Gender differences in ethmoid sinus morphology_ 3D reconstruction of computed tomographic images.

BACKGROUND: The ethmoid sinus (ES) is a three-dimensional (3D) complex structure, a clear understanding of the ES anatomy is helpful to plan intranasal surgery. However, most prior studies use 2D measurements, which may not accurately depict the 3D structure. The current study measured the gender differences in ES morphology based on 3D reconstruction of computed tomography (CT) images. METHODS: The 3D models were reconstructed using CT images. Twenty-one males and 15 females were enrolled in the study. The ES dimensions, including width, height and aspect ratio (AR) of each cutting-plane section, were measured at 10% increments along with the anteroposterior axis of the ES. The gender differences in the above parameters were further evaluated by an independent t-test. RESULTS: The width of the ES for males is 12.0 ± 2.1 mm, which was significantly greater than that in females (10.0 ± 2.1 mm). The average height for males is 18.4 ± 3.5 mm, and 18.2 ± 3.4 mm for females. The AR of female (male) is around 0.56 (0.63) for the anterior ES and 0.66 (0.75) for the posterior. There are significant differences between genders in the parameters of width and AR (p < 0.05). CONCLUSION: This study found that the aspect ratio greatly varies along the length of ES, indicating that the cross-section of the ES in the anterior is closer to an elliptical shape and turns closer to a circular shape near its posterior. There is a significant difference between genders in width and aspect ratio. The results would be helpful to know the complex anatomic details of the ethmoid sinus.

Endoscopic repair of nasal septal perforation with anterior ethmoidal artery flap using tunnel technique.

PURPOSE: Septal perforations (SPs) present a distinct challenge. There are many described surgical approaches with variable success rates. The goal of this study is to describe a new technique in repairing SP. METHODS: A case series of eighteen patients with anterior septal perforation who underwent endoscopic repair with the "tunnel technique" based on anterior ethmoid artery flap (AEA) were analyzed. Demographic data, etiology, size of perforation, and success rate were collected. RESULTS: Eighteen cases with male predominance (67%) were enrolled from 2019 to 2022. The average perforation size was 1.5 cm (0.5- 3.6 cm). The success rate of complete SP closure was 94% (n = 17/18) with no complications after surgery. The patients were followed up for 7 ± 5.2 months. CONCLUSIONS: AEA flap reconstruction with the tunnel technique is associated with favorable outcomes in SP closure. The tunnel technique provides a useful flap bolster and minimizes the use of other supportive measures. This technique offers an addition to other techniques for septal perforation repair. LEVEL OF EVIDENCE: Level 4.

Relation between anterior ethmoidal artery course on computed tomography and supraorbital ethmoid cell and Keros classification.

PURPOSE: The anterior ethmoidal artery (AEA) is an important risk area in endoscopic sinus surgery. This study aimed to evaluate the course of AEA according to the Keros classification and the presence of supraorbital ethmoid cell (SOEC) and to prevent possible complications by emphasizing the importance of preoperative paranasal computed tomography (CT) imaging. This approach will increase the effectiveness of endoscopic sinus surgery and improve patient safety. METHODS: The paranasal CT scan images of patients aged > 18 years between October 2020 and November 2021 from our center were retrospectively analyzed. The images were primarily evaluated in the coronal plane, and the sagittal and axial planes were utilized to evaluate variations in AEA regarding the skull base. Furthermore, the relation of AEA course with Keros classification and SOEC was evaluated. The study included 1000 patients aged 18-80 years (right and left, a total of 2000 samples). RESULTS: Grade 3 AEA was the most common regarding the skull base. Keros Type 2 was the most common classification. Overall, 48.7% patients had SOEC. The incidence of Grade 3 AEA was higher among patients with SOEC and a higher Keros classification compared with those without SOEC and a lower Keros classification. Furthermore, Keros Type 3 was the most associated with SOEC presence. CONCLUSION: Consistent with the literature, the probability of Grade 3 AEA in patients with high Keros classification and SOEC was significantly higher in our study. Therefore, we consider that preoperative imaging according to Keros classification and SOEC presence can predict AEA course and guide surgery.

