It's Just a Sinus CT…What Could Possibly Go Wrong! Dr. Suresh Mukherji (5-15-25)
HIDEInteractive Transcript
0:02
Hello and welcome to Noon Conference, hosted by Modality
0:06
Noon Conference connects the global radiology community
0:08
through free live educational webinars that are accessible
0:11
for all and is an opportunity
0:13
to learn alongside top radiologists from around the world.
0:16
You can access the recording of today's conference
0:18
and previous noon conferences by creating a free account.
0:22
Today we are honored to welcome Dr.
0:24
eSSH McCury for a lecture entitled, it's Just a Sign, A ct.
0:27
What Could Possibly Go wrong? Dr.
0:30
McCury received his undergraduate degree from Duke
0:32
University and an MD degree from Georgetown University.
0:35
He currently holds academic appointments at multiple
0:38
institutions and is a devoted educator who's been an invited
0:41
speaker on over 500 occasions and has written
0:43
and edited 15 textbooks.
0:45
We're especially grateful for his supportive modality
0:48
and for serving as our head and neck neuroradiology advisor.
0:51
At the end of the lecture, please join him in a q
0:53
and a session where he will address questions
0:55
you may have on today's topic.
0:57
Please remember to use that q
0:58
and a feature to submit your questions so we can get to
1:01
as many as we can before our time is up.
1:03
With that already. To begin today's lecture, Dr.
1:06
Erie, please take it from here.
1:08
Okay. Um, it's great to be back.
1:11
Um, hopefully you'll be able to, uh, see my screen uh,
1:15
pretty soon here.
1:16
There we go. But it's great to be back in modality.
1:19
I appreciate the invitations.
1:20
Um, and we always have a q
1:24
and a afterwards, so just, uh, FYI, you know, part
1:27
of the thing I love about modality in these sessions is
1:30
that not only do we get a chance to give a talk,
1:34
but for me the most important thing is to interact
1:36
with, with you all.
1:37
So if you do have any questions, you know, feel free,
1:40
free to ask at the end.
1:41
So the title of this talk is, it's called,
1:44
it's Just a Sinus ct.
1:46
And, and the reason why I created this talk is that we
1:51
as radiologists, um,
1:54
basically all love sinus cts,
1:56
but as I kind of reflect back on with me as a head
1:59
and neck radiologist, I was always taught this in a
2:02
relatively structured approach.
2:03
But then when you actually look at sinus cts, everyone sort
2:06
of reads sinus cts
2:08
and at times what ends up happening is that there are a lot
2:10
of pitfalls in sinus cts that you just may not be aware of.
2:14
So that's why in the title
2:16
of this talk it's just a sinus ct.
2:18
So when you look at this, I was at on a safari a couple
2:21
years ago and this is just a Serengeti
2:23
and it's just like a really, really beautiful view of the,
2:26
the Serengeti and all the bushes and things like that.
2:28
And you just feel like taking a walk in it.
2:31
But on the other hand, you have to realize there are in
2:34
that in the Serengeti, a bunch
2:36
of lions there sitting out there.
2:38
So the issue is what could possibly go wrong?
2:40
So it's just the sinus ct, what could possibly go wrong?
2:44
So when we look at sinus cts, the funny thing about uh,
2:47
sinus CT is that when we talk about head
2:50
and neck radiology in general, head
2:52
and neck radiology is radiology.
2:54
Nobody want, you know, I think it
2:57
the neuro folks in general don't like
2:59
to go below the skull base.
3:00
The musculoskeletal radiologists sort of when you get down
3:04
to brachial plexus, they really don't want
3:05
to get up to the base of the neck.
3:07
The chest radiologists certainly don't want
3:09
to go above the clavicle.
3:11
And so as a result, the head
3:12
and neck tends to be an area nobody wants.
3:15
But surprisingly enough,
3:18
the funny thing about sinus cts is everyone tends
3:20
to like sinus cts and,
3:23
but the sinus cts are actually a type of head and neck CT
3:27
or head and neck imaging.
3:29
So it's kind of a strange thing in the sense
3:31
that if I ask them if they wanna do head
3:33
and neck imaging, like a CT in the neck,
3:35
oh no, no, I don't wanna do that.
3:36
But on the other hand, yeah, gimme your sinus cts.
