Assessing the Anatomical Variations in Route CT Scan of Paranasal Sinuses in Patients with Chronic Rhinosinusitis

The ability of computed tomography (CT) to create detailed, high-resolution images to support the development of treatment plans makes it a definitive diagnostic and management tool for patients with sinus disease. Clinical experts can assess the severity of the disease by distinguishing between various inflammatory, benign and malignant sinus disorders and using CT scans to identify clear changes in the contours of the sinus bone. To maximize the follow-up plan, detailed high-resolution images created by CT scans are extremely important to determine the type of treatment approach a patient need [1]. CT scans are usually used to assess the pathology of CRS and are considered essential for clear decisions related to manipulation of conditions [2]. Computed tomography, commonly known as CT scanning, (as shown in Fig 1) is widely recognized in the medical community as the gold standard when it comes to accurately diagnosing various sinus conditions and aiding in the meticulous planning of surgical interventions based on detailed and comprehensive imaging results [3]. Sinus scans allow for clear visualization and examination of most anatomical nasal structures, such as sinus cells, haller cells, and tumor cells, according to successful diagnostic imaging, and conditions such as nasal septal cells and Concha Bullosa [4]. The recent advancement of Functional Endoscopic Sinus Surgery (FESS) has significantly transformed sinus surgical procedures by introducing a significant dependence on nasal endoscopes [5].

Fig 1 Computed Tomography Machine [6]

Sinusitis, inflammation of the sinus mucosa, is a common suffering that can cause symptoms in many people and narrow breathing. Note that sustained nasal overload or relief that lasts more than a week without improvement is an indicator of chronic rhinitis. Chronic rhinitis is a disease caused by when the nose’s interior mucosa is repeatedly irritated or inflamed, and if left undetected, it can lead to deterioration of symptoms over time [7]. CRS is characterized by inflammation of the paralytic cave (PNS), which can cause many stressful symptoms. Inflammation is the main cause of the nose running and is the cause after the nose drip, where mucus accumulates in the throat [8]. The four major sinuses in the human body the frontal, maxillary, ethmoid, and sphenoid sinuses are critical anatomical structures that play distinct roles, performing various significant physiological processes in the body. Firstly, the maxillary sinuses, which are also the largest of the paranasal sinuses, are found in the area of the cheekbone called the maxilla. The sinuses play a very important role in reducing the weight of the entire skull, aiding intranasal verbal resonance and air moisture [9]. The Ethmoid voucher consists of a hollow chain filled with small air in Ethmoid bones between the orbital hole and the passageway of the nose. The sinuses are extremely important as they are involved in the air filtration process to provide enough clean air and wetting processes within the body. This is because it provides the optimal amount of water needed for the nasal cavity, which is very important for general respiratory function [10]. Furthermore, the sphenoid bone vaunts are located in the spinal bones behind the nasal cavity. The sinuses the skull and is involved in the production of mucus. This is essential to maintain nose function [11]. Finally, the frontal sinuses, which are located in the frontal bone above the eyebrows, are another important part of the sinus system. Like their counterparts, these sinuses help decrease skull weight to support proper head structure and also contribute to voice resonance, thereby facilitating effective vocal communication [12]. The importance of understanding the complexity and interconnection of these sinus structures cannot be overstated in the understanding of their debilitating impact on respiratory function and general well-being (as Shown in Fig. 2) [12], [13].

Fig 2 Location of the paranasal sinuses [13]

Patients with CRS should plan or plan FESS and undergo an appropriate assessment of the occurrence of paralysis crimes against CT scans. These variations affect the management of CRS and affect the occurrence of air and drainage pathways. These variations should be identified preoperatively as they can tighten up early CRS problems [14]. Gathering local health information based on these reviews is useful as it provides a better understanding of how extensive and types of sinus structure variation exist in the study population. This information is the advantage of designing effective treatments for CRS patients and ensuring that surgery is as safe as possible. Finally, considering sinus shape variation on CT scans is an important part of the complete management plan for CRS. This is key to optimizing patient care and surgical outcomes in ear, nose and neck specialties [15]. Various forms of sinuses are the main reasons for the worsening of chronic sinusitis. They block normal drainage pathways, alter airflow, and increase the risk of sinus infections a d inflammation. This increases the likelihood of successful surgery and allows us to understand how to influence treatment for CRS [16]. Using imaging that may indicate whether patients with sinus PNS need surgically treatment according to their anatomy, potentially predict outcomes of chronic sinusitis [17]. Currently, we still have no information on how structural variations influence the severity of CRS and the effectiveness of treatments. A number of studies have investigated a number of body structure issues related to CRS. Nevertheless, to date, no studies have established a definitive long-term relationship between these shape problems and clinical outcomes, such as the severity of symptoms, the success of the treatment, and the likelihood of having CRS again [8], [3]. The potential advantages of studying the relationship between imaging findings and long- term patient status demonstrate why additional research is necessary to link radiologic assessment with overall treatment and prognosis for chronic rhino sinusitis [18].

