0:01

This was an outpatient who was sent

0:04

in, and the request slip stated CRS.

0:11

So CRS is an abbreviation for chronic rhinosinusitis.

0:17

So, in a patient who has inflammation in the

0:21

nasal cavity as well as the paranasal sinuses.

0:24

So this is CRS.

0:26

What we're seeing here is near complete

0:29

opacification of the maxillary antra

0:31

bilaterally, not really seeing air-fluid levels.

0:34

Some people might say, well,

0:36

could there be a few bubbles here?

0:38

To me, it just sort of looks like

0:39

residual aeration of the maxillary sinus.

0:42

We see that the ethmoid sinus also

0:45

has diffuse mucosal thickening.

0:47

Again, no air-fluid levels or

0:50

dependent areas of fluid that you can see in

0:54

the paranasal sinuses. In the sphenoid sinus,

0:57

a little bit of mucosal thickening.

0:59

I wouldn't call any of this a meniscus.

1:02

And then let's look at the frontal sinus.

1:04

So just a little bit of mucosal thickening

1:06

in the right frontal sinus, a little bit

1:09

also on the left side.

1:12

So this would be an example of

1:15

a patient who's got pretty bad

1:17

chronic sinusitis.

1:18

So this is a potential candidate

1:21

for endoscopic sinus surgery.

1:23

So what would I say in this case?

1:25

I would also note the presence of soft tissue

1:28

opacification of the right nasal cavity.

1:31

Here's the nares on the left side where you can

1:34

see the passage going in back to the pharynx.

1:37

On the right side, you have a soft tissue

1:40

mass that is pretty close to the anterior nares.

1:44

On the right side, this may be a polyp.

1:47

It could just be a very

1:49

thickened mucosa of a turbinate.

1:52

So let's look on the coronal image.

1:54

So in the coronal image, we're more impressed

1:57

with some polypoid change here that's

1:59

occurring in this right nasal cavity, extending

2:03

back to the posterior pharyngeal wall.

2:05

So this is coming back here,

2:09

kind of polypoid anteriorly.

2:13

Again, we have complete opacification

2:17

of the right nasal cavity.

2:20

At this point, I'm looking for any type

2:22

of expansion of the nasal cavity or the

2:25

airways that might suggest additional polyps.

2:28

So polyps usually have some mass effect.

2:31

In the description of this case, we're gonna say,

2:33

oh, yep, both maxillary sinus ostia are opacified.

2:36

The infundibulum's opacified.

2:37

The hiatus semilunaris is opacified.

2:40

The middle meatus is opacified.

2:42

The frontal recess bilaterally is opacified.

2:48

When we come to the sphenoid sinus, here's our

2:52

sphenoid sinus ostium — that’s opacified bilaterally.

2:56

All these are very important.

2:57

So I wanna point out the anatomic

3:00

structure that I had previously mentioned.

3:02

You see this little almost nipple here,

3:05

where it gets kind of triangulated

3:08

on the coronal image, this is the entry

3:12

point of that anterior ethmoid air cell.

3:15

I had mentioned previously that sometimes when

3:18

they're doing surgery in the anterior ethmoid

3:20

complex,

3:21

they could injure this area where the anterior

3:23

ethmoid artery enters the ethmoid air cell,

3:28

and if it gets injured, it retracts back into

3:31

the orbit and can lead to an orbital hematoma.

3:33

So this is a normal variant that you would

3:36

see here and here representing the anterior

3:39

ethmoid artery entry. More posteriorly,

3:42

you will see a smaller one.

3:44

Here's the little posterior one.

3:47

There it is.

3:48

This is for the posterior ethmoid artery, and

3:52

on the axial scans, let me see what I can

3:54

point this out, is right here, and here are

3:58

the posterior ethmoid artery entries. And

4:03

here is that same thing for

4:05

the anterior ethmoid air cells.

4:07

So there are these natural dehiscence

4:09

where the arteries come in for the

4:11

anterior and posterior ethmoid air cells.

4:14

So since I'm doing my review of a patient who has

4:17

chronic rhinosinusitis and could be a potential

4:20

candidate for endoscopic sinus surgery, I'm

4:23

gonna look along the walls of the optic nerves.

4:25

They look like they're intact.

4:27

I'm gonna look along the walls of

4:28

the sphenoid sinus and look at

4:30

see whether there's any dehiscence

4:32

along the carotid artery.

4:34

No such thing.

4:35

Here's our lamina papyracea, the medial orbital wall.

4:39

It's intact bilaterally.

4:40

We look at the cribriform plate. We don't see

4:43

any dehiscence along the cribriform plate

4:46

at this point.

4:46

Someone might be interested in the Keros

4:50

classification, so we would measure down here,

4:54

and it's five millimeters — Keros B — on the

4:58

left side. We'd measure on the right

5:00

side, and it's still, uh, Keros B. So,

5:04

we could do the Keros classification.

5:06

So this is a pretty typical report for the evaluation

5:12

of a patient with chronic rhinosinusitis.

5:15

We'll next look at the soft tissue windows and make sure

5:19

that we don't have any inflammation in the orbits.

5:21

We don't have any inflammation intracranially.

5:23

We don't have any inflammation down in the

5:26

soft tissues of the neck.

5:27

We don't have any periantral fat infiltration

5:30

and, uh, make the negative comments.

5:33

So my report here — and look how low density

5:37

this little polyp is coming back from the

5:39

right nasal cavity into the nasopharynx.

5:42

So, I would call this probably something

5:45

along the lines of chronic pansinusitis with

5:48

polypoid change within the right nasal cavity,

5:51

projecting into the right side of the nasopharynx,

5:55

crossing the midline in the nasopharyngeal airway.

5:58

No complications.