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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 466-469

Prevalence of Haller Cell and Accessory Maxillary Ostium: A Cone-Beam Computed Tomographic Study


1 Department of Oral Medicine and Radiology, Bharati Vidyapeeth (Deemed to Be) University Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth (Deemed to Be) University Dental College and Hospital, Pune, Maharashtra, India

Date of Submission21-May-2022
Date of Decision22-Nov-2022
Date of Acceptance23-Nov-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Subharina Mahapatra
Ambegaon BK, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_154_22

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   Abstract 


Introduction: Haller cell and accessory maxillary ostium (AMO) do not represent a diseased state, but they can be responsible for the development of maxillary sinusitis. Aim and Objectives: The study aimed to evaluate the frequency and volumetry of Haller cell and the prevalence of AMO on cone-beam computed tomography (CBCT). Materials and Methods: The two hundred CBCT scans of patients (400 bilateral maxillary sinus region) were evaluated for the presence of Haller cell, and AMO coronal, axial, and sagittal plane was inspected; then, volumetric measurement was carried out at the maximum mediolateral dimension. Based on the size, two observers arbitrarily categorized the Haller cell into small, medium, and large. Finally, descriptive statistics and Chi-square test were done. Results: Fifty-six Haller cell were identified with a prevalence of 28%, of which 20% were unilateral, and 8% were bilateral. Small-sized Haller cell was seen in 11%, medium-sized was seen in 13%, and large sized was seen in 4%. AMO was present unilaterally in 5% of the studied scans. Conclusion: Knowledge of Haller cell and accessory maxillary ostium may aid in interpreting CBCT, which may also forewarn surgeons before surgeries.

Keywords: Accessory maxillary ostium, cone-beam computed tomography, Haller cell


How to cite this article:
Mahapatra S, Hebbale M, Tepan M, Halli R, Singh S, Modak R. Prevalence of Haller Cell and Accessory Maxillary Ostium: A Cone-Beam Computed Tomographic Study. J Indian Acad Oral Med Radiol 2022;34:466-9

How to cite this URL:
Mahapatra S, Hebbale M, Tepan M, Halli R, Singh S, Modak R. Prevalence of Haller Cell and Accessory Maxillary Ostium: A Cone-Beam Computed Tomographic Study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Jan 28];34:466-9. Available from: http://www.jiaomr.in/text.asp?2022/34/4/466/363017




   Introduction Top


“Haller cell” are named after anatomist Albert Von Haller, who first identified this ethmoidal pneumatization of the orbital floor in 1765.[1],[2]

The prevalence of Haller cell in the literature has been reported to be extremely variable, ranging from 2.7 to 45.1%.[3] Age and race imaging procedures may account for this difference.

Accessory maxillary ostium (AMO) may contribute to maxillary sinusitis. Infundibular obstruction or maxillary sinus infection increases AMO prevalence. The possible obstructive role of Haller cell in sinus drainage and their role in sinusitis, which may result in the development of AMO, has prompted investigations to assess possible associations between these anatomical variants.

Cone-beam computed tomography (CBCT) has been introduced in diagnostic imaging in dentistry as a digital, three-dimensional radiographic technique that provides isometric images in all three planes. In addition, CBCT involves less radiation exposure and can easily be performed.

This study was primarily aimed at evaluating the frequency and volumetry of Haller cell and the prevalence of AMO on CBCT.


   Materials and Methods Top


This retrospective study was carried out in the Department of Oral Medicine and Radiology following the fundamental principles of the Declaration of Helsinki. The ethical clearance for the study was obtained from the Institutional Ethical Committee (Approval No: EC/NEW/INST/2019/329). The scans were taken using KODAK 9300 CONE-BEAM 3D SYSTEM six months from January 2021 to October 2021. Out of respect for doctor–patient confidentiality, all personal information and the diagnostic cause of the scan were hidden.

The objectives of this study were to evaluate the presence and size of the Haller cell on either side and to evaluate the frequency of AMO on either side. Inclusion criteria were bilateral maxillary complete CBCT scans and patients within the age group of twenty to sixty years of either gender. In addition, CBCT scans with errors with partially reconstructed images and artifacts compromise the diagnostic quality of the scans with any pathology or fracture in or around the paranasal sinus area, scans with any bony changes, scans of patients below twenty and above sixty years, and patients with surgery in the sinonasal region were excluded from this study.

