|Year : 2018 | Volume
| Issue : 1 | Page : 41-45
Evaluation of haller cell on CBCT and its association with maxillary sinus pathologies
Pallavi Kamdi, Vijayalakshmi Nimma, Amit Ramchandani, Easwaran Ramaswami, Ajas Gogri, Hemant Umarji
Department of Oral Medicine and Radiology, Govt. Dental College, Mumbai, Maharashtra, India
|Date of Submission||23-Feb-2018|
|Date of Acceptance||12-Mar-2018|
|Date of Web Publication||23-Apr-2018|
Dr. Pallavi Kamdi
Department of Oral Medicine and Radiology, Ground Floor, Room No. 23, Government Dental College and Hospital, Sent George Hospital Compound, Mumbai - 400 001, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Haller cells, an anatomical variation in paranasal sinuses, have also been suggested as a causative factor in maxillary sinus disease because of their ability to cause narrowing of the infundibulum because of their complex positioning. Research in the past had suggested the probable etiology for maxillary pathology from the obstruction at the osteomeatal complex leading to localized infection and inflammation. These further proceed to the sequel of another sinus pathology. Aim and Objective: The purpose of this study was to calculate the prevalence of Haller cells and to evaluate the association of the presence of Haller cells with maxillary sinus diseases. Materials and Methods: Cone beam computed tomography (CBCT) image volumes of 200 patients were retrieved from Planmeca ProMax 3D Mid machine and evaluated using Romex 3.1 software, in coronal section and keeping slice thickness of 4 mm. In total, 400 sites were analyzed for Haller cells and maxillary sinus disease. Haller cells were identified using criteria given by Mathew et al. Data obtained were subjected to the Chi-square test and Cohen' kappa test for statistical analysis and P values of <0.05 were considered statistically significant. Results: Out of 400 sites, Haller cells were noted at 129 sites and reported with the prevalence of 49%. Maxillary sinus pathology was noted at a total of 144 sites out of which 68 were associated with Haller cells. Maxillary sinusitis in association with Haller cells was reported at 50 sites where as benign mucosal cyst was reported at 18 sites. Conclusion: Haller cells should be used as an important anatomical variation in maxillary sinus pathologies.
Keywords: CBCT, Haller cells, maxillary sinus diseases
|How to cite this article:|
Kamdi P, Nimma V, Ramchandani A, Ramaswami E, Gogri A, Umarji H. Evaluation of haller cell on CBCT and its association with maxillary sinus pathologies. J Indian Acad Oral Med Radiol 2018;30:41-5
|How to cite this URL:|
Kamdi P, Nimma V, Ramchandani A, Ramaswami E, Gogri A, Umarji H. Evaluation of haller cell on CBCT and its association with maxillary sinus pathologies. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2020 Sep 18];30:41-5. Available from: http://www.jiaomr.in/text.asp?2018/30/1/41/230889
| Introduction|| |
Haller cells are the anatomical variation in paranasal sinuses  which were named after anatomist Albert Von Haller, who first identified this ethmoidal pneumatization of orbital floor in 1765., Haller cells are considered as an anterior extension of ethmoidal sinuses in to the orbital floor or superior aspect of maxillary sinus and they are located medial to the infraorbital canal and lateral to the nasolacrimal duct [Figure 1]. These cells are also named as orbito-ethmoidal cells or maxillo-ethmoidal cells., Posterior extension of ethmoidal cells is rarely seen and should be differentiated from lateral extension of the posterior portion of the middle meatus. Haller cells themselves do not represent diseased state, but they can be responsible for patient symptoms. Large sized Haller cells can cause compression of infundibulum of maxillary sinus which may block mucociliary flow, which will lead to disruption of transport and stagnation of fluid, which will produce favorable environment for bacterial growth which can further contribute to maxillary sinus diseases. Haller cells can act as contributory factor in diseases such as orofacial pain, persistent sinogenic headache, and orbital edema.
