Role of Multi-Detector CT in Paranasal Sinuses

Role of Multi-Detector CT in Paranasal SinusesSUMMARY OF THESIS summon of speciality Radio-diagnosisName of System Head and NeckTitle of Thesis and Role of Multi-Detector Computed Tomography in Paranasal SinusesPathology, 2015.Lakshmi Kumar ChalamarlaName of Supervisor Dr. Kavita Kapoor, ConsultantImaging, Batra infirmary andMedical Research Centre, New Delhi.Hospital/Institute Batra Hospital and Medical ResearchCentre, New Delhi-110062.AIMS AND OBJECTIVESTo characterize pathologies of paranasal sinuses on MDCT and to delineate their anatomical location, point of reference and bony involvement.To correlate the multi detector computed tomography findings with clinical/operative/histopathological/ microbiological findings.MATERIAL AND METHODSSTUDY AREAThe have was conducted at the Department of Radio-diagnosis and Imaging in quislingism with the Department of ENT, Department of Pathology, and Department of Microbiology, Batra Hospital and Medical Research Centre. Other departme nts are collaborated for acquiring cases, and follow up of patients to correlate clinically or histopathologically or microbiologically.STUDY POPULATION100 patients were included in our examine mostly urban population. Patients belonged to both OPD and IPD cases. The study comprised of 65 males and 35 females. The number of male patients were high than the female patients. at that place were 15 patients in 0 20 years age group, 36 patients in 21 40 years age group, 37 in 41 60 years age group and 12 were greater than 60 years. The age group of patients ranged from minimum of 9 months to maximum of 81 years. The highest number of patients were in 41 60 years age group.SAMPLE SIZE100 patients referred for evaluation of sinus complaints were enrolled in the study after fulfilling the comprehension and exclusion criteria and taking written/verbal informed coincide from July 2013 to April 2015.INCLUSION CRITERIAPatients with complaints like headache/nasal obstruction/discharge/h yposmia /swelling over boldness and with clinically suspected paranasal sinuses lesions referred for MDCT PNS evaluation.EXCLUSION CRITERIAAcute sinonasal inflammatory disease.Previous evidence of sinonasal surgical procedure.All cases of trauma.SAMPLE SIZE CALCULATION(Ref. Methods in biostatistics, Dr. B. K. Mahajan, 7th edition, pg. 85)For numeration of sample size Mahajans allowable error formula was applied.N = 4pq/e2Where p = % of population = Target population/Total population100q = 1-pe = 20% of pAs per CT room register over last 3 yearsMinimum no. of MDCT PNS cases at our hospital/month = 20Maximum no. of MDCT PNS cases approach shot under exclusion criteria/month = 5So,Minimum no. of MDCT PNS cases at our hospital/year = 240Maximum no. of cases coming under exclusion criteria/year = 60So, p = 180/240100 = 75q = 25e = 20% of p = 15N = 47525/152 = 33.The minimum sample size thus calculated should be 33.STUDY DESIGNObservational study.CT PNS of the patients was evaluated fo r the cause of sinus complaints. Causes deduced from CT PNS were correlated with clinical/histopathological/surgical/ microbiological findings.ETHICAL ISSUESThe study was conducted after necessary approval from the Institutional review board and ethics committee. MDCT is a non-invasive modality. All sentry duty and screening measures were undertaken as per the American College of Radiology practice guidelines for performing Computed Tomography.INSTRUMENTATIONLight VCT 64 slice MDCT of GE radical system with advanced workstation 4.3 GE.communications protocol followed for MDCT PNS1. Scout LateralkV 120mA 10Scout Plane 9002. Axial ImageskV 120mA 120Start/ cobblers last 0 to 74.3Total Exposure Time 5.4 secGantry tilt 0Interval 0.625 mmSlice thickness 0.625 mmHelical contemplateRotation Time 0.6 secRotation Length FullPitch and Speed 0.5311 10.62 mm/rotationDetector Coverage 20 mmPROFORMAUnique ID NoHISTORYPresenting ComplaintsNasal discharge HeadacheNasal obstruction EpistaxisSwelling over cheek Hyposmia/AnosmiaOthersH/O roll of tobaccoOccupational exposureHistory of AllergyAny other Systemic IllnessFamily HistoryEXAMINATIONGeneral ExaminationLocal Examination brushupProbe testOthersImportant Surgical FindingsInvestigational ResultsMDCT PNS HistopathologyMicrobiological and other important lab testsDepartment of Radio-diagnosis and ImagingBatra Hospital and Medical research CentreM.B.Road, New Delhi-110062. certified CONSENT FORMI s/d/w of r/odo hereby declare that I give informed take to participate in the thesis study titled, ROLE OF MULTI-DETECTOR COMPUTED TOMOGRAPHY IN PARANASAL SINUSES PATHOLOGY.Dr. Lakshmi Kumar Chalamarla has informed me to my full satisfaction, in the language understand, about the purpose, nature of study and various investigations to be carried out for the study. I have been informed about the duration of the study and the possible benefits and risks.I give full, free and voluntary consent for being enrolled in the above study and reserve the right to look at from the study whenever I wish to without any prejudice of my right to undergo barely treatment at this hospital and its associated hospitals. I have been given a copy of this form on with the patient reading piece of paper.For illiterates patient information sheet will be shared with the family members. The family members are expected to read out and then get the informed consent. We will try to take written consent, if non we will take verbal consent in front of relatives.