OPns 1 11-13 final


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  • Inverted papilloma;71-year-old male with history of nasal papilloma that developed malignancy.AAxial CT image showssoft-tissue mass in right nasal cavity with some deviation of nasal septum extending into nasopharynx (arrows).B CoronalCT image shows complete opacification of right nasal cavity, maxillary sinus (arrow), and right ethmoid sinus, andsome widening of the osteomeatal complex.
  • 82 year male complaining of nasal obstruction. MSCT(a) shows unilateral opacification of right sinus cavities,suggesting the presence of a lesion obstructing the middlemeatus. On MRI, a maxillary sinus lesion is demonstratedprotruding through an enlarged ostium into the nasal fossa.Both TSE T2 (b) and contrast enhanced SE T1(c) show a ratherpeculiar striated pattern consistent with inverted papilloma(confirmed at biopsy). Arrows point to the spur representing theattachment site of the lesion
  • a–d Sinonasal SCC,follow-up obtained 6 monthsafter radical maxillectomyincluding resection of the lefthemipalate. The surgicaldefect was repaired rotating atemporalis muscle flap.Although partially effaced byedema and intense contrastenhancement (due to subacutedenervation), the striatedappearance of muscular fibersis still recognizable
  • 70 year, maleaffected by SCC. TSE T2(a) and contrast enhanced SET1 (b). Smallmass, arising from theposterior tip of the middleturbinate
  • 46 year, male affected by SNUC. On TSE T2 (a), thelarge ethmoid mass cannot be demarcated by the medial wall ofthe right orbit (white arrows), invades the left sphenoid sinuscontacting the orbital apex (black arrowhead) and the carotidcanal (white arrowhead). On the sagittal reformations of VIBE(b), although the ethmoid roof is invaded, the displaced andenhancing dura (black arrows) is not substantially thickenedand therefore probably not invaded
  • 59 year male, affected by intestinal-type adenocarcinoma.The left nasal fossa is occupied by a heterogenousmasswithhyperintense TSE T2 signal (a) and irregular enhancement (c).Themass displaces the leftmiddle turbinate laterally (arrows), thusobstructing themiddlemeatus. The leftmaxillary sinus is occupiedby inflammatory secretions; (b) expansion of an anterior ethmoidcell filled with spontaneously T1 hyperintense material correspondsto mucocele (asterisk)
  • 26 year male complaining with headache; incidentalfinding on screening sinus MSCT (a). Sphenoid sinus tumorsare overall quite rare: the TSE T2 hyperintense (c) andenhancing (b) mass vegetating into the left sinus turned out tobe adenoid cystic carcinoma. Chordoma and chondrosarcomahad been considered in the differential diagnosis although thenormal aspect of the clivus and midline location made thesehypotheses less likely. Note some coarse calcifications withinthe mass (a)
  • a–c Olfactory neuroblastoma. A strongly enhancingmass with intermediate TSE T2 signal intensity originates fromthe left ethmoid roof and encases the superior turbinate (st).The mass is limited to the nasal cavity; the paranasal sinusesand the anterior cranial fossa are not invaded (Kadish stage A).Retained secretions are seen into the posterior ethmoid cells(asterisks)
  • Ewing sarcoma, mandible; 10-year-old male with painlessswelling at right mandibular angle.A Panoramic view shows noabnormality. B Axial CT imageshows soft-tissue mass and radiatingbone production on buccalaspect (arrow)
  • Maxillary Ewing sarcoma; 30-year-old male with huge facial mass, proptosis, shortness of breath and dysphasia.ACoronalCT image shows enormous tumor (arrow) with destruction of maxilla, zygoma, orbital floor, and nasal cavity, crossingmidline with expanding medial wall of left maxillary sinus. B Axial CT image shows the huge destruction and displacementof right globe (arrow). C Axial T1-weighted fat suppressed MRI shows the huge exophytic tumor (arrow) sparingonly left maxillary sinus.DAxial T1-weighted post-Gd MRI after first surgery, showing contrast enhancement of tumor recurrence(arrow)
  • arrow).E Coronal CT image, after second surgery with facial flap (arrowhead).F Axial CT image shows facial flap(arrowhead).G Axial T1-weighted MRI shows facial flap (arrowhead).H Axial T1-weighted fat-suppressed MRI shows facialflat (arrowhead)
  • a, b 51 year, female.Melanoma of the nasal cavity.The lesion is spontaneouslyhyperintense due to theparamagnetic properties ofmelanin, thus its extensioncan be clearly depicted onplain SE T1. Also the focalhyperintensities within the leftmaxillary sinus (arrows)turned out to be melanoma
  • administration (Maroldi et al. 2004a) (Fig. 17). Similar findings are shared by several other highly vascularized sinonasal lesions, both benign and malignant,such as haemangioma, haemangiopericytoma, JAF, paraganglioma and highly vascularized metastases (i.e. from kidney, thyroid, lung and breast cancer). Unfortunately,
  • Osteosarcoma, mandible; 37-year-old female with aggressivetumor growth, which “exploded” after extractionof molar tooth in right mandible. A Clinical photographshow rapidly growing tumor mass. B Axial CTimage shows bone destruction and aggressive tumorboth buccally and lingually (arrow)
  • Maxillary osteosarcoma; 27-year-old male with swellingof right maxilla and loose teeth.AAxial CT image showslarge soft-tissue mass in entire maxillary sinus with destructionof most of sinus wall, and scattered bone production(arrow).B Coronal CT image confirms extensivetumor mass to about midline (arrow), also extendinginto ethmoid cells, and with bone production. C AxialT2-weighted fat-suppressed MRI shows heterogeneouslow to high signal intensity (arrow). D Coronal T2-weighted fat-suppressed MRI shows heterogeneouslow to high signal intensity (arrow). E Surgical material
  • whereas cartilage and mucoid matrix do not,
  • Sinonasal chondrosarcoma. a, b In a 65 year female,MSCT shows a large soft tissue mass with coarse calcificationslocated in the left posterior ethmoid and sphenoid sinus. Focaldemineralization of the posterior wall of the sphenoid sinus andthe carotid canal is seen (arrowheads); however, the lowdensity of the material in the posterior part of the sinusmight indicate chronically retained inflammatory secretions.c, d 15 year, male. Both nasal fossae are completely occupiedby a mass displaying hyper T2 signal and a typical ‘rings andarcs’ pattern on post-contrast SE T1. The nasal septum is notrecognizable, the inferior and middle turbinates (arrows) arepushed against the lateral nasal wall (c, d courtesy of RobertHermans, MD, Ph.D, Leuven, Belgium)
  • Maxillary plasmablastic lymphoma; 39-year-old male, HIV-positive status, presented with left facial pain and swelling.A Coronal CT image, soft tissue window, shows soft-tissue mass in infratemporal fossa that invades left maxillary sinuswith bone destruction (arrow). B Coronal CT image shows severe destruction of maxillary sinus wall, alveolar ridge(arrow). C Coronal CT image, soft tissue window, posttreatment shows normal structures. D Coronal CT, posttreatment,shows almost normal maxillary sinus wall
  • 70 year, female affected by B-cell lymphoma. Themass lesion arising from the right maxillary sinus encroachesthe posterolateral wall to invade the infratemporal fossa(arrowhead), PPF (white arrow) and masticator space (blackarrows). Downwards extension to the alveolar process and hardpalate (black arrowhead) is also seen. Signal intensity ishomogenous on both TSE T2 (a) and SE T1 (b)
  • 4.—65-year-old woman with acutemyeloblastic transformation of 1-yearhistory of aplastic anemia who presentedwith ptosis of right eye of 2-week duration.A, Contrast-enhanced CT scan in coronalplane through mid orbit revealssoft-tissue mass involving right medialrectus muscle and right maxillary sinus.Ethmoid mass with bony destruction ofleft ethmoid cells also can be seen.B, Contrast-enhanced T1-weighted MRimage in coronal plane shows dense andheterogeneous enhancement of lesions.Biopsy subsequently showed right orbitaland paranasal sinus granulocyticsarcoma. Despite therapy, patient died6 months later
  • 63-year-old man with nasal extramedullary plasmacytoma. Unenhancedaxial CT scan through head shows large soft-tissue mass arises from right nasalpassage and extends anteriorly (black arrow) through nasal ala resulting in deviationand erosion of nasal septum and erosion of medial wall of right maxillary sinus (whitearrows).
