Open Jou nal o Radiology, 2017, 7, 23-34
h p://www.sci p.o g/jou nal/oj ad
ISSN Online: 2164-3032
ISSN P in : 2164-3024
DOI: 10.4236/oj ad.2017.71003 Ma ch 7, 2017
Poo Rep oducibili y in he E alua ion o
Pa anasal Sinus X-Rays in Ch onic
Rhinosinusi is
A. Luukkainen1,2*, E. Te na1*, J. Numminen3, A. Ma kkola4, P. Das ida 5, J. Ja ns ed 5, H. Huh ala6,
M. Ka jalainen3, K. Blomg en7, P. Kauppi8, M. Rau iainen3,9, S. Toppila-Salmi1,8
1T ansplan a ion Labo a o y, Haa man Ins i u e, Uni e si y o Helsinki, Helsinki, Finland
2Depa men o O ola yngology, Yong Loo Lin School o Medicine, Na ional Uni e si y o Singapo e, Singapo e
3Depa men o Ea and O al Diseases, Tampe e Uni e si y Hospi al, Tampe e, Finland
4Uni e si y o Helsinki and HUS Imaging, Helsinki, Finland
5Medical Imaging Cen e, Depa men o Radiology, Tampe e Uni e si y Hospi al, Tampe e, Finland
6School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland
7Depa men o O o hinola yngology, Uni e si y o Helsinki and Helsinki Uni e si y Hospi al, Helsinki, Finland
8Depa men o Alle gy, Uni e si y o Helsinki and Helsinki Uni e si y Hospi al, Helsinki, Finland
9Depa men o O o hinola yngology, Uni e si y o Tampe e, Tampe e, Finland
Abs ac
Objec i e:
The aim o his s udy was o e alua e in a- and in e -obse e
e-
p oducibili y o sinus x-
ays in compa ison o sinus compu ed omog aphy
(CT) in ch onic hinosinusi is (CRS) pa ien s.
Me hods:
This was a
p ospe
c-
i e con olled s udy
o which 14 adul CRS pa ien s we e ec ui ed. Pa ien s
unde wen a sinus mul i-de ec o CT scan as well as addi ional sinus x-
ays a
he same ime. Symp om in e iew and skin p ick es s we e pe o med.
Lund-Mackay (LM) sco es and 43 o he indings in p
a anasal sinuses we e
analyzed by h ee blinded obse e s om CT-scans and x-
ays. We compa ed
ag eemen be ween sinus CT and x- ays (in a-
obse e ep oducibili y) and
be ween h ee obse e s (in e -
obse e ep oducibili y) by Cohen’s kappa.
Resul s
: In a leas 90% o he cases, he s a us o 47/49 s uc u es was de ec
-
able in CT scans, whe eas he s a us o only 8/49 s uc u es was de ec able in
x- ays. The majo i y o he 25 isualized s uc u es had poo in a-
obse e
and in e -obse e ep oducibili y.
Conclusion
: Only a
ew s uc u es can be
isualized in pa anasal sinus x- ays and compa ed o pa anasal sinus CT
-
scans, hei ep oducibili y is poo . Ou esul s s ongly suppo he cu en
consensus o adia ion dose educ ion by limi ing he numbe o x- ays.
*The au ho s con ibu ed equally o his wo k.
How o ci e his pape :
Luukkainen, A.,
Te na, E
., Numminen, J., Ma kkola, A.,
Das ida , P
., Ja ns ed , J., Huh ala, H., Ka -
jalainen, M
., Blomg en, K., Kauppi, P., Rau-
iainen
, M. and Toppila-Salmi, S. (2017
)
Poo Rep oducibili y in he E alu
a
ion o
Pa anasal Sinus X
-Rays in Ch onic Rhino-
sinusi is
.
Open Jou nal o Radiology
,
7
, 23-
34
.
h ps://doi.o g/10.4236/oj ad.2017.71003
Recei ed:
Janua y 24, 2017
Accep ed:
Ma ch 4, 2017
Published:
Ma ch 7, 2017
Copy igh © 201
7 by au ho s and
Scien i ic
Resea ch Publishing Inc.
