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Objective: We evaluated the extent of asymmetry evident in paranasal sinus computed tomography (CT) scans of Turkish patients without sinusitis in the ethmoid roof. Our data contribute to the body of knowledge on the subject., Materials and Methods: We retrospectively studied multiplanar reformatted CT images of the paranasal sinus (1-mm sections) from 110 patients (50 male, 60 female). Ethmoid roof variations on either side were compared and the lateral lamellar length of the cribriform plate was measured. The results were scored using the Keros classification., Results: The lateral lamella of the cribriform plate averaged 5.78 mm in height on the right side and 5.98 mm on the left. The most common Keros type was type 2 (67.72%), followed by type 3 (22.28%), and type 1 (10%). Keros asymmetry (≥ 0.01 mm, affecting either side) was apparent in all patients (48.2% right-sided and 51.8% left-sided)., Results: Preoperatively, paranasal sinus CT scans should be evaluated carefully to eliminate the possibility of life-threatening complications, including intracranial trauma, which may develop during endoscopic sinus surgery; the left and right sides of the ethmoid roof may differ in depth.

Objective: The objective of this study was to radiologically determine frontal sinus drainage pathway variations with respect to superior attachment of uncinate process (SAUP) and their effect on prevalence of frontal rhinosinusitis., Design: This was a retrospective cohort study., Methods: Computed tomography scans of the 919 frontal sinus sides of 460 patients (252 female, 208 male; mean age, 35.1 ± 10.5 years) who were candidates for endoscopic sinus surgery were evaluated retrospectively between August 2012 and January 2013 by 3 radiologists to determine the SAUP types and the presence of frontal rhinosinusitis., Results: The frontal sinus outflow tract was localized medial to the SAUP in 651 frontal sinus sides and lateral to the SAUP in 268 sides. We determined 3 types (types 7, 8, and 9) of SAUP in addition to 6 types defined in literature. The most common type of SAUP was type 3 (n = 332, 36.1%) followed by type 2 (n = 256, 27.8%) and type 7 (n = 160, 17.4%). Of the evaluated sides, 316 (34.3%) had frontal rhinosinusitis. Frontal rhinosinusitis was more common in the sides where the frontal sinus outflow tract was localized medial to the SAUP than those localized lateral (37.2% vs 27.6%, P = 0.006)., Conclusions: Endoscopic approach to frontal recess usually requires uncinectomy, and it is necessary to know SAUP to prevent postoperative retained superior portion of the uncinate process. The location of frontal sinus outflow tract on the SAUP affects the prevalence of frontal rhinosinusitis as well. Frontal rhinosinusitis is significantly more common when the frontal sinus outflow tract was localized medial rather than lateral to the SAUP., Level of Evidence: 2b.

Background: Nasal encephaloceles are uncommon in North America and may be diagnosed only as incidental findings. The presence of an encephalocele and malignant hypertension in the parturient requires complex coordination of care., Case: We present a case of severe chronic hypertension in a pregnant patient with a seizure disorder and new finding of a basal transethmoidal encephalocele. She required 5 antihypertensive agents and cesarean delivery at 34 weeks' gestation under general anesthesia. The obstetric and anesthetic management of encephalocele are reviewed., Conclusion: Nasal encephaloceles are rarely reported in pregnancy and present additional peripartum obstetric and anesthetic considerations that require multidisciplinary planning for optimization of maternal and fetal outcomes.

The bony naso-orbital-ethmoid (NOE) complex is a 3-dimensional delicate anatomic structure. Damages to this region may result in severe facial dysfunction and malformation. The management and optimal surgical treatment strategies of NOE fractures remain controversial. For a patient with NOE trauma, doctors should perform comprehensive clinical examination and radiographic analysis to assess the type and extent of fracture. The results of assessment will assist doctors to make a patientspecific program for the sake of reducing post-operation complications and restoring normal appearance and function as much as possible. This review focuses on the advancement of management of NOE fractures including symptoms, classifications, diagnosis, approaches, treatment and new techniques in this field.

Clinical Case: The case is presented of a 21 year-old male with a history of left proptosis and diplopia of two weeks of onset. The MRI showed an ethmoid-orbital vascular lesion with anterior skull base invasion and orbital extension. Biopsy of the ethmoid confirmed fibrovascular tissue, which supported the diagnosis of angiofibroma., Discussion: It is a benign neoplasm with local characteristics of malignancy due to its ability to invade adjacent areas. In this case, the debut presented with manifestations of orbital extension. A broad and multidisciplinary approach is needed in order to improve prognosis., (Copyright © 2013 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: To compare field junction robustness and sparing of organs at risk (OARs) during craniospinal irradiation (CSI) using intensity modulated proton therapy (IMPT) to conventional passively scattered proton therapy (PSPT)., Methods and Materials: Ten patients, 5 adult and 5 pediatric patients, previously treated with PSPT-based CSI were selected for comparison. Anterior oblique cranial fields, using a superior couch rotation, and posterior spinal fields were used for IMPT planning. To facilitate low-gradient field junctioning along the spine, the inverse-planning IMPT technique was divided into 3 stages. Dose indices describing target coverage and normal tissue dose, in silico error modeling, and film dosimetry were used to assess plan quality., Results: Field junction robustness along the spine was improved using the staged IMPT planning technique, reducing the worst case impact of a 4-mm setup error from 25% in PSPT to <5% of prescription dose. This was verified by film dosimetry for clinical delivery. Exclusive of thyroid dose in adult patients, IMPT plans demonstrated sparing of organs at risk as good or better than PSPT. Coverage of the cribriform plate for pediatric (V95% [percentage of volume of the target receiving at least 95% of the prescribed dose]; 87 ± 11 vs 92 ± 7) and adult (V95%; 94 ± 7 vs 100 ± 1) patients and the clinical target in pediatric (V95%; 98 ± 2 vs 100 ± 1) and adult (V95%; 100 ± 1 vs 100 ± 1) patients for PSPT and IMPT plans, respectively, were comparable or improved. For adult patients, IMPT target dose inhomogeneity was increased, as determined by heterogeneity index (HI) and inhomogeneity coefficient (IC). IMPT lowered maximum spinal cord dose, improved spinal dose homogeneity, and reduced exposure to other OARs., Conclusions: IMPT has the potential to improve CSI plan quality and the homogeneity of intrafractional dose at match lines. The IMPT approach developed may also simplify treatments and reduce workload per patient relative to PSPT., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Computed tomography (CT) is widely used in the initial evaluation of patients with craniofacial trauma. Due to anatomical proximity, craniofacial trauma often involves concomitant injury to the eye and orbit. These injuries may have devastating consequences to vision, ocular motility, and cosmesis. CT imaging provides a rapid and detailed evaluation of bony structures and soft tissues of the orbit, is sensitive in detection of orbital foreign bodies, and often guides clinical and surgical management decisions in orbital trauma. For this reason, radiologists should be prepared to rapidly recognize common orbital fracture patterns, accurately describe soft tissue injuries of the orbit, detect and localize retained foreign bodies within the globe and orbit, and recognize abnormalities of the contents and integrity of the globe. In this review, we present a systematic approach to assist radiologists in the rapid evaluation of orbital trauma using the "BALPINE" mnemonic-bones, anterior chamber, lens, posterior globe structures, intraconal orbit, neurovascular structures, and extraocular muscles/extraconal orbit. Using this approach, we describe common traumatic findings within each of these spaces, and present common postsurgical appearances that can mimic findings of acute trauma.

