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Sinonasal imaging

Article  in  Imaging · March 2007

DOI: 10.1259/imaging/

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Imaging, 19 (2007), 39–54

Sinonasal imaging
1,3 2
S E J CONNOR, MRCP, FRCR, S HUSSAIN, MRCS, FRCR and 3E K-F WOO, MRCP, FRCR

1
Neuroradiology Department, King’s College Hospital NHS Foundation Trust, Denmark Hill, London
SE5 9RS, 2Department of Clinical Radiology, University College London Hospitals NHS Foundation
Trust and 3Radiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Summary
N CT is the initial imaging of choice for patients with symptoms of inflammatory
paranasal sinus disease.
N The aim of imaging the paranasal sinuses is to confirm diagnosis, localize the
disease, characterize the extent of pathology and describe any anatomical
variations.
N An understanding of the anatomy is important for surgical planning and some
normal variants can impair functional drainage pathways.
N As well as imaging findings in acute and chronic rhinosinusitis, there are five
patterns of inflammatory disease. This classification helps the surgeon to elucidate
whether surgery has a role and the type of surgery to perform.
N Beware of mimics of inflammatory disease such as tumours, odontogenic disease
and cephalocoeles.
N A wide variety of neoplasms, both benign and malignant, may arise in the
sinonasal cavity. Use the pattern of bony modelling to help distinguish aggressive
and non aggressive masses. DOI: 10.1259/imaging/
N MRI is complementary to CT. T2 weighted imaging is used for differentiating 52620519
tumour and inflammatory mucosal secretions. Orbital, infratemporal, intracranial
and perineural spread of disease is important. ’ 2007 The British Institute of
Radiology

Abstract. The purpose of imaging the paranasal sinuses is to
confirm diagnosis, localize the disease, characterize the extent
of pathology and describe any anatomical variations. In this
review article, we aim to demonstrate the complex anatomy, its
variations and the appropriate imaging techniques. We will
describe and illustrate the wide spectrum of disorders affecting
the paranasal region and provide useful imaging features
which are important for surgical planning and aid the
differential diagnosis of sinonasal abnormality.
Imaging techniques
CT is routinely used for pre-operative planning prior
to functional endoscopic sinus surgery (FESS) or in
patients with persisting symptoms post sinonasal sur-
gery. It is also used to evaluate for the likelihood of sinus
pathology being the basis of more non-specific symp-
toms such as facial pain. Rarer indications include the
evaluation of CSF rhinorrhea. It delineates the bony
anatomy, extent of sinus disease, obstruction of drainage
pathways and it serves as a road map for surgical
planning. CT is far superior to plain radiography in
terms of diagnostic accuracy and anatomic definition [1].
Radiographs are occasionally used to distinguish
between rhinitis and acute rhinosinusitis to decide on
the appropriateness of antibiotic therapy. With the
advent of multidetector CT, multiplanar reformats can
provide further insights into sinonasal anatomy and the
extent of pathology, whilst shortening the scan time.
Multidetector CT is acquired axially which avoids the
obscuration of anatomy by dental restoration.
Submillimetric slices are reconstructed. Any reversible
disease should ideally be treated with antibiotics and
steroids prior to imaging. Low dose CT techniques
should be employed and imaging should be reviewed
with a wide window width of 1500–2500 HU centred at
100–400 HU. Whenever soft tissue abnormality is
detected, its attenuation should be assessed with narrow
window widths and the perisinus soft tissues should be
studied, particularly in the setting of facial pain. Coronal
reformats are most useful for evaluating the ostiomeatal
complex, whilst sagittal reformats are particularly
relevant to analysing the inferior frontal sinus drainage
pathways, the sphenoethmoid recess, and the posterior
walls of the sphenoid and frontal sinuses. A volume of
data may also be provided for image-guided surgery,
which is used in some centres to provide a real-time
anatomical localization of a sensing probe during
surgery. If there is any suspicion of a neoplastic or
complicated inflammatory process then either a higher
mA CT technique with additional contrast medium
enhancement or an MRI study should be supplemented.
MRI with its superior contrast resolution is important
in differentiating tumour and inflammatory mucosal
thickening or secretions [2, 3]. It is also used for tumour
mapping, vascularity evaluation and assessment of

