ORIGINAL ARTICLE
Variations of lamina papyracea position from the endoscopic view:
a retrospective computed tomography analysis
Islam R. Herzallah, MD1,2 , Osama A. Marglani, MD, FRCSC2,3 and Ahmed M. Shaikh, MS, DNB2
Background: Accidental injury of lamina papyracea (LP) re-
mains one of the most common complications reported in
endoscopic sinus surgery (ESS) even in most recent studies.
The purpose of this study was to categorize the LP position
radiologically and from an endoscopic perspective.
Methods: A total of 207 computed tomography (CT) scans
(414 sides) including both diseased and control groups were
retrospectively reviewed by 2 examiners. Inferior turbinate
aachment to the lateral nasal wall and the inferior mar-
gin of the planned middle meatal antrostomy (MMA) were
identified anteriorly. Position of LP in relation to the verti-
cal line passing through MMA inferior margin was reported.
LP was categorized to lie either within 2 mm on either side
of the MMA inferior margin (type I), more than 2 mm me-
dial to the MMA line (type IIa: 2 to 4 mm; type IIb: >4 mm),
or more than 2 mm lateral to the MMA line (type IIIa: 2 to
4 mm; type IIIb: >4 mm).
Results: Of the 221 sides in the control group, 69.7% were
classified as type I, 24.9% as type II, and 5.5% as type III.
Among the 193 diseased operated sides examined, 60.1%
E ndoscopic sinus surgery (ESS) has been used for
almost 3 decades in the treatment of medically resis-
tant chronic rhinosinusitis.1–4 Like any surgical procedure,
there is a learning curve in order to consistently perform
safe and efficient surgery.5–7
Outcomes of ESS have improved due to technologic
advances and improved surgical training.8 Despite these
1 Department of Otolaryngology–Head and Neck Surgery, Faculty of
Medicine, Zagazig University, Egypt; 2 Ear, Nose, and Throat (ENT)
Department, King Abdullah Medical City (KAMC), Makkah, Saudi
Arabia; 3 Department of Otolaryngology–Head and Neck Surgery,
Umm Al-Qura University, Makkah, Saudi Arabia
Correspondence to: Islam R. Herzallah, MD, Department of Otolaryngology
Head and Neck Surgery, Faculty of Medicine, Zagazig University, Egypt;
e-mail: iherzallah@gmail.com
Potential conflict of interest: None provided.
Received: 23 July 2014; Revised: 1 October 2014; Accepted: 7 October 2014
DOI: 10.1002/alr.21450
View this article online at wileyonlinelibrary.com.
263 International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
were classified as type I, 20.2% as type II, and 13.5% as type
III. Weighted kappa coefficient showed good interexaminer
reliability. Five sides (2.6%) in the case group had acciden-
tal LP penetration intraoperatively, 4 of them were type II
and type III LP.
Conclusion: This study improves surgeons’ awareness of LP
variations in the endoscopic field and can be of help for res-
idents in training. 
C 2014 ARS-AAOA, LLC.
Key Words:
radiologic classification; anatomical types; maxillary hy-
poplasia; prevention of sinus surgery complications; orbit
complication; allergic fungal sinusitis; chronic rhinosinusi-
tis with nasal polyps; medial orbital wall injury; paranasal
sinuses anatomy; residual ethmoid cells
How to Cite this Article:
Herzallah IR, Marglani OA, Shaikh AM. Variations of lam-
ina papyracea position from the endoscopic view: a ret-
rospective computed tomography analysis. Int Forum Al-
lergy Rhinol. 2015;5:263–270.
developments, complications can and do still occur.9–14
With important anatomical structures surrounding
paranasal sinuses, the likelihood of violating related areas is
always present. Risk of complications has been associated
with surgeon’s experience, extent of sinonasal disease, in-
traoperative visualization, history of previous surgery, and
presence of anatomical variations.15
Ocular complications of ESS have been reported for many
years owing to the close anatomical relationship between
paranasal sinuses and the orbit. Accidental penetration
of the lamina papyracea (LP) together with periorbita or
orbital fat exposure during ESS were reported in up to
5% of polyposis cases in a systematic review published
about a decade ago.16 More recently, LP injury continued
to be the most frequent complication in a large prospec-
tive multicenter study on patients undergoing ESS.12
Inadvertent penetration of the LP commonly occurs in the
anterior part during uncinectomy, while performing middle
meatal antrostomy (MMA), or during removal of the bulla
Herzallah et al.
ethmoidalis.17, 18 Consequences related to violation of the
medial orbital wall include periorbital ecchymosis or em-
physema, venous orbital hematoma, medial rectus injury,
and blindness.19, 20 On the other hand, residual unopened
ethmoid cells at the LP is a common finding in patients
requiring revision ESS even in most recent studies.21, 22
