CJBAS Vol.

(01) - September - Issue 02 (2013) 125-134

A Three Dimensional Computed Tomography (3D-CT): A Study of Maxillary Sinus in

Malays
Ahmed A. Masri1,, Asilah Yusof1, Rozita Hassan1
1

School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia

Keywords:

Maxillary sinus;
Growth;
3D Scans;
Volume

Abstract
Objective: To study the size of the maxillary sinus which includes linear and volume
measurements.
Methods: Three dimensional computed tomography (3D CT) images of 144 Malays
(288 maxillary sinuses) with no clinical evidence of craniofacial and maxillary sinus
abnormalities were selected. The subjects aged from 0.4 to 30 years (mean = 13.7 ; SD
= 8.53), underwent the CT scanning using General Electric (GE) Light Speed Plus CT
Scanner System (Wisconsin, USA) at the Radiology department, HUSM for reasons
other than research purposes. The initial 2D formats were then reconstructed into 3D
utilising OsiriX V3.7 (Geneva, Switzerland) software. Linear dimensions and volume
of maxillary sinus were measured for different age categories and gender.
Results: The maxillary sinus increased in sizes and volume from birth to 30 years of
age. Females demonstrated to have significantly larger maxillary sinus width (p=0.02),
height (p=0.04) and depth (p<0.01) than males in 0-6 years age category. The males
maxillary sinus width and height were significantly larger than females in 7-12
(p<0.01) and 21-30 (p=0.02) years age categories. Moreover, maxillary sinus depth
were found to be larger in males than females in 21-30 years age category (p<0.01).
Males also exhibited larger maxillary sinus volume than females in 7-12 (p<0.01) and
21-30 (p<0.01) years age categories.
Conclusions: The maxillary sinus sizes and volume showed sexual dimorphism at most
age categories. Gender consideration should be taken into account in clinical
assessment and procedures which may affect the maxillary sinus.

1. Introduction
The maxillary sinus is the largest and the first paranasal sinus to develop [1]. It is located in the left
and right maxillary bones and consists of two spaces, which is air-filled cavity lined with mucosa
(mucosal epithelium and lamina propria). It serves many functions such as, to decrease the weight
of the skull, increases voice resonance, protects against blows to the face, insulation of the eyes and
roots of theteeth against temperature fluctuations, humidification of inhaled air and contributes to
the maxillary growth [2].
When fully developed, each sinus has a complex pyramidal shape. The broadest or basal surface is
parallel to the lateral nasal fossa. The inferior concha arises along the midplane of the nasal surface.

Corresponding Author (Email: [email protected] Tel. (+60) 142 935 931)

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In most cases, the ostium of the maxillary
sinus interacts with the nasal fossa at the
posterior border of the hiatus semilunaris, just
above the inferior turbinate [2].
Researchers have revealed that the shape and
size of the maxillary sinus differ among
individuals, between males and females, and
in various populations. Fernandes (2004)
showed that ethnic and gender differences in
maxillary sinus size existed among the study
populations [3]. They found that 48.6% of
European maxillary sinuses had significantly
larger antral volumes than Zulu maxillary
sinuses, and men had larger maxillary sinus
volumes than women. Moreover, Butaric et
al. reported that the mean values for the
maxillary sinus ranged from 18.86 cm3 for the
Peruvian sample and 36.15 cm3 for the
Australian sample [4]. Another study reported
that the mean maxillary sinus volume of girls
was larger than that of boys at ages 4 and 9
years in a Japanese population and the
maxillary sinus volume of boys tended to be
larger than those of girls at ages 10 to 15
years. Moreover, the maxillary sinus volume
in subjects aged 10 to 15 years tended to be
larger than those of subjects aged 40 years
and older [5].
The purpose of the present study was to
determine and compare the size and volume
of the maxillary sinus, between the left and
right, and between the males and females.

