Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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On Aug 2018

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : ZC32 - ZC37 Full Version

Analysis of Olfactory Fossa Anatomy using Cone Beam Computed Tomography

Published: June 1, 2022 | DOI:
Madhura Mahajan, Manjushri Waingade, Raghavendra S Medikeri, Daya K Jangam

1. Postgraduate Student, Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India. 2. Reader, Department of Oral Medicine and Radiology, Sinhgad Dental College And Hospital, Pune, Maharashtra, India. 3. Professor, Department of Periodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India. 4. Professor and Head, Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India.

Correspondence Address :
Manjushri Waingade,
Sinhgad Dental College and Hospital, S. No: 44/1, Ste’s Campus, Vadgaon (Bk.), Off Sinhgad Road, Pune-411041, Maharashtra, India.


Introduction: Olfactory fossa is an important structure in the anterior skull base. It is made of Lateral Lamella of Cribriform Plate (LLCP) and fovea ethmoidalis which are very delicate parts that can get damaged during surgical procedures causing numerous serious complications. To avoid such complications, the knowledge of anatomical variations of these parts is mandatory. As there are very few studies which have used Cone Beam Computed Tomography for evaluation of olfactory fossa, we have assessed the olfactory fossa with the help of Kero’s and Gera’s classification for lateral lamella of cribriform plate.

Aim: To evaluate the anatomy of olfactory fossa using Cone beam computed tomography.

Materials and Methods: A retrospective observational study was conducted in the Department of Oral Medicine and Radiology, from 1st January 2019 to September 2021. CBCT scans of 107 adults were analysed to evaluate the height of lateral lamella of cribriform plate according to Kero’s classification and the angle between the LLCP and the true horizontal plane according to Gera’s classification. Comparison of height of lateral lamella (mm) and Gera angle (degree) among right and left sides were done using Student’s Independent t-test. The comparison of Gera angle with Kero’s type was analysed by one way Analysis of Variance (ANOVA) test. Chi-square test was performed to assess categorical data on the right and left sides.

Results: A total of 107 CBCT scans consisting of 59 males (55.14%) and 48 females (44.86%) were included in the study. The mean age of the study population was 31.60±11.17 years. Kero’s type II (69.6%) and Gera’s class II (92.1%) LLCP were found to be most commonly seen. The Gera angle on right side (60.26±9.84) was greater than on left side (56.38±10.16) which was statistically significant (p-value=0.005). On right side, Kero’s type II was more common in males (71.2%) and on left side, Kero’s type II was more common in females (77.1%).

Conclusion: Kero’s type II Olfactory fossa (OF) was found as most common type, with no significant difference between gender and /or side. Similarly, class II Gera angle was most common and the values were higher on right side.


Ethmoid roof, Fovea ethmoidalis, Gera angle, Kero type, Lateral lamella of cribriform plate

Olfactory fossa (OF) is a depression or valley present in an anterior cranial cavity. A floor of the OF is formed by ethmoid bone and cribriform plate (1),(2). It is laterally bounded by Lateral Lamella of Cribriform Plate (LLCP) and medially by crista galli (1),(3). The lateral lamella where ethmoid artery penetrates anterior cranial fossa is known as the thinnest and delicate bone present in the anterior skull. This bone is dehiscent in about 14% of the population (4),(5),(6). LLCP laterally articulates with fovea ethmoidalis (FE). FE which is a part of frontal bone helped in the development of roof of the ethmoid bony labyrinth (2),(7). Thus, LLCP and FE are one of the most delicate and vulnerable parts of the skull base which can contribute to various complications while performing endoscopic surgeries or surgeries of paranasal sinuses (8),(9),(10).

Functional Endoscopic Sinus Surgery (FESS) is the frequently used technique to treat chronic or recurrent sinusitis, mucoceles, CSF leak closure, nasal polyposis, sellar tumors, optic nerve decompression, management of epistaxis and epiphora originated by lower lacrimal duct obstruction (11),(12),(13). Serious complications like herniation of orbital fat, injury to extraocular muscles, optic nerve injury and intracranial injuries like injury to major blood vessels, etc. can occur in 0-1.5% of the cases (5),(13). A thorough knowledge of different anatomical variations in patients will help to reduce the unwanted iatrogenic complications by knowing the risks while performing surgeries (14).