3:39
So when we look at the sinuses, I think we're all aware
3:42
of the frontal, the maxillary, the ethmoid,
3:45
and the sphenoid sinus.
3:46
So I'm not really gonna go into the anatomy of this
3:49
because I think this has been covered in previous lectures.
3:52
And in general, if you're gonna be reading a sinus ct,
3:55
I think you pretty much know the basic anatomy.
3:57
So I'm not gonna get into the real drill down anatomy.
4:00
I will just say when we do look at the maxillary sinus,
4:03
we do want to be aware of the osteo unit.
4:06
So this is our primary osteum here.
4:08
This is the unsaid process.
4:10
It's actually better seen here on the left side.
4:12
So that's the anate process.
4:14
Here's a primary osteo, the alveolar re recess,
4:17
the zygomatic recess.
4:18
Then we come up here
4:19
and we have the highest simul, then we have the middle atu,
4:24
and this enlarged ethmoid air cell is what we refer to
4:27
as the ethmoid Ebola.
4:28
So that's really mostly the regular anatomy I'm gonna cover
4:32
'cause I have a full talk on anatomy and,
4:35
and various types of pathology involving the sinuses,
4:38
whether it's infectious or inflammatory.
4:40
So when we do talk about the sinuses though, what's kind
4:43
of interesting is that everyone wants the sinus et
4:46
and part of it, everyone sort of considers
4:49
that low hanging fruit.
4:50
I mean, when you look at something like this, it's like,
4:52
yeah, I, anyone can can read these things
4:55
and in the US it's pretty reimbursed reasonably well.
4:58
The RVU are relatively value units are about 0.85.
5:03
The reimbursement professionally is about $44
5:05
and then the facility fees about 97.
5:08
So it's okay reimbursed, I would say,
5:11
but in generally, you know, it doesn't take
5:13
that long to read 'em.
5:14
So as a result, everyone sort of wants
5:16
to read the sinus cts,
5:18
but the challenge that you get into is there's a lot
5:21
of pitfalls that you may not realize that you may run into.
5:25
And the interesting thing is
5:28
that when I was putting this together, a friend of mine, uh,
5:31
is a, a radiologist
5:33
and their wife is actually a medical malpractice lawyer.
5:37
And I was asking them about a sinus ct.
5:40
I said, you know, if we're gonna do a sinus CT
5:43
and we read the sinuses,
5:44
but let's just say on the corner
5:46
of the study there's something abnormal.
5:49
You know, is this something that we need to worry about?
5:51
Because when we're really interested are the
5:53
perinasal sinuses.
5:55
And the response I got kind of scared me
5:57
because they said, well, if it's on the images
6:00
and it's relevant, I'm gonna come after you.
6:03
So those are the exact words is
6:04
that I'm gonna come after you.
6:05
So as a result, we always have
6:08
to be careful about these sinus cts.
6:10
So when we do our technique, especially now, you know,
6:13
everything is essentially done with some type
6:15
of helical technique.
6:16
I always include this because when I trained
6:20
and did my residency, I actually did in the days
6:22
of single slice ct.
6:23
So I was at the Brigman Women's Hospital when we first got,
6:26
we used to call it spiral ct, now it's helical ct.
6:29
We do our acquisitions in the sub-millimeter plane.
6:32
In general, most people do axial images
6:35
and they reconstruct in coronal and sagittal recons.
6:38
You know, when I was growing up,
6:39
we would do our coronal recons in a separate acquisition,
6:42
but now it's basically axial acquisitions.
6:45
For me, it's really important
6:46
to reconstruct in bone algorithms
6:48
and then we reconstruct that in soft tissue algorithms.
6:51
And you know, in the q and a, we can actually have a debate
6:53
as to how different people do this,
6:56
but for me, I always do bone algorithms and then reconstruct
7:01
and soft tissue algorithms too.
7:03
Again, back in the old days it take, used to take forever
7:05
to do these algorithms, but now it's really, really quick.
7:08
So that's the basic technique that we should,
7:11
we should all be doing.
7:13
Now the next thing is always kind of interesting
7:16
and that is if you have a sinus ct,
7:18
how exactly do you interpret it?
7:20
And as I've kind of come through the journey
7:22
and I've seen interpretations for the last 30 years
7:26
and literally all over the globe
7:28
and in different types of practices, um, I kind
7:31
of divided into two separate, uh,
7:35
buckets, if you will.
