Evaluation of Maxillary Sinus and Nasolacrimal Canal Relationship Via Paranasal Sinus Tomography Imaging

Eur J Rhinol Allergy 2019; 2(3): 71-4 Original Article

Evaluation of Maxillary Sinus and Nasolacrimal Canal Relationship via Paranasal Sinus Tomography Imaging

Servet Akyüz1 , Fatma Nur Yıldırım1 , Nimet Ersöz2 , Hatice Sema Başak1 , Can Zafer Karaman2

1Department of Otolaryngology, Adnan Menderes University School of Medicine, Aydın, Turkey 2Department of Radiology, Adnan Menderes University School of Medicine, Aydın, Turkey

Abstract Objective: Transnasal endoscopic surgical treatments of the maxillary sinus (MS) and nasolacrimal canal (NLC) pathologies are very common. A detailed understanding of the anatomy of this region preoperatively affects the chances of surgical success. Advances in paranasal sinus computed tomography (PNSCT) have yielded a better understanding of the surgical anatomy. Material and Methods: The anatomical relationships between the medial and anterior walls of MS and NLC involving 81 patients (41 males and 41 females) were analyzed by means of PNSCT sections. The anatomical relationship of NLC with the MS anterior wall was evaluated and classified into unified and separate types. The separate-type NLC was further classified as protruding or nonprotruding according to the localization of the medial wall of the MS. In addition, the vertical height of the lower meatus and long and short diameters of the NLC were measured. Results: The unified type was detected in 54 (32.9%) patients out of the total MSs of 164 patients. The distance between the anterior walls of the MS and NLC was 3.50 mm in females and 3.95 mm in males; this did not significantly differ between the genders. Further, 26 MSs were of the protruding type. The vertical height of the lower meatus was 10.75 mm in females and 12.15 mm in males. The long diameter of the NLC was 6.30 mm in women and 6.80 mm in men. The short diameter of the NLC was 4.85 mm in women and 5.00 mm in men. Conclusion: The relationship between the NLC and MS shows anatomical variations. Understanding these variations before surgery can increase the success rate of endoscopic surgical procedures directed toward the medial wall of MSs. Keywords: Maxillary sinus, medial maxillectomy, nasolacrimal canal

INTRODUCTION

For a long time, transnasal endoscopy has been successfully used in the treatment of sinonasal pathologies and has Cite this article as: Akyüz led to revolutionary innovations in this field. In addition to paranasal sinuses, procedures involving endoscopic S, Yıldırım FN, Ersöz N, approaches have been formulated for surgeries involving the skull base, pterygopalatine fossa, infratemporal fossa, Başak HS, Karaman CZ. orbita, and nasolacrimal canal (NLC) (1-3). Because of its anatomical localization, the NLC system can be damaged Evaluation of Maxillary Sinus and Nasolacrimal Canal during various surgical interventions to the maxillary sinus (MS) (4). In all surgical procedures, comprehensive evalu- Relationship via Paranasal ations of the anatomical structure and the regional neighborhoods of the paranasal sinuses during preoperative Sinus Tomography Imaging. preparation processes are one of the most important factors that can increase the chance of success of surgical Eur J Rhinol Allergy 2019; procedures. The close relationship between the MS and NLC increases the importance of radiological evaluation 2(3): 71-4. before any planned surgical procedure. Studies have reported that the dimensions of NLC and its relationship with the anterior and medial walls of the MS affect the strategy to be selected (5). The prelacrimal approach to the MS Address for Correspondence: Servet Akyüz facilitates panoramic views of the entire sinus, anterior maxillary wall, and prelacrimal recess, as well as the complete E-mail: removal of the existing pathology. In this study, we aimed to investigate the anatomic variations between these two [email protected] structures by analyzing the anatomical relationships between the anterior and medial walls of the NLC and MS by Received: 01.10.2019 means of computerized tomography sections. Accepted: 29.11.2019 DOI: 10.5152/ejra.2019.209 MATERIAL AND METHODS ©Copyright 2019 by Turkish Rhinologic Society - Available This study was retrospectively performed using paranasal sinus computed tomography (PNSCT) sections of adults. online at www.eurjrhinol.org Computed tomography sections were evaluated under the following five headings. Akyüz et al. Evaluation of Maxillary Sinus and Nasolacrimal 72 Canal Relationship via Paranasal Sinus Tomography Imaging Eur J Rhinol Allergy 2019; 2(3): 71-4