Objectives: The aim of this study was to evaluate the reliability of high-pitch ultra-low-dose computed tomography (CT) for detecting important paranasal sinus anatomic landmarks and pathologies., Materials and Methods: Sixty patients (22 females, 38 males) aged 15 to 67 years (mean age, 33.68 y; SD, 9.83 y) underwent high-pitch ultra-low-dose CT of the paranasal sinuses between February and June 2012. To determine the lowest possible dose for evaluation of the paranasal sinuses, the patients were divided into three groups randomly and prospectively. A different low-dose CT protocol was applied to each group. The image quality was assessed subjectively by a radiologist and an otorhinolaryngology head and neck surgeon independently using a 4-point grading scale (0 = structures could not be identified, 1 = indistinctly defined structures, 1.5 = relatively well-defined structures, 2 = very well-defined structures). Anatomic landmarks and mucosal structures were evaluated. Mean scores were evaluated to assess statistical significance., Results: According to the anatomic landmark scoring, excluding the ethmoid foramen for ethmoid artery identification, all of the structures in all 3 groups were very well-defined structures. The ethmoid foramen for ethmoid artery identification was scored as either could not be identified or an indistinctly defined structure in all groups. On evaluating the mucosa of the paranasal sinuses, normal and pathologic mucosal structures were scored as very well defined in all of the patients. The interobserver agreement was excellent., Conclusion: High-pitch ultra-low-dose CT is a safe, reliable paranasal sinus screening tool.

Introduction: Osteomas are slow- growing, benign tumors. They are the most common neoplasms of the paranasal sinuses. They are usually originates from the frontal and ethmoid sinus and much less frequently seen in the maxillary and sphenoid sinuses. Although the lamina papyracea is a part of ethmoid bone, a giant osteoma originated from the lamina papyracea is very uncommon. An osteoma of the paranasal sinus is usually asymptomatic. Headache, proptosis, epiphora, diplopia, dizziness, facial deformity, face pain and cerebral complications are possible symptoms. The treatment of the paranasal osteomas are controversial., Case Report: A 65 year old patient that applied with stuffiness and headache to our clinic. She has had a smooth mass in the right nasal cavity. Paranasal sinus tomography showed an osseous lesion, the size of 4x 3 cm, arising from the right lamina papyracea. The mass excised endoscopically and reported as osteoma histopathologically. There was no complication. After 9 months, there was no recurrence., Conclusion: Giant osteomas of paranasal sinuses, especially originated from the lamina papyracea are rare. They can be treated successfully by endoscopic approaches without any recurrence and complication despite its size.

