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AJR Integrative Imaging


Imaging of Chronic and Exotic Sinonasal Disease: Review
Arash K. Momeni1, Catherine C. Roberts2, and Felix S. Chew3

Objective This review focuses on the anatomy, pathophysiology, mi-
Chronic sinusitis is one of the most commonly diagnosed crobiology, and diagnosis of sinonasal disease, including
illnesses in the United States. The educational objectives of chronic and fungal sinusitis, juvenile nasopharyngeal angio-
this review article are for the participant to exercise, self- fibroma, inverted papilloma, and chondrosarcoma.
assess, and improve his or her understanding of the imaging
evaluation of sinonasal disease. Anatomy and Pathophysiology
Understanding the normal anatomy and physiology of
Conclusion the paranasal sinuses is important to understanding the
This article describes the anatomy, pathophysiology, mi- pathogenesis of sinus disease. There are four pairs of sinuses
crobiology, and diagnosis of sinonasal disease, including named for the bones of the skull they pneumatize. They are
chronic and fungal sinusitis, juvenile nasopharyngeal angio- the maxillary, ethmoid, frontal, and sphenoid sinus air cells
fibroma, inverted papilloma, and chondrosarcoma. and they are lined by pseudostratified columnar epithelium-
bearing cilia. The mucosa contains goblet cells that secrete
Introduction mucus, which aids in trapping inhaled particles and debris.
Chronic sinusitis is one of the most commonly diagnosed The maxillary antrum consists of a roof, floor, and three
illnesses in the United States. It is estimated to affect more walls: the medial, anterior, and posterolateral. The roof and
than 30 million individuals and is increasing in incidence [1]. medial walls are shared with the orbit and nasal cavity, forming
The number of office visits and the annual expenditures on the orbital floor and lateral wall of the nose, respectively [3].
prescription medications for sinusitis rose from $50 million The cilia in the maxillary antrum propel the mucous stream in
to $200 million from 1989 to 1992 alone. In addition to the a starlike pattern from the floor toward the ostium, which is
economic impact, chronic sinusitis has a significant impact situated superomedially. From the ostium, mucus is swept su-
on quality of life. It can lead to significant physical and periorly through the infundibulum, which is located lateral to
functional impairment even when compared with chronic the uncinate process and medial to the inferomedial border of
debilitating diseases such as congestive heart failure and the orbit (Figs. 1 and 2). The uncinate process is a sickle-shaped
chronic obstructive pulmonary disease [2]. bone extension of the medial maxillary wall that extends an-
Sinusitis may be defined as an inflammatory process in- terosuperiorly to posteroinferiorly [4]. The uncinate process is
volving the mucous membranes of the paranasal sinuses or rarely pneumatized. The hiatus semilunaris, situated immedi-
the underlying bone. It is subdivided into acute, subacute, ately superior to the uncinate process, is a slitlike air-filled space
and chronic on the basis of the duration of symptoms [2]. anterior and inferior to the largest ethmoid air cell, the ethmoi-
Acute sinusitis is sudden in onset and may last up to 4 weeks. dal bulla. It is clinically significant because disease located here
Subacute is a continuum of the natural progression of acute results in obstruction of the ipsilateral maxillary antrum, ante-
sinusitis and lasts 4–12 weeks. Chronic disease is defined as rior and middle ethmoid air cells, and frontal sinus, whereas
inflammation of the mucosa of the paranasal sinuses and disease in the infundibulum results in isolated obstruction of
lasts for at least 12 consecutive weeks [2]. the ipsilateral maxillary sinus alone [5].

Keywords: chondrosarcoma, chronic sinusitis, CT, fungal sinusitis, inverted papilloma, juvenile nasopharyngeal angiofibroma, MRI
Received August 3, 2007; accepted after revision August 29, 2007.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force or
the Department of Defense.
Department of Radiology, David Grant Medical Center, Travis Air Force Base, Fairfield, CA.

Department of Radiology, Mayo Clinic College of Medicine, 5777 E Mayo Blvd., Phoenix, AZ 85054. Address correspondence to C. C. Roberts (

Department of Radiology, University of Washington, Seattle, WA.

