EXAMINATION Computer Tomography ON chronic sinusitis

EXAMINATION Computer Tomography
ON chronic sinusitis

By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

PreliminaryChronic sinusitis is one of the diseases that are common in the community. According to the survey conducted in the United States, chronic sinusitis was a disease that most often reported. As many as 14.7% of the total American population have suffered from chronic sinusitis panyakit (Slavin, 20 002). Other data from sub-section Rinologi FKUI ENT ​​/ Dr. Ciptomangunkusumo Jakarta, also showed a high incidence of sinusitis is 248 patients (50%) of 496 outpatients who came in 1996 (Soetjipto, 2000).End - the end of this treatment of chronic sinusitis experienced a shift from standard surgery techniques Caldwell Luc, a Functional Endoscopic Sinus Surgery or abbreviated BSEF (Kennedy and Zinriech, 1991; Stamberger, 1998; Zinriech and Gotwald, 2001). According Messerklinger quoted by Stammberger (1998) hampit all chronic sinusitis paranasal sinus large (maxillary and frontal sinuses), occurs secondary to abnormalities in Ostio Meatal Complex (OMC). OMC is part of the anterior sinus etmoid, this area is very narrow and rimut. The blockage in the OMC will cause disruption sinus drainage and air flow, causing an infection of the sinuses paranasalis large. The basic principle is to improve mucociliary BSEF with smooth drainage and air flow in the paranasal sinuses, `by removing blockages and raised mucosal pathological abnormalities in the OMC without damaging healthy tissue (Kennedev and Zinriech, 1991; Stammberger, 1998; Zinriech and Gotwald , 2001).To make a diagnosis of chronic sinusitis and then set the Rx, required investigation radiologist Computer Tomography (TK). This examination can show clearly the structure of paranasal sinus anatomy in particular OMC (Zinriech and Gotwald, 2001). In addition, kindergarten to evaluate extent of disease, thus helping the operator in directing the operation according to the extent of abnormality found (Muslim, 1999; Mangunkusumo, 2000; Zinriech and Gotwald, 2001). Bolger et al (1991) do pemeriiksaan TK in 202 patients, 86.7% found abnormalities in the OMC and right ipsilateral maxillary sinus, while the left as much as 80.8%. This examination abroad has been routinely done in patients with chronic sinusitis (Stammberger, 1998; Yousen, 2001). While in Indonesia, including in Surabaya, plain paranasal sinuses is still frequently used. This is because the kindergarten is still perceived cost of inspection and operating expensive cukuo BSEF itself is not yet a routine procedure which transactions are carried out here.This paper will discuss the examination of TK in chronic sinusitis. Will be discussed here regarding the role of TK in chronic sinusitis, examination techniques, radioanatomi and important anatomic variation is known.
1. The role of computer tomography examination in chronic sinusitis.The ability of TK in the show are simnulatan bone architecture - Maxillofacial bone, soft tissue and air, making this examination is the modality of choice to evaluate the anatomy of rice rgio cavity and paranasal sinuses (Zinriech and Gotwald, 2001). Perpaduannya dengn examination keonis sinusitis disease (Stammberger, 1999). Examination kindergarten can give a picture of anatomical structure in an area that is not visible through the endoscope. This examination is very good in showing the cell - cell etmoid anterior, two-thirds of the rice and resesus frontal cavity. In this area kindergarten to show the location of factors of chronic sinusitis, the OMC (Zinriech and Gotwald, 2001).With daapt coronal cuts are identified and evaluated in a systematic structure - structures such as maxillary sinus ostium, infundibulum etmoid, meatus medius, unsinatus process, bull etmoid, resesus frontal, frontal sinus, maxillary sinus, sinus and sphenoid sinus etmoid. Special attention is focused on etmoid infundibulum, frontal resesus meatus medius and that is where drainage. Some anatomical variations that may be predisposing factor for stricture OMC can be identified (Bolger et al, 1991; Muslim, 1999; Zinriech and Gotwald, 2001). If there is any shortage of funds or facilities, kindergartens koronak piece is sufficient to guide the operation BSEF. But if there are abnormalities in the sphenoid sinus or posterior etmoid axial cuts should be made to see the optic nerve and artery road that may run in the posterior sinus. In addition to evaluating the degree of thickening can be assessed mukoperiosteum sinusitisnya. It can also be measured the distance and angle from the aperture piriformis definite until resesus frontal or anterior edge of the sphenoid sinus. This will greatly assist the planning of operations BSEF (Muslim, 1999; Zinriech and Gotwald, 2001).
2. Examination TechniqueShould TJ examination performed, patients are prepared to be given adequate antibiotic treatment and amtiinflamasi. This treatment is given to eliminate the process of acute inflammation of the sinus so that the picture will be clearer. Thus there is a blockage in the OMC a factor causing chronic sinusitis can be identified (Yousem, 2001; Zinriech and Gotwald, 2001).The necessary pieces are cut coronal and axial cuts with soft tissue techniques (soft tissue settings), thick slices of 3-5 mm, with zoom (nagnifikasi). Coronal pieces provide much convenience in meniali surgeons three-dimensional aspects of OMC and the change in pathology. On coronal cuts ideally patient in the prone position with the head of maximum extension. While the axial piece, position the patient supine (Muslim, 1999; Yousem, 2001; Zinriech and Gotwald, 2001).Provision of contrast media is not recommended. Contrast media is only required when the evaluation period piece is suspected in the sinonasal cavity. Contrast media are also given when the intrakarnial complications of sinonasal infections such as abscesses intrakarnial (Muslim, 1999; Zinriech and Gotwald, 2001).


