PARANASAL LESIONS CASE DISCUSSION

PARANASAL
CASE DISCUSSION
LESIONS
01
Nantinee Eiamworasin, M.D.
02
• Background
- Normal Anatomy & Development
- Drainage Pathway
- Variations
- Approach
• Cases
CASE DISCUSSION
TOPICS to COVER
Introduction
Normal Anatomy & Development

Paranasal Sinuses
• Air-filled spaces located within the bones of the
skull and facial bones
• Lined with pseudostratified columnar epithelium
• 4 paired sinuses:
Frontal sinuses Ethmoid sinuses
Sphenoid sinuses Maxillary sinuses
• All sinuses open into the lateral wall of the nasal
cavity through their corresponding ostia
Development of PNSs
Scuderi AJ, et al. Pneumatization of the paranasal sinuses: normal features of importance to the
accurate interpretation of CT scans and MR images. AJR Am J Roentgenol. 1993 May;160(5):1101-4.
Introduction
Drainage Pathway
Anterior Complex POSTERIOR Complex
• Frontal Sinus • Posterior Ethmoid Sinus
• Anterior Ethmoid Sinus • Sphenoid Sinus
• Maxillary Sinus
Middle Meatus Superior Meatus

Frontal Sinus DrainagE
Anterior Complex Drainage
Frontal Sinus
Frontal Sinus Ostium
Frontal Recess
Hiatus Semilunaris
Osteomeatal Unit
Anterior Complex Drainage
Maxillary Ostium
Uncinate Process
Infundibulum
Hiatus Semilunaris
Middle Meatus
Ethmoid Sinus DrainagE
Anterior Complex Drainage Posterior Complex Drainage
Anterior Ethmoid Air Cells Posterior Ethmoid Air Cells
Hiatus Semilunaris Superior Meatus
Middle Meatus
Anterior Ethmoid Air Cells Posterior Ethmoid Air Cells
basal lamella of
middle turbinate
Hiatus Semilunaris Superior Meatus
Middle Meatus
Anterior Ethmoid Air Cells
Hiatus Semilunaris
Middle Meatus
Posterior Ethmoid Air Cells
Superior Meatus
Spenoid Sinus DrainagE
Sphenoid Sinus
Sphenoid Sinus Ostium
Sphenoethmoidal Recess
Superior Meatus
Introduction
Variations
Variations of PNSs
Agger Nasi Cells Haller Cells Concha Bullosa Paradoxical Onodi Cells
- Most anterior ethmoid cell - Pneumatization of Curve of Middle - Posterior ethmoid air
- May narrow frontal recess middle turbinate Turbinate cell that pneumatizes
- Inferomedial surface of - May narrow middle superolaterally to the
orbital floor meatus & infundibulum sphenoid sinus
- May narrow maxillary - May narrow middle - Increased risk optic
infundibulum if expanded meatus nerve injury
William T , et al. The Preoperative Sinus CT: Avoiding a “CLOSE” Call with Surgical Complications. Radiology 2016 281:1, 10-
Systematic Approach to Opacified Sinus
1. isolated sinus process VS sinonasal process

2. size (normal, small, expanded)
3. internal attenuation (isodense, hypodense, hyperdense, calcified)
4. bony margins (normal, thickened, sclerotic, thinned, eroded)
5. dental involvement
6. extension beyond the sinus
7. intracranial involvement or extension
8. enhancement
1
CASE DISCUSSION
54-year-old male
Known case of chronic rhinosinusitis S/P FESS for 4 years
Presented with recurrent sinusitis
54y M, recurrent sinusitis
54y M, recurrent sinusitis
Represents
subgaleal
abscess (Pott's
puffy tumor) as a
complication of
frontal sinusitis
- Opacification of the right frontal sinus with sclerotic sinus wall
- Heterogeneous enhancing soft tissue lesion protruding from small defect at anterior wall of the
right frontal sinus associate with swelling of overlying scalp
54-year-old male
Known case of chronic rhinosinusitis S/P FESS for 4 years
Presented with recurrent sinusitis
Chronic frontal sinusitis with subgaleal