craniofacial abnormalities or sinus problem,

from the years 2001-2002. Subjects were
Malays with family background of at least
two generations of both parents are of Malay
origin.
3D-CT data of 144 subjects were selected
from the data collected in previous study [6].
Osirix V3.7 software was used to measure the
maxillary sinus distances along straight lines
between the identified landmarks based on the
previous definitions of landmarks by [7].
Three landmarks height, width and depth of
the maxillary sinus size were measured
according to [8]:
Width: the longest distance perpendicular
from the medial wall of the sinus to the most
lateral wall of the lateral process of the
maxillary sinus in the axial view (Figure 1).
Depth: the longest distance from the most
anterior point to the most posterior point of
the medial wall in the axial view (Figure 1).
Height: the longest distance from the
lowest point of the sinus floor to the highest
point of the sinus roof in the coronal view
(Figure 1).
Using the Osirix V3.7 software (Figure 2), the
volumetric limits of the maxillary sinus were
defined and selected. Then the anterior and
posterior boundaries for bony maxillary sinus
were defined. All measurements were
performed through contiguous coronal
sections. The closed polygon function was
selected to segment the bony maxillary sinus
region of interest (ROI) of each single slice
using a specific cursor. At the end of the
segmentation process, all the regions of
interest were grouped and the volume was
computed [9].

2. Materials And Methods

All healthy Malays aged between 0.4 to 30
years who had their CT scan at the Radiology
Department, Hospital Universiti Sains
Malaysia for reasons other than due to

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a)

b)

Measurements the width and depth of the maxillary

Measurements
Figure 1. a) Measurements
sinus, b) Measurements the
height of the maxillary sinus.
Figure the width and
3.1

Figure the width and

depth of the

3.1

depth of the

maxillary

maxillary

sinus.

sinus.

a)
Measurements
Figure the width and
3.1

depth of the
maxillary
sinus.

b)
Measurements

Figure 2. a) Image showing the grouping of all the regions of interest at the end of the
segmentation Figure
process the
by width
usingand
the group selected region of interest (ROI) function, b) Image
showing the volume computation process by using computed volume of the selected ROI
depth of the
3.1
function.
maxillary
sinus.

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Ahmed A. Masri et al. CJBAS Vol. (01)-September Issue 02 (2013) 125-134

0.02, 0.01, and 0.01 with the percentage of
dimorphism of -95.1%, 19.4% and 10.6%
respectively. On the other hand, in the age
group 13-20 years the difference between
males and females was not statistically
significant.

3. Results
3.1. Left maxillary sinus width.
Table 1 shows comparisons of the left
maxillary sinus width between the males and
females in each age group. Sexual
dimorphisms were demonstrated in the age
groups 0-6, 7-12 and 21-30 years with p value

Table 1 Comparison of the left maxillary sinus width (in cm) between Malay males and
females in each age group.
Left maxillary sinus
width

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

0.02*
0.01*
0.37
0.01*

-95.1
19.4
2.40
10.6

Age group (year)

0-6
7-12
13-20
21-30

0.62 (1.07)
2.67 (0.37)
2.89 (0.50)
3.09 (0.62)

1.21 (1.08)
2.15 (0.84)
2.82 (0.76)
2.76 (0.39)

-2.27
-2.40
-0.88
-2.54

*significant at p < 0.05

sinus width between males and females were

observed in the age groups 0-6, 7-12 and 2130 years with the percentage of dimorphism
of -138%, 11.6% and 9.46% respectively
(Table 2).

3.2. Right maxillary sinus width.

No difference was detected in the size of the
right maxillary sinus width between males
and females in the age group 13-20 years. In
contrast, differences in the right maxillary

Table 2. Comparison of the right maxillary sinus width (in cm) between Malay males and
females in each age group.
Right maxillary sinus
width

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

Age group (year)

0-6
7-12
13-20
21-30

0.60(1.26)
2.66(0.41)
2.87(0.54)
3.17(0.36)

1.43(0.80)
2.35(0.75)
2.61(0.54)
2.87(0.50)

-2.24
-2.43
-1.67
-2.32

0.02*
0.01*
0.09
0.02*

-138
11.6
9.05
9.46

*significant at p < 0.05

dimorphism of the left and right maxillary

sinus depths can be observed in 0-6 and 21-30
years age groups (Table 3).

