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Original Article |

Diagnostic Value of Nasal Allergen Challenge Combined With Radiography and Ultrasonography in Chronic Maxillary Sinus Disease FREE

Zdenek Pelikan, MD, PhD
[+] Author Affiliations

Author Affiliation: Allergy Research Foundation, Breda, the Netherlands.


Arch Otolaryngol Head Neck Surg. 2009;135(12):1246-1255. doi:10.1001/archoto.2009.189.
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Published online

Objective  To investigate the possible role of nasal allergy in chronic disease of the maxillary sinuses (CDMS) by means of nasal provocation test (NPT) with allergen combined with radiography and ultrasonography.

Design  Prospective clinical controlled study.

Setting  Academic referral center.

Patients  Seventy-one patients with CDMS and 16 control subjects with allergic rhinitis but no history of sinus disease.

Interventions  In the 71 patients, a total of 135 NPTs and 71 control challenges with phosphate-buffered saline were performed by rhinomanometry combined with radiography and ultrasonography. In the control patients, 16 positive NPTs were repeated and combined with radiography and ultrasonography.

Main Outcome Measures  Number, type, and timing of nasal responses with accompanying changes on radiographs and ultrasonograms.

Results  Of the 71 patients, 67 developed 104 positive nasal responses of various types (P < .001), 89 of which were accompanied by significant changes on radiographs (P = .008), whereas 83 were also associated with significant changes on ultrasonograms (P = .007). No significant changes on the radiographs or the ultrasonograms were recorded during the 71 phosphate-buffered saline control tests in the patients with CDMS (P = .14 and .06, respectively) or during the 16 NPTs in control subjects (P = .15 and .12, respectively). The radiographic and ultrasonographic findings were significantly correlated (r = 0.81; P < .01).

Conclusions  Nasal allergy may be involved in some patients with CDMS, resulting in appearance of a maxillary sinus response. Monitoring this response by means of serial ultrasonography and, if necessary, also by conventional radiography or computed tomography simultaneously with the nasal challenge with allergen seems to be a very useful diagnostic supplement allowing additional therapeutic measures focused on the nasal allergy.

Figures in this Article

Chronic disease of the maxillary sinuses (CDMS) is a common disorder, affecting a wide adult as well as pediatric population.14 Although the involvement of hypersensitivity mechanisms, and especially of nasal allergy, in CDMS has been recognized, the diagnostic procedures for this disorder and this relationship vary.1,327 There is a dearth of information regarding the direct causal involvement of hypersensitivity mechanisms of the nasal mucosa and potential consequences within the maxillary sinuses.13,7,8,2830 Moreover, few data are available to illustrate the possible existence of various types of maxillary sinus response caused by immunologic events in the nasal mucosa.1,8,29 Another issue discussed is the recording of particular changes in the paranasal sinuses and their mucosal membrane.1,2,1127 Diagnostic value of the various imaging techniques differs and depends on a variety of factors, such as purposes, basic indications, practice facilities, and costs.1,916,1923,31 The imaging techniques are usually used in a single application for evaluation of the temporary state of the particular sinuses.1,20,22 However, most of these techniques are not suitable for serial application for several reasons, such as relatively higher costs and unnecessary exposure to radiation or magnetic resonance.1,3235 On the other hand, hypersensitivity mechanisms, such as allergic reaction in the nasal mucosa, represent a dynamic process necessitating a dynamic approach, which means recording of the relevant variables before and repeatedly after the allergen exposure.3237 Therefore, although they may gather excellent data, not all imaging techniques are suitable for this aim.3235 In our previous studies, we demonstrated involvement of nasal allergy in chronic maxillary sinus disease as monitored by conventional radiography.3235 The purpose of this study was (1) to investigate the existence of particular types of maxillary sinus response induced by nasal allergy as recorded by radiography and ultrasonography and (2) to evaluate the suitability of ultrasonography in combination with nasal challenge for diagnostic screening of the role of nasal allergy in patients with CDMS.

PATIENTS

Eighty-four patients with CDMS of longer than 3 years' duration, without an air-fluid level on radiographs, were referred to the Department of Allergology and Immunology, Institute of Medical Sciences “De Klokkenberg,” Breda, the Netherlands, from 1999 through 2000 by otolaryngologists with the request to perform further diagnostic procedures focused on possible involvement of allergy in their CDMS. All of these patients had previously been examined by otolaryngologists using standard procedures, including computed tomographic scans of the paranasal sinuses. They had been previously treated with various antibiotics, decongestants, and H1-receptor antagonists. They had undergone sinus puncture and some had also had tonsillectomy and adenoidectomy, but without satisfactory improvement of their complaints. None of them was treated with immunotherapy, oral corticosteroids, nasal cromolyn sodium (disodium cromoglycate), or leukotriene modifiers. Of these 84 consecutively referred patients, 71 were willing to participate voluntarily in this study (Table 1). These patients, 16 to 48 years of age, underwent a routine diagnostic procedure consisting of a detailed disease history, physical and basic laboratory examination, bacteriologic examination of the nasal secretions and sputum, blood differential cell count, nasal secretion cytogram, serum skin tests with basic inhalant allergens, paper radioimmunosorbent test, radioallergosorbent test, rhinoscopy, and screening plain radiography of paranasal sinuses. Nasal histamine thresholds were determined, and 135 nasal provocation tests (NPTs) with various inhalant allergens were performed by means of rhinomanometry combined with simultaneous conventional radiography and ultrasonography of the maxillary sinuses.

Table Graphic Jump LocationTable 1. Characteristics of Patients and Control Subjects

In each patient, a control nasal challenge with phosphate-buffered saline (PBS) was also performed according to the same schedule as that used for the NPTs with allergens and supplemented with radiographs and ultrasonograms of the maxillary sinuses. A 4-day interval was always inserted between the consecutive tests. Patients were examined when they were without manifest sinus and nasal complaints and without nasal infection. Topical glucocorticosteroids and long-acting H1-receptor antagonists were withdrawn 6 weeks before the study, whereas short-acting H1-receptor antagonists and nasal decongestants were stopped 48 hours before the study. The local ethics committee approved this study, and informed consent was obtained from all participants.

