Abstract
The Onodi cell is defined as the posterior-most ethmoid cell. Haller cells are defined as infraorbital ethmoid cells. HRCT scanning provides excellent bone detail and accurate soft tissue mapping. The aim of this study is to know the prevalence of Haller cells and Onodi cells and to find variations in them on HRCT. Also to find co-relation between HRCT findings and Intra operative findings. A Hospital based prospective and cross-sectional study which included 30 patients above 15 years of age coming to ENT OPD with complaints related to sinonasal disease and polyposis;willing for HRCT followed by operative procedures. A total of 30 patients are included in the study. The mean age was found to be 38.70 ± 14.37. Prevalence of haller cells and onodi cells was 30% and 33.3% respectively. Statistical significance was found between association of haller cells with sinusitis. Intra-operative findings corresponded to 8 out of 9 HRCT findings (p-value = 0.001). We conclude that the actual prevalence of haller cell and onodi cell is best noted on HRCT-PNS and this holds a significant role in imparting thorough knowledge of the anatomical variations of PNS and hence preventing intraoperative complications due to presence of these variant cells.
Keywords: Onodi cell, Haller cell, HRCT, Lund-Mackay score, Recurrence
Introduction
The Onodi cell is defined as the posterior most ethmoid cell, and may extend up to the sphenoid sinus superiorly and laterally. The importance of these cells comes from their close relationship with the optic nerve, sphenoid sinus and hypophyseal fossa [1]. Identifying the anatomic variants of the Onodi cells is vital during preoperative paranasal sinus CT examination because certain operative complications may arise from critical features of anatomic variation within the sphenoid sinus region. A systematic evaluation of CT scans have shown to help avoid potential complications of endoscopic sinus surgery [2].
Haller cells also known as maxillo-ethmoidal cells, orbito-ethmoidal cells, or infraorbital ethmoid cells are defined as air cells situated beneath the ethmoid bulla along the roof of the maxillary sinus and the inferior most portion of the lamina papyracea, including air cells located within the ethmoid infundibulum [3]. Detection of Haller cells may forewarn the surgeons before endonasal procedures, thus preventing any untoward intraoperative complications [3].
Radiologic evaluation has been relied upon for many years in the diagnosis of paranasal sinus pathology. High resolution CT scanning provides excellent bone detail and accurate soft tissue mapping. CT is accepted as the gold standard for pathological-anatomical evaluation of paranasal sinus disease. CT is especially considered a compulsory part of planning, surgical procedures [4]. High resolution CT is used routinely before endoscopic surgery to evaluate extent of the inflammatory disease and to assess important anatomic landmarks and their variations. [5]
The aim of our study is to know the prevalence of Haller cells and Onodi cells, to find variations in Haller cells and Onodi cells on HRCT – PNS, to find co-relation between Radiological [HRCT] findings and clinicosurgical [Intra operative] findings, to establish a relationship between presence of these cells and presence of sinonasal disease or polyposis. Also to analyse and prevent the associated complications in presence of such cells.
Materials and Methods
This hospital based prospective and cross sectional study was carried out in 30 patients above 15 years of age who come to the ENT outpatient department of Dr B.R. Ambedkar Medical College and hospital from November 2018 to May 2020; with complaints related to sinonasal disease and who are willing for HRCT followed by operative procedures.
Patients above 15 years of age who have complaints related to sinonasal disease and polyposis and are willing for HRCT followed by operative procedures were included in the study. Patients younger than 15 years, with prior surgery of nose and PNS, with sinonasal tumours and head and neck injuries. and those not willing for diagnostic or operative procedures were excluded from the study.
All patients who come with complaints related to sinonasal disease and polyposis will be taken in the study. Their demographic details will be noted. They will be thoroughly examined and their clinical signs will be noted. After which, the patients will be asked to get a HRCT PNS done. Axial cuts are taken of the PNS. All findings on the scan will be noted. Especially, the presence of haller cells and onodi cells. Then the patients will be examined Intraoperative to confirm the CT findings as well as to assess the degree of sinonasal disease and polyposis according to Lund-Mackay scoring system.(Table 1) Also, any complications during or immediate post operatively will be noted.
Table 1.
