- Email: [email protected]
The unilateral opaque maxillary sinus on computed tomography
British Journal of Oral and Maxillofacial Surgery (2002) 40, 504–507 © 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S0266-4356(02)00225-5, available online at http://www.idealibrary.com on
The unilateral opaque maxillary sinus on computed tomography M. Rudralingam, ∗ K. Jones, † T. J. Woolford ‡ ∗ Department
of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK; †Department of Oral and Maxillofacial Surgery, Derbyshire Royal Infirmary, Derby DE1 2QY, UK; ‡Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK SUMMARY. Computed tomography (CT) is the imaging method of choice for conditions that affect the paranasal sinuses. We reviewed all paranasal CT scans in the ear nose and throat (ENT) and maxillofacial surgery departments in 1 year. Of these 372 scans, unilateral opacity of the maxillary sinus was seen in 20 cases. Neoplastic disease was diagnosed in six of these, four of which were malignant. We describe the cases of neoplastic disease, particularly features of the history, examination, and scans that should alert the clinician to the possibility of sinister pathology. We emphasise the importance of nasendoscopic examination in the accurate assessment of sinonasal disease. © 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.
INTRODUCTION
RESULTS
The air-containing, mucosa-lined paranasal sinuses are largely inaccessible to the inspecting eye and palpating hand. The clinician has to depend on accurate history taking, examination, including nasendoscopic examination, and information obtained by radiological studies for the diagnosis of paranasal sinus disease. Most patients with rhinological symptoms present to general practitioners and it is only resistant cases that are referred to the ear nose and throat (ENT) or maxillofacial departments. In the past there has been a tendency to request plain radiographs to investigate sinus disease.1 This subject was recently reviewed by the Royal College of Radiologists, who confirmed the low sensitivity and specificity of plain X-rays and suggested that they were superfluous for the study of sinus disease .2 Computed tomography is now the first line imaging method for the investigation of paranasal sinus disease.
Of the 372 scans, 340 showed mucosal thickening to a lesser or greater extent, 12 had entirely clear sinuses, and the remaining 20 patients with unilateral opacity of a maxillary sinus were studied in detail. In some of these patients other paranasal sinuses were opacified to a variable degree but all 20 had complete unilateral opacification of a maxillary sinus. Of these 20 patients, 14 were diagnosed as having benign inflammatory conditions and six had neoplastic diseases. None of the patients with inflammatory conditions had nasal polyps, three had infective sinusitis, one a mucus retention cyst and one diabetic patient had mucormycosis. Of the six patients with neoplastic disease, two had benign conditions (inverted papilloma and ameloblastic fibroma) and in the four patients with malignant disease there were two cases of adenoid cystic carcinoma, one squamous cell carcinoma, and one lymphoma. Inflammatory conditions Most of these patients presented with nasal obstruction and rhinorrhoea. Only those with acute sinusitis complained of pain. Swelling was not a feature. Those who presented with persistent rhinosinusitis despite prolonged medical treatment had nasendoscopy and CT scanning. When nasendoscopy showed pus in the middle meatus, CT (Fig. 1) showed opacification of the maxillary sinus secondary to obstruction to the ostium.
PATIENTS AND METHODS We reviewed of all the CT scans of the paranasal sinuses in the ENT and maxillofacial surgery departments at the Derbyshire Royal Infirmary in 1 year. There was a total of 372 scans, 352 from the ENT department and 20 from the maxillofacial department. 504
The unilateral opaque maxillary sinus on computed tomography
505
Fig. 1 Opacification of maxillary sinus secondary to obstruction to the ostium.
Neoplastic conditions The clinical presentations of three of the four patients are described below to illustrate features in the history, examination, and CT which suggested neoplastic disease.
Fig. 2 Case 1. Opacification of right maxillary sinus and destruction of anterior sinus wall.