(Signature/Thumb (Signature/ThumbImpression of patient) Impression of relative)Name NameDate Relation vocal Consent DatePATIENT INFORMATION SHEETTitle ROLE OF MULTI-DETECTOR COMPUTED TOMOGRAPHY IN PARANASAL SINUSES PATHOLOGY.Introduction This statement describes the purpose, procedures, benefits, risks and discomforts of the study and your right to withdraw from the study at any point of time.Purpose This study involves MDCT scan evaluation of patients with paran asal sinus complaints.Study Procedure Your relevant clinical record will be recorded, clinical examination will be conducted and findings noted. MDCT PNS will be performed and the radiological findings will be recorded. These findings are correlated with clinical/surgical/histopathological/microbiological findings.Benefits No monetary benefits will be given to you. However, any new information that can come to light regarding any new findings in the study will help in further management of the disease and help all other ailing patients suffering from this problem.Confidentiality Records of your study participation will be kept confidential, under safe custody. Any publication of data will not identify you by name. By signing the consent form you realise the sharing of your study related medical records to the regulatory authorities and the Institutional Ethical Committee.Information regarding withdrawal You have the right to withdraw yourself from the study at any time during the course of the study without any prejudice to you or your familys right to undergo future treatment at BATRA HOSPITAL.Contact for additional information Any time during or after the study, you can obtain further information about the study from Dr. Lakshmi Kumar Chalamarla, Department of Radio-diagnosis, BHMRC, New Delhi.DATA ANALYSISSensitivity, specificity, exacting predictive value and prejudicial predictive values were calculated, followed by use of Fischer Exact test. Diagnostic accuracy of MDCT for different pathologies were calculatedThe research hypothesis and statistical methods were formed in consultation with the Biostatistician.SALIENT FINDINGSKey imaging features considered were significant anatomical variations, site of involvement, bony and soft tissue changes, invasion of surrounding structures, pathognomic features and correlation coefficient with clinical complaints/surgical/pathological/microbiological findings.The patients were divided into five categories bacte rial sinusitis, fungal sinusitis, benign tumors, malignant tumors, and others. 84 patients presented with sub acute or chronic bacterial sinusitis, 4 patients were of fungal sinusitis, 4 patients presented with benign tumors, 3 patients with malignant tumors and 5 patients with other conditions.Among 84 patients with bacterial sinusitis, 26 patients presented with sporadic pattern, 23 patients with infundibular pattern, 23 patients with ostiomeatal whole pattern, 8 patients with polyposis pattern, and 4 patients with sphenoid recess pattern.The various causative factors which came across in infundibular pattern were Haller cells in 6 cases, giant bulla ethmoidalis in 6 cases, uncinate process pneumatisation in 1 case, and mucoperiosteal modify in 10 cases.The various causative factors for ostiomeatal pattern which were found during our study were inferior turbinate hypertrophy in 6 cases, giant bulla ethmoidalis in 6 cases, deviated nasal septum with or without septal spur in 4 cas es, concha bullosa in 3 cases, concha lamella in 2 cases, agger nasi cell in 1 case, and paradoxical middle turbinate in 1 case.The various findings which were encountered in bacterial sinusitis in our study were mucoperiosteal thickening in 84 cases, ostiomeatal unit block in 31 patients, swot thickening in 20 patients, bone thinning in 8 cases, and bone sclerosis in 6 patients.Various anatomical variations were encountered during our study. One or the other anatomic variation was found in 99 cases ( 99% ).Of the structures virtually ostiomeatal unit, giant bulla ethmoidalis was found in 35 cases, middle turbinate pneumatisation in 33 cases, paradoxical curvature of middle turbinate in 19 cases. Haller cell was found in 15 cases. Type 1 frontal sinus drainage pathway in 78 cases, type 2 frontal sinus drainage pathway in 21 cases. Deviated nasal septum with or without septal spur in 55 cases, inferior turbinate hypertrophy in 30 cases, accessory maxillary ostia in 26 cases, and a gger nasi cell in 93 cases. Type 1 optic