Naso-ethmoido-maxillary protrusion (NEMP) is a rare dental and facial dysmorphosis, with excessive growth of basicranium, ethmoid, maxillary, and nasal bones. The clinical presentation includes nasal and upper lip protrusion, telecanthus, a class 2 malocclusion with maxillary protrusion and exoclusion. The craniofacial field is increased in Delaire's analysis. Contrary to isolated maxillary protrusion secondary to membranous ossification dysfunction, NEMP is a constitutional anomaly resulting from an excessive primary growth of the chondrocranium. The therapeutic management of NEMP should take into account these specificities., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: The bony-cartilaginous crooked nose is characterized by a deviation of the nasal dorsum from the median sagittal plane. Since the nasal dorsum and the septum form an anatomical entity, a deviation of the external nose always results in a deviation of the cartilaginous and bony nasal septum. The aim of this study was to analyze the pathologies of the septum in patients with crooked noses based on CT images of the midface., Methods: The CT images of patients with a documented crooked nose, who presented between 2005 and 2011 in our hospital, were analyzed retrospectively considering photo documentation and nasal findings. The CT scans were performed due to suspected sinusitis unrelated to the study., Results: The study includes a total of 138 patients. In all patients a deviated septum was found in the CT. In particular, there was not only a deviation of the cartilaginous septum, but also a deviation of the perpendicular plate (PP) in 86% of the cases. This PP deviation distorted to the opposite side of the deviation of the crooked nose in 79% of the cases. However, the base of the PP at the cribriform plate was in a median position in 99% of the cases of the patients. Furthermore, in 96% of cases, the caudal septum was located in midline on the anterior nasal spine, -although 15% presented clinically a dislocation of the caudal septum., Conclusions: The bony-cartilaginous crooked nose usually results in a deviation of the cartilaginous and bony septum. In particular, a high deviation of the PP to the opposite side of the deviation of the external nose was present in a majority of the -cases. Therefore, a septo-rhinoplasty with particular consideration of the deviation of the PP is necessary in patients with a deviated external nose., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The surgical approach through nasal and ethmoid cells to sphenoid sinus is a common clinical method to do the decompression of the optic canal. During this surgery, we can follow landmarks such as ethmoidal arteries. However, when we do the surgery, it is possible to open excessively in lateral operation and damage orbital medial wall. To prevent this from happening, we do a lot of measurements to estimate the distance in lateral operation. We hope to give surgeons some help in clinical use., Methods: We chose 120 brain imaging findings that showed a normal appearance in our measuring area by means of three-dimensional reconstruction based on high-resolution spiral computed tomography scans. We chose several anatomic landmarks and measured the distances in lateral operation and located a projection point for directing this surgery., Results: The mean values of distance from dacryon and the anterior foramen of the optic canal to the index plane were 5.439 ± 2.4496 and 9.334 ± 2.0628 mm. The mean values of distance from trisection points to the orbital medial wall were 7.359 ± 2.2262 and 6.911 ± 2.3102 mm. The mean value of distance from the projection point to the ipsilateral outer edge of the supraorbital notch was 30.379 ± 5.3676 mm. There are no significant differences for all the distance between the left side and right side. The median of right-side angle between the straight line connecting both sides of the outer edge of supraorbital notch and the straight line connecting the projection point with the ipsilateral outer edge of the supraorbital notch is larger than the left one and has a less variation than the left one., Conclusions: The lateral distance in surgical operation is consistent among individuals, which can give a safe area to surgeons in lateral operation. The location of the projection point gives surgeons an indication of direction to this surgery.

Objective: To investigate discrepancies in results of facial asymmetry analysis using different cone beam computed tomography (CBCT) image reorientation methods and the effectiveness of soft tissue as a reorientation reference for analysis of facial asymmetry., Materials and Methods: An asymmetric group of 30 patients with 4 mm or more of chin point (menton [Me]) deviation and a symmetric group of 30 patients with less than 4 mm of deviation of Me were chosen as study subjects. Three orientation methods were used to calculate and compare Me deviation values of the 60 subjects. Two methods used only skeletal landmarks for reference, and one method included the soft tissue landmarks around the eye. Preferences of an expert group for the facial midline as determined by each reorientation method were also examined., Results: The examinations showed significant discrepancies in Me deviation values between the three reorientation methods. The expert group showed the greatest preference for the facial midline reorientation method that incorporated soft tissue landmarks of the eye., Conclusions: These study findings suggest that the inclusion of soft tissue landmarks, especially those around the eyes, is effective for three-dimensional CBCT image reorientation for facial asymmetry analysis.

Nasal polyps were once believed to originate in sinus cavities, and from there to pass through ostia and into the nasal cavity. However, data gained from subsequent anatomic studies revealed that they can actually originate in numerous locations in the sinonasal area. We report a case of a nasal polyp that originated in the cribriform plate, which is a very rare site of origin for a nasal polyp.

With the advancement of transnasal endoscopic technique, endoscopic repair of basal skull fractures has considerably substituted former external approaches. The endoscopically feasible pedicled flap, named nasoseptal flap has been extending its range of application, since it was introduced for the reconstruction of the defect after resection of skull base tumors. We introduce two patients with complicated basal skull fractures at different sites who were successfully treated by the transnasal endoscopic approach using nasoseptal flap., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Malignant chondroid syringoma is a very rare type of malignant sweat gland tumor. Diagnosis is based on pathologic features but is complicated by the low frequency of this tumor. The authors report a new case of malignant chondroid syringoma, initially misdiagnosed as basal cell carcinoma, that exhibited very aggressive local behavior and was located on the face, a rare site for this tumor. The authors describe its histopathologic appearance and highlight the importance of including adenoid cystic carcinoma in the differential diagnosis.

A case of craniofacial duplication is presented. Details on this rare form are described, and its treatment is discussed with brief review of the pertinent literature. We excised the duplicate maxilla and also discovered bilateral macrostomia. A year later, a mass appeared again. By CT scan, we found that there was a mass in the skull base extruding to the superior wall of cavitas pharyngis. The mass below the sphenoid bone and the ethmoid bone connected with the skull base. CT scan also showed malformation of the first cervical vertebra and odontoid process had bifurcated. Once again, we excised the mass and found a cranial meningocele on the skull base, repaired the palate cleft, and closed the cerebral meningocele. The patient had a palate fistula after operation. A year later, the palate fistula and macrostomia were repaired. We think the patient should be operated on immediately after she was born so that we could relieve the dyspnea; furthermore, by one well-planned operation, we could repair the palate cleft and other deformity just after we excised the mass.

Context: Kallmann syndrome (KS) is characterized by congenital hypogonadotropic hypogonadism (CHH) and an impaired sense of smell related to defective development of the olfactory system., Objective: The aim of the study was to use high-resolution computed tomography (CT) to detect specific abnormalities in the ethmoid bone region surrounding the olfactory bulbs in patients with KS., Patients: Thirty-seven KS patients were compared to normosmic CHH (nCHH) patients (n = 15) and controls (n = 30) of similar age., Design and Methods: We conducted a prospective study in a single referral center. Subjects underwent CT in bone windows with axial, coronal, and sagittal reconstructions centered on the olfactory fossa (OF) and cribriform plate (CP). We characterized the OF structure by measuring OF height, width, and surface area and a series of angles. The CP foramina were counted bilaterally. Olfactory bulb magnetic resonance imaging, performed in parallel, was compared with CT findings., Results: OF height, width, and surface area were all significantly lower in KS patients than in nCHH patients and controls (P < .0001). KS patients also had wider angles than nCHH patients and controls (P < .0001). KS subjects with olfactory bulb agenesis on magnetic resonance imaging or who harbored KAL1 mutations had the most marked changes in OF measurements and angles. Coronal OF height distinguished KS patients from controls with the best sensitivity and specificity. The mean number of CP foramina was similar in KS, nCHH, and control subjects., Conclusions: KS is associated with specific ethmoid bone abnormalities. The preserved number of CP foramina in KS patients suggests that the integrity of olfactory structures is not mandatory for their formation during fetal development or their maintenance in adult life.