CONTROL GROUP

Sixteen patients with allergic rhinitis, confirmed by positive history, skin tests, and nasal challenges with various inhalant allergens but without any history of sinusitis and with normal radiographic findings, volunteered to participate in this study. In these patients, 16 positive NPTs with Dermatophagoides pteronyssinus or grass pollen were repeated out of season and supplemented with radiographs and ultrasonograms of the maxillary sinuses.

ALLERGENS

Dialyzed and lyophilized allergen extracts (Allergopharma, Reinbek, Germany) were diluted in PBS and used in concentrations of 500 biological units/mL for skin tests and 1000 to 3000 biological units/mL for NPTs (Table 2). If indicated, the higher dilutions of the allergen extracts were used for the skin tests as well as for the NPTs.

Table Graphic Jump LocationTable 2. Allergens Used for Nasal Provocation Tests
SKIN TESTS

The intradermal tests were performed and evaluated 20 minutes after the injection, according to a standard schedule. A skin wheal reaction (>7.0 mm in diameter) appearing 20 minutes after the injection was considered to be a positive immediate skin response.3237

NASAL PROVOCATION TESTS

The NPTs with allergens were performed by the rhinomanometry technique, described previously.3437 The nasopharynx-nostril pressure gradients (NPGs) (ΔP, expressed in centimeters of water) recorded by this technique were considered to be the basic measures of the nasal mucosa response (nasal obstruction). The NPTs were performed according to the following schedule: (1) initial (baseline) values were recorded at 0, 5, and 10 minutes; (2) PBS control values were recorded at 0, 5, and 10 minutes after a 3-minute application of PBS to the nasal mucosa of the nonintubated nasal cavity by means of a saturated wad of cotton wool on a nasal probe, inserted under the concha media and placed away from the natural ostia of the maxillary sinus; and (3) test values were recorded similarly after a 3-minute application of allergen at 0, 5, 10, 20, 30, 45, 60, 90, and 120 minutes, then every hour up to the 12th hour, and then every second hour between the 24th and 38th hours and between the 48th and 56th hours. Nasal response (NR) was considered to be positive when the mean NPG values after the allergen challenge increased by at least 2.0 cm H2O (mean [SE], 1.2 [0.3] cm H2O) with respect to the mean PBS values, recorded during at least 3 consecutive time intervals. The NPG changes occurring within 60 minutes after the allergen challenge were considered to be a positive immediate NR; those appearing within 4 to 12 hours, a positive late NR; and those occurring later than 24 hours, a positive delayed NR. Allergens for the NPTs were chosen with respect to the patient's history, positive skin test, or positive radioallergosorbent test results (Table 2).

RADIOGRAPHS

Conventional radiographs of maxillary sinuses in Waters projection, while other parts have been shielded, were performed before and then 0.5, 1, 2, 6, 8, 12, 24, 36, and 48 hours after the nasal allergen challenge and evaluated by a radiologist in a blinded manner, without knowledge of the patient as well as the sequence. The following parameters and their changes on the radiographs were evaluated: (1) osseous skeleton; (2) air-fluid level; (3) profile of the increased mucosal membrane in the maxillary sinuses (an increase in the mucosal thickening >3 mm, due to edema and/or infiltration, was considered to be abnormal); (4) decrease in aeration; and (5) appearance of opacification.3335 The changes were evaluated by means of a grading score system (Pelikan scoring system) and calculated from both the maxillary sinuses as a total mean score (Table 3).

Table Graphic Jump LocationTable 3. Pelikan Scoring System in Maxillary Sinusesa
ULTRASONOGRAPHY

Ultrasonography was performed by means of a 1-dimensional A-scan (Enterscan model 270; Pie Medical Imaging BV, Maastricht, the Netherlands) with a single crystal 3.5- to 5.0-MHz probe and a printer (model P50E; Mitsubishi Digital Electronics America, Irvine, California). The ultrasonograms were recorded before and repeatedly after the nasal allergen challenge at the same time intervals as the NPG recording. The ultrasonograms were evaluated in a blinded manner. The ultrasonographic findings were evaluated according to the following criteria: (1) x-axis (scale in centimeters), visualizing the depth of the maxillary sinus: (a) 0 to 0.3 cm = “initial echo” (standard calibration) and (b) the echo distances of less than 1.0 cm = normal appearance, representing echo penetration through the skin and frontal wall of maxillary sinus (no pathology) (grade 0); 1.0 to less than 2.0 cm = slight thickening of the sinus mucosal membrane (grade 1); 2.0 to less than 3.0 cm = moderate thickening of the sinus mucosal membrane plus mucus layer (grade 2); 3.0 to less than 4.0 cm = distinct thickening of the sinus mucosal membrane plus mucus layer (grade 3); 4.0 to less than 5.0 cm = distinct thickening of the sinus mucosal membrane plus fluid in the sinus cavity (grade 4); greater than or equal to 5.0 cm = back wall echo (grade 5); (2) y-axis (scale in millimeters), representing the volume (intensity) of the echo signal (correlating with the density of the particular tissue or medium): less than 1.0 mm = weak signal or low volume (normal appearance) (grade 0); 1.0 to less than 2.0 mm = moderate volume (abnormal) (grade 1); 2.0 to less than 3.0 mm = distinct volume (grade 2); greater than or equal to 3.0 mm = large volume (distinct pathology) (grade 3).11,16,18,19,24,26,27 The changes were evaluated by means of our grading scale and calculated from both of the maxillary sinuses as a total mean score (Table 3).

STATISTICAL ANALYSIS

The NRs and the PBS control tests recorded in individual patients were statistically evaluated by Wilcoxon matched-pair signed rank test, comparing the NPG values recorded after the allergen or PBS challenge at each time point with the mean prechallenge values. The positive and negative NRs of the same type were compared and statistically evaluated by the Mann-Whitney test.