7:37
So some people are like cheetahs,
7:40
they're really, really fast.
7:41
So this is, uh, actual dictation that that came through.
7:45
And findings were mucosal thickening
7:47
and right maxillary sinuses.
7:48
Other sinuses are clear bony structures,
7:51
intact osteo openin, conclusion, mucosal thickening
7:54
and right maxillary sinus consistent
7:56
with the right chronic maxillary sinusitis.
7:58
Thank you for the opportunity for the interpretation.
8:00
So basically the findings are two lines
8:04
and then the conclusion is kind of two lines,
8:06
and it probably would be one line, but the font was bigger.
8:09
So you could actually make the argument
8:11
that this could have all be one line of each one.
8:13
So those are sort of the cheetahs, if you will.
8:16
And then there are other people that interpret sinuses.
8:19
And I sort of call these the turtles.
8:21
And again, this is an actual template from a major academic
8:25
institution, uh, in the United States.
8:28
And this is their interpretation.
8:30
So they go through every single, not every single piece,
8:34
but close to every piece
8:35
of anatomy in the maxillary, in the sinuses.
8:37
So you have maxillary sinus, maxillary osteum,
8:40
frontal sinus, frontal I flow tract,
8:42
anterior ethmoid, posterior ethmoid.
8:44
That's on the right side, that's on the left side.
8:46
So that's page one.
8:48
And then when you get to page two,
8:50
we have the sphenoid sinuses, again,
8:51
four separate checkpoints.
8:53
Then you go to page three,
8:55
and then you have interpretations of lamina caprice,
8:57
the cribriform plate, the anterior ethmoid canals,
9:00
nasal cavity, nasopharynx, and all the way down.
9:03
So basically that is three pages worth of interpretations.
9:09
Now I'm not saying anything's good or bad
9:11
because one thing that I've learned over time is I,
9:14
I tend not to be really prescriptive about the reports.
9:18
Um, we've been talking about personalized reports
9:20
and standardized reports ever since I was a resident again,
9:23
I did my residency from 88 to 92.
9:26
So that was back in the last century.
9:28
And over time when I have realized is that you can only, uh,
9:32
literally no pun intended, dictate to
9:35
what people do to a certain level.
9:37
So from my standpoint, what I like
9:39
to do in my reports is somewhere in the middle.
9:42
So this is what I do.
9:44
I comment on the frontal sinuses,
9:46
I comment on the ethmoid sinuses, then the sphenoid sinuses,
9:50
then I have a right maxillary sinus, left maxillary sinus,
9:53
the nasal cavity, the anterior skull base,
9:55
the temporal bone, the orbits in the brain.
9:58
And basically this is what I do in my reports.
10:01
And this lecture is basically going
10:04
to be outlined on this approach to the sinuses.
10:07
So what I try to do in my report,
10:09
and you'll see this as we kind of step through things,
10:13
is I like to talk about key elements.
10:15
Now, in the old days we would sort
10:17
of talk about, uh, checklist.
10:18
I've been doing checklists actually back in the late 1990s
10:21
before Atul Gawande kind of made it popularized.
10:24
But now I've, we've sort
10:26
of switched over the term key elements.
10:28
So in each one of these we tend to talk about key elements
10:32
and key observations.
10:33
So what I wanna go to go through is sort of some
10:37
of the interpretations that I do
10:39
and some of the pitfalls that you run into
10:41
and also try to clear up some mis uh,
10:44
conceptions about the sinuses.
10:47
So the first thing that we're gonna talk about is this
10:49
concept of sinusitis.
10:52
Now sinusitis is a clinical diagnosis.
10:55
It is not a radiological diagnosis.
10:58
And the reason I'm so dogmatic about this is, again,
11:01
back in the last century when I was a resident, I knew
11:04
that I wanted to become a head and neck radiologist.
11:07
On the second day of my residency,
11:10
I was on my neuro rotation.
11:12
I remember my attendings
11:13
and my fellows at that time,
11:15
we were using something called film
11:17
and we had something called alternators.
11:19
And so what they did, uh,
11:21
that you knew guys have no idea what it was like.
11:23
You can google the archives
11:24
and figure out what an alternator in film was.
11:26
But basically when we would point at things,
11:28
we would unwind a paperclip.
