Communication issue - What should the radiologist report
before functional endoscopic sinus surgery
Poster No.: C-0509
Congress: ECR 2015
Type: Educational Exhibit
Authors: 1 1 2 1 1
A. M. Dobra , C. A. Badiu , A. Balint , I. Barsan , M. Buruian , G.
1 1 2
Muhlfay ; Targu Mures/RO, Bistrita/RO
Keywords: Ear / Nose / Throat, Anatomy, CT, Diagnostic procedure, Surgery,
Normal variants, Education and training
DOI: 10.1594/ecr2015/C-0509
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Page 1 of 13
Learning objectives
The aim of this poster is to improve communication between radiologist and ENT
surgeon, by presenting a systematic approach in the computed tomography evaluation
of paranasal sinuses prior to functional endoscopic sinus surgery.
Background
FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) is a minimally-invasive
surgical procedure which aims to restore normal sinus drainage and ventilation. It
involves removal of diseased mucosa and bone in order to reestablish the normal flow
of mucosal secretions.
INDICATIONS for FESS include:
- chronic sinusitis refractory to medical treatment
- recurrent sinusitis
- nasal polyposis
- sinus mucoceles
- selected tumors excision
- cerebrospinal fluid leak closure
- orbital decompression
- optic nerve decompression
- foreign body removal
COMPLICATIONS associated with FESS vary from minor and temporary to permanent.
Anatomical variants predispose certain structures to injury during FESS. Possible
complications include:
- hemorrhage
- recurrent inflammatory disease
- synechiae formation
- orbital injury
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- diplopia
- orbital hematoma
- nasolacrimal duct injury
- CSF leak
- intracranial complications
Today, MULTIDETECTOR COMPUTED TOMOGRAPHY is the reference standard,
mandatory in the preoperative evaluation of paranasal sinuses.
Patient preparation prior to paranasal sinus MDCT evaluation is very important. If signs
of acute sinusitis are present, mucosal abnormalities and inflammatory fluids will distort
the anatomy encountered by ENT surgeon after resolution of acute inflammatory phase.
Imaging of paranasal sinuses involves scanning in axial plane. From the raw data
additional MPR images are obtained in coronal and sagittal planes, using both bone and
soft tissue windows. Coronal plane is preferred because it simulates the plane seen by
the ENT surgeon.
In the majority of patients evaluated for sinusitis only unenhanced scans are performed
but if a neoplastic process is suspected intravenous contrast is given.
RADIOLOGIC REPORT should include information about 4 key points:
- the pathological transformation of the normal anatomy
- anatomical variants if they are present
- evaluation of critical variants
- condition of soft tissues of brain, neck and orbits
Findings and procedure details
Using a 64-slice CT scanner we will present a systematic approach that will guide
radiologist to give the best clues to the surgeon before a functional endoscopic sinus
surgery.
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Based on the key points that have to be included in the radiological report and the
structures encountered in FESS technique we will make a stepwise presentation.
A systematic approach is required in interpreting MDCT scans. Reading the scans has
to be organized from top to bottom (on axial plane) and from anterior to posterior (on
coronal plane) in order to analyze all the structures.
In order to offer to the ENT surgeon a preoperative anatomical road-map, the radiologist
has to know the NORMAL ANATOMY.
It is also mandatory for the radiologst to identify ANATOMICAL VARIANTS and
their implications. These can have intraoperative consequences affecting operative
techniques or postoperative effects predisposing to possible complications.
NASAL SEPTUM
- one of the first structures encountered, intraoperatively, on entering nasal cavity
- forms the medial border of nasal cavity and has two parts:
o soft mobile septum (anterior)
o hard portion (posterior)
- extends to the perpendicular plate of the ethmoid bone postero-superiorly and the vomer
postero-inferiorly [Figure 1]
SEPTAL DEVIATION may cause nasal cavity obstruction and may limit endoscopic
visualization and access during procedure. Septoplasty in conjunctions with FESS may
be needed. [Figure 2]
INFERIOR TURBINATE
- first structure encountered intraoperatively, beside nasal septum
- extends along the inferior nasal wall posteriorly towards the nasopharynx [Figure 1]
- the nasolacrimal duct opens in the posterior part of inferior meatus
Edematous and enlarged inferior turbinate may be present in patients with allergic
component in their disease. Turbinate reduction in conjunction with FESS may be
benefic.
