An Atlas of Imaging of

the Paranasal
.
Sinuses
An Atlas of Imaging of the
Paranasal Sinuses
Lalitha Shankar
Department of Diagnostic Imaging
University of Toronto
St Joseph's Health Centre
Toronto
Canada

Kathryn Evans
Ear, Nose and Throat Department
St Bartholomew's Hospital
London
United Kingdom

Michael Hawke
Department of Otorhinolaryngology
University of Toronto
Canada

Heinz Stammberger
University Ear, Nose and Throat Hospital
Graz
Austria

Martin Dunitz London

J.B. Lippincott Company Philadelphia

Contents

Contributors vi
Preface vii
Acknowledgments viii

1 Introduction to functional endoscopic sinus surgery 1

2 Nasal physiology 5

3 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 1O

4 Basic principles of radiography of the nasal cavity and paranasal sinuses 24

5 The role of conventional radiographs in paranasal sinus disease 33

Martyn Mendelsohn Arnold Noyek

6 The normal anatomy of the paranasal sinuses as seen with Computed Tomography and
Magnetic Resonance Imaging 41

7 The role of anatomic variants of the ostiomeatal complex and paranasal sinuses 73

8 The radiologic appearance of benign inflammatory paranasal sinus disease 82

9 The radiologic appearance of tumors and tumor-like conditions of the paranasal

sinuses 106

1 O The postoperative appearances of the paranasal sinuses 122

11 Basic principles of Magnetic Resonance Imaging of the paranasal sinuses 140

12 Magnetic Resonance Imaging of inflammatory conditions and tumors of the paranasal

sinuses 148

13 Three-dimensional reconstruction imaging of the paranasal sinuses 172

Neal Lofchy John Stevens Judy Trogadis

14 Computer-assisted surgery of the paranasal sinuses 179

Ludger Klimek Ralph Mosges Michael Hawke

15 The ostiomeatal unit in childhood 186

Sunil Ummat Michael Riding David Kirkpatrick

Bibliography 199
Index 204
Contributors

Kathryn Evans Arnold Noyek

Ear, Nose and Throat Department, St Department of Otorhinolaryngology and Department
Bartholomew's Hospital, London, United Kingdom of Radiology, University of Toronto; Department of
Otorhinolaryngology, Mount Sinai Hospital, Toronto,
Michael Hawke Canada

Department of Otorhinolaryngology, University of

Toronto, Canada
Michael Riding
Department of Radiology, Dalhousie University,
David Kirkpatrick Halifax, Canada

Department of Otolaryngology, Dalhousie

University, Halifax, Canada
Lalitha Shankar
Department of Diagnostic Imaging, University of
Ludger Klimek Toronto, St Joseph's Health Centre, Toronto,
Canada
Department of Otorhinolaryngology, Plastic Surgery
of the Head and Neck, Medical Faculty, Aachen
Technical University, Germany
Heinz Stammberger
University Ear, Nose and Throat Hospital, Graz,
Neal Lofchy Austria

Department of Otorhinolaryngology, University of

Toronto, Canada
John Stevens
The Eye Institute, Toronto Western Division, The
Martyn Mendelsohn Toronto Hospital, Canada

Department of Otorhinolaryngology, Mount Sinai

Hospital, University of Toronto, Canada
Judy Trogadis
Volume Investigation Laboratory, Toronto Western
Ralph Mosges Division, The Toronto Hospital, University of
Toronto, Canada
Department of Otorhinolaryngology, Plastic Surgery
of the Head and Neck, Medical Faculty, Aachen
Technical University, Germany
Sunil Ummat
Department of Otolaryngology, Dalhousie
University, Halifax, Canada
Preface

This atlas attempts to provide a comprehensive interpretation of the various anatomic variants,
review of the current imaging modalities that play pathology and postoperative changes in the
an important role in the management of sinonasal paranasal sinuses will use this book to enhance
disease. Computed tomography (CT) and magnetic their clinical knowledge.
resonance (MR) imaging have revolutionized the It is obvious that technology continuously plays a
diagnosis of diseases of the paranasal sinuses. leading role in the practice of medicine. New tech­
These imaging techniques can generate images in niques constantly change the management of
any desired plane. This atlas will familiarize the various disorders: CT and MR images are the
reader with the normal anatomy and the common present-day gold standards in the management of
pathological entities as seen by these modalities. It paranasal sinus disease.
will also enable the otorhinolaryngologist to LS
become competent in interpretation of CT and/or MH
MR images. We hope that practicing radiologists KE
who wish to develop greater proficiency in the HS
1
Introduction to functional endoscopic sinus
surgery

The concept of functional endoscopic sinus surgery Hilding, in 1944, elegantly demonstrated in
was developed by Professor Walter Messerklinger in animals that there were definite pathways along
Graz, Austria, in the early 1970s following extensive which the cilia transported and cleared the mucus
research into the pathophysiology and anatomy of produced within a sinus, and that the mucus would
the paranasal sinuses. Messerklinger's concepts inevitably pass to and through the natural ostium
have revolutionized, improved and radically altered despite the presence of an inferior meatal intranasal
the techniques used for the diagnosis and treatment antrostomy, which would be circumnavigated. The
of patients with sinus disease. The concepts of importance of this work was not realized at the time
functional endoscopic sinus surgery were popular­ and intranasal antrostomies and Caldwell-Luc pro­
ized and exported from the German-speaking cedures remained the mainstay of surgical treat­
countries by Heinz Stammberger in 1984 and David ment.
Kennedy in 1985. Messerklinger's research established that the
Endoscopic sinus surgery evolved from a combi­ health of the frontal and the maxillary sinuses is
nation of the techniques of intranasal surgery, which subordinate to the anterior ethmoid, as these
originated in the nineteenth century, and from sinuses are ventilated from and drain into the nasal
endoscopy of the lateral nasal wall, a technique that cavity via their prechambers (the frontal recess at
was initially used only as a diagnostic tool. the entrance to the frontal sinus and the ethmoid
Intranasal surgery to facilitate the drainage of infundibulum at the entrance to the maxillary sinus)
purulent secretions was initially reported in the late which connect their ostia to the middle meatus. He
nineteenth century. Inferior meatal antrostomy also demonstrated that occlusion of the narrow and
(fenestration) was described in the late 1890s and stenotic clefts {prechambers) of the ethmoid
middle meatal antrostomy in 1886 by Mikulicz and labyrinth, which connect the ostia of the frontal and
again in 1899 by Siebenmann. At that time it was maxillary sinuses to the anterior ethmoid led to disor­
noted that middle meatal antrostomies did not dered ventilation and decreased mucociliary clear­
stenose with the same rapidity as did those ance from the larger (the frontal and maxillary)
performed in the inferior meatus; however, the paranasal sinuses and therefore predisposed the
surgeons of those pre-antibiotic times were deterred patient to recurrent infections in these larger
by the close anatomic relationship of the orbit to the sinuses.
site of the middle meatal antrostomy. Messerklinger noted that infection of these larger
Inflammatory disease of the paranasal sinuses sinuses was usually rhinogenic in origin, spreading
requiring surgery has until recently been treated from the nose through the anterior ethmoid to
surgically with radical procedures such as the involve the frontal and maxillary sinuses secondarily.
Caldwell-Luc radical antrostomy, intranasal eth­ He also demonstrated that, despite the fact that the
moidectomy and external frontoethmoidectomy. All symptoms of infection in these larger sinuses were
of these radical surgical procedures ·involve the usually clinically dominant, the underlying cause was
extensive removal of diseased mucosa. While these generally not to be found in the larger sinuses
procedures should not be totally excluded from the themselves, but instead in the clefts of the anterior
list of available surgical options for the treatment of ethmoid in the lateral nasal wall (Figure 1.1).
benign sinus disease, the majority of patients with Messerklinger observed that, when infections in the
chronic sinusitis are more appropriately treated with frontal and maxillary sinuses did not heal or recurred
the minimally invasive and more conservative promptly, a focus of infection usually persisted in
technique of functional endoscopic sinus surgery. one of the narrow clefts of the anterior ethmoid, with
2 An atlas of imaging of the paranasal sinuses

the focus of infection interfering with normal ventila­ the endoscopes to perform a precise surgical resec­
tion and drainage of the sinuses, the infection tion under direct vision.
spreading locally to involve the prechambers and The precise surgical techniques aimed at restor­
secondarily the larger sinuses. ing normal physiological conditions and the preser­
Messerklinger also noted that after a limited vation of as much mucosa as possible have only
endoscopic resection of the disease within the developed with the additional anatomic and patho­
anterior ethmoid that was responsible for the physiologic information that has been provided by
obstruction of the ventilation and drainage pathways radiographic imaging. Indeed, functional endoscopic
of the larger paranasal sinuses, and the re-estab­ sinus surgery has only been developed to its current
lishment of drainage and ventilation through the level because of the advances that have occurred in
natural pathways, even massive mucosa! pathology the fields of radiology.
within the frontal and maxillary sinuses usually Messerklinger's initial work in Graz was conducted
healed without direct surgical intervention into these with information derived from conventional
larger sinuses (Figure 1.1 ). Mucosa! changes within tomographs. This technique has now been super­
the frontal and maxillary sinuses that had previously seded by computed tomography (CT) and such
been regarded- as irreversible returned to normal imaging is now considered an essential component
several weeks following what was essentially a of the diagnostic investigation of patients presenting
minimal, endoscopically controlled resection of with symptoms suggestive of benign inflammatory
disease. disease of the paranasal sinuses. CT is the ideal
In summary, the key theory of functional endo­ method for the demonstration of the delicate bony
scopic sinus surgery is that by removing localized leaflets of the ethmoid labyrinth. It also identifies
disease obstructing the narrow ethmoidal clefts, and those anatomic variants that may compromise the
thereby restoring normal mucociliary drainage and ventilation of the sinuses, and it can demonstrate
ventilation, spontaneous resolution of the mucosa! those discrete areas of diseased mucosa that are
disease in the maxillary and frontal sinuses will responsible for recurrent disease in the larger
follow without the need for radical mucosa! excision. paranasal sinuses (the frontal and the maxillary
Developments in both the design of diagnostic sinuses). The majority of these latter abnormalities
endoscopes and the re-evaluation of radiographic will not be evident on even careful diagnostic
imaging have been instrumental in the evolution of endoscopic assessment. Because the rhinologist is
these endoscopic surgical techniques. Hirschmann interested in the detail of the fine structures within the
first described endoscopy of the nasal cavities in lateral wall of the nose, the radiologists will have to
1903. He used an instrument that was designed as direct their focus towards the drainage pathways and
a cystoscope. There were many subsequent prechambers of the larger paranasal sinuses and
attempts by a variety of rhinologists to develop a away from the obvious abnormalities that may be
more sophisticated instrument. The development of secondarily present in the larger paranasal sinuses.
the operating microscope in the early 1950s CT is now regarded as essential when the patient
improved the intraoperative view of the nasal cavity, has undergone previous sinus surgery. In this situa­
especially that of the posterior ethmoid and tion, the scans will provide valuable information
sphenoid sinuses. The main disadvantage to the about the presence of potential hazards such as
microscope was its straight visual field which did not dehiscence of the lamina papyracea, the proximity
permit an adequate view into the ethmoid clefts. of the orbit to areas of disease, or septation of the
The development of fiberoptic rod telescopes by frontal or sphenoid sinuses, and about the location
Hopkins in the late 1950s was a dramatic advance. of the internal carotid artery and optic nerve. Other
This optical system includes a light source distant important variations, such as a low-lying ethmoid
from the instrument and a quartz-rod air-lens fovea and cribriform plate, and adhesions of the
system that provides excellent resolution with high uncinate process to the medial orbital wall, will be
contrast and, despite the small diameter of the discussed in subsequent chapters.
endoscope, a wide field of vision. With the addition A systematic endoscopic assessment of the lateral
of angled lenses, these endoscopes have made it nasal wall in conjunction with CT of the nose and
possible to examine in detail the clefts and recesses paranasal sinuses allows the precise localization of
of the nasal cavity (Figures 1.2-1.4). Initially, they the underlying disease processes and thus aids the
were used only for diagnostic purposes; however, clinician in planning the appropriate therapy. The
Messerklinger showed that it was possible to intro­ ability to radiologically identify those abnormalities
duce appropriately designed instruments alongside that may increase surgical morbidity prior to
 Introduction to functional endoscopic sinus surgery 3

commencing the surgical dissection is important The aim of this book is to provide a simple concise
both for the surgeon and the patient. atlas to introduce both rhinologists and radiologists
Understandably, there is considerable interest to the essential concepts of functional endoscopic
amongst both radiologists and rhinologists in the sinus surgery, and to point out the relevant anatomy
radiologic anatomy of the paranasal region. Until and, in particular, the anatomic variants that may
recently, knowledge of the required radiographic predispose the patient to recurrent sinusitis. This
techniques, anatomy and significant pathology of the information is important to both surgeons and radi­
structures identified by CT has not been included in ologists so that the CT scans can be interpreted
the curriculum of most radiologists. prior to and at the time of surgery.
4 An atlas of imaging of the paranasal sinuses

Figure 1.1 Figure 1.2

This schematic drawing demonstrates the key diseased area of Concha bullosa: endoscopic view. The grossly widened left
the anterior ethmoid on the left. The situation after functional middle tubinate contained a single large air cell. This type of
endoscopic sinus surgery is shown on the right. middle turbinate is known as a concha bullosa.

Figure 1.3 Figure 1.4

Chronic sinusitis: endoscopic view. This patient presented with Nasal polyps: endoscopic view. Several yellowish nasal polyps
left-sided chronic maxillary sinusitis. Note the creamy white can be seen arising from the right middle meatus.
purulent material draining from the left semilunar hiatus.
2
Nasal physiology

The nose and paranasal sinuses have multiple more viscous layer, the gel phase which is trans­
functions that include the provision of an upper ported on top of the sol phase by the ciliary beat.
respiratory air channel, filtering and humidification of The balance between the underlying sol phase and
inspired air, olfaction, vocal resonance, speech and the outer gel phase is critically important for the
nasal reflex functions. For the purpose of this text, maintenance of normal mucociliary clearance. Under
attention will only be drawn towards those functions normal conditions dust and other fine particles
which are of significance in the pathogenesis of become incorporated into the gel phase and are
sinusitis, or in the interpretation of sinus radiographs transported with the mucus out of the sinuses. The
and computed tomographs (CT) of the paranasal mucous layer is continuously produced and steadily
sinuses. transported away from the sinus. A healthy maxillary
The nose and paranasal sinuses are lined with a sinus renews its mucous layer on average every 20
ciliated, pseudostratified columnar epithelium, to 30 minutes.
beneath which lies the tunica propria, containing
serous and mucous glands. The main function of the
nose is to transmit, filter, warm and humidify the
inspired air. The two most important factors VENTILATION AND DRAINAGE
contributing to the maintenance of the normal physi­
ology of the paranasal sinuses and their lining of The ostia of the two largest and clinically most
mucous membranes are drainage and ventilation. important sinuses, the frontal and the maxillary
Normal drainage of the paranasal sinuses requires sinuses, communicate with the middle meatus by
a complex balance between the production of very narrow and delicate 'prechambers'. The frontal
mucous and its transportation through and out of the sinus opens into an hour-glass shaped cleft, the
sinus. This balance is to a large extent dependent frontal recess (Figure 2.3). The maxillary sinus
upon the amount of mucus produced within the ostium opens into a cleft in the lateral nasal wall, the
sinus, and its composition and viscosity, the effec­ ethmoid infundibulum (Figure 2.4). Both of these
tiveness of the ciliary beat, mucosa! reabsorption clefts or prechambers (the frontal recess and the
and the condition of the ostia and the ethmoid clefts infundibulum) are part of the anterior ethmoid
through which the mucus must pass on its way into complex. If these prechambers become obstructed,
the nasal cavity. Ventilation and drainage of the then the drainage and ventilation of the frontal and
frontal and maxillary sinuses depend primarily upon maxillary sinuses will be impaired, and a secondary
the patency of both the actual sinus ostia and their infection within these sinuses is likely to develop.
ethmoid prechambers, which connect the ostia with The nasal mucosa is innervated by the autonomic
the nasal cavity via the anterior ethmoid. nervous system, with parasympathetic stimulation
causing an increased serous type of secretion and
sympathetic stimulation causing an increased
mucinous secretion.
SECRETION OF MUCUS
Under normal conditions the mucous blanket that
covers and protects the nasal mucosa is continu­ NASAL BLOOD FLOW AND
ously produced by the mucoserous nasal glands and SUPPLY
the intraepithelial goblet cells. The mucous blanket
has two layers, an inner serous layer which is called The nasal mucosa has an abundant blood flow
the sol phase in which the cilia beat, and an outer which is derived from both the internal and the exter-
6 An atlas of imaging of the paranasal sinuses

nal carotid arterial systems. The main arterial supply on the autonomic control of the blood flow and on
is derived from the sphenopalatine branch of the the nasal cycle.
maxillary artery, as well as contributions from the The erectile tissue of the nasal cavity is also
anterior and posterior ethmoidal branches of the affected by postural changes. For example, when
ophthalmic artery. lying on one'S' side in bed, the mucosa of the depen­
Special areas of erectile cavernous tissue overlie dent nasal cavity slowly undergoes engorgement as
the inferior turbinate and the inferior margin and blood pools in the venous sinusoids under the effect
posterior end of the middle turbinate. Similar tissue of gravity.
may also be present in the submucosa of the nasal
septum anteriorly, where it is known variously as the
'septal swell body', the 'tuberculum septi' or as the
'tumescence of Zuckerkandl' (Figure 2.1 ).
The autonomic nerve supply of the blood vessels THE NASAL CYCLE
is derived from the superior cervical sympathetic
ganglion and from the sphenopalatine ganglion, The nasal cycle is the term used to describe the
which relays the parasympathetic nerve fibers. normal paradoxical opening and closing of alternate
Sympathetic stimulation causes vasoconstriction and sides of the nasal airway. This normally alternates
parasympathetic stimulation causes vasodilatation. from side to side approximately every 2-3 hours.
Blood flow can be affected by a variety of local The factors controlling the nasal cycle are at present
factors, including temperature, humidity, trauma and unknown (Figure 2.6).
infection, as well as by the administration of vaso­ Zinreich and Kennedy (1988c) have demonstrated
dilator or vasoconstrictor drugs. Blood flow is also the cyclical changes of the nasal cycle in normal
altered by hormonal change, i.e. hyper- and hypo­ volunteers using magnetic resonance imaging. On
thyroidism, as well as by estrogens being raised T2-weighted scans, the increase in signal intensity
during menstruation and pregnancy. Emotional and mucosal volume was seen to be limited to the
stress may cause either vasoconstriction or vaso­ turbinates (inferior and middle), the ethmoidal
dilatation. prechambers and the nasal septum. These changes
Our experience with the administration of topical alternated from side to side over the course of the
nasal decongestants prior to CT examination day. This increased signal intensity is indistinguish­
demonstrated several changes in the nasal mucosa able from inflamed mucosa. To define the extent of
following the administration of 0.1 % xylometazoline inflammation separate from the normal nasal cycle,
hydrochloride nasal solution (Figures 2.2, 2.5). topical decongestants can be administered. This
There was shrinking of the inferior turbinates and of results in a prompt reversal of the nasal cycle.
the nasal swell body. The middle turbinates and the Malignancy, such as squamous cell carcinoma, has
ethmoidal prechambers remained unaffected. a low signal intensity relative to brain on T2-
The extent of vasodilatation (thickness) of the weighted images, so that it can be easily differenti­
nasal mucosa has a great effect upon the resistance ated from the normal nasal cycle and from inflamed
of the nasal airway. Vasodilatation is dependent both mucosa.
 Nasal physiology 7

2.1

2.2A 2.28

Figure 2.1 Figure 2.2

The septa! swell body. The bulbous swelling on the anterior The effects of topical decongestants. The effect of a topical
nasal septum in this coronal CT scan is produced by an area nasal decongestant upon the nasal mucous membranes is
of submucosal erectile tissue known variously as the nasal illustrated in this pair of photographs. The coronal CT scan
septa! swell body, the tuberculum septi and the tumescence of seen in A was taken prior to the administration of a 0.1 %
Zuckerkandl. solution of xylometazoline. Note, in 8, the vasoconstriction of
the inferior turbinates 10 minutes after the application of the
topical nasal decongestant solution.
8 An atlas of imaging of the paranasal sinuses

2.3

2.4A 2.48

Figure 2.3 Figure 2.4

This schematic drawing shows the normal mucociliary These schematic drawings show the normal transportation
transportation route inside and out of the frontal sinuses. FO, pathways of mucus inside (A) and moving out of (B) a maxillary
the frontal sinus ostium; FR, the frontal recess, which is the sinus. EB, the ethmoid bulla; MO, the maxillary sinus ostium.
ethmoid prechamber which connects the frontal sinus ostium to Note the infundibulum, the prechamber which connects the
the anterior ethmoid. (After Stammberger, 1991.) maxillary sinus ostium with the nasal cavity via the semilunar
hiatus. The infundibulum is the space lying between the
uncinate process and the ethmoid bulla. (After Stammberger,
j 991.)
 Nasal physiology 9

2.5A 2.58

2.6

Figure 2.5 Figure 2.6

The effects of topical decongestants: endoscopic view. The The nasal cycle. The engorgement and vasodilatation of the left
submucosal layer of the inferior turbinates contains large areas inferior turbinate from the normal nasal cycle is seen in this T2-
of erectile tissue. The view in A is of a normal left inferior weighted MR scan as a hyperintense (white) area.
turbinate: the anterior end of the left middle turbinate can just
be seen above and posterior to the inferior turbinate. The same
inferior turbinate is seen in B 1 O minutes after the application of
a topical nasal decongestant. The inferior turbinate is much
smaller and the anterior end of the middle turbinate is more
readily seen.
3
Gross and sectional anatomy of the nasal
cavity and paranasal sinuses

The nasal cavity is a midline structure extending of the nasal septum. These deviations may occur in
from the base of the skull to the roof of the mouth. either the cartilaginous septum, the bony septum or
It is divided in the midline by the nasal septum into in both parts. The nasal septal cartilage may be
two symmetrical nasal fossae (Figure 3.1 ). The dislocated from the maxillary crest. Such deviations
nasal cavity communicates anteriorly through the may be due to asymmetrical growth or trauma, either
nares with the exterior and posteriorly through the during parturition or at a later date. There is not
posterior choanae with the nasopharynx. The nasal infrequently an apparent thickening of the cartilagi­
cavity also communicates through the lateral nasal nous nasal septum in its upper third, known as the
wall with the maxillary and frontal sinuses, and more tuberculum septi or nasal septal swell body,
posteriorly with the sphenoid sinuses. described by Zuckerkandl. This is caused by an area
The roof of the nasal cavity is formed by the nasal of rudimentary erectile tissue found on each side of
and frontal bones anteriorly; the cribriform plate of the septum. This swell body often overlies a thick­
the ethmoid bone in the middle; and the sphenoid, ening of the bony septum.
alae of the vomer and the sphenoidal process of the The lateral wall of the nasal cavity can be divided
palatine bone posteriorly. The cribriform plate, into three parts. Anteriorly the lateral nasal wall
which is only 2-3 mm wide, is perforated by approx­ consists of the frontal process of the maxilla and the
imately 20 foramina which transmit fibers of the lacrimal bone. The middle portion is formed by the
olfactory nerve. The thin lateral lamina of the cribri­ ethmoid labyrinth, the maxilla and the inferior
form plate is the most vulnerable area surgically turbinate. The posterior portion of the lateral nasal
(Figure 3.2). wall is formed by the perpendicular plate of the
The floor of the nasal cavity is formed by the palatine bone and the medial pterygoid plate of the
bones of the hard palate, namely the palatine sphenoid. Protruding from the lateral wall are three
process of the maxilla anteriorly and the horizontal shelf-like structures, the superior, middle and
plate of the palatine bone posteriorly. inferior turbinates with their corresponding meatus
The medial wall of each nasal cavity is formed by inferolaterally. The lateral wall of the nasal cavity
the nasal septum which passes from the roof of the (Figures 3.3-3.5) will be discussed in greater detail
cavity to the floor. The nasal septum is partly bony later.
and partly cartilaginous. The anterior attachment of Anteriorly the nasal cavity communicates with the
the cartilaginous septum is with the upper and lower exterior through the piriform aperture of the maxilla,
lateral nasal cartilages superiorly, and the maxillary the nasal bones and the cartilage comprising the
crest inferiorly. An accessory cartilage of Huschke external nose.
may lie along this latter articulation and narrow the Posteriorly the nasal cavity communicates with the
nasal cavity. The bony septum is composed of the nasopharynx through the choanae. These are
perpendicular plate of the ethmoid superiorly and the bounded superiorly by the body of the sphenoid and
vomer posteroinferiorly. The bony septum is the alae of the vomer; inferiorly by the posterior
attached posteriorly to the body of the sphenoid and border of the horizontal process of the palatine bone
anteriorly to both the nasal bones and the spine of and soft palate; laterally by the medial pterygoid
the frontal bone. plate of the sphenoid bone and medially by the
Up to 25% of the population have some deviation posterior border of the vomer.
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 11

THE INFERIOR TURBINATE AND inferior portion of the sphenoethmoid recess through
the sphenopalatine foramen and the oral cavity
THE INFERIOR MEATUS through the greater and lesser palatine foramina.
The inferior turbinate is a thin curved lamina which
attaches to the nasal surface of the maxilla and the
perpendicular plate of the palatine bone. Its lower
tree border is gently curved. Three bony promi­ GROSS ANATOMY OF THE
nences project from the superior free border of the PARANASAL SINUSES
inferior turbinate. The most anterior is the lacrimal
process, which attaches to the lacrimal bone and the The paranasal sinuses consist of the maxillary, the
nasolacrimal groove of the maxilla, thereby helping ethmoid, frontal and sphenoid sinuses. The anatomy
to form the medial wall of the nasolacrimal duct. The of each sinus is variable, but it is the anatomy of the
ethmoidal process of the inferior turbinate is ethmoid bone and its attendant air cells that is the
attached to the. uncinate process and separates the most challenging to comprehend. Understanding the
anterior fontanelle from the posterior fontanelle. The anatomy of the middle meatus and lateral nasal wall
third prominence, the maxillary process, projects is paramount for the practising surgeon using sinus
inferiorly and laterally to attach on to the maxilla and endoscopy.
the maxillary process of the palatine bone, thus
forming part of the medial wall of the maxillary sinus.
lnferolateral to the inferior turbinate lies the inferior
meatus, which is deepest at the junction of its The frontal sinus
anterior and middle thirds. The nasolacrimal duct
open into this part of this meatus and is protected The frontal bone is one of the unpaired skull bones
by Hasner's valve (Figure 3.6). forming the anterior portion of the calvarium. The
frontal bone articulates with the ethmoid, the
sphenoid, the parietal and the nasal bones, as well
as with the zygoma and the maxilla. The frontal bone
is occasionally divided in the midline by a persistent
THE P TERYGOPALATINE FOSSA metopic suture. The frontal bone contains marrow,
and consequently, it is susceptible to osteomyelitis.
The pterygopalatine fossa is an inverted pyramidal The frontal bone makes a major contribution to the
space located between the posterior surface of the floor of the anterior cranial fossa and in so doing
maxillary sinus and the anterior surface of the ptery­ forms the roof of the orbits (Figure 3.6). The inferior
goid plates. The pterygopalatine fossa should not surface of the frontal bone is notched by the ethmoid
be mistaken for the pterygoid fossa which lies foveolae which close the open roof of the ethmoid
between medial and lateral pterygoid plates. The labyrinths (Figure 3.8).
principle contents of the pterygopalatine fossa are The frontal sinus is undeveloped at birth, appear­
the sphenopalatine ganglion, the maxillary nerve, ing in the second year as an outgrowth of the frontal
and the maxillary artery and its accompanying recess. On average, the top of the frontal sinus lies
veins. The sphenopalatine ganglion relays the at the level of the midvertical height of the orbit by
parasympathetic nerve supply to the lacrimal gland, the age of 4 years and reaches the height of the
the mucous glands of the nose, nasopharynx and supraorbital rim by 8 years. It extends above the orbit
paranasal sinuses, and the palate. The maxillary by 10 years of age. The frontal sinus extends superi­
nerve is the second division of the trigeminal nerve, orly into the superciliary region and posteriorly above
which supplies sensation to the middle third of the the medial part of the roof of the orbit. The two frontal
face. sinuses are usually unequal in size and separated by
The pterygopalatine fossa connects through a bony septum which does not lie in the midline.
fissures and foramina with several important spaces There may be numerous incomplete septa giving the
(Figure 3.7): laterally, with the infratemporal fossa sinus its characteristic scalloped outline. Secretions
through the pterygomaxillary fissure; anteriorly, to from the frontal sinus drain through the frontal recess
the orbit through the infraorbital fissure; posteriorly, into the middle meatus (Figure 3.21 ).
to the middle cranial fossa through the foramen The thin posterior wall of the frontal sinus overlies
rotundum and the pterygoid canal; medially, to the the dura of the anterior cranial fossa, and, conse-
 12 An atlas of imaging of the paranasal sinuses

quently, infections within the frontal sinus can spread The sphenoid sinus
through its posterior wall, resulting in an extradural
abscess. The sphenoid bone is another of the unpaired skull
bones (Figures 3.7 and 3.9). The sphenoid bone
consists of a body that gives origin to the lesser
wings superiorly, and the greater wings and ptery­
goid processes inferiorly. It attaches to the basi­
The maxillary sinus occiput, the petrous and the squamous temporal
bones, the parietal bone, the frontal bone, the vomer
The maxilla consists of a body and several and the perpendicular plate of the palatine bone.
processes: the zygomatic, frontal, palatine and The sphenoid bone is traversed by the foramen
alveolar processes. The maxilla attaches to the rotundum, the foramen ovale, the pterygoid canal
frontal bone, the palatine bone, the zygoma, the (vidian canal), the optic canal and the superior
ethmoid, the nasal bone and with the lacrimal bones. orbital fissure.
The maxillary sinus is a space within the body of The sphenoid sinus lies within the body of the
the maxilla which is usually present at birth as a slit­ sphenoid bone. The front of the body of the
like cavity. Normally, this rudimentary maxillary sinus sphenoid bone is ridged by the rostrum which artic­
extends under the infraorbital canal by 2 years and ulates with the perpendicular plate of the ethmoid
into the zygoma by 9 years of age. and the nasal septum. This ridge projects into the
The maxillary sinus is pyramidal in shape, with the sinus as the intersinus septum which rarely lies in
base forming the medial wall of the sinus and the the midline. The sphenoid sinus is barely present at
apex pointing into the zygomatic process of the birth, and its subsequent pneumatization is both
maxilla. In some instances, the maxillary sinus may variable and asymmetrical. The sphenoid sinus may
be compartmentalized by usually incomplete bony lie solely anterior to the pituitary fossa and gland, or
septa. The anterior and posterior walls of the maxil­ it may extend posteriorly into the basiocciput and
lary sinus consist of the anterior and posterior walls laterally into the roots of the pterygoid process. The
'l!i of the maxilla. The roof of the maxillary sinus is the floor of the sphenoid sinus may be ridged by the
floor of the orbit, which exhibits a ridge occupied by pterygoid canal transmitting the vidian nerve. The
the infraorbital nerve. The floor of the maxillary sinus sphenoid sinus ostia, which are located on the
is formed by the alveolar recess, which lies at a lower anterior wall of the sinus, open into the spheno­
level than the floor of the nasal cavity. This area ethmoidal recess which is located posterior to the
bears upon the upper teeth, with the roots of the first superior turbinate (Figures 3.4-3.6 and 3.21).
molar and the second premolar lying in close proxim­ The optic nerve has an intimate relationship with
ity to the floor of the sinus. Later in life these roots the internal carotid artery. The internal carotid artery
may project through the floor, although they are still courses through the petrous temporal bone to
usually covered by a thin layer of bone and mucosa. emerge medially at the petrous apex above the
Superomedially, the ethmomaxillary plate separates foramen lacerum (Figures 3.11 and 3.12). It deeply
the maxillary sinus from the posterior ethmoid air grooves the body of the sphenoid in an S-shape
cells (Figure 3.13). before turning back upon itself medial to the anterior
The bony medial wall of the maxillary sinus is clinoid process. Above the body of the sphenoid lies
deficient in two areas. These areas, which are the pituitary fossa, containing the pituitary gland
closed by periosteum and mucous membrane, are surrounded by the cavernous sinus. The optic
the anterior and the posterior nasal fontanelles. The chiasma lies above the pituitary gland. From it
ostium of the maxillary sinus opens into the depth of extends the two optic nerves, surrounded by the
the ethmoid infundibulum at a point approximately meninges and accompanied by the ophthalmic arter­
transecting the midpoint between the anterior and ies as they pass through the optic canals.
posterior insertions of the inferior turbinate.
Accessory maxillary sinus ostia are frequently found
in both the anterior and the posterior fontanelles.
When wesent, these accessory maxillary sinus ostia
can usually be seen on diagnostic endoscopy, The ethmoid sinuses
whereas the true maxillary ostium cannot usually be
seen as it remains concealed by the uncinate The ethmoid bone contributes to the medial wall of
process (Figures 3.3 and 3.14). the orbit, the nasal septum, the floor of the anterior
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 13

cranial fossa and the lateral wall of the nasal cavity. adjacent ethmoid air cells and tends to dip inferiorly
It is another of the unpaired skull bones and is as it passes posteriorly. The attendant dura, olfac­
composed of five parts: a perpendicular plate (which tory bulb and frontal lobe should always be consid­
comprises a portion of the bony nasal septum), a ered to be at risk during ethmoidal surgery. Injury to
horizontal plate (the cribriform plate), a superior the cribriform plate may cause a cerebrospinal fluid
prominence (the crista galli), and two multicellular leak and/or permanent anosmia. Behind the cribri­
labyrinths, containing the anterior and posterior form plate the nasal cavity is roofed by the thicker
ethmoid air cells, suspended laterally. The ethmoid horizontal plate of sphenoid bone, the planum
labyrinths are narrow anteriorly and expend as they spenoidale.
pass posteriorly and follow the natural lateral curve
of the medial wall of the orbit (Figure 3.2).
The anatomy of the ethmoid labyrinths is initially
challenging. These bony chambers are enclosed by The agger nasi
the ethmoid bone in the lateral and medial planes
only. Anteriorly the cells are closed by the lacrimal The agger nasi (the agger mound) is a smooth bony
bone laterally. Superiorly the labyrinthine cells are swelling or eminence in the frontal process of the
closed by the indentations in the thicker inferior maxilla; it lies in front of the anterior insertion of the
surface of the frontal bone known as the ethmoid middle turbinate (Figures 3.6 and 3.16). The agger
foveolae. The posterior ethmoid air cells are closed nasi may be pneumatized in a variable manner by
by the anterolateral walls of the sphenoid sinus the agger nasi air cells of the anterior ethmoid, and
(Figure 3.22). its bony wall may therefore be either thick or thin.
The lateral bony plate of the ethmoid, which is Both the lacrimal sac and the frontal recess lie
named the lamina papyracea, forms the medial wall lateral to the agger nasi when the agger is not
of the orbit. The lamina papyracea is extremely thin pneumatized. Anterolateral to the agger nasi and
and it may be dehiscent in part, allowing disease to running parallel to it is the nasolacrimal duct. The
track through into the orbit (Figure 3.11). The medial frontal recess the nasolacrimal duct and the agger
wall of the ethmoid labyrinth is composed of the nasi all lie in a similar coronal plane.
middle turbinate, the superior turbinate and, when
present, the supreme turbinate. Inferior and lateral
to the middle turbinate is a cleft known as the middle
meatus, and inferolateral to the superior turbinate is
the superior meatus (Figures 3.14 and 3.15). The The middle turbinate and the
ethmoid clefts open medially into the nasal cavity ground lamella
and posteriorly into the choanae. The spheno­
ethmoidal recess is located posterosuperior to the The middle turbinate is an integral part of the
superior turbinate (Figure 3.13). ethmoid bone. It has a vertical, anterior free border
The ethmoid air cells are divided into an anterior and that may be slender or bulbous. Occasionally this
a posterior group. The anterior ethmoid air cells drain free border is lobulated. The posterior margin is
into the middle meatus, whereas the posterior ethmoid attached to the lateral nasal wall and to the perpen­
air cells drain into the superior meatus. The largest dicular plate of the palatine bone. Immediately
and most constant anterior ethmoid air cell is named posterior to this attachment lies the sphenopalatine
the e.thmoid bulla and the most anterior of these cells foramen transmitting the sphenopalatine vessels and
are the agger nasi cells (both the ethmoid bulla and the posterior superior nasal nerves. The middle
the agger nasi cells will be discussed in more detail turbinate may be pneumatized in both the anterior
later) (Figures 3.16 and 3.20). The most posterior or the posterior segments. Such a middle turbinate
ethmoid air cells are called Onodi's cells (cells of air cell is called a 'concha bullosa'.
Onodi). They may extend posterolaterally to embrace The middle turbinate (Figure 3.10) attaches to the
or even surround the optic nerve (Figure 3.12). These skull base and to the lateral wall of the nasal cavity
cells may migrate into the body of the sphenoid and in a diverse manner. This attachment can be divided
even reach the anterior wall of the sella turcica. into three parts.
Medial to the vertical insertion of the middle
turbinate lies the cribriform plate through which the The anterior portion of the middle turbinate lies
olfactory nerve fibers pass (Figure 3.2). The cribri­ in a paramedian sagittal plane. The vertical
form plate lies at a lower level than the roofs of the lamella of the middle turbinate inserts into the
14 An atlas of imaging of the paranasal sinuses

lateral border of the cribriform plate and is orly in its lower portion. The uncinate process forms
covered medially by olfactory epithelium contain­ the medial wall of the infundibulum, and its posterior
ing fibers of the olfactory nerve in the superior free margin forms the anterior boundary of the
portion. Careless dissection leading to avulsion semilunar hiatus.
of this medial lamella may lead to leakage of At the posterior inferior insertion of the uncinate
cerebrospinal fluid and the risk of intracranial process, fine bony spicules attach the uncinate
sepsis (Figure 3.14). process to the perpendicular plate of the palatine
bone. Further bony spicules arise from the inferior
ii The vertical plate of the central portion of the
margin of the uncinate process and articulate with
middle turbinate rotates to lie in the coronal
the ethmoid process of the inferior turbinate. It is this
plane between the anterior portion medially and
latter bony attachment that separates the anterior
the lamina papyracea laterally. This part is
and posterior fontanelles. These are bony defects,
known as the ground or basal lamella of the
of variable size, in the medial wall of the maxillary
middle turbinate. This lamella is anatomically
sinus; they are covered by mucoperiosteum and
important because it divides the anterior ethmoid
transmit the accessory maxillary ostia when they are
air cells from the posterior ethmoid air cells. All
present.
of the air cells anterior to the ground lamella
have their ostia located in the anterior ethmoid,
whereas all of the ethmoid air cells posterior toi
the ground lamella have their ostia located in the
superior meatus. The sphenoid sinus ostia open The semilunar hiatus
into the sphenoethmoid recess (Figure 3.15).
The semilunar hiatus is a two-dimensional cleft that
iii The posterior portion of the insertion of the
lies between the posterior free margin of the
middle turbinate runs in a horizontal plane
uncinate process and the anterior wall of the
forming the roof of the posterior middle meatus.
ethmoid bulla. It is usually 1-2 mm wide and forms
The bone inserts into the lamina papyracea or
the entrance into the ethmoid infundibulum, which
medial wall of the maxilla.
lies lateral to the uncinate process (Figure 3.4).
The lateral wall of the middle meatus houses
several key anatomic features (Figures 3.3, 3.4, 3.6,
3.14 and 3.21). These are the uncinate process,
semilunar hiatus, ethmoid infundibulum, ethmoid The ethmoid infundibulum
bulla, lateral sinus and frontal recess.
The ethmoid infundibulum is a three-dimensional
space lying lateral to the uncinate process. The
medial wall of the infundibulum is formed by the
uncinate process, whereas its lateral wall is formed
The uncinate process by the lamina papyracea with a variable contribution
from the frontal process of the maxilla and from the
The uncinate process is a fine bony leaflet which lies lacrimal bone (Figure 3.20).
immediately posterior to the agger nasi. This thin The anatomy of the superior part of the infundibu­
bony prominence is usually found posterior to the lum varies depending on the bony insertion of the
leading vertical edge of the middle turbinate on the uncinate process. If the uncinate process inserts later­
lateral wall of the nasal cavity. It can be exposed by ally onto the lamina papyracea the infundibulum ends
gentle medial retraction of the middle turbinate. The superiorly as a blind pit known as the terminal recess.
superior origin of the uncinate process from the The frontal sinus drains into the frontal recess which,
lateral bony nasal wall is variable. It may insert into in this situation, is separated from the infundibulum,
the lamina papyracea, the lacrimal bone or the skull thereby limiting the spread of infection from the maxil­
base, and it may even swing medially to insert into lary sinus to the frontal sinus. If the uncinate process
the lateral surface of the middle turbinate (Figures inserts into the roof of the ethmoid, or passes medially
3.14, 3.19 and 3.21). Its upper extremity is usually to insert into the middle turbinate, the frontal sinus
concealed by the anterior insertion of the middle and the frontal recess will open directly into the
turbinate. The uncinate process then sweeps down infundibulum and infection in the maxillary sinus may
in a posteroinferior direction, curving more posteri- affect frontal sinus drainage or vice versa.
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 15

The infundibulum usually terminates posteriorly at the frontal recess or it may be separated by the bulla
the anterior wall of the ethmoid bulla, where it inserting into the roof of the ethmoid.
communicates with the middle meatus via the
semilunar hiatus.
The maxillary ostium is hidden deep in the pos­
terior inferior portion of the infundibulum and cannot
The frontal recess
normally be seen with an endoscope in the middle
meatus. However, accessory maxillary ostia may be
The frontal sinus originates from pneumatization of
readily seen perforating the anterior and posterior the anterior part of the frontal recess (Figures 3.2
fontanelles.
and 3.4). The posterior wall of the frontal recess is
Pneumatization of infundibular cells, agger nasi variable, depending on the insertion of the ethmoid
cells or even the uncinate process may occur, bulla (Figure 3.19). If the anterior wall of the
distorting the anatomy and sometimes causing the ethmoid bulla inserts into the roof of the ethmoid,
uncinate process to bend medially or even to double
it will form the posterior wall of the frontal recess,
back anteriorly.
thus separating it from the lateral sinus. However,
The lateral margin of the infundibulum is rarely
this wall is often incomplete or absent allowing the
further than 1.0-1.5 mm from the lamina papyracea.
frontal recess to communicate with the lateral
It may be further collapsed if there are anatomic
sinus. Depending on the anterosuperior insertion of
variations such as concha bullosa, or pathologic
the uncinate process, the frontal recess may open
conditions that compress the uncinate process
into the middle meatus or into the ethmoid
against the lateral nasal wall.
infundibulum. The frontal recess may be reduced
in volume by surrounding structures such as a
prominent ethmoid bulla or prominent agger nasi
cells.
The ethmoid bulla The frontonasal duct is more appropriately named
the frontal recess. It is rarely duct-like and consists
The ethmoid bulla is the most constant and largest instead of a waisted bony recess facilitating ventila­
of the anterior ethmoid air cells (Figures 3.3, 3.6 tion between the frontal sinus and the nasal cavity.
and 3.14). It is pneumatized in a variable manner The shape of the duct depends mainly on the
and, in some individuals, a bony lateral torus is surrounding structures. The medial border is usually
found in the same position. Laterally, the bulla is the lateral lamella of the most anterior portion of the
attached to the lamina papyracea. Posteriorly, it middle turbinate. The lateral border consists mainly
may attach to the ground lamella of the middle of lamina papyracea with a small contribution from
turbinate or be separated from it by a posterior the uncinate process. Superiorly, the frontal bone
extension of the lateral sinus, if present. Superiorly, forms the roof with its anterior ethmoid foveolae,
the bulla may fuse with the roof of the ethmoid and further anteriorly curving ,upwards to form the
,
form the posterior wall of the frontal recess, or it anterior wall of the frontal sinus. The frontal ostium
may be separated from the ethmoid roof by a space is usually found in the most anterosuperior part of
(the lateral sinus) allowing communication between the frontal recess, but this can rarely be seen directly
these two spaces. with the endoscope during a routine diagnostic nasal
examination (Figure 3.21).

The lateral sinus

The ostiomeatal complex
The lateral sinus is a variable cleft found superior
and posterior to the ethmoid bulla (Figure 3.18). It The term ostiomeatal complex is used to refer
lies between the lamina papyracea and the middle collectively to the maxillary sinus ostia, the ethmoid
turbinate medially. The roof of the ethmoid is found infundibulum, the semilunar hiatus, the middle
superiorly and the ethmoid bulla inferiorly. meatus, the frontal recess, the ethmoid bulla and the
Posteriorly, the cleft may be extensive between the uncinate process. It describes the final common
bulla and the ground lamella of the middle turbinate. drainage pathways of the frontal, maxillary and
Anteriorly, the lateral sinus may communicate with anterior ethmoid sinuses.
16 An atlas of imaging of the paranasal sinuses

Haller's cells are ethmoid air cells that invaginate The orbital apex
the floor of the orbit in the vicinity of the maxillary
sinus ostium. If enlarged, Haller's cells may restrict Structures in the orbital apex are in close proximity
the ethmoid infundibulum and the ostium of the to the posterior ethmoid and the sphenoid sinuses,
maxillary sinus. The presence of such a cell usually and must be considered at risk from disease or
remains obscured on endoscopic examination of the surgery in the vicinity (Figures 3.7, 3.11 and 3.12).
nasal cavity, however it may be revealed on maxil­ The bony orbital apex houses three canals:
lary sinuscopy and certainly by coronal computed
tomography. The origin of these cells is as yet the optic canal, transmitting the optic nerve and
uncertain, but the majority have been noted to open the ophthalmic artery;
into the middle meatus and therefore are assumed ii the superior orbital fissure transmitting the
to be of anterior ethmoid origin.
lacrimal, frontal and nasociliary nerves of the
ophthalmic division of the trigeminal nerve, and
the oculomotor, trochlear and abducent cranial
nerves;
The anterior and posterior iii the inferior orbital fissure transmitting the infra­
ethmoid arteries orbital nerve and artery.

The anterior ethmoid artery arises from the A tendinous ring surrounds the medial aspect of
ophthalmic artery in the orbit, which in turn arises the superior orbital fissure and the optic canal. From
from the internal carotid artery. It passes through the this ring arise the medial, lateral, superior and
anterior ethmoid foramen, running obliquely through inferior recti muscles. Levator palpebrae superioris
the frontoethmoid suture, approximately 2-4 mm and the superior oblique muscles arise from bone
posterior to the lacrimal crest. The anterior ethmoid just superior to the tendinous ring. In this way, the
artery is surrounded by thin bone and lies above the optic nerve and globe are surrounded by a cone of
anterior border of the ethmoid bulla. This bony canal muscle. The lacrimal, frontal and trochlear nerves
may be embedded in the roof of the ethmoid or pass anteriorly within the ring.
connected to it by a bony mesentery. The artery
passes through the lateral lamina of the cribriform
plate posterior to the crista galli and enters the
anterior cranial fossa through the lateral margin of The lacrimal apparatus and
the cribriform plate. It should be noted that this is nasolacrimal duct
the thinnest and weakest portion of the skull base.
The anterior ethmoid artery supplies the anterior The lacrimal gland is a serous gland situated in a
ethmoid air cells and the frontal sinus, and sends shallow fossa in the superolateral aspect of the orbit
intracranial branches to supply the dura. Further (Figure 3.11 ). It has an orbital lobe and a smaller
terminal branches pass down through the cribriform palpebral lobe. Twelve or more ducts release tears
plate to supply the superior part of the medial and to moisten the conjunctiva. Excessive tears drain
lateral wall of the nasal cavity and a part of the exter­ through the lacrimal canaliculi into the lacrimal sac
nal nose. situated in the lacrimal fossa, anterior to the pos­
The posterior ethmoid artery is also a branch of terior lacrimal crest. Behind the lacrimal sac, arising
the ophthalmic artery. It passes through the posterior from the posterior lacrimal crest, is the medial palpe­
ethmoidal foramen in the frontoethmoid suture bral ligament of the orbit. Between this and the lat­
approximately 12 mm posterior to the anterior erally placed Whitnall's tubercle is the suspensory
ethmoid foramen and passes behind the cribriform Lockwood's ligament which plays an important role
plate. It also supplies the dura, and further terminal suspending the globe in the orbit. The lacrimal sac
branches pass inferiorly through the cribriform plate drains inferiorly into the nasolacrimal duct, which
to supply the posterosuperior aspects of the lateral finally opens into the inferior meatus through
and medial nasal wall. Hasner's valve (Figures 3.16 and 3.20).
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 17

3.1 3.2

3.3 3.4

Figure 3.1 Figure 3.2

Osteology. This anterior view of the skull demonstrates some of Inferior aspect of the frontal bone. This inferior view shows the
the bony features of the nasal cavity and orbit. The nasal spine ethmoid notch with the depressions of the ethmoid foveolae
(NS) can be seen at the base of the bony nasal septum. The (foveolae ethmoidales ossis frontalis) in situ. The relationship of
prominent middle turbinate (MT) and the inferior turbinate (IT) the vomer (V) and the cribriform plate (CP) to the ethmoid
are shown. The superior orbital fissure (SOF) and the inferior foveolae, seen in Figure 3.8, is demonstrated. The curved
orbital fissure (IOF) are demonstrated. The inferior orbital arrow indicates the frontal recess entering the frontal sinus. The
foramen (10) transmits the infraorbital nerve. orbital plate is also shown (OP).

Figure 3.3 Figure 3.4

Lateral wall of the nose. This half skull shows the bony features Lateral wall of the nose. This half skull shows the bony features
of the lateral wall of the nose. The middle turbinate and of the lateral wall of the nose. The middle turbinate and
superior turbinate have been removed, opening the posterior superior turbinate have been removed, opening the anterior
ethmoid air cells (PE). Features demonstrated include the (AE) and the posterior (PE) ethmoid air cells. The small curved
frontal sinus (FS), the crista galli (CG), the piriform aperture arrows lies within the frontal recess and the frontal sinus,
(PA), the medial (MP) and lateral (LP) pterygoid plates, the respectively. Other features demonstrated include the sphenoid
inferior turbinate (IT) and the inferior meatus (IM). The uncinate sinus (S), the perpendicular plate of the palatine bone (PB), the
process (UP) lies anterior to the ethmoid bulla (EB). The anterior (AF) and posterior (PF) fontanelles, the lacrim,;11 bone
semilunar hiatus is the two-dimensional cleft lying between (LB) and the semilunar hiatus (HS).
these two structures.
18 An atlas of imaging of the paranasal sinuses

3.5 3.6

3.7 3B

Figure 3.5 Figure 3.6

The lateral wall of the nose. This cadaver dissection has The lateral wall of the nose. This cadaver dissection has
revealed the lateral wall of the nose by removing the nasal revealed more detail of the lateral wall of the nose by removing
septum. The posterior portion of the nasal septum remains at the nasal septum and reflecting the middle turbinate
the level of the choana (open arrow). Features demonstrated posteroinferiorly (curved arrow). The cut edge of the middle
include the inferior turbinate (IT), the inferior meatus (white turbinate is emphasized with small white arrows. Other features
curved arrow), the middle turbinate (MT), the middle meatus demonstrated include the frontal sinus (F), the sphenoid sinus
(black curved arrow), the superior turbinate (ST), the sphenoid (S), the ethmoid bulla (EB), the uncinate process (UP) and the
ethmoid recess (SER) above it and the sphenoid sinus (S) and agger nasi (A). Part of the inferior turbinate (IT) has been
the eustachian tube orifice (ET). resected and a fine polyethylene tube is shown protruding from
the opening of the nasolacrimal duct.

Figure 3.7 Figure 3.8

Anterior aspect of the sphenoid bone. This view demonstrates Inferior aspect of the frontal bone. This inferior view of a
the greater (GW) and lesser wings (LW), the planum disarticulated frontal bone demonstrates the ethmoid notch
sphenoidale (PS), the superior orbital fissure (SOF), the (EN), which receives the crista galli and cribriform plate, the
pterygoid vidian canal (VC), the foramen rotundum (FR), the nasal spine (NS) and the ethmoid foveolae which roof the
optic canal (OC), the medial (MP) and lateral (LP) pterygoid anterior and posterior ethmoid air cells (FE). The curved arrow
plates, and the sphenoid rostrum (SR). The lateral and the is directed into the frontal recess and frontal sinus. The orbital
medial pterygoid plates are separated from the maxillary sinus plate (OP), forming the roof of the orbit is also shown.
by the pterygopalatine fossa, which receives the nerves from
the foramen rotundum and the pterygoid canal.
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 19

3.9

3.10

MCF-
ICA
3.11 3.12

Figure 3.9 Figure 3.10

Posterior aspect of the sphenoid bone. This view demonstrates Parasagittal section through the orbital canal. This section
the greater (GW) and lesser wings (LW), the pterygoid vidian demonstrates the frontal sinus (FS) extending into the orbital
canal (VC), the foramen rotundum (FR), the optic canal (QC), roof, the posterior ethmoid sinus (PE), the sphenoethmoid
the medial (MP) and lateral (LP) pterygoid plates, and the recess (SER), the optic nerve (ON), the superior turbinate (ST),
superior orbital fissure (SOF). the sphenoid sinus (S), the middle turbinate (MT) and the
inferior turbinate (IT). (Masson's trichrome stain.)

Figure 3.11 Figure 3.12

Axial section at the level of the lacrimal sac and orbital apex. Axial section at the level of the roof of the nasal cavity and the
This section demonstrates the lacrimal sac (LS), the anterior diaphragm sellae. This section demonstrates the lamina
ethmoid air cells (E), the nasal septum (NS), the inferior rectus papyracea (arrowheads), the nasal cavity (N), the posterior
(IR), the lamina papyracea (arrowheads), the posterior ethmoid ethmoid sinus (PE), the optic nerve (ON), the sphenoid sinus
sinus with an Onodi's cell (PE), the orbital apex (QA), the (S), the pituitary fossa (P) and the internal carotid artery (ICA).
sphenoid sinus (S), the middle cranial Iossa (MCF) and the (Masson's trichrome stain.)
internal carotid artery (ICA). (Masson's trichrome stain.)
20 An atlas of imaging of the paranasal sinuses

'1

I
f
PE
SER
MT'
MT
,u
r
I /EB

\
I UP
IT
�-
IT
3.13
3.14

·J
FE
CP ...
ST :R
\
MT MN
l/
'J�L
IT I Q
NS
.u.
3.15 3.16

Figure 3.13 Figure 3.14

Cross section through the posterior ethmoid sinus. The Cross section through the ethmoid infundibulum and maxillary
posterior ethmoid sinus (PE), the sphenoethmoid recess (SER), sinus ostium. The cribriform plate (CP), the lamina papyracea
the middle turbinate (MT), the inferior turbinate (IT), the (arrowhead), the middle turbinate (MT), the ethmoid bulla (EB),
maxillary sinus (MS) and the ethmomaxillary plate (open arrow) the uncinate process (UP), the inferior turbinate (IT) and the
are demonstrated. (Masson's trichrome stain.) inferior meatus (IM) are demonstrated. The curved arrow
passes through the maxillary sinus ostium into the ethmoid
infundibulum. (Masson's trichrome stain.)