11:30
And my attendings at
11:31
that time went over every neural freeman on
11:34
my second day of the rotation.
11:35
I'm like, this is great. I just decided to be a head
11:37
and neck radiologist and I've never looked back on it.
11:40
But because I was so passionate about radiology,
11:44
neuroradiology and head neck radiology,
11:46
when I came back on the rotation the following year,
11:50
I would read out the neuro ICU board.
11:53
And so in the ICU would have all these patients
11:56
with these terrible hemorrhages, these, you know,
11:58
intraventricular hemorrhages, subarachnoid hemorrhages,
12:01
intraparenchymal hemorrhages, they were all herniating
12:03
and so on and so forth.
12:05
But I remember dictating out my reports,
12:06
it's a true story, I would say.
12:09
Um, the impression was number one,
12:12
extensive intracranial hemorrhage with potential herniation.
12:15
Item two, um,
12:17
mucosal thickening involved in the ethmoid sinuses
12:20
consistent with ethmoid sinusitis.
12:23
So I thought I was being pretty smart.
12:25
And then about two weeks into the rotation,
12:27
my division director comes to me
12:29
and says, Hey Siresh, how's it going?
12:31
I said, um, hello Dr. Rumba, I'm doing fine.
12:34
Um, you know when someone comes up to you
12:36
and says something like that, you
12:37
say, if something's not right.
12:38
And I said, is there anything wrong Dr. Rumba?
12:40
And he said, well, you know, you may not want to say
12:45
sinusitis when you see disease involving
12:47
the ethmoid sinuses.
12:49
And I said, why? He said, there's disease here
12:52
so it's sinusitis.
12:53
And he said, well the thing is
12:56
that the ENT surgeons are getting a little upset.
12:58
I said, why are they upset?
13:00
I'm such a good resident,
13:01
I'm picking up all these great findings.
13:03
And he said, well, anytime you put sinusitis into the report
13:07
in these ICU patients,
13:08
the neurosurgeons are consulting the ENT surgeons
13:11
and now they're getting consulted on a bunch
13:13
of comatose patients that they have
13:15
to work up for sinusitis.
13:17
So after that I learned a pretty important lesson
13:21
and that is sinusitis is a clinical diagnosis,
13:24
it is not a radiological diagnosis.
13:27
So what do I do in situations such as this?
13:29
This is a patient that has quote unquote frontal sinusitis.
13:32
Now I do not look at this and say there's an air fluid level
13:36
and call it sinusitis.
13:37
What I would say here is
13:39
that there's an air fluid level involving the left frontal
13:42
sinus, which would be consistent with the diagnosis
13:45
of acute frontal sinusitis.
13:47
So it really is a clinical diagnosis
13:50
and we know that anytime
13:51
that you have an air fluid level here,
13:54
we should always mention that
13:55
because if this goes untreated, remember the anterior wall
14:00
of this extends into the soft tissue.
14:02
So we can develop what's what we used to call
14:04
or still is called apo puffy tumor.
14:07
But remember this posterior wall
14:08
of the frontal sinus is relatively thin.
14:11
And what can happen is
14:13
that you have these traversing emissary veins
14:15
that run within the par the frontal sinus,
14:18
perverse the posterior wall of the frontal sinus,
14:21
and then it's continuous intracranial.
14:23
So if you do have some type of infection in this area,
14:26
then these little germs can extend posteriorly.
14:29
They can eventually erode the posterior wall
14:31
of the frontal sinus.
14:33
And once it does this,
14:34
you could end up having right here meningitis
14:37
and eventually you can sometimes end up having
14:39
an as well too.
14:41
So anytime that I do have an air fluid level involving the
14:44
frontal sinus, I always mention
14:45
that I don't use the term frontal sinusitis,
14:48
but I always say it should be correlated with with
14:52
clinical findings of frontal sinusitis.
14:54
And if the patients continue to have symptoms,
14:57
then I have a relatively low threshold about at least
15:00
suggesting that they get a follow-up Mr.
15:03
And the terminology that I tend to use is
15:05
that if the symptoms persist
15:08
or progress, they may want to contin, uh,
15:11
consider getting an MR of the perinasal sinuses.
15:14
How about in this situation here?
15:16
Here we have a patient that has disease
15:18
involving the frontal sinus.
15:19
Is this really, really bad frontal sinus?