Objectives of the study:

1.             To Compare the severity of rhino sinusitis among patients in different paranasal sinuses.

2. To evaluate anatomical variations in paranasal sinuses among patients suffering from chronic rhino sinusitis.

METHODOLOGY:

This study is a retrospective based from where research can assess the Anatomical variation of PNS with respect to chronic rhino sinusitis. Retrospective analysis is performed by reviewing existing computed tomography (CT) scans to identify and evaluate anatomical variants and their association with CRS. The target population comprises patients clinically diagnosed with chronic rhino sinusitis (CRS), based on standard diagnostic criteria, including:

• Clinical Symptoms: Nasal obstruction, nasal discharge, facial pain/pressure, and reduction or loss of smell, persisting for at least 12 weeks.

• Nasal Endoscopic Findings: Mucosal enema, nasal polyps, or mucopurulent discharge within the middle meatus or nasal cavity.

This study conducted over a period of six months, starting from December 2024 and continuing through June 2025.This study uses convenience sampling technique, selecting patients who underwent CT imaging of the PNS during the specified study period and fulfilled the inclusion criteria. The expected sample size will depend on the number of eligible cases presenting within the study duration. For the research, using computed tomography machine of 128 slices (Somatom go top). A high-resolution computed tomography (CT) scanner with 128-slice capability will be utilized to acquire detailed images of the paranasal sinuses. Imaging protocols are standardized to optimize visualization of bony anatomy and anatomical variants, particularly focusing on:

• Osteomeatal complex

• Septal deviation

• Concha bullosa

• Haller cells

• Agger nasi cells

• Onodi cells

• Frontal sinus variants

Axial, coronal, and sagittal planes will be reviewed to ensure comprehensive assessment. Study was conducted after collecting the ethical approval of Chitkara University. Patient confidentiality and privacy were strictly maintained throughout the research process. As this is a retrospective study, no direct patient involvement or interventions were performed, and anonymized data were used solely for academic and research purposes.

• Inclusion Criteria

• Age: 16-85 years

• Diagnosis of CRS based on clinical symptoms and endoscopic findings.

• Availability of CT scan images of PNS

• Allergy patient

• Dental patient

• Pre- operative

• Exclusion Criteria

• Patients with acute infections

• Previous sinus surgery

• Presence of nasal tumors or cysts

• Below 15 age and above 85 years

• Pregnant women

• Post-operative

• Traumatic case

• Elimination of artifact image

Fig 3 Flow Chart of Lund- Mackay CT sinus scoring system [19]

• Scoring per Sinus:

• No Abnormality
• Partial Opacification
• 2 Complete Opacification

• Osteo-Meatal Complex:

• Not Obstructed
• 2 Obstructed

• Interpreting the score:

• 1-4: Mild
• 5-12: Moderate
• 13-24: Severe

RESULTS:

• Introduction

In the present research undertaking, an investigation was conducted to explore and thoroughly analyse the diverse anatomical variations of the paranasal sinuses by utilizing commonly employed routine computed tomography (CT) scans within a designated cohort comprising 350 patients who had been clinically diagnosed with the persistent medical condition known as chronic rhino sinusitis (CRS).

• Objective of the study

1.To compare the severity of rhino sinusitis among patients in different paranasal sinuses.