Figure 3.15 Figure 3.16

Cross section through the posterior ethmoid sinus. The superior Coronal section through the anterior ethmoid. This section
turbinate (ST), the middle turbinate (MT) with its horizontal demonstrates the frontal recess (FR), the agger nasi (AN), the
insertion (arrowhead), the inferior turbinate (IT) and the nasolacrimal duct (NL), the nasal septum (NS), the maxillary
ethmomaxillary plate (open arrow) are demonstrated. Note how sinus (MS) and the infraorbital nerve (ION). (Masson's
the ethmoid fovea (FE) which roofs the ethmoid air cells lies at trichrome stain.)
a much higher plane than the cribriform plate (CP). (Masson's
trichrome stain.)
 Gross and sectional anatomy of the nasal cavity and paranasal'sinuses 21

3.17A 3.178

3.18

Figure 3.17 Figure 3.18

The middle turbinate. These diagrams show the ground lamella The lateral sinus. This diagram of the middle turbinate
of the middle turbinate from laterally (A) and medially (B). The demonstrates how the ground lamella may be distorted by the
posterior tip of the lateral view has been divided to demonstrate lateral sinus (arrow 1) and the posterior ethmoid (arrow 2).
the vertical and horizontal plates of the turbinate.
22 An atlas of imaging of the paranasal sinuses

Figure 3.19
The insertion of the uncinate process. These diagrams simplify
the variations of the insertion of the uncinate process and its
effect upon the drainage pattern of the frontal recess. El,
ethmoid infundibulum; FR, frontal recess, FSO, frontal sinus
ostium; FS, frontal sinus; MSO, maxillary sinus ostium; CM,
concha media; Cl, concha inferior.
 Gross and sectional anatomy of the nasal cavity and paranasal sinuses 23

/
I

ST EB s
FA,' f
J
B SER

JUP
'MT
\'

3.20 3.21

ON

3.22

Figure 3.20 Figure 3.21

Cross section through the ethmoid infundibulum anterior to the Parasagittal section through the cribriform plate. This section
maxillary sinus ostium. This coronal section demonstrates the demonstrates the frontal sinus (FS), the uncinate process (UP),
frontal recess (FR), the ethmoid bulla (EB), the uncinate the ethmoid bulla (EB), the superior turbinate (ST), the
process (UP). the middle turbinate (MT) and the nasolacrimal sphenoethmoid recess (SER), the sphenoid sinus (S), the
duct (NL). (Masson's trichrome stain.) inferior turbinate (IT), and the middle turbinate (MT). The
curved arrow shows the path from the frontal recess into the
ethmoid infundibulum. (Masson's trichrome stain).

Figure 3.22
Parasagittal section through the sphenoid sinus. This section
demonstrates the frontal sinus (F), the medial rectus (MR), the
optic nerve (ON), the sphenoid sinus (S), the posterior ethmoid
sinus (PE) and the maxillary sinus (MS). (Masson's trichrome
stain.)
4
Basic principles of radiography of the nasal
cavity and paranasal sinuses

For many years rhinologists and radiologists have by computed tomography (CT). Conventional tomo­
had to rely upon plain radiographs of the paranasal graphy still maintains some advantages: in the ready
sinuses for assistance in the diagnosis and manage­ availability of the equipment required to take conven­
ment of paranasal sinus disease. The information tional tomograms, and in its ability to record images
gleaned from these films is mainly relevant to the in the sagittal plane while the patient remains in a
general condition of the larger paranasal sinuses comfortable position, unlike direct sagittal plane CTs,
(especially the frontal, maxillary and sphenoid which require the patient to assume awkward and
sinuses), and yields minimal information about the uncomfortable positions. The major disadvantage of
delicate bony anatomic or mucosa! changes that conventional tomography is the dose of radiation
may be present in the ethmoid air cells of the lateral administered, which is significantly greater than that
wall of the nose. With the development of functional delivered during CT. This is a particular disadvan­
endoscopic sinus surgery, such imaging has proved tage with respect to the lens of the eye. The quality
inadequate. of conventional tomograms is further diminished by
Conventional or plain radiographs usually involve the appearance of phantom artifacts which may
four projections; Caldwell's projection, the lateral obscure small anatomic structures and limited areas
projection, Water's projection and the submento­ of significant disease. The soft-tissue resolution with
vertical projection. While these films are adequate CT is far superior to that with conventional tomo­
tor a basic or preliminary assessment of the larger graphy.
paranasal sinuses they tail to demonstrate CT is currently regarded as the imaging modality
adequately the anterior ethmoid sinuses, the upper of choice for the paranasal sinuses. It should be
nasal cavities, the surrounding soft tissue or the used to complement noninvasive diagnostic endo­
frontal recesses clearly. Nevertheless, plain radio­ scopy in the assessment of the individual patient,
graphs continue to have a place in the diagnosis and and it will help to demonstrate normal and pathologic
management of acute sinusitis and will readily anatomy prior to commencing surgery.
demonstrate the presence of an air-fluid interface or There are many advantages to be gained from
a totally opacified sinus (Figures 4.1 and 4.2). A using CT as opposed to conventional tomography.
repeat Water's view is generally appropriate tor The contrast and resolution are of higher quality with
following the clinical progress of acute maxillary or CT. This helps to differentiate minor opacities that
frontal sinus infections. may be obscured by the blurring effect of the
conventional tomogram, and bony decalcifications
that may be concealed by inflammatory changes. In
a similar manner, malignant bony infiltration can be
more readily differentiated from inflammatory / '
POLYTOMOGRAPHY changes.

Conventional tomography, especially hypocycloidal

polytomography can provide excellent images of the
bony margins of the sinuses and thin bony leaflets
in the ethmoid labyrinth. The development of these COMPUTED TOMOGRAPHY
imaging techniques was fundamental in the evolu­
tion of functional endoscopic sinus surgery. In CT, a well-collimated slit-like beam is produced
Conventional tomography has now been superseded from the X-ray tube. This tube-detector unit, housed
 Basic principles of radiography of the nasal cavity and paranasal sinuses 25

in the gantry encircles the patient being examined, linear relationship between dose and MAS, with the
moving in 1• intervals while X-rays are continuously dose increasing as the MAS increases. The dosage
produced. These projected rays pass through the to the patient is also dependent upon the voltage,
patient, some being absorbed, others passing filters and collimators used, as well as the slice thick­
through unchanged. An array of detectors receives ness. The MAS setting will vary depending on the
the X-ray signals which have been attenuated during noise level, kVP, patient size and the scan slice
the passage through the various tissues. The quality thickness. For imaging the paranasal sinuses, the
of the image depends primarily upon the number of kVP is usually set at 125 and the MAS at 450.
picture elements (pixels) used, which will either be
on a 256 x 256 or a 512 x 512 matrix. With the
knowledge of the scan thickness, the volume of the
picture elements can be measured and stored as Resolution
units named voxels. The absorption of X-ray photons
in a voxel is. related to the average absorption co­ High-resolution computed tomography (HRCT)
efficient. The image produced is a reflection of the involves the scanning of thin sections for the
number of photons absorbed by each voxel. This enhancement of bony details. High-resolution
density distribution is readily detected electronically, scanning is made possible by the use of special
leading to production of a superior image. reconstruction software available with most CT
CT has a tremendous capacity for density resolu­ scanners.
tion, and 4000 grades of density, from air to metal, The best high-resolution images are achieved with
can be identified, which allows the differentiation of the thinnest slices. This improved spatial resolution
all clinically relevant tissue. These density grades enables one to see bony microanatomy, subtle
are measured in Hounsfield units (HU) and range erosions and fractures. Some of the volume
from -1000 to +3000 HU. These different densities elements (voxels), will contain both bone and soft
are projected as different tones of gray on an tissue and the gray value displayed in the image is
electronic screen. Unfortunately, the human eye is based on the average absorption value for that
only capable of differentiating approximately 40 voxel. It is therefore inaccurate for the separate
different tones of the same color. To overcome this, tissue types. If there is a large difference between
the computer is able to manipulate the electronic raw the tissue densities within a voxel, streak artifacts
data within variable electronic 'windows'. Within a will appear on the image (Figure 4.3). This is also
given window, the density values will be shown as known as the partial volume effect. This artifact may
different shades of gray while, outside that particu­ be diminished by reducing the scan thickness.
lar window, the greater density values will be shown Imaging of the paranasal sinuses is usually
as white and the lesser densities as black. This has conducted with a 4-5 mm scan thickness with the
the advantage that the raw data can be manipulated table moving in 3-4 mm increments. This allows
by the computer to provide information about both some overlap of contiguous scans to facilitate refor­
bony structures (using a wide window setting), and matting in a different plane or three-dimensional
soft-tissue structures (using a narrow window reconstruction. The scan time, for each slice, is
setting), from only one exposure to the X-rays (the usually between 5 and 7 s.
raw data). Each window is centered at a specific The raw data of regions with a large difference in
value. This determines which density of tissue will contrast, i.e. bone soft-tissue edges, may be recon­
be displayed with the medium tone of gray. The structed directly or subsequently into high-resolution
recommended window width and the window centers images by special algorithms that improve spatial
vary with each anatomic region. For imaging of the resolution. This creates more clearly defined images
paranasal sinuses and the ostiomeatal complex, a of regions such as the inner ear and the paranasal
wide window setting (between 2000 and 3000 HU) sinuses, but it is an inappropriate technique for the
is used, centered around -250 HU. This usually imaging of soft-tissue regions. The image is more
demonstrates both the bone and the soft tissues likely to be distorted by noise and artifact with this
adequately. When soft-tissue pathology is to be technique; however, this may be reduced by using
emphasized, the scanner is set with a narrower a wide window and a thin scan slice. Wide windows
window width of 300 centered around +65 HU. are unable to differentiate small variations in density.
Other parameters are also of importance including In contrast, the narrow window enables separation
the dose, milliamperes/per second (MAS), kilo­ of very small density differences at the expense of
voltage (kVP) and the slice thickness. There is a bony detail.
26 An atlas of imaging of the paranasal sinuses

Artifacts
The image produced with CT can be degraded by
artifacts of various origin and these may obscure the
differentiation of contiguous soft tissue or soft tissue
and tumor. A grainy appearance on the image is due
to noise. This is caused by slight variations of the
density value measured by the scanner for
substances of a fixed density. This effect may be
limited by increasing the MAS or the scan thickness
in areas of soft tissue, but it has little effect in areas
of high density contrast. Ring artifacts may be
caused when individual detector channels show
slight differences in signal output. This may result
from infrequent unit calibration and may be corrected
by a balancing algorithm. Streak artifacts, as already
mentioned, appear if there are sudden changes in
tissue density within a voxel. These may be limited
by an extended balancing algorithm used while at
the raw data stage or by reducing the scan slice
thickness. Careful patient positioning and gantry
angulation may allow such areas of density change
(e.g. dental fillings) to be avoided.
X-ray tubes produce radiation of varying levels,
the lower levels being attenuated to a greater degree
and thereby increasing the spectrum of energy
levels measured. This effect is known as beam
hardening. Much of this effect may be reduced by
beam filtering and the addition of a correcting
algorithm before scanning the patient. The artifacts
produced are most pronounced in areas where high­
density structures are in close proximity to low­
density structures. Careful positioning of the patient,
and careful filtering of the beam before entry into the
patient, may lead to a reduction in such artifacts.
Artifacts due to dental amalgam may be avoided by
scanning in a different plane. Some artifacts may be
caused by movement of the patient. This may be
reduced by explaining to the patient what events to
expect during the examination and by ensuring that
they are comfortably positioned and well supported.
The patient should be asked to refrain from swallow­
ing and breathing at the start of the scan time.

Enlargement
Specific areas of interest may be enlarged by one
or two methods. The first, magnification, involves the
expansion of each picture element. With this second technique, zooming, a segment of the image
technique there is no increase in detail and the is coned to produce increased detail resolution. The
tissue interfaces may become stepped. With the zoom factors vary from 1 to 10, the larger zoom
 Basic principles of radiography of the nasal cavity and paranasal sinuses 27

factor being associated with smaller pixels and having limited neck extension or scanners with
therefore greater definition. The latter technique is limited gantry angulation. In these circumstances, it
more appropriate when studying the paranasal may be preferable to scan the patient in the axial
sinuses, and zoom factors between 4 and 6 are plane and reconstruct the images in the coronal
generally applied. plane (Figure 4.4). This ability to reconstruct the
images enables the radiologist to study any abnor­
mality in a variety of planes, including the sagittal
plane. Unfortunately reconstruction diminishes the
definition of the scan and may obscure minor
Projections mucosal or bony defects.
For scanning in the coronal plane, the patient is
Coronal scans of the paranasal sinuses are positioned either prone or supine and the gantry is
preferred to axial scans because they allow more angled to lie perpendicular to the infraorbitomeatal
appropriate orientation of the anatomy and path­ line (also known as Reid's line). In the supine
ology in the perspective by which they will be position, the neck is hyperextended at the gantry
approached by the endoscopist. This orientation also end of the table, and if the patient is prone, then the
allows more accurate visualization of those struc­ chin is fixed and supported after extending the neck.
tures that lie parallel to the infraorbital line, such as Initially a lateral 'scout' scan is taken, and if neces­
the orbital roof and floor, the roof of the nasal cavity, sary the gantry angulation is modified to take into
the ethmoid and the sphenoid sinus. This is of partic­ account special problems as limited extension of the
ular value when it is suspected that disease or neck or metal dental fillings that may degrade the
fracture have penetrated these structures. image (Figure 4.5). The patient is then scanned from
A cooperative patient with good neck extension is the posterior margin of the sphenoid sinus to the
essential for adequate scanning in the coronal axial frontal sinus.
plane. Many elderly patients may not be able to The technique used for axial scanning is not
comply with this; in this event, the problem can be dissimilar to that used for coronal scanning. The
overcome by the computer's ability to reconstruct patient is usually positioned supine with the gantry
images in a different plane to that studied from the parallel to the orbitomeatal line. The limits of the
information within the data store. This overcomes scan extend from the alveolar ridge to the top of the
some of the problems encountered with patients frontal sinus. For both planes, the scan thickness is
28 An atlas of imaging of the paranasal sinuses

4-5 mm and the table moves in 3-4 mm increments distinction between allergic and inflammatory polyps
(Figure 4.6). may also be aided by contrast administration as
Imaging of the paranasal sinuses in the axial and inflammatory polyps have been noted to enhance
coronal planes each have their own separate advan­ whereas allergic polyps do not.
tages and disadvantages, as illustrated in Tables 4.1 The administration of intravenous contrast does
and 4.2. Axial scans are generally regarded as being have some disadvantages. The major medical disad­
excellent for the evaluation of the anterior and poste­ vantage is the occurrence of a potentially fatal
rior walls of the paranasal sinuses and the ptery­ anaphylactic reaction to the contrast agent. The
gopalatine fossa, and especially the relationships of major nonmedical disadvantage is the expense of
the optic nerve to the posterior ethmoid and nonionic intravenous contrast. In general intra­
sphenoid sinuses. Coronal scans more clearly venous contrast enhancement is limited to those
demonstrate abnormalities of the paranasal sinuses, cases of tumors, vascular lesions and complicated
especially those involving the lateral wall of the paranasal disease. It is rarely administered in cases
nose, as well as the nasopharyngeal and para­ of uncomplicated inflammatory and allergic sinus
pharyngeal regions. Multiplanar scanning is consid­ disease because of its cost.
ered the ideal; however, time, patient compliance
and the increased radiation dose restrict the use of
this more extensive examination when benign
disease is being investigated.
Interpretation and reporting
The system developed to interpret and report the
images will depend on the individual radiologist's
Administration of contrast preferences. With such complex anatomy, and any
pathological abnormality further distorting this
Intravenous contrast is not used routinely during the anatomy, it is wise to develop a systematic approach
investigation of benign inflammatory disease and is and thereby avoid omitting important details. A
administered at the discretion of the radiologist. reporting scheme has been developed by the
Ideally, contrast should. be administered with an authors which not only allows thorough and accurate
automatic injector. Approximately 80-100 ml of examination of the radiological images, but is also
nonionic contrast is given at the rate of 1 ml/s and of value in standardizing reports, and in allowing
a rapid sequential series is taken. Abnormalities will data collected over a period of time or from different
enhance if there is increased vascularity and the pathologies to be reviewed with ease (Table 4.3).
degree of enhancement can be estimated by
comparison with the enhancement of the great
vessels. Contrast is indicated if vascular abnormali­
ties or malignancy are suspected from either the Comparison of Computed
history or diagnostic examination. The vascularity of
the lesion as well as its relationship to the major Tomography with Magnetic
vessels can be assessed preoperatively. If emboliza­ Resonance Imaging
tion is being contemplated, angiography may be
used to complement the CT findings. Narrow window Magnetic resonance (MR) imaging involves rapidly
settings delineate the extent of soft tissue and loss changing magnetic fields instead of ionizing radi­
of the fat planes may indicate malignancy, whereas ation. MR depends upon the physical and the
a wide window setting will help to demonstrate the biochemical properties of the tissue, i.e. the hydro­
bony features, especially erosion due to benign or gen density, and the T1 and T2 (the longitudinal and
malignant lesions. the transverse magnetic) relaxation constants. The
The administration of contrast may help to distin­ other important parameters that influence MR
guish between active and chronic inflammatory imaging are the pulse repetition time (TR time) and
disease as mucosal enhancement is visible in cases the echo delay (TE). A pulse sequence with a short
of active inflammation. Intravenous contrast is TR and a short TE is called a t1 -weighted
certainly indicated when inflammatory sinus disease sequence. A sequence with a long TR and a long
is complicated by abscess formation, thrombosis, TE is called a T2-weighted sequence. Fat and
intracranial or intraorbital spread of infection. The marrow produce a high signal intensity (a brighter
Table 4.3

Pathology
seen
30 An atlas of imaging of the paranasal sinuses

image), water and inflammation produce a low signal increases the likelihood of patient movement
intensity (a darker image), whereas bone and air and therefore degradation of the scan.
produce no signal. The physics of MR will be
iv Patient comfort: MR scanners tend to be noisier
discussed later in more detail.
and more confining than CT scanners, and
CT and MR imaging have added a third dimen­
therefore patients with claustrophobia may not
sion to radiologic imaging of the paranasal sinuses.
be able to tolerate the procedure.
It is now possible to detect early disease, be it
inflammatory or neoplastic, and the spread of such
The main advantages of MR imaging over CT
disease, either intracranially or into the orbit, is well
include the following:
demonstrated by both modalities. MR imaging is
complementary to CT because of its superior soft
Superior soft-tissue discrimination: this permits
tissue resolution, and each modality has indepen­
better assessment of the interface between a
dent benefits.
pathologic mass and the surrounding normal
The particular advantages of CT over MR imaging
structures, and rarely requires the administra­
include the following.
tion of intravenous contrast.
Bony detail: CT identifies bony details such as ii Multiplanar capability any anatomic plane may
the proximity of the orbital floor to the site of a be examined without the patient being asked to
middle meatal antrostomy, the extent of take up an uncomfortable position and without the
pneumatization of the ethmoid air cells, the application of low-resolution computer reforma­
location of the natural maxillary sinus ostium, tions. The coronal plane is usually the most infor­
septations of the sphenoid sinus and the mative plane when examining the head and neck.
position of the internal carotid artery, as well as
iii Vascular anatomy: vascular structures are
the degree of pneumatization and depth of the
readily seen without intravenous contrast and
frontal sinus.
are easily separated from other soft-tissue
ii Cost at present CT is significantly less expen­ structures. MR angiograms may soon super­
sive and more readily available than MR sede conventional angiograms.
imaging.
iv Artifacts: on MR, the artifacts from dental
iii Examination time: CT takes only seconds per amalgam and cortical bone are insignificant in
scan slice, whereas MR imaging at present contrast to those on CT, in which significant
requires several minutes per slice. This image degradation can occur.
 Basic principles of radiography of the nasal cavity and paranasal sinuses 31

4.1 4.2

4.3 4.4

Figure 4.1 Figure 4.2

Acute maxillary sinusitis. This plain radiograph clearly Chronic maxillary sinusitis. The limitations of plain radiographs
demonstrates an air-fluid level in the right maxillary sinus are demonstrated by this Water's view. There is diffuse
(arrow). There is also some mucosal thickening in the left mucosal thickening in both maxillary sinuses which is typical of
maxillary antrum. Patients �hould not undergo CT during the chronic maxillary sinusitis. Little information can be gained from
acute phase of an uncomplicated sinus infection, as the acute plain radiographs about the ostiomeatal complex or the
inflammatory swelling prevents the ostiomeatal complex from adjacent ethmoid sinuses in patients with recurrent or persistent
being clearly visualized. The maximum information is gleaned sinusitis.
from scans conducted when the patient is in a quiescent phase.

Figure 4.3 Figure 4.4

Dental amalgam causing streak artifacts. This CT scan shows Coronal reconstruction. This coronal reconstruction from axial
the extensive artifacts that can occur from metallic dental CT scans demonstrates the ostiomeatal complex. Unfortunately,
amalgam. This phenomenon is also known as the partial the anatomic definition is not as clear as that seen in direct
volume effect. coronal scans. Coronal reconstruction is usually limited to those
patients who are unable to cooperate with direct scanning,
because of limited neck movement.
32 An atlas of imaging of the paranasal sinuses

�5 �6

Figure 4.5 Figure 4.6

The lateral topogram (the lope or scout image). This topogram For coronal scans, the topogram will demonstrate the scanning
shows the scan lines for CT of the paranasal sinuses in the lines perpendicular to the infraorbitomeatal line. The gantry
axial plane. The scanning lines lie parallel to the angulation may be altered to avoid metal dental fillings which
infraorbitomeatal line. will degrade the image.
5
The role of conventional sinus radiographs
in paranasal sinus disease
Martyn Mendelsohn Arnold Noyek

For many decades, plain sinus radiographs provided

the family practitioner and the otolaryngotogist with a
road map of sinus pathology. The antrum, which was
formerly the putative focus of sinus disease, is well
displayed by plain radiographs. However modern
theory focuses upon the importance of the ethmoids
in sinus infection. This shift in emphasis dramatically
increased the role of computed tomography (CT)
scans, which can image the ethmoids and provide a
guide to endoscopic surgery. In this light, modern
reviews have underemphasized the role of plain
radiography. Has the pendulum swung too far? This
chapter discusses the role of plain sinus films in the
current era, and indicates the range of pathology
which can be imaged by plain sinus radiography.

TECHNIQUE
The standard views include the Water's (occipito­
mental), Caldwell (occipitofrontal), lateral and basal
(submentovertical) views. Many supplementary
films are available, including the panoramic
tomogram and orbital oblique views. The features
displayed on each are summarized in Table 5.1.
Technical data is covered in greater detail by
Valvasori et al (1982).

Caldwell view
Water's view This view highlights frontoethmoidal disease and the
orbits. In this view, the patient's face is in contact
The Water's view is the primary view to observe the with the film holder. This ensures minimal magnifi­
maxillary antra and the anterior ethmoid sinuses. cation of the frontal bone so that the image can be
The orbits, nasal cavities and zygomatic arches are the basis for a frontal sinus template in osteoplastic
also well seen. flap surgery.
34 An atlas of imaging of the paranasal sinuses

Lateral view
This is the only view that can consistently display an
air-fluid level in the sphenoid sinus. The trans­
parency of the sinuses is difficult to judge due to the
overlap of the two sides. The sella turcica and
nasopharynx are well seen.

Basal view
This view provides comparison of each sphenoid
sinus, and also the ethmoid sinuses and nasal
cavities. The mastoid air cells may be included in
this view in patients who have associated ear
symptoms.

Panoramic tomogram (Panorex,

Orthopantomogram)
Although not a standard paranasal sinus view, the
panoramic tomogram can provide unique information
on the floor of the antrum, the pterygopalatine
surface of the sinuses and the teeth. This view is
invaluable to investigate any case of dental involve­
ment. Panoramic machines are now commonly
available in the dental department of most hospitals.

RADIOLOGIC FEATURES
Interpretation of plain radiographs requires an
assessment of bone, soft tissue and air. Radiologic
signs are summarized in Tables 5.2 and 5.3. These
signs must always be correlated with the clinical
picture.

Anatomy
The role of each view in imaging the sinuses is hypoplasia, bony sclerosis and the presence of a
summarized in Table 5.1. The plain films indicate the sinus septum, are a useful guide for surgeons under­
size and symmetry between the two sides. The taking antral surgery or frontal sinus trephine.
frontal sinuses are frequently asymmetric and may The panoramic tomogram demonstrates the maxil­
be absent. The thickness and integrity of the bony lary teeth and the antral floor. The relationship of the
walls are well seen. Anatomic variations, such as tooth roots has some variability, but generally the
 The role of conventional sinus radiographs in paranasal sinus disease 35

two premolars and the first two molar teeth have disorder. These often require further investigation,
roots in the floor of the maxillary sinus. Tooth roots, as indicated by the clinical presentation.
supernumary teeth and unerupted teeth seen on
plain films may be associated with cysts and antral
pathology.

THE ROLE OF PLAIN

RADIOGRAPHS
Paranasal sinus disease Sinusitis is the most common health care complaint
in the USA, affecting more than 31 million people
Radiologic abnormalities have been demonstrated in (Havas et al 1988). As a community problem, most
40% of asymptomatic patients on CT (Yanagisa and cases of sinusitis are diagnosed by the family practi­
Smith, 1976). Most abnormalities are mucosal thick­ tioner, based upon the history and physical exami­
ening or polyps in the ethmoid sinus and the floor of nation. In many cases, the patient responds to
the antra. This reinforces the importance of cor­ medical management and no imaging is necessary.
relating the radiologic signs with the clinical features. There are many situations in which plain radiog­
Acute maxillary, frontal and sphenoid sinusitis can raphy may be used as a screening examination to
be identified by mucosal thickening and the diagnose paranasal sinus pathology (Table 5.4). The
presence of fluid. Fluid is most reliably indicated by symptoms may be atypical. The clinician may be
an air fluid level. Whether the fluid is pus, serous reluctant to prescribe antibiotics, or the patient reluc­
transudate, blood, cerebrospinal fluid or other must tant to take antibiotics, until the diagnosis is more
be established on clinical grounds. Generalized
mucosal thickening without fluid may indicate acute
or chronic inflammatory change. Total luminal opaci­
fication may be the result of empyema or a soft­
tissue mass, or may reflect thicker bone or soft
tissue overlying that sinus. In cases suggesting
luminal opacification, an alternate view is mandatory
to verify the presence of pathology.
Chronic sinusitis, resulting from infection or
allergy, may be evidenced by localized or diffuse
soft-tissue thickening or cysts. Osteitis is suggested
by bony sclerosis or rarefaction. Polypoid disease
may obliterate an entire sinus. An antrochoanal
polyp may be seen in the lateral view. Antral cysts
warrant a panoramic view, to establish the relation­
ship between the cyst and any normal or abnormal
teeth.
Unlike the other paranasal sinuses, ethmoid
pathology is usually identified on plain radiographs
by obliteration of multiple small cells rather than
mucosal thickening or fluid level changes within a
sinus. Consequently, in comparison with CT scans,
plain radiographs have limited resolution and hence
ability in identifying early ethmoid changes. The
newly recognized importance of ethmoid sinusitis
and the increasing vogue for functional endoscopic
sinus surgery have resulted in the increased
popularity of CT scanning in imaging of the ethmoid
region in chronic sinusitis.
Other radiologic signs, which are listed in Table
5.2 and 5.3, may result from complications of sinus
infection, benign or malignant tumor, trauma or other
36 An atlas of imaging of the paranasal sinuses

definite. The symptoms may persist despite an initial Not all patients with sinusitis want or need
course of antibiotics. Plain radiographs may be endoscopic sinus surgery. Plain radiographs provide
useful in screening for some complications of sinus the surgeon with a 'road map' before antral
disease, such as mucocele, orbital abscess, puncture, intranasal antrostomy, radical antrostomy
osteomyelitis, Pott's puffy tumor, etc. However, and frontal sinus trephine. The radiographs can
definitive management of these complications invari­ reveal the presence of a hypoplastic sinus, bony
ably requires CT examinations. septae or thickened bony walls, and so improve the
Plain radiographs are ideally suited to screen for safety and efficiency of the surgical procedure. The
a widespread community illness such as sinusitis. Caldwell view provides the template for osteoplastic
Most acute infections involve more than one sinus frontal sinus surgery.
and are well displayed on plain radiographs. Plain Plain radiographs may aid the localization or
radiography is cheaper and more readily available identification of foreign bodies. The exact position
than CT or magnetic resonance imaging. Sinus can be correlated by observing multiple views. Plain
radiographs can often be obtained on the day on films are useful in screening for facial trauma,
which radiography is performed, for immediate although clear evidence of complex maxillofacial
review by the referring practitioner. The reduction in trauma requires CT scanning.
cost for imaging such a large-scale problem results Figures 5.1-5.8 illustrate some of the potentials
in a major health savings compared to other inves­ and pitfalls of plain radiographs of the paranasal
tigations, which are substantially more expensive. If sinuses. In Figures 5.1-5.4 are shown cases in
plain sinus radiographs appear normal despite which the plain radiographs provide adequate infor­
strong clinical suspicion, the clinician may then mation for clinical decision making. The subsequent
choose to proceed to more elaborate and expensive Figures illustrate cases that required CT evaluation.
tests based upon clinical features. Furthermore, the
clinician may recognize one or more sinister radio­
graphic signs that also indicate the need for further
investigation.
Dental disease is a well-recognized cause of CONCLUSION
sinusitis that may be resistant to simple therapy.
Plain sinus radiographs supplemented by panoramic Despite the current excitement surrounding CT of
and dental views display the antrum and coexistent the paranasal sinuses, plain radiographs still have
dental pathology, including apical disease, abnormal several clinical applications. The discerning clinician
or supernumary teeth, dental cysts and the presence selects the most cost-efficient and time-efficient test
of an oroantral fistula. that can provide adequate information.
 The role of conventional sinus radiographs in paranasal sinus disease 37

5.1A

5.18

5.2A 5.28

Figure 5.1 Figure 5.2

Plain radiography. (A) The material in the lower half of the left Sphenoidal sinusitis. The sphenoidal fluid level seen on plain
antrum (on the upright Water's view) has a concave meniscus, radiographs (A) resolved with conservative treatment (B).
diagnostic of an air-fluid level. The density in the right maxillary
sinus has a convex surface, characteristic of a mucous
retention cyst in the floor of the antrum. The comparison is
striking. (B) The superimposed images of the fluid level and the
cyst are well seen in the lateral view.
38 An atlas of imaging of the paranasal sinuses

5.M 5.�

5.4

Figure 5.3 Figure 5.4

Barotrauma and hematoma. This patient experienced left frontal Left antral mucous retention or serous cyst. The superior
pain upon descent in an aeroplane. (A) The plain radiograph surface of the lesion is smooth and convex, and there is a
demonstrates a soft-tissue mass in the superior left frontal pocket of air in the antrum. The plain radiograph is adequate
sinus. (8) A similar film 2 weeks later shows resolution, for the diagnosis of a large mucous retention cyst arising from
confirming the diagnosis of frontal sinus hematoma secondary the lower portion of the antrum.
to barotrauma.
 The role of conventional sinus radiographs in paranasal sinus disease 39

5.5A 5.58

5.6A 5.68

Figure 5.5 Figure 5.6

Antral roof polyp. (A) Plain radiography (Water's view) (A) The plain radiograph demonstrates a left ethmoid opacity
demonstrated an unusual finding in the left antrum. This with bone destruction of the lamina papyracea (arrows). (8) CT
required CT evaluation (8) which revealed a polyp hanging was required to display the full extent of the soft-tissue
from the antral roof on a long stalk. expansion into the orbit by an ethmoid mucocele (small arrow).
The thick arrow indicates displaced thickened bone.
40 An atlas of imaging of the paranasal sinuses

s.�
s.m

5.8A 5.8B

Figure 5.7 Figure 5.8

Dentigerous cyst. (A) The antrum appears opaque and Completely opaque left antrum without bone destruction. The
expanded, and the crown of an ectopic tooth is clearly patient had a 15-year history of 'chronic sinusitis'. (A) On the
displayed on complex motion tomography. (B) The axial CT plain radiograph complete antral opacification gives no clue as
demonstrates that the mass is cystic, extrinsic in origin and has to the nature of the antral pathology. No bone destruction is
expanded to virtually replace the antrum and adjacent nasal seen. (B) CT demonstrates a solid mass eroding the posterior
cavity. antral wall and destroying the pterygoid plates. Biopsy revealed
malignant schwannoma.
6
T he normal anatomy of the paranasal
sinuses as seen with Computed
Tomography and Magnetic Resonance
Imaging

The radiologist must be familiar with the anatomy of sinus lumen. Computed tomographic (CT) evaluation
the ethmoid labyrinth, the larger paranasal sinuses of the sinuses with narrow window settings alone
and their associated ventilation and drainage may also lead to misinterpretation of the under­
channels in the lateral nasal wall. The relevant developed sinus as a sinus exhibiting pathology. A
anatomy is described in this chapter in the axial, sagit­ wide- or bone-window setting will identify this as
tal and coronal planes, with additional information hypoplasia and exclude the possibility of a well­
about the more commonly occurring anatomic developed sinus with pathology affecting its lumen.
variants. Each radiologist will need to develop their Asymmetry of the frontal sinuses is more common
own scheme for the systematic reporting of computed in those races with dolichocephalic heads, such as
tomographs of this challenging anatomic area. the mongoloid race.
Extensive pneumatization of the superciliary
portion of the frontal bone is a common variant in
both normal individuals and acromegalics (Figure
THE EXTERNAL NOSE 6.4). It is not uncommon for this to be the only part
of the frontal bone that is pneumatized and the
The external nose is the first structure visualized in normal supraorbital extension of the frontal sinus
the coronal scans (Figure 6.1 ). If the frontal sinuses may be absent.
are prominent, they will also appear in the most The anterior ethmoid air cells may encroach upon
anterior scans. the frontal sinuses. These anterior ethmoid cells
become clinically significant when they are so closely
related to the frontal recess that they obstruct venti­
lation and drainage of the frontal sinus. This variant
THE FRONTAL SINUS may be seen on the coronal scan as either a solitary
air cell or a collection of air cells situated in the medial
The frontal sinuses are asymmetrical paired cavities part of the floor of the frontal sinus, projecting into the
located between the two tables of the frontal bone lumen of the frontal sinus. These cells, which may
{Figure 6.1 ). The frontal sinuses are frequently also be referred to as a frontal bulla (Figure 6.5),
divided by numerous incomplete bony septi into usually drain into an already narrowed frontal recess.
several intercommunicating air cells (Figure 6.2).
The frontal air cells usually lie in the same coronal
plane, but occasionally one sinus lies behind the
other, in which case·, it is referred to as a super­ THE FRONTAL RECESS
numerary frontal sinus. The frontal sinus is
connected to the nasal cavity via the frontal recess. The term frontonasal duct is a misnomer, as this
The shape and size of the frontal sinus are highly area has no duct-like features and is composed
variable, and it may be hypoplastic or even absent instead of a variably waisted hour-glass shaped
{Figure 6.3). On plain radiographs this anomaly may bony channel through which the frontal sinus drains
be misinterpreted as disease that has obliterated the into the ostiomeatal complex. The frontal recess is
42 An atlas of imaging of the paranasal sinuses

rarely visualized at the time of routine, preoperative cells, hypertrophied middle turbinates, concha
endoscopy, and CT in the coronal plane is ideal for bullosa or large anteriorly protruding ethmoid bulla.
assessing this region. A short, wide frontal recess Deviations of the nasal septum may also narrow the
may be easily visualized on a single scan. However, frontal recess and the premeatal region of the
a more tortuous and narrow frontal recess usually ethmoid infundibulum.
cannot be seen on a single scan because the frontal
recess runs obliquely with its distal (inferior) end
more posterior than its proximal (superior) end.
The route of ventilation and drainage of the frontal
sinus through the frontal recess depends upon the THE AGGER NASI CELLS
embryologic development as described in Chapter 3.
The frontal recess may open into: CT in the coronal plane demonstrates the agger
mound as a small prominence seen anterior and
the premeatal groove anterior to the semilunar superior to the insertion of the vertical plate of the
hiatus (Figure 6.6), and therefore drain indepen­ middle turbinate. When present, the agger nasi air
dently of the ethmoid infundibulum and the cells are situated within the agger mound and are
maxillary and ethmoid sinuses; part of the anterior ethmoid sinuses (Figure 6.11).
ii the ethmoid infundibulum; in this situation The agger mound may be acellular or it may contain
inflammation affecting the maxillary sinus may between one and four air cells (Figure 6.12).
spread along the infundibulum to affect the Pneumatization of the agger mound may be so
frontal sinus. extensive that it encroaches either upon the lacrimal
bone or upon the neck of the middle turbinate.
The dimensions of the frontal recess are variable. Pneumatization of the agger mound can shorten the
If wide and short, the sinus is easily ventilated neck of the middle turbinate, resulting in a tight
(Figure 6.7). However, if the frontal recess is long, frontal recess (Figure 6.13).
tortuous and narrow and runs between crowded Most agger nasi cells arise from, and are there­
anterior ethmoid air cells, then minimal swelling can fore aerated from, the frontal recess. The agger nasi
impede the drainage of the frontal sinus and predis­ cells are closely related to the lacrimal sac, being
pose it to recurrent infection. separated from the lacrimal sac by only the delicate
The frontal recess may be localized on CT or MR lacrimal bone. This thin bony plate may be naturally
scans by identifying the superior insertion of the dehiscent and as a result, inflammation can spread
uncinate process (Figures 6.7-6.1 O; see also Figure readily into the lacrimal sac, resulting in epiphora,
3.19). This superior insertion of the uncinate process dacryocystitis and sometimes preseptal or periorbital
is variable and determines whether the frontal cellulitis.
recess drains into the ethmoid infundibulum or the
premeatal groove. When the uncinate process
inserts laterally into the lamina papyracea, the
ethmoid infundibulum forms a blind recess, the
terminal recess (recessus terminalis), and the frontal
recess drains medially into the premeatal chamber DEVIATIONS OF THE NASAL
of the ethmoid sinus (Figure 6.8). When the uncinate SEPTUM
process inserts into the roof of the ethmoid sinus, or
medially onto the middle turbinate, the frontal sinus The nasal septum, which is almost never perfectly
drains directly into the ethmoid infundibulum (see midline, is formed partly by the perpendicular plate
Figure 3.19). The frontal recess may pneumatize the of the ethmoid, the vomer, the palatine bones and
crista galli, middle turbinate or the agger nasi, and the quadrilateral cartilage (Figures 6.3 and 6.14).
can thus both influence and be influenced by While deviations of the nasal septum are common,
disease in these adjacent air cells. not all deviations are of clinical significance. Most
septa! deviations are the result of developmental
anomalies and asymmetric growth of the facial
Anatomic variants skeleton, although the nasal septum may deviate
due to trauma. There may be a deviation of either
The frontal recess may be obstructed by several the bony nasal septum, the cartilaginous septum or
anatomic variants, including enlarged agger nasi air a combination of both (Figure 6.15).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 43

Deviation of the nasal septum often allow compen­ cavities, with the apex pointing towards the zygoma
satory hypertrophy of the contralateral inferior and and the base forming the medial wall of the maxil­
sometimes the middle turbinate (Figure 6.15). A lary sinus. Most maxillary sinuses are symmetrical
septa! deviation may limit surgical access to the (Figures 6.6-6.8 and 6.10). CT in the coronal plane
middle meatus, and a septoplasty n-ay be required demonstrates the maxillary sinus to be narrow
(Figure 6.16). Bony projections may extend laterally anteriorly, i.e. in the same plane as the vertical plate
from the nasal septum. These bony spurs, (Figure of the middle turbinate (Figure 6.19), widest in its
6.17) which vary in size, may be large enough to midportion, i.e. in the same plane as the horizontal
push into the lateral nasal wall, coming into contact plate of the middle turbinate, and narrow again
with the middle or inferior turbinates or, in extreme posteriorly.
cases, curling up into the middle meatus. Such The roof of the maxillary sinus forms the orbital
contact may lead to severe headaches as well as floor which is narrow posteriorly and wider anteriorly.
nasal obstruction. The inferior surface of the orbital floor is grooved by
The nasal septum may be pneumatized, either in the infraorbital canal (Figure 6.19), which contains
continuity with an aerated crista galli, or posteriorly the infraorbital nerve as its accompanying vessels.
as an extension of the sphenoid sinus (Figure 6.18). This nerve passes through the infraorbital fissure
Defects of the cartilaginous or bony septum with (Figure 6.20), traverses the infraorbital canal and
intact mucosa are usually the result of a previous exits through the infraorbital foramen, which is
submucous resection or septoplasty. Small perfora­ situated below the inferior margin of the orbital rim
tions seen in the septum are most commonly the (Figures 6.19-6.21). The bone surrounding the
result of a previous septoplasty. Causes of larger infraorbital nerve is usually thin and may be affected
cartilaginous traumatic septa! hematomas, repeated by erosion and reactive osteitis, with new bone
local trauma, excessive cautery for epistaxis (chronic formation in cases of chronic inflammatory sinus
nose picking), midline granulomas (Stewart's or disease.
Wegener's), cocaine abuse, tuberculosis and The posterior wall of the maxillary sinus is narrow
leprosy. Atraumatic bony septal perforations are and forms the anterior boundary of the pterygopala­
usually secondary to syphilis. tine fossa (Figure 6.22). This region is better demon­
strated by CT in the axial plane (see Figure 6.22).
The medial wall of the maxillary sinus forms part
of the lateral wall of the nasal cavity. The bone of
the medial wall is usually deficient over a large area,
THE PNEUMATIZED CRISTA GALLI and the dehiscence is closed by the mucosa of both
the nasal cavity and the maxillary sinus, covering a
The crista galli is the vertical extension of the perpen­ thin fibrous layer in continuation with the periosteum.
dicular plate of the ethmoid bone above the cribriform This area is divided into the anterior and posterior
plate into the anterior cranial cavity (Figure 6.11). The nasal fontanelles. These latter two sections are
dura mater is attached to the crista galli. The crista separated by the ethmoid process of the inferior
galli may be pneumatized from the frontal recess and turbinate. These fontanelles should not be mistaken
a large air cell may replace the entire body (Figure for bony erosion associated with disease. Small
6.8); it may be filled with fatty marrow (Figure 6.7). If defects are frequently found in the membranous
the lumen of the air cell is narrow, it may become fontanelles; these are the accessory maxillary sinus
obstructed by minimal mucosa! swelling. Patients with ostia. They are usually situated immediately aoove
such an anomaly may present with headaches. In the inferior turbinate and open directly into the
isolated frontal recess disease with secondary infec­ middle meatus (Figure 6.20}.
tion of a crista galli air cell, endoscopic and plain The maxillary sinus has three recesses: the alveo­
radiographic findings may be normal. lar recess, the lateral recess and the superior
recess. The most frequently encountered recess is
the alveolar recess, which is an inferior extension of
the sinus into the alveolar ridge (Figure 6.23).
Extension of the maxillary sinus into the zygoma is
THE MAXILLARY SINUS called the lateral recess of the maxillary sinus. The
superior recess is the supermedial extension of the
The maxillary sinuses are the largest of the sinus, which can have a variable relationship to the
paranasal sinuses. They are pyramidal shaped orbit (Figures 6.24 and 6.25}. The superior recess is
44 An atlas of imaging of the paranasal sinuses

well demonstrated by CT in the axial plane and may and 6.27). The pterygopalatine fossa and the
be mistaken for a large ethmoid air cell. The ethmoid superior and the inferior orbital fissures are
sinus should be noted to be lying medially (Figure enlarged, and the bony walls are thick. The natural
6.25). ostium is bony.
The maxillary sinus is separated from the pos­ In Type II maxillary sinus hypoplasia, there is
terior ethmoid sinus by the ethmomaxillary plate marked retraction of the posterior fontanelle into the
(Figures 6.20 and 6.21). Defects secondary to a cavity of the maxillary sinus and the membranous
previous transnasal ethmoidectomy may be seen in fontanelle may be misdiagnosed as an air-fluid level
this plate. (Figures 6.28 and 6.29). The uncinate process is
fused with the inferomedial wall of the orbit.
Asymmetric sinuses may be demonstrated by
plain radiographs. The smaller sinus may however
be misinterpreted as a sinus of normal dimensions
Anatomic variants with chronic maxillary sinusitis, especially when the
patient has a history of persistent upper respiratory
Anatomic variants of the maxillary sinus that may be tract infections. In such circumstances these
demonstrated by CT include asymmetry, hypoplasia patients may be erroneously subjected to prolonged
of one or both maxillary sinuses, septated sinuses, medical management and may undergo surgical
a double maxillary sinus, an atelectatic maxillary exploration only to find normal sinus mucosa within
sinus and an ethmomaxillary sinus. the smaller sinus cavity. The superior bone, air and
soft-tissue contrast resolution of CT enables the
radiologist to accurately diagnose such variants and
has led to the finding of the association of hypo­
Hypoplasia of the maxillary sinus
plasia of the uncinate process, with hypoplasia of
Hypoplasia of the maxillary sinus is a developmen­ the maxillary sinus. With increasing severity of the
tal abnormality that can be identified radiologically in hypoplasia, a corresponding degree of hypoplasia
patients with and without sinus disease. Bolger, or aplasia of the uncinate has been noted. This
Butzin and Parsons (1991) analyzed a series of 202 finding should be documented because an
consecutively obtained CT scans, and noted an attempted uncinectomy in these patients will lead to
incidence of maxillary sinus hypoplasia of 10%. They inadvertent entry into the orbit through the lamina
presented a classification system based upon the papyracea or orbital floor.
radiographic features of the sinus as seen on CT. Hypoplasia of the maxillary sinus that is acquired
Type I maxillary sinus hypoplasia (incidence 7%) following infection, trauma or radiation is repre­
has only a mild degree of hypoplasia of the maxil­ sented by a maxilla of normal size, with the inflam­
lary sinus, with a normal uncinate process and a matory reaction producing a partial or complete
normal infundibulum. Type II maxillary sinus obliteration and resorption of the sinus lumen.
hypoplasia (incidence 3%) has a mild to moderate
reduction in the volume of the maxillary sinus,
combined with CT evidence of a hypoplastic
Atelectatic maxillary sinus
uncinate process and an absent or poorly defined
infundibulum. In Type Ill maxillary sinus (incidence This anatomic variant may present as an asymp­
0.5%), the maxillary sinus is largely absent and tomatic incidental finding or in a patient with chronic
consists of only a cleft. The uncinate process is sinusitis.
absent in Type Ill.
The nasal cavity and orbit on the involved side are
usually enlarged. The maxillary sinus and the nasal
Maxillary sinus hyperplasia
cavity are inversely proportional to one another. The
smaller the sinus, the larger the nasal cavity on the Maxillary sinus hyperplasia is an uncommon condi­
same side. The orbital rim may be at a lower level tion in which there has been extensive pneumatiza­
than the normal side with the eyeball appearing tion of the maxilla, with large recesses that
deeply placed, with an apparent 'exophthalmos' on pneumatize the alveolar ridge, and the zygoma
the contralateral side. The sinus does not extend (alveolar and lateral recesses). There is compen­
laterally as expected, and the infraorbital foramen satory narrowing of the nasal cavity in these
appears to be more laterally placed (Figures 6.26 patients.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 45

Septated maxillary sinus or posterior nasal fontanelles. These are situated

immediately above the inferior turbinate and usually
The maxillary sinus may be subdivided by septi that
open directly into the anterior or posterior portions
may be either fibrous or bony and which divide the
of the middle meatus (Figure 6.20). Accessory maxil­
sinus into two unequal halves. These septi usually
lary sinus ostia do not normally assist in the
extend from the infraorbital canal to the lateral wall
drainage of the maxillary sinus. They may be readily
of the sinus, thereby forming a superolateral and an
identified on endoscopy and may be misinterpreted
inferomedial compartment. Such anomalies should
as the true maxillary sinus ostium. The latter which
be identified to prevent incomplete drainage proce­
opens into the depths of the ethmoid infundibulum
dures which may result in the persistence of sinus
is rarely visualized without resection of the uncinate
disease (Figure 6.30).
process.
Because the maxillary sinus ostium is rarely seen
during routine office endoscopy, it can be difficult to
Double maxillary sinus identify any anatomic variations that may be compro­
mising the ventilation of this sinus and therefore
This is a rare anomaly in which two independent
predisposing the sinus to recurrent infections. Those
cavities in the same maxilla drain into the middle
common anomalies that may compromise the
meatus through two separate ostia.
natural ostium include Hailer's cells, lateral devia­
tions of the uncinate process and a large ethmoid
bulla. All of these anomalies which compromise the
Ethmomaxillary sinus maxillary sinus ostium are best demonstrated by
coronal CT.
In this condition, the posterior ethmoid sinus
extends laterally into the maxilla, forming an ethmo­
maxillary sinus (Figure 6.31 ). This anomaly has the
appearance of a septated sinus, but it can be differ­
entiated by identifying the superior compartment
which, having developed from the posterior
HALLER'S CELLS
ethmoid, drains into the superior meatus. The
Hailer's cells are named after the eighteenth-century
adjacent superior meatus is usually deeper and
anatomist, Albert von Haller, who described this
larger, whereas the related maxillary sinus is
particular anatomic variant. These cells are a lateral
smaller or normal in size.
extension of the anterior ethmoid cells into the
inferomedial margin of the orbit. Hailer's cells cannot
be seen on endoscopic examination of the nasal
cavity, however they are clearly demonstrated by CT
in the coronal plane (Figure 6.32). A solitary large
MAXILLARY SINUS OSTIUM Hailer's cell situated lateral to the maxillary sinus
ostium may narrow the lumen and predispose the
The natural ostium of the maxillary sinus is located
sinus to recurrent infections. The pneumatization of
in the superomedial aspect of the medial sinus wall.
This natural ostium is radiographically located at the the floor of the orbit by Hailer's cells may be exten­
lateral end of the ethmoid infundibulum (the narrow sive (Figure 6.33).
channel lying between the lateral surface of the
uncinate process, the lamina papyracea and the
anterior surface of the ethmoid bulla). The ethmoid
infundibulum opens through the semilunar hiatus
into the middle meatus (Figure 6.19).
THE ETHMOID SINUS
The ethmoid bone lies between the orbits. It is
comprised of a horizontal plate, a vertical plate and,
on either side of the latter, the ethmoid labyrinths
Anatomic variants (Figures 6.19, 6.25 and 6.34-6.37). The ethmoid
labyrinth is separated from the orbit by the delicate
The accessory maxillary sinus ostia are small lamina papyracea. Natural dehiscences in the
defects frequently found in the membranous anterior lamina papyracea may serve as small channels
46 An atlas of imaging of the paranasal sinuses

allowing the spread of infection into the orbit. These The ethmoid bulla
findings should not be misinterpreted as pathologic
erosions. The largest and most constantly present anterior
The vertical plate extends above the horizontal ethmoid air cell is the ethmoid bulla. The ethmoid
cribriform plate into the anterior cranial fossa as the bulla is the most prominent structure seen clinically
crista galli. The horizontal plate of the ethmoid is when the middle turbinate is retracted medially
perforated for the transmission of the olfactory nerve (Figure 6.39). The anterior wall of the ethmoid bulla
fibers from the roof of the nasal cavity (Figure 6.38}. forms the posterior margin of the ethmoid infundi­
The gyrus rectus of the frontal lobe and the olfac­ bulum. The roof of the ethmoid bulla may be cont­
tory bulb rest upon the olfactory fossa on either side inuous with the roof of the ethmoid sinus or it may
of the crista galli. be separated by a suprabullar extension of the
The cribriform plate lies at a variable level in lateral sinus. The ethmoid bulla is variable in its
relation to the ethmoid foveolae. It may lie well pneumatization. It may be absent or it may be
below the roof of the ethmoid or, in some cases, in expanded, inferiorly, medially or anteriorly, narrow­
the same plane as the ethmoid foveolae (Figures ing the middle meatus. If the ethmoid bulla expands
6.35 and 6.38). This is well demonstrated on CT in medially it may make contact with the adjacent
the coronal plane. If sinus surgery is being contem­ lateral surface of the middle turbinate, resulting in
plated, the surgeon will use this information to avoid facial pain and contact headaches (Figure 6.40). If
injury to the cribriform plate. Such injuries may be the ethmoid bulla enlarges anteroinferiorly it may
complicated by permanent anosmia or cerebro­ overhang the semilunar hiatus and occlude the
spinal fluid rhinorrhea and the risk of intracranial ethmoid infundibulum, thus obstructing its narrow
infection. drainage pathway (Figures 6.39 and 6.41). The
The ethmoid labyrinths are divided into an anterior frontal recess may be occluded by an ethmoid bulla
and a posterior group of air cells (see Figure 6.37). that expands anteriorly. The ethmoid bulla often
The ground lamella of the middle turbinate is the appears to have no mucosal disease, but it may be
dividing line between the anterior and the posterior responsible for inflammatory disease in the neigh­
ethmoid cells. The anterior ethmoid air cells are boring larger paranasal sinuses (Figure 6.42).
usually smaller and more numerous than the pos­
terior group of air cells. The anterior ethmoid cells
drain into the middle meatus whereas the posterior
ethmoid cells drain into the superior meatus.
THE UNCINATE PROCESS
The uncinate process forms the anterior and medial
The anterior ethmoid sinuses walls of the ethmoid infundibulum. The posterior free
margin of the uncinate process forms the anterior
The anatomy of the anterior ethmoid sinus is border of the semilunar hiatus. The uncinate process
variable. These variations are of clinical interest of the ethmoid bone extends inferiorly to fuse with
when they cause obstruction of the ostiomeatal the ethmoidal process of the inferior turbinate
complex. The ostiomeatal complex is the key to the (Figure 6.19). This fusion is usually at least 1 cm
development of most inflammatory diseases of the posterior to the distal end of the nasolacrimal duct.
frontal, maxillary and ethmoid sinuses. However, it is not uncommon to see this area of
The ostiomeatal complex is a term used to collec­ fusion quite close to the nasolacrimal duct (Figures
tively describe that area of the anterior ethmoid into 6.24 and 6.35). This observation should alert the
which the frontal, the maxillary, and the anterior surgeon to the risk of injury to the nasolacrimal
ethmoidal sinuses drain. The ostiomeatal complex is apparatus because a generous uncinate resection
comprised of the frontal recess, the infundibulum, may result in chronic epiphora if the nasolacrimal
the semilunar hiatus and the adjacent portion of the duct is transected. With such an anomaly the
middle meatus. Anatomically, this area is bounded ethmoid infundibulum extends more anteriorly and
by the medial wall of the maxillary sinus and the disease in this area may affect the nasolacrimal
lamina papyracea laterally, the lateral surface of the apparatus, especially the more distal duct which has
uncinate process anteriorly and medially, and the a membranous wall. The superior insertion of the
anterior wall of the ethmoid bulla posteriorly (Figures uncinate process is variable. It may turn laterally to
6.6, 6.8 and 6.19). insert into the lamina papyracea or it may insert
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 47

superiorly into the root of the ethmoid (Figure 6.43; when present, the lateral sinus, which lies between
see also Figure 3.19). In some instances the the ethmoid bulla and the basal lamella, also opens
uncinate process turns medially and inserts into the via the semilunar hiatus into the ethmoid infundibu­
vertical plate of the middle turbinate (Figures 6.26 lum.
and 6.44), as discussed in the section on anatomic
variations of the frontal recess.
Various anomalies of the uncinate process can
occur. Rarely the uncinate process is hypoplastic.
This anomaly has been associated with hypoplasia
The semilunar hiatus
of the maxillary sinus and with the atelectatic maxil­
The semilunar hiatus is a semilunar two-dimensional
lary sinus. In the latter condition, the middle meatus
aperture bounded posteriorly by the anterior surface
is wide and the posterior fontanelle retracted into the
of the ethmoid bulla and anteriorly by the posterior
cavity of the maxillary sinus. The uncinate process
tree margin of the uncinate process (Figure 6.19). It
appears to be 'plastered' to the interomedial wall of
is the opening through which the ethmoid infundibu­
the orbit, and attempted uncinectomy will inevitably
lum drains into the middle meatus.
lead to orbital injury (Figure 6.28).
The uncinate process may be medially deviated,
causing obstruction of the middle meatus (Figures
6.44 and 6.45). It may instead deviate laterally,
causing obstruction of the ethmoid infundibulum and The lateral sinus (recess) and the
the maxillary sinus ostium (Figure 6.39). Should the basal lamella
posterior tree margin of the uncinate process be
deflected medially, it may resemble a turbinate and The basal lamella of the middle turbinate is the
has, in this position, been incorrectly referred to as septum that divides the anterior from the posterior
an accessory or double middle turbinate (Figure ethmoid sinuses. The lateral sinus is an inconstant
6.46). The uncinate process may protrude anteriorly space that lies between the ethmoid bulla and the
and compromise the middle meatus. basal lamella (see Figure 3.18). The lateral sinus
Occasionally the uncinate process is pneuma­ can extend above the bulla and thus create a supra
tized. This air cell may be large enough to occlude bullar space (Figure 6.51). The lateral recess opens
the ethmoid infundibulum (Figure 6.47), or it may directly into the posterosuperior part of the semi­
even be the site of polyp formation. The uncinate lunar hiatus and is sometimes referred to as the
process may also be hypertrophied (Figures 6.48 superior recess of the semilunar hiatus. A large
and 6.49). ethmoid bulla overhanging this aperture or a
swollen medially bent uncinate process can impede
the drainage of the lateral recess into the middle
meatus. The radiologist must be able to identify the
lateral sinus, as inflammatory disease may be
THE ETHMOID INFUNDIBULUM confined to the lateral sinus and only identifiable on
CT scan.
This critical drainage channel is bordered by the
uncinate process anteromedially, the anterior
surface of the ethmoid bulla posteriorly and the
lamina papyracea laterally (Figure 6.19). The
ethmoid infundibulum connects the natural ostium of THE MIDDLE TURBINATE AND
the maxillary sinus to the middle meatus via the
semilunar hiatus. Variations in the anatomy of the MIDDLE MEATUS
related structures that border the ethmoid infundi­
bulum, i.e. the uncinate process and the ethmoid The middle meatus
bulla, can result in permanent narrowing or intermit­
tent obstruction of this channel (Figure 6.41). The The middle meatus is the space inferolateral to the
ethmoid infundibulum may also be compromised by middle turbinate, into which the anterior ethmoid, the
anomalies of the middle turbinate (Figure 6.50). frontal and the maxillary sinuses eventually drain
Anteriorly and superiorly, the frontal recess may (Figures 6.19 and 6.21). The middle meatus can be
open into the ethmoid infundibulum. Posteriorly, more clearly seen by medial retraction of the middle
48 An atlas of imaging of the paranasal sinuses

turbinate during endoscopy. The most prominent bone covered by soft tissue and projects medially
structure within the middle meatus is usually the from the lateral nasal wall into the middle meatus
ethmoid bulla. The uncinate process lies anterior to before turning superiorly within the meatus to appear
the ethmoid bulla. The size of the middle meatus can as an inverted turbinate. This anomaly has not been
vary; for example, it may be deep when the maxil­ noted to compromise the ostiomeatal complex. A
lary sinus is atelectatic and the posterior fontanelle secondary middle turbinate should not be confused
is retracted laterally (Figures 6.28 and 6.29). The with a medially bent uncinate process, also called an
middle meatus and the nasal cavities are small when 'accessory middle turbinate', nor should it be
the sinuses are well developed. mistaken for a polyp.

