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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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A B
Figs. 20.13A and B: Hemophilic pseudotumor. (A) Noncontrast computed tomography
(NCCT)showinganexternallyprotrudinglargesofttissuemasswithhighdensity(arrow).
(B)Bonewindowimagesshowserosionofanteriornasalseptumandsmoothscallopingof
theadjoiningbones(arrow).
Hemophilic Pseudotumor
■ is is a complication of hemophilia and represents a chronic hematoma
that expands slowly because of recurrent bleeding.
■ Gets encapsulated by a thick brous tissue.
■ Leads to slow pressure destruction of adjacent structures/bones.
■ Pediatric sinonasal involvement rare (exact incidence not known).
■ Clinically, these may sometimes present with rapidly expanding mass in
undiagnosed patient.
■ Computed tomography scan—demonstrates a high-density mass and
mass eects on surrounding structures, especially bony changes of
chronic pressure erosion/scalloping (Figs. 20.13A and B) are seen.
■ Magnetic resonance imaging—delineates soft tissue extent and
intramedullary extension within the bone.
■ Treatment:
• Factor VIII replacement + complete surgical excision of entire mass to
prevent recurrence.
• Radiotherapy: 600–2,350 cGy with or without factor replacement,
where surgery is not feasible is shown to have good response.
Sinonasal Chloroma
■ It is a rare malignant extramedullary neoplasm of myeloid precursor
cells.
■ Synonym: Granulocytic sarcoma or myeloid sarcoma.
■ It is seen in acute myeloid leukemia (AML) or other myeloproliferative
disorder.
■ Seen in 3–9.1% of AML, preferentially in young patients or in children
with no gender preference.
■ Its presence is a sign of poor prognosis.
■ It frequently involves bones and periosteum with associated soft tissue.
275Chapter 20 Pediatric Sinonasal Disorders: Imaging
Section 5 Congenital/Pediatric Diseases276
A B
Figs. 20.14A and B:Leftmaxillarysinusgranulocyticsarcomainachildwithacutemyelocytic
leukemia(AML).(AandB)Axialcomputedtomography(CT)imagesshowhyperdensesoft
tissuemassintheleftmaxillarysinuscausinglyticdestructionofallthewallsofthemaxillary
sinus(arrows).
■ In the head and neck region, sites aected include soft palate, nasopharynx, orbit, salivary glands, scalp, face, jaw, lips, nasal cavity, maxilla,
and temporal bone.
■ e CT shows nonspecic soft tissue mass with homogenous contrast
enhancement. When aecting the sinuses, it shows lytic destruction
of the bony walls of the sinuses with inltration into adjacent tissues
(Figs. 20.14A and B).
■ e MR shows T1 hypointense and T2 iso to hypointense signal within
the soft tissue mass.
■ Chloromas are radiosensitive and local radiotherapy in conjunction with
chemotherapy is treatment of choice.
MISCELLANEOUS
Chronic Adenoid Hypertrophy
■ Adenoids are situated in the nasopharynx and are small at birth, grow till
5 years of age and gradually get atrophied by adolescence.
■ When enlarged, these may lead to obstructive sleep apnea.
■ Lateral neck radiograph depicts the enlarged adenoid with obstruction
of nasopharynx to variable extent (Figs. 20.15A and B).
■ e size of the adenoids is less of a consideration than the degree to
which they encroach on the nasopharyngeal airway.
■ Adenoid grades based on airway to soft palate ratio are:
1. Normal (airway-to-soft-palate ratio ≥1)
2. Mild-to-moderate hypertrophy (airway-to-soft-palate ratio between
0.5 and 1)
3. Severe hypertrophy (airway-to-soft-palate ratio <0.5).
Dierential diagnosis of pediatric sinonasal masses according to the
region of involvement is summarized in Flowchart 20.1.
Various congenital masses presenting in the region of root of nose are
discussed in chapters 21,23 and the current chapter. A brief imaging based
approach for these masses is summarized in the Flowchart 20.2.
A B
Figs. 20.15A and B:(A)Normal adenoid. No nasopharyngeal airway comprise seen. (B)
Hypertrophiedadenoids—showingthickeningofposteriornasopharyngealsofttissue,which
isindentingandnarrowingnasopharyngealaircolumnonposterioraspect(arrow).
Flowchart 20.2: Imaging approach to congenital masses presenting in the region of root of
nose.
277Chapter 20 Pediatric Sinonasal Disorders: Imaging
REFERENCES
1. Hedlund G. Congenital frontonasal masses: developmental anatomy, malformations, and MR imaging. Pediatr Radiol. 2006;36(7):647-62.
2. Visvanathan V, Wynne DM. Congenital nasal pyriform aperture stenosis: a report
of 10 cases and literature review. Int J Pediatr Otorhinolaryngol.2012;76(1):28-30.
3. Lowe LH, Booth TN, Joglar JM, et al. Midface anomalies in children. Radiographics.
2000;20(4):907-22.
4. Rodriguez DP, Orscheln ES, Koch BL. Masses of the nose, nasal cavity, and
nasopharynx in children. Radiographics. 2017;37(6):1704-30.
5. Kim YS, Kim HJ, Kim CH, et al. CT and MR imaging ndings of sinonasal schwannoma: a review of 12 cases. Am J Neuroradiol. 2013;34(3):628-33.
Section 5 Congenital/Pediatric Diseases278
ILLUSTRATIVE CASES
Nasal Cavity Masses
Case 1: Intranasal Dermoid Cyst
A and B. Computed tomography (CT) images depict a cystic well-dened
mass in the anterior nasal cavity in the midline septum (arrows).
