Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript addresses an important anatomical and radiological topic regarding the prevalence and morphometric characteristics of Haller cells in an Iraqi population using high-resolution computed tomography. The study is well designed, and the methodology is adequately described. The statistical analyses are appropriate, and the results are clearly presented and supported by the conclusions.

The manuscript provides valuable population-based anatomical data and contributes to the understanding of sino-nasal anatomical variations and their potential associations with sinusitis and related variants.

However, several minor revisions are recommended before acceptance:

1. The English language should be carefully revised to improve clarity, grammar, and readability in several sections of the manuscript.
2. Some sentences in the Introduction and Discussion sections are overly long and may benefit from simplification for better readability.
3. Minor formatting inconsistencies should be checked throughout the manuscript.
4. The ethical approval section should clearly present the complete institutional approval information if available.

Overall, the manuscript is scientifically sound and suitable for publication after minor revision.

Comments on the Quality of English Language

The English language is generally understandable; however, minor grammatical and stylistic revisions are recommended to improve clarity, sentence structure, and readability throughout the manuscript.

Author Response

• Comment: The manuscript addresses an important anatomical and radiological topic regarding the prevalence and morphometric characteristics of Haller cells in an Iraqi population using high-resolution computed tomography. The study is well designed, and the methodology is adequately described. The statistical analyses are appropriate, and the results are clearly presented and supported by the conclusions. The manuscript provides valuable population-based anatomical data and contributes to the understanding of sino-nasal anatomical variations and their potential associations with sinusitis and related variants. However, several minor revisions are recommended before acceptance.

Response: Dear Sir/Madam, the Respected Reviewer, we sincerely thank you for your careful evaluation and constructive comments on our manuscript. On behalf of all co-authors, I confirm that we have addressed all comments and revised the manuscript accordingly using the track-changes feature in Microsoft Word.

            Also, thank you for highlighting the anatomical and radiological significance of our study in the Iraqi population. We have also addressed and fully complied with all the minor revision requests outlined in your comments.

1. Comment: The English language should be carefully revised to improve clarity, grammar, and readability in several sections of the manuscript.

Response: We sincerely appreciate your careful evaluation of both the scientific content and the linguistic quality of our manuscript, including its clarity, readability, and grammatical accuracy. The manuscript has been revised according to your comments.

2. Comment: Some sentences in the Introduction and Discussion sections are overly long and may benefit from simplification for better readability.

Response: We agree that some sentences in the Introduction and Discussion sections were long or redundant. Accordingly, we have shortened, simplified, and revised these sections in accordance with your valuable comments.

3. Comment: Minor formatting inconsistencies should be checked throughout the manuscript.

Response: Thank you for your careful observation regarding the manuscript formatting. We have thoroughly reviewed the full-text manuscript for minor formatting inconsistencies and ensured full compliance with the Instructions for Authors of the Journal of the Oman Medical Association (JOMA).

4. Comment: The ethical approval section should clearly present the complete institutional approval information if available.

Response: We sincerely thank you for this important comment regarding research ethics. We confirm that the present Iraqi-based study was approved by the Research Ethics Committee and the Institutional Review Board (IRB) of the College of Medicine, University of Baghdad (Approval No. 1436; 26 November 2024). The IRB approval document was submitted to JOMA's editorial office with the original manuscript. However, the identifying details were blinded in the "Institutional Review Board Statement" section to preserve the integrity of the editorial and peer-review process.

We have now incorporated these details into the "Research ethics" subsection of the Methods (Lines 101–105). "Ethical approval for the study was obtained from the Research Ethics Committee and the Institutional Review Board (IRB) of the College of Medicine, University of Baghdad (Approval No. 1436; 26 November 2024). All radiological images were treated confidentially, and all datasets were anonymized prior to analysis, with no personal identifiers retained.".

• Comments on the Quality of English Language: The English language is generally understandable; however, minor grammatical and stylistic revisions are recommended to improve clarity, sentence structure, and readability throughout the manuscript.

Response: Once again, we thank you for your careful attention to the linguistic quality and grammatical accuracy of our manuscript. We have thoroughly revised the English language throughout the manuscript to the best of our ability.