  • 51-year-old woman with multiple solitary plasmacytomas.A, Coronal CT scan through orbits shows slightly hyperdenseintraorbital superiorextraconal mass compressing left globe with erosion through roof of orbit (arrows)into anterior cranial fossa.B, On T1-weighted sagittal scan of brain, a second lesion (M) is revealed to arisebehind dorsum sella and clivus. It appears isointense to white matter.C, Second lesion (M) is markedly enhancing with dural tail (arrowheads) ongadolinium-enhanced T1-weighted sagittal scan.
  • Fibrous dysplasia.CT image (a) shows the leftgreater sphenoid wing,pterygoid root and medialpterygoid plate to be grosslyenlarged. Spongiotic bone isreplaced by immature wovenbone with a typical groundglass appearance on MSCT.MRI pattern on TSE T2(b) and SE T1 before (c) andafter (d) contrast agent areless characteristic, althoughbone expansion is clearlyshown also with thistechnique. Note narrowing ofthe foramen rotundum(arrow) and vidian canal(arrowheads)
  • Fibrous dysplasia, maxilla; 10-yearoldmale with unilateral painlessswelling of maxilla.C Coronal CT image showswell-defined process with typicalground-glass appearance (arrow);this could have been diagnosedas an ossifying fibroma.
  • Fibrous dysplasia, maxilla and mandible; 21-year-old male with chronic renal failure, end-stage, and several monthshistory of slowly enlarging maxillary mass. A Axial CT image shows maxilla and mandible with bilateral ground-glassappearance (arrows).B Axial CT image shows maxillary sinus involvement bilaterally (arrows)
  • 59 year male, affected by lung carcinoma, complainingof trismus. Two metastases are shown on TSE T2, locatedin the ethmoid (asterisk) and masticator space (arrowheads)
  • The buttress system of the midface. The buttress system of the midface is formed by thestrong frontal, maxillary, zygomatic, and sphenoid bones and their attachments to one another.The central midface consists of several fragile bones that easily ‘‘crumple’’ when subjected tostrong forces. These more fragile bones are surrounded by the thicker bones of the buttresssystem, which provide structure and absorb the forces applied to the face. Most of the forcesabsorbed by the face are masticatory, therefore the vertical buttresses are the most well developed.These include the medial nasomaxillary buttress and the lateral zygomaticomaxillary buttress.Three horizontal buttresses interconnect and provide support for the vertical buttresses:the frontal bone and supraorbital rims (frontal bar), the nasal bones and inferior orbitalrims, and the maxillary alveolus. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imagingof high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:17–32;with permission.)
  • LeFort 1 osteotomies; 48-year-old female with pain and facial swelling after maxillary surgery.ACoronal CT image showsosteotomy defects in anterolateral maxillary walls (arrows) and through inferior portion of nasal cavity. Associated mucosalthickening in maxillary sinuses characteristically seen after surgery. B Coronal CT image shows osteotomy defectsin pterygoid plates (arrows)
  • LeFort 1 fracture. Axial CT image shows fracture line inanterior, inferior part of nasal cavity (arrow), in posterior,inferior part of maxillary sinus, most prominent on leftside and in left pterygoid plate (arrow). Note also fracturein right medial maxillary sinus wall (arrow) (courtesyof Dr. A. Kolbenstvedt, Rikshospitalet UniversityHospital, Oslo,Norway)
  • LeFort 2 fracture with a zygomatic arch nondisplacedfracture; 37-year-old male who was assaulted.AAxial CTimage shows bilateral fractures of anterior part of maxilla(arrow), lateral-posterior part of maxilla (arrow), andpterygoid plates (arrow). Hemorrhage in maxillary sinusesand multiple air collections. B Axial CT imageshows bilateral fracture of nasal bone (arrow) and fracturesof right zygomatic arch (arrows). Note large emphysemain cheek. C Coronal, reformatted CT imageshows bilateral fractures of medial orbital walls (arrows),superior and inferior lateral maxillary sinus walls(arrows), and nasal aperture. Note intratracheal tube
  • LeFort 3 and mandibular body fractures; 45-year-oldmale after motor vehicle crash with trauma to face andhead, and loss of consciousness. A Coronal CT imageshows bilateral fractures of superior nasal aperture nearnasal bone and inferior nasal aperture above palate (arrows),opacification due to hemorrhage of nasal cavity,bone fragments and air collections in right cheek, andintratracheal tube. B Coronal CT image shows bilateralfractures of orbital floor and maxillary sinus wall (arrows),and opacification of nasal cavity and all sinusesexcept left frontal,due to hemorrhage.CCoronal CT imageshows fracture of left lateral orbital wall (arrow),necessary for definition of a LeFort 3 fracture; zygomaticarch was also fractured.DCoronal CT image shows bilateralfractures of pterygoid plates (arrow) and leftmandibular ramus (arrow).
  • Tripod fracture, classic; 45-year-old and with facial trauma. A Axial CT image shows fractures of anterior maxillary sinuswall, lateral–posterior maxillary sinus wall and zygomatic arch (arrows), and intrasinus hemorrhage. B Axial CT imageshows fracture of lateral orbital wall (arrow), hemorrhage in ethmoid cells, and swelling due to subcutaneous edema
  • Blow-out fracture, classic; 60-year-old female with fallon face 10 days previously, with infra-orbital hematomaand some tenderness. A Coronal CT image showsfracture of orbital floor (arrow). B Coronal CT image,more posterior section, shows otherwise normal sinuses.
