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Sinonasal imaging

Article  in  Imaging · March 2007

DOI: 10.1259/imaging/

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Imaging, 19 (2007), 39–54

Sinonasal imaging
1,3 2
S E J CONNOR, MRCP, FRCR, S HUSSAIN, MRCS, FRCR and 3E K-F WOO, MRCP, FRCR

1
Neuroradiology Department, King’s College Hospital NHS Foundation Trust, Denmark Hill, London
SE5 9RS, 2Department of Clinical Radiology, University College London Hospitals NHS Foundation
Trust and 3Radiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Summary
N CT is the initial imaging of choice for patients with symptoms of inflammatory
paranasal sinus disease.
N The aim of imaging the paranasal sinuses is to confirm diagnosis, localize the
disease, characterize the extent of pathology and describe any anatomical
variations.
N An understanding of the anatomy is important for surgical planning and some
normal variants can impair functional drainage pathways.
N As well as imaging findings in acute and chronic rhinosinusitis, there are five
patterns of inflammatory disease. This classification helps the surgeon to elucidate
whether surgery has a role and the type of surgery to perform.
N Beware of mimics of inflammatory disease such as tumours, odontogenic disease
and cephalocoeles.
N A wide variety of neoplasms, both benign and malignant, may arise in the
sinonasal cavity. Use the pattern of bony modelling to help distinguish aggressive
and non aggressive masses. DOI: 10.1259/imaging/
N MRI is complementary to CT. T2 weighted imaging is used for differentiating 52620519
tumour and inflammatory mucosal secretions. Orbital, infratemporal, intracranial
and perineural spread of disease is important. ’ 2007 The British Institute of
Radiology

Abstract. The purpose of imaging the paranasal sinuses is to provide further insights into sinonasal anatomy and the
confirm diagnosis, localize the disease, characterize the extent extent of pathology, whilst shortening the scan time.
of pathology and describe any anatomical variations. In this Multidetector CT is acquired axially which avoids the
review article, we aim to demonstrate the complex anatomy, its obscuration of anatomy by dental restoration.
variations and the appropriate imaging techniques. We will Submillimetric slices are reconstructed. Any reversible
describe and illustrate the wide spectrum of disorders affecting disease should ideally be treated with antibiotics and
the paranasal region and provide useful imaging features steroids prior to imaging. Low dose CT techniques
which are important for surgical planning and aid the should be employed and imaging should be reviewed
differential diagnosis of sinonasal abnormality. with a wide window width of 1500–2500 HU centred at
100–400 HU. Whenever soft tissue abnormality is
detected, its attenuation should be assessed with narrow
window widths and the perisinus soft tissues should be
Imaging techniques studied, particularly in the setting of facial pain. Coronal
reformats are most useful for evaluating the ostiomeatal
CT is routinely used for pre-operative planning prior complex, whilst sagittal reformats are particularly
to functional endoscopic sinus surgery (FESS) or in relevant to analysing the inferior frontal sinus drainage
patients with persisting symptoms post sinonasal sur- pathways, the sphenoethmoid recess, and the posterior
gery. It is also used to evaluate for the likelihood of sinus walls of the sphenoid and frontal sinuses. A volume of
pathology being the basis of more non-specific symp- data may also be provided for image-guided surgery,
toms such as facial pain. Rarer indications include the which is used in some centres to provide a real-time
evaluation of CSF rhinorrhea. It delineates the bony anatomical localization of a sensing probe during
anatomy, extent of sinus disease, obstruction of drainage surgery. If there is any suspicion of a neoplastic or
pathways and it serves as a road map for surgical complicated inflammatory process then either a higher
planning. CT is far superior to plain radiography in mA CT technique with additional contrast medium
terms of diagnostic accuracy and anatomic definition [1]. enhancement or an MRI study should be supplemented.
Radiographs are occasionally used to distinguish MRI with its superior contrast resolution is important
between rhinitis and acute rhinosinusitis to decide on in differentiating tumour and inflammatory mucosal
the appropriateness of antibiotic therapy. With the thickening or secretions [2, 3]. It is also used for tumour
advent of multidetector CT, multiplanar reformats can mapping, vascularity evaluation and assessment of

