INTRODUCTION:

Chronic rhinosinusitis (CRS) is a disease characterized by inflammation of the mucosa of the nose and paranasal sinuses (PNS) that has lasted for twelve weeks or more. Chronic rhinosinusitis can be diagnosed by obtaining the complaints and objective signs of nasal endoscopy or paranasal sinuses Ct-scan¹. Nasal obstruction and nasal discharged are the main presentation of CRS, while facial pain and hyposmia are secondary symptoms infrequently expressed by patients. Polyps and or mucopurulent discharge or edema in meatus medius are objective signs that can be assessed through nasal endoscopy. Paranasal sinuses mucosal changes can be seen through Ct-scan.

The anatomical variations of the PNS and osteomeatal complex is one of the etiologies of CRS. A healthy mucociliary system is a key defense against infection in the nasal mucosa and PNS^1,2.

The nose and PNS have complex anatomical structures and high variability between individuals. Paranasal sinuses are basically air cavities located in the bones of the skull. Sinuses are named according to the bone in which they are located. PNS anatomical variations have long been associated with the occurrence of CRS. Mucociliary drainage impairment in the PNS owing to anatomical variations can result in recurrent infection and inflammation of the PNS mucosa. Deviated nasal septum (DNS), agger nasi cell, Haller cell, Onodi cell, and concha bullosa are anatomical variations that are often thought to contribute towards CRS etiology, but this association remains unsettled^1,2.

CT-scan of PNS is a common examination performed for the assessment of sinonasal conditions. This investigation is expedient to assess any anatomical variations, thickening of the mucosa and PNS bony structure. The sensitivity level of the CT-scan is 94% and the specificity is 41%. Confusion arising from failure to identify anatomical variations prior to endoscopic sinus surgery may lead to complication in the surrounding vital structures^1,2. The purpose of this study was to determine the anatomical variations in Javenese patients with CRS based on CT-scans of PNS.

METHODS:

The study is a retrospective chart review of the medical record from the outpatient unit rhinology division of the nose throat surgery head and neck Dr. Soetomo hospital, from January 2019 to December 2020. All Javanese patients with CRS who met the inclusion and exclusion criteria were selected. Inclusion criteria were complete medical records, patients with or without polyps who have available CT-scan of PNS with no prior sinus endoscopic surgery or nasal surgery. The exclusion criteria were patients with nasal tumor, craniofacial deformity and history of facial or sinonasal traumatic injury. The data collated were age, gender, anatomical variations, and Keros classification. Ethical approval was obtained from the Research Ethics Committee for the Research and Development Sector of Dr. Soetomo Hospital, Surabaya (0346/117/XI/2020).

Each CT-Scan first scored by resident, after that discussed and reviewed by senior physician in rhinology department. All Ct-Scans were carried out using the Philips Brilliance 128 slice scanners. Each CT was evaluated for the anatomical variation in axial, coronal and sagital views. Anatomical definitions were made based on the European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses and International Frontal Sinus Anatomy Classification (IFAC).

RESULTS AND DISCUSSION:

Two hundred and five patients were treated at the ORL-HNS outpatient clinic during the study period. Sixty-three patients presented with CRS and planned for sinus endoscopic surgery. Eight patients were excluded due to previous nasal surgeries.

Table 1: Distribution of CRS patients by age group and gender.

Age Group (years)	Male		Female
Age Group (years)	N	%	N	%
≤16	2	7	3	12
16 - 30	9	31	10	38
31 - 45	3	10	7	27
46 - 60	13	45	5	19
≥61	2	7	1	4
Total	29	100	26	100

A total of 55 patients were included in the study of which 29 were men and 26 were women (Table 1). The age group in the male gender was 46-60 years old (38%) and female was 16-30 years old (38%).

Table 2: Anatomical variations identified on Ct-scan of paranasal sinuses.

