Paranasal sinus development in children: A magnetic resonance imaging analysis

Metopism in adult South Africans and its relationship to frontal sinus size

This study documents the incidences of complete and partial metopism and their possible relationship to frontal sinus volume (FSV) in a sample of modern adult black South Africans with a view to evaluating the hypothesis that metopism affects frontal sinus hypoplasia. FSV was measured from CT scans and the incidence of metopism was recorded from direct observations of dried cadaveric crania. The sex of each individual was known. Four linear cranial dimensions were used to compute a geometric mean by which to scale FSV. The incidence of partial metopism (38%) is comparable to that reported for other population samples, although there is considerable variation among these global sample frequencies. It is significantly more common in male than female South Africans. FSV in individuals with complete metopism is smaller than average but not inordinately so. On the other hand, FSV is significantly larger in individuals with partial metopism than in those that do not present with this sutural remnant. The data on FSV in individuals with and without partial metopism contradict the hypothesis that there is a relationship between partial metopism and frontal sinus hypoplasia. As such, the metopic remnant evinced by the Late Pleistocene cranium from Hofmeyr, South Africa is unlikely to be related to its very small FSV.

Variation, sexual dimorphism, and enlargement of the frontal sinus with age in adult South Africans

OBJECTIVES

To document frontal sinus volume (FSV) in a sample of sub-Saharan Africans with a view to evaluating claims that such populations exhibit comparatively small sinuses. This study also addresses questions related to sexual dimorphism, incidence of sinus aplasia, and the possibility that FSV continues to increase through adulthood.

MATERIALS AND METHODS

FSV was measured from CT scans of adult crania from the Dart Collection. Sex and age were known for each individual. Linear cranial dimensions were used to compute a geometric mean from which a scaled FSV was computed for each cranium.

RESULTS

FSV does not differ significantly between sexes, but females exhibit a higher incidence of aplasia. There is considerable variation in FSV in this sample, with the average ranking among the higher means reported for other population samples. The incidence of FS aplasia falls within the range of values recorded for other population samples. Although our study is cross-sectional rather than longitudinal, there is strong evidence that FSV continues to increase with age throughout adulthood.

DISCUSSION

The FSV mean of our sample contradicts the notion that sub-Saharan Africans possess small sinuses. In a global context, geography (climate and altitude) does not appear to be related to FSV. The absence of sexual dimorphism in our sample is unexpected, as significant dimorphism has been reported for most other population samples. Our results support other indications that the frontal sinus continues to expand throughout adulthood, especially in females, and that it is likely due to bone resorption.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

The development of paranasal sinuses in patients with cystic fibrosis: sinuses volume analysis

BACKGROUND

Cystic fibrosis (CF) is a severe systemic disease that affects many aspects of patients' lives. It is known that the progression of the disease adversely affects lower and upper airways including the paranasal sinuses. However, its impact on sinus development in the pediatric population is not fully examined. The purpose of this study was to evaluate the development of the paranasal sinuses in a pediatric population with CF and compare it to a control group consisting of healthy children.

METHODS

The results of computed tomography (CT) scans of children with the disease and the control group were evaluated. The study included 114 CT images of children in the study group and 126 images of healthy children aged 0-18 years. The volumes of maxillary, frontal, and sphenoid sinuses were analyzed. The obtained results were compared with those of the control group and analyzed statistically.

RESULTS

The volume and the development of the paranasal sinuses in both groups increased with age, but statistically significant differences were found between the study and the control group.

CONCLUSIONS

The obtained results provide valuable knowledge regarding the impact of the CF on sinuses development. Also, they may be important in understanding the progression of the disease and its influence on the quality and length of life of patients. The results may contribute to enhanced diagnostics and have implications for improving therapy for patients with chronic sinusitis associated with CF.

Comparison of endoscopic sinus sampling versus intracranial sampling for microbiological diagnosis of intracranial infection in children: a case series and literature review

INTRODUCTION

Intracranial infection is often associated with contiguous sinus infection, with Streptococcus intermedius being the most common pathogen. Microbiological assessment is possible via sinus or intracranial sampling. While a sinus approach is minimally invasive, it is not clear whether this yields definitive microbiological diagnosis leading to optimized antimicrobial therapy and avoidance of intracranial surgery.

METHODS

A retrospective review of a prospectively collected electronic departmental database identified patients between 2019 and 2022. Further demographic and microbiological information was obtained from electronic patient records and laboratory management systems.

RESULTS

Thirty-one patients were identified with intracranial subdural and/or epidural empyema and concurrent sinus involvement during the 3-year study period. The median age of onset was 10 years with a slight male predominance (55%). All patients had intracranial sampling with 15 patients undergoing sinus sampling in addition. Only 1 patient (7%) demonstrated identical organism(s) grown from both samples. Streptococcus intermedius was the most common pathogen in intracranial samples. Thirteen patients (42%) had mixed organisms from their intracranial cultures and 57% of samples undergoing bacterial PCR identified additional organisms, predominantly anaerobes. Sinus samples had a significant addition of nasal flora and Staphylococcus aureus which was rarely grown from intracranial samples. Of concern, 7/14 (50%) of sinus samples did not identify the main intracranial pathogen diagnosed on intracranial culture and additional PCR. Literature review identified 21 studies where sinus drainage was used to treat intracranial empyemas, with only 6 authors reporting concurrent microbiology results. This confirmed our cohort to be the largest comparative study in the current literature. No center has observed a greater than 50% concordance in microbiological diagnoses.

CONCLUSION

Endoscopic sinus surgery may have therapeutic benefit, but it is not an appropriate approach for microbiological diagnosis in pediatric subdural empyemas. High rates of contaminating nasal flora can lead to misdiagnosis and inappropriate treatment. Routine addition of 16S rRNA PCR to intracranial samples is recommended.

The Influence of Nonaerated Paranasal Sinuses on DTI Parameters of the Brain in 6- to 9-Year-Old Children

BACKGROUND AND PURPOSE

DTI is prone to susceptibility artifacts. Air in the paranasal sinuses can cause field inhomogeneity, thus affecting measurements. Children often have mucus in their sinuses or no pneumatization of them. This study investigated the influence of lack of air in the paranasal sinuses on measurements of WM diffusion characteristics.

MATERIALS AND METHODS

The study was embedded in the Generation R Study, a prospective population-based birth cohort in Rotterdam (the Netherlands). Brain MR imaging studies (1070 children, 6-9 years of age) were evaluated for mucosal thickening of the paranasal sinuses. Nonaeration of the paranasal sinuses (modified Lund-Mackay score) was compared with that in a randomly selected control group. The relationship between nonaerated paranasal sinuses and fractional anisotropy and mean diffusivity in the DTI fiber tracts was evaluated using ANCOVA and independent t tests.

RESULTS

The prevalence of mucosal thickening was 10.2% (109/1070). The mean modified Lund-Mackay score was 6.87 (SD, 3.76). In 52.3% (57/109), ≥ 1 paranasal sinus was not pneumatized. The results are reported in effect sizes (Cohen's d). Lower mean fractional anisotropy values were found in the uncinate fasciculus (right uncinate fasciculus/right frontal sinus, d = -0.60), superior longitudinal fasciculus (right superior longitudinal fasciculus/right ethmoid sinus, d = -0.56; right superior longitudinal fasciculus/right sphenoid sinus, d = -2.09), and cingulate bundle (right cingulum bundle/right sphenoid sinus, d = -1.28; left cingulum bundle/left sphenoid sinus, d = -1.49). Higher mean diffusivity values were found in the forceps major/right and left sphenoid sinuses, d = 0.78.