Imaging, Volume 19 (2007) Number 1 39

 S E J Connor, S Hussain and E K-F Woo

orbital, infratemporal, intracranial and perineural spread
of disease.
MRI should be acquired with a slice thickness of 3–
4 mm and a field of view of 18 cm. T2 weighted imaging
and post gadolinium imaging is particularly important
for differentiating tumour (intermediate T2 weighted
signal) from inflammation (increased T2 weighted signal)
and multiplanar sequences should be employed. Sagittal
images are important to assess the posterior extent of
abnormality and fat saturated imaging is useful to
visualize extrasinus and central skull base involvement.
MRI is used in some centres to assess the extent of
inflammatory disease in young patients.
Anatomy
The paranasal sinuses consist of the maxillary,
ethmoid, frontal and the sphenoid sinuses [4]. The
maxillary sinus drains via the maxillary ostium to the
infundibulum, which is bordered by the uncinate plate
laterally. The uncinate plate is attached to the neck of the
inferior turbinate. The anterior attachment is a critical
surgical landmark and it usually attaches to the lamina
papyracea although it may attach to either the middle
turbinate or anterior skull base. The free superior end of
the uncinate plate results in an uninterrupted air channel
to the hiatus semilunaris bordered superiorly by the
ethmoid bulla (Figure 1a). The hiatus semilunaris drains
into the middle meatus. Bone is often naturally absent
along the medial wall of the maxillary sinus posterior to
the uncinate plate forming a posterior nasal fontanelle. If
the mucosa is also deficient, as is often the case in chronic
sinusitis, then an accessory ostium is created. The
ethmoid sinus is separated into the anterior and poster-
ior compartment (Figure 1b). The anterior ethmoid air
cells drain into middle meatus often via the ethmoid
bulla (Figure 1a). The posterior ethmoid air cells drain to
the superior meatus.
The frontal sinuses appear within the frontal bone and
are often asymmetric or occasionally hypoplastic. They
drain to the middle meatus or infundibulum (depending
on the site of anterior attachment of the uncinate process)
via the frontal ostium and then the inferior frontal sinus
drainage pathway (Figure 1b). The anterior border of the
inferior frontal sinus drainage pathway is the agger nasi
cell, which represents the most anterior ethmoid air cell,
and the posterior border is the ethmoid bulla (Figure 1b).
The sphenoid sinus drains via the sphenoid sinus
ostium into the sphenoethmoidal recess (Figure 2).
The nasal cavity is divided by the nasal septum in the
midline. It contains bony projections – the superior,
middle and inferior turbinates (Figure 1a). This then
defines the superior, middle and inferior meati. The
middle turbinate has two constant attachments which
are critical surgical landmarks. There is a superior
attachment to the anterior skull base and a lateral
attachment to the nasal wall termed the basal lamella.

(a) (b)

Figure 1. (a) CT scan in coronal plane shows the normal paranasal sinus anatomy. The maxillary sinus borders with the orbital
floor (superiorly), lateral nasal wall (medially) and the retromaxillary fat and pterygopalatine fossa (posteriorly) (f 5 frontal
sinus, ae 5 anterior ethmoid air cells, mo 5 maxillary ostium, mt5 middle turbinate, it 5 inferior turbinate, u 5 uncinate
process, ei 5 ethmoid infundibulum, m 5 maxillary sinus, arrow 5 attachment of the middle turbinate on the anterior skull
base). (b) CT scan in sagittal plane shows the normal anatomy of the frontal sinus drainage pathway and the basal lamella
inserting to the skull base. This separates the anterior to the posterior ethmoid air cells. The anterior border of the inferior
frontal sinus drainage pathway is the agger nasi cell, which represents the most anterior ethmoid air cell, and the posterior
border is the ethmoid bulla. The borders of the ethmoid sinuses are the lamina papyracea laterally, the nasal cavity medially and
the fovea ethmoidalis and cribriform plate superiorly (f 5 frontal sinus, fo 5 frontal sinus ostium, bl 5 basal lamella, pe 5
posterior ethmoid air cells, s 5 sphenoid sinus).

40 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

(a) (b)

Figure 2. (a) CT scan in coronal plane. (b) CT scan in the sagittal plane. The normal anatomy of the sphenoid sinus and the
sphenoethmoidal recess is demonstrated. The sphenoid sinus borders with the sella turcica superiorly, ethmoid sinuses
anteriorly, clivus posteriorly and the nasopharynx inferiorly. (s 5 sphenoid sinus, se 5 sphenoethmoidal recess, sso 5 sphenoid
sinus ostium.)

The basal lamella is orientated in an oblique coronal
plane, high anteriorly and low posteriorly. It is important
in that it separates the anterior and posterior ethmoid air
cells (Figure 1b). Posterior to the ethmoid bulla and
anterior to the basal lamella there is frequently an air
cleft or sinus lateralis, which is demonstrated on sagittal
sections.
The ostiomeatal complex is the junction where the
mucociliary drainage of the frontal, maxillary and anterior
ethmoid air cells occurs and this is the main focus of FESS
[5]. This includes the inferior frontal sinus drainage
pathway, infundibulum, uncinate process, ethmoid bulla,
hiatus semilunaris and the middle meatus.
and potentially impairs the drainage of the middle
meatus. A lamella air cell or conchal neck air cell is
located in the middle turbinate above the level of the
ostiomeatal complex and is unlikely to affect sinonasal
drainage. Pneumatization of the superior and inferior
turbinates is occasionally identified but is of little clinical
importance. A middle turbinate may also be paradoxical
with a medial convexity and may impair surgical access
to the ostiomeatal unit.

Normal variants
Normal variants are important to report for the
purposes of surgical planning and because they may
have a profound effect on sinonasal physiology predis-
posing to outflow obstruction. Normal anatomical
dehiscences may also facilitate the spread of infection.
Frontal cells are commonly seen and may be multiple.
They lie superior to the agger nasi cell and may impinge on
frontal sinus outflow. In the ethmoid region, there may be
extramural air cells, which extend outside the confines of
the ethmoid bone, and enlarged intrinsic ethmoid air cells.
The agger nasi cells and suprabullar air cells may be large
and obstruct drainage from the frontal sinus whilst
infraorbital (Haller) cells (Figure 3) and large ethmoid
bulla air cells may impinge on the ethmoid infundibulum.
Dehiscent lamina papyracea, low fovea ethmoidalis and
hypoplastic ethmoid labyrinth should be identified in
order to pre-warn the surgeon of variant anatomy.
The middle turbinate is usually rounded with a lateral
convexity. Variations of the middle turbinates include
pneumatization, which is termed a concha bullosa air cell Figure 3. CT scan in coronal plane shows bilateral infra-
if it is seen within the inferior bullous portion (Figure 4) orbital (Haller) cells (arrows). (dns 5 deviated nasal septum.)

