International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151

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International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

Development of the maxillary sinus in infants and children

Bharat Bhushan a, b, *, Karen Rychlik c, James W. Schroeder Jr. a, b
a
Department of Surgery, Division of Otolaryngology Head & Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, USA
b
Department of Otolaryngology Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
c
Biostatistics Research Core, Stanley Manne Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To examine the age related volume change of the maxillary sinus in children by measuring the
Received 12 September 2016 change of the height, weight, and depth using computed tomography (CT).
Received in revised form Methods: Children <18 years of age who underwent a CT Scan of the sinuses for reasons other than sinus
20 October 2016
related issues were included in the study.
Accepted 21 October 2016
Available online 26 October 2016
Results: 139 patients were included (68 females and 71 Males) and the mean age of the patients was
9.6 ± 5.4 years. The cohort was divided into three groups based on their ages e Age <6 years (n ¼ 45),
age between 6 and 12 years (n ¼ 44) and age > 12 years (n ¼ 50). Patients in each age group demon-
Keywords:
Maxillary sinus
strated an increase in their Maxillary sinus height (p<0.001). Patients < 6years of age and between 6 and
Sinus development 12 years of age had a significant increase in their maxillary sinus width and depth (p < 0.001). The
Children maxillary sinus width, depth and volume did not increase significantly after the age of 12 years in these
Development patients.
Infant sinus Conclusion: We demonstrated periods of significant size increase of the maxillary sinuses as determined
by different dimensions in children at various ages. The height of the maxillary sinus has steady growth
from birth to at least the age of 18 years. The width and depth increase up to 12 years of age.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The maxillary sinuses are complex anatomical structures with
significant inter-individual variations. The developmental pattern
of the maxillary sinuses also varies widely with age [4] [8]. It has
been reported that the development of the maxillary sinus begins
in the prenatal period but the majority of growth occurs after birth.
The development of maxillary sinuses can occur at different rates
and in different dimensions and therefore the shape and size of the
sinuses may be the most variable of all the anatomical structures of
the body.
A keen understanding of the normal development and physi-
ology of the maxillary sinuses is key for the physician who treats
abnormal sinus pathology. Moreover, an understanding of age-
related changes in the dimensions and volume of the normal
maxillary sinus may help in the understanding and development of
sinus abnormalities. Few studies have reported age related changes
in size. Some anatomic studies have proposed scales that may be
used to determine growth rate but most of these scales are grouped
into two axes - width and length [12]. Other studies have specu-
lated on how the size of the sinuses relates to different pathologic
conditions such as chronic sinusitis, cleft palate, nasal obstruction
and allergic rhinitis. Little information is available on the devel-
opment of maxillary sinuses in healthy children.
The current study examines the age related volume change of
the maxillary sinus in children by measuring the change in the
height, weight, and depth using computed tomography (CT). The
differing measurements of each dimension at various ages and the
way in which these differences contribute to the overall volume
change of the sinus are determined. Differences based on gender,
ethnicity and laterality are also explored.

2. Materials and methods

* Corresponding author. Pediatric Otolaryngology Head & Neck Surgery, Ann &
Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Box#25, Chicago,
IL 60611-2605, USA.
E-mail address: BBhushan@luriechildrens.org (B. Bhushan).
URL: http://www.Luriechildrens.org/
2.1. Study design and subjects
This study was conducted at Ann & Robert H. Lurie Children's
hospital of Chicago, a tertiary care hospital located in Chicago, USA

http://dx.doi.org/10.1016/j.ijporl.2016.10.022
0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.
 B. Bhushan et al. / International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151 147

and was approved by its institutional review board. Children less Table 1
than 18 years of age who underwent a Computed Tomography (CT) Piecewise mixed effects models for each sinus measurement by age groups.

