Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 62
  • Home
  • Print this page
  • Email this page
Cover page of the Journal of Health Sciences


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 116-123

Correlation of computed tomography and nasal endoscopic findings in chronic rhinosinusitis: A hospital-based study


Department of ENT and Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Hospital, Belagavi, Karnataka, India

Date of Web Publication30-May-2017

Correspondence Address:
Dharmistha Rajesh Kaku
4th Floor, Room No: 410, NRI Ladies Hostel, Jawaharlal Nehru Medical College Campus, Nehru Nagar, Belagavi - 590 010, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.ijhs_305_16

Rights and Permissions
  Abstract 

Background: Computed tomography (CT) scan is a diagnostic tool for chronic rhinosinusitis (CRS). This study was attempted to correlate preoperative CT scan and endoscopic findings in patients with CRS.
Aims: This study aimed to correlate CT scan and nasal endoscopic findings in the assessment of patients with CRS.
Study Design: This is a hospital-based study.
Subjects and Methods: One-year observational study was conducted in the Department of Otorhinolaryngology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum. Thirty patients meeting 2007 revised criteria for CRS underwent CT scan of paranasal sinus, diagnostic nasal endoscopy, and functional endoscopic sinus surgery.
Statistical Analysis: Statistical analysis was performed by Kappa's measure of agreement and P value.
Results: Correlation between CT scan and endoscopy was good in cases of anterior ethmoids (right, k = 0.867; P< 0.02, left, k = 0.525, P = 0.003), concha bullosa (right, k = 0.68; P< 0.001, left, k = 0.520; P = 0.003), and maxillary sinus (right, k = 0.786; P< 0.001, left, k = 0.636; P< 0.001). Correlation was acceptable for frontal sinus (right, k = 0.488; P = 0.007, left, k = 0.493; P< 0.05), mucosal thickening (k = 0.525; P = 0.003), polypoidal changes (k = 0.457; P = 0.012), posterior ethmoids (right, k = 0.590; P = 0.04; left, k = 0.432, P = 0.015), and sphenoid sinus (right, k = 0.492; P = 0.006, left, k = 0.444; P = 0.013). Correlation was poor in cases of paradoxical middle turbinate (k = 0.384; P = 0.051) and osteomeatal complex (OMC) occlusion (right, k = 0.416; P = 0.011, left, k = 0.367; P = 0.020).
Conclusions: Endoscopy was superior to CT scan in localizing pathologies such as polyp, edema, and discharge, whereas CT scan was useful for OMC assessment to visualize paranasal sinus and anatomical variations.

Keywords: Chronic rhinosinusitis, computed tomography scan paranasal sinuses, functional endoscopic sinus surgery


How to cite this article:
Kaku DR, Harugop AS. Correlation of computed tomography and nasal endoscopic findings in chronic rhinosinusitis: A hospital-based study. Indian J Health Sci Biomed Res 2017;10:116-23

How to cite this URL:
Kaku DR, Harugop AS. Correlation of computed tomography and nasal endoscopic findings in chronic rhinosinusitis: A hospital-based study. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2017 Jun 29];10:116-23. Available from: http://www.ijournalhs.org/text.asp?2017/10/2/116/207252


  Introduction Top


Chronic rhinosinusitis (CRS) is an inflammatory disease affecting the paranasal sinuses (PNS) with a lifetime prevalence of ~15%[1] and around 1 in 8 Indians suffer from CRS.[2]

Computed tomography (CT) scan acts as a roadmap for functional endoscopic sinus surgery (FESS) but has limitations such as overdiagnosing asymptomatic individuals, the cost factor, and potential radiation hazard for the patients. FESS is the treatment of choice for CRS.[3]

There are various comparative studies on the imaging modalities, anatomical variations, histopathology, culture pattern, and mucosal disease by intranasal endoscopy, but a clear correlative study between preoperative CT scan and anatomical defects and mucosal assessment, which is found during nasal endoscopy, is lacking.

This study was undertaken to correlate the CT scan findings and endoscopic findings in patients with CRS.