  3. Paranasal sinuses RadioanatomiBased on radiographic images obtained, the evaluation is directed primarily at a narrow region that is the sine etmoid and its relationship with other sinuses. From anterior to posterior, the first - directed primarily at the group evaluation cells - the cells surrounding the anterior frontal resesus. Note the relationship between frontal sinus and etmoid, as well as sinus drainage is directed at resesus sfenoedmoidalis, sinuses and sinus posterior etmoid sfenoid (Zinriech and Gotwald, 2001). The following will be explained in more detail about radionatomi paranasal sinuses are normal.
3.1 Sinus etmoidSinus etmoid can be seen on coronal and axial cuts. On coronal cuts collection of cells - a labyrinth of air cells appear almost vertical etmoid with thin septa like wasp nests. In the circumstances of this vertical cell - small air cells in the anterior and widened posteriorly. The boundaries of the labyrinth structure is papirasea sebalah lateral lamina, lamina next to the superior frontal os orbita, medially to the lamina and perpendicular to the inferior by the media Konka (Scuderi et al, 1993; Stamberger and Kennedy, 1995; Bolger, 2001).Cells - cells etmoid sinus consists of three groups of air cells of the anterior, medium and posterior. Anterior and media group called air cells separated by etmoid anterior basal lamina with air cells posterior etmoid. This basal lamina slow the spread of infection to the posterior etmoid. Tues etmoid open at ostiumnya directly related to rice pouch. Ostium is not going to look at the kindergarten (Muslim, 1999).
 3.2 processus UnsinatusProcessus unsinatus is thin and curved plate of bone which is an extension of the posterior type os lacrimal. As the anterior boundary hiatus semilunaris and a medial wall infundibulun etmoid. Processus attachment to the lateral unsinatus most of the lamina papirasea, but can also central to the cranial base and to the medial at Konka media (Figure 1). Unsinatus process was evident on coronal cuts (Stammberger and Kennedy, 1995; Bolger, 2001; Zinriech and Gotwald, 2001).









