RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate & : DR. HYDER ALI GONI Address (In block letters) DEPT OF RADIODIAGNOSIS MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA 585105.

Permanent Address : DR. HYDER ALI GONI FLAT NO SF 02 2ND FLOOR GAJANAND AVENUE STATION WAY , GULBARGA-585102

2. Name of the institution : H.K.E. SOCIETY’S MAHADEVAPPA RAMPURE MEDICAL COLLEGE-585105

3. Course of study and Subject : M.D. RADIODIAGNOSIS

4. Date of admission to Course : 2nd June 2011

5. Title of the topic : SPIRAL CT EVALUATION OF INFLAMMATORY AND NEOPLASTIC LESIONS OF PARANASAL SINUSES AND NASAL CAVITY

6. Brief resume of the intended work 6.1 Need for the study:

A large number of patients present with inflammatory and neoplastic lesions of paranasal sinuses and nose in the outpatient and inpatient departments of ENT every year. These lesions usually need a thorough investigation to evaluate type, site and extent of lesion so that a proper medical and surgical management can be undertaken. In the past decade imaging of the paranasal sinuses has progressed from the realm of conventional radiographs almost exclusively into the realm of computed tomography (CT) and magnetic resonance imaging (MRI). Technological advances in these two modalities have provided more precise differential diagnosis and greater detail about the anatomic extent of the disease. CT and MR provide complimentary information ; each has advantages and potential drawbacks. (Branstetter B.F. and Weissman J.L. 2005). MR scans tend to be more complex than CT scan, because there are more parameters to adjust when acquiring MR images. Once MR images are acquired, however few manipulations are performed to tailor the study to the specific needs of the surgeon. Modern CT equipment, with high resolution multi channel helical scanning capability, produces a data set that can be manipulated more extensively to make the precise anatomic relationships of the sinus structures more evident to clinicians and radiologist (Weissman J.L. and Branstetter B.F. , 2005). CT of the sinuses is now widely available and is performed in a relatively short time, especially when compared to magnetic resonance imaging(MRI). A mojor advantage of the CT is that it is able to image bone, soft tissue and blood vessels all at the same time. CT is less expensive than MRI and is less sensitive to patient movement. CT can be performed even in the presence of implanted medical device such as cardiac pacemaker. CT imaging provides real time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and needle aspirations. CT scan of paranasal sinuses have become mandatory for all patients undergoing functional endoscopic sinus surgery. It depicts the anatomical complexities of osteomeatal complex in a much simpler way and acts as a roadmap for endoscopic sinus surgery. Removal of disease in osteomeatal complex region is the basic principle of functional endoscopic sinus surgery (FESS) which is best appreciated on CT scan (Dua et al., 2005). CT scan is also of great importance to evaluate the lateral nasal walls and septum, which are structures of great value to evaluate preoperatively for endoscopic surgeons (Danielsen et al., 2006). CT of the paranasal sinus has emerged as a standard tool for management of chronic rhinosinusitis. For patients with a clinical history and findings on physical examination suggestive of chronic rhinosinusitis. CT is often subsequently obtained to confirm the diagnosis of chronic rhinosinusitis. Although the diagnosis of chronic rhinosinusitis is based primarily on clinical criteria, the sinus CT provides objective evidence for diagnosis and staging of chronic rhinosinusitis and also provides an important roadmap to paranasal sinus anatomy should surgery be considered. CT provides excellent anatomical soft tissue and bony details. It can detect even 2mm mucosal thickening within the paranasal sinuses which makes it highly sensitive for diagnosis of chronic rhinosinusitis (Bhattacharya et al., 2003). CT is preferred modality for detailed assessment of tumours of paranasal sinuses and the nasal cavity (Brown et al., 1992). CT has the advantage of showing both bone destruction and soft tissue extent of the disease. In malignant disease it provides most accurate method of staging a tumour prior to radiotherapy/surgery and is important postoperatively to show recurrence of tumour. In addition it has extended the possibilities of differential diagnosis in the sinuses not only by showing soft tissue extent of sinus neoplasm, but a more sensitive demonstration of calcification with in a tumour, which in some instance is characteristic. Occasionally CT may enable the radiologist to make primary diagnosis of sinus malignancy prior to the clinical manifestation and indicate the likely area for confirmatory biopsy. CT is the gold standard for imaging of the fibrosseous lesion of the paranasal sinuses and is also helpful in differentiating them from malignant tumours. In other words CT is indispensable for management of tumour of the paranasal sinuses (Kondo et al., 1986). Spiral or helical CT scanning is a technique which has proved very useful in the evaluation of the nose and paranasal sinus disease. The duration of the examination can be significantly reduced by spiral techniques without any loss of image quality. The intricate anatomical structures including the important variations can be well defined applying this technique (Beus et al., 1995). Spiral CT with a lowered tube voltage and power is widely used which means that the patient is exposed to 70% less radiations than in other CT investigations (Reith, 2005). This study will be undertaken with the purpose to assess the role of spiral CT in evaluation of inflammatory and neoplastic lesions of nasal cavity and paranasal sinuses. 6. 2 REVIEW OF LITERATURE

