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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 4  |  Page : 278-281

Cone Beam Computed Tomography Analysis of Incidental Maxillary Sinus Pathologies in North Indian Population


Department of Oral Medicine and Radiology, Subharti Dental College, Meerut, Uttar Pradesh, India

Date of Submission09-Oct-2017
Date of Acceptance10-Jan-2018
Date of Web Publication15-Feb-2018

Correspondence Address:
Dr. Aarfa Nasim
Department of Oral Medicine and Radiology, Subharti Dental College, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_97_17

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   Abstract 

Introduction: Maxillary sinus can be visualized in both two-dimensional and three-dimensional images. Computed tomography (CT) is considered the gold standard method for the examination of maxillary sinus. Cone beam computed tomography (CBCT) addresses the limitation of CT and provides many dental advantages. It can provide valuable knowledge about the pathology with limited exposure and low cost compared with other imaging used for diagnostic purposes. Aims and Objectives: The aim of the study is to analyze the prevalence of pathological changes in maxillary sinus of asymptomatic cases using CBCT for diagnostic purposes. Materials and Methods: This retrospective study evaluated 231 patients for incidental maxillary sinus pathologies. Pathological findings were categorized as mucosal thickening, polypoid mucosal thickening, radiopacification, and no pathological findings. Evaluation of pathological findings was done using factors of age and gender. Results: The present study showed 86 cases with maxillary sinus pathology and 145 cases with no pathological findings. Patients with maxillary sinus pathology were mostly diagnosed with mucosal thickening on both sides. In right maxillary sinus, 45 cases (52.3%) showed mucosal thickening, and on the left side 36 cases (41.9%) were diagnosed with mucosal thickening. Among 86 cases reported, 20 right maxillary sinus (23.3%) and 25 left maxillary sinus (29.1%) showed no signs of pathology. Conclusion: The incidental maxillary sinus pathologies are highly prevalent in asymptomatic patients. Therefore, oral radiologists should be aware of these incidental findings which will help in early diagnosis and treatment of disease.

Keywords: Cone beam, maxillary sinus, mucosal, pathology, polypoid, radiopacification


How to cite this article:
Malik SS, Nasim A, Mohan RP, Kamarthi N, Goel S, Gupta S. Cone Beam Computed Tomography Analysis of Incidental Maxillary Sinus Pathologies in North Indian Population. J Indian Acad Oral Med Radiol 2017;29:278-81

How to cite this URL:
Malik SS, Nasim A, Mohan RP, Kamarthi N, Goel S, Gupta S. Cone Beam Computed Tomography Analysis of Incidental Maxillary Sinus Pathologies in North Indian Population. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2019 May 22];29:278-81. Available from: http://www.jiaomr.in/text.asp?2017/29/4/278/225571




   Introduction Top


Dental radiography provides essential information in the diagnosis of orofacial pathology and subsequent treatment planning. Diagnosis of orofacial pathology is difficult with the 2D images obtained from conventional radiography. Cone beam computed tomography (CBCT) has been developed with 3D modalities and has become a better alternative against conventional radiography. CBCT systems with reduced radiation exposure and high-contrast images resulted in an increase in the indications for CBCT application for the evaluation of orofacial structures. Dental implant site assessment, maxillofacial trauma, and orthodontics are frequent indications for CBCT wherein the area of the nose and the maxillary sinus can be within the imaging field. This frequently encounters the operator with incidental findings in the area of the maxillary sinus.

The increase in the use of CBCT by dentists and maxillofacial surgeons suggested an assessment of the prevalence of incidental findings relevant for further evaluation. Incidental findings of the maxillary sinus also have to be followed-up. The comprehensive radiologic examination of the maxillary sinus includes assessment of the maxillary mucosa, fluid levels, bone alterations, and position, size, and patency of the ostium. Staging of chronic sinusitis based on CT imaging evaluates the level of opacification, the osteomeatal complex, and further abnormalities.[1],[2] Hence, the incidental findings viewed in the area of the maxillary sinus increase the use of CBCT by dentist for assessing the prevalence which would be relevant for further evaluation. The incidences of sinus abnormalities of the asymptomatic subjects varied between 10.9% and 69.1% in few reported studies.[3],[4],[5],[6],[7] To provide appropriate treatment and follow-up, the significance of incidental pathologic findings should be clarified. The aim of the present study was to record the prevalence of incidental maxillary sinus pathologies in patients presenting with dental problems using CBCT scans performed for maxillofacial diagnostic purposes.


   Materials and Methods Top


This retrospective study of 231 patients (462 maxillary sinuses) was conducted in the department of oral medicine and radiology at Subharti Dental College for a period of 9 months for incidental findings. Approval for this study was obtained from the institutional review board. The cases were selected based on the following criteria.

Inclusion criteria

This retrospective study included CBCT scans of bilateral maxillary sinus where individual factors of gender and age had been recorded.

Exclusion criteria

  • Patient with maxillofacial trauma involving maxillary sinus
  • Patient with known pathology in maxillary sinus.


