Objective

Paranasal sinuses
Neck
Normal Radiographic Anatomy
Common diseases
Sinusitis
Upper airway obstruction

Paranasal Sinuses
PNSs

PNSs
PNSs are hallow airfills sac line by
mucosa;
Pseudostratified columnar
ciliated epithelium (both
mucinous & serous gland)

Ethmoid and Maxillary

sinus are present at
birth.
Frontal sinus: 2nd year
Sphenoid sinus: 3rd
year
Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

PNSs
Four pairs of PNSs
Frontal sinuses
Maxillary sinuses
Ethmoid sinuses
Sphenoid sinuses

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

PNSs
PNSs have small
orifices (ostia), open
into recesses (meatus)
of nasal cavities.
Meati covered by
turbinates (conchae)
Meatus: air space beneath each
conchae

3 Turbinate & 3 Meati

in each nasal cavity
Superior - Middle - Inferior

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Imaging Modality
Plain films
Initial Diagnosis or follow up study
Three standard views:
Caldwell view
Water view
Lateral view

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Imaging Modality
Screening Coronal sinus CT
Pre-op For FESS

Full sinus CT with contrast

enhancement

Complex inflammatory disease

Extensive polyposis
Suspected osteomyelitis
Persistent symptom after sinus Sx

Benign or malignant tumor

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Imaging Modality
Magnetic Resonance Imaging
(MRI)
Severe complication

Orbital abscess or cellulitis

Intracranial complication
Brain abscess
Subdural empyema

Staging of malignant tumor of sinus

with deep tissue extension

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Plain Radiography

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Caldwell view

Best for frontal and ethmoid

sinuses
Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Caldwell view
Frontal sinus:
Density < Orbit

Crista galli

Frontal sinus

Ethmoid sinus
Density = air in
inf. Turbinate

Normal Anatomy

Imaging Modality

Ethmoid
sinus

Interpreration

Lamina papyracea

Sinusitis

Water view

(Occipitomeatal view)

Best For Maxillary sinuses and Facial bone

Orbits, frontal sinuses, nasal bone

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Water view

(Occipitomeatal view)
Frontal sinus

Orbital roof
Anterior ethmoid sinus
Infraorbital
Foramen

Maxillary sinus

Sphenoid sinus
Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Water view

(Occipitomeatal view)

Anterior ethmoid sinus

Maxillary sinus

Sphenoid sinus
Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Lateral view

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Lateral view
Frontal sinus

Roof and
floor of orbit

Sphenoid sinus

Maxillary sinus

Hard Palate

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Interpretation
Shape and Size

Frontal, ethmoid, sphenoid, maxilla,

nasal cavity (symmetry, septum
center)

Pneumatization
Radiolucency
Sinus clouding
Air fluid level

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Interpretation
Contour

Smooth and sharp

Contour defect
Cortical thickening
Expansion

Others

Facial skeleton, orbits

Soft tissue (FB, calcification,
swelling)

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Sinusitis
Inflammatory process of PNSs
Complication of URI in children (510%)
Maxillary & ethmoid sinuses are
frequently involved

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Sinusitis
Usually follows rhinitis; viral or
allergic
May result from abrupt pressure
changes (air plane, diving) or dental
extraction or infections

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Sinusitis
Inflammation of the linings of the
sinuses and cavities of the nose
The ostia from PNSs to the nose are blocked
Small hairs (cilia) in PNSs that help move the
normally produced mucous out are not working
Too much mucous is produced, often simply a result
of inflammation

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Acute Sinusitis
1 day 4 weeks
Sinus opacification
Bony sinus wall unaffect
Mucosal thickening
paralleling the bony wall
Air-fluid level

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Acute Sinusitis

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Chronic Sinusitis
8-12 wks
Irregular mucosal
thickening
Sinus opacification;
mucosal thickening
or cyst or polyps
Bone change: loss of
mucoperiosteal line

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Chronic Sinusitis

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Imaging Modality
Plain Radiography: Soft tissue
technique
Initial evaluation of soft tissue neck
Define anatomy
Detect Radio-opaque FB

Imaging Modality
Barium swallow

Anatomic & dynamic

assessment of upper
aerodigestive tract
Dysphagia/odynophagia
Traumatic or iatrogenic
perforations & postoperative
fistulae
Look for second primary tumor
in pt with SCCA of upper
aerodigestive tract

Imaging Modality
CT of the neck with IV contrast
Abscess
Mass/ tumor

MRI

Tumor

Normal Anatomy

Normal Anatomy
Nasopharynx
Oropharynx

Hypopharynx

Adenoid
Oral Cavity

Soft Palate

Epiglottis
Hyoid B.
Cricoid Cartilage

Aryepiglottic fold
Laryngeal Ventricle

Esophagus
Trachea

How thick of retropharyngeal soft

tissue is considered abnormal ?