Watson et al (1942) studied 127 cases of primary cancer originating in paranasal sinuses and concluded that the primary cancer occurs in maxillary antrum much more frequently than in all other paranasal sinuses combined (105 to 22). The ethmoid sinus is next most frequently involved (7 cases). Third sinus is the frontal sinus (4 cases). In only 1 case was the primary tumour definitely located in the sphenoid. Dixon et al (1958) evaluated clinical significance of the anatomical arrangement of the paranasal sinuses on 200 wet specimens and pointed out the value of closely observing the fovea ethmoidalis, which is an excellent landmark when performing surgery on the ethmoids via the intranasal approach. William et al (1968) studied craniofacial mucormycosis in 2 cases and described characteristic combination of roentgenographic changes which consist of the following (1) nodular thickening of soft tissue lining of many paranasal sinuses with sparing of the frontal sinuses. (2) absence of fluid levels in erect roentgenograms (3) spotty destruction of the bony walls of multiple paranasal sinuses. Wortzman et al (1976) first underlined the role of computed tomography in otorhino laryngology. Later on Robertson et al (1976) reviewed 14 cases of mucocele of sphenoid sinus using detailed tomography in frontal, lateral submento vertex projection and found that opacification of sinus (usually bilateral), expansion and thinning of sinus wall were constant features. It was also noticed that contiguous opacification of ethmoid sinus was present in most of the cases. Distinction from intrasellar lesion was also possible to enable the early correct diagnosis and appropriate surgical approach. Direct coronal computed tomography was first studied by Rothman et al (1977) who obtained images in coronal plane and found them to be useful in diagnosis of diseases of facial bones, sinuses, orbits and parasellar area. CT was performed in the paranasal sinus neoplasms by Jing et al (1978) and found it extremely useful in assessing the bone destruction and soft tissue extent of disease. Air fluid level in maxillary and sphenoid sinus was better demonstrated by CT scan. The authors were impressed in general with the remarkable accuracy of CT scanning in showing location, size and extent of tumour in paranasal sinuses. Based on their experience they also observed that CT is equal to polytomography in demonstrating bony involvement, and is superior to polytomography in soft tissue tumor limits. Computer assisted tomography was reported to be superior to other roentgenographic modalities in evaluation of the paranasal sinus lesions whenever extension into the orbit was suspected. This was the conclusion drawn by Bilaniukk et al (1980) based on 43 cases of paranasal sinuses with orbital involvement, its location and extent but also the nature of sinus lesion. The entities included sinusitis, orbital cellulitis, mucocele, polyposis, ossifying fibroma, fibrous dysplasia, cylindroma, osteoblastom, lymphoid carcinoma and rhabdomyosarcoma. Hasso (1984) found that high resolution CT is an ideal technique for evaluating tumors of paranasal sinuses, offering excellent morphological detail of both bony and soft tissue structures. CT could also demonstrate a tumor early in the course of illness along with extent of lesion for optimal staging. In CT evaluation of 400 cases of ethmoid sinus disease by Som et al (1986), 186 had inflammatory disease and 214 had tumor. Squamous cell carcinoma, metastasis and a few aggressive sarcoma were found almost exclusively to have bone destruction, while 94% of the remaining neoplasms were characterized by cavity remodeling. Futher differentiation was sometimes possible because of pattern and degree of tumor enhancement. Malignant lesions cannot be diagnosed with CT unless bone destruction is present. Similarly although the significance of persistent, benign appearing soft tissue disease during chemotherapy