  Subjects and Methods Top


Thirty patients with symptoms suggestive of CRS attending the Department of ENT, KLES Dr. Prabhakar Kore Hospital And Medical Research Centre, Belgaum, during January 2015 to December 2015.

Inclusion criteria

  1. Patients meeting the revised 2007 diagnostic criteria for CRS and willing to undergo CT scan of paranasal sinus, diagnostic nasal endoscopy, and FESS
  2. Age 20–70 years.


Exclusion criteria

  1. Patients with the clinical evidence of sinusitis of dental origin, traumatic origin, and fungal sinusitis
  2. Patients with a history of previous nasal surgery
  3. Pregnancy
  4. Patients with chronic diseases such as cystic fibrosis, primary ciliary dyskinesia, immune deficiencies, and suspected malignancy.


Methodology

The established cases of CRS with major and minor signs and symptoms of CRS who have failed maximal medical therapy for 3 weeks were included in the study. These patients were counseled regarding CT scan imaging of the nose and PNS and further about the need for endoscopic evaluation and surgery.

Informed consent was taken from all the cases, and data regarding the patients were collected in a pro forma as per the [Annexure 1].[Additional file 1]

Technique of computed tomography scanning performed

CT scan was done with Siemens Somatom Sensation 64 slice CT scan machine.

Patient position

Patients are in prone position with hyperextension of head. In patients with cervical spondylosis as the head extension is contraindicated, the gantry tilt was adjusted.

Angulation

Perpendicular to infraorbitomeatal line.

Extent

Contiguous axial and coronal scans of slice thickness 3 mm were obtained from frontal sinus till posterior extent of sphenoid sinus with thin sections in the region of osteomeatal complex (OMC).

Exposure

Exposure was 125 kV and 450 mAs with a scan time of 5–7 s and window width of 1500–2000 HU.

Scans were evaluated preoperatively as per Lund–Mackay CT scan score.[4],[5]

Technique of endoscopic sinus surgery

The patients underwent endoscopic sinus surgery (ESS) after obtaining written and informed consent for the same.

Position: Supine with head slightly elevated and turned toward the surgeon, who stands/sits at the right side of the patient.

Premedication: 0.6 mg atropine, 25 mg promethazine, and 30 mg pentazocine were given 30 min before procedure.

Anesthesia: All the patients in the study underwent the procedure under local anesthesia. Exactly 4% of lignocaine-soaked cotton strips were used for topical anesthesia. Lignocaine 2% with 1:200,000 adrenaline was used for infiltration.

After installing the nasal decongestion, the patient was examined gently and systematically using 0° rigid endoscope. Nasal endoscopy findings were considered positive when there was a presence of either or combination of polyps, mucopus in the middle meatus, or diseased mucosa.

Peroperative findings during ESS were scored using Perioperative Sinus Endoscopy score by Wright and Agrawal.[6]

Procedure

The extent of procedure was according to the extent of disease determined preoperatively by CT scan and intraoperatively by endoscopic findings. A typical complete procedure consists of the following:

  1. Uncinectomy
  2. Middle meatal antrostomy
  3. Frontal recess and frontal sinus clearance
  4. Opening bulla and anterior ethmoidal clearance
  5. Posterior ethmoidal clearance
  6. Sphenoidal clearance.


Messerklinger surgical technique as described by Stammberger was used.[7]

Following the above procedures, the findings were recorded in the pro forma.

Statistical analysis was done by calculating Kappa's measure of agreement and P value using SPSS 13 software.