Imaging, Volume 19 (2007) Number 1 39

 S E J Connor, S Hussain and E K-F Woo

orbital, infratemporal, intracranial and perineural spread into the middle meatus. Bone is often naturally absent
of disease. along the medial wall of the maxillary sinus posterior to
MRI should be acquired with a slice thickness of 3– the uncinate plate forming a posterior nasal fontanelle. If
4 mm and a field of view of 18 cm. T2 weighted imaging the mucosa is also deficient, as is often the case in chronic
and post gadolinium imaging is particularly important sinusitis, then an accessory ostium is created. The
for differentiating tumour (intermediate T2 weighted ethmoid sinus is separated into the anterior and poster-
signal) from inflammation (increased T2 weighted signal) ior compartment (Figure 1b). The anterior ethmoid air
and multiplanar sequences should be employed. Sagittal cells drain into middle meatus often via the ethmoid
images are important to assess the posterior extent of bulla (Figure 1a). The posterior ethmoid air cells drain to
abnormality and fat saturated imaging is useful to the superior meatus.
visualize extrasinus and central skull base involvement. The frontal sinuses appear within the frontal bone and
MRI is used in some centres to assess the extent of are often asymmetric or occasionally hypoplastic. They
inflammatory disease in young patients. drain to the middle meatus or infundibulum (depending
on the site of anterior attachment of the uncinate process)
via the frontal ostium and then the inferior frontal sinus
Anatomy drainage pathway (Figure 1b). The anterior border of the
inferior frontal sinus drainage pathway is the agger nasi
The paranasal sinuses consist of the maxillary, cell, which represents the most anterior ethmoid air cell,
ethmoid, frontal and the sphenoid sinuses [4]. The and the posterior border is the ethmoid bulla (Figure 1b).
maxillary sinus drains via the maxillary ostium to the The sphenoid sinus drains via the sphenoid sinus
infundibulum, which is bordered by the uncinate plate ostium into the sphenoethmoidal recess (Figure 2).
laterally. The uncinate plate is attached to the neck of the The nasal cavity is divided by the nasal septum in the
inferior turbinate. The anterior attachment is a critical midline. It contains bony projections – the superior,
surgical landmark and it usually attaches to the lamina middle and inferior turbinates (Figure 1a). This then
papyracea although it may attach to either the middle defines the superior, middle and inferior meati. The
turbinate or anterior skull base. The free superior end of middle turbinate has two constant attachments which
the uncinate plate results in an uninterrupted air channel are critical surgical landmarks. There is a superior
to the hiatus semilunaris bordered superiorly by the attachment to the anterior skull base and a lateral
ethmoid bulla (Figure 1a). The hiatus semilunaris drains attachment to the nasal wall termed the basal lamella.

(a) (b)

Figure 1. (a) CT scan in coronal plane shows the normal paranasal sinus anatomy. The maxillary sinus borders with the orbital
floor (superiorly), lateral nasal wall (medially) and the retromaxillary fat and pterygopalatine fossa (posteriorly) (f 5 frontal
sinus, ae 5 anterior ethmoid air cells, mo 5 maxillary ostium, mt5 middle turbinate, it 5 inferior turbinate, u 5 uncinate
process, ei 5 ethmoid infundibulum, m 5 maxillary sinus, arrow 5 attachment of the middle turbinate on the anterior skull
base). (b) CT scan in sagittal plane shows the normal anatomy of the frontal sinus drainage pathway and the basal lamella
inserting to the skull base. This separates the anterior to the posterior ethmoid air cells. The anterior border of the inferior
frontal sinus drainage pathway is the agger nasi cell, which represents the most anterior ethmoid air cell, and the posterior
border is the ethmoid bulla. The borders of the ethmoid sinuses are the lamina papyracea laterally, the nasal cavity medially and
the fovea ethmoidalis and cribriform plate superiorly (f 5 frontal sinus, fo 5 frontal sinus ostium, bl 5 basal lamella, pe 5
posterior ethmoid air cells, s 5 sphenoid sinus).

40 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

(a) (b)

Figure 2. (a) CT scan in coronal plane. (b) CT scan in the sagittal plane. The normal anatomy of the sphenoid sinus and the
sphenoethmoidal recess is demonstrated. The sphenoid sinus borders with the sella turcica superiorly, ethmoid sinuses
anteriorly, clivus posteriorly and the nasopharynx inferiorly. (s 5 sphenoid sinus, se 5 sphenoethmoidal recess, sso 5 sphenoid
sinus ostium.)

The basal lamella is orientated in an oblique coronal and potentially impairs the drainage of the middle
plane, high anteriorly and low posteriorly. It is important meatus. A lamella air cell or conchal neck air cell is
in that it separates the anterior and posterior ethmoid air located in the middle turbinate above the level of the
cells (Figure 1b). Posterior to the ethmoid bulla and ostiomeatal complex and is unlikely to affect sinonasal
anterior to the basal lamella there is frequently an air drainage. Pneumatization of the superior and inferior
cleft or sinus lateralis, which is demonstrated on sagittal turbinates is occasionally identified but is of little clinical
sections. importance. A middle turbinate may also be paradoxical
The ostiomeatal complex is the junction where the with a medial convexity and may impair surgical access
mucociliary drainage of the frontal, maxillary and anterior to the ostiomeatal unit.
ethmoid air cells occurs and this is the main focus of FESS
[5]. This includes the inferior frontal sinus drainage
pathway, infundibulum, uncinate process, ethmoid bulla,
hiatus semilunaris and the middle meatus.

Normal variants
Normal variants are important to report for the
purposes of surgical planning and because they may
have a profound effect on sinonasal physiology predis-
posing to outflow obstruction. Normal anatomical
dehiscences may also facilitate the spread of infection.
Frontal cells are commonly seen and may be multiple.
They lie superior to the agger nasi cell and may impinge on
frontal sinus outflow. In the ethmoid region, there may be
extramural air cells, which extend outside the confines of
the ethmoid bone, and enlarged intrinsic ethmoid air cells.
The agger nasi cells and suprabullar air cells may be large
and obstruct drainage from the frontal sinus whilst
infraorbital (Haller) cells (Figure 3) and large ethmoid
bulla air cells may impinge on the ethmoid infundibulum.
Dehiscent lamina papyracea, low fovea ethmoidalis and
hypoplastic ethmoid labyrinth should be identified in
order to pre-warn the surgeon of variant anatomy.
The middle turbinate is usually rounded with a lateral
convexity. Variations of the middle turbinates include
pneumatization, which is termed a concha bullosa air cell Figure 3. CT scan in coronal plane shows bilateral infra-
if it is seen within the inferior bullous portion (Figure 4) orbital (Haller) cells (arrows). (dns 5 deviated nasal septum.)