  • C Sagittal MRI of another patient shows orbitalfat (arrow), and bone fragment and mucosal swellingor muscle tissue (arrowhead) in maxillary sinus due toblow-out fracture; note intact orbital rim (courtesy of Dr.A. Kolbenstvedt, Rikshospitalet University Hospital,Oslo, Norway). D Coronal CT image of another patientshows orbital air collection (arrow). E Axial CT image ofsame patient as in D shows large subcutaneous emphysema(arrow)A BC DE
  • Blow-out fracture,extensive with fractures of maxillary wall and nasal bone;15-year-old male with trauma to left face andeye; now to postoperative examination of bone graft from calvarial bone. A Coronal CT image shows fractures of leftorbital floor, and medial and superior walls (arrows), some air collection in orbit, and soft-tissue swelling in ethmoid cells,nasal cavity and maxillary sinus.BCoronal CT image,postoperative, shows normal configuration of left orbit, with opacification of ethmoid cells and maxillary sinus
  • Acute rhinosinusitis secondary to common cold. CoronalCT shows fluid-level in right maxillary sinus (arrow),probably also in left sinus, and mucosal thickening ofethmoid cells bilaterally. Normal bone structures
  • Figure 10.2Acute sinusitis; 37-year-old female with a history of LeFort I osteotomy now with facial pain and swelling. A Coronal CTimage shows bilateral osteotomies through maxilla and nasal cavity (arrows) and mucosal thickening of ethmoid andmaxillary sinuses, and nasal cavity. B Coronal CT image, soft-tissue window, shows inflammatory tissue penetrating leftmaxillary osteotomy being responsible for facial swelling (arrow). Sinusitis does normally not cause facial swelling butsince there was a passage from the maxillary sinus to the facial soft tissue via the osteotomy defect in this patient facialswelling resultedA B
  • Pansinusitis; 19-year-old male with history of sinusitis and cough, now with headache, eye and cheek pain.A Axial CT image shows complete opacification of the maxillary sinuses (asterisks). B Axial CT image shows completeopacification of ethmoid sinuses (asterisks). C Axial CT image shows complete opacification of sphenoid sinuses (asterisks).D Axial CT image shows complete opacification of frontal sinuses (asterisks)
  • Chronic sinusitis; 61-year-old female with history of previoussurgery for sinusitis.AAxial CT image shows surgicalmaxillary defects bilaterally (arrows), opacificationof left sinus, and thickening with sclerosis of sinus wallsbilaterally. B Coronal CT image shows opacificationof ethmoid sinuses bilaterally (asterisks). C Coronal CTimage shows evenly thickened maxillary sinus wall inentire sinus bilaterally (arrows)
  • Chronic sinusitis; 69-year-old male with history of previoussinus surgery, now with history of motor vehicle accidentand trauma to head. Axial CT image shows thatmedial maxillary sinus walls are removed surgically (arrows),as also part of right anterior maxillary sinus walldot some bilateral mucosal thickening and uneven sinuswall sclerosis
  • Chronic aspergillus sinusitis; 57-year-old female withhistory of acute lymphatic leukemia, neutropenicstatus post chemotherapy, now with eye and cheekpain. A Coronal CT image shows opacification of rightmaxillary sinus (arrow) and ethmoid sinus (arrowhead).B Coronal T1-weighted MRI shows intermediate to highsignal in maxillary sinus (arrow) and low signal in ethmoidsinus (arrowhead). C coronal T2-weighted MRIshows low „normal“ signal in right maxillary sinus(arrow) and high signal in ethmoid sinus (arrowhead).D Axial T1-weighted MRI shows intermediate to low signalin right maxillary sinus (arrow). E Axial T1-weightedpost-Gd MRI shows heterogeneous contrast enhancement(arrow)
  • Mucosal maxillary thickening; incidental finding in 43-year-old male under treatment for dental implants and examinedwith cone beam CT.A Axial sections (upper) and coronal sections (lower) with reference lines (upper right) show maxillarymucosal thickening bilaterally (arrows). B Panoramic images (reference lines in A upper right) show maxillary mucosalthickening bilaterally (arrows) (courtesy of Drs. S. C.White and S.Tetradis, UCLA School of Dentistry)
  • Retention cyst in maxillary sinus; incidental finding.ACoronal CT image shows retention cyst in maxillary sinus (asterisk)with soft-tissue lining (arrow), without expansion of sinus walls, but with remaining air.BAxial CT image of same patientshows soft-tissue lined retention cyst (asterisk). C Sagittal T1-weighted MRI shows retention cyst with intermediate signal(arrow) in patient with blow-out fracture. D Axial T2-weighted MRI shows retention cyst with high signal (arrow) inpatient with osteosarcoma of right maxilla
  • Nasal polyposis; 38-year-old male with nasal obstruction. Conventional films show complete opacification of nasalcavity and all paranasal sinuses (asterisks), except some air in right frontal sinus (courtesy of Dr.A. Kolbenstvedt, RikshospitaletUniversity Hospital, Oslo,Norway)
  • Nasal polyposis; patient with history of chronic nasal obstruction and sinusitis.ACoronal CT image shows opacificationof nasal cavity (arrow).B Coronal CT image shows opacification of nasal cavity with soft tissue bulging through widenedostiomeatal complex particularly on left side (arrow) but to a lesser extent also on right, with secondary sinusitis
  • Nasal polyposis; 43-year-old male with previous surgeryfor nasal polyposis, now with recurrence. Coronal CTimage shows polyps in nose bulging through ostiomeatalcomplex (arrow), but also mucosal thickeningin ethmoid and maxillary sinuses (courtesy of Dr. A.Kolbenstvedt, Rikshospitalet University Hospital, Oslo,Norway)
  • Antrochoanal polyp; 12-year-old male with history ofsinusitis and nasopharyngeal mass. A Axial CT imageshows left maxillary sinus thickening (asterisk) withextension of soft tissue mass into posterior nasal cavitydown to nasopharynx (asterisk), via ethmoidal infundibulum.No bone destruction. B Axial CT imageshows polyp in nasopharynx (asterisk) and soft tissuethickening in maxillary sinus (arrow). C Lateral viewwith contrast in nose of another patient shows howpolyp blocks nasopharynx (arrow) (C: courtesy of Dr.A. Kolbenstvedt, Rikshospitalet University Hospital,Oslo, Norway)
  • Frontal sinus mucocele; 50-year-old male with diplopiaand right eye down and laterally deviated.ACoronal CTimage, soft-tissue window, shows ovoid well-definedsoft tissue mass in right orbit (arrow) with displacementof globe laterally down. B Coronal CT image, bone window,shows bone expansion and absent frontal sinuswall against orbit (arrow), but otherwise normal bonestructures. C Axial CT image shows well-defined delineationof bone expansion (arrow)
  • Frontal sinus mucocele; 60-year-old male presented with headache and diplopia. A Coronal T2-weighted MRI showsintermediate signal large expansive mucocele (arrow). B Axial T2-weighted MRI shows expansion into cranial fossa withdisplacement of left frontal lobe (arrow). C Axial T1-weighted post-Gd MRI shows no enhancement except in thinperipheral rim (arrow).D Axial diffusion-weighted MRI shows high signal (arrow)
  • OPns 1 11-13 final

    2. 2. (A) NEOPLASM ( 1 ) EPITHELIAL TUMORS i. Papiloma ii. Squamus Cell Carcinoma iii. Sinonasal Undifferenciated Carcinoma iv. Adenocarcinoma v. Adenoid Cyst Carcinoma
    3. 3. ( 2 ) NON EPITHELIAL TUMORS i) Neuro Ecto-Dermal Tumour ii ) Vascular iii) Soft Tissue Tumors iv) Osseous and Cartilaginous Tumors v) Hematologic Tumors vi) Fibro-Osseous Disease vii) Metastasis
    4. 4. PAPILLOMA Definition Benign tumor of nasal cavity composed of vascular connective tissue covered by well-differentiated stratified squamous epithelium that tends to grow under and elevate mucosa (inverted). Clinical Features ▬ Less common than allergic polyps; less than 3% in general population. ▬ Most common in males aged 40–70 years. ▬ Unilateral from lateral sinus wall near ethmoids. ▬ Nasal stuffiness or obstruction. ▬ Secondary bacterial sinusitis. ▬ Postoperative recurrence 35–40%. ▬ May be associated with malignancy (about 10%).
