THE LARYNGOSCOI'lil 88 :1978
COMPUTERIZED TOMOGRAPHY OF PARANASAL SINUS NEOPLASMS.*t BAO-SHAN JING, M.D., HELMUTH GOEPFERT, M.D.,
and LANNY GARTH CLOSE, M.D.,
Houston, Tex. ABSTRACT. Computerized tomography represents a new and valuable diagnostic tool to the otolaryngologist and head and neck surgeon . in several ever-increasing aspects of his clinical practice. This report presents CT scans utilizing the E.M.I. SOOS body scanner on patients with neoplasms of the paranasal sinuses presenting to the Head and Neck Service of The University of Texas System Center M. D. Anderson Hospital and Tumor Institute. Only patients undergoing surgical resection of such lesions are included so that actual operative and surgical pathological findings can be used for critical comparison of diagnostic information derived from polytomography and computerized tomography. Seven illustrative cases are presented. In general, computerized tomography has been found to be equal to polytomography in assessing bone destruction or involvement by tumor, and superior to polytomography in determining accurately the soft tissue extent of disease. CT scanning, however, has been found to have limitations in the delineation of soft tissue disease in areas of high contrast in tissue density, and in the evaluation of possible intracranial tumor extension in isodense, avascular lesions.
0 INTRODUCTION.
Since the time of Roentgen, radiologists have had to deal with the relative insensitivity of the roentgenogram plate to variations in soft tissue density. The advent of computerized tomography (CT) represents a significant landmark now allowing us to distinguish between tissues with densities only 4% different from that of water. 1 The first description of a system which combines the roentgenogram with a computer was published in 1973 by Hounsfield. 2 His work was followed by that of Ambrose 3 in 1973 describing clinical applications of the system. The first CT scanner in the United States was installed at the Mayo Clinic in June 1973, 4 and the second at the Massachusetts General Hospital in July 1973. ~ Since that time, numerous articles have appeared in the otolaryngology and radiology literature concerning the use of computerized tomography in the neuroradiological assessment of a variety of intracranial processes. 1 •6 • 11 With one exception, 1 2 however, no study has been made of its use in other forms of head and neck pathology. Since the installation of the E.M.I. 5005 body scanner at M. D. Anderson Hospital in February 1977 numerous scans have been performed on a variety of head and neck neoplasms. In this study, patients undergoing surgical resection of paranasal sinus tumors were assessed preoperatively with poly• P r esented at the Meetin g of th e Southern Section or the Am erica n Lary ngologlcal, Uhlnologlcal a nd Otolog lcal Soc iety, Inc. , Hous ton, T ex., J a nu a ry 13, 197 8. t From th e U niver s ity or T ex as Syst em Ca n cer Center, M. D. And er s on H os pital a nd Tumor ln$tltute a nd th e Univer s ity or T ex as Medi cal School a t H ous t on. Send R eprint R eques ts to H elmuth Goepfert, M.D ., M. D . And er son H ospita l, 672 3 Dertn er Dr., H ous t on, T ex. 770 30.
1485
CT
Extended Lateral Rhinotomy
3
Small Cell Adenocarcinoma Olfactory Bulb and Tract, Ethmoid Sinus and Superior Nasal Cavity CT (4+)
CT (3+)
Local Resection
Combined Frontal Craniotomy and Lateral Rhinotomy
CT (l+)
Local Resection
=
Plain roentgenograms (3+)
polytomes (4+ )
polytomes {4+)
polytomes {4+)
>
=
-
=
=
=
>>
>
>
>
Equal accuracy.
CT (O )
CT (l+ )
(4+) CT (3+)
CT
CT (4+)
CT (4+)
CT (4+)
(0)
polytomes
polytomes (l+)
plain roentgeno grams and arteriogram (l+) polytomes (3+)
polytomes (3+)
polytomes {3+)
polytomes (3+ )
< - Less accuracy. - Greater accuracy. >> - Much greater accuracy.