An eosinophil peroxidase activity assay accurately predicts eosinophilic chronic rhinosinusitis.

BACKGROUND: A definitive diagnosis of eosinophilic chronic rhinosinusitis (eCRS) requires invasive surgical tissue sampling and histologic enumeration of intact eosinophils. Eosinophil peroxidase (EPX) is an accurate biomarker of sinonasal tissue eosinophilia in CRS regardless of polyp status. A less invasive and rapid method that accurately identifies tissue eosinophilia would be of great benefit to patients. OBJECTIVE: We sought to evaluate a new clinical tool that uses a nasal swab and colorimetric EPX activity assay to predict a diagnosis of eCRS. METHODS: A prospective, observational cohort study was conducted using nasal swabs and sinonasal tissue biopsies obtained from patients with CRS electing endoscopic sinus surgery. Patients were classified as non-eCRS (n = 19) and eCRS (n = 35) on the basis of pathologically determined eosinophil counts of less than 10 or greater than or equal to 10 eosinophils/HPF, respectively. Swab-deposited EPX activity was measured and compared with tissue eosinophil counts, EPX levels, and CRS-specific disease metrics. RESULTS: EPX activity was significantly increased in patients with eCRS than in patients without eCRS (P < .0001). With a relative absorbance unit cutoff value of greater than or equal to 0.80, the assay demonstrated high sensitivity (85.7%) and moderate specificity (79.0%) for confirming eCRS. Spearman correlations between EPX activity and tissue eosinophil counts (rs = 0.424), EPX levels (rs = 0.503), and Lund-Kennedy endoscopy scores (rs = 0.440) in eCRS were significant (P < .05). CONCLUSIONS: This investigation evaluates a nasal swab sampling method and EPX activity assay that accurately confirms eCRS. This method could potentially address the unmet need to identify sinonasal tissue eosinophilia at the point-of-care, as well as to longitudinally monitor eosinophil activity and treatment response.

A Safe Technique for Excising the Perpendicular Plate of the Ethmoid Bone in Patients with Crooked Nose: A Finite Element Analysis.

BACKGROUND: Correction of the crooked nose, especially the perpendicular plate of the ethmoid bone, has the potential to cause skull base injury. At present, the safe and effective method for perpendicular plate resection has not been clearly defined through biomechanics. METHOD: CT scan data of 48 patients with crooked nose and deviated nasal septum were divided into C-type, angular deformity-type, and S-type based on the morphology of the 3D model. Different types of finite element models of the nasal bony septum and skull base were established. The osteotomy depth, angle, and force mode of the PPE resection were simulated by assembling different working conditions for the models. The von Mises stress of the anterior cranial fossa was observed. RESULTS: When the osteotomy line length was 0.5 cm, the angle was at 30° to the Frankfurt plane, and 50 N·mm torque was applied, the von Mises stress of the skull base was minimal in the four models, showing 0.049 MPa (C-type), 0.082 MPa (S-type), 0.128 MPa (angular deformity-type), and 0.021 MPa (control model). The maximum von Mises stress values were found at the skull base when the osteotomy line was 1.5 cm, the angle was 50°, and the force was 10 N along the X-axis, showing 0.349 MPa (C-type), 0.698 MPa (S-type), 0.451 MPa (angular deformity-type), and 0.149 MPa (control model). CONCLUSION: The use of smaller resection angle with the Frankfurt plane, conservative resection depth, and torsion force can better reduce the stress value at the skull base and reduce the risk of basicranial fracture. It is a safe and effective technique for perpendicular plate resection of the ethmoid bone in the correction of crooked nose. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Double Reinforcing Strategy with Perpendicular Plate of Ethmoid in Asian Secondary Unilateral Cleft Rhinoplasty: A Finite Element Analysis.

