Surg Radiol Anat

DOI 10.1007/s00276-017-1842-y

ORIGINAL ARTICLE

The effects ofchoanal atresia ondevelopment oftheparanasal

sinuses andturbinates
SuatTerzi1 EnginDursun1 FatmaBeyazaleliker2 Metineliker1
MehmetBeyazal2 Abdulkadirzgr1 EmeladallTatar3
MehmetHakanKorkmaz4

Received: 4 January 2017 / Accepted: 27 February 2017

Springer-Verlag France 2017

Abstract Keywords Choanal atresia Paranasal sinuses Volume

Purpose The objective of this study was to evaluate the Turbinate
volume of paranasal sinuses (PNS) and turbinate in patients
with unilateral choanal atresia (CA).
Materials and method Computed tomography images of Introduction
PNS in 11 individuals with unilateral CA were evaluated
retrospectively. Mucosal thickness and volume of the max- Choanal atresia (CA) is a rare but well-known anomaly.
illary, frontal and sphenoidal sinuses were determined, in CA is the complete unilateral or bilateral obstruction of
addition to the volume of the middle and inferior turbinate. posterior choanae that provide a space between the nose
The unaffected nasal side of patients was used as a control and nasopharynx. The incidence of CA is 8 000 per live
group for the measurements. The results comprised the births. The majority of individuals with CA have unilateral
measurements of the atresic side compared to those of the CA (60%). Bone is only affected in 71% of patients, while
healthy side. there is bone and membranous involvement in 29% of cases
Results There was no significant difference between the [1]. Bilateral atresia is diagnosed in the early post-partum
atresic and healthy side of the nose in patients with CA period following the development of respiratory distress
with respect to mucosal thickness and volume of the PNS and eventually cyanosis. However, it is usually difficult to
(the maxillary, frontal and sphenoidal sinuses) and the mid- recognise unilateral CA, which rarely leads to neonatal res-
dle and inferior turbinate (p>0.050). piratory distress [2].
Conclusion The complete absence of nasal unilateral air- Mechanisms in the development of the paranasal sinuses
flow had no effect on the development of the PNS and the (PNSs) largely remain unknown. However, a number of
middle and inferior turbinate. Moreover, mucosal thickness factors, including nasal airflow, brain growth, muscle mass
in the sinuses was similar to that in the control group. traction, facial structures and cell mechanisms, have been
proposed to explain the development of paranasal cavity
[36]. The transfer of nasal airflow from the nasopharynx
* Suat Terzi to the PNSs, due to positive air pressure in the nasophar-
drsterzi@hotmail.com ynx, is considered to influence the development and pneu-
1 matisation of PNSs [7, 8]. Moreover, great variation is
Department ofOtorhinolaryngology, Faculty ofMedicine,
Recep Tayyip Erdogan University, Rize, Turkey demonstrated in the development and eventual final PNS
2 shape. All sinuses are formed and reach adult size in early
Department ofRadiology, Faculty ofMedicine, Recep
Tayyip Erdogan University, Rize, Turkey adulthood [9].
3 To the best of our knowledge, the effects of CA on the
Department ofOtorhinolaryngology, Ministry ofHealth,
Training andResearch Hospital, Ankara Dkap Yldrm development of PNSs have been evaluated in only a few
Beyazt, Ankara, Turkey studies. However, an assessment of the development of the
4
Department ofOtorhinolaryngology, Faculty ofMedicine, three PNSs (maxillary, frontal and sphenoidal) and turbi-
Yldrm Beyazt University, Ankara, Turkey nate by volumetric methods has not been carried out in any

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 Surg Radiol Anat

study. Therefore, the purpose in this study was to evaluate

mucosal thickness and volume of the PNSs and turbinate in
patients with unilateral CA.