Anatomic variants
The middle meatus may be compromised by a large
The middle turbinate
ethmoid bulla, a deviated nasal septum, a bony
The middle turbinate arises from the medial aspect
septal spur or one of the many variants of the middle
of the ethmoid labyrinth. Anteriorly, the middle
turbinates (such as an abnormally aerated middle
turbinate is suspended from the roof of the ethmoid
turbinate - a concha bullosa), a secondary middle
by a vertical bony plate (Figures 6.10, 6.34, 6.35 and
turbinate or an accessory middle turbinate.
6.38). The vertical plate of the middle tu(9inate
serves as an important anatomic landmark for the
cribriform plate during intranasal surgery and should
'Accessory middle turbinate' not be resected, in case revision surgery is required
in the future. The head of the middle turbinate is
When the free posterior margin of the uncinate
slightly bulbous in shape and is continuous posteri­
process deflects medially it resembles a Mexican hat
orly with the free margin of the middle turbinate. The
and may be incorrectly identified clinically as an
head usually protrudes anterior to the vertical plate
accessory or double middle turbinate (Figures 6.46
by 1-2 mm, although it may protrude by over 1 cm.
and 6.52). This anomaly may cause mucosa! apposi­
It is therefore an unreliable landmark for the uncinate
tion, which subsequently leads to inflammatory
process.
changes and polypoidal degeneration. The acces­
Several thin inconstant plates may be seen arising
sory middle turbinate may be mistaken for a polyp
from the middle turbinate and insert laterally on to
on casual examination.
the lamina papyracea. The largest and most
constant of these horizontal plates curves laterally to
insert on to the lamina papyracea (Figures 6.20 and
Deviated nasal septum 6.46), and forms the roof of the middle meatus. This
is referred to as the basal or ground lamella, which
Deviations of the cartilaginous or bony parts, or both,
separates the anterior ethmoid sinuses from the
of the nasal septum may obstruct the nasal cavity.
posterior ethmoid sinuses.
Contact between the opposing mucosal surfaces
The free margin of the middle turbinate is usually
can cause headaches and may be the site of
bulbous but it can be triangular or bifid or hav� a
polypoidal degeneration of the mucosa. Septal
sagittal groove which incompletely divides it into
deviations are well demonstrated by CT and a wider
unequal parts (Figures 6.28 and 6.53).
perspective may be gained of the influence of bony
spurs on the nasal cavity. This is of great clinical
value because it may be extremely difficult to assess
the nasal cavity beyond a marked deviation or spur
(see earlier section deviations of the nasal septum). Anatomic variants
The advent of CT has advanced our understanding
of the variations that occur in the middle· turbinate.
Secondary middle turbinate
These anatomic variants are readily identified by CT
Rarely, a small secondary turbinate is seen in the and include aeration of the middle turbinate (a
middle meatus (Figure 6.52). This is comprised of concha bullosa), hypertrophy of the middle turbinate,
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 49

paradoxically bent middle turbinate, lateralization of Paradoxically bent middle turbinate

the turbinate, bony hypertrophy of the middle
Normally the lateral surface of the middle turbinate
turbinate (Figure 6.54), and partial or complete
is concave, curving away from the lateral nasal wall
agenesis (Figure 6.49).
to allow space for the middle meatus. When the
lateral surface of the middle turbinate is convex or
the turbinate appears to be bending medially, it is
Concha bullosa: aeration of the middle turbinate called a paradoxically bent middle turbinate (Figure
6.50). This usually occurs bilaterally and may reduce
The middle turbinates may be pneumatized from the
the middle meatus considerably. A concha bullosa
ethmoid sinuses or directly from the middle meatus.
occurring in a paradoxically bent middle turbinate
An air cell in a middle turbinate is called a concha
may further reduce the middle meatus and thus
bullosa (Figures 6.50 and 6.55). The incidence of
contribute to the pathogenesis of sinus disease.
concha bullosa is approximately 24%, and it may be
unilateral or bilateral. The pneumatization of a
concha bullosa is usually from the frontal recess,
from a lateral sinus or from the agger nasi, but Lateralized middle turbinate
occasionally it is directly from the nasal cavity. Not
A lateralized middle turbinate is an unusually small
all conchae bullosae cause symptoms, and they may
turbinate that is laterally placed, resulting in contact
simply be an incidental radiographic finding. A
with the adjacent uncinate process. It may obstruct
concha bullosa becomes of clinical significance
the ethmoid infundibulum (Figure 6.57).
when it is large enough to compress the ethmoid
infundibulum, obstruct the nasal cavity or cause
lateral displacement of the uncinate process. Such
patients present with sinugenic headaches or recur­ Hypertrophied middle turbinate
rent sinusitis (Figure 6.50).
On routine clinical examination it is not possible to
The air cell may be confined to the free margin,
differentiate between a hypertrophied and a
the vertical plate, or the horizontal plate of the
pneumatized middle turbinate. However, the differ­
middle turbinate. In some instances, the entire
ence becomes apparent on examination of CTs. The
middle turbinate may be pneumatized. The superior
hypertrophy may be of either soft tissue (Figure
meatus may extend into the vertical plate of the
6.58) or bone (Figure 6.54).
middle turbinate. This particular type of air cell is
referred to as an 'interlamellar cell'. There may be
more than one interlamellar cell (up to three) (Figure
6.56). The middle meatus may be narrowed by large
concha bullosa, and an anteriorly protruding concha
may obstruct the frontal recess (see Figure 7.8). If THE INFERIOR TURBINATE AND
this occurs, then there will usually be an increased INFERIOR MEATUS
incidence of inflammatory disease of the associated
neighboring paranasal sinuses (Figure 6.55). The anterior end of the inferior turbinate and the
In the asymptomatic phase, CTs may demonstrate inferior meatus are the first structures that are seen
early mucosal apposition between a concha bullosa on clinical examination of the nasal cavity. The
and the adjacent structures. A large concha bullosa inferior turbinate is an independent bone that fuses
may appear to cause a secondary deflection of the laterally with the conchal ridge of the medial process
nasal septum to the opposite side, and the contralat­ of the maxilla. The inferior meatus lies inferolateral
eral middle turbinate may be small or paradoxically to the inferior turbinate and the nasolacrimal duct is
bent (Figure 6.50). the only structure that opens into this meatus
The small cleft between the ethmoid bulla later­ (Figures 6.8, 6.19, 6.22 and 6.59).
ally, and the middle turbinate medially, is called the The mucous membrane of the inferior turbinate
conchal or turbinate sinus. Here the adjacent contains erectile tissue, the dilatation of which may
mucosa may make contact if any one of these struc­ be responsible for much of the soft-tissue hypertro­
tures is enlarged. Prolonged contact results in phy. A marked reduction in the size of the inferior
inflammatory changes in this space, with or without turbinate may be noted following the application of a
polypoidal degeneration. This is one of the common­ topical vasoconstrictor such as 0.1 % xylometazoline
est sites for polyp formation (Figure 6.40). hydrochloride nasal solution, thus indicating that such
50 An atlas of imaging of the paranasal sinuses

patients may benefit from cauterization or a limited extreme hazards to the patient's vision.
turbinectomy (Figures 6.60 and 6.61). Irreversible The lateral extension of the posterior ethmoid into
hypertrophy of the inferior turbinates may be indica­ the maxilla is called the ethmomaxillary sinus and has
tive of vasomotor rhinitis or allergic rhinitis. already been discussed. Another variant is the lateral
Preoperative CT is rarely indicated to assess hyper­ and posterior extension of the ethmoid air cells around
trophy of the inferior turbinates. However, if there is the sphenoid sinus on either side. This variant is
susp1c1on of ethmoid sinus disease causing referred to as the ethmosphenoid sinus. The ethmo­
secondary inferior turbinate vasodilatation, or the sphenoid sinus is clinically important because of the
presence of a large bony inferior turbinate causing structures related to the lateral wall of the sphenoid
obstruction, then the ethmoid sinus disease or the sinus, especially the internal carotid artery which may
bony abnormality can be well demonstrated by CT. have a close relation to the posterior ethmoid sinus.
Submucosal resection of the enlarged bony portion of Surgical intervention is more common in the posterior
the inferior turbinate bone may be curative (Figure ethmoid sinus than the sphenoid and, in the posterior
6.62). Soft-tissue hypertrophy of the inferior turbinate ethmoid, the internal carotid artery may only be
is much commoner than bony hypertrophy and is also separated from the sinus by a thin plate of bone.
easily demonstrable (Figures 6.15 and 6.63). An Irrespective of the bone that is pneumatized by
uncommon cause for enlargement of the inferior these ethmoids, all these additional air cells drain
turbinate is pneumatization of the turbinate bone. This into the posterior ethmoid sinus and superior meatus
is an unusual finding and the pneumatization is (Figure 6.31).
usually derived from the maxillary sinus (Figure 6.64).

The posterior ethmoid sinuses THE SPHENOID SINUS

The posterior ethmoid air cells are larger in size than The sphenoid is a complex bone with several
the anterior ethmoid air cells, but fewer in number. processes. The lesser wing and the anterior clinoid
They drain into the superior meatus, which is process are attached anteriorly to the planum
situated inferolateral to the superior turbinate. An sphenoidale (Figure 6.65). The anterior clinoid
inconstant additional turbinate may be situated process houses the canal of the optic nerve and also
above the superior turbinate and is called the forms the superior margin of the superior orbital
supreme turbinate (Figures 6.38 and 6.46). The fissure. The superomedial aspect of the superior
largest and most posterior of the posterior ethmoid orbital fissure is separated from the optic nerve
air cells is called Onodi's cell, after the anatomist canal by a thin piece of bone called the optic strut
who first described it, when it exposes a lateral (Figure 6.66). The greater wing of the sphenoid is
bulging of the optic canal, a so-called 'tuberculum situated more inferiorly and forms part of the orbital
opticum'. Onodi's cell shares a common wall with the wall and the inferior margin of the superior orbital
adjacent sphenoid sinus and is best demonstrated fissure. The pterygoid processes arise from the
by CT in the axial plane (Figure 6.36). greater wing of the sphenoid and form the posterior
Onodi's cells are of great clinical importance as border of the pterygopalatine fossa (Figures 6.22,
they have an intimate relationship with the optic 6.67 and 6.68). The greater wing of the sphenoid
nerve, from which they are separated by a thin makes a major contribution to the anteromedial part
delicate bony septa. It is not uncommon for the bone of the middle cranial fossa (Figure 6.65). The
to be dehiscent in this region and it is of critical foramen rotundum and the pterygoid (vidian) canal
importance that the relationship of the optic nerve to traverse the body of the sphenoid and are lateral
the posterior ethmoid is identified, in order to avoid relations of the sphenoid sinus (Figures 6.24, 6.66
injury to the optic nerve and blindness. and 6.67). Posteriorly, the foramen ovale and
The pneumatization of the posterior ethmoids is foramen spinosum perforate the greater wing close
variable and it is not uncommon for the posterior to the petrous apex (Figure 6.24).
ethmoid sinuses to extend beyond the confines of the The sphenoid sinuses are asymmetrical and vary
ethmoid bone. The posterior ethmoid may expand in size. Superiorly the sphenoid sinus is related to
superiorly into the orbit forming supraorbital cells, or the pituitary fossa and the pituitary gland (Figures
it may expand laterally to encompass the optic nerve. 6.14 and 6.36). On either side of the sinus lie the
These variants, if not identified preoperatively, pose cavernous sinuses which transmit the internal
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 51

carotid artery and the third, fourth and sixth cranial pterygoid plates of the sphenoid bone (Figures 6.22,
nerves. The intracavernous portion of the internal 6.25 and 6.26). The pterygopalatine fossa commu­
carotid artery passes superiorly alongside the body nicates with the orbit, the nasopharynx, the
of the sphenoid sinus (Figure 6.68). It comes to lie paranasal sinuses, the infratemporal fossa and the
medial to the anterior clinoid process before per­ middle cranial fossa, and it may form a major
forating the dura, which roofs the cavernous sinus, channel for the spread of infection or tumor. The
and then becomes the terminal or cerebral part of contents of the fossa include the terminal branches
the artery (Figures 6.24, 6.25, 6.36 and 6.69). The of the maxillary artery, accompanying small veins,
internal carotid artery may sometimes lie within the the maxillary nerve and the pterygopalatine
lumen of the sphenoid sinus. It is usually separated ganglion, which transmits the parasympathetic nerve
by a thin plate of bone, but this may be dehiscent. supply to the lacrimal gland, nasal cavity and
Inferiorly, the sphenoid sinus is related to the nasopharynx. All of these structures are surrounded
nasopharynx, the eustachian tubes and eustachian by loose connective tissue and fat. CT does not
cushions (Figures 6.23 and 6.69). clearly demonstrate the contents of the pterygopala­
Plain lateral radiographs of the skull demonstrate tine fossa, but following the administration of intra­
the sphenoid sinus well, but the adjacent structures venous contrast the terminal branches of the
related to the lateral wall of the sphenoid sinus are maxillary artery may be seen as small enhancing
poorly demonstrated by the Caldwell view. Several structures. Obliteration of the fat spaces in the ptery­
anatomic variations occur in the sphenoid sinus, and gopalatine fossa is indicative of disease, the
these are well demonstrated by CT. It is not uncom­ commonest being malignancy invading the space.
mon to find a multiseptate sinus (Figure 6.66). The pterygopalatine fossa communicates directly
Several pneumatized recesses extend from the with many of the surrounding anatomic regions, and
sinus into the surrounding structures. The common­ these channels may be identified by CT. Posteriorly,
est is the lateral recess that when present passes the pterygopalatine fossa communicates with the
between the pterygoid (vidian) canal and the middle cranial fossa via the foramen rotundum,
foramen rotundum (Figure 6.66). In some instances, which transmits the maxillary nerve (Figure 6.72).
the entire greater wing of the sphenoid bone, which Inferiorly, the pterygopalatine fossa tapers to its
makes a major contribution to the floor of the middle apex and receives the pterygoid (vidian) canal. This
cranial fossa, is pneumatized. The anterior clinoid, canal passes anteriorly through the body of the
the lesser wing of the sphenoid, the dorsum sella sphenoid from the foramen lacerum and transmits
and sometimes the posterior clinoid process may be the vidian nerve (Figure 6.24). The pterygopalatine
pneumatized. The sinus may also extend into the fossa communicates with the oral cavity through the
pterygoid processes. The floor of the sphenoid sinus greater and lesser palatine canals (Figures 6.23 and
may be dehiscent. This finding should not be misin­ 6.50), and laterally with the infra temporal fossa,
terpreted as the natural ostium of the sinus (Figures containing the medial and lateral pterygoids via the
6.70 and 6.71 ). The dehiscence may be further pterygomaxillary fissure (Figures 6.24 and 6.73).
eroded by benign or malignant disease. This is well Medially, it communicates through the sphenopala­
demonstrated by CT in the coronal plane. tine foramen with the sphenoethmoid recess and the
The sphenoid sinus drains through a small ostium nasal cavity (Figure 6.73). Anterosuperiorly, it
in the anterior wall, close to the roof of the sinus, communicates with the orbit through the infraorbital
into the sphenoethmoid recess. This is usually not fissure (Figures 6.24 and 6.25).
well demonstrated by CT in the coronal plane, but it
is well demonstrated on scans taken in the axial
plane or following sagittal reformation of images
taken in the axial plane (Figure 6.36).
THE ORBITAL A PEX
The orbit is the bony cavity that houses the eyeball,
extraocular muscles and neurovascular structures,
THE PTERYGOPALATINE FOSSA including the optic nerve. The apex of the orbit
communicates through the optic canal, the superior
The pterygopalatine fossa is shaped like an inverted orbital fissure and the inferior orbital fissure with the
pyramid bounded anteriorly by the maxillary sinus, middle cranial fossa, the pterygopalatine fossa and
medially by the palatine bone and posteriorly by the the inferior temporal fossa, respectively (Figure 6.74).
52 An atlas of imaging of the paranasal sinuses

The optic canal traverses the lesser wing of the orbit, the lacrimal sac and the nasolacrimal duct. The
sphenoid bone, between the middle cranial fossa lacrimal sac and the nasolacrimal duct are the final
and the orbit, and transmits the optic nerve and the drainage pathways for the tears produced by the
ophthalmic artery (Figure 6.65). Medially, the optic lacrimal gland. The lacrimal sac is a membranous
canal and nerve are separated from the posterior sac situated in the lacrimal fossa inferolateral to the
ethmoid and sphenoid sinuses by the lamina medial canthus. The lacrimal fossa is bounded
papyracea and a small part of the lesser wing of the anteriorly by the anterior lacrimal crest of the frontal
sphenoid. lnferolaterally the optic canal and nerve process of the maxilla and posteriorly by the pos­
are separated from the superior orbital fissure by a terior lacrimal crest, which is a ridge on the lacrimal
spicule of bone, called the optic strut, which is the bone (Figure 6.13 and 6.25). The lacrimal sac has
root of the lesser wing of the sphenoid (Figure 6.65). a bulbous fundus superiorly. Inferiorly, it tapers to
The optic nerve is surrounded by a prolongation of become continuous with the nasolacrimal duct.
the meninges. The ophthalmic artery usually lies The nasolacrimal duct has two parts,
inferior to the optic nerve. intraosseous and membranous parts. It is directed
The superior orbital fissure lies obliquely between inferiorly, posteriorly and slightly laterally. The
the greater and the lesser wing of the sphenoid intraosseous part is bounded by the maxilla, the
(Figures 6.36 and 6.65), and transmits the third, lacrimal bone and the inferior turbinate (Figures
fourth and sixth cranial nerves, as well as the 6.12 and 6.78). The nasolacrimal duct is narrowest
ophthalmic division of the fifth cranial nerve and the in the middle (Figure 6.72). Inferiorly, it lies beneath
superior ophthalmic vein. A tendinous ring surrounds the nasal mucosa and opens into the highest point
the medial aspect of the superior orbital fissure and of the inferior meatus, where it is protected by the
the optic canal and gives origin to the four rectus Hasner's valve.
muscles (Figures 6.75-6.77). The lacrimal fossa is readily identified by CT in
The infraorbital fissure transmits the infraorbital both the axial and coronal planes as a small impres­
nerve and is the main communication between the sion in the inferomedial orbital wall. The lacrimal sac
orbit and both the pterygopalatine fossa and the is usually seen as a soft-tissue density in the
infratemporal fossa (Figures 6.24, 6.25 and 6.74). lacrimal fossa (Figure 6.13). It may be air-filled on
CTs of the orbital apex usually demonstrate these occasions and should not be mistaken for orbital
anatomic features clearly separated by fat. If the fat emphysema (Figure 6.79).
planes are obscured this may indicate early infiltration The membranous part of the nasolacrimal duct
by tumor or aggressive infection. The tendinous ring varies in its relationship to the base of the uncinate
giving origin to the rectus muscles occasionally shows process and the ethmoidal infundibulum. This
enhancement following the administration of intra­ relationship should be identified prior to any surgery
venous contrast and should not be mistaken for tumor. in this region. The nasolacrimal duct may be injured
by a generous uncinectomy conducted during an
endoscopic procedure (Figures 6.24 and 6.33), or by
an excessive resection of the anterior margin of the
natural ostium of the maxillary sinus. If the inferior
THE LACRIMAL SAC AND turbinate is resected close to the base, the duct may
NASOLACRIMAL DUCT be injured, resulting in permanent occlusion of the
nasolacrimal canal and epiphora. The nasolacrimal
The nasolacrimal apparatus consists of the lacrimal duct may also become obstructed by inflammatory
gland situated in the superolateral aspect of the disease, trauma or neoplastic processes.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 53

6.1 6.2

6.3 6.4

Figure 6.1 Figure 6.2

The nasal pyramid. This anterior coronal CT scan cuts through Septation of a normal frontal sinus. This coronal CT scan of the
the external nose and the most anterior portion of the frontal frontal sinuses demonstrates a multiseptated frontal sinus,
sinus. The frontal sinus (FS), the frontal process of the maxilla normal nasal bones and an anterior deviation of the
(N), the nasal bones (open arrow), the cartilaginous portion of cartilaginous nasal septum (NS) to the left. Note the nasal cell
the nasal septum (NS) and the nasal vestibule (NV). (N) which, if extensive, may compromise the frontal recess.

Figure 6.3 Figure 6.4

Aplasia of the right frontal sinus (CT). This is a common Extensive pneumatization of the frontal sinus. This coronal CT
anomaly where one of the frontal sinuses is partially or scan of the frontal sinuses demonstrates extensive
completely undeveloped. pneumatization of the frontal bone (arrows). In this case the
anterior ethmoid air cells narrow the frontal recess and contain
diseased mucosa. These anterior ethmoid cells are
characteristically located along the floor of the frontal sinus,
close to the midline.
54 An atlas of imaging of the paranasal sinuses

6.5 6.6

6.7 6.8

Figure 6.5 Figure 6.6

A frontal bulla. This anterior CT scan through the frontal sinus CT of the normal frontal recess. This scan demonstrates a
demonstrates a small, anteriorly placed ethmoid air cell normal, wide, patent frontal recess (upper arrow). In this
projecting into the floor of the frontal sinus (arrow). This is patient, the frontal recess drains directly into the middle meatus
called a frontal bulla. (lower arrow). The vertical insertion of the middle turbinate (MT)
can be clearly seen.

Figure 6.7 Figure 6.8

MR of the normal maxillary and ethmoid sinuses. This T1- Normal frontal recess (CT). A wide frontal recess is seen
weighted anterior coronal MR scan demonstrates the maxillary (arrows). The crista galli is pneumatized (CG). The ethmoid
sinuses (M) and the ethmoid sinuses (E) as signal void (dark) bulla (EB), and the middle (MT) and inferior turbinates (IT) are
spaces. The middle turbinate (m) and the inferior turbinate (I) demonstrated. Inferior and lateral to the turbinates are the
are isointense with muscle. The bright signals in the orbits and corresponding meati. The uncinate process attaches medially to
cheeks (F) are due to fat. The bright midline signal is the result the anterior ethmoid air cells (curved arrows). The right
of fat in the crista galli (arrow). This scan demonstrates the maxillary ostium is also demonstrated (open arrow) opening into
intimate relationship of the frontal lobes to the ethmoid fovea the ethmoid infundibulum.
(open arrow).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 55

6.9 6.10

6.11 6.12

Figure 6.9 Figure 6.10

Sagittal MR scan through the frontal sinus. This T1-weighted Normal MR scan through the middle of the maxillary sinus. This
MR scan demonstrates a normal frontal sinus (F) draining into T1-weighted scan demonstrates the middle (M), inferior (IT) and
the frontal recess (arrows). The other structures seen are the superior turbinates. The intraorbital muscles (black arrows) are
inferior turbinate (I), the middle turbinate (m), the ethmoid well seen in the bright hyperintense intraorbital fat. The ethmoid
labyrinth (E) and a polyp in the sphenoid sinus (S). sinus (E) and the uncinate process (white arrow); the lamina
papyracea and the air in the ethmoid sinuses appear as signal
Figure 6.11 void areas against the bright orbital fat.

Agger nasi cells. This coronal CT scan shows an agger nasi Figure 6.12
cell (AN). The right agger mound is acellular. Note the nasal
septum formed superiorly by the perpendicular plate of the CT of multiple agger nasi cells. The agger mound may be
ethmoid bone (1), the cartilaginous portion of the nasal septum acellular or it may contain between one and seven air cells
(the quadrilateral cartilage) (2). The localized expansion at the (AN). The nasolacrimal duct (NL) is also demonstrated.
junction of the bony and cartilaginous portion of the nasal
septum is the body of Zuckerkandl (3), which represents the
vestigial remnants of erectile tissue. The frontal process of the
maxilla (white arrow) and the crista galli (CG) are also shown.
56 An atlas of imaging of the paranasal sinuses

6.13 6.14

6.15 6.16

Figure 6.13 Figure 6.14

CT demonstrating a large agger nasi cell (AN) occluding the Normal sagittal MR scan of the sphenoid sinus. This sagittal
frontal recess (arrows). The larger the agger nasi cell, the T1 -weighted scan demonstrates the normal nasal septum (NS),
greater the encroachment on the neck of the middle turbinate the sphenoid sinus (S), the pituitary gland and its stalk (P), the
(MT), resulting in a restricted frontal recess. The normal nasal bone (arrow), the soft palate (SP), the tongue (T), the
lacrimal fossa (L) is seen on the right side. nasopharynx (N) and the clivus (C), which is hyperintense due
to its fatty marrow.

Figure 6.15 Figure 6.16

Deviated nasal septum. This CT scan shows a deviation of the Post-traumatic nasal septa! deviation. The nasal septum (NS) is
nasal septum to the right. There is compensatory hypertrophy seen deviated to the left. The left frontal recess (open arrow)
of the left inferior turbinate (IT), and a paradoxically bent, would be difficult to approach without a prior septoplasty. The
hypoplastic right inferior turbinate. The left uncinate process deviation of the nasal septum was the result of trauma. Note
(UP) is curved and bends inferiorly. the fractureline at the base of the septum (arrow). The crista
galli is aerated (CG).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 57

6. 7 6.18

6.20

Figure 6.17 Figure 6.18

asal septal spur. Note, in this CT scan, the massive nasal CT of an aerated nasal septum. This posterior portion of the
septal spur which is impinging onto the lateral nasal wall in the perpendicular plate of the ethmoid is aerated (arrow).
middle meatus (arrow).

Figure 6.19 Figure 6.20

ormal maxillary sinus. THis CT scan demonstrates the anterior Accessory maxillary ostia. This coronal CT scan of the posterior
portion of the maxillary sinus (MS) draining through the ethmoid air cells (PE) and maxillary sinus demonstrates a large
maxillary ostia into the ethmoid infundibulum (open arrow). The accessory maxillary sinus ostium on the right ju_st lateral to the
infundibulum channel is bounded superolaterally by the ethmoid middle turbinate and a smaller one on left (open arrow) close to
bulla (EB) and inferomedially by the uncinate process (UP). The the posterior part of the middle meatus (MM). The thin plate of
ethmoid infundibulum opens into the semilunar hiatus. The bone separating the superomedial margin of the maxillary sinus
semilunar hiatus is a two-dimensional, slit-like opening that from the posterior ethmoid air cells is the ethmomaxillary plate
connects the infundibulum to the middle meatus (short white (arrowheads). Note the inferior orbital fissure (IOF) and the
arrow). The infraorbital foramen (IOF), inferior turbinate (IT) and inferior meatus (IM).
inferior meatus (IM) are also shown.
58 An atlas of imaging of the paranasal sinuses

6.21
6.22

6.� 6.�

Figure 6.21 Figure 6.22

The turbinates. This is a coronal CT scan through the middle This normal axial CT scan demonstrates the maxillary sinus
portion of a normal maxillary sinus (MS). The superior (ST), (MS), the pterygopalatine fossa (PPF) and the pterygoid
middle (MT) and inferior (IT) turbinates with their corresponding process (PP). The superior aspect of the inferior meatus (I), is
superior, middle (MM), and inferior (IM) meatii, are clearly transected in this view.
shown. The posterior ethmoid sinus (PE) is separated from the
maxillary sinus by the ethmomaxillary plate (arrowheads).

Figure 6.23 Figure 6.24

This normal axial CT scan demonstrates a section through the This normal axial CT scan demonstrates the uncinate process
hard palate (HP), and the alveolar recesses of the maxillary (UP) arising close to the wall of the nasolacrimal duct (NL).
sinuses (MS). The palatine foramina which transmit the greater Also demonstrated are the pterygoid (vidian) canal (VC), the
and lesser palatine nerves are also shown (arrows). foramen ovale (FO), the foramen spinosum (FS) the
pterygopalatine fossa (PPF), the infraorbital fissure (IOF), the
maxillary sinus (MS) and the internal carotid artery (ICA).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 59

6.26

6.28

Figure 6.25 Figure 6.26

This normal axial CT scan demonstrates the anterior and Hypoplasia of the maxillary sinus. This coronal CT scan
posterior lacrimal crests (arrowheads), the ethmoid labyrinth (E), demonstrates a hypoplastic maxillary sinus. Note that the right
e superior recess of the maxillary sinus (M), the zygoma (Z), orbital floor lies at a lower level than the left orbital floor, with
· e pterygopalatine Iossa (black arrow), the inferior orbital the right orbit showing apparent enlargement. The infraorbital
'oramen (open arrow), the infratemporal Iossa (ITF), the middle nerve canal (open arrow) appears more laterally placed. On the
cranial Iossa (MCF), the sphenoid sinus (S) and the internal left is a paradoxically bent middle turbinate that is apposed to
carotid artery (ICA). the uncinate process (arrow).

Figure 6.27 Figure 6.28

Hypoplasia of the maxillary sinus. This coronal CT scan Hypoplasia of the maxillary sinus. On this CT the right maxillary
demonstrates bilateral hypoplasia of the maxillary sinuses; sinus is atelectatic. Note how the posterior fontanelle has been
consequently, the nasal cavity is wide and the floor of the orbit laterally retracted. The uncinate process appears absent, but on
depressed. closer inspection it can be seen adherent to the inferior orbital
wall (arrow). An incidental finding is the sagittal groove which
can be seen in the right middle turbinate (curved arrow).
60 An atlas of imaging of the paranasal sinuses

6.� 6.�

6.31 6.32

Figure 6.29 Figure 6.30

Hypoplasia of the maxillary sinus. This is a more posterior CT Septated maxillary sinus. On this CT scan, a bony septum
scan of the patient in Figure 6.28. The 'fibrous septum' that is (arrow) is seen arising from the region of the infraorbital canal,
seen in the maxillary sinus (arrowhead) actually represents an which extends to the lateral wall dividing the right maxillary
invagination of the posterior fontanelle. The middle meatus is sinus into two unequal parts. These compartments usually
deep, as a result of lateral retraction of the large posterior communicate with each other through a defect somewhere in
fontanelle (arrow) into the maxillary sinus. the septum.

Figure 6.31 Figure 6.32

CT of the ethmomaxillary sinus. Note the ethmomaxillary sinus Hailer's cells. On this CT scan, bilateral Hailer's cells (H)
(arrow) which is connected to the superior meatus by a short compromising the ethmoid infundibulum on both sides are seen.
and medially directed bony channel. A small cyst (C) can be Note the appositional changes (arrows) in the mucosa.
seen in the left maxillary sinus.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 61

6.33 6.34

-.35 6.36

Figure 6.33 Figure 6.34

=.xtensive Hailer's cells. This CT scan demonstrates CT of the anterior ethmoid sinuses and the nasal septum. The
eumatization of the floor of the left orbit from a posterolateral nasal septum is formed by the perpendicular plate of the
e ension of a large Hailer's cell. The floor of the orbit is thin ethmoid bone (1), the cartilaginous septum (2) and the vomer
" d appears to be dehiscent (arrowheads). A large ethmoid inferiorly (3). The anterior ethmoid cells (ES) are located lateral
Ila (EB) is seen on the right compromising the hiatus to the vertical insertion of the middle turbinate (MT). Note the
semilumaris (HS). lacrimal Iossa (L), which contains the lacrimal sac, the
cribriform plate (CP) and the anterior end of the inferior
turbinate (IT).

1gure 6.35 Figure 6.36

- e anterior ethmoid sinuses. This is a more posterior CT scan This normal axial CT scan demonstrates the posterior ethmoid
-�an Figure 6.34. The lamina papyracea (LP) separates the Onodi's cell (QC), the superior orbital fissure (SOF), the
erior ethmoid cells (ES) from the orbit (0). The nasolacrimal sphenoid sinus (S), the sphenoid sinus ostium (arrowhead), the
ct (NL), the uncinate process (UP), inferior turbinate (IT) and impression of the internal carotid artery (open arrow), and the
· e vertical insertion of the middle turbinate (MT) are also anterior wall (AW) and posterior bone (OS) of the dorsum sella.
emonstrated in this anterior coronal scan.
62 An atlas of imaging of the paranasal sinuses

6.� 6.�

6.� 6.�

Figure 6.37 Figure 6.38

Normal sagittal MR scan. This T1 -weighted scan demonstrates The cribriform plate and ethmoid fovea. The ethmoid fovea can
the frontal sinus (F), the ethmoid sinus (E), the sphenoid sinus clearly be seen to be both higher (arrowhead) and thicker than
(S), the superior (st), the middle (M), and the inferior (IT) the cribriform plate (arrow) on this CT. This demonstrates the
turbinates, as well as the nasopharynx (N), the soft palate (SP) hazards of surgery in this area. Note the bony channel for the
and the tongue (T). Note that the posterior ethmoid cells are anterior ethmoidal artery on the right (open arrow). The crista
larger than the anterior cells. galli is also demonstrated (CG). Other findings include bilateral
bony hypertrophy of the middle turbinates and a small air cell in
the left middle turbinate (concha bullosa).

Figure 6.39 Figure 6.40

Large ethmoid bulla. On this CT scan, a large ethmoid bulla Large ethmoid bulla and concha bullosa. This patient presented
(EB) is present on the left side, obstructing the semilunar hiatus with headaches. The coronal CT scan demonstrates a large
(arrowhead). The ethmoid infundibulum, semilunar hiatus and ethmoid bulla (EB) in contact (arrowhead) with a large air cell
middle meatus on the right are normal (arrow). in the vertical plate of the right middle turbinate (CB; a concha
bullosa) on the right side. The patient had previously undergone
a right intranasal antrostomy (arrow), but had remained
symptomatic. Following resection of the ethmoid bulla and the
middle turbinate air cell, the contact headaches were relieved.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 63

6.41 6.42

6.43 6.44

Figure 6.41 Figure 6.42

Inferiorly extending ethmoid bullae. This coronal CT scan Multiseptate ethmoid bulla. This CT scan demonstrates an
through the ostiomeatal complex demonstrates large ethmoid enlarged left ethmoid bulla (EB) divided by multiple septae. The
bullae (EB) overhanging the semilunar hiatus (arrow) with grossly enlarged bulla has compromised the frontal recess and
compromise of the ethmoid infundibulum and therefore the the semilunar hiatus. There is a considerable amount of
ventilation and drainage of the maxillary sinus. There is retained secretions in the left maxillary sinus; there is
retained mucus (open arrow) in the floor of the maxillary sinus. hypoplasia of the right maxillary sinus.
Mucosal thickening can be seen in the inferior meatus and in
the floor of the nasal cavity (arrowheads).

Figure 6.43 Figure 6.44

The uncinate process. This coronal CT scan demonstrates the Medially bent uncinate process. On this CT scan, the right
uncinate process (UP) inserting high into the lamina papyracea. uncinate process (UP) is seen to be turned medially and has
The frontal recess (arrowheads) drains medial to the ethmoid come into intimate contact with the middle turbinate. Although
infundibulum (arrow). the semilunar hiatus is not obstructed, the medially bent
uncinate process is occluding the middle meatus. This scan
also demonstrates a very large left-sided concha bullosa (CB),
onto which the left uncinate process abuts.
64 An atlas of imaging of the paranasal sinuses

6.45 6.46

6� 6M

Figure 6.45 Figure 6.46

Enlarge uncinate process. This CT scan shows grossly Medially bent uncinate process. The right uncinate process
enlarged uncinate processes projecting anterior medially into (UP) in this coronal CT scan is medially bent to such an extent
the middle meatus (UP). On the left side, the middle meatus that it projects into the middle meatus. Note the inferior
appears to be almost filled by the uncinate process. The nasal turbinate (IT) and the horizontal plate of the middle turbinates
septum, which is deviated to the left side, shows evidence of (MT(H)). The superior and the supreme turbinates (S}. The
previous trauma. ethmomaxillary plate (arrow), separates the maxillary sinus from
the posterior ethmoid air cells (PE). The inferior orbital fissure
is shown (open arrow).

Figure 6.47 Figure 6.48

Pneumatized uncinate process. On this CT scan, both uncinate Enlarged uncinate processes. This coronal CT scan
processes are pneumatized (arrows). The aerated uncinate demonstrates bilateral enlargement and medial deviation of the
process on the left is compromising the frontal recess and uncinate processes (arrows). These enlarged uncinate
ethmoid infundibulum. processes have narrowed the infundibula.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 65

6.49 6.50

6.51 6.52

Figure 6.49 Figure 6.50

Enlarged uncinate process. This patient presented with a history Compromised ethmoid infundibulum. This large right-sided
of nasal obstruction and recurrent sinusitis. There was no history concha bullosa (CB) has reduced the adjacent infundibulum
of previous surgery; however, on the CT scan, the right middle complex to a narrow slit. A paradoxical middle turbinate can be
turbinate was found to be vestigial (open arrow) and the seen on the left.
uncinate process (UP) grossly enlarged. The right ethmoid bulla
(EB) and the left middle turbinate (MT) are normal.

Figure 6.51 Figure 6.52

The lateral sinus. This coronal CT scan demonstrates bilateral Secondary middle turbinate. A secondary middle turbinate
concha bullosa. The horizontal insertion of the left middle (arrows) is seen in both middle meatii on this CT scan. This
turbinate (arrowhead) is seen. The space between the posterior anomaly should not be mistaken for a polyp. The uncinate
margin of the ethmoid bulla (EB) and the horizontal insertion of process (UP) is bent medially in its posterior part.
the middle turbinate is the lateral recess (LR).
66 An atlas of imaging of the paranasal sinuses

6.� 6.�

6.55 6.56

Figure 6.53 Figure 6.54

Grooved middle turbinate. This CT scan demonstrates a sagittal Bony hypertrophy of the middle turbinates: CT scan. Both wide­
groove (arrow) along the inferior free margin of the right middle and soft-tissue window settings demonstrate that the right
turbinate. There is evidence of chronic sinusitis with reactive middle turbinate (MT) is predominantly bony with no soft tissue
osteitis near the infraorbital canal (arrowheads), which is hypertrophy. This informs the surgeon that resection of this
characteristic of benign disease. There is an unerupted tooth in portion of the middle turbinate may be difficult. Inflammatory
the floor of the maxillary sinus (curved arrow). disease is seen in the right ethmoid infundibulum and in the left
suprabullar space (black arrowheads). The ethmoid bulla (EB),
is demonstrated.

Figure 6.55 Figure 6.56

Concha bullosa. This CT scan demonstrates bilateral large Bilateral concha bullosa (CB): CT scan. Note the
concha bullosa (CB) with attendant narrowing of the ostiomeatal pneumatization of the middle turbinates is derived from the
complexes and turbinate sinuses (small arrows). ethmoid bulla. The ground lamella is seen to insert onto the
lamina papyracea (arrowheads). The base of the uncinate
processes (UP) inserts close to the nasolacrimal duct (NL).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 67

6.57 6.58

6.59 6.60

Figure 6.57 Figure 6.58

Lateralized middle turbinate. Although small, this lateralized Soft-tissue hypertrophy of the middle turbinate. This CT scan
right middle turbinate (MT) is seen on the CT scan to be demonstrates soft tissue hypertrophy of the right middle
occluding the ostiomeatal complex. A left concha bullosa with turbinate (MT). Despite this hypertrophy there is no evidence of
aeration of the vertical plate is also seen. compromise of the ostiomeatal complex. A slight deviation of
the nasal septum to the left is apparent. The site of the
infraorbital nerve is demonstrated (arrow).

Figure 6.59 Figure 6.60

This normal axial CT scan demonstrates the maxillary sinuses Decongested inferior turbinates. This coronal CT scan shows
(MS), the inferior turbinate (IT) and the inferior meatus (IM). the inferior turbinates to be small within a roomy nasal cavity.
Posterior to the maxillary sinus lies the medial (MP), and lateral This is the characteristic appearance of the inferior turbinate
pterygoid (LP), plates which enclose the pterygoid Iossa. The following chronic use of topical decongestants. The thickened
palatine canals are shown (arrow). The eustachian cushion mucosa in the small right sided maxillary sinus follows from a
(EC), is shown protruding into the nasopharynx. previous Caldwell-Luc procedure. Normal inferior (I) and middle
meati (M) are seen.
68 An atlas of imaging of the paranasal sinuses

6.61
6.62

6.63 6.64

Figure 6.61 Figure 6.62

Decongested inferior turbinates. This coronal CT scan Bony hypertrophy of the inferior turbinates. The narrow window
demonstrates extensive polypoidal soft-tissue densities in the scan demonstrates bony hypertrophy of the inferior turbinates
maxillary and ethmoid sinuses. As a consequence of the (IT). The uncinate process is deviated medially leading to
chronic abuse of topical decongestants the inferior turbinates disease in the ethmoid infundibum (arrow). The orbital apex is
(IT) are small and shrunken. There has been little effect on the also well demonstrated.
middle turbinates. This is probably due to erectile tissue which
is abundant on the inferior turbinate but which is limited in its
distribution on the middle turbinate.

Figure 6.63 Figure 6.64

Inferior turbinate hypertrophy. This patient has such extensive Pneumatized inferior turbinate: CT scan. The inferior turbinate
soft-tissue hypertrophy of the posterior ends of the inferior is an independent bone articulating with a ridge on the medial
turbinates that the choanae are almost totally occluded. The aspect of the maxilla. Rarely, the inferior turbinate is
turbinates are hyperintense in the T2-weighted MR scan. incorporated into the maxilla and pneumatization of the inferior
turbinate (IT) from the adjacent maxillary sinus may occur.
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 69

6.65 6.66

6.67 6.68

Figure 6.65 Figure 6.66

The sphenoid sinus: CT scan. The sphenoethmoid recess The sphenoid sinus: CT scan. The lateral recesses of the
(open white arrow) communicates with the pterygopalatine sphenoid sinus (arrows) and dehiscence of the roof of the
fossa through the sphenopalatine foramen (between white sphenoid close to the optic nerve on the left side (arrowhead)
arrows). The optic foramen (0), is separated from the superior can be seen, as well as the foramen rotundum (RF), pterygoid
orbital fissure (SOF) by the optic strut (black arrow). The (vidian) canal (VC), and the posterior ends of the inferior
planum sphenoidale of the lesser wing of the sphenoid is turbinate (IT) and of the middle turbinate (MT).
demonstrated (open black arrow); the middle cranial fossa
(MCF) is also seen.

Figure 6.67 Figure 6.68

The sphenoid sinus. This CT scan demonstrates the sphenoid The sphenoid sinus. This T1-weighted MR scan demonstrates
sinus (S), the foramen rotundum (RF), the pterygoid (vidian) the sphenoid sinus (S) and internal carotid artery (arrows)
canal (VC), the anterior clinoid process (A), the sphenoid located on the lateral wall of the sinus. The other normal
rostrum (SR), as well as the lateral (1) and medial (2) pterygoid structures shown include the soft palate (SP) and the temporal
plates and the pterygoid fossa (3). lobes (T) in the middle cranial fossa.
70 An atlas of imaging of the paranasal sinuses

6.� s.m

6.71 6.72

Figure 6.69 Figure 6.70

The sphenoid sinus. This sagittal T1-weighted MR scan The sphenoid sinus. This sagittal T1 -weighted MR scan
demonstrates the signal void internal carotid artery (IC), which demonstrates the normal sphenoid sinus (S) draining through
is located close to the roof of the sinus (S). an anterior placed opening close to the roof of the nasal vault
(curved arrow). The small space (straight arrow) above the
superior turbinate is the sphenoethmoid recess. The optic nerve
(0) lies above and lateral to the sphenoid sinus and the
pituitary gland (P) lies above the sinus.

Figure 6.71 Figure 6.72

The sphenoid sinus. This coronal T1-weighted MR scan This normal axial CT scan demonstrates the nasolacrimal duct
demonstrates the sphenoid sinus (S), the maxillary division of (NL), the sphenopalatine foramen (curved arrow), entering the
the trigeminal nerve running through the foramen rotundum (M), pterygopalatine fossa (PPF), the sphenoid sinus (S), and the
the vidian nerve within the pterygoid (vidian) canal (V) and the infratemporal fossa (ITF).
optic chiasm (OC).
 The normal anatomy of the paranasal sinuses as seen with CT and MRI 71

6.73 6.74

6.75 6.76

Figure 6.73 Figure 6.74

This normal, narrow-window, axial CT scan demonstrates the Orbital apex. This CT scan demonstrates the normal
muscles of mastication, namely the lateral pterygoid (LP), the characteristics of the inferior orbital fissure (IOF), the superior
medial pterygoid (MP), and masseter (M). The muscles are orbital fissure (SOF), the optic nerve (ON) and the anterior
clearly separated by fat planes. clinoids (AC). The nasal septum is pneumatized (A).

Figure 6.75 Figure 6.76

The orbital apex. The orbital apex is well demonstrated on this The orbital apex and extraocular muscles. This axial CT scar.
coronal T1-weighted MR scan showing the medial rectus (4), demonstrates the bony optic canal (0), the optic nerve (ON)
lateral rectus (2), inferior rectus (3), superior rectus (1) and passing through this canal and the laterally placed superior
superior oblique (SO) muscles as well as the optic nerve (ON). orbital fissure (SOF). The medial (MRM) and lateral (LRM)
This scan also demonstrates inflammatory and polypoidal rectus muscles are well demonstrated.
disease in the sinuses. The fat in the orbit is bright on this T1-
weighted sequence.
72 An atlas of imaging of the paranasal sinuses

6.77 6.78

6.79

Figure 6.77 Figure 6.78

The tendinous ring of Zinn (annulus of Zinn). This posterior The nasolacrimal duct. This anterior coronal CT scan
coronal T1-weighted MR scan through the sphenoid sinus (S) demonstrates air in both nasolacrimal ducts (NL). The
demonstrates the tendinous ring of Zinn at the orbital apex, nasolacrimal duct is bounded by the maxilla, the lacrimal bone
which gives origin to the recti muscles (arrows). The optic and the inferior turbinate. Both uncinate processes (UP) are
nerve (0) is superomedial to the annulus. elongated. Note the intimate relationship between the origin of
the uncinate processes and the nasolacrimal duct.

Figure 6.79
Air in the lacrimal sac. The small air collections seen on this
CT scan along the inferomedial aspect of the orbits are air
within the lacrimal sac (arrows). This should not be mistaken
for orbital emphysema following fracture or infection. An agger
nasi cell is also demonstrated (A).
7
The role of anatomic variants of the
ostiomeatal complex and paranasal sinuses

As Messerklinger has stated, the ventilation and resection of tissue, to widen the natural clefts and
drainage of the anterior ethmoidal sinus, the maxil­ improve sinus ventilation, has led to the reversal of
lary sinus and the frontal sinus are dependent upon mucosal disease in the larger paranasal sinuses.
the convoluted clefts of the 'ostiomeatal complex' The direct endoscopic visualization of the small
through which healthy, ciliated mucosa promotes clefts of the ostiomeatal complex is limited, but
optimal sinus ventilation and drainage. Most sinus computed tomography (CT), especially in the
infections are rhinogenic in origin and spread from coronal plane, is complementary in defining the
the ostiomeatal complex to secondarily involve the anatomy, and the site and extent of disease in the
frontal and the maxillary sinuses. The small clefts of paranasal sinuses and in the surrounding soft
the ostiomeatal complex in the lateral nasal wall are tissues.
easily compromised or occluded by mucosal edema Those anatomic variants that may compromise the
resulting in poor ventilation, failure of mucociliary ostiomeatal complex, and promote recurrent sinusitis
clearance and stagnation of mucus and pus in the are discussed in this chapter and in chapter 6.
sinuses. This process is usually reversible; once the The various structures that are adjacent to the
normal drainage pathways are reopened, the drainage pathway of the major sinuses can compro­
secondary disease within the larger maxillary and mise the drainage if these structures are large or
frontal sinuses usually resolves spontaneously. deflected from their normal position. The important
However, if there is an anatomic.variant that narrows variations are listed in Table 7.1.
these key ethmoidal clefts, then minimal mucosal
edema will predispose the patient to recurrent infec­
tions and may result in chronic inflammatory
changes in the mucosa,
Previously, surgical procedures to alleviate recur­ AGGER NASI CELLS
rent or chronic inflammatory episodes have been
directed at the larger paranasal sinuses. The venti­ The extent of pneumatization of the agger mound
lation of these sinuses was improved by creating new can be clearly seen on CTs in the coronal plane.
and theoretically effective alternative drainage Agger nasi cells are usually pneumatized from the
pathways and by resecting a large amount of bone frontal recess. Enlarged agger nasi cells may involve
and diseased mucosa. Additional drainage proce­ the frontal recess either mechanically by obstructing
dures, such as inferior meatal antrostomies, are now the recess, if they are well developed, or by the
known not to redirect the mucosal flow through the direct spread of inflammation. Inflammation may also
newly created opening but only to act as a drain spread through a dehiscence of the lateral nasal wall
when the mucociliary system is overwhelmed by to involve the orbit or the lacrimal sac (Figure 7.3;
mucus and pus. The persistence of symptoms follow­ see also Figure 6.13).
ing these procedures is usually secondary to disease
in the anterior ethmoid, affecting the natural ostia and
the ostiomeatal complex. Recurrent sinus infections
may also occur despite there being a widely patent
natural accessory ostium when ostiomeatal complex AERATED CRISTA GALLI
disease is present (Figure 7.1 and 7.2).
Functional endoscopic sinus surgery is directed at A pneumatized crista galli may become involved by
the natural drainage pathways. The limited surgical benign inflammatory disease and present clinically
74 An atlas of imaging of the paranasal sinuses

with headaches. Clinical examination and plain A long or a thickened uncinate process will narrow
radiographs are normal in the majority of these the semilunar hiatus between its posterior margin
cases; however, CT in the coronal plane will demon­ and the ethmoid bulla, especially if the bulla is well
strate the air cell within the crista galli. This air cell pneumatized (Figure 7.7).
usually drains into the frontal recess, and both of A swollen, inflamed uncinate process is clearly
these regions are usually involved simultaneously visualized by endoscopy, but pneumatization of the
with inflammatory disease (Figure 7.3 and 7.4). If the uncinate process cannot be differentiated from
ostium of this air cell is occluded, a mucocele of the hypertrophy by endoscopy (see Figure 6.49).
crista galli may develop.

