Tomography in Expansile Lesions of the Nasal and Paranasal Sinuses 1

Neuroradiology

Philip J. Dubois, M.B.B.S., Joseph C. Schultz, M.D., Ronald L. Perrin, M.D., and Kurshed J. Dastur, M.D.

Of 35 nasal and paranasal sinus masses examined by radiography and tomography, 22 malignant tumors showed purely destructive growth. Bone expansion was observed in 13 benign, and 2 slowly growing malignant masses. Pluridirectional tomography in carefully selected projections is often necessary to reveal expansile growth. The 13 expansile lesions, including mucocele, neurofibroma, dermoid, epidermoid, cementifying fibroma, angiofibroma, inverting papilloma, and cylindroma, arebriefly described. Tomographic appearances alone didnotcharacterize histopathologic entities. However, distinctions may be made between fibro-osseous and epithelial tumors, and between fast growing and slowly growing tumors. INDEX TERMS: Angioma. Epidermoid • Neurofibroma. Papilloma • (Paranasal sinuses, tomography [23.121]). Sinuses, paranasal • Tomography, indications

Radiology 125:149-158, October 1977

mography was not performed in the remaining 9 patients who showed extensive destruction on plain films. Plain film examinations in Caldwell, Water's, base, lateral and (in 12 cases) oblique orbital projections were obtained in all cases by a specialized skull unit, O.3mm or O.6mm focal spot, and fixed fine line grid. Stereopairs were not used. Preliminary plain film examination guided tomography in each instance. The projections utilized in tomography were determined by the radiologist with respect to: (a) optimal projection to demonstrate the lesion and its bony surroundings, (b) radiation dose to the patient, and (c) the patient's cooperation. Ancillary procedures, including computed tomography, angiography, pneumoencephalography, and isotope studies, were performed where it was appropriate to confirm the tomographic findings.

ONE DESTRUCTION is typical of cases of malignant tumors in the paranasal sinuses. Bony expansion in the peripheral and axial skeleton is characteristic of slowly growing mass lesions, and slowly growing lesions of the paranasal sinuses might therefore be expected to expand bone. Mucoceles commonly exhibit expansile growth, although tomography is often necessary to demonstrate this. We have found that several less common lesions show bone expansion when appropriate pluridirectional tomography is performed. The study had four aims: (a) To analyze mass lesions of the paranasal sinuses recently examined by radiography and tomography at the University of Pittsburgh Health Center. (b) To determine whether bony expansion by a mass reliably indicates slow growth or benignity. (c) To assess the usefulness of different tomographic projections in demonstrating expansile growth of nasal and paranasal sinus lesions. (d) To ascertain whether specific tomographic features characterize any pathologic entities.

B

RESULTS

Salient clinical features of the patients studied are listed in TABLE I. Lesions with purely destructive radiographic features (TABLE II) were all malignant, comprising squamous carcinoma (14 cases), undifferentiated carcinoma (2 cases), malignant lymphoma (2 cases), metastasis (1 case), plasmacytoma (1 case), cylindroma (1 case) and malignant melanoma (1 case). However, 11 of the 13 lesions with expansile features at tomography (TABLE I) were benign, and 2 were cylindromas. Tomographic findings in the 13 patients with expansile lesions are tabulated in TABLE III. The detection of lesions and the demonstration of an expanded bony rim by each tomographic projection, compared to conventional radiographs, is illustrated in TABLE IV. The frontal tomographic projection detected the lesion in every case, and enabled diagnosis in 4 patients, thereby eliminating the

MATERIALS AND METHODS

Our study included all patients with nasal and paranasal sinus mass lesions who had histopathologic proof of diagnosis, and available radiographic studies performed during the period 1973 to 1976. Thirty five patients were studied, and their lesions were divided into destructive and expansile categories on the basis of radiographic features. Two patients (Patients 10 and 11) with expansile lesions had linear tomography while the remaining 11 patients in this group had pluridirectional tomography (stratomatic or polytome). Of the 22 patients with destructive lesions, 7 had pluridirectional and 6 had linear tomography. To1

From the Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh. Accepted for puoucatlon in February 1977. emt 149

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TABLE PATIENT

1.