Lund mackay scoring system
| Sinus | Right sinus | Left sinus |
|---|---|---|
| Frontal | 0–2 | 0–2 |
| Anterior ethmoids | 0–2 | 0–2 |
| Posterior ethmoids | 0–2 | 0–2 |
| Maxillary | 0–2 | 0–2 |
| Sphenoid | 0–2 | 0–2 |
| Ostiomeatal complex | 0 or 2 | 0 or 2 |
For the sinuses: 0 = no inflammation; 1 = partial inflammation; 2 = 100% inflammation
For the ostiomeatal complex: 0 = not occluded; 2 = occluded
Maximum total score: 24
Statistical Analysis
Descriptive and inferential statistical analysis has been carried out in the SD ± present study. Results on continuous measurements are presented on Mean (Min–Max) and results on categorical measurements are presented in Number (%). Significance is assessed at 5% level of significance. The Statistical software namely SPSS 22.0, and R environment ver.3.2.2 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.
Observation and Results
A total of 30 patients are included in the study. The mean age was found to be 38.70 ± 14.37, with majority of the patients in the age group of 20–30 years. (Fig. 1) There was an equal distribution of gender, i.e. 50% males and 50% females. The most common complaint of patients included in the study was headache, i,e. 80% followed by nasal discharge (76.7%) then nasal obstruction (70%) followed by post nasal drip (26.7%) and nasal mass, smell disturbances (20%) each. One patient came with complaints of epistaxis.
Fig. 1.
Age distribution
On examination, 70% patients had DNS which is the most common anatomical variation of the nasal cavity. 73.3% of patients had paranasal sinus tenderness of which maxillary sinus tenderness was most common and 23% of patients had visible nasal polyps on anterior rhinoscopy. 13 patients had a LMS score of less than 5, 12 patients had a score of 6–10, 2 patients between 11–15 and 16–20 each and one patient having a score of 20. (Fig. 2).
Fig. 2.
Lund mackay scoring
The prevalence of Haller cells in our study is 30% i.e. 9 patients. Out of which 6 patients had unilateral haller cells and 3 patients had bilateral haller cells. (Table 2) The most common type of Variation in haller cells was oval followed by triangular, trapezoid, square. (Fig. 3) Out of the 9 people with haller cells, 8 patients had associated sinusitis, which showed the statistical significance of p-value less than 0.001. The HRCT evidence of haller cells corresponded the intraoperative finding in 8 out of 9 patients also with a statistical significance of p-value less than 0.001.(Fig. 4) There were no intra-operative or immediate post-operative complications associated with the presence of haller cells.
Table 2.
Haller cells
| Variables | Haller cells | Total (n = 30) | P value | |
|---|---|---|---|---|
| Absent (n = 21) | Present (n = 9) | |||
| Variation/Type | ||||
| Absent | 21 (100%) | 0 (0%) | 21 (70%) | < 0.001** |
| Present | 0 (0%) | 9 (100%) | 9 (30%) | |
| Associated sinusitis/Polyposis | ||||
| Absent | 21 (100%) | 1 (11.1%) | 22 (73.3%) | < 0.001** |
| Present | 0 (0%) | 8 (88.9%) | 8 (26.7%) | |
| Intra-operative findings | ||||
| Absent | 21 (100%) | 1 (11.1%) | 22 (73.3%) | < 0.001** |
| Present | 0 (0%) | 8 (88.9%) | 8 (26.7%) | |
| Intra-Op | ||||
| Absent | 21 (100%) | 9 (100%) | 30 (100%) | 1.000 |
| Present | 0 (0%) | 0 (0%) | 0 (0%) | |
| Immediate Post-op | ||||
| Absent | 21 (100%) | 9 (100%) | 30 (100%) | 1.000 |
| Present | 0 (0%) | 0 (0%) | 0 (0%) | |
Fig. 3.
Types of haller cells
Fig. 4.
Intra-operative finding of haller cell
The prevalence of Onodi cells in our study is 33.3% i.e. 10 patients. Out of which 8 patients had unilateral Onodi cells and 2 patients had bilateral Onodi cells.(Table 3) The most common type of Variation in Onodi cells was type III (40%) followed equally by I and II (30%). (Fig. 5) Out of the 10 people with Onodi cells, 1 patient had associated sphenoidal sinusitis, with no statistical significance. The HRCT evidence of Onodi cells corresponded the intraoperative finding in 3 out of 10 patients which showed statistical significance of p value of 0.027 (ie less than 0.05).(Fig. 6) There were no intraoperative complications. However, there was an immediate post-operative complication seen in 1 patient, who had severe periorbital edema.
Table 3.