is unclear, tumor must always be suspected, even after many months of stable CT appearance. Dubey et al (1988) subjected histologically confirmed 21 cases of malignant tumors of nasal cavity and paranasal sinuses to CT. CT showed precise extent of tumor. Sinusitis due to obstruction in some cases was indistinguishable from tumor without bone destruction. The authors of this study recommended the use os CT for treatment, evaluation and staging of tumour of these sites. In a study involving 37 patients with various frontal sinus pathologies Antonis et al (1990) found that CT gave final diagnosis with high degree accuracy. Similarly, in a retrospective study of 36 patients Lamoral et al (1990) reported the great diagnostic value of CT in demonstrating the location and extension of ethmoid adenocarcinoma. Shibiya et al (1991) noticed that some CT features are helpful for distinguishing early second maxillary sinus cancer. The specific CT findings of early sinus carcinoma were : uneven soft tissue distribution in the antrum and tumour permeation with bone fragments remaining at the original tumour site. The pterygoid process, medial bony wall and ethmoid sinus had a tendency to be spared in most of the 5 patients with second maxillary cancer compared to the 21 control cases. With help of CT and MRI, Llyod et al (1992) decribed the peculiar imaging features of naso-sinus chondrosarcoma helpful in the diagnosis. CT as also found to be helpful in differentiating Non-Hodgkin lymphoma from squamous cell carcinoma of the maxillary sinus in 33 patients studied by Matsumote et al (1992). Chow et al (1993) studied the epithelial tumors of paranasal sinuses and nasal cavity with CT and MR scan. MR imaging delineated tumor from surrounding soft tissue, inflammed edema and retained secretions while CT allowed evaluation of the fine bony details and osseous tumor. Spraggs et al (1993) reviewed CT findings in rare entity sphenochoanal polyp. CT appearance of a sphenochoanal polyp were an attenuating mass arising from the opaque sphenoid sinus extending through sphenoethmoidal recess to the posteror conchae and inferiorly to a variable degree into nasopharynx. Although, they present in the same manner as the common antro-choanal polyps which arises from a maxillary sinus. Identification of the site of origin of a choanal polyp is determined preoperatively as it can influence surgical approach in its removal. Som et al (1994) found that inflammatory pseudo tumor of the maxillary sinus causes bone changes on CT and MR images, that mimic a malignant tumor. They identified 6 patients suffering from pseudo tumor of the maxillary sinus in a retrospective study where diagnosis was based on biopsy specimens. Bone involvement appears to be more common in pseudo tumor of maxillary antrum than in its orbital counterpart. Beus et al (1995) evaluated the role of coronal paranasal sinus CT using the spiral technique and concluded that the duration of examination can be significantly reduced by spiral technique without any loss of image quality. The intricate anatomical structures including the important variations can be well defined applying this technique. Suojanen et al (1995) compared the quality of conventional coronal CT images with coronally reconstructed axially acquird spiral CT images. The spiral reconstructions compared favorably with the conventional images and had significantly less motion and dental amalgam artifacts. Liang et al (1996) studied the features of sinonasal polyposis on 100 consecutive coronal sinus CT examinations done for chronic inflammatory sinonasal disease and found that truncation of bony middle turbinate is a characteristic and easily recognizable ancillary sign and is not seen in other patients of sinusitis. Bhattacharya N (1999) studied test-retest reliability of CT in the assessment of chronic rhinosinusitis and concluded that CT scan is a reliable test for assessment of chronic