3.3. Left and right maxillary sinus depths.

Both left and right maxillary sinus depths do
not differ in size between males and females
for age group 7-12 and 13-20 years. Sexual

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Table 3. Comparison of the left and right maxillary sinus depths (in cm) between Malay males
and females in each age group.
Left maxillary sinus
depth

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

-2.94
-0.76
-9.18
-2.75
Z statistics

0.00#
0.44
0.35
0.00#
P value

-55.9
5.64
2.27
7.92
Dimorphism
%

-2.83
-1.33
-0.69
-2.69

0.00#
0.18
0.48
0.00#

-64.4
4.15
6.56
5.02

Age group (year)

0-6
7-12
13-20
21-30
Right maxillary
sinus depth

1.09 (0.69)
1.70 (1.18)
3.19 (0.34)
3.01 (1.15)
3.95 (0.53)
3.86 (0.44)
4.29 (0.66)
3.95 (0.24)
Median (IQR)
Male
Female

Age group (year)

0-6
7-12
13-20
21-30

1.04 (0.61)
3.13 (0.66)
3.96 (0.56)
4.18 (0.38)

1.71 (0.98)
3.00 (1.09)
3.70 (0.86)
3.97 (0.21)

# significant at p < 0.01

between males and females was detected in

the age groups 7-12 and 21-30 years with the
percentage of dimorphism of 18.6% and
16.5% respectively (Table 4).

3.4. Left maxillary sinus height.

There is no difference in the size of the left
maxillary sinus height between males and
females for 0-6 and 13-20 years age groups.
Differences in the left maxillary sinus height

Table 4. Comparison of the left maxillary sinus height (in cm) between Malay males and
females in each age group.
Left maxillary sinus
height

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

-1.89
-2.94
-0.19
-2.54

0.05
0.00#
0.84
0.01*

-72.9
18.6
-1.81
16.5

Age group (year)

0-6
7-12
13-20
21-30

0.85 (1.37)
2.74 (0.52)
3.30 (0.86)
3.81 (0.87)

1.47 (1.22)
2.23 (0.88)
3.36 (0.76)
3.18 (0.94)

*significant at p < 0.05, # significant at p < 0.01

males and females in the age groups 0-6, 7-12

and 21-30 years with the percentage of
dimorphism of -76.7%, 20% and 9.89%
respectively (Table 5).

3.5. Right maxillary sinus height.

There is no difference in the size of the right
maxillary sinus height between males and
females in the age group 13-20 years. The
right maxillary sinus height differed between

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Table 5. Comparison of the right maxillary sinus height (in cm) between Malay males and
females in each age group.
Right maxillary
sinus height

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

Age group (year)

0-6
7-12
13-20
21-30

0.86(1.18)
2.79(0.66)
3.30(1.01)
3.74(0.48)

1.52(1.15)
2.23(0.94)
3.32(0.65)
3.37(0.43)

-1.99
-3.04
-0.69
-2.24

0.04*
0.00#
0.48
0.02*

-76.7
20.0
-0.60
9.89

*significant at p < 0.05, # significant at p < 0.01

volume can be observed in 21-30 years age

group with the percentage of dimorphism of
29.6% on the left and 26.6% on the right
(Table 6).

3.6. Left and right maxillary sinus volumes.

Both right and left maxillary sinus volumes
do not differ in size between males and
females from 0 to 20 years of age. However,
sexual dimorphism of the maxillary sinus

Table 6. Comparison of the left and right maxillary sinus volume (in cm3) between Malay
males and females in each age group.
Left maxillary sinus
volume

Median (IQR)
Male
Female

Z statistics

P value

Dimorphism
%

1.74 (4.45)
2.87 (3.49)
10.0 (7.13)
8.73 (3.42)
17.4 (6.50)
12.8 (5.75)
19.2 (8.72)
14.1 (5.55)
Median (IQR)
Male
Female

-0.12
-1.20
-1.89
-2.97
Z statistics

0.89
0.22
0.05
0.00#
P value

39.3
11.4
26.4
29.6
Dimorphism
%

-0.06
-1.04
-1.93
-2.87

0.95
0.29
0.05
0.00#

Age group (year)

0-6
7-12
13-20
21-30
Right maxillary
sinus volume
Age group (year)
0-6
7-12
13-20
21-30

1.89 (3.77)
10.4 (5.33)
17.2 (6.70)
20.3 (8.53)

2.75 (3.46)
9.80(5.68)
14.2 (4.79)
14.9 (6.28)