W.S.

2.

MD.

3. 4.

H.S. E.M.

5.

VD.

6. 7.

J.U. W.H. J.C. R.S. D.N. R.Sh. C.J. M.T.

8. 9. 10. 11. 12. 13.

PATIENT

I.C. R.B. L.P.

17.

D.T.

18. 19. 20. 21.

P.B. B.B. B.M. L.McD.

22.

E.L.

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

E.K. H.R. L.McC MW. A.H. P.C.

M.S. P.L. T.S.

L.W. T.M. L.M. T.L.

EXPANSILE LESIONS

AGE/SEX

PATHOLOGIC DIAGNOSIS

PRESENTING COMPLAINT

16M 63F 49F 53F 28F 62M 14M 50F 15M 13M 74M 52F 68F

Ethmoid mucocele Frontal mucocele Frontal mucocele and epidermoid Ethmoid mucocele Ethmoidal neurofibroma Sphenoidal mucocele Ethmoidal dermoid cyst Cementifying fibroma maxillary sinus Fibrous dysplasia Nasopharyngeal angiofibroma Inverting papilloma maxillary sinus Ethmoidal cylindroma Maxillary cylindroma

Swelling medial aspect of the left orbit, diplopia Swelling left orbit, intermittent bloody nasal discharge "Sebaceous cyst" forehead, asymptomatic Chronic sinusitis, left periorbital edema, two months Left exophthalmos, mass left medial canthal area Spontaneous CSF rhinorrhea Cyst on bridge of nose since birth Asymptomatic mass at dental radiography Left exophthalmos, progressive over six months Progressive nasal obstruction, three months Nasal obstruction, frontal headaches, six months Progressive nasal obstruction over three years Mass hard palate for ten years, enlarging

TABLE

14. 15. 16.

I:

October 1977

II: DESTRUCTIVE LESIONS

AGE/SEX

PATHOLOGIC DIAGNOSIS

PRESENTING COMPLAINT

60M 54M 64F 45M 67M 64F 79F 55F M 76F 74F M 53M 75F 77F 64F 75M 83M 80M 72M 73F 82M

Maxilloethmoid cylindroma Histiocytic lymphoma, maxilla S.C.C. nasal cavity Lymphocytic lymphoma, nasal cavity S.C.C. nasal cavity and maxilla S.C.C. maxilla and ethmoids Metastatic renal carcinoma maxilla Carcinoma, nasal cavity S.C.C. ethmoid Mal. melanoma nasal cavity and maxilla Carcinoma nasopharynx and sphenoid S.C.C. nasal cavity S.C.C. maxilla S.C.C. maxilla Plasmacytoma sphenoid sinus S.C.C. maxilla S.C.C. maxilla S.C.C. nasal cavity and maxilla S.C.C. nasal cavity and maxilla S.C.C. maxilla S.C.C. maxilla S.C.C. maxilla

Proptosis, nasal mass Mass gingival buccal sulcus Nasal obstruction and discharge Nasal obstruction Nasal obstruction Nasal discharge, facial pain Facial swelling, sinusitis Nasal obstruction, discharge Proptosis Sinusitis and nasal obstruction Paralysis, left cranial nerves V, VII, and XII Palpable submandibular and parotid nodes Left facial swelling Nasal obstruction, sinusitis Headache, paralysis cranial nerves III, IV, and VI Cheek swelling, enophthalmos Cheek swelling, enophthalmos Nasal obstruction and epistaxis Nasal obstruction, diplopia, proptosis Nasal mass, enophthalmos, discharge Sinisitis, otitis media Pain, epistaxis, mass

