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Nasal Cavity Lesions
A 13-year-old boy presenting with epistaxis. CT, computed tomography; FS, fat saturated.
A 62-year-old man presenting with epistaxis.
A 73-year-old man presenting with chronic sinusitis. CT, computed tomography.
A 51-year-old man presenting with persistent nasal congestion. CT, computed tomography.
A 47-year-old man presenting with a 1-month history of right frontal and temporal pain. FS, fat saturated.
DESCRIPTION OF FINDINGS
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Case A: An avidly enhancing, expansile mass is centered at the sphenopalatine foramen with extension anteriorly into the nasal cavity, laterally into the pterygopalatine fossa and pterygomaxillary fissure, and into the inferior orbital fissure.
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Case B: An avidly enhancing nasal cavity mass is extending anteriorly into the nasal vestibule.
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Case C: A nonspecific nasal cavity mass.
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Case D: Bilateral low-density polypoid nasal cavity lesions.
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Case E: A heterogeneous nasal cavity mass extending into the ethmoid air cells.
Diagnosis
Case A
Juvenile angiofibroma (proven by pathology)
Case B
Melanoma (proven by pathology)
Case C
Inverting papilloma (proven by pathology)
Case D
Nasal polyposis (proven clinically and by radiology)
Case E
Squamous cell carcinoma (SCC) ex inverting papilloma (proven by pathology)
Summary
Because most disease in the nasal cavity relates to inflammatory mucosal thickening or polyp formation, the radiologist must be attuned to subtle findings that might suggest a different diagnostic possibility. More broadly, nasal cavity lesions may include neoplastic, inflammatory, or infectious etiologies. Often a nasal cavity mass has nonspecific imaging characteristics, and the job of the radiologist is to locally stage and evaluate for lymphadenopathy and perineural tumor spread, with a definitive diagnosis made at biopsy.
It is useful to evaluate for aggressive imaging features, namely bone destruction, on CT, which might suggest a more sinister diagnosis compared with remodeling, which is suggestive of a slow-growing lesion. However, even malignant lesions can have a pushing margin with remodeling. In addition, “evil gray” at MRI (i.e., intermediate T2 and T1 postgadolinium signal) is strongly suggestive of tumor, in contradistinction to typically T2 bright and peripherally enhancing inflammatory change. That being said, significant overlap exists in the imaging appearance of benign and malignant lesions.
Typically, nonaggressive lesions include polyps/polyposis, inverted papilloma, and juvenile angiofibroma. Aggressive lesions typically include sinonasal carcinoma (either SCC, sinonasal undifferentiated carcinoma, or adenocarcinoma), olfactory neuroblastoma (esthesioneuroblastoma), lymphoma, sarcoma, or melanoma. Neither of these lists is exhaustive.
Nasal septal perforation constitutes a unique and somewhat specific differential diagnosis. This condition is discussed in the following sections.
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