abscess (Pott's puffy tumor)
Pott’s Puffy Tumor
• Subgaleal/ subperiosteal
abscess secondary to
frontal sinusitis
• Osteothrombophlebitis
• ± asso. frank osteomyelitis
Complication
• Intraorbital/ intracranial
spread
• Venous thrombosis
Treatment
• Drain abscess+remove
necrosis
• ATB
Koch BL, et al. Diagnostic Imaging: Head and Neck. Elsevier Health Sciences; 2017
Chronic Rhinosinusitis
• Sinonasal infection/inflammation > 12 weeks

Gold standard imaging= Non-enhanced bone CT
(thin slice)
• Evaluates changes in bone & identifies
anatomic variants that may predispose to
recurrent disease
• Contrast not necessary in uncomplicated cases
Chronic left sphenoid sinusitis: Opacified left sphenoid sinus

with thickened walls and Koch BL, et al. Diagnostic Imaging: Head and Neck. Elsevier Health Sciences; 2017
• Sinus mucosal thickening and opacification with

thickening & sclerosis of bony walls
• Involved sinus normal or decreased volume
• Intrasinus hyperdensity or calcifications: common
• Mucus retention cysts and polyps are common
Chronic right maxillary inflammation: prominent calcifications

within the inspissated right maxillary sinus secretions Koch BL, et al. Diagnostic Imaging: Head and Neck. Elsevier Health Sciences; 2017
Sphenoethmoidal recess
Infundibular pattern Ostiomeatal unit pattern pattern
• Isolated ipsilateral • Ipsilateral frontal, anterior • Ipsilateral sphenoid,

maxillary sinusitis ethmoid and maxillary posterior ethmoid sinusitis
sinusitis
Sporadic (unclassifiable)
Sinonasal polyposis pattern pattern
• Polyps in PNSs & nasal cavity • Not related to ostial

obstruction/ polyposis
(mucous retention cyst,
mucocele, post-op)
Radiopedia.com
Complications of rhinosinusitis
Subperiosteal postseptal abscess

Peripherally enhancing, central low-
density mass in extraconal space with
surrounding infiltration of fat
Cavernous sinus thrombosis

Multiple filling defect in enlarged cavernous
sinus, may seen dilate or thrombosed SOV
Subgaleal abscess/ Pott’s puffy tumor (red arrow), usually with a soft tissue swelling of the
forehead. Noted frontal bony destruction.
Brain abscess (green arrow): ring-enhancing mass in parenchyma with restricted diffusion
Subperiosteal abscess (yellow arrow)
2
CASE DISCUSSION
83-year-old female
spontaneous epistaxis S/P nasal packing
83y F, spontaneous epistaxis S/P nasal packing
Soft tissue lesion at

bilateral sphenoid
sinuses and
posterosuperior nasal
cavities with sclerotic
wall and bone
destruction
Represents
chronic invasive
fungal sinusitis
- Fluid/blood retention in bilateral nasal

cavities, bilateral maxillary sinuses, and
bilateral mastoid air cells.
- A small pseudoaneurysm originating
from inferomedial wall of the right
cavernous ICA, pointing through the
bony defect into the right sphenoid sinus
83-year-old female
spontaneous epistaxis S/P nasal packing
Chronic invasive fungal sinusitis

