2. Clinical overview
Tumors of paranasal sinuses are rare.
Symptoms of benign & early malignant tumors mimic rhinosinusitis:
stuffy nose, rhinorrhea, epiphora & epistaxis.
Symptoms of advanced malignant tumors are related to tumor spread: pain,
facial swelling, cranial nerve palsies, anosmia & visual disturbances .
Often detected when they are large.
Imaging cannot give histopathological diagnosis in most instances.
Patient demographics & characteristic location of tumor may give diagnostic
clue in some cases.
3. CT, MRI, FDG PET-CT, FDG PET-MRI, Angiography
CT & MR compliment each other.
CT: detects bone remodelling & destruction, provides
surgical roadmap.
MRI: soft tissue morphology, diffusion & perfusion
parameters, direct & perineural spread.
FDG PET-CT/MRI is a problem solving tool & useful for
detection of recurrence.
Angiography is useful for pre-surgical evaluation &
embolisation.
4. CT & MRI protocols
CT:
• Pre & post-contrast volume acquisition in axial plane.
• Multiplanar reconstructions in soft tissue algorithm (3mm slice
thickness) & bone algorithm (1mm).
MRI:
• T1W in axial & T2W in axial & coronal plane.
• Axial T2FS & STIR coronal.
• High-resolution post-gadolinium T1W & T1WFS sequences in
axial & coronal planes,
• DWI (b-value 500 &1000).
6. Osteoma
• Benign slow growing tumour containing mature compact or
cancelleous bone.
• M.C site- frontal sinus ,followed by ethmoid & maxillary sinus.
• Sporadic
• Rarely autosomal dominant (Gardner syndrome)
• 3 grades: ivory, mature and mixed.
• < 5% are symptomatic: obstruction to sinus drainage & mass
effect.
8. Posterior extension may lead to the compromise of the optic nerve and allow the
infections to spread intracranially and pneumocephalus will be seen.
10. Fibro-osseous lesions
• Benign bony tumor (dysplasia) of the
craniofacial bones usually involving maxilla
and rarely the mandible, causing cosmetic/
functional deformity and occurs commonly in
young females.
11. Variants
Depends on the proportion of the fibrous and
osseous components -
• Fibrous dysplasia
• Ossifying fibroma
12. Fibrous dysplasia
• Fibrous dysplasia (FD) is a pathologic condition in which
normal bone is altered by abnormal fibro-osseous tissue,
causing distortion and overgrowth of the affected bone.
• Common in females.
• Infancy or childhood
• Painless, slow growing swelling of the maxilla. Rarely the
mandible is involved
• Cosmetic deformity.
• Functional deformity -
– Orbit: Diplopia, proptosis, blindness, etc..
– Oral cavity: Malocclusion, dysarthria, difficulty in
mastication.
• Growth usually ceases after puberty.
13. CT:
• Ground-glass opacities: 56%.
• Homogeneously sclerotic: 23%.
• Cystic: 21%.
• Well-defined borders.
• Expansion of the bone, with intact overlying bone.
• Endosteal scalloping may be seen.
MRI:
• T1: usually intermediate to low heterogeneous signal.
• T2: variable signal.
• T1 C+ (Gd): heterogeneous moderate to avid contrast enhancement
Monostotic FD, where only one bone is involved (70%);
Polyostotic FD, where multiple bones are involved (30%)
15. Axial computed tomography scan. Expansive lesion of the left ethmoid cells
reaching medial wall of the orbital cavity. Evident the image of “ground glass.”
16. Ossifying fibroma (OF)
• Benign fibro-osseous tumor, locally aggressive, F>M,
20-40 years.
• Variants of ossifying fibroma differ in the nature of,
– calcification (cementum or bone),
– location (oral, paranasal or orbital),
– morphological differences (presence or absence of psammomatoid
component) and
– behavior (aggressive or static)
• Treatment: Complete surgical resection.
17. Plain radiograph / CT
• well-circumscribed lesion.
• evidence of intracortical osteolysis with a characteristic
sclerotic band (osteoblastic rimming)
• moderate cortical expansion.
• homogeneous lesion matrix.