  Results Top


In this study, sex distribution showed male preponderance with twenty (66.66%) males and ten (33.33%) females. Common age group of presentation in our study was between 40 and 50 years. Least number of patients was in the sixth decade (3.33%) [Graph 1]. Fifteen (50%) patients had CRS with polyposis and 13 (43.33%) patients had CRS without polyposis. Intraoperatively, two (6.66%) patients were diagnosed to have rhinitis caseosa. Seventeen (56.66%) patients had associated nasal septum deviation [Table 1].
Table 1: Distribution by type of disease

Click here to view



Correlation between CT scan and endoscopy was good in cases of anterior ethmoid sinus (right, k = 0.867; P< 0.02, left, k = 0.525, P = 0.003), concha bullosa (right, k = 0.68; P< 0.001, left, k = 0.520; P = 0.003), and maxillary sinus (right, k = 0.786; P< 0.001, left, k = 0.636; P< 0.001). Correlation was acceptable for frontal sinus (right, k = 0.488; P = 0.007, left, k = 0.493; P< 0.05), mucosal thickening (k = 0.525; P = 0.003), polypoidal changes in sinuses (k = 0.457; P = 0.012), and sphenoid sinus (right, k = 0.492; P = 0.006, left, k = 0.444; P = 0.013).

Poor correlation was seen in the cases of paradoxical middle turbinate (k = 0.384; P = 0.051) and OMC occlusion (right, k = 0.416; P = 0.011, left, k = 0.367; P = 0.020) [Table 2].
Table 2: Correlation between preoperative CT scan and endoscopic findings in chronic rhinosinusitis patients

Click here to view



  Discussion Top


The study included thirty patients with chronic sinusitis who underwent CT PNS and diagnostic nasal endoscopy and ESS; comparison was done between CT scan and endoscopic findings under various parameters.

In our study, concha bullosa was found in 15 patients (50%) on endoscopy [Figure 1] and 13 patients (43.32%) on CT scan [Figure 2] and it was the most common anatomical variant of middle turbinate with good correlation between CT scan and endoscopic findings. The rate of detection of concha bullosa was better on endoscopy as compared to CT scan. Paradoxical middle turbinate was the second most common anatomical variant of middle turbinate with poor correlation between CT scan and endoscopic findings.
Figure 1: Endoscopic appearance of concha bullosa of the left middle turbinate

Click here to view
Figure 2: Plain computed tomography scan of paranasal sinus showing bilateral concha bullosa

Click here to view


OMC occlusion was seen on the right side in 21 patients (70%) on CT scan, while only in 14 patients (46.33%) on endoscopy. Similarly, on the left side, OMC occlusion was present in 21 patients (70%) and 13 patients (43.33%) on CT scan and endoscopy, respectively. A study by Jeelani et al.[8] found OMC block in 68% and 74% of patients on the right and left side, respectively, on endoscopy as compared to 36% and 32% on CT scan on the right and left side, respectively. They stated that endoscopy was better than CT scan in detecting osteomeatal occlusion. This was in contrast to our study where CT scan was found to be better than endoscopy in detecting OMC occlusion, and there was moderate correlation between CT scan and endoscopic findings.

In the present study, mucosal thickness on CT scan was seen in 14 patients (46.66%) and 16 patients (53.33%), while endoscopically it was seen in 9 patients (30%) and 11 patients (36.66%) on the right and left side, respectively. Our study showed that detection of mucosal thickness on CT scan and endoscopy was almost equal with moderate degree of correlation between them.

In our study, polypoidal change on CT scan was seen in 10 patients (33.33%) and 15 patients (50%), while endoscopically it was seen in 10 patients (33.33%) and 14 patients (46.66%) on the right and left side, respectively. The detection of polypoidal change on CT scan and endoscopy was almost equal to a moderate degree of correlation between them.

In our study on CT scan, maxillary sinus involvement was seen in 17 patients (56.66%) and 18 patients (60%) on the right and left sides, respectively. Endoscopic findings of maxillary sinus secretions were present in 23 patients (76.6%) and 24 patients (80%), whereas edema and narrowing of sinus ostia were seen in 21 patients (60%) and 24 patients (80%) on the right and left side, respectively. A study by Bolger et al.[9] found that mucosal abnormalities in chronic sinusitis patients were present more common in anterior ethmoid sinus (78.2%) followed by maxillary sinus (68.8%). This was similar to our study. Zeid et al.[10] in their study found polyps as the most common pathology in maxillary sinus (45% cases) followed by discharge (25% cases) and fungal mud (15% cases), whereas in our study, edema was the most common pathology in the maxillary sinus followed by secretions/discharge. In the present study, maxillary sinus was the second most common sinus to get affected and substantial correlation was present between CT scan and endoscopic findings.