Table 1. Descriptive statistics and comparison results of the qualitative and quantitative variables according to gender Gender Variable Female Male χ2 U p MS combined separate 32 (39) 50 (61) 22 (26.8) 60 (73.2) 2.761 - 0.097 MS overflow present absent 12 (14.6) 70 (85.4) 14 (17.1) 68 (82.9) 0.046 - 0.831 NLC distance 3.50 (0-5) 3.95 (0-5.25) - 2978.50 0.199 Inferior meatus height 10.75 (6.45-14.78) 12.15 (7.50-17.55) - 2737.50 0.040 Vertical diameter 6.30 (5.70-7.30) 6.80 (5.88-8.23) - 2543.50 0.007 Horizontal diameter 4.85 (4.2-5.53) 5 (4.40-6) - 2907.50 0.134 χ2: Chi-square test statistics; U: Mann-Whitney U test statistics

a b

Figure 1. a, b. NLC and MS classified as separate types (a). NLC and MS classified as combined type (b)

1. The relationship between the NLC lower anterior border and the MS the quantitative variables were shown as the median (25th-75th percen- anterior wall was classified as either the “combined type” or “separate type” tile). The descriptive statistics for the age variables were preferably (Figure 1. a, b). expressed as average±standard deviation. The dependence between the qualitative variables was examined by performing a chi-square 2. The distance between the MS anterior wall and NLC anterior border analysis. The descriptive statistics of these variables were expressed as was measured in the “separate-type” patients. frequency (%). Here, p<0.05 was considered to be statistically significant. 3. If the MS medial wall is more medial than the NLC medial wall, it is classified as “overflow”; if not, it is classified as “not overflow” RESULTS (Figure 2). Here, 41 (50%) patients were female and 41 (50%), male. The average age 4. The vertical height of the lower meatus was measured. of the patients was 44.49±15.56 years.

5. The longest and shortest diameters of the nasolacrimal duct were mea- Combined-type MS was detected in 32 females (39%) and 22 males sured in sections where the NLC is the widest (Figure 3. a, b). (26.8%). It was determined that the overflow status did not differ according to gender (p=0.097). The study included 82 patients (41 females and 41 males). The Kolmogorov–Smirnov test was used to determine whether the quanti- The overflow cases in MS were detected in 12 females (14.6%) and 14 tative variables were suitable for normal distribution. The groups were males (17.1%). It was determined that the overflow status did not differ compared with the Mann-Whitney U test. The descriptive statistics of according to gender (p=0.831). Akyüz et al. Evaluation of Maxillary Sinus and Nasolacrimal Eur J Rhinol Allergy 2019; 2(3): 71-4 Canal Relationship via Paranasal Sinus Tomography Imaging 73