Detailed knowledge of the radiological and endoscopic
sinonasal anatomy is a key to safe and effective ESS. In fact,
avoiding complications begins with preoperative prepara-
tion. A precise review of the anatomic situation and pos-
sible variations by computer tomography (CT) should be
performed. In surgery, the key to preventing orbital injury
is identifying the LP, which is located just superior to the
maxillary antrostomy.23, 24 Similarly, efficient clearance of
ethmoid air cells also requires proper identification of the
LP.
Known conditions that specifically increase the risk of
orbital injury include thinning or dehiscence of the LP and
hypoplastic maxillary sinus. The latter condition increases
the risk of orbital entry because the uncinate process is
plastered against the LP.13, 25–29 Even in the absence of
maxillary sinus hypoplasia, proper orientation to the LP
position can help avoiding its injury as well as more ef-
ficient clearance of ethmoid air cells. No previous studies
had focused on thorough analysis of the LP location in the
surgical trajectory relevant to other anatomical structures
in nonhypoplastic cases. Therefore, we have conducted this
work to evaluate and radiologically categorize different LP
positions in relation to nearby landmarks while taking in
account the endoscopic perspective. This information can
be of great help in preoperative evaluation and operative
training, and can also provide a base for future studies to
confirm LP positions associated with higher risk of injury
or residual disease.
Materials and methods
Study design
This study was set in the ENT Department, King Abdul-
lah Medical City (KAMC), a Tertiary/Quaternary Care
Hospital.
We have conducted a retrospective analysis of paranasal
sinus (PNS) CT scans that were obtained for adult patients
as part of evaluation of their sinonasal or anatomically re-
lated disorders at our institution. The study included 207
PNS CT scans performed between January 2012 and Febru-
ary 2014. Reviewed CT scans sides were grouped either to
have sinus pathology requiring ESS and involving ethmoid,
maxillary, and/or frontal sinuses (diseased or case group) or
to be with clear anterior group of sinuses (control group).
In addition to demographic data, retrospective review of
medical files in the patient group included details about
any orbital complications of ESS (eg, accidental injury of
LP with exposure of periorbita or orbital fat, periorbital ec-
chymosis, orbital hematoma, medial rectus, or optic nerve
injury).
FIGURE 1. Identification of the inferior turbinate attachment to lateral nasal
wall and the lower limit of the planned MMA (white arrow), at the coronal
plane of the maxillary ostium. MMA = middle meatal antrostomy.
Exclusion criteria were the presence of sinonasal neo-
plasms, invasive fungal sinusitis, or craniofacial abnormal-
ities. Revision sinus cases were not excluded because one
of our objectives was to determine the applicability of LP
localization in these cases using the method described in the
CT examination and analysis section. The retrospective re-
view was approved by the Institutional Review Board (IRB)
before commencement of the study.
CT examination and analysis
All PNS CT scans reviewed at our institution were per-
formed using Siemens Somatom Definition Scanner, Syngo
CT 2012B, 64-slice (Siemens Healthcare, Forchheim, Ger-
many). CTs were obtained at 3-mm section thickness and
interval, 120 to 320 mA, 120 kV, 1-second rotation time,
and about 16-cm to 18-cm field of view.
The coronal plane identifying the maxillary ostium was
selected. Here, the inferior turbinate attaches to the lateral
nasal wall (medial wall of maxillary sinus) forming the
lower limit of the planned middle meatal antrostomy
(MMA) (Fig. 1). MMA inferior margin is frequently
identified early in the endoscopic procedure and the line
passing through this margin was termed the MMA line
(Figs. 1 and 2). The uncinate process may be also identified
attaching to the upper border of the inferior turbinate at
this line.
The LP position was examined in relation to the MMA
line in the relevant coronal image. The relationship of the
LP to the MMA line was analyzed and classified as in
Table 1 and Figure 2. Because the LP obtains some convex
contour, the distance from the line to the lamina was
obtained to the midpoint of the LP. The anteroposterior
plane of the maxillary ostium was fixed in all examinations
and this coronal plane can be easily identified even in cases
with nasal polyps approximately 1 to 2 cuts (ie, 3 to 6 mm)
behind the posterior edge of frontal process of maxilla.
Determination of LP positions and taking distances were
performed on IMPAX v6.5.1 software (AGFA Healthcare
International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015 264
