SINONASAL

IMAGING

Kim O. Learned, MD
Assistant Professor
Department of Radiology/Division of
Neuroradiology
University of Pennsylvania Health System
REVIEWS
•Key Anatomy:
•Sinus Drainage Pathways

•Practical approach to CT and MR

•Pathologies
 DRAINAGE PATHWAYS
Ostiomeatal Units
• Anterior  Middle Meatus
• Frontal sinus
• Maxillary sinus
• Anterior Ethmoid air cells

• Posterior  Superior Meatus

• Sphenoid sinus
• Posterior ethmoid air cells
 Ostio-Meatal Unit
Anterior OMU Middle Meatus

• Frontal sinus Ostium & Recess

• Maxillary sinus ostium
• Infundibulum
• Anterior Ethmoid cells
 Sphenoethmoidal Recess
Posterior OMU

• Sphenoid sinus Ostium

• Sphenoethmoidal Recess
• Posterior Ethmoid cells
• Superior Meatus
 Ventral Skull Base

Nasal vault: Cribriform plate

Ethmoid Fovealis (frontal bone)
Planum Sphenoidale
Skull Base
• Pterygo-Maxillary Fissure  Pterygo-Palatine
Fossa (PPF)  Foramen Rotundum 
Cavernous sinus
• Inferior orbital fissure  Orbital Apex
PRACTICAL APPROACH
Sinonasal Imaging

Pathology

Location
Pattern

CT  MR
 Approach to CT Calcification
•Fungus ball center, punctate
•Concretion of CRS: periphery, egg-shell,
marginated
 Approach to CT Calcification
•Chondroid/Osteoid Matrix
•Bone Destruction or Dehiscence
 Approach to CT
Attenuation

•Low density: Mucoid, Fluid, Polyps

•Hyperdense: Fungus, Concretion, Blood

•Soft tissue: Neoplasm, Scar, Thick Secretion

 Approach to CT
Bone changes
Deficiency/Dehiscence Destruction/Erosion

 Long standing  Aggressive

• Mucocele, Polyps, IP • Tumor
• SCCA, SNUC, SNEC,
esthesioneuroblastoma
• Slow growing neoplasm
• Lymphoma, RCC met
• Schwannoma

• Osteomyelitis sinusitis
?Cephalocele • Invasive fungal sinusitis
• Granulomatous disease
 Fibrous Dysplasia

•Begin and End with CT

Why MR ?

Pathology

Location
Pattern

CT  MR
SINONASAL IMAGING

• Begin and end with CT:

• Bone change
• Bone Matrix
• MR:
• Tissue characteristic
• Extent
• Intracranial
 Approach to MR
↑ T2, Peripheral Gd + ↕ T2, Solid Gd +
Retention cyst •Neoplasm
 Submucosal Mucinous/Serous gland
collection
 Partially aerated sinus
Polyp
 Fluid deep to lamina propria
 Mass effect
Mucocele
 Trapped secretion in obstructed sinus
 Airless Expanded sinus
 Sinonasal Polyposis
Frontal Mucocele

 Polypoid T2 Hyperintensity Polyps

 MR Pitfall: concretion & fungus signal void
 Severe Deficiency at skull base mimics Destruction
Mucocele, Sinonasal Polyposis, Inverted Papilloma
 Acute Sinusitis
Complications

T2 hyperintensity  NOT tumor

Osteomyelitis Sinus
Epidural empyema
Meningitis, Cerebritis
Tumor Mapping
PATTERN Approach

• Diffuse/Pan-sinus  Rhinosinusitis

• Focal Obstructive pattern 

• Rhinosinusitis
• Neoplasm
RhinoSinusitis
• Poor Correlation of Symptoms with CT/Endoscopy

• Acute RS: 1-4 weeks

• Bacterial infection
• Fluid level

• Chronic RS: 12 weeks

• Multiple factors, Idiopathic, Allergy, Impaired Cilliary
function, Granulomatous disease
• Hypertrophic Mucosa, Polyp, Scar, Atrophy
• Osteitis  Neo-osteogenesis
Chronic Rhino-Sinusitis

Neo-osteogenesis

 Cystic Fibrosis
o Bronchiectasis
o Hypoplastic sinuses
 Wegener, Sarcoid,
Churg Strauss
o Chronic inflammatory/
granulomatous
destruction
o Systemic disease
Pan-sinusitis
Polypoid Opacification
•Allergic Rhinosinusitis
•Sinonasal Polyposis
•Allergic Fungal Sinusitis

Jack Jill
 Fungal Sinusitis
Immuno-competent Immuno-compromised
Non-invasive Invasive
 Mycetoma  Acute
Immunocompromised, DM
 Allergic Fungal Sinusitis  Chronic
DM
 Allergic Fungal Sinusitis

