SINONASAL IMAGING. Kim O. Learned, MD. Assistant Professor Department of Radiology/Division of Neuroradiology University of Pennsylvania Health System

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1 SINONASAL IMAGING Kim O. Learned, MD Assistant Professor Department of Radiology/Division of Neuroradiology University of Pennsylvania Health System

2 REVIEWS Key Anatomy: Sinus Drainage Pathways Practical approach to CT and MR Pathologies

3 DRAINAGE PATHWAYS Ostiomeatal Units Anterior Middle Meatus Frontal sinus Maxillary sinus Anterior Ethmoid air cells Posterior Superior Meatus Sphenoid sinus Posterior ethmoid air cells

4 Ostio-Meatal Unit Anterior OMU Middle Meatus Frontal sinus Ostium & Recess Maxillary sinus ostium Infundibulum Anterior Ethmoid cells

5 Sphenoethmoidal Recess Posterior OMU Sphenoid sinus Ostium Sphenoethmoidal Recess Posterior Ethmoid cells Superior Meatus

6 Ventral Skull Base Nasal vault: Cribriform plate Ethmoid Fovealis (frontal bone) Planum Sphenoidale

7 Skull Base Pterygo-Maxillary Fissure Pterygo-Palatine Fossa (PPF) Foramen Rotundum Cavernous sinus Inferior orbital fissure Orbital Apex

8 PRACTICAL APPROACH Sinonasal Imaging Pathology Location Pattern CT MR

9 Approach to CT Calcification Fungus ball center, punctate Concretion of CRS: periphery, egg-shell, marginated

10 Approach to CT Calcification Chondroid/Osteoid Matrix Bone Destruction or Dehiscence

11 Approach to CT Attenuation Low density: Mucoid, Fluid, Polyps Hyperdense: Fungus, Concretion, Blood Soft tissue: Neoplasm, Scar, Thick Secretion

12 Approach to CT Bone changes Deficiency/Dehiscence Long standing Mucocele, Polyps, IP Slow growing neoplasm Schwannoma?Cephalocele Destruction/Erosion Aggressive Tumor SCCA, SNUC, SNEC, esthesioneuroblastoma Lymphoma, RCC met Osteomyelitis sinusitis Invasive fungal sinusitis Granulomatous disease

13 Fibrous Dysplasia Begin and End with CT

14 Why MR? Pathology Location Pattern CT MR

15 SINONASAL IMAGING Begin and end with CT: Bone change Bone Matrix MR: Tissue characteristic Extent Intracranial

16 Approach to MR T2, Peripheral Gd + T2, Solid Gd + Retention cyst Submucosal Mucinous/Serous gland collection Partially aerated sinus Polyp Fluid deep to lamina propria Mass effect Mucocele Trapped secretion in obstructed sinus Airless Expanded sinus Neoplasm

17 Sinonasal Polyposis Frontal Mucocele Polypoid T2 Hyperintensity Polyps MR Pitfall: concretion & fungus signal void Severe Deficiency at skull base mimics Destruction Mucocele, Sinonasal Polyposis, Inverted Papilloma

18 Acute Sinusitis Complications T2 hyperintensity NOT tumor Osteomyelitis Sinus Epidural empyema Meningitis, Cerebritis

19 Tumor Mapping

20 PATTERN Approach Diffuse/Pan-sinus Rhinosinusitis Focal Obstructive pattern Rhinosinusitis Neoplasm

21 RhinoSinusitis Poor Correlation of Symptoms with CT/Endoscopy Acute RS: 1-4 weeks Bacterial infection Fluid level Chronic RS: 12 weeks Multiple factors, Idiopathic, Allergy, Impaired Cilliary function, Granulomatous disease Hypertrophic Mucosa, Polyp, Scar, Atrophy Osteitis Neo-osteogenesis

22 Chronic Rhino-Sinusitis Neo-osteogenesis Cystic Fibrosis o o Bronchiectasis Hypoplastic sinuses Wegener, Sarcoid, Churg Strauss o Chronic inflammatory/ granulomatous destruction o Systemic disease

23 Pan-sinusitis Polypoid Opacification Allergic Rhinosinusitis Sinonasal Polyposis Allergic Fungal Sinusitis Jack Jill

24 Fungal Sinusitis Immuno-competent Non-invasive Mycetoma Allergic Fungal Sinusitis Immuno-compromised Invasive Acute Immunocompromised, DM Chronic DM

25 Allergic Fungal Sinusitis High density NOT tumor Inspissated secretion or fungal Focal or Diffuse Allergy, Fungus-specific IgE, Allergic Mucin Debridement, Path: no invasion of mucosa Rx steroid