Finally, we thank the journal's editorial team and the respected reviewer for their time and valuable feedback. We are prepared to address any further requests from the editors or reviewers, if needed.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

hello thank you for doing this study about haller cells

Indeed this is the less studied cell within the ethmoid sinus but it is interesting to analyse its presence morphology connexion with the middle meatus or even the superior one as it can be a "challenge" during surgery

 

The study is well done and merit publication

I do not have major comment to do

One of the problem is to be sure that we analyse a series of consecutive CT

It could be also interestted to do such a study in patients with and without CRS to demonstrate that Haller cell can have various form but do not play a major role alonein the pathogenesis of CRS

Author Response

• Comment: Thank you for doing this study about Haller cells. Indeed, this is the less studied cell within the ethmoid sinus, but it is interesting to analyze its presence, morphology connexion with the middle meatus or even the superior one, as it can be a "challenge" during surgery. The study is well done and merits publication.

Response: Dear Sir/Madam, the Respected Reviewer, we sincerely thank you for your careful evaluation and constructive comments on our manuscript. On behalf of all co-authors, I confirm that we have addressed all comments and revised the manuscript accordingly using the track-changes feature in Microsoft Word.

            Also, thank you for highlighting the limited literature on Haller cells (HCs) and for your valuable suggestion regarding the assessment of HCs morphology in relation to both the middle and superior meatus and turbinates. In the present study, we focused specifically on the association between HCs and the pneumatized middle turbinate (concha bullosa, CB). Nevertheless, we have incorporated your insightful idea into the "Recommendations" subsection of the Discussion to stimulate future research on the morphology of HCs and their relationships with other anatomical landmarks of the nasal cavity, including the superior and middle meatus.

Please refer to the "Recommendations" subsection of the Discussion (Lines 389–391), where these details have been incorporated. "Future research can investigate the morphological subtyping of HCs and their associations with anatomical variations of the middle and superior meatuses and turbinates, given the potential clinical and surgical relevance of these relationships.".

1. Comment: One of the problems is to be sure that we analyze a series of consecutive CTs.

Response: Thank you for your valuable comment emphasizing the importance of analyzing serial CT scans to evaluate potential changes in HCs over time. In response, we have incorporated your recommendation into the "Recommendations" subsection of the Discussion, highlighting the need for future prospective studies using serial CT imaging to investigate the temporal (time-based) development and morphological changes of HCs.

Please refer to the "Recommendations" subsection of the Discussion (Lines 398–401), where these details have been incorporated. "In addition, prospective longitudinal studies, using serial (consecutive) CT imaging in conjunction with time-series analyses, can examine the temporal changes in HCs pneumatization and determine whether these changes might precede, accompany, or result from the development of sinusitis.".

2. Comment: It could also be interesting to do such a study in patients with and without CRS to demonstrate that Haller cells can have various forms, but do not play a major role alone in the pathogenesis of CRS

Response: Once again, we sincerely thank you for your valuable observation and thoughtful analysis of our study on HCs. In response, we have incorporated your insightful suggestion into the "Recommendations" subsection of the Discussion, emphasizing the need for future research to investigate the clinical and anatomical significance of different morphological variants (subtypes) of HCs in patients with and without chronic rhinosinusitis (CRS).

Please refer to the "Recommendations" subsection of the Discussion (Lines 396–398), where these details have been incorporated. "Future investigations can also evaluate whether different HCs' morphological subtypes might, or might not, differentially contribute to the pathogenesis of sinusitis by comparing well-defined cohorts of patients with and without CRS.".

Finally, we thank the journal's editorial team and the respected reviewer for their time and valuable feedback. We are prepared to address any further requests from the editors or reviewers, if needed.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the manuscript entitled “Prevalence and morphometrics of Haller cells in Iraqis, and their association with sinusitis and sino-nasal anatomical variants of interest using high-resolution computed tomography.”

The topic is clinically relevant and relatively underexplored in the Iraqi population. The retrospective CT-based design is appropriate for the stated aims, and the manuscript is generally well structured and methodologically sound. The study contributes useful population-based data on sinonasal anatomical variation.

