Paranasal sinuses

Dr. Netty D. Lubis,SpRad

Dr.Syaifuddin Lubis Sp.Rad
Department of Radiology
H.Adam Malik Hospital/Faculty of medicine on
Universitas of North Sumatra
LEGEND: F - Frontal sinuses, E - Ethmoid sinuses, M - Maxillary sinuses, O -
Maxillary sinus ostium, SS - Sphenoid sinus ST- Superior turbinate, T - Middle
turbinate, IT- Inferior turbinate, SM- Superior meatus, MM- Middle meatus, SR -
Sphenoethmoidal recess, S- Septum, ET - Eustachian tube orifice, A - Adenoids .
 Plain X-Ray Technique
The standard projections which may be
employed are :
1. Occipito-frontal projection (Water’s position)
The subjects sits facing the film with the
orbitomeatal line raised 20°, the beam
horizontal and the tube centred to the nasion.
This projection demonstrates the fine detail of
the frontal sinuses; the lateral walls of the
antra are also seen.
2. Lateral projection
The subject sits with the
radiographic base line horizontal
and the sagittal plane parallel to
the film. The beam is centred
through the anthrum.
• Examination of the sinuses should
always be made in the erect position with
a horizontal x-ray beam.

To allow the demonstration of the air

fluid level within the sinus.

Fluid in the sinus may be pus or

mucopus occuring as a sequel to infection
or allergy, but may be due to blood after
trauma.
Nasal bone
 Computerized Tomography
CT is an important addition to the radiographic
investigation of the paranasal sinuses.
The advantages :
1. To evaluate minimal sinuses pathology that is
not seen in plain x-ray.
2. To disclose the OMC (Ostio_Meatal Complex)
there is obstruction or not for further
management in sinusitis.
3. Showing both bone destruction and the soft
tissue extent of the disease.
4. In malignant disease it provides an accurate
method of staging a tumor prior to
radiotheraphy or surgery and is important to
show recurrence of tumor.
 Technique
Routine axial and coronal section.
Direct coronal scanning is necessary for adequate
demonstration of sinus disease.
Administration of CM (Contrast Media) should be
reserved for the following categories:
Patients with vascular tumors such as
angiofibroma
To demonstrate extension of sinuses tumor or
nasopharyngeal tumor.
Patients with sinus infection who are suspected
of having an abscess either in the anterior fossa
or in the orbit, when there is an associated
orbital cellulitis.
Frontal sinuses
 Inflammatory and allergic sinus
disease
 Acute sinusitis
Most often due to secondary bacterial
infection following an upper respiratory
tract infection. Infection can also occur in
the maxillary anthrum by secondary
extension from an infected tooth in the
upper jaw.
The primary site of infection is the lining
mucosa of the sinuses.
 Radiographic shows
Swelling of the mucosa:
an opaque rim around the periphery of the
sinus.
Infective sinusitis:
rim of mucous membrane follows the
contour of, and is parallel to the walls of
sinus.
 Allergic sinusitis:
- Mucosa assumes a polypoid aspect with
a convex inner border.
- Thickening of the nasal turbinates is
characteristic of allergic sinusitis.

Acute sinusitis :
- Total loss of translucency
- A fluid level.
Acute sinusitis
 Chronic sinusitis
Usually follows an acute infection and is
generally manifest as a thickening of the
lining membrane of the membrane.
Reactive change may occur in the sinus
wall causing an increased bone density or
partial obliteration of the sinus cavity.
Frontal sinuses are most commonly
affected but multiple sinuses may also be
involved.
Chronic sinusitis
 Benign tumor
1. Osteoma
The commonest benign tumor, occur in
1% of individu.
 Asymptomatic
 Large osteomas in the frontal sinus or
ethmoid cells may cause proptosis by
direct invasion of the orbit or they may
obstruct the fronto nasal duct, causing a
mucocele.
Osteoma
2. Juvenile angiofibroma

 A rare, benign but highly

vascular tumour occuring almost
exclusively in adolescent boys.

 Well demonstrated by
angiography and may require
preop embolization.
 Malignant tumour
Most commontly: Squamous cell ca
Arise in the nose or maxillary anhtrum.

Plain x-ray:
Bone destruction of the sinus walls with the
presence of a soft tissue mass in the nasal
cavity.
Malignant nose and sinuses
tumours is best assesed by a
combination CT + Contrast or Gd
MR (Gadolinium MR)
 Temporal Bone
Plain Radography
1. Lateral view
- To show mastoid air cells
- Erosion of the atticoantral region by a
cholesteatoma.
2. Stenver’s view
Petrous bone is demonstrated by placing
it parallel to the x-ray film with the
incident ray passing at right angles to it.
CT Scan

Axial and coronal sections

Thin sections (1 or 2 mm thick)
Mastoid normal
 Inflammatory Disease
Acute Mastoiditis
The most compication of acute otitis media and
results from the spread of the infective process
beyond the mucosal lining of the middle eae
cleft into the underlying bone.
Radiographic finding :
- Breakdown of the cell wall trabeculations, in
addition to the loss of translucency
CT : to evaluate if there is abscess formation.
 Cholesteatoma
1. Congenital cholesteatoma in petrous
apex

 Punched out area of bone

dectruction.

 The middle ear may be normal

clinically and radiologically
Cholesteatoma of the petrous apex
2. Acquired cholesteatoma
 Majority arise in the postero superior
part of the middle ear and extend
into other parts of the middle ear
cleft, into the rest of the tympanic
cavity and backwords into the
mastoid antrum and air cells.
 Associated with disorders of the
middle ear cleft with or without
infection.
Plain mastoid views:
Pneumatization is usually poor or absent.

CT_Scans:
CT in coronal plane is the best method for
demonstrating small cholesteatoma in the
attic and antrum.
Ossicles may be eroded or slightly
displaced.