15:22
No sinusitis or sinus disease?
15:24
No, this just happens to be
15:25
a large squamous cell carcinoma involving the frontal sinus.
15:29
And in this case we have replacement
15:31
of the normal marrow within the frontal bone.
15:33
And in this case, this enhancement right here that we see
15:37
is not due to infectious, rather this is likely due
15:41
to either dural involvement by the tumor
15:43
or it can be due to peritumoral inflammation.
15:47
And I do wanna point out,
15:49
because this really is talking about infectious processes,
15:52
but I do wanna emphasize that if you do have any type
15:55
of tumor involving the region of the forehead,
15:57
these tumors can extend intracranial
16:00
and that bone does not have to be eroded.
16:02
Sometimes you can see a little sclerosis in the bone,
16:05
but I can tell you there are numerous times
16:07
where I've seen this tumor extend intracranial
16:10
and part of it is just involving a slow
16:12
involvement of the marrow.
16:14
Sometimes it's lymphoma that involves a bone
16:16
and it creeps in and then on other occasions it can actually
16:19
grow per neurally along V ones.
16:22
So anytime that you do have a patient
16:24
with squamous cell carcinoma, I have a very low threshold
16:27
of ordering an MR just to make sure, uh, that that dura
16:31
and there's no intercranial involvement in
16:33
that dura is not involved.
16:36
Now here's an example of another area
16:38
where you can quote unquote get sinusitis.
16:41
This is involving this phen sinus.
16:44
So this is an example of a patient
16:45
that has an air fluid level involving the sphenoid sinus.
16:49
And oftentimes you'll see these little bubbles here.
16:51
The term that I use
16:53
and others use is called frothy secretions.
16:56
So if I see something like this,
16:57
I will say there's a partial near complete opacification
17:01
or partial ification, the sphenoid sinus,
17:03
there's an ear fluid level with frothy secretions
17:06
and these can be correlated with clinical signs
17:09
of sphenoid sinusitis.
17:12
So this one is pretty obvious.
17:14
Now in this case a different patient.
17:16
What we see here is that there's an ear fluid level
17:19
with the little frothy secretions.
17:21
And when you first look at this, it doesn't look bad at all,
17:24
but realize the way you in window these CT scans,
17:28
sometimes you can underestimate the full
17:30
extent of the disease.
17:31
So this was a case I saw two weeks ago when I would looked
17:34
at it didn't look too bad,
17:36
but when that opened it up I was like, holy cow,
17:38
there are secretions completely involving
17:40
that right sphenoid sinus.
17:42
So in these situations when I look at this,
17:44
it's always important to use a wider windows
17:47
because sometimes you can actually blow past literally
17:51
complete opacification
17:52
or complete involvement of the sinus if you have these very,
17:56
very narrow windows and you may not see these
17:58
using the wide windows.
18:01
So when we do talk about the sphenoid sinus, we always have
18:04
to worry about potential complications
18:07
and some anatomic variants.
18:09
So this is an example of a normally aerated sphenoid sinus.
18:12
But what I do wanna point out is this.
18:15
Now this is the carotid artery
18:17
that's extending posterior laterally into
18:20
the sphenoid sinus.
18:21
Now if we look at the left side,
18:22
here's a carotid artery here
18:24
and we see a very, very thick wall right here.
18:27
So this is a completely covered, if you will,
18:29
the bony covering of the carotid arteries intact.
18:32
Now on the right side here, look what we're seeing here,
18:34
that there's complete dehiscence in
18:36
that carotid arteries extending into the posterior lateral
18:40
aspect of the sphenoid sinus.
18:42
So I always try to mention this, I have
18:45
to admit if this sphenoid sinus
18:46
and the sinus study is negative, I may not mention that,
18:50
but I always try to.
18:51
But the reason why I always try to
18:53
and to get in the habit is in situations such as this.
18:57
So this is an example where there's complete opacification
19:00
of the sphenoid sinus.
19:02
And you'll see right here there's a little
19:05
bony defect right here.
19:06
A dehiscence involving
19:07
that carotid artery in the sphenoid sinus.
19:10
And why is that important?
19:12
Because if the surgeons want to operate on this patient,
19:15
this is a patient that probably wouldn't benefit
19:18
from a sphenoid otomy.
