Sinus Cases 31-40

Pneumosinus Dilatans

Case 31: What is the most likely diagnosis?

Pneumosinus dilatans (PD) is defined as hyperaeration and expansion of a sinus (red arrows) with normal thickness of the adjacent bone. It is uncommon and likely results from a ball valve mechanism which allows air to enter a sinus ostium but causes obstruction of outflow. It is also incorrectly referred to as a hypersinus or pneumocele (Urken et al). Hypersinus is an abnormal enlargement of a sinus, without extension beyond the involved bone. PD is an abnormal expansion of the aerated sinus, with sinus walls of normal thickness. Pneumocele is an abnormal enlargement of a sinus with focal thinning or destruction of the bone.

The maxillary, frontal, and sphenoid sinuses are most commonly involved by PD. The thinnest wall of a sinus is typically involved.

PD is more frequently seen in males aged 20-40. Presenting symptoms typically correspond to the structures that are displaced but usually includes facial pain. The sinus mucosa is normal without fluid or signs of inflammation. Treatment is designed at improving aeration at the sinus ostium. An unrelated cause of sinus expansion can result from hyperemia of bone adjacent to a meningioma. This is incorrectly called pneumosinus dilatans, however.

DDx: Pneumosinus Dilatans 1.

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Dyke-Davidoff-Masson Syndrome Acromegaly Meningioma Pneumocele Hypersinus Mucocele

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DDx: Torus Mandibularis

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Case 32: What is the most likely diagnosis?

Abscess formation Bone cancer Salivary gland tumors Vascular tumors

Torus Mandibularis A bony growth along the lingual surface of the mandible. Mandibular tori are usually present near the premolars and above the mylohyoid’s attachment. It is bilateral in 90% of cases and is less common than similar bony growths on the palate (torus palatinus). It is more common in Asian and Inuit populations, and slightly more common in males. Prevalence is 7-10% in the general US population. Mandibular tori are associated with bruxism. It is believed that they are caused by local stresses and not solely on genetic influences. Usually no treatment is necessary, although it is possible for ulcers to form overlying the area. Surgical removal may be done, but the tori may reform. Tori are inherited as an autosomal dominant trait.

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Torus Palatinus and Maxillaris

Case 33: What is the most likely diagnosis?

A torus palatinus (TP) is a bony protrusion on the palate, usually on the midline of the palate. Most palatal tori (red arrows) are less than 2 cm in diameter. The prevalence of tori is 20-35% in the US, and they are more commonly occurring on the mandible. Palatal tori usually present in early adult life and are believed to be caused by a combination of local stresses and genetic influences. Usually, no treatment is necessary, although it is possible for ulcers to form on the area. Similar lesions can arise on the medial surface of the maxillary alveolus (torus maxillaris) (blue arrows).

DDx: Torus Palatinus and Maxillaris 1.

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Hyperostosis from Infection Osteoblastic Metastasis Case 1 Fibrous Dysplasia Foreign Body

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Case 34: What is the most likely diagnosis?

Torus Palatinus (Additional Case) 1 of 1

Caldwell-Luc Procedure

Case 35: What is the most likely diagnosis?

The purpose of the Caldwell-Luc (CL) procedure was to completely remove the diseased mucosa of a sinus and to allow subsequent creation of an inframeatal naso-antral window (NAW) (blue arrow). It was also used to close oroantral fistula, biopsy/remove sinus masses, reduce orbital floor fractures, and drain mucoceles. The access point is just above the roots of the maxillary teeth. A small bone window (red arrows) is made in the anterior wall of the maxillary sinus. Often, a NAW was also created along the inferior aspect of the medial maxillary sinus wall into the nasal cavity to improve drainage of the maxillary sinus. Common complications include facial cellulitis, facial/dental pain, and severe post-op bleeding, facial asymmetry, epiphora from injury to the nasolacrimal duct, and tooth root injury. The CL procedure has been replaced almost exclusively by FESS.

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Case 36: What is the most likely diagnosis?

2/21/08 1 of 2

Iatrogenic Injection of Radiopaque Material into Maxillary Sinus for Dental Implant

Case 36: What is the most likely diagnosis?

To prepare the maxilla for implantation of a dental implant, the floor membrane of the maxillary sinus must be raised to augment the formation of vital bone to allow osseointegration of implants. This is achieved by apical displacement of the maxillary sinus membrane with or without the addition of bone or bone substitute material.