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

AJR:189, December 2007 S35

but is usually complete by puberty. and middle meatus make up the ostiomeatal unit or os. but the septum is midline in only 25% of patients [7]. as well as middle crania fossa (M) and lamina papyracea (LP). Sinus excretions then pool and thicken. December 2007 . other organisms in the cause of chronic sinusitis remains tiomeatal complex include allergy. uncinate process recess. which is space between uncinate process and ethmoid bulla. They are anatomically divided into anterior. A and B. Still. The ethmoid bulla is the air cell directly superior and posterior to the infundibulum and hiatus semilunaris. because obstruction may result in maxillary. which lies above the superior nasal concha. and posterior groups according to the location of the draining ostia. The fron- (I). pneumatization. The ostiomeatal complex (Fig. Acute illness is classically caused by Hae- A B Fig. infundibu. pollutants [6]. discrete cells that may num- ber 18 or more. turbinates (T). leading to interfer- ence with the drainage of the maxillary and anterior ethmoid sinuses through the ostiomeatal complex [4]. is slow. The frontal sinuses drain inferomedially via the frontal Fig. the patency of which is criti. and air unidentified [8]. A large ethmoidal bulla can obstruct the infundibulum and hiatus semilunaris. At level of mid globe. inferior nasal turbinate sinus and the anterior part of the middle meatus. and nasopharynx (NP). Predisposing factors that induce local in. whereas the extramural invade the adjacent bones of the cranial vault or the face [3]. ethmoid (E) and sphenoid (S) sinus are visible. including each maxillary ostium (arrows). S36 AJR:189. maxillary (M) sinuses have adjacent nasolacrimal duct (NLD). The sphenoid sinus is usually sep- considered the underlying cause of most cases of sinusitis tate. directly into the middle meatus via the frontal recess. middle. is not uncommon [3]. and the pos- as the common drainage pathway of the frontal. ethmoid bulla (B). resulting in a permanent infantile appear- Obstruction of the ostiomeatal complex is commonly ance. uncinate process. maxillary. Pneumatization of the sphenoid sinuses and anterior ethmoid air cells. hiatus semilunaris. pterygo- palatine fossa (PtPF). Coronal unenhanced CT scan shows normal sinus anatomy. or Microbiology frontal disease. creating a nidus for superinfection. Noncontiguous axial unenhanced CT images show normal paranasal sinus anatomy. commonly. 1—39-year-old woman with headache. viral infections. ethmoidal. or less The entire complex of the maxillary ostium. Unlike in acute sinus disease. ethmoid bulla. fore draining to the middle meatus [4]. and infraorbital ethmoid cells or Haller cells (asterisks). At level of mid face. which is a space between the inferomedial frontal (arrowheads). 3) acts cess. into the superior ethmoidal infundibulum. Momeni et al. the exact role of bacteria or flammation of the sinonasal mucosa and occlude the os. 2—59-year-old woman with headache. middle nasal turbinate (M). infratemporal fossa (ITF). Mucosal swelling impairs mucociliary clear- ance and results in sinus ostia obstruction. The sphenoid sinuses drain into the sphenoethmoidal re- tiomeatal complex. Maxillary ostium enters tal sinus and the anterior ethmoid air cells together drain infundibulum. There are two primary types of cells: intramu- ral and extramural. The ethmoid sinuses are paired. terior ethmoid cells. The intramural cells remain confined to the ethmoid bone. failure of cal for normal sinus drainage and ventilation [4]. be- lum.

