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AJR:189, December 2007 S35

AJR Integrative Imaging

LIFELONG LEARNINGFOR RADIOLOGY

Imaging o Chronic and Exotic Sinonasal Disease: Review

Arash K. Momeni

, Catherine C. Roberts

, and Felix S. Chew

Keywords:

chondrosarcoma, chronic sinusitis, CT, ungal sinusitis, inverted papilloma, juvenile nasopharyngeal angiobroma, MRIDOI:10.2214/AJR.07.7031Received August 3, 2007; accepted ater revision August 29, 2007.The opinions and assertions contained herein are the private views o the authors and are not to be construed as ocial or as refecting the views o the Department o the Air Force or the Department o Deense.

Department o Radiology, David Grant Medical Center, Travis Air Force Base, Faireld, CA.

Department o Radiology, Mayo Clinic College o Medicine, 5777 E Mayo Blvd., Phoenix, AZ 85054. Address correspondence to C. C. Roberts (roberts.catherine@mayo.edu).

Department o Radiology, University o Washington, Seattle, WA.

AJR

2007;189:S35–S45 0361–803X/07/1886–S35 © American Roentgen Ray Society

Objective

Chronic sinusitis is one of the most commonly diagnosedillnesses in the United States. The educational objectives of this review article are for the participant to exercise, self-assess, and improve his or her understanding of the imagingevaluation of sinonasal disease.

Conclusion

This article describes the anatomy, pathophysiology, mi-crobiology, and diagnosis of sinonasal disease, includingchronic and fungal sinusitis, juvenile nasopharyngeal angio-

broma, inverted papilloma, and chondrosarcoma.

Introduction

Chronic sinusitis is one of the most commonly diagnosedillnesses in the United States. It is estimated to affect morethan 30 million individuals and is increasing in incidence [1].

The number of ofce visits and the annual expenditures on

prescription medications for sinusitis rose from $50 millionto $200 million from 1989 to 1992 alone. In addition to the

economic impact, chronic sinusitis has a signicant impacton quality of life. It can lead to signicant physical and

functional impairment even when compared with chronicdebilitating diseases such as congestive heart failure andchronic obstructive pulmonary disease [2].

Sinusitis may be dened as an inammatory process in

-volving the mucous membranes of the paranasal sinuses orthe underlying bone. It is subdivided into acute, subacute,and chronic on the basis of the duration of symptoms [2].Acute sinusitis is sudden in onset and may last up to 4 weeks.Subacute is a continuum of the natural progression of acute

sinusitis and lasts 4–12 weeks. Chronic disease is dened asinammation of the mucosa of the paranasal sinuses and

lasts for at least 12 consecutive weeks [2].This review focuses on the anatomy, pathophysiology, mi-crobiology, and diagnosis of sinonasal disease, includingchronic and fungal sinusitis, juvenile nasopharyngeal angio-

broma, inverted papilloma, and chondrosarcoma.

Anatomy and Pathophysiology

Understanding the normal anatomy and physiology of the paranasal sinuses is important to understanding thepathogenesis of sinus disease. There are four pairs of sinusesnamed for the bones of the skull they pneumatize. They arethe maxillary, ethmoid, frontal, and sphenoid sinus air cells

and they are lined by pseudostratied columnar epithelium-

bearing cilia. The mucosa contains goblet cells that secretemucus, which aids in trapping inhaled particles and debris.

The maxillary antrum consists of a roof, oor, and three

walls: the medial, anterior, and posterolateral. The roof andmedial walls are shared with the orbit and nasal cavity, forming

the orbital oor and lateral wall of the nose, respectively [3].

The cilia in the maxillary antrum propel the mucous stream in

a starlike pattern from the oor toward the ostium, which is

situated superomedially. From the ostium, mucus is swept su-periorly through the infundibulum, which is located lateral tothe uncinate process and medial to the inferomedial border of the orbit (Figs. 1 and 2). The uncinate process is a sickle-shapedbone extension of the medial maxillary wall that extends an-terosuperiorly to posteroinferiorly [4]. The uncinate process israrely pneumatized. The hiatus semilunaris, situated immedi-

ately superior to the uncinate process, is a slitlike air-lled space

anterior and inferior to the largest ethmoid air cell, the ethmoi-

dal bulla. It is clinically signicant because disease located here

results in obstruction of the ipsilateral maxillary antrum, ante-rior and middle ethmoid air cells, and frontal sinus, whereasdisease in the infundibulum results in isolated obstruction of the ipsilateral maxillary sinus alone [5].

