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Orlandi et al.

TABLE XII-29 Anatomic relationships to consider during sinus surgery Anatomic Findings Description

Importance

Inadvertent injury to the skull base is more likely to occur if the maxillary to ethmoid vertical height ratio is greater than 1:1. Risk for intracranial injury is positively correlated with higher Keros classification. It is critical to note for any asymmetry of the skull base or areas of bony dehiscence. Arteries suspended below the skull base are more susceptible to injury during sinus surgery. Damage to the artery can result in hemorrhage, CSF leak, or orbital hematoma. The sphenoid sinus is helpful in identifying the anterior skull base.There is an increase risk of optic nerve injury if an Onodi cell is

Maxillary-to-Ethmoid Ratio

Ratio of the maxillary sinus height to the posterior ethmoid height (just posterior to the basal lamella) in the coronal plane The length of the lateral cribriform lamella relative to the fovea ethmoidalis

Height of the lateral lamella (Keros Classification)

–Keros I: 1-3 mm –Keros II: 3-7 mm –Keros III: 8-16 mm

Ethmoidal Arteries

Determine if the location of the anterior and posterior ethmoid arteries are traversing through the skull base or suspended below Classify the pneumatization pattern of the sphenoid sinus (conchal, presellar, sellar).Identify the presence or absence of: –Onodi cell –Intersinus septation inserting onto carotid canal –Dehiscence over the carotid canal or optic nerve

Sphenoid Sinus Pneumatization/Onodi Cell

present or there is bony dehiscent present.Risk of carotid artery injury increases if there is an insertion of a intersinus septation or overlying bony dehiscence.

Inadvertent injury to the skull base is more likely in the presence of an asymmetric skull base or areas of bony dehiscence. Similarly, injury to the orbit, carotid artery, and optic nerve is increased with areas of bony dehiscence/abnormalities.

Skull base asymmetry/bony dehiscence Evaluate for any areas of asymmetry (height and thickness) within the skull base. Examine the continuity of the bone overlying the lamina papyracea, carotid canal, and optic nerve

were queried from 2007 to 2013. There was a 44.4% reduc tion in pediatric ARS cases (1,025 to 569 ARS diagnoses per 10,000 inhabitants) during the study period. 2295 Pediatric ARS is a common diagnosis, but the interpreta tion of data regarding incidence and prevalence is limited by heterogeneity of individual studies’ diagnostic criteria, methodology, and study population. XIII.A.2 Pediatric ARS: Contributing Factors Conditions that can contribute to ARS include allergic (AR) and non-allergic rhinitis (NAR), coexisting medi cal conditions (CF, immune deficiency, ciliary dyskine sia), and environmental factors (smoking, daycare). 2296,2297 Influenza in 5-14 year old at risk children (chronic car diovascular disease, bronchitis, asthma, diabetes mellitus and malignancy) increases the occurrence of ARS (Tables XIII-1 and XIII-2). 2298 Chronic conditions such as CF, immune deficiency, and ciliary dyskinesia are more likely to be associated with CRS. Allergic Rhinitis. There are scant data on the correla tion of AR and ARS in children. In a retrospective study

of 92 patients with RARS, children with positive skin tests to common inhalant allergens sustained 1.09 more sinus infections than non-allergic patients, a significant difference. 2299 In another study of children with ARS and CRS, there were statistically significantly more patients with a clinical history of AR in the CRS group (90.2%) vs the ARS group (74.8%). 223 The percentage of positive skin prick test results was similar in both groups (96.4% in ARS and 96.9% in CRS). In a prospective study evalu ating the incidence of ARS in allergic children during the grass pollen season, Leo et al. enrolled 242 children with grass pollen allergic rhinitis (mean age = 13.2 years) and 65 children with no allergies (average age = 12.3 years). 357 Symptom diaries and drug use were monitored and ARS was confirmed by nasal endoscopy. Seventeen out of 242 allergic children (7%) had confirmed ARS compared to 3 out of 65 (4.6%) in the control group. The difference was not significant suggesting the lack of importance of grass allergy in the occurrence of ARS. Lin and colleagues used a population-based retrospective cohort study design to analyze data based on the Longitudinal Health Insur ance Database in Taiwan in children aged 5-18 years. 351 The intent of the study was to investigate whether allergic rhinitis was associated with an increased incidence of ARS,