In the ostiomeatal unit pattern. CT is the imaging study of choice in both adult and pediatric patients [14]. CT has surpassed radiography in the evaluation process be- cause of its superior anatomic detail and. however. reformatted images are rods. it is the preferred study for the surgeon per- forming functional endoscopic sinus surgery (FESS) because mophilus or Streptococcus species. tion exposure [17]. work artifacts. the frontal and ethmoid sinuses are pre- The location of the facial pain and pressure may also served. however. polymicrobial infections are more common in pa. maxillary sinus. Chronic and Exotic Sinonasal Disease experienced in the forehead. the recovered images from axial scans are as diagnostic as images acquired in organisms included Staphylococcus aureus. The offending organisms of The characteristic findings of sinus disease include air–fluid polymicrobial disease include anaerobic bacteria. which often coexists with chronic sinusitis. CT can differentiate pathologic varia- tions and show anatomic structures that are inaccessible by physical examination or endoscopy. and levels. Graphic modified with permission from Mayo Foundation for Education and Research. Ethmoiditis may present with tenderness over the medial canthal region. sphenoethmoidal recess. The most common present. whereas pain due to frontal sinusitis is usually lent results in most cases. According to Sonkens et al. os- for at least 12 consecutive weeks. aerated sinus lumen. In the infundibular pattern. ing is common to both acute and chronic sinusitis. on the duration of symptoms: acute disease is sudden in on. The real distinction is based itis (mycetoma). 13]. If an MDCT scan- study of 94 cases of endoscopically guided ethmoid sinus ner acquiring near isotropic voxels is used. Location CT images most closely correlate with the surgical approach of anterior ethmoid artery (A) is important in endoscopic sinus surgery. Chronic sinusitis often develops secondary to acute disease thickened bone of the sinus wall [18] (Fig. Therefore. coronal reformatted cultures from 50 adults with chronic sinusitis. chronic sinusitis symptoms include facial pressure. headache. The primary role of CT is to aid in the diagnosis and man- agement of recurrent and chronic disease and to define the anatomy before surgery. Strepto. and sporadic (unclassifiable). chronic disease coronal images simulate the appearance of the sinonasal cavity may result from a number of disparate organisms. Coronal cociliary clearance. The two primary diagnostic imaging techniques for eval- uating the paranasal sinuses are CT and MRI. The use of a bone algorithm pro- vides excellent resolution of the complete ostiomeatal complex Fig. my is the therapeutic method of choice and produces excel- per teeth. The single distinguishing feature of acute sinusitis is the air–fluid level as an isolated finding. mucosal thickening. AJR:189. whereas the Chronic Sinusitis only characteristic finding in chronic sinusitis is sclerotic. 4). sinonasal polyposis ing symptoms for acute sinusitis include fever and toxicity. Potential areas of obstruction are denoted with X. and other anatomic factors that play a role in sinusitis. few signs or symp. CT is the technique of choice in the preoperative evaluation of the nose and paranasal sinuses and is the gold standard for delineation of inflammatory sinus disease result- ing from obstruction [15]. Haemophilus influenzae. Infundibuloto- disease typically causes cheek discomfort or pain in the up. fungi. The differ- toms reliably differentiate acute from chronic disease because ential diagnosis of sinus wall thickening includes fungal sinus- they present in a similar fashion. tients with chronic sinusitis. and Corynebacterium diphtheriae [9]. and fatigue. polypoid lesions. Arrows show direction of mu. postnasal drip. and Haller cells. and opacification of the normally Pseudomonas aeruginosa [10]. Maxillary mucosa. Clinically. tiomeatal unit. pain from sphe- noid sinus involvement is often retroorbital. but may radi- ate to the occipital and vertex regions [11]. whereas chronic disease lasts of inflammatory paranasal sinus disease: infundibular. preferable to direct coronal images because of decreased dental coccus pneumoniae. [16]. and decreased radia- Moreover. when a lower mA protocol is used. Radiography was once the most commonly ordered study. disease is limited to the infundibulum and the adjacent nasal obstruction. 3—Anterior drawing of ostiomeatal complex. Mucosal thicken- that is refractory to treatment. limited patient mobility. December 2007 S37 . In some cases. [19]. group A streptococci. In a from the perspective of the endoscope [4]. Pathophysiologic causes for this pattern are swollen help localize the infection to a particular sinus. It is the method of choice for defining the complex sinus anatomy because of its 3D high resolution. a radiation dose similar to a standard four- view radiographic series [12. gram-negative the direct coronal plane. there are five patterns set and may last up to 4 weeks.

