Vertical and sagittal combinations of concha bullosa media and paradoxical middle turbinate

Giant concha bullosa presented as left nasal mass: a case report and literature review

Concha bullosa (CB) is not considered to be a disease, but rather a variation of the paranasal sinus. A CB is defined as the presence of an air cell within the turbinate (pneumatization). The main function of CB is to maintain upper respiratory humidity, regulate thermoregulation, and regulate airflow and filtration. It is common for CB to occur in the middle turbinate, while superior and inferior locations appear to be rare. The patient in this case report was presented mainly with nasal obstruction. During examination, a large mass was found in the left nasal cavity, causing a deviated nasal septum to the right. For this patient, surgery was the last resort. Either perioperative or postoperative complications were observed, and the quality of life of patients improved after surgery.

Anatomical Changes in a Case with Asymmetrical Bilateral Maxillary Sinus Hypoplasia

Background and Objectives: The maxillary sinus hypoplasia (MSH) is an occasional variation of the maxilla, occurring either unilaterally or bilaterally. Previous studies dealing with MSH have not detailed the consequent anatomical changes of the maxilla and adjacent fossae. Materials and Methods: A 58-year-old female case was scanned in Cone Beam Computed Tomography and found to have asymmetrical bilateral MSH, who was then further evaluated anatomically. Results: The maxillary sinuses were hypoplastic and had mild mucosal thickenings. The orbital floors were curved. The uncinate process and the ethmoidal infundibulum were laterally displaced beneath the orbit floor. On each side, the lateral nasal wall protruded within the respective maxillary bone to reach above the vestibular cortical plate of the alveolar process. This expansion of the lateral nasal walls was limited to the premolar and first molar regions. The inferior turbinates were laterally curved. The perpendicular palatine plate was building a postero-lateral nasal wall in front of the pterygopalatine fossa. Conclusions: The classification systems of MSH should be detailed to indicate whether the normal uncinate process is medial or inferior to the orbit. The lateral expansion of the lateral nasal wall in MSH is limited to the anterior part of that wall. The laterally expanded nasal fossa could reach anterior to the pterygopalatine fossa in MSH. Seemingly, CBCT is a better tool than CT to evaluate the detailed anatomy of the modified anatomical structures in MSH; as such, it could be of help in a surgical approach.

Patterns of Pneumatization of the Posterior Nasal Roof

(1) Background: For good surgical performance, sound knowledge of anatomy is required. Although the ethmoid air cells and sphenoid sinuses are subject to a high degree of variation, their possible extensions above the nasal fossa at the posterior end of the cribriform plate of the ethmoid bone (CPEB) were seemingly overlooked. (2) Methods: We retrospectively studied 162 case files from 55 male and 107 female cases, with ages varying from 42 to 80, which were scanned using Cone Beam Computed Tomography. (3) Results: In 56.17% of cases, an unpneumatized CPEB (type I) was found. Nasal roof recesses of ethmoidal origin (type II) were found at the posterior end of the CPEB in 20.37% of cases. Different types of sphenoidal pneumatizations of the posterior end of the CPEB (type III) were found in 22.83% of the cases. Onodi cells projected nasal roof recesses (type IV) in only 10 cases. In all types, nasal roof recesses were found either above the CPEB or within/underneath it. Moreover, such nasal roof recesses were found to be either unilateral, extended contralaterally, or bilateral. (4) Conclusions: As such recesses of the posterior CPEB, previously overlooked, belong to the posterior rhinobase, they should be carefully documented preoperatively to avoid unwanted surgical damage to the olfactory bulb or CSF fistula.

The sphenoethmoidal sinus and the modified anatomy of the related structures

The anterior extent of the sphenoidal sinus in the posterior ethmoid was less investigated. Our purpose was to study whether, or not, the occurrence of a sphenoethmoidal sinus (SES) relates to a sagitally-shortened ethmoid. A retrospective cone-beam computed tomography (CBCT) was performed on 36 patient files. In six patients were found SES extended anteriorly above the posterior third of the middle turbinate (MT). Two of these patients had bilateral SES with ethmoidal chambers included in the lateral and superior nasal walls and draining in the sphenoethmoidal recesses. The correlation between the nasion-to-concha sphenoidalis distance and the presence of SES was statistically significant (less than 40 mm in SES cases and more than 40 mm in non-SES cases). We also found: (i) superior turbinates (STs) with ethmoidal and sphenoidal insertions on one side and ethmoidal and maxillary insertions on the opposite side (the maxillary insertion of ST modifies surgical landmarks and was not previously reported), (ii) MT perforation and (iii) pterygoid recess of the maxillary sinus located beneath the pterygopalatine ganglion fossa. The SES thus shortens sagitally the lateral nasal wall but does not modify its morphology. The MT perforation, ST maxillary insertion and the pterygoid recess are rare anatomic variants not reported previously in our knowledge.

The unusually lower position of the mandibular foramen and the canal of the neck of mandible

BACKGROUND

The inferior alveolar nerve (IAN) courses through the mandibular foramen (MF) to enter the first segment of the mandibular canal (MC) in the mandibular ramus, to further supply with trigeminal fibers the lower teeth of that hemimandible. As the IAN also supplies the mylohyoid nerve, it is a mixed nerve.

METHODS

Unusual morphologies of the mandibular ramus were encountered during a retrospective study of archived CBCT files.

RESULTS

A previously unreported anatomic variation was found bilaterally in an edentulous mandible, consisting of a lowered position of the MF, with seemingly compensatory lengthening and enlargement of the sulcus colli, thus shortened MCs. Also, a rare neurovascular canal of the neck of the mandible was incidentally found unilaterally in another case and is reported here.

