Comparison of Clinical Symptoms, Plain Radiographs, Coronal CT and Antral Lavage in Patients with Chronic Maxillary Sinusitis
Ayad A. Al-Azzawi , Khalil K. Al-Umeri
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Keywords : Comparison of Clinical Symptoms, Plain Radiographs, Coronal CT and Antral Lavage in Patients
|Medical Journal of Babylon 8:1 , 2014
Aim of the study : this study was conducted to compare the clinical symptoms of chronic maxillary sinusitis ,
plain x-ray ( Water s view) , CT scan of the maxillary sinuses and the results of antral lavage .
Material and Methods: 150 patients had been examined at the otolaryngology department of Al-Diwaniya
teaching hospital and diagnosed as chronic maxillary sinusitis.
Plain x-ray ( Water s view ) and CT scan done to all of these patients. Radiological features of chronic sinusitis
found in 118 patients , 84 bilateral (71% ) and 34 unilateral (29% ) , the radiological findings classified as
well aerated , mucosal thickening , fluid level, haziness and complete opacity .
Antral lavage done to 202 sinus and return classified to be clear, mucoid , mucopurulent and frank purulent .
Results: plain x-ray and CT scan show sinus opacity in 32 patients (16%) , haziness 80 patients ( 39 % ) ,
fluid level 54 patients ( 27% ) , mucosal thickening 36 patients (18%).
False negative plain x-ray found in 8 patients ,while false positive found in 14 patients . The antral lavage
return was 100% purulent in opaque sinus , while hazy sinus shows 50% purulent , 31% clear , 19% mucoid .
Fluid level 80% purulent , 18.5% mucoid , 1.5% clear .
Mucosal thickening 55.5% clear , 44.5% mucoid return .
Conclusions: radiological findings of maxillary sinus opacity is the most reliable evidence of sinus infection
followed by fluid level .
Water s view gives good information about sinus pathology but CT scan is the most sensitive radiographic
modality for the diagnosis of chronic sinusitis.
The paranasal sinuses are air filled spaces
within the bones of the skull.They are
lined with respiratory epithelium , and all
communicates with the lateral wall of the
nose via openings known as ostia .
The epithelium secrets mucus which
transported by cilia through the ostia. The
mucus thus drains into the nose and is
eventually swallowed . The sinuses are
usually considered as four paired
structures , the frontal , ethmoids ,
maxillary and sphenoid sinuses .
The paranasal sinuses are closely related
to the nasal cavities embryo logically ,
structurally and functionally. As the lining
of the nose and paranasal sinuses is
continuous , inflammatory process tend to
involve both areas to greater or lesser
Symptoms of sinusitis include
mucopurulent nasal discharge , nasal
congestion , facial pain , pressure or
fullness and decrease perception of taste
or smell. These symptoms result in
substantial adverse effects on mood ,
physical functioning , energy level and
social functioning .
Sinusitis is classified by the duration of
the symptoms into :
· acute less than 4 weeks
· subacute 4-12 weeks
· chronic 12 weeks or more
· recurrent acute 4 episodes or more per
year of acute bacterial sinusitis, signs
and symptoms of sinusitis between
Most of the clinical features of chronic
sinusitis overlap considerably and the type
and extent of disease may need to be
classified by doing some investigations.
Plain radiography of the paranasal sinuses
remains the commonest investigation done
, the others being endoscopy, immunology
and bacteriology .
The computerized tomography (CT) of the
paranasal sinuses exhibits good sensitivity
for the diagnosis of chronic sinusitis and it
is the ultimate imaging modality of choice
Radiology of sinuses :
Pathological process affecting the sinuses
encroach on the air in the sinuses , and are
seen on x-rays as alteration in their
translucency. Unfortunately the
clinician can often be misled by both
x-rays [6,7] , as there are both false
positives and false negatives . Indeed in
one study  plain sinus x-rays had a
false positive rate of 4% (i.e 4% of xrays
showed pathology when endoscopy
of the sinuses were normal) , and more
worryingly , plain x-rays had a false
negative rate of 31% ( i.e 31% of x-rays
incorrectly suggested normality when
compared with sinus endoscopy).
Computed tomography ( CT ) provides a
much better anatomical display of soft
tissue densities , and it is capable of
accurately demonstrating pathology both
within and beyond the sinuses.
Magnetic resonance imaging ( MRI ) is of
limited value as the bony margins of the
sinuses are not visible by this technique .
Materials and methods
This is a prospective, randomized, clinical study conducted at the department of
otolaryngology in Al-diwanyia teaching hospital from November 2008 to October
There are 150 patients of various age groups. The age, sex and number
distribution are given in table I .
These patients were examined clinically and diagnosed to have chronic maxillary
The diagnostic criteria used for chronic rhinosinusitis were at least two of the
symptoms of :
1. Mucopurulent discharge ( anterior ,
posterior or both ) .
2. Nasal obstruction ( congestion) .
3. Facial pain , pressure or fullness .
4. Decrease sense of smell and/or perception of taste . For at least 12 weeks duration
Data from one hundred and fifty (150)
patients that were analyzed consisted of 72
females and 78 males , the age distribution
between 10-60 years.
The duration of symptoms ranged from 3
months ( 13 weeks ) to 2 years. The plain
x-ray of maxillary sinuses were normal in
18 patients , CT scan were normal in 32
patients ( including those with normal
plain x-ray ) .