Hahnel et al. medial (arrows) and mucosal thickening causing near-complete opacification of sinus. and sphenoethmoidal re. respectively) and lateral maxillary wall (arrowhead) appear as nor- es. a deviated septum. tions. Obstruction of the sinuses. in tage of avoiding radiation exposure to patients. The in- bone structures have low signal intensity. Thus. December 2007 . 4—80-year-old woman with chronic sinusitis. Unenhanced coronal CT Fig. success in patients with inflammatory disease. when evaluating the consistency of peanut butter or cottage cheese. as are middle (M) and inferior (I) turbinates. and in patients with dental tal sinuses are involved. usu- that CT is superior to MRI in the preoperative planning of ally due to local lesions such as nasal polyps. In the sinonasal polyposis pattern. py [24]. is of particular interest to the otorhinolaryngologist lergic and invasive fungal sinusitis. in the diagnosis of compli- terior and middle ethmoid cells and the maxillary and fron. combination with ethmoid bullectomy. the sphenoid sinus and sinuses. In effect. polypoid lesions fill the nasal Fungal Sinusitis cavity and the sinuses bilaterally. this is a mixture Fungal sinusitis encompasses a wide variety of infec- of infundibular. mal low-signal linear structures. making them diffi. The two primary forms of fungal disease with the The extent of disease. accumulations of intact and degenerating eosinophils. the middle meatus of the nasal cavity and the adjacent an. Therefore. 5). tissue surrounding infundibulum (asterisk) is well delineated. and there may be reten. [20] concluded alized without fungal stains. accentuated by adjacent high-signal fat. Charcot- In their comparison of CT and MRI in the evaluation of Leyden crystals. FESS. and nasal tumor. Intrasinus anatomy is distorted from prior bilateral antrostomies and eth. With MRI. and inferior. volved sinuses contain brown or greenish-black material with cult to completely assess (Fig. 5—64-year-old man with history of sinus disease. ostiomeatal unit. It should cess patterns. has intractable symptoms despite adequate bacterial thera- tion cysts. In the sporadic (unclassifiable) pattern. thus. it is critical to Allergic Fungal Sinusitis identify the technique of choice for preoperative screening Allergic fungal sinusitis is a benign. CT is superior to MRI for the delineation of caused by a hypersensitivity reaction to fungi in the sinuses. planning therapeutic intervention. The lev. and postsurgical changes. orbital floor. Moreover. polypoid lesion. MRI is superior to CT [20. noninvasive disease and evaluation. vide an environment conducive for fungal growth [24]. However. MRI might be used to assess therapeutic pattern are swollen mucosa. Soft moidectomies. Therefore. MRI may be used as a primary diagnostic or inflamed mucosa from chronic sinusitis. Coronal T1-weighted MR scan shows extensive chronic thickening and sclerosis of maxillary sinus walls image shows normal low signal of bone. extent of the disease does not appear to be related to the particularly when the patient is immunocompromised or known mucous drainage patterns. mucoceles. This mate- for orbital or intracranial complications of sinus disease or rial has been called “allergic mucin” and contains laminated surgical intervention. and sparse hyphae rarely visu- inflammatory paranasal disease. is often required. Orbital lamina and floor (arrows. concha bullo. Fig. cellular debris. from relatively innocuous to rapidly fatal. the fine bone structures of the infundibular complex. most patients with allergic superior to MRI in planning FESS [21]. cations of sinus infection or FESS. Momeni et al. with the advan- sa. orbital The immune response is predominantly an IgE-mediated type lamina. the be considered in any patient with chronic inflammation. with its main limitations being a decreased ability to the ipsilateral posterior ethmoid cells are involved. these fungal sinusitis have a history of atopy or asthma. Infundibulotomy. according to one of the patterns associated imaging characteristics reviewed here include al- above. delineate bone detail and its higher cost [19]. 23]. However. septal deviation. In MRI is an alternative to CT in the evaluation of the paranasal the sphenoethmoidal recess pattern. el of obstruction is in the sphenoethmoidal recess. Pathophysiologic causes for this implants. is required to pro- instrument in screening for foci of septic disease before im. and cribriform lamina [20]. 22. CT is I hypersensitivity reaction. plantation of organs or prostheses. S38 AJR:189.

