Imaging in Sinonasal Inflammatory Disease

Imaging Nasal Obstruction: An Objective Evaluation for a Subjective Complaint

Nasal obstruction (NO) is a common clinical symptom characterized by a subjective sensation of insufficient airflow through the nasal cavity and may result from various factors, including changes in nasal anatomy, inflammatory conditions, tumoral lesions, and other etiologies. While a thorough medical history and physical examination can often identify its cause, imaging is usually necessary to fully understand the problem. Computed tomography (CT) is the primary imaging modality used to evaluate the nasal cavity and paranasal sinuses, allowing for the identification of potential causes and structural abnormalities. However, when soft tissue characterization is required, magnetic resonance imaging (MRI) is also useful. Understanding the anatomical and pathological basis of NO is crucial for accurate diagnosis and appropriate management. Imaging techniques provide valuable information for identifying the underlying causes of NO and guiding treatment decisions. This article reviews the normal anatomy of the nasal cavity and adjacent paranasal sinuses as well as the several conditions that may affect breathing comfort (tumors, inflammatory diseases, bony and cartilaginous anatomical variants, and "nonobstructive" mucosal thickenings), showing their normal presentation on CT and MRI.

Imaging of the Sinonasal Cavities

This article describes the various abnormalities that affect the sinonasal cavities and discusses inflammations, tumors, and tumor-like conditions. Specific imaging evaluations that focus on the sinonasal cavities are described in more detail.

Pediatric Odontogenic and Paranasal Sinus Infections

Odontogenic and sinogenic infections are frequently encountered in the pediatric population. Although the diagnosis is often suspected clinically, imaging can play a significant role in localizing the site of infection, assessing for involvement of deep neck spaces, detection of abscess and other potentially life-threatening complications, and providing valuable information to help with treatment planning. This article reviews the general imaging considerations and anatomy relevant to odontogenic and paranasal sinus infections and describes the salient clinical and imaging features of infectious diseases of the dentition and sinuss.

Sphenoid sinus anatomical variants and pathologies: pictorial essay

The sphenoid sinus (SS) is one of the four paired paranasal sinuses (PNSs) within the sphenoid bone body. Isolated pathologies of sphenoid sinus are uncommon. The patient may have various presentations like headache, nasal discharge, post nasal drip, or non-specific symptoms. Although rare, potential complications of sphenoidal sinusitis can range from mucocele to skull base or cavernous sinus involvement, or cranial neuropathy. Primary tumors are rare and adjoining tumors secondarily invading the sphenoid sinus is seen. Multidetector computed tomography (CT) scan and magnetic resonance imaging (MRI) are the primary imaging modalities used to diagnose various forms of sphenoid sinus lesions and complications. We have compiled anatomic variants and various pathologies affecting sphenoid sinus lesions in this article.

Infectious and Inflammatory Sinonasal Diseases

Rhinosinusitis is a commonly encountered disease. Imaging is not typically required in acute uncomplicated rhinosinusitis; however, it is integral in the evaluation of patients who present with prolonged or atypical symptoms or when acute intracranial complications or alternate diagnoses are suspected. Knowledge of the paranasal sinus anatomy is important to understand patterns of sinonasal opacification. Bacterial, viral, and fungal pathogens are responsible culprits and, with duration of symptoms, serve to categorize infectious sinonasal disease. Several systemic inflammatory and vasculitic processes have a predilection for the sinonasal region. Imaging, along with laboratory and histopathologic analysis, assist in arriving at these diagnoses.

