Sinus Cases 41-50

DDx: Throat Lozenge

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Case 42: What is the most likely diagnosis?

Torus Palatinus, Maxillaris, or Mandibularis Exostosis Osteoma Cementoma - Cementoblastoma

Throat Lozenge It is not an infrequent occurrence that patients having sinus CT scans will have Life-Savers or throat lozenges (red arrows) present because of a cough or throat irritation. Lozenges may contain benzocaine, an anesthetic, or eucalyptus oil. Non-menthol throat lozenges generally use either zinc gluconate glycine or pectin.

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Chewing Gum in Buccal Cavity

Case 42b: What is the most likely diagnosis?

This patient is chewing gum and presently storing it in their buccal cavity.

DDx: Gum in Buccal Cavity 1.

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Other foreign body Lozenges - Candy Chewing Tobacco SCCA

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Case 43: What is the most likely diagnosis?

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DDx: Silent Sinus Syndrome

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Case 43: What is the most likely diagnosis?

Post-traumatic Sinus Deformity Inferior Orbital Wall Decompression Chronic Sinusitis with Mucoperiosteal Thickening Maxillary Sinus Hypoplasia Mucocele: Not A Chance

Silent Sinus Syndrome A spontaneous, symptomatic or asymptomatic collapse (atelectasis) of the maxillary sinus. The orbital floor and, often, the walls of the maxillary sinus are pulled toward the sinus lumen by negative sinus pressure. It can cause painless and long-term facial asymmetry, diplopia, and enophthalmos. Characteristic imaging features include maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls (red arrows). There is gradual inward bowing of all four maxillary sinus walls.

Orbital volume increases producing enophthalmos. The treatment goal is to improve aeration of the obstructed sinus via FESS. The cause is usually idiopathic or from trauma.

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Prenasal Dermoid/Epidermoid Cyst

Case 44: What is the most likely diagnosis?

During development a projection of dura extends through the foramen cecum and attaches to the skin on the dorsum of the nose. The dura normally separates from the nasal skin and retracts through the foramen cecum losing connection with the skin. If the skin maintains attachment to underlying fibrous tissue, nasal capsule, or dura, epithelial elements may be pulled into the prenasal space with or without a dural connection. Debris from the epithelial lining may proliferate to form an epidermoid cyst (EC). Dermoid cyst (DC) also occur through the same mechanism. They are made up of the same elements that are present in normal skin - epithelial cells, fat, sebaceous material, hair and bone. EC or DC are usually subcutaneous (green arrow), but may lie under the nasal bone with tracts extending up through the foramen cecum (blue arrows) or even into the cranial cavity (red arrows). A dorsal nasal pimple, dimple, hair follicle, or a slightly broadened nose may herald the diagnosis. Infection or intermittent discharge of sebaceous material may also be a presenting feature. These lesions are usually 1st identified in pediatric patients. Treatment is usually surgical removal.

DDx: Prenasal Dermoid/Epidermoid Cyst 1.

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Meningocele Meningoencephalocele Nasal Hemangioma Intranasal Melanoma Mucous Retention Cyst

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Case 44b: What is the most likely diagnosis?

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Prenasal Dermoid Cyst

Case 44b: What is the most likely diagnosis?

Dermoid cyst (red arrows) will typically be of fat density and will fat-suppress.

DDx: Prenasal Dermoid Cyst 1.

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Prenasal Epidermoid Cyst Meningocele Meningoencephalocele Intranasal Melanoma Mucous Retention Cyst

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Case 45: What is the most likely diagnosis?

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Case 45: What is the most likely diagnosis?

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DDx: Meningocele

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Case 45: What is the most likely diagnosis?

Epidermoid Cyst Retention Cyst Mega Concha Bullosa (:>) Nasal Foreign Body

Meningocele Meningocele (MC) (red arrows) or meningoencephalocele (MEC) represents herniation or displacement of meninges and/or glial tissue into the nasal cavity or nasopharynx. Clinical presentation depends on the extent and location of the lesion. Presentation ranges from soft cystic swelling over the bridge of the nose, nasal obstruction, and difficulty breathing. There may be a degree of hypertelorism. MC-MEC may present as an intranasal mass on sinus or head imaging studies. Less severe ends of the spectrum (MC) are more frequent.

MRI is usually best to evaluate the lesions. Look for meninges and brain tissue (MEC) or a sac containing CSF (MC) extending through the skull base into the nose or sinuses. MC and MEC may extend through the prenasal space, ethmoid sinus, or sphenoid sinus.