The term “dangerous ethmoid” was introduced to define the position of anterior ethmoid artery and the position of lateral lamella in relation to the cribriform plate (3),(11),(15). The relationship between OF and ethmoid roof was studied by Kero in 1962 and he derived a three category classification system for assessing the depth of OF in relation to ethmoid roof (16). Even if the role of OF depth has been given importance earlier, only limited data regarding the slope of the anterior skull base, particularly the angulation of the LLCP in the coronal plane are known. This angulation might have a role when approaching the paranasal sinuses during the dissection of more medial ethmoidal cells (17). A classification system given by Gera which focuses on the angle formed by LLCP and the horizontal plane passing through cribriform plate may serve this purpose. Some authors suggests that the risk of complications is directly proportional to the depth of OF, while others propose that the complications are closely associated with the angle between LLCP & horizontal plane (15),(17),(18).

Though Multislice Computed Tomography (MSCT) is the gold standard in the estimation of anatomy and pathologies of cranial structures, paranasal sinuses and nasal cavity, CBCT can definitely be used as a promising alternative by dental surgeons and otolaryngologists to assess cranial and nasal structures and paranasal air sinuses. CBCT is preferred because of its advantages such as low radiation exposure, high quality images with lower costs [19-21]. Though the role of radiographic analysis of OF was emphasised earlier, there is very limited data available till date. Thus, the aim of this study was to assess the anatomy of OF using CBCT.

Material and Methods

A retrospective observational study was conducted in the Department of Oral Medicine and Radiology using CBCT scans taken during the period of 1st January 2019 to 31st January 2021. The data collection including the statistical analysis and interpretation was done from February 2021 to September 2021.The study protocol was reviewed and approved by the Institutional Review Board of Ethics Committee (SDCH/IEC/2021/49) performed according to Helsinki Declaration guidelines.

CBCT scans of 107 adults above 18 years were obtained retrospectively from the Department of Oral Medicine & Radiology. The CBCT images obtained using a Promax 3D unit (Planmeca, Helsinki,Finland), operating at 84 kVp, 9-14 mA, with a 0.16 mm voxel size, exposure time of 12 seconds and a field of view of 8×8 cm2.

Inclusion and Exclusion criteria: CBCT images showing the medium and superior regions of the face including the crista galli of the ethmoidal bone and nasal fossa were included in the study. Patients having a history of maxillofacial trauma, pathologies in the paranasal sinuses and paranasal sinus surgery were excluded. CBCT scans with inferior quality images or images with artifacts, producing visualisation of anatomical forms difficult were excluded.

Two investigators evaluated the CBCT images with inbuilt software (Planmeca, Romexis viewer 4.3.0.R) on a 24-inch Nvidia Quadro FX 380 screen with 1280x1024 resolution in a quiet room with subdued ambient lighting. Investigators were checked for intra and inter-examiner variability to refine the intra and interpersonal reliability. Before the study analysis in between each measurement both examiner examined all measurements with an interval of 1 week. The average was considered, if the variability in between two examiners was set up to be upto 10%. If the variability was more than 10%, another investigator reassessed it. The coronal slices (thickness: 1 mm) were used and linear measurements were done by using the software’s ruler to evaluate the following parameters:

1. Kero's classification: Olfactory fossa depth was decided by the Height of lateral lamella of cribriform plate , measured as the distance between fovea ethmoidalis (F) to cribriform plate (P) of ethmoid bone using the Kero’s classification (Table/Fig 1) (16).
(i) Type I-height lower than 3.0 mm
(ii) Type II-height between 4.0 and 7.0 mm
(iii) Type III-height between 8.0 and 16.0 mm
2. Gera’s classification: Angle between lateral lamella of cribriform plate and the continuation of the horizontal plane passing through cribriform plate was measured using the Gera’s classification (Table/Fig 2) (17).
• Class I 80o, low risk)
• Class II (45 to 80o, medium risk)
• Class III (<45 o, high risk)

Statistical Analysis

The data analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0. The mean and percentage were used to assess the prevalence and gender distribution. Comparison of height of lateral lamella (mm) and Gera angle (degree) among right and left sides were done using Student’s Independent t-test. The comparison of Gera angle with Kero’s type was analysed by one way ANOVA test. Chi-square test was performed to assess categorical data on right and left side. Spearman’s correlation test was applied to find the correlation between Kero’s and Gera’s Class. The p≤0.05 was considered as statistical significant.


A total of 107 CBCT scans consisting of 59 males (55.14%) and 48 females (44.86%) were included in the study. The mean age of the study population was 31.60±11.17 years.