THE FRONTAL RECESS

UNCINATE PROCESS
Whether the frontal recess opens into the ethmoid
The uncinate process has an intimate relationship infundibulum is determined by the superior insertion
with the ethmoid infundibulum and the middle of the uncinate process, as discussed in Chapter 3.
meatus. The commonest anatomic variant associ­ This superior insertion determines whether the
ated with inflammatory disease of the adjacent frontal recess and frontal sinus are at risk from
paranasal sinuses is a medial deviation of the inflammation spreading from the anterior ethmoid
uncinate process. The uncinate process may abut and maxillary sinuses. If the uncinate process inserts
the middle turbinate, thus obstructing the middle laterally onto the lamina papyracea, this is less likely
meatus (Figures 7.5 and 7.6). as the frontal recess in this situation drains directly
 The role of anatomic variants of the ostiomeatal complex and paranasal sinuses 75

into the middle meatus. If, however, the uncinate matory disease by obstructing the ostiomeatal
process inserts superiorly into the roof of the complex. It is unusual to find isolated ethmoid bul­
ethmoid or medially into the middle turbinate, then litis (Figure 7.16), and the ethmoid bulla is more
the frontal recess will drain into the ethmoid commonly involved in generalized inflammatory
infundibulum. disease of the ethmoid sinus (Figure 7.17}.
The frontal recess may also be compromised by If the ethmoid bulla is large, it may obstruct the
anatomic variations of the surrounding anatomic middle meatus by impinging on the middle turbinate
structures, such as well-developed agger nasi cells, and so cause headaches and nasal obstruction
a prominent ethmoid bulla, a concha bullosa or without any inflammatory changes in the adjacent
abnormalities of the uncinate process (Figure 7.8). paranasal sinuses (see Figure 6.38). However, the
Inflammatory disease within these structures (Figure ethmoid bulla may also predispose to recurrent or
7.3) or in the lateral recess may spread into the chronic inflammation in the adjacent sinus if its
frontal sinus and thus interfere with the ventilation configuration causes obstruction of the ostiomeatal
and drainage of the frontal sinus (Figure 7.9). complex (Figures 7.17 and 7.18). A large ethmoid
bulla may overhang the semilunar hiatus (see Figure
6.35), or it may reduce the lumen of the ethmoid
infundibulum, reducing the ventilation and drainage
of the adjacent sinuses.
CONCHA BULLOSA
Concha bullosa is the term used to refer to a
pneumatized middle turbinate. When large, a concha
bullosa may compromise the middle meatus and THE LATERAL SINUS
ostiomeatal complex (Figures 7.1 O and 7.11). If a
hypertrophied or pneumatized middle turbinate The lateral sinus is a variably present space. When
protrudes anteriorly, it may obstruct the frontal present, the lateral sinus is located posterior to the
recess (see Figures 6.66 and 6.68). ethmoid bulla and anterior to the ground lamella. It
The air cell within a concha bullosa is lined with may extend above the ethmoid bulla, as the supra­
respiratory epithelium arid thus is predisposed to the bullar space, and communicate anteriorly with the
same inflammatory disorders that can occur in any frontal recess. The lateral sinus normally drains into
paranasal sinus. An acute sinusitis or concha bullitis the posterosuperior aspect of the semilunar hiatus
may be demonstrated as an air-fluid level (Figure which is also called the superior recess of the
7.12), or bubbles of air may be seen within the semilunar hiatus. The lateral sinus may be
retained secretions (Figures 7.8 and 7.13). obstructed by an enlarged ethmoid bulla, a concha
Occlusion of the ostium of a concha bullosa may bullosa, or an edematous or hypertrophic uncinate
result in the development of a mucocele, the clinical process (Figure 7.19). If the lateral sinus communi­
features of which are nasal obstruction and cates with the frontal recess, then inflammatory
headaches (Figure 7.12). As with any other disease may spread along this route (Figures 7.20
mucocele, secondary infection will result in a and 7.21).
pyocele (Figure 7.14). Resection of the lateral plate
of the middle turbinate is indicated.
CT is less helpful in diagnosing a concha bullosa
in the presence of extensive sinonasal polyposis. In
this situation, the normal demarcation planes of air, HALLER'S CELLS
bone and soft tissue are obscured, and detail cannot
always be ascertained (Figure 7.15). Hailer's cells are thought to arise from the anterior
ethmoid sinus and project in a variable manner into
the inferomedial aspect of the orbital floor, opposite
the natural ostium of the maxillary sinus. Hailer's
cells may be an incidental finding or, when enlarged,
ETHMOID BULLA they may predispose to recurrent or chronic inflam­
matory disease in the maxillary and frontal sinuses
The ethmoid bulla may be the site of inflammatory by narrowing the ethmoid infundibulum (Figures 7.15
disease or it may predispose the patient to inflam- and 7.22).
76 An atlas of imaging of the paranasal sinuses

7.1 7.2

7.3 7.4

Figure 7.1 Figure 7.2

Obstruction of the ethmoid infundibulum: CT scan. Disease in Accessory maxillary sinus ostium: CT scan. A large patent
the right ethmoid infundibulum is seen occluding the natural posterior fontanelle can be seen on the right (arrow). The
ostia (El). ventilation and drainage of the maxillary sinus occurs primarily
through the natural ostium even when there is an accessory
ostium.

Figure 7.3 Figure 7.4

Frontal recess disease: CT scan. The left frontal recess (arrow) Pneumatized crista galli: CT scan. The pneumatized crista galli
is occluded by inflammatory disease. (curved arrow) is occluded by inflammatory disease.
 The role of anatomic variants of the ostiomeatal complex and paranasal sinuses 77

7.6

7.8

Figure 7.5 Figure 7.6

edially deviated uncinate process: CT scan. Medial deflection Obstruction of the ethmoid infundibulum. The coronal CT scan
the uncinate processes (UP) results in compromise of the demonstrates early compromise of the infundibulum caused by
iddle meatus. As a result, inflammatory changes have edema of the mucosa (arrow). As a result there is inflammatory
occurred in the left ostiomeatal unit. debris in the floor of the maxillary sinus (open arrow). Surgery
comprising of excision of the uncinate process and establishing
an adequate middle meatal antrostomy would lead to resolution
of the maxillary sinus disease.

Figure 7.7 Figure 7.8

Uncinate process: CT scan. A long uncinate process (UP) can Inflammatory disease in a concha bullosa. This coronal CT
bstruct the semilunar hiatus, especially if the ethmoid bulla is scan demonstrates a large diseased concha bullosa (CB)
large; the ethmoid infundibulum is arrowed. extending far anteriorly compromising the premeatal region and
the frontal recess. Inflammatory disease is seen in both frontal
sinuses. Normally, the middle turbinate is not seen in the
anterior coronal CT scans where the frontal sinus and the
lacrimal Iossa (arrow) are visualized.
78 An atlas of imaging of the paranasal sinuses

7.9 7.10

7.11 7.12

Figure 7.9 Figure 7.10

Concha bullosa mucocele. This is a coronal CT scan of the Bilateral concha bullosa: CT scan. The large air cell in the left
patient shown in Figure 7.14. Note the huge mucus-filled middle turbinate (CB) has produced apposition of the middle
concha bullosa (CB) which extends both inferiorly and laterally and the inferior turbinates. The large ethmoid bulla together
and compromises the middle meatus. with the concha bullosa has occluded the left middle meatus;
the ethmoid infundibulum is arrowed.

Figure 7.11 Figure 7.12

Concha bullosa. This coronal CT scan demonstrates an Concha bullitis: CT scan. Note the air-fluid level in the left
unusual configuration of the middle turbinate (CB) with concha bullosa (arrowhead). There is inflammatory disease in
pneumatization of the horizontal portion of the middle turbinate. the right concha bullosa (CB), with significant compromise of
The floor of the orbit is thin (open arrow) close to the ethmoid the adjacent ostiomeatal complex.
infundibulum. This emphasizes the value of the preoperative
scan so that inadvertent entrance into the orbits may be
prevented.
 The role of anatomic variants of the ostiomeatal complex and paranasal sinuses 79

7.14

7.16

Figure 7.13 Figure 7.14

Concha bullosa mucocele. Coronal CT scan demonstrates Concha bullosa mucocele. This axial CT scan demonstrates a
oilateral mucocele of the concha bullosa, with extensive large mucocele of the coronal bullosa (CB) with mucosal
ostiomeatal complex disease. enhancement. This patient would have remained symptomatic if
surgery aimed specifically at the middle turbinate had not been
undertaken.

Figure 7.15 Figure 7.16

Ostiomeatal complex disease. This CT scan shows extensive Enlarged ethmoid bulla: CT scan. The ethmoid bulla (EB) in
ostiomeatal complex disease as well as disease in both this patient extends medially to such an extent that it has come
conchae bullosa (CB). The narrowed ethmoid infundibulum are into contact with the vertical plate of the middle turbinate. Note
further compromised by Hailer's cells (H). the isolated inflammatory disease seen within the lumen of this
medially protruding ethmoid bulla.
80 An atlas of imaging of the paranasal sinuses

7.17 7.18

7.19 7.20

Figure 7.17 Figure 7.18

Large ethmoid bulla. This CT scan demonstrates a large Large ethmoid bulla. This CT scan demonstrates early
ethmoid bulla (EB) overhanging the semilunar hiatus on the left compromises of the right maxillary sinus ostia and ethmoid
side. Similar findings on the right side resulted in a unilateral infundibulum (arrow), with a large ethmoid bulla (EB)
ethmomaxillary sinusitis. overhanging the semilunar hiatus. This has resulted in early
infundibular disease.

Figure 7.19 Figure 7.20

Lateral sinus disease. This CT scan demonstrates a normal Frontal recess draining into the lateral sinus: CT scan. The
ethmoid bulla (EB), a concha bullosa (CB) and inflammatory frontal recess (curved arrow) is occluded by inflammatory
disease in the lateral sinus (LR). The ground lamella (arrow) is disease. There is also disease in the anterior ethmoid air cells.
shown as is the occluded ethmoid infundibulum (El). The anterior aspect of the maxillary sinus is shown (MS).
 The role of anatomic variants of the ostiomeatal complex and paranasal sinuses 81

7.21 7.22

Figure 7.21 Figure 7.22

Frontal recess draining into the lateral sinus. This CT scan Hailer's cell: CT scan. This patient has a large Hailer's cell on
demonstrates disease in the right lateral recess (arrow). The the right side (H). The right infundibulum is severely
lateral sinus on the left (LR) is normal. The maxillary sinus is compromised by this huge Hailer's cell (curved arrow). Despite
small and hypoplastic. previous drainage procedures (arrows), this patient presented
with recurrent sinus disease.
8
The radiologic appearance of benign
inflammatory paranasal $inus disease

ACUTE SINUSITIS exudate will make the sinus appear totally opaque.
The infection may be confined to only one cavity
Acute sinusitis is characterized clinically by nasal (usually the maxillary or the frontal sinus), or it may
obstruction, purulent nasal discharge, postnasal drip involve all of the sinuses on one side as a pansi­
and facial pain. The characteristics and distribution nusitis. Spread of infection from the anterior ethmoid
of the pain or headache may help the clinician locate complex to the posterior ethmoid sinus is usually
the origin of the disease. The pain of frontal sinusi­ through defects in the ground lamella. If an empyema
tis radiates to the forehead and is usually associated develops, plain radiographs will not exhibit any
with a generalized headache. In acute maxillary changes other than that of an acute sinusitis, i.e. the
sinusitis, the pain usually radiates from the inner bony walls of the sinus do not bow outwards and
canthus to the cheek. The pain may also radiate to there is no expansion of the sinus lumen. On
the alveolar region, mimicking dental disease. computed tomography (CT), however, rarefaction of
Ethmoid sinusitis is associated with pain that tends the sinus walls may be seen in addition to the opaci­
to localize to the bridge of the nose and behind the fication of the sinus and will indicate that a major
medial canthus of the eye. It is often cyclical, being complication is imminent if the infection is not
worse first thing in the morning after rising. Sphenoid controlled. Recurrent infection suggests that the
sinusitis is now realized to be generally underdiag­ dental roots should be examined, as disease in the
nosed. It usually occurs as part of a pansinusitis, but roots may be a predisposing factor.
it may arise in isolation, leading to occipital or verti­ Plain radiographs of an infected frontal sinus will
cal headache as well as retro-orbital pain. In all reveal loss of definition of the superior bony margin,
types of sinusitis the pain is more severe if the with mucosal thickening. Opacification may be
ostium of the sinus becomes totally obstructed and minimal in the acute phase, becoming more marked
an empyema forms. This situation is dangerous clini­ with chronicity.
cally, because lytic lesions may develop in the sinus In patients who are immunocompromised, the
walls leading to intraorbital or intracranial sepsis. symptoms and signs of acute sinusitis may be
Plain radiographs are usually adequate for the disproportionately insignificant to the danger they
investigation of patients with symptoms suggestive of present. Clinical features of fever, rhinorrhea, sinus
an uncomplicated acute sinusitis (Figure 8.1 ). Plain tenderness and facial edema may only give rise to
radiographs are also useful for the documentation of radiologic · evidence of mucosal thickening. This
sinus infections in the frontal, maxillary or sphenoid finding should not be disregarded as the patients are
sinuses. A Water's view is usually sufficient for follow often unable to mount the appropriate inflammatory
up examination of those patients with sinusitis of response, i.e. produce a purulent exudate in the
these larger paranasal sinuses. The mucosa will be sinus. Sinus infections in the immunocompromised
thickened and, if mucus or pus collects in .the sinus, patient can easily spread intracranially. Delayed
an air-fluid interface will be evident (Figure 8.1 ). If diagnosis and treatment may result in fulminant
the radiologist is uncertain about the existence of an infection which can be fatal. Opaque sinuses may
air-fluid level, the patient's head can be tilted to one indicate bony involvement, with or without destruc­
°
side by 45 and the radiograph repeated. In severe tion by the infection, and the outlook is poor (Figures
sinusitis, the extensive mucosal edema and fluid 8.2 and 8.3).
 The radiologic appearance of benign inflammatory paranasal sinus disease 83

CHRONIC SINUSITIS sinusitis. However, Aspergillus is becoming increas­

ingly discovered to be as dangerous in some clini­
The symptoms of chronic sinusitis are variable, cal groups. Both Aspergillus and the Mucoraceae
sometimes being severe but more often being mild. can cause vasculitis, mycotic aneurysms, and throm­
There is usually a combination of nasal obstruction, bosis and may spread intracranially causing hem­
rhinorrhea and postnasal drip. Epistaxis, anosmia or · orrhage and infarction (Figures 8.2 and 8.3). The
cacosmia and vestibulitis may also be associated diagnosis may be suspected from the clinical
with chronic sinusitis. Patients frequently present features and characteristic features identified on
with recurrent headaches and facial pain. subsequent radiographs, and is confirmed by exami­
The radiologic features of chronic sinusitis are nation of nasal scrapings and mucosal biopsies.
similar to those of acute sinusitis if there is an acute The findings on plain radiographs and on conven­
process superimposed on the chronic disease. The tional tomographs include nodular mucoperiosteal
mucoperiosteum becomes thickened, and chronic thickening, absent air-fluid levels, clouding of the
fibrosis with polypoid proliferation and retained ethmoid sinuses and bony erosion. There may also
secretions · contribute to the opacification of the be areas of increased attenuation which represent
sinuses involved (Figures 8.4-8.6). Recurrent or calcium phosphate and calcium sulphate in the
chronic sinusitis will produce an osteitis with new necrotic fungal mass (Figures 8.10 and 8.11).
bone formation . along the contours of the sinus Sclerotic thickening of the bony walls of the sinusi­
cavity. The extent of the osteitis is proportionate to tis, with both remodeling and destruction, can be
the frequency of infection and the length of the seen in some cases. It may be impossible to radio­
history. The resulting sclerosis can lead to thicken­ logically differentiate fungal sinusitis from malig­
ing of the sinus wall and a diminished volume of the nancy, especially when there is extensive bony
sinus cavity (Figures 8.7-8.9). The sinus walls may destruction.
be eroded by chronic benign inflammation, usually Areas of increased attenuation in a diseased
occurring along the medial wall of the maxillary sinus sinus, in the absence of intravenous contrast admin­
and around the infraorbital canal. If chronic infec­ istration, are readily identified by CT and are highly
tions occur during childhood, the sinus may remain suggestive of fungal infection. Heavy metals such as
small and hypoplastic. iron and magnesium are essential components of
fungal metabolism. It is these heavy metals that
cause the high-density signal on CT. The nodular
mucoperiosteal thickening and bony sclerosis and
erosion are clearly documented. The differential
FUNGAL INFECTIONS OF THE diagnosis of such a high-density area includes high­
PARANASAL SINUSES density polyps and inverting papilloma with
dystrophic calcification.
Fungal sinusitis is an unusual condition that is being Magnetic resonance imaging (MR) evaluation of
recognized with increasing frequency. It is caused this condition can be diagnostic. There is a
mainly by Aspergillus, but fungi of the Mucoraceae decreased signal intensity in the T1- and T2-
group are also implicated. The disease can present weighted MR sequences, due to the presence in the
in two forms, either as extramucosal disease or as . fungal concretions of iron, magnesium and
the more dangerous fulminant form. The extra­ manganese, which are known to be essential to the
mucosal disease presents with symptoms that are fungal amino-acid metabolism, and calcium. These
not dissimilar to chronic sinusitis, with nasal obstruc­ metals are an essential ingredient for fungal amino­
tion, purulent rhinorrhea and facial pain, all of which acid metabolism (see Chapter 12).
are resistant to treatment with antibiotics (Figures Fungal sinusitis is treated with a combination of
8.10 and 8.11). This may be associated with the systemic antifungal agents and surgical debride­
slow development of a fungus ball. The fulminant ment.
form of fungal sinusitis usually occurs in immuno­
suppressed or uncontrolled diabetic patients with
ketoacidosis and has, in the past, been primarily
attributed to mucormycosis, especially as this occurs COMPLICATIONS OF SINUSITIS
in the aggressive rhinocerebral form. Necrosis of the
turbinates, with black crusting in the nasal cavity, is The complications of sinusitis are usually related to
suggestive of this aggressive form of invasive fungal disease of the frontoethmoid complex, sphenoid
Ha An atlas Of imaging Of the paranasal sinuses

sinus and their adjacent structures. These compli­ Osteomyelitis

cations are potentially life,threatening, and may be
considered in three groups: local, orbital and Osteomyelitis affects the frontal bone most
intracranial. The various complications are listed in commonly, the maxillary sinus being the second
Table 8.1. In the pre-antibiotic era it was not uncom­ most commonly affected. Osteomyelitis of the frontal
mon to see osteomyelitis or intraorbital abscesses. bone is either spontaneous or occurs following
With the widespread use of antibiotics there has trauma, either accidental or operative. The sepsis
been a significant decline in the incidence of such spreads directly or via thrombophlebitis of the diploic
complications and they now more commonly occur veins. Osteomyelitis occurs with infection of diploetic
in association with resistant bacteria or immuno­ bone, and osteitis is due to infection of compact
compromised patients, such as those with AIDS. bone, such as is found in the floor of the frontal
Very few patients with sinusitis develop intracranial sinus. For this reason, surgical drainage of an acute
or orbital sepsis. Congenital deficiencies of the sinus frontal sinusitis should only be undertaken through
walls, fractures or surgical defects may predispose the sinus floor.
some individuals to such complications. The infec­ Osteomyelitis tends to manifest itself as a sub­
tion spreads through various portals, including along periosteal abscess limited by the attachment of the
the interstitium surrounding the veins, through periosteum or, intracranially, by the dura (an
emissary foramina and through the diploic veins. extradural abscess). Clinically, osteomyelitis of the
Perineural spread may occur around the branches frontal bone presents with a soft doughy swelling of
of the olfactory nerve traversing the cribriform plate. the frontal bone. The patient is unwell, with a fever,
These complications need immediate treatment rigors, diffuse headache and spreading edema of the
with high-dose intravenous antibiotics and often forehead. This condition, with an extradural abscess,
require surgical drainage. If such treatment is insti­ subperiosteal abscess and intervening osteomyelitis,
tuted without delay, permanent ocular and neuro­ is known as Pott's puffy tumor.
logic damage may be avoided. Even though There may be little radiologic evidence for 7-10
magnetic resonance imaging is of diagnostic value, days if the osteomyelitis is untreated. When radio­
the patients are usually too ill and too uncooperative logic change occurs there is poor- definition of the
to undergo this lengthier examination. Thus the sinus walls with the disruption of the mucoperiosteal
diagnosis is often confirmed by CT, which is lining. If the infection is not controlled at this stage
conducted in both the axial and the coronal planes with high-dose antibiotics, the bone becomes less
following the administration of intravenous contrast. dense and lytic lesions appear in the adjacent bone.
The scans should be examined with both wide- and The appearance on plain radiographs is similar tci
narrow-window settings, to allow adequate assess­ that on CT, with unevenly distributed multiple lytic
ment of the sinus cavities, the bony walls and the foci (Figures 8.12-8.14). Bony sequestra are less
soft-tissue structures. common in chronic osteomyelitis of the facial bones
 The radiologic appearance of benign inflammatory paranasal sinus disease 85

or skull than in chronic osteomyelitis of the long vision may rapidly deteriorate. This condition
bones. In chronic cases, sclerotic changes are requires aggressive treatment with intravenous
superimposed over areas of rarefaction, and the antibiotics and surgical drainage of any abscess
margins of the sinus become indistinct. Following collection, using the same approach as used for an
intravenous contrast administration the acutely external ethmoidectomy. Orbital decompression may
inflamed mucosa exhibits intense enhancement. also be indicated. The commonest cause of extra­
This should be differentiated from the enhancement conal inflammation is ethmoiditis.
of pyoceles. The smooth expansion of the sinus lntraconal inflammation has similar clinical
walls associated with pyoceles is usually absent with features, such as exophthalmos, restricted eye
osteomyelitis. movements and chemosis, but there may also be
Osteomyelitis following maxillary sinusitis usually papilledema of the optic disc and there is a grave
affects the alveolar bone, which is cancellous, risk of retrograde infection causing cavernous sinus
between two plates of thin compact bone. It may thrombosis. If intraorbital abscess formation occurs
occur in both adults and in infants. The commonest there is usually marked exophthalmos and rapid
cause is dental infection, and it may lead to a subpe­ decrease in the visual acuity. Again the treatment is
riosteal abscess spreading across the maxilla. aggressive antibiotic therapy and orbital decompres­
Radiologic features are minimal in some cases with sion.
slight opacity of the maxillary sinus. In some cases CT of preseptal inflammation shows a diffuse
there may be marked sclerosis of the maxilla. increase in density and thickening of the eyelid and
conjunctiva. Abscess formation is indicated by an
area of low density which may or may not exhibit rim
enhancement following the administration of intra­
lntraorbital complications venous contrast. The globe usually does not exhibit
exophthalmos and occasionally is displaced slightly
lntraorbital complications include cellulitis, sub­ posteriorly.
periosteal abscess, orbital abscess, thrombosis of With subperiosteal inflammation, the exudate
the superior and/or inferior ophthalmic veins, optic accumulates between the lamina papyracea and the
neuritis and central artery occlusion. These compli­ loose periosteum. Initially this may only be a phleg­
cations are usually associated with infection of the monous cellulitis, but if inadequately treated it will
frontal or ethmoid sinuses or with a pansinusitis. The progress to abscess formation. The CT characteris­
usual route of spread is either through bony dehis­ tics are similar for both subperiosteal phlegmon and
cences of the sinus wall or through the valveless subperiosteal abscess. The medial rectus muscle is
venous pathways. The patient may become blind if displaced laterally, is broadened due to inflammatory
treatment, such as high-dose intravenous antibiotics, edema and may enhance slightly. The elevated
abscess drainage and orbital decompression (if periosteum is displaced laterally and is demon­
indicated), is not commenced immediately. strated as an enhancing line running alongside the
An important clinical differentiation must be made medial rectus muscle. The thickened periosteum
in this group regarding the position of the focus of may be indistinguishable from the medial rectus
infection in relation to the orbital septum, i.e. the muscle. An abscess becomes apparent by the
fibrous band that spans from the orbital margins to development of an area of low density which may
the tarsal plates. Both preseptal and postseptal be localized or spread along the entire medial wall
orbital inflammation present with swelling of the of the orbit. The inflammation may cause deminer­
upper eyelid. The skin assumes a dusky, reddish alization of the lamina papyracea or even osteitis
blue hue. In a case of preseptal orbital cellulitis the which becomes evident with bony loss or thinning
eye will be found in its normal position, and will (Figures 8.15 and 8.16).
have normal movements if the lids are prised apart. Usually the infection is limited by the periosteum
Postseptal inflammation can be divided into two and it rarely spreads into the intraconal space.
groups, each requiring different management. Should spread occur, the fat in the intraconal space
These infactions are either extraconal, i.e. sub­ is infiltrated with linear strands of inflammatory
periosteal, or they are intraconal, i.e. within the reaction, making it difficult to distinguish either the
periosteum. extraocular muscles or the optic nerve. Abscess
Extraconal orbital cellulitis is associated with formation is indicated by the characteristic develop­
exophthalmos of the globe, restricted eye ment of an area of low density with an enhancing
movements and chemosis of the conjunctiva, and rim (Figures 8.16 and 8.17).
86 An atlas of imaging of the paranasal sinuses

lntracranial complications and will be limited by the dural attachment to the

suture lines between the individual skull bones
These are the rare but life-threatening complications (Figure 6.18). The adjacent brain is usually
of uncontrolled sinus disease and include meningi­ hypodense because the surrounding tissue. is
tis, extradural abscess, intradural abscess, subdural edematous. If an abscess forms in the subdural
abscess, intracerebral abscess and cavernous sinus space, i.e. between the dura and the arachnoid, it
thrombosis. Such complications usually occur as a tends to have a semilunar shape. It may extend into
consequence of inadequate antibiotic treatment, the the interhemispheric fissures or along the margins of
presence of resistant bacteria or immunosuppres­ the tentorium. Both the periosteum and the
sion. The infection may spread by one of several meninges will enhance following the administration
routes: of intravenous contrast. The collection of pus will
vary in density depending on the contents and how
direct spread if the infected sinus is involved in long the abscess has been present. Air may be seen
trauma; in the fluid collection.
ii through congenital bony dehiscences, such as An intracerebral abscess may result from the
defects in the wall of the sphenoid sinus; direct spread of infection from the sinus into the
iii by retrograde phlebitis; cerebral tissue, or following septic embolization. In
iv through erosion of the bony wall by infection or the former situation the abscess is usually in close
tumor; proximity to the infected sinus responsible,
v by hematogenous spread as part of a general­ whereas in the latter situation the abscess may be
ized septicemia; distant to the infected sinus. Infection of the frontal
vi by extension along pre-existing anatomic sinus is frequently responsible for intracerebral
pathways, i.e. perineurally along the olfactory abscesses, and these may reach some size before
nerves or via nerves that communicate into the the diagnosis becomes clinically evident. The CT
pterygopalatine fossa, the vidian nerve or the findings will vary depending on the stage of devel­
maxillary division of the trigeminal nerve. opment that the abscess has reached at the time
of the scan. Early in the abscess formation there
The clinical features of intracranial sepsis may may be only a poorly defined hypodense area
at first be nonspecific and include malaise and exhibiting little enhancement. If untreated, this will
generalized headache. As the clinical picture progress to exhibit a well-demarcated, encap­
develops, the symptoms depend on the site of the sulated lesion surrounding an area of pus. The
intracranial infection. A high index of suspicion is capsule enhances brightly following intravenous
needed to make the appropriate diagnosis and contrast administration, and the surrounding brain
arrest the infection before serious neurologic appears hypodense reflecting the edema in the
sequelae occur. The headache becomes more region.
severe with progression of the infection. Focal Cavernous sinus thrombosis is a further rare
signs and convulsions may occur as well as intracranial complication of sinusitis. Acute throm­
changes in personality and conscious level. bophlebitis secondary to infection in an area with
Vomiting and papilledema occur at a late stage. venous drainage into the cavernous sinus, such as
Examination of the cerebrospinal fluid may be of acute sphenoiditis, is the usual predisposing factor.
value in identifying elevated protein and leukocyte The clinical features include fever, headache and
levels and reduced glucose levels, as well as rigors. There is edema of the eyelids, exophthalmos,
providing information after bacteriological culture. chemosis, ophthalmoplegia, and low-grade
However, CT is invaluable in identifying if and papilledema. The white cell count is elevated and
where an intracranial abscess has occurred. blood cultur.e is often positive.
If meningitis is localized to the base of the skull, On CT a normal cavernous sinus is seen to as a
multiple cranial nerve palsies may present. brightly enhancing structure surrounding the pituitary
Obstruction to the flow of cerebrospinal fluid leads fossa, with a sharply defined lateral border. Usually
to dilation of the ventricles and hydrocephalus. the intracavernous part of the internal carotid artery
Cortical and gyral enhancement may be seen follow­ is indistinguishable from the surrounding venous .
ing the administration of intravenous contrast. structure. In contrast, in cavernous sinus thrombosis
An extradural abscess occurs between the bone the venous structure fails to enhance and the inter­
of the calvarium and the dura mater. CT will usually nal carotid arteries will become very prominent as
demonstrate a collection that is lentiform in shape enhanced tubular structure.
 The radiologic appearance of benign inflammatory paranasal sinus disease 87

NASAL POLYPS cases, the bony leaflets may become sclerotic and
make a more definite impression on the image
The etiology of nasal polyps remains unclear. (Figures 8.28 and 8.29). Sometimes, following intra­
Chronic inflammation, be it allergic or infective, venous administration, slightly enhancing curvilinear
results in hyperplasia and edema of the sinonasal looping strands will be seen in the diseased area.
mucosa. There is accumulation of fluid in the stroma This represents areas of mucous membrane
of the polyps due to a deranged vascular mecha­ surrounded by the mucoid material within the polyp.
nism. The cellularity of the polyps varies and This becomes more apparent if the scans are
eosinophils are predominant in polyps derived from examined with narrow-window settings. If the polyps
allergic or atopic patients. are longstanding, there may be hypertelorism and
Clinically these patients present with a long history smooth expansion of the bony walls of the sinuses
of nasal obstruction, rhinorrhea, recurrent sinusitis secondary to pressure effects.
and/or headaches. Rarely, hypertelorism or exoph­ It may be difficult to accurately interpret CTs of
thalmos may be found on examination. Both the patients with massive polyposis if they have under­
nasal cavities are usually filled with multiple polyps, gone previous surgery. There may be extensive
and the finding of a unilateral polyp should raise the resorption of bone following pressure necrosis and
suspicion of tumor or even malignancy. all that may be seen is an amorphous mass of
Endoscopically it has been shown that most of the disease indicating the need for radical procedure,
polyps appearing in the nasal cavity arise from the which may be at variance to the decision based on
ethmoidal area. The most frequent sites of origin are the diagnostic endoscopy (Figures 8.30 and 8.31 ).
the areas of contact between the infundibulum, the Surgical decisions should not be based solely on the
middle turbinate and the uncinate process (Figures radiographic findings. However, in those who have
8.19-8.21 ). In many patients, polyps arise from the undergone previous surgery, CT is of value in deter­
anterior aspect of the ethmoid bulla and protrude mining the presence of any bony defects at critical
into the middle meatus. In up to 50% of patients, points and the site of recurrent polyps which may be
polyps are found in the frontal recess (Figure 8.22). attached to the dura.
Polyps have also been identified arising in a concha There are no unique radiologic features that will
bullosa and in the lateral recess. The latter is most lead to a definite diagnosis of polyposis. In view of
frequently affected when there is simultaneous the bone resorption that may occur, a tissue biopsy
polypoid involvement of the posterior ethmoid sinus must always be taken to exclude malignancy. The
(Figures 8.23 and 8.24). In uncomplicated polyposis, associated bony sclerosis may be suggestive of a
the anterior ethmoid is almost always involved; chronic inflammatory process, but it is also associ­
isolated polyps have not been identified arising ated with inverting papilloma. The internal architec­
solely from the posterior ethmoid sinus, except ture of the polypoid mass helps to differentiate it
around tumor. Only 8% of sphenoid sinuses show from a mucocele which is usually non-enhancing
any polypoid change. Relatively minor polypoid and isodense, being filled with fluid of uniform
change in the ostiomeatal complex revealed by density (Figures 8.32 and 8.33). The finding of mixed
diagnostic endoscopy may be found to be extensive density or the alternating radiating bands of high and
when the patient is examined by CT. low density associated with polyposis may lead to
Plain radiographs of patients with diffuse nasal suspicion of a fungal sinusitis. However, bilateral
polyposis show nonspecific changes. There is often and extensive involvement is an unusual feature of
widespread loss of translucence from mucosal thick­ fungal sinusitis (Figures 8.26-8.28) in an otherwise
ening, sinus opacification and, occasionally, healthy patient, unless the patient has allergic fungal
evidence of bony expansion in the ethmoid sinuses. sinusitis.
The findings on CTs are of unilateral or bilateral
soft-tissue masses within the nasal cavity and
paranasal sinuses. These are usually of alternating
mucoid density and soft-tissue density, which
becomes more marked on examination with narrow­ ANTROCHOANAL POLYPS
window settings (Figures 8.25 and 8.26). If the
polyps are tightly packed together there may be The etiology of these unilateral polyps is unclear,
resorption of the ethmoid bony leaflets (Figure 8.27). although they are histologically similar to ordinary
This is represented by areas of high density inflammatory nasal polyps. An antrochoanal sinus,
surrounded by areas of mucoid density. In other which originates most commonly from the postero-
88 An atlas of imaging of the paranasal sinuses

lateral wall, and a solid part that extends by a stalk a biopsy may be necessary to exclude sinister
through the maxillary ostium or via an accessory disease. Dental disease in the form of odontogenic
ostium in the anterior or posterior nasal fontanelles, cysts should also be excluded.
into the middle meatus, which progressively expands
to reach the choana. Antrochoanal polyps occur
more frequently in children and young adults and
have a tendency to recur if inadequately excised.
The radiographic appearance on plain radiographs MUCOCELES
shows a homogenous area in the maxillary sinus
which reflects the cystic component, and an opaque A mucocele is a sac containing mucus and desqua­
nasal cavity. A lateral view may demonstrate the mated epithelium; it completely fills the sinus and is
smooth posterior margin of the polyps hanging in the capable of slow expansion, which may lead to
nasopharynx. The CT demonstrates on opaque compression of the adjacent structures. The causes
maxillary sinus of uniform density, with a soft-tissue are multifactorial and include obstruction of the
mass in the ipsilateral nasal cavity. The sinus ostium ostium with chronic inflammation or polyps, trauma
and the nasal cavity may be widened to accom­ (surgical or accidental), allergy and tumor.
modate the polyp (Figure 8.34). Occasionally the Mucoceles may occur in any sinus cavity includ­
surrounding bone may exhibit a mixture of resorp­ ing that of a concha bullosa. They present more
tion and reactive osteitis. The differential diagnosis commonly in the frontoethmoid complex; occasion­
includes hemangioma, juvenile angiofibroma and ally, multiple mucoceles may occur in the same
inverting papilloma, as well as any other relatively patient (Figure 8.40). Mucoceles of the frontal sinus
slow-growing malignancy. present with swelling of the upper eyelid and inferior
displacement of the globe. There may also be
swelling over the anterior wall of the frontal sinus
with the characteristic 'eggshell crackling' on palpa­
tion. Mucoceles of the ethmoid sinus tend to cause
RETENTION CYSTS exophthalmos and lateral displacement of the globe.
There may be an associated swelling in the super­
These benign cysts have multiple causes, including omedial quadrant of the orbit and both these
trauma infection and allergy (Figure 8.35). They features may cause diplopia. Encroachment on the
occur following obstruction of either a minor salivary lacrimal apparatus cause� epiphora. Sphenoid
gland or a mucus-secreting gland. The former, sinus mucoceles tend to present with headache or
nonsecretory cysts consist of serous fluid which retroorbital or periorbital pain. They may expand
forms loculated collections in the connective tissue into the cavernous sinus and the orbital apex
of the mucous membrane. The cyst has no definable causing ophthalmoplegia and retroorbital pain
lining. The mucus-secreting cyst is lined with respi­ known as the 'orbital apex syndrome'. There may
ratory epithelium: it is usually asymptomatic and be an associated gradual loss of v1s1on,
presents as an incidental finding on 2-5% of radio­ papilledema and optic atrophy. These patients can
graphs of the facial region. The radiographic also present with multiple cranial nerve palsies.
features are of a dome-shaped density, usually Mucoceles of ihe maxillary sinus may present in
arising in the floor of the sinus (Figure 8.36). many ways; as a mass in the nasal cavity if there
However cysts may arise at any mucosa! site is medial extension, with diplopia if there is superior
(Figures 8.37-8.39). The surrounding anatomy is extension, with cheek swelling if there is anterior
usually normal unless the cyst is of a large dimen­ expansion and swelling of the gums if there is
sion, when some bone remodeling may occur. If the extension into the alveolus (Figures 8.41-8.43). A
cyst fills the sinus cavity, a crescentic rim of air significant number of maxillary sinus mucoceles
above the cyst usually allows one to differentiate the follow surgical procedures on the maxillary sinus,
cyst from a mucocele. Retention cysts may sit on the and these are characteristically found to be laterally
infraorbital nerve where it passes through the roof of placed in the sinus as opposed to filling the entire
the maxillary sinus, ar.j so cause paresthesia of the antrum (Figure 8.44). Rarely, mucoceles of the
infraorbital nerve. These cysts rarely. need any treat­ lacrimal sac may occur. These usually occur in
ment, but when they are observed it is important to infants and present with a swelling in the region of
make certain that there is no altered anatomy or the medial canthus. These are usually related to
paresthesia (Figure 8.37). Should this be the case, congenital anomalies of the nasolacrimal duct.
 The radiologic appearance of benign inflammatory paranasal sinus disease 89

Clinical examination and plain radiographs may to enhance slightly following the administration of
indicate the diagnosis. For confirmation of the intravenous contrast, which is at variance to the
diagnosis and delineation of the extent of the behavior of the classic mucocele. These polypoid
mucocele, CT is invaluable. The early radiologic mucoceles are usually associated with multiple sinus
features of a mucocele are nonspecific in compari­ inflammatory disease and not infrequently with other
son with those of allergy or inflammatory disease. mucoceles developing in the supraorbital ethmoid air
However, as the mucus accumulates within the cells.
sinus, there is gradual expansion of the sinus cavity, Sphenoid sinus mucoceles may be localized
with thinning and loss of the peripheral bony unilaterally within the sinus or may expand to fill the
margins. Later, this bone remodeling will change to whole sinus. Early features include a hemispherical
bony destruction and malignancy will enter the differ­ opacity of the sinus. There may be displacement of
ential diagnosis. The contents of the mucocele the intersinus septum and the lesion may then
usually appear homogenous and are isodense or spread into the posterior ethmoid and the
hypodense relative to brain tissue. They do not sphenoethmoid recess. If extensive the mucocele
usually enhance following administration of intra­ will be seen expanding into any of the related
venous contrast. Should the mucocele become anatomic regions, for example, into the cranial
acutely infected, and develop into a pyocele, the cavity, nasopharynx, pterygopalatine fossa, infra­
administration of intravenous contrast will demon­ temporal fossa or orbit. The latter may be associ­
strate rim enhancement. While poorly demonstrating ated with widening of the superior orbital fissure.
bony defects, MR imaging has superior ability in This extensive appearance may be suggestive of
differentiating contrast between soft tissue and it malignancy.
may help in the differentiation of mucoceles and Maxillary sinus mucoceles in the early stage will
solid tumors. On MR imaging, the signal intensity of exhibit opacification of the sinus on plain radio­
mucoceles varies according to the number of hydro­ graphs. As the mucocele expands, the bony walls
gen protons and glycoprotein complexes present become thinned and displaced medially into the
with the mucocele. nasal cavity, superiorly into the orbit, posteriorly into
Frontal sinus mucoceles cause erosion of the the pterygopalatine fossa or laterally reversing the
incomplete septa normally found within the sinus natural convexity of the lateral antral wall (Figures
cavity. This leads to loss of the normal scalloped 8.41, 8.42 and 8.56). If the patient has had surgery
appearance and gives rise to a smooth outline. to the maxillary sinus, the mucocele may be lateral­
There may be an associated reactive sclerosis of the ized within a small compartment and the surround­
bone. With increased expansion, the anterior and ing wall may be sclerotic (Figure 8.44). The density
posterior bony walls of the sinus may become dehis­ of the fluid is less than that of muscle and isodense
cent, risking intracranial extension and sepsis or with brain. The differential diagnosis includes malig­
escape of the mucocele into the upper eyelid nancy, especially if bony erosion is present.
(Figures 8.45-8.51 ). Lacrimal sac mucoceles are an uncommon finding
Ethmoid mucoceles are difficult to diagnose on in infants. CT is an invaluable aid to confirming the
plain radiographs. they may be either radiolucent or diagnosis as it will demonstrate a cystic mass in the
slightly opaque. Supraorbital extension may be medial canthus in continuity with an expanded
indicated by thinning or loss of the superomedial nasolacrimal duct and a contiguous submucosal
orbital rim and the adjacent roof of the orbit. CT will intranasal mass.
demonstrate expansion of the ethmoid sinus and
loss of the fine bony septa dividing the air cells
(Figures 8.40 and 8.52). The lamina papyracea may
be displaced laterally and may be deficient in parts
(Figures 8.53-8.55). PYOCELE
The polypoid mucocele is a separate entity which
has been described in the ethmoid sinus. Patients A pyocele is a mucocele that has become secon­
with this pathology present with diplopia and exoph­ darily infected. This usually exacerbates the
thalmos. It exhibits involvement and expansion of symptoms. The radiologic features are similar to
the whole ethmoid labyrinth with preservation and those of mucoceles, but following the administration
sclerosis of the lamina papyracea and the bony of intravenous contrast there is usually a ring of
leaflets separating the ethmoid air cells (Figures enhancement within the cavity of the pyocele, repre­
8.54 and 8.55). These lesions have also been noted senting the inflamed mucosa (Figure 8.57).
90 An atlas of imaging of the paranasal sinuses

ATROPHIC RHINITIS as a primary disease of the nasal cavity or it may

follow intranasal surgery.
Atrophic rhinitis is a poorly understood condition On CTs, there are characteristic findings associ­
which is characterized by atrophy of the nasal ated with atrophic rhinitis. These include bony
mucosa and reabsorption of the underlying bone. resorption and mucosal atrophy of the inferior and
The lateral nasal wall becomes bowed and therefore middle turbinates, enlargement of the nasal cavity
the nasal cavity becomes enlarged. This process is with lateral bowing of the lateral nasal wall, hypo­
usually symmetrical, but may occur unilaterally. plasia of the maxillary sinuses, bony resorption of
Despite the greater dimensions of the nasal cavity, the ethmoid bulla and ethmoid sinuses, loss of
these patients usually complain of nasal obstruction. definition of the ostiomeatal complex, and mucosal
Other clinical features include anosmia and an offen­ thickening in the paranasal sinuses (Figures 8.58
sive purulent rhinorrhea. Atrophic rhinitis may occur and 8.59).
 The radiologic appearance of benign inflammatory paranasal sinus disease 91

8.1 8.2

8.3 8.4

Figure 8.1 Figure 8.2

Acute sphenoid sinusitis. An upright lateral plain radiograph of Mucormycosis. This axial CT scan demonstrates sinusitis
he paranasal sinuses demonstrates an air-fluid level in the involving the right maxillary and ethmoid sinuses in addition to
sphenoid sinus consistent with acute sphenoid sinusitis cellulitis of the right orbit. This patient was an uncontrolled
{arrows). diabetic who had undergone root canal therapy 4 days
previously.

Figure 8.3 Figure 8.4

Mucormycosis. This angiogram was obtained after an Chronic maxillary sinusitis: CT scan. A large retention cyst or
intracranial hemorrhage was identified on the CT scan of the polyp can be seen in the left maxillary sinus. There is mucosa!
patient shown in Figure 8.2. Note the mycotic aneurysm (arrow) thickening in the right maxillary sinus.
which is the most likely cause of the intracranial hemorrhage.
92 An atlas of imaging of the paranasal sinuses

8.5 8.6

8.7 8�

Figure 8.5 Figure 8.6

Frontal sinusitis. This coronal CT scan demonstrates some Maxillary sinusitis. This coronal CT scan demonstrates mucosa!
mucous in the left frontal sinus containing characteristic bubbles disease with fluid in the maxillary sinus and an area of
of air. The right frontal sinus is well developed. characteristic of mucous discharge in the maxillary sinus
(arrow).

Figure 8.7 Figure 8.8

Sphenoid sinusitis. This coronal CT scan demonstrates chronic Pansinusitis. This coronal CT scan demonstrates unilateral
sphenoid sinusitis with reactive osteitis of the sinus walls maxillary sinusitis and inflammatory disease in the frontal
(arrow). Sphenoid sinusitis occurs more frequently than it is recess.
appreciated. These patients are more often investigated for the
cause of headache by neurologists with routine head scans.
 The radiologic appearance of benign inflammatory paranasal sinus disease 93

8.9 8.10

8.11 8.12

Figure 8.9 Figure 8.10

Pansinusitis. This coronal CT scan, taken more posteriorly than Fungal (Aspergillus) sinusitis. This axial CT scan demonstrates
Figure 8.6, demonstrates right maxillary sinusitis which also fluid filling the entire left maxillary sinus lumen and a mass is
involves the anterior ethmoid sinus. There is some sclerosis of seen causing smooth expansion of the medial sinus wall. The
he lateral maxillary sinus wall and the floor of the orbit. high-density mass noted in the lumen (arrow) of the maxillary
sinus was subsequently proven to be aspergillosis.

Figure 8.11 Figure 8.12

Fungal (Aspergillus) sinusitis. This CT scan demonstrates Osteomyelitis. This plain radiograph demonstrates extensive
inflammatory reaction in the sinuses. The high-density areas destruction of the frontal bone (arrowheads) with opacification
are the result of heavy metal accumulation in the mycelia. of the frontal and the ethmoid sinuses, consistent with
frontoethmoid sinusitis and osteomyelitis.
94 An atlas of imaging of the paranasal sinuses

8.13 8.14

8.15 8.16

Figure 8.13 Figure 8.14

Osteomyelitis. This plain radiograph demonstrates left-sided Osteomyelitis: CT scan. This patient presented with acute
frontal sinusitis, with rarefaction progressing along the sagittal frontal sinusitis which progressed to osteomyelitis. Widespread
suture (arrowheads). lytic lesions are seen in the frontal bone.

Figure 8.15 Figure 8.16

Orbital cellulitis on radiograph. This patient presented with facial Subperiosteal abscess: CT. The non-enhancing mass along the
and orbital cellulitis, fever and a high white cell count. This medial aspect of the left ethmoid complex (arrow) is a
Water's view demonstrates extensive destruction of the medial subperiosteal abscess. The medial rectus muscle and the
wall of the left orbit, destruction of the floor of the orbit and a elevated periosteum (arrowheads) are seen as an enhancing
subperiosteal abscess extending into the left orbit (arrowheads). linear density lateral to the abscess. This abscess is the result
The left maxillary, frontal and ethmoid sinuses are opaque. An of the spread of infection from the ethmoid sinus through the
air fluid level is seen in the right frontal sinus consistent with an lamina papyracea.
acute right frontal sinusitis. The intact lamina papyracea is
marked (LP) on the right. The patient refused to cooperate tor
CT.
 The radiologic appearance of benign inflammatory paranasal sinus disease 95

8.17 8.18

8.19 8.20

Figure 8.17 Figure 8.18

Mucopyocele and orbital cellulitis. On this T2-weighted MR scan Epidural abscess: CT. This patient presented with acute frontal
the signal-void masses are the mucoceles (arrows). The sinusitis which rapidly progressed to osteomyelitis. A small
hypointense masses are the infected pyoceles (curved arrows); epidural abscess (arrow) developed adjacent to the infected
normal signal intensity is seen on the other side. Orbital fat is sinus, as can be seen on this CT.
altered due to orbital cellulitis on the left side.

Figure 8.19 Figure 8.20

Solitary polyp. This coronal CT scan demonstrates a large Solitary polyp. This coronal CT scan demonstrates a small
polyp wedged in the middle meatus (arrow). The large concha polyp in the left ethmoid infundibulum (arrow). Although easily
bullosa (CB) which compromises the middle meatus is the most demonstrated on the scan, the polyp could not be identified on
likely cause of the polypoid degeneration of the mucosa in the clinical examination.
middle meatus.
96 An atlas of imaging of the paranasal sinuses

8.21 8.22

8.� 8.�

Figure 8.21 Figure 8.22

Solitary polyp. This coronal CT scan demonstrates occlusion of Solitary polyp. This coronal CT scan demonstrates a soft-tissue
the left maxillary ostium by a solitary polyp (P). Despite a density above the right agger nasi cell in the frontal recess
previous intranasal antrostomy the patient had remained (arrow). The adjacent lamina papyracea is intact and normal.
symptomatic. This transpired to be an inflammatory polyp.

Figure 8.23 Figure 8.24

Nasal polyps. This coronal CT scan demonstrates a solitary Nasal polyps. This posterior coronal CT scan demonstrates
polyp (arrow) in the right posterior ethmoid air cell or Onodi's inflammatory mucosal thickening in the sphenoid sinuses
cell. (arrowheads), as well as a polyp arising in the right
sphenoethmoid recess (arrow).
 The radiologic appearance of benign inflammatory paranasal sinus disease 97

8.25 8.26

8.27 8.28

Figure 8.25 Figure 8.26

Nasal polyposis. This coronal CT scan, examined with a wide Nasal polyposis. This coronal CT scan, examined with a narrow
window, demonstrates that the maxillary sinuses, the anterior window, demonstrates that the soft-tissue abnormality has the
ethmoid sinuses and the nasal cavity are occluded by either alternating high- and low-density areas characteristic of benign
soft-tissue or fluid-filled densities. nasal polyposis. The alternating features are due to the mixture
of high-density mucoid material and low-density fluid.

Figure 8.27 Figure 8.28

Nasal polyposis. This coronal CT scan demonstrates extensive Nasal polyposis. This coronal CT scan, examined with a narrow
polyposis occluding the entire nasal cavity. The plane of window, demonstrates benign nasal polyps associated with a
demarcation between the lateral nasal wall and the maxillary mucocele in the ethmoid sinus following obstruction of the ostia.
sinus is indistinct. The inferior turbinates are small and The alternating densities are due to the mucoid material in the
shrunken from chronic abuse of topical decongestants (arrow). polyp (low density) and the dense mucosal folds. The
superomedial margin of the orbit is eroded.
98 An atlas of imaging of the paranasal sinuses

8.� 8.�

8.31 8.32

Figure 8.29 Figure 8.30

Nasal polyposis. This narrow-window axial CT scan of the Recurrent nasal polyps. This coronal CT scan, examined with a
same patient as in Figure 8.28, demonstrates widening of the wide window demonstrates the defect of a radical drainage
ethmoid labyrinth into the right orbit with preservation of the procedure conducted for chronic maxillary sinusitis. The medial
bony septa that separate the ethmoid air cells. This has some wall of the maxillary sinus, the middle and inferior turbinates on
of the features of an ethmoid polypoid mucocele. The lamina the right side have been removed. The remainder of the
papyracea is thickened and sclerotic. sinuses are filled with apparently homogenous soft tissue.

Figure 8.31 Figure 8.32

Recurrent nasal polyps. This narrow-window coronal CT scan of Polypoidal mucocele. This coronal CT scan demonstrates
the same patient as in Figure 8.30 demonstrates alternating extensive soft tissue filling the ethmoid air cells. The bony
high and low densities in the left maxillary sinus, consistent with erosion seen in the right lamina papyracea (arrows) raises the
recurrent polypoid tissue. possibility of either polypoid disease or a mucocele. The
smooth expansion characteristic of a mucocele is absent.
 The radiologic appearance of benign inflammatory paranasal sinus disease 99

8.33 8.34

8.35 8.36

Figure 8.33 Figure 8.34

Polypoidal mucocele. This coronal CT scan is more posterior Antrochoanal polyp. This coronal CT scan demonstrates a large
than that in Figure 8.32. The extensive soft tissue seen inflammatory antrochoanal polyp that extends from the left
throughout the paranasal sinuses was due to polypoidal maxillary sinus into the middle meatus. Chronic inflammation
disease. There is a diseased concha bullosa on the right has resulted in extensive reactive osteitis and thickening of the
(arrow). left lateral maxillary sinus wall and orbital floor (arrows). A small
polyp is demonstrated in the right frontal recess (arrowhead).

Figure 8.35 Figure 8.36

Mucous retention cyst. This coronal CT scan demonstrates Mucous retention cyst. Radiograph: this Water's view
bilateral intranasal antrostomies (arrows) despite which the demonstrates a dome-shaped soft-tissue filling defect arising
patient continues to be symptomatic. There remains bilateral from the floor of the right maxillary sinus (arrows).
ostiomeatal complex disease with inflammatory disease in the
right middle meatus (arrowhead). A small retention cyst or
polyp is seen within the lumen of the left maxillary sinus (C).
Most cysts are situated in the dependent part of the sinus
cavity.
100 An atlas of imaging of the paranasal sinuses

8.� 8.�

8.� 8.�

Figure 8.37 Figure 8.38

Mucous retention cyst. This coronal CT scan demonstrates a Mucous retention cyst. This coronal CT scan demonstrates a
mucous retention cyst (C) adjacent to the right infraorbital large cyst or polyp arising in the right sphenoid sinus.
canal. The left infraorbital canal is demonstrated (arrow).

Figure 8.39 Figure 8.40

Mucous retention cyst. This coronal CT scan demonstrates a Ethmoid mucocele. This coronal CT scan demonstrates an
multiseptate sphenoid sinus with a retention cyst (C), in the left isodense soft-tissue mass with expansion and erosion of the
lateral recess. Note the pneumatization of the left anterior ethmoid fovea (arrowhead) and the superomedial margin of the
clinoid process. orbit (arrows). This has the features of a mucocele (M). The
scan also demonstrates the limited surgical access as a result
of encroachment of the middle turbinate and of the deviated
nasal septum onto the middle meatus. The arrowhead
demonstrates the erosion of the ethmoid fovea.
 The radiologic appearance of benign inflammatory paranasal sinus disease 101

8.41 8.42

8.43 8.44

Figure 8.41 Figure 8.42

Maxillary sinus mucocele. This coronal CT scan demonstrates Maxillary sinus mucocele. This more posterior CT scan
an expansile soft-tissue density within the maxillary sinus, with demonstrates irregular bony resorption in the lateral wall
bowing of the medial wall of the maxillary sinus (arrowheads). (arrowheads), of the maxillary sinus. This was found to be a
pyocele.

