Role of Multi-Detector CT in Paranasal Sinuses

exercise of Multi-Detector CT in Paranasal SinusesSUMMARY OF THESISName of speciality Radio-diag noisName of System principal sum and NeckTitle of Thesis and Role of Multi-Detector Computed Tomography in Paranasal SinusesPathology, 2015.Lakshmi Kumar ChalamarlaName of Supervisor Dr. Kavita Kapoor, adviserImaging, Batra Hospital andMedical Research Centre, refreshing Delhi.Hospital/Institute Batra Hospital and Medical ResearchCentre, modernistic Delhi-1 c62.AIMS AND OBJECTIVESTo characterize pathologies of paranasal sinuses on MDCT and to delineate their anatomical location, addition and cadaverous involvement.To correlate the multi detector computed resource findings with clinical/surgical/histopathological/ microbiological findings.MATERIAL AND METHODSSTUDY AREAThe sight was conducted at the Department of Radio-diagnosis and Imaging in collaboration with the Department of ENT, Department of Pathology, and Department of Microbiology, Batra Hospital and Medical Research Centre. Other departments are collaborated for acquiring cases, and follow up of patients to correlate clinically or histopathologically or microbiologically.STUDY POPULATION100 patients were include in our poll mostly urban population. Patients belonged to both OPD and IPD cases. The subject field comprised of 65 staminates and 35 females. The number of male patients were higher than the female patients. There were 15 patients in 0 20 geezerhood age group, 36 patients in 21 40 days age group, 37 in 41 60 years age group and 12 were greater than 60 years. The age group of patients ranged from minimum of 9 months to maximal of 81 years. The highest number of patients were in 41 60 years age group.SAMPLE SIZE100 patients referred for military rank of sinus complaints were enrolled in the bring aft(prenominal) fulfilling the inclusion and exclusion criteria and taking indite/ vocal in resileed consent from July 2013 to April 2015.INCLUSION CRITERIAPatients with complain ts like headache/nasal obstruction/discharge/hyposmia /swelling everyplace cheek and with clinically suspected paranasal sinuses lesions referred for MDCT PNS evaluation.EXCLUSION CRITERIAAcute sinonasal inflammatory distemper.Previous evidence of sinonasal surgical process. in all cases of trauma.SAMPLE SIZE CALCULATION(Ref. Methods in biostatistics, Dr. B. K. Mahajan, 7th edition, pg. 85)For calculation of warning size Mahajans allowable wrongdoing formula was applied.N = 4pq/e2Where p = % of population = Target population/Total population100q = 1-pe = 20% of pAs per CT room register over last 3 yearsMinimum no. of MDCT PNS cases at our hospital/month = 20Maximum no. of MDCT PNS cases coming beneath exclusion criteria/month = 5So,Minimum no. of MDCT PNS cases at our hospital/year = 240Maximum no. of cases coming under exclusion criteria/year = 60So, p = 180/240100 = 75q = 25e = 20% of p = 15N = 47525/152 = 33.The minimum adjudicate size thus calculated should be 33.STUDY DE SIGNObservational athletic field.CT PNS of the patients was evaluated for the cause of sinus complaints. Causes deduced from CT PNS were correlated with clinical/histopathological/surgical/ microbiological findings.ETHICAL ISSUESThe study was conducted after necessary approval from the institutional review board and ethics committee. MDCT is a non-invasive style. All safety and screening measures were undertaken as per the Ameri behind College of radioscopy practice guidelines for performing Computed Tomography.INSTRUMENTATIONLight VCT 64 slice MDCT of GE radical system with ripe(p) workstation 4.3 GE.Protocol followed for MDCT PNS1. Scout LateralkV 120mA 10Scout Plane 9002. axial ImageskV 120mA 120Start/End 0 to 74.3Total Exposure clock 5.4 secGantry tilt 0Interval 0.625 mmSlice thickness 0.625 mm voluted S buttocksRotation Time 0.6 secRotation Length FullPitch and Speed 0.5311 10.62 mm/rotationDetector Coverage 20 mmPROFORMAUnique ID NoHISTORYPresenting Compl aints os nasale discharge HeadacheNasal obstruction EpistaxisSwelling over cheek Hyposmia/AnosmiaOthersH/O SmokingOccupational exposure memorial of AllergyAny other Systemic IllnessFamily HistoryEXAMINATIONGeneral ExaminationLocal ExaminationInspectionProbe testOthersImportant surgical FindingsInvestigational ResultsMDCT PNS HistopathologyMicrobiological and other important lab testsDepartment of Radio-diagnosis and ImagingBatra Hospital and Medical research CentreM.B.Road, New Delhi-110062.INFORMED CONSENT FORMI s/d/w of r/odo hereby declare that I give informed consent to participate in the thesis study titled, ROLE OF MULTI-DETECTOR COMPUTED TOMOGRAPHY IN PARANASAL SINUSES PATHOLOGY.Dr. Lakshmi Kumar Chalamarla has informed me to my full satisfaction, in the language understand, about the purpose, nature of study and various investigations to be carried out for the study. I have been informed about the duration of the study and the possible benefits and risks.I give full, free and voluntary consent for being enrolled in the above study and reserve the sound to withdraw from the study whenever I wish to without any prejudice of my right to brook provided treatment at this hospital and its associated hospitals. I have been given a copy of this form along with the patient information sheet.For illiterates patient information sheet forget be shared with the family members. The family members are expected to read out and then get the informed consent. We will try to take written consent, if non we will take verbal consent in front of relatives.