Onodi cells
| Onodi cells | HRCT findings: | Total (n = 30) | P value | |
|---|---|---|---|---|
| Absent (n = 20) | Present (n = 10) | |||
| Variation/Type | ||||
| Absent | 20 (100%) | 0 (0%) | 20 (66.7%) | < 0.001** |
| Present | 0 (0%) | 10 (100%) | 10 (33.3%) | |
| Associated sinusitis/Polyposis | ||||
| Absent | 20 (100%) | 9 (90%) | 29 (96.7%) | 0.323 |
| Present | 0 (0%) | 1 (10%) | 1 (3.3%) | |
| Intra-operative findings | ||||
| Absent | 20 (100%) | 7 (70%) | 27 (90%) | 0.027* |
| Present | 0 (0%) | 3 (30%) | 3 (10%) | |
| Intra-Op | ||||
| Absent | 20 (100%) | 10 (100%) | 30 (100%) | 1.000 |
| Present | 0 (0%) | 0 (0%) | 0 (0%) | |
| Immediate Post-op | ||||
| Absent | 20 (100%) | 9 (90%) | 29 (96.7%) | 0.323 |
| Present | 0 (0%) | 1 (10%) | 1 (3.3%) | |
Fig. 5.
Types of onodi cells
Fig. 6.
Intra-operative finding of onodi cell
Among the other anatomical variations, we found that the Agger nasi cell was the most common variant present in 50% of the patients followed by frontal cells 23.3% (of which type 1 frontal cells were more common). Concha bullosa 20% paradoxical middle turbinate and anterior clinoid pneumatization 10% each. Pneumatization of the greater wing of sphenoid and sphenoid septations were present in 1 patient each.
Out of the 30 patients, 2 patients had recurrence of sinusitis. 1 patient had recurrence of maxillary sinusitis that can be attributed to the presence of haller cell and another patient had recurrence due to residual sphenoid sinusitis which can be related to the presence of onodi cell. However, there is no statistical significance.
Discussion
Sino-nasal diseases are idiopathic perennial, reactive inflammatory conditions of mucus membrane of nose and paranasal sinuses with an unclear etiology. The probable associations could be allergy, asthma, infections, cystic fibrosis etc. The anatomical variations include septal deviation, concha bullosa, agger nasi, haller cell, onodi cell, frontal sinus aplasia, uncinate process pneumatisation, accessory ostium, sphenoid septations which may affect the functional drainage pathways and predispose to sinus disease. Therefore the recognition of these anatomical variations is important to avoid surgical complications [6].
Computed tomography (CT) of the paranasal sinuses is required for the diagnosis and treatment of sino-nasal disease. CT demonstrates the extent of the disease as well as anatomical variations predisposing to rhino-sinusitis and delineates any nearby vital structures so that iatrogenic damage can be avoided. The goal of endoscopic sinus surgery is to restore physiological sinus ventilation as well as drainage. Minor complications of this procedure include haemorrhage, sepsis, adhesions and major complications include orbital injury, optic nerve injury, internal carotid injury, intracranial injury and CSF leaks [7].
It provides a preoperative road map for functional endoscopic sinus surgery (FESS). Hence a combination of CT and diagnostic nasal endoscopy is the keystone in management of paranasal sinus disease [8].
Haller cells are ethmoidal air cells located anteriorly to the ethmoidal bulla along the orbital floor. These may cause mucociliary drainage obstruction predisposing to sinusitis [9]. Depending upon the number and size of these haller cells, narrowing of the infundibulum can occur compromising the maxillary ostium and leading to recurrent maxillary sinusitis [11].
Onodi cells are the lateral extensions of the posterior ethmoidal air cells. Their clinical importance lies in their close proximity to the internal carotid artery and the optic nerve [10]. Onodi cell is best visualized on coronal sequence by first locating an air cell above the sphenoid sinus and identifying its continuity with the posterior ethmoidal air cells. Onodi cells form a bulge at the optic nerve canal and if prominent the optic nerve can be at risk for iatrogenic damage [11].
The prevalence of Haller cells in our study is 30%, with Oval-shaped Haller cells being most common. Our result is almost close to Maru and Gupta [12] reporting 36% and Asruddin [13] reporting 28%. In a study by Kamdi et al., [14] the prevalence of haller cells was 49.5% and they found a statistical significance between the presence of haller cells and maxillary sinusitis. Based on the size and shape medium sized (2–4 mm) and oval shaped haller cells were more common in their study. In our study too, there is a stastistical significance between the presence of Haller cells and maxillary 112 sinusitis (p-value < 0.001).