Imaging, Volume 19 (2007) Number 1 41

 S E J Connor, S Hussain and E K-F Woo

Figure 4. CT scan in coronal plane shows a large concha

bullosa in the right middle turbinate (arrow).

The uncinate process also has normal variations

including pneumatization, deviation, duplication or Figure 6. CT scan in coronal plane shows dehiscence of both
optic nerves (arrows).
atelectasia [6, 7]. An atelectatic uncinate plate abutting
a non-pneumatized orbital wall will be at risk of orbital
penetration if removed. Nasal septal deviation and an carotid artery being particularly relevant. An anterior
associated bony septal spur may be the cause of nasal ethmoid artery traversing the ethmoid air cells without a
obstruction and also will impair surgical access to the bony covering is at risk of damage, retraction and orbital
nasal cavity necessitating correction. haematoma if not identified pre-operatively.
In the sphenoethmoidal region, there is extensive
variation in pneumatization. Sphenoethmoidal (Onodi)
cells (Figure 5) represent contiguous extension of the Inflammatory disease
posterior ethmoid into the sphenoid bone and results in
an unexpected ethmoid air cell abutting the optic canal. General concepts
There are frequent areas of bony thinning and dehiscence
in the walls of the sphenoid sinus with dehiscent optic The paranasal sinus anatomy is closely related to
nerve canal (Figure 6) and medial or dehiscent internal functional physiology. An understanding of the func-
tional drainage pathways is important and helps with
classifying sinus inflammatory disease. Mucociliary
clearance is the result of functional ciliated cells moving
mucous from the sinuses to the choana [8]. These cells
beat in a certain direction and create a characteristic flow
pattern. When this pattern is disrupted, stagnation of
mucous results and this in turn will cause sinusitis. The
main goal of surgery is to enlarge the natural sinus ostia
and preserve physiological mucociliary clearance.
Normal sinus mucosa is not identified on CT.
However thickening of the lining of the paranasal
sinuses may not represent inflammation or infection
since asymptomatic submucosal oedema and mucoid
secretions may both mimic inflammatory mucosal
thickening. Opacification of the sinonasal drainage
channels without significant proximal sinus disease is
most likely to represent transient changes. In general
mucosal thickening should not be seen in the frontal or
sphenoid sinuses in a healthy patient [9].
However, mucosal thickening less than 4 mm in the
maxillary sinus [9, 10] and less than 2 mm in the ethmoid
sinuses and the nasal cavity has been shown to be
Figure 5. CT scan in coronal plane shows an Onodi cell with frequently asymptomatic. That within the nasal cavity
a horizontal septum separating it from the left hemisphe- and ethmoid air cells also undergoes periodic changes
noid sinus (arrow). with the nasal cycle [9, 10]. Conversely, inflamed and

42 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

irritated mucosa may not appear thickened on CT. In excluded in children presenting with persistent sinusitis.
paediatric patients and in particular those under 2 years Similar findings on CT and MRI are seen to those in
of age, sinus opacification is most likely due to retained acute disease. However, in addition, mucosal thickening
secretions, tears and redundant secretions so there is or atrophy and inspissated secretions can result. There
little correlation with active infection. have been various objective staging systems used to
For these reasons a negative or nearly negative CT quantify the degree of sinonasal inflammatory disease.
indicates a low probability of chronic rhinosinusitis [11]. The most commonly used is the Lund classification of
The relationship between the severity of symptom of which CT scoring is an integral component [21]. On CT,
rhinosinusitis and CT findings remains controversial this will demonstrate higher attenuation in the opacified
[12–16]. The side demonstrating increased severity of CT sinus than in acute disease. New bone formation (bone
changes does not necessarily correlate with asymmetry thickening) and sclerosis along the contour of the sinus
of symptoms. may also be seen (Figure 8). This appearance may be
mimicked by surgical mucosal stripping and secondary
lamina propria fibrosis. Variable signal depending on the
Acute rhinosinusitis protein content is seen on MRI. When secretions are
particularly dessicated, the T2 weighted signal may be
Acute rhinosinusitis is defined as symptoms lasting very low and mimic an air filled sinus so close
less than 4 weeks [17]. Imaging clues for acute sinusitis correlation with CT is required (Figure 9). When there
are air–fluid levels (which may also result from recent is decreased sinus volume with collapse of the antral
nasal lavage), bubbly secretions, stranding and asymme- walls and inward bowing of the orbital floor, this is
trical mucosal thickening [18] and this should prompt described as silent sinus syndrome [22].
aggressive antibiotic therapy. Imaging is infrequently
performed in this clinical setting although it may
occasionally prove helpful since there is an overlap
between the symptoms of rhinitis and rhinosinusitis. Patterns of inflammatory disease
With the increasing use of antibiotics serious compli- There are five main patterns of chronic inflammatory
cations are fortunately becoming rare; however, imaging disease which classify the disease into distinct anatomi-
is mandatory in this setting [19]. Superficial complica- cal/pathological groups [23]. This classification helps the
tions include osteomyelitis, subperiosteal abscess, orbital surgeon to elucidate whether surgery has a role and the
abscess (Figure 7) and optic neuritis The ethmoid sinuses type of surgery to perform.
are the most often source of infection via the thin lamina (1) When inflammatory disease affects the maxillary
papyracea and the valveless ethmoid veins [20]. sinus, anterior ethmoid air cells and frontal sinuses, this
Intracranial complications include meningitis, epidural is termed an OMC pattern (Figure 10). There is variable
abscess/empyema, cerebritis, brain abscess and caver- involvement of the frontal sinuses depending on the site
nous sinus thrombosis.