CONCLUSIONS

Nonaeration of the paranasal sinuses is a common incidental finding on pediatric MR imaging brain scans. The amount of air in the paranasal sinuses can influence fractional anisotropy and, to a lesser degree, mean diffusivity values of WM tracts and should be considered in DTI studies in pediatric populations.

Association among Orthodontic Malocclusions, Paranasal Sinuses Anatomic Variations and Adenoid Vegetation in Children Using CBCT

The aim of this study is to evaluate the relationship between orthodontic malocclusion, paranasal sinus (PS) variations, and adenoid vegetation in a group of pediatric patients with chronic rhinosinusitis. Clinical and radiographical data were retrospectively evaluated and 58 patients were diagnosed as having chronic sinus disease. Cone-beam computed tomography (CBCT) images were acquired with Newtom-3G. Anatomical variations of the PS were assessed on every section. Additionally, for cephalometric analysis, the images were imported into the InVivoDental software program. A total of 252 anatomical variations, which encompassed 19 different types, were detected in the current study. Concha bullosa was the most common anatomical variation, at 72.4%. Septum deviation was the second most common one, at 67.2%. The Class III group exhibited a significantly higher prevalence of concha bullosa and secondary middle turbinate than the other groups. While adenoid vegetation was most common in the Class III group, sinusitis and antral disease were most common in the Class II group. Overall, Class III subjects exhibited fewer PS variations. In conclusion, concha bullosa emerged as the most prevalent anatomical variation, with distinctive patterns observed across different malocclusion groups. Therefore, CBCT is useful, especially in pediatric patients, due to its low dose advantage.

Skeletal manifestations of disease experience: Length of illness and porous cranial lesion formation in a contemporary juvenile mortality sample

OBJECTIVES

Porous lesions of the orbit (cribra orbitalia [CO]) and cranial vault (porotic hyperostosis [PH]) are used as skeletal indicators of childhood stress. Because they are understudied in contemporary populations, their relationship to disease experience is poorly understood. This paper examines the relationship between length of childhood illness and CO/PH formation in a clinically documented sample. "Turning points," which identify the window for lesion formation for CO/PH, are defined, implications for hidden heterogeneity in frailty are considered.

METHODS

Data are from 333 (199 males; 134 females) pediatric postmortem computed tomography scans. Individuals died in New Mexico (2011-2019) and are 0.5 to 15.99 years (mean = 7.1). Length of illness was estimated using information from autopsy and field reports. Logistic regression was used to estimate predicted probabilities, odds ratios, and the temporal window for lesion formation.

RESULTS

Illness, single bouts, or cumulative episodes lasting over 1 month is associated with higher odds of CO; individuals who were never sick have lower odds of having PH. This relationship was consistent for fatal and incidental illnesses that did not cause death. The developmental window for CO formation appears to close at 8 years.

CONCLUSIONS

Those ill for over 1 month are more likely to have CO/PH than those with acute illnesses. Some individuals lived sufficiently long to form CO/PH but died of illness. Others with lesions died of circumstances unrelated to disease. This indicates hidden variation in robusticity even among ill individuals with CO/PH, which is vital in interpreting lesion frequencies in the archeological record.

Clinical Patterns and Treatment of Pediatric Facial Fractures: A 10-Year Retrospective Romanian Study

Pediatric facial fractures have different clinical patterns and require different therapeutic approaches in comparison with those of facial fractures that occur among adults. The aim of this study was to describe the main clinical characteristics of pediatric facial fractures (such as fracture location, fracture pattern, treatment, complications and evolution) in a group of pediatric patients from NW Romania. This research was a retrospective study that was conducted for 10 years in a tertiary hospital for oral and maxillofacial surgery from NW Romania. A total of 142 pediatric patients were included in this study, with ages between 0 and 18 years. Mandibular (66.2%), midface (25.4%) and combined fractures (8.5%) were identified, and patients from the 13-18 years age group were more frequently affected by facial fractures (78.9%). Most of the diagnosed fractures among all three types of fractures were total fractures, and most mandibular (92.6%) and midface (80.6%) fractures were without displacement. Hematomas, lacerations and abrasions were identified as associated lesions. Patients with associated lesions were more frequently associated with combined fractures or midface fractures than mandibular fractures. The instituted treatment was, in general, orthopedic, for all three types of fractures (mandibular-86.2%; midface-91.7%; combined-66.7%). Most fractures, mandibular (96.8%), midface (100%) and combined (91.7%) fractures, had a favorable evolution. Most fractures did not present any complications at the follow-up. Pediatric facial fractures have unique patterns and must be treated with caution, considering the particularities of pediatric facial anatomy.

A Novel Sublabial Anterior Transmaxillary Approach for Medically Refractory Mesial Temporal Lobe Epilepsy: A Comparative Anatomic Study

BACKGROUND

Current approaches for mesial temporal lobe epilepsy may result in suboptimal seizure control and cognitive decline. An incomplete treatment of the epileptogenic zone and unnecessary violation of functional cortical and subcortical areas may contribute to suboptimal results.

OBJECTIVE

To describe and test the anatomic feasibility of a novel endoscopic anterior transmaxillary (ATM) approach to the temporal lobe and to compare the described technique to other transfacial approaches.

METHODS

Twenty-four cadaveric brain hemispheres fixed in formalin were used to study anterior temporal surface anatomy. Two additional hemispheres were fixed in formalin and then frozen for white matter dissections. Subsequently, bilateral dissections on 4 injected cadaveric heads were used to describe the endoscopic ATM approach and to evaluate various anterior endoscopic corridors for the temporal pole and mesial temporal lobe structures.

RESULTS

The ATM approach was considered superior because of direct visualization of the temporal pole and natural alignment with the mesial temporal structures. The mean exposure corridor covered 49.1° in the sagittal plane and 66.2° in the axial plane. The ATM allowed direct access lateral to the maxillary and mandibular nerves with an anterior-posterior trajectory aligned to the longitudinal axis of the hippocampus formation, allowing for a selective amygdalohippocampectomy with preservation of the trigeminal branches and the lateral temporal neocortex.

CONCLUSION

The ATM approach is anatomically feasible, providing a direct and selective approach for the temporal pole and mesial temporal lobe structures, with a substantial angle of visualization because of its direct alignment with the mesial temporal lobe structures.

Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study

BACKGROUND

Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes.

METHODS

An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant.

RESULTS

Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05).

CONCLUSIONS

Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Development of the sphenoid sinus from newborn to age 18: A computed tomography imaging analysis

OBJECTIVES

The sphenoid sinus (SS) is an important anatomical formation in terms of its location and relationship with important neurovascular structures. It is essential to evaluate the pneumatization and dimensions of the SS with Computed Tomography (CT) in the preoperative period of transsphenoidal interventions to be performed on tumors located in this region. The aim of this study was to evaluate the correlation of the volume and dimensions of the SS measured with CT with age in the period from birth to 18 years of age.

METHODS

In this retrospective study, a total of 360 brain, paranasal sinus, temporal bone and maxillofacial CT scans of individuals from birth to 18 years of age were evaluated. The cohort was divided into 18 groups with 20 (10 female, 10 male) patients in each age group. The height, width, length and volume values of the SS were measured on CT and their correlations with age and the differences between genders were evaluated statistically.

RESULTS

It has been determined that the increases in the size and volume of the SS accelerate especially between 1 and 2 years of age and begins to reach adult dimensions after 12 years of age. Height and length of the sphenoid sinus showed a high correlation coefficient (r = 0.717 and r = 0.731 respectively) with age, while its width and volume showed a moderate correlation coefficient (r = 0.662 and 0.543 respectively). There was no statistically significant difference between the genders in terms of SS height, width, length and volume.