BACKGROUND: Deviation and asymmetry relapse after secondary unilateral cleft rhinoplasty with septal extension graft is a common yet serious problem especially among Asian patients. Therefore, finding an effective approach to reduce deformity relapse remains a great challenge to plastic surgeons. METHODS: In this study, authors established finite element models to simulate different nasal cartilage-corrected options and different reinforcing strategies in secondary unilateral cleft rhinoplasty. A load of 0.01N was given to the nasal tip to simulate the soft tissue pressure, while two loads of 0.5N were separately given to the anterior and posterior part of the septal extension graft to simulate the rhinoplasty condition. Maximum deformations were evaluated to make stability judgments. RESULTS: The maximum deformation of different cartilage correction models in ascending order was: UCL deformity with septum correction, normal nasal cartilage, UCL nasal deformity, and UCL nasal deformity with lower lateral cartilage correction. When applied L-strut reinforcement graft was harvested from the perpendicular plate of the ethmoid bone, the maximum deformation of the models decreased significantly, and strong fixation of the septum could further enhance this decreasing effect. CONCLUSIONS: Correcting the septum and lower lateral cartilage together could improve the structural stability and symmetry in secondary unilateral cleft rhinoplasty. To keep the corrected septum stable and thus reduce deformity relapse, reinforcing the L-strut with perpendicular plate of ethmoid graft while strongly anchoring the septal cartilage to the anterior nasal spine was proved to be effective in both finite element analysis and clinical observation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Analysis of sphenoid sinus and ethmoid sinus volume and asymmetry by sex: A 3D-CT study.

PURPOSE: To measure the volume of the sphenoid and ethmoid sinuses and to analyse the asymmetry index values by age/gender. METHODS: Three-dimensional (3D) Computed Tomography (CT) images of 150 individuals (75 females, 75 males) of both sexes between the ages of 18-75 were included in our study. Sphenoid and ethmoid sinus volumes were measured using the 3D Slicer software package on these images, and the asymmetry index was calculated. RESULTS: In our study, mean sphenoid sinus volume (female right: 4264.4 mm3, left: 3787.1 mm3; male right: 5201.1 mm3, left: 4818.2 mm3) and ethmoid sinus volume (female right: 3365.1 mm3, left: 3321.2 mm3; male right: 3440.9 mm3, left: 3459.5 mm3) were measured in males and females. Left sphenoid sinus values of males were statistically higher than females (p = 0.036). No statistically significant relationship existed between age, sinus volumes, and asymmetry index (p > 0.05). A statistically weak positive correlation existed between males' left sphenoid and ethmoid sinus volume (rho = 0.288; p = 0.012). There was no statistical relationship between asymmetry index in the whole group (p > 0.05). A statistically weak negative correlation was found between sphenoid and ethmoid sinus asymmetry index in males (rho=-0.352; p = 0.002). There was no statistical relationship between asymmetry index in females (p > 0.05). CONCLUSION: Knowing paranasal sinus morphology, morphometry, and asymmetry index value will be significant for preoperative and postoperative periods.

Cancer of the Nasal Cavity, Middle Ear and Accessory Sinuses - 15 Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period, Disease Duration and Topographic Primary Sites: A Systematic Review of 13,404 Cases for Diagnosis Years 2000-2017: (NCI SEER*Stat 8.3.8).