The shape and location of calcification in attributable to invasion by fungi that have colonized the nonfungal cases are different from those of fungal sinusitis. Bipo. poid soft-tissue mass with bone remodeling also includes pathologic visualization of fungal invasion by biopsy of the sinonasal polyposis. epistaxis. including Curvularia. round. marginated. the signal in- recent treatment with immunosuppressive drugs [24]. The most common causes of im. blood vessels. Other noteworthy Aspergillus. Calcifications (arrows) are centrally located in maxillary sinus. Calcification may occur with other pathologic processes. Complete opacification with expansion. Many patients Calcification in fungal cases is primarily centrally located in with invasive fungal sinusitis have a history of chronic si. Chronic and Exotic Sinonasal Disease The most common causative agents of allergic fungal si. or features of allergic fungal sinusitis. fulminant disease with fever. are characterized on CT by in- cally confirmed sinusitis. the anomalies are reported with equal frequency in maxillary sinus (Fig. Invasive fungal sinusitis primarily occurs in immunosup. soft tissue or bone destruction in the case of invasive fungal gestion. and Pseudallescheria species. and the hyaline molds. and MRI may show suggestions of fungal sinusitis. December 2007 S39 . sinuses or to inhalation of fungal spores. but it is un- munosuppression in patients with invasive fungal sinusitis common in nonfungal inflammatory sinonasal disease [26]. or diabetes mellitus [24]. Although not sufficiently sensitive or spe- nusitis are the pigmented fungi. absence volvement. 6). nasal con. and neoplasms. Intrasi- nus calcification on CT is also characteristic of fungal sinus- Invasive Fungal Sinusitis itis. including radiologi. the presence of mucin in a sinus. like allergic fungal sinusitis. such as Aspergillus and Fusarium organisms. immunodeficiency disease. Fusarium. Although some have anatomic abnormalities of the nonfungal cases is usually peripheral. Aspergillus species are responsible for increased density in the sinus. such pressed individuals [23]. or remodeling and thinning of the sinuses are characteristic and the absence of diabetes. AJR:189. imaging techniques such as CT laris. and changes in vision or mentation as sinusitis. Ab. Fine punctuate calcification has the asymptomatic population. facial pain. involved areas. features aid in the diagnostic evaluation. or eggshell calcification has been found gal colonization [25]. a focal mass with sive disease [24]. mucoceles. lus species. creased attenuation in the sinuses and frequent bilateral in- visualization of fungal hyphae in the allergic mucin. Smoothly marginated. whether the anatomic variants predispose patients to fun. 7—23-year-old woman with history of multiple episodes of acute sinusitis. 6—74-year-old man with diabetes and sinus infection caused by Aspergil. making it controversial as to been identified only in fungal sinusitis. Fig. Diagnosis depends on histo. However. include hematologic malignancies. or bone. Intrasinus calcification on CT with aspergillosis is a char- row transplantation. chemotherapy-induced neutropenia. as bacterial sinusitis. Five clinical Benign fungal infections secondary to Aspergillus species. The differential diagnosis of an intrasinus poly- common clinical complaints. nus wall (as is seen in chronic sinusitis). sinonasal non-Hodgkin’s lymphoma. although smooth. whereas the calcification in nusitis. peripherally located calcification (arrow) is typical of normal soft tissue extends through medial wall of maxillary sinus and enters left nonfungal disease. erosion. of fungal invasion of the submucosa. side of nasal cavity (arrowheads). Infection may be 77% of cases [27]. near the wall of the sinuses. particularly that caused by Aspergillus species. and Zygomycetes organisms and CT features of fungal sinusitis include bone change of a si- pigmented molds are most often implicated in cases of inva. Fig. solid organ or bone mar. 7). tensity on T2-weighted sequences is usually low [4]. the maxillary antrum (Fig. exclusively with nonfungal disease [28]. and infiltration of adjacent acute. acteristic feature of fungal sinusitis and is present in 69– advanced AIDS. cific to confirm diagnosis.

