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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 236-240

Evaluation of haller's cells prevalence in a sample of Polish population assessed using panoramic radiographs


Department of Dental and Maxillofacial Radiodiagnostics, Medical University of Lublin, Lublin, Poland

Date of Submission30-May-2022
Date of Acceptance26-Jun-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Dr. Karolina Futyma-Gąbka
Medical University of Lublin, Poland 6 Chodzki Street, Lublin 20-093
Poland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_68_22

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  Abstract 


Introduction: Haller's cells are air structures with variable presence in individuals. They are situated in the anterior part of the ethmoid bone on the inferior and medial walls of the orbits. Their presence can be symptomatic and they may also be an impediment in surgical procedures. A panoramic radiograph commonly used in dental diagnostics allows visualization of their presence. The aim of the study is characteristics and estimation of Haller's cell prevalence in a sample of the Polish population based on panoramic radiographs. Materials and Methods: The study consisted of 467 panoramic radiographs including patients of both genders (303 females and 164 males), aged 17–23 years with a mean of 20.2 years. All radiographs have been evaluated for Haller's cells' presence, shape, number, and location with gender predilection. Results: Haller's cells were found in 72 cases, which comprised 15.4% of the studied group, with a slightly higher prevalence in females (17.82% in females and 10.97% in males). The most predominant shape was oval. Unilateral distribution of the cells outnumbered bilateral variants. One to three Haller's cells were found on one side, in the own material. Conclusions: Panoramic radiograph revealed a relatively low prevalence of Haller's cells in a sample of the Polish population. It is possible to assess the shape and determine the exact number of these cells. Based on the panoramic examination, we can state that they are located more often unilaterally with a slightly higher prevalence in females.

Keywords: Haller cells, infraorbital ethmoid air cells, panoramic radiograph, radiological anatomy


How to cite this article:
Manaj A, Osiak A, Piskórz M, Futyma-Gąbka K, Różyło-Kalinowska I. Evaluation of haller's cells prevalence in a sample of Polish population assessed using panoramic radiographs. Indian J Med Spec 2022;13:236-40

How to cite this URL:
Manaj A, Osiak A, Piskórz M, Futyma-Gąbka K, Różyło-Kalinowska I. Evaluation of haller's cells prevalence in a sample of Polish population assessed using panoramic radiographs. Indian J Med Spec [serial online] 2022 [cited 2022 Dec 9];13:236-40. Available from: http://www.ijms.in/text.asp?2022/13/4/236/359858




  Introduction Top


Due to the dynamic development of diagnostic methods, anatomical structures can be more precisely visualized nowadays. One of these structures is infraorbital ethmoid air cells first described by Swiss anatomist Albrecht von Haller in 1795 and therefore to commemorate their discoverer, are called Haller's cells.[1]

The prevalence of Haller's cells is very diversified. Beginning from their number – they might be absent, single or multiple, and unilateral or bilateral. These cells can be circular, oval, triangular, heart-shaped, and irregular.[2] Nevertheless, their presence may be relevant in diagnostics of symptomatic head-and-neck regions.

When meticulously studying radiological and anatomical aspects regarding Haller's cells, their clinical significance is worth mentioning. Diagnostics confirming Haller's cells' presence may be relevant if the patient presents symptoms such as headaches and facial pain, sinusitis, nasal obstruction, chronic rhinorrhea, chronic cough, labored nasal breathing, and even maxillary sinus mucocele. These noncharacteristic afflictions are commonly found in the course of numerous diseases, but it has been proven that they are not always related to inflammatory processes.[1] Haller's cells are likely to contribute to the progression of chronic sinusitis. Their presence may cause narrowing of the ethmoid infundibulum, which consequently leads to narrowing of the hiatus of the maxillary sinus that ends in the middle nasal meatus.[3] Such anatomical conditions are the cause of impaired maxillary sinus drainage, which is one of the main factors predisposing to the progression of sinusitis. However, there is no agreement among the researchers concerning the direct relationship between Haller's cell presence and sinusitis. Alkire and Bhattacharyya[4] in their research have proven that the presence of the cells alone, even those not involved in inflammatory processes, may lead to the development of the disease. Different opinions are expressed by Dhanasekaran et al.,[5] who stated that infraorbital ethmoid air cells could not be considered a sole factor leading to sinusitis. Other studies also do not suggest a direct relationship between them.[6],[7] Currently, it is postulated that the presence of Haller's cells should be taken into account if some of the abovementioned symptoms are present in a patient as well as when planning endoscopic procedures in the area of nasal cavity and nasal sinuses.[8]

