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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 195-199

Prevalence of Haller Infraorbital Ethmoidal Cells on Panoramic Radiograph – A prospective study


Department of Oral Medicine and Radiology, B. V. D. U. Dental College, Sangli, Maharashtra, India

Date of Submission04-Aug-2020
Date of Decision11-Feb-2021
Date of Acceptance25-Feb-2021
Date of Web Publication23-Jun-2021

Correspondence Address:
Dr. Shridevi Adaki
Department of Oral Medicine and Radiology, B. V. D. U. Dental College, Sangli - 416 414, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_166_20

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   Abstract 


Background: Haller's cells are anatomical variations in the development of the nose and paranasal sinuses. Numerous pathologies and symptoms are associated with this entity. So the present study was planned to evaluate the prevalence and the characteristics of Haller's cells on panoramic radiographs. Aim: The aim was to determine the prevalence and evaluate the characteristics of Haller's cells on panoramic radiographs. Settings and Design: Sample was selected from the Department of Oral Medicine, Diagnosis and Radiology, and the study was carried out for 1 year. The panoramic radiographs were evaluated for the presence of Haller cells. Materials and Methods: The study included 860 patients of both genders with an age range of 18–60 years. A panoramic radiograph was made and evaluated for the presence of Haller's cells and also side, shape, number of cells, and number of loculae (unilocular or multilocular) were evaluated. Statistical Analysis Used: Descriptive statistics, Chi-square test was done Results: Haller's cells were noted in 190 patients, with a prevalence of 22.09%. Out of these, 66.84% were unilateral and 33.15% were bilateral. The majority of the cells were round and irregular in shape. The unilocular type of Haller's cells occurring unilaterally was statistically significant. Conclusion: The results of the present study revealed that panoramic radiographs can depict and provide a clear delineation of Haller's cells. The description of the Haller cells is useful in the identification of entities and helps in differential diagnosis for patients having intractable orofacial pain. Further studies will be planned to look for such entities in cases of intractable orofacial pain which will help to alter the treatment planning accordingly.

Keywords: Dental imaging, maxillo-ethmoidal cells, orbito-ethmoidal cells, orofacial pain


How to cite this article:
Adaki S, Karagir A, Shah K, Adaki R. Prevalence of Haller Infraorbital Ethmoidal Cells on Panoramic Radiograph – A prospective study. J Indian Acad Oral Med Radiol 2021;33:195-9

How to cite this URL:
Adaki S, Karagir A, Shah K, Adaki R. Prevalence of Haller Infraorbital Ethmoidal Cells on Panoramic Radiograph – A prospective study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Jul 29];33:195-9. Available from: https://www.jiaomr.in/text.asp?2021/33/2/195/319059




   Introduction Top


Haller's cells are air cells situated beneath the ethmoid bulla which are seen along the roof of the maxillary sinus and the most inferior portion of the lamina papyracea.[1] These cells even include air cells located within the ethmoid infundibulum.[1] The Swiss anatomist Albert von Haller in 1765 first described Haller's cells, which are also known as maxillo-ethmoidal or orbito-ethmoidal cells.[2],[3] Haller's cells are thought to arise with pneumatization of the lateral crus.[4]

Haller's cells are anatomical variations in the development of the nose and paranasal sinuses. But still, they are responsible for patient's symptoms, so their presence has clinical significance.[1],[2] Numerous pathologies and symptoms associated with this entity include distressing orofacial pain, sinusitis, nasal obstruction, impaired nasal breathing, headache, chronic cough, and mucoceles.[2],[3],[5],[6],[7],[8] During endonasal procedures, Haller's cells can restrict access to the maxillary sinus or the anterior ethmoidal cells. So, to avoid the risk of intra-operative complications, the surgeon has to be aware of such variations.[4],[5]

Infraorbital ethmoid cells are seen as well-defined radiolucencies, with different shapes like round, oval, or tear-drop shaped, single or multiple in number, unilocular, or multilocular with a smooth border that may or may not appear corticated.[2] They are located medial to the infraorbital foramen according to a solitary panoramic radiographic study.[2] Panoramic imaging is a radiologic technique for producing a single image of the facial structures including both the maxillary and mandibular arches and their supporting structures. The position of Haller cells disturbs the normal pattern of mucociliary flow and predispose to recurrent maxillary sinusitis. Though Haller cells are developmental variations, they may lead to pathologies related to the nose and paranasal regions sometimes. So, the clinical significance of these entities initiated this study. The study was planned to evaluate the prevalence of Haller cells and also to evaluate the characteristics of Haller's cells on panoramic radiographs.

In literature, many investigatory modalities were used to evaluate the presence of these ethmoidal cells. Basic N et al.[1] (1999), evaluated the frequency of anatomical variations in pneumatization of the ethmoid bone by using computed tomographic imaging. Yanagisawa E et al.[3] (2001) observed a mucocele in an infraorbital ethmoid cell (Haller cell) by Endoscope. Ahmad M et al.[2] (2006) evaluated the prevalence of infraorbital ethmoid (Haller's cells) on panoramic radiographs. Though advanced modalities like computed tomography and cone- beam computed tomography give better details about such entities, still where availabilities of such investigatory modalities are questionable, panoramic imaging will be helpful in such instances.


