The Journal of Laryngology and Otology

June 1990, Vol. 104, pp. 477-181

CT of the paranasal sinuses: study of a control series in

relation to endoscopic sinus surgery

G. A. S. LLoYD D.M., F.R.C.R. (London)

Abstract
A controł series of biplane CT scans of the paranasal sinuses, derived from patients examined for orbital
tumours, is described. The scans were assessed for the presence of anatomical variants in the middle meatus,
said to contribute to meatal stenosis, and for signs of asymptomatic infection revealed by the pres ence of
clouding or mucosal thickening in the sinuses.
Of the anatomical variants, only concha bullosa (pneumatisation of the middie turbinate) was assuciated with
a high incidence of infection in the sinuses (85 per cent). Evidence of asymptomatic sinus infection was as high as
39 per cent overall, the highest inçidence occurring in the ethmoid cells (28 per cent). Isolated ethmoid clouding
on CT was observed in 15 per cent and is likely to be found in as many as one in seven of the adult population in
the UK. It s concluded that in the majority of patients clouding confined to a few ethmoid cells shown on CT is
without clinical significance.
The evidence from the control series did not support the concept that mnost sinus infection starts in the
middle meatus. The presence of a large reservoir of quiescent or chronic sinus infection in the control group
suggests that in most instances sinusitis derives from a recrudescence of this pre-existing infection.

Introduction bullosa and an enlarged, overpneumatised ethmoid

Although nasal and sinus endoscopy was originally
described by Hirschmann (1903) using a cystoscope, it was
not until 1978 that Messerklinger published the first
comprehensive account in English of the technique and its
application to the diagnosis and treatment of naso-sinus
disease. Previously the same author (Messerklin-ger, 1967)
in his study of the drainage of the normal frontal sinus had
identified mucociliary backflow into
the sinus cavity from the frontal recess, providing a
potential route for the introduction of infection. He also
demonstrated a similar retrograde flow into the maxil-lary
antrum from the ethmoids via the middle meatus
(Messerklinger, 1978). His conclusion was that in the
majority of patients infection spreads from the ethmoids to
the maxillary antra and frontal sinuses via the middle
meatus, infundibulum and frontał recess. Stammberger
(1986) and Stammberger and Wolf
(1988) believe that most sinus infections are rhinogenic in
origin. The infection usually starts in the middle nasal
meatus with mucosal contact, cessation of ciliary action,
stasis and infection. They assert that most often these
processes remain localised to the middle meatus, but in
other patients the recessus frontalis or ethmoid
infundibulum may become obstructed with poor ven-
tilation and secondary infection in the larger adjacent
sinuses. Anatomical variations in the middle meatus are
said to contribute to the middle meatal blockage: these
include agger nasi cells and I
ler cells, a bent uncinate
process, a paradoxically bent middle turbinate, concha
bulla.
Messerklinger has devised surgical procedures to cor-rect
these underlying problems in sinus infections and these have
been collectively referred to as functional endoscopic sinus
surgery (Kennedy es al., 1985). The
pre-operative assessnment of these patients is based upon a
combination of nasal endoscopy and CT -the par ticular
role of the latter being to provide information about
mucosal changes deep in the osteomeatal complex not
readily evaluated endoscopically: this includes the frontal
recess, ethmoid infundibulum, anterior ethmoid cells and
the ostium of the maxillary antrum. For these studies,
direct coronal imaging is needed and a CT machine
capable of high spatial resolution.
In order to study the frequency of the anatomical vari
ants. which may contribute to middle meatal stenosis, and
also to assess the incidence of asymptomatic infec tion in
the paranasal sinuses, an analysis has been under taken of
a series of CT examinations of patients scanned to
investigate orbital disease. These were seen at the Orbital
Clinic at Moorfields Eye Hospital in the 10 years, 1978-
1988. Whilst demonstrating the orbital pathology, they
also furnish a control series of biplane CT studies of the
nose and sinuses.
Material and method
The CT scans of 100 patients investigated for three
types of orbital tumour were examined. These com
prised 52 cavernous haemangiomata, 34 optic nerve

Based on a paper given to the Section of Laryngology of the Royal Society of Mcdicine, 1 December 1989.
Accepted for publication: 7 March 1990.