Case 1 A 61-year-old man presented with a 1-month history of right sided nasal obstruction. The patient had transnasal endoscopic resection of an inverted papilloma 10 years previously and was reviewed regularly with endoscopy. Inverted papilloma is a benign condition, which has a tendency to local recurrence despite excision. The incidence of malignant degeneration ranges from 1 to 13%.3 In this case nasendoscopy showed a polypoid mass in the right nasal cavity. Biopsy confirmed recurrent inverted papilloma with areas of malignant change. This lesion produced complete opacification of the right maxillary sinus and destruction of the anterior sinus wall on CT (Fig. 2). Case 2 A 36-year-old man presented with a persistent oroantral communication after the extraction of an upper right first molar tooth 4 years previously. Examination showed slight swelling of the right cheek, which had been present for 3 weeks. At the third attempt at closing the oroantral communication, the sinus mucosa was biopsied. This showed an ameloblastic fibroma, a benign condition that can be locally invasive. The CT (Fig. 3) showed a large soft tissue mass within the right maxilla filling the maxillary sinus with bony erosion posterolaterally.
Fig. 3 Case 2. Large soft tissue mass within right maxillary sinus with bony erosion postero-laterally.
506
British Journal of Oral and Maxillofacial Surgery
Case 3 A 65-year-old man presented with a 6-month history of sinusitis followed by facial swelling, nasal obstruc-
tion, and blood stained rhinorrhoea. Examination revealed proptosis, epiphora and infraorbital anaesthesia. Nasendoscopy showed a mass in the right nasal cavity. A biopsy specimen confirmed a poorly differentiated squamous cell carcinoma of the right maxillary sinus. Axial and coronal CT (Fig. 4a and b) showed an extensive mass with destruction of the medial wall of the sinus cavity and extension into the orbit and ethmoid air cells. Minor inflammatory changes were present in the left maxillary sinus.
DISCUSSION
Fig. 4 (a) and (b) Case 3. Extensive tumour mass with destruction of medial wall of sinus and extension into orbit and ethmoid air cells.
Unilateral opacity of the maxillary sinus is rare and we found it in only 6% of all CT scans in this study. It may indicate potentially serious underlying disease as described in the three cases above. The rhinological symptoms of sinonasal disease are common and, particularly in the early stages, it can be difficult to distinguish between simple inflammatory disease and neoplastic disease. It is therefore common for a patient with an antral carcinoma to be treated for several months before the correct diagnosis is made, and for patients to present to specialist clinics with advanced disease. The cases described above illustrate that a carefullytaken history is essential. At the initial assessment of patients who had a unilateral opaque maxillary sinus, the history and clinical findings were useful in differentiating between infective and malignant diseases. Rhinological symptoms reported for the first time in older patients should always raise concern. The appearance of unilateral facial pain and swelling, numbness, orbital symptoms, and particularly blood stained mucous should alert the clinician. Examination including intraoral, orbital, and nasendoscopic examination is essential in patients with sinonasal disease. Nasendoscopy is the only way in which the nasal cavity can be examined accurately – anterior rhinoscopy gives only limited information. If necessary endoscopic biopsy can be done, avoiding the need for an open biopsy. Although unilateral nasal polyposis viewed with an endoscope raises the possibility of neoplastic disease, it is certainly not possible to reach a diagnosis simply by looking. CT scanning and nasendoscopy thus complement each other.4 The indications for CT arise from a combination of history, examination, and endoscopic findings.5 Imaging is indicated if there is any suspicion of neoplastic disease. If malignancy is suspected, magnetic resonance imaging is usually done together with CT.6 Ideally, imaging should be done before biopsy to avoid tissue disruption and the potential for misinterpretation of tumour margins. CT is also often done in cases of inflammatory disease when medical treatment has failed and surgical intervention is being considered.