This wo k is licensed unde he C ea i e
Commons A ibu ion In e na ional
License (CC BY
4.0).
h p://c ea i ecommons.o g/licenses/by/4.0/
Open Access
A. Luukkainen e al.
24
Keywo ds
Sinusi is, Pa anasal Sinus, Compu ed Tomog aphy,
Magne ic Resonance Imaging, X-Ray
1. In oduc ion
Ch onic hinosinusi is (CRS) is a mul i ac o ial and a iable disease wi h a p e-
alence o 10.9% [1]. Compu ed omog aphy (CT) scans and/o nasal endoscopy
a e he ecommended imaging modali y o CRS [1]. Co ela ion be ween sino-
nasal symp oms and endoscopic o adiologic signs is poo [2]. The main ind-
ings o CRS a e mucosal changes wi hin he os iomea al complex and/o sinuses
[1]. Pa anasal sinus ana omical a ian s a e e y common and se e al c i ical
ana omical s uc u es (such as big essels, o bi and cen al ne ous sys em) a e
closely loca ed o he sinonasal su gical a ea [3] [4].
CRS su ge y has imp o ed many pa ien s’ quali y o li e wi h ha d o ea
CRS [1]. Imaging o he nose and pa anasal sinuses has p og essed apidly du -
ing he pas decade. CT can demons a e sinus ana omy speci ically as well as
ana omical a ian s and o he impo an s uc u es, when p epa ing o su ge y
o e alua ing he cause o long las ing sinus symp oms. X- ays a e no ecom-
mended o CRS imaging [2]. A simple adiog am o he nose and pa anasal si-
nuses ca ies a adia ion dose o 0.03 mS ( ou days o na u al backg ound ad-
ia ion). Al hough x- ays a e in e io o CT in de ec ing bony s uc u es and
mucosal changes, li le compa a i e da a exis s on he ag eemen be ween sinus
CT and x- ays [2].
Despi e he no el low dose sinus CT scan modali ies, he numbe o pe -
o med sinus x- ays is high in Finland (13.1 pe 1000 inhabi an s in 2011, ac-
co ding o he s a is ics o he Radia ion and Nuclea Sa e y Au ho i y) [5]. The
aim o his p ospec i e con olled s udy was o e alua e in a- and in e -obse e
ep oducibili y o sinus x- ays in compa ison o sinus CT, in o de o con ibu e
o he need o educ ion o unnecessa y adia ion.
2. Ma e ials and Me hods
2.1. E hical Conside a ion
The s udy was app o ed by he e hics commi ee o he Pi kanmaa Hospi al Dis-
ic (no 96032) and was conduc ed in acco dance wi h he Helsinki Decla a ion
o 1975, as e ised in 1983. W i en in o med consen was ob ained om each
pa icipan . Volun ee pa ien s we e exposed o an ex a adia ion dose o 0.02
yea s (6 days o na u al backg ound adia ion in Finland).
2.2. Pa ien s
This s udy was ca ied ou in he Depa men o O o hinola yngology, a Tam-
pe e Uni e si y Hospi al, Finland om 2006 o 2015. A andom sample o 14
A. Luukkainen e al.
25
adul CRS pa ien s, who also had a his o y o AR and equi ing sinus CT scans
du ing 2007-2011, we e en olled. 3 (21%) ou o 14 pa ien s also had concomi-
an as hma. Ha ing ano he se e e disease was an exclusion c i e ion. 2 (85.7%)
ou o 14 pa ien s epo ed as ha ing o he diseases (one had a hy hmia, one
had esol ed melanoma). None o he pa ien s epo ed using egula ly o he
medica ion han hose due o in lamma o y ai way diseases. The e was no pa-
ien eco d epo o any o he diseases, no o psychia ic/psychologic diso d-
e s. Pa ien da a was collec ed om medical eco ds and by a ques ionnai e a
he ime o sinus CT scans, as p e iously desc ibed [6]. Follow-up da a was col-
lec ed om pa ien eco ds o he Tampe e Uni e si y Hospi al o Tampe e Ci y
Hospi al in 2015. The median (min-max) ollow up ime was 6.0 (0 - 8) yea s a -
e sinus CT scans we e pe o med. None o he subjec s had unde gone aspi in
desensi iza ion, alle gen immuno he apy o an i IgE he apy p io o o du ing
sinus CT scans o du ing ollow-up.