The development of pneumatized middle turbinate may affect anterior ethmoid roof formation. The aim of this study was to investigate the relationship between the pneumatized middle turbinate and the dimensions of the anterior skull base structures using computed tomography scans. The coronal reconstructed images of the computed tomography scans were evaluated retrospectively. The lateral and medial ethmoid roof points, the width of the cribriform plate (CP), and the anterior ethmoid roof were identified at the first coronal cut, which was determined by the infraorbital nerve. The pneumatized middle turbinates were measured on the axial, vertical, and sagittal planes. The images of 101 patients were evaluated. The mean axial diameters of the pneumatized middle turbinate on the right and left sides were between 6.93 and 4.95 mm, respectively. The correlation between the axial diameters of the pneumatized middle turbinate and the width of the anterior ethmoid roof (termed AER width) was significant for both sides and gender (p < 0.05). There was a higher correlation on the right side where the pneumatized middle turbinate was observed more frequently (r = 0.357). The relationship between CP width and the diameters of the pneumatized middle turbinate was not significant (p > 0.05) for both sides. Iatrogenic lesions of the skull base occur predominantly in the lateral lamella of the CP. The risk of this complication may decrease with increasing of the AER width. Pneumatized middle turbinate may cause an increase in the width of the anterior ethmoid roof and provide more reliable endoscopic intervention of the anterior skull base and frontal sinus.

Knowledge of the precise location of anatomical landmarks such as the anterior (AEC) and posterior ethmoid (PEC) canals facilitates medial orbital wall surgery and is of major importance for the protection of the orbital nerve. The aim of this study was to identify these anatomical structures in 100 consecutive CT scans and measure the distance between them. The authors investigated whether a predictable symmetry existed between the left and right side. The AEC was not identified unilaterally in one patient, the PEC was not identified unilaterally in six patients and not bilaterally in one patient. An additional PEC was found unilaterally in 12 and bilaterally in five patients. If an anatomical structure was found bilaterally, the authors obtained a strong Pearson's correlation between the sides (r=0.798-0.903, p<0.001). An anatomical variation was found in nearly every fourth patient. The authors think that these data call into question the use of the PEC and AEC as reliable surgical landmarks in medial orbital surgery., (Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this study is to compare the reproducibility of three-dimensional cephalometric landmarks on three-dimensional computed tomography (3D-CT) surface rendering using clinical protocols based on low-dose (35-mAs) spiral CT and cone-beam CT (I-CAT). The absorbed dose levels for radiosensitive organs in the maxillofacial region during exposure in both 3D-CT protocols were also assessed., Materials and Methods: The study population consisted of ten human dry skulls examined with low-dose CT and cone-beam CT. Two independent observers identified 24 cephalometric anatomic landmarks at 13 sites on the 3D-CT surface renderings using both protocols, with each observer repeating the identification 1 month later. A total of 1,920 imaging measurements were performed. Thermoluminescent dosimeters were placed at six sites around the thyroid gland, the submandibular glands, and the eyes in an Alderson phantom to measure the absorbed dose levels., Results: When comparing low-dose CT and cone-beam CT protocols, the cone-beam CT protocol proved to be significantly more reproducible for four of the 13 anatomical sites. There was no significant difference between the protocols for the other nine anatomical sites. Both low-dose and cone-beam CT protocols were equivalent in dose absorption to the eyes and submandibular glands. However, thyroid glands were more irradiated with low-dose CT., Conclusions: Cone-beam CT was more reproducible and procured less irradiation to the thyroid gland than low-dose CT., Clinical Relevance: Cone-beam CT should be preferred over low-dose CT for developing three-dimensional bony cephalometric analyses.

