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Sinonasal Overview
Summary Thoughts: Sinus and Nose
Conditions related to the nose, nasal cavities (NC), and paranasal sinuses (PS) are some of the most common cases encountered by clinicians, prompting 25 million medical visits and costing $2 billion annually. Imaging is required when patients fail 1st-line treatments for inflammatory conditions, invasive disease or neoplasm is suspected, or presurgical planning becomes necessary. Given the complex bony architecture and the intervening air-filled spaces, CT is the most common modality for evaluating the sinonasal (SN) region. CT determines the extent of disease and is also helpful for surgical planning and intraoperative guidance. MR can be complementary in the evaluation of advanced infectious or inflammatory disease, and in the evaluation of neoplasms. As in all regions of the head and neck, information such as patient demographics, presenting symptoms, and clinical exam findings are critical for interpreting imaging studies of this area.
The NC is centrally located and is surrounded by the PS. It is important to understand the drainage pathways of the PS as one can then predict patterns of disease based upon the site of an obstructing lesion. However, this can be challenging due to limitless anatomic variation. Infectious/inflammatory diseases are by far the most common pathologies. Neoplasms, both benign and malignant, are relatively rare. They tend to present at an advanced stage and encroach upon vital structures (orbit, skull base, and cranial nerves). These tumors are difficult to completely resect and are associated with high surgical morbidity. Presurgical tumor mapping in such cases is best accomplished with multiplanar MR.
Imaging Approaches and Indications
CT is the preferred modality to evaluate inflammatory disease, depicting mucosal thickening, opacification, air-fluid levels, and soft tissue masses. CT easily depicts osseous changes such as remodeling, scalloping, hyperostosis, or erosion, and is sensitive for detecting Ca⁺⁺ or bone in lesions such as osteomas, chronic fungal disease, fibroosseous lesions, chondrosarcoma, or inverted papilloma. Coronal images best demonstrate the anatomy of the ostiomeatal unit (OMU). CECT is usually reserved for complicated cases in which soft tissue abscess, neoplasm, or vascular complication (cavernous sinus thrombosis) is suspected.
MR is indicated for evaluation of complex inflammatory disease and neoplasms . It is optimal for assessing extension or invasion of disease beyond the SN cavities, evaluating perineural tumor spread, and differentiating tumor from postobstructive secretions.
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