Figure 8.43 Figure 8.44

Maxillary sinus mucocele. This narrow-window coronal CT scan Maxillary sinus mucocele. This coronal CT scan demonstrates
shows that the maxillary sinus cavity is filled with fluid. The the bony defect from previous intranasal antrostomy. As a
secondary changes caused by mucoceles such as medial result of scarring, a mucocele (M), limited to the lateral
expansion of the maxillary sinus lumen (arrows), and reactive compartment of the septated maxillary sinus has developed.
sclerosis of the orbital floor (arrowheads), are at an early stage.
102 An atlas of imaging of the paranasal sinuses

8.45 8.46

8.�
8.�

Figure 8.45 Figure 8.46

Frontal sinus mucocele. This coronal CT scan demonstrates a Left frontoethmoid mucocele. This patient had previously
defect in the floor of the right frontal sinus (arrow). The patient undergone sinus surgery for chronic sinusitis and presented
had polypoid disease with a small mucocele in the lateral part with a mass in the superomedial aspect of the orbit. This
of the frontal sinus. This is unusual, as most frontal sinus coronal CT scan demonstrates a smooth, expansile, soft-tissue
mucoceles occur close to the superomedial margin of the orbit. mass with erosion of both cribriform plates (arrowheads), and
the superomedial aspect of the orbit (arrows). This mucocele
developed after scarring occluded drainage of the frontal recess
on the left side.

Figure 8.47 Figure 8.48

Left frontoethmoid mucocele. This coronal CT scan was taken Frontoethmoid pyomucocele. This axial CT scan demonstrates
posterior to Figure 8.46 and demonstrates a smooth, expansile, an expansile, soft-tissue mass which has eroded through the
soft-tissue mass, with erosion of the left lamina papyracea and posterior wall of the frontal sinus (open arrow). There is
the left cribriform plate (arrowhead). The soft-tissue images of enhancement of the mucous membrane consistent with a
the orbital contents show the globe to be displaced pyomucocele of the left frontal sinus.
inferolaterally on the left.
 The radiologic appearance of benign inflammatory paranasal sinus disease 103

8.49 8.50

8.51 8.52

Figure 8.49 Figure 8.50

Frontoethmoid pyomucocele. This axial CT scan demonstrates Frontal mucocele. This axial CT scan demonstrates an
an expansile, soft-tissue mass which has eroded through the enhancing mass which has eroded the anterior wall of the
anterior margin of the ethmoid sinus (arrow). There is frontal sinus (arrow). Reactive sclerosis of the sinus walls is
enhancement of the mucous membrane in keeping with a noted. This was a frontal sinus mucocele. If erosion is the
pyomucocele of the ethmoid sinuses. dominant feature, a mucocele may be difficult to differentiate
radiologically from a malignant tumor.

Figure 8.51 Figure 8.52

Frontal sinus mucocele. This coronal CT scan, of the same Ethmoid mucocele. CT scan: this patient presented with right­
patient in Figure 8.50 demonstrates the laterally placed frontal sided exophthalmos. A smooth expansile mass (M) with
sinus mucocele, with erosion of the floor of the lateral part of thinning of the lamina papyracea is seen in the right ethmoid
the sinus (arrow). The intersinus septum is bowed to the left sinus. The medial rectus (MR) muscle is stretched over the
(open arrow). mucocele. The smooth margins and erosions suggest the
presence of a mucocele. The optic nerve (ON) is displaced
laterally.
104 An atlas of imaging of the paranasal sinuses

8.� 8.�

8.55 8.56

Figure 8.53 Figure 8.54

Multiple mucoceles. This patient has undergone multiple sinus Ethmoid sinus polypoidal mucoceles with bilateral
operations. The coronal CT scan demonstrates large bilateral exophthalmos. This axial CT scan demonstrates a smooth
ethmoid sinus mucoceles (arrows) with expansion and erosion expansile mass in the right ethmoid sinus, with eggshell
of the wall of the ethmoid and frontal sinuses and the lamina thinning of the lamina papyracea (LP). The bony septa in the
papyracea. left ethmoid sinus are sclerotic (arrows) and the labyrinth is
expanded in keeping with the diagnosis of a polypoid mucocele.
The right medial rectus muscle is stretched over the mucocele
(arrowheads).

Figure 8.55 Figure 8.56

Ethmoid sinus polypoidal mucoceles with bilateral Maxillary sinus mucocele. This patient presented with a mass in
exophthalmos. This narrow-window axial CT scan of the same the right cheek (arrow). The wide-window coronal CT scan
patient as Figure 8.54 demonstrates the smooth, expansile demonstrates a large, expansile mass in the right maxillary
mass in the right ethmoid sinus to be isodense. The bony septa sinus which is of similar density to water. Smooth expansion of
in the left ethmoid sinus appear sclerotic (arrows) and the the maxillary sinus with erosion of the inferolateral wall and the
labyrinth is expanded in keeping with the diagnosis of a roof of the maxillary sinus has occurred.
polypoid mucocele. The right medial rectus muscle is stretched
over the mucocele (arrowheads).
 The radiologic appearance of benign inflammatory paranasal sinus disease 105

8.57 8.58

8.59A 8.598

Figure 8.57 Figure 8.58

Pyocele. This patient presented with a furuncle on the forehead Atrophic rhinitis. This coronal CT scan demonstrates
which developed into a draining sinus. Following the inflammatory mucosal thickening in both maxillary sinuses. The
administration of intravenous contrast, CT demonstrates middle and inferior turbinates have atrophied and there are few
mucosal enhancement (arrowheads) in the frontal sinus. The bony septa in the ethmoid labyrinth. The nasal cavities appear
mucosal enhancement is suggestive of an acute inflammatory to be enlarged.
process. The erosion through the anterior wall of the frontal
sinus, not demonstrated on this scan, was the drainage
· pathway of the pyocele.

Figure 8.59
Atrophic rhinitis. These coronal CT scans demonstrate
expanded nasal cavities due to the resorption of both the
turbinates and the bony walls of the nasal cavities. There has
been a proportionate decrease in the volume of the adjacent
paranasal sinuses. Despite the spacious nasal cavities, these
patients often complain of nasal obstruction.
9
The radiologic appearance of tumors and
tumor-like
. conditions of the paranasal
sinuses

BENIGN TUMORS syndrome. Gardner's syndrome is also associated

with multiple sebaceous cysts.
Osteoma
Osteomas are benign, slowly growing tumors
containing mature compact or cancellous bone. Fibrous dysplasia and ossifying
They occur most frequently in the frontal sinus fibroma
(Figure 9.1 ), followed by the ethmoid (Figure 9.2)
and then the maxillary sinuses. Osteomas are Fibrous dysplasia and ossifying fibroma are difficult
usually asymptomatic and are an incidental finding to distinguish histologically. Both belong to a range
on radiographs conducted for an unrelated reason. of fibro-osseous lesions affecting the mandible, the
However, should the osteoma block the drainage maxilla and, occasionally, the other bones of the
pathway of the sinus, then recurrent sinus infections skull. The ossifying fibroma is usually a well-circum­
or a mucocele may develop, and surgical excision scribed lesion which lends itself to easy excision.
of the osteoma is then indicated. Large frontal sinus The radiologic appearance is that of expansion of
osteomas can erode the inner table of the frontal the affected bone with a sclerotic bony margin.
bone and produce pneumocephalus or allow a sinus There are often areas of fibrous tissue that are more
infection to spread intracranially. Rarely, if an extensive than those seen in fibrous dysplasia. The
osteoma arises in the ethmoid sinus and becomes lesion may exhibit oval areas of fibrous or osseous
extensive, it may present with exophthalmos, follow­ tissue. With increasing maturity, these lesions exhibit
ing invasion of the orbit, or visual deterioration, if the increasing radiodense opacities (Figure 9.3).
lesion extends back into the sphenoid and compro­ Fibrous dysplasia is a development disease of
mises the optic nerve. Osteomas in the maxillary bone, usually seen in childhood and adolescence; in
sinus are an infrequent finding and are usually most cases, it arises before the age of 20 years. The
resected through an antrostomy. maxilla is affected more frequently than the
The radiologic features are those of a diffusely mandible, and such cases usually present with bony
dense mass that does not enhance following the swelling. Fibrous dysplasia may also affect the
administration of intravenous contrast. The bony zygoma, the frontal bone (Figures 9.4-9.6), the
margins are sharply defined and the mass may ethmoid labyrinth and the sphenoid (Figure 9.6),
appear pedunculated or broadly based. Small osteo­ causing facial deformity. Fibrous dysplasia can be
mas may not be detected on routine radiographs monostotic or polyostotic. It may be confined to only
and are best seen on computed tomography (CT) one bone of the cranium (monostotic), in which case
scans. As bone and air are seen as signal void there will be a better chance of therapeutic success,
areas on magnetic resonance imaging (MR), osteo­ if needed. In those cases in which multiple bones of
mas will be missed on MR. the cranium are involved (polyostotic), the prognosis
The development of multiple osteomas may is worse. Extensive fibrous dysplasia can narrow the
precede the development of multiple colonic polypo­ cranial nerve foramina, producing a sometimes
sis in an autosomal dominant syndrome-Gardner's severe compressive effect upon the cranial nerves.
 The radiologic appearance of tumors and tumor-like conditions 107

Little treatment is required. The bone may be the paranasal sinuses and occur mainly in females
recontoured when there is cosmetic defect or between the ages of 20 and 50 years. They may
· function is compromised. Malignant change has complicate the second trimester of pregnancy, but
been documented in these lesions, but it usually regress spontaneously following the delivery (granu­
follows radiotherapy, which is now regarded as loma gravidarum). Hemangiomas enhance following
being of little value. the administration of intravenous contrast (Figure
The radiologic features are characteristic of this 9.11). On T1-weighted MR scans, they are interme­
disease process. The appearance varies depending diate in signal intensity; they are hyperintense on T2-
on the quantity of fibrous tissue that is present in the weighted MR scans, with a surrounding rim of low
newly formed osteoid. The bone appears thickened signal intensity. Mucosa! hemangiomas usually
and has areas of increased density, which reflects present with epistaxis and nasal obstruction. The
the calcified cartilage and osteoid. The bone exhibits osseous hemangiomas arise from the nasal septum
a 'ground-glass' texture (Figures 9.5 and 9.6) that is or the nasal bones and tend to cause deformity. The
well demonstrated by CT. The sinus is usually surgical management is different for mucosal and
expanded and the process may involve the neigh­ osseous hemangiomas.
boring structures, such as the orbit, cranial cavity
and adjacent soft-tissue spaces.
Both ossifying fibromas and fibrous dysplasia are
more clearly demonstrated using wide windows.
Angiofibroma
This rare condition usually affects male adolescents.
The lesion arises from the medial pterygoid plate,
Dentigerous cysts the pterygomaxillary fissure and the sphenopalatine
foramen, and not from the nasopharynx, where they
A solitary dentigerous cyst is found surrounding the usually present. The lesions are benign but, because
crown of an unerupted permanent tooth. These are they expand to involve the ethmoid sinuses, the
more commonly found in the mandible but they may sphenoid sinuses and the skull base, the clinical
also occur in the maxilla. Dentigerous cysts present implications are sinister. It is important to determine
as a rapidly growing mass, usually in a young adult, whether there is intracranial extension of the angiofi­
and may lead to facial asymmetry. The diagnosis is broma via the orbital apex to the superior orbital
usually readily reached with the aid of plain radio­ fissure and thence to the middle cranial fossa. If this
graphs or an orthopantomograph. If the diagnosis is has occurred, it is usual for the lesion to obtain some
in doubt, CT will delineate the anatomy clearly. of its blood supply from the internal carotid artery,
There is usually a radiolucent area in the upper or and so surgical resection becomes more difficult and
lower jaw, associated with the crown of an hazardous.
unerupted tooth (Figure 9.7). The lesion is usually Radiologic features include enlargement of the
unilocular and surrounded by sclerotic bone. As the sphenopalatine foramen, erosion of the medial ptery­
cyst grows it may drag the unerupted tooth with it goid plate, widening of the pterygopalatine fossa and
(Figures 9.8 and 9.9). When the cyst erupts into the indentation of the posterior wall of the maxillary
maxillary sinus it may grow rapidly while still retain­ sinus. The nasopharyngeal mucosa may be thick­
ing a thin lamella of bone (Figure 9.10). ened or irregular (Figure 9.12).
The angiofibroma is of homogenous density and
strongly enhances following the administration of
intravenous contrast. Angiography prior to emboliza­
tion or excision will demonstrate the main feeding
Hemangioma vessels.
These intensely enhancing tumors predominantly
originate from the nasal mucosa near the middle
meatus. They can invade the turbinates and remodel
the nasal cavity, with displacement of the nasal INVERTING PAPILLOMAS
septum and lateral bowing of the nasal wall.
Hemangiomas are usually separated into capillary, Most benign squamous papillomas occur on the
cavernous or mixed hemangiomas. They are rare in septum or in the nasal vestibule. However, some
108 An atlas of imaging of the paranasal sinuses

types of papilloma do occur within the paranasal (Figures 9.14 and 9.15). This is invaluable both in
sinuses and may be seen as soft-tissue masses. the preoperative assessment of these patients and
These rarely cause bone erosion or undergo malig­ in the long-term follow up that is required with invert-
nant transformation. One form of papilloma that does . ing papillomas. The frequent finding of mucosa!
behave in a more sinister and aggressive manner is disease from concurrent allergic rhinitis or sinusitis
the inverting papilloma. may be misinterpreted as further extension of
Inverting papillomas are uncommon neoplasms of disease. The already noted high incidence of pre­
the nasal cavity and paranasal sinuses. They occur vious nasal surgery in these cases often distorts the
more commonly in men than women, with the great­ radiographic features, making it more difficult to
est incidence in the sixth and seventh decades. identify the limits of disease (Figures 9.17 and 9.18).
Inverting papillomas are slowly growing lesions that Sclerosis of the bony sinus walls has been noted
have a propensity to recur, especially if the initial in association with inverting papillomata, although
excision is incomplete. There is much debate this may well be related to an associated long­
regarding the potential for malignant transformation standing sinusitis rather than the papillomata. The
of inverting papillomas. It is felt by many that the radiologic appearance associated with an inverting
malignant tumor, when present, develops synchro­ papilloma is variable. If it is slow growing, the bony
nously with the inverting papilloma and is present in wall may be either thinned or eroded, and the
the tissue resected at the initial operation. Others opacity of the sinus will depend on the position and
feel that the malignancy develops following transfor­ extent of the papilloma in relation to the ostia.
mation of the inverting papilloma. It is noteworthy Occasionally, areas of calcification will be demon­
that malignancy is rarely found after an initial resec­ strated within the mass of the papilloma (Figure
tion in which excision was complete. 9.18}.
The clinical features include nasal obstruction, Tumor extension outside the confines of the nasal
anosmia, rhinorrhea and epistaxis. Pain and facial cavity and the paranasal sinuses is clearly demon­
paresthesia are not characteristic features of invert­ strated by CT. It is not uncommon to find tumor
ing papillomas, but they may be indicative of concur­ extending into the nasopharynx, usually in the form
rent malignancy. Many of the patients have had of a choanal polyp which may make contact with the
multiple operations on the nose and paranasal posterior nasopharyngeal wall. The tumor may
sinuses prior to diagnosis. The most common site of extend into the retrobulbar space causing exoph­
origin is within the middle meatus, but extension into thalmos, through the cribriform plate into the anterior
the adjacent sinus occurs frequently (Figure 9.13). cranial fossa, or through the greater wing of the
The maxillary antrum is involved in 69% of cases sphenoid into the middle cranial fossa. On MR
followed by the ethmoid sinuses (Figures scans, these tumors exhibit low to intermediate
9.14-9.16), sphenoid sinus (Figure 9.16), and the signal intensity. The tumor itself can be separated
frontal sinus, in decreasing order of frequency. from the surrounding inflammatory fluid in the
Inverting papilloma arising from the nasal septum obstructed sinus, as fluid is hyperintense on T2-
are uncommon and bilateral disease is rare (Figure weighted MR sequences.
9.17). Obstruction of the sinus ostia in the middle
meatus may lead to the accumulation of secretions
in the obstructed sinus and a secondary sinusitis.
Rarely, one of the paranasal sinuses may be
involved primarily, with no evidence of tumor exten­ MIDFACIAL NECROTIZING
sion into the nasal vault (Figure 9.16). LESIONS
Plain radiographs are of limited value. One-third
of plain radiographs are reported to be either normal The midfacial destructive lesions have been given
or show nonspecific mucosa! thickening. Other many names over the years. The two histologically
features noted on plain radiographs include opacity distinct lesions described here, Wegener's granulo­
of the maxillary antrum, a soft-tissue mass in the matosis and pleomorphic reticulosis, present in a
nasal cavity, ethmoid opacification and frontal sinus similar manner but require radically different treat­
disease. The bony walls of the paranasal sinuses ment.
and of the nasal vault may show remodeling, Wegener's ,granulomatosis is a clinical diagnosis
erosion, or reactive sclerosis. based upon the finding of systemic disease affect­
CT can delineate bony erosion and clearly demon­ ing the nasal cavity, kidneys and lung. It is charac­
strate the extent of the soft-tissue abnormalities terized by a necrotizing granulomatous vasculitis.
 The radiologic appearance of tumors and tumor-like conditions 109

Not uncommonly, there is associated orbital pathol­ The rhinolith is readily demonstrated on plain
ogy, such as conjunctivitis, corneal-scleral ulcera­ radiographs or CT as a radio-opaque lesion with
tion, uveitis or optic neuritis. This may be the result sharply demarcated borders (Figure 9.20).
of primary disease of the orbit, or the orbital
symptoms may be related to spread of the disease
from the paranasal sinuses. Treatment for
Wegener's granulomatosis includes high-dose
steroids and immunosuppressants. MALIGNANT TUMORS
The radiologic features of Wegener's granulo­
matosis (Figure 9.19) are nonspecific; the lesion Malignant tumors of the nose and paranasal sinuses
appears on plain radiographs only as mucosa! thick­ are rare and account for 0.2-0.8% of all malignan­
ening with or without retained mucopus. Initially, the cies. Because of the concealed nature of the
changes are similar to chronic inflammatory disease, anatomy and the relative inocuity of the early
with mucosa! thickening in the sinonasal cavity. symptoms, these tumors may often have reached an
Subsequently, the nasal septum or the turbinates advanced stage prior to diagnosis. This and the
may be thickened or the granuloma may be seen as morbidity associated with resection of the surround­
a soft-tissue mass on these structures. The final or ing anatomic regions is responsible for their poor
the destructive stage is seen as irregular erosions of prognosis.
the septum. The turbinates may be destroyed, and Initially, the symptoms may be similar to those of
the sinuses that are affected may be sclerotic, the a chronic sinusitis with persistent rhinorrhea and
sinus lumen being compromised by the fibro­ facial pain. Progression of the symptoms to a persis­
osseous proliferation. In some cases, a secondary tent pain or paresthesia should warrant further inves­
bacterial infection within the nose and paranasal tigation. Early evidence of bone erosion or
sinuses is thought to account for the bony sclerosis asymmetrical sclerosis may be suggestive of an
that is often demonstrated by CT. Nonspecific irreg­ underlying malignancy.
ular densities may be seen within the orbit which are The sinister symptoms associated with malig­
associated with scleral-uveal thickening and muscle nancy in the paranasal sinuses will depend upon the
swelling. site of origin of the tumor. These may include facial
The other main group in this category are pain and paresthesia, loosening of the teeth or a
pleomorphic reticulosis. This lesion behaves as a change in fit of a dental plate, exophthalmos,
non-Hodgkin's (T cell) lymphoma, but the histologic epiphora and nasal obstruction with a persistent
diagnosis is difficult to reach in the early stages of discharge that may be blood stained. In the more
the disease. The condition is treated with a combi­ advanced stages of the disease, the tumor often
nation of radiotherapy and chemotherapy. The radio­ involves more than one sinus.
logic features are of destruction of the soft tissue The commonest site of malignancy in the
and bones of the midface. These changes are paranasal sinuses is the maxillary antrum, where the
nonspecific and cannot be differentiated from granu­ majority of malignant tumors arise. The second most
lomatous infection. common site is the ethmoid sinus. It is rare for
tumors to arise in either the frontal or the sphenoid
sinuses.
The commonest tumor in the paranasal sinuses is
Rhinoliths squamous cell carcinoma, followed by undifferenti­
ated carcinoma, adenoid cystic carcinoma and
Many objects, both animate and inanimate, have adenocarcinoma. Other tumors occur infrequently
been recovered from the nasal cavity. If a foreign and include malignant lymphoma, malignant
body remains undisturbed for some time it will melanoma, esthesioneuroblastoma, plasmocytoma,
become covered in salts of calcium and magnesium. metastatic tumors and the sarcomas.
These are usually phosphates, oxalates and carbon­ The diagnosis of paranasal sinus malignancy
ates. Over a period of years the rhinolith can enlarge requires an accurate history and a thorough clinical
and become molded to the shape of the cavity in examination, including endoscopic examination.
which it is situated. A rhinolith may present itself with Plain radiography and conventional tomography
nasal obstruction and a foul-smelling unilateral have a minor role in diagnosis but have been
rhinorrhea. If large, the rhinolith will need to be superceded by CT and MR. These last two modali­
disimpacted under general anesthetic. ties have a very important role in identifying features
110 An atlas of imaging of the paranasal sinuses

depending upon their position relative to Ohngren's

line. This is a plane extending from the medial
canthus of the eye to the angle of the mandible,
dividing the maxillary antrum into an anteroinferior
and a posterosuperior portion.
Imaging plays an important role in the manage­
ment of patients with malignancies in the sinuses or
nasopharynx. Both MR and CT are used to define
the margins and extent of the tumor, and for the
assessment of any involvement of the vital struc­
tures such as the cranial nerves, the orbit and the
intracranial structures. Postoperative and post­
radiation follow up is best done with these two
modalities. Neither MR nor CT can distinguish
between the various histologic types of malignancy.

Plain radiography
Plain radiographs are often the initial radiologic
investigation requested for a patient with sinus
symptoms that are refractory to medical treatment.
The bony margins should be examined for asymme­
try and/or bony destruction. The margins of particu­
lar interest are the medial wall of the antrum and the
orbit, the ethmomaxillary plate, the infraorbital
foramen and the skull base. Clouding and opacifi­
cation of the sinuses are common to both inflam­
matory and malignant lesions. Erosions where the
bone is normally thin along the medial wall of the
maxillary sinus, the lamina papyracea and the
infraorbital groove is often accompanied with
reactive osteitis in benign inflammatory diseases.
Destruction due to malignancy is seen to involve the
posterior and inferolateral walls of the maxilla, and
tumors do not usually evoke new bone formation.

Computed Tomography
suggestive of malignancy and in the staging of the
lesion. The final pathologic diagnosis follows tissue Computed tomography is the imaging modality of
biopsy and histologic examination. choice for the assessment of the bony margins and
Tumors arising in the maxillary sinus are staged soft-tissue extension of a malignancy of the
according to the TNM classification (Table 9.1 ). The paranasal sinuses. Indications for CT are given in
TNM staging is used by radiotherapists, oncologists Table 9.2.
and surgeons to decide which will be the most Usually the scans are conducted in both the axial
appropriate form of treatment for the patient and to and the coronal planes at 5 mm intervals following
compare the long-term results of different treatment the administration of a bolus of intravenous contrast.
modalities. As yet there are no adequate staging It is important to scan the whole sinus and surround­
protocols for malignancy of the frontal, ethmoid or ing soft-tissue area to identify any tumor that has
sphenoid sinuses. The maxillary sinuses are staged escaped from the sinus cavity.
 The radiologic appearance of tumors and tumor-like conditions 111

The clarity with which CT demonstrates the soft

tissue and the bony architecture of the paranasal
sinuses is of great value in assessing the presence
of malignancy within a sinus. The soft tissue within
the sinus in question may exhibit irregular margins
and the mucosa may be considerably thickened.
This mucosal thickening may be due to an inflam­
matory reaction surrounding the tumor or due to
tumor invasion itself (Figures 9.24 and 9.26). It is not
possible to distinguish which of these processes is
responsible using the imaging technique.
Most malignant tumors of the paranasal sinuses
have an homogenous appearance. The exceptions
are the minor salivary gland tumors and the schwan­
nomas, which exhibit a nonhomogenous pattern.
Areas of retained secretions and necrosis may be
demonstrated, as already discussed.
Bony remodeling or new bone formation is rarely
seen with tumors of the paranasal sinuses, with the
exception of ossifying osteosarcomas. However,
malignant tumors often arise in sinuses that have
been the site of chronic inflammation; consequently,
the bony changes may reflect this 'previous disease.
Calcified deposits occur within the tumor masses of
fibroosseous lesions, chondrosarcoma and the
osteosarcomas. With most tumors the bone is
thinned or eroded in an irregular manner (Figure
9.21 ). If the sinus is expanded and has an intact but
In the axial plane, CT is useful for demonstrating thinned bony wall, then it is more likely that the
the posterior extension of tumors of the maxilla into lesion is benign. The absence of bone destruction
,the pterygopalatine fossa, the infratemporal fossa does not exclude the possibility of an early malig­
and the soft tissue of the cheek (Figures 9.21 and nant lesion, and biopsy should be performed if clini­
9.22). The coronal plane is superior to the axial for cally indicated. However, the presence of a slowly
demonstrating intraorbital and frontal sinus involve­ growing tumor cannot be eliminated. Aggressive
ment as well as spread through the cribriform plate bone destruction of the sinus walls is usually
or planum sphenoidale into the anterior cranial fossa suggestive of a squamous cell carcinoma, but it may
(Figure 9.23). also represent a metastatic deposit from a distant
The administration of intravenous contrast demon­ primary site such as lung, breast, kidney or gastro­
strates a variable pattern of enhancement. The intestinal tract. Radioisotope bone scans are sensi­
result depends mainly upon the vascularity of the tive for bony metastases. If a sinonasal lesion is
tumor, for example, the hemangiosarcomas, suspected to be of metastatic origin, then a bone
metastatic hypernephroma, esthesioneuroblastoma scan will establish the secondary nature of the lesion
and some rhabdomyosarcomas enhance more if multiple bones are involved. Local invasion from
vigorously than other tumors. The pattern of tumors arising in the adjacent structures are not
enhancement is also influenced by the presence of uncommon. When such invasion involves the entire
retained secretions or chronic infection within a sinus, it is difficult to be sure of the exact site of
sinus; this will appear as an area of reduced origin.
enhancement (Figure 9.25). Similarly, necrotic Further evidence that a tumor has escaped
centres of tumor masses also enhance less and primarily from the confines of the sinus involved is
have a lower density than the surrounding tumor gained from a careful examination of the fat planes
which tends to be isodense with muscle. The admin­ lying between the soft tissue of the surrounding
istration of contrast also helps to identify the areas. These planes are usually well demonstrated
surrounding blood vessels and their relationship to by CT, and obliteration or distortion of them is
the tumor mass. suggestive of either edema, hemorrhage or tumor
112 An atlas of imaging of the paranasal sinuses

infiltration. When advanced, tumors of the paranasal If the patient has been treated with radiotherapy,
sinuses may involve more than one sinus and the chemotherapy or a combination of both, CT should
primary site rflay be obscured by widespread demonstrate tumor regression; again, a baseline
destruction. Likewise, it may be difficult to differen­ scan taken after the treatment response has
tiate the site of origin of a tumor if the nasopharynx, subsided will be of value in following the patient's
sphenoid and/or the pituitary fossa are involved clinical progress. There is usually an acute inflam­
(Figures 9.22 and 9.27). A tumor arising in the matory response that enhances clearly in the initial
paranasal sinuses readily escapes into the ptery­ phase of treatment, but this has usually subsided
gopalatine fossa (Figure 9.21 and 9.22), the 6-8 weeks following completion of treatment.
infratemporal fossa, the orbital apex (Figure 9.28), Difficulties arise in the assessment of the images of
the orbital cavity (Figure 9.29), the middle cranial patients who have developed extensive scar tissue
fossa, and the nasopharynx. Tumors may also as a consequence of both the tumor and the surgi­
spread through the many foramina in the skull base cal and/or radiotherapeutic treatment. In these
that transmit nerves and vessels into the orbit and patients, it is often impossible to differentiate scar
face, thus gaining easy access to the anterior and tissue from recurrent tumor without biopsy.
middle cranial fossa. Nodularity of the mucosa is more in keeping with
If lymph-node metastases is suspected clinically, tumor recurrence. Follow-up scans should be done
CT can demonstrate enlarged nodes in the at 3 month, 6 month and yearly intervals.
submandibular lateral retropharyngeal space and in It is not possible to make a sound diagnosis of the
the upper deep cervical lymph nodes. These nodes histologic type of the tumor from radiographic
are usually the first to become involved, with findings alone, and biopsy is mandatory. Certain
metastatic spread through the lymphatic system features, however, may be suggestive of the type of
secondary to malignancy in the paranasal sinuses. tumor. Aggressive bone erosion is usually caused by
Imaging is the ideal way to assess nodal metas­ squamous cell carcinoma, lymphoepitheliomas and
tases, as physical examination will not identify small lymphomas. These tumors may also contain calci­
lymph nodes in the deep spaces of the neck. fied fragments.
CT has a valuable role in the follow up of patients The mucoepidermoid and adenocarcinomas tend
who have been treated for a malignancy of the to be slow growing, and initially the sinus may
paranasal sinuses. It is important to obtain a appear expanded. If untreated, bone destruction will
baseline scan about 6 weeks following surgery to occur. These masses must be differentiated from
delineate the boundaries of the surgical defect. By metastatic deposits from lung, breast and the renal
this time most of the soft-tissue irregularities that tract.
follow as a result of the surgery will have settled and The olfactory neuroblastoma or esthesioneurob­
the margins of the cavity should be smooth. Repeat lastoma arises from cells of neural crest origin within
scans shquld then be obtained every 3-6 months to the olfactory mucosa; it may extend into the ethmoid
try to detect any tumor recurrence as early as is and sphenoid sinuses, as well as intracranially
possible, before salvage surgery becomes impossi­ (Figure 9.23). The tumor is slow growing, vascular
ble. and friable, and enhances following the administra­
Signs suggestive of recurrent tumor include soft­ tion of intravenous contrast.
tissue expansion, especially of a polypoid nature. Chondrosarcomas, osteosarcomas and other
This may only represent fibrous scarring of the tumors of cartilaginous or osseous origin often
mucosa, but it will direct the surgeon to the site(s) exhibit areas of calcification within an expanded
requiring biopsy. Either thickening or further destruc­ sinus. The histologic diagnosis may be suggested by
tion of the remaining bones of the cavity are also this appearance.
sinister findings that warrant further investigation. Angiography is not routinely done in the evalua­
Care should be taken to differentiate the bone tion of sinonasal tumors. Angiofibromas, sarcomas
dehiscence secondary to the surgical defect and that and some vascular metastases exhibit intense
which may be secondary to tumor recurrence. The vascularity. If embolization of the tumor prior to
presence of an expanded mass on the image is debulking the tumor mass is to be done, then
suggestive of advanced recurrent disease. angiography is undertaken.
 The radiologic appearance of tumors and tumor-like conditions 113

9.1 9.2

9.3 9.4

Figure 9.1 Figure 9.2

Frontal sinus osteoma: CT scan. The dense bony mass (0) Frontal recess osteoma. This CT scan demonstrates a well­
seen in the frontal sinus is an osteoma. defined bony mass in the anterior ethmoid air cells without
bony destruction. This is the characteristic appearance of a
benign osteoma (arrow). If large, the osteoma may occlude the
sinus ostium, although on most occasions it is an incidental
finding.

Figure 9.3 Figure 9.4

Ossifying fibroma. This CT scan demonstrates an unusual mass Fibrous dysplasia. This CT scan demonstrates thickening of the
in the left maxillary sinus. This has the radiologic features of an orbital roof and the superomedial aspect of the orbit. The entire
ossifying fibroma. Note the sclerotic margins of the mass left middle turbinate (MT) is thickened and replaced by
(arrows) and the ovoid areas of calcification (arrowheads) within abnormal bone.
the mass.
114 An atlas of imaging of the paranasal sinuses

9.5 9.6

9.7 9B

Figure 9.5 Figure 9.6

Fibrous dysplasia. This wide-window coronal CT scan Fibrous dysplasia: CT scan. The entire sphenoid bone is
demonstrates the characteristic 'ground-glass' appearance of thickened with the typical ground glass appearance of fibrous
fibrous dysplasia affecting the left frontal bone. If the sinuses dysplasia. The superior orbital fissure (SOF), the optic nerve
are viewed with a narrow window, then this abnormality could canal (ON) and the inferior orbital fissure (IOF) are
be mistaken for inflammatory disease in the left frontal sinus. demonstrated.

Figure 9.7 Figure 9.8

Odentogenic keratocyst. This coronal CT scan demonstrates a Dentigerous cyst: CT scan. A large expansile cyst (arrow) is
cystic lesion in the left alveolar ridge; it has a smooth scalloped demonstrated containing an unerupted tooth (open arrow). The
margin. The unerupted tooth can be seen in the base of the maxillary sinus walls are remodelled and the inferolateral wall of
cyst (arrow). The defect in the anterior bony wall of the maxilla the maxillary sinus is eroded. The sinus is extending medially
(open arrow) is evidence of a previous Caldwell-Luc procedure. into the nasal cavity (arrowheads).
Incomplete resection results in recurrence. These cysts can be
multiloculated.
 The radiologic appearance of tumors and tumor-like conditions 115

9.9 9.10

9.11 9.12

Figure 9.9 Figure 9.10

Dentigerous cyst. This CT scan taken with a narrow setting Dentigerous cyst. This coronal CT scan demonstrates an
shows the cyst and the maxillary sinus are filled with fluid of a expansile cyst (C) with a bony rim arising in the floor of the
uniform density. right maxillary sinus. This was a large pyogenic, dentigerous
cyst. The tooth to which it was related is not demonstrated in
these scans. Note the erosion and thinning of the maxillary
sinus wall (arrows). This is one of the few occasions when
Figure 9.11 inflammation of the sinus is found in conjunction with a normal
ostiomeatal complex, and where treatment must be directed at
Hemangioma. This CT scan demonstrates a soft-tissue mass the lesion itself.
(M) in the left nasal cavity. As a result of the chronic exertion
of pressure on the bone, there has been smooth expansion of
the nasal cavity with marked lateral bowing of the lateral wall of
the nose (arrows). The ostiomeatal complex is occluded by this Figure 9.12
large mass and there is a polypoid configuration of the mucosa
in the left maxillary sinus. This was proved to be a benign Angiofibroma. This axial CT scan demonstrates a soft-tissue
hemangioma, but there are no specific radiologic characteristics mass (M), in the left nasal cavity. It has caused widening of the
that can point to the diagnosis. left posterior choana and the nasal septum is deviated to the
right. There is mucosal thickening in the left maxillary sinus.
This was found to be an angiofibroma.
116 An atlas of imaging of the paranasal sinuses

9.13 9.14A

9.14B 9.15

Figure 9.13 in close proximity to the natural ostia, i.e. near the infraorbital
foramen and the medial sinus wall. In this case, the erosion
Inverting papilloma. This CT scan demonstrates a well-defined has occurrE\(i in atypical sites and the radiologist should be
soft-tissue mass with a meniscus of air in the maxillary sinus. suspicious lhat this is not a benign polyp.
The mass is seen protruding into the posterior part of the
middle meatus. There is no calcification in the mass and there
are areas of reactive new bone formation. There are no
radiologic features of this mass to distinguish it from an Figure 9.15
antrochoanal polyp. A meniscus of air above the mass (arrow)
is more a feature of polypoid disease rather than a mucocele. Inverting papilloma. This coronal CT of the paranasal sinuses
demonstrates a unilateral soft-tissue mass (arrow) arising from
the superior meatus, extending from above the horizontal plate
of the middle turbinate medially into the nasal cavity just
Figure 9.14 alongside the free margin of the middle turbinate. The mass is
in close proximity to the inferior turbinate on the left side (open
Inverting papilloma. Both the coronal (A) and axial (B) CT arrow). The middle meatus appears normal. There is no
scans demonstrate a smooth expansile mass (M) in the right evidence of erosion of the underlying bones. Clinically this was
maxillary sinus. There is erosion of the anterior, posterior, proved to be an inverting papilloma arising from the posterior
medial and inferolateral walls of the sinus (arrowheads). In ethmoid air cells and the superior meatus.
benign disease of the paranasal sinuses, bony erosion occurs
 The radiologic appearance of tumors and tumor-like conditions 117

9.16A 9.16B

9.17A 9.17B

Figure 9.16 Figure 9.17

Inverting papilloma: CT scans. One of the unusual presenting Inverting papilloma: CT scans. Postoperative views of the
sites for an inverting papilloma is the sphenoid sinus. The mass sinuses demonstrate a defect in the lamina papyracea from a
(M) which arose in the left sphenoid sinus, has caused erosion previous external ethmoidectomy (arrow) with removal of the
of the floor of that sphenoid sinus and can be seen protruding ethmomaxillary plate. There is soft-tissue proliferation, extending
into the sphenoethmoidal recess. There is reactive bony to involve the nasal septum and the opposite ethmoid sinuses
sclerosis of the lateral wall of the left sphenoid sinus. Note in (open arrows). This patient had a recurrent inverting papilloma.
(B) how the tumor has extended into the superior meatus. It is unusual for the papilloma to involve both nasal cavities,
The bony septa in the ethmoid air cells indicate that the
previous ethmoidectomy was incomplete.
118 An atlas of imaging of the paranasal sinuses

9.18 9.19

9.20 9.21

Figure 9.18 Figure 9.19

Inverting papilloma. This coronal CT scan demonstrates large Wegener's granulomatosis. This coronal CT scan demonstrates
nodular calcification (arrow) in an expansile mass involving the destruction of the turbinates, with an excessive amount of
middle meatus and right maxillary sinus. This was an inverting inflammatory reaction and reactive osteitis.
papilloma.

Figure 9.20 Figure 9.21

Rhinolith. This patient presented with a long history of halitosis Carcinoma of the floor of the mouth involving the maxillary
and a mass was seen in the nasopharynx on clinical sinus. This patient presented with an ulcer on the left cheek.
examination. The CT scan shows a rhinolith in the nose which She was a betal-nut chewer. On CT, a mass is seen eroding
has formed around a tiddlywink. This has caused extensive the hard plate and the floor of the nasal cavity and extending
inflammatory reaction and the rhinolith (arrow) was seen into the maxillary sinus. Note the fluid in the lett maxillary sinus
molding around the inferior turbinate and into the nasopharynx. and the destruction of the sinus walls (arrows). There is faint
irregular enhancement of the sinus mucosa, indicating tumor
invasion. The pterygopalatine Iossa is involved posteriorly
(arrowhead).
 The radiologic appearance of tumors and tumor-like conditions 119

9.22 9.23

9.24 9.25

Figure 9.22 Figure 9.23

Nasopharyngeal carcinoma. This patient presented with a Esthesioneuroblastoma. A soft-tissue mass is seen on this CT
history of sinusitis that was refractory to medical treatment. A in the roof of the nasal cavity with destruction of the roof of the
mass (M) destroying the base of the skull is seen on this CT. ethmoid (arrow). The mass (M) extends into the superior
The right maxillary sinusitis can be seen as well as destru_ction meatus, medial to the middle turbinate.
of the pterygoid plates and the posterior wall of the maxillary
sinus (arrow) following invasion of the pterygopalatine fossa.

Figure 9.24 Figure 9.25

Non-Hodgkin's lymphoma. This coronal CT scan demonstrates Non-Hodgkin's lymphoma. This axial CT scan, following the
a soft-tissue mass (M), filling the left nasal cavity and middle administration of contrast, demonstrates an enhancing mass
meatus. The bone of the floor of the left nasal cavity has been (M) in the frontal sinus which is surrounded by fluid of lower
eroded (arrows). density. There is destruction of the anterior wall of the frontal
sinus (arrow).
120 An atlas of imaging of the paranasal sinuses

9.26A 9.268

9.27A 9.278

Figure 9.26 Figure 9.27

Non-Hodgkin's lymphoma. These narrow- (A) and wide-window Pituitary tumor. These coronal CT scans demonstrate an
(8) coronal CT scans are of the same patient in Figure 9.24. enhancing mass that has eroded through the floor of the
The soft-tissue mass (M), can be seen extending posteriorly pituitary Iossa and extended inferiorly into the sphenoid sinus
throughout the left nasal cavity. In the narrow-window scan the (M) and laterally to involve the internal carotid artery, optic
soft tissue within the left maxillary sinus appears less dense nerve and superior part of the superior orbital fissure. This was
than the mass in the left nasal cavity and reflects retained a benign functioning chromophobe adenoma (arrows).
secretions.
 The radiologic appearance of tumors and tumor-like conditions 121

9.28 9.29

Figure 9.28 Figure 9.29

Tumor extension through the superior orbital fissure. This axial Non-Hodgkin's lymphoma. This axial CT scan shows tumor (M)
CT scan demonstrates extension of tumor through the right extending from the ethmoid sinus into the orbit. The lamina
superior orbital fissure (arrow), into the orbit. papyracea has been eroded (arrowheads). The intraorbital
extension has deviated the medial rectus muscle (open arrow)
laterally and the eyeball is exophthalmos. This was
subsequently diagnosed. as a non-Hodgkin's lymphoma.
10
The postoperative appearances of the
paranasal sinuses

It is important for the radiologist to have a working malignancy is suspected, MR is far superior to CT
knowledge of the indications for sinus surgery and because with MR the signal intensity of tumor recur­
of the variety of surgical approaches that are used, rence is different from scar tissue and might direct
as well as the surgical complications that may result the surgeon to suspicious areas for biopsy.
from these procedures. The bony defects and some Surgery conducted for the excision of an inverting
of the soft-tissue abnormalities created by the dif­ papilloma or a malignancy demands accurate follow
ferent surgical approaches are discussed in this up. These patients should have CT or MR scans at
chapter so that the incorrect interpretation of surgi­ 3-6 month intervals; the scans are compared to the
cal bony defects as bone erosion can be avoided. initial baseline postoperative scan. This process will
Comparison with the preoperative scans will also identify those changes that represent recurrent
help eliminate this potential source of error. It is disease. Following the administration of intravenous
important for the radiologist to understand the contrast, inflammatory tissue can usually be dif­
reasons why the surgeon will on occasion request ferentiated from scar tissue or mucocele, although
postoperative computed tomography (CT). A post­ this is not infallible, and adequate clinical informa­
operative CT is usually done 6-8 weeks after tion must be provided to help in the interpretation of
surgery in those problem cases where there is a the postoperative CT and MR scans.
persistence of symptoms. These may include the The second role of computed tomography is in the
identification of the reason for an unsuccessful preoperative assessment of patients requiring
procedure, such as missed disease, of scarring of revision sinus surgery. The images will enable the
the areas critical for ventilation and drainage or identification of the extent of the previous surgery,
simply of recurrent disease which may require any anatomic changes that may have occurred as a
revision surgery. In addition, it is important for the consequence of the procedure and the sites of resid­
surgeon to be aware of potential danger areas, for ual disease. Postoperative changes include scarring,
example, a previously unrecognized breech of the fibrosis, synechia and bony sclerosis. The sclerotic
lamina papyracea or of the cribriform plate. changes are usually at the expense of the interior of
Plain radiographs are inadequate for the assess­ the sinus, resulting in a small sinus cavity with
ment of a patient with recurrent paranasal sinusitis dense, thickened walls (Figures 10.14, 10.15 and
following surgery because, in these cases, recurrent 10.23).
disease and postoperative fibrosis will appear simply Surgery may fail to eradicate benign inflammatory
to be increased opacification. It is well documented disease of the paranasal sinuses for a variety of
that CT and magnetic resonance imaging (MR) are reasons. In our experience, the commonest cause
the two most reliable methods for the assessment of of failure is incomplete marsupialization of the
paranasal sinus disease. CT has two important roles ethmoid air cells, especially those of the anterior
in the management of those patients who have ethmoid or agger nasi. This is especially common
undergone previous sinus surgery. The first is to following intranasal ethmoidectomy, and the residual
indicate where residual or recurrent disease is bony septa are seen with soft-tissue abnormalities.
located if the patient either remains symptomatic or These residual bony septa are best demonstrated on
develops a recurrence of symptoms. Clinical evalu­ CT (Figures 10.17 and 10.18). Atopic individuals are
ation alone is inadequate to assess the site off more prone to recurrent disease with hyperplastic
failure, and accurate radiological assessment rhinosinusitis. Occasionally, recurrent maxillary sinus
increases the chances of identifying and subse­ disease will occur despite the absence of disease in
quently eradicating the disease. When recurrence of the ostiomeatal complex or nasal cavity. This is dif-
 The postoperative appearances of the paranasal sinuses 123

ficult to explain but may be related to disordered Indications

ciliary motility.
Chronic maxillary sinusitis, removal of dental roots,
In this chapter, we give brief descriptions of the
excision of antrochoanal polyps, tumors, mucoceles,
indications, surgical technique and related radio­ odontogenic or denteriginous cysts and repair of
graphic features of the more frequently performed
oroantral fistulae. To access the orbital floor for
sinus procedures, followed by a discussion of the
decompression surgery, for elevation of the orbital
radiologic appearances of complications of surgery.
floor for the reduction of fractures and for access to
the pterygopalatine fossa either for ligation of the
internal maxillary artery for uncontrolled epistaxis or
for a pterygoid (vidian) neurectomy in patients with
intractable vasomotor rhinitis.
INFERIOR MEATAL ANTROSTOMY
In inferior meatal antrostomy, also called an inferior
antral window, drainage is facilitated through an Technique
opening in the dependent part of the maxillary sinus.
This procedure has fallen out of favor as the A sublabial approach is made through the anterior
mucociliary beat mechanism is always directed wall of the maxillary sinus via the canine fossa. This
toward the natural ostium of the maxillary sinus. is situated superolateral to the root of the upper
canine teeth and inferior to the infraorbital nerve; it
provides wide exposure and access to the maxillary
sinus. The sublabial antrostomy is sometimes
Indication referred to as a radical antrostomy. If the indication
Chronic maxillary sinusitis and biopsy of soft-tissue for the surgery is chronic sinusitis or an antrochoanal
masses within the maxillary antrum. polyp, the mucosa is then stripped from the entire
antrum. If the indication for the procedure is to
provide access to the pterygopalatine fossa the
mucosa is left intact. An inferior meatal antrostomy is
Technique fashioned as described previously to facilitate
The inferior turbinate is retracted medially. The lateral drainage and to allow inspection of the antrum. It
wall of the inferior meatus is perforated and, if neces­ should be of sufficient proportion to prevent stenosis.
sary, the surrounding bone is excised. The antros­
tomy is extended down to the floor of the nasal cavity
and anteroposteriorly to a diameter of 1.5-2.0 cm.
Radiologic features
Some surgeons resect all or part of the inferior
turbinate to facilitate antroscopy at a later date. Both plain radiography and CT are valuable prior to
a Caldwell-Luc procedure (Figures 10.3 and 10.4).
If plain radiography fails to demonstrate a normal
volume maxillary sinus, CT will be necessary to
Radiologic features
exclude a hypoplastic maxillary sinus, which may be
The bony defect is evident in the inferior meatus. a contraindication to the surgery. A septated maxil­
With time, this may stenose, with either bony or lary sinus may also be missed, leading to incomplete
mucosal regeneration (Figures 10.1-10.3). If the surgical drainage of both compartments. A Caldwell­
patient continues to be symptomatic following this Luc procedure through a hypoplastic sinus could
conventional procedure, then obstruction to the result in dangerous complications such as perfora­
ostiomeatal complex is probably present. tion of the floor of the orbit and intraorbital soft tissue
injury.
Clinical and radiographic improvement occurs in
about 68% of patients undergoing this form of sinus
surgery. However, one should avoid routine post­
CALDWELL-LUC PROCEDURE operative radiographic examinations in the first 6-8
weeks, as the presence of blood and edematous
This is one of the oldest surgical procedures used tissue may appear radiologically similar to disease.
to treat chronic maxillary sinusitis. It is common to find an air-fluid level in the first few
124 An atlas of imaging of the paranasal sinuses

weeks following surgery and this may be misinter­ opacity of the antrum when previously it had been
preted as acute maxillary sinusitis. In assessing the noted to be partially or wholly aerated, or an air-fluid
postoperative images, the radiologist needs to diHer­ \eve\ are both positive findings. Complications tallow­
entiate between those changes that have occurred ing a Caldwell-Luc procedure are uncommon,
as a consequence of the surgical procedure and although osteomyelitis and osteoma formation have
those abnormalities that may reflect continuing or been reported. The immediate complications could
recurrent disease. The clinical history is of great be injury to the floor of the orbit, the optic nerve or
importance as some patients will still exhibit radio­ the globe (Figures 10.33-10.36).
logic evidence of disease but may in fact be asymp­ A more frequent late complication is that of
tomatic. Excessive soft-tissue proliferation in the mucocele formation that may occur many years
sinonasal cavity could be polyps, loculated fluid or following surgery. Mucocele formation is radiologi­
scarring, and without clinical information it can be cally associated with a homogenous opacification of
misdiagnosed as tumor, especially if bony septa the maxillary sinus, erosion of the bony margins of
have been surgically removed. the antrum and, occasionally dehiscence of the
Normal aeration of the maxillary sinuses occurs in antral walls. There are two types of mucocele:
approximately 20% of maxillary antra postoperatively primary and secondary. Primary mucoceles are the
and certainly the antrum may be partially aerated in most common, and occur following the obstruction
a much greater proportion. Certain chronic changes of the sinus ostium and occupy the whole sinus
have been noted to occur in the maxillary sinus cavity. Secondary mucoceles are usually laterally
following surgery. These are, in order of decreasing placed with an aerated antrum medially.
frequency, fibro-osseous proliferation, antral contrac­
tion and compartmentalization (Figures 10.4 and
10.14).
Fibro-osseous proliferation is thought to be .
secondary to both the resorption of blood and ETHMOIDECTOMY
epithelium as well as the degree of re-epithelial­
ization. New bone formation has also been noted in The surgical approaches to the ethmoid sinuses are
this area following trauma, although the mechanism many and varied. A brief description of the more
of this bony proliferation is unclear and the process commonly performed procedures follows. The radio­
uncommon. Fibro-osseous proliferation will be logic features are similar in each case, with varia­
shown by opacification of the maxillary antrum on tions in the bony defects dependent on the approach
plain radiographs, but only CT is able to accurately used. The radiographic features are summarized
differentiate between bone and soft tissue (Figures together.
10.14 and 10.18).
The second abnormality noted is antral contrac­
tion. This may be associated with depression of the
orbital floor, lateralization of the lateral nasal wall
with consequent enlargement of the ipsilateral nasal
Transnasal ethmoidectomy
cavity and is accompanied by fibro-osseous prolifer­
ation (Figure 10.5).
Transnasal ethmoidectomy
The third, and most uncommon, abnormality is
Indication
compartmentalization. This is considered to be due
to an altered tissue response during the healing Multiple ethmoidal polyps.
process (Figure 10.4).
Bony irregularities resulting from the inferior
meatal antrostomy and the sublabial antrostomy
Technique
may be seen. The sublabial antrostomy usually
closes with fibrous tissue or new bone formation, Traditionally this procedure is carried out with the
although it may persist in rare cases as an oroantral operative field being viewed directly through a
fistula. speculum. The middle turbinate is retracted medially,
Recurrent disease in the maxillary antrum follow­ thereby exposing the uncinate process and the
ing a Caldwell-Luc procedure may be difficult to ethmoid bulla. The bulla is opened and removed,
identify radiologically, especially in the presence of allowing further dissection of the ethmoid labyrinth
fibrosis of the antrum (Figures 10.3 and 10.4). Total and excision of diseased mucosa. This is easier
 The postoperative appearances of the paranasal sinuses 125

posteriorly, and the posterior ethmoid air cells and then divided and the lamina papyracea is perforated,
the sphenoid may be exposed. It is difficult to open thereby opening the ethmoid air cells. The bony
the anterior or agger nasi cells by this approach leaflets dividing the air cells are- excised and the
(Figure 10.6). middle turbinate then visualized. Access may be
Intranasal ethmoidectomy is more controlled if gained as far posteriorly as the sphenoid sinus.
conducted endoscopically; this will be discussed
later.

