AN ANALYTICAL STUDY OF ANATOMICAL VARIATIONS IN CLINICAL RHINOSINUSITIS.
The term 'rhinosinusitis' is defined as inflammation of the mucosa of the nose and paranasal sinuses. Anatomical variations are predisposing factors for causing rhinosinusitis.
A precise knowledge of the anatomy of the paranasal sinuses is essential for the clinician. With the advent of Functional Endoscopic Sinus Surgery (FESS) and Coronal Computed Tomography (CT) imaging, considerable attention has been directed toward paranasal region anatomy. Remarkable anatomic variations of nasal septum and lateral of nose 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.
Currently, CT scanning is the standard imaging in the evaluation of the paranasal sinuses. This, combined with endoscopy, gives an applied anatomical view of the region and of the anatomical variants that are often found.
Aim of the Study
To analyse the relationship of anatomical variations and rhinosinusitis.
MATERIALS AND METHODS
The present study is a descriptive study of anatomical variations in clinical rhinosinusitis, was carried out in the Department of ENT, Great Eastern Medical School and Hospital, Ragolu, Srikakulam.
Patients admitted in our hospital from 1/1/2016 31/7/2017 with symptoms of sinusitis were randomly selected for the study.
Rhinosinusitis--Symptoms/ Signs Major Minor Facial pain/pressure Headache Facial congestion/fullness Fever (Non-acute) Nasal obstruction/blockage Halitosis Nasal discharge/purulence/ Fatigue discoloured Hyposmia/anosmia Dental pain Purulence on nasal examination Cough
Fever (Acute RS only) Ear pain/pressure/fullness Requires 2 major factors or 1 major and 2 minor factors.
1. Patients with symptoms and signs of rhinosinusitis between 15 and 60 years.
2. Nasal endoscopy, suggestive of rhinosinusitis.
3. CT-PNS, suggestive of rhinosinusitis.
1. Patients with adenoid hypertrophy, sinonasal polyposis and allergic fungal sinusitis.
2. Complicated rhinosinusitis, sinonasal malignancy.
3. Previous sinonasal surgery.
Clinical material for the present study comprises of 200 cases of rhinosinusitis. The patients were examined clinically and further investigated using DNE and CT-PNS. Thickness of slice was 1 mm CT scan done for both bony and soft tissue windows. The presence of anatomical variations and mucosal changes has been found out in CT scan PNS. The presence of anatomical variations was also documented along with radiological features of chronic rhinosinusitis.
The study got clearance by the Institutional Ethical Committee before its commencement. Also, a written informed consent was taken from all the patients before participating in the study.
Of the 200, 60 patients (30%) belong to age group 21-30 years, 56 (28%) belong to age group 15-20 years, 52 (26%) belonged to 31-40 years category, 26 (13%) were in 41-50 years category, only 6 (3%) in 51-60 years and no cases below 10 years.
Sl. No. Category (Years) No. of Cases % 1 15-20 56 28 2 21-30 60 30 3 31-40 52 26 4 41-50 26 13 5 51-60 6 3 Total 200 100
Of the 200 cases, 106 (53%) were males and 94 (47%) were females.
Incidence of Symptoms in Rhinosinusitis
Major presenting symptoms were Nasal obstruction (81%), Headache (71%), Nasal discharge (36%) and Sneezing (29%). Less common symptoms include Facial congestion (24%), Posterior nasal discharge (18%), Disturbance of smell (14%), Aural symptoms (11%) and Anosmia and Halitosis (1%).
Sl. No. Symptom No. of Cases % 1. Nasal Obstruction 162 81 2. Headache 142 71 3. Nasal Discharge 72 36 4. Sneezing 58 29 5. Facial Congestion 48 24 6. Post Nasal Discharge 36 18 7. Disturbance of smell 28 14 8. Aural Symptoms 22 11 9. Halitosis 12 6 10. Cough 12 6
Incidence of Mucosal Abnormalities
In the present study, maxillary sinus was predominantly involved (86%) followed by Ethmoidal sinus (72%), Sphenoid sinus (38%) and Frontal (34%).