2. To evaluate anatomical variations in paranasal sinuses among patients suffering from chronic Rhinosinusitis.

• Results

Out of the total 350 patients included in the study, 192 (54.9%) were male and 158 (45.1%) were female. The mean age of male patients was 47.67 years (±18.70), while the mean age of female patients was 49.18 years (±16.30). The overall mean age of the study population was 48.35 years (±17.65), ranging from 16 to 85 years. This indicates a slight male predominance among patients diagnosed with chronic rhino sinusitis in the studied population (as shown in Fig 4).

Fig 4 Distribution on the basis of Gender

In the present study, the severity of chronic rhino sinusitis among the 350 patients was categorized into four levels: no disease, mild, moderate, and severe. Out of the total cases, 46 patients (13.1%) showed no significant radiological evidence of sinus involvement, while 111 patients (31.7%) had mild severity, 112 patients (32.0%) presented with moderate severity, and 81 patients (23.1%) exhibited severe disease (as shown in Fig 5).

Fig 5 Distribution on the basis severity

• Compare the severity of Rhinosinusitis among patient in different Paranasal Sinuses

Our analysis reveals a strong, statistically significant relationship between the right maxillary sinus condition and CRS severity. The extent of sinus Opacification is directly proportional to CRS severity, with normal sinuses mostly linked to mild CRS and partial and total Opacification associated with moderate and severe CRS, respectively. The Pearson Chi-Square test confirms a highly significant association (χ² = 261.989, p = 0.001).

Table 1 Comparison of Right Maxillary with CRS severity

Our analysis reveals a strong, statistically significant relationship between the right anterior ethmoid sinus and CRS severity. The degree of sinus Opacification is directly proportional to CRS severity, with normal sinuses mostly linked to mild CRS and partial and total Opacification associated with moderate and severe CRS, respectively. The Pearson Chi- Square test confirms a highly significant association (χ² = 358.665, p = 0.001). These findings highlight the critical diagnostic importance of evaluating the right anterior ethmoid sinus in CRS patients, emphasizing the value of radiological assessment in staging the disease and informing clinical management decisions.

Table 2 Comparison of Right Anterior Ethmoid with CRS severity

Our analysis reveals a statistically significant relationship between the right posterior ethmoid sinus condition and CRS severity. The extent of sinus Opacification is directly proportional to CRS severity, with normal sinuses linked to mild disease and partial and total Opacification associated with moderate and severe CRS, respectively. The Pearson Chi-Square test confirms a highly significant association (χ² = 306.071, p = 0.001). These findings highlight the importance of evaluating the posterior ethmoid sinus in CRS diagnosis and management.

Table 3 Comparison of Right Posterior Ethmoid with CRS severity

Our analysis reveals a statistically significant relationship between the right frontal sinus condition and CRS severity. Increasing Opacification of the right frontal sinus is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 192.240, p = 0.001). These findings highlight the diagnostic significance of the right frontal sinus in CRS assessment, with normal appearance linked to mild disease and total Opacification strongly associated with severe CRS.

Table 4 Comparison of Right Frontal with CRS severity

Our analysis reveals a statistically significant relationship between the right sphenoid sinus condition and CRS severity. Increasing Opacification of the right sphenoid sinus is associated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 164.588, p = 0.001). These findings highlight the importance of radiological assessment of the sphenoid sinus in CRS diagnosis and management.

Table 5 Comparison of Right Sphenoid with CRS severity

Our analysis reveals a significant association between right osteomeatal complex (OMC) obstruction and CRS severity. OMC obstruction is strongly linked to severe CRS, while a non-obstructed OMC is associated with milder disease. The Pearson Chi-Square test confirms a highly significant association (χ² = 179.136, p = 0.001). These findings highlight the critical role of OMC evaluation in CRS diagnosis and management.

Table 6 Comparison of Right osteomeatal Complex with CRS severity

Our analysis reveals a strong, statistically significant association between the left maxillary sinus condition and CRS severity. Increasing Opacification of the left maxillary sinus is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 263.369, p = 0.001). These findings highlight the diagnostic importance of assessing the left maxillary sinus in CRS patients, with normal sinuses linked to mild disease and total Opacification strongly associated with severe CRS.

Table 7 Comparison of Left Maxillary with CRS severity

Our analysis reveals a strong, statistically significant association between the left anterior ethmoid sinus condition and CRS severity. Increasing Opacification is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 387.573, p = 0.001). These findings highlight the diagnostic value of radiological assessment in determining CRS severity, enabling clinicians to predict disease severity and tailor treatment approaches.

