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Normal CT Sinus Report Template (Paranasal Sinuses)
Normal paranasal sinus CT report template: sinus-by-sinus aeration, ostiomeatal complexes, septum, turbinates and the pre-FESS anatomic variants surgeons expect, with Lund-Mackay notes.
EXAMINATION: CT paranasal sinuses without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Chronic sinusitis”] COMPARISON: None available. TECHNIQUE: Axial helical images through the paranasal sinuses without intravenous contrast, with coronal and sagittal reformats in bone algorithm. Dose reduction techniques were used. FINDINGS: Frontal sinuses: Well aerated bilaterally. The frontal recesses are patent. Ethmoid sinuses: The anterior and posterior ethmoid air cells are clear bilaterally. Maxillary sinuses: Clear bilaterally. No mucosal thickening, air-fluid level or retention cyst. Sphenoid sinuses: Clear. The sphenoethmoidal recesses are patent. Ostiomeatal complexes: Patent bilaterally. The uncinate processes, infundibula and middle meatus are unremarkable. Nasal cavity: The nasal septum is midline. No significant septal deviation or spur. The inferior and middle turbinates are normal in size. No concha bullosa. No nasal polyp. Anatomic variants relevant to surgery: The cribriform plate is symmetric (Keros type [I/II/III]). The lamina papyracea is intact bilaterally. No Onodi cell or Haller cell. The anterior ethmoid arteries are within the skull base. The optic nerves and carotid canals are covered by bone in the sphenoid sinus walls. Nasopharynx: Unremarkable. Orbits and visualized brain: Unremarkable. IMPRESSION: 1. No evidence of acute or chronic sinus inflammatory disease. Patent ostiomeatal complexes bilaterally.
Dictation notes
- When disease is present, score it — a Lund-Mackay total (0-24) in the impression lets the otolaryngologist track the response to medical therapy, and “mild mucosal thickening” does not.
- Name the drainage pathway involved (frontal recess, ostiomeatal unit, sphenoethmoidal recess) — the pattern of obstruction, not the sinus list, drives the surgical plan.
- Pre-FESS variants are safety items, not incidentals: a low or asymmetric Keros skull base, dehiscent lamina papyracea, an Onodi cell abutting the optic nerve or a dehiscent carotid canal each belongs in the impression when present.
- Hyperdense secretions with bony expansion suggest fungal sinusitis; unilateral opacification with bone destruction is a mass until proven otherwise — neither is “chronic sinusitis”.
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