However, several revisions are required prior to publication:

1. 
   There is inconsistency in reporting surface area units between the Methods (cm²) and Results (mm²). This must be checked and standardized throughout the manuscript.
2. 
   The description of the control (“healthy”) group is insufficient. It is unclear how these subjects were defined and selected, and what the indications for CT imaging were. This limitation is particularly important when interpreting negative findings, especially the lack of association with maxillary sinusitis.
3. 
   The statistical power is not clearly specified for the primary outcome. Given the relatively small number of Haller cell–positive cases (n = 38), subgroup analyses for sex and laterality (n ranging approximately from 11 to 26) are underpowered. This limitation should be explicitly acknowledged and quantified in the limitations section.
4. 
   Table 1 reports medians only, without interquartile ranges or p-values, despite these being reported in the text. The table should be revised to ensure it is fully self-explanatory and consistent with the results section.
5. 
   The exclusion of 11 cases with extensive rhinosinusitis is methodologically justified; however, this may introduce selection bias and potentially underestimate the prevalence of sinusitis and obscure any association between Haller cells and sinusitis. This should be briefly discussed as a limitation.
6. 
   Meteorological parameters are mentioned in the statistical analysis but are not described in the Methods or Results sections. This analysis should either be clearly justified and described or removed.

Overall, after addressing these issues, the manuscript provides a valuable contribution to the understanding of sinonasal anatomy and may be suitable for publication.

Author Response

• Comment: Thank you for the opportunity to review the manuscript entitled "Prevalence and morphometrics of Haller cells in Iraqis, and their association with sinusitis and sino-nasal anatomical variants of interest using high-resolution computed tomography.". The topic is clinically relevant and relatively underexplored in the Iraqi population. The retrospective CT-based design is appropriate for the stated aims, and the manuscript is generally well structured and methodologically sound. The study contributes useful population-based data on sinonasal anatomical variation. However, several revisions are required prior to publication.

Response: Dear Sir/Madam, the Respected Reviewer, we sincerely thank you for your careful evaluation and constructive comments on our manuscript. On behalf of all co-authors, I confirm that we have addressed all comments and revised the manuscript accordingly using the track-changes feature in Microsoft Word.

            Further, we sincerely thank you for highlighting the clinical significance of our study and its contribution to population-based data on sino-nasal anatomical variations, including Haller cells (HCs). We also confirm that we have addressed and fully complied with all the revisions requested in your comments.

1. Comment: There is an inconsistency in reporting surface area units between the Methods (cm²) and Results (mm²). This must be checked and standardized throughout the manuscript.

Response: Thank you for your careful observation regarding the inconsistency in reporting the sectional area of Haller cells (HCs) measured on the specified coronal sections using high-resolution CT. We have corrected this inconsistency to ensure uniform reporting throughout the Methods and Results sections of the manuscript.

2. Comment: The description of the control ("healthy") group is insufficient. It is unclear how these subjects were defined and selected, and what the indications for CT imaging were. This limitation is particularly important when interpreting negative findings, especially the lack of association with maxillary sinusitis.

Response: Thank you for your keen observation regarding the definition of the control ("healthy") group in the present Iraqi-based radiological research. In response, we have expanded the Methods section by providing additional details on the "Inclusion and exclusion criteria" subsection. Further, we have incorporated the concept you highlighted into the "Study limitations" subsection of the Discussion, emphasizing its importance when interpreting the absence of an association, or a borderline significant association, between HCs and maxillary sinusitis.

Please refer to the revised "Inclusion and exclusion criteria" subsection of the Methods (Lines 111–119), where these details have been incorporated. "The study sample included adult Iraqi patients who had retrospective high-resolution CT scans of the PNS performed at the Radiology Unit of Baghdad Medical City. The cohort consisted of two groups: a study group with radiologically confirmed CRS and a control group of individuals with no radiological evidence of sino-nasal disease. In the control group, CT scans had been obtained for non-sinonasal clinical indications, and the PNS were reported as normal on imaging. Only high-resolution CT examinations (slice thickness ≤1 mm), reconstructed using a bone algorithm and of sufficient image quality for morphometric analysis, were included. The scans were required to provide adequate spatial resolution for reliable morphometry.".