2.3. CT Scans
Pa ien s unde wen ou ine sinus mul iple de ec o CT scans o clinical pu -
poses. Two di e en CT scanne s we e used: GE Ligh Speed 16 (GE Heal hca e,
Milwaukee, Wisconsin) and Philips B illiance 64 (Philips, Bes , Ne he lands).
Pa ien s we e scanned in a supine posi ion wi h a kilo ol age o 120 kV and a
milliampe e second o 100 mAs. Wi h he GE scanne , slice hickness was 0.625
mm wi h co onal econs uc ions a 1.5 mm and a adia ion dose o 0.8 mS .
Wi h he Philips scanne , slice hickness was 0.9 mm wi h co onal econs uc-
ions a 0.9 mm and a adia ion dose o 0.9 mS . Bo h we e h ee dimensional
(3D) in na u e wi hou any gaps. In all cases, imaging was pe o med using a
bone il e echnique. Scans co e ed he en i e sinonasal a ea in bo h axial and
co onal di ec ions, s a ing om he nasal ip and ending a he pos e io wall o
he sphenoid sinuses.
2.4. X-Rays
X- ays we e pe o med a he same ime as sinus CT scans. Two X- ay p ojec-
ions, Wa e s and PA-p ojec ion (Caldwell), we e aken wi h Philips Pendo Di-
agnos (Philips, Bes , Ne he lands) skull uni in a si ing posi ion. Imaging pa-
ame e s we e 85 kV, 12 mAs wi h Wa e s, and in PA-p ojec ion 85 kV and 8
mAs. The images we e cap u ed using pho os imulable phospho pla es, pixel
size 0.1 mm and ead wi h AGFA CR 25 CR (Ag a-Ge ae N. V. Mo sel, Bel-
gium) sys em. The adia ion dose o x- ays wi h wo p ojec ions was 0.06 mS .
2.5. E alua ion o CT Scans and X-Rays
CT scans and x- ays we e obse ed by h ee independen obse e s blinded o
each o he and o pa ien his o y da a: an expe ienced head and neck adiologis
(AM), an expe ienced Ea Nose Th oa (ENT)-and hinosu geon (JN), and a
i h yea ENT esiden (ST-S). Examina ion o he same pa ien ’s images ook
place a leas a week apa . The h ee obse e s illed a 49-i em o m o sinonasal
A. Luukkainen e al.
26
s uc u es om bo h CT-scan and x- ay bila e ally o each pa ien (Table 3).
Each s uc u e lis ed in he o m could be sco ed by 2 - 5 di e en lis ed choices.
Be o e e alua ion o he CT scans, all choices we e discussed be ween obse e s.
Be o e his s udy, he obse e s had pa icipa ed a pilo s udy wi h 15 CT scans
[6]. The adiologis did no espond o he ques ion: “Need o sep oplas y”.
2.6. Da a Analysis
S a is ical analysis was ca ied ou by SPSS Base 15.0 S a is ical So wa e Package
(SPSS Inc., Chicago, IL, USA). Cohen’s kappa was used o compa e he deg ee o
ag eemen be ween CT scans and x- ays (e.g. in a-obse e ag eemen ); and he
in e -obse e ag eemen o x- ays. The calcula ion is based on he di e ence
be ween how much ag eemen is ac ually p esen compa ed o how much
ag eemen would be expec ed o be p esen by chance alone. The es ablished in-
e p e a ion o Kappa- alue is classi ied in o 6 subg oups: Poo < 0.2, Fai 0.21 -
0.4, Mode a e 0.41 - 0.6, Good 0.61 - 0.8 and Ve y Good 0.81 - 1.0. A alue un-
de ze o means ha he ag eemen is wo se han ha by chance [7]. Two- ailed
P- alues o <0.05 we e conside ed s a is ically signi ican .