Momeni et al.

S36 AJR:189, December 2007

The entire complex of the maxillary ostium, infundibu-lum, uncinate process, hiatus semilunaris, ethmoid bulla,and middle meatus make up the ostiomeatal unit or os-tiomeatal complex. The ostiomeatal complex (Fig. 3) actsas the common drainage pathway of the frontal, maxillary,and anterior ethmoid air cells, the patency of which is criti-cal for normal sinus drainage and ventilation [4].Obstruction of the ostiomeatal complex is commonlyconsidered the underlying cause of most cases of sinusitisbecause obstruction may result in maxillary, ethmoidal, orfrontal disease. Predisposing factors that induce local in-

ammation of the sinonasal mucosa and occlude the os

-tiomeatal complex include allergy, viral infections, and airpollutants [6]. Mucosal swelling impairs mucociliary clear-ance and results in sinus ostia obstruction. Sinus excretionsthen pool and thicken, creating a nidus for superinfection.The ethmoid sinuses are paired, discrete cells that may num-ber 18 or more. They are anatomically divided into anterior,middle, and posterior groups according to the location of thedraining ostia. There are two primary types of cells: intramu-

ral and extramural. The intramural cells remain conned to

the ethmoid bone, whereas the extramural invade the adjacentbones of the cranial vault or the face [3]. The ethmoid bulla isthe air cell directly superior and posterior to the infundibulumand hiatus semilunaris. A large ethmoidal bulla can obstructthe infundibulum and hiatus semilunaris, leading to interfer-ence with the drainage of the maxillary and anterior ethmoidsinuses through the ostiomeatal complex [4].The frontal sinuses drain inferomedially via the frontalrecess, which is a space between the inferomedial frontalsinus and the anterior part of the middle meatus. The fron-tal sinus and the anterior ethmoid air cells together draindirectly into the middle meatus via the frontal recess, or lesscommonly, into the superior ethmoidal infundibulum, be-fore draining to the middle meatus [4].The sphenoid sinuses drain into the sphenoethmoidal re-cess, which lies above the superior nasal concha, and the pos-terior ethmoid cells. Pneumatization of the sphenoid sinusesis slow, but is usually complete by puberty. Still, failure of pneumatization, resulting in a permanent infantile appear-ance, is not uncommon [3]. The sphenoid sinus is usually sep-tate, but the septum is midline in only 25% of patients [7].

Microbiology

Unlike in acute sinus disease, the exact role of bacteria orother organisms in the cause of chronic sinusitis remains

unidentied [8]. Acute illness is classically caused by

Hae-

Fig. 2—

59-year-old woman with headache.

and

Noncontiguous axial unenhanced CT images show normal paranasal sinus anatomy. At level o mid globe, ethmoid (E) and sphenoid (S) sinus are visible, aswell as middle crania ossa (M) and lamina papyracea (LP). At level o mid ace, maxillary (M) sinuses have adjacent nasolacrimal duct (NLD), turbinates (T), pterygo-palatine ossa (PtPF), inratemporal ossa (ITF), and nasopharynx (NP).

Fig. 1—

39-year-old woman with headache. Coronal unenhanced CT scan showsnormal sinus anatomy, including each maxillary ostium (

arrows

), uncinate process(

arrowheads

), ethmoid bulla (B), middle nasal turbinate (M), inerior nasal turbinate(I), and inraorbital ethmoid cells or Haller cells (

asterisks

). Maxillary ostium entersinundibulum, which is space between uncinate process and ethmoid bulla.

Chronic and Exotic Sinonasal Disease

AJR:189, December 2007 S37

mophilus

Streptococcus

species; however, chronic diseasemay result from a number of disparate organisms. In astudy of 94 cases of endoscopically guided ethmoid sinuscultures from 50 adults with chronic sinusitis, the recoveredorganisms included

Staphylococcus aureus

, gram-negativerods,

Haemophilus infuenzae

, group A streptococci,

Strepto-coccus pneumoniae

, and

Corynebacterium diphtheriae

[9].Moreover, polymicrobial infections are more common in pa-tients with chronic sinusitis. The offending organisms of polymicrobial disease include anaerobic bacteria, fungi, and

Pseudomonas aeruginosa

[10].