Materials andmethod

This retrospective study was approved by the local Ethics

Committee for Clinical Research, Istanbul Education and
Research Hospital, Istanbul, Turkey (08.04.2016-821).
Eleven patients with unilateral CA were included therein.
Individuals were admitted to the Department of Otorhino-
laryngology, Faculty of Medicine, Recep Tayyip Erdoan
University, and to the Department of Otolaryngology,
Ankara Numune Training and Research Hospital, between
March 2012 and February 2016. The medical records of
patients were collected retrospectively. Patients with bilat-
eral atresia or any other congenital anomaly or syndrome
were excluded from participation in the study. Seven indi-
viduals aged14 years were also excluded owing to the Fig.1Multiplanar reformatted images of the maxillary and frontal
possibility of incomplete development of all the PNSs. sinuses. The paranasal sinus volume was calculated automatically at
the workstation after volumetric analysis using volumetric rendering
Two groups were generated: an atresia and a control group. techniques
Measurements were taken for the healthy side of the nose
in patients with unilateral CA for the control group.
Images of the PNSs were obtained in 128 slices by
computed tomography (CT) (CT Scanner SOMATOM
Definition AS, Siemens Healthcare, Forchheim, Germany).
They were then evaluated by volumetric analysis at the
workstation (syngo.via VA20 software, Siemens Health-
care) using multiplanar reformatting and volumetric ren-
dering techniques (VRT). The volume of PNS was meas-
ured as follows. Slices from every 3 mm were extracted,
and the cross-sectional area of the PNS was measured from
top to bottom by manually tracing the internal surface of
the bone. The software automatically calculated the vol-
ume of the sinuses by adding the products of the 3 mm
and cross-sectional areas. Moreover, the turbinate was
assessed similarly by manually tracing the external surface
of the turbinate that was automatically determined by the
software. Multiplanar reformatted CT images, taken dur-
ing the volume measurements for the PNSs and turbinate,
are shown in Figs. 1 and 2. The volume of the PNSs was
expressed in cubic centimetres.
Mucosal thickening of the PNSs was also manually
calculated and recorded in millimetres. All measurements Fig.2Multiplanar reformatted images of the middle and inferior tur-
were performed thrice by two radiologists. To reduce the binate. Turbinate volume was calculated automatically at the worksta-
personal error rate, the size of the ethmoidal sinus was not tion after volumetric analysis using volumetric rendering techniques
measured because of its complex structure, which includes
the composition of numerous cells. to test the distribution of the analysed variables. Finally,
Statistical analysis was performed using Statistical the individual results were compared with one another.
Package for the Social Sciences 15.0 software pack- Students t-test was performed for this purpose on data
age (SPSS Inc, Chicago, USA). The parameters were that were normally distributed, and the MannWhit-
expressed as meanSD. The ShapiroWilk test was used ney U test was used for data that revealed an abnormal