The distance between the anterior walls of MS and NLC was 3.50 (range: This distance in males was significantly higher than that in females 0-5) mm in females and 3.95 (range: 0–5.25) mm in males. It was deter- (p=0.007). mined that the overflow status did not differ according to gender (p=0.199). The horizontal diameter of the nasolacrimal duct was calculated to be The height of the lower meatus from the base of the MS was calculated 4.85 (range: 4.2–5.53) mm in females and 5 (range: 4.40-6) mm in males. to be 10.75 (range: 6.45-14.78) mm in females and 12.15 (range: 7.50- There was no difference according to gender (p=0.134). 17.55) mm in males. The distance in males was significantly higher than DISCUSSION that in females (p=0.040). With the introduction of rigid endoscopes in the field of paranasal sinus The vertical diameters of the nasolacrimal ducts were found to be 6.30 surgery, many innovations have been introduced in the surgical approach- (range: 5.70-7.30) mm in females and 6.80 (range: 5.88-8.23) mm in males. es. Further, this has had a significantly positive impact on the outcomes of surgeries. Among the surgical approaches described so far, it has been observed that invasive methods have become less prominent. Prior to surgical interventions in the paranasal sinuses and related structures, the determination of a detailed anatomical structure of the region and possi- ble anatomical variations in the preoperative period can help to minimize the possibility of developing complications. The MS medial wall forms the medial border of the nasal cavity. Due to its close relationships with the inferior turbinate, middle turbinate, orbital medial wall, and NLC in the lateral nasal wall, it is involved in the surgical approach in several cases (6-8). The recognition and protection of the nasolacrimal duct during such a process is imperative for better postoperative outcomes.

In this study, we evaluated the anatomical relationship and variations between the NLC and MS on PNSCT sections that were routinely used during preoperative preparations. In their study involving 250 MSs, Sieskiewicz et al. (5) reported that the distance between the anterior walls of the MS and NLC was 4 mm (on average). In the same study, it was reported that the distance between the MS and NLC in 38 cases (30.4%) did not meet the anatomical conditions required for minimally invasive medial maxillectomy. In our study, we found that these values were, on an average, 3.5 (range: 0-5) mm in females and 3.95 (range: 0-5.25) mm in males. In the study conducted by Wang et al. (1), this distance was reported to be 2 (range: 0.1-8.2) mm in males and 1.6 (range: 0.3-3.6) mm in females. In another study evaluating the relationship between the anteri- Figure 2. Not overflowed MS in horizontal PNSCT section where the or walls of the MS and NLC, Simmen et al. (9) reported that the average medial walls of MS and NLC are aligned distance between them was 4.24 (range: 0-11.62) mm. Along with our

a b

Figure 3. a, b. Short diameter of NLC in horizontal PNSCT imaging (a). Long diameter of NLC in horizontal PNSCT imaging (b) Akyüz et al. Evaluation of Maxillary Sinus and Nasolacrimal 74 Canal Relationship via Paranasal Sinus Tomography Imaging Eur J Rhinol Allergy 2019; 2(3): 71-4

results, it is remarkable that the distance between the MS anterior wall Peer-review: Externally peer-reviewed. and NLC anterior border varies within a wide range. This is a finding that supports the importance of preoperative radiological evaluations. Author Contributions: Concept - S.A., F.N.Y., N.E., H.S.B., C.Z.K.; Design - S.A., F.N.Y., N.E., H.S.B., C.Z.K.; Supervision - S.A., F.N.Y., N.E., H.S.B., C.Z.K.; Analysis and/or The relationship between the anterior and inner walls of the MS and NLC Interpretation - S.A., F.N.Y., N.E., H.S.B., C.Z.K.; Literature Search - S.A., F.N.Y., N.E., H.S.B., becomes important during the endoscopic prelacrimal approach. Wang C.Z.K.; Writing Manuscript - S.A., F.N.Y., N.E., H.S.B., C.Z.K.; Critical Review - S.A., F.N.Y., et al. (1) classified this evaluation as “anterior” and “lateral” according to the N.E., H.S.B., C.Z.K. location and angle between the anterior and inner walls of MS with Conflict of Interest: The authors have no conflicts of interest to declare. respect to the NLC, and they concluded that the medial wall of the MS was more lateral to NLC in the combined type of MS-NLC cases. On the basis Financial Disclosure: The authors declared that this study has received no finan- of the results of our study, it was found that overflow was detected in 12 cial support. females and 14 males, and there was no difference in the overflow status according to gender. In the study by Navarro et al. (6) that included 68 MS REFERENCES PNSCT sections, they reported that the nasolacrimal recess overflowed 1. Wang X, Chen X, Zheng M, Liu C, Wang C, Zhang L. 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