    5. 5. Imaging Features ▬ Small to extensive mass ▬ Bone remodeling that may deviate, not cross nasal septum ▬ Mass may extend into ethmoid or maxillary sinuses ▬ T1-weighted MRI: low or intermediate ▬ T2-weighted MRI: infermediate to high, usually high ▬ T1-weighted post-Gd MRI: some contrast enhancement
    6. 6. (A/1/i ) Papiloma (Inverted)
    7. 7. ( A/1/ii ) Squamus Cell Carcinoma  50–80% of all malignant sinus masses.  More than 60% originate in maxillary sinuses, followed by nasal cavity, and ethmoid sinuses.  Oral symptoms and signs may be initial; occasionally considered an intraoral cancer clinically.  SCC rarely arises from the ethmoid, frontal or sphenoid sinus.  Peak incidence is in the sixth and seventh decades,with a male predominance (2:1).  Occupational factors (including nickel, chromium, thorotrast and radium exposure) are associated with an increased risk.
    8. 8. Imaging Features  Usually advanced when detected; bone destruction in 80%.  Alveolar bone destruction reported in half of patients with maxillary sinus carcinoma. ▬ Soft-tissue mass ▬ Bone radiolucency, secondary invasion of bone ▬ Border of bone destruction ill-defined ▬ Bone invasion frequent in gingival mandibular cancers, generally considered to be about 50%,but up to 85% reported in upper jaw; maxillary sinus frequently involved ▬ Floating teeth; tooth resorption uncommon ▬ Advanced stage: pathologic fracture ▬ T1-weighted MRI: intermediate–low signal ▬ T2-weighted and STIR MRI: high signal ▬ T1-weighted MRI: contrast enhancement
    9. 9. SCC does not show specific MSCT or MRI characteristics. The main goal of imaging is to determine the submucosal extent of sinonasal neoplasms.
    10. 10. ( A/1/iii )Sinonasal Undifferentiated Carcinoma and Neuroendocrine Carcinoma  SNUC is a malignant tumor with slight male predominance  peak of incidence in the fifth and sixth decades.  Short-time history of symptoms (mainly consisting of nasal obstruction with epistaxys), largesize at presentation .  high incidence of nodal metastases (15–20% of cases) denote the aggressive nature of this neoplasm
    11. 11. ( A/1/iv ) Adenocarcinoma Adenocarcinoma is a malignant neoplasm. more frequently observed in the ethmoid sinus. predilection for men in the fifth to seventh decade. composed of epithelial cells, arranged in a glandular or gland-like pattern. Occupational ITAC is strongly related to softwood dust and leather dust inhalation
    12. 12.  Imaging appearance  ITAC may show a mixed solid–fluid pattern due to mucus produced by tumoral cells .  Mild discrimination occur between the lesion and retained secretions (or mucocele) due to sinus blockage;  meticulous attention should therefore be paid to the presence of any solid component within a mucocele,  combining the information provided by pre- and postcontrast sequences and by diffusion-weighted sequences (when not degraded by artifacts).
    13. 13. A/1/V - Adenoid Cystic Carcinoma  There are 450–750 minor salivary glands scattered in the whole head and neck area, including sinonasal cavities. Adenoid cystic carcinoma (ACC) is a variant of adenocarcinoma arising from minor salivary glands. IMAGING FINDINGS  peculiar tendency of this tumor to grow submucosally and subperiosteally, thus permeating bone and soft tissues.  Invasion of muscles, vessels and fat tissue may be detected on imaging studies as effacement and encasement with no or very limited mass effect.  Similarly, replacement of spongiotic bone may occur with minimal changes of the cortical bone; furthermore, tumor growth on both surfaces of a cortical bone (such as the posterolateral maxillary sinus wall) may be seen with only focal bone destruction.  findings are much better demonstrated on MRI, because of its high contrast resolution: plain SE T1 and 3D GE T1 with fat suppression are key sequences.
    14. 14. ( 2 ) NON EPITHELIAL TUMORS i) Neuro Ecto-Dermal Tumour ii ) Vascular iii) Soft Tissue Tumors iv) Osseous and Cartilaginous Tumors v) Hematologic Tumors vi) Fibro-Osseous Disease vii) Metastasis
    15. 15. A/2/i - Neuro-Ectodermal Tumors • Olfactory Neuroblastoma • Ewing Sarcoma and Peripheral Neuroectodermal Tumor • Melanoma
    16. 16. Olfactory Neuroblastoma  Esthesioneuroblastoma , is a rare malignant tumor (2% of all sinonasal tumors) arising from the olfactory epithelium.  normally found in the cribriform plate, the ethmoid roof, the upper part of the nasal septum and the superior turbinates.  on cross-sectional imaging ONB is often seen as a dumbbellshaped mass growing across the cribriform plate.  MSCTshows the mass exhibits spontaneous hyperdensity (reflecting high cellularity) and calcifications of variable size.  MRI pattern is composed of intermediate T2 signal and T1 hypointensity;  cystic areas may be found, capping the intracranial part of the tumor.  Both iodine and paramagnetic contrast enhancement is strong sometimes making the differential diagnosis with vascular tumors is difficult.
    17. 17. a–c Olfactory neuroblastoma. A strongly enhancing mass with intermediate TSE T2 signal intensity originates from the left ethmoid roof and encases the superior turbinate (st). The mass is limited to the nasal cavity; the paranasal sinuses and the anterior cranial fossa are not invaded (Kadish stage A). Retained secretions are seen into the posterior ethmoid cells (asterisks)
    18. 18. Ewing Sarcoma and Peripheral Neuroectodermal Tumor Definition Malignant tumor with rather uniform histologic appearance composed of densely packed, glycogenrich small cells with round nuclei but without prominent nucleoli or distinct cytoplasmic outlines. Tumor tissue is typically divided into irregular strands or lobules by fibrous septa,but intercellular network of reticulin fibers, which is a feature of malignant lymphoma, is not seen. Mitoses are generally infrequent. Hemorrhage and extensive areas of necrosis are common (WHO).