with pseudoaneurysm
Denied surgery → conservative treatment

Invasive Fungal Rhinosinusitis
• CECT(best): Sinus opacification with focal bone erosion, adjacent soft tissue or fat infiltration
(TIWI). Earliest finding = unilateral nasal soft tissue thickening. May be no bone erosion as fungi
extend along vessels.
• CTA: & CTV: Arterial narrowing/occlusion, cavernous sinus thrombosis
• MR: Superior for evaluating intraorbital & intracranial extension
• T1W+Gd: Nonenhancing hypointense mucosa (black turbinate sign)= necrotic eschar
Acute IFR
• Rapidly progress (hours to days) in immunocompromised patients with vascular, bone, soft tissue,
orbit and intracranial invasion resulting in "dry gangrene"
•Facial swelling (65%)
•M/C start in middle turbinate, spreads to maxillary & ethmoid sinuses
Chronic IFR
• Weeks to months infection with dematiaceous > hyaline molds or mucormycoses; associated with
less severe immunocompromise than AIFRS (DM, AIDs, on steroid)
•Pain, nasal discharge
•M/C in ethmoid & sphenoid sinuses
Granulomatous IFR
• Gradual onset fungal invasion of orbit, nose, paranasal sinuses, or maxilla with characteristic
noncaseating granulomas in immunocompetent host with > 12 weeks
•Enlarging cheek, orbit, or sinonasal mass
E.H. Middlebrooks, et al. American Journal of Neuroradiology Aug 2015, 36 (8) 1529-1535;
Fungal VS Bacterial
Piromchai, Patorn, et al. Invasive Fungal Rhinosinusitis versus Bacterial Rhinosinusitis with Orbital
Complications: A Case-Control Study. TheScientificWorldJournal. 2013. 453297. 10.1155/2013/453297.
Acute Invasive Fungal Rhinosinusitis
AIFR correlated most strongly with

- Pterygopalatine fossa
- Periantral fat
- Nasolacrimal duct
- Lacrimal sac
100% specificity but in late-stage

- Epidural/ subdural abscess
- Venous/arterial thrombosis
- Cavernous sinus involvement
- Intraparenchymal extension
- Horizontal palate involvement
Acute Invasive Fungal Rhinosinusitis
Acute IFRS of sphenoid sinus can lead to

- Cavernous sinus thrombosis
- Carotid occlusion
- Mycotic aneurysm formation
- Cranial nerve dysfunction
- Cerebral infarction
#ASNRCOTW #56
Caution !
The signal intensity of sinus secretions
depends on the protein content
Fungus: usually high protein content (> 28%)

and can mimic aerated sinus (low on T1WI
and T2WI) → N e e d CT
Radioassistant.com
Allergic Fungal Sinusitis
• Severe form of chronic rhinosinusitis (CRS) with polyposis
• Allergic response to fungal allergen: eosinophilic mucin with
noninvasive fungal hyphae. Absence of tissue invasion
• Imaging: Opacification and expansion of multiple sinuses with
central inspissated material, with bony remodeling and erosion,
unilateral or bilateral
Centrally hyperdense & hypodense
rim (mucosal edema)
• Hx: Immunocompetent patient with longstanding CRS, asthma in 40%
T2WI: Hypointense, may mimic air ( dense fungal concretions & heavy metal),
minimal expansion
Sinus Mycetoma
Mixed density: fungal elements and
calcium deposits in the sinus
• Fungus ball, aspergilloma, chronic, noninvasive form of fungal sinus

infection
• N E C T : B est Dx in typical cases; better for detecting Ca⁺⁺
• Single paranasal sinus containing central high-density material: fine,
round-to- linear matrix calcifications, not expanded sinus, no tissue
invasion
• Maxillary > sphenoid > > frontal > ethmoid sinuses
T1 signal of solid, mycetoma

T2 signal may mimic air
3
CASE DISCUSSION
42-year-old male
Left nasal obstruction for 7 months with epistaxis on and off
Physical examination reveals an irregular pinklish mass
obstructing left nasal cavity
42y M, irregular pinklish mass obstructing left nasal cavity
An expansile lobulated heterogeneous enhancing cerebriform mass in left nasal cavity, extending to
nasopharyngeal airway with complete left OMU obstruction and mucous retention and enhancing mucosa of
the left frontal, ethmoid, sphenoid and maxillary sinuses
An expansile lobulated heterogeneous enhancing