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Case 46: What is the most likely diagnosis?

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DDx: Acquired Transalar Meningoencephalocele

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Case 46: What is the most likely diagnosis?

Sphenoid Mucosal Thickening Chronic Sinusitis Retention Cyst Meningocele Skull Base Metastasis

Acquired Transalar Meningoencephalocele A transalar (transsphenoidal ) meningoencephalocele (TAM) is a rare condition that has a congenital basis but one that may present later in life. The initial congenital findings are prominent arachnoid granulations along the inframedial floor of the middle cranial fossa. Later in life, brain or meninges may protrude through the arachnoid granulations and herniate into the sphenoid sinus producing a (TAM) (red arrows) . Spontaneous CSF leaks may develop at this location through the same mechanism.

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Case 47: What is the most likely diagnosis?

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Case 47: What is the most likely diagnosis?

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DDx: Acquired Meningoencephalocele

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Case 47: What is the most likely diagnosis?

Polyp or Retention Cyst Frontoethmoid Mucocele Meningomyelocele Fibrous Dysplasia

Acquired Meningoencephalocele Acquired meningoencephalocele (AMEC) may develop from protrusion of meninges and brain through an acquired defect of the skull base (red arrows). The defect may develop in the cribriform plate or the inner bony cortex of a sinus (frontal, ethmoid, sphenoid) that forms a portion of the skull base. Trauma, infection, neoplasm, and congenital pits may be the initiating cause. This diagnosis should always be considered when a soft tissue mass contacts the floor of the skull base.

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DDx: Acute Rhinosinusitis

Case 48: What is the most likely diagnosis?

1. Intrasinus hemorrhage 2. CSF Leak 3. Oroantral fistula

Acute Rhinosinusitis The etiology of sinus inflammation can be infectious (bacterial, viral, fungal) or noninfectious (allergic) in origin.

Normal sinus drainage can be blocked which can lead to mucous retention, decreased mucociliary clearance, sinus hypoxia, and predisposition to bacterial growth. Acute rhinosinusitis (ARS) is defined as symptoms of less than 4 weeks’ duration and affects approximately 40 million Americans annually. The most common cause of ARS is viral. Bacteria and allergens are also frequent causes. The most commonly involved sinuses are the maxillary and anterior ethmoids. The hallmark of ARS is an air-fluid level which is often bubbly in appearance (red arrows). Mucosal thickening is also quite common but may also be seen with chronic rhinosinusitis.

Allergic ARS is rarely associated with fluid levels.

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Chronic Sphenoid Rhinosinusitis

Case 49: What is the most likely diagnosis?

Chronic rhinosinusitis is comparatively more common than acute rhinosinusitis. Symptoms are often subtle and early treatment is crucial because the disease can be rapidly progressive and complications can arise due to the close relationship of the sphenoid sinus to vital structures. CT scans are the mainstay of diagnosis because they provide information about bone involvement. Sinus ossification, mucosal thickening, intrasinus polyps, and bony sclerosis (osteoneogenesis) are the common imaging findings. Superimposed acute rhinosinusitis may also be present. Antibiotics, decongestants, and/or surgery may be required to eliminate disease. Aspergillus fungal infections usually initiate florid bony sclerosis (red arrows) because of the angiophilic avidity of this organism.

DDx: Chronic Sphenoid Rhinosinusitis 1.

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Fibrous Dysplasia Primary Bone Tumors Renal Osteodystrophy Chronic Anemias

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Fungal Mycetoma

Case 50: What is the most likely diagnosis?

A noninvasive disease of the sinuses characterized by sequestration of densely tangled, concentrically arranged fungal hyphal elements. There is no mucosal invasion or granulomatous reaction and patients are usually asymptomatic. CT demonstrates complete/subtotal opacification of the affected sinus with punctate to linear areas of intraluminal calcific high density. Homogeneous hyperdense fluid is not a feature of fungal mycetoma but may be seen in a related condition (allergic fungal sinusitis). There may be sclerosis of the affected sinus wall since fungal mycetoma often arise in a chronically infected sinus. Treatment involves removal of the fungal mass followed by thorough sinus irrigation. The use of antifungal agents is highly controversial.

DDx: Fungal Mycetoma 1.

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Foreign Body Calcified Bony Neoplasm Fibrous Dysplasia Allergic Fungal Sinusitis

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