Paranasaalsiinuste normivariandid ja nende tähtsus. Artur Aramaa III a radioloogia resident 2017

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1 Paranasaalsiinuste normivariandid ja nende tähtsus Artur Aramaa III a radioloogia resident 2017

2 Millest juttu tuleb Lühidalt olulisest anatoomiast Normivariantide esinemissagedus Normivariantide seos haigustega? Normivariandid ja nende olulisus PreOP KTuuringul Soovitusi PNS KT-uuringu kirjeldamiseks

3 Anatoomia Anterioorne OMK koosneb maksillaarsiinuse ostiumist, infundiibulumist, hiatus semilunarisest, keskmisest ninakäigust, eesmistest etmoidaalrakkudest ning frontaalretsessist. OMK anterioorne osa on viimane drenaažitee frontaalsiinusele, anterioorsele etmoidaalrakustikule ja maksillaarsiinustele. Sfenoetmoidaalne retsess e tagumine OMK on viimane lõik tagumiste etmoidaalrakustike ning sfenoidaalsiinuste drenaažis. The Frontal Sinus Drainage Pathway and Related Structures. AJNR. 2003

4 Anatoomia Anterioorne OMK koosneb maksillaarsiinuse ostiumist, infundiibulumist, hiatus semilunarisest, keskmisest ninakäigust, eesmistest etmoidaalrakkudest ning frontaalretsessist. OMK anterioorne osa on viimane drenaažitee frontaalsiinusele, anterioorsele etmoidaalrakustikule ja maksillaarsiinustele. Sfenoetmoidaalne retsess e tagumine OMK on viimane lõik tagumiste etmoidaalrakustike ning sfenoidaalsiinuste drenaažis. The Frontal Sinus Drainage Pathway and Related Structures. AJNR. 2003

5 Normivariandid ja haigused Normivariandid, mis mõjutavad OMK-d ja frontaalset retsessi: Halleri rakud, bulloossed ninakarbikud, paradoksaalselt roteerunud karbikud, oluline vaheseina deviatsioon, frontaalse retsessi rakustik, Agger nasi rakud ning suured etmoidaalsed bullad. Sageli on normivariandid juhuleid ning üksinda esinedes ei põhjusta haigust, aga teatud kombinatsioonides näiteks koos limaskesta muutustega võivad need viia oluliste ahenemisteni ja kliiniliselt siis korduvate ägedate sinusiitideni või lokaalsete krooniliste protsessideni. Difuussed kroonilised protsessid on pigem seotud põletikuvastuse düsregulatsiooniga. CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis AJR.

6 Normivariant Sagedus Agger nasi rakud 83.3% Sinus sfenoidalise sellaarne variant 68.8% Ninavaheseina >1mm deviatsioon 61.4% Promineeruv etmoidaalne bulla 44.8% Halleri rakud 39.1% Aereeritud keskmised karbikud 26-37% Paradoksaalselt pöördunud karbikud 15.6% Onodi rakud 12% Lamina papyracea dehhistsents 0.5% CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis AJR.

7 Agger nasi rakud Etmoidaalrakustiku kõige anterioorsem osa. Asetsevad frontaalsest retsessist anterolateraalsel ning moodustavad selle eesseina. Paikneb pisaraluus -> kontaktis orbitaga, pisarajuhaga. Väga sage variant, bilateraalselt. ka

8 Agger nasi rakud Suured Agger nasi rakud ahendavad frontaalset retsessi, oluline seos kroonilise valu ja frontaalsinusiidiga. Selles piirkonnas võivad olla ka lisa frontaalsed rakud (2030%), mis jagunevad nelja tüüpi: tüüp1 - üksik rakk agger nasi raku kohal tüüp 2 kaks või enam rakku agger nasi raku kohal tüüp 3 suur rakk agger nasi raku kohal, mis ulatub frontaalsiinusesse tüüp 4 harv variant, mille puhul on rakud täielikult frontaalsiinuses. Role of the agger nasi cell in chronic frontal sinusitis. 1996

9 Etmoidaalrakustiku bulla Hea kirurgiline landmark kuna selle asukoht on suhteliselt konstantne, erisus ainult suuruses. Väga suur bulla võib ahendada keskmist ninakäiku ja infundibulumi. Functional anatomy and computed tomography imaging of the paranasal sinuses. 1998

10 Processus uncinatus Tähtsaim OMK struktuur. Käitub kilbina maksillaarsiinustele otsese inspireeritud õhu ja patogeenide eest. Palju normivariante. Proc uncinatuse ülemine kinnitukoht mõjutab frontaalset retsessi. Uncinate Process Variations and Their Relationship with Ostiomeatal Complex: A Pictorial Essay of Multidedector Computed Tomography (MDCT) Findings