|Figure 1: Coronal cone beam CT at Paranasal sinus level shows radiolucent, well corticated Haller cell on left side (long arrow), infra-orbital foramen lateral to Haller cell (small arrow), nasolacrimal canal medial to Haller cell (arrow head)|
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Few studies in the past have demonstrated association of Haller cells with maxillary sinusitis, but thorough evaluation using three-dimensional imaging for Haller cells and all sinus pathology is sparse. In our study, we intend to evaluate the prevalence of Haller cells on cone beam computed tomography (CBCT) and its association with maxillary sinus disease.
| Materials and Methods|| |
A retrospective study was planned in which 200 CBCT scans of patients were acquired with Planmeca Promax 3D Mid machine (Planmeca OY, Asentajankatu 60080 Helsinki, Finland) and evaluated using Planmeca Romex 3.2R software. All the scans were taken with complains of temporomandibular joint, orthodontics, dental implants and other maxillofacial indications, from which scans showing complete maxilla extending from alveolar bone to the orbit (full face scan and 90 mm maxilla scans) were included in the study and the scans distorted because of artifact, and scans not showing area of interest clearly were also excluded from the study. Scans of both male and female patients above 16 years of age were included in the study as according to Gray's anatomy the development of paranasal sinuses does not complete till the age of 16 years. A specially designed proforma was used for details of patients including age, sex, presence of Haller cells (site, size, number), presence of maxillary sinus pathology (site, unilateral, bilateral). Study was approved by the institutional ethical committee.
Random scans were selected according to inclusion and exclusion criteria, and the interpretation was done as follows.
Haller cells were recognized by the criteria given by Mathew et al. (2013), as air-filled cavities located medially on orbital floor and/or lamina papyracea, inferior to bulla ethmoidalis (large ethmoidal cell). Haller cells are surrounded by the ethmoidal capsule which distinguishes them from infra-orbital recess of maxillary sinus. Haller cells can be of different sizes and shape, can be present unilaterally or bilaterally, and can be single in number or multiple [Figure 2]. All maxillary sinus pathologies such as maxillary sinusitis, mucus retention cyst, fluid accumulation, and calcification were identified and diagnosed according to  [Figure 3]. All observations were done in coronal section of CBCT, keeping slice thickness of 0.4 mm.
|Figure 2: Coronal cone beam CT shows different shapes of Haller cells, (a) Round, (b) Oval, (c) Triangular, (d) Multiple and bilateral Haller cells|
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|Figure 3: (a) Coronal cone beam CT shows, Haller cell causing thinning of bone of orbital floor (long arrow), compression of infundibulum of left maxillary sinus (arrow head), thickened mucosa of left maxillary sinus (short arrow). (b) Left maxillary sinus showing Mucus retention cyst (white arrow). (c) Right maxillary sinus showing fluid occumulation (white arrow), more than the half of the sinus is filled. (d) Left maxillary sinus showing hyperdense area (black arrow)|
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We measured maximum medio-lateral dimensions of Haller cells and classified them according to the size as small, medium, and large (<2, 2–4 mm, and >4 mm accordingly). Independent observation by two observers was done at an interval of 15 days for the presence of Haller cells and sinus pathology; the data obtained were subjected to statistical analysis. Chi-square test was applied to find out the association between the presence of the Haller cells and maxillary sinusitis. Cohen's kappa test was applied to find out inter-observer agreement. P < 0.05 was considered to be statistically significant.
| Results|| |
Out of 200 CBCT scans of patients, 400 sites were evaluated for the presence of Haller cells and maxillary sinus pathology, out of which 69% (138) were male and 31% (62) were female. Age range of patients was from 16 to 73 years (mean age 32 years). The prevalence of Haller cells was noted to be 49.5% (99 of 200) in the study population. The ratio of male and female was 1.05:1 (52.89% in male and 49.93% in female). No significant statistical correlation was observed between occurrence of Haller cells and gender of patient (P > 0.05). The age group of 16–25 years (30.23%; 39) showed more prevalence of Haller cells.