Variations of lamina papyracea position
FIGURE 2. Classification of the lamina papyracea based on its relation-
ship to the vertical plane of the lower margin of the planned MMA (white
continuous line), as detailed in Table 1. MMA = middle meatal antrostomy.
TABLE 1. Description of the proposed types of LP based
on CT analysis of its location
LP type Description
Type I LP lies within 2 mm on either side of the vertical plane of
inferior margin of the planned MMA
Type II LP lies medial to MMA line by more 2 mm:
r IIa: 2–4 mm;
r IIb: >4mm
Type III LP lies lateral to the MMA line by more 2 mm:
r IIIa: 2–4 mm;
r IIIb: >4 mm
CT = computed tomography; LP = lamina papyracea; MMA = middle meatal
antrostomy.
N.V., Mortsel, Belgium). All measurements were carried
out by 2 independent observers and the results were re-
ported for further testing of the interexaminer reliability.
All sides were examined for signs of hypoplastic maxil-
lary sinus. The latter was defined when the lower margin
of the maxillary sinus was not exceeding nasal floor,30 or
when the maximum horizontal or vertical diameter of the
maxillary sinus was less than one-half the maximum orbital
diameter on the same side.28 When the MMA line was dif-
ficult to identify due to previous inferior turbinectomy or
because of an extensive disease, the side was marked as
non-applicable (NA).
Statistical analysis
Statistical analyses were performed using IBM SPSS 22.0
for Windows (IBM Corp., Armonk, NY). For appropriate
analysis, measurement to a medially located LP was given
a positive mark, whereas a distance to a laterally located
lamina was given a −1, with a value of 0 being the LP
at the MMA line. LP type was determined according to
each examiner’s results and the final prevalence of each LP
265 International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
type was reported based on the average measurements from
both examiners. Measurements and LP types of both study
groups as well as of right and left sides were compared. The
significance level was set at p < 0.05.
Interrater reliability of the LP classification by each ex-
aminer was analyzed using weighted kappa coefficients
on Analyse-it Version 3.76.1 for Microsoft Excel 2010
(Analyse-it Software Ltd., Leeds, UK). The weighted kappa
takes in consideration the sequential order (ie, ordinal
value) of different LP categories (from medial to lat-
eral; type IIb, type IIa, type I, type IIIa, and type IIIb)
(Fig. 2).
Results
A total of 414 sides (207 PNS CT scans) were retrospec-
tively analyzed in this study. The diseased or case group
included 193 sides with different sinus pathologies: Bilat-
eral nasal polyposis (86 sides), allergic fungal rhinosinusitis
(AFRS) (69 sides), chronic rhinosinusitis (CRS) (35 sides),
and antrochoanal polyp (ACP) (3 sides). Sixty sides (31%)
in this group were previously operated. Unilateral pathol-
ogy was observed in 19 of the studied CT scans, the normal
sides of which were included in the control group.
The control group with clear anterior group of sinuses
(221 sides) was composed of cases that had undergone
PNS CT scans for purposes such as headache workup, pre-
operative assessment for dacryocystorhinostomy, pituitary
adenomas, or cases with isolated sphenoid sinus disease.
Additionally, normal sides in cases with unilateral sinus
pathology (19 cases) were included in this group.
The mean ± standard deviation (SD) age of patients
whose CT scans were examined was 37 ± 13.7 years and
38.3 ± 15.6 years in the diseased and control groups,
respectively, with no significant difference among both
groups (p > 0.05) (range, 18 to 70 years in the case group;
range, 18 to 88 years in the control group). Overall, 58.5%
of patients were males and 41.5% were females, again with
no significant difference in sex distribution among both
study groups.
Of the 221 sides in the normal group, 154 sides (69.7%)
were classified as type I, 55 (24.9%) as type II a or b,
and 12 (5.4%) as type III a or b. Examples of different LP
types in normal CT scans are presented in Figures 3 and
4B. The location of LP ranged from 5.2 mm medial to the
MMA line, up to 4.05 mm lateral to the MMA line, with
a mean of 0.76 mm medial to the MMA line and an SD
of 1.6 mm. Both examiners reported the same LP type in
81.9% of the sides. Weighted kappa coefficient was 0.69 at
a p value < 0.001, implying good interexaminer reliability
with statistical significance.
Three sides (1.3%) in the control group were diagnosed
as maxillary sinus hypoplasia, all of them had type II LP (2
type IIa, and 1 type IIb). The remaining type II LP sides (52
sides) were nonhypoplastic.
In the case group, the location of LP ranged from
6.85 mm medial to the MMA line to 8.25 mm lateral to it,
Herzallah et al.