The mean height of LLCP was 4.63±1.68mm. The mean Gera angle was 58.32±8.50°. The mean height of LLCP in males was 4.69±1.76 mm and females 4.55±1.59 mm respectively. The mean Gera angle was 59.03±8.56° in males and females 57.44±8.43° respectively. The difference was not statistically significant (Table/Fig 3).

The height of LLCP on the left side (4.73±1.91 mm) was slightly higher than the right side (4.52±1.87 mm) but the difference was not statistically significant (p-value=0.401). Similarly, the Gera angle on right side (60.26±9.84°) was greater than the left side (56.38±10.16°) which was statistically significant (p-value=0.005) (Table/Fig 4).

On comparing the sides, Gera angle and height of lateral lamella between males and females showed no statistically significant difference (Table/Fig 5).

The Kero’s Type II (69.6 %) was most commonly seen. The Gera Type II (92.2%) was more common followed by Type III (4.7%) and Type I (3.3%) respectively (Table/Fig 6).

On comparing with sides, Kero’s Type II was prevalent in the population studied followed by type I and III. The difference in Kero’s type between right and left side was statistically non-significant (p-value=0.678) among the types. Similarly, Gera’s Class II angle was prevalent followed by Class III and Class I. However, there was no statistically significant difference in Gera angle between right and left side (p-value=0.085) among the all the classes (Table/Fig 7).

Kero’s type II was more prevalent in males than females on right side. The comparison of different types according to gender was statistically non-significant. Similar findings were noted on left side (Table/Fig 8).

There was no significant difference in Gera angle between males and females on both sides (p-value=0.281) and (p-value=0.097). Gera Class II angle was slightly more prevalent in males than females but the difference was statistically non-significant (Table/Fig 9).

There was no significant difference in mean age among Kero’s types and Gera angle between right and left side (p-value >0.05) (Table/Fig 10),(Table/Fig 11).

On left side, there was a statistically significant difference when Kero’s type was compared with Gera angle (Table/Fig 12). When the height of LLCP was compared between the Gera’s type, statistically significant (p-value=0.047) was found on the right side (Table/Fig 13).

(Table/Fig 14). shows negligible non significant correlation between Kero’s and Gera classification.


An ethmoid roof is one of the most complex and delicate bones in the skull. The thinnest structure where lateral lamella of cribriform plate attaches to middle turbinate is considered as “locus minoris resistentiae”. Understanding the complex anatomical relationship of the ethmoid roof, the anterior skull base and olfactory zone is of paramount importance as the knowledge of these structures will avoid unnecessary complications (2),(10),(12),(17),(18),(19),(22).

CBCT can be used as a potent alternative to CT for analysis of paranasal sinuses and adjacent structures as it gives high resolution spatial images with remarkable reduction in radiation dosage to the patient (19),(20),(21),(23). In the present study, viewing that the coronal plane was best for estimating, the ethmoid roof anatomy, CBCT images were selected that came up with detailed information about this segment that normally presents many dissimilarities (right and left side) in a same individual and as a result, risks were minimised in surgical interventions (12),(22).

The levels of the ethmoid roof and cribriform plate can vary considerably in different individuals and also in the same individual on right and left sides (3),(4),(5),(7),(10),(15). Analysing the Kero’s types, based on population, it is seen that majority of the studies have reported Kero’s type II to be more prevalent (Table/Fig 15) (4),(11),(12),(15),(17),(20),(22),(24),(25),(26). Shows the list of various authors that have studied the depth of OF using the Kero’s classification (1),(3),(4),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14),(15),(17),(20),(22),(24),(25),(27),(28).

Likewise, studies reported from India have also found Type II to be more prevalent except for a study by Deepa G and Shrikrishna BH., (28) who reported Type I to be more prevalent (1),(13),(27),(28).

The Kero’s type III is considered to be the most vulnerable for iatrogenic injuries due to its long length of lateral lamella (2),(28). In the literature Kero’s type III has been reported to be ranging from 0-32.3% (14),(22),(25). In this study, Kero’s type III was reported to be 11.2% which is slightly higher than previously reported in Indian population (1),(13),(27),(28).

Few authors have reported difference between Kero’s type and gender (1),(4),(5),(7),(8),(9),(11),(14),(27), while others have reported no difference which was in agreement with the present study. (15),(17),(20).

