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"Uncinate- 4 - Copy - Copy.docx"

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The study of variations in
Plagiarism detected: 6.31% https://www.ncbi.nlm.nih.gov/pmc/ar... + 5 more resources! id: 1
anatomy of uncinate process and its correlation with frontal sinusitis in Government medical college and
superfacility hospital,Azamgarh,UP.

Abstract- Anatomical variations of uncinate process have significant role in causation of frontal sinusitis. The
aim of this study was to evaluate the types of attachments of uncinate process and its implication in
development of frontal sinusitis. Variations in anatomy of uncinate process alters the anatomy of frontal
recess and ethmoidal infundibulum leading to alteration in frontal sinus drainage. A prospective CT SCAN
study of 50 patients with chronic sinusitis was done. The result was tabulated and analysed using statistical
study of 50 patients with chronic sinusitis was done. The result was tabulated and analysed using statistical
package of social science 16.0. Type 1 superior attachement of uncinate process was most common variety
found. A statistically significant association between type 1 uncinate process and frontal sinusitis was found
(p less than 0.05)

Keywords- Uncinate process, frontal sinusitis

, anatomical variations ,lamina pappyracea, ethmoid, middle turbinate.

Introduction –In the anterior ethmoidal complex, there are different anatomical variants isolated or associated.
Most of the anatomical variants involved middle turbinate, nasal septum deviation, pneumatization of Agger
nassi cells and ethmoid bulla, presence of Haller’cells and
Plagiarism detected: 0.3% http://otolaryngology.wdfiles.com/l... + 2 more resources! id: 2
anomalies of the uncinate process. Uncinate proces
s is a thin bony leaflet sagitally oriented which runs in sickle shaped
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curve from anterosuperior to posteroinferior. It has the appearance of a soft bony blade that belongs to
ethmoid and merges with the ethmoid process of the inferior nasal turb
inate (1) .The uncinate process lies parellel to anterior surfa ce of bulla, normally it is inserted inferiorly in the
posteromedial portion of agger nassi cells(2,3) when it is inserts itself into another structures, it can lead to
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obstruction. The uncinate process is an upper extension of the lateral wall of nasal fossae . Advanced
anatomy of uncinate process -Uncinate process actually forms the first layer or lamella of middle meatus .
This is the most stable landmark in the lateral nasal wall. It is a wing or boomerang shaped piece of bone. It
attaches anteriorly to the posterior edge of lacrimal bone,and inferiorly to the superior edge of inferior
turbinate (4)

The anatomical variations of uncinate process were defined as following by Stammberger and Bolger .( 5)

Superior attachment of uncinate process is highly variable. The uncinate process can be classified into three
types depe
nding upon its superior attachment .

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A-type I uncinate:-Here the uncinate process bend s laterally in its uppermost portion and insert into lamina
pappyracea, here the ethmoidal infundibulum is closed superiorly by a blind pouch called the recessus
terminalis(terminal recess). In this variation ethmoidal infundibulum and frontal recess are separated from
each other, therefore frontal recess open into middle meatus medial to the ethmoidal infundibulum.

Type-I

B–type II uncinate:-Here the uncinate process extend superiorly to the roof of the ethmoid. The frontal sinus
open directly into the ethmoidal infundibulum. In these cases if dise
ase is present in frontal recess, it may involve the ethmoidal i nfundibulum and maxillary sinus

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C-Type III uncinate process :- Here the superior end of uncinate process turn medially to get attached to
middle turbinate , therefore frontal sinus drain directly into the ethmoidal infundibulum.

Sometimes the superior end of the uncinate process may get divided into the three branches, one branch
attached to roof of ethmoid ,one getting attached to the lamina pappyracea and the last branch attached to
the middle turbinate. Rarely the uncinate process may be highly pneumatised causing obstruction to the infun
dibulum.