BACKGROUND: .-Sinonasal malignancies are rare, aggressive, deadly and challenging tumors to diagnose and treat. Since 2000, age-adjusted incidence rates average less than 1 case per 100,000 per year, male and female combined, in the United States. For the entire cohort, 2000-2017, overall median age-onset was 62.6 years. Carcinoma constitutes over 90% of these upper respiratory cancers and most cases are advanced, more than 72% (regional or distant stage) when the diagnosis is made. Composite mortality at 5 years was 108 excess deaths/1000/year with a mortality ratio of 558%, and 41% of deaths occurred in this time frame. As a consequence, observed median survival was approximately 6 years with 5-year cumulative observed survival (P) and relative survival rates (SR) 53% and 60%. This mortality and survival update study follows the World Health Organization International Classification of Diseases for Oncology-3rd Edition (ICD-O-3)1 topographical identification, coding, labeling and listing of 13,404 patient-cases accessible for analysis in the United States National Cancer Institute's Surveillance, Epidemiology and End Results program (NCI SEER Research Data, 18 Registries), 2000-2017 located in 8 primary anatomical sites: C30.0-Nasal cavity, C30.1-Middle ear, C31.0-Maxillary sinus, C31.1-Ethmoid sinus, C31.2-Frontal sinus, C31.3-Sphenoid sinus, C31.8-Overlapping lesion of accessory sinuses, C31.9-Accessory sinus, NOS. OBJECTIVES: .-1) Utilize national population-based SEER registry data for 2000-2017 to update cancer survival and mortality outcomes for 8 ICD-O-3 topographically coded sinonasal primary sites. 2) Discern similarities and contrasts in NCI-SEER case characteristics. 3) Identify current risk pattern outcomes and shifts in United States citizens, 2000-2017. METHODS: .-SEER Research Data, 18 Registries, Nov 2019 Sub (2000-2017)2,3 are used to examine the risk consequences of 13,404 patients diagnosed with sinonasal malignancies, 2000-2017, in this retrospective population-based study employing prognostic data stratified by topography, age, sex, race, stage, grade, 2 cohort entry time-periods (2000-06 & 2007-17), and disease-duration to 15 years. General methods and standard double decrement life table methodologies for displaying and converting SEER site-specific annual survival and mortality data to aggregate average annual data units in durational intervals of 0-1, 0-2, 1-2, 2-5, 0-5, 5-10, and 10-15 years are employed. The reader is referred to the "Registrar Staging Assistant (SEER*RSA)" for local-regional-distant Extent of Disease (EOD) sources used in the development of staging descriptions for the Nasal Cavity and Paranasal Sinuses (maxillary and ethmoid sinuses only) and Summary Stage 2018 Coding Manual v2.0 released September 1, 2020. Cancer staging & grading procedural explanations, statistical significance & 95% confidence levels4 are described in previous Journal of Insurance Medicine articles5,6 and other publications.7,8 Poisson confidence intervals at the 95% level based on the number of observed deaths are used in this study but not displayed here to conserve space on the mortality tables. Excluded were all death certificate only and those alive with no survival time. RESULTS: .-In the SEER 18 registries, a total of 13,404 patient cases (2000-2017) were available for analysis with an incidence of less than one patient per 100,000 people. From this group, analysis for survival and mortality totaled 10,624 patients. Males comprised 59.3% of cases and females 40.7%. Whites represented 80.3% of cases and black, others & unknown patients comprised 19.7%. The most common anatomic site of malignancy was the nasal cavity (49.7%); least common was the frontal sinus (1.2%). From diagnosis, across the span of 8 primary sites, first-year mortality rates q ranged from 14.3% (C30.0-nasal cavity) to 30.2% (C31.8-overlapping sinus) with corresponding excess death rates (EDR) of 118/1000/year and 279/1000/year. For single sites, the 5-year cumulative survival ratio (SR) was highest for the nasal cavity (69.5%) and lowest for overlapping lesions of the accessory sinuses (47.2%) with EDRs of 76 and 169 per 1000 per year respectively Overall, 5-year relative survival (SR) for all sinonasal tract malignancies combined was 60.3%, excess mortality (EDR) 108 per 1000 per year and mortality ratio 558%. CONCLUSIONS: .-The 8 sinonasal cancer primary sites are characterized by a low percentage of cases in the localized stage (28%). Since excess mortality is high even in the localized stage, overall prognosis is very poor for all patients. Excess mortality persists in cancer of the sinonasal tract as long as 10-15 years after diagnosis and treatment. EDR in the 15-year durational-interval, all sinonasal sites combined remained significant at 27.6 per 1000 per year with continuing decrease in cumulative survival ratio (SR) to 43.9%.

Strategies of vascularization of the ethmoid labyrinth in selected even-toed ungulates (Artiodactyla) and carnivores (Carnivora).