Imaging, Volume 19 (2007) Number 1 41


Figure 4. CT scan in coronal plane shows a large concha
bullosa in the right middle turbinate (arrow).
The uncinate process also has normal variations
including pneumatization, deviation, duplication or
atelectasia [6, 7]. An atelectatic uncinate plate abutting
a non-pneumatized orbital wall will be at risk of orbital
penetration if removed. Nasal septal deviation and an
associated bony septal spur may be the cause of nasal
obstruction and also will impair surgical access to the
nasal cavity necessitating correction.
In the sphenoethmoidal region, there is extensive
variation in pneumatization. Sphenoethmoidal (Onodi)
cells (Figure 5) represent contiguous extension of the
posterior ethmoid into the sphenoid bone and results in
an unexpected ethmoid air cell abutting the optic canal.
There are frequent areas of bony thinning and dehiscence
in the walls of the sphenoid sinus with dehiscent optic
nerve canal (Figure 6) and medial or dehiscent internal
Figure 5. CT scan in coronal plane shows an Onodi cell with
a horizontal septum separating it from the left hemisphe-
noid sinus (arrow).
42
S E J Connor, S Hussain and E K-F Woo
Figure 6. CT scan in coronal plane shows dehiscence of both
optic nerves (arrows).
carotid artery being particularly relevant. An anterior
ethmoid artery traversing the ethmoid air cells without a
bony covering is at risk of damage, retraction and orbital
haematoma if not identified pre-operatively.
Inflammatory disease
General concepts
The paranasal sinus anatomy is closely related to
functional physiology. An understanding of the func-
tional drainage pathways is important and helps with
classifying sinus inflammatory disease. Mucociliary
clearance is the result of functional ciliated cells moving
mucous from the sinuses to the choana [8]. These cells
beat in a certain direction and create a characteristic flow
pattern. When this pattern is disrupted, stagnation of
mucous results and this in turn will cause sinusitis. The
main goal of surgery is to enlarge the natural sinus ostia
and preserve physiological mucociliary clearance.
Normal sinus mucosa is not identified on CT.
However thickening of the lining of the paranasal
sinuses may not represent inflammation or infection
since asymptomatic submucosal oedema and mucoid
secretions may both mimic inflammatory mucosal
thickening. Opacification of the sinonasal drainage
channels without significant proximal sinus disease is
most likely to represent transient changes. In general
mucosal thickening should not be seen in the frontal or
sphenoid sinuses in a healthy patient [9].
However, mucosal thickening less than 4 mm in the
maxillary sinus [9, 10] and less than 2 mm in the ethmoid
sinuses and the nasal cavity has been shown to be
frequently asymptomatic. That within the nasal cavity
and ethmoid air cells also undergoes periodic changes
with the nasal cycle [9, 10]. Conversely, inflamed and
Imaging, Volume 19 (2007) Number 1
Sinonasal imaging
irritated mucosa may not appear thickened on CT. In
paediatric patients and in particular those under 2 years
of age, sinus opacification is most likely due to retained
secretions, tears and redundant secretions so there is
little correlation with active infection.
For these reasons a negative or nearly negative CT
indicates a low probability of chronic rhinosinusitis [11].
The relationship between the severity of symptom of
rhinosinusitis and CT findings remains controversial
[12–16]. The side demonstrating increased severity of CT
changes does not necessarily correlate with asymmetry
of symptoms.
Acute rhinosinusitis
Acute rhinosinusitis is defined as symptoms lasting
less than 4 weeks [17]. Imaging clues for acute sinusitis
are air–fluid levels (which may also result from recent
nasal lavage), bubbly secretions, stranding and asymme-
trical mucosal thickening [18] and this should prompt
aggressive antibiotic therapy. Imaging is infrequently
performed in this clinical setting although it may
occasionally prove helpful since there is an overlap
between the symptoms of rhinitis and rhinosinusitis.
With the increasing use of antibiotics serious compli-
cations are fortunately becoming rare; however, imaging
is mandatory in this setting [19]. Superficial complica-
tions include osteomyelitis, subperiosteal abscess, orbital
abscess (Figure 7) and optic neuritis The ethmoid sinuses
are the most often source of infection via the thin lamina
papyracea and the valveless ethmoid veins [20].
Intracranial complications include meningitis, epidural
abscess/empyema, cerebritis, brain abscess and caver-
nous sinus thrombosis.
Chronic rhinosinusitis
Chronic rhinosinusitis is defined as disease lasting
more than 12 weeks [17]. Cystic fibrosis, immune
deficiency, ciliary dysfunction and allergies should be
Figure 7. Enhanced coronal CT demonstrating bilateral
orbital abscesses (arrows). The ethmoid sinuses are most
often the source of infection via the thin lamina papyracea
and the valveless ethmoid veins.
Imaging, Volume 19 (2007) Number 1
excluded in children presenting with persistent sinusitis.
Similar findings on CT and MRI are seen to those in
acute disease. However, in addition, mucosal thickening
or atrophy and inspissated secretions can result. There
have been various objective staging systems used to
quantify the degree of sinonasal inflammatory disease.
The most commonly used is the Lund classification of
which CT scoring is an integral component [21]. On CT,
this will demonstrate higher attenuation in the opacified
sinus than in acute disease. New bone formation (bone
thickening) and sclerosis along the contour of the sinus
may also be seen (Figure 8). This appearance may be
mimicked by surgical mucosal stripping and secondary
lamina propria fibrosis. Variable signal depending on the
protein content is seen on MRI. When secretions are
particularly dessicated, the T2 weighted signal may be
very low and mimic an air filled sinus so close
correlation with CT is required (Figure 9). When there
is decreased sinus volume with collapse of the antral
walls and inward bowing of the orbital floor, this is
described as silent sinus syndrome [22].
Patterns of inflammatory disease
There are five main patterns of chronic inflammatory
disease which classify the disease into distinct anatomi-
cal/pathological groups [23]. This classification helps the
surgeon to elucidate whether surgery has a role and the
type of surgery to perform.
(1) When inflammatory disease affects the maxillary
sinus, anterior ethmoid air cells and frontal sinuses, this
is termed an OMC pattern (Figure 10). There is variable
involvement of the frontal sinuses depending on the site
Figure 8. CT scan in coronal plane shows complete opacifi-
cation of the right hemisphenoid sinus with thickening and
sclerosis of the sinus wall (arrow). The appearance is in
keeping with chronic sinusitis. Minor mucosal thickening is
also seen in the left hemisphenoid sinus.
43
 S E J Connor, S Hussain and E K-F Woo