Figure 1: The variation of adhesion process of unsinatus, (A) to the lamina papirasea lateral (B) the central cranial base, and (C) to medial on the media Konka (quoted from Stemmberger and Kennedy, 1995).Tues 03/03 agger nasiTues agger nasi is the most anterior ekstramural cells from cell - cell etmoid. Located slightly to the anterior of the attachment media Konka Antero superior and anterior of the frontal resesus. When berpneumatisasi akanmenonjol on the lateral wall cavity rice. As it is located very close to resesus frontal, anatomy of these cells is a benchmark for frontal sinus surgery. By opening these cells will give way to resesus frontal. Seen in the most anterior coronal cut (Stammberger and Kennedy, 1995; Bolger, 2001; Zinriech and Gotwald, 2001). Tues agger nasi there are more than 90% of patients (Yousem, 2001).
3.4 Bula etmoidBula etmoid is the largest etmoid cells, located behind the processus unsinatus and separated by a hiatus processus unsinatus semilunaris, into lateral lamina papirasea dank e superoposterior with the lateral sinus. Best seen on coronal cuts. (Stammberger and Kennedy, 1995; Bolger, 2001; Zinriech and Gotwald, 2001).
3.5 Sinus lateralisLateral sinus cavity is an air gap which is located in the posterior and superior than etmoid bull. When this gap is behind the bull etmoid that separates it from the basal lamella called resesus retrobular. Furthermore, if this resesus extends to the superior of the bull etmoid called ressesus suprabular (Stammberger and Kennedy, 1995).In about 25% of patients with posterior wall so that the bull etmoid no direct border with the basal lamina, in this case resesus retrobular not found (Ziriech and Gotwald, 2001). Resesus retrobular suprabular and this is important because it is an area identified the potential occurrence of recurrent sinusitis after etmoidektomi (Yousem, 2001).
3.6 maxillary sinus ostium and infundibulum etmoidMaxillary sinus ostium and infundibulum etmoid a primary relationship with the sinus cavity makpsila rice. Both can be shown in both the coronal cuts. Infundibulum in the lateral land border with inferomedial orbital wall, the superior border and bull etmoid semilunaris hiatus, medial to the processus unsinatus and adjacent inferior to the maxillary sinus. Superomedial ostium continues to be infundibulum (Stammberger and Kennedy, 1995; Bolger, 2001; Zinriech and Gotwald, 2001).
3.7 semilunaris hiatusSemilunaris hiatus or gap in the form of an elongated channel that is located curved on the lateral nasal wall. This channel is a continuation of the infundibulum etmoid with posteroinferior direction. Located above and below the processus unsinatus etmoid bull. It can be seen well on sagittal cuts. This gap separates the processes of bull unsinatus etmoid etmoid infundibulum and as liaison with the meatus medius (Stammberger and Kennedy, 1995; Bolger, 2001; Zinreich, 2001).
Konka 3.8 MediaKonka located inferomedial media from the cell anterior. Attachment of the lamina bones nearly veritkal premises kibrifoemis papirasea lamina superiorly and laterally. Konka anatomy visible with good media at discounted coronal and axial cuts also looked at the (Muslim, 1999 and Bolger, 2001).
3.9 Resesus frontalResesus frontal is drainage from the frontal sinus. Bounded on the anterior with agger nasi, on the posterior with the anterior artery etmoidalis or attachment with bull etmoid base of the brain. In the lateral part in limiting the lamina and the medial papirasea by Konka media. Relations with the frontal sinus cavity rice is not a straight line but the hourglass-shaped. Attachment of the processus unsinatus determine the pattern of frontal sinus drainage. If the attachment of the lamina papirasea unsinatus processus, so that the infundibulum part of the appendix as resesus terminalis, the frontal sinus drainage can go directly to the meatus medius. If the attachment on the roof of the processus unsinatus Konka etmoid or media. Then the drainage will be through the infundibulum first. On coronal pieces can be seen clearly (Stammberger and Kennedy, 1995; Bolger, 2001; Zinreich and Gotewald 2001).
3:10 sphenoid sinusSize varies depending pneumatisasinya sphenoid sinus. Congdon as quoted from Donald (1995) divide the sphenoid sinus into 3 types according to the degree that is type konkal pneumatisasinya (5%), preseler (23.5%) and small opening (67%). Called when konkal type sphenoid sinus is very small, located in front of the sella turcica. Type preselar when pneumatisasinya not reached the sella turcica. And type if pneumatisasinya small opening along the bottom of sella turcica or even pass (post-small opening.)The anterior wall of sphenoid sinus runs sloping towards the anteromedial posterolateral. The roof is a continuation of the anterior base of the brain. Lateral wall has two important structures. Protrusion at the Antero - superior lateral wall in the form of the optic nerve. Protrusion in the posterior-inferior part is formed by the carotid artery. In specimens that have a perfect pneumatization may occur dehisensi (Zinreich and Gotwald, 2001).
3:11 Resesus sfenooetmoidVisible and can be evaluated by either the sagittal or axial cuts. Located anterosuperior ostium of the sphenoid sinus. Sphenoid sinus drainage and cells - the cells posterior to resesus sfenoetmoid etmoid then into the superior meatus (Stammberger and Kennedy, 1995; Zinreich, 2001).