cerebriform mass in left nasal cavity, extending to
nasopharyngeal airway with complete left OMU
obstruction and mucous retention and enhancing
mucosa of the left frontal, ethmoid, sphenoid and
maxillary sinuses
42-year-old male
Left nasal obstruction for 7 months with epistaxis on and off
Physical examination reveals an irregular pinklish mass
obstructing left nasal cavity
Endoscopic tumor removal
Inverted Papilloma
Inverted papilloma
• Hyperplastic squamous epithelium
• Typical location: lateral wall of nasal
cavity centered at middle
meatus/turbinate ±extension to antrum
Calcification • Locally aggressive
• Squamous cell carcinoma
transformation
• Enhancing mass
• Cerebriform pattern
• Calcification
• Focal hyperostotic of adjacent bone >
point of tumor origin
SCC transformation
SCC
Tatekawa H, et al. Imaging features of benign mass lesions in the nasal cavity and paranasal
sinuses according to the 2017 WHO classification. Jpn J Radiol. 2018 Jun;36(6):361-381.
Suggesting Signs of Malignancy
Bone destruction
SCC in left nasal cavity
Perineural tumor spreading

Adenoid cystic carcinoma in left maxillary sinus
Suggesting Signs of Malignancy
Intracranial extension, dural invasion
Esthesioneuroblastoma
Metastatic lymph node

Retropharyngeal lymph nodes,
cervical node level I, II
Zollinger L, et al. Retropharyngeal Lymph Node Metastasis from Esthesioneuroblastoma: A Review of the Therapeutic and Prognostic Implications. AJNR. 2008;29(8):1561-1563.
Som P, Curtin H. Head and neck imaging. 4th ed. St. Louis: Mosby; 2003.
Critical Areas
• Anterior and middle cranial fossa

• Anterior cranial fossa : cribiform plate
• Middle cranial fossa : sellar region,
cavernous sinus, vessels
• Pterygopalatine fossa
• Orbit
• Palate
4
CASE DISCUSSION
68-year-old female
Right nasal cavity mass
68y F, right nasal cavity mass
An enhancing T1 isointense/T2 hyperintense

mass with intracranial cystic portion, extending to
right-sided anterior cranial fossa and destructing
the right cribiform plate, medial wall of right
maxillary sinus and nasal septum, abutting right
inferior frontal lobe with surrounding vasogenic
edema. No definite brain invasion. Associated
mucous filling in the right frontal and right
maxillary.
No cervical lymphadenopathy
68-year-old female
Surgery with radiotherapy

Increased size of a few enlarged

lymph nodes at left cervical level
IV, and left supraclavicular region,
measuring up to 1.7x4.2 cm in size
68-year-old female
Esthesioneuroblastoma with LN metastasis

• Neural crest in origin
• Arises in olfactory mucosa • Heterogeneous signal and enhancement
• Nasal obstruction, • CT bone remodeling mixed with
epistaxis, anosmia destruction > cribiform plate
• Bimodal age range 2nd • Small lesions > upper nasal cavity mass,
and 6th decades homogeneous enhancement
• Large mass
• Anterior cranial fossa extension
• Dumbell shape mass
• Waist at level of cribiform plate
• Hemorrhagic foci
• ***Peripheral cyst
• Calcifications
• Look for neck adenopathy 20%
• Neural crest in origin
• Arises in olfactory mucosa • Heterogeneous signal and enhancement
• Nasal obstruction, • CT bone remodeling mixed with
epistaxis, anosmia destruction > cribiform plate
• Bimodal age range 2nd • Small lesions > upper nasal cavity mass,
and 6th decades homogeneous enhancement
• Large mass
• Anterior cranial fossa extension
Calcification Dumbell shape • Dumbell shape mass
• Waist at level of cribiform plate
• Hemorrhagic foci
• ***Peripheral cyst
• Calcifications
• Look for neck adenopathy 20%
Peripheral cysts Koch BL, et al. Diagnostic Imaging: Head and Neck. Elsevier Health Sciences; 2017
5
CASE DISCUSSION
13-year-old male
Nasal congestion (right > left) for 1 year
13y F, nasal congestion (right > left) for 1 year
A well-defined avid, heterogeneously enhancing mass, epicenter of