Panoramic radiographs depict infraorbital ethmoid air cells in the form of variously shaped radiolucencies. They are located in close relation to the roof of the maxillary sinus as well as the inferior and/or medial wall of the orbit [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Panoramic radiograph showing two oval unilateral Haller's cells on the right side

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Figure 2: Panoramic radiograph showing square Haller's cell on the right side and two oval and teardrop Haller's cells on the left side

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Figure 3: Panoramic radiograph showing three circular unilateral Haller's cells on the left side

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Figure 4: Panoramic radiograph showing a single triangular unilateral Haller's cell on the right side

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A panoramic radiograph is a form of radiological imaging, especially useful in dental medicine. When the X-ray tube and the detector rotate around the patient's head, there are recorded images of a selected curvilinear layer which follows the shape of dental arches. Its two-dimensional character, low resolution, presence of virtual images, and shape distortion do not make panoramic radiographs an ideal method of imaging. However, the fact that it provides an image of all the anatomical structures located between mandible angles, chin, and the floor of the orbits, using relatively low radiation dose, and is cost-effective makes the panoramic radiograph a valuable imaging tool in dentistry.[9]

In most modern panoramic machines, several thin parallel layers are registered during the examination and the final image consists of the best quality regions derived from these layers. In some panoramic machines, this technology is called S-Pan and it allows obtaining images with higher quality and clarity than the ones taken by older X-ray units. Another advantage is shortening the exposure time to 7 s when taking a panoramic radiograph which decreases the risk of motion artifacts during image acquisition which further contributes to higher quality of the obtained radiographs. Within each of the layers, there are 1000 additional segments generated. In every layer out of these segments, there are chosen the clearest and the sharpest fragments by computer algorithm. S-Pan technology increases the possibility of taking a panoramic radiograph of patients with skeletal malocclusion in whom it is difficult or even impossible to achieve a tête-à-tête position of the upper and lower incisors during examination and consequently a good quality panoramic radiograph.[10]

The purpose of this study is to assess the prevalence and characteristics of Haller's cells in the Polish population using panoramic radiographs.


  Materials and Methods Top


The material was selected from the database of panoramic radiographs taken in 2015–2021 in the Department of Dental and Maxillofacial Radiodiagnostics, Medical University of Lublin using panoramic unit Vista Pano S with S-Pan technology, operating at the following parameters 74 kV, 14.0 mA, 7 s. The pixel size was 100 μm.

The study group comprised females and males aged from 17 to 23 years (mean age = 20.2 years), all of the patients were born in 1998 and had a Caucasian origin. All of the included examinations were taken for evaluation of the position of third molars. There were 467 panoramic radiographs selected as a study group – 303 female patients and 164 male patients. Our study did not require ethical approval because all of the data were properly anonymized.

Panoramic radiographs were analyzed by two (consensus reading) fourth-grade dentistry students from the Medical University of Lublin, members of the Student Research Group at the Department of Dental and Maxillofacial Radiodiagnostics, Medical University of Lublin.

The selection of panoramic X-ray was carried out in accordance with the inclusion and exclusion criteria.

Inclusion criteria were as follows: good quality images, symmetrical position of the patient without motion artifacts and ghost shadows, and patients of both genders between 17 and 23 years of age. Exclusion criteria comprised bone with any pathology such as cysts, tumors, inflammations, and foreign bodies in the area of interest.

The second reading was performed by an experienced dentist trained in dentomaxillofacial radiology. Only those panoramic radiographs which have been affirmed to depict Haller's cells by the supervising dental radiologist were qualified for further research.