MRI
• T1: low signal
• T2: iso-high signal; fluid-fluid levels may be present 8
• T1 C+ (Gd): typically shows enhancement
18. AP Skull radiograph shows expanded nasal cavity (asterix) with depressed left half of hard
palate (short black arrow) and ill-defined left medial orbital wall (black arrow).
B: Occipitomental view shows soft tissue opacity occupying the left nasal cavity and left
maxillary sinus region with nonvisualized maxillary sinus walls (long black arrow).
19. A large, expansile, well-circumscribed, corticated left sinonasal mass involving the left ethmoid sinus,
nasal cavity and left maxillary sinus (2a, white arrow). The mass is remodelling the left maxillary sinus
medial wall (2b, small arrow) and bulging into the left side of nasopharynx (2b, asterix). There are
plaque-like areas of high density (180 – 220 HU) within the lesion suggestive of calcification or
ossification (2c, small black arrow and 2d). The lesion extends into the left orbit via inferior orbital
fissure causing left orbital proptosis (2c, long black arrow and 2d).
20. Axial post contrast CT paranasal sinus reveals multiple pockets of nonenhancing areas of hypodensity with
likely fluid-fluid levels (4a, black arrow). Axial T2 weighted image at the same level confirms multiple fluid-
fluid levels (4b, black arrow). Few of these areas are showing T1 hyperintense signal also representing
thick secretions or blood-blood levels (4c, white arrow). Post contrast axial T1 fat suppressed image shows
irregular rim and solid areas of enhancement (4d, white arrow) with associated premaxillary soft tissue
thickening and collection (4d, short black arrow).
21. Papilloma
• The mucosal lining of the nose is derived from ectoderm and is
called the schnederian membrane.
• Can give rise to three types of papilloma:
– Fungiform- arises from the nasal septum , usually anteriorly.
– Inverted- commonest. Usually arise from lateral nasal wall.
– Cylindrical cell.
• Symptoms- nasal obstruction , epistaxis and anosmia.
22. Inverted papilloma
• Benign but locally aggressive premalignant tumor of the nasal
cavity with histologically inverted epithelial tumor cells into
the stroma and usually presents as a pedunculated reddish
mass from the lateral nasal wall.
• Etiology: HPV 6, 11, 16, 18.
• M>F, typically 40-70 years
• 13 % bilateral & 4% multifocal IP
• 10% degenerate into or co-exist with SCC.
23. • Symptoms:
– Unilateral nasal obstruction
– Blood stained nasal discharge
– Epistaxis
– Pain, epiphora, proptosis +/-
– H/O multiple previous nasal polypectomy+/-.
• Gross pathology:
– Firm, polypoidal and more vascular than inflammatory polyps.
– Commonly arises from the lateral nasal wall, usually in the region
of the middle meatus and middle turbinate
– Extension into the maxillary and ethmoid sinuses and orbit is
common.
24. • CT: Bone remodelling, conical focal hyperostosis,
entrapped bone sign.
• MRI: Post-contrast T1WFS: convoluted cerebriform
appearance.
• Bone destruction on CT & invasive-necrotic
appearane on MRI: malignant degeneration
26. • Unenhanced fast spin-echo T2-weighted coronal MR image reveals convoluted cerebriform
pattern throughout mass. Pattern consists of low-signal-intensity (arrowheads) and relatively
high-signal-intensity (small arrows) striations that probably represent metaplastic squamous
epithelium and edematous stroma, respectively. Secretions after obstruction in lateralmost
portion of right-sided maxillary antrum are of extremely high signal intensity (large arrow).
27. • Contrast enhanced spin-echo T1-weighted coronal MR image) shows well-enhancing
stroma (small arrows) and less-enhancing epithelium (arrowheads) that create
convoluted cerebriform pattern correlating with that seen in B. Trapped secretions
(large arrow) in lateralmost portion of right-sided maxillary antrum do not enhance.
28. Juvenile angiofibroma (JNA)
• Benign, locally invasive, highly vascular tumor.
• Almost exclusively adolescent males (10-25 years)
• Centred in posterior nasal cavity near sphenopalatine
foramen(SPF).