Interpretations of radiological findings on
plain x-ray and CT scan yields normal CT
scans for 14 ( 28% )patients of those who
had findings of sinusitis on plain x-ray
films ( false positive ).
Maxillary sinusitis were discovered in 8
( 16% )patients by CT scan for whom the
plain radiograph indicates no sinus disease
( false negative ).
Antral washout done in the remaining 118
patients and the result recorded :
84 patients had bilateral maxillary sinusitis
and 34 patients unilateral .
Age ( in years ) Female Male Total
The radiological findings in plain x-ray
and CT scan compared with antral
puncture and irrigation findings ( table II )
It was seen that when the radiological
findings of the maxillary sinus were :
· Completely opaque 100% purulent
return on antral irrigation
· Hazy 50% purulent return
31% clear 19% mucoid
· Fluid level 80% purulent
18.5 mucoid 1.5% clear
· mucosal thickening 55.5 % clear
44.5 % mucoid
Anatomical abnormalities found in the
nose and have radiological appearance
include : deviated nasal
septum ,engorged turbinates , this is found
in 98 (65%) patients, 63 ( 42 % )of them
Chronic rhinosinusitis is a familiar disease
of otorhinolaryngology practice , and it
The age distribution and an average age of
37 years found in this study gives credence
that it is more common in the young adults
There is no pathological process known to
predispose one gender over the other , and
no sex preponderance was found in this
Previous studies also not show a consistent
sex predisposition . The most common
modality used for substantiation of sinus
disease is plain radiography and the best
view to delineate the maxillary sinus is the
occipito-mental view with open mouth
(Water s view ) .
Air-fluid levels and opacification are
considered to be reliable pathologic
findings on plain x-ray films [9-11], some
authors also consider mucosal thickening
of 4mm or more pathologic[ 9].
CT scans of the sinuses have advanced the
fields of diagnostic radiology. Coronal CT
of the sinuses with 4mm cuts at 3mm
intervals and appropriate bone window is proving to be the best radiological tool .
CT scans can demonstrate disease that is
not shown on routine x-ray films , it can
also delineate pathologic variation and
demonstrate inaccessible anatomic
structures, such as the osteomeatal
In our study when total or intense opacity
were seen in the plain x-ray and CT scan ,
the antral puncture returns either frank
purulent or mucopurulent in all cases i.e
100% reliability for sinus infection , this
finding was in agreement with the work of
various authors .
Vourinen et al  in their study of 272
maxillary sinus showed 86% agreement of
a positive antral lavage when x-ray showed
total opacity .
Mc Neil 13 in his study of 242 sinuses ,
150 patients compared opacity with sinus
lavage and found an agreement of 81% .
Sammy Elwamy et al  in the
comparison of x-rays with operative
findings showed total opacity with
intrasinus pathology in 75% of cases.
In the maxillary sinus mucosa disease
leading to inflammation initially appear as
haziness on x-ray , progression and
recurrence of inflammation showed as
mucosal thickening of 4mm , exudated
fluid gravitate and appear as fluid level in
the antral cavity , and further progression
can lead to complete opacity of the sinus
The common antral changes in this study
were haziness ( 80 patients ) , 50% of these
patients had purulent return on antral
lavage and this has low specificity .
In cases were the x-rays and CT scan
showed fluid level , 80% of cases were
purulent returns on antral lavage, Sammy
Elwamy shows 100% purulent return on
antral lavage while Vourinen et al shows
correct prediction in 73.6%.
Mucosal thickening of the maxillary sinus
on plain x-ray and CT scan where found in
36 patients, 44.5 % of the returns were
mucoid and 55.5 % were clear , thus 100%
were negative for sinus infection , Mc Neil
in their study showed that only 37% of cases were positive on antral lavage when
x-ray showed mucosal thickening .
The drainage opening of the maxillary
antrum is located high on the sinus cavity
and it is antigravity, this relatively
unfavorable anatomy makes the maxillary
sinus to be prone to fluid retention and
infections more than any of other sinuses ,
anatomical abnormalities found in 98 ( 65
% ) patients and these are deviated or
angulated nasal septum and engorged
turbinates , this is similar to previous
studies [16-18] .
False positive findings of plain x-ray found
in 14 ( 28 %. ) while false negative found
in 8( 16%) patients .
Croft et al found that false positive 4%
while false negative 31% .
Many factors can cause the erroneous
interpretation of plain radiographs in
sinuses and these are :
1. variation in radiographic techniques.
2. sloping of lateral and superior maxillary
sinus walls .
3. double contours in maxillary sinus
4. anatomic variation in children including
hypoplastic maxillary sinus or small or
aplastic sinus .
5. slight rotation .
6. sinonasal secretion .
7. thick sinonasal mucosa .
From this study it is evident that a
radiological finding of maxillary sinus
opacity is the most reliable evidence of
sinus infection followed by fluid level .
A mucosal thickening as shown by plain
x-ray and CT scan is not an indication of
sinus infection .
Thus we can conclude that Water s view
undoubtedly yields valuable information
regarding sinus pathology , it should not be
accepted as a diagnosis in itself but
considered in the light of patient s history
and clinical findings .
Our results indicate that high resolution CT
of the maxillary sinuses is the most
sensitive and specific radiographic modality currently available for diagnosis
of chronic sinusitis .
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