Poor Reproducibility in the Evaluation of Paranasal Sinus X-Rays in Chronic Rhinosinusitis

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 .