Deeksha Seth1 Dr. Ashvini Kumar2 RISKS DURING SURGERY AND PREDISPOSITION TO PATHOLOGIES DUE TO ANATOMICAL VARIANTS OF PARANASAL SINUSES Deeksha Seth1 Dr. Ashvini Kumar2 Department of Radiology Kasturba Medical College, Manipal University, Mangalore India

INTRODUCTION Source: Biomechanical Modeling of the Nasal Cavity and Paranasal Sinuses for Endonasal Surgery Simulation 1). Dwivedi A, Singh K. CT of the Paranasal sinuses : Normal anatomy variants and Pathology. Journal of Optoelectronics and Biomedical Materials. December 2010, 2(4): 281 – 89. Marfatia YS, Modi M. Overview of HIV/AIDS in India . Indian J Sex Transm Dis 2007;28:1-5. 2). Ameri A. A, Eslambolchi A, Bakhshandeh. Anatomic Variants of Paranasal Sinuses and Chronic Sinusitis. Iran. J. Radiol., June 2005; 2(3,4): 121-24.

04 AIM To find out the common anatomical variants of the PNS and associated pathologies. OBJECTIVES To find out the frequency and types of anatomical variants in the PNS on CT Scan. To find out which anatomical variants may predispose to sinusal diseases. To relate gender and age groups with the anatomical variants. To evaluate operative risks during surgery.

Methodology Study Design: Cross-sectional Study 05 Study Design: Cross-sectional Study Study period: March 2014 – September 2014. Study setting: Department of Radiology, KMC Attavar Hospital, Mangalore. Sample Size: 130 patients. Data Collection: Osteo-meatal scans were taken using Computed Tomography (CT) Scan Machine (GE Hi Speed DX/i Single Slice Spinal CT was used & 2 mm contiguous slices were taken with reconstitution). Data on age, gender, imaging evidences of inflammatory disease for each sinus, paranasal anatomic variants, presence and types of sinusitis were recorded. Data Analysis: Using MS Excel and SPSS version 17.0. Study objectives were found out using Chi-square test. P < 0.05 was considered as significant.

Exclusion Criteria: Selection Criteria Inclusion criteria: 06 Selection Criteria Inclusion criteria: All the age groups Both genders All patients coming to the Radiology Department with CT Scan of the Osteo-meatal Complex to be done. Exclusion Criteria: Patients with cases of nasopharyngeal tumors, gross mucosal hypertrophy, previous surgery of the face, and disfigurement of the face due to trauma were not considered due to distortion of the regional anatomy.

Results Age groups (years) Total Patients N = 130 Males N=71 (54.6%) 07 Table 1. Age & Gender parameters of the patients Mean Age = 32.4±14.9years Age groups (years) Total Patients N = 130 Males N=71 (54.6%) Females N= 59 (45.4%) <20 20 (15.3%) 12 (16.9%) 8 (13.5%) 21 - 40 73 (56.1%) 39 (54.9%) 34 (57.6%) 41 - 60 30 (23.0%) 17 (23.9%) 13 (22.0%) 61 - 80 7 (5.3%) 3 (4.2%) 4 (6.7%)

Gender Anatomical variants Males Females 08 Table 2. Frequency of Anatomical variants & Gender distribution Gender  Anatomical variants   Present Absent Total Males 66 (93%) 5 (7%) 71 Females 49 (83.1%) 10 (16.9%) 59 115 (88.4%) 15 (11.5%) 130

Paradoxical Middle Turbinate 9 Table 4. Types and frequency of anatomical variants found in the study S.no Anatomical Variants Present Males Females 1 Concha Bullusa 74 (64.3%) 40 (54.1%) 34 (45.9%) 2 Deviated Nasal Septum 36 (31.3%) 13 ( (36.1%) 23 (63.8%) 3 Onodi cells 18 (15.6%) 11 (61.1%) 7 (38.8%) 4 Paradoxical Middle Turbinate 5 (4.4%) 4 (80%) 1 (20%) 5 Hallar cells 7 (6.1%) 5 (71.4%) 2 (28.7%)

Table 5. Types and frequency of Sinusitis 10 S.no Types of Sinusitis Anatomical Variant present N=(115/130) Anatomical Variant absent N=(15/130)   Present N = 57 Present N = 7 1 Maxillary Sinusitis 16 (13.9%) 1 (6.6%) 2 Frontal Sinusitis 8 (6.9%) 3 Ethmoidal Sinusitis 4 Sphenoidal Sinusitis 2 (1.7%) 5 Pansinusitis 13 (11.3%) 6 Others* 10 (8.7%) 4 (26.7%) Other*-mucosal thickening, lamellar air cells, patent ostia of OMC, sinonasal polyposis.