Figure 2: (A) OMC paranasal sinuses are normal, compared with (B) OMC resulting abnormalities in chronic sinusitis (quoted from Yousem, 2001).
4. Anatomical variation is important4.1 Deviation pneumatisasis septum and septum nasi.Septum nasi that weight gain can cause abnormalities of the lateral cavity walls of rice and can lead to abnormalities in the paranasal sinuses. This is especially if the deviation of the septum on the lateral wall of media Konka, thus narrowing the meatus medius (Zinreich and Gotwaldm 2001). In addition, septal pneumatization can also narrow the meatus nasi medius (Muslim, 1999).Konka 4.2 bullousPneumatization Konka Konka media called bullous, may occur unilaterally or bilaterally. Konka bullous can mengakbatkan emphasis on processes that can be triggered obtruksi unsinatus the meatus medius and infundibulum. (Stammberger and Kennedy, 1995; Zinreich and Gotwald, 2001). Research dilakuka Stammberger and Wolf was quoted as saying Zinreich and Gotwald (2001), found the complaint of sinusitis. If found with other anatomical variations such as the processus unsisatus bent to the medial or bull etrmoid large, small bullous Konka alone can menyenbabkan a significant narrowing of the meatus medius (Muslim, 1999).
Konka 4.3 paradoxical mediaMedia Konka Konka paradoxical occur if both of the septum nasi concave and convex on the lateral nasal wall Stammberger and Kennedy, 1995; Yousem, 2001; Zinreich and Gotwald, 2001). This variation can cause narrowing of the channel to the meatus medius. Konka paradoxical media is sometimes difficult to observe through kindergarten. Because this disorder would seem appropriate at the level of coronal cut was made. Often ditemikan Konka paradoxical in the anterior but normal in the posterior (Zinreich and Gotwald, 2001).
4.4 Deviation and pneumatization proesesus unsinatus (bull unsinatus)When the processus unsinatus experience towards the lateral deviation it will be pressing infundibulum. Sedankang when the medial will suppress meatus medius. Processus unsinatus pneumatization is also able to experience so that the front narrowed infundibulum (Zinreich and Gotwald, 2001).


Tues 05/04 HallerTues Haller is a cell - the cells that experienced etmoid pneumatization of the anterior medial maxillary sinus roof, under the lamina and laterally from the processus papirasea unsinatus. If this large Haller cells resulted in narrowing of the infundibulum ostium etmoid and pressing from above. This condition can cause maxillary sinus drainage is not smooth, so that it can cause maxillary sinusitis (Zinreich and Gotwald, 2001). Yousem (2001) mentions Haller cells can be found on examination of TK between 10-45%.