nerve course was found in 53 cases, type 2 in 14 cases, type 3 in 9 cases, and type 4 optic nerve course along with Onodi cells in 23 cases. Type 1 anterior clinoid process pneumatisation was found in 10 cases, type 2 pneumatisation in 1 case. Sphenoid septum squinty attachment in 7 cases, and sphenoid sinus septum pneumatisation in 14 cases.Among 4 patients with fungal sinusitis, the various findings were bilateral / multisinus involvement was found in 4 cases, expansion of any involved sinus was found in 4 cases, intrasinus hyperdensity was found in 4 cases. impecunious thinning was found in 4 cases, bony erosions and nasal cavity involvement was found in 3 cases.The various findings in 4 cases of benign tumors seen ( 1 inverted papilloma, 1 juvenile angiofibroma and 2 ivory osteomas ) were bony thinning in 2 cases, bony remodelling in 2 cases, multisinus involvement in 2 cases, intracranial backstage in 1 case, and intra orbital extensi on in 1 case. Bony destruction, bone thickening/sclerosis, and calcification were not seen in any of the cases.Among 3 cases of malignant tumors, various findings were Bony destruction in 3 cases, bony thinning in 3 cases, bony remodelling in 0 cases, multisinus involvement in 2 cases, intracranial extension in 2 cases, and intra orbital extension in 3 cases. Bone thickening/sclerosis, and calcification were not seen in any of the cases.In our study we found sensitiveness and specificity for bacterial sinusitis as 100% and 94.11% respectively. The fungal sinusitis had sensitivity an specificity of 75% and 100% respectively. Benign, malignant tumors and others had sensitivity and specificity of 100%. The diagnostic accuracy for bacterial sinusitis and fungal sinusitis was 99%, and the diagnostic accuracy of benign, malignant tumors and others was 100%. The p value was obtained after applying Fischer Exact test. The p value obtained was statistically significant for all the disease conditions. found on the statistical values it can be inferred that multi detector computed tomography is useful to characterize paranasal sinuses lesions with respect to anatomical delineation, extension and bony involvement.There are certain limitations in our study. Our findings cannot be generalised to the whole population because of the limited sample size. However, our findings add value to the research done. The role of contrast cannot be adequately studied. The role of magnetic resonance imaging in various paranasal sinus pathologies was not evaluated.CONCLUSIONSParanasal sinus diseases are very commonly encountered problems in clinical practice. Clinical assessment alone is not sufficient to reach a diagnosis, as the presentation of most of the conditions is nonspecific. Imaging forms the mainstay not only in making correct diagnosis, but also to know the extent of lesion, pre-operative assessment of the sinonasal anatomy and commonly encountered anatomic variations. X ray has low sensitivity, specificity, positive and negative predictive values. CT is highly sensitive and specific in determining the presence of paranasal sinus pathology and clearly demonstrates the complex anatomy. The introduction of multi detector CT has transformed the axial imaging modality into a volumetric one and allows the pathology to be displayed in any desired plane. The capability of thin-section acquisition improves visualisation of bantam pathological details, and the isotropic nature of high spatial resolution data sets enables display in multiple planes, obviating image acquisition in addicted or hyper extended patient position.RECOMMENDATIONSMDCT has proved to be highly sensitive in classifying the lesions into clinically relevant categories, making diagnosis and more so in knowing the extent of involvement with a high diagnostic accuracy.MDCT is an indispensible tool before Functional Endoscopic Sinus Surgery (FESS) to accurately delineate the mulct bony details t hat contribute to disease and also can predispose to complications which can be fatal.MDCT is very useful in predicting the diagnosis of fungal sinusitis by the presence of intrasinus hyperdensity, granulomatous diseases by the presence of nasal septal perforation and intracranial or intraorbital invasion, malignancy by bone destruction and invasion.MDCT can tailor the surgery according to the extent of disease. It helps in determining the prognosis of the malignant tumors depending on the site and extent of the disease. It can also obviate the need for surgery in certain conditions like polyposis.MRI can be problem solving tool in differentiating inflammatory sinonasal diseases from tumors, and also for the presence of intracranial or intraorbital extension.However, MRI alone cannot be performed in the evaluation of paranasal sinus diseases because of the problem of signal voids. It has to be supplemented by CT.MDCT is the preferred modality of all imaging studies purchasable beca use of its ease, availability, accuracy, precision and low cost.