31
5.7
17.4
26.6

# significant at p < 0.01

extra radiation by obtaining more than

necessary
CT
scans.
Nevertheless,
longitudinal studies are particularly useful for
determining the rate of growth and following
individual subjects.
The maxillary sinus is present as a small air
space at birth. Spurts of maxillary sinus
growth occur for both genders from birth to 2
years, from 7.5 to 10 years, and from 10 to 12

4. Discussion
A cross-sectional rather than a longitudinal
study design was performed in this study
because cross-sectional standers are more
representative of a normal population and
enable comparisons of individuals with
abnormalities. A cross-sectional approach was
also selected because it would have been
unethical to expose subjects unnecessarily to

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years. Thereafter, growth is slow but steady
until 14 to 18 years [10]. The maxillary sinus
reaches adult size varies between 14 and 18
years [5]; as well in the second decade of life
in females and the third decade in males in
Korean population [11]. However, as the
lowest extension of the cavity grows when
permanent teeth emerge, the sinus appears to
further enlarge, albeit only slightly, in the
vertical direction [12].
In this study, the maxillary sinus reached a
nearly adult size at the age of 13 to 20 years
with the mean age of 18.01.9 years for males
and 18.11.7 years for females. These results
are in agreement with [12].
Significant differences were found in most
maxillary sinus measurements between males
and females, mainly because the males
exhibited higher and wider maxillary sinuses
than females (Tables 1 to 6). Some authors
have reported differences in the volumes of
maxillary sinuses between males and females
[13, 14]. Others have shown no such
differences [12, 15, 16]. Some researchers
suggested that the development of the sinuses
was different at different ages and genders
during childhood [17].
Viraspongse et al. reported that the
pneumatization of sinuses did not change
significantly with sex and age. These
disagreements between different studies may
have resulted from differences in sample
sizes, methods of subject selections, methods
of measurements, landmarks used, regions
studied or type of analyses carried out [18].
Girls had significantly larger maxillary
sinuses than boys in the age group 0 to 6
years (Tables 1 to 6). This finding was
supported by Spaeth et al. who revealed that
in Germany population, the sinuses of girls
were significantly larger than those of boys of
the same age until they reached five or six
years old, upon which this tendency reverses,
without reported the reasons for this
phenomenon [19]. Therefore, the growth of

female sinuses was more advanced than that

of male sinuses during this time, possibly
corresponding to periods of growth
acceleration in females [6].
Schliephake reported that insulin-like growth
factor (IGF) have an important role in general
growth [7], maintenance of the body skeleton
and craniofacial growth. Vatten et al. revealed
that the levels of IGF in umbilical cord
plasma and after birth were higher in girls
than in boys [20]. These IGF discoveries are
possible explanations for the maxillary sinus
sizes being larger in girls than boys in the age
group 0 to 6 years as observed in this study
[20].
During pre-adolescence (7 to 12 years), the
maxillary sinus doubled the sizes and
volumes as compared to children (0 to 6
years) indicating that some growth
acceleration may occur (Tables 1 to 6). This
could be due to the second pneumatization
process associated with rapid period in the
maxillary sinus growth described by some
authors [12, 21].
The sizes of all variables of the maxillary
sinus (width, depth, height and volume) in
males are larger than those of females, though
only height and width showed significant
differences. These findings agree with
Kawarai et al. who revealed that male tended
to have larger sinuses at these ages [13].
Two explanations can be offered for this
reverse development changes in the size of
the maxillary sinus. First, according to Enlow,
males need to have correspondingly bigger
lungs to support their relatively more massive
muscles and body organs [22]. Males need a
larger airway, which begins with the nose and
nasopharynx. In other words, physiological
changes in nasal cavity size and shape occur
as a direct result of respiration-related needs,
such as warming and humidifying inhaled air.
As the maxillary sinus occupies the remaining
space within the nasomaxillary complex, it
also increases in size. Another possible
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explanation
would
be
the
second
pneumatization, which occurs between the
ages of 8 to 12, as described by [5, 21].
According to a study using CT scans of 91
Turkish individuals (47 men and 44 women)
from 5 to 55 years, male patients have larger
sinuses than female patients from 16 to 20
years. Significant difference in the average
maxillary sinus volume was noted where
males maxillary sinus volumes were
14.745.79 cm3 on the right and 14.554.72
cm3 on the left whereas and females
maxillary sinus volumes were 14.293.42 cm3
on the right and 13.783.41 cm3 on the left
[17].
During adolescence (13 to 20 years), our
results were similar with Karakas and
Kavakli, showing that males tended to have
larger maxillary sinus volume than females
though not statistically significant [17].
Barghouth et al. measured 224 MRI heads in
an age group of less than 17 years. They
reported no difference between males and
females [16]. Dimensions of maxillary
sinuses at 16 years were 3.9 cm deep, 3.6 cm
high and 2.7 cm wide and the volume was
18.3 cm3. These results are similar with the
current study where no significant difference
of the maxillary sinus measurements was
observed during adolescence although males
tended to have larger measurements (Tables
4.5 to 4.10). During these ages, Spaeth et al.
reported that in the German population, the
maxillary sinus depth and width for males
were 4.1 and 3.2 cm respectively, which were
larger than the females measurements of 3.8
and 2.9 cm respectively [19]. Our results
showed that the Malays tended to have lesser
maxillary sinus width and depth for both
sexes. Nevertheless, this study agreed with
Spaeth et al. where the maxillary sinus in
males tended to be wider and deeper than the
females at this age group (Tables 1 to 3) [19].
Significant differences were demonstrated
between the males and females maxillary