CONCLUSIONS

SS dimensions and volume showed a logaritmic growth pattern from birth to 18 years. The results of this study may help to better understand the normal development of SS in children and may serve as a reference for more comprehensive CT studies. In addition, it can help surgeons to evaluate the developmental characteristics of SS in surgical interventions for SS in children.

Algorithms for the management of frontal sinus fractures: A retrospective study

The aim of this study was to evaluate the long-term results and to evaluate the validity of the treatment algorithm that can be safely applied in dfrontal sinus fractures. All patients were evaluated in terms of late-term contour deformity and further craniometric analysis for measurement of maximum amount of displacement, fracture surface area (mm2) and the maximum angulation of the fracture (degree) were done. 125 patients (101 male, 24 female) with frontal sinus fractures with an average age of 22.4 years (range,17-66 years) were reviewed. All patients with isolated anterior table fractures without displacement were followed up on conservative basis. 33 patients with anterior table fractures with displacement and 39 patients with anterior and posterior table fractures were also followed on conservative basis without surgical intervention. The cut-off value of the maximum amount of displacement was confirmed to be 4.5 mm in prediction of late-term contour deformities (p < 0.001). The maximum amount of displacement was decreased by an average of 1.8 mm at late-term. Apart from the standard protocols, within the limitations of the study it seems that isolated anterior table fractures with a maximum amount of displacement of less than 4.5 mm can be treated conservatively without leading to contour deformities. CSF leakage in the acute setting might not always require cranialization and this may spontaneously resolve within 10 days. Cranialization should be considered whenever CSF leakage lasts longer than 10 days.

Role of Computed Tomography and Magnetic Resonance Imaging in the Evaluation of Headache Due to Paranasal Sinus and Teeth Disorder

When brain imaging is performed as a first-line investigation for headaches and no intracranial abnormality is found, attention should always be paid to potential non-CNS causes of headache including paranasal sinus inflammatory, infectious, and occasionally malignant disease, and also to odontogenic sinusitis. Non-enhanced CT (NECT) head offers an initial evaluation of these areas which may be an unexpected source of symptomatology. Further imaging may then be required with either dedicated sinus NECT [particularly if surgical intervention is necessary for paranasal sinus disease], a contrast-enhanced (CECT) head and sinus CT, or an MRI if intracranial complications of sinonasal disease or acute invasive fungal sinusitis is suspected.

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.

When is a multidisciplinary approach required in management of intracranial complications of sinonasal inflammatory disorders?

Intracranial complications of sinonasal inflammatory disorders are relatively unusual but can cause significant morbidity and mortality. They often occur in patients with comorbid disorders and immunocompromised but also people without risk factors can be affected. Intracranial complications of acute rhinosinusitis are rare, probably due to oral antibiotics availability, but are less predictable as they often occur in immunocompetent patients without comorbidity. Their management requires a multidisciplinary approach to plan and customize the therapeutic treatment. Intracranial complications of chronic rhinosinusitis are more predictable as they occur often in immunocompromised patient with particularly risk factors. For this reason, a multidisciplinary approach it’s important for treatment and mostly for prevention. The aim of this paper is to present an overview of different multidisciplinary management of intracranial complications of sinonasal inflammatory disorders according to their etiology and severity.

Volumetric growth analysis of maxillary sinus using computed tomography scan segmentation: a pilot study of Indonesian population

The aim of this study is to investigate the volumetric measurements of the maxillary sinus among Indonesian population through computed tomography (CT) scan semi-automated segmentation. This project collected 802 retrospective head CT scan archives from Department of Radiology, Hasan Sadikin Hospital, Bandung, Indonesia between 2019-2020. Patients with craniofacial anomalies/pathology fracture in proximity of the maxillary sinuses, and mediocre image quality were excluded from this study resulting only 97 CT scan archives (194 maxillary sinuses; 52 males; 45 females; age range 0-25 years old). Three-dimensional craniofacial structures were reconstructed and volumetric measurements of the maxillary sinus were computed through semi-automated segmentation using ITK-SNAP. This study recorded the initial phase of maxillary sinus pneumatization during infancy. The maxillary sinus developed until reaching the maximum of average maxillary sinus volume at 13,278.73 mm³ in 16 to 20 years old group in which afterwards fell to 12,325.21 mm³. There was no difference found between right and left maxillary sinus volume. This study revealed that the pneumatization of maxillary sinus begin during infancy and climb until reaching the second decade of life, in which after that slowly decrease. Moreover, no difference between right and left maxillary sinus volume was detected. The volumetric dimension of maxillary sinus presented in this study may serve as the basis knowledge surgical intervention of maxillary sinus and its related structures.

Endoscopic Endonasal Removal of Stray Bullets in the Fossa Pterygopalatine in Innocent Young Bystanders of Conflicts in Somalia in a Period of Six Months

ABSTRACT

In Somalia, which is located in the horn of Africa, a fragile and insecure state structure allowed the strengthening of terrorist groups provoking armed conflicts. Stray bullet injuries can be defined as an accidental bullet wound caused by an anonymous attacker and are usually associated with celebratory gunfire or urban violence. The anatomy of the pterygopalatine fossa (PPF) is complex and penetrating foreign body injuries pose even a greater challenge for the surgeon to operate in this area. Endoscopic approaches facilitate the removal of foreign bodies from the paranasal sinuses, orbital cavity, and aerodigestive system, minimizing potential risks. This study presents a series of removal of stray bullets found in the PPF, as a result of urban violence in Somalia in a period of 6 months. Patient demographics, foreign body origin, treatment modalities, and surgery details were evaluated and assessed. All patients were male and aged 16, 2, and 24 years, respectively. The surgeries were quite straightforward with surgery times recorded as 25, 44, and 22 minutes, respectively. The endoscopic endonasal approach proved to provide safe and sufficient access for removal. Surprisingly, even the foreign body in the PPF of a 2-year-old patient could be removed with an endoscopic endonasal approach and did not require an external approach. The management of foreign body removal in the PPF is challenging due to the potential risks of iatrogenic vascular and nervous tissue injury. The endoscopic endonasal approach for removal proved efficient in 3 cases regardless of age and anatomical dimensions.

Assessment of variations in sphenoid sinus pneumatization in Indian population: A multidetector computed tomography study

Background and Purpose:

The purpose of our study was to assess the prevalence of variations in the extent of sphenoid pneumatization in the Indian population and compare with existing literature.

Materials and Methods:

This retrospective study included 500 patients who underwent CT of the paranasal sinuses. The multiplanar reformations of paranasal sinus were assessed for the type of pneumatization of the sphenoid sinus and type of clival, lateral recess, lesser wing, and anterior recess extensions.

Results:

The conchal, presellar, incomplete sellar, and complete sellar types comprised 0%, 1.2%, 22.2%, and 76.6% of patients. The extensions of pneumatization subtypes in the study population were clival in 76.6% subjects; lateral recess, lesser wing, and anterior recess in 59.7%, 20.4%, and 20.4% of sinuses, respectively. The pure forms were seen in 25.4% and combined forms in 61% of sinuses. The presellar type (1.2%) was less common and sellar type (98.8%) being common in our population compared to the Caucasian and East Asian population. The sphenoid sinuses were extensively pneumatized in our population compared to the Chinese and Caucasian population, the prevalence being 76.6%, 68%, and 44.5% for clival; 59.7%, 46%, and 28.3% for lateral recess; 20.4%, 32%, and 12% for lesser wing extension, respectively. The pure forms were relatively less common and combined forms being more common compared to the Chinese and Caucasian population in our study.

Conclusion:

The extent of pneumatization of the sphenoid sinus has clinical and surgical implications in sellar and central skull base lesions, and variability in different populations confirms that ethnicity influences the differences in prevalence.