Figure 10. CT scan in coronal plane shows an ostiomeatal

complex pattern of inflammatory disease with mucosal
Figure 9. MRI scan (coronal fat saturation T2) shows low thickening in the left maxillary antrum, infundibulum,
signal T2 areas in the left maxillary sinus and the ethmoid air middle meatus and the anterior ethmoid air cells. Minor
cells. CT (not shown) showed opacification. The appearances mucosal thickening is seen in the right maxillary sinus and
are consistent with concentrated proteinaceous secretions anterior ethmoid air cells.
from chronic sinusitis (arrow). There is also a high T2 signal in
the right maxillary antrum (double arrows) where secretions
used. For sphenoethmoidal recess pattern, the aim is to
are less desiccated.
enlarge the sphenoid ostium and establish drainage.
Techniques include external approaches but endoscopic
of uncinate plate insertion. If the frontal sinus is involved surgery with possible image guidance is used in
in isolation, this is called frontal recess inflammatory specialist centres. For sinonasal polyposis pattern,
pattern (a limited variant of the OMC pattern) [21]. surgical options include endoscopic polypectomy, FESS
(2) The infundibular pattern involves isolated obstruc- or sphenoethmoidectomy [24–26].
tion to the ethmoid infundibulum and or maxillary ostium.
(3) Sphenoethmoidal recess pattern (SER) refers to
when inflammatory changes in the sphenoethmoidal
recess obstruct the sphenoid sinus in isolation or in
conjunction with the posterior ethmoidal air cells.
(4) When extensive polyps are occupying the nasal
cavity and the paranasal sinuses, they can cause wide-
spread obstruction (apart from the inferior meatus) and
this is termed the sinonasal polyposis pattern.
(5) The sporadic pattern occurs when it is difficult to
identify a clear pattern to the inflammatory change. This
includes random mucosal thickening, polyps, retention
cysts, and mucocoeles.

Surgical options
The aim of surgery is to open and clear the drainage
pathways. FESS is the most commonly used technique.
With an infundibular pattern, ethmoid infundibulotomy
with possible limited ethmoidectomy should suffice. In
the osteomeatal complex (OMC) pattern, uncinatectomy
with possible maxillary antrostomy and ethmoidectomy
are the standard treatment (Figure 11). For frontal recess Figure 11. CT scan in coronal plane shows bilateral uncina-
inflammatory pattern, external frontoethmoidectomy tectomies, bilateral middle meatal antrostomies (*) and
and FESS techniques to relieve the obstruction can be partial resection of the anterior ethmoid air cells (+).

44 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging
Post surgical imaging
In patients with recurrent symptoms post surgery,
imaging plays a role in assessing the extent of FESS,
detecting complications and demonstrating residual
patterns of disease. Where relevant, the radiologist
should focus on the patency of the inferior frontal sinus
drainage pathway, including lateralization of the middle
turbinate and persisting agger nasi cells. The complete-
ness of uncinatectomy should be assessed and particu-
larly whether it has been performed too far posteriorly.
The extent of ethmoidectomy and any post-operative
synechiae obstructing sinus drainage should be
recorded. Persistent sinus opacification may also result
from viscous secretions. When repeat FESS is considered,
there should also be careful examination of the integrity
of the middle turbinate attachment to the anterior skull
base (as there may be dehiscence post-turbinatectomy)
and whether there is any defect within the lamina
papyracea. Clearly there is role for imaging if there are
overt complications such as cerebrospinal fluid (CSF)
leak, orbital injury or haemorrhage.
Fungal infection
There are various different types of fungal infection.
This is mainly classified as non-invasive and invasive
forms.
Non-invasive forms include mycetoma and allergic
fungal sinusitis. Mycetoma or a fungus ball usually
affects a single sinus and it demonstrates a focal lesion
with areas of high density and possible calcification.
Calcification associated with fungal infection is reported
Figure 12. CT scan in axial plane shows complete opacifica-
tion of the left hemisphenoid sinus with hyperdensity and
sinus expansion consistent with fungal sinusitis (arrow).
Imaging, Volume 19 (2007) Number 1
to be more frequently central and punctate as opposed to
curvilinear and peripheral calcifications associated with
chronic non-fungal secretions (Figure 12). On MRI it
demonstrates low signal on T1 but can be heterogeneous
and low signal on T2.
Allergic fungal sinusitis characteristically demon-
strates multiple sinus opacification with hyperdense
material on CT and sinus expansion (Figure 13). There
is often a preserved rim of hypodense mucosa. Benign
bony remodelling, resorption and erosion into adjacent
structures can be seen. It is commonly associated with
sinonasal polyposis.
In invasive forms, there is extension outside the sinus
lumen with involvement of the blood vessels, bone
erosion and possible orbital and intracranial extension
[27, 28]. It usually, but not exclusively, occurs in diabetics
and other immunocompromised patients. Three invasive
forms were proposed by deShazo: granulomatous, acute
fulminant and chronic invasive [29]. CT findings are
non-specific but typically show sinus opacification with
bony erosion and soft tissue infiltration.
Destructive granulomatous rhinosinusitis
Systemic diseases can involve the nasal cavity and
paranasal sinuses. The imaging features of Wegener’s
granulomatosis are initially non-specific but later on,
there is typical sinonasal mass with septal perforation
and non-septal bone erosion (Figure 14). The lateral
nasal wall can be involved. There may be extension
through the hard palate and to the orbit, deep facial
spaces, nasopharynx and the skull base. The turbinates
often appear truncated and shortened. In the chronic
Figure 13. Coronal post gadolinium T1 MRI scan shows
marked expansion of both anterior ethmoid air cells,
hypointensity in the maxillary sinuses with peripheral mucosal
enhancement resulting from allergic fungal sinusitis.
45
 S E J Connor, S Hussain and E K-F Woo