This elevation of the sinus membrane is achieved via a transcrestal approach to the antrum. By injecting a gel (often radiopaque barium sulfate), the maxillary sinus floor is raised by a minimum of 15mm. This technique allows bone grafting and simultaneous implant placement. Care must be taken to ensure the sinus membrane is not perforated during the procedure.

Iatrogenic Injection of Radiopaque Material into Maxillary Sinus for Dental Implant 1. Fibrous Dysplasia 2. Cementoblastoma/Cementoma 3. Benign Cemental Dysplasia

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Inframeatal Nasoantral Windows (NAW)

Case 37: What is the most likely diagnosis?

NAWs are an older surgical drainage technique for the maxillary sinuses. It was traditionally performed after access to the sinus was obtained via Caldwell-Luc procedure. NAWs (red arrows) have been replaced by FESS.

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Case 38: What type of surgery is present?

Osteoplastic Flap with Frontal Sinus Obliteration Many conditions of the frontal sinuses can be treated endoscopically but some require complete removal of all the mucosa and sinus contents. This is accomplished using an osteoplastic flap with frontal sinus obliteration.

Osteotomies (red arrows) are first performed and the anterior table of the sinus is removed and the frontal sinus opened. The mucosa of the sinus is completely removed and the frontal ostium/recess is occluded. The sinus is filled with an autologous fat graft and/or muscle and the bony flap is replaced. The appearance on postop CT and MRI is highly variable due to the spectrum of tissue that may be present within the sinus.

Indications for an osteoplastic flap include: chronic frontal sinusitis refractory to endoscopic surgery, mucopyocele, severe trauma with fractures involving the drainage pathways, and after resection of large frontal sinus tumors near the frontal recess. The apparent frontal sinus opacification seen above (blue arrow) does NOT represent pathology.

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Nasal Septal Hematoma in Renal Transplant Patient

Case 39: What is the most likely diagnosis?

Nasal septal hematomas (red arrows) are uncommon and are usually caused by either coagulopathy or trauma. Early diagnosis and treatment is important to prevent abscess formation, septal perforation, and saddle-nose deformity. The anterior portion of the nasal septum is composed of a thin cartilaginous plate with closely adherent perichondrium and mucosa. Submucosal blood vessels are torn as buckling forces pull the perichondrium from the cartilage. Blood may then collect between the perichondrium and the septal cartilage.

The presence of stagnant blood predisposes to bacterial proliferation and abscess formation. A hematoma may become infected within 3 days of the trauma. If the cartilage is fractured, blood can dissect through the fracture line and form bilateral hematomas. The most common symptoms are nasal obstruction, pain, rhinorrhea, and fever. Especially in renal transplant recipients, septal infections and abscess remain a major clinical concern.

DDx: Nasal Septal Hematoma in Renal Transplant Patient 1.

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Nasal Septal Abscess Infection (Tuberculosis, Syphilis) Wegener Granulomatosis Neoplasm (SCCA, Melanoma, Lymphoma, SNUC) Sarcoidosis

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Cocaine Vials Under Tongue

Case 40: What is the most likely diagnosis?

This patient demonstrates extensive destruction (red arrows) of the nasal septum, orbital floor, and lateral wall of the maxillary sinus consistent with a “cocaine nose”. This destruction is related to severe drug related vasospasm and nasal septal necrosis and bone necrosis. There is a hint to the diagnosis on the image. Notice the tubular foreign bodies under the tongue, bilaterally, representing cocaine vials (blue arrows).

DDx: Cocaine Vials Under Tongue 1. He swallowed his nasal O2 prongs. (:>) 2. Wegener's Granulomatosis 3. Other foreign body

Courtesy of Wendy Smoker

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Nasal Foreign Body – Recurrent/Persistent Sinusitis

Case 41: year old recurrent sinusitis?

Symptoms of chronic4 sinusitis include: nasalchild congestion, with facial pain, headache, night-time coughing, increase in asthmatic symptoms, malaise, thick green or yellow discharge, facial fullness, dizziness, aching teeth, and halitosis. Fever is not a feature unless complications occur. All patients with persistent or recurrent sinusitis should be imaged to see if there are contributing factors. Contributing factors include: allergies, structural abnormalities, dental infection, and in pediatric patients – nasal foreign bodies. 6 months earlier, this patient lost his toy (red arrows) in his nostril but declined to tell his parents to avoid punishment.

DDx: Nasal Foreign Body – Recurrent/Persistent Sinusitis 1. Osteoma 2. Fungal Infection 3. Contract Material

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