Please also refer to the "Study limitations" subsection of the Discussion (Lines 358–361), where these details have been incorporated. "The present study has several limitations. The control ("healthy") group was selected based on radiologically normal CT scans and might have included individuals with undiagnosed sino-nasal pathology, potentially attenuating the observed association between HCs and sinusitis, especially maxillary sinusitis.".

3. Comment: The statistical power is not clearly specified for the primary outcome. Given the relatively small number of Haller cell–positive cases (n=38), subgroup analyses for sex and laterality (n ranging approximately from 11 to 26) are underpowered. This limitation should be explicitly acknowledged and quantified in the limitations section.

Response: Thank you for your important comment. We agree that the relatively small sample size may have reduced the statistical power of the study. Accordingly, we have explicitly acknowledged this issue in the "Study limitations" subsection of the Discussion.

Please refer to the "Study limitations" subsection of the Discussion (Lines 365–368), where these details have been incorporated. "Further, the relatively small number of participants with HCs (n=38), together with subgroup analyses stratified by sex and laterality, likely further reduced the statistical power of the study, thereby limiting its ability to detect statistically significant associations, particularly with maxillary sinusitis.".

4. Comment: Table 1 reports medians only, without interquartile ranges or p-values, despite these being reported in the text. The table should be revised to ensure it is fully self-explanatory and consistent with the results section.

Response: Thank you for your careful observation regarding Table 1. In response to your comment, we have added the requested numerical parameters, specifically the interquartile range (IQR), to the table to make it more self-explanatory and consistent with the Results section.

Table 1. Comparison of Haller cells' morphometrics by laterality.

Parameter	Median values		IQR values
	Right-sided HCs	Left-sided HCs	Right-sided HCs	Left-sided HCs
Width	4.9	4.6	3.3–5.7	3.5–5.6
Length	7.9	7.0	5.9–10.5	6.1–9.7
Sectional area	0.28	0.27	0.16–0.44	0.17–0.43

*. HCs, Haller cells; IQR, interquartile range.

5. Comment: The exclusion of 11 cases with extensive rhinosinusitis is methodologically justified; however, this may introduce selection bias and potentially underestimate the prevalence of sinusitis and obscure any association between Haller cells and sinusitis. This should be briefly discussed as a limitation.

Response: Once again, we sincerely thank you for your valuable comments regarding the study design and statistical analysis. We agree that the exclusion of participants with extensive rhinosinusitis-induced effusion (n=11) may have led to an underpowered study. However, this exclusion was necessary because extensive effusion could either prevent morphometric assessment of HCs or introduce substantial measurement bias (error) in one or more morphometric parameters of interest. Consequently, after applying the predefined exclusion criteria, the final study sample was reduced from 121 to 103 participants. Nonetheless, for complete methodological transparency, we have explicitly acknowledged the potential impact of these exclusion criteria on the statistical power of the study in the "Study limitations" subsection of the Discussion.

Please refer to the "Study limitations" subsection of the Discussion (Lines 361–365), where these details have been incorporated. "In addition, the exclusion of 11 Iraqi individuals (10 males and 1 female) with extensive rhinosinusitis, characterized by opacification of the PNS due to extension of inflammatory secretions into the nasal cavity, may have introduced selection bias. This exclusion could have underestimated the prevalence of sinusitis and obscured a true association between HCs and sinusitis.".

6. Comment: Meteorological parameters are mentioned in the statistical analysis but are not described in the Methods or Results sections. This analysis should either be clearly justified and described or removed.

Response: Thank you for this crucial comment. In accordance with your recommendation, we have removed the paragraph describing the meteorological parameters from the Methods section. We agree that its inclusion could be confusing to readers.

• Comment: Overall, after addressing these issues, the manuscript provides a valuable contribution to the understanding of sinonasal anatomy and may be suitable for publication.

