Radiographic imaging studies in

pediatric Chronic Sinusitis

Citra permata 03013047
Dini esfandiari 03013056
Diagnosing sinusitis

Ultrasonography : only detects maxillary sinus cavity fluid 1,2

Transilumination : only useful in older children and in case of severe
sinus disease2
Nasal endoscopy : difficult to perform in children, sedation or general
anesthesia may be required3
Sinus radiograph : safe, rather economical, high rate of false-negative
and false-positive4,5
Computed tomographic (CT) scan : excellent images, radiation
exposure, high cost
Methods

Patients
All new patients aged 2-18 years old
History of upper respiratory tract symptoms for at least 3 months

What will we study?

Classification degree of severity of abnormal sinus CT scan result and
the correlation with the clinical symptoms of pediatric chronic sinusitis
Performance of the sinus radiograph and the limited sinus CT scan
compared with the full standard sinus CT scan
Rhinitis and sinusitis symptom
score
Clinical symptom : rhinorrea/sniffling, nasal congestion, sneezing,
postnasal drip, headache, coughing, and wheezing 6
score Rhinorrea/sniffling cough
0 none none
1 sniffling or tissues needed 1 to 4 occasional cough, not
times daily uncomfortable, no interference
with school or sleep
2 sniffling or tissues needed 5 to frequent cough, annoying but
10 times daily not distressing, 2 to 3 days a
week
3 nose runs freely despite frequent cough almost every day and
use of handkerchie for tissues night, distressing spells,
possibly interfering with sleep or
school work
 category Total score
Minimal symptom 0-2
Mild symptom 3-4
Moderate to severe symptom 5-6

*Total score were calculated by adding the scores of rhinorrea and cough
Radiograph and CT scan of the
paranasal sinuses
Sinus radiograph
Caldwell (occipitofrontal) (ethmoid) : mucosal thickening, opacification, air
fluid level
Waters (occipitomental) (maxilla, frontal) : thickened mucosa,
opacification, or air fluid level at least 40% to 50%7
Lateral (sphenoid) : mucosal thickening, opacification, air fluid level
Sinus CT scan
0 : no abnormality
1 : mucosal thickening <20% - 25%
2 : mucosal thickening, air fluid (opacification 20%-40%)
3 : mucosal thickening, air fluid (opacification 40%-80%)
4 : 80% - total opacification
Severity of the sinusitis by CT
scan
Category Total score

Category 0 0

Category 1 (minmal) 1

Category 2 (mild) 2-5

Category 3 (moderate) 6-9

Category 4 (severe) >9

Definition of chronic sinusitis

Presence of two of three major clinical sign (rhinorrea, postnasal drip,

and cough) for at least 3 months7
Waters radiograph : opacification, air fluid level, or thickened mucosa
of sinus7
Statistical analysis

Data were analyzed by construction of 2 x 2 tables, chi square

analysis, Pearson's correla- tion coefficient, and multiple regression
analysis.
Calculation was performed with the Stat2 software pro- gram (Statsoft
Inc., Tulsa, Okla.)
Results
 There was a statistically significant correlation between rhinorrhea (r = 0.25, p = 0.01),
cough (r = 0.27, p = 0.009), and the severity of sinus abnormality as determined by CT
scan.
Clinically significant chronic sinusitis often occurred at multiple sites: 44% of patients had
pansinusitis, 50% had disease involvement of at least two sinuses, and 6% had disease in a
single sinus.
When sinus radiographs were compared with CT scans (n = 70 cases), radiographs could
not identify minimal disease.
The sensitivity and specificity for a Waters view to confirm clinically significant chronic
sinusitis without specifying the sites and severity were acceptable at 76% and 81%,
respectively.
When limited sinus CT scans were compared with full CT evaluation (n = 49 eases), limited
studies detected 5 of 5 (100%) frontal, 9 of! 1 (82%) sphenoidal, 14 of 19 (73%) ethmoidal,
and 39 of 40 (97%) cases of maxillary sinusitis. The overall agreement was 88%.
 Discussion
Chronic sinusitis is primarily a disease of obstruction, especially the osteomeatal
complex in the ethmoidal sinuses, which leads to a subsequently secondary
inflammation in the dependent sinuses8
minor mucosal changes on CT scans may have no relation to the clinical
symptoms, particularly if they are not causing osteomeatal complex obstruction9
Sinus radiograph
No definite criteria to identify disease in the ethmoidal or sphenoidal sinuses
except for"clouding" or opacification. 10,11
Not able to identify minimal sinus disease with sub- clinical presentation
Sensitivity and specificity were reasonably acceptable at 76% and 81%
Limited CT scan
Consist of 4 slices, Produce at least one image of frontal, ethmoidal, sphenoidal,
and maxillary sinuses
Overall rate of agreement with results of the full sinus CT scan was 88%.
Less expensive and radiation exposure
 Because the limited sinus CT scan has only 4 slices, instead of 16 to 20
slices as in the full CT scan, radiation exposure is reduced by at least
three to four times.
The use of limited numbers of slices and lower milliampere second
settings may translate into a faster study, better toleration by patients,
and more efficient use of the CT suite.
These changes would also reduce the cost further in the future.
Compared the performance of the routine sinus radiograph and the
limited sinus CT scan with the full sinus CT scan, radiograph has an
acceptable sensitivity and specificity as part of an initial evaluation for
pediatric patients with chronic upper respiratory tract symptoms,
although it cannot accurately show extent and site of sinus disease.
Conclusion

Single Waters view is an acceptable part of the initial evaluation of

pediatric chronic sinusitis; however, a limited CT scan is a better
alternative
Reference

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