Transorbital ethmoidectomy
Transantral ethmoidectomy
Indications
Indications Orbital decompression, orbital trauma.
Chronic maxillary and ethmoid sinusitis, orbital
decompression.
Technique
This technique was described by Patterson. The
Technique incision is placed 1 cm below the infraorbital margin.
This procedure was described by Jansen and The orbicularis oculi muscle is divided by the peri­
Horgan and combines a Caldwell-Luc procedure osteum. The periosteum is then elevated off the floor
with partial clearance of the ethmoid labyrinth. The of the orbit and the lacrimal fossa, taking care not
Caldwell-Luc sublabial antrostomy is conducted as to damage the origin of the inferior oblique muscle
previously described. Forceps are then directed or the nasolacrimal duct. The lamina papyracea is
upwards and medially through the ethmomaxillary removed superiorly to t.he level of the frontoethmoid
plate located in the superomedial angle of the maxil­ suture, and the floor of the orbit is removed as far
lary sinus, being angled towards the contralateral laterally as the infraorbital canal. The frontal and
parietal eminence. This opening into the posterior sphenoid sinuses may be entered using this
ethmoid air cells is then enlarged and the accessible approach.
cells cleared (Figure 10.7). It is not possible to
adequately clear the anterior cells using this proce­
dure.
Functional endoscopic sinus
surgery
External ethmoidectomy Current thinking has focused surgery on the ventila­
Indications tion and drainage channels that serve the larger
paranasal sinuses, especially the frontal and the
Chronic ethmoid sinusitis, recurrent inflammatory maxillary sinuses. The removal of disease from the
nasal polyps, approach to the pituitary fossa. fine clefts of the ethmoid complex into which these
channels connect allows normal ventilation of the
paranasal sinuses and the reversal of mucosa!
Technique disease within the larger sinuses to return to normal.
The degree to which the middle meatus can be
This operation was first described by Ferris Smith in examined has increased dramatically with the
1933. A temporary tarsorrhaphy is performed to advent of CT and rigid endoscopy. It is now pos­
protect the cornea. A curved incision is then made sible to accurately identify the sites of mucosa!
in the nasofacial fold onto the nasal bones, and the disease and anatomic variations that impede the
periosteum and lacrimal sac elevated. The orbital ventilation and drainage channels, and to resect
periosteum is then elevated to expose the anterior these areas using a focused and precisely target­
ethmoid artery and the contents of the orbit are ted minimally invasive surgical approach (Figures
retracted laterally. The anterior ethmoid artery is 10.8 and 10.9).
126 An atlas of imaging of the paranasal sinuses

Indications The ideal result is a single well-aerated cavity. In

the first 6 weeks following surgery there will be some
Chronic sinusitis, recurrent inflammatory nasal
opacification of the aerated cavity as a consequence
polyposis, frontal and maxillary sinus mucoceles,
of residual blood clot and edema of the remaining
biopsy decompression of a subperiosteal abscess.
soft tissue. At a later stage, persistent opacification
may represent scarring. This is usually of the same
density as muscle and fails to enhance, unlike
Technique inflamed mucosa. Scar tissue can appear as thin
strands of tissue filling the sinus lumen, as a solid
Following adequate vasoconstriction an incision is
mass or with a more nodular appearance.
made in the lateral wall of the nose, parallel to the
The lamina papyracea should remain intact,
free margin of the uncinate process. This bony
although it may have been breached during the surgi­
leaflet is then elevated and excised, exposing the
cal procedure (Figure 10.20). This may lead to
ethmoid bulla and the depths of the ethmoid
prolapse of the orbital fat into the ethmoid cavity,
infundibulum. It should now be possible to visualize
which may be tempting to avulse at revision surgery
the natural ostium of the maxillary sinus and that of
if not recognized as fat on CT (Figure 10.21). After
the frontal recess. Further mucosa! disease may
some time, the medial wall of the orbit may collapse
then be removed under direct vision, to ensure both
medially, reducing the lumen of the surgical defect
passages are of adequate calibre. If indicated, the
and reversing the usual convexity of the intact lamina
posterior ethmoid air cells may be opened by
papyracea. The postoperative appearance may be
penetrating the ground lamina of the middle
mimicked by an orbital blow-out fracture or by hyper­
turbinate. Dissection through these air cells leads to
trophy of the extraocular muscles associated with
the sphenoid sinus, where again disease can be
hyperthyroidism. In the latter situation, the patient
removed under direct vision.
may have undergone orbital decompression; if so,
the medial portion of the orbital floor will be absent.
Following surgery, the lamina papyracea, medial
orbital wall, the roof of the ethmoid and any remain­
Radiographic findings after ing bony septae will frequently be noted to be denser
ethmoidectomy and sclerotic (Figures 10.12 and 10.22). This is
usually secondary to reactive osteitis which on
Postoperatively, the ethmoid sinus is best visualized occasions may be extensive enough to obliterate the
using CT with a wide-window setting, to allow surgical defect.
adequate visualization of any remaining bony septa The posterior ethmoid air cells are renowned for
as well as the interface between soft tissue, bone being a difficult and hazardous area for the surgeon
and air. The bony leaflets separating the ethmoid air to operate in, and it is possible for untouched air
cells are usually absent posterior to the ethmoid cells to contain residual disease despite the
infundibulum (Figures 10.10. and 10.11). The middle surgeon's report that all of the posterior air cells
turbinate may have been partially or completely have been exenterated (Figure 10.18). Overzealous
resected. This deficit may extend back to the surgery in this area may lead to injury to surround­
sphenoid sinus if such extensive surgery was ing vital anatomic structures, such as the optic
performed. The middle turbinate may have been nerve, the eyeball or even the internal carotid artery.
resected to provide access to the more posterior air Following a transantral ethmoidectomy the post­
cells and sometimes may be the only certain indica­ operative radiologic features will include deficits of
tor that the patient has had an intranasal ethmoi­ both the anterior and medial antral walls as well as the
dectomy, especially if inadequate clinical details loss of a variable number of fine, bony leaflets separat­
have been provided by the surgeon (Figures ing tl,t� ethmoid air cells. The lamina papyracea should
10.12-10.16). Ideally, a remnant of the vertical plate be intact unless the indication for surgery was to
of the middle turbinate should remain as a landmark perform orbital decompression (Figure 10.9).
indicating the site of the cribriform plate should Following external ethmoidectomy a portion of the
revision surgery be needed (Figures 10.17 and lamina papyracea will be noted to be absent on the
10.18). In some instances, partially resected middle CTs. The surgical defect is usually sharply demar­
turbinates may cause synechia or collapse against cated, thereby differentiating it from the more
the lateral nasal wall, producing obstruction to the gradual reduction of bone thickness resulting from
ostiomeatal unit (Figure 10.19). an erosive process.
 The postoperative appearances of the paranasal sinuses 127

Following a transorbital ethmoidectomy for orbital acute sinusitis. To provide access for transethmoidal
decompression, the lamina papyracea should be hypophysectomy, dacrocystorhinostomy, and orbital
deficient below the frontoethmoid suture line, as decompression.
should the medial half of the orbital floor. The orbital
fat should prolapse into the defect.
Following endoscopic sinus surgery the bony
Technique
defects are usually confined to those sinus pre­
chambers that were noted to be obstructed during the This procedure was described by both Lynch and
initial investigations. The entire ethmoid sinus area is Howarth. A temporary tarsorrhaphy is performed to
replaced by a single large space after removal of the protect the cornea. An incision is placed curving
intervening septa. This often involves resection of the from below the medial margin of the eyebrow to
uncinate process, the ethmoid bulla and the creation pass midway between the medial canthus and the
of a wide middle meatal antrostomy. Some patients bridge of the nose. The procedure is similar to that
may have undergone more radical surgery previously of an external ethmoidectomy, except that it is
and bony defects related to these procedures will extended to include resection of the floor of the
remain evident (Figures 10.9-10.11 and 10.23). frontal sinus and the middle turbinate. A silastic tube
is often placed in the widened frontonasal duct to
prevent stenosis and will remain in place for up to 3
months.
FRONTAL SINUS TREPHINATION
Indication Radiographic findings
Acute frontal sinusitis. The radiographic features are similar to those of the
external ethmoidectomy with the additional widening
of the frontal recess and excision of the floor of the
Technique frontal sinus.

A short incision (1 cm) is made below the medial end

of the eyebrow. The floor of the frontal sinus is perfo­
rated either with a drill or a hammer and gouge. The
opening is enlarged sufficiently to allow drainage of OSTEOPLASTIC FLAP WITH
the purulent secretions and to allow the insertion of
an indwelling catheter for frequent irrigation of the
OBLITERATION OF FRONTAL
sinus. The latter remains in place until the fluid used SINUS
for irrigation passes through the frontal recess into
the nose. Indications
Chronic frontal sinusitis, exc1s1on of osteomata,
excision of mucocele and repair of trauma.
Radiographic findings
The radiographic features should reflect a resolving
sinusitis with a small bony defect in the medial part Technique
of the floor of the frontal sinus (Figure 10.24). A template of the frontal sinus is cut from a plain
radiograph. A bicoronal flap is then elevated and the
outline of the frontal sinus is marked onto the frontal
bone. The bone of the anterior wall of the frontal sinus
EXTERNAL is then divided obliquely with a fissure burr and the
intersinus septum divided with a chisel. The bony flap
FRONTOETHMOIDECTOMY is then hinged forward on an intact inferiorly based
pedicle of periosteum. Meticulous excision of all
Indications
diseased tissue is essential and the sinus is obliter­
Chronic frontoethmoid sinusitis, recurrent nasal ated with a free fat graft harvested from the anterior
polyposis, frontoethmoid mucoceles, complicated abdominal wall. The osteoplastic flap is then replaced.
128 An atlas of imaging of the paranasal sinuses

Radiographic findings maxillary antrum; (ii) the anterior wall of the maxil­
lary antrum is divided below the inferomedial angle;
Images of the frontal sinus following surgery will
(iii) the nasal bone is divided up to the level of the
appear opaque. The outline of the sinus is often
frontonasal suture line, demarcating the level of the
visible where the bone has been divided (Figure
cribriform plate; (iv) the ethmoid arteries are ligated
10.25). In these patients, it can often be extremely
and the frontoethmoid suture line is divided to the
difficult, because of the opacity, to distinguish
posterior ethmoid artery, (the limit of safety to avoid
changes that may occur as a consequence of recur­
damage to the optic nerve); (v) the orbital rim is
rent disease. There are a variety of different but
divided with the lamina papyracea and the lateral
normal CT appearances that represent different
wall removed in one piece. The amount of maxilla
stages of fibrosis of the obliterating fat graft. The
resected can be tailored depending on the pathology
bone flap should be examined with wide-window
and the extent of the disease.
settings. This will also demonstrate the air-free frontal
sinus. The sinus may appear to be air filled if it is
only examired with narrow window settings. Ideally,
the bone flap should have smooth edges and be Radiographic findings
aligned with the surrounding bone. With narrow­
The radiographic deficit includes the absence of the
window examinations the fat should demonstrate a
medial wall of the orbit extending from the infraor­
streaky appearance. This represents fibrosis in the
bital canal to the frontoethmoidal suture line. A large
graft. Complications include osteomyelitis of the bone
nasoantral cavity is formed after the removal of the
flap, infection of the fat graft and mucocele formation.
entire lateral wall of the nose including the middle
If the patient presents with recurrent symptoms, care
and inferior turbinates (Figure 10.6).
must be taken to exclude inflammatory disease in the
other paranasal sinuses. If a bony complication has
developed, CT is of greater value than MR in demon­
strating the lesion. The bone flap may be seen to be
elevated or rotated, and there may be bone erosion MAXILLECTOMY
or sequestrum formation. If the fat graft becomes
infected it appears of a similar density to soft tissue Indication
rather than fat. This may become localized. If
Malignancy involving the maxillary antrum.
intracranial or intraorbital complications occur, they
may be better visualized by MR.

Techniques
The incision used is similar to that used for the
lateral rhinotomy, but it is extended along the margin
LATERAL RHINOTOMY of the lower lid, if the globe is being preserved, or
along the margin of both eyelids, if the orbit is to be
Indications
exenterated. The hard palate is divided in the
Excision of inverted papilloma and other localized midline, the orbital floor is then dissected free
tumors such as malignant melanoma. depending on the extent of the disease, the zygoma
is divided, the lateral wall of the nose is divided
below the frontoethmoid suture line, and finally the
pterygoid plates are separated from the posterior
Technique
aspect of the maxilla.
This procedure was first described in 1902 by
Moure. The incision extends from the midpoint
between the medial canthus and the bridge of the
Radiographic findings
nose, along the natural skin crease of the nasojugal
fold, around the alae of the nostrils and into the The postoperative appearance will depend on the
philtrum. The bony wall is exposed from the infra­ extent of the surgery, that is either a partial or total
orbital canal to the frontoethmoid suture line. The maxillectomy. If the maxilla is removed in its entirety
lateral wall of the nose is excised en bloc by the pterygoid plates usually remain and may be
incisions (i) along the floor of the nose, opening the identified on the images. Usually there is a clearly
 The postoperative appearances of the paranasal sinuses 129

defined cavity which is sharply demarcated. during a postoperative scan, as can be seen in
Recurrent disease is indicated by the development Figure 10.26. Some surgeons prefer to use ribbon
of a soft-tissue mass or further bony erosion. gauze that has been impregnated with bismuth
iodoform paraffin paste (SIPP). The heavy metal,
bismuth, will cause widespread artifact if left in place
during a postoperative scan. Even following its
removal, small deposits of the bismuth paste will
RADIOLOGIC APPEARANCES OF remain as small dense areas (Figure 10.27). Other
COMPLICATIONS FOLLOWING OF later local complications include synechiae
(adhesions) (Figure 10.28), collapse of the lateral
SURGERY wall of the nose (Figure 10.29) and lateralization of
the middle turbinate causing obstruction of the
A knowledge of the neighboring structures of the frontal recess (Figure 10.19). The late complications
paranasal sinuses, already described in detail, include mucocele formation as a result of compart­
makes it understandable that there will be a certain mentalization and obstruction to drainage (Figure
morbidity from surgical injury to these structures. 10.30).
The task of the surgeon is further complicated by Orbital complications include blindness and
misleading variations in the anatomy and pneumati­ diplopia following injury to the optic nerve, the
zation or by anatomic landmarks that may be extraocular muscles or the orbital fat. The common­
disguised by disease. Serious complications are rare est cause of blindness is a retrobulbar hematoma,
but may occur even at the hands of the most experi­ causing exophthalmos and stretching of the optic
enced and well-trained surgeons. The prompt recog­ nerve. Rapid decompression of the hematoma may
nition of a complication and its appropriate preserve optic function. Bilateral blindness has been
management should allow the optimum conditions reported following bilateral retrobulbar hematoma
for recovery. and also following bilateral optic nerve section. The
The complications of sinus surgery can be classi­ optic nerve is particularly at risk if there is a large
fied into minor and major complications. The minor Onodi's cell extending laterally around the nerve
complication include postoperative bleeding, (Figure 10.31). Hematoma will become evident on
hematoma, orbital emphysema, and scarring with CT following the administration of intravenous
obstruction of the ventilation and drainage pathways. contrast. Optic nerve section becomes apparent on
The major complications include ocular or optic visualizing the injured segment of the nerve.
nerve injury, cerebrospinal fluid rhinorrhea, injury to The lamina papyracea may be injured during
the lacrimal apparatus, internal carotid artery injury intranasal ethmoidectomy. This may occur when the
and anosmia. Rare complications are brain injury, uncinate process is resected to facilitate middle
intracranial infection, brain abscess and meningitis. meatal antrostomy. Portions of the lamina papyracea
Complications most commonly occur following may be inadvertently avulsed with nasal polyps
intranasal polypectomy, intranasal ethmoidectomy allowing the orbital fat to prolapse into the nasal
and sphenoidectomy. The risks are greater if there cavity (Figures 10.30 and 10.32). Subperiosteal
has been prior surgery and some of the usual hematoma may occur in the operative area. This
landmarks may have been removed. The complica­ becomes evident with periorbital ecchymosis and
tions will be discussed in relation to the nasal cavity, exophthalmos. CTs will demonstrate an enhancing
the orbit and optic nerve, the anterior cranial fossa lesion running alongside the medial orbital wall
and the sphenoid sinus relations - the internal (Figure 10.20). The orbit may also be accidentally
carotid artery and the cavernous sinus. injured during a transantral ethmoidectomy. The
orbital floor may be breached if mistaken for the
ethmomaxillary plate (Figures 10.33-10.35).

Nasal cavity complications

A common and expected problem following
intranasal procedures is haemorrhage. This is Anterior cranial fossa injury
usually controlled with an intranasal pack which may
be left in place for up to 48 hours. Plain gauze packs To avoid injury to the anterior cranial fossa, particu­
have a characteristic appearance if left in place lar care is needed in dissecting medial to the vertical
130 An atlas of imaging of the paranasal sinuses

plate of the middle turbinate. This bony attachment Sphenoid sinus, cavernous sinus
is on the border of the cribriform plate, and careless
dissection or avulsion of the middle turbinate may
and carotid artery injury
lead to a cerebrospinal fluid leak and the risk of
meningitis (Figure 10.36). If such an accident occurs Careful assessment of the anatomy of the sphenoid
and is recognized intraoperatively then the defect sinus and its vascular relations should help to
should be repaired immediately. If the defect is prevent massive intraoperative hemorrhage. CT has
recognized later, the intervention of a neurosurgeon a greater role in the prevention of such catastrophes
may be required. The ethmoid fovea which roofs the than in their immediate diagnosis and management.
ethmoid air cells, is thicker then the cribriform plate The position of the internal carotid artery can be
but it is still vulnerable to injury. Care must be taken identified and any bony dehiscences will be noted
in operating anywhere near the roof of the anterior prior to commencing surgery. When the surgeon
ethmoid (the floor of the anterior cranial fossa), and plans to enter the sphenoid sinus, both coronal and
rocking of the perpendicular plate of the ethmoid axial CTs should be obtained. Axial CTs are superior
during its removal in a septoplasty should also be for showing the relationship of the optic nerve to the
avoided. The site of bony defects becomes evident posterior ethmoid and sphenoid sinuses, as well as
on coronal CTs, allowing accurate targetting of the relationship of the carotid artery to the sphenoid
repair, should this be necessary. sinus.
 The postoperative appearances of the paranasal sinuses 131

10.1 10.2

10.3 10.4

Figure 10.1 Figure 10.2

Intranasal antrostomy. This coronal CT scan demonstrates Bilateral intranasal antrostomies. This coronal CT scan
bilateral intranasal antrostomies with large hypertrophied inferior demonstrates wide bilateral intranasal antrostomies (curved
turbinates (IT), occluding the antrostomy sites (arrows). Note on arrows). The antrostomy on the left is widely patent, whereas
the right side how the medial antral wall has been resected to the antrostomy on the right is totally blocked by a grossly
the level of the floor of the nasal cavity, whereas on the left a enlarged inferior turbinate (IT). There is mucosa! disease in
considerable amount of the medial wall remains. both maxillary sinuses. Failure of this procedure is due to the
inflammatory disease obstruction the ostiomeatal complex.

Figure 10.3 Figure 10.4

Residual disease following Caldwell-Luc procedures. This Bilateral Caldwell-Luc procedures (open arrows): CT scan.
patient presented with persistent left malar pain and nasal Although this patient has patent ostiomeatal complex bilaterally
obstruction despite bilateral Caldwell-Luc procedures. This (arrows), scarring and compartmentalization have resulted in
coronal CT scan demonstrates a large polyp in the left middle persistent symptoms of pain and sinus infection.
meatus (P) blocking the ostiomeatal complex. Excision of the
polyp and reopening of the natural ostium of the maxillary sinus
led to resolution of the patient's symptoms. Note the dehiscent
bone in the area of the sublabial antrostomy on the left (arrow).
The mucosa! thickening in the right maxillary sinus is consistent
with chronic sinusitis. Note the blocked infundibulum on this
side (curved arrow).
132 An atlas of imaging of the paranasal sinuses

10.5 10.6

10.7 10.8

Figure 10.5 Figure 10.6

Postoperative hypoplasia of the maxillary sinus: CT scan. There Intranasal ethmoidectomy with exenteration of the lateral nasal
is thickening of the bony walls and the mucous membranes at wall. This coronal CT scan demonstrates the defect following
the expense of the sinus lumen. resection of the lateral nasal wall and intranasal
ethmoidectomy. The resulting surgical defect allows the entire
maxillary sinus to open into the empty and capacious nasal
cavity.

Figure 10.7 Figure 10.8

Transantral ethmoidectomy. This coronal CT scan demonstrates Functional endoscopic ethmoidectomy. Preoperative scan. This
a clean ethmoid cavity following a right transantral coronal CT scan demonstrates bilateral pansinusitis. Both
ethmoidectomy. There is minimal residual mucosal thickening ostiomeatal complexes are blocked (curved arrows), and
within the maxillary sinus which is probably of no clinical secondary infection has occurred in the maxillary sinuses.
significance. The defect in the anterior wall (arrow) represents
the sublabial antrostomy. The middle turbinate has been
removed. A remnant of the inferior turbinate (IT) appears to be
'floating' in an otherwise large and empty, aerated cavity.
 The postoperative appearances of the paranasal sinuses 133

10.9 10.10

10.11 10.12

Figure 10.9 Figure 10.10

Functional endoscopic ethmoidectomy. Postoperative scan of Postoperative scans following intranasal ethmoidectomy. This
the same patient as in Figure 10.8. This coronal CT scan coronal CT scan taken following functional endoscopic sinus
shows the surgical defect following a left functional endoscopic surgery shows that a complete bilateral anterior ethmoidectomy
ethmoidectomy. The uncinate process has been resected and has been performed. The ostiomeatal complexes are patent
the natural ostium of the maxillary sinus enlarged (curved (arrows). The uncinate process has been completely removed
arrow). Note how the secondary infection within the maxillary on the right and partially resected on the left.
sinus has resolved following the restoration of ventilation and
drainage.

Figure 10.11 Figure 10.12

Postoperative scan following intranasal ethmoidectomy. In this Complete Mltranasal ethmoidectomy with residual disease: CT
CT scan which is more posterior than Figure 10.10, the right scan. This patient, with recurrent nasal polyps, has had bilateral
basal lamella has been perforated (open arrow), ventilating the intranasal ethmoidectomies, bilateral intranasal antrostomies, a
posterior ethmoid air cells with good result. There is no right Caldwell-Luc procedure and resection of both middle
evidence of recurrent disease. Note the bilateral intranasal turbinates. There is recurrent inflammatory disease in the
antrostomies. anterior ethmoid along the roof of the nasal cavity (black
arrows). Note the inflammatory tissue blocking the natural
ostium of the left maxillary sinus (white arrow) and the mucosa!
disease within the sinus proper.
134 An atlas of imaging of the paranasal sinuses

10.13 10.14

10.15 10.16

Figure 10.13 Figure 10.14

Resection of the middle turbinate: CT scan. This patient has Bilateral incomplete ethmoidectomy with residual disease. This
had an incomplete left intranasal ethmoidectomy (arrow), with coronal CT scan demonstrates that the left middle turbinate has
resection of the vertical plate of the middle turbinate. Note the been resected, and the right middle turbinate has been partially
blocked left ostiomeatal complex. resected. An incomplete ethmoidectomy has been performed.
Note the inverted uncinate process (arrow). Also note the
fibrous and osseous proliferation in the left maxillary sinus.

Figure 10.15 Figure 10.16

Bilateral incomplete ethmoidectomy with residual disease. This Recurrent nasal polyps. This patient with the ASA triad had
coronal CT scan, taken posterior to Figure 10.14, demonstrates undergone multiple intranasal polypectomies. The soft-tissue
that the middle turbinate on the left has been resected. Note mass filling the upper half of each nasal cavity represents
the bilateral posterior ethmoid disease and the intact posterior recurrent polyps. In these patients, the CT scan is primarily of
portion of the middle turbinate (MT) on the right. There is use to the surgeon in identifying any remaining bony structures,
marked sclerosis of the lateral wall of the left maxillary sinus and in demonstrating any potential danger areas such as
(arrows). dehiscences of the orbital wall.
 The postoperative appearances of the paranasal sinuses 135

L
10.17 10.18

10.19 10.20

Figure 10.17 Figure 10.18

Incomplete ethmoidectomy with recurrent polyps: CT scan. This Bilateral incomplete ethmoidectomy with recurrent polyps. This
patient has undergone a complete right intranasal is a more posterior CT scan of the patient shown in Figure
ethmoidectomy with excision of the right middle turbinate 10.17. The posterior ethmoidectomies are incomplete
(arrowhead). The left ethmoidectomy is incomplete and there is (arrowheads). Bilateral patent intranasal antrostomies are
residual polypoid disease in the anterior ethmoid (black arrow). present (arrows). The air bubbles within the 'soft-tissue' mass in
the roof of the left maxillary sinus identifies this mass as thick
mucus (open arrow).

Figure 10.19 Figure 10.20

Lateralized middle turbinate. This coronal CT scan Breach of the lamina papyracea and subperiosteal intraorbital
demonstrates lateralization of the right middle turbinate (arrow) hemorrhage. This axial CT scan demonstrates a small
which occurred following surgery. Fracture of the vertical subperiosteal hematoma that followed breach of the lamina
insertion of the middle turbinate has resulted in its collapse with papyracea during intranasal ethmoidectomy (arrow). The radio­
obstruction and disease of the frontal recess (open arrow). opaque material in the nasal cavity is the remains of bismuth
iodoform paraffin paste from an intranasal pack that was placed
postoperatively.
136 An atlas of imaging of the paranasal sinuses

10.21 10.22

10.23 10.24

Figure 10.21 Figure 10.22

Defect of the lamina papyracea. This coronal CT scan Residual anterior ethmoid disease. This CT scan demonstrates
demonstrates orbital fat prolapsing through a defect in the left the defects in the lamina papyracea on the left side. Note the
lamina papyracea (arrow), following ethmoidectomy. recurrent polyps in the ethmoid cavity and sclerosis of the
lamina papyracea on the right side.

Figure 10.23 Figure 10.24

A large polyp (P} is seen in the ethmoid infundibulum. This Frontal sinus trephine. This anterior coronal CT scan
patient continued to be symptomatic despite previous sinus demonstrates a defect in the floor of the right frontal sinus
surgery (arrowheads). following a recent trephine (arrow). Both frontal sinuses are
opacified as the result of pansinusitis.
 The postoperative appearances of the paranasal sinuses 137

10.25 10.26

10.27 10.28

Figure 10.25 Figure 10.26

Osteoplastic flap. This coronal CT scan demonstrates the Gauze nasal pack. This CT scan demonstrates an area filled
surgical defect of the osteoplastic flap used for the excision of irregularly with air and soft tissue (arrow). This is a gauze pack
a frontal sinus mucocele. There are large surgical defects in the used to control epistaxis. It should not be mistaken for
roof of the frontal sinus (arrowheads). A small silastic tube is inflammatory disease. This patient has had a radical
seen displaced medially between the frontal recess and the ethmoidectomy in the past.
nasal septum (arrow).

Figure 10.27 Figure 10.28

Bismuth iodoform paraffin paste pack. This lateral CT view of Synechia. This coronal CT scan demonstrates that this patient
the skull shows radio-opague mass of a bismuth iodoform has had both intranasal antrostomies and intranasal
paraffin paste, intranasal pack which is placed in situ ethmoidectomies in the past. Synechia can be seen bridging
postoperatively to control hemorrhage. between the lateral nasal wall and the middle turbinates
(arrows).
138 An atlas of imaging of the paranasal sinuses

10.29 10.30

10.31 10.32

Figure 10.29 Figure 10.30

Fracture of the lateral nasal wall. This coronal CT scan Frontal sinus mucocele. This axial T1-weighted MR scan
demonstrates that the inferior turbinates have been resected demonstrates a hypointense mass in the left orbit. This was a
too close to the lateral nasal wall (arrow). The lateral nasal wall frontal sinus mucocele which developed as the result of an
has fractured and been displaced laterally, causing occlusion of unsuccessful obliterative procedure on the left frontal sinus.
the ostiomeatal complex and associated scarring and deformity
of the partially resected inferior turbinate and uncinate process
(UP).

Figure 10.31 Figure 10.32

Orbital emphysema. Immediately following endoscopic sinus lntraoperative orbital injury. This coronal CT scan shows the
surgery, the patient developed proptosis. The axial CT scans site at which the surgeon fractured through the floor of the orbit
demonstrate air in the orbit. (arrow). The higher density of the right orbital contents results
from intraorbital bleeding. Note the small bubble of air seen in
the superior aspect of the orbit.
 The postoperative appearances of the paranasal sinuses 139

10.33 10.34

10.35 10.36

Figure 10.33 Figure 10.34

lntraoperative orbital injury. This coronal CT scan (more lntraoperative orbital injury. This axial CT scan of the same
posterior than Figure 10.32), demonstrates the orbital patient as in Figures 10.32 and 10.33 also demonstrates orbital
emphysema more clearly in the superior aspect of the orbit emphysema (arrowheads). The optic nerve has been transected
(arrowhead). The effects of hemorrhage, causing higher density (white arrow) by a large displaced portion of the lateral wall of
of the right orbital contents, are more marked. the superior recess of the maxillary sinus (open arrow) through
which the orbit was entered. The normal left superior recess of
the maxillary sinus is shown (curved arrow). Note the
hemorrhage in the sphenoid sinus (S).

Figure 10.35 Figure 10.36

lntraoperative orbital injury. This axial CT scan of the same Fracture of the cribriform plate. This coronal CT scan was
patient as in Figure 10.32, clearly shows the difference between obtained following bilateral complete intranasal
the intact optic nerve on the left (ON), and the transected nerve ethmoidectomies. The cribriform plate has been avulsed at the
on the right. There is retro-orbital hemorrhage adjacent to a insertion of the left middle turbinate which was removed during
displaced bone fragment (arrow). the procedure (arrow). There is also a small defect in the left
lamina papyracea (arrowhead).
11
Basic principles of Magnetic Resonance
Imaging of the paranasal sinuses

Magnetic Resonance (MR) imaging is a complex coils transmit the pulses through the patient and the
process that involves magnets, radiofrequency coils smaller surface coils receive the MR signals that are
and a computer information processing system created following stimulation of the nuclei. These
similar to that used in computed tomography (CT). coils vary in size depending upon the part of the
This chapter provides a simplified introduction to the body being examined. Using an appropriately sized
basic physics and the technological aspects of MR. coil for the part being examined is important, and
close proximity to the small field of view chosen
prevents loss of the signals emitted from the excited
nuclei.
The human body is ideally suited for MR because
MAGNETS it has an abundant supply of hydrogen in the form
of water or fat. When these hydrogen nuclei are
Three types of magnets are used for MR: the main
placed in a strong magnetic field, they undergo a
magnet, the gradient coil and the shim coils.
'spin' or excitation. Not all nuclei 'spin' when placed
The main magnet consists of a superconducting
in a magnetic field. Those nuclei that have an odd
magnet, a resistive magnet or a permanent magnet.
number of protons or an odd number of neutrons
A permanent magnet is large, and the initial instal­
possess an angular momentum and so will spin.
lation is expensive; however, the maintenance costs
Among the naturally occurring elements that have an
of this type of magnet are low. In resistive or super­
odd number of protons or neutrons are hydrogen
conductive magnets the magnetic field is maintained
(one proton and no neutrons), sodium-23, carbon-13
by electric power or cryogens. These magnets are
and phosphorus-31. Hydrogen atoms are the most
made from a solenoidal material and the patient lies
abundant element in the human body, and thus
along the direction of the magnetic field. Super­
serve as the ideal ingredient for interaction with the
conductive electromagnets are cooled with both
applied external magnetic field. Rotational motion of
liquid helium and liquid nitrogen. This makes mainte­
the atom is essential; without it, a nucleus will not
nance expensive. However, with their high field
be able to precess (spin) when placed in an exter­
strengths and field homogeneity, superconductive
nal magnetic field.
magnets, are the best suited for clinical imaging.
When there is no external magnetic field, the
The gradient coil varies the magnetic field through
unpaired protons are randomly oriented and the net
x-, y- and z-axes in a systematic fashion so that
scans are possible in any plane and the signals magnetization is zero (Figure 11.1). When the nuclei
received can be spatially localized. are placed in a strong static external magnetic field,
slightly more than 50% of them align in the direction
The shim coils are resistive electromagnetic coils
of the applied external magnetic field, i.e. parallel
that make the magnetic field uniform by removing
(lower energy), and fewer protons assume the
any inhomogeneities in the magnetic field.
antiparallel (higher energy) direction. There is
constant interaction between the protons in the
higher energy, the protons in the lower energy, and
the adjacent macromolecules. This results in
RADIOFREQUENCY (RF) COILS 'equilibrium' - a net magnetization that is parallel to
the external magnetic field. The protons continue to
Radiofrequency coils transmit radiofrequency pulses spin around the axis of the external magnetic field.
through the patient to excite the nuclei. The larger This rate of precession is proportional to the exter-
 Basic principles of Magnetic Resonance Imaging of the paranasal sinuses 141

nal magnetic field. The net magnetization, i.e. longi­ reciever coil an electrical voltage proportional to the
tudinal magnetization, in the tissues cannot be strength of the transverse magnetization, constitu­
measured until it is tipped into transverse direction. ting an MR signal. The MR signal is made of variable
'Equilibrium' in the tissue is disturbed by the appli­ signal intensities, and an MR image is formed by
cation of a radiofrequency pulse of a certain ampli­ these complex signals.
tude and strength, i.e. the Larmor frequency, the
frequency at which magnetic reasonance in a
nucleus can be excited and detected. The Larmor
Frequency determines the frequency to which the
receiver coils should be tuned to receive the MR T1 RELAXATION TIME
signal from the patient.
MR image production and contrast are dependent The longitudinal magnetization recovery, i.e. the T1
on several factors. Some of these factors character­ relaxation time, is due to the transfer of energy to
ize the tissue being examined (T1, T2 and proton the surrounding tissues from the precessing nuclei.
density, which is the density of the proton spins) and This is also referred to as 'spin-lattice relaxation'.
contribute to tissue contrast. These parameters are Following excitation by a go· RF pulse, the precess­
unique to the tissue being examined and can only ing or the excited nucleus tries to gain 'equilibrium',
be altered by the use of paramagnetic agents. Most to realign with the static magnetic field. In liquids,
of these paramagnetic agents exert their effects by hydrogen protons move very easily so there are
reducing the proton relaxation time or by altering the fewer protons that fall in and out of the Larmor
proton density. The other parameters that can be frequency. The longitudinal magnetization recovery
altered to affect signal intensity include repetition is also slow for liquids, so the T1 relaxation time is
time (TR), echo time (TE), flip angle, field of view, long for liquids and they are dark on T1-weighted
matrix size and slice thickness. Some of these images. In solids, mor� protons precess at Larmor
parameters will be discussed later in this chapter to frequency, because the protons are not free to move
better explain MR. easily. A tissue with a short T1 relaxation time, such
In summary, three types of electromagnetic fields as fat, rapidly recovers longitudinal magnetization
are necessary for MR: and is bright on T1-weighted images (Figures 11.3
and 11.4). The T1 relaxation time is short for fat,
a static magnetic field to align the protons; hemorrhage, proteinaceous cysts and gadolinium­
ii a gradient magnetic field, which determines the infused tissues. Liquids, edema and tumors have
spatial location of the signals received; long T1 relaxation times. The gray and white matter
iii a radiofrequency pulse to disturb the magnetic of brain have intermediate signal intensity.
momentum of the protons.

T2 RELAXATION TIME
RADIOFREQUENCY PULSE AND
FLIP ANGLE When the go· RF pulse is turned off, the protons that
are precessing in the transverse plane slowly lose
A radiofrequency (RF) pulse that flips or tips the their momentum and start to dephase because there
longitundinal magnetization into transverse magneti­ are some changes in the local magnetic field. These
zation is a go· RF pulse. The angle through which dephasing protons eventually realign with the exter­
the longitudinal magnetization rotates to change its nal magnetic field. The decrease in the transverse
direction is called the flip angle (Figure 11.2). For magnetization is exponential and is called the free
example, an RF pulse that converts a longitudinal induction decay (FID). The rate of this decay of
magnetization to a transverse magnetization has a transverse to longitudinal magnetization states is
flip angle of go·, whilst an RF pulse that inverts called the T2 relaxation time (Figure 11.5). Some
longitudinal magnetization is a 1ao· RF pulse. The protons precess quickly, while others precess at a
protons precess in the direction of the magnetic field slow rate. The T2 relaxation time represents the
at Larmor frequency after flipping into the transverse decay due to the difference between protons in the
direction. The magnetic field continues to change precessional frequency, which results in loss of
with the precession of the nuclei. This induces in the phase coherence. It is related to the static magnetic
142 An atlas of imaging of the paranasal sinuses

field and the magnetic field that each proton creates A proton-density sequence is when all the T1
and is called the 'spin-spin relaxation'. Structures recovery is complete and T2 decay is minimal.
with long T2 relaxation time are fluid, edema and These are called spin-density weighted images, and
tumor, and these appear as bright signals. Tendons, they require a long TR and a short TE. The proton
muscles and cartilages have a short T2 relaxation density is dependent on the amount of water, that is
time, appear dark and are of low signal intensity. the number of available hydrogen protons. The
greater the proton density, the stronger will be the
MR signal. The greater the difference in the proton
density of adjacent tissues, the better the tissue
contrast. Cysts, water and edema are hyperintense
PULSE SEQUENCES (bright) on proton-density sequences, and bone, air,
cartilage and tendons are hypointense (dark) on
The pulse sequences are governed by the radio­
these sequences. Bone and air are seen as signal
frequency pulse used, the gradient manipulation
void areas or black on MR images.
done to select slices and the spatial resolution. Some
T2-weighted sequences are obtained using a long
of the sequences used for clinical imaging are spin­
TR (1500-3000 ms) and a long TE (60-100 ms).
echo, inversion-recovery and gradient sequences.
Tissues with a long T2 relaxation time are better
These sequences are appropriate for clinical imaging
differentiated on T2-weighted sequences. The longer
because minimal time is lost between stimulation of
the TE, the greater the T2 effects of a tissue will be
the tissue and the image production. Moreover, in
noted. Tissues with a long T2 relaxation time are
addition to yielding an image that is diagnostically
hyperintense (bright) on T2-weighted sequences,
acceptable, these imaging sequences are performed
because less decay of the transverse magnetization
with the least amount of discomfort to the patient.
would have occurred at a given time. Tissues with a
short T2 are hypointense (dark) on T2-weighted
sequence, as most of the T2 effect is lost before the
signal is received (Figure 11.5). In most instances,
SPIN-ECHO SEQUENCES T1-weighted sequences are best for the delineation
of anatomic structures and T2-weighted sequences
This is the most common pulse sequence used in for the assessment of pathology.
°
clinical imaging. Initially, a 90 RF pulse is transmit­
ted to flip the protons spinning in the longitudinal
plane into the transverse plane. This is followed by
°
a 180 RF pulse (phase reversal) which is necessary INVERSION RECOVERY
for rephasing the transverse magnetization. The
signal is measured during the rephasing of the trans­
SEQUENCES
verse magnetization. This is followed by a second
° Inversion recovery (IR) sequences involve initial
90 RF pulse and the sequence is repeated. The °
° excitation of the nuclei by a 180 RF pulse. This inverts
time interval between two consecutive 90 RF pulses
the longitudinal magnetization. After a pause (Tl inver­
is the repetition time (TR) (Figure 11.6). If a spin­
sion time) when some recovery of longitudinal magne­
echo sequence has a short TR (400-600 ms) °
° tization is occurring, a 90 pulse is applied to flip the
between two consecutive 90 RF pulses and the
longitudinal magnetization to transverse magnetiza­
echo time (TE) is kept short (<20' ms) so that only °
tion--: After anott:ier small pause (TR), a second 180
T1 signals are obtained, then the sequence is called
pulse is applied, following which the MR signal is
T1-weighted. The echo time (TE) is the interval
° measured. The short-Tl IR (STIR) sequences are used
between the peak of the 90 RF pulse and the detec­
to nullify the effects of fat, as the bright signals of fat
tion of the MR signal (Figure 11.6). If the TE is
often gives rise to artifacts during MR imaging.
lengthened, then the protons will have time to
dephase and the T2 relaxation effects will be seen.
T1-weighted images are obtained using short TR
and short TE settings. This makes it possible to
differentiate two tissues which have different signal GRADIENT-ECHO SEQUENCE
intensities at short TR times but have almost similar
°
intensity at long TR times. Hence TR controls T1- In gradient-echo imaging the 180 pulses are
°
weighting (Figure 11.3 and 11.4). replaced by gradient reversals. If the 90 pulse is
 Basic principles of Magnetic Resonance Imaging of the paranasal sinuses 143

°
also replaced by a flip angle that is less than 90 the remaining two planes (x-axis for frequency and
then most of the longitudinal magnetization is left y-axis for phase encoding to obtain an axial image)
undisturbed and one does not have to wait for T1 should be done. Frequency encoding involves the
signals. The RF pulse of less than 90· can be display of several frequencies arising from various
applied (TR) after the signal is obtained. Thus, in sites in a volume of tissue, for example in the x­
gradient-echo sequences, the contrast and signals direction for axial scans. Phase encoding, in the y­
are manipulated by changing the TR, TE and the flip axis for axial scans, represents the spatial resolution
angles of the RF pulse. If a flip angle of greater than along the chosen axis and is directly proportional to
°
45· is used with a short TE, the sequences appear the number of 90 pulses with different phase-encod­
more T1 -weighted. With a flip angle of less than 20· ing gradients. Multisection acquisitions using two­
the images are more T2-weighted in appearance. dimensional Fourier transformation is the ideal
The advantages of using a gradient-echo sequence method, as the information from several sections is
is its rapid acquisition of MR images. Differentiation obtained, while the frequency is shifted to excite a
between flowing blood and thrombosed vessels is different section (Figure 11.8).
possible as blood flow is seen as bright signals.
Hemosiderin and other substances with strong
paramagnetic properties appear dark on gradient­
echo sequences. These sequences are more sensi­ MAGNETIC RESONANCE
tive in identifying punctate calcifications due to the
magnetic susceptibility differences between normal IMAGING VERSUS COMPUTED
tissue and calcification. Among fast imaging TOMOGRAPHY
sequences that are used for clinical imaging are
gradient-recalled acquisition in steady state Both these technical advances in imaging have
(GRASS) and fast-low-angled shot (FLASH). made it possible to diagnose patients efficiently. As
it stands, CT and MR are two cross-sectional
imaging modalities that are complementary to olie
another. There are several advantages and disad­
vantages to both these modalities.
IMAGE RECONSTRUCTION
The MR signal obtained is amplified and received by
a computer. This information of several signal inten­ Magnetic Resonance
sities is converted into an image by a complex
mathematical analysis process. There are at least The imaging can be done in any plane without
two basic methods that are used: two- or three­ moving the patient, or making the patient assume
dimensional fast Fourier imaging method and the any uncomfortable position. It does not involve ioniz­
projection reconstruction method. The two-dimen­ ing radiation and to date there is no evidence of any
sional Fourier analysis is one of the popular methods deleterious effects from strong magnetic fields.
for MR imaging. This technique is used to generate Cortical bone, small metal clips, etc. do not cause
an image from the signal intensities acquired from a artifacts in MR imaging.
small volume of tissue. MR gives superior resolution of soft-tissue
Initially two-dimensional Fourier analysis requires contrast than CT. As MR involves direct interaction
'selective excitation' of a layer of tissue, by applying a between the applied magnetic field and the tissue,
weak magnetic field gradient in one plane. This selec­ certain tissue characterization and metabolic
tion can be in any plane. For an image in the axial changes from disease can be deduced from a
plane, the slice selection gradient is applied in the z­ combination of MR spectroscopy and imaging.
axis. If the gradient is applied in the x- or y-direction
the scans will be in the sagittal or in the coronal plane,
respectively (Figure 11.7). Thus MR imaging is possi­
ble in any plane without the patient having to assume Drawbacks to Magnetic
an uncomfortable position. The thickness of the slice Resonance
depends on the gradient chosen.
Once the layer that is to be excited is chosen, then There are however several drawbacks to imaging
the frequency and the phase encoding gradients in with MR. Some patients, such as those who are
144 An atlas of imaging of the paranasal sinuses

claustrophobic, are not able to tolerate the length of ii They should be able to produce the necessary
procedure, others cannot tolerate the noise caused effects in the tissues, making it possible to
by the gradient coils during scanning. As the image within a short time.
scanning time is lengthy (approximately 45 minutes iii They should alter the tissue relaxation rates at
to an hour for a head scan), motion and respiration non-toxic dosages.
artifacts degrade the images.
Large ferromagnetic agents and prostheses do The magnetopharmaceuticals used in imaging
degrade images, and patients with pacemakers, exhibit their paramagnetic properties due to the
aneurysm clips and cochlear transplants are a unpaired electrons in the outer shell.
definite contraindication to MR scanning. Most They remain in the extracellular compartments
medical accessories such as wheel-chairs and intra­ and have large magnetic moments; nuclei in close
venous poles have to be modified if they are to proximity to them exhibit a decrease in their T1 and
accompany a patient near the scanner. T2 relaxation times. Agents that effectively reduce
CT is sensitive to small calcifications and subtle the T1 relaxation times are best visualized on T1-
bony lesions. In contrast, MR does not image corti­ weighted sequences, and those that reduce the T2-
cal bone and calcifications, tumors that are charac­ relaxation on T2-weighted sequences. Not
terized by calcifications such as chondrogenic uncommonly, both T1 and T2 relaxation times are
tumors and other bone or calcifying lesions can be simultaneously affected.
misinterpreted on MR images. A wide variety of The most common paramagnetic agent used in
pathologic tissue and normal structures can have clinical imaging is gadolinium-diethylenetriamine­
identical T1 and T2 relaxation times, and both these penta-acetic acid (Gd-DTPA). Gadolinium is a rare
properties in a tissue can alter. The length of T1 and earth element, with seven unpaired electrons, which
T2 relaxation times are not reliable for differentiating exhibits definite paramagnetic properties. Free
benign from malignant lesions. gadolinium is toxic and not suitable for clinical use.
However, chelating gadolinium with DTPA, the
gadolinium retains its paramagnetic properties, is
stable and is rendered metabolically inert.
Gd-DTPA dimeglumine is the form that is injected
CONTRAST-ENHANCED IMAGING intravenously. The meglumine ion dissociates from
the Gd-DTPA immediately. The Gd-DTPA remains
One of the distinct advantages of MR over CT is its in the extracellular compartment, not crossing the
superior resolution of soft-tissue contrast, which blood-brain barrier, and, like other paramagnetic
made most investigators feel that intravenous agents, exerts its effects there. It is excreted by
contrast media would not be necessary. It is now glomerular filtration in an unaltered state by the
recognized, however, that intravenous contrast kidneys.
improves tissue contrast and is useful in intracranial The usual routine includes T1 and T2-weighted
and in spinal pathology. Contrast agents significantly scans prior to contrast administration, followed by a
improve lesion detectability and also increase the slow infusion of Gd-DTPA (dosage 0.2 ml/kg of body
possibility of seeing lesions that were not well deline­ weight to a maximum of 20 ml). The T1-weighted
ated in the precontrast study. Unlike the contrast sequences are repeated within the next 1.5 hours,
agents that are directly visualized in CT, the para­ as the effects of Gd-DTPA are best noted within the
magnetic agents that are used in MR imaging are first hour.
not visualized directly. Instead, the agents primarily Most adverse reactions occur immediately after
affect the proton density and the proton relaxation injection. The common side effects include nausea,
times, thus improving the contrast between normal vomiting, headaches, dizziness and pain at injection
and diseased tissues. site. Gd-DTPA is known to decrease the threshold for
Like most contrast media that are used for convulsions and should be used with caution in
conventional radiography, the paramagnetic agents patients with a history of convulsive disorder.
should have certain standard properties, including Hemolysis of red blood cells with transient increase
the following. in the serum iron and bilirubin levels have been noted.
Theroretically speaking, Gd-DTPA can accelerate the
They should be stable, non-toxic and excreted hemolytic effects in patients with hemolytic anemia.
rapidly without any deleterious effects to the There are several structures that normally
organ that excretes the media. enhance following the administration of Gd-DTPA.
 Basic principles of Magnetic Resonance Imaging of the paranasal sinuses 145

These include the pituitary gland and its stalk, the interslice distance is 1 mm. The coronal scans are
cavernous sinus, the choroid plexus and the grey localized from the axial study. Proton density and the
matter, intracranially. T2-weighted scans are obtained in the coronal
The extracranial structures that enhance are the plane, as this is the ideal plane for paranasal sinus
nasal turbinates and the sinonasal mucosa. In imaging. The sagittal plane is excellent for assess­
paranasal sinus imaging tumors show only moder­ ing the midline structures, the cribriform plate, and
ate enhancement compared with the intense the sphenoid sinus and its drainage pathway. T1-
enhancement exhibited by normal tissue. Scar tissue weighted sequences are ideal for anatomic details
and sinonasal secretions do not enhance. One has and are .done in the axial and coronal planes if this
to be careful in interpreting scans following enhance­ is necessary.
ment with Gd-DTPA. As the tumor enhances, the For T1 -weighted images, the TR is short and is
fat-tumor interface may be obscured and there is a 300-500 ms, and TE is 20-35 ms. T2-weighted
likelihood of misinterpreting the lesion to be larger sequences are obtained with a long TR (1800-
than its actual size. 200 ms) and a TE of 20-35 ms for the first echo
(also called the proton-density weighted image) and
70-120 ms for the second echo. These parameters
are dependent upon the size of the magnet.
Scans are tailored so that the imaging time is not
ROUTINE TECHNIQUE IN excessively long. ;
PARANASAL SINUS IMAGING Gadolinium-enhanced MR scans are obtained
within 30 minutes of injection. T1 -weighted
Preliminary T1-weighted MR scans are obtained in sequences are obtained, to evaluate the shortening
the axial plane. The slices are 5 mm thick and the of the T1 relaxation time.
146 An atlas of imaging of the paranasal sinuses

....
.....
Net Longitudinal Vector

Hydrogen Ions
Nat
---�-- Longitudinal
Magnetization

Without External Magnetic Field With External Magnetic Field

11.1 11.2

Signal Intensity
Longitudinal Magnetization Signal Intensity
Longitudinal Magnetization

Fat

Water

I I
o o o o o o • o O O O o o o o o o o o o o O O O � o o o o o o I O O O O O O I O O O I O O O o o o o o O IO o O O o O I I I O O o o o o

Time
Short T1 Relaxation Time
TR c 400mSecs Long TR >1000mSecs
I
so0 RF Pulse
0 1
90 RF Pulse
so 0 RF Pulse so0 RF Pulse

11.3 11.4

Figure 11.1 Figure 11.2

Without an external magnetic field the orientation of the A 90' radiofrequency pulse applied at the Larmor frequency will
hydrogens ions is random. Following the application of a tip the net longitudinal vector into the transverse plane. The
magnetic field, the hydrogen ions align with the direction of the transverse magnetization is responsible for the MR signal. The
applied magnetic field or against it. The net longitudinal angle through which the net longitudinal vector rotates to
magnetization is orientated in the same plane as the applied change direction is the flip angle.
static magnetic field.

Figure 11.3 Figure 11.4

The repetition time (TR) for the 90' radiofrequency pulse is When the TR from the 90' radiofrequency pulse is long, the
short. Fat has a short T1-relaxation time and recovers difference in the T1 values of water and fat is small and these
longitudinal magnetization rapidly. Hence fat is bright on T1- two structures will not be differentiated.
weighted images. In order to differentiate fat from water, which
has a long T1 relaxation time, a short TR is needed (see
Figure 11.4).
 Basic principles of Magnetic Resonance Imaging of the paranasal sinuses 147

Signal Intensity 180

°
180 ° 180 °
° °
90 90

Cart�ge
(Sliort T2 )
11t Echo
High Signal

2nd Echo
TE
TR
Echo
,Jl
II---

Low Signal 'I��IA ,v�I��

��Aov ,AA1 vlJv
II---

mSecs Signal
1
���V Olf�VV
Short TE
T2 Decay
Long TE

11.5 11.6

Gz Gy

Phase­
encoding
bands

Frequency-encoding bands
Frequency-encoding gradient..... Gx
Phase-encoding gradient..... Gy
Slice-selection gradient..... Gz

11.7 11.8

Figure 11.5 Figure 11.6

The T2 relaxation curve is an exponential decay curve. The Multiecho pulse sequence: TE, the time from the initial go·
tissues with a short T2 relaxation time, the transverse radiofrequency pulse to the time the first echo signal is
magnetization has decayed prior to imaging. In structures with received; TR, the repetition time between two consecutive go·
a long T2 relaxation time, the magnetization will continue to pulses.
decay for a longer time (TE), hence producing bright MR
signals on a T2-weighted sequence.