Study sample

The four hundred bilateral maxillary sinus regions of 200 CBCT scans of patients who fulfilled the inclusion and exclusion criteria were included in the present study. The male-to-female scan ratio was equal. The sample size is calculated with this formula N = Z2PQ/d2 and the final sample size was 200. This sample size is calculated from Epi Info software—C.D.C., USA (version 7.1). The sampling method was convenience sampling.

Interpretation

The identification of Haller cell on CBCT scans was made by evaluating the scans. First, the coronal plane was assessed, and then, the axial and sagittal planes were assessed to differentiate Haller cell from simple bone crests. Next, evaluation of the Haller cell was done as given by Simeunovic[4]: “ethmoid cell that advance in the orbital floor or the roof of the maxillary sinus, respectively, as far as the vicinity of the maxillary ostium, which may build the lateral wall of the infundibulum.” Finally, the volumetric measurement was carried out. First, the total cell size (total volume) of the discovered Haller cell was measured. Next, the size of the Haller cell was measured at the maximum mediolateral dimension. Haller cell was arbitrarily categorized based on their size into small (<2 mm), medium (2–4 mm), and large (>4 mm).[5] Next, AMO was evaluated as given in the literature[6] “AMO is considered any opening other than the primary ostium located below the uncinated process and above the inferior turbinate along the medial wall of the maxillary sinus.”

Observers

All scans were analyzed and interpreted by two experienced oral and maxillofacial radiologists. Each observer independently interpreted each scan, followed by a discussion of each radiograph between the two observers. Inter-observer variability was calculated using Fleiss and Cohen kappa statistics. Cohen's kappa shows almost perfect agreement between the two observers of the study.

Statistical analysis

Data was coded and proofed for entry errors. Then, it was compiled on an MS Office Excel Sheet. All analysis was carried out using Statistical Package for Social Sciences (SPSS) 24.0; I.B.M. Analytics, USA. A Chi-square test was done, and descriptive statistics were expressed in numbers and percentages.


   Results Top


The two hundred CBCT scans of 400 bilateral maxillary sinus region patients were evaluated for the presence of Haller cell.

Haller cell was present in 56 scans out of 400 bilateral maxillary sinus CBCT scans of patients, and the prevalence rate was 28% in our study population [Table 1], [Figure 1].
Table 1: Prevalence of Haller cell in the CBCT scans of the study participants

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Figure 1: Presence of Haller cell

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Out of the total 56 scans, unilateral Haller cell was seen in 40 scans (20%), and bilateral Haller cell were present in 16 scans (8%) [Table 2].
Table 2: Site specificity of the Haller cell in the CBCT scans of the study participants

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Out of 40 scans with unilateral Haller cell, in 23 scans, the Haller cell (11.5%) was seen on the right side, whereas in 17, the Haller cell (8.5%) was observed on the left side [Table 3].
Table 3: Side specificity of the Haller cell in the CBCT scans of the study participants

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Out of 56 scans with the presence of Haller cell, 44 scans (22%) were seen with single Haller cell, and 12 scans (6%) were seen with multiple Haller cell [Table 4].
Table 4: Number of Haller cell in the CBCT scans of the study participants

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Haller cell were found in small, medium, and large sizes. In our study, small-sized Haller cell was seen in 22 scans (11%), medium-sized was seen in 26 scans (13%), and large-sized was seen in eight scans (4%). Haller cell were seen [Table 5], [Figure 2].
Table 5: Size of Haller cell in the CBCT scans of the study participants

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Figure 2: Mesiodistal width of Haller cell

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The 200 CBCT scans of patients (400 bilateral maxillary sinus region) were evaluated for the presence of AMO It was present unilaterally on the right side in 10 scans, and the prevalence rate was 5%. [Table 6], [Figure 3]
Table 6: Prevalence of accessory maxillary ostium (AMO) in the CBCT scans of the study participants

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Figure 3: The presence of AMO

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   Discussion Top


Haller cell do not indicate a sick condition, but they can be accountable for patient symptoms. A literature search did not reveal any previous studies investigating the prevalence of Haller cell and AMO using CBCT in healthy participants (with no radiographic evidence of maxillary sinusitis). To the best of our knowledge, this was the first study.

Haller cell also have a role in disorders such as orofacial discomfort, chronic sinogenic headache, and orbital edema.