    19. 19. Clinical Features ▬ Only 1–4% in head and neck area; most commonly mandible ▬ Hard swelling, pain or pain-free ▬ Males more frequent than females ▬ Usually first and second decades, but may occur at any age Imaging Features ▬ Soft-tissue mass ▬ ‘Moth-eaten’ bone destruction ▬ Bone production characteristic; periosteal ‘onion mskin’ reaction (usually in long bones), but not so typical in jaw
    20. 20. Ewing sarcoma, mandible; 24-year-old female with 10-year history of Ewing sarcoma treated with radiotherapy and chemotherapy, and a rather unchanged condition; now with pain and swelling and new soft-tissue mass,possibly due to infection.A Panoramic view shows bone production in entire half of mandible (arrow).B Axial CT image shows bone production both buccally and lingually (arrow)
    21. 21. Melanoma  arises from melanocytes that migrated during embryonal life from the neural crest to the mucosa investing the nasal cavity and sinuses.  nasal septum and lateral nasal wall are the most common sites of origin, and maxillary sinus is the most frequently involve.
    22. 22. Imaging studies,  Appears as a solid soft tissue mass with local invasion and relatively high tendency to nodal spread.  A T1 spontaneous hyper intensity, atypical for nearly all other benign and malignant sinonasal tumors, is much more requently exhibited by the melanotic variant; (this is explained by the paramagnetic properties of melanin as well as by intralesional hemorrhage. )  Secondly, flow voids may be demonstrated on MRI sequences at the periphery and into the lesion, representing its rich vascular network; such finding explains the frequent epistaxis occurring in patients  affected by melanoma
    23. 23. A/2/ii -Vascular Tumors • • • • Juvenile Angiofibroma Lobular capillary hemangioma (LCH) Angiomatous Polyp Hemangiopericytoma (HPC)
    24. 24. Juvenile Angiofibroma Juvenile angiofibroma (JAF) is a highly vascular mass characterized by three distinctive features: exclusively in male adolescents; originathe posterior nasal fossa, close to the sphenopalatine foramen; it is composed of irregular vessels set in a fibrous stroma . The typical clinical symptoms are nasal obstruction and epistaxistes.
    25. 25. Imaging Finding  JAF appears as a solid, brightly enhancing lesion vegetating in the posterior nasal cavity and nasopharynx and invading the pterygopalatine and infratemporal fossa;  A combination of TSE T2 and SE T1 (before and aftercontrast administration) is essential, for characterization of JAF, and the assessment of spongiotic bone invasion;  when JAF approaches the cavernous sinus, submillimetric 3d GE T1 sequences allow to define the relationships between the lesion and vascular or nervous structures.  The role of MSCT is restricted by the issue of radiation exposure and by the lack of contrast resolution in grading medullary bone involvement; In selected cases, a volumetric data set acquired with MSCT is the basis for intraoperative navigation systems, which allow safer control of critical structures such as the internal carotid artery and the optic nerve.
    26. 26. 14 year male, affected by juvenile angiofibroma. A large, intensely enhancing mass (b, c) occupies the left nasal fossa laterally displacing the nasal septum (arrowheads in a), nasopharynx and sphenoid sinuses. TSE T2 (a) shows several vascular flow voids into the lesion. Through an enlarged sphenopalatine foramen (arrows) the mass protrudes into the PPF. The lesion encroaches the ethmoid planum and sphenoid sinus roof, displacing the dura, appearing thickened and enhancing (arrows in b, c)
    27. 27. Lobular Capillary Hemangioma  Also referred to as pyogenic granuloma, is a benign vascular tumor composed of capillaries arranged in lobules into an edematous and fibroblastic stroma.  Arises from the anterior nasal septum, although skin and oral mucosa are the preferred head and neck sites of origin.  On MSCT, LCH appears as a soft tissue density mass that may cause bone remodeling and destruction;  MRI pattern consists of T2 hyperintensity and spontaneous T1 hypointensity. Bright enhancement is obtained after contrast agent JAF is the only differential diagnosis that can be readily ruled out, based on the typical site of origin, pattern of growth, age and sex of the patient.
    28. 28. 23 year male. A large mass with hyper TSE T2 signal (a) and bright contrast enhancement (b, c) fills the ethmoid cells and protrudes into the frontal sinus (arrowhead). The sharp interface between the lesion and both the orbital and intracranial content (arrows) indicates low aggressiveness. Pathologic examination of the surgical specimen revealed lobular capillary hemangioma
    29. 29. Angiomatous Polyp  It is a sinochoanal polyp whose vascular pedicle is strangled by the pressure exerted by the bony walls of the foramen through which it exits sinus cavity of origin to reach the nasal cavity.  Such compression may trigger a cascade of dilatation and stasis of feeder vessels, necrosis (which in some cases prevails) and neovascularization.  The site and pattern of growth of the lesion as well as its mixed appearance (fluid-like intensity/density of the sinusal component, intense enhancement of its vascular compromised portion) are sufficient clues for the diagnosis on imaging studies.
    30. 30. a, b 26 year female. Post contrast SE T1 shows an antrochoanal polyp. The vascular compromised part of the lesion, strangled as it courses through an accessory ostium (arrows), is referred to as angiomatous polyp.
    31. 31. Hemangiopericytoma  Hemangiopericytoma (HPC) is a vascular tumor  that can either be benign or malignant and may be found in any part of the body; 15–20% of cases arise from the head and neck, 5% in the sinonasal region. HPC originates from pericytes, mesenchymal cells covering the outer surface of capillaries, implied in flow regulation and vasoconstriction.  Interestingly, four cases ofoncogenic osteomalacia (a rare condition manifesting with muscle weakness, bone pain and frailty)  On both MSCT and MRI, HPC appears as an indistinct soft tissue mass with moderate to bright contrast enhancement; bone changes (remodeling, destruction) are generally also found. Lesions arising in the sinonasal tract do not show aggressive behavior, distant metastases are rare.
    32. 32. A/2/iii – soft tissue tomors • • • • Peripheral Nerve Sheath Tumor Nasal Glioma Meningioma Rhabdomyosarcoma
    33. 33. Peripheral Nerve Sheath Tumor  generally benign in nature.  Schwannoma more commonly affects the ethmoid followed by the nasal septum and maxillary sinus, usually as a solitary lesion.  Neurofibroma is classically described as localized, diffuse and plexiform.( Rarely malignant transformation spindle cell sarcoma).  Triton tumor is a neoplasm composed of peripheral nerve fibers and well-differentiated striated muscle fibers, described as either benign or malignant
    34. 34. Schwannoma Definition Benign nerve sheath tumor emanating from Schwann cells. (The terminology is confusing. The following terms have been used for the same tumor: schwannoma, neuroma, neurinoma, neurolemmoma, perineural fibroblastoma.) Clinical Features ▬ Asymptomatic mass. ▬ About 13% of schwannomas are found in head and neck, most in the lateral cervical region. ▬ Almost half of oral schwannomas reported to occur in the tongue. Imaging Features ▬ Well-defined homogeneous soft-tissue mass, enhancement, but variable appearance because of cystic and solid components. Schwannoma is often cystic, as opposed to neuroma, which is seldom cystic. ▬ Enlarged foramina. ▬ Atrophy of muscles. ▬ Associated with neurofibromatosis. ▬ T1-weighted MRI: isointense with muscle. ▬ T2-weighted MRI: hyperintense, homogeneous, both cystic and solid components, or heterogeneous. ▬ T1-weighted post-Gd MRI: cystic nature with rim enhancement.
