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Normal and Abnormal Appearance of Nose and Paranasal Sinuses After Microendoscopic Surgery, Open Surg., and RT
285
Fig. 11.37a-b. Follow up of right frontal sinus undifferentiated carcinoma four months after radiation therapy and chemotherapy. TSE T2 on coronal plane show the extent of tumor before (a) and
after treatment (b). a Marked deformation of the orbital roof is caused by tumor, which is still
separated from the orbital fat by the residual bone/periorbital lining (white arrows). The superior
rectus muscle (black arrows) is compressed and displaced inferiorly. b The shrinkage of tumor after
treatment is associated with partial restoration of the normal position of the orbital roof (white
arrows). At surgery, the orbit was spared, being intraoperative frozen sections negative. The superior rectus muscle (black arrows) has a more normal position. Thickened mucosa in the anterior
ethmoid is seen (asterisk)
imaging might be quite reassuring if the areas under questions undergo stabilization or continuous
shrinkage or show a diminishing degree of enhancement (Loevner and Sonners 2002; Ng et al. 2002)
(Fig. 11.37). These fi ndings are particularly useful in
case tumor was treated by exclusive radiotherapy and
the location does not allow an easy assessment by endoscopy or it was totally extramucosal.
An additional key issue to improve early detection
of recurrences encompasses the careful analysis of
anatomically related cranial nerve branches to rule
out perineural spread, which – though more frequent
in malignant glandular carcinomas and in lymphomas – is also likely in squamous cell carcinoma.
Perivascular spread is also possible, although rarer
than perineural spread (Fig. 11.38).
It is important to note that in case of treatment
of repeated local recurrences, mostly by combined
therapies, the chance of developing relapses in unusual sites increases. Whereas the occurrence within
neck fat tissue may be theoretically explained by intraoperative seeding (Fig. 11.39-43), the development
of lesions in contralateral facial bony framework or
in the epidural location does probably account for
metastasis through the vascular system (Fig. 11.44).
Although single photon emission computed tomography and positron emission computed tomography with 18F-2-fl uoro-deoxyglucose - without and
with CT - appear promising for detecting recurrent
or residual disease, their role in the follow up of malignant neoplasms of the sinonasal tract is not yet established (Ninomiya et al. 2004).
ba
286
R. Maroldi et al.
ba
c
Fig. 11.38a-e. Progression of mucoepidermoid carcinoma of
the right palate after craniofacial resection, right orbital exenteration, reconstruction with myo-cutaneous fl ap (rectus
abdominis muscle). Pre- (a) and post-treatment (b) TSE T2
coronal images show invasion of right cavernous sinus (ar-
rows), which was not treated by surgery. Post surgical changes
of the masticator space (asterisk) and greater wing of the
sphenoid bone (arrowheads) are present. c-e Post-treatment
enhanced axial T1 images demonstrate (c) extensive invasion
of right Meckel’s cave (thick white arrows) with enhancement
of internal carotid artery wall (black arrows), enhancement of
right tentorium (thin white arrows), heterogeneous scar tissue
replaces the right pterygoid process (asterisk); d retrograde
perivascular spread along the internal carotid artery to reach
e
the extracranial segment (black arrows). e A retrolateropharyngeal metastatic node involves the right internal carotid
d
Normal and Abnormal Appearance of Nose and Paranasal Sinuses After Microendoscopic Surgery, Open Surg., and RT
ab
cd
287
Fig. 11.39a-d. Left maxillary sinus squamous cell carcinoma in a male patient 31 years old. TSE T2 (a-c) and CT (d) in the axial
plane, obtained before treatment (a), after the fi rst cycle of chemotherapy (b), after radiation and chemotherapy, four (c), and
six (d) months from treatment beginning. a Baseline study shows that the tumor has four major pathways of spread: marked
displacement of the anterior sinus wall (arrowheads); invasion of the cortical and cancellous zygomatic bone (long thin white
arrow); disruption of the most anterior part of the posterolateral sinus wall (coupled white arrows); remodeling and displace-
ment of the medial sinus wall towards the nasal cavity (thick white arrow). b After the fi rst cycle of chemotherapy, a very limited
decrease of volume is observed, and the tumor signal is unchanged. c After adjuvant of radiation and chemotherapy, shrinkage
of tumor is observed, resulting in residual questionable hyperintense tissue located in the anterior portion of maxillary sinus
(asterisk). Relevant thickening of the previously invaded anterior sinus wall (coupled thin white arrows) is associated with
diffuse signal hypointensity and clearly detectable outlines (double white arrowheads arrow). d On CT, the residual thickened
bone cannot be clearly separated from the intrasinusal questionable tissue (asterisk). While any progression of zygomatic bone
erosion is observed, shrinkage of tumor enables the eroded posterolateral wall to retract. MR is more precise than CT in demonstrating that a residual wall separates intrasinusal tissue from masticator space fat. In fact a continuous hypointense signal
corresponding to the demineralized bone and periosteum is demonstrated (black arrows)
