ISSN : 2321-3841

Journal of Oral and

Maxillofacial Radiology
May-August 2021 Issue 2 Volume 9
www.joomr.org
 Original Article

Evaluation of olfactory fossa depth using

computed tomography in South Indian
population: A retrospective study
Divya Teja Patil, L. Yashas Ullas,   A. Chaithanya, Dhanvarsha S1, Aluru Venkata Sai Nikhilendra Reddy2,
Harshadeepa Srinivasa3
Departments of Radiodiagnosis and 2Radio‑Diagnosis, Sri Devaraj Urs Academy of Higher Education and Research Centre, Kolar, 1Department
of Medicine, Chinmaya Mission Hospital, 3 Department of Medicine,  Sapthagiri Institute of Medical Sciences, Bengaluru, Karnataka, India

A B S T R A C T

Context: Anatomical variations are very important in planning a paranasal sinus ( PNS) surgery. Currently, there are limited data
on olfactory depth in the South Indian subpopulation. Aim: The aim of this study was to determine the olfactory fossa (OF) depth
using  Computed Tomography (CT) in the South Indian population. Settings and Design: This retrospective study was conducted
in radiology, Sri Devaraj URS Medical College, Tamaka, Kolar. Materials and Methods: A single radiologist analyzed computed
tomography (CT) and medical records of 287 patients from October 2020 to March 2021. OF depth (Keros classification) was considered
the primary outcome variable. Statistical Analysis Used: Descriptive analysis was carried out by mean and standard deviation for
quantitative variables, frequency, and proportion for categorical variables. P <  0.05 was considered statistically significant. Data
were analyzed using coGuide_V.1.0. Results: The mean age was 44.2 years in the study population. Among the study population,
183 (63.76%) were male, and the remaining 104 (36.24%) were female. In people with Keros classification right side, 62 (21.60%)
falls under Type I, 209 (72.82%) were Type II, and 16 (5.57%) were Type III. In people with Keros classification left side, 33 (11.50%)
were Type I, 240 (83.62%) were Type II, and 14 (4.88%) were Type III. Conclusion: Keros Type II OF was more common in the
study population, and the least common was Type III. The knowledge of OF depth may help the radiologists analyze this region’s
scans and minimize complications associated with surgeries in this delicate area.

Key words: Anterior cranial fossa, computed tomography, keros classification, olfactory fossa, paranasal sinus

Introduction the cribriform plate of the ethmoid.[1] The olfactory bulbs

and tracts are present in OF. The thinnest and extremely
variable part of the anterior skull base is the OF, which is
The olfactory fossa (OF) is seen in the anterior cranial
dehiscent in about 14% of patients.[2] Three main forms
fossa as depression and a cribriform plate of ethmoid
of OF were noted by Keros after analyzing 450 cadaveric
forms its floor. This bony plate is delicate and separates the
nasal cavity from the anterior cranial fossa. OF is bounded
medially by crista galli and laterally by the lateral lamella of This is an open access journal, and articles are distributed under the
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Cite this article as: Patil DT, Ullas LY, Chaithanya A, Dhanvarsha S,
DOI: Sai Nikhilendra Reddy AV, Srinivasa H. Evaluation of olfactory fossa depth
10.4103/jomr.jomr_20_21 using computed tomography in South Indian population: A retrospective study.
J Oral Maxillofac Radiol 2021;9:40-4.

Address for correspondence: Dr. L. Yashas Ullas, No. 59/2 Kannur Village and Post Hennur Baglur Main Road,
Bengaluru ‑ 562 149, Karnataka, India.
E‑mail: dryashasullas@gmail.com
Submission: 05‑06‑2021,  Decision: 11-07-2021, Acceptance: 12‑07‑2021, Web Publication: 30-08-2021