Sphenoid Bone Pneumatisation on Lateral Cephalograms of Patients With Neurofibromatosis Type 1

BACKGROUND/AIM

Neurofibromatosis type 1 (NF1) is an autosomal dominant hereditary disease that causes tumors and many developmental disorders, e.g., cranial dysplasia. The purpose of this retrospective study was to analyse the pneumatisation of the sphenoid bone in NF1.

PATIENTS AND METHODS

The anonymised lateral cephalograms of 166 NF1 patients and 166 age- and sex-matched controls were examined for anterior-posterior sphenoid pneumatisation. The patient group analysis considered whether the patients had been affected by a facial plexiform neurofibroma (FPNF).

RESULTS

Sphenoid pneumatisation was significantly lower in NF1 patients than in controls [odds ratio (OR)=0.184; 95%CI=0.11-0.32; p<0.001]. A FPNF statistically significantly reduced sinus formation in patients (OR=0.38; p=0.002).

CONCLUSION

The condition 'NF1' has an effect on sphenoid pneumatisation. The findings are relevant for planning surgical procedures in this region and confirm current concepts to evaluate NF1 as a histogenesis control gene. The examination technique and basis of calculation presented here are easy-to-use and low-irradiation exposure instruments for screening for differences in sphenoid bone pneumatisation in defined populations.

Magnetic Resonance Imaging Detects Chronic Rhinosinusitis in Infants and Preschool Children with Cystic Fibrosis

Rationale: Chronic rhinosinusitis (CRS) contributes to disease burden of patients with cystic fibrosis (CF). However, its onset and progression in infants and preschool children with CF remain poorly understood.Objectives: To determine the prevalence and extent of CRS in young children with CF using magnetic resonance imaging (MRI).Methods: MRI was performed in sedation in 67 infants and preschool children with CF (mean age 2.3 ± 2.1 yr; range 0-6 yr) and 30 non-CF control subjects (3.5 ± 2.0 yr; range 0-6 yr). Paranasal sinus dimensions and structural abnormalities, including mucosal swelling; mucopyoceles; and nasal polyps of the maxillary, frontal, sphenoid, and ethmoid sinuses; and, in addition, medial maxillary sinus wall deformation, were assessed using a dedicated CRS MRI scoring system.Results: Pneumatization and dimensions of paranasal sinuses did not differ between the two groups. MRI detected an increased prevalence of mucosal swelling (83% vs. 17%; P < 0.001), mucopyoceles (75% vs. 2%; P < 0.001), polyps (26% vs. 7%; P < 0.001), and maxillary sinus wall deformation (68% vs. 2%; P < 0.001) in infants and preschool children with CF compared with age-matched control subjects. Furthermore, the extent of these abnormalities was also increased with a MRI sum score of 22.9 ± 10.9 in CF compared with 4.5 ± 7.6 in non-CF control subjects (P < 0.001).Conclusions: MRI detected normal dimensions of paranasal sinuses, and a high prevalence and severity of paranasal sinus abnormalities due to CRS in infants and preschool children with CF without radiation exposure. Our results support the development of MRI for sensitive noninvasive diagnosis and monitoring of CRS in young children with CF, and as outcome measures for clinical trials.Clinical trial registered with www.clinicaltrials.gov (NCT00760071).

Clinical and Radiologic Characterization of Frontal Sinusitis in the Pediatric Population

INTRODUCTION

Frontal sinusitis in the pediatric population is a disease that has not been thoroughly studied or characterized. The goals of this study are to characterize the clinical presentation, radiologic variables, treatment modalities, complications, and prognosis associated with acute and chronic frontal sinus disease in the pediatric population.

METHODS

IRB-approved retrospective cohort study of pediatric patients who were diagnosed with acute (AFS) or chronic frontal sinusitis (CFS) and underwent frontal sinus surgery at a tertiary level Children's Hospital from 2006 to 2016. Patients with AFS were compared to patients with CFS. Statistical analysis completed using chi-square test or Fisher's exact test, statistical significance set at P < .05.

RESULTS

A total of 19 patients with AFS and 15 patients with CFS were analyzed. There was a male predominance in AFS and female predominance in CFS (P < .05).AFS patients were less likely to have allergies, prior sinus disease, or significant comorbidities (P < .05).Additionally, AFS patients presented with constitutional, neurologic, and ocular symptoms. The CFS group had predominantly sinonasal symptoms. CT-scan analysis showed that AFS patients had higher prevalence of complex frontal anatomy (Type-II cells, concha bullosa) compared with CFS patients (P < .05). Culture results were positive in 78% of the AFS group, with S. Anginosus (53%), Anaerobes (20%), and normal flora (17%). In the CFS group cultures were positive in 60% of the patients, 56% grew normal flora, 13% H. Influenzae, 6.5% Pseudomonas, and 24.5% other species. CFS patients were more likely to have persistent sinus disease and require repeat sinus procedures (P < .05).

CONCLUSION

There are 2 distinct presentations of frontal sinus disease in the pediatric population. Patients with AFS vary significantly from those with CFS. Males, ages 13 to 18 years old, who cultured positive for S. Anginosus (former S.Milleri) dominated the AFS subgroup. Whereas as female patients with a history of allergic rhinitis and muco-cilliary disease were more prominent in the CRS subgroup. Correct identification and understanding of these 2 different entities are crucial for the appropriate short and long-term patient management.

Acute isolated sphenoid sinusitis in children: A case series and systematic review of the literature

OBJECTIVE

This study aims to present a case series and systematic review of acute isolated sphenoid sinusitis (AISS) in children in order to better characterize clinical presentation, diagnosis, treatment, and outcomes of this condition.

DATA SOURCES

Ovid MEDLINE, Pubmed, Embase, Cochrane Library, and Google Scholar.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text, peer-reviewed journal publications from 1994 to 2020 in English; focus on acute sphenoid sinusitis; pediatric patients (<18 years of age); series with two or more children. Studies were assessed for data including demographics, presenting symptoms and signs, radiological investigations, treatment, outcomes and complications.

RESULTS

Ten studies identifying 71 patients were included. Average age at presentation was 12.0 years (range 5-17 years). M:F ratio 1:1. The most common presenting symptoms were headache (98.6%), fever (50.7%), nasal symptoms (22.5%) ocular symptoms (19.7%) and decreased level of consciousness (12.7%). Twenty patients (28.1%) had neurological signs. Twenty-three patients (32.4%) presented with headache in isolation. Unsuspected diagnosis at presentation was noted in 54.0%. Average time to initial presentation was 14.0 days (median = 5.5 days, range 1-90 days). The majority of children were treated with antibiotics (98.6%) with 31.0%, 2.8% and 2.8% also undergoing sinus surgery, revision sinus surgery and neurosurgery, respectively. Intracranial complications occurred in 16.9% of patients. Significant long term sequelae occurred in 2 children (2.8%) and one death (1.4%) was also reported.

LIMITATIONS

All studies were retrospective case note reviews.

CONCLUSIONS

Acute sphenoid sinusitis is a rare and difficult condition to diagnose in children. The majority of patients make a full recovery with appropriate treatment. If treatment is delayed however consequences can be life-threatening.