The correlation between the positive as well as negative radiographic and ultrasonographic changes was analyzed by the Spearman rank correlation coefficient. The agreement between the radiographic and ultrasonographic changes during the particular types of NR was analyzed by means of the Mann-Whitney test. P < .05 was considered to be statistically significant for all statistical methods used.

NASAL RESPONSES

In the 71 patients, 135 NPTs were performed. Sixty-seven patients developed 104 positive NRs (P < .001) compared with the PBS control tests (Table 4): 31 isolated immediate NRs (P < .001), 48 isolated late NRs (P < .001), 10 dual late NRs (immediate + late; P < .01 and P < .001, respectively), 13 isolated delayed NRs (P < .01), 2 dual delayed NRs (immediate + delayed; P < .01 and P < .05, respectively), and 19 negative NRs (P > .05) (Tables 4, 5, and 6; Figures 1B, 2B, and 3B).The remaining 4 patients showed 12 negative NRs (P > .05). The 71 PBS control tests did not display any significant changes in the NPG values with respect to the baseline values (P > .1). The difference between the positive and the negative NRs was statistically significant (P < .01). No significant differences were found in the appearance of particular NR types with respect to the individual allergens (P > .05). The agreement between the positive skin test results and positive NRs was 77% (P ≤ .05).

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Figure 1.

Maxillary sinus responses accompanying isolated immediate nasal responses (IINR; n = 31). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during IINR and PBS. I indicates initial (baseline) values.

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Figure 2.

Maxillary sinus responses accompanying isolated late nasal responses (ILNR; n = 48). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during ILNR and PBS. I indicates initial (baseline) values.

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Figure 3.

Maxillary sinus responses accompanying isolated delayed nasal responses (IDYNR; n = 13). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during IDYNR and PBS. I indicates initial (baseline) values.

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Table Graphic Jump LocationTable 4. MSRs Accompanying Positive and Negative NRsa
Table Graphic Jump LocationTable 5. MSRs Accompanying Particular Types of NR
Table Graphic Jump LocationTable 6. Changes on Radiographs and Ultrasonograms Recorded During Particular Types of NR
RADIOGRAPHS OF THE MAXILLARY SINUSES

In 69 of the 71 patients (97%), a slight thickening of the maxillary sinus mucosa (1-2 mm) had already been recorded on the radiographs before the NPTs. Eighty-nine of the 104 positive NRs (28 isolated immediate, 43 isolated late, 6 dual late, 11 isolated delayed, and 1 dual delayed) and 5 of the 31 negative NRs were accompanied by significant changes of the radiographs of maxillary sinuses (P = .008) (Table 4 and Table 5). The changes included a distinct increase in the thickening of the mucosal membrane (>3.0 mm) and sometimes also a decrease in aeration and the appearance of opacification (Table 6; Figures 4, 5, and 6). The mean (SD) total point score of radiographic changes after allergen challenge, evaluated by the Pelikan point grading score (Table 3), was 476 (48). The mean total point scores of the radiographic changes recorded at individual time intervals are presented in Table 7, and those recorded during each type of NR are displayed in Figures 1A, 2A, and 3A. The agreement between the positive NRs and the appearance of radiographic changes was statistically highly significant (P < .001). No significant radiographic changes were recorded during the 71 PBS control tests (P = .14).

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Figure 4.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated immediate nasal response to challenge with dog danders (500 biological units/mL). A, Before allergen challenge; B through D, 1 hour, 2 hours, and 12 hours after challenge, respectively.

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Figure 5.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated late nasal response to challenge with grass pollen mix (1000 biological units/mL). A, Before allergen challenge; B through D, 6 hours, 12 hours, and 24 hours after challenge, respectively.

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Figure 6.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated delayed nasal response to challenge with Dermatophagoides pteronyssinus (1000 biological units/mL). A, Before allergen challenge; B through D, 24 hours, 36 hours, and 56 hours after challenge, respectively.

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Table Graphic Jump LocationTable 7. Comparison of Total Point Score Recorded on Radiograms and Ultrasonograms for 135 NPTs by Time Intervals
ULTRASONOGRAMS OF THE MAXILLARY SINUSES

Significant changes on the ultrasonograms of the maxillary sinuses (P = .007) were found in association with 83 of the 104 positive NRs (25 isolated immediate, 41 isolated late, 5 dual late, 11 isolated delayed, and 1 dual delayed) and 2 of the negative NRs recorded in 67 patients, as well as with 3 of the 12 negative NRs recorded in the remaining 4 patients (Table 4 and Table 5). The ultrasonographic changes included increased thickening of the mucosal membrane in the maxillary sinuses, sometimes associated with a transient accumulation of the secretions at the bottom of the sinuses (Table 6; Figures 4, 5, and 6). The mean (SD) total point score of ultrasonographic changes after allergen challenge, evaluated by the Pelikan point grading score (Table 3), was 399 (41). The mean total point scores of the ultrasonographic changes recorded at individual time intervals are summarized in Table 7, and the mean point scores recorded during each type of NR are presented in Figures 1A, 2A, and 3A. The agreement between the positive NRs and the appearance of the ultrasonographic changes was statistically significant (P < .01). No ultrasonographic changes were observed during the 71 PBS control tests (P = .06).

RELATIONSHIP BETWEEN RADIOGRAPHIC AND ULTRASONOGRAPHIC CHANGES

The agreement between the appearance of radiographic and ultrasonographic changes recorded during the positive and negative NRs, during the particular types of positive NRs and at individual time intervals after the allergen challenge, was statistically significant (P < .01) (Tables 4, 5, 6, and 7). However, this agreement demonstrated some smaller nonsignificant variations with respect to the individual types of NRs. The total correlation between the radiographic and ultrasonographic changes evaluated by means of Spearman rank correlation coefficient was highly significant both for the positive and for the negative cases (r = 0.89, P < .001; r = −0.73, P < .01, respectively). The correlation coefficients between the radiographic and ultrasonographic changes recorded at individual time intervals after the allergen challenge are presented in Table 7.