Chronic rhinosinusitis
Chronic rhinosinusitis is defined as disease lasting
more than 12 weeks [17]. Cystic fibrosis, immune
deficiency, ciliary dysfunction and allergies should be

Figure 8. CT scan in coronal plane shows complete opacifi-

Figure 7. Enhanced coronal CT demonstrating bilateral cation of the right hemisphenoid sinus with thickening and
orbital abscesses (arrows). The ethmoid sinuses are most sclerosis of the sinus wall (arrow). The appearance is in
often the source of infection via the thin lamina papyracea keeping with chronic sinusitis. Minor mucosal thickening is
and the valveless ethmoid veins. also seen in the left hemisphenoid sinus.

Imaging, Volume 19 (2007) Number 1 43

 S E J Connor, S Hussain and E K-F Woo

Figure 10. CT scan in coronal plane shows an ostiomeatal

complex pattern of inflammatory disease with mucosal
Figure 9. MRI scan (coronal fat saturation T2) shows low thickening in the left maxillary antrum, infundibulum,
signal T2 areas in the left maxillary sinus and the ethmoid air middle meatus and the anterior ethmoid air cells. Minor
cells. CT (not shown) showed opacification. The appearances mucosal thickening is seen in the right maxillary sinus and
are consistent with concentrated proteinaceous secretions anterior ethmoid air cells.
from chronic sinusitis (arrow). There is also a high T2 signal in
the right maxillary antrum (double arrows) where secretions
used. For sphenoethmoidal recess pattern, the aim is to
are less desiccated.
enlarge the sphenoid ostium and establish drainage.
Techniques include external approaches but endoscopic
of uncinate plate insertion. If the frontal sinus is involved surgery with possible image guidance is used in
in isolation, this is called frontal recess inflammatory specialist centres. For sinonasal polyposis pattern,
pattern (a limited variant of the OMC pattern) [21]. surgical options include endoscopic polypectomy, FESS
(2) The infundibular pattern involves isolated obstruc- or sphenoethmoidectomy [24–26].
tion to the ethmoid infundibulum and or maxillary ostium.
(3) Sphenoethmoidal recess pattern (SER) refers to
when inflammatory changes in the sphenoethmoidal
recess obstruct the sphenoid sinus in isolation or in
conjunction with the posterior ethmoidal air cells.
(4) When extensive polyps are occupying the nasal
cavity and the paranasal sinuses, they can cause wide-
spread obstruction (apart from the inferior meatus) and
this is termed the sinonasal polyposis pattern.
(5) The sporadic pattern occurs when it is difficult to
identify a clear pattern to the inflammatory change. This
includes random mucosal thickening, polyps, retention
cysts, and mucocoeles.

Surgical options
The aim of surgery is to open and clear the drainage
pathways. FESS is the most commonly used technique.
With an infundibular pattern, ethmoid infundibulotomy
with possible limited ethmoidectomy should suffice. In
the osteomeatal complex (OMC) pattern, uncinatectomy
with possible maxillary antrostomy and ethmoidectomy
are the standard treatment (Figure 11). For frontal recess Figure 11. CT scan in coronal plane shows bilateral uncina-
inflammatory pattern, external frontoethmoidectomy tectomies, bilateral middle meatal antrostomies (*) and
and FESS techniques to relieve the obstruction can be partial resection of the anterior ethmoid air cells (+).

44 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

Post surgical imaging to be more frequently central and punctate as opposed to

curvilinear and peripheral calcifications associated with
In patients with recurrent symptoms post surgery, chronic non-fungal secretions (Figure 12). On MRI it
imaging plays a role in assessing the extent of FESS, demonstrates low signal on T1 but can be heterogeneous
detecting complications and demonstrating residual and low signal on T2.
patterns of disease. Where relevant, the radiologist Allergic fungal sinusitis characteristically demon-
should focus on the patency of the inferior frontal sinus strates multiple sinus opacification with hyperdense
drainage pathway, including lateralization of the middle material on CT and sinus expansion (Figure 13). There
turbinate and persisting agger nasi cells. The complete- is often a preserved rim of hypodense mucosa. Benign
ness of uncinatectomy should be assessed and particu- bony remodelling, resorption and erosion into adjacent
larly whether it has been performed too far posteriorly. structures can be seen. It is commonly associated with
The extent of ethmoidectomy and any post-operative sinonasal polyposis.
synechiae obstructing sinus drainage should be In invasive forms, there is extension outside the sinus
recorded. Persistent sinus opacification may also result lumen with involvement of the blood vessels, bone
from viscous secretions. When repeat FESS is considered, erosion and possible orbital and intracranial extension
there should also be careful examination of the integrity [27, 28]. It usually, but not exclusively, occurs in diabetics
of the middle turbinate attachment to the anterior skull and other immunocompromised patients. Three invasive
base (as there may be dehiscence post-turbinatectomy) forms were proposed by deShazo: granulomatous, acute
and whether there is any defect within the lamina fulminant and chronic invasive [29]. CT findings are
papyracea. Clearly there is role for imaging if there are non-specific but typically show sinus opacification with
overt complications such as cerebrospinal fluid (CSF) bony erosion and soft tissue infiltration.
leak, orbital injury or haemorrhage.