need for further projections. Expansile growth was not seen on frontal tomograms in 3 of the 13 cases (Patients 2, 8, and 12). In 3 other cases (Patients 2, 4, and 5), other projections better demonstrated expansile growth. Frontal sinus lesions (Patients 2 and 3) were demonstrated best in lateral projection, ethmoid lesions (Patients 4, 5, and 12) in submentovertex projection, and a lesion which expanded the posterior wall of the maxillary sinus (Patient 8) in lateral projection. Sphenoid sinus and nasal cavity lesions were visualized best on frontal tomograms. We looked for specific tomographic features of different histopathologic entities. Fibro-osseous lesions were distinguished from epithelial and other non-osseous tumors by homogeneous calcific density. Concomitant destructive and expansile growth in cylindromas (Patients 12 and 13) was observed, but fast growing benign lesions including angiofibroma (Patient 10) and inverting papilloma (Patient 11) had similar features. No other distinctive characteristics emerged. DISCUSSION

Many slowly growing pathologic conditions of the paranasal and nasal sinuses enable remodeling by periosteal

new bone deposition at a rate similar to bony erosion by the mass, a process analagous to the "accommodative growth" described for slowly growing skeletal tumors. The 22 fast growing malignant tumors studied revealed no instance of a bone rim expanded by slow growth of the tumor mass. This suggests that the "rim sign" is useful in differentiating benign, or slowly growing, malignant lesions from aggressive malignant lesions, although tomographic examination in multiple projections is often required. Judicious use of tomographic projections helps to assess the extent of disease, the precise anatomic localization, and the density of the mass lesion. The most common lesion which produces an expanding rim of bone in the paranasal sinuses is the mucocele (defined as an accumulation of secretions behind the blocked ostium of a sinus, resulting in slow progressive expansion of the sinus). Obstruction is most often the result of inflammation, tumor, allergy, or trauma (1). Recent reports emphasize the possibility of frontal sinus carcinoma presenting as mucocele (6, 16). The 4 patients in this series with fronto-ethmoid mucoceles illustrate several typical features. In clinical examination Patient 1 was thought to have a retention cyst of the lacrimal duct and sac (lacrimal mucocele), until

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Neuroradiology

Fig. 1. Patient 1: ethmoid mucocele. A. A soft tissue mass (arrows) can be seen. A firm palpable mass, inferomedial aspect of left orbit, had enlarged slowly over one year. This sixteen year old boy had longstanding sinusitis (note hypoplastic maxillary sinuses). B. Caldwell projection. Increased density in the left ethmoid region is shown. The lamina papyracea is apparently intact. C. Frontal tomogram. A defect in the medial orbital margin with parts of a thin bony rim (arrowheads) is shown encompassing the mass. At surgery a left anterior ethmoid mucocele was removed.

frontal tomography (Fig. 1) revealed an expanded rim of bone and soft-tissue mass in an anterior ethmoid air cell. Patient 2 had the classic features of a frontal mucocele extending into the supraorbital region. Patient 3 had an expanding midline frontal epidermoid cyst with communication to an extensive frontal sinus mucocele, revealed by tomography (Fig. 2). Patient 4 had an ethmoid mucocele which was shown best on submentovertex projection tomography (Fig. 3). In this view a low density mass expands the lamina papyraceas and mucosal thickening is seen in adjacent air cells. A similarly located expanding mass observed in a younger patient without evidence of adjacent sinus disease proved to be a neurilemmoma. (Patient 5) (Fig. 4). Sphenoid sinus mucocele are rare but well recognized lesions which cause expansion of the walls of the sphenoid sinus (19). Cerebrospinal fluid rhinorrhea, the presenting complaint in our patient, is less common than headache

and the orbital apex syndrome (10, 12). Expansion of the sinus walls was not demonstrated unequivocally in our case (Fig. 5) because inferolateral extension of the sphenoid sinus is a common variant. However, strong evidence of expansion is provided by the smooth outline of the sinus wall, foci of bone erosion, and adjacent welldefined, rounded soft-tissue mass. Similar cases were described by Minagi et al. (11). After a mucocele has been ruled out, the major differential diagnostic considerations in purely expansile lytic lesions of the fronto-ethmoid and sphenoid regions are polyposis, dermoid cysts, and congenital or acquired dehiscences. Only rarely will tumors, including meningioma, neurofibroma, lipoma, cholesteatoma, hemangioma, estheseoneuroblastoma, papillomas and cartilaginous tumors, be encountered. A congenital midline dermoid which causes expansion of the perpendicular plate of the ethmoid shows slow and