pterygoid process. Coronal reformatted CT (A). A–C. Momeni et al. unenhanced T1-weighted MR (B). MRI sinuses. gillosis or mucormycosis because of its ability to identify Invasive fungal infections have a propensity for orbital. orbit. Invasive fungal plays a vital role in the diagnostic evaluation of patients sinusitis is typically hyperdense on CT and hypointense on A B Fig. December 2007 . the spread of mycotic infections from the turbinates to the cavernous sinus. C S40 AJR:189. pterygopalatine fossa. and non- contiguous enhanced T1-weighted MR (C) images show large heterogeneously enhancing mass (arrows) in posterior nasopharynx that involves sphenoid si- nus. and Wegener’s granulomatosis. and intracranial cavity [28]. and middle cranial fossa. 8—19-year-old man with juvenile nasopharyngeal angiofibroma who pre- sented with epistaxis. all of which can be difficult with aggressive fulminant fungal sinus infections by asper- to differentiate with imaging alone. and neurovascular structure invasion.

C. A and B. C AJR:189. December 2007 S41 . Early arterial phase right IMA angiogram after embolization shows marked reduction of vascularity (arrowhead). Chronic and Exotic Sinonasal Disease A B Fig. Early (A) and late (B) anteroposterior arterial phase right internal max- illary artery (IMA) injection angiograms before embolization show marked vas- cularity of juvenile nasopharyngeal angiofibroma (arrow). 9—19-year-old man with juvenile nasopharyngeal angiofibroma who pre- sented with epistaxis.

but they chose CT because it depicts the close inter- actions between the bone anatomy and residual disease bet- ter than MRI and provides good soft-tissue definition. in men than in women. most postoperative paranasal sinuses shows complete opacification of right maxillary sinus and ab- normal soft tissue extending through infundibulum on right into right nasal cavity imaging studies take place between 6 weeks and 6 months (arrows). They arise from the fibrovascular stroma of counting for only 0. The diagnosis cal and imaging enhancements. Preopera- tions of the maxillary sinuses. Inverted papillomas can be associated with malignancy. The arterial supply of juvenile nasopharyngeal angiofi- rhinorrhea. They state the choice between contrast- enhanced CT and MRI to identify residual disease is open to debate. and stage IV. the base of the pterygoids and clivus. Immediate detection of this complication can lead to management of persistent disease. Early detec- tion of residual disease may allow treatment and recurrence reduction. Contrast-enhanced CT and MRI are valuable in the eval- Because an increased association with squamous cell carci- uation of juvenile nasopharyngeal angiofibroma. lim- for this lesion because life-threatening hemorrhage may re- ited to the ethmoid sinuses and the medial and superior por- sult if a limited resection or biopsy is attempted. The location of residual disease may be cor- related with certain extension paths of juvenile nasopha- ryngeal angiofibroma in the skull base. S42 AJR:189. Momeni et al.4–4. limited to the nasal cavity alone. 8) and invades the verted papillomas. 30]. such as the sphenoid sinus. spread facilitate a more complete and uncomplicated surgical re- outside the nose and sinuses [4]. but it constitutes only 0. Juvenile nasopharyngeal angiofibroma en- papillomas are benign epithelial neoplasms that classically hances markedly with contrast-enhanced CT. December 2007 . stage III. sive revision surgery may remove the residual disease in most instances.7% of all sinonasal tumors [33]. A mean recurrence sion with histologic changes summarized as patchy severe rate as high as 40–50% in cases of skull base invasion has squamous metaplasia on polypoid protuberances of nasal been reported [31]. and carcinomas. These are locally Inverted Papilloma aggressive benign tumors that classically present in adolescent Nasal papillomas are uncommon benign neoplasms. especially when the juvenile nasopharyngeal Grossly inverted papillomas appear as a mucosal polypoid le- angiofibroma involves the skull base. CT appearance is nonspecific and could represent polyposis or inverted after surgery to identify tumors. but not to initiate early papilloma. The Recurrence of juvenile nasopharyngeal angiofibroma is typically due to the growth of residual disease. Proposed staging classification in- branches. Middle meatal antrostomy has been performed on left (asterisk). high recurrence rates have is made by histologic examination of biopsy specimens. anosmia. Coronal CT scan of ous sinus and anterior fossa. Because minimally inva- life. 10—50-year-old man with intractable nasal congestion. germ cell tumors. cylindric. with sur- noma exists. benign tumor arising from the nasopharynx. nasal obstruction. broma can arise from internal or external carotid artery and frontal headache [33]. with inverted papillomas accounting for pterygopalatine fossa where it bows the posterior wall of the max- approximately 47% of all nasal papillomas [32]. been reported. 9) may reduce sur- lateral or inferior aspects of the maxillary sinuses or exten- gical blood loss and improve the surgical field of view to sion into the frontal or sphenoid sinuses. To date. extension to the tive angiography and embolization (Fig.5% of all head and neck neoplasms [29].or orbit-saving therapy [4]. stage II. mucosa and submucosa and in related ductal epithelium. sinusitis. [31] investigated the diagnostic ac- curacy of contrast-enhanced CT to detect residual disease immediately after surgical excision of juvenile nasopharyn- geal angiofibroma. section [5. The results of Kania et al. differentiating it arise from the lateral nasal wall or maxillary sinus and have from the more rare lymphangioma and from encephaloceles. and the cavern. ac- boys with epistaxis. rhabdomyosarcomas. The mass three most distinct forms are fungiform. Fig. it is recommended that inverted papillomas be gical resection being the standard treatment. Kania et al. MRI. and in- characteristically fills the nasopharynx (Fig. It is important to have a high clinical suspicion cludes stage I. Oth- significant malignant potential. They most often affect pa- er masses that can be found in this location include hypervascular tients 40–70 years old and occur two to four times more often polyps. postoperative imaging may be a novel ap- Juvenile Nasopharyngeal Angiofibroma proach in the evaluation process and may help reduce the Juvenile nasopharyngeal angiofibroma is the most common recurrence rate of juvenile nasopharyngeal angiofibroma. The the nasal wall adjacent to the sphenopalatine foramen. facial pain. Inverted illary sinus anteriorly. [31] indicate that contrast- enhanced CT enables early detection of residual disease in the early postoperative stage after lesion excision involving the skull base. Despite surgi- surgically resected with wide mucosal margins. The common symptoms are epistaxis.