C. e intracranial extension is suggested by the presence of bid crista galli
(arrow).
Imaging pearl
Apart from these, CT may show a large (> 3 mm in diameter) foramen
cecum in the case of intracranial extension.
Case 2: Nasal Dermal Sinus Tract
A. Plain radiograph lateral view shows marker at the site of dimple at the tip
of the nose (arrow).
B. Contrast injection from this site opacied a linear tract coursing up to the
level of foramen cecum (arrow). e intracranial portion usually remains
extra-axial involving the dura and falx cerebri.
C. Sagittal T1 postcontrast MR image shows similar enhancing linear tract
(arrow) from the nasal cavity up to the foramen cecum.
Imaging pearl
e transcranial tract mostly courses through the foramen cecum, and less
commonly through crista galli or cribriform plate.
Case 1 (Figs. 20.16A to C) Case 2 (Figs. 20.17A to C)
279Chapter 20 Pediatric Sinonasal Disorders: Imaging
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Section 5 Congenital/Pediatric Diseases280
ILLUSTRATIVE CASES
Nasal Cavity Masses (Contd..)
Case 3: Intranasal Glioma
A. T1 postcontrast axial image shows a nonenhancing (arrow) soft tissue
mass in the right nasal cavity.
B. Magnetic resonance imaging (MRI) T2 sagittal image shows T2 iso to
hyperintense mass (arrow) with no intracranial communication. Intracranial
attachment with a brous stalk is seen in up to 15% cases.
C. Computed tomography (CT) coronal image shows an intranasal hypodense
mass with no fat, calcication or enhancement. Normal crista galli is noted
(arrow).
Imaging pearl
Clinically nasal gliomas show telangiectatic overlying skin when presenting
as root of nose mass.
ey are nonpulsatile, do not transilluminate and do not enlarge on
valsalva maneuver/crying (negative Furstenberg test).
Case 4: Intranasal Encephalocele
A. Computed tomography (CT) sagittal image shows herniation of cranial
content (predominantly cerebrospinal uid) through a bony defect (arrow)
in the anterior skull base into the nasal area.
B. Bone window shows the defect in the anterior part of cribriform plate
(arrow).
C. Coronal CT image showing the intranasal mass in continuity with the
anterior cranial fossa through the defect (arrow).
Imaging pearl
Clinically, these show positive Furstenberg test, are pulsatile and also
transilluminate.
ey may be associated with hypertelorism and corpus callosum
dysgenesis.
Case 3 (Figs. 20.18A to C) Case 4 (Figs. 20.19A to C)
281Chapter 20 Pediatric Sinonasal Disorders: Imaging
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Section 5 Congenital/Pediatric Diseases282
ILLUSTRATIVE CASES
Masses presenting in frontonasal region.
Case 1: Hemangioma Presenting as a Frontonasal Mass
A. Surface rendered computed tomography (CT) image shows a bulge in
the frontonasal region (arrow) in a 6-year-old female.
B and C. CT shows well-circumscribed mass with arterial feeders and
enhancement (arrows). No phleboliths were seen. ere was no intranasal
or intracranial extension.
Imaging pearl
Hemangiomas are vascular tumors and clinically present as bluish red
mass. ese are nonpulsatile and do not transilluminate and show negative
Furstenberg test. On MRI, ese are T2 hyperintense, show ow voids and
intense enhancement.
Case. 2: Nasal Benign Nerve Sheath Tumor
A. Axial T2-weighted images show intermediate hyperintense mass in the
nasal cavity with extension in the anterior ethmoid sinuses (arrow).
B. T1 coronal shows intracranial, extradural extension of the mass (arrows).
C. T1 post-contrast sagittal image shows the enhancing mass bulging in the
frontonasal region and extension of the mass in the frontal sinus (arrow).
Imaging pearl
Sinonasal schwannoma is generally a well-dened soft-tissue mass most
frequently occurring in the nasal cavity and ethmoid sinus and frequently
associated with pressure remodeling of the adjacent bone. ese tumors
are isoattenuating on CT and show strong enhancement on MR images.
Although sinonasal schwannomas are rare and their imaging ndings are
rather nonspecic, CT and MR imaging studies are helpful for preoperative
diagnosis and surgical planning in patients with schwannoma of the
sinonasal cavity.
Case 1 (Figs. 20.20A to C) Case 2 (Figs. 20.21A to C)
283Chapter 20 Pediatric Sinonasal Disorders: Imaging
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Section 5 Congenital/Pediatric Diseases284
ILLUSTRATIVE CASES
Medial canthus masses (Figs. 20.22A to F).
Dierential diagnosis of masses presenting in the region of medial canthus
includes:
■ NLD cyst/infection
■ Dermoid
■ Epidermoid
■ Encephalocele
■ Glioma
■ Hemangioma.
A and B. Encephalocele presenting as bulge in right medial canthus
region. Coronal computed tomography (CT) image shows the intracranial
communication of the mass (arrows).
C. Dermoid/epidermoid cyst. A well-circumscribed high-attenuation mass
seen on right side in medial canthus region (arrow).
D. Lipodermoid. A fat containing well-circumscribed mass (arrow) in right
medial canthal region.
E. Dacryocystoceles. Dilated bilateral nasolacrimal sacs (arrow) seen in the
region of medial canthus with peripheral enhancement due to secondary
infection.
F. Dacryocystitis. Heterogeneous enhancement and inammatory changes
seen in the right medial canthus region in a case of unilateral dacryocystitis
(arrow).
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