Figure 3: Variations in anatomy (A) Konka bullous and (B) cells Haller (quoted from Zinreich and Gotwald, 2001).
4.6 Bull etmoid largeBula etmoid very large to suppress etmoid infundibulum, which disturb the drainage of the maxillary sinus ostium into the meatus medius (Zinreich and Gotwald, 2001). Research conducted by Lloyd, as quoted from Zinreich and Gotwald (2001) found variations inisebanyak 17% but when compared with other anatomical variations have a lower correlation in the relationship as a cause of sinusitis

Tues 04/07 OnodiTues etmoid the very back of the posterior triangular prism-shaped with a peak in posterlateral while basically overlooking the telescope. If these cells berpneumatisasi to posterolatral or posterosuperior to the front wall of the sphenoid, called cell-etmoid sfeno otherwise known as cell Onodi. This Onodi Tues selingkari optic nerve (Stammberger and Kennedy, 1995; Zinreich and Gotwald, 2001). As many as 24% of patients found to have cell Onodi (Yousem, 2001). On axial cuts can diihat cells are Onodi. Tues Onodi is very important for operators to be - careful in cleaning the area etmoid posterior (Muslim, 1999).
4.8 Variation of the sphenoid sinus septum and its relationship to optic nerve and carotid artery.Septumnya sphenoid sinus and can be seen clearly on coronal cuts towards the posterior. Variations of sphenoid sinus septum needs to be cut coronal direction that crosses to the lateral septum, the location of the septum located just below the carotid artery (Muslim, 1999). As many as 8-14% of cases otopis, between the carotid artery and sphenoid sinus was found not restricted by bone. As many as 4% of patients found in nerve optikusnya not covered with bone and between 78-88% covered by thin bone with peace of balan less than 0.5 mm (Zinreich and Gotwald, 2001).







Figure 4: Cell Onodi and optic nerve in the schematic drawing of axial cuts (quoted by Stammberger and Kennedy, 1995).










Figure 5: Cell Onodi appear on axial cuts, in it there is a thin bony optic nerve canal or dehisensi (quoted from Yousem, 2001).
Lamina 4.9 papiraseaPapirasea lamina is a thin plate that limits the cell - air cells etmoid with orbita on the lateral. Because of orbital hematoma often occurs as a complication of BSEF, so if there is dehisensi in this area should be known in advance. The result of this defect autopsy found approximately 50-10% (Yousem, 2001)








Figure 6: (A) Dehisensi canal carotid artery in the right sphenoid sinus and (B) in lamina papirasea dehisensi right (quoted from Yousem, 2001).4:10 Roof etmoid and lamina kribiformisSinus etmoid separated from the anterior cranial fossa by etmoid roof. Two-thirds of the roof etmoid formed by the frontal bone and foveea etmoidalis a thick and dense. In the medial lamina kribosa united with forming a linkage that is very weak because of very thin called the lateral lamina of the lamina kribosa (Mangunkusumo, 1999; Bolger, 2001). Place this linkage can be decreased. Depending on the distance of the decline can be divided into 3 types according to Kerose, namely:a. Keros Type 1:Olfactory fossa flat, its depth is only about 1 - 3mm. Lamina of the lamina kribosa lateeralis low even almost non-existent.
 b. Keros Type 2:Olfactory fossa is more in reach 4 - 7mm. Lateral lamina of the lamina kribosa longer.
  c. Keros Type 3:Roof etmoid higher than the lamina kribosa. Lateral lamina of the lamina kribosa long and thin. The depth of the olfactory can reach 8 - 16mm. This type is most dangerous for surgery because of the possibility of perforation through the lateral lamina of the lamina kribosa (Stammberger and Kennedy, 1995; Bolger, 2001).






Figure 7: Configuring the roof etmoid (A) type 1, (B) type 2, (C) type 3 (quoted by Stammberger and Kennedy, 1995).SUMMARYIn line with the shift in the management of chronic sinusitis from the standard surgical technique Caldwell Luc into Functional endoscopic sinus surgery, the computer tomography examination becomes necessary. Computer tomography can show clearly the structure of the complex anatomy of paranasal sinuses especially osteometal. The combination of axial and coronal cuts provide a lot of convenience surgeons in assessing aspects of three-dimensional structure - important structures and anatomical variations exist. This will assist in determining and guiding the management of chronic sinusitis surgery jaannya when dailakukan.
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