=
polytomes (3+)
polytomes (3+ )
(4+)
=
=
4+ - Excellent correlation with operative and pa thological findings. a+ - Good correlation. 2+ - Fair correlation. 1+ - Inadequate correlation. o+ - Inaccurate assessment.
7
6
5
Adenocarcinoma Hard Palate and Maxillary Sinus Squamous Cell Carcinoma Hard Palate
CT (4+ )
Lateral Rhinotomy
Squamous Cell Carcinoma Ethmoid and Maxillary Sinuses Malignant Meningioma Ethmoid and Frontal Sinuses
2
(4+)
CT (4+)
Lateral Rhinotomy
Neuroblastoma, Ethmoid Sinus and Nasal Cavity
l
4
CT (4+ )
!lfaxillectomy
Squamous Cell Carcinoma Maxillary Sinus
Case
Relative Accuracy of Radiological Studies To Operative and Pathological Findings Bone Involvement Soft Tissue Extent
Diagnosis
Operation
TABLE I.
scan
The CT scan does not delineate soft tissue tumors or subtle bony changes in areas with very high contrasts in tissue density Neither radiological study can provide adequate information to allow distinction between post-therapeutic changes from soft tissue neoplasm in this area The CT scan better demonstrates the defect in the cribriform plate and the extension into the orbital apex. Polytomes, arteriograhhy, and computerized tomograph{ fail to s ow the intracranial component o tl1is isodense, avascular tumor
The CT scan more clearly defines the extent of soft-tissue neoplasm even demonstrating tumor involvement of the infraorbital nerve The CT scan adds information regardin~ tumor extension into the orbital apex, and emonstrates air-fluid levels in the non-involved sphenoid and maxillary sinuses The CT scan is especially valuable in delineating the extent of tumor involvement in the orbital and retroorbital areas The CT is far superior to plain films and the arteriogram in demonstrating the soft tissue extent of the tumor, especially in the areas of the orbit and frontal lobe dura
Comments
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
1487
tomography and computerized tomography. We have attempted to compare the diagnostic information derived from polytomography to that from computerized tomography and then assess the accuracy of both utilizing actual operative and surgical pathological findings. MATERIALS AND METHODS. Patients with suspected or biopsy proven tumors of the paranasal sinuses were examined by routine roentgenograms, polytomography and computerized tomography. Computerized tomography of the paranasal sinuses was performed with the E.M.I. 5005 body scanner, in both coronal and base projections. A series of tomographic slices 13 mm in thickness were taken at 10 mm intervals. In selected cases, contrast enhancement study was done after intravenous injection of 300 ml of 30% diatrizoate meglumine ( Reno-M-Dip). A 320 x 320 matrix is employed to improve the picture definition. The coronal projection of the computerized tomography is used particularly for evaluating the extent of the soft tissue tumor mass and demonstrating the intracranial extension of the lesion. TI1e base projection is used to define the size of the soft tissue lesion with bony Invasion of the base of the skull. More important, it is used to delineate the extension of the lesion of the orbit with involvement of the intraorbital structures. To date, 40 patients with lesions of the paranasal sinuses have been examined with the E.M.I. 5005 body scanner. Among them, 15 had an additional contrast enhancement study. Only patients undergoing surgical resection of such lesions are included in this report. CASE REPORTS.