   Materials and Methods Top


The sample was selected by simple random sampling method from the Department of Oral Medicine, Diagnosis and Radiology, and the study was carried out for 1 year. Ethical clearance was obtained by the Institutional ethical committee (IEC Approval No: BV (DU) MC&H/Sangli/IEC/D-14/18). Patients aged 18 years and above who visited the Department of Oral Medicine, and for whom the panoramic radiograph was advised for their treatment purpose were included in the study. The patient's health was kept at high priority and panoramic radiographs were included for those patients who require it for the treatment purpose and radiographs were not advised for study purpose. Patients with a history of trauma and/or surgery involving the maxillofacial region, systemic diseases affecting growth and development, or clinical and/or radiographic evidence of developmental anomalies/pathologies affecting the maxillofacial region were excluded from the study.

Sample size was calculated by considering a population size of 20,000, 5% margin of error, 95% of confidence level, and 50% response distribution, the recommended sample size was 377. So in the present study, 860 radiographs were evaluated which fulfilled the inclusion and exclusion criteria and the sample was collected in 1 year.

After taking a written informed consent, a complete clinical examination of the maxillofacial region was carried out for the evaluation of odontogenic & non odontogenic infections. A digital panoramic radiograph was taken for each patient, using Vatech digital X-ray imaging system, model PCH 2500, 2014, with kVp of 65–90 and 10 mA and exposure of 18 seconds with a total filtration of 2.8 mm aluminum. The digital images were then saved on the computer and interpreted for the presence of Haller cells.

The presence of Haller cells was confirmed by Ahmad et al.'s criteria.[2]

  1. Well-defined round, oval, or tear-drop shaped radiolucency, single or multiple, unilocular or multilocular, with a smooth border, which may or may not appear corticated.
  2. Located medial to infraorbital foramen.
  3. All or most of the border of the entity in is visible in the panoramic section.
  4. The inferior border of the orbit lacks cortication or remains indistinguishable in areas superimposed by this entity.


Entities were considered to be Haller cells only when they fulfilled these criteria. Single observer enlisted the various observations and entered in the study proformas consisting of age, gender, presence or absence of Haller cell, side, shape, number of cells, and number of loculae (unilocular or multilocular). The data collected were tabulated and subjected to descriptive statistical analysis and Chi-square test.


   Results Top


The study was done to identify and assess the characteristics and prevalence of Haller cells in digital panoramic radiographs. The total sample included was 860, out of which 470 were males and 390 were females.

Among 860 radiographs evaluated, Haller cells were found in 190 radiographs. The prevalence rate of Haller cells was 190 (22.09%), out of which 117 & 73 were found in male and female subjects respectively [Table 1]. The mean age of subjects with Haller cells was 32.84 years. Age-wise distribution of Haller cells is shown in [Table 2] and [Graph 1].
Table 1: Prevalence of Haller cells

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Table 2: Age-wise distribution of Haller cells

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Out of 190 radiographs with Haller cells, 127 cells were seen unilaterally (66.84%) and 63 cells were seen bilaterally (33.15%) [Figure 1]. Among the 127 unilateral Haller's cells, 56 (44.1%) were localized on the right side and 71 (55.9%) were localized on the left side [Table 3].
Table 3: Distribution of Haller cells according to side and number of loculae

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Figure 1: Cropped panoramic radiographs showing Haller cells bilaterally

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The 190 radiographs with Haller cells, 127 showed unilateral unilocular occurrence (66.84%), and 52 (27.36%) showed bilateral unilocular occurrence and 11 (5.8%) showed a bilateral mixed pattern, that is, both unilocular and multilocular patterns and on the right and left side [Table 4] and [Figure 2].
Table 4: Distribution of Haller cells according to number of loculae

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Figure 2: Cropped panoramic radiographs showing multilocular Haller cells

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In 190 radiographs with Haller cells, a total of 295 cells were noticed. Among them, 119 cells were round, 61 ovoid in shape [Figure 3], 12 depicted a teardrop shape, 13 showed trapezoid shape, and 85 were irregular in shape [Figure 4], [Table 5] and [Graph 2].
Table 5: Distribution of Haller cells according to shape

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Figure 3: Cropped panoramic radiographs showing Haller cells of oval shape

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Figure 4: Cropped panoramic radiographs showing Haller cells of irregular shape

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The inter-relationships among age, gender, and side were not found to be significant (P > 0.05). Unilocular Haller's cells occurring unilaterally were statistically significant (P < 0.05).