11 Processus uncinatus Uncinate Process Variations and Their Relationship with Ostiomeatal Complex: A Pictorial Essay of Multidedector Computed Tomography (MDCT) Findings

12 Proc uncinatuse bullad Võivad ahendada infundibulumi ja frontaalset retsessi. Uncinate Process Variations and Their Relationship with Ostiomeatal Complex: A Pictorial Essay of Multidedector Computed Tomography (MDCT) Findings

13 Paradoksaalselt roteerunud karbikud Normaalselt roteerivad keskmised karbikud oma arengu jooksul väljapoole, aga anatoomilise variandina võivad nad roteeruda ka sissepoole paradoksaalne rotatsioon. Sageli esineb bilateraalselt, aga võib olla ainult ühel pool. See võib viia infundibulumi ahenemiseni, eriti kui esineb koos bulloosse karbikuga. Nasal, septal, and turbinate anatomy and embryology. Otolaryngol. 2009

14 Halleri rakk Ehk infraorbitaalsed etmoidaalrakud. Etmoidaalrakustiku osa, mis asetseb lateraalsel maksillo-etmoidaalsest sutuurist orbita mediaalset põhja pidi. Mitte segamini rakkudega. ajada Agger nasi Sinusiidi põhjustajana on selle tähtsus uuringutes vastuoluline. Kui muutus on suur võib viia maksillaarse antrumi ja proksimaalse infundibulumi ahenemiseni. Etmoidektoomia käigus selle mitte ära tundmine võib viia orbita vigastusele. Endoscopic paranasal sinus surgery. 2004

15 Keskmise karbiku bulla(d) Suured bulloossed keskmised karbikud võivad ahendada keskmist ninakäiku ja põhjustada proc uncinatuse lateraalset nihkumist, mis viib infundibulumi ahenemisele. Kliiniline olulisus kohati vaieldav, sõltub suurusest. Seotud ninavaheseina deviatsiooniga. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR

16 Keskmise karbiku bulla(d) Mõjutatud sarnaste haiguste poolt nagu muud ninakõrvalkoopad. Bulloossed karbikud võivad infitseeruda ja olla varjustatud. Mukotseele. Võimalik neoplasma teke. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR

17 Keskmise karbiku bulla(d) Jagunevad kolmeks: Lamellaarne Bulbous Totaalne The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR

18 Ninavaheseina deviatsioon Kaasasündinud või omandatud. 1/3 ninavaheseina deviatsioonidest esineb spur e luuline kannus. Suured luulised kannused võivad olla karbikuga ühenduses. Väljendunud ninavaheseina deviatsioon koos luulise kannusega võib viia keskmise karbiku nihkumisele ja selle tõttu õhuteede takistusega. Lihtne klassifikatsioon: 1) Vähesed deviatsioonid kaebusi ei põhjusta ja ravi ei vaja. 2) Keskmised deviatsioonid, mille puhul dekongestantidega õhuteed läbitavad lõikust ei vaja. 3) Rasked deviatsioonid, mille puhul ninavahesein kontaktis nina lateraalseinaga ning dekongestandid õhuteed ei ava näidustatud lõikus. CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis. AJR Nasal Septum Anatomy and Deviations: beyond straight and flat. ESR.

19 Ninavaheseina deviatsiooni lihtne klassifikatsioon CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis. AJR Nasal Septum Anatomy and Deviations: beyond straight and flat. ESR.

20 PreOP KT FESS on hea meetod kroonilise sinusiidiga patsientide raviks, aga see pole ilma riskita. FESS lõikus sihib peamiselt OMK-d ja mõnikord ka frontaalset retsessi. PreOP KT uuring aitab leida normivariante ja vähendada riske, aga sageli jäävad need vastustes mainimata. Ühe uuringu järgi kuni 75% LOR arstidest said ravikäsitluse seisukohast ebapiisavat informatsiooni PreOP KT-uuringu vastusest. 2/3 arstidest leidis, et täpsematest vastustest oleks neile kasu. Normivariantide mitte leidmine PreOP uuringul võib mõjutada kirurgilist lähenemise meetodit ning võib viia komplikatsioonideni. Radiologic reporting for paranasal sinus computed tomography: a multi-institutional review of content and consistency. Laryngoscope. 2013

21 CLOSE Normivariante on väga palju ja nende olulisus on varieeruv. On välja töötatud ka teisi checkliste, et vastuste kvaliteeti parandada, aga need on olnud liiga mahukad ja sisaldanud ebaolulist infot. Mnemonic CLOSE käsitleb kriitilisi normivariante, mis peaksid kindlasti vastuses mainitud olema.