Background: Endoscopic sinus surgery is a common and generally safe ENT procedure. Orbital injury is a rare but devastating complication. The distance between the uncinate process and the lamina papyracea is the safety margin to avoid entering the orbital cavity and has not been measured previously., Methods: The authors reviewed 330 consecutive coronal CT scans of the paranasal sinuses to measure this distance and identify variation., Results: The distance can be as narrow as 0.1 mm and varies between sides. An air cell lateral to the uncinate is not uncommon; it increases the distance considerably p < 0.001 but is frequently unilateral (22%). Gender does not have an effect on this distance p = 0.90., Conclusion: It is essential to carefully examine the area on a CT scan especially when performing front-to-back uncinectomy during endoscopic sinus surgery. The variation between the right and left sides should be considered to avoid unsafe assumptions., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: We evaluated two mobile cone beam computed tomographs (mCBCT) comparing image quality with respect to radiation dosage. Image quality was analyzed by using different scanning modes., Materials and Methods: The skulls of three human cadavers were scanned by use of conventional Computed Tomography (CT) as well as with two mobile cone beam computed tomographs (Siemens Arcadis Orbic 3D and Ziehm Vision Vario 3D). Six different acquisition modes with different radiation dosages were used. The axial views of all scans were evaluated by five medical doctors regarding image quality by identifying predefined anatomical structures of the skull. A five-point ranking scale was used. The inter-rater reliability was statistically depicted by Cohen's Kappa coefficient. A Wilcoxon signed rank test was used to evaluate the rater's results. For evaluating the signal-to-noise ratio (SNR) a Catphan 600 reference body with two different inlays was used., Results: Comparing the mCBCTs, the image quality of the Siemens Arcadis Orbic 3D in high-dosage mode received the best score (median: 2.27). The inter-rater reliability was fair (Kappa=-0.030 to 0.328). The Wilcoxon test showed significant (p<0.05) different median rating values in 18 out of 21 imaging modes. The SNR was higher (better) in the high-dosage modes., Conclusion: Intra-operative 3D imaging by using mCBCT for maxillofacial surgery in low-dose mode acquisition is adequate in terms of signal-to-noise ratio and image quality. The image quality does not correlate in a linear manner with a higher radiation dosage. Surgeons using this technique should gather their own experience with the different acquisition modes., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Zygomaticomaxillary complex fractures associated with ipsilateral naso-orbito-ethmoidal fractures are more complex injuries than isolated zygomaticomaxillary complex fractures. This injury pattern can have significant long-term morbidity if not recognized and treated appropriately during the initial operation. The purpose of this study is to compare mechanisms of injury, treatment, and outcome between patients with zygomaticomaxillary complex fractures and those with zygomaticomaxillary complex and ipsilateral naso-orbito-ethmoidal fractures., Methods: A 5-year retrospective review of all patients treated with zygomaticomaxillary complex fractures at a level I trauma center was performed. Computed tomographic scans were reviewed to divide patients into those with zygomaticomaxillary complex fractures alone and those with zygomaticomaxillary complex and ipsilateral naso-orbito-ethmoidal fractures. Demographics, treatment protocols, outcomes, complications, reoperations, and length of follow-up were identified for both groups and compared to determine differences between these populations., Results: A total of 245 patients were identified by the Current Procedural Terminology codes for zygomaticomaxillary complex fractures. One hundred eighty-five patients had zygomaticomaxillary complex fractures and 60 patients had zygomaticomaxillary complex/naso-orbito-ethmoidal injuries. The demographics for both populations were similar. There are differences between the groups with regard to mechanism of injury, operative findings, and techniques. The patients with zygomaticomaxillary complex/naso-orbito-ethmoidal fractures had higher rates of postoperative complications and deformities., Conclusions: Patients who sustain a zygomaticomaxillary complex fracture associated with an ipsilateral naso-orbito-ethmoidal fracture have a higher incidence of postoperative complications and deformities. It is important to recognize this fracture pattern early to help minimize postoperative morbidity., Clinical Question/level of Evidence: Risk, II.

We report a case of a late ethmoidal mucocele occurring after transpalpebral bony orbital decompression. A 39-year-old man presented with a recurrence of a right-sided proptosis without signs of orbital inflammation. The patient had undergone bilateral transpalpebral bony orbital decompression for dysthyroid orbitopathy 2 years prior. Orbital CT scan showed a large mucocele in the supero-lateral right ethmoidal sinus with lateral extension to the medial rectus. The patient was therefore referred to an ear, nose and throat (ENT) surgeon, who performed an anterior ethmoidectomy with marsupialization and drainage of the mucocele via an endoscopic approach. A complete postoperative resolution of proptosis was observed without recurrence of the mucocele to date, approximately 6 months postoperative. Sinus complications occurring after orbital decompression may include sinusitis, hematoma, imploding antrum syndrome and mucoceles. Recurrent proptosis secondary to an ethmoidal mucocele is a rare event after bony orbital decompression surgery, with only two cases reported in the international literature. Management requires ophthalmologic diagnosis and collaboration between the ophthalmologist and otorhinolaryngologist., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: The maxillary sinus roof has long been regarded as a reliable reference point for both endoscopic and skull base surgery., Objective: This study was designed to evaluate the maxillary sinus roof as a preoperative guide for posterior ethmoid and sphenoid sinus surgery., Method: This was a cross-sectional observational study of 50 randomly selected computed tomographic (CT) sinus scans from patients previously seen at a tertiary rhinology clinic. Each side of the sinuses was treated independently, giving a total of 100 sides for analysis. Using the medial maxillary sinus roof as a fixed reference point, the vertical distance to the posterior ethmoid skull base, natural sphenoid ostium, and anterior sphenoid roof and floor were measured. In addition, the maxillary sinus to posterior ethmoid height ratio was calculated for each patient., Results: Relative to the medial maxillary sinus roof, the mean vertical height of the posterior ethmoid skull base was 14.08 ± 3.03 mm. Using this same reference point, the mean vertical distance to the natural sphenoid ostium, sphenoid roof, and sphenoid floor was 2.76 ± 2.80 mm, 12.18 ± 3.20 mm, and 5.94 ± 2.94 mm, respectively. The mean maxillary sinus to posterior ethmoid height ratio was 2.49:1., Conclusion: The medial maxillary sinus roof is a reliable preoperative reference point for guiding safe surgical entry into the posterior ethmoid and sphenoid sinus. In addition to providing a margin of safety away from the skull base, it may also help with localization of the natural sphenoid ostium. A classification scheme for evaluating posterior ethmoid height is proposed.