(9 sides) or due to previous inferior turbinectomy (3 sides).

FIGURE 3. Bilateral Type I lamina papyracea.
with a mean of 0.27 mm medial to the MMA line and an SD
of 2.3 mm. Among the 193 diseased sides examined, 116
(60.1%) were classified as type I, 39 (20.2%) as type II a or
b, and 26 (13.5%) as type III a or b. Examples of different
LP types in diseased cases are presented in Figures 4A and
5, and the prevalence of each category is shown in Figure 6.
In 12 sides (6.2%), examiners were unable to define LP type
due to extensive pathology obscuring the inferior turbinate
Both examiners reported the same LP type in 86.1% of the
classifiable 181 sides. The weighted kappa coefficient was
0.78 at a p value < 0.001, implying good interexaminer
reliability with statistical significance. Comparing case and
control groups, the difference in agreement of both examin-
ers on the same classification was statistically insignificant
(p = 0.24).
Five sides (2.5%) in the case group were diagnosed as
maxillary sinus hypoplasia, 4 of them had type IIa LP, and
1 was of type IIb (Fig. 7), while all the remaining type II LP
sides (34 sides) were nonhypoplastic. Out of the 69 sides
with AFRS, 19 sides (27.5%) were classified as type III.
Detailed prevalence of each LP type in different diagnoses is
presented in Table 2. Dehiscent LP was identified in 12 sides
(6.2%) of the diseased group, 8 sides of which belonged to
type III category.
The difference in the mean of measurements (distances)
between case and control groups was statistically significant
(0.27 mm vs 0.76 mm medial to MMA line; p = 0.013).
When comparing the prevalence of different LP types, the
frequency of type III LP in diseased group was found to
be significantly higher compared with the control group
(13.5% vs 5.4%; p = 0.002). In both study groups, there

