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Optimum imaging for sinonasal malignancy

A combination of computed tomography (CT) and magnetic resonance imaging (MRI) is now established as the optimum assessment of sinonasal malignancy. CT and MRI are of particular value in assessing the skull base, orbit and pteryo-palatine and infratemporal fossae. Although MRI offers better differentiation of tumour from surrounding tissue and fluid, coronal CT is still required for the demonstration of bone erosion particularly in the region of the cribriform plate. Thus the extent of local tumour spread may be determined with a degree of accuracy in excess of 98 per cent. However, the final determinant of penetration of the dura and orbital periosteum requires per-operative frozen section assessment. A knowledge of the tissue characteristics and site of origin can be of value in distinguishing some of the commoner sinonasal malignancies such as squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, olfactory neuroblastoma and chondrosarcoma. Imaging, particularly MRI also plays an important role in the post-therapeutic follow-up of patients, indicating areas of residual or recurrent disease, defining suspicious areas for biopsy. Post-operative surveillance is best achieved with three planar T1-weighted MRI, with, and without, gadolinium and axial T2-weighted sequences. The subtraction of the T1 pre- and post gadolinium T1 sequences can be of particular value in delineating recurrence

Optimum imaging for mucoceles

A mucocele is an epithelial lined mucus-containing sac completely filling a paranasal sinus and capable of expansion. They are relatively unusual, occurring most frequently in the fronto-ethmoidal region. The imaging features on plain X-ray, computerized tomography and magnetic resonance imaging are relatively characteristic allowing distinction of the lesion from other pathologies in this area although the mucoceles may occur in association with other pathologies such as nasal polyposis and neoplasia

Optimum imaging for inverted papilloma

Inverted papilloma is the most common benign tumour of the nose and paranasal sinuses, and usually arises in the lateral wall of the nasal cavity and the middle meatus. The diagnosis is suggested on computed tomography (CT) when there is a mass continuous from the middle meatus into the adjacent maxillary antrum, through an expanded maxillary ostium. The mass may contain areas of high density or calcification, and there may be sclerosis of the wall of the affected sinus. The main advantage of magnetic resonance imaging (MRI) is in defining the extent of the tumour, and in differentiating it from adjacent inflammatory tissue, but there are no certain signal intensity or enhancement characteristics to help differentiate inverted papilloma from sinus malignancy. In the differential diagnosis, antro-choanal polyp, malignant sinus tumours and chronic rhinosinusitis and fungal disease need to be excluded. The combination of bone deformity and sclerosis with the typical antro-meatal mass suggests a slow-growing tumour such as inverted papilloma

Rhinologic changes in Wegener's granulomatosis

Twenty-eight patients with a clinical diagnosis of sinonasal Wegener's granulomatosis were referred for imaging during the period 1990-2001. Of these, 10 had clinical symptoms and signs confined to the nose and sinuses and 18 had classical systemic Wegener's. The computed tomography (CT) and magnetic resonance (MRI) scans of the series were reviewed by a panel of one otolaryngologist and two radiologists. From the total of 28 patients, 85.7 per cent showed non-specific mucosal thickening in the nasal cavity or paranasal sinuses, 75 per cent showed evidence of bone destruction, and 50 per cent new bone formation in the walls of the sinus cavities. In addition the orbit was affected in 30 per cent of patients.The diagnosis of systemic Wegener's granulomatosis is made clinically but the condition may present characteristic features on imaging by CT and MRI. In a patient without a history of previous sinonasal surgery, a combination of bone destruction and new bone formation on CT is virtually diagnostic of Wegener's especially when accompanied on MRI by a fat signal from the sclerotic sinus wall. These changes are important diagnostically in localized sinonasal Wegener's granulomatosis where the clinical diagnosis may be uncertain and the cANCA test can be negative

Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea

Imaging is an important component in the investigation of unilateral watery rhinorrhoea suspicious of cerebrospinal fluid (CSF). Whilst the demonstration of the presence of beta 2 transferrin confirms that CSF is present it may prove difficult to demonstrate the exact site of origin. Fine detail coronal computed tomography (CT) with sections of 1-2 mm thickness through the anterior skull base may show small dehiscences and fractures. The commonest site for congenital dehiscences is the cribriform niche adjacent to the vertical attachment of the middle turbinate anteriorly and the superior and lateral walls of the sphenoid posteriorly. In the presence of frequent or constant CSF rhinorrhoea a CT cisternogram can be helpful in defining the exact site of the leak. Magnetic resonance imaging (MRI) is reserved for defining the nature of soft tissue Le. inflammatory tissue, meningoencephalocele or tumour. Finally, per-operative intrathecal fluorescein is helpful when imaging does not prove positive. A management algorithm for CSF rhinorrhoea is presented

Imaging for juvenile angiofibroma

Juvenile angiofibroma presents characteristic imaging signs, many of which allow diagnosis and accurate estimation of extent without recourse to the dangers of biopsy. The diagnosis by computed tomography (CT) is based upon the site of origin of the lesion in the pterygopalatine fossa. There are two constant features: (1) a mass in the posterior nasal cavity and pterygopalatine fossa; (2) erosion of bone behind the sphenopalatine foramen with extension to the upper medial pterygoid plate. Good bone imaging on CT is essential to show invasion of the cancellous bone of the sphenoid. This is the main predictor of recurrence: the deeper the extension, the larger the potential tumour remnant likely to be left following surgery. The characteristic features on magnetic resonance imaging (MRI) are due to the high vascularity of the tumour causing signal voids and strong post-contrast enhancement. MRI shows the pre-operative soft tissue extent of angiofibroma optimally, but its more important application is to provide post-operative surveillance: to show any residual or recurrent tumour, record tumour growth or natural involution and monitor the effects of radiotherapy

Fungal rhinosinusitis

Fungal infections in both their invasive and non-invasive forms can prove difficult to diagnose. The often characteristic appearances on imaging are of great assistance. CT is the primary imaging modality and is probably more accurate than MRI in diagnostic specificity and determining the extent of bone erosion. However this may require a modified scanning technique to adequately demonstrate the typical soft tissue density variations of fungi. MRI should be used to supplement CT when intra-cranial or intra-orbital extension is suspected