Haller cell were investigated in cadaver studies, OPG studies, CT studies, and CBCT studies.

A cadaveric study[7] on the prevalence of Haller cell concluded that ethmoid cells are extremely variable in anatomic characteristics and can readily be identified and segregated.

Very few studies have used OPG as a radiographic imaging tool. A study by Raina et al.[8] reported a prevalence of 16%, and Davoodi[9] showed a prevalence of 17.8% in their studies. This difference could have been due to variations in the population studied sample sizes and subjective judgment. The authors concluded that further studies employ advanced imaging modalities. One of the OPG studies conducted by Ahmad et al.[10] concluded that OPG is not the best method to check the prevalence of the presence of Haller cell.

Among the many studies using CT for the presence of Haller cell, one study[11] indicated that even on a CT, the infraorbital ethmoidal cell might be missed due to different image acquisition protocols.

The first study that used CBCT in evaluating Haller cell was conducted by Mathew et al.[5] and concluded that the prevalence of Haller cell in their study was relatively high, about 60%. This could be explained by the imaging tool used in the investigation; because CBCT is a volumetric imaging technique, it captures any Haller cell present, regardless of size; in contrast, small-sized Haller cell in multislice CT scans could easily be missed in the interslice intervals.

CBCT studies have been carried out by Özcan et al.,[12] Friedrich et al.[4] They reported a prevalence rate of 7.73% and 23.62% and concluded that the relationship between Haller cell and maxillary sinus pathology was insignificant. Still, Ali et al.[13] and Kamdi et al.[14] reported a prevalence rate of 36.3% and 49%. They concluded that there was a relation between the presence of Haller cell and maxillary sinus disease.

In our study, we found Haller cell predominantly on the unilateral side with a prevalence rate of 11.5%, and the same result was noted by Raina et al.[8] and Mathew et al.[5] Still, Ahmed et al.[10] suggested contradictory results as they recorded both unilateral and bilateral Haller cell. This difference could have been to variations in the population studied.

In our study, small-sized Haller cell was seen in 22 scans (11%), medium-sized was seen in 26 scans (13%), and large-sized was seen in eight scans (4%). Medium-sized (2–4 mm) Haller cell were recorded more in our study, around 13%.

In our study, a single Haller cell is more commonly seen than multiple Haller cell, and a similar result was noted by Adaki et al.[15]

Defects in the fontanel region of the lateral nasal wall have been described in the literature as “accessory” or “secondary” Ostia. Earlier cadaveric and clinical examinations have reported the prevalence of AMO in humans to range from 0 to 43%.[16] Ali et al.[13] conducted the first study to investigate the prevalence and clinical significance of AMO using CBCT in human subjects. They concluded that the prevalence rate of AMO was 23.7%. In several studies, AMO is an anatomical variation associated with chronic sinusitis development. It was reported that AMO is present in 30% of chronic maxillary sinusitis patients and 10–20% of healthy individuals.[17]

In our study, we have seen the unilateral presence of AMO in 5% of healthy individuals with no radiographic evidence of maxillary sinusitis, which is quite high as compared to the study conducted by Mladina et al.[18] who noted the unilateral AMO in healthy volunteers with the prevalence rate of 0.48%. According to them, the fontanel defect is not a physiological AMO because if one were required for human maxillary sinuses, it would have evolved in all of us. This defect, however, is very rare in healthy people and more common in those with chronic maxillary sinusitis, which theoretically involves disturbances in the mucociliary clearance of the related maxillary sinus.

Limitations

The maxillary sinus scans of the Maharashtrian population were used in this investigation to determine the overall prevalence of Haller cell.

Future prospects

The study sample should be drawn from around India and have a large sample size.


   Conclusion Top


This study employed CBCT to investigate the prevalence of Haller cell and AMO in the participants with no radiographic evidence of maxillary sinusitis. Knowledge of Haller cell & AMO may aid in the interpretation of CBCT, which may also forewarn surgeons before endo-nasal surgeries, averting any unfavorable intraoperative problems.