3. Resul s
3.1. Pa ien Cha ac e is ics
Pa ien cha ac e is ics a e shown in Table 1. The median (min-max) age was
36.9 (20.0 - 54.3) yea s. 57.1% o pa ien s unde wen sinonasal ope a ion wi hin
a yea a e he CT scans (Table 1). 2 (14.3%) o he pa ien s epo ed su e ing
om diseases besides CRS ± AR ± as hma wi h egula need o medica ion. One
o he pa ien epo ed ha ing melanoma and he o he pa ien ca diac a hy h-
mia.
3.2. Visualized S uc u es in X-Rays
The numbe o isualized s uc u es in x- ays was 25, e.g. he s uc u es ha
we e isualized in a leas one pa ien ´s pa anasal sinus x- ays, whe eas he
numbe o isualized s uc u es in a leas one pa ien ’s CT scan was 49 (Table
2). The isualized 25/49 s uc u es in x- ays we e Lund-Mackay (LM)-sco es
(excep os iomea al uni ), mucosa and size o pa anasal sinuses, mucosa o in e-
io and middle u bina es, nasal mucosal oedema and sep al abno mali ies
(Table 2). Ye , eliabili y o e en de ec hese s uc u es in mos cases o x- ays
was poo (Table 2). In a leas 90% o he cases, he s a us o 47/49 s uc u es
was de ec able in CT scans, whe eas o x- ays i was only 8/49 (Table 2). Se e al
diagnos ically and su gically impo an s uc u es we e no isible in x- ays,
such as os iomea al complex, inse ion o he uncina e p ocess, lamina papy a-
chea and an e io e hmoid a e y (Table 2).
3.3. In a-Obse e Ag eemen
We compa ed he deg ee o ag eemen be ween x- ays and CT scans o he 25
s uc u es ha we e isualized in x- ays. In gene al, he in a-obse e ag ee-
A. Luukkainen e al.
27
Table 1. Cha ac e is ics o he pa ien s.
Ch onic hinosinusi is
pa ien s
n = 14 %
Gende
Male 2 14.3
Female 12 85.7
Age
<45 yea s 11 78.6
≥45 yea s 3 21.4
Smoking
No 9 64.3
Ex 3 21.4
Cu en 1 7.1
Unknown 1 7.1
Alle gic hini is
No 2 14.3
Yes 11 78.6
Unknown 1 7.1
SPT posi i i y
No 3 21.4
Only pollen(s) 5 35.7
Only animal dande (s) 1 7.1
Mul iple alle gen ypes 5 35.7
As hma
No 10 71.4
Yes 3 21.4
Unknown 1 7.1
Nasal polyps
No 12 85.7
Yes 1 7.1
Unknown 1 7.1
AERD
No 13 92.9
Yes 0 0.0
Unknown 1 7.1

A. Luukkainen e al.
28
Con inued
O he diseases2
No 12 85.7
Yes 2 14.3
Cu en use o in anasal co icos e oids
No 1 7.1
Yes 12 85.7
Unknown 1 7.1
≥1 pe o al co icos e oid cou se(s) du ing he pas 1 yea
No 13 92.9
Yes 0 0.0
Unknown 1 7.1
P e ious sinonasal ope a ion(s)
No 11 78.6
Yes 2 14.3
Unknown 1 7.1
Radiological signs in CT scans o p e ious sinus ope a ion
No 11 78.6
Yes 3 21.4
To al Lund-Mackay sco e o CT scans
0 - 3 7 50.0
4 - 12 7 50.0
13 - 24 0 0.0
Sinonasal ope a ion pe o med wi hin a yea a e he CT scans
No 5 35.7
Yes 8 57.1
Unknown 1 7.1
≥1 sinonasal ope a ion(s) du ing he 6-yea ollow-up
No 12 85.7
Yes 1 7.1
Unknown 1 7.1
Numbe o an ibio ic cou ses du ing he
pas 2 yea s, median (min-max) 6.0 (2 - 15)
Du a ion o symp oms in yea s, median (min-max) 2.5 (0.3 - 25.0)
Cu en symp oms by VAS, mean (min–max)
Sense o smell 3.7 (0.0 - 7.3)
Pos -nasal d ip 5.5 (1.0 - 8.1)
Obs uc ion 6.1 (0.7 - 9.8)
Facial pain 5.5 (2.4 - 9.9)
Abb e ia ions: SPT = skin p ick es ; AERD = pa ien - epo ed aspi in exace ba ed espi a o y disease; CT
= compu ed omog aphy; VAS= isual analogue scale (0 - 10). 1A leas one pe o al co icos e oid ea men
du ing he las 12 mon hs. 2Sel - epo ed and pa ien - eco d in o ma ion.