The anatomy of the nasal cavity and its structures, as well as other elements building a scaffold for olfactory organs, differs significantly among various groups of mammals. Understanding anatomical conditions of quality of olfaction are being studied worldwide and is a complex problem. Among many studies regarding bone and epithelial structures of turbinates and connected anatomical structures, few studies describe the vascularization of turbinates. Ethmoid turbinates are above all covered in olfactory epithelium containing branched axons that receive olfactory stimuli and as olfactory nerves penetrate the cribriform lamina of the ethmoid bone conveying information from smell receptors to the brain. Differences in vascularization of the cribriform plate and turbinates may add crucial information complementing studies regarding the olfactory organ's bone and soft tissue structures. In the study, we describe the vascularization of the cribriform plate of the ethmoid bone of 54 Artiodactyla and Carnivora.

Compressive optic neuropathy due to posterior ethmoid mucocele.

Mucoceles are cystic formations characterized by the presence of mucus-secreting epithelial cells, which enlarge when the excretory duct becomes obstructed. Posterior ethmoidal mucoceles are rare conditions that can lead to severe ocular complications requiring immediate intervention. The close anatomical proximity of posterior ethmoidal mucoceles to the optic nerve underscores their significance. In this case report, we present a case of rapidly progressing compressive optic neuropathy secondary to a posterior ethmoidal mucocele. A previously healthy forty-six-year-old woman presented with sudden visual loss in her left eye, preceded by left-sided headache and periorbital pain. Clinical examination and imaging studies revealed an oval-shaped mass within the posterior ethmoid cell compressing the left optic nerve. Emergency surgery was performed to alleviate optic nerve compression, which successfully relieved periocular pain. However, the patient's visual acuity and visual field defect remained unchanged postoperatively. Thinning of the ganglion cell layer in the macula region was observed during follow-up examinations. The role of corticosteroids and antibiotics in visual rehabilitation and the impact of delayed surgical decompression on visual outcome remain subjects of debate. Additional cases of mucocele-associated optic neuropathy should be published and analyzed to establish optimal treatment approaches.

Anterior ethmoid and frontal sinus drainage pathways: five patterns formed and defined by their bony walls.

PURPOSE: To perform endoscopic sinus surgery safely and effectively, surgeons need to visualize the complex anatomy of the anterior ethmoid and frontal sinus region. Because this anatomy is so variable and individualized, the foundation of understanding lies in identifying, following, and visualizing the drainage pathway patterns and anticipating possible variations. METHODS: We studied 100 sides (50 cases: 22 male, 28 female, aged 12-86, average age 46.5 years, ± 19.5) using computed tomography (CT) and multiplanar reconstruction (MPR) to identify and classify the drainage pathways leading to the frontal sinus and anterior ethmoidal cells. RESULTS: Analysis revealed five patterns of drainage pathways defined by their bony walls: between the uncinate process and the lamina papyracea [UP-LP]; between the uncinate process and the middle turbinate [UP-MT]; between the uncinate process and the accessory uncinate process [UP-UPa]; between the uncinate process and the basal lamella of the ethmoidal bulla [UP-BLEB]; and between the basal lamella of the ethmoidal bulla and the basal lamella of the middle turbinate [BLEB-BLMT]. In most cases, BLEB formed the posterior wall of the drainage pathway of the frontal sinus, indicating BLEB could be one of the most important landmarks for approaching the frontal sinus. CONCLUSIONS: As endoscopic sinus surgery depends on an understanding of this anatomy, this study may help surgeons to identify and follow the drainage pathways more accurately and safely through the anterior ethmoid to the frontal sinus.

Sinonasal undifferentiated carcinoma with metastasis to the extradural spine.

Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive cancer of the sinonasal tract and is often characterized by intracranial invasion. However, SNUC rarely metastasizes to the spine. In this paper, we present a case of extradural metastasis and invasion of the adjacent spine by SNUC. A 42-year-old man presented to our hospital with two-month history of anosmia and nosebleeds. Imaging studies showed a neoplasm of the ethmoid sinus with extension into the anterior cranial fossa. The patient underwent resection of the carcinoma and began chemoradiotherapy. After completing chemoradiotherapy the patient complained of neck pain radiating down the right arm, and imaging showed an extradural mass at the C5 vertebral level. The patient underwent laminectomy for debulking of this tumor. One month later, the patient complained of recurrent weakness and pain in the right shoulder and arm. Imaging showed an extradural tumor wrapping around the C7 and C8 nerve roots, as well as a separate tumor at C2 adherent to the dura. The extradural tumor at C2 was surgically resected. Further imaging showed multiple new soft tissue masses at the thoracic level. We present a case of SNUC metastasis to the extradural spine representing the second case reported in the literature. Peri-dural metastasis and resulting symptoms should be included in the differential diagnosis and assessment of patients with SNUC.

Anatomic misconceptions regarding the agger nasi cell: A preliminary analysis utilizing endoscopic anatomic dissection and three-dimensional computed tomography.

The agger nasi cell is a key anatomic landmark in endoscopic frontal sinus surgery. However, discord amongst authors regarding anatomic definition and prevalence raises questions of its suitability as a surgical landmark. The purpose of this investigation is to evaluate the agger nasi cell using radiographic imaging correlated with endoscopic anatomic dissection to consider the cell's role as a surgical landmark and to explore if three-dimensional computed tomography (3D-CT) technology can provide enhanced insight into this anatomy. CT scans of 11 cadaveric sinonasal complexes were studied using triplanar CT or 3D-CT scanning with stereoscopic 3D imaging. Endoscopic dissections were performed and video recorded. Attention was given to identify agger nasi pneumatization and its origin. Pneumatization of the agger nasi region was noted in 4/11 cases (36.4%) (in two cases the pneumatization arose from the frontal recess, in two from a true agger nasi cell). The agger nasi region appeared as solid unpneumatized bone in 4/11 cases (36.4%). In 3/11 cases (27.3%) limited pneumatization was noted, bordering on but not pneumatizing the agger nasi proper. It may be confusing for otolaryngologic surgeons in training to rely on the "agger nasi cell" as a surgical landmark due to misconceptions regarding the anatomy, prevalence and anatomic definitions. Using standard CT scans to teach anatomy may have shortcomings as compared to the gold standard of surgical dissection. However, new 3D-CT holds promise to more accurately reflect small microanatomic features and provide an improved road map of a patient's anatomy in surgery.

Trans-superior meatal surgery: A targeted approach for isolated posterior ethmoid diseases.

BACKGROUND: Surgical treatment for posterior ethmoid diseases has historically been performed through a trans-ethmoid approach which usually required medialization of the middle turbinate, a middle meatal antrostomy and total ethmoidectomy. This can destabilize the basal lamella of the middle turbinate and also sacrifices the integrity of ostiomeatal complex and the healthy bulla if the patient has the disease only in the posterior ethmoid sinus. The aim of this study is to present of a novel minimally disruptive approach for the management of isolated posterior ethmoid diseases. METHODS: Retrospective case series analysis. RESULTS: 19 patients with isolated posterior ethmoid fungal balls were operated on via a trans-superior meatal approach. The most common signs and symptoms were headache (78.9%), and purulent/mucoid discharge from the superior meatus (89.5%). The technique is described in detail with the preservation of the ostiomeatal complex and bulla ethmoidalis. Complete removal of the disease was achieved in all cases through this access, with no intra-operative complications. The posterior ethmoid cavity remained patent postoperatively in all patients. No recurrence was noted during the follow-up period which ranged from 6 to 12 months. CONCLUSION: This is a minimally invasive approach, which is safe and effective for the surgical management of isolated posterior ethmoid diseases.

Recurrent epistaxis due to cribriform plate dural arteriovenous fistula: are they related? Should the treatment be from venous, pial or arterial side?