Figure 11.7 Figure 11.8

Two-dimensional Fourier imaging. Spatial information is Image generation by two dimensional Fourier transformation.
obtained by frequency encoding in the Gx plane and phase After slice selection, the frequency-encoding gradient is applied
encoding in the Gy plane, following the selection of layer by the in one plane (x) and the layer is subdivided into bands. The
application of the Gz gradient for an axial MR scan. phase encoding is applied in the other plane (y). The signal
strength from each pixel within a frequency band is resolved by
the Fourier transformation of each projection.
12
Magnetic Resonance Imaging of
inflammatory conditions and tumors of the
paranasal sinuses

Computed tomography (CT) and magnetic The disadvantages of MR are the long imaging
resonance imaging (MR) are the leading imaging time, which may cause image degradation from
modalities for the investigation of most disease motion. In addition, bone destruction and
affecting the paranasal sinuses. Benign inflamma­ amorphous calcifications are easily overlooked on
tory disease is mainly investigated by CT, MR being MR scans.
used as a complementary investigation in the follow­
ing circumstances:

When CT examination has not established the

diagnosis. THE NORMAL PARANASAL
ii When differentiation between benign and malig­ SINUSES
nant lesions is not possible by CT alone: in this
event, then MR, because of its superior soft­ Both CT and MR will image sinonasal mucosa. The
tissue resolution, may help establish a definitive high rate of detection of asymptomatic abnormalities
diagnosis. As MR is dependent upon the of the paranasal sinuses during routine CT imaging
biochemical characteristics of the tissues, it can of the head is well known. MR is far more sensitive
distinguish between the signal intensities of than CT, as it detects mucosal thickening in addition
normal, inflammatory, vascular and malignant to imaging changes in the nasal cavity resulting from
lesions. Generally speaking, all malignant lesions the normal nasal cycle (Figure 12.1). The mucosa in
in the sinuses produce intermediate signal inten­ the nasal cavity, the turbinates and the ethmoid
sities (Figures 12.48, 12.50 and 12.59). complex are seen as low signal intensity on the T1-
iii When multiplanar capabilities of MR imaging are weighted sequence, intermediate signal intensity on
useful in precisely defining tumor or inflam­ the proton-density (PD) weighted sequence and
matory disease margins prior to treatment: this hyperintense (i.e. brighter) on the T2-weighted
is possible without the patient having to assume sequence. The normal nasal cycle alternates from
any uncomfortable positions during scanning. one side to another and is seen on T2-weighted
iv When intracranial or intraorbital extension of sequences as increased brightness in the turbinates,
pathology is, suspected: intracranial tumor exten­ the ethmoid sinuses and the mucosa overlying the
sion and dural seeding are best demonstrated nasal septum. As a result of the normal nasal cycle
on MR because dental fillings and dense bone the turbinates are also larger and brighter on the
do not cause any artifacts (Figures side where the mucosal volume is high. This
12.47-12.4�). The presence of intracranial changes from one side to another during the course
spread will alter the management of the patient. of the day, the cycle being anything from 1 to 6
v When superior tumor-edge definition, soft-tissue hours. This should not be misinterpreted as inflam­
anatomy and fascial plane delineation are matory change. Up to 3 mm thickness in the
required: these are far superior with MR sinonasal mucosa is considered to be clinically
scanning, Gd-DTPA enhanced MR scans further insignificant. These cyclical changes are seen only
improve the definition of the tumor, its margins in the ethmoid sinuses and do not occur in the larger
and extension into the surrounding structures paranasal sinuses. The normal sinuses are seen as
(Figures 12.57). signal void cavities.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 149

Mucosal thickening of more than 4 mm is probably gen proton level. This makes inflammatory fluid
pathologic, although it is not uncommon to see appear either as a bright signal on both T1-weighted
patients with less than 3 mm thick hyperintense and T2-weighted sequences or as a combination of
mucosa who are symptomatic. The MR changes low and high signal intensities.
observed in the sinonasal mucosa must be correlated Chronic obstruction to the ventilation and drainage
with the patient's clinical history and physical . pathway of a sinus results in the prolonged retention
findings. As neither the bone nor the air within the and hence accumulation of fluid. The biochemical
sinuses produce signals, the demarcation between characteristics of retained fluid secretions in the
air and bone is not possible on MR scans. The major sinuses may change over a period of time. The
disadvantages of MR is that air, bone, calcifications water is slowly absorbed, resulting in thicker fluid. If
and metallic densities are all seen as signal void the obstruction of the sinus continues, then the
areas, and, consequently, the subtle calcifications chronic reaction may stimulate the goblet cells of the
that characterize certain tumors can go undetected. lining epithelium to produce a fluid which is rich in
The thin healthy mucosa may on occasion be seen protein. Histologically, goblet-cell metaplasia will be
as a thin layer of low signal intensity on T1-weighted seen. As a consequence, the water is slowly
sequences. The normal turbinates and the nasal absorbed and is replaced by a protein-rich secretion.
septum are isointense with brain, or of intermediate This makes the fluid gelatinous, thick and viscous.
signal intensity on MR sequences. As protein molecules shorten the T1 and T2 relax­
ation time, a proteinaceous fluid is bright or hyper­
intense on T1 and T2-weighted sequences. With an
increase in the amount of glycoprotein production,
there is an increase in the binding of the hydrogen
BENIGN DISEASE molecules. This further reduces the amount of
mobile hydrogen. The decrease in the water content
Inflammation further reduces the T1 relaxation motion of the
glycoprotein complex results in a shorter T2 relax­
Inflammatory changes in the paranasal sinuses can ation time. The pasty thick material may eventually
be due to a number of causes, benign and malig­ be replaced by a dry desiccated material in the sinus
nant. Without bony destruction, small polyps and lumen. As there are no remaining free mobile hydro­
early malignant lesion are identical on CT. Most gen protons, the substance has an extremely short
malignant lesions evoke an inflammatory reaction in spin-echo time and is seen as signal void (black)
the sinonasal mucosa, thus making a carcinoma areas on T1- and T2-weighted sequences (Figures
appear larger than its actual size on CT scans. With 12.6-12.9). These dynamic biochemical and physio­
MR scans it is possible to ·differentiate tumor from logic changes in an obstructed sinus are the basis
benign inflammatory changes, due to the wide differ­ of the MR appearance of fluid in the various MR
ences in their signal intensities (Figure 12.2-12.5). spin-echo sequences. MR is thus complementary to
The precise size and the tumor margins are better CT sinus as it characterizes the fluid by the
delineated on MR scans because the signal intensi­ biochemical changes taking place in the obstructed
ties for inflammation and tumor are different. cavity.
Normal sinonasal mucus is a combination of Signal void areas may be misinterpreted as a
secretions from the submucosal glands, and the normal sinus on MR scans if a CT scan is not avail­
proteinaceous secretion from the goblet cells. able for comparison. Clotted blood, fibrotic scar,
Trans!,.ldates are serous collections with hydrogen mycetomas, calcium, tooth, bone or a pocket of air
protons in abundance. The free mobile hydrogen can also cause a signal void area in a sinus.
protons in fluids give rise to long T1 and T2 relax­
ation times. Consequently, the classic appearance is
low signal intensity on T1-weighted scans and
hyperintensity (brighter) on T2-weighted sequences. Sinusitis
Other factors that influence the T1 and T2 relaxation
times of sinus fluid are the presence of protein­ The classic MR appearance of benign inflammatory
aceous material, hemorrhage, the viscosity of the sinusitis is thickened mucosa of low to intermediate
fluid and the temperature. signal intensity on T1-weighted sequences. On
Unlike serous collections, inflammatory fluid is proton-density weighted and T2-weighted sequences,
composed of protein-rich fluid, with a variable hydro- the signal of thickened mucosa is hyperintense
150 An atlas of imaging of the paranasal sinuses

(brighter) (Figures 12.10-12.13). Following the admin­ polyps (Figure 12.27). The hyperintense signal on
istration of Gd-DTPA, there is intense enhancement T2-weighted MR sequences is due to high water
of the inflamed mucosa. The high signal intensity of content. The signal-void septa are well demon­
inflamed mucosa on T2-weighted imaging sequences strated on MR scans, in which hyperintense polyps
helps one to differentiate active inflammation from are seen in the sinus lumen (Figures 12.28 and
fibrosis and/or scarring, both of which are intermedi­ 12.29).
ate or low signal intensity on all imaging sequences Chronic longstanding polypoid lesions in the
(Figures 12.14-12.21). Tumors are also intermediate sinonasal cavity undergo biochemical changes. The
in signal intensity; consequently, differentiation water content decreases significantly, and the polyps
between tumor and fibrosis is not possible by MR. Not become richer in protein. Consequently the polyps
uncommonly, the sinus cavity is obliterated by fascia have a high signal on all imaging sequences. Thus,
or fat, and in such instances hyperintense fat in the from the MR features, one can confidently predict if
sinus cavity is detected on T1-weighted MR scans the polyps have been present for a long time. On
(Figure 12.22). CT scans, diffuse sinonasal polyposis, which are
seen as soft-tissue densities in the lumen, may
sometimes seem aggressive enough to be-misdiag­
nosed as a malignant mass. On MR scans such
masses demonstrate a variation of signal intensity,
Retention cysts varying anywhere from hyperintense signals to
signal-void areas on all imaging sequences. This MR
Retention cysts seen in the floor of the maxillary
appearance is classic for benign sinonasal polyposis
sinus are most frequently the result of occlusion of
(Figures 12.30-12.33). Even in the presence of
the seromucinous glands. These are often seen in
erosions, the inhomogenous appearance of the
healthy and asymptomatic patients. Some patients
lesions in all sequences characterizes their benignity
develop these cysts close to the infraorbital nerve,
(Figure 12.34).
and this can be symptomatic. Retention cysts are
hypointense on T1 -weighted, and hyperintense on
T2-weighted MR sequences (Figures 12.2, 12.3,
12.23 and 12.24). Retention cysts cannot be differ­
entiated from polyps in the sinus cavity; however,
such differentiation is irrelevant, as these two entities
Mucocele
are benign, and the treatment of the two conditions
By definition a mucocele is the result of prolonged
are identical. One should exercise caution in the
obstruction of the drainage pathway of a sinus,
diagnosis of benign cysts in the sphenoid sinus, as
which results in the remodeling of the sinus cavity.
cystic pituitary gland lesions eroding through the
Mucoceles are the commonest expansile lesions
floor of the sella may present as cystic lesions in the
seen in the paranasal sinuses. The sinuses involved
sphenoid sinuses (Figures 12.25 and 12.26).
in the decreasing order of frequency are the frontals,
ethmoids, maxillary and the sphenoid sinuses.
Mucoceles commonly present as painless masses
adjacent to the superomedial margin of the orbit,
Sinonasal polyposis with or without exophthalmos, and diplopia.
Mucoceles are associated with smooth erosions of
The clinical features and CT appearance of benign the sinus walls and expansion of the sinus. These
nasal polyps have been discussed in Chapter 8. The bony changes are best demonstrated on CT scans
characteristic MR features of sinonasal polyposis are (Figures 12.6 and 12. 7) and can be easily
reflections of the rich proteinaceous and watery overlooked on MR scans (Figures 12.8 and 12.9).
contents of the polyps. As a polyp ages, the number As mentioned earlier, the secretions in a mucocele
of free hydrogen protons decreases; as a result, the can be serous, proteinaceous, thick and pasty, or
MR characteristics are variable. These polyps are dry and desiccated. Depending on their biochemical
low to intermediate in signal intensity on T1- constituents, mucoceles can be hypo-, iso- or hyper­
weighted, and proton-density weighted MR intense or signal void on both T1- and T2-weighted
sequences. The hyperintensity of polyps on T1- sequences (Figures 12.14-12.16 and 12.35-12.39):
weighted scans is usually due to increase in the the lower the water content, the shorter the T1 and
protein content or due to hemorrhage within the T2 relaxation times.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 151

Those mucoceles that are signal void on T1- and hemorrhage vary. Without good understanding of the
T2-weighted sequences due to their desiccated differences in signal intensities one could be easily
contents pose a problem because they can be easily misled. Deoxyhemoglobin is hypointense on T1-
overlooked as a normal air-filled sinus. The differ­ weighted MR sequences and becomes more
entiation is done by a CT scan, which will demon­ hypointense on T2-weighted sequences. If the sinus
strate the desiccated material in the sinus, in is not completely filled with blood and has residual
addition to the expansion of the sinus by the air in it, this air aids in oxidizing the clot in the sinus.
mucocele (Figures 12.6-12.9). Following oxidation, the sinus contents are predom­
A recent-onset mucocele has a high water content inantly intracellular methemoglobin which is hyper­
and is hypointense on T1-, intermediate signal on intense on T1- and hypointense on T2-weighted
proton-density and hyperintense on T2-weighted MR sequences. Once the cells break down, the intracel­
sequences. The water content of a mucocele that lular methemoglobin becomes extracellular and is
has been present for a few months is slowly hyperintense on T1- and T2-weighted sequences
absorbed and is replaced by protein rich secretions (Figure 12.40).
from the seromucinous glands. This makes the It is not uncommon to see blood in the paranasal
mucocele intermediate in signal intensity on T1-, and sinuses. Blood is often associated with trauma,
hyperintense on T2-weighted MR sequertces. With bleeding dyscrasias and, less frequently, with
further loss of free and mobile hydrogen protons, hemorrhage from benign or malignant lesions.
and an increase in the protein content, the mucocele Hemorrhage following trauma can produce an
is hyperintense on T1- and T2-weighted MR imaging inflammatory reaction of the sinus mucosa and can
sequences. A long standing mucocele is dry and be easily mistaken for sinonasal polyposis.
desiccated, there are no free hydrogen protons, and
the mucocele is seen as a signal void cavity on T1-
and T2-weighted MR scans. If the expansile nature
of the mucocele is overlooked, these longstanding Fungal sinusitis
mucoceles can be misinterpreted as a normal sinus
on MR scans, as air in a normal sinus is signal void. Fungal sinusitis occurs both in the otherwise healthy
The other features one should look for in addition to and in the immunocompromised population. The
expansion of the bony walls is the hyperintense clinical presentation varies.
sinus mucosa seen on T2-weighted sequences. The commonest presentation is a long history of
Mucosa also enhances following Gd-DTPA adminis­ sinusitis that is not responding to medical therapy.
tration. In most cases, the diagnosis is rarely made from the
clinical findings. Patients are usually investigated by
a CT scan to exclude any complications from chronic
sinusitis. Aspergillosis is the commonest fungal
Sinus hemorrhage infection seen in the population at large. These fungi
are commonly found in the soil, decaying fruits and
Hemorrhage within the paranasal sinuses usually vegetables. The three species responsible for sinus
has a higher CT number than serous fluid. Visually and respiratory infections are Aspergillus fumigatus
it is difficult to differentiate fluid from blood and thick­ (the commonest), Aspergillosis niger, and
ened mucosa on CT scans. However, MR is ideal Aspergillus f/avus. The sinonasal and the pulmonary
for assessing an opacified sinus. forms of aspergillosis are unrelated, the pulmonary
The signal characteristics for blood varies accord­ form primarily being seen in immunocompromised
ing to the chemical form in which the blood products patients.
are present. The constituents of blood undergoes The noninvasive form of aspergillus sinusitis usually
several changes. In the first step in this process, the presents as recurring sinus infections refractory to
oxyhemoglobin component of the red blood cell is conventional antibiotic therapy. The nasal discharge
converted into deoxyhemoglobin, which is subse­ is purulent and foul smelling. Air-fluid levels are not
quently oxidized to methemoglobin. The intracellular common. With mucoperiosteal erosion, pain referred
methemoglobin following red blood cell lysis to the cheek is prominent and the routine radiographs,
becomes free methemoglobin. Hemosiderin is the and CT scans may show bony destruction similar to
final degradation product of this free methemoglobin. malignancy. The invasive form of aspergillosis is a
The importance of these biochemical changes is rapid destructive process. In immunocompromised
that the MR characteristics of acute and chronic patients, the symptoms may not be severe enough to
152 An atlas of imaging of the paranasal sinuses

seek medical attention as the immune response is refinement in MR technique and software, it may be
poor. This further delays therapy, with grave conse­ possible to image bone, teeth enamel and calcifica­
quences. Dissemination of fungal disease is due to tions. MR will continue to play a major role in sinus
vascular invasion with spread to the intracranial struc­ imaging, especially where benign lesions, such as
tures and other remote vital organs. This form of mucoceles or fungal infections, present as appar­
fulminant disease significantly increases the mortality ently aggressive and malignant lesions on CT
and morbidity in the immunosuppressed. Irrespective examinations.
of the type of fungal disease, early establishment of
the diagnosis is essential as the treatment is surgical
removal of the fungus balls, with debridement of the
infected mucosa.
Early diagnosis is now possible with CT and MR MALIGNANT TUMORS OF THE
imaging. On CT scans, fungal infections are seen as SINUSES
high-density concentrations in the sinonasal cavity,
surrounded by some fluid (Figures 12.41 and 12.42). Primary tumors of the paranasal sinuses can remain
Reactive mucoperiosteal thickening of the sinus confined within the sinonasal cavity for long periods
walls with or without bony destruction is seen. The of time without producing any symptoms. When
treatment is surgical debridement, re-establishment patients present to the physician, it may be too late,
of ventilation to the sinus and antifungal treatment. as they are symptomatic only if there is local spread
With some invasive forms of aspergillosis systemic to the orbital, facial or nasal surfaces of the maxil­
steroid therapy is also instituted. lary sinuses. Hence, these tumors have a poor
Areas of calcifications that are easily discerned on prognosis, due to the rapidity of dissemination after
CT examinations are not well demonstrated on MR their early asymptomatic stage. The key to the
scans (Figure 12.41). The specimens from fungal management of these tumors is early diagnosis and
infection are rich in iron, magnesium, calcium and treatment. Early diagnosis is now possible with CT
manganese. These heavy metals are responsible for and MR. CT is superior in assessing the presence
the increase in the CT number and the hyperdensity and extent of bony destruction, while MR is superior
seen on the scans. in assessing the extent of the tumor, especially when
On MR scans, the Ti-weighted sequences usually intracranial and intraorbital extension is suspected
demonstrate a hypointense mass in the sinus cavity, (Figure 12.47-12.49).
surrounded by fluid. On protein-density weighted and The commonest histologic type of malignant tumor
T2-weighted sequences the fungus balls usually seen in the sinuses is squamous cell carcinoma. The
show signal-void areas, and signal intensities are commonest sites, in order of frequency, are the
lower than those seen on a Ti-weighted scan. In maxillary sinus, nasal cavity, ethmoid complex,
some areas, there may be no signal, due to the frontal sinus and sphenoid sinus (Figure
calcium and other heavy metal content. Inflamed 12.48-12.50). Most of these tumors are low to inter­
sinus mucosa is usually hyperintense (Figures mediate in signal intensity on MR imaging. The
12.42-12.46). The signal-void areas are easily exceptions to this rule are the glandular minor
mistaken for normal air in the sinus cavity. Most salivary gland tumors, which have brighter signal
masses and polyps on T1-weighted sequences are intensities on T2-weighted sequences due to the
hypointense, but their signal intensities on T2- high seromucinous contents. The schwannomas are
weighted sequences vary, thus making it possible to also bright on T2-weighted sequences, due to the
differentiate between benign inflammatory polyps, cystic degeneration that these tumors frequently
malignant lesions and hemorrhage. Benign polyps undergo.
are hyperintense and malignant lesions are hypo- or
intermediate intensity. Acute hemorrhage is
hypointense on T1- and T2-weighted sequences.
Subacute hemorrhage is hyperintense on T1- and
T2-weighted sequences. The signal characteristics of Clinical presentation and
various abnormalities are summarized in Table 12.1. diagnostic imaging
Obviously there are certain limitations to MR
imaging. Teeth, calcifications and air, all easily differ­ The initial clinical symptoms may not be debilitating
entiated on CT scans, produce no signals and can enough to prompt radiologic investigations. Patients
easily go undetected on MR scans. With further often receive treatment for sinusitis, which does not
 Magnetic Resonance Imaging of inflammatory conditions and tumors 153

Table 12.1 Signal intensity relative to brain.a

Abnormalities Appearance on Appearance on

T1 -weighted MR scans T2-weighted MR scans
Sinusitis Thick mucosa Thick mucosa
hypointense hyperintense

Retention cysts Hypointense Hyperintense

Polyposis Hypointense Hyperintense

Longstanding polyps Variable Variable

Mucocele
high water content Hypointense Hyperintense
lower water and higher protein Hyperintense Hyperintense
content
thick, pasty content Hypointense rvlore hypointense to signal yoid
dessicated, dry and without Signal void Signal void
mobile hydrogen

Hemorrhage
acute Hypointense Hypointense to signal void
chronic Hyperintense Hyperintense

Mycetoma
cheesy content Hypoihtense or isointense More hypointense on
T2-weighted MR or signal void
dry content Signal void Signal void

aHypointense = dark; hyperintense = bright; isointense = same intensity as brain; signal void = black;
variable = hypo-, hyper- or isointense or signal void.

respond to antibiotics. The patients often fail to see the persistent unilateral sinusitis will often enable the
the prolonged and chronic nature of their disease, diagnosis to be established without further delay.
which results in a further delay of the diagnosis. A Hence the proper diagnosis and management of
high index of suspicion and further investigation of sinonasal malignancies include:
154 An atlas of imaging of the paranasal sinuses

a thorough clinical and endoscopic examination; its margins and extension into the surrounding struc­
ii CT and/or MR examination, so that tumor stage tures (Figure 12.57).
can be established on the basis of tumor (T) The disadvantages of MR are the long imaging
location, size, nodal (N) spread, if any, and time, resulting in image degradation due to motion
metastasis (M), if any; and the fact that bone destruction and amorphous
iii postoperative follow up with CT and/or MR calcifications can be easily overlooked.
examinations at 6 weeks, 3 months, 6 months
and yearly intervals.

The importance of imaging is to assess the extent

of tumor involvement, its operability, postoperative Angiofibroma
course and define the margins for radiotherapy.
The TNM staging of tumors is used by surgeons, Angiofibromas are highly vascular, with a tendency
radiotherapists and oncologists. The radiologist's to recur locally. They are seen predominantly among
role is to assist the specialists in the precise staging adolescent males. The common clinical presenta­
of tumors. tions include nasal obstruction, epistaxis, recurrent
sinusitis and anosmia. The tumor arises from the
nasopharynx and extends intracranially or into the
orbit via the pterygopalatine fossa. Superiorly, the
tumor can extend into the sphenoid sinus. Anteriorly
Comparison of Computed and inferiorly, the tumor can enlarge and remodel
the posterior wall of the maxillary sinus. Imaging is
Tomography and Magnetic undertaken primarily to localize the tumor and define
Resonance of tumors its margins prior to treatment.
Histologically, angiofibromas are benign, unencap­
Apart from being more cost-effective, more avail­ sulated and very vascular. They are hypointense on
able, and less susceptible to motion artefacts, the T1-weighted scans (Figure 12.53). On proton­
advantages of CT over MR are that bony destruc­ density and T2-weighted sequences they are of
tion is best demonstrated on CT, and that calcifica­ intermediate signal intensity (Figure 12.54). Being
tions that characterize certain tumors, such as very vascular, these tumors can exhibit a salt and
chondrogenic and osteogenic tumors, are well seen peppery appearance on T2-weighted sequence due
on CT and may go undetected on MR scans. to the tumor vessels, which are seen as flow-void
The major limiting factor of CT imaging is the lack channels.
of differentiation between tumor, surrounding inflam­
mation that the tumor may have caused and
stagnant viscid sinonasal secretions that may result
from inadequate drainage of the obstructed sinus.
The dense bones of the skull base cause significant Esthesioneuroblastoma
image degradation and loss of soft-tissue details
(Figures 12.47-12.50). These tumors arise from the olfactory mucosa and
As MR signals depend upon the presence of free are classically located in the roof of the nasal
hydrogen protons, fat has a short T1- relaxation, and cavity. The type of surgery to be performed on
is seen as bright signals on T1-weighted sequences, these patients depends on the precise definition of
making the contrast in MR images superior to that these tumor margins. Those tumors that are local­
in CT. Most inflammatory changes and benign ized to the nasal cavity, with or without extention
polyps produce bright signal intensities on T2- into the adjacent ethmoid sinuses, are approached
weighted sequences. Malignant lesions are low to by a lateral rhinotomy. If intracranial extension is
intermediate in signal intensity. This difference in seen on MR or CT examination, then a more
signal intensities between malignant tumors and the radical approach, with removal of the cribriform
benign inflammatory reaction that these tumors often plate and the olfactory bulb, is undertaken.
invoke assists in delineation of the tumor margins Esthesioneuroblastomas are intermediate or low in
(Figure 12.51 and 12.52). signal intensity on all MR sequences. Following
Contrast enhancement with Gd-DTPA further Gd-DTPA administration, they can enhance
improves on MR scans the definition of tumor and (Figures 12.55-12.58).
 Magnetic Resonance Imaging of inflammatory conditions and tumors 155

Metastasis and contiguous Direct invasion into the sinuses from neighbour­
ing structures is not uncommon. The most
spread of tumor from adjacent common tumors that directly invade the sinuses
structures are the oropharyngeal cancers, odontogenic
tumors and local skin tumors, such as basal cell
Rarely, the sinuses may be the site for metastasis. carcinoma or melanoma (Figures 12.51, 12.52 and
The commonest primary tumors metastasizing to the 12.59-12.62).
sinuses are lung cancer, renal cell carcinoma, breast The odontogenic tumors are inhomogenous on
cancer or melanoma. The symptoms are non­ T1-weighted �R sequences, and on T2-weighted
specific. The CT appearances of these tumors are MR sequences they exhibit varying signal intensities,
similar to primary sinonasal neoplasms. Destruction with focal areas of hyperintensity in the tumor matrix.
of bone, with or without tumor enhancement, is the Another pathway for spread of tumor is perineural
usual feature. The MR features are similar to primary extension of tumors to the skull base and the under­
tumors, with intermediate or low signal intensity on lying sinuses from primary tumors on the face and
all imaging sequences. scalp.
156 An atlas of imaging of the paranasal sinuses

12.1 12.2

12.3 12.4

Figure 12.1 Figure 12.2

Normal nasal cycle. This axial T2-weighted MR scan Malignant tumor and retention cyst. The T1 -weighted MR scan
demonstrates high signal intensity in the enlarged turbinates in the axial plane shows the entire right maxillary sinus lumen
(arrow) and nasal septum on the right side. This is the normal to be filled by a mass of varying signal intensity (T), A
nasal cycle and should not be misinterpreted for an abnormality hypointense, rounded, well-defined mass (C) is seen in the left
or infection. maxillary sinus.

Figure 12.3 Figure 12.4

Malignant tumor and retention cyst. On this T2-weighted axial Maxillary sinus polyp. A lobulated mass (P) in the right
MR scan the malignant tumor (T) seen in Figure 12.2 is seen maxillary sinus, isointense with brain, is seen on this T1-
to be surrounded by inflammatory hyperintense (bright) sinus weighted sagittal MR.
mucosa. The cyst in the left maxillary sinus (C) is hyperintense,
and the bright outline seen in the left maxillary sinus is the
mucosal lining.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 157

12.5

12.6

12.7 12.8

Figure 12.5 Figure 12.6

Maxillary sinus polyp. This T2-weighted MR scan in the axial Frontal sinus mucocele. This patient presented with
plane demonstrates the mass (P) in the right maxillary sinus in exophthalmos. The coronal CT scan demonstrates a large
Figure 12.4 to be hyperintense. mucocele with smooth erosions of the bony wall, extending into
the right orbit: two mucocele cavities are seen (A and B).

Figure 12.7 Figure 12.8

Frontal sinus mucocele. The axial CT scan of the same patient Frontal sinus mucocele. This axial T2-weighted MR scan of the
as Figure 12.6 demonstrates two mucoceles (A,B) separated by same patient as Figure 12.6 demonstrates the signal intensity
a sclerotic and thickened bony septa in the frontal sinuses. The of the contents of two mucoceles to be markedly different. One
fluid collections in the two mucoceles are similar in density. is isointense (A) with brain, while the contents of the other (B)
are signal void.
158 An atlas of imaging of the paranasal sinuses

12.9 12.10

12.11 12.12

Figure 12.9 Figure 12.10

Frontal sinus mucocele. In this T2-weighted MR scan of the same Maxillary sinusitis. This T1 -weighted MR scan shows a
patient as Figure 12.6 the mucocele is seen as a signal void area collection in the right maxillary sinus to be isointense with brain.
(B). If the expansion of the sinus wall is subtle, such a mucocele A hypoplastic left maxillary sinus with ipsilateral enlargement of
can be easily overlooked on MR scans. Mucoceles have variable the nasal cavity is noted.
signal intensities depending upon their contents. Thick viscid
mucoid material with few hydrogen protons will be signal void;
material that has abundant hydrogen protons and is fluid will be
hyperintense on T2-weighted sequences (A).

Figure 12.11 Figure 12.12

Maxillary sinusitis. This T2-weighted MR scan shows Chronic sinusitis. This T2-weighted MR scan shows a thickened
hyperintense mucosa, while the fluid in the sinus cavity is not hyperintense mucosa in the maxillary and ethmoid sinus
as hyperintense as water is expected to b�. Longstanding bilaterally. The dark area is air in the diseased sinus (arrow).
obstruction of the sinuses may lead to decreased quantities of
hydrogen protons.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 159

12.13 12.14

12.15 12.16

Figure 12.13 Figure 12.14

Chronic sinusitis. Thickened and hyperintense mucosa is seen Post-traumatic mucocele and scarring. This T1-weighted MR
in the maxillary sinuses on this T2-weighted MR scan. Chronic scan shows an expansile mass in the inferomedial aspect of
reactive osteitis is seen as thickened signal void lateral the orbit (arrows). This patient underwent surgery for multiple
maxillary sinus wall (arrows). fractures to the sinuses and facial bones. The left maxillary
sinus lumen is replaced by linear strands of varying signal
intensities (open arrows).

Figure 12.15 Figure 12.16

Post-traumatic mucocele and scarring. The mucocele remains Post-traumatic mucocele and scarring on a T2-weighted MR
unchanged in signal intensity on this proton-density weighted scan. A mucocele is seen as an unusual multiseptated mass
MR scan (arrows). The scarring in the maxillary sinus appears (arrows) with hyperintense contents. The fibrosis and scarring
darker (open arrows). (open arrows) is further reduced in signal intensity: this
progressive decrease is more in keeping with scarring. Active
inflammatory reaction would be hyperintense.
160 An atlas of imaging of the paranasal sinuses

12.17 12.18

12.19 12.20

Figure 12.17 Figure 12.18

Chronic maxillary sinusitis. On this T1-weighted MR sequence Chronic maxillary sinusitis. On this T2-weighted MR scan the
the right maxillary sinus contents are of mixed signal intensity. right maxillary sinus mucosa is hyperintense (same patient as
Figure 12.17). The fluid is of a lower signal intensity due to
fewer mobile hydrogen protons. This is typical of longstanding
obstruction and sinusitis.

Figure 12.19 Figure 12.20

Ethmoid and sphenoid sinusitis. This T1-weighted MR scan Ethmoid and sphenoid sinusitis. This T2-weighted MR scan of
demonstrates inflammatory mucosal thickening in the ethmoid the same patient as Figure 12.19 demonstrates hyperintensity
sinuses (E). An air-fluid level is seen in the right sphenoid of the inflamed mucosa in the ethmoid sinuses (E), and fluid in
sinus (S). the right sphenoid sinus (S) is hyperintense due to an
abundance of hydrogen protons.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 161

12.21 12.22

12.23 12.24

Figure 12.21 Figure 12.22

Postoperative recurrent sinusitis. The T1-weighted MR scan Postoperative changes in the sphenoid sinus. This T1-weighted
(not shown) demonstrated densities in the ethmoid and MR scan shows the left sphenoid sinus lumen to be obliterated
maxillary sinuses to be isointense with brain. This T2-weighted by high signal intensity fatty tissue (F) obliterating the lumen,
MR axial scan shows hyperintensity of the thickened mucosa in following pituitary gland surgery. Residual pituitary tissue is
the postoperative ethmoid cavity and in the maxillary sinus seen in the sella (arrow).
(arrows). These are nonspecific inflammatory changes in the
ostiomeatal complex bilaterally. A large hypertrophied inferior
turbinate is seen on the left side (IT).

Figure 12.23 Fig\ure 12.24

Retention cyst. A dome shaped hypointense mass in the right Retention cyst. The axial T2-wighted MR scan of the cyst (C)
maxillary sinus (C) is seen. shown on Figure 12.23 is hyperintense in signal intensity.
162 An atlas of imaging of the paranasal sinuses

12.25 12.26

12.27 12.28

Figure 12.25 Figure 12.26

Cystic tumor of the pituitary gland. This sagittal T1-weighted MR Pituitary tumor. On this coronal T2-weighted MR scan the cystic
scan shows a multiseptated cystic mass (small arrows) arising pituitary (C) tumor seen in Figure 12.25 fills the sphenoid sinus and
from the gland. This cystic neoplasm has eroded through the is hyperintense. The roof of the sphenoid sinus is eroded. Without
sellar floor and fills the sphenoid sinus. Note the sinus ostium the clinical information, this could be mistaken for a mucocele.
anteriorly (curved arrow), the optic nerve (ON) and high signal
intensity from the posterior lobe of the pituitary gland (P).

Figure 12.27 Figure 12.28

Hemorrhagic nasal polyposis. This patient had undergone Nasal polyposis. This axial proton-density weighted MR scan
several operations for massive sinonasal polyposis. This T1- demonstrates the masses in the ethmoid sinuses to be of
weighted MR scan shows the polyps to be of varying signal intermediate signal intensity. The bony septae in the ethmoid
intensities. The high signal intensities (arrows) seen on T1- complex are well preserved.
weighted images are due to hemorrhage within polyps.

- - ·- --- -- -- ------- - -
 Magnetic Resonance Imaging of inflammatory conditions and tumors 163

12.29

12.31 12.32

Figure 12.29 Figure 12.30

Nasal polyposis. On this axial T2-weighted MR scan of the Benign nasal polyposis. This sagittal T1-weighted MR scan
polyps seen in Figure 12.32, the masses are demonstrated to shows the masses in the frontal, sphenoid and the ethmoid
be hyperintense in signal intensity. sinuses to be of mixed signal intensity. The signal-void bone
(arrows) is not eroded by the massive polyposis.

Figure 12.31 Figure 12.32

Benign nasal polyposis. This T2-weighted MR scan in the axial Sinonasal polyposis. This patient underwent multiple
plane of the same patient as Figure 12.30 demonstrates the polypectomies, and ethmoidectomy. The T1-weighted MR scan
varying signal intensities ranging from signal void to demonstrates masses of intermediate signal intensity in the
hyperintensity. This MR appearance is classic benign polyps in maxillary and ethmoid sinuses bilaterally, with hypertelorism.
contrast to malignant polyps, which are of intermediate signal The bright signals seen in the orbits and the cheeks are from
intensity in all imaging sequences. the fat (black arrows).
164 An atlas of imaging of the paranasal sinuses

12.33 12.34

12.35 12.36

Figure 12.33 Figure 12.34

Sinonasal polyposis. This T2-weighted scan of the same patient Sinonasal polyposis with skull-base erosion. The sagittal T1-
as Figure 12.32 demonstrates hyperintensity of the large polyps weighted MR scan demonstrates the erosion of the skull base
in the maxillary sinuses, and in the ethmoid complexes anteriorly (arrows) by polyps. The inhomogenous appearance of
bilaterally. the polyps nevertheless characterizes the benign nature of this
disease despite the presence of erosions.

Figure 12.35 Figure 12.36

Mucocele of the sphenoid sinus. A mucocele of the sphenoid Mucocele of the sphenoid sinus. This T2-weighted MR scan of
sinus (M) is seen as an isointense mass with a hypointense the same patient as Figure 12.35 demonstrates the mucocele
centre, surrounding the left internal carotid artery (arrow) and (M) to be hyperintense due to its high water content.
encroaching on to the prepontine cisterns. This T1-weighted
scan defines the relationship to vital neurovascular structures.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 165

12.37 12.38

12.39 12.40

Figure 12.37 Figure 12.38

Mucocele. This T1-weighted MR scan demonstrates high signal Mucocele. This coronal CT scan of the same patient as Figure
intensity from fat (F) and a hypointense, well-circumscribed lesion 12.37 demonstrates the obliterative procedure done for frontal
(m) posteriorly in the left frontal sinus. The patient, who had sinus mucoceles. The cause for recurrence of the patient's
reported recurrent frontal headaches, had been referred for MR symptoms could not be ascertained from the CT scan, and MR
scanning after CT scanning (Figure 12.38) proved inconclusive. scanning was required.

Figure 12.39 Figure 12.40

Mucocele. This T2-weighted MR scan of the same patient as Sinus hemorrhage. This T1-weighted MR scan demonstrates
Figure 12.37 shows the mucocele (m) to be hyperintense. The hyperintense hemorrhage (H) in the left sphenoid sinus.
posterior wall of the mucocele is eroded (arrows).

-- -- - . -
166 An atlas of imaging of the paranasal sinuses

12.41 12.42

12.43 12.44

Figure 12.41 Figure 12.42

Fungal sinusitis. This coronal CT scan demonstrates sinusitis in Fungal sinusitis. This coronal CT scan demonstrates a high­
the left maxillary sinus, with dystrophic calcifications in the density mass in the left maxillary sinus, with a rim of inflamed
fungus ball (arrow). sinus mucosa, which is low density (black arrows). The high­
density mass is also seen in the ethmoid complex.

Figure 12.43 Figure 12.44

Fungal sinusitis. This T1-weighted MR sequence of the same Fungal sinusitis. Proton-density weighted MR scans (not shown)
patient as Figure 12.41 demonstrates a signal-void area in the demonstrated further decrease in the signal intensities of the
mass which is isointense with brain (arrows). Ferromagnetic contents of the maxillary sinus. This T2-weighted MR scan
compounds and calcium in the mycelia of the fungus cause the shows the fungus concretions to be darker (black arrows), i.e.
signal void. There is an inhomogenous increase in the signal signal void. This is surrnunded by intensely bright high signal
from the inflamed sinus mucosa (arrowhead). intensity from the inflamed maxillary sinus mucosa (arrowheads).
 Magnetic Resonance Imaging of inflammatory conditions and tumors 167

12.45 12.46

12.47 12.48

Figure 12.45 Figure 12.46

Fungal sinusitis. This T1-weighted MR scan demonstrates a Fungal sinusitis. This T2-weighted MR scan shows the hyperintense
hyperintense mass in the left maxillary sinus, surrounded by focus in the left maxillary sinus seen in Figure 12.45 as signal void
hypointense fluid (arrow). A second hyperintense focus is seen (arrow). The remaining contents of the sinus are decreased in
in the maxillary sinus. signal intensity in comparison to the T1-weighted MR scan. The
inflamed sinus mucosa is hyperintense (open arrows). The proton­
density weighted scan showed the maxillary contents as of lower
signal intensity in comparison to the T1 -weighted scan. This
Figure 12.47 progressive decrease in the signal intensity on T2-weighted scans
compared to T1-weighted scans is typical of fungal infection in the
Squamous cell carcinoma of the sphenoid sinus. This axial CT sinuses. lntrasinus hemorrhage can resemble fungal sinusitis: the
scan demonstrates an enhancing, destructive mass (T) eroding difference is in the T2-weighted scan, where the hemorrhagic area
the sphenoid sinus and the petrous ridge. Artifacts from the is decreased in signal intensity, but not to the extent seen in fungal
dense bones of the base of the skull are seen to cause sinusitis. The inflamed sinus mucosa is hyperintense.
significant degradation of the image.
Figure 12.48
Squamous cell carcinoma of the sphenoid sinus. This sagittal T1-
weighted MR scan of the same patient as Figure 12.47 clearly
delineates tumor (T) extension anteriorly into the ethmoid
complex, with destruction and erosion of the anterior wall of the
sphenoid sinus. There are no artifacts from bone on MR scans.
168 An atlas of imaging of the paranasal sinuses

12.49 12.50

12.51 12.52

Figure 12.49 Figure 12.50

Squamous cell carcinoma of the sphenoid sinus. This T2- Squamous cell carcinoma of the sphenoid sinus. This proton­
weighted MR scan of the same patient as Figure 12.47 density weighted sagittal MR sequence of the same patient as
demonstrates the malignant lesion (T) to be inhomogeneous and Figure 12.47 shows a mass of varying signal intensity arising
of varying signal intensity, with focal areas of hyperintensity. The from the sphenoid sinus. The mass (T) extends superiorly to
internal carotid artery is encased by the mass. involve the sella and encases the right internal carotid artery
(arrow). Posterior extension (black arrows) into the prepontine
region, with shift of the basilar artery, is well seen. As bone does
not cause artifacts on MR scans, this is an excellent example of
the superior soft-tissue resolution unobtainable on CT.

Figure 12.51 Figure 12.52

Ameloblastoma. This T1-weighted MR scan shows an Ameloblastoma. This T2-weighted MR sequence of the same
inhomogenous mass (lower T) of intermediate signal intensity in patient as Figure 12.51 shows the tumor (T) to have focal
the right maxillary sinus, with scattered hypointense foci areas of hyperintensity from necrosis, surrounded by the
(necrotic areas) in the mass. The mass is seen to destroy the hyperintense inflamed mucosa. A cyst is seen in the left
walls of the maxillary sinus, visualized on MR as loss of the maxillary sinus, with inflammatory changes in the left anterior
signal void bony margins (arrows). Medially, the mass is seen ethmoid sinus. The roof of the ethmoid sinus is intact; there is
to block the entire nasal cavity; superiorly, it extends (second no evidence of intracranial extension of tumor (arrows).
T) into the ethmoid sinus.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 169

12.53 12.54

12.55 12.56

Figure 12.53 Figure 12.54

Angiofibroma. This coronal T1-weighted MR sequence Angiofibroma. This axial T2-weighted MR scan of the same
demonstrates a mass (M) isointense with brain in the patient as Figure 12.53 demonstrates the mass to be variable
nasopharynx, left ethmoid complex, and the nasal cavity. The in signal intensity. The mass is seen invading the middle cranial
mass extends laterally into the left pterygopalatine Iossa, and Iossa, inferior orbital fissure and cavernous sinus. The inflamed
the pterygoid muscles are involved. Note the normal sinus mucosa is hyperintense.
demarkation of the muscles by the bright signals from fat on
the normal side (arrows). These fatty planes are lost by tumor
infiltration on the left side.

Figure 12.55 Figure 12.56

Esthesioneuroblastoma. This sagittal T1-weighted MR scan Esthesioneuroblastoma. This coronal T1-weighted MR scan of
demonstrates a homogenous mass isointense with brain (A). the same patient as Figure 12.55 shows the mass (T) to arise
The mass is eroding the cribriform plate (arrows) and extends from the roof of the nasal cavity, with invasion of the ethmoid
outside the dura on the undersurface of the frontal lobe in the complex on the right side. The ethmoid fovea is destroyed
anterior cranial Iossa. (arrow).
170 An atlas of imaging of the paranasal sinuses

12.57 12.58

12.59 12.60

Figure 12.57 Figure 12.58

Esthesioneuroblastoma. The Gd-DTPA enhanced MR scan of Esthesioneuroblastoma. This sagittal T1-weighted scan
the same patient as Figure 12.55 shows enhancement of the demonstrates a homogenous sinonasal mass (T) isointense
tumor matrix, with intracranial extension and meningeal with brain. This mass has destroyed the floor of the anterior
involvement (arrows). The brain is elevated by the tumor, cranial Iossa. Although bone is not imaged on MR scans, the
though tumor does not infiltrate the brain. normal signal-void floor (open arrows) of the anterior cranial
Iossa is replaced by the tumor. There is direct tumor invasion
into the frontal lobe (black arrows).

Figure 12.59 Figure 12.60

Metastatic melanoma. On this T1-weighted scan a mass (M) Metastatic melanoma. On this T2-weighted scan of the same
isointense with muscle is seen in the maxillary sinus extending patient as Figure 12.59, the mass (M) in the maxillary sinus is
to involve the floor of the nasal cavity. The mass is destroying of mixed signal intensity. The thin rim of hyperintensity is the
the walls of the sinus. The inferior rectus muscle is involved by inflamed sinus mucosa. There are no specific signal intensity or
the tumor mass in the orbit (arrow). other features that can characterize any tumor on MR.
 Magnetic Resonance Imaging of inflammatory conditions and tumors 171

12.61 12.62

Figure 12.61 Figure 12.62

Basal cell carcinoma. This T1 -weighted MR scan demonstrates Basal cell carcinoma. This T2-weighted MR scan of the same
a mass (T) of intermediate signal intensity in the ethmoid sinus, patient as Figure 12.61 demonstrates the inhomogenous mass
destroying the lamina papyracea, with extension into the orbit. to be of varying signal intensity, with hyperintense areas in the
ethmoid complex and in the medial aspect of the orbit (arrows).

- rt
13
Three-dimensional reconstruction imaging of
the paranasal sinuses

Neal Lofchy John Stevens Judy Trogadis

Recent advances in computer technology have vastly In a typical clinical study, a set of serial images
changed the practice of medicine today. Perhaps the may be obtained using nondestructive techniques
most striking of these have been advances in diagnos­ such as CT or MR. For optimal accuracy, these
tic imaging. Computed tomography (CT), magnetic should be adjacent cross sections with no overlap or
resonance (MR), and positron-emission tomography gaps from one section to the next.
(PET) scans have greatly improved diagnostic capabil­
ities. We now, however, have the ability to convert
these two-dimensional (2D) images into three-dimen­
sional (3D) objects. In the early and mid 1980s,
Reconstruction
researchers developed the use of computer-assisted
The serial images used at a VI workstation are
3D reconstructions from serial electron micrographs
composed of a 2D array of small dots or pixels. The
for the study of neuronal form and function (Stevens
software of the workstation in the reconstruction
et al. 1980, Stevens and Trogadis, 1984). More
process creates a 3D representation by converting
recently, clinical applications for this technology have
each pixel into a cube of data, called a voxel. This
been developed that culminated in the first 3D
array of voxels represents the total 3D structure of
neuroimaging meeting at Johns Hopkins University in
the original object.
October of 1990 (Price and Zinreich 1989, Zinreich et
It is important that the outline or edge of each
al. 1990a, b). This chapter is concerned with the
object of interest within the voxel volume be identi­
technique of 3D imaging and its applications in recon­
fied. This is accomplished by a process termed
struction of the paranasal sinuses.
segmentation (Figure 13.1 ). For example, bone and
soft tissue can be distinguished on CT scanning as
objects with differing Hounsfield densities (between
500 and 2000, and between O and 50, respectively).
These selected densities can then be converted into
VOLUME INVESTIGATION groups of identified voxels. More sophisticated
methods, however, are required for MR scan data
The process of 3D imaging is part of a larger process
as one must distinguish between objects of differing
termed volume investigation (VI). In order to under­
signal intensity, not density. Identifying where a
stand VI, it is helpful to compare it with computer­
surface starts and stops - whether it is by differing
assisted design (CAD). CAD uses a computer
densities or signal intensities - is always called
workstation to create or design new objects, whereas
object segmentation. Once appropriate segmenta­
VI uses a workstation to convert an existing object
tion levels and boundaries are determined, recon­
into a 3D computer image. This image is created or
struction can begin in order to create a 3D image.
reconstructed from serial 2D cross sections taken
from the original object. These may be obtained
nondestructively from CT, MR, and PET scans, or
confocal microscopy, or destructively from light and Display
electron microscopy or serial digitized photographs.
Volume investigation involves three basic steps: 1, Viewing of the reconstructed 3D image represents
reconstruction; 2, display and 3, analysis. the next step. Here the object of interest can be
 Three-dimensional reconstruction imaging of the paranasal sinuses 173

seen as a solid rotating surface or volume, which slice width decreases. A slice width of 3.0 mm is
helps in understanding its relationship to other adequate to provide an accurate reconstruction
objects, its relative size, geometric shape, etc. without undue radiation exposure to the patient.
Figures 13.2-13.6 give examples of 3D scan recon­
structions.
Reconstructions from serial MR slices are pos­
sible, but these will not give adequate information on
Analysis bone. MR data, however, will provide superior soft­
tissue resolution. This is advantageous for 3D
This step involves both qualitative and quantitative
imaging of neoplastic processes within the sinuses.
examination of the volumetric data. Qualitative
The technique of 3D imaging is proving to be
analysis consists of detailed study of the recon­
beneficial for patient communication, medical educa­
structed object using a variety of display options.
tion, and preoperative surgical planning. Further­
Examples include rotation, magnification, light and
more, new technology has recently been developed
surface texture enhancement, selective trans­
to assist intraoperatively as well (Leggett et al.
lucency, and the shaving of objects to reveal inner
1991). This so-called viewing wand is an intra­
structure. A user can thereby interact with a VI
operative localization device that combines a 3D
workstation in order to more fully understand the
imaging workstation loaded with the patient's pre­
geometric relationships within an object's volume.
operative CT study and a hand-guided, position­
More objective analysis can be achieved by quanti­
sensing, articulated arm mounted on the side of the
fying these relationships with volumes, distances
operating table. This arrangement enables correla­
and surface areas, as well as statistical characteri­
tion of the patient on the operating table with the 3D
zation of the object itself. In this regard, quantitative
CT image, thereby providing visualization, localiza­
analysis has proven to be of value in both scientific
tion, and guidance during an operative procedure.
applications and clinical research (Stevens and
This is currently being used in vivo for selected
Trogadis, 1990).
neurosurgical procedures. Further development of
this technology will allow for its use with functional
endoscopic sinus surgery. The potential advantages
include reduced risk of damage to orbital and/or
intracranial structures and improved surgical training
APPLICATIONS FOR IMAGING techniques.
THE PARANASAL SINUSES There are inherent limitations of VI, however, that
require consideration. It is a time-intensive proce­
Three-dimensional images of the paranasal sinuses dure requiring a skilled technician with knowledge of
are reconstructed from serial CT scan slices. These radiographic anatomy - the VI process is interac­
slices may be axial or coronal; however axial images tive, not automated. In addition, the accuracy of the
are preferable, to avoid inclusion of dental artifact shape or calculated volume of the reconstructed 3D
that often obscures sinus anatomy on coronal slices. object is dependent upon the quality of the original
Reconstructions have been made using varying slice 2D data. As techniques of paranasal sinus imaging
width intervals - accuracy, of course, increases as improve, so will the quality of the 3D reconstructions.
174 An atlas of imaging of the paranasal sinuses

13.1A 13.18

13.1C 13.1D

Figure 13.1
Object segmentation of tissues of varying Hounsfield densities
on an axial CT image through the maxillary sinuses. The
original 20 image (A) is shown, together with segmentation for
reconstruction of bone (B), soft tissue (C) and air (D).
 Three-dimensional reconstruction imaging of the paranasal sinuses 175

13.2 13.3

Figure 13.2 Figure 13.3

Reconstructed lateral wall of right nasal cavity. The frontal and Reconstructed lateral wall of left nasal cavity. The bone
sphenoid sinuses (in red) are seen as well as the semilunar overlying the optic nerve (in green) has been made transparent
hiatus, and the middle ethmoid air cells opening onto the to demonstrate. the nerve's proximity to the posterior ethmoid
ethmoid bulla. cells.
176 An atlas of imaging of the paranasal sinuses

13.4A 13.48

13.4C 13.5

Figure 13.4 Figure 13.5

Reconstructions with selected coronal views (A) through the Posterobasal view of orbits and nasal cavity with globes and
maxillary antra showing the ostia bilaterally, (B) at the level of optic nerves (green). The maxillary sinus ostia are clearly
the optic nerves showing their relationship to the posterior visible.
ethmoid air cells,.and (C) through the sphenoid sinus.
 Three-dimensional reconstruction imaging of the paranasal sinuses 177

13.6A 13.68

13.6C 13.60

Figure 13.6
Three-dimensional reconstruction of a CT scan of a patient with
an antral choanal polyp. (A) Overlying skin intact. (B) Skin
selectively cut away to reveal underlying bone and polyp (red)
within the nasal cavity. (C) Skin removed. (D) Bone overlying
maxillary antrum made translucent to reveal antral portion of
polyp.
178 An atlas of imaging of the paranasal sinuses

13.6E 13.6F

Figure 13.6 continued

(E) Bony maxilla removed to display entire polyp. (F) Polyp with
antral (1) and choanal (2) portions.
14
Computer-assisted
. surgery of the paranasal
sinuses
Ludger Klimek Ralph Mosges Michael Hawke

Endonasal surgery has become standard for the THE COMPUTER-ASSISTED

treatment of diseases of the paranasal sinuses. The
endonasal approach is no longer the exception, as SURGERY SYSTEM
there are very few diseases of the paranasal sinuses
that must be treated via the external approach. This The computer-assisted surgery (CAS) system
was not always the case. Ever since its introduction described here was assembled from existing and
before the turn of the century, and up to the late newly developed hardware in collaboration with the
1970s, endonasal sinus procedures were considered Institute for Measuring Techniques, and the
to be extremely risky and in many hospitals were Department of Otorhinolaryngology, Plastic, Head
prohibited as they were felt to be too dangerous. The and Neck Surgery, Aachen Technical University
renaissance of these procedures arose when visual (RWTH), Aachen, Germany, from 1984 to 1987
aids such as the microscope, the endoscope and (Schlondorff et al 1987, Mosges and Schlondorff
magnifying glasses were introduced and used in 1988, Mosges et al 1989, Adams et al 1990). The
combination with newly developed functional surgi­ CAS system has been shown to be extremely helpful
cal techniques (Wigand 1981, Stammberger 1991). as an orientation aid in skull-base surgery, orbital
Extensive statistics have proved that the compli­ surgery and neurosurgical procedures (Mosges and
cations of endonasal sinus surgery are rare and no Schlondorff 1988, Klimek et al 1991a,b, Laborde et
more frequent than with the external approach. al, in press). CAS has since been further developed
However a 2% complication rate during endonasal and adapted to the special requirements of
surgery is still widely accepted (Freedmann and Kern paranasal sinus surgery. The system consists of
1979, Wigand 1981, Stankiewics 1989, Rauchfuss three components: an image generation device,
1990). The complications are: orbitoocular, vascular image processing equipment and a location measur­
and encephalomeningeal. The reasons for the resid­ ing system (Figure 14.1).
ual complication rate are often found in a lack of
intraoperative orientation. When paranasal sinus
procedures are carried out endonasally, orientation is
often reduced by bleeding, with a resulting impair­ Image generation
ment of the surgeon's field of view. Moreover, pro­
cedures that rely on topographic landmarks are less For image generation a tomographic imaging
precise when previous surgical procedures or tumor system, either computed tomography (CT) or
have destroyed these landmarks. magnetic resonance imaging (MR) is required. At
The objective of the computer-assisted surgical our hospital the computer tomographs Somatom 2,
system presented in this chapter is to reduce the Somatom DR or Somatom Plus, or a magnetic
rate of complications by improving the surgeon's resonance tomograph Magnetom (Siemens,
intraoperative orientation. The prerequisite of Germany) are available. For paranasal sinus
preventing the surgeon from violating critical struc­ surgery, CT scans utilize 1 or 2 mm thick transverse
tures is the necessity to indicate at any given time (axial) cuts that are continuous and non-overlapping
the topographic relationship between the instrument slices are taken {approximately 30-60 slices). Axial
and the vulnerable structures. cuts are taken primarily for the avoidance of dental
180 An atlas of imaging of the paranasal sinuses

artifacts. The data are then transmitted either by and counterbalanced arm elements. We have
floppy disks or via a fiberoptic network, the trans­ applied optical increment encoders for shaft angle
portation medium of the experimental PACS (Picture measurement. A dedicated 68008 microcomputer
Archiving and Communication System) of Aachen calculates the position of the tip of the stylus from
University Hospital. the measured angles and the given arm lengths.

Image processing Applications in intraoperative

A specially developed workstation is used for the localization
creation of the three-dimensional model and for
further image processing. The computer system For practical application, a preoperative high-resolu­
currently employed is based on the VME-bus. The tion CT or MRI scan is carried out. To correlate the
central processing unit (CPU) module is an Eltee R co-ordinate system of the created 3D model with the
Eurocom-5-R equipped with a MC 68020 processor actual position of the patient's skull relative to the
and 68681 coprocessor. The most important task of measuring arm, four reference points must be
the CPU is the generation of the voxel model and defined (Figure 14.4). These markers must be visible
the transformation of the co-ordinates of the 3D co­ on the CT images and also be identifiable during the
ordinate digitizer. 360 and 80 MB hard disks are operation. We use radiopaque plastic markers for
used for mass storage. The memory capacity is this purpose. The markers are attached to the
sufficient for the storage of 128 CT or MR images. patient's skull for imaging and replaced afterwards
As usual, the images are displayed in grey shades, with color markings. The co-ordinates of the markers
whereas graphic and alphanumeric information - are entered into the computer by touching them with
such as the co-ordinate digitizer's position or pull­ an electronic 'mouse'.
down menus - are superimposed in arbitrary colors The system must be calibrated at the beginning of
via a color 'look-up' table. For the display of the 3D the operation. This is achieved by tipping the
model, special hardware has been developed: the markings with the stylus within 15 s. This procedure
3D co-ordinate transformer. It takes only 90 ms for must be repeated after every displacement of the
the visualization of a 5122 image, independent of the skull during surgery.
specific transformation coefficients (angle of the After the calibration procedure, the position of the
sectional views, zoom factors, etc.) Either a pseudo­ instrument in the region of interest and its presenta­
plastic 3D image can be produced or the examiner tion on the screen are visually tied together; that is,
can look into the area from all sides and in all layers the display image dynamically moves to the cor­
by moving an electronic 'mouse'. Visualization of responding three perpendicular sectional views of
three perpendicular slices (sagittal, coronal, axial) is the voxel model respective to the chosen cut in the
standard (Figure 14.2). 3D presentation. In this way, the surgeon gets
precise orientation instantaneously, at a rate of 20
slices/s determined by the motion of the digitizer.
The accuracy with which instruments can be
positioned with the CAS system was first determined
Three-dimensional co-ordinate by in vitro measurements. In the laboratory, the
measurement inaccuracy proved to be within 0.4 mm in a measur­
ing volume of 0.36 m3 • The accuracy of measure­
Electromechanical 3D co-ordinate digitizers have ment with the CAS system decreases if instruments
been developed for applications in mechanical that are too thin, and thereby too flexible, are used.
engineering. The individual arm segments of these Additionally, we determined the accuracy for bone
devices are connected to each other through rotary using a phantom skull furnished with the customary
joints. The angles of each of the rotary joints is CAS markers. A study of 128 sequential CT slices
measured by rotary encoders so that the co­ with 1 mm slice thickness and 1 mm intervals was
ordinates of the tip of a measuring probe mounted carried out and stored in the CAS system. Different
to the arm can be calculated. Such an electro­ measuring probes were introduced into the skull and
mechanical measuring device has been developed the position of the instrument as indicated on the
by our group (Figure 14.3). It has six rotary joints CAS monitor was compared with the actual position
 Computer-assisted surgery of the paranasal sinuses 181

of the probe inside the skull. Measurements were possibility to turn objects, by means of movements
repeated 80 times for each instrument. The standard of the 'mouse' in split seconds on the monitor, as
deviation was 0.6 mm. In less than 15% of the the surgeon moves the patient during paranasal
measurements, the deviation exceeded voxel size of sinus surgery to improve the view.
1 mm. During intraoperative applications, soft-tissue Besides this easily operated basic function,
deviations and incorrect registration of the measur­ special options are available which expand the appli­
ing points may decrease accuracy. cations of the system. First, using the zoom function
CAS can be used alone or as an addition to visual the user can have optional details enlarged on the
aids such as the endoscope and the microscope. monitor. Small pathologies are represented more
For use in endoscopic paranasal sinus surgery, two clearly, and critical regions can be examined more
different methods of application are available. With exactly. Second, a detailed differentiation of soft
the first method, the position of the endoscope itself tissue becomes possible by the selection of the
is exactly determined with the help of CAS. For this Hounsfield scale. The Hounsfield unit is the measure
application the endoscopes are fitted into special of density for CT and encompasses densities from
mounts and the established dimension data of -1000 to +3000, including all clinically relevant
several endoscopes are integrated into the CAS tissues. The density values are represented as
software, so that every single endoscope can be varying shades of gray on a CT image: the CT can
used as a measuring instrument of the CAS system. display 4000 different shades of gray, whilst the
To date, the hardware and sottware com\)onents human e"{e can d,'2>\.\n�&'2>h (:)n\i ati\)\l\ i�. ,\\���\���,
ava1)ab)e a))ow combination of CAS with rigid the observer would see approximately 100 adjacent
endoscopes of 2.7 and 4.0 mm in diameter (Karl density values as only a single shade and would be
Storz, Endoscopy America Inc., Kennesaw, GA, unable to differentiate structures in areas in which
USA). The surgeon looks through the endoscope at tissues differ by only a few Hounsfield units. To
questionable structures and can display cuts at a overcome this problem, the raw image data is
given distance behind these structures on the selected by the radiologist for a special tissue
monitor. This provides the surgeon with a method for window. Structures of interest to the examiner can
looking ahead of i.e. beyond surfaces; this is so be displayed as visually distinguishable shades
especially helpful when opening ethmoid cells near of gray. In general the radiologist, not the surgeon
the skull base. is responsible for this selection procedure. The
In the second method, a measuring probe is used surgeon normally receives film copies and has no
in addition to an endoscope (Figure 14.5). The possibility of tissue selection of his own. As a result,
surgeon points the measuring probe at questionable the major part of the raw CT image information is
structures and compares the endoscopic appear­ lost. With the help of a CAS workstation, surgeons
ance with the image displayed on the CAS monitor. can use the whole information to obtain better tissue
This second technique also allows the CAS system differentiation.
to be used with the operating microscope.

