CORRELATION AND EVALUATION OF COMPUTED TOMOGRAPHIC FINDINGS AND FINDINGS OF FUNCTIONAL ENDOSCOPIC SINUS SURGERY IN CASES OF CHRONIC RHINOSINUSITIS.
Brief resume of the intended work:
6.1 Need for the study: chronic rhinosinusitis (CRS) is one of the most common chronic diseases and affects nearly 50 million individuals every year world over. The diagnosis of chronic rhinosinusitis relies heavily on clinical judgement based on number of subjective symptoms and signs. However the degree of accuracy of many reported cases of chronic rhinosinusitis is difficult to ascertain, because symptoms and signs are inherently vague. During the past two decades, the concept of sinusitis and its management have undergone tremendous changes. The patency of the ostia is the most important in the development of chronic rhinosinusitis .CT has become the standard diagnostic tool in evaluation of paranasal sinuses1. CT scan evaluation of the patients, who have to undergo eventually FESS, is extremely useful in confirming the clinical diagnosis of chronic rhinosinusitis 2. The aim of this study is to evaluate and correlate between CT findings and endoscopic findings in FESS.
1) Sheetal D et al. in 2011 conducted a study to correlate between CT findings and endoscopic findings in FESS. This was a time bound cross sectional study design. 45 patients with chronic rhinosinusitis underwent pre operative CT paranasal sinuses ,followed by functional endoscopic sinus surgery (FESS).In this study , the uncinate process attachment, the agger nasi,cells and the, anterior and posterior ethmoid sinuses showed excellent correlation .The maxillary sinus did not show good correlation, but this was acceptable. Most of the anatomical abnormalities can be studied on by CT scan and it is mandatory as a pre operative work up in patients who have to undergo FESS1.
2)R. Zojaji MD.et al. in 2008 conducted a study on paranasal sinus CTs of 51patients aged between 15 and 77 who subsequently underwent FESS for chronic rhinosinusitis at two training hospitals during a 2-year period, was performed. They concluded that , combined sinus endoscopy and CT can be considered complementary techniques for effective demonstration of nasal anatomy and paranasal sinuses . CT would be more specific for the assessment of paranasal sinuses and can serve as an anatomic map for the surgeon2.
3) A M M Shahizon,et al in 2008 conducted a cross sectional study of 40 patients diagnosed with chronic rhinosinusitis using nasal endoscopy , and on computer tomography (CT) of the paranasal sinuses. The purpose of the study is to demonstrate the effectiveness and limitations of CT, and NE in the assessment of chronic rhinosinusitis. This study shows that CT was superior in detecting OMC involvement, presence of concha bullosa, paradoxical turbinate and nasal septal deviation3.
4) Dua K et al. in 2006 conducted a study on all patients undergoing functional endoscopic sinus surgery. Fifty patients of chronic sinusitis were evaluated by CT Scan PNS - coronal and axial views. The anatomical variations and changes in osteomeatal complex on CT Scan were studied. In majority of patients, osteomeatal complex and anterior ethmoids were involved (88%). Agger nasi cells (40%) were the most common anatomical variations followed by concha bullosa (16%). Apart from this deviated nasal septum was found in 44% of patients. The variations found on CT Scan were later confirmed on nasal endoscopy. All the patients then underwent endoscopic sinus surgery4.
5) Awaida et al. in 2003 conducted a study on four-cut sinus computed tomographic scanning in screening for sinus diseases. They conducted a retrospective case series. From the complete sinus CT scan, the limited series were obtained by blocking from view all the other cuts and leaving the radiologist only four slices to read (midfrontal, anterior maxillary sinuses, posterior maxillary sinuses, and midsphenoidal).
The complete CT scan was the “gold standard. They observed 81.3% sensitivity,
89.5% specificity, a 73.9% negative predictive value, and a 92.9% positive predictive value for the limited CT scan for the detection of sinus disease5.
6) Rudralingam et al. in 2002 reviewed all paranasal CT scans in the ear nose and throat (ENT) and maxillofacial surgery departments in 1 year. Of these 372 scans, unilateral opacity of the maxillary sinus was seen in 20 cases. Neoplastic disease was diagnosed in six of these, four of which were malignant. In the cases of neoplastic disease, particularly features of the history, examination and scans should alert the clinician to the possibility of sinister pathology. In conclusion they emphasised the importance of endoscopic examination along with CT scan in the accurate assessment of sinonasal diseases6.
6.3 Objectives of the study:
1) To correlate between CT findings and the endoscopic findings in Functional Endoscopic Sinus Surgery of chronic rhinosinusitis.
Materials and Methods: 7.1 Source of data: In this study, clinically diagnosed cases of chronic rhinosinusitis, referred from Department of ENT, M.V. Jayaraman Medical College & Research Hospital, Hoskote, will undergo CT scan and functional endoscopic sinus surgery during the period from November 2011 to October 2013.