Chronic Sinusitis

Chronic sinusitis often develops secondary to acute diseasethat is refractory to treatment. Clinically, few signs or symp-toms reliably differentiate acute from chronic disease becausethey present in a similar fashion. The real distinction is basedon the duration of symptoms: acute disease is sudden in on-set and may last up to 4 weeks, whereas chronic disease lastsfor at least 12 consecutive weeks. The most common present-ing symptoms for acute sinusitis include fever and toxicity;chronic sinusitis symptoms include facial pressure, headache,nasal obstruction, postnasal drip, and fatigue.The location of the facial pain and pressure may alsohelp localize the infection to a particular sinus. Maxillarydisease typically causes cheek discomfort or pain in the up-per teeth, whereas pain due to frontal sinusitis is usuallyexperienced in the forehead. Ethmoiditis may present withtenderness over the medial canthal region; pain from sphe-noid sinus involvement is often retroorbital, but may radi-ate to the occipital and vertex regions [11].The two primary diagnostic imaging techniques for eval-uating the paranasal sinuses are CT and MRI. Radiographywas once the most commonly ordered study; however, CThas surpassed radiography in the evaluation process be-cause of its superior anatomic detail and, when a lower mAprotocol is used, a radiation dose similar to a standard four-view radiographic series [12, 13]. CT is the imaging study of choice in both adult and pediatric patients [14].The primary role of CT is to aid in the diagnosis and man-

agement of recurrent and chronic disease and to dene the

anatomy before surgery. CT can differentiate pathologic varia-tions and show anatomic structures that are inaccessible byphysical examination or endoscopy. It is the method of choice

for dening the complex sinus anatomy because of its 3D high

resolution. CT is the technique of choice in the preoperativeevaluation of the nose and paranasal sinuses and is the gold

standard for delineation of inammatory sinus disease result

-ing from obstruction [15]. The use of a bone algorithm pro-vides excellent resolution of the complete ostiomeatal complexand other anatomic factors that play a role in sinusitis. CoronalCT images most closely correlate with the surgical approach[16]. Therefore, it is the preferred study for the surgeon per-forming functional endoscopic sinus surgery (FESS) becausecoronal images simulate the appearance of the sinonasal cavity

from the perspective of the endoscope [4]. If an MDCT scan

-ner acquiring near isotropic voxels is used, coronal reformattedimages from axial scans are as diagnostic as images acquired inthe direct coronal plane. In some cases, reformatted images arepreferable to direct coronal images because of decreased dentalwork artifacts, limited patient mobility, and decreased radia-tion exposure [17].

The characteristic ndings of sinus disease include air–uidlevels, mucosal thickening, and opacication of the normally

aerated sinus lumen. The single distinguishing feature of acute

sinusitis is the air–uid level as an isolated nding, whereas theonly characteristic nding in chronic sinusitis is sclerotic,

thickened bone of the sinus wall [18] (Fig. 4). Mucosal thicken-ing is common to both acute and chronic sinusitis. The differ-ential diagnosis of sinus wall thickening includes fungal sinus-itis (mycetoma), which often coexists with chronic sinusitis.

According to Sonkens et al. [19], there are ve patternsof inammatory paranasal sinus disease: infundibular, os

-tiomeatal unit, sphenoethmoidal recess, sinonasal polyposis

and sporadic (unclassiable). In the infundibular pattern,

disease is limited to the infundibulum and the adjacentmaxillary sinus; the frontal and ethmoid sinuses are pre-served. Pathophysiologic causes for this pattern are swollenmucosa, polypoid lesions, and Haller cells.

Infundibuloto-my is the therapeutic method of choice and produces excel-lent results in most cases. In the ostiomeatal unit pattern,

Fig. 3—

Anterior drawing o ostiomeatal complex. Arrows show direction o mu-cociliary clearance. Potential areas o obstruction are denoted with X. Locationo anterior ethmoid artery (A) is important in endoscopic sinus surgery. Graphicmodied with permission rom Mayo Foundation or Education and Research.