sinus measurements in adults (21 to 30 years)

(Tables 1 to 6). Emirzeoglu et al. examined
coronal CT scan images taken from 77
Turkish patients (38 female and 39 male
subjects) aged between 18 and 72 years
(Mean(SD): 34.5(11.8) years), and reported
significant difference of maxillary sinus
volume between males and females (Males:
19.86.3 cm3; Females: 165 cm3) [14]. The
difference in maxillary sinus volume may
account for the difference in the shape and
morphology of the male and female face
particularly around the midfacial region.
Furthermore, Fernandes , who examined
South Africans and Europeans, reported no
significant difference between males and
females for the maxillary sinus width [3]. On
the other hand, maxillary sinus depth, height
and volume showed significant differences
between the sexes. Slight differences between
our results and those of Fernandes may be
attributed
to
different
geographical
populations and differences in sample size (53
CT scans for Fernandes) [3].
Maxillary sinus measurements in children (0
to 6 years) showed the highest percentage of
sexual dimorphism in the range of -31 to 138%.
This result revealed that the
magnitude of differences between the males
and females were high during these ages. The
negative values indicated that the females
measurements were larger than the males.
Low magnitude of sexual differences of the
maxillary sinus measurements were noted in
pre-adolescents (7 to 12 years) exhibited by
the percentage of sexual dimorphism in the
range of 4.2 to 20.0%. The percentage of
sexual dimorphism during adolescence (13 to
20 years) ranged between -0.6 to 26.4%
revealing low magnitude of differences of the
maxillary sinus measurements between the
sexes. The left and right maxillary sinus
height measurements were demonstrated to be
slightly higher in females though not
statistically significant (Tables 1 to 6).
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Maxillary sinus measurements in adults (21 to
30 years) also showed low magnitude of
sexual differences with the percentage of
dimorphism in the range of 5.0 to 29.6%.

[5] Ikeda A., Ikeda M., Komatsuzaki A.: A

CT study of the course of growth of the
maxillary sinus: normal subjects and
subjects with chronic sinusitis. ORL;
Journal for Oto-rhino-laryngology and its
related Specialties, 60, 147-52 (1998).

Conflict interest:
The authors declare that they have no
competing interests.

[6] Yusof A.: Craniofacial growth changes in

Malaysian Malay children and young
adults: a cross-sectional 3-dimensional CT
study. PhD thesis. Adelaide, Australia
(2007).

Acknowledgement
The authors of this paper would like to thank
the School of Dental Sciences, Universiti
Sains Malaysia.

[7] Schliephake H.: Bone growth factors in

maxillofacial skeletal reconstruction. The
International Journal of Oral and
Maxillofacial Surgery, 31, 469-484
(2002).
DOI: 10.1054/ijom.2002.0244

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