Objective: To examine the three-dimensional virtual anatomical features of the sphenoid sinus and adjacent structures during virtual surgery and explore their relevance to actual transsphenoidal surgery., Methods: CT images of the sphenoid sinus and surrounding structures from 28 Chinese adult patients were measured using a 16-slice helical CT scanner. Image analysis was performed using the volume-rendering method. Two experienced neurosurgeons wearing stereoscopic glasses performed virtual transsphenoidal surgery by the transnasal approach., Results: The virtual anatomical features of the sphenoid sinus and the adjacent structures during virtual surgery were described. The distance from the sphenopalatine foramen to the left and right sphenoid ostium was 10.1 ± 2.7 mm and 10.5 ± 3.2 mm, respectively, to the left and right sphenoidal crest 12.9 ± 2.0 mm and 12.8 ± 2.2 mm, respectively, and to the left and right uncinate process 24.0 ± 1.9 mm and 23.9 ± 2.0 mm, respectively. The distance from the uncinate process to the medial and lateral edge of the most prominent part of the anterior bend of the cavernous internal carotid artery (ICA) was 33.7 ± 3.7 mm and 34.8 ± 3.7 mm, respectively, and the angle between the two lines was 9.7 ± 1.9°., Conclusion: The study provides virtual anatomical information about the sphenoid sinus and important surrounding structures that is essential for successful real life transsphenoidal surgery., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The attachment of the superior turbinate to the sphenoid face may be an important factor in determining the approach for sphenoidotomy. We sought to validate a previously described 4-type grading system for superior turbinate attachment (Type: A, within its medial one-third; B, in its middle one-third; C, to its lateral one-third; and D, directly to the orbit) to the face of the sphenoid sinus and to make recommendations for its use in determining the method of sphenoidotomy (transethmoidal vs transsphenoethmoidal)., Methods: Single-slice images through both sphenoid sinus ostia were obtained from axial series of computed tomography (CT) scans. Eighteen (36 ostia) sets of scans were used. Attachment type (A-D) in each image was classified by 10 experienced sinus surgeons and compared against a "gold standard" grading performed by the senior author (A.J.), who was the developer of the grading system., Results: Mean accuracy was 63% (95% confidence interval [CI], 54%-72%) for the 4-type grading system. When Types A+B and Types C+D were grouped together, mean accuracy was 91% (95% CI, 84%-97%). For the 2-group classification system, bootstrap analysis suggested that 97% of physicians attain an accuracy of at least 80%., Conclusion: Accuracy using the 4-type classification is too low to be practically useful. Accuracy using the 2-group system may be sufficiently high to be a useful aid in selecting a surgical approach. We recommend a transethmoid sphenoidotomy for Types A and B and a transsphenoethmoidal approach to the sphenoid for Types C and D., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Osteoma is the most common benign neoplasm of the paranasal sinuses. Intraorbital extension is rare. Here we report a 16-year-old adolescent boy who presented with epiphora and pain in the medial canthal area. A computed tomographic scan revealed a bone density mass in the left ethmoid cavity extending into the adjacent orbit. The tumor was removed via endoscopic endonasal surgery. The pathologic evaluation was consistent with osteoma. After surgery, all complaints have been resolved and there was not any sign of recurrence in the computed tomographic scan.

Chronic paranasal sinus disease is one of the most common causes of application to physicians in pediatric and adult patients. In the surgical treatment of these diseases, endoscopic sinus surgery is an application that is often done to increase the quality of the patient's life. On account of this, the anatomic variations in skull basement must be well known to avoid possible major complications that may occur during the operation. Recent developments in paranasal sinus surgery also enhanced the need for examining exhaustively the anatomy of this region and existing pathology. Superiority of computed tomography (CT) has an unquestionable importance for the evaluation of anatomic structure and pathology compared with conventional radiographs. A likely anatomic knowledge is needed for a safe surgery. Before the surgery, determining the anatomic variations makes the operation safer and increases the prospects, so we can prevent complications that may occur during the surgery. In this study, CT coronal sections of 300 patients who were admitted to the Department of Ear Nose Throat of Medical Faculty of Cumhuriyet University Research and Training Hospital between the dates December 2008 and January 2011 with complaints of nasal flow and postnasal drip were studied. According to coronal section CT examinations, the patients were divided into 2 groups. Group 1, with 156 cases (64%), showed mucosal changes, and in 144 cases (36%), no mucosal changes were established (group 2). In comparison between the sexes, in groups 1 and 2 females, significant difference was determined for other parameters except the average height of the ethmoid roof. In the comparison between the sexes, in groups 1 and 2 males, significant difference was determined for all parameters. The difference between these 2 rates was statistically significant. Keros types 1 and 2 cases were compared with the control group, and there was no statistically significant difference. Notwithstanding, at the comparison of the Keros type 3 with the control group, there was a statistically significant difference for all the parameters (maximum orbital height, the length of the middle concha, and the nasal wall). It seems to be important for us to know the average length of the peripheral anatomic structures to avoid serious complications that may occur during the operation. Careful preoperative review of paranasal sinus CT scans in patients undergoing sinus surgery seems to be the most important to prevent severe intraoperative complications.

Objective: To ascertain the prevalence of the lateral lamella of the cribriform plate height according to Keros classification in the Malaysian population, and to find if there is any difference between the major ethnic groups in Malaysia (Malay, Chinese, Indian)., Methods: Retrospective analysis of 150 CT scan studies of the paranasal sinuses., Results: The mean height of the lateral lamella of the cribriform plate (LLCP) in 300 sides was 2.64mm. Keros type I was seen in 240 sides (80%), while, Keros type II was seen in 60 sides (20%). There was no significant difference in the distribution of Keros classification among the major ethnic groups of Malaysia (Malay, Chinese, Indian). Keros type I was seen in 103 sides in males and 137 sides in females. Significant difference was observed in type II between the male and female (47 sides in males and 13 sides in female; p-value <0.001). When comparing the difference in the height of the LLCP in the same individual, asymmetry was observed in 139 patients. The LLCP height was higher on the left side in 71 patients and higher on the right in 68., Conclusion: The understanding of the anatomy of the ethmoid roof with its possible variation is crucial to give the surgeon the optimal information about the possible risk that one can face during the surgery., (Copyright © 2011. Published by Elsevier Ireland Ltd.)