Destructive granulomatous rhinosinusitis

Fungal infection
Systemic diseases can involve the nasal cavity and
There are various different types of fungal infection. paranasal sinuses. The imaging features of Wegener’s
This is mainly classified as non-invasive and invasive granulomatosis are initially non-specific but later on,
forms. there is typical sinonasal mass with septal perforation
Non-invasive forms include mycetoma and allergic and non-septal bone erosion (Figure 14). The lateral
fungal sinusitis. Mycetoma or a fungus ball usually nasal wall can be involved. There may be extension
affects a single sinus and it demonstrates a focal lesion through the hard palate and to the orbit, deep facial
with areas of high density and possible calcification. spaces, nasopharynx and the skull base. The turbinates
Calcification associated with fungal infection is reported often appear truncated and shortened. In the chronic

Figure 13. Coronal post gadolinium T1 MRI scan shows

Figure 12. CT scan in axial plane shows complete opacifica- marked expansion of both anterior ethmoid air cells,
tion of the left hemisphenoid sinus with hyperdensity and hypointensity in the maxillary sinuses with peripheral mucosal
sinus expansion consistent with fungal sinusitis (arrow). enhancement resulting from allergic fungal sinusitis.

Imaging, Volume 19 (2007) Number 1 45

 S E J Connor, S Hussain and E K-F Woo

Figure 15. CT scan in coronal plane shows a large lesion

occupying the left maxillary sinus which widens the maxillary
ostium and extends to the nasal cavity and choana (not
shown) consistent with an antrochoanal polyp (arrow).
Figure 14. CT scan in coronal plane shows a soft tissue nasal
mass with bone destruction and nasal perforation (arrow). dumbbell shaped low density mass with widening of the
This was secondary to sarcoidosis. The imaging differential maxillary ostium extending to the nasal cavity is
diagnoses include Wegener’s granulomatosis and lymphoma.
characteristic [34, 35]. Nasochoanal, ethmochoanal and
sphenochoanal polyps are rare [36, 37].
phase, the sinus walls often become thickened and a
double cortical line with central marrow can be seen. The
imaging differential diagnoses include sarcoidosis,
cocaine and other inhaled irritants and lymphoma. Sinonasal polyposis
Rarer causes of granulomatous infection include leprosy, The sinonasal structures maybe expanded by polypoid
syphilis and tuberculosis. masses and obstructed secretions and there is benign
bone remodelling or erosion (Figure 16). Aggressive
polyposis can extend into adjacent structures. The
Intensive care sinusitis ethmoid sinus walls often become thin and can be barely
visible. The maxillary infundibulum and ostium is
Nasal tubes result in impairment of sinonasal drai- widened if the polyps extend from the maxillary sinuses.
nage. This results in a diagnostic dilemma in a septic Concurrent fungal infection is common.
patient in whom other sources of sepsis have been
excluded. CT or MRI is not diagnostic and sinus
aspiration may be required.

Inflammatory masses

Cysts and polyps

Retention cysts and solitary polyps are usually
asymptomatic and found incidentally and are regarded
as complications of inflammatory sinusitis [30, 31].
Retention cysts are common, particularly in the max-
illary sinuses, and are of little significance unless they are
causing obstruction to the mucociliary clearance [32, 33].
Sporadic polyps are also commonly asymptomatic and
found incidentally. On imaging, these retention cysts and
polyps appear as soft tissue masses with a smooth
convex border. Desiccated polyps may demonstrate
increased CT density. The signal intensity on MRI is
dependent on the water and protein content. When an
inflammatory polyp arises from the maxillary antrum
and herniates through a major or accessory ostium into Figure 16. CT scan in coronal plane shows complete
the nasal cavity and to the postnasal space, this is termed pansinonasal opacification with benign bony remodelling
an antrochoanal polyp (Figure 15). On imaging, a large in keeping with sinonasal polyposis.

46 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

If there is superimposed infection this is called a

pyocoele. On CT, a low density airless sinus with smooth
bony wall expansion is diagnostic [33]. On MRI the
signal intensity depends on the water and proteinaceous
content (Figure 17). There may be a thin rim of
enhancement as opposed to an expansile tumour which
will demonstrate internal enhancement.