PURPOSE: Dural arteriovenous fistula (DAVF) of the anterior cranial fossa with cortical venous reflux is an aggressive neurovascular entity with a high rate of intracranial bleeding. Only two cases of anterior cranial fossa DAVF presenting with epistaxis alone have been reported. Endovascular approaches have emerged as the primary and safer treatment modality for most DAVFs. Certain fistulas are better treated with open surgical approaches and disconnection. CASE DESCRIPTION: A 55 years old male presented with the history of multiple episodes of severe epistaxis. Cerebral angiography revealed an anterior cranial fossa DAVF of the cribriform plate with cortical venous reflux and a venous varix. The patient was successfully managed with a bifrontal craniotomy and disconnection from the arterial side. CONCLUSION: Atypical or severe epistaxis may arise from a DAVF. Surgical arterial disconnection my be a curative treatment option.

Computed Tomography Analysis of the Anterosuperior Portion of the Bulla Lamella in Chinese Subjects and Its Surgical Significance in Endoscopic Frontal Sinusotomy.

INTRODUCTION: The anterosuperior portion of the bulla lamella can extend into the frontal sinus and form the supra bulla frontal cell (SBFC) and supraorbital ethmoid cell (SOEC). This can affect the frontal drainage pathway and make surgery more challenging. OBJECTIVES: The aim of the study was to compare the anatomical characteristics of SBFC and SOEC in Chinese chronic rhinosinusitis (CRS) patients and explore the relationship between the cells and frontal sinusitis (FS). The surgical skills in dealing with these cells were also studied. METHODS: We prospectively identified SBFC and SOEC in 114 patients with CRS by computed tomography (CT). The sides of the patients were divided into groups A (with FS) and B (without FS). CT scans were analyzed to distinguish the SBFC, SOEC, and the drainage pathway. Statistical analysis was conducted to determine whether the cells were associated with the occurrence of FS. RESULTS: The prevalence of frontal cells was as follows: SBFC: 9.65%, SOEC: 21.93%. There was an association between the presence of SBFC and FS (p < 0.05). The anterior drainage pathway was present in patients with SBFC and SOEC, anterolateral pathway in those with SBFC/SOEC coexisting with the frontal septal cell, and anteromedial pathway in those with SBFC/SOEC coexisting with the supra agger frontal cell. CONCLUSIONS: There was an association between the presence of SBFC and the occurrence of FS. Extension of the anterosuperior portion of the bulla lamella into the frontal sinus obstructed the drainage pathway posteriorly. Understanding the anatomy may help surgeons thoroughly dissect the bulla lamella.

Pediatric paranasal sinuses-Development, growth, pathology, & functional endoscopic sinus surgery.

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid sinuses) are complex anatomical structures. The development and growth of these have been investigated utilizing a number of different methods ranging from cadaveric analysis to modern cross sectional imaging with 3D modeling. An understanding of normal pediatric paranasal sinus embryology and development enables us to better determine when pathology may be affecting the normal developmental process. Cystic fibrosis, chronic sinusitis, deviated nasal septum and cleft lip and palate are some of the conditions which have been shown to effect paranasal sinus development to varying degrees. Functional endoscopic sinus surgery (FESS) is becoming increasingly common and an understanding of sinus anatomy together with when periods of rapid growth occur during childhood is important clinically. Although concerns have been raised regarding the impact of FESS on facial growth, there is limited evidence of this in regards to either changes in anthropomorphic measurements or clinical assessments of symmetry post operatively.

Anosmia following middle nasal concha resection: An anatomic and developmental review with clinical correlation.

Losing the sense of smell can be associated with a significant decrease in quality of life. Fortunately, this occurs infrequently with modern paranasal sinus surgery that has stressed minimally invasive, tissue-sparing principles. However, over time, more extensive surgical applications have emerged that incorporate increased tissue removal. Post-operative period sequelae can occur, including anosmia. Understanding the potential implications of expanded tissue removal, such as middle nasal concha (turbinate) resection, is clinically important and is facilitated by an understanding of anatomy. Our understanding of anatomic nuances is enhanced through an appreciation of embryonic and fetal development. We herein review the developmental anatomy of the middle nasal concha of the ethmoid sinus and olfactory nerve area as it relates to middle nasal concha removal during endoscopic sinus surgery. We present images from our analysis of 12 embryonic and fetal specimens that highlight the important relationship between the middle nasal concha and olfactory nerves. We also review the clinical issues surrounding turbinate preservation versus resection and present a clinical correlation to underscore the uncommon but significant complication of anosmia following sinus surgery with middle nasal concha resection. We highlight knowledge gaps, discuss case selection and review surgical technique modifications for middle nasal concha surgery to reduce the chance of this complication in the future.

