With the advent of functional endoscopic sinus surgery (FESS) and coronal computed tomography (CT) imaging, considerable attention has been directed toward paranasal region anatomy. Detailed knowledge of anatomic variations in paranasal sinus region is critical for surgeons performing endoscopic sinus surgery as well as for the radiologist involved in the preoperative work-up. To be in the known anatomical variants with some accompanying pathologies, directly influence the success of diagnostic and therapeutic management of paranasal sinus diseases. A review of 512 (1024 sides) paranasal sinus tomographic scans was carried out to expose remarkable anatomic variations of this region. We used only coronal sections, but for some cases to clear exact diagnosis, additional axial CT scan, magnetic resonance imaging (MRI) and nasal endoscopy were also performed. In this pictorial essay, rates of remarkable anatomic variations in paranasal region were displayed. The images of some interesting cases were illustrated, such as the Onodi cell in which isolated mucocele caused loss of visual acuity, agger nasi cell, Haller's cell, uncinate bulla, giant superior concha bullosa, inferior concha bullosa, bilateral carotid artery protrusion into sphenoid sinus, maxillary sinus agenesis, bilateral secondary middle turbinate (SMT) and sphenomaxillary plate. The clinical importance of all these variations were discussed under the light of the literature. It was suggested that remarkable anatomic variations of paranasal region and their possible pathologic consequences should be well defined in order to improve success of management strategies, and to avoid potential complications of endoscopic sinus surgery. The radiologist must pay close attention to anatomical variations in the preoperative evaluation.
"The nasal septum is easily identified on both axial and coronal CT (Laine & Smoker). It is impossible to differentiate the pneumatisation and hypertrophy of the INC without CT (Kantarci et al., 2004; Yang et al.; Dogru et al.; Aydin et al.). CB and SD are frequently present together and there is a relationship between these two issues (Stallman et al., 2004; Keles et al., 2010; Lloyd, 1990; Zinreich et al., 1988; Bolger et al.; 1991; Uygur et al., 2003; Blaugrund, 1989). "
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to evaluate the relationship between variations of the lateral wall of the nasal cavity and septal deviation (SD). Coronal and axial paranasal sinus CT images of 115 individuals (65 females, 50 males) were reviewed and the presence of pneumatisation and hypertrophy of the conchae was evaluated. Pneumatisation of the concha was classified as lamellar concha bullosa (LCB), bulbous concha bullosa (BCB), or extensive concha bullosa (ECB). If bulbous and extensive conchae and hypertrophic conchae were bilateral the side on which it was greatest was accepted as the dominant concha. The relationship between these variations and nasal septum deviation was also taken into account. Eighty-six (74.8%) of the 115 subjects had SD. Of these, 20 were not affected by the size of the middle nasal concha (MNC) or inferior nasal concha (INC). Thirty-four cases had dominant MNC, 20 had dominant INC, and 11 had both dominant MNC and dominant INC, and all of which had SD towards the opposite side. In one case there was SD towards the side in which the MNC was dominant. Our data indicate that coexistence of pneumatisation or hypertrophy of the conchae and SD was more common in adults compared to the results of similar studies conducted with a wide range of age groups, including children. Thus the presence of SD together with a large concha increases with age. A prospective study, which will include infants, will elucidate the relationship between conchae and SD.
International Journal of Morphology 06/2013; 31(2):438-443. DOI:10.4067/S0717-95022013000200012 · 0.32 Impact Factor
"However, there is controversy regarding the incidence of this variation and more importantly the clinical symptoms associated with it. It has been estimated that the incidence of secondary middle turbinate ranges from 0.8% to 14.3% (Khanobthamchai et al., 1991a; Aykut et al., 1994; Kantarci et al., 2004; Ozcan et al., 2008). This is a bony structure covered by mucosa and originating from the lateral wall of the middle meatus as illustrated in Figure 1C. "
[Show abstract][Hide abstract] ABSTRACT: The aim of the current anatomical and clinical study was to audit our cases of patients who presented with secondary and/or accessory middle turbinates during a two-year period. We investigated the incidence and the clinical impact of these variations. Twenty-eight patients, 19 males and 9 females with a mean age of 41.5 years, representing different ethnic origins, were diagnosed with double middle turbinates based on endoscopic examination. Of those, 92.8% had a main symptom of refractory frontal headache. A secondary nasal symptom was sensation of blocked nose. Patients who underwent endoscopic surgery (n = 13) for reduction of the extra turbinate, reported significant symptom scores improvement (P < 0.0001) of frontal headache and blocked nose, from means of 9.07 ± 0.26 and 8.57 ± 1.39 to 1 ± 0.31, and 1.42 ± 0.35, respectively. Our results indicate that double middle turbinates may be encountered in rhinology practice (2%). Clinically they may present with refractory headache and blocked nose. Endoscopic surgical approach seems to be an effective way of improving the symptoms.
[Show abstract][Hide abstract] ABSTRACT: The most common anatomic variations of the structures of the middle nasal meatus are variations of agger nasi cells, variations of the middle turbinate, variations of uncinate process, variations of the ethmoidal bulla, deviations and deformations of nasal septum in the region of the middle nasal meatus, Haller's cell (orbitoethmoidal) and Onodi's cell (sphenoethmoidal cell). In 1997, the Otorhinolaryngology-Head Neck Surgery, Task Force on Chronic Rhinosinusitis defined chronic sinusitis and nasal disease initially by including sinusitis and rhinitis with one term-chronic rhinosinusitis. This was done because it was apparent to many that nasal disoders often affected the sinuses, and vice versa. Also they established baseline parameters, major and minor signs and symptoms, for definition of rhinosinusitis. Two major factors or one major factor and two minor factors constitute a strong history for rhinosinusitis.
The following methods were used in the study: 1. Anamnestic data processing about: disease symptoms that were recognized by American Academy for ENT as major and minor criteria in diagnosing nosinusitis; the duration of symptoms; the kind of sinonasal disorder and the secondary disorders. 2. Data processing obtained by anterior/posterior rhinoscopy. 3. Data processing obtained by endoscopic examination. 4. Data processing obtained by CT of paranasal cavities and the nose. The data about anatomic variations were statistically processed by Eives's correlation coefficient that indicates the degree of correlation between sinonasal disorders and anatomic variation.
By analyzing the obtained data in the examined patients with sinonasal disorders, anatomic variations were present in over 50% of the patients and are defined by percentage. 1. The deviation of nasal septum in 83.33% patients. 2. The variations of the form of the middle nasal chonha in 58.92% patients. 3. The presence of agger nasi cells in 50% patients. 4. Variations of the form of ethomoidal bulla in 50% patients. Eives's correlation coefficient i.e. the degree of correlation between sinonasal disorders and the presence of anatomic variation statistically significantly correlate at r > or = 0.05 of anatomic variation of the middle nasal chonha (r = 0.23) and the presence of deviation/deformation of nasal septum (r = 0.6) with sinonasal disorders.
Anatomic variations of the structures of the middle nasal meatus can additionally complicate the anatomy of the lateral nasal wall and the conditions of the ostiomeatal unit. Therefore we must view these variations as factors predisposing to more rapid and frequent appearance and persistence of chronic inflammations. Also, familiary with the variations in sinonasal anatomy is a prerequisite to safe and effective surgical treatment of sinonasal disease. Recognition of this anatomic variation should minimize catastrophic violation of vital structures such as orbit or skull base.
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