CONTROL SUBJECTS

In 16 control subjects who developed 16 positive NRs to the repeated allergen challenge (5 isolated immediate NRs [P < .01] and 11 isolated late NRs [P < .01]), no significant radiographic or ultrasonographic changes of the maxillary sinuses were observed (P = .15 and .12, respectively).

The possible involvement of allergy, and especially of nasal allergy, in some forms of sinus disease has already been reported in the literature.1,310,29,30,3235 There are a number of anatomic and physiologic similarities between the nasal mucosa and mucosa of the maxillary sinuses.14,7,8,27,30,3335 The maxillary sinuses open into the middle meatus of the nasal cavity through the ostium, which plays a pivotal role in their functions. The ostium acts as an anatomic and functional valve, facilitating secretion drainage and gas exchange from the sinus into the nasal cavity. The factors disturbing the drainage functions of ostia, and thus leading to the retention of secretions and gases and negative pressure in the maxillary sinuses, include (1) edema of the nasal mucosa causing limitation of ostium patency, (2) reduced transport capacity of mucus on the surface of sinus mucosal membrane due to abnormalities of the cilia and their function, and (3) increased production of secretions and gases in the sinuses, exceeding the drainage capacity of ostia.14,6,7,35,38,39 The cross-sectional area of the ostium is also the primary determinant of the gas exchange in the human maxillary sinuses.33,3841 In addition, the nasal airflow influences gas exchange in the sinuses, which is twice as fast by nasal breathing than during oral breathing.3942 The increased nasal mucosal edema may lead not only to mechanical occlusion of the maxillary ostia from outside by surrounding nasal mucosal tissue but sometimes also to extension of the edematous nasal mucosa beyond the ostium margin.1,5,33,34,3841

All of these changes lead to partial or total closing of the ostia, resulting in accumulation of secretions, gases, and soft-tissue mass in the sinus. This process leads to subsequent edema and/or infiltration of the sinus mucosa, expressed as mucosal thickening, decreased aeration, appearance of opacification, and sometimes formation of fluid level and soft-tissue mass, which is referred to as a sinus response.3235

Two possible pathways—one of them upon involvement of the nasal mucosa, and the other upon passing the nasal mucosa without affecting it—could probably explain some of our results.3335 Of the 104 positive NRs, 89 positive NRs were accompanied by radiographic and 83 by ultrasonographic changes of the maxillary sinuses (Table 4). In these cases, which can be viewed as a “secondary” form of sinus response, the immunologic event located primarily in the nasal mucosa may induce an additional sinus response.3335 This mechanism is identical to that leading to the obstruction of the ostia through the edema of the nasal mucosa as reported by other investigators.68,2830,3842 In contrast, during 5 of 31 negative NRs to allergen challenge, significant radiographic and ultrasonographic changes were also recorded (Tables 4, 5, and 6). In such cases, which represent a “primary” form of sinus response, the allergen may pass the nasal cavity barrier and penetrate through the ostium into the sinus without causing any nasal response.28,3335,42 This mechanism seems to be similar to that described by Slavin4 as “trapping of foreign particles” (allergens) into the mucus of the sinuses. The secondary form of sinus disease occurs more frequently than the primary form; preliminary data indicate an approximate ratio of 1:150.34

The diagnostic noninvasive imaging techniques for paranasal sinuses include a number of radiation techniques, such as conventional radiography (plain film), plain tomography, computed tomography (CT scan), and single-photon emission computed tomography (SPECT); techniques on electromagnetic principle, such as magnetic resonance imaging (MRI); or, finally, ultrasonography (echography) techniques.1,3,6,1127,31,33,34,40,4246 The advantages and disadvantages of these techniques can be evaluated by various criteria, such as indication (eg, preoperative assessment, screening examination, and evaluation of therapy), accuracy of the imaging, radiation dose, capability for serial use, and costs.1,1127,31,33,34,4246

In our study, radiography and ultrasonography were compared and tested on their capability for serial documentation of the changes in the maxillary sinuses due to hypersensitivity mechanisms. Conventional radiography is an easy, inexpensive technique, producing limited radiation, that can be repeated up to certain limits, and the results are reproducible.

This technique is suitable for evaluation of the changes appearing in the whole sinuses, including osseous skeleton, air-fluid level, aeration and opacification, and partial changes of the mucosal membrane. Nevertheless, the radiation, even limited, remains a disadvantage of this technique.1,12,13,1517,20,22,27,31,33,34,4346 Undoubtedly, computed tomography, used currently as a standard technique for imaging of paranasal sinuses, is more accurate and generates more information than conventional plain radiographs.20,22,31 However, for purposes of this study, plain radiographs were sufficient to provide simple comparative data to ultrasonography. Ultrasonography is an inexpensive, easy, time- and labor-saving technique generating directly accessible results and without ionizing radiation.1,1116,1820,2427,3235 The important advantage of this method is its unlimited use in time and in number, the possibility of its use also in extramural offices, and low costs.3335 This technique is suitable for reliable evaluation of mucosal thickening adjacent to the anterior and posterior sinus wall and presence of fluid level. However, this technique cannot visualize aeration and opacification of the sinus, and its results depend on the investigator's skill. There are 2 basic types of ultrasonography: A- and B-mode.11,13,26,27 The A-scan is a 1-dimensional method, modulating amplitude, whereas the B-scan modulates the brightness in a 2-dimensional manner. We have used the A-scan because of its reliable evaluation of the mucosal thickening and presence of fluid and its simple operation.3335

The changes on the ultrasonograms and radiographs were evaluated by means of the previously developed Pelikan grading and score system.34,35,47 This semiquantitative system allows comparison of results not only within the same technique, eg, ultrasonography, but also between the different techniques, such as radiography and ultrasonography. In the past my group has also studied reproducibility of ultrasonography, the results of which have been published in part.34,47 The repeated ultrasonograms did not demonstrate any significant differences from the initial ultrasonograms (P > .01).