Ethmoid roof morphometric measurements of a pediatric population using computed tomography.

OBJECTIVE: To reveal the anatomical relationships of the ethmoid roof on CT in pediatric case group. METHODS: We measured the depth of olfactory fossa (DOF), the width of olfactory fossa (WOF), the angle between lateral lamella and cribriform plate (LLCPA), the width of the olfactory cleft (WOC), the length of lateral lamella (LLL), orbital roof fovea to ethmoidal distance (ORFED) and orbital roof to cribriform plate distance (ORCPD) and we determined Keros and LLCPA types from paranasal sinus CT of subjects under 16 years of age retrospectively. RESULTS: The incidence of Keros type I was higher in females and Keros Type II in males. The ORCPD, DOF and LLL values were found to be higher in 13-16 years age group and WOF and LLCPA in 4-6 years age group. The prevalence of Keros type II was higher in the 13-16 age group, and Keros type I was higher in other age groups. LLCPA type A was the most frequent in all age groups and in both sexes. There was a positive correlation between age and ORCPD, DOF, LLL, and a negative correlation with ORFED, WOF, LLCPA. Olfactory fossa width and depth had a negative correlation. LLCPA had a positive correlation with WOF and a negative correlation with DOF. There was a positive correlation between LLCPA and LLL. DOF and LLL had a positive correlation too. CONCLUSIONS: Paranasal sinus CT provides useful information about frontal skull base anatomic relations before sinus surgery in pediatric cases.

Highly Aggressive Osteosarcoma of the Ethmoids and Maxillary Sinus-A Case of Successful Surgery and Proton Beam Radiotherapy in a 65-Year-Old Man.

Sarcomas in the head and neck area are rare diseases with an incidence of under 1% of all head and neck malignant tumours. Osteosarcomas or osteogenic sarcomas consist of neoplastic cells that produce osteoid bone or immature bone. Sarcomas develop more in the mandible than the maxilla. The exact diagnosis of different types of sarcomas is based on the immunohistochemical investigation. These rare tumours are of mesenchymal origin; osteosarcomas and chondrosarcomas are the most common types-Ewing's sarcomas. The use of proton beam radiotherapy in the treatment of osteosarcoma of the maxilla is rarely reported in the literature. We present a case of successfully treated (surgery and proton beam radiotherapy) poorly differentiated highly aggressive osteosarcoma in the ethmoids and maxillary sinus and morbidity after the treatment. We were presented with a case of a 65-year-old man with anaesthesia and palsy of the right face. The stomatology department performed the extraction of a tooth. One month later, the wound was still open. The histology showed an osteogenic sarcoma in the area of the wound. The oncologist and maxillofacial surgeons in a catchment hospital recommended a nonsurgical approach. Hence, we performed a radical maxillectomy and ethmoidectomy, after which we continued with proton bean radiotherapy. The patient is now five years after therapy without signs of sarcoma; however, he has blindness in the right eye and reduced vision in the left eye, as well as gliosis of the brain, vertigo, tinnitus, trismus, and ancylostomiases. Head and neck osteosarcomas treatment is considered a complex multidisciplinary task. It is currently argued that there is no clear therapeutic protocol for successful treatment. Innovations in treatment modalities such as proton beam radiotherapy appear to have potential, although their effects on long-term morbidity and survival outcomes are still undetermined. We present a rare case report of an osteosarcoma of the maxilla involving an innovative, successful treatment procedure combining surgical excision followed by proton beam radiotherapy. This treatment approach may enable maximum tumour control. This protocol has not been adequately described in the world literature for this diagnosis.