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Surg Radiol Anat
distribution. A p value of 0.050 was considered to be
statistically significant.
Results
Individuals (n=11) diagnosed with unilateral CA (seven
females and four males) were included in our study. The
mean age was 23 years (a range of 1432 years). Seven
patients had right-sided CA and four patients had left-sided
CA. The results obtained from measuring the PNS and tur-
binate mucosal thickness and volume in both the atresic
and healthy side of the nose are represented in Table 1.
There was no significant difference between the results col-
lected from the heathy nasal side and those recorded for
the atresic nasal side regarding volume in the three PNSs
(maxillary, frontal and sphenoidal sinus), mucosal thick-
ness in the sinuses and volumes in the inferior and middle
turbinate (p value0.050).
Discussion
The mucosal thickness and volume of all PNSs, with the
exception of the ethmoidal sinus, were analysed in this
study, in addition to the volume of the inferior and mid-
dle turbinate in 11 patients with unilateral CA. The results
indicated that PNS mucosal thickness and volume, and the
volume of the middle and inferior turbinate in the nasal
side, were not different to that recorded in the healthy nasal
side in patients with unilateral CA.
There was a difference in the pneumatisation of each
PNS. The sphenoidal sinus can be detected at the age of
roughly two years, and it is fully developed by the age of
14years. PNS is the last frontal sinus to develop. Its growth
starts after the age of two years, and is fully developed by
puberty [7, 9]. Thus, patients aged14years were included
in this study to ensure assessment of the development of
the frontal sinuses. Mechanisms responsible for the growth
Table1Mean mucosal thickness and volume recorded in the paranasal sinuses and turbinates
Measurements of the paranasal sinuses and turbinates
Maxillary sinus volume (cm3)
Sphenoid sinus volume (cm3)
Frontal sinus volume ( cm3)
Mucosal thickness in the maxillary sinus (mm)
Mucosal thickness in the sphenoidal sinus (mm)
Mucosal thickness in the frontal sinus (mm)
Volume of the inferior turbinate ( cm3)
Volume of the middle turbinate (cm3)
cm3 cubic centimetres, mm millimetres, PNSs paranasal sinuses
of the PNSs remain not fully understood. However, it is
perceived that the nasal passage of airflow plays an impor-
tant role in the development and growth of PNSs (12). By
contrast, the focus has been on the absence of effects of
nasal airflow on the development of PNSs in other studies
[4, 911].
The development of the maxillary sinus in patients with
CA was assessed by Diner etal. through the collection of
data from conventional imaging. It was suggested that uni-
lateral nasal obstruction did not impair sinus pneumatisa-
tion [11]. Recently, Behar and Todd conducted a study on
16 patients with CA and measured the volume in the max-
illary sinus on PNS CT imaging using VRT. Interestingly,
there were slightly larger volumes of maxillary sinuses in
the atresia side (compared to the healthy side), while muco-
periosteal thickening in the atresia side was observed to
be similar to that recorded in the healthy side [10]. More
recently, Guimaraes etal. similarly measured the maxillary
sinus areas on PNS CT imaging using AutoCAD soft-
ware and found no significant difference between the atre-
sia and the healthy side [4]. However, other PNSs, includ-
ing the sphenoidal and frontal sinus, were not evaluated in
these studies.
The effects of CA on the development of the sphenoi-
dal and maxilla-facial sinus were evaluated by Leclerc etal.
[9]. In this study, measurements of the frontozygomatic,
zygomatic, maxillary sinus, and sphenoid sinus widths on
the atresic side were obtained by PNS CT imaging and
compared to those for the healthy controls. The zygomatic
width was only found to be larger in the control group,
compared to that in the bilateral CA patients. A significant
difference was not found with regard to the other studied
parameters in patients with both unilateral and bilateral CA
when a comparison was made with the normal controls.
However, the development of turbinate and changes in
the volume of the three PNSs, including maxillary, sphe-
noidal and frontal sinus, in patients with CA, has not been
evaluated in a prior study. In the current study, we per-
formed three-dimensional volume analysis of these PNSs
Atresic side (n=11) Healthy side (n=11) p value
11.205.10 (5.6022.00) 12.707.40 (5.4028.60) 0.898
3.002.00 (0.507.30) 3.902.20 (1.608.40) 0.243
3.902.50 (1.209.60) 4.202.90 (1.209.60) 0.949
0.170.10 (0.100.40) 0.170.10 (0.100.40) 0.699
0.140.05 (0.100.20) 0.100.05 (0.100.30) 0.076
0.100.08 (0.100.40) 0.100.09 (0.100.60) 0.519
2.901.40 (1.305.40) 3.302.10 (1.308.60) 0.652
1.400.50 (1.002.70) 1.600.50 (1.202.80) 0.133
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using CT imaging, in addition to measuring mucosal thick-
ness. A significant difference was not determined with
respect to either PNS volume or mucosal thickness in the
atresia side, when compared with that in the controls. It
was difficult to evaluate the ethmoidal sinus as it has irreg-
ular borders.
Indeed, it has been suggested that there is a connection
between abnormal facial and dentoalveolar growth and
adenoid hypertrophy, characterised by a reduction in nasal
ventilation [1214]. However, a significant difference could
not be determined in patients with unilateral CA, consider-
ing the growth of the PNSs. This might relate to adequate
unilateral nasal airflow passage.
The association between nasal airflow and the growth of
the PNSs was also evaluated in patients with septal devia-
tion. However, consensus has not yet been reached on this
issue. Recently, Karatas et al. suggested that severe sep-
tal deviation had no remarkable effect on volumes in the
maxillary and frontal sinus [15]. By contrast, a significant
increase was established in contralateral maxillary sinus
volume in the severe septum deviation group, when com-
pared to that in the ipsilateral maxillary sinus [16]. Another
study was conducted to determine the influence of CA
on nasal mucosa. Elsheikh et al. suggested that there was
no major difference in mucosal volume in the atresia side
for the main histological features. Despite the presence of
general histological features, changes were determined in
the tissue sample, including distorted cilia and a marked
increase in mucosal secretion from the submucosal glands,
associated with a marked reduction in goblet cell density
and cellular lymphocytic infiltration [17].
The main limitation of our study was that all patients
had unilateral CA. Therefore, it was difficult to make an
unconditional inference about on the effects of CA on
maxilla-facial development. The retrospective design was
another limitation, while the sample size in the study was
relatively small.
Conclusion
The unilateral complete absence of nasal airflow did not
influence the development of mucosal thickness and vol-
ume in the PNSs in our study, with the exception of the
ethmoidal sinus and the middle and inferior turbinates. In
addition, owing to the similarity in mucosal thickness of
all the PNSs in both the atresia and control sides, it is pro-
posed that total obstruction of airflow did not result in the
development of sinusitis. However, having taken the previ-
ously mentioned limitations into account, making a distinct
assumption could not be achieved. Further studies need to
be conducted on a larger population of patients with bilat-
eral atresia in order for this goal to be achieved.
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Surg Radiol Anat
Financial support The authors declare no financial support or
interest to this study.
Compliance with Ethical Standards
Conflict of interest All the authors have made significant contribu-
tions to this work, with all co-authors approving the final version of
this article and agreeing with its submission for publication. This study
has not been published elsewhere, nor is currently being considered for
publication in another journal. All the authors have no conflict of inter-
est regarding the production of this article. This study was approved by
the local Ethics Committee for Clinical Research, Istanbul Education
and Research Hospital, Istanbul, Turkey (08.04.2016-821).
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