Figure 15. CT scan in coronal plane shows a large lesion

Figure 14. CT scan in coronal plane shows a soft tissue nasal
mass with bone destruction and nasal perforation (arrow).
This was secondary to sarcoidosis. The imaging differential
diagnoses include Wegener’s granulomatosis and lymphoma.
phase, the sinus walls often become thickened and a
double cortical line with central marrow can be seen. The
imaging differential diagnoses include sarcoidosis,
cocaine and other inhaled irritants and lymphoma.
Rarer causes of granulomatous infection include leprosy,
syphilis and tuberculosis.
Intensive care sinusitis
Nasal tubes result in impairment of sinonasal drai-
nage. This results in a diagnostic dilemma in a septic
patient in whom other sources of sepsis have been
excluded. CT or MRI is not diagnostic and sinus
aspiration may be required.
occupying the left maxillary sinus which widens the maxillary
ostium and extends to the nasal cavity and choana (not
shown) consistent with an antrochoanal polyp (arrow).
dumbbell shaped low density mass with widening of the
maxillary ostium extending to the nasal cavity is
characteristic [34, 35]. Nasochoanal, ethmochoanal and
sphenochoanal polyps are rare [36, 37].
Sinonasal polyposis
The sinonasal structures maybe expanded by polypoid
masses and obstructed secretions and there is benign
bone remodelling or erosion (Figure 16). Aggressive
polyposis can extend into adjacent structures. The
ethmoid sinus walls often become thin and can be barely
visible. The maxillary infundibulum and ostium is
widened if the polyps extend from the maxillary sinuses.
Concurrent fungal infection is common.

Inflammatory masses

Cysts and polyps

Retention cysts and solitary polyps are usually
asymptomatic and found incidentally and are regarded
as complications of inflammatory sinusitis [30, 31].
Retention cysts are common, particularly in the max-
illary sinuses, and are of little significance unless they are
causing obstruction to the mucociliary clearance [32, 33].
Sporadic polyps are also commonly asymptomatic and
found incidentally. On imaging, these retention cysts and
polyps appear as soft tissue masses with a smooth
convex border. Desiccated polyps may demonstrate
increased CT density. The signal intensity on MRI is
dependent on the water and protein content. When an
inflammatory polyp arises from the maxillary antrum
and herniates through a major or accessory ostium into Figure 16. CT scan in coronal plane shows complete
the nasal cavity and to the postnasal space, this is termed pansinonasal opacification with benign bony remodelling
an antrochoanal polyp (Figure 15). On imaging, a large in keeping with sinonasal polyposis.

46 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

If there is superimposed infection this is called a

pyocoele. On CT, a low density airless sinus with smooth
bony wall expansion is diagnostic [33]. On MRI the
signal intensity depends on the water and proteinaceous
content (Figure 17). There may be a thin rim of
enhancement as opposed to an expansile tumour which
will demonstrate internal enhancement.

Mimics of sinonasal inflammatory disease

Figure 17. MRI scan (coronal fat saturation T2 sequence)
shows a moderately high signal area in the left anterior
ethmoid air cells with expansion of the sinus compatible
with an ethmoid mucocoele (arrow).
Mucoceles
With an obstructed sinus ostium from trauma,
previous surgery, polyps or chronic rhinosinusitis, an
opacified expanded sinus or mucocoele can result. The
sinus shows benign bony remodelling presumably from
pressure erosion. The frontal sinuses are most commonly
affected followed by the ethmoid and maxillary sinuses.
Mimics of inflammatory disease should also be
considered [8]. In unilateral sinus opacification, particu-
larly in the OMC, a middle meatal mass needs to be
excluded and direct inspection of the middle meatus
should be suggested. Odontogenic origin of infection can
extend to the maxillary sinus and cause an OMC pattern
of disease. With nasal septum pathology and bilateral
advanced disease, a systemic cause should be consid-
ered. The pattern of bone involvement may be helpful in
formulating a differential diagnosis. Bony sclerosis is
usually associated with a chronic relapsing process (or
previous surgery) and this is typically infective. A
destructive pattern of bony involvement is rarely seen
with inflammatory conditions such as fungal or granu-
lomatous infection and is usually seen with carcinoma
(Figure 18a,b), metastases, some sarcomas and some
lymphomas. This should be distinguished from the
pressure deossification at the advancing edge of an
expansile slower growing lesion which will typically
demonstrate some bony remodelling at its margins. This
pattern is found with inflammatory lesions such as
mucoceles and polyps but may be seen with slower
growing tumours such as melanomas, plasmocytomas
and slower growing sarcomas (Figure 18c). If a bony
defect is seen in the anterior skull base adjacent to a
lesion, then a cephalocele should also be excluded
(Figure 19). The presence of calcification usually signifies
a chronic inflammatory process (Figure 12) particularly
if more discrete. However, if present within a tumour, it