the mass in the right nasal cavity, involving the right PPF and
cause obstruction of the right OMU, right SER.
A lobulated avidly enhancing T1 isointense mass

occupying in right SPF, right PPF, right posterior
nasal cavity, right-sided nasopharynx, right sphenoid
sinus and right posterior ethmoid sinus
13-year-old male
Nasal congestion (right > left) for 1 year
Juvenile angiofibroma
S/P preoperative particle embolization x III
Sphenopalatine Foramen
• Benign vascular mass, angiomatous tissue
with fibrous stroma
• Adolescent male
• Presentation • Avidly enhancing mass centered
• Epistaxis, unilateral nasal obstruction at the sphenopalatine foramen
• Pain in cheek, swelling • Locally aggressive
• Feeding artery • Nasal cavity, nasopharynx,
• Dominant from internal maxillary artery sphenoid sinus, pterygopalatine
from ECA branch fossa, masticator space,
intracranial extension (via IOF,
vidian canal, foramen
rotundum)
• Benign vascular mass, angiomatous
tissue with fibrous stroma
• Adolescent male
• Presentation • Avidly enhancing mass centered
• Epistaxis, unilateral nasal obstruction at the sphenopalatine foramen
• Pain in cheek, swelling • Locally aggressive
• Feeding
Locally artery
aggressive • Nasal cavity, nasopharynx,
• dominant from internal maxillary artery sphenoid sinus, pterygopalatine
from ECA branch fossa, masticator space,
intracranial extension (via IOF,
vidian canal, foramen
rotundum)
Intratumoral flow void Koch BL, et al. Diagnostic Imaging: Head and Neck. Elsevier Health Sciences; 2017
Connecting lateral nasal wall with the
pterygopalatine fossa
Spreading of infection to orbit,
masticator space, intracranial space
Tatekawa H, et al. Imaging features of benign mass lesions in the nasal cavity and paranasal
sinuses according to the 2017 WHO classification. Jpn J Radiol. 2018 Jun;36(6):361-381.
6
CASE DISCUSSION
58-year-old male
Epistaxis, nasal congestion and numbness at left cheek
for 2 months
58y M, epistaxis, nasal congestion and numbness at left cheek for 2 months
58y M, epistaxis, nasal congestion and numbness at left cheek for 2 months
A enhancing infiltrative mass in left maxillary sinus, eroding nasal

septum, left orbital floor and lateral wall of left maxillary sinus
58-year-old male
Epistaxis, nasal congestion and numbness at left cheek for 2 months
Squamous cell carcinoma
• Malignant epithelial tumor with • Location > 80% involve maxillary antrum
squamous cell of epidermoid • Soft tissue mass, irregular margin
differentiation • Aggressive bone destruction
• Age : 50-70 years old • MRI T2 low signal > high NC ratio
• 15% adenopathy (SCC in maxillary sinus) • Less enhancement
• DDx • Perineural tumor spreading
• Sinonasal adenocarcinoma
• Sinonasal undifferentiated carcinoma
• Invasive fungal sinusitis
• Wegener granulomatosis
• Malignant epithelial tumor with • Location > 80% involve maxillary antrum
squamous cell of epidermoid • Soft tissue mass, irregular margin
differentiation • Aggressive bone destruction
• Age : 50-70 years old • MRI T2 low signal > high NC ratio
• 15% adenopathy (SCC in maxillary sinus) • Less enhancement
• DDx • Perineural tumor spreading
• Sinonasal adenocarcinoma
• Sinonasal undifferentiated carcinoma
• Invasive fungal sinusitis
• Wegener granulomatosis
7
CASE DISCUSSION
39-year-old female
clear fluid discharge via the right nose for 4 weeks
39y F, clear fluid discharge via the right nose for 4 weeks
A bony defect at inferolateral wall of the right sphenoid sinus, connecting to antero-infero-
medial aspect of the right middle cranial fossa
A bony defect at inferolateral wall of the right sphenoid sinus, connecting to the right middle cranial
fossa. Extension of CSF fluid and the brain tissue through the defect into the right sphenoid sinus
39-year-old female
clear fluid discharge via the right nose for 4 weeks

