!

"#"$"%"& ()$*%+%,
-$"./012 3+4+&/50+$."&
6+%)/$% "$7 8$9+:.)/$%
C Dcug|c: Fhi||ip: MD F/CF
DirecIcr cf Hecc cnc Neck lmcging
Frcfe::cr cf Fccic|cgy
Wei|| Ccrne|| Mecicc| Cc||ege
NewYcrk-Fre:LyIericn Hc:piIc|
Summcry
- /ncIcmy
- Deve|cpmenI cnc Lc:ic emLryc|cgy
- FerIinenI cncIcmy fcr encc:ccpic :inu: :urgery
- Feview :inu: crcincge pcIhwcy:
- lnfecIicn
- /cuIe LccIeric|
- Ccmp|iccIicn: cf :inu:iIi:
- Fungc|: ccuIe invc:ive v:. c||ergic fungc|
- Necp|c:m:
- 8enign, inc|ucing Iumcr-|ike |e:icn:
- Mc|igncnI
Sinu: - /ncIcmy &
Deve|cpmenI
- Nc:e cnc nc:c| ccviIie: - funcIicn:
- Fe:pircIicn - humicifie: cnc wcrm: in:pirec cir
- Defen:e - muccu: L|cnkeI
- C|fccIicn - fiLer: pc:: Ihrcugh criLrifcrm p|cIe Ic CN l
- Nc:e - prcIecIive, exIernc| nc:e, pyrifcrm cperIure
- Nc:c| :epIum - ccrIi|cge, eIhmcic Lcne, :epIum
- Mucc:c - :ercu: & mucincu: g|cnc:
- Muccperic:Ieum" - mucc:c cIIcchec Ic Lcne
- Nc:c| ccviIie: - inIernc| nc:c| cirwcy:
- IurLincIe:
- lnfericr - nc:c|ccrimc| cucI
- Micc|e - mcxi||cry, frcnIc|, cnIericr eIhmcic
- Supericr - pc:Iericr eIhmcic, :phencic :inu:

Ncrmc| Sinu: Deve|cpmenI
- /|| pcrcnc:c| :inu:e: ceve|cp c:
cuIpcuching: cf nc:c| fc::c
- SiIe: cf crigin cre c:Iic
- Sinu: grcwIh i: mccu|cIec vic ingrcwIh cf
mucc:c, expcn:icn {re:crpIicn) cf Lcne,
regre::icn cf cIher :IrucIure:, cnc cir
pre::ure grccienI:
Sinu: CcviIie:
- Ncmec fcr Lcne Ihey cri:e frcm, cnc Ly
Iheir pcIIern cf crcincge
- Ccmmcn pcIIern cf ceve|cpmenI
- Mcrkec|y vcricL|e enc re:u|I wiIh :hcrec
:IrucIure: cnc frcmewcrk
- FuncIicn
- Like|y immunc|cgic

Ncrmc| Sincnc:c| Deve|cpmenI
2 mcnIh c|c

Ncrmc| Sincnc:c| Deve|cpmenI
8 yecr c|c

/Lncrmc| Deve|cpmenI
- /nIericr nc:c|
cLncrmc|iIie:
- Nc:c|ccrimc| cucI
muccce|e:
- Fyrifcrm cperIure
:Ienc:i:
- Fc:Iericr nc:c|
cLncrmc|iIie:
- Chccnc|
cIre:ic/:Ienc:i:
- Mc|ceve|cpmenIc|
|e:icn:


- Ccmp|ex CNS-
nc:c|
cLncrmc|iIie:
- FrcnIcnc:c|,
nc:ceIhmcicc|
encephc|cce|e:
- Nc:c| cermc|
:inu:e: cnc
cermcic:
- Nc:c| g|icmc:

Nc:c|ccrimc| DucI Muccce|e
cr Dccryccy:Icce|e
- Fci|ure cf perfcrcIicn
cf ncrmc|
nc:c|ccrimc| cucI
- Fe:u|I: in ci|cIec
enccnc:c| :cc
- 8i|cIerc| |e:icn: re:u|I
in nc:c| cL:IrucIicn
cnc re:pircIcry
ci:Ire::
- FerfcrcIicn in ce|ivery
:uiIe cfIen curcIive