Haller's cells' presence was confirmed if an anatomical variation fulfilled the criteria suggested by Ahmad et al.[3]

  • Well-defined round, oval, or teardrop-shaped radiolucency, single or multiple, and unilocular or multilocular, with a smooth border, which may or may not appear corticated
  • Located medially to infraorbital foramen
  • All or most of their border is visible in panoramic radiograph
  • The inferior border of the orbit is nonsolid or remains indistinguishable in areas superimposed by this entity.



  Results Top


The results were analyzed using descriptive statistics methods. There have been 103 Haller's cells found in 72 patients – 54 females (17.82% of all examined females) and 18 males (10.97% of all examined males). The total prevalence of Haller's cells in the study group equaled 15.4%. Regardless of the sex infraorbital ethmoidal air cells were more often located unilaterally (61%) than bilaterally (39%). There was no inclination toward one of the sides; their distribution was similar on the left and on the right side [Table 1]. In men, unilateral distribution of Haller's cells equaled 78% while in females 56%. The presence of a singular, unilateral cell has been noticed in 39 patients (54%) which is almost one half of the total number of the patients. At the same time, two or three cells located unilaterally were very rare findings. There have not been observed more than 3 Haller's cells on one of the sides. In 20 patients, there have been found singular bilateral cells, seven of the patients showed the presence of 2 cells on one of the sides accompanied by 1 cell on the opposite side. The discovered cells had various shapes in descending order – oval, circular, teardrop, triangular, rectangular, square, and irregular [Table 2]. It has been observed that in men Haller's cells were more regular in shape – mostly oval and circular when in females, there was a greater variety of the shapes [Table 3].
Table 1: Distribution of Haller's cells regarding sex and side

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Table 2: Distribution of Haller's cells regarding shape

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Table 3: Distribution of Haller's cells regarding sex and shape

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  Discussion Top


Despite being discovered in the late 18th century, Haller's cells are still quite an unexplored anatomical structure. An effective tool in assessing Haller's presence is a panoramic radiograph. It depicts their localization along the inferomedial orbital floor line. Attempts to estimate the prevalence of infraorbital ethmoid air cells among different populations by interpreting panoramic radiographs have been undertaken by researchers worldwide. However, this study is the first one to be carried out among the Polish population. In accordance with the available scientific literature also based on the analysis of panoramic radiographs, the incidence of Haller's cells in various study groups is diverse. They are found in 2%–45% of the patients.[11] A study conducted in India by Raina et al.[1] comprising 600 individuals has found Haller's cells in 16% of the study group. Another research carried out in India by Solanki et al.[8] has established that the prevalence of the cells was 19.2%. In the study conducted by Chaudhari et al.,[2] Haller's cells were reported in 10% of the Indian group. Results obtained by the abovementioned researchers are akin to the results of our study, i.e., 15.4%. On the other hand, almost three times higher incidence of infraorbital ethmoid air cells has been reported by Ahmad et al.[3] – 38.2% of the study conducted in the USA.

Scientists assume that the presence of Haller's cells is affected by multiple factors such as race, age, or even gender. Our research did not focus on race as a determining factor as it comprised a sample of the Polish population of Caucasian origin. In our study, we interpreted panoramic radiographs of a study group that consisted of patients born in the same year aged 17–23 on the day of taking a panoramic radiograph. Some of the previously conducted studies[1],[2] comprising various age groups reported less Haller's cells in older patients. A study conducted by Dhanasekaran et al.[5] reports that the number of these cells in diversified age groups was higher in patients aged between 20 and 30 years than in patients past this age, but the differences were not statistically significant.

When analyzing the prevalence of Haller's cells regarding gender, we found that it was slightly higher in females. Comparing our results to different studies, we observed that the gender-related differences noted by other researchers are similar. Solanki et al.[8] in their study estimated that Haller's cells occur in 25.5% of females and 14.8% of males. Both cited studies and remaining available literature do not implicate that the number of infraorbital ethmoid air cells is gender-related.[1],[2],[12] In most of the studies, the prevalence of these cells differs by a few percent in favor of females or males.