2. Medially bent uncinate process.

 Plagiarism detected: 0.35% https://www.ncbi.nlm.nih.gov/pmc/ar... id: 7
3. Laterally bent uncinate process

4.Hypertrophi
ed uncinate process

In a study conducted on 800 cases,Earwaker( 6, 7 )provide a detailed description of the

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variants of superior insertion of uncinat
e process , by classifying them in association with other variants of osteomeatal complex ( ethmoid bulla,
middle turbinate, septal deviation, degree of
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angulation of uncinate process). When the uncinate process is
inserted into pappyracea lamina, maxillary sinus drainage may be affected.(6,8 )

Approach to frontal recess requires uncinectomy for the treatment of frontal sinusitis. Anatomy of uncinate
process and its superior attachment and its variations are of very much significance in surgery of frontal recess.

Material and method---

This prospective and retrospective study was carried out in department of otorhinolaryngology and anatomy of
GMC Azamgarh,UP from November 2013 to November
Plagiarism detected: 0.57% https://link.springer.com/article/1... id: 10
2015. A prospective CT scan study was done on 50 patients of chron
ic rhinosinusitis. CT scan of sinuses were done in coronal and axial view.

Patients with symptoms of nasal congestion, nasal discharge, headache, facial pain and hyposmia, who were
not responding to 3 weeks of medical treatment were evaluated with CT scan paranasal sinuses in coronal
view and axial view.

Patients with history of previous sinus surgery were excluded from this study. The data are entry in Cs-Pro
software and after that its transfer in SPSS data. Statistical analysis was
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done using CHI square statistical test with statistical programme for social science version 16.0. A P value
0.05 was considered statistically significant.

Observation-----The present study was carried out in department of otorhinolaryngology , government medical
college , Azamgarh ,on 50 patients (100 sides) of chronic sinusitis were included.

Table No- 1 – Sex Distribution

SEX

PERCENTAGE %

Male

Female

48

52

Table No- 2 – Age Distribution

Age Group

Percentage%

0-20

20-30

31-40
31-40

40

18

24

44

14

Table No- 3- Distribution of patient on the basis of different type of bent.

Variation

Percentage

Medial Bent

Lateral Bent

Hypertrophied

Pneumatised

20

04

08

08

Table No- 4 distribution on

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the basis of superior attachment.

Type of superior attachment

P
ercentage

Type 1 attached to lamina papracea

Type 2 attached to Skull base

Type 3 attached to middle turbinate

Type 4 uncinate lying free

40
32

18

10

Figure No- 1- Type 1 uncinate process atta ched to lamina paparacea. Type3 uncinate Process attached to
middle turbinate.

Figure No -2 Type 2 uncinate process attached to skull base. Type 4 uncinate process lying free .

Fi gure no-1 Above figure shows that 52.00 percent patients are female category and remaining 48.00 percent
of patient male category. Present study carries out in rural area in government medical college & super facility
hospital Azamgarh. Result shows that no major variation in data on the basis of gender in this area.

Figure No- 2 Above data distribution on basis of age group shows that majority of patient was in age group 31-
40 years.14.00 percent patient belonging to above 40 years and 18.00 percent belonging to age less than
equal to twenty years.

Figure No- 3 Present study shows that medially bent patient was most common in uncinate process seen in
maximum 20 (20.00%) case in total of 100 sides. only 4 cases find laterally bent out of 100 ,8.00(8.00 percent)
cases hypertrophied & similarly in Pneumatized.

Figure No- 4 Distribution of patient on the basis of

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superior attachment of unicinat
e process.

In this
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study 52% patients were female and 48% patients w
ere male. Majority of patients,44% were in age group of 31-40 years. 14% patients belonged to the age above
4 0 years,18% belonged to age less than 20 years and 24% patients were in age group of 20 to 30 years.
Present study shows that medially bent uncinate was most common(20%),in 4% cases uncinate was found
laterally bent and in 8% cases hypertrophied uncinate was found. Pneumatised uncinate was found in 8%
cases in this study. Out of 100 uncinate process ,type 1 superior attachment was found in 40%patients, type 2
in 32% patients, type 3 in 18% patients and type 4 in 10% patients. Type 1 superior attachment was most
common. Few studies had
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 described deviation of uncinate process either me
dially or laterally leading
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to narrowing of the infundibulum, frontal and anterior ethmoidal recess producing impaired sinus ventilation in
maxillary, frontal and ethmoida
l sinuses(9, 10,11,12),contradicting claims by some studies that deviations of uncinate process prevents
contaminated air entering the sinuses(13,14.15).