rhinosinusitis. The CT findings in patients with chronic rhinosinusitis remain consistent over time. 13 cases of pathologically confirmed esthesioneuroblastoma were analysed retrospectively by Yuan et al (1999). They concluded that CT is valuable in preoperative staging and monitoring recurrence of esthesioneuroblastoma. Cui YH et al (2000) retrospectively analysed the CT manifestations of Non- Hodgkin's lymphoma initially located in nasal cavity and paranasal sinuses and concluded that hypertrophic mucosa lies on septum cheifly and mass with soft tissue density always involves inferior meatus and inferior turbinate. Simmen et al (2001) evaluated the role of CT and MR in paranasal sinus imaging. According to them CT is the method of choice to clearly depict preoperative osseous anatomy and to distinguish between benign and malignant intraosseous lesions. 171 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis were evaluated by CT by Bhattacharya et al (2003). The paranasal sinus CT scan can exhibit good sensitivity and above average specificity. Kingdom et al (2003) reviewed the CT findings in 23 immuno-compromised patients of invasive fungal sinusitis. CT findings included severe soft tissue edema on nasal cavity mucosa, sinus mucoperiosteal thickening, bone erosion, orbital invasion and facial soft tissue swelling. A comparison of symptom scores and radiographic staging systems in chronic rhinosinusitis was done by Bhattacharya (2005) who concluded that the Lund staging system exibited best correlation between nasal symptom scores and CT stage in chronic rhinosinusitis. Reith (2005) proposed that in patients with chronic sinusitis CT should be performed before surgery to ascertain the condition of bones and use of spiral CT with a low voltage reduces the examination time and patient dose significantly. Eggesbo (2006) concluded that CT is primary modality in diagnosing and mapping suspected inflammatory sinonasal disease. Langer et al (2006) studied the sinonasal CT findings in patients with Wegener's Granulomatosis. Bony destruction, sclerosing osteitis, bony thickening and mucosal thickening of nasal cavity and sinuses were the main observations. The role of CT in endoscopic sinus surgery was evaluated by Reitan et al (2006). CT scans from 100 patients undergoing endoscopic sinus surgery were examined and the researchers concluded that operative findings correlated well with the CT if taken between 4 to 6 weeks before the operation. 124 patients aged between 5 to 83 years, all having biopsy confirmed malignant neoplasms of nose and paranasal sinuses where evaluated with CT by Morshed et al (2007). CT revealed that the most common tumor sites were nasal cavity, maxillary and ethmoid sinuses. The most common extra sinusal involvements were orbit, subcutaneous cheek tissue and infratemporal fossa. CT demonstrated the extension of nasal and paranasal sinus malignancies accurately. Lee et al (2007) reported the CT characteristics of focal hyperostosis in patients with sinonasal inverted papilloma and correlated these characteristics with detection of the origins of these tumors. Surgical evaluation of 55 lesions with focal hyperostosis in CT images revealed that 49(89.1%) of these lesions coincided with actual origin of tumor. Sham et al (2008) evaluated the roles and limitations of CT in the preoperative assessment of sinonasal inverted papillomas. Focal hyperostosis or bony strut is the most important CT sign predicting the origin of tumor. Although CT provides a reasonable assessment of tumor origin and extent, accurate tumor mapping was still difficult because of inadequate differentiation of tumor from inflammatory pathologies. This drawback can be overcome by a complementary MRI scan. Braun et al (2008) evaluated CT features of allergic fungal sinusitis. CT showed pan or polysinusitis, unilateral or bilateral, with mucosal thickening, bony changes, fluid trapping and pseudo-tumoral appearance.