19:19
We know the sphenoid sinus drains through a primary osteo.
19:23
So in this case, the surgeons would take their endoscope
19:26
back here, they would create an osteotomy
19:29
and then they may take a little bit more aggressive approach
19:32
and try to remove some of this polyp disease.
19:35
Now you have to ask your question. So what and who cares?
19:39
Well, again, another story for my journey if you will.
19:42
This was, this happened just
19:43
before I started my first faculty position
19:45
when I was at UNC.
19:47
So about two weeks before I started there was an ENT surgeon
19:51
that was then, this was back, you know, 30 years ago,
19:53
35 years ago that was doing an endoscopic sinus surgeon was
19:58
in this sphenoid sinus.
19:59
So they had taken their small little clips or
20:02
however they removed their polyps, their forceps
20:05
and was removing the polyps.
20:07
All of a sudden there was a tremendous amount of bleeding
20:10
and the surgeon thought they had
20:12
re resulted in a hypervascular polyp.
20:15
Well, they tried to stop the bleeding
20:17
and they couldn't stop it
20:18
and all of a sudden it became pulsatile
20:20
and they actually had to emergency call in an
20:23
interventional neuroradiologist.
20:24
And at that time we didn't have onsite
20:26
interventional neuroradiologist.
20:27
So they had to fly someone in from a different institution
20:30
because what had happened is
20:32
that the surgeon had inadvertently clipped
20:34
or punctured the internal carotid artery.
20:37
And that was likely due
20:38
because there was dehiscence of
20:40
that bone overlying the carotid artery.
20:43
So I think I saw a cut film of that one time, that
20:46
that time we were using cut films,
20:48
but I never really saw the preoperative study.
20:51
But as a result, it's one of these those things
20:53
that I always remembered.
20:55
And I always have to remind myself anytime
20:57
that you see something like this, make sure you mention it
21:00
because if it is dehisce,
21:01
it certainly is gonna be a risk of a complication.
21:05
Now in these situations, when you look at this,
21:07
your eye probably goes right here.
21:09
You can say there's complete opacification
21:11
of the sphenoid sinus,
21:13
but in this particular case what we see is erosion
21:16
of the roof of the sphenoid sinus.
21:18
And this is what we call the planum sphenoid alley.
21:20
So when you are looking at the sphenoid sinus
21:23
and it's completely opacified,
21:24
take a real close look at the bony covering
21:27
because in this particular case, this is the same patient.
21:30
What we see here is diffuse dural enhancement.
21:33
So this patient actually had a, an meningitis
21:37
that was result of all of this sphenoid sinus disease
21:40
that eroded the plenum sphenoid alley
21:42
and resulted in this meningeal thickening
21:44
and this meningeal irritation.
21:47
And this was a different patient.
21:48
This was another patient that had complete opacification
21:51
of the sphenoid sinus.
21:52
In fact, you can probably argue it could have been a mucus
21:55
seal because if you look at this, you can see expansion
21:58
of the sphenoid sinus as completely opacified
22:01
and it's enlarged compared to the left.
22:03
And now when we look at this,
22:04
we can see there's erosion right here of the posterior wall.
22:08
So as a result, this patient probably had a cusal.
22:12
And when we look at the brain we can see this little dural
22:15
thickening right here.
22:16
So this is all again, meningeal enhancement
22:19
that's arising from the sphenoid sinus.
22:22
So these are all examples of potential complications
22:26
that we can have from sphenoid disease.
22:28
And again, I don't necessarily call it sphenoid sinus.
22:30
I'm uh, I'm distri descriptive,
22:33
I talk about the boney erosion.
22:34
But I have to tell you anytime
22:36
that I talk about quote unquote sphenoid disease,
22:40
I always worry about it
22:41
because this is the high rent district.
22:43
So I don't know, we'll find out later how many
22:45
of you in the United States,
22:46
but if you've ever been to New York, there is a large group
22:50
of apartments that are right along Central Park
22:53
and this is what they call Billionaires Row.
22:56
So basically all of these apartment complexes
22:59
for billionaires like these sky scrape the penthouses run
23:01
for hundreds of millions of dollars.
23:03
So this is billionaires row with the point being
23:06
that anytime that you're in this sphenoid sinus, there's a,
23:09
this is the high rent district.