Out of the total 400 sites, Haller cells were noted at 129 sites, out of which 69 were unilateral and 30 were bilateral. About 30.23% (69) of Haller cells were observed on the right side, whereas 23.25% (60) were observed on the left side. There was no significant statistical association between the occurrence of Haller cells and their site of occurrence (P > 0.05). Haller cells were found in different shapes such as oval 51.85% (70), round 38.51% (52), triangular 3.70% (5), pear 4.44% (6), and irregular 1.48% (2) [Figure 2]. In our study, we noted small sized 20% (27), medium sized 63.70% (86), and large sized 16.29% (22) Haller cells.
Maxillary sinusitis is encountered at 94 sites, out of which 50 (38.75%) sites were associated with Haller cells in. Mostly it was encountered in patients with medium and large sized Haller cells. Chi-square test showed significant statistical association with maxillary sinusitis (P < 0.05) [Table 1]. Mucus retention cyst was recorded in 50 cases out of which 18 (13.95%) were associated with Haller cells. No significant statistical association was noted with mucus retention cyst (P > 0.05) [Table 1]. Cohen's kappa shows almost perfect agreement between two observers of the study.
|Table 1: Statistical correlation of the Haller cells with maxillary sinusitis and mucus retention cyst|
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| Discussion|| |
Haller cells are the anatomical variation in paranasal sinuses which can be seen in association with the other anatomical variations in osteomeatal complex such as concha bullosa, deviated nasal septum, and maxillary sinus septa. Haller cells showed varied range of prevalence of 2.5%–45.1%. This variability in prevalence can be attributed to imaging modality that is used for viewing Haller cells. In our study, we noted prevalence of 49.5% which is higher than the prevalence found in other studies. CBCT being an advanced imaging modality provides slice thickness of less than 0.4 mm, allowing us to identify Haller cells that measure less than 1 mm. This variability may also be attributed to the difference in sample size, age group, and race.
In our study, we evaluated variation in Haller cells according to age, gender, site, number, size, and shape. The incidence of Haller cells was more among younger population than older. This finding was consistent with the findings of Raina et al. and Kantarci et al. This could be because of the presence of maximum patients in the age group below 25 years and less number of elderly patients for the study. There was no significant association between prevalence of Haller cells and gender of the subjects which is similar to the finding of Raina et al. and Basic et al. In our study, we found Haller cells predominantly on the right side, and the same result was noted by Ahmed et al. and Raina et al. but Khayam et al. and Mathew et al. gave contradictory results as they recorded more of bilateral Haller cells. This difference can be attributed to the differences in size selected in the study. According to size and shape, medium sized (2–4 mm) and oval shaped Haller cells were recorded more in our study, whereas Mathew et al. reported large size (>4 mm) Haller cells more in their study.
Haller cells are the anatomical variation in paranasal sinuses and not the pathology itself, but they can predispose some patient to sinus diseases by causing obstruction of the opening of the maxillary sinus that can lead to inflammatory disease. Therefore, the diagnosis of Haller cells by rhinologist becomes important to rule out the cause of sinusitis when no other significant finding on physical examination and endoscopy is seen in association with the disease. The tools that can be used to diagnose Haller cells are listed in [Table 2] with their own advantages and challenges.
|Table 2: The tools that can be used to diagnose Haller along with their advantages and challenges|
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A Haller cells is an anomaly that can narrow osteomeatal complex when larger in size which further will cause blockage of the sinus drainage pathway, which may result in inadequate sinus ventilation, vacuum headache, and pressure headache. These headaches are mostly located at frontal area followed by face and periorbital area. This association of Haller cells in Maxillary sinus pathology was also observed by authors in the past from 1991 to till date where different imaging modalities were used [Table 3].
|Table 3: List of authors who observed association of Haller cells in Maxillary sinus pathology from 1991 to till date using different imaging modalities|
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There are other pathologies of orofacial region which have been associated with the presence of Haller cells that included rhinosinusitis, nasal diseases, nasal obstruction, impaired nasal breathing, orbital floor dehiscence, thinning of orbital floor, sinogenic headache, and others.,, Treatment of Haller cells extends from conservative to more definitive treatment such as surgical therapy. In cases where Haller cells were considered as etiology for maxillary sinusitis, medical therapy can be initially advocated; if unproductive, then surgical therapy such as the functional endoscopic approach  or lateral rhinotomy approach was done  for reliving patient's symptoms. The association of Haller cells in causing maxillary sinus pathologies could be emphasized with large sample and improve study design such as longitudinal prospective studies.