Objective: Imaging of the anterior skull base and paranasal sinuses is essential before surgery of the nose and paranasal sinuses. It is important to know individual anatomical variations to define a "dangerous ethmoid" to prevent complications such as considerable bleeding or injury to the brain. This study aimed to analyze the relevant parameters with special regard to age-dependent differences., Methods: This was a retrospective, single center study of 865 patients. Data from cone beam computed tomography (CBCT) of 116 patients less than 18 years of age and 749 adult patients were analyzed. Keros type, the course of the anterior ethmoid artery, the course of the uncinate process and the angle between the lateral lamella and the cribriform of the olfactory fossa were evaluated., Results: Different frequencies of the course of the uncinate process between young and adult persons could be shown: onset at the lamina papyracea 67% vs. 64%; onset at the skull base, 22% vs. 26%; and onset at the middle turbinate, 11% vs. 10%. Differences in the course of the anterior ethmoid artery could be evaluated in the same way: course at the skull base, 49% vs. 44%; free course with a distance to the skull base of less than 3mm, 11% vs. 19%; and free course with a distance to the skull base more than 3mm, 40% vs. 37%. Significant differences could be found in the frequencies of the height of the olfactory fossa: Keros type I, 28% vs. 16%; Keros type II, 51% vs. 60%; and Keros type III, 21% vs. 24%. The angle between the lateral lamella and the cribriform plate showed significant differences dependent on the course of the anterior ethmoid artery (skull base=123° vs. distance<3mm=117° vs. distance>3mm=110°) and dependent on the height of the olfactory fossa (Keros type I=135° vs. Keros type II=117° vs. Keros type III=104°). Analysis of the angle as a factor of age and Keros type showed a significant difference in Keros type I (125° vs. 132°) and Keros type II (105° vs. 110°)., Conclusion: Cone beam computed tomography (CBCT) of the anterior skull base allows the assessment of individual anatomical-radiological risk profiles and the identification of a "dangerous ethmoid". Significant age-dependent differences in the frequencies of anatomic landmarks and the angles of the ethmoid roof could be evaluated and led to significantly different risk profiles between children and adults., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Iatrogenic ethmoid skull base (ESB) injury during endoscopic sinus surgery (ESS) is a potentially devastating complication. The height of the ESB can vary substantially and should be assessed during preoperative evaluation of the sinus computed tomography (CT) scan., Methods: The objective of this study is to describe an objective preoperative CT evaluation technique to assist the surgeon in defining the height of the ESB prior to performing ESS., Results: We propose a technique which measures the height of the ESB from a single horizontal mid-orbital line located on a standardized coronal sinus CT image at the level of the anterior ethmoid artery canal., Conclusions: Utilization of an objective preoperative CT measurement technique may quantify identification of a low ESB and optimize surgical awareness of this potentially dangerous anatomic skull base variation., (Copyright © 2012 American Rhinologic Society-American Academy of Otolaryngic Allergy, LLC.)

Objectives: Fibrous dysplasia is a congenital bone disease, where normal bone is replaced by a fibrous-like tissue with immature osteogenesis. The cephalic extremity is affected in one out of three cases. The aim of this study was to describe a case of fibrous dysplasia and review workup and management of this pathology., Material and Methods: We reviewed relevant publications using the Medline database and presented a case of isolated paranasal sinus fibrous dysplasia to illustrate this disease., Results: The clinical onset was headache and left palpebral oedema in a twelve-year old. Imaging showed a left fronto-ethmoidal bone lesion with epidural empyema. No other radiological anomaly or phosphor-calcic disorder was present. The clinical course was positive using intravenous antibiotics, with a two-year follow-up., Discussion: Fibrous dysplasia is diagnosed using CT-scan, without the need for histologic confirmation in most cases. Initial workup includes axial skeleton X-rays and hormonal dosages. The efficiency of biphosphonates drugs has significally reduced the number of surgical procedures., Conclusions: Fibrous dysplasia is often a multifocal disease and should be treated medically first. Management requires a multi-disciplinary team.

Introduction: Intracranial complications are recognised as rare, but serious, sequelae of endoscopic sinus surgery., Case Report: A 56-year-old woman was referred after developing meningitis following elective functional endoscopic sinus surgery. Computed tomography demonstrated a significant defect of the skull base in the right posterior ethmoid, clearly visible on both coronal and sagittal sections. Operative exploration demonstrated the skull base to be intact in the posterior ethmoid area identified on the scan, and the overlying mucosa appeared undisturbed. Scans were reviewed in the light of operative findings; coronal and sagittal images were found to be reconstructions. Directly acquired coronal computed tomography, undertaken three weeks after surgery, demonstrated a complete bony plate in the right posterior ethmoid at the site previously identified as dehiscent., Discussion and Conclusion: We speculate that the posterior ethmoid defect was actually an artefact of reconstruction. We cannot exclude the alternative possibility of remineralisation, but given the time frame this seems unlikely. This case highlights the need for caution when interpreting reconstructed images of the thin bony plates of the skull base and lamina papyracea, as regards both clinical significance and medicolegal reporting. While virtual defects have been reported in the superior semicircular canals as a result of reconstructed images, we believe this to be the first reported case demonstrating a similar problem in the anterior skull base.

Background: Bilateral, spontaneous cerebrospinal fluid rhinorrhoea is extremely rare, with only one previous case report (this patient developed contralateral cerebrospinal fluid leakage four years after successful endoscopic repair). We present the first English-language report of simultaneous, bilateral, spontaneous cerebrospinal fluid rhinorrhoea., Objective: To recommend a simple alternative endoscopic technique for simultaneous closure of bilateral, spontaneous cerebrospinal fluid rhinorrhoea., Case Report: A 47-year-old woman presented with recent onset of bilateral, spontaneous cerebrospinal fluid rhinorrhoea, a recent history suggestive of meningitis, and a past history of pneumococcal meningitis. Bony defects on both sides of the cribriform plate were closed endoscopically in the same anaesthetic session, via a uninasal, trans-septal approach, enabling both leakage sites to be sealed simultaneously., Conclusion: In cases of bilateral, spontaneous cerebrospinal fluid rhinorrhoea, uninasal, trans-septal endoscopic repair is a simple and effective technique for simultaneous closure of cerebrospinal fluid leakage.

