Dry Crusty Nose: Not Just Rhinosinusitis! Hidden IgG4-related Disease Without IgG4 Level Rise.

IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition that can affect various organs. Localized sinonasal IgG4-RD is a rare condition characterized by bone and soft-tissue invasion. In this report, we present a case of a patient initially diagnosed with chronic rhinosinusitis, who underwent endoscopic sinus surgery and was later found to have biopsy proven IgG4-related sinonasal disease despite having normal serum levels of IgG4, resulting in erosion of the right lamina papyracea.

An Innovative Use of Point-of-Care Ultrasound for Identification and Management of a Rare and Uncommon Perioperative Complication: Periorbital Emphysema Following Sinus Surgery in a Pediatric Patient.

Periorbital emphysema is a rare complication following functional endoscopic sinus surgery (FESS) with potential sight-threatening consequences. We present a case of an eight-year-old male who developed periorbital emphysema after FESS for allergic fungal sinusitis. Prompt diagnosis was made using point-of-care ultrasound (POCUS), facilitating timely intervention and conservative management. This case underscores the importance of perioperative imaging to identify lamina papyracea abnormalities, smooth extubation to prevent complications, and the innovative use of POCUS in diagnosing perioperative orbital emphysema and managing it conservatively while examining the eye at regular intervals. These findings highlight the significance of vigilance during FESS procedures and the utility of POCUS in diagnosing and managing rare perioperative complications.

Evaluation of lamina papyracea dehiscence with paranasal computed tomography.

INTRODUCTION: The lamina papyracea is the thin line between the ethmoid sinus and the medial orbital wall. Knowledge of the presence of the lamina papyracea dehiscence (LPD) bears critical importance to prevent misdiagnosis of fractures at this level and to define the anatomy before sinonasal surgery, including Functional Endoscopic Sinus Surgery (FESS). The present study is therefore intended to determine the incidence of LPD in paranasal computed tomography, to identify its imaging characteristics in CT, and to compare with the literature. MATERIALS AND METHODS: The current study included patients who underwent paranasal CT scanning for any reason in our clinic between January 2018 and January 2022. Patients were evaluated in terms of age, gender, and presence of LPD. Patients with dehiscence were evaluated in terms of age, gender, dehiscence localization (right, left), tissue at the level of dehiscence, dehiscence size, and dehiscence grade. RESULTS: 1000 patients with a mean age of 32. ± 16.3 (min = 18-max = 79) were included in the study. 20 patients (2%) were found to have LPD. Of those with LPD, 14 (70%) were grade 1, 4 (20%) were grade 2 and 2 (10%) were grade 3. Again of those with LPD, 14 (70%) had LPD localized on the right and 6 (30%) had LPD on the left. In 12 (60%) of the patients with LPD, herniated tissue was detected. Among these patients with herniation, fatty tissue herniation was observed in 10 (83.3%) and medial rectus muscle herniation was observed in 2 (16.7%). DISCUSSION AND CONCLUSION: Comprehensive evaluation for and identification of LPD are very important before possible sinus surgery.

Traumatic Orbital Emphysema Following Blunt Trauma and Nose Blowing.

Orbital emphysema commonly resolves with no morbidity. However, sight-threatening complications, such as central retinal artery occlusion and ischemic optic neuropathy, may occur, which can result in poor visual outcomes. Plain skull X-ray, which is widely available, is a useful tool in identifying orbital emphysema. We report a case of a 29-year-old gentleman with underlying allergic rhinitis who presented with a painless, progressively increasing periorbital swelling of the right eye, which was aggravated by nose blowing. He had a history of blunt trauma one day prior to the presentation. Visual acuity was unaffected and optic nerve function tests were unremarkable. There was right upper lid swelling with crepitations, right hypoglobus with restricted upward gaze movement, and right conjunctival injection. Intraocular pressure was within normal limits. The posterior segment examination was unremarkable. A plain skull radiograph revealed a "black eyebrow sign" over the right orbit with no obvious orbital wall fracture. Computed tomography of the orbit showed focal indentation over the right lamina papyracea with superior orbito-palpebral emphysema. Systemic antibiotics, steroid nasal spray, and oral antihistamines were initiated with the prohibition of nose blowing. On post-trauma day five, he made an uneventful recovery. High clinical suspicion and thorough clinical examination with the aid of a plain skull radiograph can diagnose orbital emphysema in order for prompt referral to be undertaken to prevent morbidity. Clinicians should consider orbital emphysema as a differential diagnosis for periorbital swelling, especially if there was a preceding trauma.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit.