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TABLE III: RADIOGRAPHIC AND TOMOGRAPHIC FEATURES OF EXPANSILE LESIONS PLAIN FILMS

PATIENT

FRONTAL TOMO

LATERAL TOMO.

0

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0

I:!

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4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

0

!Z ziii w

00

W.S. M.D. H.S. E.M. V.D. J.U. W.H. J.C. R.S. D.N. R.Sh. C.J. M.T.

Z

w ...J

z z

1. 2. 3.

00


I

WW

+ + + + + + + + + + +

< a:

I-

00

z

0

~

w

c

z

0

W

ex:

:> l WW

+ +

+ +

+ + + + +

Plain Films: Tomography: Frontal I-ateral Submentovertex

EXPANSION DEMONSTRATED

(13 cases)

10 (77%)

6(46%)

(13 cases) (7 cases) (4 cases)

13

9(69%)

7

5 (71%)

4

3(75%)

< ex:

I-

w ex:

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l-

0

Z

z ~

w

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z

0

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iii Z

expansile growth of a longstanding mass, and results in a relatively thick bone rim almost completely enclosing the lesion (Fig. 6). These lesions characteristically exhibit a cutaneous midline lesion at any point from the glabella to the alae of the nose, a soft-tissue mass, widened interethmoidal distance, and a bifid nasal septum (8). Fibro-osseous lesions of the paranasal sinuses are common. They comprised the second largest category in a large surgical series of non-epithelial tumors of the paranasal sinuses (5). Fibro-osseus lesions of 2 patients in our series had expansile rather than infiltrative growth. The patient with fibrous dysplasia of the right maxillary, ethmoid, and sphenoid sinuses had radiologically documented rapid growth of these regions over two years. The Intact bony margins of these sinuses were preserved throughout this interval. Expansile growth of the cementifying fibroma is evidenced by the well-circumscribed margin of a spheroidal, homogeneously dense mass. The slow growth rate of this lesion (Fig. 7) was indicated by remodeling of the posterolateral antral wall, evident only when lateral tomography was performed. Plain film examination suggested destruction of the posterior antral wall. Cementifying fibromas are uncommon lesions of the mandible or maxilla (3), and are most often encountered

!Z

w

iii w

-l

~g X > WW

+

-

+ +

+ +

+ + +

TABLE IV: SUCCESS INDEMONSTRATING EXPANSILE GROWTH LESIONS DETECTED

ANCILLARY PROCEDURES

0

0

w

W

SUBMENTO VERTEX TOMO.

CT scan CT scan Orbital B scan Orbital B scan and CT scan Angiogram

Angiogram

+

+

Angiogram

in children and young adults. These tumors tend to be radiolucent in the young, and may grow rapidly in an expansile fashion. In adults they are usually more radiodense and slowly growing. While differentiation of these lesions from fibrous dysplasia is well established histologically, the distinction from ossifying fibroma remains controversial in some cases (5). Both cementifying and ossifying fibromas are invariably benign, but the progressive expansile growth may necessitate surgical removal. The lesions in Patients 10 through 13 showed some features of expansile growth as well as fairly extensive destruction. Destructive changespredominatedin the more fast growing cylindromas, while considerable bone remodeling was observed in the more benign angiofibroma. Bony changes in the patient with inverting papilloma suggested a growth rate intermediate between these two lesions. Juvenile angiofibromas are uncommon tumors which occur almost exclusively in adolescent males. The tumors are highly vascular and locally invasive. They originate in the posterior nasopharynx although they may arise in adjacent regions. Nasal obstruction and bleeding are the common presenting symptoms. Expansile growth is typically manifested by widening of the pterygomaxillary fissure (7) and, less often, by displacement of the nasal septum and lateral nasal cavity walls (Fig. 8). There may be sclerosis of the expanded bony structures (18), and accompanying destructive changes, seen in our patient, are also typical with large lesions. Cylindroma (adenoid cystic carcinoma) accounts for 1.3 % (17) to 14 % (13) of nasal and paranasal sinus cancers. A history of slow progressive growth over several years is often obtained, as it was for both our patients. The maxillary antrum is the most common site of sinus involvement, and cylindromas may arise wherever there are