Another examined feature was the location of Haller's cells. Nedunchezhian et al.[13] conducted a similar study in India and concluded that the number of cells on the right and on the left side was almost equal. Right-sided cells equaled 30.91%, whereas left-sided cells totaled 31.16%. Ahmad et al.[3] have also obtained very similar results in their study conducted on the USA population – there was no significant difference in the prevalence of infraorbital ethmoid cells between right side which equaled 27.8% and left side – 28.9%.

In our study, unilateral distribution of infraorbital ethmoid air cells was noted in 61.1% of 72 patients. There were Haller's cells located on both sides in 28 of the cases, which gives the percentage value of 38.9%. In a similar study conducted in India Satvinder et al.[12] estimated that there is no difference in the frequency of unilateral and bilateral cells on the given side. Our observations are in accordance with the studies of Solanki et al.[8] and Raina et al.,[1] who have also found cases of single unilateral cell and bilateral cell most frequently. More than two cells in an individual were sporadic findings.

The last feature we assessed was the shape of examined cells. It turns out that Haller's cells can take various forms, although most of them are oval or circular and only few of them distinguish themselves with peculiar shapes. Our results correlate with those by Chaudhari et al.,[2] who concluded that the dominating shape was oval – 53.3% of the cells followed by circular shape – 46.7% of the cells. Based on our study and the quoted literature, it is noticeable that in most cases Haller's cells take ovoid and circular forms, other shape variations are sporadic.


  Conclusions Top


The analysis of 467 panoramic radiographs has concluded that Haller's cells are present in 15.4% of the patients with slightly higher prevalence in females in a sample of the Polish population. Unilateral distribution of the cells and most predominant oval shape outnumbered all the other variants.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raina A, Guledgud MV, Patil K. Infraorbital ethmoid (Haller's) cells: A panoramic radiographic study. Dentomaxillofac Radiol 2012;41:305-8.  Back to cited text no. 1
    
2.
Chaudhari RS, Sagar K, Sagar N, Sanjeev O, Abhay K, Pratik P. Prevalence of Haller's cells: A panoramic study. Ann Maxillofac Surg 2019;9:72-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ahmad M, Khurana N, Jaberi J, Sampair C, Kuba RK. Prevalence of infraorbital ethmoid (Haller's) cells on panoramic radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:658-61.  Back to cited text no. 3
    
4.
Alkire BC, Bhattacharyya N. An assessment of sinonasal anatomic variants potentially associated with recurrent acute rhinosinusitis. Laryngoscope 2010;120:631-4.  Back to cited text no. 4
    
5.
Dhanasekaran B, Kanagamuthu P, Srinivasan R, Paventhan K, Somu P, Navin N, et al. Prevalence of Haller cells – A retrospective observational study at a tertiary health care centre. MedPulse Int J ENT 2019;12:24-8.  Back to cited text no. 5
    
6.
Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:56-64.  Back to cited text no. 6
    
7.
Yanagisawa E, Citardi MJ. Endoscopic view of the infraorbital ethmoid cell (Haller cell). Ear Nose Throat J 1996;75:406-7.  Back to cited text no. 7
    
8.
Solanki J, Gupta S, Patil N, Kulkarni VV, Singh M, Laller S. Prevelance of Haller's cells: A panoramic radiographic study. J Clin Diagn Res 2014;8:RC01-4.  Back to cited text no. 8
    
9.
Hanisch M, Hanisch L, Kleinheinz J, Jung S. Primary failure of eruption (PFE): A systematic review. Head Face Med 2018;14:5.  Back to cited text no. 9
    
10.
Różyło-Kalinowska I, Różyło TK. Współczesna Radiologia Stomatologiczna. Vol. 3. Lublin: Wyd. Czelej; 2021. p. 99-104.  Back to cited text no. 10
    
11.
Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol 2004;25:1613-8.  Back to cited text no. 11
    
12.
Satvinder S, Vibhuti K, Rimsha A, Rudra K, Sandip R. Original research paper prevalence of ethmoidal infraorbital cells in panoramic radiography. Int J Sci Res 2018;7:40-2.  Back to cited text no. 12
    
13.
Nedunchezhian K, Aswath N, Amudhan A. Quest for haller cells: A digital orthopantomography study. Indian J Dent Res 2018;29:181-5.  Back to cited text no. 13
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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