Scan of the sinuses from January 2011 through December 2013 for Model Intercept Estimate 95% LCI 95% UCI p-Value
reasons other than sinus related issues were included in the study. Height
Indications for obtaining the CT scan included evaluation of Ages <6 1.015 0.210 (±0.061) 0.086 0.333 0.001
persistent headache, new onset seizures, and other neurological Ages 6e12 1.555 0.127 (±0.022) 0.082 0.173 <0.0001
disease. Details of the CT scan and other demographic factors were Ages > 12 1.325 0.144 (±0.041) 0.062 0.226 0.001
Width
obtained from patient medical records. Patients with a known
Ages < 6 0.799 0.24 (þ0.052) 0.135 0.345 <0.0001
history of developmental abnormalities, craniofacial syndromes, Ages 6e12 1.641 0.068 (±0.027) 0.013 0.123 0.02
mid-facial injuries or fractures, chronic pulmonary diseases, pa- Ages > 12 2.224 0.019 (±0.029) 0.038 0.077 0.50
thologies in the skeletal system, neuromuscular diseases, or those Depth
Ages < 6 1.395 0.322 (±0.072) 0.176 0.467 <0.0001
who were at special risk (wards of the state, those with mental
Ages 6e12 2.42 0.091 (±0.025) 0.041 0.142 0.001
handicaps, were incarcerated, with facial injuries or fractures Ages > 12 3.692 0.001 (±0.029) 0.058 0.06 0.97
within the skull and paranasal sinus disease) were excluded. Each Volume
CT scan was analyzed by a pediatric radiologist and by a pediatric Ages < 6 0.31 2.245 (±0.434) 1.367 3.123 <0.0001
otolaryngologist. In addition, the pertinent data were extracted Ages 6e12 3.28 1.908 (±0.419) 1.063 2.752 <0.0001
Ages > 12 10.273 1.544 (±0.853) 0.175 3.263 0.08
from the patient's chart that included the age, gender, ethnicity and
the indications to scan to be performed. LCI, Lower confidence Interval; UCI, Upper confidence Interval.

2.2. CT scans
The sinus CT scans of the patients less than18 years of age were
reviewed. Patients were divided into 3 groups based on their age:
0e5.99 years old, 6e11.99 years old, and 12e18 years old. The
length, width and depth of the maxillary sinuses were measured.
All measurements were performed using the measure tool avail-
able on the CT viewing software (iConnect access). The measure-
ment technique of the maxillary sinuses in our study population are
similar to the previously reported by Kim et al. [5], who performed
the sinus measurements of cadaveric maxillary sinuses. To avoid
observer variation and to obtain the maximum accuracy, all mea-
surements were taken three times and the mean of those three
values were entered into an excel document.
Maximum horizontal diameter of the maxillary sinus was called
maxillary sinus width. The Maximum vertical diameter of the
maxillary sinus defined as the longest distance from the lowest
point of the inferior wall to the highest point of the superior wall as
presented on the sagittal image was considered as maxillary sinus
height. The maximum antero-posterior diameter of the maxillary
sinus was called as maxillary sinus length was defined as the
longest distance from the most anterior point of the anterior wall to
the most posterior point of the posterior wall on the axial image.
The volume of the maxillary sinus was calculated using the
formulae: Length x width x height.
2.3. Statistical analysis
Descriptive statistics include mean and standard deviation of
sinus measurements. Categorical data is reported as frequencies
and percentages. Age groups were determined by distribution,
clinical relevance and to better understand the growth periods of
children sinuses: pre-school, grade school, and beyond grade
school. To determine demographic differences, piecewise mixed
effects models were run for each age group and each sinus. Models
include age as a continuous fixed effect and patient id as a random
effect to control for variability within each subject's left and right
sinus. Table 1 reports piecewise mixed models by sinus measure-
ment and age group. Figures graphically depict the linear rela-
tionship of age and sinus measurement by age group. Statistical
significance was defined as p-value <0.05 and data were analyzed
in SAS 9.3 (SAS Institute Inc., Cary, North Carolina).
in the final analysis. Sixty-eight (48.6%) were female and 71 (50.7%)
were Male. The mean age of the patients was 9.6 ± 5.4 years. The
patients were divided into three groups based on their ages:
Age<6years (n ¼ 45), age between 6 and 12 years (n ¼ 44) and
age>12 years (n ¼ 50). We did not observe any significant differ-
ence between gender (p ¼ 0.25), race or ethnicity (p ¼ 0.06).
3.1. Maxillary sinus height
In patients less than 6 years of age the mean height of the left
maxillary sinus was 1.76 ± 0.48 and of the right Maxillary sinus was
1.78 ± 0.50 (p ¼ 0.85). In patients between 6 and 12 years of age, the
mean height of the left maxillary sinus was 2.7 ± 0.38 and of the
right Maxillary sinus was 2.7 ± 0.43 (p ¼ 1.00). In patients greater
than12 years of age the mean height of the left maxillary sinus was
3.58 ± 0.62 and of the right Maxillary sinus was 3.56 ± 0.65
(p ¼ 0.87). There was no significant difference between the left and
right maxillary height between any age group. The subsequent data
analysis uses the dimensions of both left and right measurements.
Patients in each age group had significant (p<0.001) increase in
their Maxillary sinus height (Table 1). There was a continuous and
steady increase in the height of the maxillary sinus from birth to the
age of 18years in these children (Fig. 1).
3.2. Maxillary sinus width
In patients who were less than 6 years of age the mean width of
the left maxillary sinus was 1.60 ± 0.51 and of the right Maxillary
sinus was 1.65 ± 0.53 (p ¼ 0.65). In patients between 6 and 12 years
of age, the mean width of the left maxillary sinus was 2.27 ± 0.43
and of the right maxillary sinus was 2.25 ± 0.37 (p ¼ 0.82). In pa-
tients greater than12 years of age the mean width of the left
maxillary sinus was 2.49 ± 0.46 and of the right maxillary sinus was
2.46 ± 0.48 (p ¼ 0.75). There was no significant difference between
the left and right maxillary width between any age group. Patients
<6years of age had a significant increase in their maxillary sinus
width (Table 1). Patients between 6 and 12 years of age also had a
significant increase in the width of maxillary sinus but the increase
was less robust than the patients less than 6 years of age. The re-
sults demonstrated that the maxillary sinus width did not increase
significantly after the age of 12 years. (Fig. 2).