Treatment: Complete surgical resection + pre surgical
embolization/ combination of endoscopic + open
resection/ radiation therapy.
30. CT: Avidly enahncing mass centred at SPF, bony remodelling +/- erosion,
various extensions
• q
31. • Coronal section, contrast-enhanced computed tomography scan shows a large
heterodense destructive soft tissue lesion with intense contrast enhancement on the
right maxillary antrum (yellow arrow), crossing the midline and displacing the nasal
septum to the left (red arrow) and superiorly into the nasal cavity (blue arrow)
32. • contrast-enhanced computed tomography scan shows a large heterodense destructive soft
tissue lesion seen in the superior postero-lateral wall of the right nasal cavity, extending
into the nasopharynx and adjacent pterygopalatine fossa, right pre-maxillary space causing
bowing of the posterior antral wall: The characteristic Holman Miller sign (yellow arrow)
with erosion/ destruction of adjacent bones.
33. MRI: Heterogeneous, intermediate to high signal on T2W, flow voids +
• Axial section, T1-weighted magnetic resonance image shows a large, well-defined
mass (arrow) in the region of the pterygo-maxillary fissure and sphenopalatine
foramen on the right side with a heterogenous intensity.
35. Angiography: Tumor blush, internal maxillary artery is feeding
artery.
• Right external carotid artery angiogram reveals the feeding internal maxillary
artery (red arrow) and the hypervascular lesion (yellow arrows).
36. Angiomatous polyp
• Angiomatous nasal polyp (ANP) is a relatively rare benign
lesion, which may be misdiagnosed as a malignant tumor.
• Located in the nasal fossa and not the nasopharynx.
Unlike the nasopharyngeal angiofibroma.
• Does not extend into the ptergopalatine fossa or
intracranially.
• The vascular supply of these lesions is less extensive than
angiofibromas.
• Does not enhance avidly following intravenous contrast
and vascular flow voids are not seen on MRI.
37. • Sinonasal angiomatous polyp. A, Axial T1WI shows a slightly hypointense lesion in left maxillary sinus and
nasal cavity. B, Axial T2WI demonstrates a well-defined lesion, which shows hyperintense signal intensity
centrally with a peripheral hypointense rim (white arrows). The hyperintense signal intensity in the ipsilateral
maxillary sinus indicates obstructive sinusitis. C, Axial fat-suppressed contrast-enhanced T1WI shows the
marked patchy enhancement with the nonenhanced hypointense rim. D, Axial DWI shows the mass of slightly
high signal intensity with a peripheral low-signal-intensity rim. E, Photomicrograph shows numerous
extravasated red blood cells, fibrosis, and thin-walled vessels. Scattered hemosiderin-laden macrophages and
inflammatory cells are also seen (hematoxylin-eosin, original magnification ×200).
40. Pathology – gross
• Maxilla commonest site of sinonasal malignancy- 50%
• Followed by ethmoids, Frontal and Sphenoid.
• May extends to orbit/ intra-cranium/ oral cavity/
cheek
41. Clinical features
Asymptomatic (10%)
Nasal(Medial)-Nasal obstruction,Blood stained
nasal discharge, Epistaxis, Headache/ facial pain.
Orbital(Superior)-Diplopia, Blindness, Ocular Pain,
Epiphora.
Facial (Anterior)- Swelling of Cheek, Paresthesia.
Oral(Inferior)- Loosening of tooth, Expansion of
Alveolus, Oroantral fistula, Ill-fitting dentures,
Swelling in Hard Palate, Ulceration of Gingiva.
42. T-staging
Maxillary Sinus SCC
• Tis -In situ
• T1- Restricted to mucosal lining.
• T2 - Bone destruction, limited to hard palate and middle
meatus
• T3 - Bone destruction of post wall of maxillary sinus; floor and
medial wall of orbit; tumor extension to ethmoid sinus and
pterygoid fossa
• T4a - Tumor growth in anterior orbit; pterygoid plate;
infratemporal fossa; cribriform plate; frontal-sphenoid sinus; skin
• T4b - Tumor growth into orbital apex; dura; brain; middle cranial
fossa; cranial nerves other than V2; nasopharynx; clivus
43. Ohngren’s line
• An imaginary plane extending between medial cantus
of eye and angle of mandible.