40 © 2021 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow
 Patil, et al.: Olfactory fossa depth using computed tomography
skulls. The classification was based on the level of the
ethmoid roof. The depth of the OF in Keros Type I is
1–3 mm; in Type II, 4–7 mm; and Type III, 8–16 mm. Due
to the high incidence of complications during surgeries
in Keros Type III OF is called “dangerous ethmoid”.[3‑5]
Functional endoscopic sinus surgery (ESS) is a minimally
invasive technique used to treat sinusitis. This causes
a significant reduction in the symptoms, the disease
process, and reduces the rate of postsurgery complications
compared to other techniques. It is paramount for the
surgeon to be aware of variations in the OF and ethmoidal
roof region to prevent complications such as cerebrospinal
fluid leakage and anterior ethmoidal artery injury due to
iatrogenic trauma to the skull base, especially the lateral
lamella of the cribriform plate.[6‑8]
Preoperative imaging needs to be carried out to identify
various anatomical variants of the OF, the marginal
thickness of the cribriform plate, and the variable width
of the cribriform plate in the anterior and posterior
third. Imaging modalities such as computerized
tomographic (CT) scans and digital volume tomography
helps in the evaluation of the OF bony configuration.
Computed tomography (CT) is used to detect the type
and extent of anatomical perturbations in the nose and
paranasal sinus region.[4] Although radiological studies have
been done in the past on the occurrence of the different
types of variants of OF, studies in the Indian population
are limited.[9‑12]
Currently, there are limited data on OF depth in the South
Indian subpopulation. Thus, the present study aims to
evaluate the depth of the OF using CT in the South Indian
population.
Objective
To classify the OF depth according to Keros classification.
To determine the association between gender with Keros
classification of OF depth.
Materials and Methods
Study population and study site
The study population was all the patients who attended
the department of radiology of Sri Devaraj Urs Medical
College, Tamaka, Kolar.
Inclusion criteria
All patients who underwent contrast‑enhanced/noncontrast
CT brain and PNS.
Journal of Oral and Maxillofacial Radiology / Volume 9 / Issue 2 / May‑August 2021
Exclusion criteria
• Patients aged <18 years and above 90 years
• Patients with neoplastic lesions of the PNS
• Patients with fractures/trauma to the PNS.
Study design
The study was a retrospective record‑based study.
Sample size and sampling method
All the 287 patient records, which fulfill the inclusion and
exclusion criteria, attended the department from October
2020 to March 2021 were included in the study.
Ethical considerations
The study was approved by the institutional review board
and the ethics committee of the hospital.
Data collection tools and clinical examination
Demographic data were retrieved from the records, and a
single radiologist measured the OF depth from the CT images
according to the protocol used by Shama and Montaser.[8]
The OF depth was calculated from the coronal sections at
the section of maximum depth by drawing three lines.
Line A: Horizontal line connecting the bony boundaries
of orbital foramina (inferior).
Line B: Vertical line joining the junction of the lateral
lamella and fovea ethmoidalis with line A.
Line C: Vertical line joining lateral bony boundary of the
cribriform plate to that of line A.
Computed tomography used was Siemens SOMATOM (16
slice configuration) with the patient in the supine position.
Statistical method
OF depth (Keros classification) was considered the primary
outcome variable. Gender was considered an explanatory
variable. Descriptive analysis was carried out by mean and
standard deviation for quantitative variables, frequency, and
proportion for categorical variables. All quantitative variables
were checked for the normal distribution within each
category of an explanatory variable using visual inspection
of histograms and normality Q‑Q plots. Shapiro–Wilk test
was also conducted to assess normal distribution. Shapiro–
Wilk test P > 0.05 was considered a normal distribution.
The association between categorical explanatory variables
and the quantitative outcome was assessed by comparing
the mean values. The mean differences along with their
95% confidence interval was presented. Paired t‑test was
used to assess statistical significance. The categorical
outcomes were compared using Chi‑square test. P < 0.05
was considered statistically significant. Data were analyzed
using coGuide software. V.1.0.[13]
41
 Patil, et al.: Olfactory fossa depth using computed tomography