Mimics of sinonasal inflammatory disease

Mimics of inflammatory disease should also be
considered [8]. In unilateral sinus opacification, particu-
larly in the OMC, a middle meatal mass needs to be
excluded and direct inspection of the middle meatus
should be suggested. Odontogenic origin of infection can
extend to the maxillary sinus and cause an OMC pattern
of disease. With nasal septum pathology and bilateral
advanced disease, a systemic cause should be consid-
ered. The pattern of bone involvement may be helpful in
formulating a differential diagnosis. Bony sclerosis is
usually associated with a chronic relapsing process (or
previous surgery) and this is typically infective. A
destructive pattern of bony involvement is rarely seen
with inflammatory conditions such as fungal or granu-
lomatous infection and is usually seen with carcinoma
(Figure 18a,b), metastases, some sarcomas and some
Figure 17. MRI scan (coronal fat saturation T2 sequence) lymphomas. This should be distinguished from the
shows a moderately high signal area in the left anterior pressure deossification at the advancing edge of an
ethmoid air cells with expansion of the sinus compatible expansile slower growing lesion which will typically
with an ethmoid mucocoele (arrow). demonstrate some bony remodelling at its margins. This
pattern is found with inflammatory lesions such as
Mucoceles mucoceles and polyps but may be seen with slower
growing tumours such as melanomas, plasmocytomas
With an obstructed sinus ostium from trauma, and slower growing sarcomas (Figure 18c). If a bony
previous surgery, polyps or chronic rhinosinusitis, an defect is seen in the anterior skull base adjacent to a
opacified expanded sinus or mucocoele can result. The lesion, then a cephalocele should also be excluded
sinus shows benign bony remodelling presumably from (Figure 19). The presence of calcification usually signifies
pressure erosion. The frontal sinuses are most commonly a chronic inflammatory process (Figure 12) particularly
affected followed by the ethmoid and maxillary sinuses. if more discrete. However, if present within a tumour, it

(a) (b) (c)

Figure 18. (a) CT scan in coronal plane shows a large irregular soft tissue mass with bone destruction secondary to a sinonasal
squamous cell carcinoma. Erosion through the lamina papyracea into the left orbit (double arrows) and erosion through the
fovea ethmoidalis into the anterior cranial fossa (arrow) are demonstrated. (b) CT scan in axial plane shows a large irregular soft
tissue mass with bone destruction and invasion into the right orbit (arrow). This was a rapidly growing tumour consistent with a
sinonasal undifferentiated carcinoma. (c) A coronal CT scan showing a chondrosarcoma arising from the left maxillary antrum
with benign bony expansion of the antral wall.

Imaging, Volume 19 (2007) Number 1 47

 S E J Connor, S Hussain and E K-F Woo

evidence of a bifid crista galli with a large foramen caecum

and a sinus or cyst in the frontonasal region [42]
(Figure 20). MRI is used to identify any intracranial
extension of a dermoid which may be purely extradural
or extend between the leaves of the falx.

Sinonasal neoplasms
A wide variety of neoplasms, both benign and
malignant, may arise in the sinonasal cavity. They are
generally rare, particularly relative to ubiquitous inflam-
matory disease. The imaging appearances of the major
categories will be discussed.
CT and MRI are often complementary in the staging of
these tumours, with CT being more sensitive to bone
changes and MRI providing superior soft tissue contrast.
The morphology of the tumour, enhancement pattern
and pattern of bony involvement may also help limit the
differential diagnosis.

Benign tumours and tumour like lesions

Osteoma
Osteoma is the most common benign lesion of the
paranasal sinuses. They are well marginated areas of
compact bone, with almost 80% occurring in the floor of
the frontal sinus.
They are usually detected incidentally as a dense
Figure 19. Coronal T1 MRI shows a low signal lesion in the calcified mass although occasionally, a patient may present
left anterior ethmoid air cells (arrowhead). This represented
an ethmoid meningocoele.
with an obstructive sinusitis and secondary mucocoele
formation (Figure 21) and rarely pneumocephalus.
is suggestive of particular neoplasms such as chondro-
sarcoma or olfactory neuroblastoma.
Fibrosseous lesions
Fibrous dysplasia most frequently involves the max-
Congenital lesions illa, with involvement of the ethmoid and sphenoid
sinuses being uncommon. CT shows ill-defined expan-
Choanal atresia is the most common congenital sion of bone and hazy or ‘‘ground glass’’ density. MRI
abnormality of the nasal cavity. It can be unilateral shows decreased T1 signal with variable signal intensity
(more common) or bilateral, bony (more common) or on T2 weighted, due to variations in the degree of
membranous [38]. In bilateral disease, it causes respira- cellularity or cystic change within the lesion [43, 44].
tory distress in the newborn. CT would show narrowing There is also heterogeneous enhancement following the
of the posterior nasal cavity at the level of the choana administration of gadolinium (Figure 22).
with obstruction from a membranous or osseous cause. Ossifying fibroma is a rare lesion, more closely
There is often thickening of the vomer. resembling an osteoma than fibrous dysplasia, but can
Nasolacrimal duct dacrocystocoeles represent a cystic be indistinguishable from the latter on CT imaging [45].
dilatation of the nasolacrimal apparatus secondary to
obstruction of the nasolacrimal duct [39]. Bilateral medial
canthal cystic masses are characteristic.
Papillomas
Piriform aperture stenosis is a rare condition in which
there is bony narrowing of the anterior nasal cavity. It is Papillomas are benign epithelial growths [46, 47] and may
associated with holoprosencephaly or other anomalies. be fungiform, inverting or cylindrical cell. Fungiform
There is often a central mega-incisor [40]. papillomas almost always arise from the nasal septum.
Cephaloceles are congenital herniations of neural tissue Inverting papillomas typically arise from the lateral wall of
(brain, CSF, meninges) through a mesodermal defect in the the nasal cavity. The rare cylindrical cell papilloma also
anterior skull. There are three main types – frontonasal, arises from the lateral wall. Although histologically benign,
nasoethmoidal and naso-orbital cephalocoeles [41]. A inverting papillomas may behave aggressively, causing
defective anterior neuropore may also result in a dermal adjacent bone erosion or remodelling. There is a well
sinus tract, dermoid or nasal glioma (an extracranial rest of recognized association between inverting papilloma and
glial tissue rather than a neoplasm) in the frontonasal squamous cell carcinoma so follow up imaging is almost
region. A frontonasal dermoid maybe associated with CT mandatory [47, 48].