FIGURE 4. (A) An example for type IIa lamina papyracea. (B) An example for type IIb lamina papyracea. In both examples, the maxillary sinus is not hypoplastic.

FIGURE 5. (A) One example for type IIIa lamina papyracea that may be due to hyper-pneumatization. (B) An example for type IIIb lamina papyracea with
dehiscence due to the expansile nature of allergic fungal rhinosinusitis.

International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015 266
Variations of lamina papyracea position

was no statistically significant difference in measurements

FIGURE 6. Prevalence of LP types among both diseased and control sides
based on average measurements of 2 examiners. Due to the lateralization
of LP in allergic fungal rhinosinusitis cases, the frequency of type III LP in
diseased group was found to be significantly higher compared with the
control group (13.5% vs 5.4%; p = 0.002). Therefore, an adjusted grading
system for AFRS cases is suggested with 3 mm (and 6 mm) cutoff points
to categorize types III a (and b), respectively. Percentages in the diseased
group based on this adjusted classification would be: 6.2% for type IIIa 3.1%
for type IIIb and 64.2% for type I. LP = lamina papyracea.
among right and left sides, nor among males and females
(p > 0.05).
Because the prevalence of lateralized LP in AFRS cases
was found to be significantly higher than in other CT scans,
a separate analysis and grading system for LP position in
those cases proved to be necessary. In AFRS, the mean
distance from LP to MMA line was 0.46 mm (ie, lateral
to the MMA line) with an SD of 2.99 mm. Therefore, on
dealing with AFRS cases, 3 mm and 6 mm cutoff points are
suggested for categorization of type III a and b, respectively.
Doing so, 11 (instead of 19) AFRS sides (15.9%) would be
classified as type III (7 sides as type IIIa, and 4 sides as type
IIIb).
Retrospective review of medical records has identified 5
sides of “accidental” penetration of LP as appears on op-
erative data. In correlation with CT scans, these were as
follows: 2 sides of type III (2/26, 7.7%, of which 1 had
also orbital fat exposure with minimal periorbital ecchy-
mosis); 2 sides of type II (2/39, 5.1%; Fig. 8), and 1 side of
type I (1/116, 0.8%). None of the 5 sides with maxillary
sinus hypoplasia had a reported LP injury. Intraoperative
identification of the periorbita in the setting of dehiscent
LP viewed on preoperative CT scans was not considered
a complication. There was no reported incidence of optic
nerve or medial rectus injury.

Discussion
Despite the progress in ESS training and the widespread
availability of teaching courses, both complications and in-
efficient surgeries continue to occur. A systematic review
was performed in 2006 to examine all ESS complications
in the setting of nasal polyposis, including 42 studies from
1994 to 2004.16 In the latter review, the most frequent or-
FIGURE 7. Bilateral maxillary sinus hypoplasia with type IIa and IIb lamina
bital complication during ESS was accidental penetration
papyracea. of the LP and periorbita or orbital fat exposure in up to 5%
of cases (median, 2.1%). In 2012, a prospective multicen-
ter Japanese study has shown complications in 80 of 1382

TABLE 2. Number of sides (and prevalence) of LP types among different diagnoses*

Type II Type III

Type I a b a&b a b a&b NA

CRSwNP (86 sides) 64 (74.4) 16 (18.6) 2 (2.3) 18 (20.9) 1 (1.2) 2 (2.3) 3 (3.5) 1 (1.2)
a
AFRS (69 sides) 31 (44.9) 9 (13.0) 2 (2.9) 11 (15.9) 13 (18.8) 6 (8.7) 19 (27.5) 8 (11.6)
CRS (35 sides) 19 (54.3) 7 (20.0) 2 (5.7) 9 (25.7) 4 (11.4) 0 4 (11.4) 3 (8.6)
ACP (3 sides) 2 (66.7) 1 (33.3) 0 1 (33.3) 0 0 0 0
Total (193 sides) 116 (60.1) 33 (17.1) 6 (3.1) 39 (20.2) 18 (9.3) 8 (4.2) 26 (13.5) 12 (6.2)

*Values are n (%).

a
The high prevalence of type III LP in AFRS resulted in higher overall prevalence of type III LP in the diseased group. Therefore, an adjusted grading system for AFRS
cases with 3 mm (and 6 mm) cutoff points is suggested to categorize types III a (and b), respectively. Using this adjusted grading system, the prevalence of type III LP in
AFRS would be 15.9%, and that of type I would be 56.5%.
ACP = antrochoanal polyp; AFRS = allergic fungal rhinosinusitis; CRS = chronic rhinosinusitis; CRSwNP = chronic rhinosinusitis with bilateral nasal polyps; LP = lamina
papyracea.