in roughly 50% of cases. They can erode the skull base similar in both signal intensity and enhancement. tively predict the diagnosis. Inverted papillomas enhance (Fig. Nasal carcino. might otherwise go unappreciated and greatly alter the sur- the lesion is isodense to muscle on T1-weighted images (Fig. antrochoa. may be distinguished from postoperative thickening by dy- A B Fig. because signal intensity characteris- briform pattern on T2-weighted sequences or enhanced T1. Recurrences bone. MRI reveal- 11A) and isointense to hypointense on T2-weighted images. CT may show a nonspecific mass sociated malignancy. the lesions are heterogeneous the anterior cranial fossa. even when the preoperative biopsy centered in the middle meatus with associated bone remodel. with biopsy-proven inverted papilloma can help warn the Diagnostic imaging may help identify an inverted papillo. 11B) destruction because they may cross the cribriform plate into and. The diagnosis is evident in only approximately be on the lookout for signs of locally invasive disease that 20% of cases when CT contains stippled calcium. the recurrence rate is 20–40%. Chronic and Exotic Sinonasal Disease polypoid protuberances are possibly formed by invagination The morphology of a sinonasal mass on MRI in a patient of surface mucosa in polyps [34]. ing a typical convoluted cerebriform pattern can have small Most other polypoid masses (sinonasal polyposis. foci of in situ squamous cell carcinoma [33]. as is seen with inverted papillomas. A convoluted cere. gical approach when a necrotic mass is present. A. surrounded by more intensely enhancing mucosa. December 2007 S43 . Coronal T1-weighted gadolinium-enhanced MR image highlights mildly enhancing mass (arrow). Radiologists should ing (Fig. there is no way to preopera- weighted sequences is typical of inverted papillomas [4. Inverted papillomas can show an aggressive pattern of bone weighted sequences. tics overlap those of malignancies. B. On MRI. identifies only an inverted papilloma. 33]. despite ag- mas are more likely to destroy bone rather than remodel gressive operations. AJR:189. Unfortunately. Coronal T1-weighted MR image shows mass (arrow) in posterior nasopharynx with signal intensity similar to that of muscle. nal polyp) have high homogeneous signal intensity on T2. 10). to aggressive cancers and. Central ne- ma when a sinonasal mass with polypoid morphology arises crosis in a sinonasal tumor requires consideration of an as- on the lateral nasal wall. surgeon of a probable associated malignancy. The lesion is especially problem- Juvenile nasopharyngeal angiofibromas tend to be located in atic for surgeons who treat the condition as if it were malignant the posterior nasal cavity of younger patients. by an aggressive surgical approach. 11—45-year-old-man with inverted papilloma.