Results males (63.76%). Most of the participants had Keros Type II

OF (72.82% right side and 83.62% left side), followed by
Keros Type  I OF. There was no statistically significant
A total of 287 participants were included in the final analysis. gender‑wise difference observed in the distribution of
The mean age was 44.2 years in the study population. Keros classification in this study.
Among the study population, 183 (63.76%) were male,
The mean OF depth was 5.3 ± 1.25 mm on the right side
and the remaining 104 (36.24%) were female. The mean
and 5.42 ± 1.2 mm on the left side in the present study.
OF depth right side was 5.3 mm in the study population.
Similarly, Babu et al. have reported that the mean depth of
In people with Keros classification right side, 62 (21.60%)
OF on the right side is 5.27 ± 1.72 mm and 5.25 ± 1.65 mm
had Type I, 209 (72.82%) had Type II, and 16 (5.57%) had
on the left side in their study.[14] The mean depth in the
Type III. The mean OF depth left side was 5.42 mm in the
studies by Jacob and Kaul and Salroo et al. was 5.08 and
study population. In people with Keros classification left
4.9 mm, respectively.[1,15]
side, 33 (11.50%) had Type I, 240 (83.62%) had Type II,
and 14 (4.88%) had Type III [Table 1].
In the present study, the majority of the participants had
The mean OF depth on the right side was 5.3 ± 1.25 mm Type II OF on both sides (72.82% right side and 83.62%
and on the left side was 5.42 ± 1.21 mm. The difference left side) followed by Type I OF on both sides (21.60% right
between right and left was statistically significant (P value side and 11.50% left side). Similarly, many authors have
0.006) [Table 2]. reported Keros Type II as the predominant type OF. In
the original study by Keros, Type II was the most common
Among the male participants, 40 (21.86%) had Type I Keros Type OF, followed by Type I, which was conducted in
classification right side, 135 (73.77%) had in Type II, and
8 (4.37%) had in Type III. Among the female participants, Table 1: Summary of baseline parameter (n=287)
22  (21.15%) were in Type  I Keros classification right Summary Mean/percentages
Age (years) 44.2±18.62 (ranged 8-95)
side, 74 (71.15%) in Type II, and 8 (7.69%) in Type III. Gender, n (%)
Among the male participants, 24 (13.11%) were in Type I Male 183 (63.76)
Keros classification left side, 149 (81.42%) in Type II, and Female 104 (36.24)
Olfactory fossa depth (right) (mm) 5.3±1.25 (ranged 2.50-8.40)
10 (5.46%) in Type III. Among the female participants, Kero’S classification (right), n (%)
9 (8.65%) in Type I Keros classification right side, Type I 62 (21.60)
91 (87.50%) in Type II, and 4 (3.85%) in Type III. There Type II 209 (72.82)
Type III 16 (5.57)
was no significant difference among males and females in Olfactory fossa depth (left) (mm) 5.42±1.2 (ranged 2.10-8.20)
Keros classification on both right and left sides [Table 3]. Kero’s classification (left), n (%)
Type I 33 (11.50)
Type II 240 (83.62)
The overall mean OF depth, right side, was 3.79 mm in Type III 14 (4.88)
Type I, it was 5.59 mm in Type II, and it was 7.33 mm
in Type III. The overall mean OF depth, left side, was
Table 2: Comparison of mean olfactory fossa depth at
3.11 mm in Type I, it was 5.64 mm in Type II, and it was
right and left positions (n=287)
7.17 mm in Type III. Among the male participants, the
Olfactory fossa depth Mean±SD (mm) P
mean OF depth, right side, was 3.79 mm in Type I, it was Right 5.3±1.25 0.006
5.65 mm in Type II, and it was 7.33 mm in Type III, and Left 5.42±1.21
the mean OF depth left side was 3.12 mm in Type I, it SD: Standard deviation
was 5.5.69 mm in Type II, and it was 7.27 mm in Type III.
Among the female participants, the mean OF depth right Table 3: Summary of Kero’S classification with gender
side was 3.79 mm in Type I, it was 5.49 mm in Type II, and (n=287)
it was 7.33 mm in Type III, and the mean OF depth left side Keros Gender P
classification
was 3.10 mm in Type I, it was 5.55 mm in Type II, and it Male, n (%) Female, n (%)
was 6.93 mm in Type III in the study population [Table 4]. Right
Type I 40 (21.86) 22 (21.15) 0.49
Type II 135 (73.77) 74 (71.15)
Discussion Type III 8 (4.37) 8 (7.69)
Left
Type I 24 (13.11) 9 (8.65) 0.41
In the present study, the mean age of the participants Type II 149 (81.42) 91 (87.50)
Type III 10 (5.46) 4 (3.85)
was 44.2 ± 18.6 years, and the majority of them were