The results of this study demonstrated significant correlation between the radiographic and ultrasonographic changes of the maxillary sinus mucosal membrane accompanying both positive NRs (P < .001) and negative NRs (P < .01). The differences between the positive and negative responses of maxillary sinuses were statistically highly significant both for the radiographic (P < .001) and for the ultrasonographic (P < .001) changes. Our results showing a correlation of 95% between the radiographic and ultrasonographic findings in the maxillary sinuses are in agreement with results of some investigators,11,12,1416,19,24,25,43 whereas they disagree with data reported by other authors.17 This disagreement may be related to differences in diagnostic procedures, clinical indications, and variables measured.

In conclusion, nasal allergy may be involved in CDMS in some patients. Nasal challenge with allergen combined with ultrasonography and, if necessary, also with one of the radiographic imaging methods may be a useful supplement for the diagnosis of this disorder in the clinical practice, especially in children. The confirmation of involvement of nasal allergy in patients with CDMS would indicate an additional treatment of the nasal allergy.

Correspondence: Zdenek Pelikan, MD, PhD, Allergy Research Foundation, Effenseweg 42, 4838 BB Breda, the Netherlands (zpelikan@casema.nl).

Submitted for Publication: February 4, 2009; final revision received June 23, 2009; accepted July 19, 2009.

Financial Disclosure: None reported.