3. Results 3.3. Maxillary sinus depth

Total of 139 patients met inclusion criteria and all were included In patients less than 6 years of age the mean depth of the left
148 B. Bhushan et al. / International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151

Fig. 1. Growth of the maxillary sinus height in children by age group.

Fig. 2. Growth of the maxillary sinus width in children by age group.

maxillary sinus was 2.43 ± 0.65 and of the right Maxillary sinus
was 2.51 ± 0.65 (p ¼ 0.56). In patients between 6 and 12 years of
age, the mean depth of the left maxillary sinus was 3.27 ± 0.38
and of the right Maxillary sinus was 3.25 ± 0.36 (p ¼ 0.80). In
patients greater than 12years of age the mean depth of the left
maxillary sinus was 3.67 ± 0.47 and of the right maxillary sinus
was 3.60 ± 0.54 (p ¼ 0.49). There was no significant difference
between the left and right maxillary depth between any age
group. The subsequent data analysis uses both left and right
measurements. Patients less than 6 years of age and age 6e12
years had a significant (p<0.001) increase in their maxillary sinus
depth (Table 1). These results demonstrated that the maxillary
sinus depth did not increase significantly after the age of 12 years
in these patients. (Table 1, Fig. 3).
 B. Bhushan et al. / International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151
Fig. 3. Growth of the maxillary sinus depth in children by age group.
3.4. Maxillary sinus volume
In patients less than 6 years of age the mean volume of the left
maxillary sinus was 8.12 ± 5.66 and of the right maxillary sinus was
8.76 ± 6.67 (p ¼ 0.63). In patients between 6 and 12 years of age, the
mean volume of the left maxillary sinus was 20.78 ± 6.96 and of the
right maxillary sinus was 20.28 ± 6.71 (p ¼ 0.73). In patients greater
than12 years of age the mean volume of the left maxillary sinus was
34.14 ± 11.95 and of the right maxillary sinus was 33.16 ± 12.86
(p ¼ 0.69). There was no significant difference between the left and
right maxillary volume between any age group. The subsequent
data analysis uses both left and right measurements. Patients less
than 6 years of age and age 6e12 years had a significant increase in
their maxillary sinus volume (Table 1). Our results also showed that
the maxillary sinus volume did not increase significantly after the
age of 12 years in these patients. (Table 1, Fig. 4).
4. Discussion
The volume of maxillary sinus increases from the postnatal
period to adulthood [11,13]. It has been reported that the size of the
maxillary sinus may even continue to increase until the age of
20e30 years [4], [7]. However, it is unclear how the volume of the
maxillary sinus changes over time and whether or not the increase
in size is steady or marked by growth spurts. Furthermore, it has
not been determined if and at what time period one particular
dimension (with, length, height) drives the volume change of the
sinus. Difference in the growth rate of paranasal sinuses in children
would have implications in the treatment of children with sinus
disease.
Jun et al. [4] conducted a study in Korean patients aged from 0 to
80 years and suggested that the maxillary sinuses of males reach
their maximum volume at ages 21e30 years and in women at ages
11e20 years. In another study conducted on Japanese population,
Ariji et al. [1] reported that the volumes of the sinuses increased up
to the age of 20 years and then decreased. The same authors also
reported that the difference in right and left sided dentition had no
149
influence on the maxillary sinus volume over the age of 20 years.
Study by Schatz et al. [9] suggested that the maxillary sinus in-
creases in volume for a period up to 15 years and maintains a
similar volume thereafter. In contrast to these findings, Weiglein
et al. [13] conducted a study on dried skulls of Australian cadavers
and reported that the maxillary sinus reaches its final size by the
end of 12 years.
Recently, Lorkiewicz-Muszynska et al. (2015) conducted a study