The possibility of injury to the skull base increases with increasing height of LLCP. As the LLCP height increases, OF will become narrower and deeper; also the ethmoid roof will be more low lying [2,28]. The mean height of LLCP was 4.63±1.68 mm in the current study which is slightly lesser than that reported in the previous studies by Skorek A et al.,. (15) 5.77 mm, Erdem G et al., (25) 6.1 mm; Meloni F et al., (29) 5.9 mm and Jacob TG et al., (3) 4.9 mm respectively (Table/Fig 16) (1),(8),(10),(13),(25),(28).

Studies reported from India by Babu AC et al., (5.26±1.69mm) Murthy AV and Bollineni S (5.21mm) have shown mean height to be more than that reported in the present study, except that reported by Deepa G and Shrikrishna BH (3.3±1.63 mm) (1),(13),(28).

In the present study, no difference was noted in the height of OF between the right and left sides which is in accordance to the previous studies (3),(9),(13),(15),(20),(25),(29). It is possible to speculate that the differences in the anatomic development in the ethmoidal roof might be related not only with heredity, environmental factors and previous chronic infections that could have affected the development of the sinuses, but also with ethnicity (30). Similarly, according to Jacob TG et al., (3) the degree of pneumatisation of frontal sinus and ethmoid labyrinth varies in different populations which could be a factor for different results (3). Furthermore, differences in technique may influence the apparent measurements.

Some studies have demonstrated that the LLCP is uniformed in less than 50% of people, and that this asymmetry is associated with flattening of the fovea ethmoidalis (FE) with angulation of the LLCP, which may result in surgical difficulties (4),(12). Whereas other authors noted a high percentage of asymmetry and describe a wide range of 9.5-93% (3),(4),(5),(6),(7),(10),(15),(31),(32). In the present study no asymmetry was seen on the right and left sides. Shorek A et al., (15) and Abdullah B et al., (14) observed that only Kero’s classification was not enough to identify the ‘dangerous ethmoids’; since the Kero’s classification does not describe the risk of intracranial entry. So, the angle between the LLCP to horizontal plane, which is called as Gera angle was proposed to analyse the theoretical risk of iatrogenic injuries (2),(12),(14),(18).

In the present study, the mean degree of Gera angle was reported as 58.32±8.50° which is lesser than reported in the previous studies (Table/Fig 17) (14),(17),(18),(26).

Class I angle denotes a higher risk of iatrogenic injury followed by Class II and Class III (17),(26). In the present study, most commonly reported Gera angle was Class II (92.1%) followed by Class III (4.7%) and Class I (3.3%) respectively which is in accordance with previous studies (14),(17),(18). The prevalence of Class II in the present study is more as compared to previous studies (Table/Fig 17) (14),(17),(18). Also, there was no significant difference in Gera angle with gender which is in accordance to previous studies (14),(17).

Thus, it can be noted that individuals classified as low risk according to Kero’s classification may show high risk according to the Gera classification. Considering the risk of iatrogenic injury, in this study authors reported 16.7 % having Gera Class III as Kero type III on left side which is not in accordance with the previous study (14).

In the present study we found no significant correlation between Kero and Gera classification which is in accordance with Abdullah B. et al., (14) while Gera R et al., (17) found a positive correlation. This difference could be due to anatomical variation in different populations.


The sample size was small with unequal distribution among gender including age wise distribution of study participants was limitation of the study.


Thus, in the present study, Kero’s type II OF was found as most common type, with no significant difference associated with gender and /or side. Similarly, class II Gera angle was also most common and the values were higher on right side with no difference in age and gender. The occurrence of substantial relationships between multiple ethmoidal measurements emphasises the need of examining more than simply the height of the ethmoidal skull base. Authors believe that the implementation of categorisation systems could be effective in the preoperative assessment of ethmoid sinus imaging in order to avoid serious issues.

Large scale collaborative studies including classification systems that are based on axial, sagittal and coronal planes are required to improve our knowledge of anatomical variations and their distribution. The estimate of the depth of the olfactory fossae and ethmoidal roof asymmetry presence should be included in routine description of CBCT reports because it constitutes a significant facet in endoscopic surgeries. Further prospective longitudinal studies or retrospectively analysing patients who showed iatrogenic complications during surgical procedures will help to validate the postulated results.


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DOI and Others

DOI: 10.7860/JCDR/2022/53527.16494

Date of Submission: Dec 03, 2021
Date of Peer Review: Feb 18, 2022
Date of Acceptance: Apr 02, 2022
Date of Publishing: Jun 01 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. Yes/NA

• Plagiarism X-checker: Dec 04, 2021
• Manual Googling: Feb 17, 2022
• iThenticate Software: Apr 01, 2022 (16%)

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