Background: Nasal deviation plays an important role in plagiocephaly nosography, and it is frequent in plagiocephaly and objectivable both in early treated patients and in those patients who did not undergo any surgical correction., Patients and Methods: The group analyzed consisted of 12 patients affected by anterior synostotic plagiocephaly. All of them had reached the end of growth. A morphological analysis was made by using anthropometry. All patients were asked to undergo computed tomography, and all the scans were then reconstructed into three-dimensional models using a dedicated software. We made two-dimensional assessments on coronal and axial slices, and three-dimensional reconstruction was used to evaluate the volumetry of ethmoidal cells., Results and Discussion: From anthropometry, we realized that, in all patients, not only that the tip of the nose is deviated to the not affected side but also that the root itself does not lie on the midline and it is tilted to the synostotic side. Analysis of the computed tomographic scan results shows that the ethmoid bone, as much as the vomer and the upper maxilla, is deeply involved in these nasal abnormalities, presenting a deviated position and an altered development., Conclusions: We concluded that nasal morphology in plagiocephaly is strictly related to basicranium dysmorphism.

The objective of the present work was to analyse computed tomograms of brain and paranasal sinuses obtained from 3,054 patients with a view to elucidating specific features of the latter's structure. The following structural variants were distinguished: agenesia, hypogenesia, and hypergenesia. Orbital, zygomatic, temporal, cock's comb, ethmoidal, and nasal recesses in the frontal sinuses were described. It is concluded that the marked structural variability of frontal sinuses is responsible for the great variety of clinical manifestations of frontitis.

We describe a case of inadvertent intracranial placement of a nasotracheal tube in a patient with an undiagnosed major congenital cranial anomaly (a variant of Goldenhar syndrome, which included absence of the cribriform plate). We believe that this is the first reported case in which this complication arose as a result of a congenital abnormality rather than traumatic or iatrogenic disruption of the skull base. We conclude that patients with known craniofacial abnormalities or associated syndromes scheduled for procedures involving planned nasotracheal intubation or nasogastric tube placement should undergo preoperative cranial imaging studies to verify an intact skull base.

Objective: To establish normative dimensions for the depth of the olfactory fossa, the length and angulation of the lateral lamella of the cribriform plate, and the height of the ethmoid roof, in adult males and females., Design: The study assessed 300 high resolution, multislice computed tomography scans of the paranasal sinuses, which were evaluated using Merge Efilm software (version 2.0.0, build 37)., Results: According to the original Keros classification, the type II olfactory fossa was the commonest type in men (66.7 per cent), while the type I fossa was commonest in women (53 per cent). A difference of 3 mm or more between the depths of the right and left olfactory fossae was present in 11 per cent of men and 2 per cent of women. The lateral lamella of the cribriform plate was significantly shorter and less oblique in men than in women. The length of the lateral lamella was greater anteriorly than posteriorly in both sexes. There was a statistically significant difference between the angle of the lateral lamellae, comparing right and left sides. The ethmoid roof was lower in women than men., Conclusion: The observed differences between men and women and between the right and left sides are of surgical importance, and should alert surgeons to the need for thorough, systematic pre-operative evaluation of computed tomography scans.

We report a unique case of minimally invasive endoscopic removal of a penetrating orbitocranial foreign body (POCFB), and present a review of the literature. A 12-year-old boy was impaled in the orbit with a gate latch. Neurosurgical consultation ascertained that removal via bifrontal craniotomy would necessitate extensive brain retraction and result in permanent anosmia. Attempting nasal endoscopic removal was deemed prudent, given this morbidity and a lack of brain parenchymal violation. The patient recovered without a cerebrospinal fluid leak or other neurologic sequelae. To date, craniotomy is the only reported management of POCFBs in the literature. We herein report the first nasal endoscopic removal of a POCFB.

The nasal septum consists of multiple components with various developmental origins and is considered a mosaic structure. Few studies have focused on anatomical relationships among the components of the nasal septum, even though they are essential for clinical assessments of morphological abnormalities in the nasal septum. This study was performed to evaluate anatomical correlations among components of the nasal septum using computed tomography (CT) of the paranasal sinus. We studied images from CT scans of 168 paranasal sinuses collected at a secondary referral hospital between July 2008 and February 2009. The area of each component of the nasal septum was measured using median sagittal images of CT scans after three-dimensional reconstruction using computer software. The area of the cartilaginous septum decreased with age, whereas the area of the total nasal septum remained constant. The area of the perpendicular plate of ethmoid increased with age at the expense of the area of the septal cartilage.

Background: The identification of anatomic landmarks in endoscopic skull base or revision sinus surgery can be challenging. Normal anatomy is significantly altered with many paranasal tumors. Traditional endoscopic surgical landmarks extrapolated from inflammatory disease, such as the superior turbinate, may have been previously removed or involved in pathology. A frequently used rule to enter the sphenoid, "stay below or at the level of the orbital floor as dissection proceeds posteriorly and one will avoid the skull base," is assessed anatomically., Methods: The maxillary sinus roof height, relative to the nasal floor, was assessed as an operative landmark. Computed tomography (CT) performed on paranasal sinuses was studied. The relative height, ratio, and proportions of the maxillary sinus, ethmoid roof, cribriform fossa, and sphenoid planum were measured using computerized assessments., Results: Three hundred paranasal sinus systems were evaluated. The roof of the maxillary sinus was below the level of the skull base in 100% relative to the cribriform and 100% relative to the sphenoid planum. The mean distance of the maxillary roof below the skull base was 10.1 +/- 2.7 mm for the cribriform and 11.0 +/- 2.9 mm for the sphenoid., Conclusion: The maxillary sinus roof can be used as a robust landmark to allow safe dissection and debulking of pathology. Pathology removal can proceed posterior with this landmark to enable a safe entry to the sphenoid sinus, and thus the true skull base, when normal structures such as the superior turbinate and ostium are not available.

Intracranial penetrating injury through the nose is rare. We present a case of a 79 year-old patient who had intracranial penetrating injury with a wooden object accompanied by massive bilateral pneumoencephaly with the presence of a foreign body in the ethmoid bone with fracture and displacement of crista galli. This is a hitherto unreported retained foreign body with fractured ethmoid resulting in bilateral pneumoencephaly.