CONCLUSIONS

Such possibilities of variation could justify the individual effect of the IAN block.

False and true accessory infraorbital foramina, and the infraorbital lamina cribriformis

The infraorbital nerve (ION) and artery (IOA) course in the infraorbital canal (IOC) to exit through the infraorbital foramen (IOF). Few previous studies brought evidence of accessory IOF. Evaluation of the IOF in Cone Beam Computed Tomography (CBCT) is more accurate to determine whether or not foramina of maxilla are supplied by canaliculi deriving from the IOC. We performed a retrospective anatomical study of the CBCT files of 200 patients. An accessory infraorbital foramen located inferior to the infraorbital margin (AIOF) was found in 18/200 right maxillae and in 13/200 left ones. Canaliculi deriving from the IOC supplied accessory foramina in the sutura notha- AIOF(SN) - in 15 maxillae. Noteworthy, the AIOF(SN)-negative maxillae displayed the SN and the vascular foramina of Macalister. In 94% of cases the AIOF were unique. A single maxilla (3%) had a double AIOF. In a different case (3%) were found three accessory infraorbital foraminules transforming the anterior wall of the antrum into a veritable lamina cribriformis infraorbitalis. A single prior study distinguished AIOF from AIOF(SN), while most of different other ones were performed on dry bones. Therefore, the reports of prevalence for the number and location of AIOF should be regarded with caution. Foramina of the SN could equally get intraosseous and extraosseous supply, this distinction being accurately made in CBCT.

Air spaces neighbouring the infraorbital canal

OBJECTIVE

The infraorbital canal (IOC) courses through the roof of the maxillary sinus (MS). Different grading systems concerning the topography of the IOC have been proposed. Further, it has been suggested that a transantral IOC would be morphologically related to Haller's cells (HCs). However, we hypothesized that this is not necessarily the case. Hence, we aimed to study the anatomical possibilities of the air spaces located medially to the IOC.

MATERIALS AND METHODS

The cone-beam computed tomography (CBCT) files of 40 adult patients were retrospectively evaluated.

RESULTS

The transantral type of IOC was found in 32.5% of patients. The infraorbital recesses of the MS were found medial to the IOC in 20% of patients. As referred to the nasolacrimal canal, these recesses were either prelacrimal (appearing as false isolated air cells) or retrolacrimal (appearing as false HCs). True HCs were found in 10% of patients. They were located medial to the IOC and they drained into the ethmoidal infundibulum (EI), which was distinct from the MS drainage. In 15% of patients, aerated nasolacrimal ducts (NLDs) were found anterior to the EI and medial to the antral angle. They were capable of masquerading either a HC or an infraorbital recess of the MS.

CONCLUSION

Previous classifications of the IOC, which related it to HCs, were reviewed and the evidence was found to be insufficient to assess the HC-related topography of the IOC. Therefore, to achieve the accurate anatomical identification of the air spaces neighbouring the IOC, the infraorbital recesses of the MS, the HCs, and the aerated NLDs should be carefully discriminated within the antero-supero-medial antral angle.

Agger Nasi Cells Versus Lacrimal Cells and Uncinate Bullae in Cone-Beam Computed Tomography

The maxillary bone's frontal process, lacrimal bone, and ethmoidal labyrinth's uncinate process can each harbor pneumatizations, referred to as agger nasi cells (ANCs), lacrimal cells (LCs), and uncinate bullae (UBs), respectively. Different studies have failed to differentiate ANCs from LCs. We aimed at studying these 3 anatomic sites to establish the anatomical patterns that could be encountered. We performed a retrospective study on cone-beam computed tomography scans of 36 patients (72 sides); the anatomic identification was supported by bidimensional multiplanar reconstructions (MPRs) in all 3 planes and 3-dimensional volume renderings. We established 6 patterns of pneumatization as follows: (1) type I: single LCs (47%), (2) type II: distinctive adjacent LCs and ANCs (8%), (3) type III: LCs expanded as UBs (6%), (4) type IV: ANCs adjacent to LCs expanded with UBs (1%), (5) type V: ANCs expanded as LCs (27%), and (6) type VI: ANCs expanded as LCs and further expanded as UBs (11%). In a type I pattern case, we found a cell-in-cell aspect on sagittal MPRs, which was further demonstrated as being an anterolateral recess of the middle nasal meatus projected in front of an LC. Such an "agger nasi recess" of the middle meatus was not previously described. For an accurate anatomical diagnosis, computed tomography studies should use complementary MPRs in all anatomical planes, as well as 3-dimensional models, to avoid confusing ANCs with LCs and better document the drainage pathways.

Rare anatomic variation: Giant unilateral concha bullosa superior

The lateral nasal wall attaches the nasal turbinates, which could be, either pneumatized, or paradoxically curved. The turbinate pneumatization-concha bullosausually indicates the pneumatization of the middle turbinate. However, concha bullosasuperior (CBS) is also, although rare, anatomic possibility of variation. We report here a case of unilateral giant septated CBS, which was not, to our knowledge, previously reported. The case was documented in Cone Beam Computed Tomography (CBCT). Subtle pneumatizations of inferior turbinates were found bilateral, as also were the middle conchae bullosae. The left concha bullosasuperior was very large (17.43/5.34mm), dropping down between the left middle turbinate and the contralaterally deviated nasal septum, and contacting the paradoxical curvature of the middle turbinate on that side. An incomplete oblique septum divided it incompletely into anterior and posterior chambers, it was communicating with a posterior ethmoid air cell, and was draining in the superior meatus. Care should be taken not to misdiagnose a giant CBS as a middle turbinate pneumatization, in order not to misjudge surgical corridors. Therefore, a careful anatomic CT or CBCT diagnosis would be of use for the plan of treatment.