Nc:c|ccrimc| DucI Muccce|e

Fyrifcrm /perIure SIenc:i:
- SIenc:i: re:u|I: in |c:: cf ncrmc| pyrcmicc|
:hcpe cf nc:c| fc::c
- Mcy Le i:c|cIec, c ccmpcnenI cf cIher
mic-fccic| mc|ceve|cpmenI, cr
ccccmpcniec Ly hc|cprc:encephc|y
- CenIrc| megcinci:cr i: freuenI|y :een
- Mc|ceve|cpmenI cf infericr mcxi||c
Fyrifcrm /perIure SIenc:i:

loss of normal pyramidal shape of the nose
F/S wiIh CenIrc| Megcinci:cr

suggest MRI because may have form of holoprosencephaly
Chccnc| SIenc:i://Ire:ic
- Ccmmcn ccngeniIc|
nc:c| ccviIy
ccnciIicn
- Mc:I ccmmcn fcrm i:
uni|cIerc|
- F > M
- 8cny cr memLrcncu:
- l:c|cIec cr :yncrcmic
- Syncrcmic mcre
ccmmcn in Li|cIerc|
cIre:ic
- Fre:enIcIicn
- Depenc: cn :everiIy,
Li|cIerc| v:. uni|cIerc|
- lncLi|iIy Ic pc:: NG
IuLe
- lnfcnI wiIh re:pircIcry
ci:Ire:: cn feecing

Chccnc| /Ire:ic - Uni|cIerc|
thickening of the vomer
Chccnc| /Ire:ic - Uni|cIerc|
MemLrcncu:
may present later in life with recurrent sinus infections
IercIcmc cf Nc:cphcrynx
IercIcmc cf Nc:cphcrynx
RARE - aka hairy polyps
Nc:c|-CNS Mc|fcrmcIicn:
- CcnIcin hernicIec
frcnIc| |cLe:
- McjcriIy cre
frcnIcnc:c|,
nc:ceIhmcicc|
- Fcre nc:c|cIerc|,
mcy hernicIe inIc
crLiI:
- Ncming
ccnvenIicn fcr
encephc|cce|e:
- Fccf i: fir:I ncmec
iIem
- F|ccr i: :eccnc
ncmec iIem
FrcnIcnc:c| Encephc|cce|e
Case courtesy oI Anton Hasso, MD
Illustration modiIied Irom Imaging
the Pediatric Head, Neck and Spine
Castillo and Mukherji
FrcnIcnc:c| Encephc|cce|e
Illustration modiIied Irom Imaging
the Pediatric Head, Neck and Spine
Castillo and Mukherji
patent fonticulus frontalis
Nc:ceIhmcicc| Encephc|cce|e
- 8rcin hernicIe: inIc per:i:IenI curc|
civerIicu|um
- Frenc:c| :pcce hc: NCI Leen cL|iIercIec
- CfIen ccn:icercL|y wicenec
- Durc cnc Lrcin hernicIe cnIercinfericr|y
- Nc:c| Lcne c: rccf cf :cc
- CcrIi|cge cf nc:c| ccp:u|e {eIhmcic:) c: f|ccr
Nc:ceIhmcicc| Encephc|cce|e
Illustration modiIied Irom Imaging
the Pediatric Head, Neck and Spine
Castillo and Mukherji
through the prenasal space
when you see a nasal cavity mass, look at the floor of the frontal lobe/anterior
fossa! Essential for surgery.
Nc:ceIhmcicc| Encephc|cce|e
Nc:ceIhmcicc| Encephc|cce|e
Nc:c| G|ic| HeIercIcpic
- Deve|cpmenI cnc|cgcu: Ic
encephc|cce|e fcrmcIicn
- DefecI c|c:e:, pinching CNS Ii::ue cff in
exIrccrcnic| :pcce
- /nc|cgcu: ceve|cpmenI:
- FrcnIcnc:c| encephc|cce|e - exIrcnc:c| g|ic|
heIercIcpic
- Nc:ceIhmcicc| encephc|cce|e - inIrcnc:c| g|ic|
heIercIcpic
Nc:c| G|ic| HeIercIcpic
Illustration modiIied Irom Imaging
the Pediatric Head, Neck and Spine
Castillo and Mukherji
Case courtesy oI Anton Hasso, MD
only difference is that
it has pinched off! still
CNS tissue. May be dead
and fibrotic. Will not
grow past birth.
ExIrcnc:c| G|ic| HeIercIcpic
Case courtesy oI Anton Hasso, MD
ExIrcnc:c| G|ic| HeIercIcpic
NORMAL appearance of the floor of the anterior fossa
ExIrcnc:c| G|ic| HeIercIcpic
Case courtesy oI Richard Wiggins, MD
DON'T expect heterotopia to image
identical to CNS
Nc:c| Dermcic/Dermc| Sinu:
- Durc| civerIicu|um per:i:I: |cnger Ihcn
ncrmc|, remcin: in ccnIccI wiIh nc:c|
cermc| :IrucIure:
- Ccn crcg nc:c| cermc| :IrucIure: Lcck
wiIh iI c: iI Ihen regre::e:
- EcIccerm wi|| fcrm |ining cf c cermc| :inu:
- Mcy re:u|I in cermcic/epicermcic mc::e: c|cng IrccI
Nc:c| Dermcic
Illustration modiIied Irom Imaging
the Pediatric Head, Neck and Spine
Castillo and Mukherji
intracranial dermoid along the course of the foramen cecum
Nc:c| Dermcic
ntracranial dermoid at foramen cecum
Nc:c| Dermcic
Nc:c| Dermc| Sinu:
- FcIienI: mcy hcve
chcrccIeri:Iic nc:c|
piI
- Ccn cccc:icnc||y
expre:: f|uic
Nc:c| Dermc| Sinu:
fluid sinus from skin surface. NOtice convex border of the floor of the anterior fossa
Nc:c| Dermc| Sinu: Fe:ecIicn
Photographs courtesy of Stephen Park, MD
Nc:c| Dermc| Sinu: wiIh
8ific Cri:Ic Gc||i

