The diagnostic value of cone-beam computed tomography (CBCT) in the evaluation of sinonasal pathology: a narrative review

INTRODUCTION

Rhinosinusal inflammation is highly prevalent and generates a significant burden of disease and system costs. EPOS 2020 remains the European reference for diagnosis and management, emphasizing the role of imaging in selected situations, such as preoperative anatomical confirmation, clinical-endoscopic discrepancies, suspicion of complications, or alternative causes. The ICAR-RS 2021 consensus statements and the ACR Appropriateness Criteria (2022) converge: high-resolution native CT is the standard for bone, and MRI is preferred for soft tissues, orbit, and intracranial structures; plain radiography has limited utility. In the last decade, CBCT has gained ground due to its high spatial resolution, lower cost, and compact “office-based” infrastructure. However, its performance in soft tissues and density standardization (HU) is limited, and its rational adoption requires clarity on the clinical question and technological alternatives [4–8].

At the population level, chronic rhinosinusitis (CRS) is associated with a significant prevalence, affecting quality of life, productivity, and the use of medical resources, with a disproportionate impact on subgroups with comorbidities (asthma, nasal polyposis, allergies). In this context, the role of imaging is not to “diagnose” CRS in isolation—which remains a clinical diagnosis supported by endoscopy— but to inform the therapeutic decision: delineating the anatomy before functional endoscopic sinus surgery (FESS), confirming alternative suspicions (e.g., odontogenic causes), or clarifying situations with clinical-endoscopic discordance [1–3]. Thus, the choice of imaging modality must stem from a well-formulated clinical question (of the type “what will I change if I find out X?”), respecting the principles of justification and dose minimization (ALARA).

CBCT has positioned itself as an attractive option in the evaluation of the bony compartment of the osteomeatal complex, where high spatial resolution and the possibility of fields of view (FOV) adapted to the region of interest can provide fine details of relevant anatomical variants (agger nasi, Haller/Onodi cells, concha bullosa, vascular tracts) with favorable cost and logistics in an outpatient setting [4–6]. In addition, the “point-of-care” (POC) availability in some clinics reduces the time between consultation, imaging, and therapeutic decision, which can increase the efficiency of the clinical workflow. However, these advantages must be weighed against its intrinsic limitations: weaker tissue contrast than MDCT, reduced sensitivity for complications in soft tissues (orbital, intracranial), variability of HU values, and susceptibility to dental metallic artifacts [5–8]. Consequently, CBCT does not replace CT/MRI in alarm scenarios (orbital/neurological signs, suspected tumor, invasive fungal rhinosinusitis), where guidelines explicitly recommend MDCT and/or MRI.

An area where CBCT has particular added value is the dento-sinus interface. A significant proportion of maxillary sinusitis has an odontogenic etiology, and CBCT offers superior visualization of the sinus wall, dental apices, periapical lesions, and possible oro-antral communications, with direct relevance for planning the interdisciplinary ENT–dentistry therapeutic sequence [1–3,4–6]. At the same time, in uncomplicated CRS, CBCT can support FESS planning by mapping anatomical variants and assessing the degree of obstruction of the osteomeatal complex, when endoscopy and the response to medical treatment leave the next step in suspense [1–3].

Radioprotection considerations are central. In practice, CBCT tends to offer lower effective doses than standard MDCT in usual protocols; however, the comparison becomes closer with the emergence and dissemination of “ultra-low-dose” MDCT (ULD-CT) protocols, demonstrated even in early clinical studies as being able to maintain diagnostic utility at very low doses, and with the adoption of photon-counting CT (PCCT), which, in the evaluation of paranasal sinuses, has shown the possibility of doses even below many CBCT protocols, while maintaining or improving image quality. In sensitive populations (young patients, repeated examinations), the choice between CBCT, optimized MDCT (ULD), and PCCT must be based on clear clinical benefits, in the spirit of EPOS/ICAR-RS/ACR [1–3,9,10].

Finally, reporting standardization and integration with clinical practice are essential: the use of reporting schemes (such as LM or structured descriptions of critical variants), and making explicit the method’s limitations and the situations that require escalation to CT/MRI. At the same time, specific training for prescribing physicians and CBCT interpreters (including awareness of artifacts and interpretation pitfalls) remains a condition for safe and effective implementation [4–8].

The purpose of this article is a clinically oriented systematic synthesis of the value of CBCT in rhinosinusal pathology, compared to MDCT/MRI, with an emphasis on performance, dose, indications, limitations, and practical implementation. In particular, we will address: (i) situations where CBCT is appropriate as a first-line test (e.g., suspicion of odontogenic sinusitis or FESS planning in uncomplicated CRS), (ii) alarm signals that directly require CT/MRI, (iii) the pragmatic comparison of dose and information quality between CBCT and modern MDCT/PCCT, and (iv) operational recommendations for integrating CBCT into clinical workflows, aligned with the principles of justification and optimization defined in European and North American guidelines [1–3,9,10].