A. Luukkainen e al.
29
Table 2. The lis o isualized o non- isualized sinonasal s uc u es o pa anasal sinus x- ays.
Visualized in x- ays
Non- isualized in x- ays
Non-de ec able
cases%
Non-de ec able
cases%
CT-scans
x- ays
CT-scans
x- ays
A ophy-no mal hype ophy o in e io u bina e 0.0 28.6 An e io e hmoidal a e y 25.0 100.0
A ophy-no mal hype ophy o middle u bina e 3.6 50.0 A ophy-no mal hype ophy
o supe io u bina e 21.4 100.0
Hypoplasia/no mal/hype plasia
o an e io e hmoidal sinus 0.0 14.3 Con ac o middle u bina e o
o bi al lamina o e hmoidal bone 0.0 100.0
Hypoplasia/no mal/hype plasia o on al sinus 0.0 14.3 F on al ecess 0.0 100.0
Hypoplasia/no mal/hype plasia o maxilla y sinus 0.0 14.3 In ao bi al cell 0.0 100.0
Hypoplasia/no mal/hype plasia o pos e io
e hmoidal sinus 0.0 14.3 Ke os classi ica ion 0.0 100.0
Hypoplasia/no mal/hype plasia o sphenoid sinus 0.0 14.3 Lund-Mackay os iomea al uni 0.0 100.0
Lund-Mackay an e io e hmoidal sinus 0.0 0.0 Mucosa o pneuma ized middle u bina e 0.0 100.0
Lund-Mackay on al sinus 0.0 7.1 Mucosa o pneuma ized supe io u bina e 0.0 100.0
Lund-Mackay maxilla y sinus 0.0 0.0 OMC egion, accesso y maxilla y sinus os ium 7.1 100.0
Lund-Mackay pos e io e hmoidal sinus 0.0 7.1 OMC egion, hia us 0.0 100.0
Lund-Mackay sphenoid sinus 0.0 3.6 OMC egion, in undibulum 0.0 100.0
Mucosa o nasal ca i y (ex en o edema) 0.0 14.3 OMC egion, maxilla y an um 0.0 100.0
Mucosa o nasal ca i y (no mal-polypous) 0.0 14.3 OMC egion, pneuma ized
supe io a achmen o uncina e p ocess 0.0 100.0
Need o sep oplas y1 0.0 35.7 OMC egion, p ominen e hmoid bulla 0.0 100.0
Sep al de ia ion obs uc ing middle mea us 0.0 32.1 OMC egion, supe io a achmen
o uncina e p ocess 7.1 100.0
Sep um, c es 0.0 17.9 Op ic ne e 0.0 100.0
Sep um de ia ion 0.0 21.4 Sphenoe hmoidal ecess 3.6 100.0
Sep um u bina e 0.0 32.1 Pa adoxical middle u bina e 0.0 100.0
Sep um, spu 0.0 21.4 Pa adoxical supe io u bina e 7.1 100.0
Sinus mucosal abno mali ies
o an e io e hmoidal sinus 0.0 7.1 Pneuma ized middle u bina e 0.0 100.0
Sinus mucosal abno mali ies o on al sinus 0.0 17.9 Pneuma ized supe io u bina e 7.1 100.0
Sinus mucosal abno mali ies o maxilla y sinus 0.0 3.6 P e ious sinus su ge y pe o med 0.0 100.0
Sinus mucosal abno mali ies
o pos e io e hmoidal sinus 0.0 7.1 Thickness o o bi al lamina o e hmoidal bone 0.0 100.0
Sinus mucosal abno mali ies o sphenoid sinus 0.0 10.7
The CT scans and x- ays we e aken om 14 pa ien s wi h ch onic hinosinusi is symp oms. Each pa ien unde wen CT scans and x- ays a he same ime.