44. • Supra structural growths-situated above this plane
have a poor prognosis.
• Infra structural growths – situated below this plane
have better prognosis.
46. • Suprasturctures : ethmoid, sphenoid & frontal sinuses;
olfactory area of nose.
• Mesostructures: maxillary sinus & respiratory part of
nose.
• Infrasturctures: alveolar process.
• The Lederman T-classification was more prognostic for
locoregional control and disease-specific survival than
the UICC TNM classification. In addition, the Lederman
classification is easy to use and has a broader
applicability as it covers all sites in the sino-nasal area.
47. Squamous cell carcinoma (SCC)
• SCC accounts for 80% of all sinonasal cancers, of which about
75% are located in maxillary sinus.
• M>F, 50-70 years
• Risk factors: Noxious fume inhalation/ HPV/ inverted papilloma/
previous radiation/ immunosuppression.
• 5 - year survival: For T1 stage about 100%, for T4a stage about
34%.
• Better prognosis: Ethmoid sinus SCC, low tumor stage, HPV+ve,
inverted papilloma
• Poor prognosis: Large tumor size, extension beyond sinus walls,
nodal metastases, perineural spread.
48. • MRI: Intermediate-high signal on T2W, moderate enhancement, restricted diffusion, direct tumor
extensions, perineural spread, retropharyngeal lymph nodes
• CT: Moderately enhancing mass/ irregular margins/ bone destruction
49. Adenoid cystic carcinoma (ACC)
• Malignant salivary gland-type adenocarcinoma, M>F,50-70 years.
• Aggressive, high incidence of recurrence, distant metastasis &
perineural spread.
• Recurrence or metastasis can occur even decades after treatment.
Poor prognosis.
50. • MRI: On T2W-intermediate signal with areas of high signal,
heterogeneous enhancement, restricted diffusion, perineural
spread,
• CT: Solid or heterogeneously enhancing mass, bone destruction
• Treatment: Chemoradiotherapy + surgery
51. Mucoepidermoid carcinoma (MEC)
• Malignant salivary gland-type adenocarcinoma, rare, M>F,
50-70 years.
• Aggressive & poor prognosis
• MRI: On T2W- intermediate to high signal, diffuse
heterogeneous enhancement, perineural spread.
• CT: Solid or heterogeneously enhancing mass, bone
destruction
• Treatment: Chemoradiotherapy + surgery
53. Esthesioneuroblastoma (ENB)
• Also known as Olfactory neuroblastomas,.
• Rare malignant neuroectodermal tumor arising from
olfactory mucosa.
• Bimodal distribution - 2nd & 6th decade
• Kadish Classification: A - nasal tumor, B - involvement
of nasal cavity + sinuses, C - beyond sinuses, D –
involvement of cervical lymph nodes.
54. • CT: Cribriform plate destruction, bony remodelling of nasal cavity.
•MRI: Intermediate-high signal on T2, dumb-bell shaped, avid
enhancement, cysts in intracranial component -Peritumoural cysts between
it and the overlying brain are often present, T2*GRE- blooming foci.
• Treatment: Craniofacial resection + radiotherapy
56. Undifferentiated sinonasal carcinoma
• Rare non-squamous cell type tumor.
• Elderly > 60 years
• Aggressive & high propensity for distant
metastasis; perineural spread.
• Unlike ENB, it extends beyond sinonasal
cavity.
57. •CT: Typically large
enhancing mass, aggressive
bony destruction, often
erode cribriform plate,
dumbbell shape due to
intracranial component
•MRI: Low-intermediate T2
signal, areas of necrosis,
heterogenous enhancement
•Treatment:
Chemoradiotherapy &
surgery
60. Sinonasal malignant melanoma
• Neural crest malignancy arising from melanocytes.
• 90% seen in Caucacians, M>F, 50-80 years.
• Propensity for systemic metastasis, poor prognosis,
mean survival is 24 months.
• Melanotic & amelanotic.