MATERIALS AND METHODS

We performed a systematic search (until September 7, 2025) on PubMed/Medline and consulted guidelines and society positions (EPOS 2020, ICAR-RS 2021, ACR 2022; AAO-HNS positions). Terms: cone-beam computed tomography, sinonasal, chronic rhinosinusitis, odontogenic sinusitis, fungal sinusitis, radiation dose, photon-counting CT, point-of-care CT, anatomic variations, endoscopic sinus surgery, navigation. We included: guidelines/consensuses; original/comparative studies relevant to CBCT in rhinosinusitis; papers on doses and image quality; reports on artifacts/limitations. Exclusions: non-sinonasal applications, series without clinically useful data, contrast-enhanced CBCT. A narrative synthesis on clinical questions is presented, and no formal metaanalysis was performed.

RESULTS

Technical principles, image quality, and inherent limitations

CBCT uses a conical beam and a flat detector, reconstructing volumetrically with a single arc or partial rotation. The major advantage is the high spatial resolution for fine bone structures (ethmoidal laminar plane, lamina papyracea, uncinate processes, Haller/Onodi cells), often surpassing MDCT at the same target dose; in contrast, soft tissue contrast is inferior due to noise, scatter, and beam hardening artifacts, especially in the presence of dental metals [4–6,31,32]. HU values are not standardized in CBCT (gray-level), so quantitative density estimates are unreliable and should not be used for inferences of tissue composition; recent literature confirms the variability of HU between devices and software [7,8]. Metal artifacts can be mitigated by reconstruction techniques/MAR algorithms and FOV settings, but remain a limiting factor in the dento-maxillary region [31–33].

Radiation dose: CBCT vs MDCT and new generations (ULD-CT, PCCT)

Clinical data report effective CBCT doses for sinuses of the order of 0.05–0.48 mSv (mean ~0.27 mSv), dependent on FOV, kVp/mAs, filtration, and protocol [11,21]. Optimization studies show scenarios for sinusitis diagnosis with ~77 μSv and protocols for surgical planning at ~0.21 mSv, confirming the potential for low-dose with adequate quality [14]. A systematic review (2024) on non-dental applications reported average dose reductions of ~12× for CBCT compared to MSCT in 19 studies, with wide variability (1.7–50×) [18]. However, advances in clinical CT — “ultra-low dose” MDCT and photon-counting CT (PCCT) — can lower the dose below many CBCT protocols while maintaining/superiorizing image quality; a 2024 sinus PCCT study reported 0.038 mSv (PCCT) vs 0.14 mSv (CBCT), with superior CNR and subjective appreciation for PCCT [15]. The pragmatic conclusion: CBCT has a dose advantage over classic MDCT, but not always over optimized ULD/PCCT protocols; the device-protocol selection must be local-specific and respect the principles of justification and ALARA. For context, a chest radiograph has ~0.1 mSv [5].

Uncomplicated chronic rhinosinusitis (CRS): diagnosis, scoring, planning

Guidelines indicate native high-resolution CT for anatomical confirmation and FESS planning. CBCT, as a technology, meets these requirements for bone and provides details of the osteomeatal complex, septum, concha bullosa, and accessory cells; the accuracy for bone lesions/anatomy is very good [1–3,17]. Studies correlate CBCT with endoscopy and show agreement in detecting CRS and OMC variations [17]; one study suggested that the accuracy of CBCT approaches that of endoscopy for the evaluation of CRS in certain clinical contexts, with the potential for an alternative to endoscopy in selected cases (patients with contraindications) [18].

Scoring: the Lund–Mackay (LM) system remains the reporting standard on CT, being robust inter-observer; however, the correlation with symptomatic severity is modest, and volumetric scoring or endoscopic phenotyping may have stronger links to quality of life [19,20]. CBCT allows for LM-analogous scoring (on reconstructed coronal/sagittal-axial images), but does not provide contrast to noninvasively differentiate mucosal subtypes or soft tissue complications. In practice, for uncomplicated CRS requiring anatomical confirmation and planning, CBCT is adequate, especially if available “point-of-care” and if there is no suspicion of complication. For complicated CRS (orbital pain, neurological signs, fever, immunosuppression), MDCT/MRI is required according to ACR/EPOS [1–3].

Anatomical variations of the OMC and critical structures

Documenting variations — Haller/Onodi cells, agger nasi, septal deviations, thin lamina papyracea, prominent anterior ethmoidal artery — is essential preoperatively [21–23]. CBCT excellently highlights these variants and reports prevalences similar to CT, including in patients with dental or orthognathic indications [3,17,21–23]. These findings must be integrated into standardized reports (e.g., the CLOSE/RELEVANT scheme) to reduce intraoperative risks [22,23].