(a) (b) (c)

Figure 18. (a) CT scan in coronal plane shows a large irregular soft tissue mass with bone destruction secondary to a sinonasal
squamous cell carcinoma. Erosion through the lamina papyracea into the left orbit (double arrows) and erosion through the
fovea ethmoidalis into the anterior cranial fossa (arrow) are demonstrated. (b) CT scan in axial plane shows a large irregular soft
tissue mass with bone destruction and invasion into the right orbit (arrow). This was a rapidly growing tumour consistent with a
sinonasal undifferentiated carcinoma. (c) A coronal CT scan showing a chondrosarcoma arising from the left maxillary antrum
with benign bony expansion of the antral wall.

Imaging, Volume 19 (2007) Number 1 47


Figure 19. Coronal T1 MRI shows a low signal lesion in the
left anterior ethmoid air cells (arrowhead). This represented
an ethmoid meningocoele.
is suggestive of particular neoplasms such as chondro-
sarcoma or olfactory neuroblastoma.
Congenital lesions
Choanal atresia is the most common congenital
abnormality of the nasal cavity. It can be unilateral
(more common) or bilateral, bony (more common) or
membranous [38]. In bilateral disease, it causes respira-
tory distress in the newborn. CT would show narrowing
of the posterior nasal cavity at the level of the choana
with obstruction from a membranous or osseous cause.
There is often thickening of the vomer.
Nasolacrimal duct dacrocystocoeles represent a cystic
dilatation of the nasolacrimal apparatus secondary to
obstruction of the nasolacrimal duct [39]. Bilateral medial
canthal cystic masses are characteristic.
Piriform aperture stenosis is a rare condition in which
there is bony narrowing of the anterior nasal cavity. It is
associated with holoprosencephaly or other anomalies.
There is often a central mega-incisor [40].
Cephaloceles are congenital herniations of neural tissue
(brain, CSF, meninges) through a mesodermal defect in the
anterior skull. There are three main types – frontonasal,
nasoethmoidal and naso-orbital cephalocoeles [41]. A
defective anterior neuropore may also result in a dermal
sinus tract, dermoid or nasal glioma (an extracranial rest of
glial tissue rather than a neoplasm) in the frontonasal
region. A frontonasal dermoid maybe associated with CT
48
S E J Connor, S Hussain and E K-F Woo
evidence of a bifid crista galli with a large foramen caecum
and a sinus or cyst in the frontonasal region [42]
(Figure 20). MRI is used to identify any intracranial
extension of a dermoid which may be purely extradural
or extend between the leaves of the falx.
Sinonasal neoplasms
A wide variety of neoplasms, both benign and
malignant, may arise in the sinonasal cavity. They are
generally rare, particularly relative to ubiquitous inflam-
matory disease. The imaging appearances of the major
categories will be discussed.
CT and MRI are often complementary in the staging of
these tumours, with CT being more sensitive to bone
changes and MRI providing superior soft tissue contrast.
The morphology of the tumour, enhancement pattern
and pattern of bony involvement may also help limit the
differential diagnosis.
Benign tumours and tumour like lesions
Osteoma
Osteoma is the most common benign lesion of the
paranasal sinuses. They are well marginated areas of
compact bone, with almost 80% occurring in the floor of
the frontal sinus.
They are usually detected incidentally as a dense
calcified mass although occasionally, a patient may present
with an obstructive sinusitis and secondary mucocoele
formation (Figure 21) and rarely pneumocephalus.
Fibrosseous lesions
Fibrous dysplasia most frequently involves the max-
illa, with involvement of the ethmoid and sphenoid
sinuses being uncommon. CT shows ill-defined expan-
sion of bone and hazy or ‘‘ground glass’’ density. MRI
shows decreased T1 signal with variable signal intensity
on T2 weighted, due to variations in the degree of
cellularity or cystic change within the lesion [43, 44].
There is also heterogeneous enhancement following the
administration of gadolinium (Figure 22).
Ossifying fibroma is a rare lesion, more closely
resembling an osteoma than fibrous dysplasia, but can
be indistinguishable from the latter on CT imaging [45].
Papillomas
Papillomas are benign epithelial growths [46, 47] and may
be fungiform, inverting or cylindrical cell. Fungiform
papillomas almost always arise from the nasal septum.
Inverting papillomas typically arise from the lateral wall of
the nasal cavity. The rare cylindrical cell papilloma also
arises from the lateral wall. Although histologically benign,
inverting papillomas may behave aggressively, causing
adjacent bone erosion or remodelling. There is a well
recognized association between inverting papilloma and
squamous cell carcinoma so follow up imaging is almost
mandatory [47, 48].
Imaging, Volume 19 (2007) Number 1
Sinonasal imaging
(a)
Figure 20. (a) CT scan in coronal plane showing a bifid crista galli (arrow) in keeping with a nasal dermoid. (b) CT scan of the
same patient in sagittal plane shows an enlarged foramen caecum (arrow). (c) Coronal T2 MRI of the same patient shows an
intermediate signal lesion (arrow) from an extradural dermoid.
CT of an inverted papilloma typically demonstrates an
enhancing mass centred in the middle meatus, extending
into the adjacent maxillary antrum through a widened
ostium [52] (Figure 23). The mass may contain areas of
calcification (possibly corresponding to fragments of
residual destroyed bone) and there may be adjacent bony
sclerosis. MRI may show heterogeneous enhancement
and identify a ‘‘convoluted cerebriform pattern’’ which
is highly suggestive of inverted papilloma [50].
Juvenile angiofibroma
Juvenile angiofibroma is a rare, benign vascular
tumour arising adjacent to the sphenopalatine foramen.
Figure 21. Coronal CT scan demonstrating bilateral frontal
sinus osteomas with a developing mucocoeles on the right
(arrows).
Imaging, Volume 19 (2007) Number 1
(b) (c)
It is the most common benign tumour of the nasophar-
ynx in adolescents, almost always occurring in males
[51]. Although benign, juvenile angiofibroma is locally
invasive with extension into the pterygopalatine fossa in
over 90% of cases and frequent extension to the
infratemporal fossa, sphenoid sinus, orbit and intracra-
nial compartment [52].
CT and MR imaging demonstrate a large, strongly
enhancing lobular mass widening the sphenopalatine
foramen and bowing the posterior wall of the maxillary
sinus (Figure 24).
Despite surgery, high local recurrence rates have been
reported, especially if there has been skull base invasion
in the region of the pterygoid base [52, 53].
Haemangioma
Haemangioma of the paranasal sinuses is extremely
rare [54]. Haemangioma of the nasal vault usually arises
from the anterior nasal septum. Intense enhancement of
a lesion, in combination with a history of recurrent
epistaxis, should lead to consideration of a mass of
vascular origin [55] and the differential diagnosis would
include angiomatous polyp, melanoma or angiofibroma.
Odontogenic lesions
Odontogenic cysts and tumours should always be
considered when a mass extends into the sinonasal
region from the maxillary alveolus or palate. An
odontogenic cyst may be confused with a polyp or
maxillary sinus mucocele if the double cortical line
(representing the displaced upper border of the max-
illary alveolus and the orbital floor) is not identified
within the superior antrum (Figure 25).
Sinonasal malignancy
Malignant lesions of the sinonasal tract are an
important group of neoplasms, which despite their low
49