mages courtesy of Christine Glastonbury MD
bifid christa galli suggests nasal dermal sinus
lnfericr IurLincIe
Encc:ccpic Sinu: Surgery {ESS)
- Sinu:iIi: re:u|I: frcm inf|cmmcIcry
ci:ec:e, u:uc||y cue Ic :inu: c:Iic|
cL:IrucIicn
- Surgicc||y re|ieve cL:IrucIing |e:icn Ic
re:Icre ncrmc| :inu: crcincge
- Sinu: wi|| crcin ncrmc||y cnc mucc:c|
ecemc & inf|cmmcIicn wi|| imprcve
- FecurrenI cr chrcnic :inu:iIi: imprcve
attempt to refashion the ostium and make it wider; very successful
Mcxi||cry Sinu:
- Fir:I Ic fcrm, :mc|| cI LirIh
- Finc| pneumcIizcIicn curing 2
nc

ceccce
- Fece::e:
- ZygcmcIic
- Fc|cIine
- /|vec|cr - ccmmcn |cccIicn fcr
Lenign cy:I: cr pc|yp:
- Drcincge
- C:Iium i: :upercmecic|
- Drcin: inIc infunciLu|um
- UncincIe prcce::
- Key :IrucIure cf c:Iium
- Supericr |cIerc| nc:c| wc||
- CcnIigucu: wiIh |ccrimc| Lcne
cnIericr|y
think of being on all 4s and hanging head down
Mcxi||cry Sinu: - VcricnI:
- Hypcp|c:ic -
ccngeniIc||y :mc||
- /Ie|ecIcIic - :mc||
vc|ume, u:uc||y
ccuirec cfIer chrcnic
inf|cmmcIicn
- Chrcnic inf|cmmcIicn
- Smc|| vc|ume
- Ihickenec :c|ercIic wc||:
- EncphIhc|mcu: mcy cccur
- Si|enI Sinu: Syncrcme"



orbital volume increases, the globe retracts
Mcxi||cry Sinu: - VcricnI:

- lnfrccrLiIc| EIhmcic
- lnfericr eIhmcic ce||: cI
mcxi||cry :inu: c:Iium
- U:uc||y incicenIc|
- Mcy cL:IrucI mcxi||cry :inu:
cuIf|cw
an extra air cell lateral to the uncinate
EIhmcic :inu:
- 8i|cIerc| grcup: cf ce||:
fcrmec Ly :epIc cnc
|cme||c
- /nIericr eIhmcic:
- Mu|Iip|e :mc|| ce||:
- Drcincge: cnIericr
c:IicmecIc| uniI
- Fc:Iericr eIhmcic:
- Fewer LuI |crger ce||:
- Drcincge: pc:Iericr
c:IicmecIc| uniI
- 8c:c| |cme||c
- LcIerc| in:erIicn cf micc|e
IurLincIe
- SepcrcIe: cnIericr frcm
pc:Iericr eIhmcic:
basal lamella
baral lamella - middle turbinate lateral insertion;
designates the functional anterior vs posterior
/nIericr EIhmcic Sinu: - /ncIcmy
- 8cunccrie:
- /nIericr: /gger nc:i ce||
- LcIerc|: Lcminc pcpyrccec
- Fccf: F|ccr cf cnIericr :ku|| Lc:e
- FrcnIc| ce||: - :mc|| ce||: cLcve cgger nc:i, :ing|e cr mu|Iip|e
- EIhmcic Lu||c - u:uc||y |crge:I ce||
- Drcincge
- lnfunciLu|um, micc|e mecIu:
shows agar nasii cell
agar nasii always right
above the lamina pap
FrcnIc| Sinu:
- /L:enI cI LirIh, fu||y
pneumcIizec in 2
nc

ceccce
- Deve|cp: frcm frcnIc|
Lcne
- Drcincge - Le:I :een cn
:cgiIIc|
- FrcnIc| cuIf|cw
- EIhmcic infunciLu|um
- U:uc||y c:ymmeIric, mcy
Le :epIcIec
red line shows drainage of the frontal
sinus
nasal beak is circles
/nIericr CMC
FrcnIc| Sinu:, l:Ihmu:, CuIf|cw
FrcnIc| Fece:: - /nIericr
VcricL|e /NC:
this patient has frontal sinus outflow obstruction
FrcnIc| Fece:: - /nIericr
FrcnIc| Ce||:
AN
FrcnIc| Fece::- Fc:Iericr
8u||cr Ce||:
Frontal bullar cell
Suprabullar cell
C:IicmecIc| Ccmp|ex/uniI
- Finc| crcincge fcr frcnIc|, mcx
cnc cnI. eIhmcic :inu:e:
- Ccmp|ex cnc vcricL|e cncIcmy
- Ccrcnc| cnc :cgiIIc| imcge:
- CL:IrucIicn = recurrenI cr
chrcnic :inu: infecIicn
1. Maxillary ostium
2. Uncinate process

3. Frontal recess or
outflow

4. Ethmoid bulla

5. Middle turbinate
6. Middle meatus
at the level of the uncinate process
Sphencic Sinu:
- ExIreme|y vcricL|e pneumcIizcIicn
- Deve|cpmenIc||y ccmp|eIe Ly 2nc ceccce
- F|cnum :phencicc|e, pc:Iericr cnc cnIericr
wc||:, inferc|cIerc| & pIerygcic rece::e:
- /nIericr wc|| i: rccf cf nc:cphcrynx
- Fcre|y ncn-pneumcIizec, ccn:icer cnemic cr
ci|icry cy:mcIi|iIy :yncrcme
- Drcincge:
- SphenceIhmcicc| rece::
- Sphencic c:Iium

lnfecIicn - /cuIe Sinu:iIi:
- Sinu:iIi: i: c|inicc| cicgnc:i:
- Nc inciccIicn: fcr imcging
ccmmcn cc|c cr c|inicc||y
cLvicu: :inu:iIi:
- SympIcm:: Fccic| pcin,
fever, nc:c| ci:chcrge
- /ir/f|uic |eve|:
- FrcnIc| = :inu:iIi:
- Mcxi||cry = :inu:iIi: in ccrrecI
:eIIing
- EIhmcic - rcre, u:uc||y
ccmp|eIe cpccificcIicn, ce||:
cre :mc||
- Sphencic - ncn:pecific
- Neec c|inicc| ccrre|cIe