In our study on CT scan, anterior ethmoid sinus involvement was seen in 17 patients (56.66%) and 19 patients (63.3%) on the right and left sides, respectively. Endoscopic findings of anterior ethmoid sinus secretions were present in 19 patients (63.33%) and 21 patients (70%), mucosal edema was seen in 20 patients (66.66%) and 19 patients (63.33%), polypoidal change in sinuses in 19 patients (63.33%) and 20 patients (66.66%), and frank polyposis in ten patients (33.33%) and eight patients (26.66%) on the right and left sides, respectively. Bolger et al.[9] in their study found that mucosal abnormalities in CRS patients were more common in anterior ethmoid sinus (78.2%). This was similar to our study. A study by Zeid et al.[10] found polyps as the most common pathology in anterior ethmoidal sinus (50% cases) followed by fungal mud (30% cases) and discharge (5% cases). Similarly, in our study, the most common pathology in anterior ethmoids was polypoidal change followed by mucosal edema, sinus secretion, and frank polyposis. Anterior ethmoid sinus was the most common sinus to be affected, and excellent correlation was present between CT scan and endoscopic findings.

In our study, posterior ethmoid sinus was involved on CT scan in nine patients (30%) and ten patients (33.33%) on the right and left sides, respectively. Endoscopic findings of posterior ethmoid sinus secretions were present in 11 (36.66%) and 13 patients (43.33%), mucosal edema in 12 patients (40%) on each side, polypoidal change in sinuses in nine (30%) and twenty patients (66.66%), and frank polyposis in ten (33.33%) and eight patients (26.66%) on the right and left sides, respectively. In studies by Lloyd (1990)[11] and Bolger et al.,[9] polypoidal change in posterior ethmoidal sinus was found in 28% and 32.2% of patients, respectively. In our study, there was a moderate degree of correlation between CT scan and endoscopic findings in posterior ethmoids and endoscopically polypoidal change was the most common pathology in posterior ethmoids followed by mucosal edema, sinus secretion, and frank polyposis.

In our study, frontal sinus was involved on CT scan in 12 patients (40%) and 10 patients (33.33%) on the right and left sides, respectively. Endoscopic finding of mucosal edema and involvement of frontal sinus was seen in 11 (36.666%) and 12 (40%) patients on the right and left side, respectively, with moderate degree of correlation between CT scan and endoscopic findings. Studies by Zojaji et al.[12] and Amodu et al.[13] found frontal sinus involvement on CT scan in 20% and 40% of patients, respectively.

In our study, sphenoid sinus was involved on CT scan in seven patients (23.33%) and six patients (20%) on the right and left sides, respectively. Endoscopic finding of mucosal edema and involvement of sphenoid sinus were seen in nine (30%) patients on the right and eight (26.66%) patients on the left side with a moderate degree of correlation between CT scan and endoscopic findings. Studies by Zojaji et al.[12] and Amodu et al.[13] had found sphenoid sinus involvement on CT scan in 25% and 20% of patients, respectively. This was similar to our study.

Studies by Zeid et al.[10] (right, r = 0.713; left, r = 0.841, P< 0.001), Jiannetto and Pratt [14] (r = 0.791, P< 0.001), and Stanojkovic [15] (r = 0.831, P< 0.001) showed positive correlation between preoperative CT scan and operative findings. Jiannetto further stated that operative findings are better consistent with surgeon's CT scan interpretation than with the radiologist's CT report.[14] In addition, Zojaji et al.[12] and Duarte et al.[16] in their studies showed similar results as our findings.

In contrast to our study, Stankiewicz and Chow [17] in their studies showed poor correlation between preoperative endoscopy and CT scan staging scores.


  Conclusions Top


Overall, endoscopy was superior to CT scan in localizing pathologies such as polyp, edema, and discharge, whereas CT scan was useful for OMC assessment to visualize paranasal sinus and anatomical variations.