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Fig. 2. Patient 2: frontal sinus mucocele and frontal epidermoid. A. Water's projection: a drain (arrow) was placed in the cavity of a curretted epidermoid cyst encountered unexpectedly at removal of a "sebaceous cyst" of the forehead. Note the opaque frontal sinuses, loss of sharp margination of the frontal sinuses, and depression of the left orbital roof suggesting mucocele. B. Lateral tomogram. A communication is shown between the mucocele of the left frontal sinus and the cavity of the epidermoid. Both lesions are expansile. Note defect in the posterior table of the frontal bone (arrow), and the epidermoid cavity (asterisk). C. Frontal tomogram. This view confirms expansion of the opaque supraorbital extension of the left frontal sinus, depressing the orbital roof (open arrow). Evidence of advanced polypoid disease of the ethmoid labyrinth is shown by water density, lobulated mucosal elevations, expansion, demineralization and destruction of the ethmoid septa, and much of the perpendicular plate of the ethmoid.

Neuroradiology

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Fig. 3. Patient 4: ethmoid mucocele. A. Water's projection: mucosal thickening of both maxillary, frontal and ethmoid sinuses reflects chronic pansinusitis with polypoid mucosal changes. A fluid level in the right maxillary sinus indicates current acute sinusitis. Lateral bowing of the right lamina papyracea (arrow) and nonvisualization of the right medial orbital margin in the region of a palpable bony defect are shown. B. Frontal tomogram. A defect in the right lamina papyracea with a thin expanded rim of bone (arrowheads) surrounding a low density rounded mass is shown. C. Submentovertex tomogram. A bony rim (arrowhead) encompassing a low density mass in the left anterior ethmoids (asterisk) is shown. Note the mucosal thickening which blurs the outlines of the ethmoid septa.

c mucous and salivary glands. While the radiological appearance may be indistinguishable from other carcinomas (14), tomography in our two patients demonstrated some characteristics of both expansile and destructive growth (Fig. 10). This probably reflects a slower growth rate than that of faster growing sinus malignancies, in view of the long clinical history in each case. Inverting papillomas are uncommon epithelial neoplasms with distinctive histologic features (2) which predominantly occur in male patients over 40. In Vrabec's series of 24 patients (20), unilateral nasal obstruction was

the most common presenting symptom and there was a history of previous nasal surgery in 70 % of the patients. The lesion is almost universally unilateral and usually originates in the lateral wall of the nasal sinus. Extension into the ethmoid and maxillary sinuses occurs with progressive growth of the lesion. Involvement of the frontal or sphenoid sinuses is rare and orbital involvement is also uncommon. The most common radiographic feature is unilateral opacification of the nasal cavity and adjacent ethmoid and maxillary sinuses. Destruction of the medial wall of the maxillary sinus, secondary to pressure erosion

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Fig. 4. Patient 5: ethmoid neurofibroma. A. In this frontal tomogram an ethmoid mass lesion with a well-defined bony rim (arrowheads) due to expansion of lamina papyracea is seen. Note the density of the mass compared to Figure 3, B. This was a palpable mass in a 28-year-old woman with a 13-month history of left proptosis. B. Submentovertex tomogram. The location in the left anterior and middle ethmoid cells is established, and the bony rim (arrowheads) and high density of the mass are confirmed. There is no evidence of sinusitis (compare to Patient 4).