A summary of cases presented and the relative accuracy of the radiological studies under assessment is presented in Table I. By convention, all radiographs and CT scans are shown with the patient's left side on the reader's right. Case 1. A 75-year-old man presented with a six-month history of pain In the left eye, followed by puffiness of the left cheek for five months. Three months prior to admission, he noted paresthesia of the left cheek and eyelid. An ulceration on the left side of the roof of his mouth had been present for two months. Examination showed a mass 3 cm in diameter involving the posterior third of the hard palate on the left. Also noted was anesthesia over the distribution of the left infraorbital nerve. Polytomography (Fig. 1 ) shows a mass of the hard palate on the left extending Into the maxillary antrum with sclerosis and destruction of the pterygoid plates on that side. Also present is a soft tissue density in the area of the infraorbital nerve. A CT scan (Fig. 1) confirms the bone involvement, showing destruction of the medial pterygoid plate and the inferior aspect of the medial wall of the maxillary antrum. The extent of the soft tissue mass in the maxillarr antrum is seen with clarity equal to that of the polytomograms, a nodular density at the level o the infraorbital nerve is shown especially well. Multiple speckled areas of increased attenuation within the tumor mass represent calcifications and/or bone with tumor. A left maxillectomy was performed, and a squamous cell carcinoma arising In the left posterior hard palate was confirmed; it extended into the maxillary antrum and involved the second branch of the Vth cranial nerve up to the level of the foramen rotunclum. Destruction of the pterygoid plate was noted, and histologic sections confirmed bone inclusions within the tumor (Fig. 1). COMMENT.
In this case, the CT scan confirmed the extent of bone destruction and more clearly defined the extent of soft tissue neoplasm, demonstrating involvement of the infraorbital nerve. Histologic sections showed the densities within the tumor to be inclusive of bone. Case 2. A 25-year-old woman presented with a six-month history of right-sided nasal stuffi-
1488
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
FJ g. 1. A. Squ a mous cell car cin om a , left ma x ill a ry s inus. AP polytomogram of t he para na s a l s inuses ( a nte1·lor c ut) s hows a s ort tlss uo mass In th e In fe r ior aspect o! the left maxllla ry antrum with bone des truction In the ! loor of th e s inus a nd left na sa l ca vity (arrows ). A nodu la r density ls seen In th e a r ea of tho lnfra orb lta l n erv e (a now) .
Fi g. 1. D. Squ a mous cell car c in oma , left m a x ill a r y s in us. AP polytomoi;ram of the pa r a nas a l s inuses (pos t e rior cut ) shows sclcros la a nd des tru ction ot th e le!t pterygold pla tes.
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
1489
F ig. 1. C. Sq uamous cell carcinom a , Jett m axIlla r·y s inu s. CT sca n, coron a l vi ew. throug h th e m a xilla ry s inus shows o. d ens ity In the area or th e lnfl"aorblta l n erve on th e left.
Fig. 1. D . Squ o.mous cell carcinoma, left m ax ill a r y s inu s . CT scan, basal vi ew, shows a so rt ti ss ue mass In th e left maxflla ry s inus with d es truction of the m edia l wall of th e s inu s ( a rrow 1) and the medial pterygold pla t e (ar1·ow 2 ) . ll'fultfple speckled a r eas of Jn creased a ttenu a ti on within th e tumor mass r epresent calc ifi cation s a nd/or bon e within the tumor.
Fig. 1. E. Squamous cell ca r c lnomo., left mo.xlllary s inu s. Photomicrog raphy of th e resec t ecl s pecimen s h ows a sq ua mous ce ll carcin oma Involving th e pe rln e ura l space of th e lnfraorblta l n erve (I-! and E, original m agnifi cati on x 70).
F ig. 1. l~. Squamous c ell carcinom a , l crt m a xillary s inus . Photomicr ograph of th e rnsect ed specim en shows bone fragmen ts within th e s quamous cell carcinoma (H a nd E, origin a l m ognlflcatf on x 50 ).
1490
JING, ET AL . : PARANASAL SINUS NEOPLASMS.
l!'lg. 2. . Neurob lns tomo., r ight n asa l co.v lty o.nd e thm old s inu s s. AP polytomog ra m oC the pn1·01 naRal s inus s (ant r lor cu t) s hows a. mass les ion In th e ri gh t n nso. I cav ity o.nd a nterior e th rnold s in us .