477
478 sheath meningiomas and 14 orbital dermoids, all of which were
verified histologically. The average age of the patients
concerned was 39 years (age range 10-78). There were 45
males and 55 females. The patients came from all parts of the
United Kingdom, no area predom-inating, so that they
presented a fair cross section of the adult population. They
satisfied two criteria: 1) They ail had been investigated by
high resolution biplane CT, which included the sinuses as
well as the orbits; 2) the orbital tumour did not affect the
paranasal sinuses in any way. For this reason, only
intraconal tumours (cavern-ous haemangioma and sheath
meningioma) were used in the control series, or extraconal
tumours affecting the lateral orbit (dermoids).
Results
Examination of the CT scans of these patients
revealed the following frequency of the anatomical vari
ants affecting the middle meatus:
Concha bullosa
14%
Bent uncinate process
16%
Reversed or paradoxical middle turbinate
17%
Overpneumatised ethmoid bulla
17%%
Agger nasi cells
3%
Haller cells
2%
Asymptomatie sinus infection in the control group
A feature of the control group was the high incidence of
clouding of the sinuses or mucosal thickening, indica-tive of
infection or allergic sinus disease. Overall, 39 of the patients
in the control group showed some evidence of sinus clouding
on CT and this was judged to be exten-sive in 21 with at least
two sinuses involved. A retrospec tive study of 16 of the
latter group of patients revealeda clinical record of sinus
infection in only one, so that in the case notes available 94
per cent were apparently
i. 1
Coronal CT. Concha bullosa (arrow) associated with mucosal
occlusion in the middle meatus.
CTOF THE PARANASAL STNUSES
G.AS. LLOYD
asymptomatic. The following sinuses were involved:
ethmoids (28 per cent), maxillary antra (18 per cent).
sphenoids (3 per cent) and frontal sinuses (2 per cent).
The low percentage for the frontal sinuses was largely
due to underdiagnosis: the CT sections taken for the orbit
did not always include the vertical part of the sinus in the
frontal bone.
Discussion
Concha bullosa
Pneumatisation of the middle turbinate is usually bilateral
and may grow to such extent that the bulging heads of the
turbinates completely fill the space between the septum and
the lateral nasal wall. The entrance to the middle meatus
may become completely blocked cre ating areas of mucosal
contact (Stammberger and Wolf, 1988) (Figs. 1, 2). The fact
that thiş anatomical variant may predispose to sinus
infection was supported by the control group in which 11 of
the 14 patients showing this anomaly were associated with
CT evidence of asympto-matic sinus infection. The affect of
concha bullosa on the
middle meatus is similar to that of an hypertophied middle
turbinate seen in association with septal
deviation.
Bent uncinate process
The uncinate process may be bent in two directions: its
posterior margin may be deflected medially so that it
approximates to the middle turbinate (Fig. 3); or it may be
curvcd laterally narrowing the hiatus semilunaris and
ethmoid infundibulum. Athough this anomaly was pres-ent
in 16 per cent of the control group, it was not associ-ated
with any increase in asymptomatic sinus infection either
when present singly or in association with the other two
variants listed below.
2
Coronal CT. Infected concha bullosa (arrow) associated with
middle meatus oclusion.
 479

Paradoxicaly bert or reversed middle turbinare (Fig. 4) This

anomaly consists of a reversal of the normal out-ward
concavity of the middle turbinate; when it occurs it may
block the entrance to the middle meatus (Stamm-berger and
Wolf, 1988). In the control series it was pres ent in 17 per
cent of patients but was found to be a very variable feature
and to some extent depends upon the level of the coronal CT
section; some patients showed a paradoxical turbinate
anteriorly and a normal curve pos teriorly. Alternately a
normal turbinate may be seen on one side and a paradoxical
turbinate on the other. As in the bent uncinate process, this
variant was not associ-ated with any increase in
asymptomatic sinus infection.

Enlarged ethmoid bulla

The ethmoid bulla can be over-pneumatised so that it
encroaches on the middie meatus and completely fills the
space in the convexity of the middle turbinate (Fig. s).This
anomaly is not always easy to assess and initially tended to
FiG. .3 be overdiagnosed in the control group, so that the figure of
Coronal CT. Bilateral bent uncinate process with medial 17 per cent is probably an over-estimate of its true
incurvation (arrows). frequency. This variant was associated with CT evidence of
sinus infection in 35 per cent, which was slightly below
average for the series as a whole.