(Signature/Thumb (Signature/Thumb spirit of patient) Impression of relative)Name NameDate RelationVerbal Consent DatePATIENT teaching SHEETTitle ROLE OF MULTI-DETECTOR COMPUTED TOMOGRAPHY IN PARANASAL SINUSES PATHOLOGY.Introduction This statement describes the purpose, procedures, benefits, risks and discomforts of the study and your right to withdraw from the study at any point of time.Purpose This study involves MDCT scan evaluation of patients with paranasal sinus complaints.Study Procedure Your relevant clinical history will be recorded, clinical test will be conducted and findings noted. MDCT PNS will be performed and the radiological findings will be recorded. These findings are correlated with clinical/surgical/histopathological/microbiological findings.Benefits No monetary benefits will be given to you. However, any new information that can come to light regarding any new findings in the study will help in further management of the disease and help all other ailing patients suffering from this problem.Confidentiality Records of your study participation will be kept confidential, under safe custody. Any publication of data will not bring out you by name. By signing the consent form you authorise the sharing of your study related medical exam records to the regulatory authorities and the Institutional Ethical Committee.Information regarding withdrawal You have the right to withdraw y ourself from the study at any time during the course of the study without any prejudice to you or your familys right to abide future treatment at BATRA HOSPITAL.Contact for additional information Any time during or after the study, you can obtain further information about the study from Dr. Lakshmi Kumar Chalamarla, Department of Radio-diagnosis, BHMRC, New Delhi.DATA psychoanalysisSensitivity, specificity, appointed predictive value and negative predictive values were calculated, followed by use of Fischer Exact test. diagnostic accuracy of MDCT for different pathologies were calculatedThe research hypothesis and statistical methods were formed in consultation with the Biostatistician. conspicuous FINDINGSKey imaging features considered were significant anatomical variations, site of involvement, cadaverous and soft tissue changes, invasion of border structures, pathognomic features and correlation with clinical complaints/surgical/pathological/microbiological findings.The pa tients were divided into five categories bacterial sinusitis, fungous sinusitis, kind tumors, cancerous tumors, and others. 84 patients presented with sub acute or chronic bacterial sinusitis, 4 patients were of fungal sinusitis, 4 patients presented with benign tumors, 3 patients with malignant tumors and 5 patients with other conditions.Among 84 patients with bacterial sinusitis, 26 patients presented with sporadic normal, 23 patients with infundibular pattern, 23 patients with ostiomeatal unit pattern, 8 patients with polyposis pattern, and 4 patients with sphenoid recess pattern.The various causative factors which came across in infundibular pattern were Haller cells in 6 cases, giant bulla ethmoidalis in 6 cases, uncinate process pneumatisation in 1 case, and mucoperiosteal thicken in 10 cases.The various causative factors for ostiomeatal pattern which were shew during our study were inferior turbinate grow in 6 cases, giant bulla ethmoidalis in 6 cases, deviated nasal septum with or without septal further in 4 cases, concha bullosa in 3 cases, concha lamella in 2 cases, agger nasi cell in 1 case, and paradoxical middle turbinate in 1 case.The various findings which were encountered in bacterial sinusitis in our study were mucoperiosteal thickening in 84 cases, ostiomeatal unit block in 31 patients, bone thickening in 20 patients, bone cutting off in 8 cases, and bone sclerosis in 6 patients. various anatomical variations were encountered during our study. One or the other anatomic variation was found in 99 cases ( 99% ).Of the structures around ostiomeatal unit, giant bulla ethmoidalis was found in 35 cases, middle turbinate pneumatisation in 33 cases, paradoxical curvature of middle turbinate in 19 cases. Haller cell was found in 15 cases. Type 1 frontal sinus drainage pathway in 78 cases, type 2 frontal sinus drainage pathway in 21 cases. Deviated nasal septum with or without septal spur in 55 cases, inferior turbinate hypertrophy in 30 cas es, accessory maxillary ostia in 26 cases, and agger nasi cell