The unilateral opaque maxillary sinus on computed tomography
CONCLUSION This study reminds us of the importance of accurate history-taking and comprehensive examination including nasendoscopy to aid diagnosis and particularly to ensure that neoplastic disease is identified. The wider availability of nasendoscopy, and training in its use, should be sought by maxillofacial surgeons and these skills are essential for those who practice in head and neck oncology. ACKNOWLEDGEMENT We thank Dr S Elliott, consultant radiologist, for reviewing the CT scans.
REFERENCES 1. Houghton DJ, Aitchison FA, Wilkinson L, Wilson JA. Use of sinus X-ray films by general practitioners. Br Med J 1994; 308: 1608–1609. 2. Eli Konen, Faibel M, Kleinbaum Y et al. The value of the occipitomental (Waters’) view in the diagnosis of sinusitis: a comparative study with computed tomography. Clin Radiol 2000; 55: 856–860. 3. Segal K, Atar E, Mor C, Har-El G, Sidi J. Inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1986; 96: 394–398. 4. Babbel R, Harnsberger HR, Nelson B et al. Optimization of techniques in screening CT of the sinuses. Am J Neuroradiol 1991; 12: 849–854.
507
5. Bateman ND, Woolford TJ. The practical approach to the diagnosis and management of facial pain. CME bulletin. Otolaryngol Head Neck Surg 2001; 5: 50–53. 6. Sievers KW, Greess H, Baum U, Dobritz M, Lenz M. Paranasal sinuses and nasopharynx CT and MRI. Eur J Radiol 2000; 33: 185–202.
The Authors Meenakshi Rudralingam FDS, RCS, FRCS Specialist Registrar Department of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK Keith Jones FRCS Consultant Oral and Maxillofacial Surgeon Department of Oral and Maxillofacial Surgery, Derbyshire Royal Infirmary, Derby DE1 2QY, UK T. J. Woolford MD FRCS (ORL) Consultant in Otorhinolaryngology Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK Correspondence and requests for offprints to: Ms Meenakshi Rudralingam, Specialist Registrar Department of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK. Tel: +44 (0) 116 258 6953; Fax: +44 (0) 116 258 5205; E-mail: meena [email protected] Accepted 17 August 2002
The unilateral opaque maxillary sinus on computed tomography M. Rudralingam, ∗ K. Jones, † T. J. Woolford ‡ ∗ Department
of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK; †Department of Oral and Maxillofacial Surgery, Derbyshire Royal Infirmary, Derby DE1 2QY, UK; ‡Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK SUMMARY. Computed tomography (CT) is the imaging method of choice for conditions that affect the paranasal sinuses. We reviewed all paranasal CT scans in the ear nose and throat (ENT) and maxillofacial surgery departments in 1 year. Of these 372 scans, unilateral opacity of the maxillary sinus was seen in 20 cases. Neoplastic disease was diagnosed in six of these, four of which were malignant. We describe the cases of neoplastic disease, particularly features of the history, examination, and scans that should alert the clinician to the possibility of sinister pathology. We emphasise the importance of nasendoscopic examination in the accurate assessment of sinonasal disease. © 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.
INTRODUCTION
RESULTS
The air-containing, mucosa-lined paranasal sinuses are largely inaccessible to the inspecting eye and palpating hand. The clinician has to depend on accurate history taking, examination, including nasendoscopic examination, and information obtained by radiological studies for the diagnosis of paranasal sinus disease. Most patients with rhinological symptoms present to general practitioners and it is only resistant cases that are referred to the ear nose and throat (ENT) or maxillofacial departments. In the past there has been a tendency to request plain radiographs to investigate sinus disease.1 This subject was recently reviewed by the Royal College of Radiologists, who confirmed the low sensitivity and specificity of plain X-rays and suggested that they were superfluous for the study of sinus disease .2 Computed tomography is now the first line imaging method for the investigation of paranasal sinus disease.