Introduction Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Endoscopic Transnasal Management of Giant Paediatric Sinonasal Ossifying Fibroma.

The ossifying fibroma is a rare fibro-osseous benign lesion of bone in the head and neck region. The mandible is the most common site reported followed by maxilla and other bones of the skull. A paediatric male presented with protrusion of the right eyeball for one-month duration. Further evaluation by diagnostic nasal endoscopy revealed a smooth mass confined to the superior and middle meatus on the right side. Computed tomography of paranasal sinus showed a large heterogenous bony lesion involving the ethmoid and sphenoid sinus and extending laterally into the orbit and superiorly into anterior skull base. Endoscopic biopsy was suggestive of ossifying fibroma. Transnasal endoscopic excision of the lesion was done and the patient is currently on follow-up. This case is reported for the rarity of presentation and the difficulties in management.

Presentation and Management of a Complex Orbital Apex Syndrome From Penetrating Mechanical Spring Hook: A Case Report.

Our case report demonstrates the management of a unique penetrating orbital injury. The intraorbital foreign body was an approximately 22 cm long metal dishwasher spring hook lodged into the left orbital apex. An ophthalmological check-up a couple of weeks following the removal surgery discerned the patient had an unprecedented case of orbital apex syndrome. We present this unique case so physicians, medical students, and other emergency and medical professionals can learn about the diagnostic, surgical, and multidisciplinary management necessary to achieve a favorable clinical outcome.

[Endoscopic management and outcome of nasosinusitis in non-traumatic dehiscence of the lamina papyracea with orbital content herniation].

Objective:To analyze the CT manifestations, clinical features, and endoscopic management and outcome of nasosinusitis in non-traumatic dehiscence of the lamina papyracea with herniation of orbital contents. Methods:From January 2019 to October 2020, a total of 686 cases with chronic nasosinusitis or nasal septum deviation were admitted to our department, including 448 male cases and 238 female cases. No patient had prior maxillofacial or orbital trauma as well as surgery related to nose and eyes. The clinical data were retrospectively analyzed. Results:Twelve patients were diagnosed as dehiscence of the lamina papyracea. Preoperative CT revealed that the location of dehiscence was only in the ethmoid sinus. Conclusion:For nasosinusitis patients with non-traumatic dehiscence of the lamina papyracea, all ethmoid cells should be opened during FESS. Precise and skillful operation, good bleeding control and clear visual field were critical. no damage to the herniated periorbital fat during the operation and appropriate cavity packing after the operation are essential, which could avoid the orbital-related complications as well as improve the symptom resolution. No recurrence was found during the follow-up period.

Misdirection of a nasopharyngeal SARS-CoV-2 swab: An unexpected complication.

Background: The diagnosis of coronavirus disease (COVID-19) is based on detecting viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasal cavities and the nasopharynx. Millions of nasopharyngeal swab tests are currently performed daily worldwide; complications of the procedure are uncommon, but occasionally they occur. Case report: We describe the case of a 79-year-old man who developed right orbital cellulitis after a nasopharyngeal swab test for SARS-CoV-2. He underwent two surgeries for nasal polyposis 20 and 15 years prior, that probably caused an easy pathway to the medial wall of the orbit. At hospital admission he presented right visual loss, proptosis, palpebral edema, conjunctival chemosis, and limitations in eye movements. Computed tomography showed violation of the lamina papyracea, which appeared related to misdirection of the nasopharyngeal swab. He received intensive antibiotic treatment and achieved complete resolution of the orbital infection. To our knowledge this is the first case report concerning this dangerous complication. Conclusion: Orbital cellulitis is a serious condition that requires prompt diagnosis and treatment, as it may result in permanent visual loss or life-threatening complications, such as intracranial abscess and cavernous sinus thrombosis, if inadequately treated. This case highlights the importance of providing adequate instruction about nasal anatomy to health care professionals performing nasopharyngeal swab tests to avoid misdirections leading to potentially dangerous complications.