 High density  NOT tumor

 Inspissated secretion or fungal
 Focal or Diffuse
 Allergy, Fungus-specific IgE, Allergic Mucin
 Debridement, Path: no invasion of mucosa
 Rx steroid
Acute Invasive Fungal Sinusitis
Mucormycosis

25 yo
ALL

Path shows Fungal invasion:

Mucosa  dark ulcer
Vessel  vasculitis, thrombosis, hemorrhage, tissue infaction
 Invasion of Orbit & CNS
 Angioinvasive Fungal Sinusistis
Mycotic Aneurysm

68 yo NHL on Chemotherapy,
ESRD on HD. Acute right eye
ptosis blurry vision
 Chronic Invasive Fungal Sinusitis

3 WEEKS

• Epidural abscess, Meningitis, Cerebritis, Abscess

• Slowly progressive, low-grade invasive fungal infection
• Path: Necrosis of the mucosa, submucosa, and blood
vessels, with low-grade inflammation
 PATTERN
Diffuse Pansinus 
Rhinosinusitis

•Focal Obstructive pattern 

• Rhinosinusitis
• Neoplasm
 OMU obstructive lesion

Inverted Papilloma
Cerebriform pattern can be seen
with other neoplasm

? Antrochoanal
polyp
PRACTICAL APPROACH
Sinonasal Imaging

Pathology

Location

Pattern
CT  MR
 Approach to
Sinonasal Neoplasm
•Location  Pathology

•Imaging feature

•Clinical presentation
 Sinonasal Neoplasm
• Most common locations for Primary CA:
• Maxillary sinus > Nasal cavity > Ethmoid cells
• Frontal/Sphenoid < 2 %

• Most common tumors in Adults

• SCCA >> Esthesioneuroblastoma, Melanoma, Adenoid cystic
carcinoma

• Odontogenic (Odontoma, Ameloblastoma)

• Osteoid/Chondroid
• Fibrous dysplasia
• Osteo/Chondro-Sarcoma
 Obstructive Lesions

• OMU:
• Infundibulum-Maxillary ostium
• Frontal recess

• Nasal cavity

• Naso-ethmoidal

• Sphenoid sinus
 Nasal Cavity lesion
• Nasal septum
• Lateral nasal wall
• Inferior turbinate

↑ T1 of Melanin Melanoma
 Esthesioneuroblastoma

• Widening of Nasal vault

• Intermediate T2
• Enhancement (Similar to mucosa)
 Sphenoid sinus
•Rarely sinonasal tumor
•Adjacent process
•Fungal Sinusitis
•Pituitary adenoma
•Clival/skull base lesion
AFS
 Osteosarcoma

Focal disease
Maxillary sinus

Sunburst periostitis
Ameloblastoma

• Soap-Bubble lesion
• Hard, painless. 30-50 yo. 2nd most common odontogenic lesion
• 20 % Maxilla. 20% associated with Dentigerous cyst & unerupted teeth
• Locally aggressive, high recurrence
• Simple or luminal (mural): Without or with nodule(s) in the wall of
the cyst
Nasal obstruction
Refractory seizure x 13 years
Juvenile Nasopharyngeal
Angiofibroma

• Internal maxillary artery feeder

• Tumor starts in the nose, spreads to NP
• Benign, locally invasive
• Adolescent male
• Tx: preop embolizationresection adjuvant radiation for
unresectable intracranial disease
 References
 Daniels DL, et al. The Frontal Sinus Drainage Pathway and Related Structures.
AJNR 2003 Sep;24(8):1618-27.
 Huang BY, et at. Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in
the Frontal Recess. Radiographics 2009
 Younis R et at. The role of computed tomography and
magnetic resonance imaging in patients with sinusitis with complications.
Laryngoscope 2002;112(2):224–9.
 Stewart MG, et al. Chronic sinusitis: symptoms versus CT scan findings. Curr
Opin Otolaryngol Head Neck Surg 2004 Feb;12(1):27-9.
 Som PM, et al. Sinonasal tumors and inflammatory tissues: differentiation with
MR imaging. Radiology 1988;167(3):803–8.
 Yousem DM. Imaging of sinonasal inflammatory disease. Radiology
1993;188(2):303–14.
 Yoon JH, et al. Calcification in Chronic maxillary sinusitis: comparison of CT
findings with histopathologic results. AJNR 1999;20:571-74
 Ilica AT, et al. Clinical and Radiologic features of fungal diseases of the
paranasal sinuses. Comput Assist Tomogr. 2012 Sep;36(5):570-6
 Loevner LA, Sonners AI. Imaging of neoplasms of the paranasal sinuses.
Neuroimaging Clin N Am 2004 Nov;14(4):625-46.
 Jeon T.Y, et al. Sinonasal Inverted Papilloma: Value of Convoluted Cerebriform
Pattern on MR Imaging. AJNR 29:1556–60