on 170 children who underwent CT imaging of skull with suspicion
of trauma or neurological disease [6]. Authors divided their patients
in 17 groups based on the age and found that the growth of the
maxillary sinus was most extensive up to the end of the 8th year.
Authors did not observe a bilateral dimorphism but found a gender-
related difference in sinus growth in children older than 8 years. In
their study population, the maximal values of all diameters and the
maxillary sinus volume are reached by the end of 16 years. The
study was conducted on polish children and authors used an
automated software method to obtain the value of volume mea-
surements from the CT scans. Studies on different population have
shown different measurements and growth pattern because of the
developmental changes and different facial structures. These re-
ports suggest inconsistent and contradicting findings between
different set of patients and different population.
In this study of only pediatric patients, we determine that the
postnatal development of maxillary sinus progresses on both sides
at the same rate. We also determined that the height of the
maxillary sinus contributed to the increase of the sinus volume
until the age of 18 years. The width and the depth of maxillary sinus
contributed only until the age of 12 years and a very slight increase
was observed in these dimensions thereafter.
In a study conducted on children less than 17 years, Barghouth
et al. [2] reported that a difference exists for the maxillary sinus
length when the age is less than 9 months or over 8 years. The right
maxillary sinus length was systematically greater than the left one
in their study. In contrast to their findings, we did not find any
significant difference between any left and right dimension of the
maxillary sinus. Authors also reported that males have non-
150 B. Bhushan et al. / International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151
Fig. 4. Growth of the maxillary sinus volume in children by age group.
significant larger maxillary sinuses than females. We did not find a
difference between sinuses of males and females in our data,
Confidence Intervals: 0.3894, 0.1998. There could be several rea-
sons behind these variations reported in different studies.
Methodical differences could be a possible explanation but it may
not be easy to compare between different studies. Morphological
variability of different population also plays an important role in
the developmental biology. Genetic variations in conjunction with
environmental factors would also contribute in the development of
different sinuses with the increment of age [3]. In addition, some
previous studies were conducted by taking measurements from X-
ray studies. We present analysis using high resolution CT scans
which provide more precise anatomical measurements [6].
There are some limitations to this study. We were unable to
analyze serial CT scans performed on the same patents due to obvious
ethical considerations. However, we were able to evaluate a relatively
large number of otherwise healthy, similarly matched children who
underwent CT imaging. Our study evaluated children without sinus
or other musculoskeletal or pulmonary disease. This is an advantage
over other studies which evaluated predominantly diseased sinuses.
The ability to predict size variations in healthy children may be
obscured in an unknown way by the presence of a disease process.
Difference in sinus size related to race was insignificant. However, the
p value was 0.06 indicating that differences related to ethnicity or
race, might become significant if the sample size was greater. In
addition, data from adult subjects were not collected for comparison.
The anatomical and developmental descriptions of the maxil-
lary sinus is of great clinical importance. The ability to understand
the variation in sinus development in a child can lead to a better
understanding of disease processes. The variation in the paranasal
structures will assist the physicians to determine pathological