48 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

(a) (b) (c)

Figure 20. (a) CT scan in coronal plane showing a bifid crista galli (arrow) in keeping with a nasal dermoid. (b) CT scan of the
same patient in sagittal plane shows an enlarged foramen caecum (arrow). (c) Coronal T2 MRI of the same patient shows an
intermediate signal lesion (arrow) from an extradural dermoid.

CT of an inverted papilloma typically demonstrates an It is the most common benign tumour of the nasophar-
enhancing mass centred in the middle meatus, extending ynx in adolescents, almost always occurring in males
into the adjacent maxillary antrum through a widened [51]. Although benign, juvenile angiofibroma is locally
ostium [52] (Figure 23). The mass may contain areas of invasive with extension into the pterygopalatine fossa in
calcification (possibly corresponding to fragments of over 90% of cases and frequent extension to the
residual destroyed bone) and there may be adjacent bony infratemporal fossa, sphenoid sinus, orbit and intracra-
sclerosis. MRI may show heterogeneous enhancement nial compartment [52].
and identify a ‘‘convoluted cerebriform pattern’’ which CT and MR imaging demonstrate a large, strongly
is highly suggestive of inverted papilloma [50]. enhancing lobular mass widening the sphenopalatine
foramen and bowing the posterior wall of the maxillary
sinus (Figure 24).
Juvenile angiofibroma Despite surgery, high local recurrence rates have been
Juvenile angiofibroma is a rare, benign vascular reported, especially if there has been skull base invasion
tumour arising adjacent to the sphenopalatine foramen. in the region of the pterygoid base [52, 53].

Haemangioma
Haemangioma of the paranasal sinuses is extremely
rare [54]. Haemangioma of the nasal vault usually arises
from the anterior nasal septum. Intense enhancement of
a lesion, in combination with a history of recurrent
epistaxis, should lead to consideration of a mass of
vascular origin [55] and the differential diagnosis would
include angiomatous polyp, melanoma or angiofibroma.

Odontogenic lesions
Odontogenic cysts and tumours should always be
considered when a mass extends into the sinonasal
region from the maxillary alveolus or palate. An
odontogenic cyst may be confused with a polyp or
maxillary sinus mucocele if the double cortical line
(representing the displaced upper border of the max-
illary alveolus and the orbital floor) is not identified
within the superior antrum (Figure 25).

Sinonasal malignancy
Figure 21. Coronal CT scan demonstrating bilateral frontal
sinus osteomas with a developing mucocoeles on the right Malignant lesions of the sinonasal tract are an
(arrows). important group of neoplasms, which despite their low

Imaging, Volume 19 (2007) Number 1 49

 S E J Connor, S Hussain and E K-F Woo

(a) (b)

Figure 22. (a) Axial CT scan demonstrated a soft tissue mass centred in the posterior nasal space. There is a ground glass
appearance to the bone of the left greater wing of sphenoid and posterior wall of the left orbit, consistent with fibrous
dysplasia. (b) Post-gadolinium T1 fat saturation axial MRI of the same patient as in (a), showing a heterogeneous enhancement
pattern of the mass.

incidence have an overall grave prognosis. Advanced a particular characteristic of adenoid cystic carcinoma, but
local disease is common at diagnosis with 20% having may be observed with SCC, lymphoma and melanoma. Its
nodal metastases. There is marked overlap in the radiological diagnosis is important as curative resection is
imaging features of malignant tumours, and there are unlikely and it signifies a grave prognosis.
only a few instances in which CT and MR imaging are
pathogonomic with biopsy usually being required.
Imaging is critical for tumour mapping with assessment Epithelial malignancy
of tumour spread into the pterygopalatine fossa, orbit, or
skull base. If there is extensive anterior cranial fossa
Squamous cell carcinoma
extension, they should be distinguished from intracranial
SCC comprises 80% of malignant tumours of the
lesions extending into the nasoethmoid region such as
sinonasal tract, with the majority of these (85%) arising in
meningiomas. The T2 weighted signal is typically low
the maxillary antrum [56].
with sinonasal malignancy and it may thus be delineated
CT imaging shows a unilateral sinus mass with
from sinonasal secretions. Although inspissated secre-
aggressive bone destruction (Figure 18a). It may involve
tions may sometimes demonstrate low T2 weighted
the alveolar ridge of the maxilla, buccal space and hard
signal they are generally of increased T1 weighted signal.
palate. SCC shows moderate enhancement following
Nodal metastases are common in squamous cell carci-
contrast medium, but to a lesser extent than adenocarci-
noma (SCC) and lymphoma. Perineural spread of tumour is
noma or olfactory neuroblastoma.

Adenocarcinoma
Adenocarcinomas account for 10–20% of malignant
sinonasal tumours [57]. There are salivary and intestinal
subtypes, and unlike SCC, adenocarcinoma most often
arises in the ethmoid sinus and may calcify.

