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The abstraction agreement was advised and accustomed by the Human Research Ethics Committee of Universiti Sains Malaysia (Ethical Approval Code: USM/JEPeM/16090342), performed in adherence with the Declaration of Helsinki and accustomed guidelines. Written abreast accord was acquired from all patients afore their accord in this study. All accessible CT PNS of capacity 18 years and aloft were retrieved from the Radiology Information System (RIS) and Picture Archive Communication System (PACS) from 9th January 2017 until 8th January 2018. The admittance belief were CT PNS with allotment array of 1 mm and able of multiplanar about-face (MPR). The exclusion belief were antecedent anaplasty to paranasal sinuses and skull base, antecedent skull abject or facial trauma, antecedent anaplasty to ethmoid or sphenoid sinuses, sinonasal malignancy, astringent rhinosinusitis with or after nasal polyps, abiding maxillary atelectasis with cogent OF changes and craniofacial abnormalities.



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The CT PNS images were calm from computers at the workstation with 2 Mega Pixel adviser (Barco MPG 2121 monitor– resolution 2048 × 1536) via Picture Archive Communication System (PACS) in PACS Universal Viewer Adaptation 5.0 SP6. The CT browse was performed with Siemens SOMATOM Definition AS on collapsed accommodating with collimation of 64 × 0.6, acknowledgment of 135 kV and 200 mAs, 1 mm allotment array and circling time of 1.0 s. The cartilage appearance images were acclimated for measurement. The abstracts were done by three of the authors (CSC, MEA and BA). All abstracts were taken 3 times and the boilerplate was acclimated in the abstracts analysis. Back there was antagonistic opinion, added appraisal of the angel was done to access a alternate consensus. The nasal attic is advised as the advertence even to admeasurement all the added landmarks5.



Multiplanar (MPR) CT images were reconstructed to access the OF altitude in accurate accumbent even in both the chaplet and sagittal views. A band fatigued forth the nasal attic served as the advertence point. In the chaplet view, the appropriate alternate attic was abstinent at the point area the appropriate centermost bank of the maxillary atrium roof was apparent at its best height. In the chaplet appearance (Fig. 1), the heights from nasal attic to appropriate ER (labelled A), from nasal attic to appropriate OF (a distinct appearance at the best acme to the appropriate maxillary sinus) (labelled B), and from nasal attic to appropriate CP (labelled C) were measured. Anniversary vertical acme was abstinent 90° erect to the nasal floor. Back there was a lower cribriform acme at addition point antecedent to the sphenoid (based on sagittal view), again this was acclimated for the CP height. The abstracts were again on the left. To appraise the accident of skull abject abrasion application the TMS classification, the distances from OF to CP (OF-CP) and from OF to ER (OF-ER) were used. We classified the accident of skull abject abrasion into blazon 1, blazon 2 and blazon 3 (Fig. 2). Blazon 1 (low risk) is both OF-CP and OF-ER are 10 mm and above, or added than alert the abyss of thru-cutting forceps back ESS is advised as safe, blazon 2 (moderate risk) is back either OF-CP or OF-ER is beneath than 10 mm, or beneath than alert of the abyss of thru-cutting forceps back ESS should advance with attention and blazon 3 (high risk) is both OF-CP and OF-ER are beneath than 10 mm or beneath than the abyss of thru-cutting forceps back ESS should advance with acute caution.

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 2

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The heights of the ethmoid roof (A), alternate attic (B), and cribriform bowl (C) about to the nasal attic in chaplet CT PNS. Anniversary vertical acme was abstinent 90° erect to the nasal floor. To appraise the accident of skull abject abrasion application TMS classification, the distances from alternate attic to cribriform bowl (OF-CP) and from alternate attic to ethmoid roof (OF-ER) were used. Red asterisk denotes the best acme of the maxillary atrium which is the akin taken as the alternate attic landmark.



CT PNS chaplet area assuming the three types of TMS classification; (A) is Blazon 1 (low risk) area both OF-CP and OF-ER are 10 mm and above, (B) is Blazon 2 (moderate risk) area either OF-CP or OF-ER is beneath than 10 mm and (C) is blazon 3 (high risk) area both OF-CP and OF-ER are beneath than 10 mm.

The abyss of the CP, abstinent as the vertical acme of the adenoids fossa in the chaplet even on anniversary ancillary (Fig. 3), was abstinent and classified as blazon 1 (1 to 3 mm depth), blazon 2 (4 to 7 mm depth) or blazon 3 (more than 7 mm depth). Asymmetry in the abyss (difference of added than 3 mm) amid the appropriate and larboard CPs was additionally recorded. The abstracts were again on the left.

Keros classification7 was adjourned according to the abyss of the cribriform plate, abstinent as the vertical acme of the adenoids fossa in the CT chaplet even and classified as blazon 1, 2 and 3.

The Gera allocation was classified into 3 classes depending on its amplitude and on the academic accident of iatrogenic injuries: chic I (>80 degrees, low risk), chic II (45 to 80 degrees, average risk) and chic III (<45 degrees, aerial risk). Altitude was done at the bend formed by the crabbed cell of the CP and the assiduity of the accumbent even casual through the CP (Fig. 4). The abstracts were again on the left.

Gera classification9 was adjourned by barometer at the bend formed by the crabbed cell of the cribriform bowl and the assiduity of the accumbent even casual through the cribriform bowl in the CT chaplet even and classified as Chic I, II and III.

Descriptive parametric abstracts were presented as allotment and beggarly (standard aberration [SD]). The correlations amid the abyss of cribriform, ambit of OF-ER, ambit of OF-CP, and bend formed by the crabbed cell of CP and the assiduity of the accumbent even casual through CP, were estimated application Pearson’s alternation accessory (r). Chi Square assay was acclimated to appraise the relationships amid TMS, Keros and Gera classifications. A p amount of <0.05 was advised statistically significant. The intraclass alternation accessory assay was acclimated to appraise the inter-rater reliability. Statistical assay was performed application SPSS software adaptation 22.0.

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