(a)
Figure 22. (a) Axial CT scan demonstrated a soft tissue mass centred in the posterior nasal space. There is a ground glass
appearance to the bone of the left greater wing of sphenoid and posterior wall of the left orbit, consistent with fibrous
dysplasia. (b) Post-gadolinium T1 fat saturation axial MRI of the same patient as in (a), showing a heterogeneous enhancement
pattern of the mass.
incidence have an overall grave prognosis. Advanced
local disease is common at diagnosis with 20% having
nodal metastases. There is marked overlap in the
imaging features of malignant tumours, and there are
only a few instances in which CT and MR imaging are
pathogonomic with biopsy usually being required.
Imaging is critical for tumour mapping with assessment
of tumour spread into the pterygopalatine fossa, orbit, or
skull base. If there is extensive anterior cranial fossa
extension, they should be distinguished from intracranial
lesions extending into the nasoethmoid region such as
meningiomas. The T2 weighted signal is typically low
with sinonasal malignancy and it may thus be delineated
from sinonasal secretions. Although inspissated secre-
tions may sometimes demonstrate low T2 weighted
signal they are generally of increased T1 weighted signal.
Nodal metastases are common in squamous cell carci-
noma (SCC) and lymphoma. Perineural spread of tumour is
Figure 23. CT scan in coronal plane shows a soft tissue mass
in the left middle meatus with extension into the maxillary
sinus consistent with an inverted papilloma (arrow).
50
S E J Connor, S Hussain and E K-F Woo
(b)
a particular characteristic of adenoid cystic carcinoma, but
may be observed with SCC, lymphoma and melanoma. Its
radiological diagnosis is important as curative resection is
unlikely and it signifies a grave prognosis.
Epithelial malignancy
Squamous cell carcinoma
SCC comprises 80% of malignant tumours of the
sinonasal tract, with the majority of these (85%) arising in
the maxillary antrum [56].
CT imaging shows a unilateral sinus mass with
aggressive bone destruction (Figure 18a). It may involve
the alveolar ridge of the maxilla, buccal space and hard
palate. SCC shows moderate enhancement following
contrast medium, but to a lesser extent than adenocarci-
noma or olfactory neuroblastoma.
Adenocarcinoma
Adenocarcinomas account for 10–20% of malignant
sinonasal tumours [57]. There are salivary and intestinal
subtypes, and unlike SCC, adenocarcinoma most often
arises in the ethmoid sinus and may calcify.
Salivary tumours
Minor salivary glands are found in the mucosa
throughout the upper aerodigestive tract. These may
give rise to adenoid cystic carcinoma, adenocarcinoma or
mucoepidermoid carcinoma. Of all minor salivary gland
tumours, adenoid cystic carcinoma is the most common
with the majority occurring in the maxillary antrum and
nasal cavity. It appears of relatively increased T2
weighted signal due to their seromucinous content
unlike most other sinonasal malignancies [3].
Adenoid cystic carcinoma has a propensity for
perineural spread (Figure 27). The maxillary division of
the trigeminal nerve is most often affected, and the nerve
may show abnormal enhancement and enlargement [58].
Imaging, Volume 19 (2007) Number 1
Sinonasal imaging
(a)
Figure 24. (a) Axial enhanced CT scan demonstrating a large avidly enhancing lesion from a juvenile angiofibroma. There is
widening of the sphenopalatine foramen (arrow) with marked distortion of the posterior wall of the maxillary antrum. (b) A
selective angiogram of the right external carotid artery shows a strong vascular blush in the vicinity of the internal maxillary
artery (arrow) territory.
Neuroectodermal and neuronal malignancy
Olfactory neuroblastoma
This neoplasm, also termed esthesioneuroblastoma,
arises from the neural crest cells within the olfactory
epithelium of the high nasal vault.
Figure 25. CT scan in axial plane shows a well circumscribed
corticated cystic lesion seen extending form the left maxillary
alveolus representing an odontogenic keratocyst (circle 1).
Imaging, Volume 19 (2007) Number 1
(b)
Imaging shows an enhancing mass centred high in the
nasal vault. An isolated area of soft tissue within the
superior meatus in a patient presenting with epistaxis
should be regarded with suspicion and closely inspected
for bony erosion. It is frequently more advanced with
destruction of the anterior skull base and should be
considered if a lesion is centred on the cribriform plate.
Punctate intratumoural calcifications have been
reported, as well as hyperostosis of adjacent sinus walls.
The classic description of an intracranial cyst with a
‘‘dumbbell’’ shaped sinonasal mass occurs in a minority
of cases [59]. Local recurrence rates tend to be high and
craniofacial resection with radiotherapy remains the gold
standard for treatment [60].
Sinonasal undifferentiated and neuroendocrine
carcinoma (SNUC and SNEC)
These are less well-differentiated neuroendocrine
tumours. Clinically, the tumour is highly aggressive
and has a poor prognosis. It arises in the superior nasal
cavity or ethmoid sinus and although it is initially
unilateral, it tends to be quite large at presentation. The
imaging features of SNUC are non-specific (Figure 18b),
making it difficult to distinguish from other aggressive
tumours in this region such as SCC [61].
Melanoma
Malignant melanoma arising within the sinonasal
mucosa is rare [62]. It occurs more frequently within
the nasal cavity, arising from the septum, lateral wall or
51