Salivary tumours
Minor salivary glands are found in the mucosa
throughout the upper aerodigestive tract. These may
give rise to adenoid cystic carcinoma, adenocarcinoma or
mucoepidermoid carcinoma. Of all minor salivary gland
tumours, adenoid cystic carcinoma is the most common
with the majority occurring in the maxillary antrum and
nasal cavity. It appears of relatively increased T2
weighted signal due to their seromucinous content
unlike most other sinonasal malignancies [3].
Adenoid cystic carcinoma has a propensity for
Figure 23. CT scan in coronal plane shows a soft tissue mass perineural spread (Figure 27). The maxillary division of
in the left middle meatus with extension into the maxillary the trigeminal nerve is most often affected, and the nerve
sinus consistent with an inverted papilloma (arrow). may show abnormal enhancement and enlargement [58].

50 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

(a) (b)

Figure 24. (a) Axial enhanced CT scan demonstrating a large avidly enhancing lesion from a juvenile angiofibroma. There is
widening of the sphenopalatine foramen (arrow) with marked distortion of the posterior wall of the maxillary antrum. (b) A
selective angiogram of the right external carotid artery shows a strong vascular blush in the vicinity of the internal maxillary
artery (arrow) territory.

Neuroectodermal and neuronal malignancy Imaging shows an enhancing mass centred high in the
nasal vault. An isolated area of soft tissue within the
Olfactory neuroblastoma superior meatus in a patient presenting with epistaxis
This neoplasm, also termed esthesioneuroblastoma, should be regarded with suspicion and closely inspected
arises from the neural crest cells within the olfactory for bony erosion. It is frequently more advanced with
epithelium of the high nasal vault. destruction of the anterior skull base and should be
considered if a lesion is centred on the cribriform plate.
Punctate intratumoural calcifications have been
reported, as well as hyperostosis of adjacent sinus walls.
The classic description of an intracranial cyst with a
‘‘dumbbell’’ shaped sinonasal mass occurs in a minority
of cases [59]. Local recurrence rates tend to be high and
craniofacial resection with radiotherapy remains the gold
standard for treatment [60].

Sinonasal undifferentiated and neuroendocrine

carcinoma (SNUC and SNEC)
These are less well-differentiated neuroendocrine
tumours. Clinically, the tumour is highly aggressive
and has a poor prognosis. It arises in the superior nasal
cavity or ethmoid sinus and although it is initially
unilateral, it tends to be quite large at presentation. The
imaging features of SNUC are non-specific (Figure 18b),
making it difficult to distinguish from other aggressive
tumours in this region such as SCC [61].

Melanoma
Figure 25. CT scan in axial plane shows a well circumscribed Malignant melanoma arising within the sinonasal
corticated cystic lesion seen extending form the left maxillary mucosa is rare [62]. It occurs more frequently within
alveolus representing an odontogenic keratocyst (circle 1). the nasal cavity, arising from the septum, lateral wall or

Imaging, Volume 19 (2007) Number 1 51

 S E J Connor, S Hussain and E K-F Woo

Figure 26. Axial T2 weighted MRI maps the intermediate T2

signal squamous cell carcinoma relative to high signal
inflammatory secretions.

inferior turbinate. Its most specific imaging feature of

melanotic melanoma is a high T1 signal, due to a
combination of the paramagnetic properties of melanin,
methaemoglobin and free radicals.

Lymphoma
Figure 28. Axial CT demonstrating nasal septal chondrosar-
The nasal cavities and paranasal sinuses are rarely coma. Note the central area of chondroid calcification.
affected by primary non-Hodgkin’s lymphoma (NHL).
The majority of these lymphomas are of large B cell
subtype. T cell lymphoma occurs in a younger popula- based on extensive involvement of the extrasinus soft
tion and is more likely to arise in the nasal cavity [63, 64]. tissues, the involvement of multiple sites or the presence
A further distinct subtype is also recognized called nasal of lymphadenopathy in the neck, which are both more
T cell/natural killer cell lymphoma, formerly known as commonly seen with B cell lymphomas.
‘‘lethal midline granuloma’’ [65].
Lymphoma of the sinonasal tract is often highly
aggressive showing local bone destruction or skull base Sarcomas
invasion. Imaging may provide clues to the diagnosis
Primary sarcomas of the sinonasal cavity are very rare,
with chondrosarcoma being the most common. Imaging
shows a large, multilobulated mass with bone erosion
and destruction. Chondroid calcification is almost
always present and best seen on CT (Figure 28). MRI
demonstrates characteristic high signal intensity on T2
weighted images with differential enhancement on post-
gadolinium sequences.
Rhabdomyosarcoma is the most common soft tissue
sarcoma in children. 40% occur in the head and neck
region [66, 67], and those arising in the nasal cavity and
paranasal sinuses are classified as parameningeal sites of
disease. They have a propensity for meningeal invasion
and intracranial extension through the skull base
foramina [67].

Plasmacytoma/multiple myeloma/metastases

Figure 27. Coronal post gadolinium T1 MRI shows enhance-

Extramedullary plasmacytoma and multiple myeloma
ment of the left maxillary nerve in the foramen rotundum are manifestations of plasma cell neoplasms. The
(arrow) and the left vidian nerve in the vidian canal majority of head and neck extramedullary plasmacytoma
(arrowhead). This was due to perineural spread from a is found in the sinonasal cavity [68]. Myeloma may also
palatal adenoid cystic carcinoma. arise in the sinonasal cavity and is more likely to affect

52 Imaging, Volume 19 (2007) Number 1

Sinonasal imaging

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