    35. 35. Nasal Glioma  Nasal glioma is a congenital fronto-nasal mass composed of dysplastic neuroglial tissue and fibrovascular tissue.  This mass is thought of as a cephalocele that lost connection to the skull base. It is found at birth or during infancy as a subcutaneous lesion located on the nasal dorsum, typically at the glabella,,on the midline (although this is not the rule)  MRI should be considered the imaging technique of choice, because its low invasiveness and better depicts the absence of connections with the brain;  the lesion displays hypointense T1 signal (as compared to gray matter) and T2 hyperintensity (due to gliosis); no contrast enhancement is expected.
    36. 36. Meningioma  Meningioma may be found in the sinonasal cavities in four different forms: as the direct extension of a lesion arising in anterior cranial fossa; as a metastasis of an intracranial meningioma; as an extracranial neoplasm arising from arachnoid cells located in the sheath  surrounding cranial nerves in their course through skull base foramina; as an extracranial lesion with no connection with the anterior cranial fossa .  The nasal cavity is the most common site of sinonasal meningiomas.  MSCT density is generally homogeneous, MRI signal is iso- to hyperintense on T2 sequences and iso- to hypointense on T1, compared with gray matter; contrast enhancement is bright. Bone erosion, sclerosis and hyperostosis may be found.
    37. 37. Rhabdomyosarcoma  Rhabdomyosarcoma is the most common sinonasal malignant tumor in children,  characteristic are aggressive local behavior and early metastases. Three subtypes (embryonal, alveolar and pleomorphic) are described, however the differentiation may be difficultat histology.  As the nasal symptoms produced by this tumor are similar to allergic or infectious diseases, at the time of diagnosis rhabdomyosarcoma is often a large mass invading adjacent structures.  On MRI, TSE T2 signal is hyperintense to muscle.  Contrast enhancement is heterogeneous; necrosis, calcifications and hemorrhage are rare (Hagiwara et al. 2001).
    38. 38. A/2/iv - Osseous and Cartilaginous Tumors • Osteosarcoma • Chondrosarcoma • Ameloblastoma
    39. 39. Osteosarcoma Synonym: Osteogenic sarcoma Definition Malignant tumor characterized by direct formation of bone or osteoid by tumor cells (WHO). Clinical Features ▬ Most common primary malignancy in skeleton (apart from myeloma), usually in bones around the knee and primarily in children and adolescents; pain common ▬ Only 5–10% in head and neck; mostly in jaws ▬ Usually painless swelling in jaws,but also pain and mental nerve paresthesia ▬ Mandible slight predominance ▬ Males slight predominance ▬ May occur in any age group; peak in fourth decade ▬ Jaw osteosarcomas have tendency to occur in older patients than osteosarcomas in other bones and less likely to metastasize ▬ However, prognosis of jaw sarcoma is poor and does not seem to have improved with chemotherapy in a similar way to sarcomas in other bones
    40. 40. Imaging Features ▬ Soft-tissue mass, may grow aggressively and rapidly ▬ Radiolucent or most frequently, a combination of radiolucent and radiopaque appearance; bone production may be extensive ▬ Border of bone destruction ill-defined ▬ Bone production may typically have ‘sunburst’ appearance, best seen on CT images ▬ T1-weighted MRI: heterogeneous (intermediate–low) signal ▬ T2-weighted and STIR MRI: heterogeneous signal (variable high to intermediate–low) epending on bone production and cellular content ▬ T1-weighted post-Gd MRI: heterogeneous (intense to low) contrast enhancement
    41. 41. Chondrosarcoma  Chondrosarcoma generally affects long bones, ribs and pelvis;  60% of cases occurring in the alveolar process of the maxilla, although several cases of nasal septal chondrosarcoma are reported.  Sinonasal chondrosarcoma tend to be high grade lesions,. Imaging feature  MSCT appearance consists of a soft tissue matrix with scattered calcifications (which may represent a helpful hint for the differential diagnosis) and bone destruction.  On MRI, chondrosarcoma exhibits bright T2 signal and T1 hypointensity with variable, heterogeneous contrats enlacement .  Typically, scalloped margins and intralesional septa display enhancement, resulting in a peculiar rings and arcs pattern.  Although calcifications are less evident than on MSCT, the T2 hyperintensity (uncommon for neoplasms) and pattern of enhancement may suggest chondrosarcoma on MRI.
    42. 42. Ameloblastoma  benign but locally aggressive neoplasm  originate from remnants of the odontogenic epithelium, from the lining of odontogenic cysts or from the basal membrane of the overlying oral mucosa.  The mandible and maxilla as common site of origin (80 vs. 15–20% of cases),  fifth and sixth vs. second and third decade  to show more aggressive behavior than those originating from the jaw.
    43. 43.  Imaging feature  On cross-sectional imaging, appear as a uni- or multilocular cystic and solid lesion arising from the alveolar ridge.  Bone remodeling and destruction are often seen, along with maxillary sinus and nasal cavity invasion.  A peripheral (generally incomplete) bony shell may surround the lesion the presence of multiple septa within the lesion may result in a honeycomb appearance;  In 10% of cases a dental element may be embedded into the lesion .  MRI appearance of plexiform ameloblastoma may be similar to the columnar pattern of inverted papilloma: this is due to the presence of thin septa and papillary projections of solid tissue within the lesion, both enhancing after contrast administration
    44. 44. a–c 73 year male. The left maxillary sinus is occupied by a mass protruding in the nasal fossa. Although the upper part of the mass (arrows) shows a columnar pattern resembling inverted papilloma, the destruction of the posterolateral sinus wall (b) indicates a more aggressive pattern of growth. Involvement of the alveolar process of maxillary bone (arrowheads) suggests odontogenic origin. Pathology proved the lesion to be ameloblastoma
    45. 45. A/2/V - Hematologic Tumors • • • • • Lymphoma Granulocytic Sarcoma Plasmacytoma Fibro-Osseous Disease Metastasis
    46. 46. Non-Hodgkin’s Lymphoma Definition Malignant neoplasm of cells from the lymphatic system. Clinical Features ▬ Lymph node disease most common ▬ Non-Hodgkin’s lymphoma of involves extranodal sites (as opposed to Hodgkin’s lymphoma which is predominantly nodal) ▬ Extranodal involvement may include maxillary sinus and maxilla or, less frequently, mandible ▬ All age groups, adults in particular (except Burkitt’s lymphoma) ▬ Burkitt’s lymphoma was initially described as African jaw lymphoma; affects children; shows rapid growth and may involve one or both jaws
    47. 47. Imaging Features ▬ Soft-tissue mass ▬ Radiolucency ▬ Border of bone destruction ill-defined ▬ Non-Hodgkin’s lymphoma, and rarely Hodkin’s lymphoma, may present with necrofic lymph nodes ▬ However, it is not possible to definitely distinguish between nonHodgkin’s,Hodgkin’s and metastatic lymph nodes based on CT and MRI ▬ T1-weighted MRI: intermediate–low signal ▬ T2-weighted and STIR MRI: intermediate signal ▬ T1-weighted MRI: contrast enhancement
    48. 48. Granulocytic Sarcoma  Also known as chloroma, granulocytic sarcoma is a rare tumor composed of precursors of the granulocyte series, including myeloblasts, promyelocytes and myelocytes.  develop during the course of, or as a presenting sign of a variety of myeloproliferative disorders among which is acute myelogenous leukemia; seldom, granulocytic sarcoma may even precede leukemia by weeks or months.  Although more commonly described in the orbit  (actually it was first described as a green ocular tumor hence the name chloroma),  Imaging shows a homogeneously enhancing soft tissue mass.