6.3 OBJECTIVES OF STUDY: Aims and objectives of this study will be to describe the spiral CT features of neoplastic and inflammatory conditions of nose and paranasal sinuses with special attention to :- 1. Detect the presence of inflammatory disease of sinuses. 2. Evaluate sinuses that are filled with fluid or thickened sinuses membranes. 3. Detect the presence of sinonasal tumors. 4. Detect the exact extent and precise radiological staging of sinonasal tumors. 7. MATERIAL AND METHODS:

7.1 SOURCE OF DATA:

All patients with sinonasal complaints referred to the department of radiodiagnosis, Basaveshwar teaching & General Hospital, Gulbarga attached to M.R. Medical College, Gulbarga.

7.2 METHODS OF COLLECTION OF DATA (Including sampling procedures)

The study will be conducted on a minimum of fifty patients with sinonasal complaints who are referred to the department of radiodiagnosis, Basaveshwar teaching & General Hospital, Gulbarga attached to M.R. Medical college, Gulbarga during the period of December 2011 to September 2013. But the scope for increasing the number of cases depending on the availability of patients within the study period.

Before evaluating a patient by CT imaging informed consent will be obtained from the patient or guardian. The patient will be informed about the radiation exposure in the examination. Pregnant patients will be excluded from the study.

The patients progress will be followed up clinically and repeat serial CT scans when necessary. A detailed clinical and CT examination will be carried out as per the following performa : 1. Name 2. Parentage 3. Age 4. Sex 5. Occupation 6. Address 7. Chief complaints 8. History of present illness 9. Relevant past Medical/Surgical history 10.General physical examination 11.ENT examination 12.Systemic examintion 13.Investigations (a) Hb, TLC, DLC, ESR (b) Blood sugar (F), blood urea, serum creatinine, LFT. (c) Routine conventional radiography of paranasal sinuses. (i) Occipitomental veiw (Water's view) (ii) Occipitofrontal veiw (Caldwell's view) (iii)X-ray lateral veiw of sinuses. (iv)X-ray base of skull (submento vertical view)

(d) Computed Tomography : The CT will be performed in the department of Radiodiagnosis, Basaveshwar teaching and general hospital, attached to M.R.Medical college, Gulberga on Spiral CT. Direct axial and direct coronal images will be taken on permanent record. Patients will be given a course of antibiotic before the scan to eliminate acute sinusitis. Nose will be blown just prior to the study to clear any thick mucus which may resemble a polyp or a mass. The axial examination will be performed with the patient supine, the hard palate perpendicular to the table top, and the scanning plane parallel to the inferior orbitomeatal (IOM) line. The IOM line is readily identified on a lateral scout view. Cranial limit of the scan will be just above the top of the frontal sinuses and caudal limit will be just below the bottom of the maxillary teeth. The routine study will be obtained with 3mm contiguous cuts. Coronal examination will be performed with scan plane perpendicular to the IOM plane and patient's neck hyper extended. Both soft tissue and bone windows will be studied. The routine CT study of sinonasal cavities does not require intravenous contrast. However, if we need to determine if a nasal mass extends into an adjacent sinus or simply obstructs the sinus, or if there is suspected intracranial extension of disease, contrast will be given.

STATISTICAL METHODS : Rates , ratios and percentages of different diagnosis and outcome made by Computed tomography will be computed and compiled. Chi square test will be used for comparision of CT findings of different variables and P value will be calculated.

INCLUSION CRITERIA: 1. Patients of all age groups with sinonasal complaints .

EXCLUSION CRITERIA: 1. Patients with sinonasal complaints with no positive CT findings

2. Pregnant patients will be excluded from the study

3. Patients who cannot be followed up.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY.

YES. The study is mainly based on investigations, as radiology is a prime modality of investigation. The patient will undergo CT as a neuroimaging tool of investigation. No interventional procedure is required for this study. 7.4 HAS EHTICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?

YES. Ethical clearance has been obtained from ethical clearance committee of the institution. 8. LIST OF REFERENCES:

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4. Bhattacharya N. A comparison of symptom scores and radiographic staging system in chronic rhinosinusitis. Am J Rhinol 2005; Mar-Apr: 19(2):175-9

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23. Matsumoto S, Shibuya H, Tatera S et al. Comparison of CT findings in Non- Hodgkin lymphoma and squamous cell carcinoma of maxillary sinus. Acta Radiol 1992; 33(6) : 523-527.

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9. Signature of Candidate

10. Remarks of the Guide The study has immense value in the management of patients with sinonasal complaints and has been suggested by me as the topic for dissertation 11. NAME & DESIGNATION (in block letters) 11.1 Guide DR. SURESH B. MASIMADE M.D.R.D PROFESSOR DEPT OF RADIOLOGY, M.R. MEDICAL COLLEGE, GULBARGA. 11.2 Signature

11.3 Co-Guide DR. NEELKANT. B. GOURA M.D.R.D PROFESSOR DEPT OF RADIOLOGY, M.R. MEDICAL COLLEGE, GULBARGA 11.4 Signature

11.5 Head of the DR. SURESH B. MASIMADE Department M.D.R.D PROFESSOR & H.O.D., DEPT OF RADIOLOGY, M.R. MEDICAL COLLEGE, GULBARGA. 11.6 Signature:

12. 12.1 Remarks of the Chairman & Principal

12.2 Signature