Anatomical and Volumetric Analysis of the Sphenoid Sinus by Semiautomatic Segmentation of Cone Beam Computed Tomography

This investigation was performed to analyze and evaluate anatomical and volumetric data of the sphenoid sinus by semiautomatic segmentation of cone beam computed tomography (CBCT) datasets.This analysis was carried out on cone beam computed tomography images of 100 patients. By using the discretionary software "ITK-Snap", the volumetric investigation of 197 sphenoid sinuses was conducted. The statistical analyses were carried out by using the paired and independent Student t-test. In addition, the Pearsons chi-square test was performed. P values P < 0.05 were considered significant.The volumetric mean was 4.438 ± 2.434 cm for the right and 4.809 ± 3.000 for the left side. Results did not indicate statistically significant differences according to the side, irrespective of gender (P > 0.05). The further investigation of differences between male and female patients did assess significant results (P < 0.05), males (10.477 ± 3.851 cm) present a larger total sinus volume than females (8.219 ± 3.574 cm). In accordance to patients' age (median 54 years), smaller volumes were related to younger patients and larger volumes to older ones. But, no statistically significant results in accordance to age could be detected (χ = 1.258; P > 0.05).Endoscopic sinus surgery of the vulnerable and intricate anatomy of the sphenoid sinus requires an explicit knowledge and orientation about the anatomical variations such as septums and volumetric capacity. Concerning this matter, semiautomatic segmentation of CBCT images can aid the surgeon in preoperative planning. Our investigation shows that a small sinus volume, that is, affecting female patients and a complex sinus anatomy by the occurrence of a septum, especially located close to neurovascular structures could essentially aggravate endoscopic sphenoid sinus surgery. In this regard, volumetric analysis of the sphenoid sinus by CBCT images can provide presurgical information and facilitates an individualized treatment.

Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves' orbitopathy

BACKGROUND

Endoscopic orbital decompression is a well-established technique for Graves orbitopathy treatment.

AIMS

Measurement of the ethmoid volume and its correlation with proptosis reduction in patients undergoing endoscopic orbital decompression for Graves' orbitopathy.

METHODS

We retrospectively reviewed clinical charts of 209 patients (319 orbits) operated by a surgeon at our institution between 1998 and 2019.

RESULTS

Average age was 46.9 years. About 83.3% of the patients were female, 54.6% were smokers, 93.8% were euthyroid at the time of decompression, 3.8% were hypothyroid and 2.4% were hyperthyroid. About 77.5% of the patients underwent bilateral surgery, the remainder and unilateral. Subsequent stages included strabismus surgery in 22.5% patients, Müllerectomy 37.8%, with or without canthoplasty (14.8 vs. 23%). Mean proptosis reduction was 4.61 mm. Mean ethmoid volume was 5.57 mm³. Ethmoid volume had a moderate positive correlation with proptosis reduction (r _s = 0.49, p < .001). Further investigation, statistically significant moderate correlation was found only in the small (SE) and big (BE) ethmoid groups.

CONCLUSION

We advise evaluating ethmoid sinus pneumatization on computed tomography before decompression to estimate possible anatomical limitations. Additional wall decompression might be advocated in most severe cases.

Using 3D-reconstruction to analyse typical growth trends of the maxillary sinus in children

OBJECTIVES

There remains a lack of consistent evidence surrounding the developmental anatomy of the maxillary sinus (MS), despite its clinical significance in radiological interpretation and surgical intervention. Our aim was to analyse the typical growth trends of the MS throughout development, to better understand its morphological transformation from birth until late adolescence.

METHODS

Computed Tomography (CT) scans of individuals aged 0-18 years within the Auckland District Health Board region in New Zealand were examined retrospectively. Sixty-five patients were selected for the study after careful review of criteria. Manual 3D-reconstruction was utilised to replicate the MS from CT images and the mean changes in size, volume and shape with increasing age were analysed. Principal component analysis (PCA) was performed to statistically calculate the mean 3D shapes of the MS in each age group and analyse the independent modes of variation evident in sinus morphology between individuals of each age category.

RESULTS

At 0-1 years of age, mean MS size was 1.03 × 1.82 × 1.27 cm (width, length, height) with a mean volume of 0.81 cm³. By 16-18 years, mean size increased to 3.39 × 4.30 × 4.63 cm and mean volume became 21.63 cm³. Growth increased linearly but most rapid expansion occurred in the first 4-5 years of life. No significant differences were observed between males and females or right and left sides. Sinus morphology gradually progressed throughout the course of growth from an ellipsoidal structure at its rudimentary phase to a pyramidal shape when fully matured. PCA revealed that within younger age groups significant variation was observed in MS size, while older age groups had relatively less size variation but increased variability in 3D shape.

CONCLUSIONS

The results of this study can be used as a reference for typical MS growth in healthy children and as a basis to study how disease or surgical intervention may influence sinus development in children.

A hypothesis on the role of the human immune system in covid-19

The COVID-19 pandemic has not spared any continent. The disease has affected more than 7,500,000 individuals globally and killed approximately 450,000 individuals. The disease is caused by a very small virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is an enveloped single-stranded RNA virus with a spike-like structure on its envelope that can interact with the angiotensin-converting enzyme 2 (ACE2) receptor after cleavage. ACE2 receptors are present in the human lungs and other organs. SARS-CoV-2 is a new virus that belongs to the subgenus Sarbecovirus; viruses in this subgenus have spread widely in the previous years and caused outbreaks of severe acute respiratory syndromes.

Ten must know pseudolesions of the head and neck

Patients may present in the emergency setting for a variety of head and neck complaints such as fever, trouble swallowing, or a newly palpable mass. When reviewing radiologic head and neck exams for etiology of complaints, it is important to be familiar with the multiple pseudolesions that may mimic pathology. These may be normal variant anatomy, normal anatomy located in an atypical location, as well as iatrogenic or self-introduced foreign bodies. This review article discusses ten common pseudolesions encountered in the head and neck and their typical imaging appearance so that one does not mistake them for ominous pathology, thus preventing unnecessary follow-up, biopsy, or continued concern for the patient.

Imaging of Paranasal Sinus Infections in Children: A Review

Paranasal sinuses (PNS) infections are common in children. They may cause common and well-known complications, but also, unusual and potentially devastating complications. Diagnosing PNS infections and complications in children requires knowledge of the unique anatomy of the nasal cavity and the PNS. In fetal life, nasal mucosa evaginations into the lateral nasal walls initiate the development of the PNS. The PNS continue to develop after birth and complete their maturation and pneumatization at different ages during childhood which makes the pattern of PNS infections determined by patient age. Complications are caused by direct spread of the infection to the orbit, face, intracranial or osseous structures or hematogenous spread of the infection to the intracranial structures. Emergent imaging studies are often necessary in the evaluation of the complications in pediatric patients when the symptoms persist for 10 days and/or if there is evidence of intracranial or orbital complications. In addition, immunocompromised children are especially vulnerable to developing unusual complications. Computed tomography (CT) is excellent for determining whether there is intraorbital extension of PNS disease. However, when the infection approaches the orbital apex, a magnetic resonance imaging (MRI) study with contrast is necessary to assess spread into the cavernous sinus and the intracranial compartment. The goal of this manuscript is to review and characterize imaging findings of PNS infections using CT and MRI allowing determination of the extent of PNS infections and their common and unusual complications in children. In addition, a summary of the development of the normal PNS is provided.

The Pediatric Sinus Staging System: A Computed Tomography-Based Approach to Grading Pediatric Sinus Disease

OBJECTIVES/HYPOTHESIS

Pediatric chronic rhinosinusitis (CRS) is a prevalent disease with few objective measurements available to predict which patients will require surgical intervention. The Lund-Mackay (LM) score for computed tomography (CT) scans is one objective data point available for the adult population; however, a dedicated scoring system in the pediatric population has not been popularized. We present a Pediatric Sinus Staging System (PSSS) that considers both opacification and the varying developmental stages of each sinus.

STUDY DESIGN

Retrospective chart review.

METHODS

We analyzed CT scans of pediatric patients with a diagnosis of CRS. Both LM and PSSS scores were calculated for each scan. Groups were formed based on treatment outcomes and included patients who were treated successfully with medical therapy and/or adenoidectomy (med/adenoid), patients who required functional endoscopic sinus surgery (FESS), and patients who required revision FESS.

