Anatomical variations of the lateral nasal wall: The secondary and accessory middle turbinates

A Crowded Nasal Cavity

A 41-year-old male patient had symptoms of chronic rhinosinusitis lasting several years. Endoscopy revealed edematous mucosa without discrete mass and was followed by a computed tomography scan to assess severity and inform surgical planning. What is your diagnosis?

Investigation of nasal cavity alterations in individuals with neurofibromatosis type 1 using CBCT

OBJECTIVES

This study aimed to investigate nasal septum deviation (NSD), nasal bone length (NBL), and the morphology of the middle nasal conchae (MNC) and inferior nasal conchae (INC), as well as their correlations.

MATERIALS AND METHODS

The sample included 56 cone-beam computed tomography scans divided into two groups: a study group (SG; individuals with NF1; n = 28) and a control group (CG; individuals without NF1; n = 28). NSD, NBL, MNC, and INC classifications were assessed. MNC images were classified as normal, bullous, paradoxical, secondary, and accessory. INC images were classified as normal, lamellar, compact, combined, and bullous. Intra- and interobserver reliability were evaluated.

RESULTS

SG had a mean NSD of 11.6° (±4.5°) compared with 9.6° (±3.2°) for the CG, showing moderate deviations with no significant difference between groups. SG had a mean NBL of 22.4 mm (±3.4 mm) compared with 22.1 mm (±3.2 mm) for the CG, with a statistically significant difference. Both groups exhibited normal, bullosa, and accessory MNC classifications. SG INC were normal, lamellar, and combined, whereas CG INC were normal and lamellar. There was a weak correlation between NSD and NBL across groups.

CONCLUSION

Individuals with NF1 showed longer NBL. The weak correlation between NSD and NBL suggested multifactorial influences on these variations. These findings advance our understanding of craniofacial development in NF1 and highlight the need for further research into nasal cavity involvement in this complex genetic disorder.

Endoscopic appearance of duplicated middle turbinate, case series and literature review

INTRODUCTION AND IMPORTANCE

Duplication of the middle turbinate is an extremely rare condition encountered in rhinology clinic. Knowledge and awareness of the nasal turbinates' variations are important to perform a safe endoscopic surgery and evaluate patients with inflammatory sinus diseases.

CASE PRESENTATION

Case series of two patients who visited rhinology clinic in academic university hospital. Case 1: presented with 6-month history of nasal blockage. Nasal endoscopy revealed bilateral duplication of the middle nasal turbinates. Computed tomography scans showed bilateral medially curved and anteriorly folded uncinate process, and right middle turbinate concha bullosa and its superior end of the middle turbinate was turned medially. Case 2: A 29-year-old gentleman presented with nasal obstruction mainly to the left side for several years. Nasal endoscopy showed bifid right middle turbinate and severe deviated nasal septum to the left. Upon imaging, a sinus computed tomography scan demonstrated a duplication of the right middle turbinates in the form of two middle nasal concha.

CLINICAL DISCUSSION

Different rare anatomical variations can occur at different points during the embryological development. These rare variations include double middle turbinate, accessory middle turbinate, secondary middle turbinate, and bifid inferior turbinate. The appearance of double middle turbinate can be encountered in rhinology clinic only 2 % of the time. Upon reviewing the literature, only few case reports were found regarding the double middle turbinate.

CONCLUSION

A double middle turbinate has important clinical implications. Anatomical variation may lead to narrowing in the middle meatus which makes the patient vulnerable to sinusitis or maybe associated with secondary symptoms. We report rare cases of middle turbinate duplication. Awareness of the nasal turbinates' variations is important for detection and management of inflammatory sinus diseases. Further studies are needed to identify the association of other pathology.

Bilateral accessory middle turbinate presenting as double middle turbinate: A unique case report

Many anatomical variations of the middle turbinate (MT), including pneumatized, paradoxically curved, bifurcate, trifurcate, secondary, and accessory, have been described. The most common is pneumatized MT (concha bullosa), but other less common variations may also impact the outcome of clinical management. Anatomical variations of the MT, particularly with a concomitant deviated nasal septum, tend to obstruct the middle meatus leading to disruption of the normal sinus drainage and worsening the symptoms of rhinosinusitis. By recognizing the unique anatomical variant by endoscopy or imaging will help us to improve the management. We report an endoscopic presentation of a rare accessory MT.

Anatomic Variation for the Endoscopic Endonasal Transsphenoidal Approach

Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.

A study on the association between accessory maxillary ostium and maxillary sinus mucosal thickening using cone beam computed tomography

BACKGROUND

Accessory maxillary ostium (AMO) has a major role to play in the aetiology of maxillary sinusitis. Mucosal thickening is one of the key radiographic features of chronic maxillary sinusitis. The aim of this study was to identify the location of the AMOs and investigate the association between Mucosal Thickening [MT] and AMO using Cone Beam Computed Tomography [CBCT].

METHODS

CBCT scans of 400 maxillary sinuses from the records of 200 patients who seeked various dental treatments at the Thumbay Dental Hospital, Gulf Medical University, Ajman, United Arab Emirates were evaluated. The incidence, anatomical position and maximal length of accessory maxillary ostia (AMO) in the maxillary antrum were reviewed using CBCT by two examiners. The association between MTs and AMOs were also analysed.

