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

2. Sinonasal Overview

3. Sinonasal Overview

4. OSTIOMEATAL UNIT (OMU)

5. Sinonasal Overview

6. Sinonasal Overview

7. Sinonasal Overview

8. 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%

9. Benign Lesions Papillomas Osteomas Fibrous Dysplasia Neurogenic tumors
Juvenile Angiofibroma

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

11. 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

13. Inverted papilloma

15. Inverted papilloma

17. Inverted papilloma

18. 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)

20. Osteoma

22. Osteoma

24. Mycetoma

25. 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

27. Fibrous dysplasia

29. Fibrous dysplasia

31. Ossifying fibroma

32. 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

34. Nerve sheet tumor

36. Nerve sheet tumor

38. Nerve sheet tumor

39. 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

41. Juvenile Angiofibroma

43. Juvenile Angiofibroma

44. 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

45. 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

47. SCC

49. Lymphoma

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

52. Adenoid Cystic Carcinoma

53. 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

55. Adenocarcinoma

57. Adenocarcinoma

58. 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

60. Melanoma

62. Melanoma

63. 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

65. Esthesioneuroblastoma

67. Esthesioneuroblastoma

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

70. Chondrosarcoma

72. Chondrosarcoma

74. Osteosarcoma

76. Rabdomyosarcoma

78. Fungal Sinositis

80. Fungal Infection, Invasive

81. 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

83. Lymphoma

85. Lymphoma

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

88. Metastasis

89. Thanks for your attention