RESULTS

Overall, 76 patient scans were reviewed. PSSS values were significantly less than LM for the control group (P = .001) and significantly higher for patients with cystic fibrosis (P = .027) and with CRS with polyps (P = .001). The ideal cutoff for PSSS to distinguish between med/adenoid and single FESS treatment with a sensitivity 90.6% and specificity of 50.0% was ≥2.

CONCLUSIONS

The PSSS gives a more descriptive score by accounting for the opacification and pneumatization of each sinus. Our current results show similar values between PSSS and LM scores, which suggests internal validity. In addition, a PSSS score of ≥2 may help physicians better counsel families on the likelihood of requiring FESS. Further investigation is needed to fully validate the PSSS.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E642-E648, 2021.

Sphenoid sinuses: pneumatisation and anatomical variants-what the radiologist needs to know and report to avoid intraoperative complications

PURPOSE

Sphenoid sinuses are pneumatised structures, placed in the body of the sphenoid bone, with highly variable morphology. The strict relationships with vascular and nervous structures determine the importance of their anatomical variants in otorhinolaryngology and neurosurgery; a precise understanding of the complex anatomy and anatomic variations of these structures is pivotal for radiological diagnosis of paranasal sinuses pathology and for surgical planning, to avoid potential complications. Our aim is to describe the anatomical variants of sphenoid sinuses, and to help general radiologists and specialists in endoscopic surgery in becoming familiar with these sensitive anatomical structures.

METHODS

A literature search of PubMed and Embase (Elsevier) databases was performed using the keywords "sphenoid sinus" and "anatomy, "sphenoid sinus" and "anatomic variants", "sphenoid sinus", and "anatomic variations".

RESULTS

We described the anatomical variants of the sphenoid sinuses anatomy, according to their size, shape, degree of pneumatisation, protrusion of anatomical structures into their lumen, superimposition of ethmoid cells (Onodi cells), and presence of accessory septations CONCLUSION: The information provided by this study may help in the identification and description of the anatomical variations of the sphenoid sinuses and their relationship to neurovascular structures.

The maxillary sinus: physiology, development and imaging anatomy

OBJECTIVES

The maxillary sinus is of paramount importance for otolaryngologists, rhinologists, oral and maxillofacial surgeons, head and neck and dental and maxillofacial radiologists. A comprehensive review article concerning the physiology, development and imaging anatomy was undertaken.

METHODS

Relevant literature pertaining to the physiology of the sinonasal cavity, development of the paranasal sinuses and imaging anatomy of the maxilla and maxillary sinus from 2000 to 2019 was reviewed. Emphasis was placed on literature from the last 5 years.

RESULTS

Extensive recent research using imaging has provided new insights into the development of the maxillary sinus, the other paranasal sinuses and the midface. The fundamental physiological concept of mucociliary clearance and its role in sinus health is emphasized. The paranasal sinuses are an integral part of a common mucosal organ formed by the upper and lower airway.An in-depth understanding of the soft-tissue and neurovascular relationships of the maxillary sinus to the deep fascial spaces and branches of the trigeminal nerve and external carotid artery respectively is required to evaluate and report imaging involving the maxillary sinus.Sinusitis of rhinogenic, rather than odontogenic origin, originates from nasal inflammation followed by anterior ethmoid disease and secondary obstruction of the ostiomeatal unit. The role of anatomical variants that predispose to this pattern of disease is discussed in detail with illustrative examples.The maxillary sinus is intimately related to the roots of the posterior maxillary teeth; the high frequency of mucosal disease and sinusitis of odontogenic aetiology is now well recognized. In addition, an understanding of the anatomy of the alveolar process, morphology of the alveolar recess of the maxillary sinus and neurovascular supply are essential both for deliberate surgical intervention of the sinus and complications related to oral surgical procedures.

CONCLUSIONS

An understanding of the fundamental principles of the development, physiology, anatomy and relationships of the maxillary sinus as depicted by multi-modality imaging is essential for radiologists reporting imaging involving the paranasal sinuses and midface.

The Possible Associations of Nasal Septal Deviation with Mastoid Pneumatization and Chronic Otitis

BACKGROUND:

The nasal septum deviation is the most common deformity of the nasal, and that can be congenital or acquired. Despite many studies exist about the impact of nasal septum deviation on chronic sinusitis and also association between chronic otitis and mastoid pneumatization; few studies exist about the impact of nasal septum deviation on chronic otitis and mastoid pneumatization.

AIM:

The aim of this study was to evaluate the associations of nasal septum deviation and mastoid pneumatization and chronic otitis.

METHODS:

In this study review, all CT scans of PNS and Mastoid View in the imaging section from Imam Ali hospital in 2016-2017 years and cases of nasal septum deviation were enrolled. The nasal septum deviation was recorded, and the degree of nasal septum deviation in the coronal plane that showed the maximum deviation of the nasal septum was recorded. The volume of the mastoid cells automatically and directly was calculated using three diameter measurements (2 coronal diameters and 1 axial diameter) by the program. The software of SPSS 22 was used for statistical analysis.

RESULTS:

There was no relationship between nasal septum deviation severity and incidence of mastoid pneumatization in patients with nasal septum deviation (P > 0.05). There was relationship between nasal septum deviation severity and chronic otitis in patients with nasal septum deviation (P < 0.05). In patients with moderate and severe intensity of nasal septum deviation, the volume of mastoid air cells in deviation side was lower than the front side (P < 0.05).

CONCLUSION:

Based on the results of the CT scan, in patients with moderate and severe nasal septum deviation intensity, the volume of mastoid air cells in deviation side was lower than the front side. Also, there was a relationship between nasal septum deviation severity and chronic otitis.

Classification and volumetric study of the sphenoid sinus on MDCT images

PURPOSE

We aimed to determine the position and size of the sphenoid sinus (SS) in our study and compare the results of the measurements relative to age, gender, and the presence of pituitary adenoma using multidetector computerized tomography (MDCT).

METHODS

We retrospectively evaluated the paranasal sinus computerized tomography (CT) images of 200 individuals (age range of all the individuals 4-84 years; 101 females, 99 males; age range of individuals with pituitary adenoma 15-63 years; 15 females, 9 males) with 24 pituitary adenomas. The shape of SS were identified and classified, volume were measured by MDCT also for individuals with pituitary adenoma.

RESULTS

It was determined that the volume averages were significantly affected by the type of SS. Among all the individuals studied, the sellar type of SS was most frequently observed (41.5%), followed by the postsellar type (38.5%), and the least observed was the presellar type (9%). The volume of the SS is bigger in males than females although the volume is not affected by the presence of pituitary adenomas. The development of the SS continues until the age of nine.

CONCLUSION

The morphology and morphometry of the SS show individual differences. These anatomic variations are important for decision making and application for surgical interventions (especially transsphenoidal surgery).

Computed tomography analysis of intranasal distance of frontal and sphenoid sinus ostiums in children

PURPOSE

Pediatric population may be more prone to complications in comparison to adults because of the variability of developmental changes of paranasal sinuses and skull base. Knowledge of standard columellar distances regarding age in addition to anatomical landmarks is an important guide during functional endoscopic sinus surgery. We aimed to identify standard distances from columella and anterior nasal spine to the anterior and posterior border of frontal and sphenoid sinus ostiums and provide an objective reference graph in regard to age in children.

METHODS

Subjects who are older than 1 year and younger than 18 years who had undergone a head-and-neck, maxillofacial or temporal bone region high resolution computed tomography scan during the last 3 years were obtained from radiological database. The distances from columella and anterior nasal spine to the anterior and posterior border of frontal and sphenoid sinus ostiums were measured and nasofrontal and nasosphenoid angles were calculated.