in 93 cases. Type 1 optic nerve course was found in 53 cases, type 2 in 14 cases, type 3 in 9 cases, and type 4 optic nerve course along with Onodi cells in 23 cases. Type 1 anterior clinoid process pneumatisation was found in 10 cases, type 2 pneumatisation in 1 case. os sphenoidale septum lateral attachment in 7 cases, and sphenoid sinus septum pneumatisation in 14 cases.Among 4 patients with fungal sinusitis, the various findings were bilateral / multisinus involvement was found in 4 cases, expansion of any involved sinus was found in 4 cases, intrasinus hyperdensity was found in 4 cases. Bony thinning was found in 4 cases, bony erosions and nasal cavity involvement was found in 3 cases.The various findings in 4 cases of benign tumors seen ( 1 inverted papilloma, 1 juvenile angiofibroma and 2 ivory osteomas ) were bony thinning in 2 cases, bony remodelling in 2 cases, multisinus involvement in 2 cases, intracranial e xtension in 1 case, and intra orbital extension in 1 case. Bony destruction, bone thickening/sclerosis, and calcification were not seen in any of the cases.Among 3 cases of malignant tumors, various findings were Bony destruction in 3 cases, bony thinning in 3 cases, bony remodelling in 0 cases, multisinus involvement in 2 cases, intracranial extension in 2 cases, and intra orbital extension in 3 cases. Bone thickening/sclerosis, and calcification were not seen in any of the cases.In our study we found sensitivity and specificity for bacterial sinusitis as 100% and 94.11% respectively. The fungal sinusitis had sensitivity an specificity of 75% and 100% respectively. Benign, malignant tumors and others had sensitivity and specificity of 100%. The diagnostic accuracy for bacterial sinusitis and fungal sinusitis was 99%, and the diagnostic accuracy of benign, malignant tumors and others was 100%. The p value was obtained after applying Fischer Exact test. The p value obtained was stat istically significant for all the disease conditions.Based on the statistical values it can be inferred that multi detector computed tomography is useful to characterize paranasal sinuses lesions with respect to anatomical delineation, extension and bony involvement.There are certain limitations in our study. Our findings cannot be generalised to the whole population because of the limited sample size. However, our findings add value to the research done. The role of contrast cannot be adequately studied. The role of MRI in various paranasal sinus pathologies was not evaluated.CONCLUSIONSParanasal sinus diseases are very commonly encountered problems in clinical practice. Clinical assessment alone is not sufficient to reach a diagnosis, as the introduction of most of the conditions is nonspecific. Imaging forms the mainstay not only in making correct diagnosis, but also to know the extent of lesion, pre-operative assessment of the sinonasal anatomy and commonly encountered anatomic variations. X ray has low sensitivity, specificity, positive and negative predictive values. CT is highly sensitive and specific in ascertain the presence of paranasal sinus pathology and clearly demonstrates the complex anatomy. The introduction of multi detector CT has transformed the axial imaging modality into a volumetric one and allows the pathology to be displayed in any desired plane. The capability of thin-section acquisition improves visualization of tiny pathological details, and the isotropic nature of high spatial resolution data sets enables display in multiple planes, obviating image acquisition in prone or hyper extended patient position.RECOMMENDATIONSMDCT has turn up to be highly sensitive in classifying the lesions into clinically relevant categories, making diagnosis and more so in knowing the extent of involvement with a high diagnostic accuracy.MDCT is an indispensible tool before in operation(p) Endoscopic Sinus Surgery (FESS) to accurately delineate the fine bony details that contribute to disease and also can predispose to complications which can be fatal.MDCT is very useful in predicting the diagnosis of fungal sinusitis by the presence of intrasinus hyperdensity, granulomatous diseases by the presence of nasal septal perforation and intracranial or intraorbital invasion, malevolence by bone destruction and invasion.MDCT can tailor the surgery according to the extent of disease. It helps in determining the prognosis of the malignant tumors depending on the site and extent of the disease. It can also obviate the need for surgery in certain conditions like polyposis.MRI can be problem solving tool in differentiating inflammatory sinonasal diseases from tumors, and also for the presence of intracranial or intraorbital extension.However, MRI alone cannot be performed in the evaluation of paranasal sinus diseases because of the problem of signal voids. It has to be supplemented by CT.MDCT is the preferred modality of all imaging stud ies available because of its ease, availability, accuracy, precision and low cost.