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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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■ e dierentials of lesions based on evaluation of the status of bony walls
are detailed in Flowcharts 28.2 and 28.3.
■ In general, malignant masses show erosive bone changes which
have an ill-dened permeative pattern. Benign mass lesions such as
Flowchart 28.2: Differentials of lesions based on status of bony walls.
Flowchart 28.3: Differentials of lesions based on bone erosion.
397Chapter 28 Imaging Approach to Sinus Lesions
Section 7 Clinico-Radiological Approach398
A
C
B
Figs. 28.8A to C: Benign lesions showing
bone destruction. (A) Invasive fungal sinusitis;
(B) Complicated acute sinusitis; and (C) Granulomatosis with polyangiitis (GPA).
A B
Figs. 28.9A and B: Malignant lesions showing bone expansion and remodeling:
Lymphoma. (A) Diffuse large B-cell lymphoma; and (B) Non-Hodgkin’s lymphoma.
inammatory polyps display bone expansion with remodeling. Bone
in these cases shows thinning but not ill-dened erosive changes (Figs.
28.8 and 28.9). However, benign lesions may show erosive change, and
conversely malignant lesion may display expansion (Table 28.1).
Table 28.1: Atypical pattern of bony changes in benign and malignant lesions.
Benign lesions showing bone destruction
(Figs. 28.8A to C)
• Invasive fungal sinusitis
• Complicated acute sinusitis
• Granulomatosis with polyangiitis (GPA)
• Giant cell reparative granuloma
Malignant lesions showing bone expansion
and remodeling (Figs. 28.9A and B)
• Minor salivary gland tumors
• Lymphoma
399Chapter 28 Imaging Approach to Sinus Lesions
A
C
B
Figs. 28.10A to C: Hyperdense sino nasal
lesions. (A) Chronic sinusitis (retained secre-
tions); (B) Mycetoma; and (C) Allergic fungal
sinusitis (AFS).
DENSITY OF LESION
■ Lesions may be primarily hyperdense of osseous density, heterogeneous
density, or cystic. e pattern of calcication can also give a clue to the
etiology of the lesion.
■ e dierentials of lesions according to the density are the following:
• Hyperdense (Figs. 28.10A to C):
▶ Chronic sinusitis (retained secretions)
▶ Mycetoma
▶ Allergic fungal sinusitis (AFS).
1,4,5
Section 7 Clinico-Radiological Approach400
A B
Figs. 28.11A to C: Sinonasal lesions of
osseous density. (A) Osteoma; (B)
Antrolith/rhinolith; and (C) Fibrous
C
dysplasia (ground glass).
• Osseous density (Figs. 28.11A to C):
▶ Osteoma
▶ Rhinolith
▶ Fibrous dysplasia (ground glass).
• Heterogeneous density (Figs. 28.12A and B):
▶ Ossifying broma
▶ Tumors.
• Cystic lesions (Figs. 28.13 to 28.16):
▶ Detailed in Table 28.2.
• Specic pattern of calcications (Figs. 28.17A and B) is seen in the
following entities:
▶ Inverted papilloma
▶ Chondrosarcoma (arc like)
▶ Osteosarcoma (dense, scattered).
A B
Figs. 28.12A and B: Sinonasal lesions of heterogeneous density. (A) Juvenile ossifying
broma;and(B)Tumors:Maxillarynonseminomatousgermcelltumor.
401Chapter 28 Imaging Approach to Sinus Lesions
A
C
Figs. 28.13A to D: Cystic/ Cystic-Solid in maxillary sinus. (A) Retention cyst; (B) Dentigerous
cyst; (C) Keratocystic odontogenic tumor (KOT); and (D) Ameloblastoma.
B
D
Section 7 Clinico-Radiological Approach402
A B
Figs. 28.14A and B: Cystic lesions in ethmoid sinus. (A) Mucocele; and (B) Esthesioneuro-
blastoma (solid cystic).
A B
Figs. 28.15A and B: Cystic lesions in frontal sinus. (A) Mucocele; and (B) Frontonasal
meningoencephalocele.
A B
Figs. 28.16A and B: Cystic lesions in sphenoid sinus. (A) Mucocele; and (B) Retention cyst.