Anterior Ethmoidal Artery: A Computed Tomography Analysis and New Classifications.

Objective to determine the anterior ethmoidal artery (AEA) anatomy and variations by computed tomography (CT) in adult and their relations to and presents new AEA classifications. Methods One hundred and fifty paranasal CT scans (300 sides) were included. Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes. Results One hundred and forty-four AEAs canal (48%), 293 AEAs foramen (97.7%), and 229 AEAs sulcus could be detected (76.3%). The mean AEA intranasal length was 6.7 ± 1.27 mm (range: 4.24-10.6 mm). The mean angle between AEA and lamina papyracea was 105.49 ± 9.28 degrees (range: 76.41-129.76 degrees). Of them, 95.8% AEAs had an angle with lamina >90 degrees, while 4.2% had angle <90 degrees. The mean angle between AEA and lateral lamella of cribriform plate was 103.95 ± 13.08 degrees (range: 65.57-141.36 degrees). Of them, 87.5% AEAs had an angle >90 degrees and 12.5% had an angle <90 degrees. The mean distance between AEA and skull base was 1.37 ± 1.98 mm (range: 0-8.35 mm). The AEA types in relation to skull base was type 1 (0-2 mm from skull base; 64.6%), type 2 (2-4 mm; 22.2%), type 3 (4-6 mm; 11.1%), and type 4 (>6 mm; 2.1%). The mean distance between the AEA and frontal sinus ostium was 9.17 ± 4.72 mm (range: 0-25.36 mm). AEA classification according to distance from AEA to frontal sinus ostium was 17.4% type 1 (<5 mm), 41.7% type 2 (5-10 mm), 31.9% type 3 (10-15 mm), and 9% type 4 (>15 mm). Conclusion Provided AEA details improve surgeons' awareness of AEA variations in the endoscopic field and can help residents in training.

Does endoscopic sinus surgery alter the biomechanics of the orbit?

OBJECTIVE: The purpose of this study is to determine if removal of ethmoid cell septations as commonly performed in endoscopic sinus surgery leads to a change in orbital wall fracture patterns and the force required to create them. METHODS: Six fresh-frozen cadaveric heads were acquired and underwent endoscopic uncinectomy, maxillary antrostomy, and anterior and posterior ethmoidectomy on one, randomized, side. The contralateral sinuses were used as intra-specimen control. Hyaluronic acid gel globe injections were performed to simulate normal intra-ocular pressure. Post-op CT scans confirmed no orbital fractures or violation of the lamina papyracea prior to trauma testing. Orbital trauma was induced using a guided weight-drop technique. Both orbits were tested in random order, and sequentially higher drops were performed until both the test and control side demonstrated an orbital fracture on CT scan. RESULTS: In all six heads, the post-sinus surgery side incurred a medial orbital wall fracture, and no orbital floor fractures were identified. On the other hand, on the control side, all six heads incurred orbital floor fractures at drop heights equal to, or higher than, the surgical side. Fisher's exact test demonstrated a significant difference in fracture pattern (p <  0.001). CONCLUSIONS: To our knowledge, this is the first demonstration that the structures removed during sinus surgery may act as a buttress for the medial orbital wall. The anatomic changes of sinus surgery may alter the biomechanics of the orbit and affect the pattern of subsequent traumatic blowout fractures.

"L" shape technique for endoscopic sinus surgery: An alternative method.