Involved Sinus Bilateral Only Right Only Left Total % Maxillary 112 38 22 172 86 Ethmoidal 99 27 18 144 72 Frontal 27 21 20 68 34 Sphenoid 37 22 17 76 38
Incidence of Anatomical Variations
Sl. No. Anatomical Variation Bilateral Only Right 1. Concha Bullosa Lamellar 16 17 Bulbous 23 19 2. Deviated Nasal Septum -- 39 3. Agger Nasi 58 14 4. Haller Cell 11 07 Paradoxical 5. Middle 06 09 Turbinate 6. Large Bulla 10 04 7. Onodi Cell 06 05 8. Pneumatised Uncinate 02 02 Sl. No. Anatomical Variation Only Left Total Incidence (%) 1. Concha Bullosa1. 86 43 Lamellar 05 38 Bulbous 06 48 2. Deviated Nasal Septum 31 70 35 3. Agger Nasi 10 82 41 4. Haller Cell 05 22 11 Paradoxical 5. Middle 07 22 11 Turbinate 6. Large Bulla 02 16 08 7. Onodi Cell 01 12 06 8. Pneumatised Uncinate 02 06 03
In the present study of 200 cases Concha bullosa was seen in 86 cases, of which 38 were lamellar and 48 were bulbous. Deviated nasal septum was seen in 70 cases, of which 39 showed right deviation and 31 showed left deviation. Agger nasi cells were seen in 82 cases, of which 58 were bilateral, 14 were to the left and 10 were to the right. The Haller cells were seen in 22 cases of which 11 were bilateral, 7 were to the right and 5 were to the left. The paradoxical middle turbinate was seen in a total of 22 cases of which 6 were bilateral, 9 were to the right and 7 were to the left. The large bulla were noted in a total of 16 cases of which 10 were bilateral, 4 were to the right and 2 were to the left. Onodi cells were seen in a total of 12 cases of which 6 were bilateral, 5 were towards the right and only 1 was to the left. A pneumatised uncinate was seen in a total of 6 cases of which 2 each were seen to have a bilateral distribution, right unilateral and left unilateral distribution respectively.
Anatomical variations in the sinonasal region in cases of clinical sinusitis are very common. Messerklinger  (1978) found anatomical variations like nasal septum deviation, spur, concha bullosa, Agger nasi cells, paradoxical middle turbinate, abnormal uncinate process and enlarged bulla are responsible for decreased sinus ventilation and pathogenesis of sinus disease. Mafee MF  et al described the use of coronal plane CT scans PNS to evaluate the topographic relations of anatomical structures at lateral wall of nose in cases of sinus disease.
Concha bullosa is a result of pneumatisation of the osseous plate of middle turbinate. The concha pneumatisation may occur at several degrees, from that affecting only the bulbous portion (distal) or lamellar portion (proximal) or called the true variant where there is pneumatisation of both portions.  Zinreich et al report that concha bullosa are best diagnosed radiographically and easily identified with CT.  Bolger et al reported this pneumatisation in 53% of the sinus patients, as an extension of the anterior air cells (55%) or posterior (45%) ethmoidal air cells.
In the present study of 200 cases Concha bullosa was seen in 86 cases, of which 38 were lamellar and 48 were bulbous.
Deviated Nasal Septum
Deviation of the nasal septum can be defined as any midline deviation. [5,6] Septal deviations may be cartilaginous, cartilaginous-bony type or a combination of both. Since septal deviation causes lateral compression of the middle turbinate and uncinated process pushing them into the infundibulum and thus causes obstruction of osteomeatal complex. Deviation of the nasal septum was found in 35% of cases in the present study.
Agger Nasi Cells
Agger nasi cells are the most anterior ethmoid cells and extend anteriorly into the lacrimal bone. They are located in the anterior floor of the frontal sinus, on the drainage pathway of the frontal sinus and therefore are possibly involved in recurrent or chronic frontal sinusitis. Schaefer et al  reported an incidence of 10%, while Van Alyea  had observed an incidence of 89% in their series of anatomic dissections. In the present study, 41% of the patients showed Agger nasi indication.