Response: On behalf of all my co-authors, I would like to express our sincere gratitude for your careful evaluation of our manuscript. Your insightful comments and constructive recommendations have significantly enhanced the scientific rigor and scholarly quality of our research. We also deeply appreciate the time and effort devoted by you, other reviewers, and the Editorial Office to the evaluation of our manuscript, and we are grateful for the opportunity to address your valuable comments.

Finally, we thank the journal's editorial team and the respected reviewer for their time and valuable feedback. We are prepared to address any further requests from the editors or reviewers, if needed.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

This study found that Haller cells (HCs) were the least common sinus anatomical variation assessed in the studied Iraqi population, with a prevalence of 36.9%. Furthermore, HCs showed no significant association with sex, NSD, OCs, or maxillary sinusitis, suggesting that they primarily occurred as an independent anatomical structure in this population. Although this study appears to have no significant difference, a prevalence of 36.9% is not low in international literature. Therefore, it is recommended that this finding could be emphasized in the discussion. Further comparisons could be made between the Iraqi population data and those of other Middle Eastern countries (such as Iran and Jordan) or Western populations to explore whether there is genetic or ethnic specificity. 

Author Response

• Comment: This study found that Haller cells (HCs) were the least common sinus anatomical variation assessed in the studied Iraqi population, with a prevalence of 36.9%. Furthermore, HCs showed no significant association with sex, NSD, OCs, or maxillary sinusitis, suggesting that they primarily occurred as an independent anatomical structure in this population. Although this study appears to have no significant difference, a prevalence of 36.9% is not low in international literature. Therefore, it is recommended that this finding be emphasized in the discussion. Further comparisons could be made between the Iraqi population data and those of other Middle Eastern countries (such as Iran and Jordan) or Western populations to explore whether there is genetic or ethnic specificity.

Response: Dear Sir/Madam, the Respected Reviewer, we sincerely thank you for your careful evaluation and constructive comments on our manuscript. On behalf of all co-authors, I confirm that we have addressed all comments and revised the manuscript accordingly using the track-changes feature in Microsoft Word.

Thank you for highlighting the importance of the relatively high prevalence of Haller cells (HCs) observed in the studied Iraqi population compared with reports from the literature, including studies from the Middle East. We have emphasized this finding in the Discussion and its "Limitations" subsection, highlighting the need for future studies to investigate potential genetic and ethnic factors that may contribute to population-specific differences in HCs prevalence.

Please refer to the Discussion section (Lines 311–322), where these details have been incorporated: "The overall prevalence of Haller cells (HCs) in the present study was 36.9%, which falls within the broad range reported in the literature. It is higher than the prevalence reported in CT-based studies by Leunig et al. (2008) (16%) and Ragab et al. (2025) (13.7%) [8,9], but lower than the CBCT-based estimate of 56.7% reported by Moshfeghi et al. (2023) [10], highlighting the influence of imaging modality, image resolution, and diagnostic criteria on prevalence estimates. Population-specific variation may also contribute to these differences, as evidenced by reported prevalences of 24% in an Omani population [3], 19.3% in a Turkish population from Istanbul [5], and 37% in individuals from the Eastern Anatolia region of Türkiye [4]. The relatively high prevalence observed in the present Iraqi cohort further emphasizes the importance of population-specific radiological investigations, particularly within the Middle East, and suggests that genetic or ethnic factors may partly underlie regional differences in HCs prevalence".

Please also refer to the "Limitations" subsection of the Discussion (Lines 403–409): "Although the present study did not identify a conclusive statistically significant association, the observed prevalence of HCs (36.9%) remains noteworthy compared with regional and international reports. The lack of comparative data from other Middle Eastern and Western populations limits the interpretation of potential population-specific variations. Future multicenter studies including Iraqi, regional populations (e.g., Iran, Jordan, and Saudi Arabia, among others), and Western nations are warranted to clarify the possible contributions of genetic or ethnic factors to HCs' prevalence.".

Finally, we thank the journal's editorial team and the respected reviewer for their time and valuable feedback. We are prepared to address any further requests from the editors or reviewers, if needed.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you to the authors for accepting the requested corrections and for revising the manuscript accordingly.