Figure 26. Axial T2 weighted MRI maps the intermediate T2
signal squamous cell carcinoma relative to high signal
inflammatory secretions.
inferior turbinate. Its most specific imaging feature of
melanotic melanoma is a high T1 signal, due to a
combination of the paramagnetic properties of melanin,
methaemoglobin and free radicals.
Lymphoma
The nasal cavities and paranasal sinuses are rarely
affected by primary non-Hodgkin’s lymphoma (NHL).
The majority of these lymphomas are of large B cell
subtype. T cell lymphoma occurs in a younger popula-
tion and is more likely to arise in the nasal cavity [63, 64].
A further distinct subtype is also recognized called nasal
T cell/natural killer cell lymphoma, formerly known as
‘‘lethal midline granuloma’’ [65].
Lymphoma of the sinonasal tract is often highly
aggressive showing local bone destruction or skull base
invasion. Imaging may provide clues to the diagnosis
Figure 27. Coronal post gadolinium T1 MRI shows enhance-
ment of the left maxillary nerve in the foramen rotundum
(arrow) and the left vidian nerve in the vidian canal
(arrowhead). This was due to perineural spread from a
palatal adenoid cystic carcinoma.
52
S E J Connor, S Hussain and E K-F Woo
Figure 28. Axial CT demonstrating nasal septal chondrosar-
coma. Note the central area of chondroid calcification.
based on extensive involvement of the extrasinus soft
tissues, the involvement of multiple sites or the presence
of lymphadenopathy in the neck, which are both more
commonly seen with B cell lymphomas.
Sarcomas
Primary sarcomas of the sinonasal cavity are very rare,
with chondrosarcoma being the most common. Imaging
shows a large, multilobulated mass with bone erosion
and destruction. Chondroid calcification is almost
always present and best seen on CT (Figure 28). MRI
demonstrates characteristic high signal intensity on T2
weighted images with differential enhancement on post-
gadolinium sequences.
Rhabdomyosarcoma is the most common soft tissue
sarcoma in children. 40% occur in the head and neck
region [66, 67], and those arising in the nasal cavity and
paranasal sinuses are classified as parameningeal sites of
disease. They have a propensity for meningeal invasion
and intracranial extension through the skull base
foramina [67].
Plasmacytoma/multiple myeloma/metastases
Extramedullary plasmacytoma and multiple myeloma
are manifestations of plasma cell neoplasms. The
majority of head and neck extramedullary plasmacytoma
is found in the sinonasal cavity [68]. Myeloma may also
arise in the sinonasal cavity and is more likely to affect
Imaging, Volume 19 (2007) Number 1
Sinonasal imaging
the bony walls of the paranasal sinuses, occurring more
frequently than metastatic disease.
The most common primary tumour to metastasise to
the sinuses is renal cell carcinoma. Metastases from lung
and breast carcinoma may also occur. The sinonasal
cavity may also be secondarily involved by tumour
extension through the skull base, for example by
pituitary tumours, or by tumours from the oral cavity
and palate.
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Imaging, Volume 19 (2007) Number 1