22 C - Cribriform plate e lamina Cribrosa lamina cribrosa horisontaalne osa, eraldab omavahel anterioorset koljupõhimikku ning ninaõõnt. Lamina cribrosa ja fovea etmoidaliste vaheline pikkus mõjutab lateraalse lamelli pikkust mida pikem see on, seda suurem on vigastuse oht liikvori leke, infektsiooni risk, pseudomeningotseele, meningoentsefalotseele. Võib esineda pooltevahelist asümmeetriat.

23 C - Cribriform plate e lamina Cribrosa Keros klassifikatsioon: Tüüp 1 <= 3 mm Tüüp 2 4-7mm Tüüp 3 >7mm

24 L - Lamina papyracea e lamina orbitalis Paberõhuke etmoidaalluu osa orbita mediaalses seinas. Varasema vigastuse tõttu tekkinud dehistsentsi tõttu võib olla nihkunud mediaalsemale etmoidaalsiinusesse risk koos sellega nihkunud orbita struktuuride (silmaliigutajalihas) vigastuseks ja või hematoomi tekkeks.

25 O Onodi ehk sfenoetmoidaalrakud Tagumise etmoidaalsiinuse rakud, mis ulatuvad sfenoidaalsiinuse lateraalse ja ülaosa piirkonda. Neid on tähtis ära tunda ja mainida, kuna n opticused sageli neid läbivad ja on eraldatud ainult peenikese luulise seinaga.

26 S Sfenoidaalsiinuse õhustatus Tuleb hinnata sfenoidsiinuse ülemise ja tagumise osa luulise seina intaktsust. Lisaks hinnata, sfenoidaalsiinuse õhustatust / ulatust.

27 S Sfenoidaalsiinuse õhustatus Pneumatisatsiooni variandid: Karbikuni Presellaarne Sellaarne

28 E (anterioorne) Etmoidaalarter A opthalmica haru. Vigastuse puhul ohtlik orbitaalne hematoom. Kaks varianti: Kaitstud Mitte-kaitstud

29 Ideaalne Pre-OP uuringu vastus Paranasaalsiinuste hüpo/hüperplaasiat ei esine. Mõlemapoolselt OMK ja frontaalsed retsessid läbitavad või esineb OMK ahenemine x-normivariandist tingituna. Maksillaarsiinused, anterioorne etmoidaalrakustik ja frontaalsiinus aereeritud. Sfenoetmoidaalsed retsessid on läbitavad. Tagumine etmoidaalrakustik ja sfenoidaalsiinus on aereeritud. Õhk-vedelik nivoosid ei esine. Luulisi erosioone ega dehhistsentsi ei esine. Ninavaheseina deviatsioon on/ei ole ja on/ei ole kontaktis lateraalse ninaseinaga. Lamina cribrosa on intaktne. Keros klassifikatsiooni järgi tüüp 1/2/3. Lamina papyracea on intaktne / esineb dehhistents koos orbitaalse rasvkoe prolapsiga. Onodi rakustik on / ei ole nähtav vasakul / paremal. Sfenoidsiinuse aeratsioon on karbikuni / presellaarne / sellaarne. N opticuse kanalid on luuliselt kaetud / esineb luuline õhenemine / ei ole kaetud. Supraorbitaalset pneumatisatsiooni esineb / ei esine ehk anterioorne etmoidaalarter ei ole kaitstud / on kaitstud. Orbita, koljupõhimik, kaela pehmed koed ning lülisammas uuringule jäänud osas normi piires.

30 Kokkuvõte Normivariantide kliiniline olulisus sinusiidi põhjustajana erinevate uuringute andmetel vaieldav. Tõenäoliselt seoses normivariandi suuruse ja kombinatsioonidega. Pre-OP KT-uuringul tuleks kindlasti ära mainida tähtsamad normivariandid, et vähendade riske mnemonic CLOSE. Suhtuda uuringusse kui Pre-OP, isegi kui seda mainitud ei ole. Mainida ära vastuses ka kriitiliste normivariantide puudumine.

31 Kasutatud kirjandus The Frontal Sinus Drainage Pathway and Related Structures. AJNR CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis. AJR Nasal Septum Anatomy and Deviations: beyond straight and flat. ESR. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Endoscopic paranasal sinus surgery Nasal, septal, and turbinate anatomy and embryology. Otolaryngol Uncinate Process Variations and Their Relationship with Ostiomeatal Complex: A Pictorial Essay of Multidedector Computed Tomography (MDCT) Findings Functional anatomy and computed tomography imaging of the paranasal sinuses Role of the agger nasi cell in chronic frontal sinusitis. 1996

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