Table 8 Comparison of Left Anterior Ethmoid with CRS severity

Our analysis reveals a strong, statistically significant association between the left posterior ethmoid sinus condition and CRS severity. Increasing Opacification is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 332.826, p = 0.001). These findings highlight the diagnostic importance of evaluating the left posterior ethmoid sinus in CRS patients, enabling clinicians to predict disease severity and tailor treatment approaches.

Table 9 Comparison of Left Posterior Ethmoid with CRS severity

Our analysis reveals a strong, statistically significant association between the left frontal sinus condition and CRS severity. Increasing Opacification is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 209.065, p = 0.001). These findings highlight the diagnostic importance of evaluating the left frontal sinus in CRS patients, enabling clinicians to predict disease severity and tailor treatment approaches.

Table 10 Comparison of Left Frontal with CRS severity

Our analysis reveals a strong, statistically significant association between the left sphenoid sinus condition and CRS severity. Increasing Opacification is directly correlated with escalating CRS severity. The Pearson Chi-Square test confirms a highly significant association (χ² = 189.420, p = 0.001). These findings highlight the diagnostic importance of evaluating the left sphenoid sinus in CRS patients, enabling clinicians to predict disease severity and tailor treatment approaches.

Table 11 Comparison of Left Sphenoid with CRS severity

Our analysis reveals a statistically significant association between left osteomeatal complex (OMC) obstruction and CRS severity. OMC obstruction is strongly linked to severe CRS. The Pearson Chi-Square test confirms a highly significant association (χ² =167.059, p = 0.001). These findings highlight the importance of evaluating the OMC in CRS assessment and guiding treatment strategies.

Table 12 Comparison of Left osteomeatal Complex with CRS severity

Table 13 Chi-square test to compare severity with sinuses

• Compare Anatomical variation in Paranasal sinuses among patients suffering from Chronic Rhinosinusitis

The analysis of anatomical variations in relation to chronic rhino sinusitis (CRS) severity reveals significant patterns. Deviated nasal septum, compensatory hypertrophy, and lamellar concha bullosa are common across CRS severities, with varying frequencies. Mucosal thickening and bony nasal spurs are consistently observed across all CRS categories. Notably, severe anatomical alterations such as sinonasal polyposis, osteomeatal complex occlusion, and soft tissue opacification are predominantly associated with moderate and severe CRS. Rare findings like Onodi cells and Haller cells are identified sporadically in CRS patients. These observations highlight the importance of detailed anatomical assessment in CRS evaluation, guiding diagnostic and therapeutic decision- making. These observations highlight the importance of detailed anatomical assessment in the evaluation of CRS, as specific variations may contribute to disease pathophysiology and severity, potentially guiding both diagnostic evaluation and therapeutic decision- making (as shown in Table 14).

Table 14 Comparing Anatomical Variants in patients with Chronic Rhinosinusitis

DISCUSSION:

This study focuses on Pointing out that CRS patients have numerous and diverse anatomical variations. Strengthening the need of regular CT examination of every patient with CRS and, particularly, prior to the operation. CRS is a major health issue worldwide which is defined as the recurrent inflammation of the paranasal sinuses mucous lining, occurring even at a period of 12 weeks [16]. CT is known to be the gold standard image technique to assess the paranasal sinuses anatomy and disease. Determine important surgical planning-based bony landmarks. Identify fine anatomical changes [20]. Illustrate how much of mucosal disease is present. Direct proper and secure Functional Endoscopic Sinus Surgery (FESS) performance [21]. It has also been highlighted in this thesis that accurate CT imaging plays a very crucial role in the diagnosis of CRS and also in the identification of anatomical variants that may be involved in the pathogenesis of disease [22].