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MIDDLE TURBINATE
- next structure encountered as the endoscope is advanced through nasal cavity [Figure
1]
- it has three anatomical parts:
o anterior third runs vertically from posterior to anterior; superior it is attached at the
lamina cribrosa of the cribriform plate to the skull base
o middle third inserts laterally on lamina papyracea
o posterior third becomes horizontal and attaches to the lateral nasal wall
- the cranial part referred to as BASAL LAMELLA divides the anterior and posterior
ethmoid air cells [Figure 3]
- represents the landmark for access to the posterior ethmoidal air cells
CONCHA BULLOSA represents pneumatized middle turbinate and is a relatively
common anatomical variant. It may cause obstruction of ethmoid infundibulum. [Figure 4]
PARADOXICAL MIDDLE TURBINATE appears when the convexity of the bone is
directed laterally (unlike the normal situation when the convexity of middle turbinate is
deviated medially). This may lead to obstruction of middle meatus.
UNCINATE PROCESS
- the next key structure encountered in FESS
- it is a L-shaped bone of the lateral nasal wall, part of the ethmoid bone
- it runs along the inferior margin of the ethmoid infundibulum or hiatus semilunaris, which
is the location of osteomeatal complex (OMC), where the ostium of the maxillary sinus
opens [Figure 5]
- it has a complex attachment:
o anteriorly - to nasolacrimal apparatus
o inferiorly - to ethmoidal process of the inferior turbinate
o posteriorly - it has a free margin
o superiorly - variable to the middle turbinate, lamina papyracea or skull base
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- surgically, the uncinate must be removed in order to gain access to the ethmoid
infundibulum; maxillary sinus ostium can be visualized and enlarged by a maxillary
antrostomy
Uncinate process may be deviated laterally causing narrowing of the hiatus semilunaris
and infundibulum. If it is too laterally, there is a risk of entry into the orbit, and subsequent
risk of loss of vision.
MAXILLARY SINUS
- with an approximate volume of 15 ml, it is bordered by:
o superiorly: inferior orbital wall
o medially: lateral nasal wall
o inferiorly: alveolar portion of maxillary bone
[Figure 1]
ETHMOID SINUS
- consists of a variable number of air cells (7-15)
- it is bounded:
o laterally: lamina papyracea
o superiorly: the floor of the anterior cranial fossa
- the basal lamella of the middle turbinate separates the anterior ethmoid air cells from
the posterior ethmoid air cells [Figure 3]
- anterior ethmoid cells drain to the middle meatus and posterior ethmoid cells drain into
the superior meatus
Due to the location and close relationship with the orbit and anterior skull base,
intraoperative there is a risk of penetration superiorly into the floor of anterior cranial fossa
or laterally through lamina papyracea.
ETHMOID BULLA
- reliable surgical landmark in FESS
- it is the largest and most constant anterior ethmoid air cell [Figure 1]
Page 6 of 13
- located on the lateral wall of the middle meatus, it is bounded inferiorly by the ethmoid
infundibulum into which it drains
AGGER NASI CELL is the most anterior ethmoid air cell, present anterior to the
attachment of middle turbinate and frontal recess. They are consistent findings and if they
are large they may cause medial displacement of the middle turbinate causing narrowing
of the frontal recesess.
HALLER CELL represents ethmoidal air cells located into the roof of maxillary sinus or
into the floor of the orbit. If they are large they may obstruct maxillary sinus ostium.
ONODI CELL is the most posterior ethmoid air cell which extends superiorly and laterally
to the sphenoid sinus lying medial to the optic nerve. Intraoperative entering sphenoid
sinus through what is thought to be the most posterior ethmoid cell rather than an Onodi
cell may cause damage to the optic nerve and internal carotid artery.