THE COMPUTER-ASSISTED
Interactive planning of surgery on SURGERY SYSTEM IN PRACTICE
the monitor
The Aachen GAS-system has been used for surgi­
Another advantage of the CAS system is that it cal purposes of the paranasal sinuses in 193 cases
allows the surgeon to call up optical views of the by 11 surgeons in five hospitals. In our department,
operating field preoperatively. With the electronic 127 cases of endonasal procedures have been
'mouse' one can move in all directions back and documented (Figure 14.6). Surgeons report that the
forth through the CT slices, and the additionally localizing aid in all cases functioned exactly as soon
produced image reconstructions as if walking as calibration procedures had been carried out.
through a corridor. These dynamics allow excellent lntraoperative in situ deviation never exceeded pixel
orientation and have proven to be of assistance in quantification of the CT scan (1-2 mm). For surgery
the simulation of operations on the monitor. The of infectious disease, the system was used
advantages of the CAS system in operation planning whenever more than just the maxillary sinus was
lie in its real-time behavior, that is to say in · the affected. In agreement with Stammberger (1991)
182 An atlas of imaging of the paranasal sinuses

the surgeon's main interest focused on the restora­ the middle turbinate, which is an important landmark
tion of the normal anatomy of the ethmoid sinus. In in this region, is often missing because turbinectomy
most cases, ventilation of the ethmoid was carried was part of the previous radical surgery. The dura
out. Some surgeons have however used the CAS then is often injured at its typical weak point, the roof
system for radical surgery of the paranasal sinuses. of the ethmoid near the exit of the anterior ethmoid
In cases of disease of the sphenoid sinus, it has artery through the cribriform plate (Stammberger,
been ventilated and drained using a transethmoid 1991). The missed diagnosis of a cerebrospinal fluid
approach (Figure 14.7). Also the frontal sinus has leak can result in life-threatening conditions such as
been approached via the ethmoid under CAS con­ meningitis or brain abscess. In clinical trials, none of
ditions. This has meant that surgeons could refrain the above described major complications have
from the time-consuming exposure of topographic occurred. A solution for the problem of intraopera­
landmarks. The duration of surgery also decreased tive localization was found in combining the pre­
dramatically. operatively generated image data with a
sophisticated 30 co-ordinate measuring device and
modern computer graphics. Similar devices have
been described by several authors for navigation in
neurosurgery, using either electromechanical
POTENTIAL FOR THE FUTURE (Watanabe et al 1987, 1989, Kosugi et al 1988,
Mosges and Schlondorff 1988, Reinhard et al 1988,
Endonasal surgery in the vulnerable regions near Mosges et al 1989, Guthrie and Adler 1991, Laborde
the skull base require a safe and precise surgical et al in press) or ultrasonic co-ordinate measuring
technique. Most complications occur when the systems (Roberts et al 1986, Friets et al 1989,
surgeon is not aware of the exact position of his Zweifel et al 1990). These freehand navigation
instruments. Orbital complications have been systems are quite different from automated surgery
described due to injuries to the lamina papyracea, robots (Young 1987, Kwoh et al 1988, Drake et al
the orbital muscles or the optic nerve itself. The optic 1991).
nerve is at the greatest risk in the posterior ethmoid We feel, that interactive frameless devices such
and sphenoid sinus. Another severe condition can as the one developed by our group can fill the
occur if the anterior ethmoid artery is severed and special needs of paranasal sinus surgery in a highly
the vessel retracts into the orbit, producing a effective manner. As well as on-line localization
massive orbital hematoma with compression of the assistance within the operation, CAS provides the
globe and the optic nerve. This may result in surgeon with valuable information for presurgical
immediate blindness if decompression cannot be planning. Although the number of cases is not yet
achieved under emergency conditions. Damage to sufficient for statistical analysis, we have observed
the internal carotid artery is a potential fatal compli­ that CAS enables the surgeon to avoid major compli­
cation that may occur from direct injury to the artery cations by providing highly accurate information of
within the sphenoid sinus; it may also occur when the location of surgical instruments. In addition to
massively pneumatized Onodi's cells are present, safer surgery, the thoroughness of the procedure
and the internal carotid artery bulges into these may be increased, especially in ethmoid surgery
posterior ethmoid air cells and is injured in this where overlooked diseased ethmoid cells or fissures
region. Encephalomeningeal complications most may be the reason for peristent or recurring
often occur when missing landmarks render orienta­ problems (Stammberger 1991). CAS enables the
tion difficult. surgeon to overcome the difficulties that occur
A typical indication for the use of the CAS system during practically every intervention when the view
is in patients with massive nasal polyposis who have is reduced by bleeding or pathologies. Based upon
undergone previous operations and in whom the an individual model of the patient's anatomy, the
anatomic landmarks are absent, due to either the surgeon can be guided through this extremely
disease itself or the previous operation(s). The vulnerable part of the body. Complication rates of
anatomy in the ethmoid region can be extremely 2% or more are no longer tolerable. The CAS
difficult to identify in these cases because of exten­ systems lead the way towards a zero complication
sive scarring and many adhesions. The insertion of rate in endonasal surgery.
 Computer-assisted surgery of the paranasal sinuses 183

.;_J:'_._·,,,,., ,__., ,•J.'.--', ,:·.

-
Figure 14.1
Principles of the CAS device.
184 An atlas of imaging of the paranasal sinuses

0.0

Zoom

14.2

14.4 14.3

Figure 14.2 Figure 14.3

Standard CAS display showing three perpendicular views The electromechanical measuring arm (co-ordinate digitalizer).
(sagittal, coronal, axial) of the sinus.

Figure 14.4
Display of reference markers as visualized on the CAS monitor
screen.
 Computer-assisted surgery of the paranasal sinuses 185

14.5 14.6

14.7

Figure 14.5 Figure 14.6

Combination of CAS and endoscope for endonasal procedures. lntraoperative scenario using CAS in endonasal and paranasal
surgery.

Figure 14.7
Display of instrument position during endonasal surgery.
15
The ostiomeatal unit in childhood
Sunil Ummat Michael Riding David Kirkpatrick

The techniques of intranasal endoscopic and micro­ ing a group of patients over time with successive CT
scopic sinus surgery have introduced new tools to scanning, could be done. This however would be
the armamentarium for the treatment of sinus cost-prohibitive and result in unnecessary radiation
disease, in which the role of sinus surgery has exposure to children. Our study utilized existing
shifted in emphasis towards functional preservation scans for data acquisition. The use of the computer
and restoration. A renewed interest in the anatomy allowed the magnification of images and greater
and radiologic appearance of the paranasal sinuses accuracy in measurement.
has arisen from the advent of these techniques.
Recurrent chronic sinusitis is a common problem
in the pediatric patient population. Although the
majority of patients will respond to medical manage­
ment, some may require further intervention. METHODS USED IN THE STUDY
Recently, functional endoscopic sinus surgery has
been utilized for treatment of pediatric sinus disease. We reviewed 196 pediatric CT scans. The children's
When operating upon children, the sinus surgeon ages ranged from 1-16 years. Patients with coronal
must be aware of the differences between adult and scans, no or minimal sinus disease, and adequate
pediatric sinus anatomy; consequently, knowledge of anatomic resolution for measurement were included
the developmental anatomy of the paranasal sinuses in the study. Patients with facial deformity, tumor
is a prerequisite for safe endoscopic and micro­ involvement of the paranasal sinuses, growth delay
scopic sinus surgery in children. or obscured anatomic detail were excluded. Ninety­
The ostiomeatal unit is now considered to be the six patients met the criteria and were further
critical area involved in the pathogenesis of the sinus studied.
disease. Efflux of secretions from the ethmoid, All patients had previously undergone CT
maxillary and frontal sinuses enter this region en scanning on a GE 9800 Quick scanner, utilizing a
route to the posterior nasal cavity. When one high spatial resolution program on a field of 120 x
contemplates the development of the paranasal 120 mm, displayed with a 512 x 512 matrix. The
sinuses, the frontal, maxillary and sphenoid sinuses collimation of the beam was 3 mm, using 120-140
are those that are commonly discussed. kV and 40 mA.
Unfortunately, however, little information is available Digital radiography to obtain a scout film was done
on the development of the ostiomeatal complex in all cases. The coronal scans were done in the
through childhood. In response to this, we standard position for the evaluation of the
commenced a study utilizing a CT scanner to chart ostiomeatal complex. Bone algorithms and bone
the anatomy and development of the ostiomeatal windows were used for the coronal scans.
unit area in childhood, from the age of 1 to 16 years. The patients were divided into groups of 1-year
The emphasis was on obtaining information that intervals as shown in Table 15.1. The measure­
would be of use to the endoscopic sinus surgeon. ments were done utilizing images generated by the
Furthermore, an attempt was made to obtain a set computer. The images were displayed, magnified
of normal values that could be of use in future and subsequently analyzed using cursor placement.
comparative studies on diseased patients. Each side was measured. The scans were random­
Ideally, a longer study, looking prospectively at the ized for age. Results were analyzed statistically
development of the ostiomeatal complex by follow- using Student's t-test with unpaired samples.
 The ostiomeatal unit in childhood 187

Anterior and posterior ethmoid

s�s\em w\d\hs
In measuring the anterior ethmoid system width,
each side was measured separately, as shown in
Figure 15.2A. The results shown here are mean
distances of one side from 1 to 16 years. The means
ranged from 0.39 to 0.79 cm. This represents a
doubling in size. When depicted graphically, these
results also suggest a linear rate of change (Figure
15.2C).
The width of each side of the posterior ethmoid
system was measured separately, as shown in
Figure 15.3A. The mean distance ranged from 0.48
to 1.1O cm. This increase is slightly more than that
seen in the anterior system. The plotted results also
depict a linear rate of change (Figure 15.38).
It appears, then that the ethmoid cell system
enlarges through childhood. There is approximately
a twofold increase in width of this system, with a
slighter greater increase in the posterior cells. Most
endoscopes and forceps currently in use are 3 mm
or greater in width. Our results suggest that further
care must be taken in smaller children because of
the decreased width and reduced margin of error.

lnfundibular length
The infundibular length was measured as shown in
Figure 15.4A. There appeared to be a greater
variability in the means. This finding is best shown
on a graph, through which a trend line is drawn
(Figure 15.48). The trend line shows an upward
slope. The maxillary ostia open at different areas
DIMENSIONS OF THE along the semilunar hiatus, and this may explain the
OSTEOMEATAL UNIT results seen.

Distance between right and left

lamina papyraceae
lnfundibular width
This measurement was taken at the level of ethmoid
bulla, and coinciding with a line drawn through the The infundibular width measurement was found to
orbits at their midpoint (Figure 15.1A). The line be surprisingly constant through childhood. This
represents the upper limit of the ostiomeatal measurement was taken at the entrance of the maxil­
complex. The results shown in Figure 15.1 B and C lary portion of the infundibulum (Figure 15.5A); at this
are the mean distances throughout the various age location, it remained at about 0.2 cm (P < 0.001).
categories. The mean ranged from 1.70 to 2.44 cm. This suggests that there may be a minimum width
The tabulated results can be plotted as shown in required for mucus flow. lnfundibular width measure­
Figure 15.1C. The slope of the curve suggests a ments were also taken further up along the infundibu­
linear change. lum where the range was from 0.09 to 0.15 cm. The
188 An atlas of imaging of the paranasal sinuses

maxillary inlet gives a constant point of reference, distance from the anterior nasal spine to the ethmoid
which is why measurements were taken at this level. roof was measured, at a constant angle of 55' (Figure
15.8A). The range of mean distances varied from 3.38
to 5.52 cm. The data show a gradual increase
throughout the early childhood years, with a plateau
The uncinate angle over the age of 1O years (Figure 15.8C).
The reults show that the distance from the anterior
The uncinate angle was measured as shown in the
spine to the miduncinate process in adults is virtu­
CT scan in Figure 15.6A. The angle was determined
ally the same as the distance from the anterior spine
by the point of contact between the uncinate process
to the ethmoid roof in a child over 1 O years of age.
and the lateral nasal wall at the origin of the inferior
Again a guideline may be established by the data
turbinate. Again the results (Figure 15.6B and C)
obtained in this study.
showed very little change of this parameter through
childhood (P<0.001), although there does appear to
be a slight decrease in the angle through childhood.

Anatomic variants
Distance between the inferior Haller's cells
turbinate and cribriform plate
We found a high incidence of Hailer's cells (Figure
In order to better appreciate the change of the 15.9A) in the pediatric age group. The presence of
ostiomeatal unit area in relation to the roof of the Hailer's cells was found to be 79/96 or 82%. The
nasal cavity, the distance between the inferior cells ranged in size from 0.22 to 0.52 cm in width.
turbinate and the cribriform plate was measured When present, Hailer's cells compose a portion of
(Figure 15.7A). The mean distances ranged from the lateral infundibular wall. In the CT scans we
1.76 to 2.58 cm. We can see that there is an initial examined, the cells did not appear to appreciably
steady change in this distance, followed by a plateau alter the infundibular width.
during the later childhood years (Figure 15.7B). This This increased prevalence of Hailer's cells in
measurement additionally conveys an estimate of children is an interesting finding. The Hailer's cell is
the distance superiorly that is present when one is situated in the lateral wall of the infundibulum and
working at the level of the base of the uncinate. contributes to its shape. The presence of these cells
did not appear to result in narrowing of the infundibu­
lum. The information, along with the finding that the
Distance from the anterior nasal infundibular width remains similar throughout child­
hood, suggests that there are factors which affect
spine to the ethmoid roof the growth of the ostiomeatal unit and maintain its
patency. The patency may be affected by superim­
The nasal spine is a landmark for various anatomic posed mucosal edema, closing the narrow infundibu­
measurements. Studies of cadavers and skulls have lum. The reason why the infundibulum is narrow
frequently used the anterior nasal spine as a point remains to be answered. Does the proximity of the
of reference. Calhoun et al (1990) have measured infundibular walls create a distance between the
the distance from the anterior spine to the ethmoid mucosa which allows for the most efficient efflux of
foreola and the miduncinate process. The means secretions from the sinuses in the normal individual?
were found to be 5.0 and 3.6 cm respectively. The
mean angle from the nasal floor to the mid uncinate
process was 50'. The mean angle from the nasal
floor to the fovea was reported to be 62'. We
computed a distance from the nasal spine to the Concha bullosa
ethmoid roof at a constant angle of 55' (Figure
15.9A}. We found that in smaller children, 62' was Concha bullosa was found in the middle turbinate in
too large an angle and the line of trajectory would 4/96, 4.2% of patients. Three had bilateral concha
land much more anterior than in older children; 55' bullosa and one only on the left side. The size was
was a more suitable angle for measurement. not determined.
Using the scout film generated by the computer, the These results indicate the prevalence of concha
 The ostiomeatal unit in childhood 189

bullosa to be quite low in the pediatric population. imaging. There appears to be predictable linear
Concha bullosa has been reported to be anatomi­ growth of the ethmoid sinus system and upper nasal
cally associated with an increased incidence of sinus cavity width. Little change occurs within the
disease. Since we studied children who had no or ostiomeatal unit itself in terms of the infundibular
minimal sinus disease, we can only conclude that width and uncinate angle. There appears to be an
the prevalence of this anatomical variant is less than early growth pattern of the nasal cavity in terms of
is seen in adults. height, with a plateau in the later childhood years.
And, finally, there appears to be an increased preva­
lence of Hailer's cells and a decreased prevalence
of concha bullosa in the pediatric population.
CONCLUSIONS We hope that our results provide further insight
into the understanding of the development of the
The results of our study have implications for the ostiomeatal complex in childhood, and that some of
endoscopic and for the microscopic sinus surgeon. the measurements may be useful to the functional
Knowledge of the developmental anatomy of the sinus surgeon. We still feel, nevertheless, that
ostiomeatal unit and surrounding structures is impor­ preoperative assessment of coronal CT scans is of
tant for safe functional sinus surgery in children. In utmost importance in order to assess abnormal
our study, we have attempted to quantitate this anatomy in each individual case. Identification of
development by examining several parameters. landmarks still remains the most important form of
In conclusion, we feel that the ostiomeatal unit is intraoperative guidance available to the functional
readily identifiable radiographically in children sinus surgeon.
through the use of computerized tomographic
190 An atlas of imaging of the paranasal sinuses

AGE MEAN LAMINA-LAMINA

(years) distance (cm)

1-2 1.70
2-3 1.75
3-4 1.85
4-5 1.93
5-6 1.94
6-7 1.96
7-8 2.03
8-9 2.04
9-10 2.21
10-11 2.26
11-12 2.25
12-13 2.32
13-14 2.44
14-15 2.41
15-16 2.43

15.1A 15.18

2.5

C
E
2.0
C
.E
1.5

0 2 4 6 8 10 12 14 16
Age (years)

15.1C

Figure 15.1
lnterlaminar distance. (A) 3 mm coronal CT section of the
ostiomeatal unit demonstrates the method for measuring the
interlaminar distance (between arrows). (B) Mean for each age
group. (C) The plotted data: note the linear rate of change.
 The ostiomeatal unit in childhood 191

AGE MEAN ANTERIOR ETHMOID

(years) WIDTH (cm)

1-2 0.39
2-3 0.40
3-4 0.50
4-5 0.55
5-6 0.48
6-7 0.53
7-8 0.65
8-9 0.63
9-10 0.62
10-11 0.60
11-12 0.69
12-13 0.75
13-14 0.79
14-15 0.76
15-16 0.78

15.2A 15.28

(cm)
1.0

0.8

-�
0.6
"6

0.4
-�
0.2

0
0 2 4 6 8 10 12 14 16
Age (years)

15.2C

Figure 15.2
Anterior ethmoid width. (A) 3 mm coronal CT section of the
ostiomeatal unit demonstrates the method for measuring the
anterior ethmoid width. The lines shown are computer­
generated graphics. (B) Mean for each age group. (C) The
plotted data.
192 An atlas of imaging of the paranasal sinuses

AGE MEAN POSTERIOR

(years) WIDTH (cm)

1-2 0.48
2-3 0.56
3-4 0.67
4-5 0.72
5-6 0.78
6-7 0.78
7-8 0.90
8-9 0.89
9-10 0.89
10-11 0.93
11-12 0.87
12-13 0.96
13-14 1.04
14-15 1.09
15-16 1.10

15.3A 15.38

(cm)
1.2

1.0
..c

·:;: 0.8

·o
..c 0.6

0
0.4
-�

0.2

0
0 2 4 6 8 10 12 14 16
Age (years)

15.3C

Figure 15.3
Posterior ethmoid width. (A) 3 mm coronal CT section of the
ostiomeatal unit demonstrates the method for measuring the
posterior ethmoid width. (B) Means for each age group. (C) The
plotted data: note the linear rate of change.
 The ostiomeatal unit in childhood 193

AGE MEAN INFUNDIBULAR

(years) LENGTH (cm)

1-2 0.86
2-3 0.86
3-4 0.88
4-5 0.90
5-6 0.95
6-7 0.89
1.:;;a 1.14
8-9 0.94
I �;; :10 1.15
10-11 1.20
11....12 1.10
12-13 1.36
h 1�;;141>5. ,,j.36
14-15 1.10
1!:t-16 ·,:1...28

15.4A 15.48

(cm)

1.5-
D D
- -
D -- ------------- - 0-
-
---------D -
D - �------ D D
g> 1.Q­
..9! --il-

---CJ. -8---ri---cr
-
D

:s
=i 0.5-

0 ...;------�-----�--�--�--�-----1
1 1 1 1 1 1 l

0 2 4 6 8 10 12 14 16
Age (years)

15.4C

Figure 15.4
lnfundibular length. (A) Magnified 3 mm CT section of the
ostiomeatal unit demonstrates the method for measuring the
infundibular length (between arrows). Note presence of Haller
cell (asterisk). (B) Means for each age group. (C) The plotted
data: note the variability.
194 An atlas of imaging of the paranasal sinuses

AGE MEA�.f INF0NDIBULAR

(y1�ars) +r w1oi � (9T
,; )
1.-2 0.19
'2-3 0.18
0.19
0.20
§:1�
-�,;(
5-6
0:11
g:.;.7
7-8 0.18
8-9 ·d.19
9-10 0.19
10-11 · 0.22
1

11-12 0.22
12:L.13 t·,0.21,ii;.
13-14 0.20
14-15 0.21
15-16 0.22

15.5A 15.58

(cm)
0.5

0.4

"§ 0.3

0.2

0.1

0
0 2 4 6 8 10 12 14 16
Age (years)

15.5C

Figure 15.5
lnfundibular width. (A) Magnified 3 mm CT section of the
ostiomeatal unit demonstrates the method for measuring the
infundibular width (open arrow). (B) Means for each age group.
(C) The plotted data show little change in this parameter.
 The ostiomeatal unit in childhood 195

AGE MEAN UNCINATE ANGLE

(years) (degrees)

1-2 146
2-3 149
3-4 145.,
4-5 142
,5-6 14.�
6-7 . 145
7�;, 148..
8-9 143
·9-::10 140
· 10...:fl 146
11-1,2 142
'12-13 140
..13-14
' L\·
141
14-15 139
.',,,'

15---tp
j'.' >.,}i
141

15.6A 15.6B

(degrees)

200

To
C
150
Cll

·§ 100
C
::J

50

0 2 4 6 8 10 12 14 16
Age (years)

15.6C

Figure 15.6
Uncinate angle. (A) 3 mm coronal CT section of the ostiomeatal
unit demonstrates the method for measuring the uncinate angle.
The angle indicated by the arrow was measured. (B) Means for
each age group. (C) The plotted data: note the slight decrease.
196 An atlas of imaging of the paranasal sinuses

AGE MEAN INFERIOR TURBINATE TO

,,(years) CRIBl�9,R� �1,,tJE �i�tJ�p�e (cn;i)

1-2 1.76
2-3 1.93
3---4 "1.91
4-5 2.07
5-6 2.11
6-7 2.34
7-8 2.28
8-9 2.32
9-10 1
2.47
0-11 2.49
11-12 2.48
12-13 2.58
3�14 "
1
2.53·
14-15 2.51
15-16 2.56

15.?A 15.?B

(cm)
3.0

2.5

2.0

·5
.8 1.5

1.0

0 0.5
·�

0
0 2 4 6 8 10 12 14 16
Age (years)

15.?C

Figure 15.7
Distance between the inferior turbinate and cribriform plate. (A)
3 mm coronal CT section of the ostiomeatal unit demonstrates
the method for measuring the distance from the inferior
turbinate to the cribiform plate (between arrows). Note the
pneumatized cell along the lateral wall of the infundibulum
(open arrow). (B) Means for each age group. (C) The plotted
data.
 The ostiomeatal unit in childhood 197

AGE MEAN NASAL SPINE -

(years) ETHMOID �.QVEOLA
distance (cm)
1-2 3.38
2-3 3.60
3-4 4.05
4-5 4.40
5-6 4.48
6-7 4.48
7-8 4.61
8-9 4.73
9...:10 4.90
10-h 5.1?
11�12 5.34
12-13 5.45
13-14 5.52
14-15 5.50
15-16 5.51

15.8A 15.8B

(cm)
6

ct! 5
Q)

4
·o
3
a,
I
Q)
2
·o..

ct!

0
0 2 4 6 8 10 12 14 16
Age (years)

15.8C

Figure 15.8
Distance between the anterior nasal spine and ethmoid roof.
(A) Scout film of the skull showing method of measuring the
distance between the nasal spine and the roof of the ethmoid
sinus. The angle indicated (curved arrow) is 55". (B) Means for
each age group. (C) The plotted data: note the slope of the
curve.
198 An atlas of imaging of the paranasal sinuses

15.9A 15.9B

Figure 15.9
Anatomic variants. (A) Coronal scan through the ostiomeatal
unit. Hailer's cell present bilaterally (arrow). (B) This coronal
scan reveals th� presence of a left middle turbinate concha
bullosa (asterisk).
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Index
Page numbers in italic refer to the illustrations.

Abscesses: Atrophic rhinitis, 90, 105 Computed tomography (CT), 2,

intracranial, 12, 86, 95 Autonomic nervous system, 5, 6 24-30
intraorbital, 36, 84, 85, 94 Axial scans, 26-7, 27-8, 31, 145 administration of contrast, 28
intravenous contrast, 28 artifacts, 26
osteomyelitis, 84, 85 Barotrauma, 38 comparison with MR, 28-30
Accessory maxillary sinus ostia, 12, Basal cell carcinoma, 155, 171 computer-assisted surgery, 179
15, 43, 45, 57, 76 Basal projection, radiography, 33, enlargement, 26-7
'Accessory middle turbinate', 48 33, 34 interpretation and reporting, 28,
Acromegaly, 41 Basiocciput, 12 29
Acute sinusitis, 31, 35, 82, 91 Beam hardening, 26 malignant tumors, 110-12, 111,
Adenocarcinoma, 109, 112, 120 Benign disease: 154
Adenoid cystic carcinoma, 109 inflammatory disease, 82-90, normal anatomy, 41-52, 53-72
Adhesions (synechiae), 129, 137 91-105 postoperative, 122, 126
Agger nasi, 13, 18, 20 MR, 149-52, 156-67 projections, 27-8
Agger nasi cells: polyposis, 27 resolution, 25-6
anatomic variants, 73, 74 tumors, 106-7, 113-18 scanning planes, 26-7, 27, 31-2
anatomy, 13, 15 Bismuth iodoform paraffin paste three-dimensional reconstruction,
CT and MR, 42, 55-6, 72 (BIPP), 129, 135, 137 172-3, 174-8
AIDS, 84 Blindness, 129, 182 versus MR, 143-4, 154
Allergic polyps, 28 Blood, MR, 151 Computers:
Alveolar process, 12 Blood flow, 5-6 computer-assisted surgery,
Alveolar recess, 12, 43, 58 Bone: 179-82, 183-5
Ameloblastoma, 168 advantages of CT, 30 MR, 143
Anatomy, 10-16, 17-23 MR, 142 three-dimensional reconstruction
CT and MR, 41-52, 53-72 metastatic tumors, 111 imaging, 172-3, 174-8
conventional radiographs, 34-5 remodelling, 111 Concha bullosa:
Angiofibroma, 107, 112, 115, 154, Brain, MR, 141 anatomic variants, 75, 77-8
169 Breast cancer, metastases, 155 anatomy, 13, 15
Angiography, 28, 112 in childhood, 188-9, 198
Anterior clinoid process, 69, 71 Calcium, fungal sinositis, 83, 152 CT and MR, 49, 62-3, 65-7
Anterior cranial fossa injury, 129-30 Caldwell's projection, 24, 33, 33, 36 inflammatory disease, 75, 77
Antibiotics, 35-6, 83, 84 Caldwell-Luc procedure, 123-4, mucoceles, 75, 78-9
Antral puncture, 36 125, 131 polyps, 87
Antrochoanal polyps, 87-8, 99, 108, Caldwell-Luc radical antrostomy, 1 Concha inferior, 22
177-8 Carcinoma, 109, 118-19, 149 Concha media, 22
Antrostomy, 1, 36, 73, 123, 131 Carotid artery, 2, 6, 12, 16, 19, 50, Conchal sinus, 49
Antrum, 33 51, 58-9, 69-70, 130, 182 Congenital anomalies, scanning
cysts, 35, 37, 38 Cartilage, MR, 142 plane, 27
polyps, 35, 39 Cartilage of Huschke, 1O Contrast:
Arteries: Cavernous sinus thrombosis, 86, 130 administration of, 28
carotid, 2, 6, 12, 16, 19, 50, 51, Cellulitis, orbital, 85, 94-5 MR, 144-5
58-9, 69-70, 130, 182 Cerebrospinal fluid, 13, 14, 130, Coronal scans, 26-7, 27-8, 31, 32,
ethmoid, 16, 182 182 145
infraorbital, 16 Chemotherapy, 112 Costs, advantages of CT, 30
maxillary, 6, 11, 51 Children: Cranial fossa, 19, 59
ophthalmic, 6, 12, 16 ostiomeatal unit, 186-9, 190-8 Cranial nerves, 16, 51, 106
Artifacts, 24, 25, 26, 30, 31, 143, surgery, 186 Cribriform plate:
144, 148 Choanae, 10, 13 anatomy, 10, 13, 16, 17, 20, 23
Aspergillosis, 151-2 Chondrosarcoma, 111, 112 in childhood, 188, 196
Aspergillus, 83, 93 Chronic sinusitis, 31, 35, 83, 91-3, CT and MR, 46, 61-2
Aspergillus flavus, 151 123, 131, 158-61, 186 postoperative complications, 139
Aspergillus fumigatus, 151 Ciliary beat, 5 scanning plane, 26
Aspergil/us niger, 151 Complications, postoperative, Crista galli:
Atelectatic maxillary sinus, 44, 59 129-30, 137-9, 179, 182 anatomic variants, 73-4, 76
 Index 205

anatomy, 13, 17 ethmoidectomy, 1, 124-7, 132-5 external frontoethmoidectomy, 127

CT and MR, 43, 62 ethmomaxillary sinus, 45, 50, 60 intracerebral abscesses, 86, 95
Cysts: ethmosphenoid sinus, 50 inverting papillomas, 108
antral, 35, 37, 38 external frontoethmoidectomy, 127 malignant tumors, 152
dentigerous, 36, 40, 107, 114-15 inverting papillomas, 108 mucoceles, 88, 89, 102-3, 138,
MR, 141, 142 key diseased area, 4 150, 157-8
retention, 37, 38, 88, 91, 99-100, malignant tumors, 109, 112, 152 osteoma, 106, 113
150, 156, 161 mucoceles, 39, 88, 89, 100, osteoplastic flap with obliteration
102-4, 150 of, 127-8, 137
Decongestants, 6, 7, 9, 67-8 osteoma, 106 osteoplastic surgery, 36
Dental disease, 36 persistent infections, 1-2 scanning plane, 26
Dental fillings, 26, 27, 31, 148 polyps, 35, 87, 162 sinusitis, 92
Dentigerous cysts, 36, 40, 107, postoperative appearance, 126-7 trephination, 36, 127, 136
114-15 scanning plane, 26, 28 ventilation and drainage, 5, 8
Deoxyhemoglobin, 151 sinusitis, 82, 160-1 Frontal sinus ostium, 22
Diabetes, 83, 91 Ethmoidal clefts, persistent Functional endoscopic sinus
Dorsum sella, 61 infections, 1-2 surgery, 1-3, 125-6, 132-3
Drainage, 5 Ethmoiditis, 85 Fungal sinusitis, 83, 87, 91, 93,
Ethmomaxillary plate, 12, 20, 44 151-2, 166-7
Ectopic teeth, 40 Ethmomaxillary sinus, 45, 50, 60
Edema, MR, 141, 142 Ethmosphenoid sinus, 50 Gadolinium-diethylenetriamine­
Electromagnetic fields, 141 Eustachian cushion, 51, 67 penta-acetic acid (Gd-DTPA),
Embolization, 28 Eustachian tube, 18, 51 144-5, 150
Emphysema, orbital, 52, 72, 138-9 Examination time, advantages of Gardner's syndrome, 106
Empyema, 35, 82 CT, 30 Gauze packs, 129, 135, 137
Endoscopic sinus surgery, 1-3, External ethmoidectomy, 124-5 Gel phase, mucous blanket, 5
125-6, 179 External frontoethmoidectomy, 1, 127 Glycoprotein, 149
computer-assisted surgery, 181 External nose, CT and MR, 41, 53 Goblet cells, 149
Enlargement, CT, 26-7 Extraconal orbital cellulitis, 85 Gradient coils, 140
Epidural abscesses, 86, 95 Extradural abscesses, 12 Gradient-echo sequence, MR,
Epithelium, 5 142-3
Erectile tissue, 6, 7, 9, 10, 49, 68 Fast-low-angled shot (FLASH), 143 Gradient-recalled acquisition in
Esthesioneuroblastoma, 109, 111, Fat, MR, 141, 142, 146 steady state (GRASS), 143
112, 119, 154, 169-70 Fiberoptic rod telescopes, 2 Granuloma gravidarum, 107
Estrogens, 6 Fibroma, ossifying, 106-7, 113 Greater wings, sphenoid, 18, 19,
Ethmoid air cells: Fibroosseous lesions, 111 50, 51
anatomy, 13, 14, 15, 16, 17, 18, Fibrous dysplasia, 106-7, 113-14 Ground lamella, 14, 15, 21, 46, 48
19 Fistulas, oroantral, 36
CT and MR, 41, 46 Flip angle, 141 Hailer's cells:
postoperative appearance, 126 Fontanelles, 11, 12, 15, 17, 43 anatomic variants, 74, 75, 79, 81
Ethmoid artery, 16, 182 Foramen lacerum, 12 anatomy, 16
Ethmoid bone, 12-13 Foramen ovale, 12, 58 in childhood, 188, 198
Ethmoid bulla: Foramen rotundum, 11, 12, 18, 19, CT and MR, 45, 60-1
anatomy, 13, 14, 15, 17, 18, 20, 69, 70 Hard palate, 10, 58
23 Foramen spinosum, 58 Hasner's valve, 11, 16, 52
anatomic variants, 74, 75, 79-80 Foreign bodies, 36, 109, 118 Heavy metals, fungal sinositis, 83,
CT and MR, 46, 61-3 Fourier analysis, 143, 147 152
polyps, 87 Free induction decay (FID), 141 Hemangioma, 107, 115
Ethmoid fovea, 2, 20, 62, 130 Frontal bone: Hemangiosarcoma, 111
Ethmoid foveolae, 11, 13, 17, 18, 46 anatomy, 11, 12, 17 Hematoma, 38, 129, 182
Ethmoid infundibulum: fibrous dysplasia, 106, 114 Hemorrhage:
anatomic variants, 76-7 osteomyelitis, 84, 93 intraoperative, 130, 139
anatomy, 12, 14-15, 16, 20, 22-3 Frontal bulla, 41, 54 MR, 151, 162, 165
in childhood, 187-8, 193-4 Frontal recess: postoperative, 129, 135
CT and MR, 42, 45, 47, 65 anatomic variants, 74-5, 76, 80-1 Hemosiderin, 143, 151
functions, 5, 8 anatomy, 5, 14, 15, 17, 20, 22, 23 High-resolution CT, 25
polyps, 87, 95, 136 CT and MR, 41-2, 54 Hormones, and blood flow, 6
Ethmoid labyrinth, 10, 11, 13, 45, osteoma, 113 Hounsfield units, 25, 181
59, 106 polyps, 87, 99 Hydrogen, MR, 140, 146
Ethmoid notch, 17, 18 Frontal sinus: Hyperplasia, maxillary sinus, 44
Ethmoid sinus: acute sinusitis, 35 Hyperthyroidism, 6
anatomy, 10, 12-13, 20 anatomy, 11-12, 17, 18, 19, 22, Hypertrophied middle turbinate, 49
in childhood, 187, 191-2 23 Hypocycloidal polytomography, 24
computer-assisted surgery, 182 aplasia, 53 Hypoplasia, maxillary sinus, 44,
conventional radiography, 34, 35 computer-assisted surgery, 182 59-60, 132
CT and MR, 45-6, 50, 54, 61-2 CT and MR, 41, 53-5, 62 Hypothyroidism, 6
206 Index

Image reconstruction, MR, 143 postoperative complications, 129 fungal sinusitis, 166-7
lmmunocompromised patients, 82, Larmor frequency, 141, 146 hyperplasia, 44
83, 84, 151-2 Lateral projection, radiography, 24, hypoplasia, 44, 59-60, 132
Inferior meatus: 33, 33, 34 inferior meatal antrostomy, 123,
anatomy, 11, 17, 18, 20 Lateral recess, 43, 87 131
antrostomy, 1, 123, 131 Lateral rhinotomy, 128 inverting papillomas, 108, 116
CT and MR, 49-50, 67 Lateral sinus: malignant tumors, 109, 110, 110,
Inferior orbital fissure, 17, 71 anatomic variants, 75, 80-1 118, 152, 168
Inferior orbital foramen, 17, 59 anatomy, 14, 15, 21 mucoceles, 88, 89, 101, 104, 124,
Inferior rectus, 22 CT and MR, 47, 65 150
Inferior turbinate: Lateral topograms, 32 osteoma, 106
anatomy, 10, 11, 17, 18, 19, 20, 23 Lateralized middle turbinate, 49 osteomyelitis, 84, 85
in childhood, 188, 196 Lesser wings, sphenoid, 18, 19, 50, polyps, 156-7
CT and MR, 49-50, 58, 62, 67-8 69 recurrent disease, 122-3
nasal cycle, 6, 9 Lockwood's ligament, 16 retention cysts, 150, 161
postoperative complications, 138 Luminal opacification, 35 scanning plane, 26
topical decongestants, 6, 7, 9 Lung cancer, metastases, 155 septated, 45, 60
Inflammatory disease: Lymph-node metastases, 112 sinusitis, 31, 35, 82, 91-3, 123,
intravenous contrast, 28 Lymphoepitheliomas, 112 131, 158-61
MR, 148-9, 156-61 Lymphoma, 109, 112 three-dimensional reconstruction
radiologic appearance, 82-90, imaging, 174
91-105 Magnesium, fungal sinositis, 83, 152 ventilation and drainage, 5, 8
scanning plane, 27 Magnetic resonance imaging (MR): Maxillary sinus ostium, 15-16, 20,
surgery, 122 basic principles, 140-5, 146-7 22, 23, 45
lnfraorbital artery, 16 compared with CT, 28-30 Maxillectomy, 128-9
lnfraorbital canal, 43 computer-assisted surgery, 179 Measuring probes, computer­
lnfraorbital fissure, 11, 51, 52, 58 drawbacks, 143-4, 149 assisted surgery, 181
lnfraorbital foramen, 43 inflammatory disease, 148-9, Meatus see Inferior meatus;
lnfraorbital nerve, 12, 16, 17, 20, 156-61 Middle meatus; Osteomeatal
43, 88 normal anatomy, 41-52, 54-72 complex; Superior meatus
lnfratemporal fossa, 11, 59, 70, 112 postoperative, 122 Medial rectus, 23
lnfundibulum see Ethmoid three-dimensional reconstruction, Melanoma, malignant, 109, 128
infundibulum 172-3 metastases, 155, 170
lnterlamellar cells, 49 tumors, 148-9, 152-5, 156, Meningitis, 86, 130, 182
Interpreting CT, 28 167-71 Metastatic hypernephroma, 111
lntersinus septum, 12 versus CT, 143-4, 154 Metastatic tumors, 109, 111, 112,
lntraconal inflammation, 85 Magnetopharmaceuticals, 144 155, 170
lntracranial complications, 86, 95 Magnets, 140 Methemoglobin, 151
lntraepithelial goblet cells, 5 Magnification, CT, 26-7 Microscopes, 2, 179
Intranasal ethmoidectomy, 1 Malignant tumors: Middle cranial fossa, 11, 69, 112
lntraorbital complications, 85 CT, 154 Middle meatus:
Intravenous contrast media, 28, intravenous contrast, 28 anatomic variants, 48
144-5 MR, 152-5, 156, 167-71 anatomy, 13, 15, 18
Inversion recovery sequences, MR, radiologic appearance, 109-12, antrostomy, 1
142 118-21 CT and MR, 47-8
Inverting papillomas, 107-8, scanning plane, 27 Middle turbinate:
116-18, 122, 128 Manganese, fungal sinositis, 152 anatomic variants, 48-9, 65-6,
Iron, fungal sinositis, 83, 152 MAS setting, 25 74, 75, 78
Mastoid air cells, 34 anatomy, 13-15, 17-21, 23
kVP setting, 25 Maxilla: basal lamella, 47
anatomy, 11, 12 CT and MR, 48-9, 58, 62, 65-8
Lacrimal bone, 10, 11, 12, 13, 17, 42 fibrous dysplasia, 106 polyps, 87
Lacrimal crests, 59 nasolacrimal groove, 11 postoperative complications, 130
Lacrimal fossa, 16, 52, 61 Maxillary artery, 6, 11, 51 secondary middle turbinates, 48,
Lacrimal gland, 11, 16, 52 Maxillary crest, 1O 65
Lacrimal sac: Maxillary nerve, 11, 51 surgery, 126, 134-5
anatomy, 16, 19 Maxillary ostium, 12, 15 Midfacial necrotizing lesions, 108-9,
CT and MR, 42, 52, 72 Maxillary sinus: 118
mucoceles, 88, 89 anatomic variants, 44-5, 59-60 Molars, 12, 35
Lamina papyracea, 2 anatomy, 11, 12, 20, 23 Movement artifacts, 26
anatomy, 13, 14, 15, 19 atelectatic, 44, 59 Mucoceles:
bone destruction, 39 Caldwell-Luc procedure, 123 anatomic variants and, 75, 78-9
in childhood, 187 CT and MR, 43-5, 54-5, 57-8, conventional radiographs, 36, 39
CT and MR, 45-6 67 MR, 150-1, 157-9, 164-5
postoperative appearance, 126-7, double, 45 postoperative appearance, 124,
135-6 ethmomaxillary sinus, 45, 50, 60 129, 138
 Index 207

radiologic appearance, 87, 88-9, Optic chiasm, 70 Piriform aperture, 10, 17

98-104 Optic foramen, 69 Pituitary fossa, 12, 19, 50, 112
scanning plane, 27 Optic nerve: Pituitary gland:
Mucoepidermoid tumors, 112 anatomy, 12, 16, 19, 23 anatomy, 12
Mucoraceae fungi, 83 computer-assisted surgery, 182 contrast agents, 145
Mucormycosis, 83, 91 CT and MR, 50, 52, 70-1 CT and MR, 50, 70
Mucosa: postoperative complications, 2, cysts, 150, 162
blood flow and supply, 5-6 129, 139 tumors, 112, 120, 162
drainage, 5, 8 safety during surgery, 2 Pixels, 25, 172
MR, 148-9 scanning planes, 26, 28 Planum sphenoidale, 13, 18
mucous glands, 5, 11 three-dimensional reconstruction Plasmocytoma, 109
topical decongestants, 6, 7, 9 imaging, 175-6 Pleomorphic reticulosis, 108, 109
Mucous retention cysts, 37, 38, BB, Optic strut, 50, 52, 69 Polypoid mucoceles, 89
91, 99-100 Orbital abscesses, 36 Polyps, 49, 87, 95-9
Multiplanar scanning, 28 Orbital apex: antrochoanal, 39, 87-8, 99, 108,
Muscles: anatomy, 16, 19 177-8
MR, 142 CT and MR, 51-2, 71-2 contrast media, 28
mastication, 71 malignant tumors, 112, 121 conventional radiographs, 35
orbital apex, 16 'Orbital apex syndrome', 88 ethmoid infundibulum, 136
Orbital canal, 19 MR, 50, 162-4
Nasal bone, 12 Orbital cavity, malignant tumors, 112 maxillary sinus, 156-7
Nasal cavity, anatomy, 10-16, 19 Orbital cellulitis, 85, 94-5 middle meatus, 131
Nasal cycle, 6, 9, 156 Orbital emphysema, 52, 72, 138-9 surgery, 124-5, 134-5
Nasal fossae, 1 O Orbital injuries: Polytomography, 24
Nasal septum: decompression, 126, 127, 182 Postoperative appearance, 122-30,
aerated, 57 radiation, 24 131-9
anatomic variants, 74 surgical, 129, 138-9, 182 Pcitt's puffy tumor, 36, 84
anatomy, 10, 18, 19-20 Orbital plate, 17, 18 'Prechambers', 5
CT and MR, 61 Oropharyngeal cancers, 155 Premeatal groove, 42
deviations, 10, 42-3, 48, 53, 56 Orthopantomogram, 34 Premolars, 12, 35
spurs, 57 Ossifying fibroma, 106-7, 113-14 Projections, CT, 27-8
Nasal spine, 17, 18, 188, 197 Osteitis, 35, 83, 126 Protons, 140-2
Nasolacrimal duct, 11, 13, 16, 18, Osteoma, 106, 113 Pterygoid canal, 11, 12
20, 23, 49, 52, 58, 70, 72 Osteomyelitis, 11, 36, 84-5, 93-4 Pterygoid fossa, 11, 69
Nasolacrimal groove, 11 Osteoplastic flap, 127-8, 137 Pterygoid plates, 10, 11, 17-19, 58,
Nasopharynx: Osteosarcoma, 111, 112 67
anatomy, 10, 11 Ostiomeatal complex: Pterygoid (vidian) canal, 18, 19, 51,
conventional radiographs, 34 anatomic variants, 73-5, 76-81 58, 69, 70
CT and MR, 51, 62, 67 anatomy, 15-16 Pterygomaxillary fissure, 11, 51
inverting papillomas, 108 in childhood, 186-9, 190-8 Pterygopalatine fossa:
malignant tumors, 112, 119 CT and MR, 46 anatomy, 11
Necrotizing lesions, midfacial, polyps, 87 CT and MR, 43, 51, 58, 59, 69,
108-9, 118 scanning plane, 26 70
Nerves, 5, 6 malignant tumors, 112
cranial, 16, 51, 106 Palatine bone, 1O, 11, 12, 14, 17 scanning plane, 26
infraorbital, 12, 16, 17, 20, 43, 88 Palatine canals, 51, 67 Pulse sequences, MR, 142-3
maxillary, 11, 51 Palatine foramina, 11, 58 Pyoceles, 27, 75, 89, 102-3, 105
olfactory, 10, 13, 14, 46, 84 Panoramic tomograms, 33, 33, 34,
optic, 2, 12, 16, 19, 23, 26, 28, 36 Radiofrequency pulse, 141, 142,
50, 52, 70-1, 129, 139, 175-6 Panorex, 34 146
trigeminal, 11, 16, 70 Pansinusitis, 92-3 Radiofrequency (RF) coils, 140-1
vidian, 12, 51, 70 Papillomas, inverting, 107-8, Radiography, conventional (plain), 2,
Neuroblastoma, 112 116-18, 122, 128 24, 31, 33-6, 37-40
Noise artifacts, 26 Paradoxically bent middle malignant tumors, 11O
Non-Hodgkin's lymphoma, 109, turbinate, 49 postoperative, 122
119-21 Parasympathetic nervous system, 5, Radiotherapy, 112
6, 11 Reconstruction:
Odentogenic keratocysts, 114 Parietal bone, 12 MR, 143
Odontogenic tumors, 155 Partial volume effect, 25, 31 scanning plane, 27, 31
Ohngren's line, 11O Patients: three-dimensional imaging, 172-3,
Olfactory nerve, 10, 13, 14, 46, 84 advantages of CT, 30 174-8
Onodi's cells, 13, 19, 50, 61, 129, drawbacks to MR, 143-4 Recurrent disease, 73, 82, 122-3,
182 scanning position, 27 161, 186
Ophthalmic artery, 6, 12, 16 Petrous bone, 12 Reid's line, 27
Optic canal, 12, 16, 18, 19, 51-2, Photons, 25 Renal cell carcinoma, metastases,
71 Physiology, 5-6, 7-9 155
208 Index

Reporting CT, 28, 29 postoperative complications, 130 Topograms, lateral, 32

Resolution, CT, 25 retention cysts, 150 Transnasal ethmoidectomy, 124-5,
Retention cysts, 37, 38, 88, 91, scanning plane, 26, 28 132
99-100, 150, 156, 161 sinusitis, 35, 37, 82, 91, 92, 160 Transorbital ethmoidectomy, 125
Retrobulbar hematoma, 129 Sphenoid sinus ostia, 12, 14, 61 Trauma:
Rhabdomyosarcoma, 111 Sphenopalatine foramen, 11, 13, 69, conventional radiography, 36
Rhinitis, atrophic, 90, 105 70 hemorrhage, 151
Rhinoliths, 109, 118 Sphenopalatine ganglion, 11 mucoceles, 159
Rhinotomy, lateral, 128 Spin-density weighted images, MR, scanning plane, 27
Ribbon gauze, 129 142 Trephination, frontal sinus, 36, 127,
Ring artifacts, 26 Spin-echo sequences, MR, 142 136
'Spin-lattice relaxation', 141 Trigeminal nerve, 11, 16, 70
Sagittal scans, 27, 145 'Spin-spin relaxation', 142 'Tuberculum opticum', 50
Salivary gland tumors, 111, 152 Squamous cell carcinoma, 6, 109, 'Tuberculum septi', 6, 7, 10
Sarcomas, 109, 112 111, 112, 152, 167-8 'Tumescence of Zuckerkandl', 6, 7,
Scan thickness, 25 Squamous temporal bone, 12 10
Scanning plane, 26-7, 27, 31-2 Streak artifacts, 25, 26, 31 Tumors:
Scar tissue, 112, 126, 145, 159 Submentovertical projection, 24, 33 benign, 106-7, 113-18
Schwannoma, 40, 111, 152 Superconductive magnets, 140 MR, 141, 142, 145, 148-9,
Sella turcica, 13, 34 Superior meatus, anatomy, 13 152-5, 156, 167-71
Semilunar hiatus, 14, 15, 17, 47, Superior orbital fissure, 12, 17-19, malignant, 109-12, 118-21
62, 74 26, 61, 69, 71 Tunica propria, 5
Septal swell body, 6, 7, 10 Superior recess, maxillary sinus, Turbinate sinus, 49
Septoplasty, 43 43-4 Turbinates:
Serous glands, 5 Superior turbinate, 13, 18, 19, 20, anatomy, 10, 13
Shim coils, 140 23, 58, 62 scanning plane, 26
Sinus ostia, 5 Supernumerary frontal sinus, 41 see also Inferior turbinate;
Sinusitis, 37 Supreme turbinate, 13, 50 Middle turbinate; Superior
acute, 31, 35, 82, 91 Surgery: turbinate
chronic, 31, 35, 83, 91-3, 123, children, 186
131, 158-61, 186 complications following, 129-30, Uncinate process:
complications, 83-6 137-9, 182 anatomic variants, 74, 74, 77
fungal infections, 83, 87, 91, 93, computer-assisted, 179-82, 183-5 anatomy, 11, 12, 14, 15, 17-18,
151-2, 166-7 endoscopic, 1-3 20, 22-3
MR, 149-50, 158 postoperative appearance, in childhood, 188, 195
role of plain radiography, 35-6 122-30, 131-9 CT and MR, 42, 46-7, 58, 63-5
Skin tumors, 155, 171 Synechiae, 129, 137 polyps, 87
Soft palate, 10, 62, 69
Soft tissue, advantages of MR, 30 T1 relaxation time, 141, 146 Vascular anatomy, advantages of
Sol phase, mucous blanket, 5 T1-weighted images, 142 MR, 30
Sphenoethmoid recess, 11, 12, 13, T2 relaxation time, 141-2, 147 Vasoconstriction, 6, 7, 49-50
23, 69, 70 T2-weighted sequences, 142 Vasodilatation, 6, 9
Sphenoid: Tears, 16, 52 Ventilation, 5
anatomy, 10, 12, 18, 19 Teeth: Vidian canal, 12
CT and MR, 50 dental disease, 36 Vidian nerve, 12, 51, 70
fibrous dysplasia, 106, 114 dentigerous cysts, 107, 114-15 Viewing wands, 173
Sphenoid ethmoid recess, 18 ectopic, 40 Volume investigation, three-
Sphenoid rostrum, 18, 69 fillings, 26, 27, 31, 148 dimensional imaging, 172-3
Sphenoid sinus: roots, 12, 34-5, 82 Vomer, 10, 12, 17
anatomy, 12, 17, 18, 19, 23 Tendinous ring of Zinn, 72 Voxels, 25, 172
computer-assisted surgery, 182 Terminal recess, 14, 42 Water's projection, 24, 31, 33, 33, 82
conventional radiography, 34 Three-dimensional reconstruction Wegener's granulomatosis, 108-9,
CT and MR, 50-1, 56, 59, 61-2, imaging, 172-3, 174-8 118
69-70 Thrombophlebitis, 86 Whitnall's tubercle, 16
ethmosphenoid sinus, 50 Thrombosis, 28 Windows, CT, 25
hemorrhage, 165 TNM classification, tumors, 110, 11O
inverting papillomas, 108, 117 Tomography, 2, 24 X-rays, CT, 24-5
malignant tumors, 112, 152, panoramic tomograms, 33, 33, Xylometazoline hydrochloride, 6, 7,
167-8 34, 36 49
mucoceles, 88, 89, 150, 164 see also CT
polyps, 87 Tongue, 62 Zooming, CT, 26-7
postoperative changes, 161 Topical nasal decongestants, 6, 7, 9 Zygoma, 11, 12, 59, 106
An Atlas of Imaging of the Paranasal Sinuses