CBCT scans were obtained with 3D imaging Cone-Beam CT Scanner [Sirona GALILEOS comfort CBCT scanner (Sirona Dental System GmbH, D 64625 Bensheim, Germany) with the effective radiation dose of 27-166 μSv]. Pathological findings were evaluated in all three planes (axial, coronal, sagittal). Pathological findings were categorized as mucosal thickening, polypoid mucosal thickening, and radiopacification. Mucosal thickening was evaluated by measuring the distance between the air-mucosal surface and inner bony margins of the sinus. The sinus pathology was considered when the mucosal thickening was more than 3 mm. Any dome-shaped radiopacity of maxillary sinus was considered as mucus retention cyst or mucocele and with attenuation to mucosal surface were diagnosed as polyp and were grouped under the heading of polypoid mucosal thickening. Radiopacification were evaluated in cases having chronic sinusitis [Figure 1].
Figure 1: CBCT scans (a-f) showing polypoid mucosal thickening, radiopacification and mucosal thickening in axial and coronal section

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After data collection, data entry was done in Excel and analysis was done. Statistical analysis of the data was performed using Statistical Package for Social Sciences (SPSS 17.0) and inferences were drawn. Qualitative data was presented with the help of frequency and percentage table. The Chi-square test was used to compare groups. P < 0.05 was taken as the significant level.


   Results Top


The age of the patients included in the study ranged from 10 to 79 years. A total of 231 cases were recorded over a period of 9 months interval, wherein 86 cases were with pathological findings in at least one sinus or both and 145 cases were without any maxillary sinus pathology on both right and left sides. Most patients with maxillary sinus pathology were generally between the 2nd and 3rd decade of life (36%) [Figure 2]. The patient pool consisted of 126 males (62.8%) and 105 females (37.2%) [Figure 3]. There was no statistically significant difference between gender and age group. Patients with maxillary sinus pathology were mostly diagnosed with mucosal thickening on both sides. In right maxillary sinus, 45 cases (52.3%) showed mucosal thickening, and on the left side 36 cases (41.9%) were diagnosed with mucosal thickening. Among 86 cases, 20 right maxillary sinus (23.3%) and 25 left maxillary sinus (29.1%) showed no signs of pathology [Table 1].
Figure 2: Prevalence of incidental maxillary sinus pathologic findings in different age groups

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Figure 3: Prevalence of incidental pathologic findings in males and females

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Table 1: Frequency of incidental pathological findings in maxillary sinuses

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   Discussion Top


This study conducted retrospectively among 231 patients for a period of 9 months showed 86 cases with incidental findings of maxillary sinus pathology. The present study showed 37.2% incidence of maxillary sinus pathologies. A study conducted by Cho and Jung found 37.7% incidence of maxillary sinus opacification.[8] In orthodontic patients, Pazera et al.[9] examined 46.8% incidental maxillary sinus pathologies. Ritter et al.[10] showed prevalence of incidental maxillary sinus pathologies in 56.3% by using CBCT as a diagnostic tool. Studies carried out using CT imaging reported in literature showed 63% and 83.2%[11],[12] prevalence of pathologies whereas MRI found prevalence of 50% even in children,[13] and panoramic imaging found prevalence 12% of mucosal thickening and 7% polypoid mucosal changes in 5,021 individuals.[14] Raghav et al.[15] and Rege et al.[16] reported 59.7% and 68.2% prevalence, respectively, of incidental findings of mucosal pathologies which was on higher limit than our study. The difference in the findings can be due to indication and sample present in the study, the different age and patients group present, the applied classification system in different studies, and visualization quality of different imaging modalities.

We found a higher frequency of pathological findings in males as compared with other studies,[10],[16] but the result was not statistically significant in our study. In the present study, patients showed higher incidence in the second decade when compared with other studies, such as Ritter et al.[10] which showed prevalence of pathological findings in the sixth decade and a study by Raghav et al.[15] showed prevalence in the third decade. In this study, the most prevalent finding was mucosal thickening – 52.3% in the right and 41.9% in the left maxillary sinus, radiopacification in 12.8% right and 14% in left maxillary sinus and polypoid mucosal thickening in right 11.6% and left 14%, respectively. On comparison with different studies, mucosal thickening was more prevalently found than other pathologies. The radiopacification found in our study was less significant compared to other studies. The reason for the variation could be attributed to the different imaging methods used in evaluation.

According to literature, comparison between CT and MRI imaging showed that CT is the better alternative for visualizing fine bone, although it is affected by metal artifacts, and therefore MRI had a higher sensitivity in visualizing mucosal thickening.[12] CT is currently the preferred imaging technique to screen for maxillary sinus disease. CBCT as a 3D imaging technique can be used in the clinical application of assessing paranasal sinus. Studies have showed the importance of CBCT in intraoperative imaging of paranasal sinus.[17] The major advantage of using CBCT in assessing maxillary sinus could be low dose compared with CT imaging. Moreover, CBCT delivers an isotropic volume resolution facilitating diagnosis of delicate structures in multiplanar reconstructions.[18] According to the perspective of a dentist or maxillofacial surgeon, the evaluation of the maxillary sinus in CBCT appears to be relevant for several reasons. Incidental findings in scans primarily taken for other indications are another aspect of visualizing the maxillary sinus. Here, the operator of a CBCT has to carefully evaluate the maxillary sinus to rule out any significant pathologic changes. Most findings here are benign because inflammation in the paranasal sinus is a frequent disease. However, malignancies have to be identified. Incidental findings were the main focus of our study and, within its limits, it provides information on the frequency of pathologic findings in the maxillary sinus in CBCT images.