Anatomical Variations		Present		None		Total
Anatomical Variations		N	%	N	%	N	%
Frontal	Frontal Septum Cell	3	4	52	96	55	100
Anterior Ethmoid	Agger Nasi Cell	12	22	43	79	55	100
	Supra Agger Cell	10	18	45	82	55	100
	Supra Agger Frontal Cell	2	4	53	96	55	100
	Ethmoid Bulla	11	20	44	80	55	100
	Suprabullar Cell	5	9	50	91	55	100
	Suprabullar Frontal Cell	3	4	52	96	55	100
	Supra Orbital Ethmoid Cell	3	4	52	96	55	100
	Haller cell	4	7	51	93	55	100
Anterior Ethmoid Artery	Hanging Anterior Ethmoid Artery	2	4	53	96	55	100
Posterior Ethmoid	Onodi Cell	1	2	54	98	55	100
Posterior Ethmoid	Ethmomaxilary Sinus	1	2	54	98	55	100
	Retro Pneumatization of Posterior Ethmoid Cell	0	0	55	100	55	100
Ostiomeatal	Bent Uncinate Process	0	0	55	100	55	100
Ostiomeatal	Uncinate Process Pneumatization	3	4	52	96	55	100
	Paradoxical middle turbinate	4	7	51	93	55	100
	Concha Bullosa	15	27	40	73	55	100
Septum	Deviated Nasal Septum	39	71	16	29	55	100
	Posterior Nasal Septal Pneumatization	2	4	53	96	55	100
	Pneumatized crista galli	2	4	53	96	55	100
Maxilla	Alveolar Recess	2	4	53	96	55	100
	Palatine Recess	1	2	54	98	55	100
Sphenoid	Lateral Recess	6	11	49	89	55	100
	Intersinus Septum	2	4	53	96	55	100

The most common variant was deviated nasal septum (DNS) occurring in 39(71%) patients. Concha bullosa ranked second with fifteen patients (27%) and agger nasi 22%. Other notable findings are presented in Table 2. Interestingly, retro pneumatization of posterior ethmoid cells and bent uncinate process were not found in all patients (100%). The prevalence of the nasal roof according to Keros classification is shown in Table 3.

Table 3: Distribution of patients according to Keros classification.

Keros Classification	N	%
Keros 1	23	42
Keros 2	26	47
Keros 3	6	11
Total	55	100

Most CRS patients in this study were in the age group of 16-30 years (35%); the youngest was ten years old and the oldest was seventy-seven years old. Based on a study in the United States, the number of people affected by CRS increases with an increase in age at approximately 3% between the age group of 20-29. Conversely, the incidence of CRS decreases by 5% after the age of sixty years. Nonetheless, both age groups have similar risk of exposure to pollutants, viruses and bacteria in addition to air pollution^1,2.

The most widely encountered anatomical variations in this study were deviated nasal septum in thirty-nine patients (71%), concha bullosa in fifteen patients (27%) and agger nasi cell in twelve patients (22%). Concha bullosa was defined as aeration within the vertical part of the middle turbinate (Figure 1A,1B). This is supported by a study conducted by Kamble, the most common variation is deviated nasal septum (63%)^3,4,5. Anatomical variations often associated with CRS are septum deviation and concha bullosa. Though the role of the deviated nasal septum in the occurrence of CRS is controversial, it is believed that the abnormal position of the nasal septum pushes the middle turbinate laterally causing narrowing of the middle meatus disrupting drainage from the surrounding sinuses^6,7,8. This theory is supported a study by Luo et al. which observed the incidence of CRS was higher on the side of septum deviation that was narrower⁹. In contrast, other studies found there was no significant association between the incidence of CRS and deviated nasal septum. Septum deviation is more associated with the occurrence of nasal congestion complaints moreover if we found the evidence of nasal polyp. Concha bullosa is thought to cause narrowing in the ostiomeatal area thus disrupting airflow and sinus drainage, depending on the size. It is said to increase the risk of CRS, but does not affect the distribution of the affected paranasal sinuses^10,11. The third-most common anatomical variation in the study was the agger nasi cell. Contrariwise, a study in Nepalese population foundhypertrophy agger nasi cell was the most common variation (75.8%) which suggests ethnicity is a contributing factor in anatomical variation. Hypertrophic agger nasi cell has been suggested as one of the causes of frontal sinusitis by impeding the frontonasal drainage pathways¹².

