A COMPARATIVE EVALUATION BETWEEN CT SCAN PNS WTH NASAL ENDOSCOPY FINDINGS IN PATIENTS OF CHRONIC RHINOSINUSITIS.

Background : Chronic Rhinosinosinusitis (CRS) is one of the common diseases affecting people globally with significant negative impact on quality of life. The objective of this study is to compare the efficacy of CT and nasal endoscopy finding for the evaluation of CRS in patients with persistant complains despite appropriate medical therapy. Methods: Patients attending ENT OPD of SIMS, with any complains of CRS for more than 4 weeks not responding to medical treatment . Patients are selected by Random sampling method. Results : The commonest major presenting symptom among the patients was observed as nasal obstruction and headache the minor factor. Males were affected more commonly on nasal endoscopy , the most common finding was congested nasal mucosa and mucopurulent nasal discharge .Frontal cells most commonly seen on Ct scan and maxillary sinus was most commonly involved .DNS In of Deosthale N et al (2014) 16 , congested nasal mucosa (45.08%) and purulent middle meatus discharge (42.62%), edematous nasal mucosa (31.14%), non-purulent nasal discharge (25.40%), pale nasal mucosa and polyps (15.57%)

Diagnostic Nasal Endoscopy (DNE) enables clear visualization of all structures of the middle meatus and of the osteameatal complex and ability to accurately access these areas for evidence of localized disease, or for the anatomical defects that compromise ventilation and mucociliary clearance and also it avoids landmarks for complications to guide surgeon during surgery. Nasal Endoscopy is valuable in the work up of CRS in conjunction with detailed history 10 .
Computerized Tomography (CT) provides essential preoperative information for the assessment of patients undergoing functional endoscopic sinus surgery. It has high sensitivity and provides objective findings regarding the condition of the paranasal sinuses and the presence of fluid or polyps. Furthermore, CT findings are an integral part of several severity staging systems that are used for CRS. 3 Its advent in the delineation of the sinonasal pathology and anatomic variations has proveninvaluable to the Otolaryngologists in the preoperativeplanning but CT scan is not always accurate in depicting the disease and anatomical variants. These discrepancies though minor, need further evaluation and correlation of CT findings to that of findings observed during endoscopy. 11. The aim of the study was to compare the CT findings with the nasal endoscopy findings in patients with Chronic Rhinosinusitis, to study the incidence of different anatomical variation in nose & paranasal sinuses in patient of sinusitis by nasal endoscopy and CTscan,to study association between anatomical variations, to demonstrate the effectiveness and limitations of nasal endoscopy and CT scan in identifying variations in nose and paranasal sinus and to compare which is better investigation modality in diagnosis or if both are needed.

Material and methods:-
This is a prospective study carried out over a period of year from 2014 to 2016 at the department of ENT,Shadan institute of medical sciences , Hyderabad, Telangana.Total of 104 patients were included in this study who were exposed to direct nasal endoscopy and CT scanning of paranasal sinuses after they were diagnosed as chronic rhinosinusitis and were resistant to medical management.
Inclusion criteria: 1. Age >15years and <70years. 2. Patient diagnosed as per the criteria given by AAO-HNS Task force 1997 and willing to undergo endoscopic examination and CT scanning of paranasal sinuses.

Results and observation:
The present study includes 104 patients diagnosed as chronic rhinosinusitis as per the criteria given by AAO-HNS Task Force 1997 2 between the period of July 2014 to September 2016. Their clinical features, endoscopic and CT scan findings were studied in detail as per pretested proforma.     The presentation of chronic sinusitis was common in age group 21-30 years. This is the most active age group and comprises the most productive age group of society. In present study we found male preponderance in cases of chronic rhinosinusitis.However , studies conducted by AR Talaiepour et al (2005) 12 and Madani S et al (2013) 13 showed slight female preponderance of 51.7% and 51.4% respectively.In present study, the most common major factor seen in patients of chronic rhinosinusitis was nasal obstruction seen in 92 (88.46%) cases, followed by nasal discharge/post nasal drip in 84 (80.77%) cases. Least common presenting symptom was hyposmia or anosmia seen in 16 (15.38%) cases.
In minor factors, headache was the most common presenting factor seen in 74 (71.15%) cases, followed by fatigue in 34 (32.69%) cases and fever in 24 (22.08%) cases. Least common symptom among the minor factors was halitosis in 14 (13.46%) cases.
Nasal obstruction may be due to anatomical abnormalities such as deviated septum, nasal polyps and enlarged turbinates. An overactivity of the parasympathetic nerve supply as compared to the sympathetic nerve supply will cause dilatation of the vascular tree, and hence engorgement, leading to nasal obstruction.
Headache is also the most common presenting symptom reported by many studies. Headache can be attributed to mal-ventilation of sinuses leading to local hypoxia, reduced pH, reduced ciliary beat and thick viscous mucous and increased vulnerability to infection, thus leading to headache. Other factors include constant intense mucosal contact leading to facial pain and headache or pressure from proliferating polyps.  15 studied 45 patients of chronic rhinosinusitis and reported most common presenting symptom as headache (90%) followed by nasal discharge (80%).Gautam P et al (2014) 20 studied 50 patients. 84% of patients had both headache and nasal obstruction, which were the most common minor and major symptoms respectively. 70% had nasal discharge; postnasal discharge was seen in 44% and sneezing in 30%. In the study conducted by Deosthale N et al 16  It is stated in literature that straight septum is an exception rather than a rule. Nasal septum deviation is highly accounted disease in population.
Gautam P et al 20