    49. 49. Plasmacytoma  Plasmacytoma is a soft tissue mass composed of monoclonal plasma cells.  most commonly affecting the sinonasal cavities, followed by the nasopharynx and oropharynx, and manifesting in 90% of cases as a solitary mass .  15–20% of plasmacytomas convert into multiple myeloma, although such transformation is thought to occur in intramedullary lesions, whereas extramedullary lesions (such as sinonasal plasmacytoma) are generally solitary lesions.  Imaging findings (soft tissue mass, bone destruction) are completely nonspecific
    50. 50. Fibrous Dysplasia Definition Genetically based sporadic disease of bone that may affect single or multiple bones monostotic or polyostotic). Fibrous dysplasia occurring in multiple adjacent craniofacial bones is regarded as monostotic (craniofacial fibrous dysplasia).May be part of the McCune-Albright syndrome (WHO). Non-neoplastic, self-limiting but non-capsulated lesion occurring mainly in young subjects, showing replacement of normal bone by cellular tissue containing islands or trabeculae of metaplastic bone. Clinical Features ▬ Monostotic most common (70–80%, femur, ribs) ▬ Craniofacial bones up to 25% of monostotic forms ▬ Maxilla, lateral region in particular,more frequent than mandible ▬ Painless swelling, jaw asymmetry ▬ Second and third decades ▬ No sex predilection ▬ McCune-Albright syndrome; polyostotic
    51. 51. Imaging Features ▬ Radiolucency ▬ Mixture of radiolucency and radiopacity ▬ Radiopacity; ground-glass appearance ▬ Unilocular or multilocular ▬ Border poorly defined; blend into normal bone, but may be more well defined (and thus difficult to distinguish from ossifying fibroma; same histopathology) ▬ Usually expanded bone ▬ May displace teeth, walls of nasal cavity, paranasal sinuses, orbits ▬ Mandibular canal may be displaced cranially ▬ Tooth resorption rare ▬ T1-weighted MRI: intermediate signal ▬ T2-weighted MRI and STIR: heterogeneous low signal ▬ T1-weighted MRI: contrast enhancement
    52. 52. Fibrous dysplasia and ossifying fibroma share overlapping histologic features, making the differential diagnosis challenging, particularly when biopsy does not achieve an adequate sample. Some imaging findings may be helpful for the characterization of the lesion (Fig. 23).
    53. 53. Metastasis  Rarely, the nose and Paranasal sinus are the site of a distant metastasis, mostly of renal cell, breast or lung carcinoma.  Signs and symptoms are similar to those caused by benign and malignant lesions.  Imaging appearance is nonspecific, although intense enhancement is expected in hypervascular metastases, such as those produced by renal cell carcinoma and melanoma.  Maxillary sinus (33%) is the most commonly involved site followed by sphenoid sinus (22%), ethmoid (14%) and frontal sinus (9%); simultaneous involvement of more than one cavity occurs in as many as 22% of cases.
    54. 54. TRAUMA CT is the superior imaging modality to assess bone structures and routinely the examination will include axial and coronal sections.With multidetector CT, high-quality images can be obtained in any desired plane and 3D reconstruction can be very valuable in the evaluation of the complex facial skeleton.
    55. 55. The buttress system of the midface. The buttress system of the midface is formed by the strong frontal, maxillary, zygomatic, and sphenoid bones and their attachments to one another. The central midface consists of several fragile bones that easily ‘‘crumple’’ when subjected to strong forces. These more fragile bones are surrounded by the thicker bones of the buttress system, which provide structure and absorb the forces applied to the face. Most of the forces absorbed by the face are masticatory, therefore the vertical buttresses are the most well developed. These include the medial nasomaxillary buttres and the lateral zygomaticomaxillary buttress. Three horizontal buttresses interconnect and provide support for the vertical buttresses: the frontal bone and supraorbital rims (frontal bar), the nasal bones and inferior orbital rims, and the maxillary alveolus. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imaging of high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:17–32; with permission.)
