen im koronaren nasennebenhohlen- CT.Fortshr R’ntegnstr 1993;159:506-510.  Back to cited text no. 19
Jones N,Strobl A.Holland I. A study of the CT findings in 100 patients with rhinosinusitis and 100 controls. Clin Otolaryngol 1997;22:47-51.  Back to cited text no. 20
Teatini G.Computed tomograophy : Anatomical aspects. Rhinology 1992;Suppl 14:126-130.  Back to cited text no. 21
Zinreich SJ, Kennedy DW, Rosenbaum AE.Gaylor BW,Kumar AJ, Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987;163:769-775.  Back to cited text no. 22
East CA.Annis JAD. Preoperative CT scaning for Endoscopic sinus surgery : rational approach. Clin Otolaryngol 1992;17:60-66.  Back to cited text no. 23
Tonai A,Baba S. Anatomic variations of the bone in sinonsasal CT. Acta Otoloaryngol Suppl 1996;525:9-13.  Back to cited text no. 24
Kamal MD. Nasal endoscopy in chronic maxillary sinusitis.J Laryngol Otol 1989;103:275-258.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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