267 International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
Herzallah et al.
FIGURE 8. CT and intraoperative endoscopic views of right side type IIa LP in a 49-year-old male patient with bilateral nasal polyps. The LP was accidentally
penetrated with exposure of the PO, which was confirmed intraoperatively. Note the medial location of the LP in relation to the imaginary line passing through
the lower border of the middle meatal antrostomy. CT = computed tomography; LP = lamina papyracea; PO = periorbita.
subjects (5.8%), the most frequent complication still be-
ing LP injury.12
In the 1990s, residual ethmoid air cells was described as
a common finding in revision ESS cases.31 This observa-
tion was again highlighted in similar studies over the past
decade.22, 31, 32 In 2013, Gore et al.21 found residual eth-
moid air cells on the LP in 79% of 55 patients undergoing
revision ESS. These data clearly signify that efficient clear-
ance of ethmoid air cells on the LP remains challenging in
certain cases and probably for some surgeons.
LP can usually be easily delineated by experts. However,
because LP injury was reported in up to 5% of ESSs in re-
cent multicenter prospective and retrospective studies,12, 16
this indicates it is not as easy for residents and less experi-
enced surgeons. Similarly, residual ethmoid cells on the LP
remain 1 of the most common findings in revision ESS.21
Our description of the variable positions of LP can help
surgeons predict its location during preoperative evalua-
tion, as well as intraoperatively, which should allow safer
and more effective surgery while acquiring more experi-
ence in the learning curve. Figure 8 presents the radiologic
and endoscopic views of a type II LP in which accidental
intraoperative injury was documented. In Figure 9, a corre-
lation between the CT and endoscopic views is also shown
for type III LP.
We have identified hypoplastic maxillary sinus in 5
(2.5%) of all diseased sides; of the 5 sides, 3 belonged
to the CRS subgroup (3/35; 8.6%). Similarly, hypoplastic
maxillary sinus was identified in approximately 7% to 10%
of chronic rhinosinusitis patients in previous studies.29, 30
None of our patients had silent sinus syndrome, which is
defined when a hypoplastic maxillary sinus is accompa-
nied by spontaneous and progressive enophthalmos.33 In
the setting of a hypoplastic maxillary sinus or silent si-
nus syndrome, several investigators have brought attention
to the concomitant medial position of the LP,13, 25–29 but
probably at the same time giving a false impression that
International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
the LP is otherwise safely located. In fact, many reported
instances of LP breaching, as well as occasional injuries of
the LP that we had in our experience, occurred without the
presence of a hypoplastic maxillary sinus. It should be also
noted that 1 previous study on anatomical PNS variations
in 400 patients’ CT scans found LPs to lie medial to the
vertical plane of the maxillary ostium in 10% of sides with
normal maxillary sinuses.34 However, thorough analysis
of the LP location was not performed in that study and no
clear data were provided on the position of the LP in other
sides.
In our study, we have radiologically classified the LP po-
sition from an endoscopic perspective. The inferior mar-
gin of the MMA is frequently identified early in the endo-
scopic procedure, and the inferior turbinate attachment to
the lateral nasal wall is also uncommonly obscured by the
sinonasal disease process and is seldom removed in prior
nasal surgeries. In type I, the LP lies in close relationship
(within 2 mm) to the vertical plane of the MMA line. The
2 mm range on either side was chosen as it approximately
equals the SD of measurements, and also for more sound
surgical perception and easier reproducibility. When the
LP is modestly medial to the MMA line (2 to 4 mm), type
IIa was described and requires closer attention; eg, during
uncinectomy. A more medial position of the LP (type IIb;
>4 mm) presumably puts the LP even at more risk. A lat-
erally located LP (type III) should alert the surgeon that a
variable degree of lateral work is required for effective eth-
moid cell clearance. A laterally pushed lamina may result
from the expansile action of nasal polyps or fungal debris
with thinning of the lamina bone that can be easily and
accidentally penetrated.