Fi g, 2. D. N enrobl as to mo., ri g ht n osu I cnv lty a.ml e thmolcl A In us s . AP poly tomogram or th o s inuses (middle c ul) s hows th ri ght n asa l mass a nd clou
COMPUTERIZED TOMOGRAPHY OF PARANASAL SINUS NEOPLASMS.*t BAO-SHAN JING, M.D., HELMUTH GOEPFERT, M.D.,
and LANNY GARTH CLOSE, M.D.,
Houston, Tex. ABSTRACT. Computerized tomography represents a new and valuable diagnostic tool to the otolaryngologist and head and neck surgeon . in several ever-increasing aspects of his clinical practice. This report presents CT scans utilizing the E.M.I. SOOS body scanner on patients with neoplasms of the paranasal sinuses presenting to the Head and Neck Service of The University of Texas System Center M. D. Anderson Hospital and Tumor Institute. Only patients undergoing surgical resection of such lesions are included so that actual operative and surgical pathological findings can be used for critical comparison of diagnostic information derived from polytomography and computerized tomography. Seven illustrative cases are presented. In general, computerized tomography has been found to be equal to polytomography in assessing bone destruction or involvement by tumor, and superior to polytomography in determining accurately the soft tissue extent of disease. CT scanning, however, has been found to have limitations in the delineation of soft tissue disease in areas of high contrast in tissue density, and in the evaluation of possible intracranial tumor extension in isodense, avascular lesions.
0 INTRODUCTION.
Since the time of Roentgen, radiologists have had to deal with the relative insensitivity of the roentgenogram plate to variations in soft tissue density. The advent of computerized tomography (CT) represents a significant landmark now allowing us to distinguish between tissues with densities only 4% different from that of water. 1 The first description of a system which combines the roentgenogram with a computer was published in 1973 by Hounsfield. 2 His work was followed by that of Ambrose 3 in 1973 describing clinical applications of the system. The first CT scanner in the United States was installed at the Mayo Clinic in June 1973, 4 and the second at the Massachusetts General Hospital in July 1973. ~ Since that time, numerous articles have appeared in the otolaryngology and radiology literature concerning the use of computerized tomography in the neuroradiological assessment of a variety of intracranial processes. 1 •6 • 11 With one exception, 1 2 however, no study has been made of its use in other forms of head and neck pathology. Since the installation of the E.M.I. 5005 body scanner at M. D. Anderson Hospital in February 1977 numerous scans have been performed on a variety of head and neck neoplasms. In this study, patients undergoing surgical resection of paranasal sinus tumors were assessed preoperatively with poly• P r esented at the Meetin g of th e Southern Section or the Am erica n Lary ngologlcal, Uhlnologlcal a nd Otolog lcal Soc iety, Inc. , Hous ton, T ex., J a nu a ry 13, 197 8. t From th e U niver s ity or T ex as Syst em Ca n cer Center, M. D. And er s on H os pital a nd Tumor ln$tltute a nd th e Univer s ity or T ex as Medi cal School a t H ous t on. Send R eprint R eques ts to H elmuth Goepfert, M.D ., M. D . And er son H ospita l, 672 3 Dertn er Dr., H ous t on, T ex. 770 30.
1485
CT
Extended Lateral Rhinotomy
3
Small Cell Adenocarcinoma Olfactory Bulb and Tract, Ethmoid Sinus and Superior Nasal Cavity CT (4+)
CT (3+)
Local Resection
Combined Frontal Craniotomy and Lateral Rhinotomy
CT (l+)
Local Resection
=
Plain roentgenograms (3+)
polytomes (4+ )
polytomes {4+)
polytomes {4+)
>
=
-
=
=
=
>>
>
>
>
Equal accuracy.
CT (O )
CT (l+ )
(4+) CT (3+)
CT
CT (4+)
CT (4+)
CT (4+)
(0)
polytomes
polytomes (l+)
plain roentgeno grams and arteriogram (l+) polytomes (3+)
polytomes (3+)
polytomes {3+)
polytomes (3+ )
< - Less accuracy. - Greater accuracy. >> - Much greater accuracy.