Table 6: Association of Sinusitis with the various Anatomical variants 11 Table 6: Association of Sinusitis with the various Anatomical variants Deviated nasal Septum Concha Bullosa Onodi cells Paradoxical Middle Turbinate Hallar cells Maxillary Sinusitis <0.001 0.09 0.23 0.04 0.35 Frontal Sinusitis 0.03 0.002 0.12 0.27 0.18 Ethmoidal Sinusitis 0.26 0.43 0.52 0.37 Sphenoidal Sinusitis 0.07 0.38 0.47 0.45 Pansinusitis 0.02 0.21 0.17

12 Discussion Anatomical variants were found in 88.4% (115/130) patients. [3,4] Maximum patients with variants were in the age group of 21-60yrs [56.1% (73/115)]. [5] Male predominance [57.4% (66/130)] was seen for variants (p=0.01). [5,6] Concha Bullosa 64.43% [7] > DNS 31.3% [8]> Onodi cells 15.6% [9]> Hallar cells 6.1% [8]> Paradoxical middle turbinate 4.4%[8] > Aggar nasi cells [8,10] , Bulla ethmoidalis, Uncinate process. [10] L-Concha bullosa, R-Bony spur, L-DNS, and R- Onodi cells were more common.[5]

13 More than 1 variant was present in 21.7% (25/115) patients out of whom 72% had DNS with concha bullosa and 28% were found to have Concha bullosa with onodi cells. [11] The association of DNS with maxillary sinusitis was significant (p<0.001). [12] The p value for the association of Concha bullosa with maxillary sinusitis was 0.09. [13]

14 Paradoxical Middle Turbinate was found to be associated with Maxillary sinusitis. There was no significant relation between DNS and Concha bullosa. [5,13,14]. The presence of these variants modifies the anatomy which poses risks for sinus surgeries. (eg. Onodi cells-optic nerve is at risk, Concha bullosa-obstructs ethmoid infudibulum, Hallar cells-risk of orbital injuries, Septal deviation-complicated surgery).

Conclusion 15 1. Anatomical variants were found in 88.4% patients. 21-40 years is the dominant age group with Male predominance 2. Concha Bullosa is the most common anatomical paranasal variant present. 3. Maxillary Sinusitis is the most common pathology which is significantly associated with DNS and Paradoxical Middle Turbinate. 4. Pansinusitis is significantly associated with DNS and Concha Bullosa.

16 Take Home Message… The Anatomical variants and their association with sinusal pathologies varies in individuals and also geographically. A detailed knowledge of the patients paranasal anatomy will aid in the management of the pathology and will decrease the incidence of complications during sinus surgery.

Acknowledgements… My Guide: Dr. Ashvini Kumar 17 Acknowledgements… My Guide: Dr. Ashvini Kumar Radiology Department and Staff My Greatest Teachers: My Patients Source of funding: Indian Council of Medical Research (ICMR)

REFERENCES-1/2 (a) Dwivedi A, Singh K. CT of the Paranasal sinuses : Normal anatomy variants and Pathology. Journal of Optoelectronics and Biomedical Materials. December 2010, 2(4): 281 – 89. Ameri A. A, Eslambolchi A, Bakhshandeh. Anatomic Variants of Paranasal Sinuses and Chronic Sinusitis. Iran. J. Radiol., June 2005; 2(3,4): 121-24. Pérez-Piñas, J. Sabaté, A. Carmona, et al. Anatomical Variations in the Human Paranasal Sinus Region Studied by CT,” Journal of Anatomy, Vol. 197, No. 2, 2000, pp. 221-227. Armani A, Karadi RN, Kumar S. A Study of Anatomical Variations of Osteomeatal Complex in Chronic Rhinosinusitis Patients-Ct Findings. Journal of Clinical and Diagnostic Research. 2014 Oct; 8(10): 1-4. M Daghighi, A Daryani, K Chavoshi Nejad. Evaluation of Anatomic Variations of Paranasal Sinuses. The Internet Journal of Otorhinolaryngology. 2006; 7 (1): 334-351. Gupat A, Gupta B, Gupta N, Tripathi N. Computerized Tomography of Paranasal sinuses: A Road map to Endoscopic Surgery. Clinical Rhinology: An International Journal,2012; 5(1): 1-10. Biswas J, Patil C, Deshmukh P, Kharat R, Nahata V. Tomographic Evaluation of Structural Variations of Nasal Cavity in Various Nasal Pathologies. International Journal of Otolaryngology and Head & Neck Surgery, 2013; 2:129-134.

REFERENCES-2/2 (b) 8). Bolger EW, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities - CT analysis for endoscopic sinus surgery. Laryngoscope1991; 101: 56-64. 9). Jones NS. CT of the paranasal sinuses: a review of the correlation with clinical, surgical and histopathological findings. Clin.Otolayngol.2002; 27: 11-17. 10). Maru YK, Gupta V. Anatomic varaitions of the bone in sinonasal CT. Indian Journal of Otolaryngol and Head Neck Surgery 2001; 53:123-128. 11). Bhandary S & Kamath K. Study of relationship of concha bullosa to nasal septal deviation and sinusitis. Indian Journal of Otolaryngology and heand and neck surgery 2009; 61(3): 227-229. 12). Deosthale N, Khadakkar Sonali, Singh B, Harkare V, Dhoke P, Dhote S. Anatomical variations of Nose and Paranasal Sinuses in Chronic Rhinosinusitis. People’s Journal of Scientific Research July 2014; 7 ( 2):1-7. 13). M Daghighi, A Daryani, K Chavoshi Nejad. Evaluation of Anatomic Variations of Paranasal Sinuses. The Internet Journal of Otorhinolaryngology. 2006; 7 (1): 334-351. 14). Hamoud F. The Incidence of Concha Bullosa and Its Association with Chronic Rhinosinusitis Deviated Nasal Septum and Osteomeatal Complex Obstruction. Bahrain Medical Bulletin 2011; 33 (4): 1-7.

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INDEX Aims and Objectives Conclusion Materials and Methods Acknowledgments Results References Discussion