Anatomical variations detected on CT imaging -
CT scan is considered as gold standard for identifying bony anatomical variations. Various authors had shown incidence of anatomical variations on CT scan in patients of chronic rhinosinusitis and its correlation with present study. 1187

Agger nasi cells -
The preoperative knowledge of presence of accessory ostium on CT scan will prevent a common pitfall in surgery of not connecting it to the natural ostium which may lead to recurrent sinusitis because of recirculation of mucous leading to recurrence.

Septal variations -
In present study most common septal variation was septal deviation seen in 88 (84.62%) cases. It was more common on left side 52 (50%) cases. Septal deviation with spur was seen in 24 (23.08%) cases on left side and 16 (15.38%) cases on right side. The incidence of septal deviation ranges from 40% (Calhoun et al) 23 to 96.6% (Takanishi et al) 31 .
The prevalence of septal spur is reported as 33% by Danese et al 32 15 also reported superior attachment of uncinate process, most commonly to lamina papyracea (70% on right side and 66% on left side), followed by the middle turbinate (24% on right and 31% on left side)

Frontal cells
In present study frontal cell type I was most commonly seen in 16 (15.38%) cases, followed by frontal cell type II 08 (7.69%). Frontal cell type III was seen in 04 (3.85%) and type IV in only 02(1.92%) cases.

Severity of septal deviation -
In present study we have classified septal deviation depending upon the severity angle of deviation as mild, moderate and severe as described by Jin HR et al 37 .
Septal deviation and its relation to concha bullosa -In present study, we found septal deviation and concha bullosa related to each other in its appearance. Presence of septal deviation to one side was related to concha bullosa on opposite side.

Correlation of nasal endoscopy and CT imaging findings -
In the present study of 104 cases, nasal endoscopy has good sensitivity for hypertrophied middle turbinate/concha bullosa (CB) and septal deviation (SD). Sensitivity of nasal endoscopy is low for large ethmoidal bulla (EB) and accessory ostium (AO). In our study, all parameters were statistically significant (p<0.05) except pneumatized uncinate process that is only seen on CT scan. Thus, there is a correlation between nasal endoscopic findings and CT scan findings. In another study by Bhattacharyya N 43 it was concluded that combined with a symptom history, endoscopy can be a highly specific technique for predicting positive CT findings of chronic rhinosinusitis. Rosbe 10 in his study, came to the conclusion that nasal ensoscopy was moderately sensitive and highly specific in predicting results of CT Scanning.
Arun Kumar Patel et al (2015) 44 concluded that in patients with CRS symptoms (AAO-HNS) nasal endoscopy has high specificity in identifying CRS but doesnot rule it out which as compared to CT scan has high sensitivity. Out of 90 patients studied ,49 (54.44%) were with positive CT findings and 41 (45.55%) with negative CT findings. 33 (36.66%) patients had positive endoscopic findings and 57 (63.3%) with negative endoscopic results. Out of 33 (36.66%) positive endoscopic findings patients, 23 (25.55%) were CT positive and 10 (11.11%) were with CT negative findings.
Thus, there is a correlation between nasal endoscopy and CT scan findings in CRS patients i.e. most of the endoscopic positive findings were having CT positive findings also. Therfore CT scan is much useful to confirm the CRS prior to any surgical intervention and with the use of high specificity of DNE and high sensitivity of CT Scan PNS , patients with CRS symptoms can be selected for surgical intervention.

Limitations of the Study:
However there are certain limitations of nasal endoscopy which includes inability to look for disease in patients with deviated nasal septum, constricted middle meatus and presence of hidden air spaces like sphenoid sinus, ethmoid bulla and posterior ethmoids where it is impossible to pass on the scope beyond a certain point. Also , extent of the disease , posterior anatomical variations and density of each sinus is very well recognized in CT scan PNS which is important in evaluation and surgical planning for CRS.

Conclusion:-
In present study , we found , Chronic Rhinosinusitis can be reliably identified using the AAO-HNS Task force criteria 1997.Diseased oedematous or congestion of nasal mucosa , pathological secretion , purulence or mucous in middle meatus mucosa middle meatus have non-specific features on coronal CT and nasal endoscopy has essential role in accurately diagnosing this pathology as well as anterior anatomical variations. Also , DNE is better diagnostic to detect early polypoidal changes in mucosa which are otherwise missed on CT PNS. it is an outpatient procedure, relatively economic, with no radiation hazards. Thus , by performing DNE prior to CT , can aid in early diagnosis and medical management of CRS as it is easily available , is an outpatient procedure , relatively economic and can spare patient from unnecessary cost and radiation exposure .Hence we conclude that nasal endoscopy and