Fig. 5. Patient 6: sphenoid mucocele. In this frontal tomogram a soft-tissue mass expands the inferolateral recess of the left sphenoid sinus. Note the bony erosion of the foramen rotundum, lateral wall of the sinus, and roof of the Vidian canal (arrowheads). A normal right Vidian canal is shown (arrow) for comparison. Scinticisternography showed a cerebrospinal fluid leak in the left sphenoid region. The mucocele was opened and curetted, and the sinus packed with muscle.

Fig.6. Patient 8: congenital dermoid cyst. A well-circumscribed round defect (arrowheads) is shown in the perpendicular plate of ethmoid. A water density defect enables differentiation from an aberrant air cell.

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Fig. 7. Patient 10: cementifying fibroma. A. A well circumscribed lobulated mass apparently traversing the posterolateral maxillary antral wall (arrowheads) is shown in this submentovertex radiograph. B. Lateral tomogram through lesion. Note the posterior bulging of the posterior antral wall (arrowheads). At surgery the mass was removed and the posterior wall was intact, though remodeled.

Fig. 8. Patient 12: juvenile nasopharyngeal angiofibroma. A. A soft tissue mass in the nasal cavity and left ethmoid and maxillary sinuses, and bowing of the nasal septum to the right by the mass (arrowheads) are shown in this frontal tomogram. The left turbinates and left naso-antral wall are obscured, and at surgery were partly destroyed. B. Lateral tomogram. Note the expanded right pterygomaxillary fissure (arrowheads).

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by the mass, is the most characteristic bony abnormality. Our case (Fig. 9) exhibited all of these clinical and radiographic features. Pluridirectional tomography is invaluable in investigation of lesions of this region because of the complex anatomy of the nasal and paranasal sinuses. The selection of appropriate projections is crucial in defining the nature and the extent of sinus lesions. Frontal tomograms alone may fail to yield valuable information which can be demonstrated in other views. In 3 of 11 patients who had two or more projections, the expansile nature of the lesion would have been missed had only frontal tomograms been obtained. Frontal, lateral, and submentovertex projection tomograms might be obtained in all cases (15), but the considerations of radiation dose, patient discomfort, and cost justify limitation of the number of projections performed. Four of our patients had a series of frontal tomograms which was sufficient to make a diagnosis, and further projections were not done. The anatomic site of the abnormality can usually be judged from a standard series of radiographs which should be performed with correct positioning and meticulous technique in all cases before considering tomography. In this series the optimal tomographic projections for demonstrating bone expansion were those in which the plane of tomographic cut was most nearly perpendicular to the rim of bone, as one would expect. Thus, a lesion of the ethmoids (Figs. 3 and 4) is often best examined in submentovertex projection (9), as is any tumor involving the posterolateral wall of the maxillary antrum. The nasal cavity, ethmoidal, and sphenoid sinuses are displayed in frontal projection (Figs. 4, 5, and 9) while the frontal sinus, posterior wall and roof of the maxillary sinus are often assessed best in lateral projection (Fig. 2). Bony expansion by a nasal or paranasal sinus mass is a valuable indicator of growth rate. Tomographic sections perpendicular to the plane of bony structures contiguous to the mass should be obtained even in the presence of obvious bony destruction in order to elicit this sign; bony expansion suggestsa benign or a slowly growing malignant lesion.