BACKGROUND: Several techniques for performing ethmoidectomy have been reported. We describe a safe, effective and efficient technique during functional endoscopic sinus surgery (FESS). We present text, images and videos to illustrate our preferred technique during an antero-posterior ethmoidectomy and to provide a multimedia tool for educational purpose. METHODS: A description of the technique without prospective or retrospective data is reported. A complete ethmoidectomy with an L-shape approach is described step-by-step, using the backbiting circular and miniature cutting forceps, with safe exposure of the lamina papyracea (LP) and skull base. RESULTS: In our hands, the L-shape approach for chronic rhinosinusitis with or without polyposis, performed with punch circular cutting and miniature cutting forceps, allowed for a reliably safe and efficient ethmoidectomy. CONCLUSION: The technique described can be added to the armamentarium of the endoscopic sinus surgeon.

Computed tomography based analysis of the lamina papyracea variations and morphology of the orbit concerning endoscopic surgical approaches / Análise tomográfica das variações da lâmina papirácea e da morfologia orbital em abordagens cirúrgicas endoscópicas

Abstract Introduction: Radiologic evaluation is mandatory to assess the type of endoscopic approach concerning sinonasal pathology and reconstruction of fractured defects before any treatment modalities are instituted related to medial wall of the orbit. Objective: The goal was to provide improved understanding of the lamina papyracea variations and the relationship with the orbital morphometry. Methods: This retrospective study was performed using computed tomography scans of 200 orbits and results were compared with respect to age, sex, laterality and LP variations. Results: Lamina papyracea variations were categorized as type A, 80.5% (161/200); type B, 16% (32/200); type C, 3.5% (7/200). For medial wall the anterior and posterior lamina papyracea heights and angles were found as 17.14 mm, 147.88º and 9.6 mm, 152.72º, respectively. Also, the length of the lamina papyracea, the mean area of the orbital floor, medial wall, lamina papyracea and orbital entrance were 33.3 mm, 7.2 cm2, 6.89 cm2, 4.51 cm2 and 12.46 cm2 respectively. The orbital height and width were measured as 35.9 mm and 39.2 mm respectively. The mean orbital cavity depth was 46.3 mm from optic foramen to the orbital entrance and the orbital volume was 19.29 cm3. We analyzed the morphometric measurements tending to increase with aging and greater in men and the relationship of them with lamina papyracea types. Conclusion: Precise knowledge of the lamina papyracea anatomy using computed tomography is essential for safer and more effective surgery and preforming the dimensions of an implant. In this way, the postoperative complications can be decreased and the best outcome can be provided.

Resumo Introdução: A avaliação radiológica é mandatória para avaliar o tipo de abordagem endoscópica no tratamento cirúrgico de doença nasossinusal e na reconstrução de fraturas antes de quaisquer modalidades de tratamento relacionadas à parede medial orbital. Objetivo: O objetivo foi proporcionar uma melhor compreensão das variações da lâmina papirácea e a relação com a morfometria orbital. Método: Este estudo retrospectivo foi realizado por meio de tomografia computadorizada de 200 órbitas, e os resultados foram comparados em relação à idade, sexo, lateralidade e variações da lâmina pairácea. Resultados: As variações da lâmina papirácea foram categorizadas como tipo A, 80,5% (161/200); tipo B, 16% (32/200); tipo C, 3,5% (7/200). Para a parede medial, as medidas das alturas anteriores e posteriores da lâmina papirácea e ângulos foram de 17,14 mm, 147,88º e 9,6 mm, 152,72º, respectivamente. Além disso, as medidas do seu comprimento da, da área média do assoalho orbital, e da parede medial, lâmina papyracea e entrada orbital foram: 33,3 mm, 7,2 cm2, 6,89 cm2, 4,51 cm2 e 12,46 cm2, respectivamente. As medidas da altura e da largura orbitais foram 35,9 mm e 39,2 mm, respectivamente. A profundidade média da cavidade orbital foi de 46,3 mm, do forame óptico até a entrada orbital, e o volume orbital foi de 19,29 cm3. Analisamos as medidas morfométricas com tendência a aumentar com o envelhecimento e nos indivíduos do sexo masculino, e a relação das mesmas com os tipos de lâmina. Conclusões: O conhecimento preciso da anatomia da lâmina papirácea por meio de tomografia computadorizada é essencial para uma cirurgia mais segura e eficaz, além de permitir pré-moldar as dimensões do implante. Assim, as complicações pós-operatórias podem ser minimizadas, obtendo-se melhores resultados.