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging of pediatric nasal masses: A review

Several conditions may present as nasal masses in pediatric age, including congenital and developmental disorders, inflammatory and infectious conditions, neoplastic and neoplastic-like lesions, and other miscellaneous disorders. A confident presurgical diagnosis can be challenging and imaging is often key in the management of these lesions. We provide a pictorial review of pediatric nasal masses and discuss a location-based approach to the diagnosis of these lesions on imaging studies. Acquaintance with the most common pathologies and awareness for its characteristic imaging features can aid the physician in the differential diagnosis. Location and extension of the lesion can be particularly helpful. Midline masses raise suspicion for developmental nasal midline lesions, including frontoethmoidal cephalocele, dermoid/epidermoid cyst, and neuroglial heterotopia. In case of trauma, nasal septum hematoma/abscess should be considered. Developmental or odontogenic cystic lesions and osseous neoplasms and neoplasm-like lesions can originate from the maxilla and palate. Although most nasal tumors show overlapping imaging characteristics, some have suggestive features, such as nasopharyngeal angiofibroma and esthesioneuroblastoma. Malignant tumors tend to be locally aggressive, demonstrating invasive features, bony erosion, intermediate signal on T2-weighted images, and restricted diffusion on diffusion-weighted imaging. In certain cases, a definite diagnosis can only be made histologically. Nonetheless, detailed characterization of the lesion is crucial prior to invasive procedures in order to avoid complications.

Is Ethmoidal Air Cell Count Relevant in Chronic Rhinosinusitis?

OBJECTIVES/HYPOTHESIS

Studies analyzing the association between the total number of ethmoid cells (EC) and chronic rhinosinusitis (CRS) are missing. Our aim was to analyze the total number of EC in patients with and without CRS.

STUDY DESIGN

Retrospective case-control study.

METHODS

A total of 50 computed tomography (CT) scans of patients with CRS, 14 CT scans of patients with odontogenic CRS, and 50 CT scans of healthy controls were retrospectively analyzed. The number of EC has been determined for each side separately.

RESULTS

In total 228 sides have been analyzed. The bilateral total EC count in both planes was more than 2 cells higher, when comparing CRS patients to healthy controls or odontogenic CRS patients (P < .01). No difference was observed, when comparing healthy and odontogenic CRS patients.

CONCLUSION

The number of EC on CT of CRS patients is significantly higher than in both, the healthy and the odontogenic CRS control group. Cell count could contribute to the pathogenesis of CRS.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1212-1216, 2021.

Eosinophilic Granulomatosis with Polyangiitis Presenting as Unilateral Acute Anterior Ischaemic Optic Neuropathy

Eosinophilic granulomatosis with polyangiitis (eGPA) is a rare vasculitis of small-medium sized vessels that can cause both anterior and posterior ischaemic optic neuropathies. Herein, the authors present a rare case of eGPA presenting initially as an acute unilateral anterior ischaemic optic neuropathy from short posterior ciliary artery vasculitis. The diagnosis presented a challenge as clinical and histopathological evidence suggested allergic rhinosinusitis, and no invasive fungal sinusitis was found. The high serum eosinophilia, asthma, optic neuropathy and paranasal sinus abnormalities fulfilled the criteria for a diagnosis of eGPA. Furthermore serum was positive for myeloperoxidase antibodies. Subsequently the case was successfully treated with oral glucocorticoids and intravenous rituximab.

Usefulness of Nasal Endoscopy for Diagnosing Patients With Chronic Rhinosinusitis: A Meta-Analysis

Background

We evaluated the accuracy of nasal endoscopy in diagnosing chronic rhinosinusitis (CRS) compared with paranasal sinus computed tomography (CT).

Methods

Two authors independently searched the 5 databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) up to March 2019. For all included studies, we calculated correlation coefficients between the endoscopic and CT scores. We extracted data on true-positive and false-positive and true-negative and false-negative results. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool (version 2).

Results

We included 16 observational or retrospective studies. A high correlation ( r = .8543; 95% confidence interval [CI] [0.7685–0.9401], P < .0001, I2 = 76.58%) between endoscopy and CT in terms of the diagnostic accuracy for CRS was apparent. The odds ratio (Lund–Kennedy endoscopic score ≥1) was 7.915 (95% CI [4.435–14.124]; I2 = 28.361%). The area under the summary receiver operating characteristic curve was 0.765. The sensitivity and specificity were 0.726 (95% CI [0.584–0.834]) and 0.767 (95% CI [0.685–0.849]), respectively. However, high interstudy heterogeneity was evident given the different endoscopic score thresholds used (Lund–Kennedy endoscopic score ≥1 vs 2). In a subgroup analysis of studies using a Lund–Kennedy endoscopic score threshold ≥2, the area under the summary curve was 0.881, and the sensitivity and specificity were 0.874 (95% CI [0.783–0.930]) and 0.793 (95% CI [0.366–0.962]), respectively.