| Conclusion|| |
Presence of Haller cells and its size are found to be associated with the maxillary sinus pathology in our study. Thus Haller cells may be considered as a cause in the recurrent or chronic sinusitis, without any significant finding on physical examination and endoscopy. CBCT adds the third dimension in imaging these Haller cells which can be best evaluated and utilized for the accurate treatment of these sinus pathologies.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ahmed M, Khurana N, Jaberi J, Sampair C, Kuba KR. Prevalence of infraorbital ethmoid (Haller's) cells on panoramic radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol and Endodontol2006;101: 658-61.
Von Haller A, Cullen W, editors. First Lines of Physiology. 1st
American ed. Edinburgh: Obrabran, Penniman; 1803. pp. 223-5.
Yanagisawa E, Marotta JC, Yanagisawa K. Endoscopic view of a mucocele in an infraorbital ethmoid cell (Haller cell). Ear Nose Throat J 2001;80:364-8.
Wanamaker HH. Role of Haller's cell in headache and sinus disease: A case report. Otolaryngol Head Neck Surg 1996;14:324-7.
Gray H. Gray's Anatomy. 37th
edn. Edinburgh, Scotland: Churchill Livingstone; 1989. pp. 376-7.
Parks ET, Mile DA, Danforth RA. Cone beam computed tomography for the nasal cavity and paranasal sinuses. Dent Clin N
Raina A, Guledged MV, Patil K. Infraorbital ethmoid (Haller's) cells: A panoramic radiographic study. Dentomaxillofac Radiol2012;41:305-8.
Kantarci M, Karasen RM, Alper F, Onbas O, Okur A, Karaman A. Remarkable anatomic variations in paranasal sinus region and their clinical importance. Eur J Radiol 2004;50:296-302.
Basic N, Basic V, Jukic T, Basic M, Jelic M, Hat J. Computed tomographic imaging to determine the frequency of anatomical variations in pneumatization of the ethmoid bone. Eur Arch Otorhinolaryngol 1999;256:69-71.
Mathew R, Omani G, Hand A, Fellows D, Lurie A. Cone beam CT analysis of Haller cells: Prevalence and clinical significance. Dentomaxillofac Radiol 2013;42:20130055.
Hammad MS, Gomaa MA. Role of anatomical nasal abnormalities in rhinogenic headache. Egypt J Ear Nose Throat All Sci 2012;13:31-5.
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.
Milczuk HA, Dalley RW, Wessbacher FW, Richardson MA. Nasal and paranasal sinus anomalies in children with chronic sinusitis. Laryngoscope 1993;103:247-52.
Earwaker J. Anatomic variants in sino nasal CT. Radiographics 1993;13:381-415.
Sebrechts H, Vlaminck S, Casselman J. Orbital edema resulting from Haller cell pathology: 3 case reports and review of literature. Acta Otorhinolaryngol Belg2000;54:39-43.
Rice DH, Schaefer SD. Endoscopic paranasal sinus surgery; with illustrations by Calver LE, Barrows ST, Ensor E. Philadelphia: Lippincott Williams & Wilkins; 2004.
Alkire BC, Bhattacharyya N. An assessment of sino nasal anatomic variants potentially associated with recurrent acute rhinosinusitis. Laryngoscope 2010;120:631-4.
Shetty SR, Al-Bayati SA, Khazi SS, Gandhiraj VK. Haller's cells – A brief review. Balkan Military Med Rev 2015;18:147-50.
Debangshu G, Dilip B, Subodh G, Sumit B. Lateral rhinotomy for a large infected Haller's cell causing proptosis. Philippine J Otolaryngol Head Neck Surg 2015;30:43-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]