Discussion-Stammberger and Wolf (1988) 16 has documented the preeminent role of osteomeatal complex in
causation of chronic rhinosinusitis. Computerised tomographic imaging of oseomeatal complex is of paramount
importance in surgery of sinuses. Variations in anatomy of oseteomeatal complex are numerous and there
detection before surgery is very much significant to avoid complications. Endoscopic examination of nose in
conjunction with CT scan paranasal sinuses is the gold standard for the treatment of chronic rhinosinusitis
nowadays. CT scan of paranasal sinuses accurately detects the bony and soft tissue anatomy of sinuses and
there variations .This study was conducted on 50 patients of chronic rhinosinunusitis,in
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which 52% patients were female and 48% m
ale. Majority of patients were in age group of 31 to 40 years (44%) .

Uncinate process variations.

Uncinate process shows an arc shaped course ,therefore in anterior coronal sections the uncinate is wide. In
middle third ,uncinate lies adjacent to nasolacrimal duct, Posteriorly, it is narrow. Free edge of uncinate process
may deviate medially. Laterally or anteriorly(16).Medially bent uncinate process is the most frequent
pathological finding in chronic rhinosinusitis patients(Stammberger and wolf 16). Medially bent uncinate comes
in contact with middle turbinate, leading to impaired drainage of paranasal sinuses. In our study ,
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we observed medially bent uncinate process in 20 %cases. Laterally bent uncinate process was seen in
4%cases.Hypertrophied uncinate process was seen in
8% cases and pneumatised uncinate in 8% cases. Zinreich (17) noted
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pneumatisation of uncinate process in
one patient (0.4%) among 230 patients of chronic rhinosinusitis . Pneumatised uncinate can also be referred to
as uncinate bulla. Pneumatisation can also impair the sinus
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drainage.

Variations of uncinate process were found in 40% cases in our series. This was similar to that of of 30%
reported by Tuli et al (18) and lower than that of 45% reported by Wana maker(19) but it was lesser than
65% reported by Mamatha et al(20).The most commonly seen superior attachment in our series was type 1
uncinate process in 40% cases as compared to 79.8% cases reported by Tuli et al(18).This was higher than
reported by Krzeski et al (17.83%)(21).Type 2 uncinate process was second most common seen in 32%
cases, and type 3 was seen in 18% cases .This is similar to that reported by krzeski et al of type 2 being
33.12% and lower than that reported by Min et al (22)of t
ype 3 being 21.5%.

Study

Our study (%)

Tuli et al. (%)

Krzeski et al (%)

Min et al. (%)

Landsberg and Friedman

Type I

40%

79.8

17.83

54

52%
52%

Type II

32%

14

33.12

24.5

Type III

18%

14.33

21.5

A study of Landsberg and Freidman(23)had

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classified the superior attachment of uncinate
process as follows:

Type1 : Insertion of lamina pappyracea (LP)

Type2 : Insertion into posterior wall of Agger nassi cell(ANP)

Type 3:Insertion into lamina pappyracea and junction of middle turbinate with cribriform plate(MTCP)

Type 4: Insertion into junction of middle turbinate with the cribriform plate

Type 5: Insertion into the ethmoid skull base (ESB)

Type 6: insertion into middle turbinate.

Conclusion—Almost
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all chronic sinusitis are associated with anatomical variations
that alter ventilation. So the preoperative evaluation of variation of uncinate process and its pneumatization
helps to avoid intraoperative damage to surrounding structures that alter normal ventilation . From this study
we concluded that chronic rhinosinusitisis associated with variations in uncinate process .In our study it was
found
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that superior attachment of uncinate process
to lamina paparacea Type 1 was most common finding that alters the drainage resulting in frontal sinusitis.
Medially bent uncinate process variation was also most common finding. CT scan study is essential before
undergoing for functional endscopic sinus surgery. It provides a precious information regarding variations in
uncinate process anatomy, which is helpful in removal of complete disease as well as preventing complications
during surgery.

Funding -This study was funded by Government medical college ,Azamgarh.

Conflict of interest -Author A and B declared that

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they have no conflict of interest.

Ethical approval - Article does not contain any study with human or animal

pa
rticipants.

Informed consent-Informed consent was obtained from all the individuals who participated in this study.
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