dysphagia. Paget’s disease and fibrous dysplasia [35]. orbit. sarcoma. and leukemia. deviation from the convoluted pat. 38]. fibro. In part because of pterygopalatine fossae. and sensory particularly in the region of the cribriform plate. ing of the cheek. or necrosis. When inverted papilloma is the biopsy bone invasion and destruction (Fig. Fig. agement of chondrosarcoma [36]. axial CT scan shows irregularly enhancing mass in sinus (black arrows). normal tissue can be achieved with greater than 98% accu- Craniofacial chondrosarcoma most commonly presents as racy using CT and MRI [36]. With T1-weighted sequences. cause of localized ossification. craniofacial chondrosarcoma appears as a lobu- quences or enhanced T1-weighted sequences is typical of in. Most cranio. plaints of impaired vision. December 2007 . the administration of gadolinium results in curvilinear sep- Chondrosarcoma tal enhancement of the fibrovascular tissues in chondrosar- Chondrosarcomas are uncommon malignant neoplasms of coma tumors. Distant facial chondrosarcomas occur in patients younger than 40 metastasis is rare and most often involves the lung. 12). thereby allowing differentiation of tumor from surrounding normalities. Coronal CT Fig. with com. and dental ab. tilage. tion of nasal septum (arrows). years and have been reported to develop in association with radionuclide bone scanning plays a limited role in the man- malignant tumors such as osteosarcoma. Intracranial extension is seen along right cavernous sinus (arrowhead) and right cerebellopontine angle (white arrow). The unenhanced areas consist mostly of car- cartilaginous or osseous origin that account for approximate. epidemiologic risk factors are poorly defined. The signal density result of a sinonasal mass. Enhanced scan of sinuses shows mass with irregular calcification destroying central por. due to immobile protons [37. with less than 10% occurring in the craniofacial region [35]. as well as benign conditions such as hancement than granulation tissue [4]. lated mass containing an irregular chondroid matrix with verted papillomas [4]. tissues or edema. mucoid tissue. nasal obstruction. recurrences have earlier and greater en. therefore. Intracra- its rarity. headaches. CT is superior in revealing bone erosion. monitoring tumor recurrence and soft-tissue visualization. The chondroid matrix has ly 11–25% of all primary sarcomatous neoplasms of bone high signal on T2-weighted sequences because of higher and are most commonly found in the long bones and pelvis. 12—65-year-old-man with chondrosarcoma of nasal septum. Convoluted cerebriform high signal on T2-weighted se. ter the administration of contrast material (Fig. namic enhanced MRI.2:1 [36]. The nial extension can also be detected as dural enhancement af- male-to-female ratio is approximately 1. In more rare cases it may also present with swell. melanoma. Delineation of chondrosarcoma boundaries relative to making craniofacial chondrosarcoma a rare disease entity. of the chondroid matrix is less than that of the bone ma- tern strongly suggests an alternative diagnosis of concomitant trix. shoulder. whereas the ossified regions have low signal They account for less than 2% of all head and neck tumors. alterations in the neck. and arm. On CT. although regions of bone density may be observed be- inverted papilloma and squamous cell carcinoma [33]. water content. Momeni et al. and infratemporal fossae. MRI is the best technique for a painless mass that progresses to symptomatic. S44 AJR:189. 13—61-year-old-man with chondrosarcoma of sphenoid sinus. 13).

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