Meningoencephalocele/ CSF fistula
• Congenital
• Acquired
ü Trauma (M/C) → fracture, iatrogenic
ü Non-trauma → infection, tumor
ü Spontaneous
– No clear cause
– Middle-aged, obesity
– Increased intracranial pressure
AJNR, 2014
Spontaneous Lateral Sphenoid Cephalocele
Associated findings
• Arachnoid pits at greater wing of sphenoid
bone → alter CSF dynamic
• Pneumatization of lateral recess of
sphenoid sinus → thin wall
Meningocele: meninges + CSF

Meningoencephalocele/cephalocele: brain tissue
AJNR, 2014
MEMO
CASE DISCUSSION
• Anatomy of paranasal sinus and variations
• Surgeon need to know
• Inflammatory & tumor
• Fungal sinusitis
• Pseudopneumatized of sinus >
confirm on CT
• Main role of imaging = tumor mapping
• Host
• Immunocompetent or • Truly tumor > spontaneous
immunocompromised, DM? meningocele/encephalocele
• Do not biopsy!
• Tumor > surrounding structure (neighborhood)
• Malignant feature in PNS tumor
• Calcification in PNS
MEMO
CASE DISCUSSION
1. isolated sinus process VS sinonasal process
2. size (normal, small, expanded)
3. internal attenuation (isodense, hypodense, hyperdense, calcified)
4. bony margins (normal, thickened, sclerotic, thinned, eroded)
5. dental involvement
6. extension beyond the sinus
7. intracranial involvement or extension
8. enhancement

PARANASAL LESIONS CASE DISCUSSION

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PARANASAL

Normal Anatomy & Development

Middle Meatus Superior Meatus

Frontal Sinus Ostium

Anterior Ethmoid Air Cells Posterior Ethmoid Air Cells

Hiatus Semilunaris Superior Meatus

Sphenoid Sinus Ostium

1. isolated sinus process VS sinonasal process

Chronic frontal sinusitis with subgaleal

• Sinonasal infection/inflammation > 12 weeks

Chronic left sphenoid sinusitis: Opacified left sphenoid sinus

• Sinus mucosal thickening and opacification with

Chronic right maxillary inflammation: prominent calcifications

• Isolated ipsilateral • Ipsilateral frontal, anterior • Ipsilateral sphenoid,

• Polyps in PNSs & nasal cavity • Not related to ostial

Subperiosteal postseptal abscess

Cavernous sinus thrombosis

Soft tissue lesion at

- Fluid/blood retention in bilateral nasal

Chronic invasive fungal sinusitis

Denied surgery → conservative treatment

AIFR correlated most strongly with

100% specificity but in late-stage

Acute IFRS of sphenoid sinus can lead to

Fungus: usually high protein content (> 28%)

• Fungus ball, aspergilloma, chronic, noninvasive form of fungal sinus

T1 signal of solid, mycetoma

An expansile lobulated heterogeneous enhancing

Endoscopic tumor removal

Perineural tumor spreading

Metastatic lymph node

• Anterior and middle cranial fossa

An enhancing T1 isointense/T2 hyperintense

Surgery with radiotherapy

Increased size of a few enlarged

Esthesioneuroblastoma with LN metastasis

A well-defined avid, heterogeneously enhancing mass, epicenter of

A lobulated avidly enhancing T1 isointense mass

A enhancing infiltrative mass in left maxillary sinus, eroding nasal

Squamous cell carcinoma

Meningocele: meninges + CSF

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