development of structures in an appropriate clinical context. De-
tailing the variations seen in the paranasal sinuses in children will
help the surgeon predict the possible anomalies that may be pre-
sent when operating or evaluating the sinuses in children for their
endonasal surgery [10].
5. Conclusions
This study analyzed the dimensions and the volume of maxillary
sinus in children less than18 years of age using CT scans. The results
demonstrate periods of significant change in the size of the
maxillary sinuses in children. There was no significant difference
between the size of the right and left maxillary sinuses in any
dimension at all ages. The height of the maxillary sinus has a
constant, steady increase from birth to at least the age of 18. The
increase of the width and depth of the maxillary sinus decreases
with time to the point where there is no significant growth after 12
years of age. This information will aid the physician when corre-
lating the clinical and radiographic findings in pediatric patients
aged less than 18 years who are being evaluated for sinus disease.
The impact of sinus disease on the growth rate of the maxillary
sinus has yet to be determined.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Grant/s
None.
Conflict of interest
None.
References
[1] Y. Ariji, T. Kuroki, S. Moriguchi, E. Ariji, S. Kanda, Age changes in the volume of
the human maxillary sinus: a study using computed tomography, Dento-
maxillofacial Radiol. 23 (1994) 163e168.
[2] G. Barghouth, J.O. Prior, D. Lepori, B. Duvoisin, P. Schnyder, F. Gudinchet,
Paranasal sinuses in children: size evaluation of maxillary, sphenoid, and
 B. Bhushan et al. / International Journal of Pediatric Otorhinolaryngology 91 (2016) 146e151
frontal sinuses by magnetic resonance imaging and proposal of volume index
percentile curves, Eur. Radiol. 12 (2002) 1451e1458.
[3] R.J. Giacchi, R.A. Lebowitz, H.T. Yee, J.P. Light, J.B. Jacobs, Histopathologic
evaluation of the ethmoid bone in chronic sinusitis, Am. J. Rhinol. 15 (2001)
193e197.
[4] B.C. Jun, S.W. Song, C.S. Park, D.H. Lee, K.J. Cho, J.H. Cho, The analysis of
maxillary sinus aeration according to aging process; volume assessment by 3-
Dimensional reconstruction by high-resolutional ct scanning, Otolaryngol.
Head Neck Surg. 132 (2005) 429e434.
[5] H.J. Kim, E.M. Friedman, M. Sulek, N.O. Duncan, C. McCluggage, Paranasal sinus
development in chronic sinusitis, cystic fibrosis, and normal comparison
population: a computerized tomography correlation study, Am. J. Rhinol. 11
(1997) 275e281.
[6] D. Lorkiewicz-Muszynska, W. Kociemba, A. Rewekant, A. Sroka, K. Jonczyk-
Potoczna, M. Patelska-Banaszewska, A. Przystanska, Development of the
maxillary sinus from birth to age 18. Postnatal growth pattern, Int. J. Pediatr.
Otorhinolaryngol. 79 (2015) 1393e1400.
[7] I.H. Park, J.S. Song, H. Choi, T.H. Kim, S. Hoon, S.H. Lee, H.M. Lee, Volumetric
151
study in the development of paranasal sinuses by ct imaging in asian: a pilot
study, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1347e1350.
[8] P. Sahlstrand-Johnson, M. Jannert, A. Strombeck, K. Abul-Kasim, Computed
tomography measurements of different dimensions of maxillary and frontal
sinuses, BMC Med. Imaging 11 (2011) 8.
[9] C.J. Schatz, T.S. Becker, Normal ct anatomy of the paranasal sinuses, Radiol.
Clin. North Am. 22 (1984) 107e118.
[10] J.P. Shah, D.H. Kraus, M.H. Bilsky, P.H. Gutin, L.H. Harrison, E.W. Strong,
Craniofacial resection for malignant tumors involving the anterior skull base,
Arch. Otolaryngol. Head Neck Surg. 123 (1997) 1312e1317.
[11] R.K. Shah, J.K. Dhingra, B.L. Carter, E.E. Rebeiz, Paranasal sinus development: a
radiographic study, Laryngoscope 113 (2003) 205e209.
[12] J. Spaeth, U. Krugelstein, G. Schlondorff, The paranasal sinuses in ct-imaging:
development from birth to age 25, Int. J. Pediatr. Otorhinolaryngol. 39 (1997)
25e40.
[13] A. Weiglein, W. Anderhuber, G. Wolf, Radiologic anatomy of the paranasal
sinuses in the child, Surg. Radiol. Anat. 14 (1992) 335e339.