Lateral neck soft tissue

Normal thickness
At C2-3 levels
Less than 7 mm or 1/2 of AP diameter of vertebral
body

At C4-7 levels

Less than 14 mm (children) 20-21 mm (adults) or

less than AP diamter of C6 vertebral body

Is there any false bulging of

Retropharyngeal soft tissue

Expiration
Neck flexion

Upper Airway Obstruction

Pharynx: Tonsils & Adenoid gland
hyperplasia, Retropharyngeal abscess
Larynx: Croup, Epiglottitis
Trachea: Congenital stenosis,
extrinsic compression
Others: Ingest/Aspirate FB

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Foreign body
Plain Radiography is the first imaging
modality for foreign body detection in
suspicious cases
Best detected radio-opaque foreign
body
If negative plain radiography
Esophagogram
or CT

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Foreign body
Common locations:
Cricopharyngeus muscle 70%
Aortic arch 20%
EG junction 10%

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Adenoid/Tonsils Hyperplasia
Lymphoid tissue of Waldeyers
ring (adenoid, palatine tonsils,
lingual tonsils)
Adenoid: soft tissue in posterior
nasopharynx
Leading cause of Obstructive
Sleep Apnea (OSA) in children
Found in 3-6 yr, absent in adult
Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Adenoid/Tonsils Hyperplasia
Enlarged Adenoid
Age dependent
Rarely visible < 6 months
Rapid proliferation during infancy
Peak 2-10 yrs
Size decreased during 2nd decade
Upper limit of normal: 12 mm

Enlarged tonsils

Prominent soft tissue mass overlying posterior

inferior soft palate

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Retropharyngeal
Space
Along
anterior
prevertebral
space
From base
of the skull
to carina

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Retropharyngeal Abscess
Receive Lymphatic drainage from
nasopharynx, adenoid and posterior
nasal sinus
causes secondary
infection
Common in < 6 yr (50%; 6-12Mo)

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Retropharyngeal Abscess

Normal Retropharyngeal soft

tissue thickness
Impact FB

Adenoid/Tonsils

Normal Step off at junction between

posterior pharyngeal wall & posterior
tracheal wall

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Acute Epiglottitis
Serious causes of common upper
airway obstruction in children 3-7
yrs
Causes: Bacterial infection
Most common Haemophilus influenzae type B

Classical triad

Drooling, Dysphagia, Respiratory distress

Abnormal inflammation and epiglottis &
aryepiglottic fold edema
Stridor
Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Acute Epiglottitis
Lateral film of neck: Upright
position
Enlargement of epiglottis.
Classic thumb printing sign

Thickening of aryepiglottic folds (AE

folds)
Others:
25% Circumferential narrowing at subglottic
trachea on inspiration
Ballooning of hypopharynx & pyriform sinuses

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Thumb printing sign

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Swollen epiglottis

Impact FB

Adenoid/Tonsils

Endoscopic view

Retroph Abscess

Epiglotitis

Croup

Croup
Croup or Laryngotracheobronchitis
Most common cause of acute stridor
in children
Common 6 Mo - 2 yrs.
Viral infection
Clinical diagnosis

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Croup
Plain film:
Exclude other condition: FB, angioneurotic
edema, epiglottitis or subglottic stenosis

AP & Lateral film of neck

Subglottic edema with subglottic space stenosis
Symmetric subglottic narrowing Steeple sign
Distension of hypopharynx and laryngeal ventricle
Normal Epiglottis

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Dilated hypopharynx (star) & laryngeal ventricle (blue arrow) and subglottic tracheal stenosis (yellow arrow)
Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Classic steeple sign: uniform narrowing of the subglottic airway

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup

Conclusion
PNSs
Plain film: Water, Caldwell, Lateral
Sinusitis
Acute sinusitis: Air-fluid levels, mucosal
thickening, sinus opacification
Chronic sinusitis: Associated bone change

Normal Anatomy

Imaging Modality

Interpreration

Sinusitis

Conclusion
Neck: Upper airway obstruction
Foreign body impaction
Adenoid/tonsil hyperplasia
Retropharyngeal abscess
Epiglottistis
Croup

Impact FB

Adenoid/Tonsils

Retroph Abscess

Epiglotitis

Croup