Agger nasi cels and Haller cells

These were seen in three and two patients respectively in
the control series. Agger nasi celis may narrow the frontal
recess and obstruct the lower end of the fronto-nasal duct
(Samuel and Lloyd, 1978). Haller cells are anterior ethmoid
cels that grow into the floor of the

FiG. .4
Coronal CT showing paradoxically bent or reversed middle Fio.S
turbinates (arrows). The turbinates prcsent a convex curve Coronal CT showing an entarged, over-pncumatiscd ethmoid bulla
laterally. encroachng on the middle meatus (arrow).
480 orbit and may narrow the adjacent ostium of the maxil lary
sinus.. This is especially likeły to occur if the cels become
infected. In the series under review both were an infrequent
finding and no conclusions could be drawn concerning their
relevance to the aetiolgy of chronic or recurrent sinus
infection.
Obstruction in the middle meatus
Recent publications (Messerkinger, 1979; Stamm-berger,
1985; Kennedy et al., 1985; Stammberger and Wolf, 1988)
suggest that most sinus disease starts in the middle nasal
meatus, which may then spread to adjacent sinuses (see
above). If the process remains localised to the middle meatus
according to these authors, it may still cause 1ypicał sinusitis
symptoms: for example feeling of pressure, congestion and
fullness; a postnasal drip, or headaches.
In the contro! series under review, eight (8 per cent)
showed unilateral or bilateral middle mcatus obstruc-tion of
whom all but one showed associated sinus cloud ing on the
CT scans. There was therefore a strong association of CT
evidence of sinus infection in those patients with a middle
meatus obstruction. On the other hand, of the 39 patients in
the series showing evidence of sinus clouding only seven
were associated with middle meatal obstruction (18 per
cent). The predominance of this large reservoir of quiescent
or chronic infection in the sinuses in the control group would
suggest that the majority of symptomatic exacerbations of
acute or chronic sinusitis stem from the sinuses rather than
the middle meatus. where only a small minority showed
abnormality. The evidence, such as it is, does not sup-port
the thesis that "sinus disease usually starts in the
middle meatus' (Stammberger and Wolf, 1988). It seems
equally likely that drainage of infected sinusesis
obstructed by secondary middle meatal infection, which in
turn exacerbates and prolongs the primary sinusitis.
Drettner (1967) in a study of the permeability of the
maxillary ostium, recorded a high ostial resistance in
chronic sinusitis, but found it impossible to judge
whether this was the cause of the chronic sinusitis or the
result of a persistent infection. He quoted the work of Flottes
et al. (1960) concerning the pathophysiology of sinusitis.
These authors postulated a vicious circle in which persistent
sinus infection and ostial obstruction interact, the one giving
rise to the other and vice versa. However, in terms of the
treatment of chronic sinusitis the argument is largely
irrelevant, since relief of the middle meatal stenosis by
endoscopic surgery is likely to abort the infection and
reduce the occurrence rate, whatever its site of origin.
The significance of opaque ethmoid ecells on CT
A feature of the control series was the high incidence of
opacity of the paranasal sinuses (39 per cent), the eth-moid
cells being the commonest affected (28 per cent). Figure 6 is a
histogram showing the relative occurence of ethmoid
clouding seen in the control group and in a group of 40
symptomatic patients from the Rhinology clinic at the Rayal
National Throat Nose and Ear Hospi-tal (Lund, 1990).
Overall it can be seen that clouding of the ethmoids on CT
was more common in the sympto-
CT OF THE PARANASAL SINUSES
2) Clouding of the sinuses indicating past or present sinus
infection was seen in 39 per cent of the patients in the control
group. This was extensive in 21l per cent with more than one
sinus involved.
G. A.S. LLoYD
matic group than the asymptomatic, but that in contrast
clouding isolated to the ethmoids was three times more
common in the control group than in symptomatic patients.
lt is probable that the clouding of the ethmoid cells seen in
the majority of the asymptomatic patients represents a
residuum of previous infection rather than active disease-a
sitauation to the radiologist analogous to the presence of
pleural thickening on a chest X-ray.
The evidence would suggest that as many as one in seven of
the adult population in the UK may exhibit clouding of a few
ethmoid cells as a result of a previous eth-moiditis. It follows
that isolated clouding in the eth-moids demonstrated on CT is
unlikely to be causative of symptoms in the majority of
patients showing this X-ray sign. It is in fact only likely to be