288
R. Maroldi et al.
ba c
d
Fig. 11.40a-d. Same patient of Figure 11.39. Post-contrast T1 axial planes obtained
caudally in respect to the level of images in Figure 11.39 (also the examination dates
of a-c are the same). Possible invasion of pre-maxillary fat tissue is indicated (ar row
in a-c) Image d, obtained after radical left maxillectomy (seven months after c) be-
sides the normal post surgical appearance shows fatty degeneration of the masticator muscles (black arrowheads), reduced hyperintensity of fat within the masticator
space (arrow), and artifacts due to mandible resection (white arrowheads)
Fig. 11.41a,b. Same patient of
Figures 11.39-40. Before maxillectomy, the patient had left superfi cial
parotidectomy and selective neck
dissection for metastasis. A PET
study fi ve months after maxillectomy shows hypermetabolic foci in
the parotid area where a lamina of
Silastic was placed. Multiple foci are
seen on both the axial and coronal
images (arrows). A contralateral lesion was suspected, not confi rmed
by fi ne needle aspiration cytology
a b
Normal and Abnormal Appearance of Nose and Paranasal Sinuses After Microendoscopic Surgery, Open Surg., and RT
abc
Fig. 11.42a-c. Same patient of Figures 11.39-41. The hypermetabolic foci detected by PET reveal to be multiple nodules dis-
seminated along the sternocleidomastoid muscle (white arrows). Silastic lamina (1)
289
a
b
Fig. 11.43a,b. Same patient of Figures 11.39-42. Nine months after revision surgery with reconstruction by mean of a vascular-
ized fl ap (arrows) local recurrence develops at the interface between fl ap and native tissues (asterisk)
290
a
R. Maroldi et al.
cb
Fig. 11.44a-d. Follow up of left ethmoid squamous cell carcinoma devel-
oped two years after removal of an inverted papilloma at the same site. a
Post-contrast coronal CT shows the mass occupying the whole left ethmoid
and nasal fossa. Bone invasion of the ethmoid roof (arrows) and extent into
maxillary sinus are noted. The patient was treated with left ethmoido-maxillectomy and radiation therapy. b The TSE T2 coronal image obtained two
years after identifi es a subclinical-submucosal recurrence (thick arrows)
with intracranial extradural extent and invasion into the nasal septum (thin
arrows) At surgery, the right lamina papyracea was normal. c The follow up
TSE T2 study fi ve months after anterior craniofacial resection shows only
the normal pattern of the meningo-galeal complex (arrows). d Two months
after, the onset of right side progressive impairment of vision prompted a
new MR study. On contrast enhanced coronal T1 image, encasement of the
internal carotid artery within the right cavernous sinus by a metastasis is
d
demonstrated (arrows)
Normal and Abnormal Appearance of Nose and Paranasal Sinuses After Microendoscopic Surgery, Open Surg., and RT
291
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Subject Index 295
Legends of Anatomic Structures
A agger nasi
AC anterior clinoid
aEC anterior canal of the ethmoid
ao accessory ostium of maxillary sinus
arMS alveolar recess of maxillary sinus
B ethmoid bulla
CB concha bullosa
CC carotid canal
CG crista galli
EI ethmoid infundibulum
ET eustachian tube opening
FE fovea ethmoidalis
FO foramen ovale
FS frontal sinus
FSp foramen spinosum
GL ground lamella
GPC greater palatine canal
GPF greater palatine foramen
H hiatus semilunaris
h hamulus of the medial pterygoid plate
hlCP horizontal lamella of the cribriform plate
hUP horizontal plate of the uncinate process
HY hypophisis
IC incisive canal
ICA internal carotid artery
IEC infraorbital ethmoid cell (Haller cell)
IF incise foramen
IM inferior meatus
IOF inferior orbital fi ssure
ION infraorbital nerve
IT inferior turbinate
L common lamina of turbinates
LB lacrimal bone posterior crest
LP lamina papyracea
LPC lesser palatine canal
LPF lesser palatine foramen
LPP lateral pterygoid plate
LS lacrimal sac
MC Meckel cave
MM middle meatus
MPP medial pterygoid plate
MS maxillary sinus
MT middle turbinate
NLD nasolacrimal duct
NS nasal septum
O maxillary ostium
oFS ostium frontal sinus
OC optic canal
OG olfactory groove
ON optic nerve
OnC Onodi cell
oSS ostium of sphenoid sinus
PEC posterior ethmoid cells
PF pterygoid (scaphoid) fossa
PMF pterygomaxillary fi ssure
PP perpendicular plate of the ethmoid
PPF pterygopalatine fossa
PPr pterygoid process
ppSS sphenoid recess pneumatizing the
pterygoid process
rs rostrum of the sphenoid bone
SL sinus lateralis
SOF superior orbital fi ssure
SPF sphenopalatine foramen
SS sphenoid sinus
ST superior turbinate
suOC supraorbital ethmoid cell
suR suprabullar recess
SuT supreme turbinate
TR terminal recess
UP uncinate process
V2 maxillary nerve
V3 mandibular nerve
VC vidian (pterygoid) canal
VN vidian (pterygoid) nerve
vlCP vertical lamella of the cribriform plate
vlMT vertical lamella of the middle turbinate
vUP vertical portion of the uncinate process
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