Of the 372 scans, 340 showed mucosal thickening to a lesser or greater extent, 12 had entirely clear sinuses, and the remaining 20 patients with unilateral opacity of a maxillary sinus were studied in detail. In some of these patients other paranasal sinuses were opacified to a variable degree but all 20 had complete unilateral opacification of a maxillary sinus. Of these 20 patients, 14 were diagnosed as having benign inflammatory conditions and six had neoplastic diseases. None of the patients with inflammatory conditions had nasal polyps, three had infective sinusitis, one a mucus retention cyst and one diabetic patient had mucormycosis. Of the six patients with neoplastic disease, two had benign conditions (inverted papilloma and ameloblastic fibroma) and in the four patients with malignant disease there were two cases of adenoid cystic carcinoma, one squamous cell carcinoma, and one lymphoma. Inflammatory conditions Most of these patients presented with nasal obstruction and rhinorrhoea. Only those with acute sinusitis complained of pain. Swelling was not a feature. Those who presented with persistent rhinosinusitis despite prolonged medical treatment had nasendoscopy and CT scanning. When nasendoscopy showed pus in the middle meatus, CT (Fig. 1) showed opacification of the maxillary sinus secondary to obstruction to the ostium.
PATIENTS AND METHODS We reviewed of all the CT scans of the paranasal sinuses in the ENT and maxillofacial surgery departments at the Derbyshire Royal Infirmary in 1 year. There was a total of 372 scans, 352 from the ENT department and 20 from the maxillofacial department. 504
The unilateral opaque maxillary sinus on computed tomography
505
Fig. 1 Opacification of maxillary sinus secondary to obstruction to the ostium.
Neoplastic conditions The clinical presentations of three of the four patients are described below to illustrate features in the history, examination, and CT which suggested neoplastic disease.
Fig. 2 Case 1. Opacification of right maxillary sinus and destruction of anterior sinus wall.
Case 1 A 61-year-old man presented with a 1-month history of right sided nasal obstruction. The patient had transnasal endoscopic resection of an inverted papilloma 10 years previously and was reviewed regularly with endoscopy. Inverted papilloma is a benign condition, which has a tendency to local recurrence despite excision. The incidence of malignant degeneration ranges from 1 to 13%.3 In this case nasendoscopy showed a polypoid mass in the right nasal cavity. Biopsy confirmed recurrent inverted papilloma with areas of malignant change. This lesion produced complete opacification of the right maxillary sinus and destruction of the anterior sinus wall on CT (Fig. 2). Case 2 A 36-year-old man presented with a persistent oroantral communication after the extraction of an upper right first molar tooth 4 years previously. Examination showed slight swelling of the right cheek, which had been present for 3 weeks. At the third attempt at closing the oroantral communication, the sinus mucosa was biopsied. This showed an ameloblastic fibroma, a benign condition that can be locally invasive. The CT (Fig. 3) showed a large soft tissue mass within the right maxilla filling the maxillary sinus with bony erosion posterolaterally.
Fig. 3 Case 2. Large soft tissue mass within right maxillary sinus with bony erosion postero-laterally.
506
British Journal of Oral and Maxillofacial Surgery
Case 3 A 65-year-old man presented with a 6-month history of sinusitis followed by facial swelling, nasal obstruc-
tion, and blood stained rhinorrhoea. Examination revealed proptosis, epiphora and infraorbital anaesthesia. Nasendoscopy showed a mass in the right nasal cavity. A biopsy specimen confirmed a poorly differentiated squamous cell carcinoma of the right maxillary sinus. Axial and coronal CT (Fig. 4a and b) showed an extensive mass with destruction of the medial wall of the sinus cavity and extension into the orbit and ethmoid air cells. Minor inflammatory changes were present in the left maxillary sinus.
DISCUSSION
Fig. 4 (a) and (b) Case 3. Extensive tumour mass with destruction of medial wall of sinus and extension into orbit and ethmoid air cells.