The study has various limitations such as the study was conducted retrospectively with less number of observers and imaging modalities. The difference between nature of fluid (i.e., pus or blood) in radiopacification images were not made as they appear radiologically identical. Patients showing radiopacity caused due to maxillofacial trauma in maxillary sinus were excluded resulting into a reduction in sample size. Although the study has some limitations, it can be helpful in the early detection and evaluation of pathology of maxillary sinus in asymptomatic patients.


   Conclusion Top


In conclusion, as the incidental findings in maxillary sinus are highly prevalent in asymptomatic patients, oral radiologists should be aware of these incidental findings to evaluate and diagnose the disease. The detection of pathologies in the maxillary sinus seems feasible by CBCT imaging. Further studies are required to prospectively compare CT and CBCT in detecting pathologic lesions in the maxillary sinus and planning maxillary sinus surgery. Pathological changes observed as incidental findings are frequent in CBCT and have to be followed-up accordingly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Friedman WH, Katsantonis GP, Sivore M, Kay S. Computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis. Laryngoscope 1990;100:1161-5.  Back to cited text no. 1
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Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology 1993;31:183-4.  Back to cited text no. 2
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McNeill E, O'Hara J, Carrie S. The significance of MRI findings for non-rhinological disease. Clin Otolaryngol 2006;31:292-6.  Back to cited text no. 3
    
4.
Havas TE, Motbey JA, Gullane PJ. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg 1988;114:856-9.  Back to cited text no. 4
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Tarp B, Fiirgaard B, Christensen T, Jensen JJ, Black FT. The prevalence and significance of incidental paranasal sinus abnormalities on MRI. Rhinology 2000;38:33-8.  Back to cited text no. 5
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Nam EC, Lee BJ. Prevalence of sinus abnormality observed in the cranial computed tomograms taken to evaluate head injury patients. Korean J Otolaryngol 1998;41:488-92.  Back to cited text no. 6
    
7.
Min YG, Choo MJ, Rhee CS, Jin HR, Shin JS, Cho YS. CT analysis of the paranasal sinuses in symptomatic and symptomatic groups. Korean J Otolaryngol 1993;35:916-25.  Back to cited text no. 7
    
8.
Cho BH, Jung YH. Prevalence of incidental paranasal sinus opacification in an adult dental population. Korean J Oral Maxillofac Radiol 2009;39:191-4.  Back to cited text no. 8
    
9.
Pazera P, Bornstein MM, Pazera A, Sendi P, Katsaros C. Incidental maxillary sinus finding in orthodontic patients: A radiographic analysis using cone beam computed tomography (CBCT). Orthod Craniofac Res 2011;14:17-24.  Back to cited text no. 9
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Ritter L, Lutz J, Neugebauer J, Scheer M, Dreiseidler T, Zinser MJ, et al. Prevalence of pathologic findings in the maxillary sinus in cone-beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:634-40.  Back to cited text no. 10
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Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:56-64.  Back to cited text no. 11
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Hahnel S, Ertl-Wagner B, Tasman AJ, Forsting M, Jansen O. Relative value of MR imaging as compared with CT in the diagnosis of inflammatory paranasal sinus disease. Radiology 1999;210:171-6.  Back to cited text no. 12
    
13.
Kristo A, Alho OP, Luotonen J, Koivunen P, Tervonen O, Uhari M. Cross-sectional survey of paranasal sinus magnetic resonance imaging findings in school children. Acta Paediatr 2003;92:34-6.  Back to cited text no. 13
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Vallo J, Suominen-Taipale L, Huumonen S, Soikkonen K, Norblad A. Prevalence of mucosal abnormalities of the maxillary sinus and their relationship to dental disease in panoramic radiography: Results from the Health 2000 Health Examination Survey. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:80-7.  Back to cited text no. 14
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Raghav M, Karjodkar FR, Sontakke S, Sansare K. Prevalence of incidental maxillary sinus pathologies in dental patients on cone beam computed tomographic images. Contemp Clin Dent 2015;14:361-5.  Back to cited text no. 15
    
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Rege IC, Sousa TO, Leles CR, Mendonca EF. Occurrence of maxillary sinus abnormalities detected by cone-beam CT in asymptomatic patients. BMC Oral Health 2012;12:30.  Back to cited text no. 16
    
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Rafferty MA, Siewerdsen JH, Chan Y, Moseley DJ, Daly MJ, Jaffray DA, et al. Investigation of C-arm cone-beam CT-guided surgery of the frontal recess. Laryngoscope 2005;115:2138-43.  Back to cited text no. 17
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Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:106-14.  Back to cited text no. 18
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