Acknowledgment

The authors would like to thank the radiologists for computed tomography scans.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bhattacharyya N. The economic burden and symptom manifestations of chronic rhinosinusitis. Am J Rhinol 2003;17:27-32.  Back to cited text no. 1
[PUBMED]    
2.
Harugop AS, Mudhol RS, Kapoor A. Subjective outcome of endoscopic sinus surgery in patients of chronic rhinosinusitis without nasal polyposis and chronic rhinosinusitis with nasal polyposis-A comparative study. Biomed J 2014;34:348-55.  Back to cited text no. 2
    
3.
John GL, Becker TS. Imaging of the paranasal sinuses for functional endoscopic sinus surgery. Endoscopic Paranasal Sinus Surgery. 3rd ed. Maryland, Missouri: Mosby; 2003. p. 69-77.  Back to cited text no. 3
    
4.
Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology 1993;31:183-4.  Back to cited text no. 4
[PUBMED]    
5.
Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg 1997;117:S35-40.  Back to cited text no. 5
[PUBMED]    
6.
Wright ED, Agrawal S. Impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: Evaluation with the novel Perioperative Sinus Endoscopy (POSE) scoring system. Laryngoscope 2007;117 11 Pt 2 Suppl 115:1-28.  Back to cited text no. 6
    
7.
Stammberger H. Endoscopic endonasal surgery: Concepts in treatment of recurrent rhinosinusitis: Anatomic and pathologic consideration. Otolaryngol Head Neck Surg 1986;94:143-6.  Back to cited text no. 7
[PUBMED]    
8.
Jeelani U, Wani UA, Khanday S, Jahan S, Jeelani H, Wani BA. Correlation of computed tomography and nasal endoscopic findings in chronic rhinosinusitis-A clinical study. Int J Contemp Med Res 2015;2:606-11.  Back to cited text no. 8
    
9.
Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101 1 Pt 1:56-64.  Back to cited text no. 9
    
10.
Zeid NG, Kamel AA, Wahba BM, Youssef M. Relationship between the endoscopic, radiological and operative findings in sinonasal polyposis. Egypt J Otolaryngol 2016;32:147-51.  Back to cited text no. 10
  [Full text]  
11.
Lloyd GA. CT of the paranasal sinuses: Study of a control series in relation to endoscopic sinus surgery. J Laryngol Otol 1990;104:477-81.  Back to cited text no. 11
[PUBMED]    
12.
Zojaji R, Mirzadeh M, Naghibi S. Comparative evaluation of preoperative CT scan and intraoperative endoscopic sinus surgery findings in patients with chronic rhinosinusitis. Iran J Radiol 2008;5:77-82.  Back to cited text no. 12
    
13.
Amodu EJ, Fasunla AJ, Akano AO, Daud Olusesi A. Chronic rhinosinusitis: Correlation of symptoms with computed tomography scan findings. Pan Afr Med J 2014;18:40.  Back to cited text no. 13
[PUBMED]    
14.
Jiannetto DF, Pratt MF. Correlation between preoperative computed tomography and operative findings in functional endoscopic sinus surgery. Laryngosocpe 1995;105 9 Pt 1:24-6.  Back to cited text no. 14
    
15.
Stanojkovic V. Correlation between CT and intraoperative findings in FESS. Acta Med Med 2010;48:19-26.  Back to cited text no. 15
    
16.
Duarte AF, Soler Rde C, Zavarezzi F. Nasal endoscopy associated with paranasal sinus computerized tomography scan in the diagnosis of chronic nasal obstruction. Braz J Otorhinolaryngol 2005;71:361-3.  Back to cited text no. 16
[PUBMED]    
17.
Stankiewicz JA, Chow JM. A diagnostic dilemma for chronic rhinosinusitis: Definition accuracy and validity. Am J Rhinol 2002;16:199-202.  Back to cited text no. 17
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Subjects and Methods
  Results
  Discussion
  Conclusions
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed71    
    Printed0    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]