    56. 56. Fractures Definition Traumatic cortical discontinuity with or without dislocation Clinical Features ▬ See Non-fracture Traumas ▬ Abnormal morphology such as flattening ▬ Palpable step-off of bone ▬ Crepitation due to emphysema ▬ Paresthesia, anesthesia ▬ Hemorrhage Imaging Features ▬ See Non-fracture Traumas ▬ Cortical discontinuity, defect ▬ Abnormal angulation ▬ Absent or displaced bone ▬ Abnormal linear density ▬ Bone overlap (“double radiopacity”) ▬ Green-stick in young patients ▬ “Empty fossa” sign on axial CT images ▬ Localized air collection
    57. 57. LeFort Fractures Definition LeFort 1 is characterized by fracture just above the floor of the nasal cavity with separation of the entire palate and maxillary alveolar process; fractures through the lower nasal septum, lower walls of maxillary sinuses, and lower pterygoid plates (“horizontal fracture”). “Floating palate” (LeFort 1)
    58. 58. LeFort 2 Characterized by fracture of the root of the nose, bilateral fractures of the lacrimal bones and medial orbital walls, the floor of the orbits near the infraorbital canals, zygomaticomaxillary sutures and anterior walls of maxilla (“pyramidal fracture”) and posteriorly, infratemporal surfaces of the maxilla and lower pterygoid plates. Wassmund 1 fracture does not include the nasal bones but is otherwise identical. “Dish face”, hemorrhage, edema, emphysema, and in near 80% anesthesia of infraorbital nerve(s) (LeFort 2)
    59. 59. LeFort 3 characterized by separation of the entire viscerocranium from the skull base (“craniofacial dysjunction”); fracture of the root of the nose, bilateral fractures of the lacrimal bones and medial orbital walls, the floor of the orbits to the inferior orbital fissure,where one fracture line extends to the lateral orbital wall and another down across the posterior maxilla to the lower pterygoid plates and additionally, fractures of the zygomatic arches. Wassmund 3 fracture does not include the nasal bones but is otherwise identical. “Dish face”, CSF rhinorrhea, hemorrhage, edema, emphysema, damage to lacrimal apparatus, and in near 70% anesthesia of infraorbital nerve(s) (LeFort 3)
    60. 60. Tripod Fracture Synonyms: Trimalar or zygomatic fracture Definition Fracture through (1) lateral orbital wall with fracture site at zygomaticofrontal suture, (2) zygoma and maxilla with fracture site at zygomaticomaxillary suture, (3) zygomatic arch with fracture site at zygomaticotemporal suture. Clinical Features ▬ Most common fracture of facial skeleton after nasal and mandibular fractures ▬ About half of all midfacial fractures (more than two-thirds in one study), either alone or in combination with other midfacial fractures ▬ Infraorbital nerve paresthesia or anesthesia in almost 95%
    61. 61. Blow-out Fracture Definition Fracture of orbital floor, usually not orbital rim (classic); but also of medial or other orbital walls. Clinical Features ▬ Only 3–5% of all midfacial fractures ▬ Diplopia ▬ Enophthalmos, exophthalmos
    62. 62. Acute Rhinosinusitis Definition Acute inflammation in nose and paranasal sinuses. Clinical Features ▬ One of most common medical afflictions. ▬ Viral rhinosinusitis most common (common cold, influenza). ▬ Bacterial rhinosinusitis may develop secondarily (Haemophilus influenzae, Streptococcus pneumoniae). ▬ Pain over sinuses; cheek, frontal, between eyes, or suboccipital. ▬ Toothache, teeth tenderness to percussion; more than one tooth of maxillary lateral segment(s). ▬ Headache seldom. ▬ Dental etiology in 10–20%; larger frequencies have been reported depending on patient materials.
    63. 63. Imaging Features ▬ Nodular or smooth mucosal thickening or complete sinus opacification ▬ Contrast-enhanced inflamed mucosa lining; variable amounts of submucosal edema and surface secretions ▬ Air-fluid level, most frequent in maxillary sinus, due to bacterial sinusitis with obstruction of ostium, but only in 25– 50% of patients with this disease ▬ T1-weighted MRI: low to intermediate ▬ T2-weighted MRI: high signal of inflamed mucosa and fluid ▬ T1-weighted post-Gd MRI: intense enhancement of inflamed mucosa; no enhancement of fluid
    64. 64. Chronic Sinusitis Definition Develops from either persistent acute inflammation or repeated episodes of acute or subacute sinusitis. ▬ Allergic sinusitis ▬ Vasomotor rhinitis ▬ Fungal sinusitis (90% Aspergillus fumigatus; may be fulminant and invasive in immunosuppressed patients) Clinical Features ▬ Anaerobic microorganisms frequently isolated
    65. 65. Imaging Features ▬ Varying mucosal swelling, smooth or irregular swelling due to edema and secretion. ▬ Thickened, sclerotic, fibrotic sinus walls, particularly of maxillary sinuses. ▬ Dystrophic calcification. ▬ T1-weighted MRI: low to intermediate. ▬ T2-weighted MRI: usually high signal of inflamed mucosa, low signal of sclerosis and fibrosis. Inspissated mucus can be dark on all sequences resulting in false-negative MR diagnosis of chronic sinusitis
    66. 66. Mucosal Imaging Findings in Asymptomatic Individuals MRI findings of paranasal sinuses in patients with brain imaging. ▬ Mucosal thickening up to 3 mm may be present in clinically normal individuals. ▬ Clinically silent focal areas of mucosal thickening occur from about one-fourth and up to two-thirds of asymptomatic individuals. Retention Cysts,Mucous and Serous Definition Mucous retention cyst: obstruction of submucosal mucinous gland, thus cyst wall of duct epithelium and gland capsule. Serous retention cyst: accumulation of serous fluid in submucosal layer of sinus mucosa, thus cyst lining of elevated mucosa.
    67. 67. Imaging Features ▬ Smooth, spherical soft tissue mass. ▬ Retention cysts found incidentally in 10–35% of patients, most commonly in maxillary sinus, but can occur in any sinus. ▬ Frequently small, may become large but always some air. ▬ Almost in every case normal bone. ▬ T1-weighted MRI: usually low to intermediate signal, but may show high signal if cyst has high protein content. ▬ T2-weighted MRI: high signal
    68. 68. Polyps Definition Expansion of fluids in deeper lamina propria of Schneiderian mucosa in nasal fossa and paranasal sinuses. Clinical Features ▬ Most common expansile condition in nasal cavity; about 4% in general population. ▬ Nasal polyps most often associated with allergy, and frequently multiple and symmetric, but may result from infectious rhinosinusitis, vasomotor rhinitis, cystic fibrosis, diabetes mellitus, aspirin intolerance, and nickel exposure. ▬ In patients with polyps up to about 70% with asthma. ▬ Nasal stuffiness. ▬ When seen in children, cystic fibrosis should be ruled out. Imaging Features ▬ Smooth, spherical soft tissue mass ▬ If multiple, complete opacification of nasal cavity and sinuses ▬ T1-weighted MRI: low to intermediate signal ▬ T2-weighted MRI: high signal ▬ Heterogeneous MR signal characteristic in chronic polyps; can also enhance
    69. 69. Mucoceles Definition Collection of mucoid secretions surrounded by mucus-secreting respiratory epithelium. Both retention and mucocele cysts consist of mucous secretions surrounded by epithelial lining, but are distinguished by their clinical and imaging features. Mucocele develops due to obstruction of sinus ostium or a compartment of a sinus with the sinus mucosa as the mucocele wall and always with expandedsinus walls. Clinical Features ▬ Most common expansile condition in paranasal sinuses. ▬ Most frequent in frontal sinuses (60–65%); only 5–10% in sphenoid as well as in maxillary sinuses. ▬ Both sexes,wide range of age: 20 to 60 years. ▬ Classic mucocele is sterile with signs and symptoms from mass effect. ▬ Pain uncommon. ▬ If infected, pain; mucopyocele or pyocele. ▬ Ostial obstruction may be caused by inflammatory scar, trauma, or tumor.
    70. 70. Imaging Features ▬ Initially, intact but remodeled, expanded surrounding bone. ▬ With progressive growth sinus wall will be destroyed. ▬ Completely airless sinus. ▬ T1-weighted and T2-weighted MRI: variable MR signals depending on protein content, state of dehydration, and viscosity of content; most frequently observed patterns are moderate-to-marked high signal on T1 and T2, or moderateto-marked low signal on T1 and T2, usually low to intermediate T1 and high T2. ▬ T1-weighted post-Gd MRI: no enhancement except of thin peripheral rim.