The radiologist also has to identify and evaluate the following CRITICAL VARIANTS:
LAMINA PAPYRACEA
- congenital or posttraumatic dehiscence of the lamina papyracea has to be identified
because it provides direct route for sinus surgery instruments intro the orbit and increases
the risk of orbital content damage [Figure 6]
CRIBRIFORM PLATE
- the lateral lamella is the thinnest part of the cribriform plate and it is at risk of fracture
during FESS
- anatomic variations as olfactory fossae depth or asymmetry may increase the risks of
intracranial penetration and anterior or posterior ethmoidal artery damage [Figure 7]
- Keros classification describes the position of the cribriform plate relative to the fovea
ethmoidalis:
o Keros I: 1-3mm
o Keros II: 3-7mm
o Keros III: 7-16mm
SPHENOID SINUS
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- the most posterior of the sinuses [Figure 8]
- it is related to important, potentially hazardous structures including:
o internal carotid artery: typically the most postero-lateral structure within sphenoid sinus
o optic nerve: produces a antero-posterior indentation in the roof of the sphenoid
Description of PATHOLOGICAL TRANSFORMATIONS should include the extent of
sinus opacification and opacification of sinus drainage pathways.
It is important to delimitate an acute sinusitis from chronic conditions. CT findings in acute
sinusitis include sinus opacification, air-fluid levels, and thickened localized mucosa. In
chronic sinusitis suggestive imaging findings include mucosal thickening, opacified air
cells, bony remodeling. Bony erosion may occur in cases associated with polyps and
mucoceles. Bone destruction raises the suspicion of tumors or granulomatous disease
processes. Polyps appear as rounded masses and may cause mass effect, obstruction
and secondary infections.
Images of SURROUNDING TISSUES should be obtained using soft tissue windows, in
order to detect and evaluate the extrasinus extension of disease in the orbit, neck and
brain. Pathologic findings may lead to contrast administration and further investigations.
Images for this section:
Page 8 of 13
Fig. 1: Coronal CT image shows normal anatomy: nasal septum (NS), inferior turbinate
(IT), middle turbinate (MD), ethmoid bulla (BE) and maxillary sinus (Max). References:
Department of Radiology, Emergency Clinical County Hospital of Targu Mures.
Fig. 2: Coronal CT image shows nasal septum deviation from right to left. References:
Department of Radiology, Emergency Clinical County Hospital of Targu Mures.
Fig. 3: Axial CT image shows basal lamella (arrow) that separates the anterior ethmoid
air cells (AnE) from the posterior ethmoid air cells (PoE). Note the nasolacrimal duct
(circle). References: Department of Radiology, Emergency Clinical County Hospital of
Targu Mures.
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Fig. 4: Coronal CT image shows an anatomic variant - concha bullosa representing
pneumatized middle turbinate. References: Department of Radiology, Emergency
Clinical County Hospital of Targu Mures.
Fig. 5: Coronal CT image shows normal aspect of the osteomeatal complex (OMC)
which consists of four structures: hiatus semilunaris (circle), uncinate process (arrow),
Page 10 of 13
infundibulum (line) and maxillary sinus otarstium (star). References: Department of
Radiology, Emergency Clinical County Hospital of Targu Mures.
Fig. 6: Coronal CT image shows lamina papyracea (LP) one of the structures that
can be potentially hazardous during FESS, especially when it is dehiscent. References:
Department of Radiology, Emergency Clinical County Hospital of Targu Mures.
Page 11 of 13
Fig. 7: Coronal CT image shows fovea ethmoidalis (FE), crista galli (CG) and another
structure that can be critical during FESS - the cribriform plate (CP). According to the
depth of the olfactory fossa (line) in this case the CP belongs to Keros II. References:
Department of Radiology, Emergency Clinical County Hospital of Targu Mures.
Fig. 8: Axial CT image shows sphenoidal ostium (arrow) and sphenoid sinus (SS), one of
the potentially hazardous structures during FESS, because of its close relationship with
internal carotid artery and optic nerve. References: Department of Radiology, Emergency
Clinical County Hospital of Targu Mures.
Page 12 of 13
Conclusion
In order to decrease possible intraoperative and postoperative complications, the
radiologist has to give precise clues to the surgeon.
The preoperative report should include not only details about the existing pathology
but also information about anatomy, including: anatomical variants, critical variants and
surrounding tissues.
An accurate approach is compulsory in the preoperative imaging evaluation but the
postoperative feedback from the ENT surgeon to the radiologist can be an important step
for better results in the future.
Personal information
References
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199-204
3. Vaid S, Vaid N, Rawat S, et al. An imaging checklist for pre-FESS CT: framing a
surgical relevant report. Clin Radiol. 2011 May; 66(5): 459-70
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multidetector computed tomography - how does it help FESS surgeons? Indian J Radiol
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