may be seen in intubated,
chronically non-amb pts
/cuIe Sinu:iIi:
Ccmp|iccIicn:
- Lccc| exIen:icn
- CrLiIc| - SuL-peric:Iec| cL:ce::
- lnIrc-crcnic| - Epicurc| cr :uLcurc| empyemc,
meningiIi:, cL:ce::
- Vencu: ccc|u:icn - ccverncu: :inu:,
Ircn:ver:e :inu: {mc:IciciIi:), :upericr
:cgiIIc| :inu:
- Chrcnic :inu:iIi:
- Chrcnic inf|cmmcIcry ci:ec:e fcr week:, ce:piIe
cnIiLicIic:
- FecurrenI ccuIe LcuI: cf :inu:iIi:
- Chrcnic - pcIienI hc: nc pericc: wiIhcuI ci:ec:e

Sinu:iIi:: EmergenI Ccmp|iccIicn:
- Lccc| exIen:icn cf pcrcnc:c| :inu:iIi:
- Mc:I ccmmcn in ycung ccu|I:
- CcmmenI cn :inu:e: invc|vec
- ExIrc-:inu: exIen:icn inIc ceep fcce, fcrehecc,
cr cheek
- Check fcr inIrccrcnic| cL:ce::, eiIher
pcrenchymc|, cr epicurc| cr :uLcurc| empyemc
- MF reccmmencec fcr:
- Epicurc| exIen:icn
- CcrIicc| v., :upericr cphIhc|mic v. cr ccverncu: :inu: IhrcmLc:i:
- MeningiIi: cr cL:ce::

can occur into orbit as well
FrcnIc| Sinu:iIi:
Pots Puffy Tumor - invasion through the frontal sinus
Fcn:inu:iIi: - lncicenIc| C:Iecmc
Subperiosteal abscess
/cuIe FrcnIc| Sinu:iIi:
Subdural empyema
Sinu:iIi:
SuLperic:Iec| lnfecIicn
- Mc:I ccmmcn |ccc| ccmp|iccIicn
in chi|cren & ycung ccu|I:
- Sx:: Fre-:epIc| :we||ing, ci:chcrge
- Fc:I-:epIc| infecIicn Le:I ceIecIec
wiIh imcging
- CECI i: Ie:I cf chcice Ic exc|uce
pc:I-:epIc|, :uL-peric:Iec| cL:ce::
- Mcy hcve crLiIc| invc|vemenI
wiIhcuI ce:IrucIicn cf Lcny crLiIc|
wc||
this is 2/2 haversian canal
Sinu:iIi: - lnIrccrcnic| ExIen:icn
- NcnccnIrc:I :inu: CI ncI encugh
- Enhcncec CI cnc MF cre
inciccIec fcr ccmp|iccIec
:inu:iIi:
- lnIrccrcnic| infecIicn ccn cccur
wiIhcuI Lcne cefecI
- SuLcurc| cr epicurc| empyemc,
pcIienI u:uc||y :ick cuI cf
prcpcrIicn Ic :ize cf cc||ecIicn
- CcrIicc| vein IhrcmLc:i: mcy
re:u|I in pcrenchymc|
hemcrrhcge
Sinu:iIi: - lnIrccrcnic| /L:ce::
intracranial abscess - patient was not all that sick clinically!
Sinu:iIi: wiIh lnIrccrcnic| /L:ce::


- SuLcrcchncic hemcrrhcge
- G|ic| necp|c:m
- Meningicmc
- Cc||cic cy:I
- Hycrccephc|u:
- SuLcurc| hemcIcmc
- Necp|c:m:


Sinu:iIi: Mimic::
Aggressive sinus processes or intracranial lesions can
present clinically like simple bacterial sinusitis with nasal
stuffiness, minor epistaxis, pain
Carefully look at extra-sinus sites, for:
Fungc| Sinu: Di:ec:e - 2 Iype:
- /cuIe invc:ive
- lmmunc:uppre::ec
- /cuIe
- Fcin, fever, |ccc|
invc:icn
- Fcpic prcgre::icn
- Spcce: cnc :cfI Ii::ue:
:urrcuncing :inu:e:
cnc nc:c| ccviIy
infecIec > > :inu:e:
- /nIi-fungc| cgenI:
- Surgicc| ceLricemenI
- High mcrIc|iIy

- /||ergic fungc|
- lmmuneccmpeIenI
- C|inicc||y we||
- /:pirin inIc|ercnce
- Chrcnic
- Nc:c| cL:IrucIicn
- Encc:ccpic pc|yp
re:ecIicn
- High rcIe cf recurrence

- lmmune-ccmpeIenI, +/- ec:incphi|ic
- Chrcnic nc:c| cL:IrucIicn, recurrenI
:inu:iIi:"
- Cyc|e cf :inu:iIi:, mucc:c| ecemc,
pc|yp fcrmcIicn, c:Iic| :Ienc:i:,
:inu:iIi:, repecI
- Fc|yp:
- CI
- Fcn:inu:/nc:c| ccviIy
cpccificcIicn
- Expcncec cir|e:: :inu:e:
- Ihin cec::ifiec :inu: wc||:
- Sinu: ccnIenI: vcricL|e in cen:iIy,
mcy rcre|y Cc++
- Mixec |cw cnc high cen:iIy cn
ncnccnIrc:I CI

/||ergic Fungc| Sinu:iIi: wiIh Fc|yp:
{/FS-SNF)
These patients have constant nasal complaints
these get superinfected with the fungus
/FS-SNF
- MFl
- Ccmp|ex Sl
- Mcy Le cr cn I1
- VcricL|e cn I2, regicn: cf
frcnk :ignc| vcic
- I1 pc:I-gcc :hcw:
enhcncemenI cf mucc:c
LuI NCI :inu: ccnIenI:
- Mcrkec expcn:i|e ncIure
- FrcpIc:i:, eIc.
/||ergic Fungc| Sinu:iIi: wiIh Fc|yp:
{/FS-SNF)
Fungc| Sinu:iIi: - lnvc:ive
- lmmune ceficienI, i.e., cicLeIe:
- Ecr|y - ncn-:pecific pre:enIcIicn
- CI - ecr|y
- Minimc| :inu: mucc:c| ci:ec:e
- Nc:c| ccviIy :cfI Ii::ue cue Ic
mucc:c|, :epIc| cr IurLincIe
necrc:i:
- CI - |cIe
- Lccc| invc:icn
- FeIrccnIrc| fcI, ccnine
fc::c, cheek
- lnIrccrcnic|/crLiIc| :precc
- 8cne ce:IrucIicn
12hr later early extension out of the sinus
Fungc| Sinu:iIi: - lnvc:ive
- Mcy hcve crcmcIic
Sl cn I1 & I2
- HeIercgenecu:
enhcncemenI
pcIIern
- Lcck fcr exIen:icn
- Ccverncu: :inu:
- CrLiI
- lnIrccrcnic|
- Vc:cu|cr
ccmp|iccIicn: {lC/)
necrotic mucous is not going to enhance!
Muccce|e
- /ir|e::, expcncec
:inu:"
- Sinu: wc||: Ihinnec,
mcy cppecr
cehi:cenI
- F>E>M>S
- CI/MF :ignc|
inIen:iIy vcricL|e
- Ecr|y: Sl I1 Sl I2
- Mic: Sl I1 Sl I2
- LcIe: Sl I1 Sl I2
this makes the Dx - NOT the T1/T2 characteristics
b/c will be variable
Summcry
- Sinu: ceve|cpmenI cnc vcricnI:
- /ncIcmy, e:pecic||y fcr encc:ccpic
:inu: :urgery {ESS)
- lnfecIicn
- /cuIe
- Ccmp|iccIicn:
- Fungc|: invc:ive cnc ncn-invc:ive