Conclusion

Nasal endoscopy is a useful diagnostic tool; the Lund–Kennedy score was comparable with that of CT.

Imaging of adult nasal obstruction

The commonest causes of nasal obstruction are rhinitis and chronic rhinosinusitis, which affect up to 30% and 14% of the adult population, respectively. The global financial burden is huge, estimated at $5 billion for rhinitis and $8.6 billion for chronic rhinosinusitis per annum in the USA. On referral for imaging, computed tomography (CT) is indicated initially when there is a suboptimal response to medical treatment of these mucosal diseases or there are "red flags," such as persistent unilateral obstruction, epistaxis, pain, and orbital or neurological symptoms. A mass visible at rhinoscopy or endoscopy in the nose or nasopharynx and lymphadenopathy are further indications. The anterior (cartilaginous) nose plays a key role in the aetiology of nasal obstruction as it accounts for 50-75% of the total resistance to airflow in the upper airway. It has been ignored in the imaging literature, but extensively evaluated by clinicians using a range of methods, including CT. Oblique reconstructions perpendicular to the parabolic curve of lamellar airflow provide accurate assessment of the anterior nose. A thorough and systematic approach to assessing the nose addresses the discrepancy between imaging and clinical evaluation of structural causes of nasal obstruction, especially septal deviation, reported in the surgical literature. Nasal tumours are a very uncommon cause of nasal obstruction; magnetic resonance imaging is commonly performed to assess their full extent and improve the specificity of diagnosis.

Imaging of odontogenic sinusitis

The aetiological relationship between dental disease and procedures and mucosal disease within the maxillary sinus has received extensive attention in the recent otolaryngological and dental literature. In contrast, the concept of an odontogenic cause for sinusitis is not well appreciated by radiologists. Review of the maxillary dentition, the alveolar process, and the relationship of the tooth roots to the floor of the maxillary sinus should be an integral part of interpretation of imaging of the paranasal sinuses. The pathogenesis, clinical presentation, and imaging features of rhinogenic and odontogenic sinusitis are discussed and compared. Clinical definitions of rhinosinusitis are explained and the huge impact on healthcare of this disease is briefly discussed. Periapical inflammatory lesions, post-extraction oroantral communication, and procedures used to augment the alveolar process prior to placement of dental implants are the commonest causes of odontogenic sinusitis. Current estimates are that an odontogenic cause for maxillary sinusitis is present in 25-40% of cases. The incidence of odontogenic sinusitis is rising, extension outside the maxillary sinus is common, and the diagnosis is often delayed, resulting in inappropriate and failed treatment. Differentiation of rhinological and odontogenic causes of sinusitis is usually difficult on clinical grounds and imaging plays a key role in the distinction.

Diffusion-Weighted Magnetic Resonance Imaging in Maxillary Sinuses Inflammatory Diseases: Report of Three Cases and Literature Review

Background

Magnetic resonance imaging is considered a preferable imaging examination in the diagnosis of inflammatory maxillary sinus disease and can provide precise sinonasal characterization. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient are complementary magnetic resonance imaging tools that can be applied to the differentiation of sinus diseases. In this report, 3 cases of inflammatory maxillary sinus diseases imaging findings considering diffusion-weighted magnetic resonance imaging features were described. Additionally, a literature review considering the use of diffusion-weighted magnetic resonance imaging in inflammatory lesions is provided.

