CT OF NOSE & PNS

BY D AZAB AHMED ENT PROFESSOR

CT
has become a useful diagnostic modality in the evaluation of the paranasal sinuses and an integral part of surgical planning. It is also used to create intraoperative road maps. Today, CT is the radiologic examination of choice in evaluating the paranasal sinuses of a patient with sinusitis

Physicians who are interested in treating patients with sinus disease must be able to read and interpret sinus CT scans. Mastery of sinus anatomy and its variant features forms the basis from which radiologic interpretation begins. Familiarization with the radiologic landmarks and cross-sectional anatomy on patient CT scans, along with clinical correlation, can further enhance the reader's ability to understand sinus CT findings.

With experience, CT findings can be accurately correlated with the anatomic and clinical realities of the particular patient. As in all radiologic surveys, sinus CT scans must be read with a systematic approach. In addition to reviewing the scan to determine the presence of disease, CT scans of the sinuses can also be reviewed to evaluate potential areas of occlusion and variations of the patient's sinus anatomy in the setting of surgical planning.

CT scans typically obtained for visualizing the paranasal sinus should include coronal and axial (3-mm) cross sections. Soft tissue and bony windows intravenous contrast material for vascular tumor. Contrast-enhanced CT is useful in evaluating neoplastic, chronic, and inflammatory processes.

Positioning

For axial views, the patient's hard palate is placed perpendicular to the CT scanner table. The images must be captured such that the external auditory canal is in line with the inferior orbital rim. .

The coronal images are taken so that the gantry is perpendicular to the patient's hard palate. Misalignment or rotation can lead to distortion of the true anatomy on the films

patients who may not tolerate the prone position required for coronal cuts, computer-generated reconstructed coronal views can be generated from thin axial sections. If sufficiently thin axial sections (1-2 mm) are available, sagittal reconstructions can also be helpful for teaching purposes and further delineating anatomic structures.

Timing waiting for at least 6 weeks before obtaining a scan is recommended to determine the patient's baseline disease status.

The middle turbinate has 3 anatomic parts and is a key landmark in endoscopic sinus surgery. The anterior third courses vertically, lying in the sagittal plane, running from posterior to anterior. Superiorly, the middle turbinate attaches to the skull base at the lamina cribrosa of the cribriform plate. The middle third turns coronally and laterally to insert on the lamina papyracea. The coronal component of the middle turbinate is referred to as the basal lamella, and it represents the dividing point between the anterior and posterior ethmoid air cells. The posterior portion of the middle turbinate becomes horizontal and posteroinferiorly attaches to the lateral nasal wall

Uncinate process: This is a 3-dimensional

sickle-shaped (also described as a hook- or Lshaped) bone of the lateral nasal wall. Anteriorly, the uncinate process attaches to the lacrimal bone; inferiorly, the uncinate process attaches to the ethmoidal process of the inferior turbinate. The posterior edge lies in the hiatus semilunaris inferioris. Superiorly, the uncinate process may attach to the middle turbinate, lamina papyracea, and/or the skull base

Important Radiologic Anatomic Landmarks Landmarks on coronal CT sections Relationship of cells within the frontal recess and their relationship to the frontal sinuses Depth of the olfactory fossa: The deeper the fossa (ie, increased distance from the cribriform plate and the fovea ethmoidalis), the higher the chance for fracture or perforation with surgical maneuvers. Slope, thickness, and asymmetries in the height of the ethmoid roof The prevalence of intracranial penetration during FESS is higher when this anatomic variation occurs. Intracranial penetration is more likely to occur on the side with the lower roof. Patency of the ostiomeatal complex

Attachment of the middle turbinate Width of the infundibulum Vertical distance from the maxillary sinus to the ethmoid roof in posterior ethmoid cells Degree of pneumatization of the maxillary sinus Status of the lamina papyracea Dehiscence in the lamina papyracea Shape of the medial orbital wall Attachment of the uncinate process Alignment of the septum Size and status of the maxillary sinuses (hypoplastic vs normal size) Other variations, such as the presence of a concha bullosa

Landmarks on axial CT sections

Depth and ratio of the anterior and posterior ethmoid cells compared to the sphenoid sinus Degree of pneumatization of sphenoid sinus Position of sphenoid intersinus septae

Presence or absence of an Onodi cell (sphenoethmoidal (cell

Dehiscence in the bony covering of the carotid artery or optic nerve Relationship of the optic nerve to the posterior ethmoid cells The presence of anterior clinoid process pneumatization Degree of indentation created by the carotid artery and optic nerve Position of uncinate (medial versus lateral) Patency of the ostiomeatal complex Patency of the V-shaped ethmoidal infundibulum Alignment of the septum

Concha bullosa: The concha bullosa

is a pneumatized middle turbinate. An enlarged middle turbinate may obstruct the middle meatus and the infundibulum causing recurrent disease. It may also serve as a focal area of sinus disease

Ethmoidal bulla: This is the largest and most anterior ethmoid cell system. It is found posterior to the middle turbinate and posteromedial to the uncinate process Ethmoidal infundibulum: This is a space bordered medially by the uncinate process and laterally by the lamina papyracea. The maxillary sinus ostium is found inferiorly and laterally within this space

Haller cell (infraorbital cell):

The Haller cell is usually situated below the orbit in the roof of the maxillary sinus. It is a pneumatized ethmoid cell that projects along the medial roof of the maxillary sinus. Enlarged Haller cells may contribute to narrowing of the ethmoidal infundibulum and recurrent sinus disease, despite previous (incomplete) surgery

Frontal recess: This is an hourglassshaped space between the inferomedial aspect of the frontal sinus and the anterior middle meatus. Unfavorable variations of the structures that define its borders may cause problems with the frontal sinus outflow tract. These structures include the agger nasi cell, supraorbital ethmoid cells, the ethmoid bulla, and inferiorly, the .uncinate process

Lamina papyracea: This is a thin, bony wall separating the orbit from the ethmoid air cells. Dehiscences may occur for congenital reasons or because of previous .surgery or facial trauma

Maxillary sinus ostium: This is the opening of the

maxillary sinus to the nasal cavity and a part of the .ostiomeatal complex Ostiomeatal complex or unit: This term refers to a collection of middle meatal structures and is not a discrete anatomic entity. It consists of the ethmoid infundibulum, anterior ethmoid cells, and the uncinate process. It also represents the final common pathway of drainage for the frontal, maxillary, and anterior ethmoid cells. A patent ostiomeatal complex is essential for the improvement of .patients with sinus disease

Paradoxical middle turbinate: The major curvature of the middle turbinate may project laterally, leading to narrowing of the middle meatus Sphenoethmoid cell (Onodi cell): This is formed by lateral and posterior pneumatization of the most posterior ethmoid cells over the sphenoid sinus. The presence of Onodi cells increases the chance that the optic nerve and/or carotid artery would be exposed (or nearly exposed) in the .pneumatized cell