The columns show in alphabe ical o de he e alua ed 49 s uc u es om pa anasal sinus CT-scans and x- ays. Visualized in x- ays = he 25 s uc u es ha
we e isualized in a leas one pa ien ’s pa anasal sinus x- ays (le column); Non- isualized in x- ays = he 24 s uc u es ha we e non- isualized in pa a-
nasal sinus x- ays o all cases ( igh column); OMC = Os iomea al complex; No de ec able = he pe cen age o he obse e ´s esponses “The s a us o he
s uc u e is no de ec able” o bo h sides. 1E alua ed by he ENT su geon. O he s uc u es e alua ed by he adiologis .
A. Luukkainen e al.
30
men was poo (kappa < 0.2) in he majo i y o s uc u es, such as LM sco es.
Mode a e and good ag eemen was only achie ed o g oss ana omical s uc u es
on he igh hand-side only, conce ning espec i ely, nasal sep um de ia ion and
size o he on al sinus (Table 3). Fai o poo ag eemen was obse ed o he
es o he s uc u es.
3.4. In e -Obse e Ag eemen
The 25 s uc u es ha we e isualized in x- ays we e e alua ed by a adiologis ,
an ENT su geon and an ENT esiden . The in e -obse e ag eemen be ween
adiologis and ENT esiden o x- ays was poo (kappa ≤ 0.02) in 88% o he
s uc u es and ai (kappa 0.21 - 0.4) o he es (12%) o he s uc u es. The
ag eemen be ween adiologis and ENT su geon o x- ays was poo o ai in
80% o he s uc u es and he ag eemen be ween ENT su geon and ENT esi-
den was poo o ai in 92% o he s uc u es.
4. Discussion
This s udy was ca ied ou o e alua e in a- and in e -obse e ep oducibili y
o sinus x- ays in compa ison o sinus CT scans. When his s udy was s a ed,
mul i- de ec o CT scans had a high adia ion dose (in a e age 0.9 mS ) and
x- ays we e s ill ela i e widely used due o a clea ly smalle adia ion dose (in
a e age 0.03 mSV pe image). A e his, low-dose CT scans (such as cone beam
CT scans) ha e eme ged ( adia ion dose be ween 0.08 - 0.27 mS ) and hence
ha e la gely eplaced bo h sinus x- ays and high-dose sinus CT scans [8]. The
numbe o pe o med sinus x- ays is s ill high in Finland [5]. Consequen ly, his
s udy could con ibu e o he educ ion o unnecessa y adia ion.
Ou main inding was ha a small p opo ion o s uc u es can be isualized
in x- ays; and x- ay e alua ions ha e poo ep oducibili y. CRS speci ic changes
ha should be obse ed in CT-scans including deg ee o opaci ica ion o he pa-
anasal sinuses and/o obs uc ion o he os iomea al complex canno be isua-
lized o only poo ly in simple x- ays, making CRS diagnosis un eliable [1]. Si-
mila ly, o he s ound in a small s udy ha engo ged u bina es and opaque nasal
ossa could be obse ed om pa anasal sinus x- ays. In he x- ays o 19.7% o
pa ien s wi h nasal and/o pa anasal symp oms du ing a leas 8 weeks, no
changes we e obse able [9].
In a-obse e ag eemen was ai o poo ega ding mos o he 25 s uc u es
ha could be isualized in plain x- ays. Simila ly o us, o he s epo in a s udy
wi h 47 pa ien s wi h acu e hinosinusi is ha plain sinus adiog ams ha e a low
sensi i i y o de ec ing sinus in lamma o y changes in o he pa anasal sinuses
besides he maxilla y sinus, in compa ison o CT-scans [10].