Methods

The cases reported were: presence of air-fluid levels, mucosal thickening and a mucous retention cyst. Conventional magnetic resonance imaging and apparent diffusion coefficient (ADC) maps, with ADC values were demonstrated. In the literature review, the studies considering inflammatory lesions were detailed, as well as ADC values established by investigators.

Results

ADC values for presence of air-fluid levels, mucosal thickening and mucous retention cyst were respectively: 1.99 x 10^-3 mm²/s; 1.83 x 10^-3 mm²/s; 2.05 x 10^-3 mm²/s.

Conclusions

It was observed that apparent diffusion coefficient values from the inflammatory lesions described in this report were different and apparent diffusion coefficient may be useful in the differentiation of these maxillary sinus alterations. Further larger sample investigations considering apparent diffusion coefficient values focusing in inflammatory lesions are recommended. The lack of studies considering the use of diffusion-weighted magnetic resonance imaging on inflammatory diseases diagnostic was the major limitation to the literature review.

[Imaging of the paranasal sinuses and anterior skull base]

Due to the complex anatomy of the anterior skull base and paranasal sinuses, radiologic diagnostics in this area are challenging. Magnetic resonance imaging (MRI) and computed tomography (CT) are the primary indicated modalities. Guidelines helping to select the appropriate modality have been published by the German Society of Head and Neck Radiology and the Society of Otorhinolaryngology. The present article presents an overview of the current radiologic procedures and their optimized implementation using clinical examples. These examples highlight the fact that a combination of at least CT and MRI is frequently required. Use of CT for intraoperative navigation is everyday practice in clinical routine. Occasionally, additional procedures such as angiography or myelography are necessary, particularly in cases of preoperative vascular diagnostics or embolization. Overall, evaluation of radiologic diagnostics in this area is complex; it requires experience and knowledge of the disease, as well as an understanding of the diagnostic procedures. Close collaboration between head and neck surgeons and radiologists is thus essential.

IV Brazilian Consensus on Rhinitis - an update on allergic rhinitis

INTRODUCTION

The guidelines on allergic rhinitis aim to update knowledge about the disease and care for affected patients. The initiative called "Allergic Rhinitis and its Impact on Asthma", initially published in 2001 and updated in 2008 and 2010, has been very successful in disseminating information and evidence, as well as providing a classification of severity and proposing a systemized treatment protocol. In order to include the participation of other medical professionals in the treatment of allergic rhinitis, it is important to develop algorithms that accurately indicate what should and can be done regionally.

OBJECTIVE

To update the III Brazilian Consensus on Rhinitis - 2012, with the creation of an algorithm for allergic rhinitis management.

METHODS

We invited 24 experts nominated by the Brazilian Association of Allergy and Immunology, Brazilian Association of Otorhinolaryngology and Head and Neck Surgery and Brazilian Society of Pediatrics to update the 2012 document.

RESULTS

The update of the last Brazilian Consensus on Rhinitis incorporated and adapted the relevant information published in all "Allergic Rhinitis and its Impact on Asthma" Initiative documents to the Brazilian scenario, bringing new concepts such as local allergic rhinitis, new drugs and treatment evaluation methods.

CONCLUSION

A flowchart for allergic rhinitis treatment has been proposed.

Nontraumatic head and neck emergencies: a clinical approach. Part 1: cervicofacial swelling, dysphagia, and dyspnea

Nontraumatic emergencies of the head and neck represent a challenge in the field of neuroradiology for two reasons: first, they affect an area where the thorax joins the cranial cavity and can thus compromise both structures; second, they are uncommon, so they are not well known. Various publications focus on nontraumatic emergencies of the head and neck from the viewpoints of anatomic location or of particular diseases. However, these are not the most helpful viewpoints for dealing with patients in the emergency department, who present with particular signs and symptoms. We propose an analysis starting from the four most common clinical presentations of patients who come to the emergency department for nontraumatic head and neck emergencies: cervical swelling, dysphagia, dyspnea, and loss of vision. Starting from these entities, we develop an approach to the radiologic management and diagnosis of these patients.