42 Journal of Oral and Maxillofacial Radiology / Volume 9 / Issue 2 / May‑August 2021

 Patil, et al.: Olfactory fossa depth using computed tomography

Table 4: Summary of Keros classification and olfactory fossa depth with gender‑wise distribution (n=287)
Gender Olfactory Keros classification
fossa depth Type I (mm) Type II (mm) Type III (mm)
Over all Right (ranged) 3.79±1.07 (2.50-5.90) 5.59±0.84 (4.10-7.10) 7.33±0.39 (7-8.40)
Left (ranged) 3.11±0.45 (2.1-3.7) 5.64±0.86 (3-7.1) 7.17±0.41 (6.2-8.2)
Male Right (ranged) 3.79±0.96 (2.5-5.9) 5.65±0.86 (4.1-7.1) 7.33±0.39 (7-8.2)
Left (ranged) 3.12±0.47 (2.1-3.7) 5.69±0.83 (3-7.1) 7.27±0.35 (7.1-8.2)
Female Right (ranged) 3.79±1.27 (2.5-5.9) 5.49±0.81 (4.1-7) 7.33±0.43 (7.1-8.4)
Left (ranged) 3.10±0.43 (2.5-3.7) 5.55±0.90 (3.5-6.9) 6.93±0.49 (6.2-7.2)

Germany.[3] Studies by Elwany et al. and Güldner et al.
reported 64%, 56.8% of the cases as Keros Type II,
followed by 13%, 42.5% of the cases as Keros Type I,
respectively.[7,16] Many Indian studies also reported Keros
Type II as the common OF type. Studies by Babu et al. and
Salroo et al. reported Keros II in 61%, 74.6% Keros I in
29%, and 17.5% in Kashmir and Kerala.[14,15] This suggests
that there is a risk of inadvertent intracranial entry through
the lateral lamella if they undergo ESS in these populations.
Gauba et al. noted that Keros classification helps provide
an objective assessment of the anatomy of the anterior
skull base and thereby guide the surgeon during surgical
procedures in this region and may help to improve the
safety profile of the procedure.[17]
The mean age of the participants was 44.2 ± 18.6 years, and
the majority of the participants were males (63.76%), in this
study. No statistically significant difference was observed in
the distribution of Keros classification between males and
females. A similar pattern was observed in Babu et al. and
Salroo et al. with a mean age of 44.5 years and 36.76 (±13.82)
years, the majority were male participants, and no statistically
significant gender‑wise difference in the distribution of
Keros classification was observed.[14,15] In contrast, in a study
by Basti et al. in South Karnataka, Type 1 Keros was more
common in the male population and Type II in females,[18]
whereas Elwany et al. reported that Keros Type II was found
more frequently in men and Keros Type I in women.[7] This
significant difference in the result between the current study
and other studies may be attributed to the difference in the
population of different ethnicity and races.
Although the occurrence of Keros Type III is low in the
present study, it was slightly more among males and on
the left side. Due to its long length of the lateral lamella,
the Keros Type III is considered to be more susceptible
to iatrogenic lesions during frontoethmoidal surgery.[19,20]
Computed tomography has contributed greatly in the
medical field to diagnose, to evaluate different sinonasal
diseases, and to understand important anatomical
landmarks. Several studies have documented this fact
highlighting the importance and precision of radiographic
evaluation of the ethmoid roof and its validity in providing
safe surgical procedures.[19,21] Thus, it is mandatory for
successful ESS to do an optimal preoperative evaluation,
including CT scan, and surgeons should have a thorough
knowledge of paranasal anatomy. These asymmetries in
the anatomy of OF need to be kept in mind to prevent
complications.[22]
Conclusion
The majority of the participants were under of Keros
Type II, followed by Type I and Type III. Adequate
data on the variability of the anatomy of the olfactory
area are very helpful in the preoperative workup of
patients with diseases of the nose and paranasal sinuses.
Inadequate attention to the anatomy of this area can lead
to damage of the cribriform plate and structures of the
olfactory analyzer with corresponding consequences such
as rhinoliquorrhoea, meningitis, loss of the sense of smell,
and brain abscesses.
Acknowledgments
We acknowledge the technical support in data entry,
analysis, and manuscript editing by “Evidencian Research
Associates.”
Financial support and sponsorship
The project was self‑funded. No external agency had
funded the project.
Conflicts of interest
There are no conflicts of interest.
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