associated with symnp-toms of sinusitis when other sinuses
are involved. In practice, therefore, it is not possible to
attribute symp toms such as headache to the presence on CT
of an opac ity confined to a few ethmoid cells.
Concusions
Study of a control series of CT scans of the paranasal
sinuses in 100 patients examined for orbital tumours
revealed the following findings:
1) Anatomical variants in the structure of the middle meatus,
said to contribute to drainage obstruction of the sinuses, were
present either singly or in combination in 40 per cent of
patients. Only pneumatisation of the middle turbinate (Concha
bullosa) was shown to be associated with the presence of
increased infection in the sinuses (8S per cent).
ETHMOID CLOUDING
70
60
50
40
30
20
10
Control Symptomatic
Group Group
lsolated Clouding
Fc. .6
Histogram showing the percentage frequency of ethmoid clouding on
the CT scans of the control group and a series of symptomatic patients.
Clouding isolated to the ethomids is scen to be three times more
common in the control group than in the symptomatic
patients.
3) The evidence from the control series did not sup-port the
concept that most sinus disease starts in the middle meatus.
Obstruction of the middle meatus was observed in only 8 per
cent of the controls. but 39 per cent showed evidence of sinus
infection. The presence of this large reservoir of quiescent or
chronic infection would suggest that in most instances sinusitis
derives from a recrudescence of pre-existent disease within the
sinuses. The effect of middle meatal obstruction is to prolong
and exacerbate the infection rather than to initiate it.
4) Isolated clouding of the ethmoid cells was shown to be
common in the control group (15 per cent) and three times as
common as in a symptomatic group of patients from the
Rhinology clinic. It is probable that as many as one in seven of
the adult population in the UK will show clouding of some
ethmoid cells from previous sinus infection whether
symptomatic or not. It is therefore not possible to attribute
symptoms such as headache to iso-lated ethmoid clouding
shown by CT, on this evidence alone.
These results have implications for the conduct of the X-ray
investigation of patients who might benefit from endoscopic
nasosinus surgery. Firstly, axial CT sections should be avoided
whenever possible because of the high radiation dose to the
eyes. Doses as high as 400-500 millisieverts may be recorded
when the ethmoid laby-rinth is shown in plan view; this can be
regarded as unacceptable when the demonstration of trivial
opac-ities in the ethmoid cells is of very doubtful significance
in terms of symptomatology. The ethmoid cells are adequately
demonstrated by plain X-ray if high kilovolt
481
age lateral views are routinely used (Lloyd, 1988) and
especially when they are augmented by coronal CT. The
latter is needed to assess the state of the middle meatus; in
particular to show the presence of concha bullosa or middle
meatal stenosis, if this cannot be demonstrated clinically.
Coronal sections have the added advantage of contributing
less than a third of the eye radiation dose given by axial
sections.
References
Drettner, B. (1967) The obstructed maxillary ostium. International
Rhinology, 5: 1O0-104
Flottes, L., Clerc, P., Riu, R., Devilla, F. (1960) Les physiologic
des sus. ses applications cliniques et theerapcutiques. Libraraire
Arnette, Paris.
Hirschmann, A. (1903) Uber Endoskopie der Nase und deren
Nebenhohlen. Archiv für Laryngologie und Rhinologie (Berlinj.
14: 195-202.
Kennedy. D. W., Zinrieich. S. J., Rosenbaum, A. E., Johns. M. E. (1985)
Functional endoscopic sinus surgery. Theory and diag-nostic
evaluation. Archives of Otolaryngology. 111: 576-582.
Lloyd. G. A. S. (1988) Diagnostic Imaging of the Nose and Para nasal
Sinuses. Springer-Verlag: London, Heidelber8
Lund. V. . (1990) In Press. Joumal of the Royal Sociery of Medi-cine.
In Press.
Messerklinger, W. (1967) On the drainage of the normal frontal
sinus of man. Acta Otolaryngologica, 63: 176-181.
Messerklinger, W. (1978) Endoscopy of the Nose. Urban and
Schwarzenberg: Baltimore, Munich.
Samuel, E., Lloyd, G. A. S. (1978) Clinical Radiology of the Ear
Nose and Throat. HK Lewis: London.
Stammberger, H. (1985) Endoscopic surgery for mycotic and chronic
rccurring sinusitis. Annals of Otology, Rhinology and
Laryngoiogy, A: (Supplemcnt) 119. 1-11.
Stammberger, H. (1986) Endoscopic endonasal surgerynew con cepts
in treatmeni of recurring rhinosinusitis. I: Anatomical and
pathophysiological considerations. Otolaryngology-Head and Neck
Surgery, 94: 143-147.
Stammberger, H.. Wolf, G. (1988) Headaches and sinus disease: the
endoscopie appraoch. Annals of Otology, Rhinology and
Laryngolo8y, 7: 3-23.