Because the prevalence of type III LP in AFRS cases is
high, we had to acknowledge the limitation of using the
same grading system in diseased cases with AFRS. There-
fore, based on the SD of measurements in these sides, an
adjusted grading system for AFRS with 3 mm and 6 mm
268
Variations of lamina papyracea position
FIGURE 9. CT and intraoperative endoscopic views of left side type III LP in a 24-year-old female patient with allergic fungal rhinosinusitis. Note the lateral
location of the LP in relation to the imaginary line passing through the lower border of middle meatal antrostomy. Adequate clearance of ethmoid air cells on
the LP was performed, while taking care not to injure the already thinned lamina. CT = computed tomography; LP = lamina papyracea.
cutoff points is suggested to categorize types III a and b,
respectively.
In this retrospective work, the incidence of accidental LP
injury was higher in types II and III LP (5.1% and 7.7%,
respectively) when compared with type I (0.8%). How-
ever, future studies are required to confirm these findings
for 2 reasons. First, the incidence of LP injury is already
low and thus a larger sample size is required to achieve
statistical significance. Second, a retrospective review may
be limited by deficient data entry coupled with the ten-
dency not to report accidental penetration of LP or ex-
posure of periorbita if it was not accompanied by major
consequences. Nevertheless, the higher incidence of LP in-
jury when the location of LP exceeds 1SD on either side
seems to be clinically significant and appears to occur for
different reasons as explained before in the fifth paragraph
of the discussion section. Attention to the relative loca-
tion of the LP should be helpful for the surgeon in avoid-
ing its inadvertent injury. This indeed might explain the
absence of LP injury in our cases of maxillary sinus hy-
poplasia, where the surgeon is already prepared for its risky
location.
The grading system presented in this study is not meant to
ask the surgeon to take measurements intraoperatively, but
instead to give him or her an estimate about where to expect
the LP in the surgical field and how much this compares to
other cases. In other words, this categorization roughly tells
the surgeon if the LP lies within or beyond 1SD (or more)
on either side of the distribution curve.
The introduction of computer-assisted surgery has def-
initely assisted in addressing difficult and challenging ar-
eas during ESS35 ; this should not, however, preclude our
anatomical knowledge and attention to different variations.
In fact, navigation systems are not universally available
and, in many centers, are not currently part of the set up
269 International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
for routine cases. 36 Nevertheless, it is the surgeon’s proper
orientation and skill in using instrumentation and technol-
ogy that contributes the most to a favorable ESS outcome.
Finally, it might be helpful to recall that “eyes cannot see
what the brain does not know.” In other words, differences
in PNS pneumatization or lengths of lateral lamella were
definitely there all the time even before the description of
such variations. However, many surgeons started to “see”
these variations only after getting the “knowledge” about
it. Attention to the LP location may similarly help surgeons
and residents to get a step forward in performing closely
related endoscopic work more safely and effectively. Larger
as well as prospective studies are required to evaluate the
relationship between different LP types and the incidence
of its accidental penetration or residual disease.
Conclusion
The current work updates our knowledge about the posi-
tion of LP from an endoscopic perspective. The variations
described in this study aim at improving surgeons’ aware-
ness of LP location in the endoscopic field. This information
can help residents in training and may also assist in defin-
ing the anatomical scenarios in which LP injury or residual
disease is more frequent. Further studies are required to
evaluate the impact of LP types on the surgical outcome at
different levels of training.
Acknowledgements
We thank the staff at the Radiodiagnosis, Research Center,
and Information Technology Departments at King Abdul-
lah Medical City for their conscientious assistance during
the course of the study.
Herzallah et al.
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