RESULTS

A total number of 119 children (73 boys, 46 girls) were reviewed. The average age was 7.7 ± 5.0 years. All subjects had normal sinonasal anatomy. We found statistically significantly positive correlation between age and all distances (p < 0.001). Although all measured distances of boys were greater than girls, this difference did not reach statistical significance. Additionally, nasosphenoidal angles were significantly obtuse in boys (p < 0.05).

CONCLUSIONS

Our columellar distance graphic can provide further improvement of surgeon confidence while performing endoscopic sinus surgery or skull base surgery.

Accuracy and precision of manual segmentation of the maxillary sinus in MR images-a method study

OBJECTIVE

To assess the accuracy and precision of segmentation of the maxillary sinus in MR images to evaluate the potential usefulness of this modality in longitudinal studies of sinus development.

METHODS

A total of 15 healthy subjects who had been both craniofacial CT and MR scanned were included and the 30 maxillary sinus volumes were evaluated using segmentation. Two of the authors did segmentation of MRI and one of these authors did double segmentation. Agreement in results between CT and MRI as well as inter- and intraexaminer errors were evaluated by statistical and three-dimensional analysis.

RESULTS

The intraclass correlation coefficient for volume measurements for both method error, inter- and intraexaminer agreement were > 0.9 [maximal 95% confidence interval of 0.989-0.997, p < 0.001] and the limit of agreement for all parameters were < 5.1%. Segmentation errors were quantified in terms of overlap [Dice Coefficient (DICE) > 0.9 = excellent agreement] and border distance [95% percentile Hausdorff Distance (HD) < 2 mm = acceptable agreement]. The results were replicable and not influenced by systematic errors.

CONCLUSION

We found a high accuracy and precision of manual segmentation of the maxillary sinus in MR images. The largest mean errors were found close to the orbit and the teeth. Advances in knowledge: MRI can be used for 3D models of the paranasal sinuses with equally good results as CT and allows longitudinal follow-up of sinus development.

An observational study of the optimal placement of a cerebral oximeter probe to avoid the frontal sinus in children

The frontal sinus is an airspace behind the brow ridge in the skull and can affect the accuracy of the regional cerebral oxygen saturation measurements. We evaluated the optimal location for placement of a cerebral oximeter probe while avoiding the frontal sinus in pediatric patients. This retrospective observational study included 203 pediatric patients aged 3-17 years who had undergone brain computed tomography from November 2010 to December 2015. The patients were divided into five subgroups based on their age. The frontal sinus height was measured from the superior orbital rim. Pneumatization of the frontal sinus was not visible in 78% (3-5 years) and 22% (6-8 years) of the patients. The mean (SD) of the frontal sinus height was 5.9 (3.4), 9.5 (4.1), 14.0 (6.2) 18.6 (8.4), and 21.1 (7.9) mm in the 3-5, 6-8, 9-11, 12-14, and 15-17 year age-groups, respectively. Age was positively correlated with the frontal sinus height (r = 0.61, P < 0.001, 95% confidence interval [CI] 0.513-0.688). A frontal sinus height shorter than 1, 2, and 3 cm were seen in 10 of 11 (91%), 69 of 74 (94%), and 108 of 118 (90%) patients aged 3-5, 6-10, and 11-17 years, respectively. When oximeter probes are applied in pediatric patients, placement based on age can help avoid the frontal sinus.

Prevalence of agenesis of frontal sinus in human skulls with metopism

BACKGROUND

The frontal bone is an anatomical structure of the skull separated by the metopic suture in the childhood. The scientific literature indicates that metopic suture consolidates with closure in the early stages of life. Metopism is the term used to describe a metopic suture that persists up to the adulthood. Persistent metopic suture is associated potentially with the agenesis of the frontal sinus.

AIM

To investigate the prevalence of absent frontal sinuses in dry skulls with metopism.

MATERIALS AND METHODS

The present study was performed after the approval of the local Committee of Ethics in Research. The sample consisted of dry skulls (n=245), aging between 17 and 50 years old, of the Forensic Medical Institute of Goiânia, Brazil. The skulls underwent anthropological exam in the search for metopism. Radiographic exam was performed in the skulls with metopism to verify the presence or absence of the frontal sinus. The radiographic assessment was performed with a Mobile DaRt Evolution device (Shimadzu, Kyoto, Japan) with protocol set in 64 kV and 16 mA).

RESULTS

From the 245 dry skulls, 17 presented metopism. The length of the metopic suture in the skulls, considering the distances between nasio and bregma craniometric landmarks, ranged between 114 mm and 137 mm. Radiographic exams were performed on 16 skulls (one skull was not analysed radiographically because of extensive destruction). Only one skull (6.25%) had the frontal sinus absent. Besides the agenesis, the present study also found four (12.5%) skulls with aplasia and eight (25.0%) hyperplasia of the frontal sinus in dry skulls with metopism.

CONCLUSION

The present study found a low prevalence rate of the agenesis of frontal sinuses in dry skulls with metopism.

Using clinically acquired MRI to construct age-specific ADC atlases: Quantifying spatiotemporal ADC changes from birth to 6-year old

Diffusion imaging is critical for detecting acute brain injury. However, normal apparent diffusion coefficient (ADC) maps change rapidly in early childhood, making abnormality detection difficult. In this article, we explored clinical PACS and electronic healthcare records (EHR) to create age-specific ADC atlases for clinical radiology reference. Using the EHR and three rounds of multiexpert reviews, we found ADC maps from 201 children 0-6 years of age scanned between 2006 and 2013 who had brain MRIs with no reported abnormalities and normal clinical evaluations 2+ years later. These images were grouped in 10 age bins, densely sampling the first 1 year of life (5 bins, including neonates and 4 quarters) and representing the 1-6 year age range (an age bin per year). Unbiased group-wise registration was used to construct ADC atlases for 10 age bins. We used the atlases to quantify (a) cross-sectional normative ADC variations; (b) spatiotemporal heterogeneous ADC changes; and (c) spatiotemporal heterogeneous volumetric changes. The quantified age-specific whole-brain and region-wise ADC values were compared to those from age-matched individual subjects in our study and in multiple existing independent studies. The significance of this study is that we have shown that clinically acquired images can be used to construct normative age-specific atlases. These first of their kind age-specific normative ADC atlases quantitatively characterize changes of myelination-related water diffusion in the first 6 years of life. The quantified voxel-wise spatiotemporal ADC variations provide standard references to assist radiologists toward more objective interpretation of abnormalities in clinical images. Our atlases are available at https://www.nitrc.org/projects/mgh_adcatlases. Hum Brain Mapp 38:3052-3068, 2017. © 2017 Wiley Periodicals, Inc.

Problem-based learning discussion: Medical treatment of pediatric chronic rhinosinusitis

This problem-based learning case focused on the approach to evaluation and management of a 5-year old girl who was "always sick" with sinus infections. The discussion unfolds in a "real life" scenario, i.e., based on information available to the clinician initially and after the acquisition of laboratory data, and, ultimately, after sinus surgery. Emphasis is placed on the differential diagnosis of the patient's symptoms, discussion of the initial management strategy for chronic rhinosinusitis (CRS), evolution from acute rhinosinusitis to CRS, the prevalence of and differential diagnosis of nasal polyps in children, treatment considerations specific for CRS with nasal polyps, the significance of Pseudomonas aeruginosa sinus infection, the significance of an abnormal sweat chloride test in a young child with nasal polyposis, special considerations in children with CRS who have cystic fibrosis, treatment considerations after endoscopic sinus surgery, and, finally, prognostic factors that impact the outcomes of endoscopic sinus surgery. This problem-based learning case highlights many facets of managing refractory CRS in children.