Unilateral opacity of the maxillary sinus is rare and we found it in only 6% of all CT scans in this study. It may indicate potentially serious underlying disease as described in the three cases above. The rhinological symptoms of sinonasal disease are common and, particularly in the early stages, it can be difficult to distinguish between simple inflammatory disease and neoplastic disease. It is therefore common for a patient with an antral carcinoma to be treated for several months before the correct diagnosis is made, and for patients to present to specialist clinics with advanced disease. The cases described above illustrate that a carefullytaken history is essential. At the initial assessment of patients who had a unilateral opaque maxillary sinus, the history and clinical findings were useful in differentiating between infective and malignant diseases. Rhinological symptoms reported for the first time in older patients should always raise concern. The appearance of unilateral facial pain and swelling, numbness, orbital symptoms, and particularly blood stained mucous should alert the clinician. Examination including intraoral, orbital, and nasendoscopic examination is essential in patients with sinonasal disease. Nasendoscopy is the only way in which the nasal cavity can be examined accurately – anterior rhinoscopy gives only limited information. If necessary endoscopic biopsy can be done, avoiding the need for an open biopsy. Although unilateral nasal polyposis viewed with an endoscope raises the possibility of neoplastic disease, it is certainly not possible to reach a diagnosis simply by looking. CT scanning and nasendoscopy thus complement each other.4 The indications for CT arise from a combination of history, examination, and endoscopic findings.5 Imaging is indicated if there is any suspicion of neoplastic disease. If malignancy is suspected, magnetic resonance imaging is usually done together with CT.6 Ideally, imaging should be done before biopsy to avoid tissue disruption and the potential for misinterpretation of tumour margins. CT is also often done in cases of inflammatory disease when medical treatment has failed and surgical intervention is being considered.
The unilateral opaque maxillary sinus on computed tomography
CONCLUSION This study reminds us of the importance of accurate history-taking and comprehensive examination including nasendoscopy to aid diagnosis and particularly to ensure that neoplastic disease is identified. The wider availability of nasendoscopy, and training in its use, should be sought by maxillofacial surgeons and these skills are essential for those who practice in head and neck oncology. ACKNOWLEDGEMENT We thank Dr S Elliott, consultant radiologist, for reviewing the CT scans.
REFERENCES 1. Houghton DJ, Aitchison FA, Wilkinson L, Wilson JA. Use of sinus X-ray films by general practitioners. Br Med J 1994; 308: 1608–1609. 2. Eli Konen, Faibel M, Kleinbaum Y et al. The value of the occipitomental (Waters’) view in the diagnosis of sinusitis: a comparative study with computed tomography. Clin Radiol 2000; 55: 856–860. 3. Segal K, Atar E, Mor C, Har-El G, Sidi J. Inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1986; 96: 394–398. 4. Babbel R, Harnsberger HR, Nelson B et al. Optimization of techniques in screening CT of the sinuses. Am J Neuroradiol 1991; 12: 849–854.
507
5. Bateman ND, Woolford TJ. The practical approach to the diagnosis and management of facial pain. CME bulletin. Otolaryngol Head Neck Surg 2001; 5: 50–53. 6. Sievers KW, Greess H, Baum U, Dobritz M, Lenz M. Paranasal sinuses and nasopharynx CT and MRI. Eur J Radiol 2000; 33: 185–202.
The Authors Meenakshi Rudralingam FDS, RCS, FRCS Specialist Registrar Department of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK Keith Jones FRCS Consultant Oral and Maxillofacial Surgeon Department of Oral and Maxillofacial Surgery, Derbyshire Royal Infirmary, Derby DE1 2QY, UK T. J. Woolford MD FRCS (ORL) Consultant in Otorhinolaryngology Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK Correspondence and requests for offprints to: Ms Meenakshi Rudralingam, Specialist Registrar Department of Oral and Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK. Tel: +44 (0) 116 258 6953; Fax: +44 (0) 116 258 5205; E-mail: meena [email protected] Accepted 17 August 2002