DNS: Recurrently described as the most prevalent anatomical variation of CRS patients in numerous studies reviewed, having a varying prevalence of 60 to 86.7% in different populations [23]. Concha Bullosa It is common among CRS patients its prevalence varies between 18.2% and more than 48% in some studies. It adds to the blockage of the osteomeatal complex (OMC) thereby predisposing to sinus disease [24]. Agger Nasi Cells: These are known as important anatomical parts that can constrict the frontal recess and result into frontal sinusitis. The prevalence rates range at 26 % and above to more than 67% [25]. Haller Cells: Existence of infraorbital cells in the ethmoid can strain the infundibulum, which may result in ill disease of the maxillary sinus with 11-20% being the commonest prevalence rate by numerous studies [26]. Onodi Cells: These cells are rarer (occurring in about 510) %of the cases but important to be recognized due to their location at the proximity of the optic nerve and the internal carotid artery, which has high surgical risks should they go unnoticed [27]. Another important theme highlighted in the reviewed literature is the significant impact of anatomical variations on the normal functioning of the paranasal sinuses. These variations, such as deviated nasal septum, concha bullosa, and enlarged turbinates, can result in the narrowing or obstruction of sinus drainage pathways. Such structural alterations hinder the efficient clearance of mucus, leading to its stagnation within the sinus cavities. This sluggish mucus clearance creates a favorable environment for bacterial growth, thereby increasing the individual’s susceptibility to recurrent or chronic infections. Over time, these persistent infections and impaired drainage may contribute to chronic inflammation and the formation of nasal polyps [28], [29]. Such studies as those by Fadda et al. (2012) and Rajendra Kumar et al. (2016) show that patients who have multiple anatomical diversifications have a more severe mucosal disease on CT [30], [31]. Nautiyal et al. (2020) recorded that the prevalence of middle turbinate pneumatization was high and was correlated with CRS symptoms [32]. Such significant statistical correlations were also noted in studies, such as the one by Mahdi et al. (2021), referring to anatomical variations and clinical manifestations of nasal obstruction and purulent nasal discharge [33]. Nevertheless, a number of studies (e.g., Katya A. et al., 2015; Tiwari TN et al., 2019) argue that the existence of anatomical variations not necessarily leads to direct correlation with the clinical severity of symptoms. This is enunciating a multifactorial character of CRS in which environmental exposure, allergic responses, immune reactions, and infections are also important [34], [35]. Increased rates of anatomical variations have been observed in men (e.g., Fadda et al., 2012; Sumaily et al., 2018) [36], [37]. The prevalence of these variations tends to be higher with advancing age, particularly for certain types, such as Onodi cells (Banaz et al., 2014) [38]. However, there are also reports indicating that some studies have failed to find a significant gender difference regarding the prevalence of anatomical variations (e.g., Reffat et al., 2022) [39]. This inconsistency in findings suggests a pressing need for more population- specific data, as anatomical changes may be influenced by genetic, racial, or even environmental factors that vary across different regions [40]. Understanding these underlying factors is crucial for comprehensively assessing anatomical variations and their implications in clinical practices.

CONCLUSION:

The study examines the connection between the severity of CRS and the extent of Opacification in various paranasal sinuses. The analysis highlights the importance of detailed radiological assessment in evaluating CRS severity and guiding clinical management. A significant correlation was found between the degree of Opacification in paranasal sinuses and CRS severity. The study emphasizes the role of evaluating individual sinuses, such as the maxillary, anterior ethmoid, posterior ethmoid, frontal, and sphenoid sinuses, in determining CRS severity. The OMC plays a crucial function in the pathophysiology of CRS, and obstruction of this complex is strongly associated with higher CRS severity. Anatomical variations, such as deviated nasal septum, concha bullosa, and sinonasal polyposis, are common in CRS patients and may contribute to disease pathophysiology and severity. These findings suggest that detailed radiological assessment can aid in accurately staging CRS and guiding treatment decisions. Understanding the association between sinus Opacification and CRS severity can help clinicians develop targeted management strategies.

Table 15 Association between Sinus Opacification and CRS Severity

Table 16 Anatomical Variations in CRS Patients

The study's findings have important implications for clinical practice. Accurate disease staging and targeted management strategies can be developed by understanding the association between sinus Opacification and CRS severity. Thorough evaluation of paranasal sinuses and anatomical variations is essential in CRS patients. The study provides valuable insights into the relationship between paranasal sinus Opacification and CRS severity, emphasizing the importance of detailed radiological assessment in evaluating and managing CRS patients.

Table 17 CRS Severity Classification