Imaging Evaluation Para nasal Sinuses By: Ali Hekmatnia, MD Hossain Ahrar, MD

Sinonasal Overview

Sinonasal Overview

OSTIOMEATAL UNIT (OMU)

Sinonasal Overview

Sinonasal Overview

Sinonasal Overview

Neoplasms of PNS Very rare 3% Predominately of older males Delay in diagnosis due to similarity to benign conditions Maxillary sinus: 70% Ethmoid sinus: 20% Sphenoid: 3% Frontal: 1%

Benign Lesions Papillomas Osteomas Fibrous Dysplasia Neurogenic tumors Juvenile Angiofibroma

Papilloma Unilateral Fungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wall Unilateral Malignant degeneration in 2-13%

Inverted Papilloma CT: Lobular mass on lateral nasal wall ± maxillary/ethmoid extension or intralesional Ca++ • MR: "Convoluted," "cerebriform“ architecture on T2 & post-gadolinium images; necrosis = coexistent carcinoma

Inverted papilloma

Inverted papilloma

Inverted papilloma

Osteomas Benign slow growing tumors of mature bone Location: Frontal, ethmoids, maxillary sinuses When obstructing mucosal flow can lead to mucocele formation CT: Density varies from dense (compact type) to less ossified (fibrous type)

Osteoma

Osteoma

Mycetoma

Fibrous dysplasia Medullary bone replaced by woven bone Monostotic vs Polyostotic Facial bone involvement greater in polyostotic form CT/MR: Appearance varies with amount of fibrous tissue (classic "ground-glass“ appearance) Malignant transformation to rhabdomyosarcoma has been seen with radiation

Fibrous dysplasia

Fibrous dysplasia

Ossifying fibroma

Neurogenic tumors 4% are found within the paranasal sinuses Schwannomas Neurofibromas When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival). Imaging: Well-circumscribed mass with bone remodeling (CT) MR: Intermediate T1 signal T2 varies with cellularity; large lesions ± cystic degeneration

Nerve sheet tumor

Nerve sheet tumor

Nerve sheet tumor

Juvenile Angiofibroma Adolescent male patient with nasal obstruction and epistaxis Centered at sphenopalatine foramen with spread into pterygopalatine fossa, nasal cavity, and nasopharynx Vascular mass with flow voids and avid enhancement

Juvenile Angiofibroma

Juvenile Angiofibroma

Malignant lesions Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Adenocarcinoma Hemangiopericytoma Melanoma Olfactory neuroblastoma Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma Lymphoma Metastatic tumors Sinonasal undifferentiated carcinoma

Squamous cell carcinoma Patient demographics: Adult patient (95%> 40 years); M > F Location: Maxillary sinus (70%) Nasal cavity (20%) Poorly defined with aggressive bone destruction; heterogeneous enhancement

SCC

Lymphoma

Minor Salivary Glands Tumors 10% of PNS Tumors Adenoid Cystic Carcinoma Mucoepidermoid Carcinoma Perineural spread

Adenoid Cystic Carcinoma

Adenocarcinoma 2nd most common malignant tumor in ethmoidal air cells Strong association with occupational exposures like hardwood workers Adult (40-60 year old) male patient Nonspecific imaging features, but may be more well defined than squamous cell carcinoma and esthesioneuroblastoma

Adenocarcinoma

Adenocarcinoma

Melanoma 0.5- 1.5% of melanoma Malignancy from mucosal melanocytes; nasal cavity> sinuses Imaging: Soft tissue mass with bone remodeling ± destruction MR: high T1 & low T2 signal in melanotic form; enhance ± foci of hemorrhage

Melanoma

Melanoma

Olfactory Neuroblastoma Esthesioneuroblastoma Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. Adolescent or middle-aged patient with unilateral nasal obstruction and mild epistaxis Morphology: "Dumbbell-shaped" mass centered at cribriform plate CT: Intralesional Ca++ MR: Avid enhancement; foci of hemorrhage; intracranial cyst formation

Esthesioneuroblastoma

Esthesioneuroblastoma

Sarcomas Osteogenic Sarcoma Fibrosarcoma Chondrosarcoma Most common primary malignancy of bone. Mandible > Maxilla Sunray radiographic appearance Fibrosarcoma Chondrosarcoma Rabdomyosarcoma: in children

Chondrosarcoma

Chondrosarcoma

Osteosarcoma

Rabdomyosarcoma

Fungal Sinositis

Fungal Infection, Invasive

Lymphoma Most common tumor of PNS Non-Hodgkin type nasal cavity> sinuses CT: Homogeneous and may be hyperdense relative to other soft tissue MR: Homogeneous signal and enhancement; decreased T2 signal due to high nuclear :cytoplasmic ratio of cells

Lymphoma

Lymphoma

Metastatic Tumors Breast and lung carcinoma most common primaries Widespread skeletal metastases present

Metastasis

Thanks for your attention