Table 28.2: Dierential diagnosis of cystic lesions.
Location (sinus involved) Cyst Cyst with solid component
Maxillary sinus
(Figs. 28.13A to D)
Ethmoid
(Figs. 28.14A and B)
Frontal
(Figs. 28.15A and B)
Sphenoid
(Figs. 28.16A and B)
• Retention cyst
• Dentigerous cyst
• Ameloblastoma
• Keratocystic odontogenic
tumor (KOT)
• Cephalocele
• Mucocele
• Dermoid
• Epidermoid
• Mucocele
• Cephalocele
• Mucocele
• Cephalocele
• Dermoid
• Epidermoid
• Ameloblastoma
• KOT
• Central giant cell reparative
granuloma
• Ossifyingbroma
• Giant cell lesions
• OF
• Esthesioneuroblastoma
• OF
• Craniopharyngioma
• Chordoma
403Chapter 28 Imaging Approach to Sinus Lesions
A B
Figs. 28.17A and B: Specic patterns of calcication. (A) Chondrosarcoma: Dense,
popcorn type; and (B) Chondrosarcoma: Ring and arc like.
MAGNETIC RESONANCE IMAGING SIGNAL
■ Normal aerated sinus is hypointense on T1-weighted image (T1WI) and
T2WI (Figs. 28.18A and B).
■ Hence the lesions hypointense on T2WI simulate normal sinus and may
thus underestimate the extent of disease (Figs. 28.19 to 28.21).
■ Lesions can have hypointense or hyperintense signal on T1WI (Table
28.3) and hypointense, intermediate, or hyperintense signal on T2WI
(Table 28.4).
5,6
Section 7 Clinico-Radiological Approach404
A B
Figs. 28.18A and B: Signal intensity on T1WI (A and B)
Hyperintense: Inspissated secretions (arrow in A), Mucocoele (asterisk in A), Melanoma
(arrow in B)
Hypointense: Mucosal thickening and secretions (arrowhead in A and B).
A
C
Figs. 28.19A to D: Hypointense SI on T2-weighted image (T2WI). (A) Inspissated secretions
with high proteinaceous content; (B) Fungal sinusitis; (C) Lymphoma; and (D) Melanoma.
B
D
405Chapter 28 Imaging Approach to Sinus Lesions
A
C
Figs. 28.20A to D: Intermediate SI on T2-weighted image (T2WI). (A) Juvenile nasopharyn-
gealangiobroma;(B)Invertedpapilloma;(C)Sinonasalangiomatouspolyp;and(D)Fungal
sinusitis.
A
B
D
B
C
Figs. 28.21A to D: Hyperintense SI on T2-weighted image (T2WI). (A) Secretions; (B)
Inammatorypolyps;(C)Pleomorphicadenoma;and(D)Chondrosarcoma.
D
Section 7 Clinico-Radiological Approach406
Table 28.3: Dierentials according to signal
intensity on T1WI (Figs. 28.18A and B).
Hyperintense Hypointense
• Inspissated secretions
• Retention cysts
• Melanoma
• Mucosal thickening with inspissated secretions
Table 28.4: Dierentials according to signal intensity on T2WI.
Hypointense
(Figs. 28.19A to D)
• Inspissated secretions with
high proteinaceous content
• Fungal sinusitis
• Lymphoma
• Melanoma
Intermediate
(Figs. 28.20A to D)
• Majority of tumors
• Inverted papilloma
• Fungal sinusitis
• Lymphoma
• Pseudotumor
High
(Figs. 28.21A to D)
• Secretions
• Inammatorypolyps
• Adenoid cystic
carcinoma (low grade)
• Pleomorphic adenoma
(hypointense capsule)
• Hemangioma
• Chondrosarcoma
• Nerve sheath tumors
• Few inverted
papillomas
ENHANCEMENT PATTERNS
■ Lesions can be nonenhancing or show variable enhancement (ranging
from mild/moderate to intense enhancement) (Figs. 28.22 to 28.25).
ese are detailed in Table 28.5.
■ Certain lesions have a specic pattern of enhancement7 which can give a
clue to its etiology (Table 28.5).
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