Growth of the maxillary sinus in children and adolescents: A longitudinal study

Maxillary sinus volumetric and surface area data and growth models from longitudinal samples of children and adolescents are presented. Cone-beam radiographic CT scans from two small retrospective longitudinal samples, one from the Baylor College of Dentistry, Dallas, TX (N=17, 12 females, 5 males, 10.9-17.4 years) and one from a group private orthodontic practice in Nevada (N=15, 9 females, 6 males, 6.4-13.4 years) were used to collect maxillary sinus volumes and surface areas from each individual imaged at two times separated by variable intervals. Volume and surface area values were collected in Analyze^® (Mayo Clinic) and growth models were produced in MLwiN^®, a multi-level modeling program. There is a large degree of inter-individual variation. Surface area and surface-area-to-volume ratio (SA:V) changes are particularly variable. Growth models suggest linear growth in both volume and surface area, without growth spurts.

Computed tomographic analysis of frontal recess cells in pediatric patients

OBJECTIVE

To describe the prevalence of frontoethmoid cells and superior uncinate process attachment in pediatric patients with sinonasal symptoms.

METHOD

Fifty high-resolution computed tomographies of the paranasal sinuses for pediatric patients were evaluated for the presence of frontoethmoid cells and uncinate process insertion. The computed tomographies were randomly collected for patients with sinonasal symptoms (age range, 4-15 years) at our clinic. The prevalence of these cells was compared against age group and type of uncinate process.

RESULTS

The prevalence of each structure was agger nasi cell (97%), type 1 frontal cell (39%), type 2 frontal cell (27%), type 3 frontal cell (11%), type 4 frontal cell (1%), supraorbital ethmoid cell (38%), suprabullar cell (57%), frontal bullar cell (9%), and interfrontal septal cell (16%). When excluding the agger nasi cell, 48 patients (96%) had at least one type of frontoethmoid cell and 43 (86%) had at least one frontal cell. The frequency of these cells did not significantly differ based on sex or uncinate process insertion, but it did with age. Lamina papyracea was the most common site of superior uncinate process attachment.

CONCLUSION

Our results indicated a high frequency of frontoethmoid cells in the pediatric age group. The prevalence of these variations changes during childhood development. As in adults, lamina papyracea is the most common site of superior uncinate process attachment. Recognition of these variations in the frontal recess can provide useful information for safe and efficient endoscopic dissection in the frontal recess region.

A principal components analysis: how pneumatization and edentulism contribute to maxillary atrophy

OBJECTIVE

The aim of this retrospective cohort study was to investigate the role of sinus pneumatization and residual ridge resorption in maxillary bone loss in 400 computed tomography (CT) scans.

MATERIALS AND METHODS

In 200 dentate and 200 edentulous patients, both sinuses were analysed using CT scans. The image analysis sequence consisted of manual placement of 24 reference points, followed by automated segmentation and final manual refinement. Finally, a principal components analysis was performed.

RESULTS

A total of 788 sinuses were included into the analysis. The edentulous group (98 female: 67.77 ± 11.28 years, 99 male: 65.22 ± 9.87) was significantly older than the group with teeth (99 female: 46.89 ± 16.77 years, 96 male: 49.74 ± 16.2). Female and male patients did not differ regarding age. The alveolar height differed significantly between the groups (edentulous: 7.1 ± 4.3 mm, with teeth: 9.7 ± 4.1 mm), but not between gender (female: 8.3 ± 4.4 mm, male: 8.5 ± 4.4 mm). Principal components analysis was able to explain 90% of the variation in sinus morphology.

CONCLUSIONS

Prolonged edentulism in the maxillary molar region leads to centripetal and to minor degrees centrifugal ridge resorption. Minor pneumatization occurs in the sinus walls, but the sinus depth underlies the anatomical variation independent of dentition.

Systematic review and case report: Intracranial complications of pediatric sinusitis

CONTEXT

Intracranial complications of rhinosinusitis are rare in the post-antibiotic era. However, due to potentially devastating outcomes, prompt recognition and management are essential.

OBJECTIVE

This study aims to perform the first systematic review of the intracranial complications of rhinosinusitis in order to better characterize their clinical presentation, diagnosis, and treatment, and report a case of frontal lobe empyema secondary to pediatric frontoethmoid sinusitis.

DATA SOURCES

Ovid MEDLINE, Cochrane Library, and Google Scholar.

STUDY SELECTION

Full-text, peer-reviewed journal publications from 1947 to January 1, 2015 in English; focus on intracranial complications of sinusitis; pediatric patients (<18 years of age); studies including data on diagnostic workup and treatment.

DATA EXTRACTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Sixteen studies involving 180 patients were included. An overwhelming majority of patients were young adolescent males (70%). The most common intracranial complications were subdural empyema (49%), epidural abscess (36%), cerebral abscess (21%), and meningitis (10%). Patients most often presented with nonspecific symptoms such as headache, fever, nausea and vomiting. Computed tomography with contrast or magnetic resonance imaging confirmed the diagnosis when intracranial complications were suspected. Typical treatment included surgical incision and drainage, often involving joint neurosurgical and otolaryngological procedures, combined with a long course of antibiotics. The morbidity rate was 27%, and the mortality rate was 3.3%.

LIMITATIONS

All studies were retrospective chart reviews, case series or case reports.

CONCLUSIONS

A review of the currently available literature shows that with a high degree of suspicion, multidisciplinary cooperation and aggressive treatment, favorable outcomes are attainable. The most effective surgical treatment for intracranial complications remains unclear and should be investigated further.

Development of the maxillary sinus from birth to age 18. Postnatal growth pattern

OBJECTIVES

Anatomical and developmental descriptions of the maxillary sinus may be of great clinical importance. An understanding of age-related changes in the dimensions and volume of the normal maxillary sinus may help in the evaluation of radiographs and identification of sinus abnormalities. The aim of the present study was to define growth patterns of maxillary sinuses in children up to the age of 18 years and evaluate the correlation between normal age-related changes in dimensions and volume.

METHODS

The research sample consisted of CT scans of 170 patients subdivided into 17 groups based on age. Normal developmental changes were investigated and linear dimensions measured.

RESULTS

The maxillary sinus, present at birth, increases in size until the end of the 18th year. The growth pattern includes changes in vertical, horizontal and antero-posterior directions. No bilateral dimorphism was observed, but gender-related differences were found in children over the age of 8 years. The most extensive period of growth occurs during the first 8 years and by the end of the 16th year the maximal values of all diameters and volume are reached.

CONCLUSIONS

A CT study of developing maxillary sinuses allowed a precise evaluation of age-related changes in all diameters and volume to be made.

Lund-Mackay and modified Lund-Mackay score for sinus surgery in children with cystic fibrosis

OBJECTIVE

Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF.

METHODS

We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems.

RESULTS

A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p<0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p<0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98).

CONCLUSION

The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

Parapharyngeal and skull base yolk sac tumor: a case report with lessons in diagnosis and management

Yolk sac tumors are rare in the head and neck. A previously healthy 2-year-old female presented with a large parapharyngeal mass. Pathology was pathognomonic for yolk sac tumor, with glandular differentiation and focal mucin production, which has not been reported in a yolk sac tumor. She was treated aggressively with chemotherapy followed by endoscopic exploration with planned resection, but no viable tumor was encountered. Yolk sac tumors can be difficult to diagnose in the head and neck, but complete clinical response can be achieved. New endoscopic approaches to skull base tumors are applicable to the pediatric population with some technical modifications.