RESULTS

Among the 200 CBCT scans, 131 belonged to male patients and 69 scans belonged to female subjects within the age group of 18-65 years (mean age 41.32 years). AMOs were found in 142 maxillary antra (35.5 %). The inter-observer reliability for using CBCT to detect AMO was (k = 0.83). There was no significant difference in the frequency of AMOs when the age (P = 0.19) and gender (P = 0.54) distribution were considered. Sinuses with AMOs, showed significantly greater frequency of MTs (p = 0.001). AMOs with maximal length of less than 1mm were most commonly observed (51.40 %). AMOs with larger greater maximal length were associated with higher degrees of MT. The location of the AMOs, were not affected by the degree of MT.

CONCLUSIONS

The study demonstrates a clear association between degree of MT and occurrence of AMO in the maxillary sinus. However, the location of the AMO is independent of the degree of the MT. There is a greater probability of finding an AMO in the maxillary sinus if the MT in the sinus is more than 3 mm.

Radiological middle turbinate variations and their relation to nasal septum deviation in asymptomatic adult

Background

Middle turbinate (MT) is one of the important anatomical and physiological structures of the nasal cavity. After the widespread use of nasal endoscope and paranasal sinus computed tomography (CT), many MT variations have been described. This study aimed to determine the incidence of MT variations by computed tomography (CT) in asymptomatic adult, their relation to each other, and to deviated septum (DS).

Results

In the included 86 subjects (172 MTs), pneumatized MT was the most common MT variation followed by paradoxical MT (PMT). Septal deviation did not appear to affect occurrence of pneumatized or PMT. Fifty-nine percent of the reported bilateral PMT were associated with pneumatized MT, while 35.7% of unilateral PMT were associated with pneumatized MT with non-significant difference.

Conclusion

MT variations in adults are common mainly pneumatized MT then PMT with no apparent relation to septum deviation.

The pterygopalatine recess of the superior nasal meatus

The pneumatizations surrounding the pterygopalatine fossa (PPF) and closely related to the sphenopalatine foramen are anatomically variable. During the assessment of a cone beam computed tomography of a 64-year-old male patient, we found bilaterally a previously unreported anatomic variant. This was represented by a lateral or pterygopalatine recess (PPR) of the superior nasal meatus which extended in the anterior wall of the PPF and protruded within the maxillary sinus to determine a maxillary bulla. The PPR was antero-superior to the sphenopalatine foramen. Additionally were found a right nasal septal deviation, seemingly compensated by a left middle concha bullosa and a left prominent ethmoidal bulla. The superior turbinates were also pneumatized. Such anatomic variants related to the pterygopalatine angle of the maxillary sinus should be explored prior to surgical or endoscopic procedures which target the maxillary sinus, the pterygopalatine fossa, or the skull base.

Normal Anatomy and Anatomic Variants of the Paranasal Sinuses on Computed Tomography

It is imperative for all imaging specialists to be familiar with detailed multiplanar CT anatomy of the paranasal sinuses and adjacent structures. This article reviews the radiologically relevant embryology of this complex region and discusses the region-specific CT anatomy of the paranasal sinuses and surrounding structures. Radiologists also need to know the clinical implications of identifying preoperatively the numerous anatomic variations encountered in this region and prepare a structured report according to the expectations of the referring clinician.

Anomalous middle turbinate with choanal obstruction and maxillary sinusitis: a case report

Introduction

Although several anatomical anomalies in the middle turbinate have been reported, they usually remain asymptomatic. However, complicated aberrant middle turbinate extending through the choana to the contralateral nasopharynx has not been reported.

Case presentation

A 23-year-old Korean woman presented with a 6-month history of nasal obstruction and postnasal discharge refractory to medical treatment. An endoscopic examination revealed an abnormal middle turbinate, and a pedunculated nasal mass covered with normal mucosa that originated from the right lateral nasal wall filled most of the right posterior choana and extended to the left nasopharynx across the posterior free edge of the nasal septum. Computed tomography of the paranasal sinus showed abnormal bony trabeculation from the posterior bony attachment of the right middle turbinate to the left posterior nasopharyngeal wall. In addition, right maxillary sinusitis was observed. From these findings, the lesion was suspected to be an abnormal configuration of the right middle turbinate with secondary maxillary sinusitis and was successfully treated by resection of the malformed middle turbinate and middle meatal antrostomy.

Conclusions

Although this case illustrates a very rare developmental anomaly of the middle turbinate, thorough knowledge of the development of and anatomical anomalies associated with the middle turbinate is of utmost importance to perform proper sinus surgery and avoid complications. Therefore, these findings should be considered by otolaryngologists, and careful examination of the nasal cavity is necessary to determine the existence of this rare anomaly.

Concha nasal média secundária: relato de caso

A concha nasal média secundária é uma rara variação anatômica na cavidade nasal, descrita pela primeira vez por Khanobthamchai et al. como uma estrutura óssea revestida por partes moles originária da parede lateral do meato médio. Na maioria dos casos relatados na literatura ocorre bilateralmente, sem complicações associadas. Neste artigo descrevemos um caso encontrado em nosso serviço, com tal variação anatômica incomum.