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5. Guerry RK, Smith JL: Paranasal sinus carcinoma causing orbital mucocele. Am J Ophthalmol 80:943-945, Nov 1975 6. Holman CB, Miller WE: Juvenile nasopharyngeal fibroma; roentgenologic characteristics. Am J Roentgenol 94:292-298, Jun 1965 7. Johnson GF, Weisman PA: Radiological features of dermoid cysts of the nose. Radiology 82: 1016-1 021, Jun 1964 8. Lloyd DM, Bartram CI, Stanley P: Ethmoid mucocoeles. Br J RadioI47:646-651, Oct 1974 9. Lundgren A, Olin T: Muco-pyocele of sphenoidal sinus or posterior ethmoidal cells with special reference to the apex orbitae syndrome. Acta Otolaryngol 53:61-79, Feb 1961 10. Minagi H, Margolis MT, Newton TH: Tomography in the diagnosis of sphenoid sinus mucocele (SSM). Am J Roentgenol 115: 587-591,JuI1972 11. More D, Tew JM, Mayfield FH: Ocular manifestations of sphenoid mucoceles. Ohio State Med J 68: 1100-11 04, Dec 1972 12. Oppenheim H, Landau GH, Dorman DW, et al: Cylindroma involving the paranasal sinuses. Eye Ear Nose Throat Monthly 47: 669-678, Dec 1968 13. Ramsden D, Sheridan BF, Newton NC, et al: Adenoid cystic carcinoma of the headand neck: a report of 30 cases. Aust NZ J Surg 43: 102-1 08, Sep 1973 14. Ratjen E: Paranasal sinuses. [In] Modern Thin Section Tomography. Berrett A, Brunner S, Valvassori GE, eds. Springfield, 111., Charles C. Thomas, 1973, p 177 15. Robinson JM: Frontal sinus cancer manifested as a frontal mucocele. .Arch OtolaryngoI101:718-721, Dec 1975 16. Scholtz HJ, Quoted in: Oppenheim H, Landau GH, Dorman DW, et al: Cylindroma involving the paranasal sinuses. Eye Ear Nose Throat Monthly 47:88, Dec 1968

REFERENCES 1. Bordley JE, Bosley WR: Mucoceles of the frontal sinus: causes and treatment. Ann Otol Rhinol Laryngol 82:696-702, Sep/Oct 1973 2. Clairmont AA, Wright RE, Rooker DT, et al: Pipillomas of the nasal and paranasal cavities. South Med J 68:41-45, Jan 1975 3. Dehner LP: Tumors of the mandible and maxilla in children. I. Clinicopathologic study of 46 histologically benign lesions. Cancer 31:364-384, Feb 1973 4. Fu YS, Perzin KH: Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx: a clinicopathologic study. II. Osseous and fibro-osseous lesions, including osteoma, fibrous dysplasia, ossifying fibroma, osteoblastoma, giant cell tumor, and osteosarcoma. Cancer 33: 1289-1305, May 1974

Fig. 9. Patient 13: inverting papilloma. A frontal tomogram through the nasal cavity and maxillary antra shows a soft-sissue mass (asterisk). Note bowing and thinning of nasal septum (open arrows) and right medial antral wall (arrowhead). Turbinate destruction may reflect several previous operations (polyp resections) or tumor destruction.

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Fig. 10. Patient 14: ethmoid cylindroma. A. Frontal tomogram. Mass effect in the right ethmoid region and the superior nasal cavity (arrowheads) is shown. Opacity of the left ethmoids is attributed to chronic sinusitis. B. Submentovertex tomogram. Destruction of ethmoid septa suggests the malignant nature of this lesion, but expansion of the left lamina papyracea (arrowheads) is evidence of slow growth.

17. Sessions RB, Wills PI, Alford BR, et al: Juvenile nasopharyngeal angiofibroma: radiographic aspects. Laryngoscope 86:2-18, Jan 1976 18. Takahashi M, Jingu K, Nakayama T: Roentgenologic appearances of sphenoethmoidal mucocele. Neuroradiology 6:45-49, Sep 1973 19. Vrabec DP: The inverted Schneiderian papilloma: a clinical

and pathological study.

Laryngoscope 85(1):186-220, Jan 1975

Philip J. Dubois, M.B.B.S. Department of Radiology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania 15261

Tomography in expansile lesions of the nasal and paranasal sinuses.

Tomography in Expansile Lesions of the Nasal and Paranasal Sinuses 1 Neuroradiology Philip J. Dubois, M.B.B.S., Joseph C. Schultz, M.D., Ronald L. P...
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