26 Acute Invasive Fungal Sinusitis Mucormycosis 25 yo ALL Path shows Fungal invasion: Mucosa dark ulcer Vessel vasculitis, thrombosis, hemorrhage, tissue infaction Invasion of Orbit & CNS

27 Angioinvasive Fungal Sinusistis Mycotic Aneurysm 68 yo NHL on Chemotherapy, ESRD on HD. Acute right eye ptosis blurry vision

28 Chronic Invasive Fungal Sinusitis 3 WEEKS Epidural abscess, Meningitis, Cerebritis, Abscess Slowly progressive, low-grade invasive fungal infection Path: Necrosis of the mucosa, submucosa, and blood vessels, with low-grade inflammation

29 PATTERN Diffuse Pansinus Rhinosinusitis Focal Obstructive pattern Rhinosinusitis Neoplasm

30 OMU obstructive lesion Inverted Papilloma Cerebriform pattern can be seen with other neoplasm? Antrochoanal polyp

31 PRACTICAL APPROACH Sinonasal Imaging Pathology Location Pattern CT MR

32 Approach to Sinonasal Neoplasm Location Pathology Imaging feature Clinical presentation

33 Sinonasal Neoplasm Most common locations for Primary CA: Maxillary sinus > Nasal cavity > Ethmoid cells Frontal/Sphenoid < 2 % Most common tumors in Adults SCCA >> Esthesioneuroblastoma, Melanoma, Adenoid cystic carcinoma Odontogenic (Odontoma, Ameloblastoma) Osteoid/Chondroid Fibrous dysplasia Osteo/Chondro-Sarcoma

34 Obstructive Lesions OMU: Infundibulum-Maxillary ostium Frontal recess Nasal cavity Naso-ethmoidal Sphenoid sinus

35 Nasal Cavity lesion Nasal septum Lateral nasal wall Inferior turbinate T1 of Melanin Melanoma

36 Esthesioneuroblastoma Widening of Nasal vault Intermediate T2 Enhancement (Similar to mucosa)

37 Sphenoid sinus Rarely sinonasal tumor Adjacent process Fungal Sinusitis Pituitary adenoma Clival/skull base lesion AFS

38 Osteosarcoma Focal disease Maxillary sinus Sunburst periostitis

Ameloblastoma Soap-Bubble lesion Hard, painless. 30-50 yo.

20% associated with Dentigerous cyst & unerupted teeth Locally

39 Ameloblastoma Soap-Bubble lesion Hard, painless yo. 2 nd most common odontogenic lesion 20 % Maxilla. 20% associated with Dentigerous cyst & unerupted teeth Locally aggressive, high recurrence Simple or luminal (mural): Without or with nodule(s) in the wall of the cyst

40 Nasal obstruction Refractory seizure x 13 years

41 Juvenile Nasopharyngeal Angiofibroma Internal maxillary artery feeder Tumor starts in the nose, spreads to NP Benign, locally invasive Adolescent male Tx: preop embolization resection adjuvant radiation for unresectable intracranial disease

42 References Daniels DL, et al. The Frontal Sinus Drainage Pathway and Related Structures. AJNR 2003 Sep;24(8): Huang BY, et at. Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in the Frontal Recess. Radiographics 2009 Younis R et at. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope 2002;112(2): Stewart MG, et al. Chronic sinusitis: symptoms versus CT scan findings. Curr Opin Otolaryngol Head Neck Surg 2004 Feb;12(1):27-9. Som PM, et al. Sinonasal tumors and inflammatory tissues: differentiation with MR imaging. Radiology 1988;167(3): Yousem DM. Imaging of sinonasal inflammatory disease. Radiology 1993;188(2): Yoon JH, et al. Calcification in Chronic maxillary sinusitis: comparison of CT findings with histopathologic results. AJNR 1999;20: Ilica AT, et al. Clinical and Radiologic features of fungal diseases of the paranasal sinuses. Comput Assist Tomogr Sep;36(5):570-6 Loevner LA, Sonners AI. Imaging of neoplasms of the paranasal sinuses. Neuroimaging Clin N Am 2004 Nov;14(4): Jeon T.Y, et al. Sinonasal Inverted Papilloma: Value of Convoluted Cerebriform Pattern on MR Imaging. AJNR 29:

Sinonasal Imaging. Mamdouh Mahfouz MD Professor of Radiology Cairo University. ssregypt.com

Sinonasal Imaging. Mamdouh Mahfouz MD Professor of Radiology Cairo University. ssregypt.com Sinonasal Imaging Mamdouh Mahfouz MD Professor of Radiology Cairo University ssregypt.com Scanning Techniques Routine Study CORONAL Coronal 3-5mm sections from the posterior wall of the sphenoid sinus