Key message

The frequency and volumetry of Haller cell and the prevalence of AMO were assessed using CBCT scans. This was the first study using CBCT to investigate the prevalence of Haller cell and AMO in the participants with no radiographic evidence of maxillary sinusitis, as Haller cell are the anatomical variation in paranasal sinuses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Von Haller A, Cullen W editors. First Lines of Physiology. 1st American. ed. Edinburgh: Obrabran, Penniman; 1803. p. 223–5.  Back to cited text no. 1
    
2.
Prescher A. Clinical anatomy of the paranasal sinuses. Descriptive anatomy, topography and important variations. HNO 2009;57:1039–50.  Back to cited text no. 2
    
3.
Ramaswamy P, Sai Kiran C, Santosh N, Smitha B, Sudhakar S. Prevalence of Haller's cells in south Indian population using digital panoramic radiographs. Int J Stomatol Occlusion Med 2015;8:12–6.  Back to cited text no. 3
    
4.
Friedrich RE, Fraederich M, Schoen G. Frequency and volumetry of infraorbital ethmoid cells (Haller cell) on cone-beam computed tomograms (CBCT) of the mid-face. GMS. Interdiscip Plast Reconstr Surg DGPW 2017;6:1–9. doi: 10.3205/iprs000109.  Back to cited text no. 4
    
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Mathew R, Omami G, Hand A, Fellows D, Lurie A. Cone beam C.T. analysis of Haller cell: Prevalence and clinical significance. Dentomaxillofac Radiol 2013;42:20130055. doi: 10.1259/dmfr. 20130055.  Back to cited text no. 5
    
6.
Ali IK, Sansare K, Karjodkar FR, Vanga K, Salve P, Pawar AM. Cone-beam computed tomography analysis of accessory maxillary ostium and Haller cell: prevalence and clinical significance. Imaging Sci Dent 2017;47:33–7.  Back to cited text no. 6
    
7.
Van Alyea OE. Ethmoid labyrinth anatomic study, with consideration of the clinical significance of its structural characteristics. Arch Otolaryngol 1939;29:881–902.  Back to cited text no. 7
    
8.
Raina A, Guledgud MV, Patil K. Infraorbital ethmoid (Haller's) cells: A panoramic radiographic study. Dentomaxillofac Radiol 2012;41:305–8.  Back to cited text no. 8
    
9.
Davoodi L, Ghaffari R, Sheykhi M, Sarikhani KH. Prevalence of infraorbital ethmoid (Hallers) Air cells on panoramic radiographs in patients older than 4 years referred to dental school of Islamic Azad University Khorasgan branch. J Shahid Sadoughi Univ Med Sci 2016;24:119–26.  Back to cited text no. 9
    
10.
Ahmad M, Khurana N, Jaberi J, Sampair C, Kuba R. Prevalence of infraorbital ethmoid (Haller's) cells on panoramic radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:658–61.  Back to cited text no. 10
    
11.
Wanamaker H. Role of Haller's cell in headache and sinus disease: A case report. Otolaryngol Head Neck Surg 1996;114:324–7.  Back to cited text no. 11
    
12.
Özcan İ, Göksel S, Çakır-Karabaş H, Ünsal G. CBCT analysis of Haller cell: Relationship with accessory maxillary ostium and maxillary sinus pathologies. Oral Radiol 2021;37:502–6.  Back to cited text no. 12
    
13.
Ali I, Sansare K, Karjodkar F, Vanga K, Salve P, Pawar A. Cone-beam computed tomography analysis of accessory maxillary ostium and Haller cell: Prevalence and clinical significance. Imaging Sci Dent 2017;47:33–7.  Back to cited text no. 13
    
14.
Kamdi P, Nimma V, Ramchandani A, Ramaswami E, Gogri A, Umarji H. Evaluation of haller cell on CBCT and its association with maxillary sinus pathologies. J Indian Acad Oral Med Radiol 2018;30:41–5.  Back to cited text no. 14
  [Full text]  
15.
Adaki S, Karagir A, Shah K, Adaki R. Prevalence of haller infraorbital ethmoidal cells on panoramic radiograph – A prospective study. J Indian Acad Oral Med Radiol 2021;33:195–9.  Back to cited text no. 15
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Kumar H, Choudhry R, Kakar S. Accessory maxillary Ostia: Topography and clinical application. J Anat Soc India 2001;50:3–5.  Back to cited text no. 16
    
17.
Jones N. CT of the paranasal sinuses: A review of the correlation with clinical, surgical and histopathological findings. Clin Otolaryngol Allied Sci 2002;27:11–7.  Back to cited text no. 17
    
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Mladina R, Vuković K, Poje G. The two holes syndrome. Am J Rhinol Allergy 2009;23:602–4.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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