Slavin  RGSpector  SLBernstein  IL  et al. American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology, The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116 (6) ((suppl)) S13- S47
PubMed Link to Article
Christodoulopoulos  PCameron  LDurham  SHamid  Q Molecular pathology of allergic disease, II: upper airway disease. J Allergy Clin Immunol 2000;105 (2, pt 1) 211- 223
PubMed Link to Article
Meltzer  EOHamilos  DLHadley  JA  et al. American Academy of Allergy, Asthma and Immunology (AAAAI); American Academy of Otolaryngic Allergy (AAOA); American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS); American College of Allergy, Asthma and Immunology (ACAAI); American Rhinologic Society (ARS), Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114 (6) ((suppl)) 155- 212
PubMed Link to Article
Slavin  RG Sinusitis in adults. J Allergy Clin Immunol 1988;81 (5, pt 2) 1028- 1032
PubMed Link to Article
Berrettini  SCarabelli  ASellari-Franceschini  S  et al.  Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999;54 (3) 242- 248
PubMed Link to Article
Ramadan  HHFornelli  ROrtiz  AORodman  S Correlation of allergy and severity of sinus disease. Am J Rhinol 1999;13 (5) 345- 347
PubMed Link to Article
Kirtsreesakul  VNaclerio  RM Role of allergy in rhinosinusitis. Curr Opin Allergy Clin Immunol 2004;4 (1) 17- 23
PubMed Link to Article
Smart  BA The impact of allergic and nonallergic rhinitis on pediatric sinusitis. Curr Allergy Asthma Rep 2006;6 (3) 221- 227
PubMed Link to Article
Hao  JPang  YWang  D Role of allergy and inflammation in nasal polyps and sinusitis [abstract 589]. J Allergy Clin Immunol 2003;111 (1) ((suppl 2)) S216
Link to Article
Gutman  MTorres  SKeen  KJHouser  SM Prevalence of allergy in patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg 2004;130 (5) 545- 552
PubMed Link to Article
Puhakka  THeikkinen  TMäkelä  MJ  et al.  Validity of ultrasonography in diagnosis of acute maxillary sinusitis. Arch Otolaryngol Head Neck Surg 2000;126 (12) 1482- 1486
PubMed Link to Article
Dobson  MJFields  JWoodford  T A comparison of ultrasound and plain radiography in the diagnosis of maxillary sinusitis. Clin Radiol 1996;51 (3) 170- 172
PubMed Link to Article
Ludwig  AMerten  HAWiltfang  JEngelke  WWiese  KG Evaluation of B-scan ultrasound, 3-D ultrasound, roentgen diagnosis and sinus endoscopy in follow-up assessment of the maxillary sinus after sinus floor elevation [in German]. Mund Kiefer Gesichtschir 2002;6 (5) 341- 345
PubMed Link to Article
Karantanas  AHSandris  V Maxillary sinus inflammatory disease: ultrasound compared to computed tomography. Comput Med Imaging Graph 1997;21 (4) 233- 241
PubMed Link to Article
Varonen  HMakela  MSavolainen  SLaara  EHilden  J Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systemic review. J Clin Epidemiol 2000;53 (9) 940- 948
PubMed Link to Article
Revonta  MKuuliala  I The diagnosis and follow-up of pediatric sinusitis: Water's view radiography versus ultrasonography. Laryngoscope 1989;99 (3) 321- 324
PubMed Link to Article
Shapiro  GGFurukawa  CTPierson  WEGilbertson  EBierman  CW Blinded comparison of maxillary sinus radiography and ultrasound for diagnosis of sinusitis. J Allergy Clin Immunol 1986;77 (1, pt 1) 59- 64
PubMed Link to Article
Otten  FWAEngberts  GERGrote  JJ Ultrasonography as a method of examination of the frontal sinus. Clin Otolaryngol Allied Sci 1991;16 (3) 285- 287
PubMed Link to Article
Lucchin  FMinicuci  NRavasi  MA  et al.  Comparison of A-mode ultrasound and computed tomography: detection of secretion in maxillary and frontal sinuses in ventilated patients. Intensive Care Med 1996;22 (11) 1265- 1268
PubMed Link to Article
Benson  MLOliverio  PJZinreich  SJ Imaging techniques: conventional radiography, computed tomography, magnetic resonance, and ultrasonography of the paranasal sinuses. Gershwin  MEIncaudo  GADiseases of the Sinuses. Totowa, NJ Humana Press Inc1996;63- 83
Esser  PDAlderson  POMitnick  RJArliss  JJ Angled-collimator SPECT (A-SPECT): an improved approach to cranial single photon emission tomography. J Nucl Med 1984;25 (7) 805- 809
PubMed
Zinreich  SJ Progress in sinonasal imaging. Ann Otol Rhinol Laryngol 2006;11561- 65
Catalano  PJPayne  SCChoi  EShah  R Correlation between computed tomography and bone single photon emission-computed tomography scintigraphy in patients with chronic rhinosinusitis. Am J Rhinol 2007;21 (4) 433- 438
PubMed Link to Article
Berger  WE Use of A-mode ultrasound for diagnosis of sinus disease in young children. Ann Allergy 1986;56 (1) 39- 43
PubMed
Landman  MD Ultrasound screening for sinus disease. Otolaryngol Head Neck Surg 1986;94 (2) 157- 164
PubMed
Mann  W A- and B- mode ultrasound diagnosis in diseases of the paranasal sinuses and soft tissues of the face. Radiologe 1986;26 (9) 427- 432
PubMed
Revonta  M Ultrasound in the diagnosis of maxillary and frontal sinusitis. Acta Otolaryngol Suppl 1980;3701- 55
PubMed Link to Article
Baroody  FMMucha  SMdeTineo  MNaclerio  RM Nasal challenge with allergen leads to maxillary sinus inflammation. J Allergy Clin Immunol 2008;121 (5) 1126- 1132, e7
PubMed Link to Article
Hamilos  DLLeung  DYWood  R  et al.  Evidence for distinct cytokine expression in allergic versus nonallergic chronic sinusitis. J Allergy Clin Immunol 1995;96 (4) 537- 544
PubMed Link to Article
Hamilos  DL Chronic sinusitis. J Allergy Clin Immunol 2000;106 (2) 213- 227
PubMed Link to Article
Garcia  DPCorbett  MLEberly  SM  et al.  Radiographic imaging studies in pediatric chronic sinusitis. J Allergy Clin Immunol 1994;94 (3 pt 1) 523- 530
PubMed Link to Article
Pelikan  Z Rhinitis, secretory otitis media and sinus disease caused by food allergy. Brostoff  JChallacombe  SJFood Allergy and Intolerance. London, England Saunders2002;497- 528
Pelikan  Z The role of allergy in sinus disease: children and adults. Clin Rev Allergy Immunol 1998;16 (1-2) 55- 156
PubMed Link to Article
Pelikan  ZPelikan-Filipek  MOssekoppele  R Chronic sinusitis maxillaris (CSM): the role of nasal allergy and the diagnostic value of echography and radiographs [abstract 1500]. Allergy Clin Immunol News 1994; ((suppl 2)) 415
Pelikan  Z The Late Nasal Response: Its Clinical and Immunologic Features, Possible Mechanisms and Pharmacologic Modulation [thesis].  Amsterdam, the Netherlands Free University of Amsterdam1996;
Pelikan  Z Late and delayed responses of the nasal mucosa to allergen challenge. Ann Allergy 1978;41 (1) 37- 47
PubMed
Melillo  GBonini  SCocco  G  et al.  EAACI provocation tests with allergens: report prepared by the European Academy of Allergology and Clinical Immunology Subcommittee on provocation tests with allergens. Allergy 1997;52 (35) ((suppl)) 1- 35
PubMed Link to Article
Aust  RStierna  PDrettner  B Basic experimental studies of ostial patency and local metabolic environment of the maxillary sinus. Acta Otolaryngol Suppl 1994;5157- 11
PubMed Link to Article
Cole  P Physiology of the nose and paranasal sinuses. Gershwin  MEIncaudo  GADiseases of the Sinuses. Totowa, NJ Humana Press Inc1996;33- 51
Paulsson  BBende  MLarsson  IOhlin  P Ventilation of the paranasal sinuses studied with dynamic emission computed tomography. Laryngoscope 1992;102 (4) 451- 457
PubMed Link to Article
Aust  R Measurements of the ostial size and oxygen tension in the maxillary sinuses. Rhinology 1976;14 (1) 43- 44
PubMed
Gwaltney  JM  JrHendley  JOPhillips  CDBass  CRMygind  NWinther  B Nose blowing propels nasal fluids into the paranasal sinuses. Clin Infect Dis 2000;30 (2) 387- 391
PubMed Link to Article
Roberts  DNHampal  SEast  CALloyd  GA The diagnosis of inflammatory sinonasal disease. J Laryngol Otol 1995;109 (1) 27- 30
PubMed Link to Article
De Sutter  ASpee  RPeersman  W  et al.  Study on the reproducibility of the Water's views of the maxillary sinuses. Rhinology 2005;43 (1) 55- 60
PubMed
Aaløkken  TMHagtvedt  TDalen  IKolbenstvedt  A Conventional sinus radiography compared with CT in the diagnosis of acute sinusitis. Dentomaxillofac Radiol 2003;32 (1) 60- 62
PubMed Link to Article
Chen  LCHuang  JLWang  CRYeh  KWLin  SJ Use of standard radiography to diagnose paranasal sinus disease of asthmatic children in Taiwan: comparison with computed tomography. Asian Pac J Allergy Immunol 1999;17 (2) 69- 76
PubMed
Pelikan  ZPelikan-Filipek  M The role of nasal allergy in chronic sinusitis maxillaris (CSM): X ray and echography during the nasal response to allergen challenge [abstract 933]. Allergy Clin Immunol News 1991;1 ((suppl)) 334

Figures

Place holder to copy figure label and caption
Figure 1.