Modeling Microdebrider-Mediated Ophthalmic Damage: A Word of Caution in Endoscopic Sinus Surgery.

BACKGROUND: The microdebrider has become nearly universal in the treatment of sinonasal pathology; however, recent case reports have demonstrated the potential for major ophthalmic complications. The goal of this study was twofold: 1) determine the anatomical proximity of ophthalmic structures to the paranasal sinuses, and 2) assess the timeframe at which ophthalmic injury may occur with the use of a microdebrider during FESS utilizing a cadaveric model. METHODOLOGY/PRINCIPAL: Computed tomography scans from 50 patients were accessed retrospectively. The distances between the lamina papyracea (LP) and orbital structures were determined at varying depths. Seven cadavers (14 sides) were studied using three microdebrider systems operated by otolaryngology residents. Following removal of a window of LP, the time from activation of the microdebrider on the periorbita until transection of the medial rectus (MR), optic nerve (ON), and to aspiration of the globe were measured. RESULTS: The mean distance between the LP and MR at the level of the anterior aspect of the anterior ethmoid and basal lamella were 3.59 ±1.2mm and 1.5 ±0.8mm, respectively. The mean distance between the LP and ON at the level of the basal lamella was 8.1 ±2.1mm. Mean transection times for the MR and ON were 13.4 ± 7.3 seconds and 37.3 ± 9.2 seconds, respectively, with minimum times of 4 seconds and 26 seconds. CONCLUSIONS: The proximity of orbital structures to the paranasal sinuses and the rapidity of ophthalmic damage following violation of the periorbita reaffirms the need for cautious use of the microdebrider during FESS.

The 'White-eyed' Orbital Blowout Fracture: An Easily Overlooked Injury in Maxillofacial Trauma.

The 'white-eyed' blowout fracture (WEBOF) is an injury that is often overlooked in head trauma patients, as it often has few overt clinical and radiographic features. Although benign in appearance, it can lead to significant patient morbidity. Here, we intend to increase the awareness of WEBOF and provide general principles for its diagnosis. WEBOF should be recognized early to ensure timely management and a successful outcome.

Computed tomography based analysis of the lamina papyracea variations and morphology of the orbit concerning endoscopic surgical approaches.

INTRODUCTION: Radiologic evaluation is mandatory to assess the type of endoscopic approach concerning sinonasal pathology and reconstruction of fractured defects before any treatment modalities are instituted related to medial wall of the orbit. OBJECTIVE: The goal was to provide improved understanding of the lamina papyracea variations and the relationship with the orbital morphometry. METHODS: This retrospective study was performed using computed tomography scans of 200 orbits and results were compared with respect to age, sex, laterality and LP variations. RESULTS: Lamina papyracea variations were categorized as type A, 80.5% (161/200); type B, 16% (32/200); type C, 3.5% (7/200). For medial wall the anterior and posterior lamina papyracea heights and angles were found as 17.14mm, 147.88° and 9.6mm, 152.72°, respectively. Also, the length of the lamina papyracea, the mean area of the orbital floor, medial wall, lamina papyracea and orbital entrance were 33.3mm, 7.2cm2, 6.89cm2, 4.51cm2 and 12.46cm2 respectively. The orbital height and width were measured as 35.9mm and 39.2mm respectively. The mean orbital cavity depth was 46.3mm from optic foramen to the orbital entrance and the orbital volume was 19.29cm3. We analyzed the morphometric measurements tending to increase with aging and greater in men and the relationship of them with lamina papyracea types. CONCLUSION: Precise knowledge of the lamina papyracea anatomy using computed tomography is essential for safer and more effective surgery and preforming the dimensions of an implant. In this way, the postoperative complications can be decreased and the best outcome can be provided.