Odontogenic sinusitis (ODS): the ideal example for CBCT

ODS represents a significant proportion of maxillary sinusitis and requires a particular diagnostic/therapeutic algorithm [24]. CBCT is the investigation of choice to identify dental sources (periapical lesions, resorptions, post-extraction complications), oro-antral communications, foreign bodies, and involvement of the sinus walls, all with superior precision to panoramic radiography [24,25]. Recent consensuses recommend multimodal diagnosis (clinical-endoscopic-imaging), but emphasize that indication-guided CBCT accelerates management and correctly directs the sequence of dental therapy/FESS [24,25].

Fungal pathology: “fungal ball” vs. invasive fungal rhinosinusitis

CBCT can capture intralesional densities/calcifications in a maxillary “fungal ball,” a classic radiological sign; however, complete detection requires a sufficiently large FOV and, in case of doubt, confirmation by MDCT [26]. For invasive fungal rhinosinusitis, ACR algorithms and recent reviews emphasize that MRI (with contrast) is more sensitive for perisinusal invasion and orbitocranial extension; CT remains useful for bone and calcifications, and CBCT is not indicated as the primary modality in this context [3,27].

Suspicion of tumor, orbital/intracranial complications

In the presence of sinonasal masses, suspicious bone erosion, signs of orbital cellulitis/abscess, or neurological symptoms, CBCT is not sufficient: ACR recommends high-resolution CT and MRI for soft tissue characterization and extensions; CBCT may miss subtle signs in soft tissue and does not allow for vascular/meningeal evaluation [3].

Preoperative planning and navigation; intraoperative role

For uncomplicated FESS, CBCT provides the necessary bone map, including anatomical variants and critical relationships; the riskbenefit equation may favor CBCT in patients without comorbidities/complications. In the operating room, intraoperative CBCT has demonstrated registration accuracy and utility for updating navigation, especially in skull base surgery; however, availability is limited, and the benefits on complications/reinterventions are heterogeneous [28]. Interfacing with augmented reality solutions based on intraoperative CBCT has achieved sub-millimeter errors in experimental models [33].

Pediatrics and “point-of-care” (POC)

In children, guideline-based practice discourages imaging in uncomplicated acute sinusitis; when images are necessary, selection is made strictly by indication [3]. POC CBCT in adults — and, occasionally, in adolescents — has logistical advantages: rapid scanning, seated/upright position, reduced sedation, integration into the same consultation, shortening the diagnostic path; recent AAO-HNS positions support the use of POC-CT when it aids management, with attention to justification, training, and interpretation quality [29]. Early data from public clinics suggest reduced time to therapeutic decision and fewer visits when CBCT is available in the outpatient setting, but robust economic evaluations are needed [30].

DISCUSSION

Key advantages of CBCT in sinonasal disease

Superior bone spatial resolution, ideal for mapping the osteomeatal complex, anatomical variations, and sinus wall defects; 2) Compact infrastructure and relatively low cost, including POC availability; 3) Lower dose than standard MDCT in most common protocols; 4) Excellently visible dento-sinusal interface, which positions CBCT as the first choice in odontogenic sinusitis; 5) Short acquisition time and good patient tolerance (useful in the clinic/outpatient workflow). These benefits can increase treatment adherence (by reviewing images with the patient) and can reduce time and cost investments in some clinical pathways [24,25,29,30].

Intrinsic limitations and critical considerations

CBCT has poor tissue contrast and artifacts (beam hardening, scatter), which reduce sensitivity for mucosa, collections, subtle fluid emissions, and perisinusal extensions. HU values are uncalibrated, with variability dependent on the manufacturer/protocol/algorithm; quantitative uses should be avoided [5,7,8,31–33]. In invasive fungal rhinosinusitis, orbital/intracranial complications, masses, and CSF fistulas, CBCT is inadequate; CT (sometimes with contrast) and MRI are standard [1–3,27]. Finally, it should not be assumed that CBCT always offers lower doses than all alternatives: ULD-CT/PCCT can achieve doses below CBCT with superior quality — an important decision point in centers with such technologies [15,18].

In diabetic patients, rhinosinusitis can rapidly evolve into loco-regional and systemic complications with lethal potential[34]. For this reason, in situations where such an evolution is suspected, CBCT does not provide sufficient information for a complete evaluation of the pathology. In these cases, the use of computed tomography (CT), with or without magnetic resonance imaging (MRI), is necessary to accurately determine the extent of sinonasal involvement and to correctly guide therapeutic management.