In e -obse e ag eemen was poo o he majo i y o s uc u es ha could be
isualized by he adiologis , ENT su geon and ENT esiden . Ve y good in e -
obse e ag eemen was only achie ed in ega d o s uc u es ha could no be
isualized, be ween ENT esiden and su geon.
A. Luukkainen e al.
31
Table 3. Compa ison o he deg ee o in a-obse e ag eemen om pa anasal sinus
x- ays and compu ed omog aphy (CT)-scans.
Compu ed omog aphy scans s. x- ays
Righ
kappa
P
Le
kappa
P
Lund-Mackay on al sinus −0.057 <0.001 −0.050 <0.001
Lund-Mackay an e io e hmoidal sinus 0.109 1.00 0.243 0.357
Lund-Mackay pos e io e hmoidal sinus 0.155 <0.001 0.200 <0.001
Lund-Mackay sphenoid sinus −0.148 <0.001 0.323 0.286
Lund-Mackay maxilla y sinus 0.125 0.560 0.087 1.00
Sinus mucosal abno mali ies o on al sinus −0.120 1.00 0.192 1.00
Sinus mucosal abno mali ies
o an e io e hmoidal sinus 0.155 <0.001 0.114 1.00
Sinus mucosal abno mali ies
o pos e io e hmoidal sinus 0.142 <0.001 0.067 1.00
Sinus mucosal abno mali ies o sphenoid sinus 0.058 <0.001 0.233 1.00
Sinus mucosal abno mali ies o maxilla y sinus 0.355 <0.001 0.339 <0.001
Hypoplasia/no mal/hype plasia o on al sinus 0.650 <0.001 0.344 <0.001
Hypoplasia/no mal/hype plasia
o an e io e hmoidal sinus 0.000 <0.001 0.000 <0.001
Hypoplasia/no mal/hype plasia
o pos e io e hmoidal sinus 0.000 <0.001 0.000 <0.001
Hypoplasia/no mal/hype plasia o sphenoid sinus 0.192 <0.001 0.208 <0.001
Hypoplasia/no mal/hype plasia o maxilla y sinus 0.000 <0.001 0.000 <0.001
Need o sep oplas y1 0.114 1.00 0.114 1.00
Sep al de ia ion obs uc ing middle mea us 0.079 1.00 0.114 1.00
Sep um u bina e 0.000 <0.001 0.000 <0.001
Sep um de ia ion 0.462 <0.001 0.385 <0.001
Sep um, c es 0.133 <0.001 −0.061 1.00
Sep um, spu 0.023 <0.001 −0.094 <0.001
A ophy-no mal-hype ophy o in e io u bina e 0.250 <0.001 0.381 .019
A ophy-no mal-hype ophy o middle u bina e −0.083 0.143 −0.051 <0.001
Mucosa o nasal ca i y (ex en o edema) 0.030 0.250 −0.054 <0.001
Mucosa o nasal ca i y (no mal-polypous) 0.175 <0.001 −0.054 1.00
Ag eemen
kappa
Poo
≤0.2
Fai 0.21 - 0.4
Mode a e 0.41 - 0.6
Good 0.61 - 0.8
Ve y good
0.81 - 1.0
The CT scans and x- ays we e aken om 14 pa ien s wi h ch onic hinosinusi is symp oms. Each pa ien
unde wen CT scans and x- ays a he same ime. Ag eemen is p esen ed only o he 25 s uc u es ha
we e de ec ed in x- ays (Table 2). The 24 s uc u es ha we e non-de ec able in x- ays ha e been wi h-
d awn om e alua ion. The o de o he s uc u es is he same as hey we e in he e alua ion o m. S uc-
u es wi h subs an ial o almos pe ec ag eemen le el by Kappa-coe icien . 1E alua ed by he ENT
su geon. O he s uc u es e alua ed by he adiologis .