Transient Orbital Compartment Syndrome Caused by Spontaneous Lamina Papyracea Dehiscence.

Orbital compartment syndrome typically occurs due to trauma or burns. Here we discuss a case of spontaneous lamina papyracea dehiscence associated with transient orbital compartment syndrome. A previously healthy woman presented to the Emergency Department complaining of unilateral eye pain after nose blowing. The patient did not have any pupillary or extra-ocular movement abnormalities; however, she did have mildly decreased visual acuity in the affected eye. Intraocular pressure was found to be elevated and a subsequent CT scan showed orbital emphysema with spontaneous dehiscence of the lamina papyracea. The intraocular pressure decreased within hours, and ultimately, she required no intervention. [Full article available at http://rimed.org/rimedicaljournal-2018-02.asp].

Lamina papyracea position in patients with nasal polypi: A computed tomography analysis.

OBJECTIVE: This study aimed to describe the positions of the lamina papyracea (LP) in patients who had nasal polypi, by computed tomography (CT) analysis. METHODS: Paranasal CT scans of patients diagnosed to have nasal polypi were included in the study. CT images were acquired with multiplanar reformates to obtain delicate details in coronal planes for all subjects. Positions of the LP were registered then analyzed in relation to nasal polypi grading. RESULTS: Forty seven subjects (94 nasal sides) were included in the current study. Grade I lamina detected in 50% or more of all cases. Patients who had larger polypi (polyp grade 3, 4) were associated with significantly more medial LP (grade II) than smaller polypi (polyp grade 0, 1, 2) (P=0.00386). CONCLUSION: The current study improves surgeons' awareness of LP position in different grades of nasal polypi and highlights that larger polypi are significantly associated with more medial LP than smaller polypi. This may be one of the causes of the higher incidence of complication in larger polypi and can help for safer surgery.

Endoscopic endonasal repair with polyethylene implants in medial orbital wall fractures: A prospective study on 25 cases.

The aim of the study was to assess the mid-term effectiveness and safety of an original technique consisting of reconstructing fractures of the medial wall of the orbit with porous polyethylene implants with an exclusive transnasal approach. Twenty-five patients were treated. Each patient underwent a pre-operative ophthalmologic evaluation and a CT scan. The surgery started with an anteroposterior ethmoidectomy of the fractured side; all the fractured bone fragments were removed and all usual landmarks of healthy bony margins were identified. A Medpor sheet was placed endoscopically to reconstruct the fractured wall. Each patient received an immediate postoperative CT scan, and was evaluated at day 1, 7, 30 and 6 months after surgery clinically and with an endoscopic examination. In all patients, preoperative enophthalmos and/or diplopia were corrected. The CT scans showed excellent reconstruction of the fractured bony walls. The immediate postoperative period was characterized by a very high degree of subjective comfort. No perioperative complications were detected. At the 6 months follow up, all meshes appeared covered by epithelialized mucosa at the endoscopic inspection, and clinical results were stable. Scars or lid complications are always prevented. The technique described has become the standard to treat medial wall fractures in our department.

CT classification and significance of lamina papyracea ingression in orbital medial wall / 中国耳鼻咽喉头颈外科

OBJECTIVE To investigate the CT classification of the lamina papyracea ingression and its significance. METHODS Data of computed tomography(CT) were analyzed retrospectively in 928 patients with nasal symptoms in out-patient department of Huairou Hospital from April 2017 to September 2017. All data were analyzed predicatively to observe the prevalence of lamina papyracea ingression. RESULTS The probability of lamina papyracea ingression in this group was 6.03％(112/1856). The lamina papyracea ingression were divided into four types on the basis of the coronal CT: upper medial rectus type, medial rectus type, under medial rectus type and generalized type. There was no difference in the incidence between the under medial rectus type and the extensive type(P=1.00), there were significant differences in the incidence of the remaining types(P=0.00). CONCLUSION In this study, the classification of the lamina papyracea ingression on coronal CT is helpful to understand lamina papyracea ingression better and reduce the intraorbital complicatians of endoscopic sinus surgery.