7.2 Method of collection of data(including sampling procedure if any):
Equipment : Toshiba Asteion Spiral CT Scanner
Scanning technique: The imaging protocol consists of acquisition of 3mm thin axial and coronal scans through the paranasal sinuses with special attention to osteomeatal units i
1) Definition of a study subject: Clinically diagnosed cases of chronic rhinosinusitis; referred to the department of Radio-Diagnosis, M.V.J. Medical College & Research Hospital , Hoskote, for CT evaluation of paranasal sinuses.
The method of study: The patients will be all clinically diagnosed cases of chronic rhinosinusitis who have to undergo pre-operative CT and FESS thereafter .The diagnostic validity will be used for correlation between CT findings & FESS. The parameters which used for correlation will be: paradoxical middle turbinate,concha bullosa,bony destruction, osteomeatal complex diseases, polypoidal changes, mucosal thickening and frontoethmoidal disease.
Prior to subjecting the patients for radiographic examinations, age, sex and detailed clinical history will be obtained along with thorough physical examination.
The CT examination will be performed with a Toshiba Asteion Spiral CT Scanner.
Images will be obtained with 3 mm collimation in the coronal plane with the patient in the prone position and the neck hyper extended. The image interval is 3 mm through the osteomeatal complex and 5 mm in the more posterior sections. The tube potential 120 kVp and tube current 200–240 mA. Images are to be reconstructed using a high spatial frequency reconstruction algorithm. The sections are to be imaged at a wide window width (WW2000) centred at 2250 Hounsfield units.
2.InclusionCriteria: Clinically diagnosed cases of chronic rhinosinusitis who will undergo FESS.
3.Exclusion Criteria : Complicated sinusitis
4. Statistical method : Statistical Package for Social Sciences will be used. Microsoft Word & Excel will be used to generate graphs, tables etc. Sensitivity, specificity, negative predictive value & positive predictive value will be used to evaluate CT scan of paranasal sinuses.
7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals?
No investigations or interventions will be conducted on animals. Only routine investigations will be conducted on the patients.
The following investigations will be done – Hemoglobin ,Total Leucocyte Count, Differential Leucocytes Count, Erythrocyte Sedimentation Rate ,X-RAY( Water’s view), CT Scan(axial & coronal) , Endoscopy
7.4 Has ethical clearance been obtained from your institution in case of 7.3? Yes
List of references: 1) Sheetal D, Devan P. P, Manjunath P, Martin.P,Satish kumar K, Sreekantha, et al. CT PNS – do we really require before FESS?. Journal of Clinical and Diagnostic Research 2011; 5(2):179-181.
2) R. Zojaji MD,M. Mirzadeh MD,S. Naghibi MD. Comparative Evaluation of Preoperative CT Scan and Intraoperative Endoscopic Sinus Surgery Findings in Patients with Chronic Rhinosinusitis . Iran J Radiol 2008; 5(2):77-82.
3) A M M Shahizon, A Suraya, Z Rozman, A A Aini, B S Gendeh . Correlation of Computed Tomography and Nasal Endoscopic Findings in Chronic Rhino sinusitis, Med J Malaysia 2008; l63(3):211-215.
4)Dua K, Chopra H, Khurana AS, Munjal M. CT scan variations in chronic sinusitis. Indian J Radiol Imaging 2005; 15:315-20.
5) Awaida, Jean-Pierre S. MD; Woods, Scott E. MD, MPH, MED; Doerzbacher, Meg RN, MSN; Gonzales, Yury MD; Miller, Timothy J. MD Four-cut Sinus Computed Tomographic Scanning in Screening for Sinus Disease, The Southern Medical Journal 2004;97:18-20.
6) Rudralingam M; Jones K; Woolford T J. The unilateral opaque maxillary sinus on computed tomography. British Journal of Oral and Maxillofacial Surgery 2002; 40:504–507.
Signature of Candidate :
Remarks of the Guide: There is difference of opinion whether CT scan is required in management of sinusitis or not. The present study is taken up to correlate between CT findings and endoscopic findings in FESS and demonstrate how helpful a pre-operative CT scan in patient management. Most of anatomical abnormalities can be detected by CT scan and provides a roadmap for surgeon who is doing FESS.
Subject: Regarding ethical clearance for my thesis.
I Dr. Gopakumar . M. G, will be doing dissertation work as part of my postgraduate course in M.D. Radiodiagnosis , the topic being ‘CORRELATION AND EVALUATION OF COMPUTED TOMOGRAPHIC FINDINGS AND FINDINGS OF FUNCTIONAL ENDOSCOPIC SINUS SURGERY IN CASES OF CHRONIC RHINOSINUSITIS ’ under the guidance of Prof. Dr. S. K. Behera as guide and Prof .Dr. G.C. Ravi as co-guide. In this study, I will examine patients from 01-11-2011 to 01-10- 2013 in M.V.J. Medical College & Research hospital.
I request you to kindly grant the ethical clearance for this study and oblige.