Integration with guidelines and radioprotection aspects

Justification of the examination is essential. EADMFR recommendations and European/national positions require that CBCT be indicated only when it changes management and after adequate clinical triage; training for prescribers and interpreters is required [13]. In ENT, ACR provides clear scenarios: CBCT may be appropriate for uncomplicated CRS and planning; CT/MRI is used in suspicion of complications, tumors, and IFRS [3]. EPOS/ICAR-RS confirm these orientations, emphasizing integration with endoscopy and clinical phenotyping [1,2].

Proposed practical algorithm (indicative)

A practical, indicative algorithm for the use of imaging in sinonasal pathology must start from the presence or absence of alarm symptoms. In cases presenting orbito-neurological signs, immunosuppression, high fever, severe pain, suspicion of tumor or invasive fungal rhinosinusitis (IFRS), the recommended imaging investigation is emergency computed tomography, with or without contrast administration, supplemented by magnetic resonance imaging with contrast for an adequate evaluation of soft tissues. In these situations, CBCT is not indicated.

For uncomplicated forms of chronic rhinosinusitis (CRS), imaging is not mandatory for diagnosis. However, if anatomical reconstruction is anticipated or FESS intervention is planned, or in case of clinical-endoscopic discrepancies, CBCT can be used, especially when point-of-care (POC) is available. The imaging report must be standardized and include details about critical anatomical variants. In centers where superior performance ultra-low dose (ULD) CT or photon-counting CT (PCCT) protocols are available, these may be preferred, especially if soft tissue evaluation is anticipated.

In case of suspected odontogenic sinusitis (ODS), CBCT is the first-line investigation, integrated with dental and endoscopic evaluation, requiring close collaboration between ENT specialists and dentists.

For suspected maxillary “fungal ball,” CBCT with an adequate field of view (FOV) is recommended, but if atypical signs appear, confirmation by CT or MRI is necessary. In cases of suspected IFRS, the imaging protocol must obligatorily include CT and MRI; CBCT is not recommended.

Implications for Practice and Research

CBCT may shorten the diagnostic and treatment pathway for patients with uncomplicated chronic rhinosinusitis (CRS) and odontogenic sinusitis (ODS), especially in point-of-care (POC) models. The following are needed:

1. standardization of reports (critical anatomy, scoring systems);
2. comparative studies between optimized CBCT and ULD-CT/PCCT regarding clinical outcomes and cost-effectiveness;
3. development and validation of MAR/AI algorithms to reduce metal artifacts and improve soft-tissue surrogates;
4. ENT-specific guidelines for training and quality interpretation in CBCT.

Recent studies have shown that CBCT can have comparable sensitivity to conventional CT in detecting sinonasal anatomical variations in patients with chronic rhinosinusitis [35]. In addition, the use of CBCT is supported by less expensive infrastructure and superior ergonomics in outpatient clinical settings, which can contribute to optimizing patient flow [36]. At the same time, recent advances in image reconstruction and artifact correction contribute to improving the diagnostic value of CBCT, including for otorhinolaryngological applications [37].

CONCLUSION

CBCT has strong diagnostic value in uncomplicated sinonasal disease, in FESS planning, and especially in odontogenic sinusitis, where bony detail and the dento-sinusal interface are crucial. Its dose advantage compared to standard MDCT and its point-of-care (POC) accessibility are real, though not universal: in centers equipped with ULD-CT or PCCT, these technologies may offer lower radiation doses and superior image quality—particularly when soft tissue assessment is required.

CBCT does not replace CT or MRI in the context of complications, tumors, or invasive fungal rhinosinusitis (IFRS).

An implementation guided by the clinical question, adherence to EPOS/ICAR/ACR guidelines, and respect for radiation safety principles maximizes patient benefit. In practice, careful case selection must be coupled with standardized reports (e.g., CBCT-adapted LM-type scoring and inventory of critical anatomical variants), optimized dose protocols, and training for prescribers/interpreters. The integration of CBCT into interdisciplinary ENT-dentistry pathways can shorten the time to therapeutic decision in ODS and reduce costs, conditioned by local quality audit and re-exposures. Direct comparisons between CBCT vs ULD-CT/PCCT are needed on clinical outcomes, cost-effectiveness, and quality of life, as well as the evaluation of MAR/AI algorithms for artifact control. Phased implementation, with monitoring of performance indicators and patient satisfaction, supports sustainable use.

Conflicts of interest and sources of funding

The authors declare no conflict of interest.

This research received no external funding.

Authors’ contribution

Conceptualization, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; methodology, CV, CA.; software, CV, CA; validation, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA.; formal analysis, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; investigation, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; resources, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; data curation, CV, CA; writing—original draft preparation, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; writing—review and editing, CV, VZ, RH, LG, AS, AR, ORP, IGI, CA; visualization, CV, VZ, IGI, CA.; supervision, CV, VA. All authors have read and agreed to the published version of the manuscript.

Ethics approval and consent to participate

Not applicable.

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