We also found a statistical correlation between HRCT finding of Haller cells and Intra- Operative endoscopy findings (p-value < 0.001). However, the diagnosis of haller cell may be difficult on endoscopy due to its location and hence identification on radiology is preferred. Non-identification of this cell could lead to recurrent maxillary sinusitis.
The prevalence of Onodi cells in our study is 33.3% which is similar to a study by Nandita et al., [15] where the prevalence was 38%. Type III was the most common variation in our study. Excessive aeration of sphenoid and surrounding structures leads to indentation of optic nerve canal into the sphenoid sinus and bony dehiscence. The anatomical relationships of Onodi cell, sphenoid sinus, optic nerve and internal carotid artery are critical while performing endoscopic sinus surgery as the optic nerve lies superolateral and carotid artery lies lateral to the sphenoid sinus [16].
According to the classification of optic nerve canal to the onodi cell and sphenoid sinus, our study correlates with Delano et al., where, type 1 was the most common variety. (Table 4) In another study by Yazici, [17] the optic nerve type I was more frequent (54.2%) followed by type IV (16.9%). Nomura et al. [18] stated that Onodi cells displace the sphenoid sinus downwards, reduces its volume and could be associated with sphenoiditis. There was no statistical significance between the presence of Onodi cells and associated Sphenoiditis (p-value 0.323). However, we found a statistical significance between the HRCT and Intra-operative findings of Onodi cells (p-value 0.027). The Onodi cell may also be mistaken for sphenoid sinus resulting in incomplete functional endoscopic sinus surgery in a patient with sphenoid sinus disease. The clinical significance of onodi cell is threefold. Onodi cell sinusitis may cause visual symptoms due to its close relation with optic nerve. Secondly the Onodi cell can be mistaken for sphenoid sinus as mentioned above. Thirdly, this cell increases the risk of injury to optic nerve and internal carotid artery [19].
Table 4.
Relationship of optic nerve to onodi cell
| Types | Description |
|---|---|
| Type 1 | Optic nerve is immediately adjacent to lateral and superior wall of sphenoid sinus without impression on sinus wall |
| Type 2 | Optic nerve causes an impression on lateral sphenoidal sinus wall |
| Type 3 | Optic nerve courses through the sphenoid sinus |
| Type 4 | Optic nerve courses immediately lateral to posterior ethmoid and sphenoid sinuses |
Our study, gives a higher prevalence of Haller and Onodi cells which is 30% and 33.3% respectively. Which is higher than most of the studies such as Lloyd et al. [20] showing 15% prevalence of haller cells and Shpilberg et al. [21] showing 12% prevalence of onodi cells. According to a study by Pereira et al., [22] the incidence of onodi cells was 29.5% and the incidence of haller cells was 32.1%. Weinberger, [23] in his study mentioned the prevalence of onodi cells in 39% of CT and 14% of endoscopic surgeries. According to a study by Hadi et al. [24], the prevalence of haller cells is 30% and onodi cells is 24%. 114 In our study, we did not come across any drastic complications like injury to the orbit, optic nerve injury or injury to the internal carotid artery except the immediate post-operative complication of peri-orbital edema in 1 patient, which resolved over 2–3 days. However, we did have 1 patient with recurrence of maxillary sinusitis and 1 patient with recurrence of sphenoid sinusitis (6.7%).
Conclusion
In our study the prevalence of haller cells and onodi cells was 30% and 33.3% respectively. The most common variation of haller cells was oval type. Most common type of variation of Onodi cells was type III (40%). There was a statistical significance was found between association of these cells with sinusitis. Intra-operative findings corresponded to 8 out of 9 HRCT findings and 3 out of 10 HRCT findings for Haller cell and Onodi cells respectively.
This study concludes that there were no drastic intra-operative complications, due to prior HRCT-PNS which was done as a specific investigation. However, there was one patient with recurrence of maxillary sinusitis and sphenoid sinusitis respectively. Therefore, we conclude that the actual prevalence of haller cell and onodi cell is best noted on HRCT-PNS and this holds a significant role in imparting thorough knowledge of the anatomical variations of PNS and hence, preventing intraoperative complications due to presence of these variant cells.
Acknowledgements
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Funding
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Declarations
Conflict of interest
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