=
polytomes (3+)
polytomes (3+ )
(4+)
=
=
4+ - Excellent correlation with operative and pa thological findings. a+ - Good correlation. 2+ - Fair correlation. 1+ - Inadequate correlation. o+ - Inaccurate assessment.
7
6
5
Adenocarcinoma Hard Palate and Maxillary Sinus Squamous Cell Carcinoma Hard Palate
CT (4+ )
Lateral Rhinotomy
Squamous Cell Carcinoma Ethmoid and Maxillary Sinuses Malignant Meningioma Ethmoid and Frontal Sinuses
2
(4+)
CT (4+)
Lateral Rhinotomy
Neuroblastoma, Ethmoid Sinus and Nasal Cavity
l
4
CT (4+ )
!lfaxillectomy
Squamous Cell Carcinoma Maxillary Sinus
Case
Relative Accuracy of Radiological Studies To Operative and Pathological Findings Bone Involvement Soft Tissue Extent
Diagnosis
Operation
TABLE I.
scan
The CT scan does not delineate soft tissue tumors or subtle bony changes in areas with very high contrasts in tissue density Neither radiological study can provide adequate information to allow distinction between post-therapeutic changes from soft tissue neoplasm in this area The CT scan better demonstrates the defect in the cribriform plate and the extension into the orbital apex. Polytomes, arteriograhhy, and computerized tomograph{ fail to s ow the intracranial component o tl1is isodense, avascular tumor
The CT scan more clearly defines the extent of soft-tissue neoplasm even demonstrating tumor involvement of the infraorbital nerve The CT scan adds information regardin~ tumor extension into the orbital apex, and emonstrates air-fluid levels in the non-involved sphenoid and maxillary sinuses The CT scan is especially valuable in delineating the extent of tumor involvement in the orbital and retroorbital areas The CT is far superior to plain films and the arteriogram in demonstrating the soft tissue extent of the tumor, especially in the areas of the orbit and frontal lobe dura
Comments
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
1487
tomography and computerized tomography. We have attempted to compare the diagnostic information derived from polytomography to that from computerized tomography and then assess the accuracy of both utilizing actual operative and surgical pathological findings. MATERIALS AND METHODS. Patients with suspected or biopsy proven tumors of the paranasal sinuses were examined by routine roentgenograms, polytomography and computerized tomography. Computerized tomography of the paranasal sinuses was performed with the E.M.I. 5005 body scanner, in both coronal and base projections. A series of tomographic slices 13 mm in thickness were taken at 10 mm intervals. In selected cases, contrast enhancement study was done after intravenous injection of 300 ml of 30% diatrizoate meglumine ( Reno-M-Dip). A 320 x 320 matrix is employed to improve the picture definition. The coronal projection of the computerized tomography is used particularly for evaluating the extent of the soft tissue tumor mass and demonstrating the intracranial extension of the lesion. TI1e base projection is used to define the size of the soft tissue lesion with bony Invasion of the base of the skull. More important, it is used to delineate the extension of the lesion of the orbit with involvement of the intraorbital structures. To date, 40 patients with lesions of the paranasal sinuses have been examined with the E.M.I. 5005 body scanner. Among them, 15 had an additional contrast enhancement study. Only patients undergoing surgical resection of such lesions are included in this report. CASE REPORTS.