The novelty of this study is the prevalence of sinonasal anatomical variants not previously reported in the Javanese population which demonstrated wide variable differences from other studies. The ethmoid bulla hypertrophy in the study was fewer than those reported by Shretsha et al. (44.8%)¹³. Other anatomical variations found to be lower than other studies wer posterior nasal septal pneumatization and aerated crista gali^12,13. For the anterior fronto ethmoidal cells, supra agger cells were found in ten patients (18%), in contrast to the reported prevalence of 49%, supra agger frontal cell found in two patients (4%) compared to prevalence reported inEuropean population (25%)¹⁴. Other notable differences are the posterior frontoethmoidal cell group consisting of supra bulla cell found in five patients (9%), supra bulla frontal cell found in three patients(4%), and supraorbital ethmoid cell in three patients (4%) lower than other studies^14,15,16.

There are also similarities in the prevalence of the variants with other studies in the case of Haller cells found in four patients (7%). Haller cells are ethmoid cells which pneumatizes inferior to the orbital floor and lateral to a line parallel with the lamina papyracea (FIgure 1C). The cell can grow at the base of the orbit and caused narrowing of the posterior infundibulum ethmoid and the medial part of the superior ostium of the maxillary sinus. When these cells are infected, it can cause inflammation in the maxillary sinuses¹⁴. Paradoxical middle turbinate was found in four patients (7%), corresponding to the study by Shrestha, et al (2019)¹³. Paradoxical middle turbinate is associated with narrowing of infundibulum drainage. The extent and angle of the paradoxical middle turbinate can be an important factor for the occurrence of obstruction, a pathogenesis of CRS¹⁴.

One of the important variant cells in sinus surgery is Onodi cell. Onodi cell is usually seen as a horizontal septum inside the sphenoid sinuseswhen viewed using coronal section of CTPNS. In the presence of Onodi cells, the surgeon must be careful while performing posterior ethmoidectomy to avoid optic nerve injury¹⁴. Onodi cells, ethmomaxillary sinuses and palatine recess were found in one patient (2%) each consistent with the prevalence in other populations. Interestingly, there were no anatomical variations of the deviated uncinate process and retro pneumatization of posterior ethmoid cells in the Javanese population. Nonetheless, their prevalence in other populations have also been reported to be rare^13,15,16,17. The Classification of Keros describes the depth of the olfactory fossa^18,19. Type 3 Keros with a lateral lamella length of 8-16mm is more susceptible to injury during surgery. Based on the Keros classification, type 2 is the most common type found in twenty-six patients (47%).

The limitation of this study includes the selected population of CRS may not represent the general population as a whole. In addition, the limited number of patients from a single center may not reflect the prevalence of the anatomical variants in the Javanese population. Thus, we recommend further studies with larger number of participants involving multiple number of sites to be conducted.

CONCLUSION:

Due to the great variability of anatomical variants of the paranasal sinuses amongst different populations, it is crucial to comprehend their prevalence in each population. Identification of anatomic variations is vital to ensure safe endoscopic surgery and prevent inadvertent complications. Preoperative CT-scan of PNS in CRS patient is helpful to evaluate anatomical variations and surgical plan. Deviated nasal septum, chonca bullosa and agger nasi are the commonest variants found while Type 2 Keros of the nasal roof is the most common in the Javanese population.

ACKNOWLEDGMENTS:

I am especially grateful for Irwan Kristyono, MD, ORL-HNS (C), FICS for his continuous encouragement and kindly advice throughout my study. I am indebted to my other half, Pandu Wicaksono, for the continuous support for my pursuit.

CONFLICT OF INTEREST:

The authors declare that they have no conflicts of interest.

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Received on 06.10.2022 Modified on 08.11.2022

Research J. Pharm. and Tech 2023; 16(8):3701-3704.

DOI: 10.52711/0974-360X.2023.00609