   Discussion Top


Haller cells are anatomical variations in the development of the nose and paranasal sinuses. The position of Haller cells in the medial portion of the orbital floor, lateral to the maxillary infundibulum, places them in a key position to disturb the normal pattern of mucociliary flow and predispose to recurrent maxillary sinusitis.[9] Several radiographic studies have shown a significant relationship between Haller cell size (>3 mm) and maxillary sinusitis.[10],[11],[12] Haller cells can also restrict access to the maxillary sinus or the anterior ethmoidal cells during endonasal procedures.

The present study was performed to determine the variations of Haller's cells considering gender, type, number, and shape. Such a description will be useful in the clear identification of these entities and helpful in giving the differential diagnosis for patients with orofacial pain. Detection of Haller's cells may also help the surgeons before endonasal procedures, which will prevent intraoperative complications.

A wide range of prevalence has been reported in the literature which ranges from 4.7 to 45.1%.[1],[2],[3],[7],[9],[10],[13] In the present study, the prevalence rate of Haller cells on panoramic radiograph is 22.09% which falls within the range of these previous studies. A wide range of prevalence rates reported could be because of variations in the populations also due to the radiographic modality used and the judgment regarding the presence or absence of Haller's cells.

The present study depicted more number of Haller cells in the age range of 18–30 years and a male-to-female ratio of 1.60:1. The distribution of Haller cells concerning gender was not statistically significant. This value is consistent with the results of a study by Basic et al.[1]

In the present study, the unilateral occurrence of Haller cells was statistically significant. This is in harmony with the previous studies where Haller cells were seen in a larger number of cases unilaterally than bilaterally.[2],[5] The presence of Haller cells when compared for right and left side, no statistically significant differences were noted. The study by Ahmad et al.[2] reported an almost equal distribution of Haller cells. The presence of a unilocular type of Haller cells unilaterally was highly significant. Among 190 cases of Haller cells, a total of 295 cells were found and the majority of the Haller cells were round and irregular in shape with very few cases depicting a teardrop shape.

The clinical significance of this study is that we can consider the pathologies related to Haller cells in the differential diagnosis in cases where orofacial pain is not responding to the treatment. Yanagisawa E et al.[3] reported mucocele in an infraorbital ethmoid cell by the endoscope. In routine dental practice, most frequently panoramic radiographs are taken for evaluation. If such entities are identified in patients with orofacial pain which is not responding to the treatment, pathologies related to Haller cells can be considered. Advanced imaging modalities will help to confirm the diagnosis and treatment can be done accordingly.

Limitations and future prospects

The study evaluated the presence of Haller cells on panoramic radiographs, but did not evaluate the correlation between history of orofacial pain / recurrent sinusitis and Haller cells.


   Conclusion Top


In conclusion, the results of the present study showed that panoramic radiographs can depict and provide a clear delineation of Haller cells. The description of the Haller cells is useful in the identification of entities and helps in differential diagnosis for patients having intractable orofacial pain. Further studies should be planned to look for such entities in cases of intractable orofacial pain which will help alter the treatment planning accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
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.  Back to cited text no. 1
    
2.
Ahmad M, Khurana N, Jaberi J, Sampair C, Kuba RK. Prevalence of infraorbital ethmoid (Haller's cells) on panoramic radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Oral Endod 2006;101:658-61.  Back to cited text no. 2
    
3.
Yanagisawa E, Marotta JC, Yanagisawa K. Endoscopic view of a mucocele in an infraorbital ethmoid cell (Haller cell). Ear NoseThroat J 2001;80:364-8.  Back to cited text no. 3
    
4.
Lang J. Clinical Anatomy of Nose, Nasal Cavity and Paranasal Sinuses: A Basis for Diagnosis and Surgery. New York, NY: Thieme; 1989.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
6.
Braun H, Stammberger H. Pneumatization of turbinates. Laryngoscope 2003;113:668-72.  Back to cited text no. 6
    
7.
Tatli MM, San I, Karaoglanoglu M. Paranasal sinus computed tomographic findings of children with chronic cough. Int J Pediatr Otorhinolaryngol 2001;60:213-7.  Back to cited text no. 7
    
8.
Holinger LD, Sanders AD. Chronic cough in infants and children: An update. Laryngoscope 1991;101:596-605.  Back to cited text no. 8
    
9.
Nedunchezhian K, Aswath N, Amudhan A. Quest for haller cells: A digital orthopantomography study. Indian J Dent Res 2018;29:181-5.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:5664.  Back to cited text no. 10
    
11.
Kainz J, Braun H, Genser P. Haller's cells: Morphologic evaluation and clinicosurgical relevance. Laryngorhinootology 1993;72:599604.  Back to cited text no. 11
    
12.
Milczuk HA, Dalley RW, Wessbacher FW, Richardson MA. Nasal and paranasal sinus anomalies in children with chronic sinusitis. Laryngoscope 1993;103:24752.  Back to cited text no. 12
    
13.
Raina A, Guledgud MV, Patil K. Infraorbital ethmoid (Haller's) cells: A panoramic radiographic study. Dentomaxillofacial Radiology 2012;41:305-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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