Haller's cell is the pneumatisation of the anterior ethmoid cells into the roof of the maxillary sinus extending into the floor of the orbit. Zinreich reported it in 10% of cases.  Bolger reported it in 45.1% of cases. Lloyd reported it in 15% of cases.  Earwaker reported it in 20% of cases. Bolger described the possible reasons for this discrepancy as a consequence of difference in interpretation of Haller cell, sample study or in the technique of CT scanning. Bolger also suggested that a narrow window setting often fails to delineate Haller cell. In the present study, Haller cells were seen in 22 cases of which  were bilateral, 7 were to the right and 5 were to the left.
Paradoxical Middle Turbinate
Paradoxical middle turbinate occurs if the convexity of the middle turbinate is directed towards the medial wall of the maxillary sinus. In the present study the paradoxical middle turbinate was seen in a total of 22 cases, of which 6 were bilateral, 9 were to the right and 7 were to the left.
An enlarged ethmoidal bulla may obstruct the infundibulum or the middle meatus. The exact prevalence of enlarged ethmoidal bulla is not known.  Its size is an important factor when associated with opacification of anterior ethmoidal cells at CT in patients diagnosed with sinusopathy.  In measurements at CT in adults, the average area of each ethmoidal cell is 0.73 [+ or -] 0.42 cm, the larger ones, situated in the posterior portion of ethmoid, measure 1.46 [+ or -] 0.64 cm. 
Since the ethmoidal bulla is the largest anterior cell,  it is implicit that its average area should not exceed 2.1 cm. In the present study the large bulla were noted in a total of 16 cases of which 10 were bilateral, 4 were to the right and 2 were to the left.
Also known as sphenoethmoidal cells, Onodi cells were first described by the Hungarian laryngologist Adolf Onodi in 1904.  Onodi cells are ethmoid cells that have migrated to the anterior region of the sphenoid sinus with anterosuperior location and intimately related to the optic nerve causing optic neuropathy in case of certain conditions that affect such cells. Onodi cell is the most posterior ethmoid air cell that extends laterally. This extension is near the carotid canal and close to the optic nerve, which emphasises the clinical importance of considering this anatomic variation prior to any attempt for invasive intervention. The surgeon must pay close attention to the occasional Onodi cell in preoperative evaluation to avoid potential complications of endoscopic sinus surgery. In the present study Onodi cells were seen in a total of 12 cases of which 6 were bilateral, 5 were towards the right and only 1 was to the left.
The pneumatisation of the uncinated process is very rare. In the present study, a pneumatised uncinate was seen in a total of 6 cases of which 2 each were seen to have a bilateral distribution, right unilateral and left unilateral distribution respectively.
The present study was conducted to analyse the relationship of anatomical variations and rhinosinusitis and observed variations like Concha Bullosa, Deviated Nasal Septum and Agger Nasi which were the major conditions that led to sinusitis. Haller Cell, Paradoxical Middle Turbinate and Large Bulla were seen in some cases.
These variations, by obstructing the drainage pathway of the paranasal sinuses, impair the drainage of secretions from the sinuses, which subsequently may get infected, which impairs ciliary activity and aggravates stasis of secretions.
Detection of these variations and their correction (those possible) at surgery is necessary to prevent recurrence of the disease. We conclude that these Anatomical Variations can play an important role in the pathogenesis of sinusitis.
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P. B. Kameswara Rao (1), S. Ramesh (2)
(1) Associate Professor, Department of ENT, GEMS, Ragolu, Srikakulam, Andhra Pradesh, India.
(2) Assistant Professor, Department of ENT, RIMS, Srikakulam, Andhra Pradesh, India.
'Financial or Other Competing Interest': None. Submission 03-08-2018, Peer Review 15-08-2018,
Acceptance 18-08-2018, Published 27-08-2018.
Corresponding Author: Dr. S. Ramesh, Assistant Professor, RIMS, Srikakulam-532001, Andhra Pradesh, India.
Caption: Figure 1. Bulla type of Concha
Caption: Figure 2. DNS huge Bulla_Paradaxical_Middle_Turbinate_ Lamellar_Concha
Caption: Figure 3. Concha Bullosa Photo
Caption: Figure 4. Onodi Cell
Caption: Figure 5. Double Middle Turbinate Appearance
SEX DISTRIBUTION MALE 53% FEMALE 47% Note: Table made from pie graph.
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|Title Annotation:||Original Research Article|
|Author:||Rao, P.B. Kameswara; Ramesh, S.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Aug 27, 2018|
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