Maxillary sinus responses accompanying isolated immediate nasal responses (IINR; n = 31). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during IINR and PBS. I indicates initial (baseline) values.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Maxillary sinus responses accompanying isolated late nasal responses (ILNR; n = 48). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during ILNR and PBS. I indicates initial (baseline) values.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Maxillary sinus responses accompanying isolated delayed nasal responses (IDYNR; n = 13). A, Mean point score of changes recorded on ultrasonograms and radiographs after allergen challenge (ALL) and on ultrasonograms and radiographs after phosphate-buffered saline (PBS) challenge. B, Mean rhinomanometric values (nasopharynx-nostril pressure gradient [NPG]) recorded during IDYNR and PBS. I indicates initial (baseline) values.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated immediate nasal response to challenge with dog danders (500 biological units/mL). A, Before allergen challenge; B through D, 1 hour, 2 hours, and 12 hours after challenge, respectively.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated late nasal response to challenge with grass pollen mix (1000 biological units/mL). A, Before allergen challenge; B through D, 6 hours, 12 hours, and 24 hours after challenge, respectively.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Radiographs (top) and ultrasonograms (bottom) of maxillary sinuses in a patient who developed an associated form of maxillary sinus response induced by primary isolated delayed nasal response to challenge with Dermatophagoides pteronyssinus (1000 biological units/mL). A, Before allergen challenge; B through D, 24 hours, 36 hours, and 56 hours after challenge, respectively.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of Patients and Control Subjects
Table Graphic Jump LocationTable 2. Allergens Used for Nasal Provocation Tests
Table Graphic Jump LocationTable 3. Pelikan Scoring System in Maxillary Sinusesa
Table Graphic Jump LocationTable 4. MSRs Accompanying Positive and Negative NRsa
Table Graphic Jump LocationTable 5. MSRs Accompanying Particular Types of NR
Table Graphic Jump LocationTable 6. Changes on Radiographs and Ultrasonograms Recorded During Particular Types of NR
Table Graphic Jump LocationTable 7. Comparison of Total Point Score Recorded on Radiograms and Ultrasonograms for 135 NPTs by Time Intervals