A summary of cases presented and the relative accuracy of the radiological studies under assessment is presented in Table I. By convention, all radiographs and CT scans are shown with the patient's left side on the reader's right. Case 1. A 75-year-old man presented with a six-month history of pain In the left eye, followed by puffiness of the left cheek for five months. Three months prior to admission, he noted paresthesia of the left cheek and eyelid. An ulceration on the left side of the roof of his mouth had been present for two months. Examination showed a mass 3 cm in diameter involving the posterior third of the hard palate on the left. Also noted was anesthesia over the distribution of the left infraorbital nerve. Polytomography (Fig. 1 ) shows a mass of the hard palate on the left extending Into the maxillary antrum with sclerosis and destruction of the pterygoid plates on that side. Also present is a soft tissue density in the area of the infraorbital nerve. A CT scan (Fig. 1) confirms the bone involvement, showing destruction of the medial pterygoid plate and the inferior aspect of the medial wall of the maxillary antrum. The extent of the soft tissue mass in the maxillarr antrum is seen with clarity equal to that of the polytomograms, a nodular density at the level o the infraorbital nerve is shown especially well. Multiple speckled areas of increased attenuation within the tumor mass represent calcifications and/or bone with tumor. A left maxillectomy was performed, and a squamous cell carcinoma arising In the left posterior hard palate was confirmed; it extended into the maxillary antrum and involved the second branch of the Vth cranial nerve up to the level of the foramen rotunclum. Destruction of the pterygoid plate was noted, and histologic sections confirmed bone inclusions within the tumor (Fig. 1). COMMENT.
In this case, the CT scan confirmed the extent of bone destruction and more clearly defined the extent of soft tissue neoplasm, demonstrating involvement of the infraorbital nerve. Histologic sections showed the densities within the tumor to be inclusive of bone. Case 2. A 25-year-old woman presented with a six-month history of right-sided nasal stuffi-
1488
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
FJ g. 1. A. Squ a mous cell car cin om a , left ma x ill a ry s inus. AP polytomogram of t he para na s a l s inuses ( a nte1·lor c ut) s hows a s ort tlss uo mass In th e In fe r ior aspect o! the left maxllla ry antrum with bone des truction In the ! loor of th e s inus a nd left na sa l ca vity (arrows ). A nodu la r density ls seen In th e a r ea of tho lnfra orb lta l n erv e (a now) .
Fi g. 1. D. Squ a mous cell car c in oma , left m a x ill a r y s in us. AP polytomoi;ram of the pa r a nas a l s inuses (pos t e rior cut ) shows sclcros la a nd des tru ction ot th e le!t pterygold pla tes.
JING, ET AL.: PARANASAL SINUS NEOPLASMS.
1489
F ig. 1. C. Sq uamous cell carcinom a , Jett m axIlla r·y s inu s. CT sca n, coron a l vi ew. throug h th e m a xilla ry s inus shows o. d ens ity In the area or th e lnfl"aorblta l n erve on th e left.
Fig. 1. D . Squ o.mous cell carcinoma, left m ax ill a r y s inu s . CT scan, basal vi ew, shows a so rt ti ss ue mass In th e left maxflla ry s inus with d es truction of the m edia l wall of th e s inu s ( a rrow 1) and the medial pterygold pla t e (ar1·ow 2 ) . ll'fultfple speckled a r eas of Jn creased a ttenu a ti on within th e tumor mass r epresent calc ifi cation s a nd/or bon e within the tumor.
Fig. 1. E. Squamous cell ca r c lnomo., left mo.xlllary s inu s. Photomicrog raphy of th e resec t ecl s pecimen s h ows a sq ua mous ce ll carcin oma Involving th e pe rln e ura l space of th e lnfraorblta l n erve (I-! and E, original m agnifi cati on x 70).
F ig. 1. l~. Squamous c ell carcinom a , l crt m a xillary s inus . Photomicr ograph of th e rnsect ed specim en shows bone fragmen ts within th e s quamous cell carcinoma (H a nd E, origin a l m ognlflcatf on x 50 ).
1490
JING, ET AL . : PARANASAL SINUS NEOPLASMS.
l!'lg. 2. . Neurob lns tomo., r ight n asa l co.v lty o.nd e thm old s inu s s. AP polytomog ra m oC the pn1·01 naRal s inus s (ant r lor cu t) s hows a. mass les ion In th e ri gh t n nso. I cav ity o.nd a nterior e th rnold s in us .
Fi g, 2. D. N enrobl as to mo., ri g ht n osu I cnv lty a.ml e thmolcl A In us s . AP poly tomogram or th o s inuses (middle c ul) s hows th ri ght n asa l mass a nd clou