References

Slavin  RGSpector  SLBernstein  IL  et al. American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology, The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116 (6) ((suppl)) S13- S47
PubMed Link to Article
Christodoulopoulos  PCameron  LDurham  SHamid  Q Molecular pathology of allergic disease, II: upper airway disease. J Allergy Clin Immunol 2000;105 (2, pt 1) 211- 223
PubMed Link to Article
Meltzer  EOHamilos  DLHadley  JA  et al. American Academy of Allergy, Asthma and Immunology (AAAAI); American Academy of Otolaryngic Allergy (AAOA); American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS); American College of Allergy, Asthma and Immunology (ACAAI); American Rhinologic Society (ARS), Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114 (6) ((suppl)) 155- 212
PubMed Link to Article
Slavin  RG Sinusitis in adults. J Allergy Clin Immunol 1988;81 (5, pt 2) 1028- 1032
PubMed Link to Article
Berrettini  SCarabelli  ASellari-Franceschini  S  et al.  Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999;54 (3) 242- 248
PubMed Link to Article
Ramadan  HHFornelli  ROrtiz  AORodman  S Correlation of allergy and severity of sinus disease. Am J Rhinol 1999;13 (5) 345- 347
PubMed Link to Article
Kirtsreesakul  VNaclerio  RM Role of allergy in rhinosinusitis. Curr Opin Allergy Clin Immunol 2004;4 (1) 17- 23
PubMed Link to Article
Smart  BA The impact of allergic and nonallergic rhinitis on pediatric sinusitis. Curr Allergy Asthma Rep 2006;6 (3) 221- 227
PubMed Link to Article
Hao  JPang  YWang  D Role of allergy and inflammation in nasal polyps and sinusitis [abstract 589]. J Allergy Clin Immunol 2003;111 (1) ((suppl 2)) S216
Link to Article
Gutman  MTorres  SKeen  KJHouser  SM Prevalence of allergy in patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg 2004;130 (5) 545- 552
PubMed Link to Article
Puhakka  THeikkinen  TMäkelä  MJ  et al.  Validity of ultrasonography in diagnosis of acute maxillary sinusitis. Arch Otolaryngol Head Neck Surg 2000;126 (12) 1482- 1486
PubMed Link to Article
Dobson  MJFields  JWoodford  T A comparison of ultrasound and plain radiography in the diagnosis of maxillary sinusitis. Clin Radiol 1996;51 (3) 170- 172
PubMed Link to Article
Ludwig  AMerten  HAWiltfang  JEngelke  WWiese  KG Evaluation of B-scan ultrasound, 3-D ultrasound, roentgen diagnosis and sinus endoscopy in follow-up assessment of the maxillary sinus after sinus floor elevation [in German]. Mund Kiefer Gesichtschir 2002;6 (5) 341- 345
PubMed Link to Article
Karantanas  AHSandris  V Maxillary sinus inflammatory disease: ultrasound compared to computed tomography. Comput Med Imaging Graph 1997;21 (4) 233- 241
PubMed Link to Article
Varonen  HMakela  MSavolainen  SLaara  EHilden  J Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systemic review. J Clin Epidemiol 2000;53 (9) 940- 948
PubMed Link to Article
Revonta  MKuuliala  I The diagnosis and follow-up of pediatric sinusitis: Water's view radiography versus ultrasonography. Laryngoscope 1989;99 (3) 321- 324
PubMed Link to Article
Shapiro  GGFurukawa  CTPierson  WEGilbertson  EBierman  CW Blinded comparison of maxillary sinus radiography and ultrasound for diagnosis of sinusitis. J Allergy Clin Immunol 1986;77 (1, pt 1) 59- 64
PubMed Link to Article
Otten  FWAEngberts  GERGrote  JJ Ultrasonography as a method of examination of the frontal sinus. Clin Otolaryngol Allied Sci 1991;16 (3) 285- 287
PubMed Link to Article
Lucchin  FMinicuci  NRavasi  MA  et al.  Comparison of A-mode ultrasound and computed tomography: detection of secretion in maxillary and frontal sinuses in ventilated patients. Intensive Care Med 1996;22 (11) 1265- 1268
PubMed Link to Article
Benson  MLOliverio  PJZinreich  SJ Imaging techniques: conventional radiography, computed tomography, magnetic resonance, and ultrasonography of the paranasal sinuses. Gershwin  MEIncaudo  GADiseases of the Sinuses. Totowa, NJ Humana Press Inc1996;63- 83
Esser  PDAlderson  POMitnick  RJArliss  JJ Angled-collimator SPECT (A-SPECT): an improved approach to cranial single photon emission tomography. J Nucl Med 1984;25 (7) 805- 809
PubMed
Zinreich  SJ Progress in sinonasal imaging. Ann Otol Rhinol Laryngol 2006;11561- 65
Catalano  PJPayne  SCChoi  EShah  R Correlation between computed tomography and bone single photon emission-computed tomography scintigraphy in patients with chronic rhinosinusitis. Am J Rhinol 2007;21 (4) 433- 438
PubMed Link to Article
Berger  WE Use of A-mode ultrasound for diagnosis of sinus disease in young children. Ann Allergy 1986;56 (1) 39- 43
PubMed
Landman  MD Ultrasound screening for sinus disease. Otolaryngol Head Neck Surg 1986;94 (2) 157- 164
PubMed
Mann  W A- and B- mode ultrasound diagnosis in diseases of the paranasal sinuses and soft tissues of the face. Radiologe 1986;26 (9) 427- 432
PubMed
Revonta  M Ultrasound in the diagnosis of maxillary and frontal sinusitis. Acta Otolaryngol Suppl 1980;3701- 55
PubMed Link to Article
Baroody  FMMucha  SMdeTineo  MNaclerio  RM Nasal challenge with allergen leads to maxillary sinus inflammation. J Allergy Clin Immunol 2008;121 (5) 1126- 1132, e7
PubMed Link to Article
Hamilos  DLLeung  DYWood  R  et al.  Evidence for distinct cytokine expression in allergic versus nonallergic chronic sinusitis. J Allergy Clin Immunol 1995;96 (4) 537- 544
PubMed Link to Article
Hamilos  DL Chronic sinusitis. J Allergy Clin Immunol 2000;106 (2) 213- 227
PubMed Link to Article
Garcia  DPCorbett  MLEberly  SM  et al.  Radiographic imaging studies in pediatric chronic sinusitis. J Allergy Clin Immunol 1994;94 (3 pt 1) 523- 530
PubMed Link to Article
Pelikan  Z Rhinitis, secretory otitis media and sinus disease caused by food allergy. Brostoff  JChallacombe  SJFood Allergy and Intolerance. London, England Saunders2002;497- 528
Pelikan  Z The role of allergy in sinus disease: children and adults. Clin Rev Allergy Immunol 1998;16 (1-2) 55- 156
PubMed Link to Article
Pelikan  ZPelikan-Filipek  MOssekoppele  R Chronic sinusitis maxillaris (CSM): the role of nasal allergy and the diagnostic value of echography and radiographs [abstract 1500]. Allergy Clin Immunol News 1994; ((suppl 2)) 415
Pelikan  Z The Late Nasal Response: Its Clinical and Immunologic Features, Possible Mechanisms and Pharmacologic Modulation [thesis].  Amsterdam, the Netherlands Free University of Amsterdam1996;
Pelikan  Z Late and delayed responses of the nasal mucosa to allergen challenge. Ann Allergy 1978;41 (1) 37- 47
PubMed
Melillo  GBonini  SCocco  G  et al.  EAACI provocation tests with allergens: report prepared by the European Academy of Allergology and Clinical Immunology Subcommittee on provocation tests with allergens. Allergy 1997;52 (35) ((suppl)) 1- 35
PubMed Link to Article
Aust  RStierna  PDrettner  B Basic experimental studies of ostial patency and local metabolic environment of the maxillary sinus. Acta Otolaryngol Suppl 1994;5157- 11
PubMed Link to Article
Cole  P Physiology of the nose and paranasal sinuses. Gershwin  MEIncaudo  GADiseases of the Sinuses. Totowa, NJ Humana Press Inc1996;33- 51
Paulsson  BBende  MLarsson  IOhlin  P Ventilation of the paranasal sinuses studied with dynamic emission computed tomography. Laryngoscope 1992;102 (4) 451- 457
PubMed Link to Article
Aust  R Measurements of the ostial size and oxygen tension in the maxillary sinuses. Rhinology 1976;14 (1) 43- 44
PubMed
Gwaltney  JM  JrHendley  JOPhillips  CDBass  CRMygind  NWinther  B Nose blowing propels nasal fluids into the paranasal sinuses. Clin Infect Dis 2000;30 (2) 387- 391
PubMed Link to Article
Roberts  DNHampal  SEast  CALloyd  GA The diagnosis of inflammatory sinonasal disease. J Laryngol Otol 1995;109 (1) 27- 30
PubMed Link to Article
De Sutter  ASpee  RPeersman  W  et al.  Study on the reproducibility of the Water's views of the maxillary sinuses. Rhinology 2005;43 (1) 55- 60
PubMed
Aaløkken  TMHagtvedt  TDalen  IKolbenstvedt  A Conventional sinus radiography compared with CT in the diagnosis of acute sinusitis. Dentomaxillofac Radiol 2003;32 (1) 60- 62
PubMed Link to Article
Chen  LCHuang  JLWang  CRYeh  KWLin  SJ Use of standard radiography to diagnose paranasal sinus disease of asthmatic children in Taiwan: comparison with computed tomography. Asian Pac J Allergy Immunol 1999;17 (2) 69- 76
PubMed
Pelikan  ZPelikan-Filipek  M The role of nasal allergy in chronic sinusitis maxillaris (CSM): X ray and echography during the nasal response to allergen challenge [abstract 933]. Allergy Clin Immunol News 1991;1 ((suppl)) 334

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