23:11
There's a lot of important structures adjacent
23:14
to this sphenoid sinus
23:15
because just lateral to the sphenoid sinus,
23:18
we're gonna see the cavernous sinus,
23:19
we're gonna see the carotid artery,
23:21
we're gonna see these various cranial nerves.
23:24
So this is cranial nerve six, this is cranial nerve three,
23:27
this is cranial four, V one and V two.
23:30
So the challenge is, is that anytime
23:32
that you can have disease involving the sphenoid sinus,
23:35
and I'll go back to this case in particularly
23:37
and notice just lateral to the sphenoid sinus,
23:40
we're gonna be right in the region of the,
23:42
of the cavernous sinus.
23:43
And in this case it's meles K.
23:46
So this is an example of a patient
23:48
that ends up having cavernous sinus thrombosis.
23:51
So when you do have patients
23:53
that have disease involved in the sphenoid sinus,
23:56
if it extends laterally,
23:57
you could end up having this cavernous sinus thrombosis.
24:00
And remember the cavernous sinus is the main venous drainage
24:03
for the deep portion of the brain.
24:06
And this is an example of a patient
24:07
that has complete opacification of the left sphenoid sinus.
24:10
This patient had clinically acute sphenoid sinusitis,
24:14
it extended into the carotid artery
24:16
and look what it did to the lumen.
24:18
The lumen is very narrowed,
24:19
but what we see here is actually clot involving a pseudo
24:24
aneurysm of the internal carotid artery.
24:27
So I always, I'm a little bit get a little jittery when I
24:31
see all of this disease involving the sphenoid sinus.
24:33
So I'm always very vigilant to mention that ear fluid level.
24:38
And part of what we do is kind
24:40
of based on our own experience.
24:42
So back when I was a resident, I decided
24:44
to do my fellowship at the University of Florida.
24:47
And so at that time it was before texts
24:50
and emails and things like that.
24:52
So the only way I could get in touch
24:53
with someone was through a phone call.
24:55
So I was a super, you know, enthusiastic resident
24:58
and I wanted to write a paper
25:00
'cause I was still gonna do my fellowship.
25:02
My, my mentor at the time was Tony Mancuso.
25:05
And so I kept calling Tony up
25:06
and so finally in order the phone to stop ringing,
25:09
I think he kind of threw me a bone
25:11
as we say in the US he said, okay,
25:13
here are six cases I want you to write up.
25:15
And there were all cases of
25:18
septic cavernous sinus thrombosis that were actually due
25:21
to sphenoid sinus disease.
25:23
And so, you know, it wasn't a major project.
25:26
Um, but the interesting thing about
25:28
as we started looking at these cases is
25:31
that cavernous sinus thrombosis, as we know,
25:34
is a very debilitating disease can that can lead to death.
25:38
And in this particular series of six patients, all six
25:43
of the patients, either five of them died
25:45
or one ended up having a severe
25:48
permanent neurological complication.
25:51
So number one that always stood out to me,
25:53
and this was that paper that we wrote,
25:55
I'm sure everyone read this paper, right?
25:56
Just kidding. It was an applied radiology in 1995.
26:01
But on the other hand, what was even more worrisome was the
26:04
fact that of the six cases that we saw, five
26:09
of those cases all actually I should say all six
26:12
of the cases, the diagnosis was there but it was missed.
26:15
So it was missed actually on the original imaging study.
26:18
So from my standpoint, there's an old saying, you only see
26:22
what you look for and you only diagnose what you know.
26:25
And because of that experience writing this paper years ago,
26:28
I'm always a concerned when I see disease involving
26:31
that sphenoid sinus.
26:33
So the other thing I wanna point out too is I'm sure we have
26:35
a lot of trainees on this, on this call as well too.
26:39
You know, I'm sure when you're in a teaching program,
26:42
you know your attendings
26:43
and your faculty are always giving you, Hey,
26:45
why didn't you write this up?
26:46
Why didn't you write this up?
26:47
Why didn't you do some scholarly activity?
26:50
The one thing I do want to emphasize is that every little,
26:52
even when I've written a case report, that body
26:55
of knowledge has stuck with me for the rest of my life.
26:57
So when you write that report,
26:59
you do become a domain expertise
27:01
and that knowledge tends to stay
27:03
with you for the rest of your life.
27:05
So even though that I, we wrote this paper many,
27:08
many years ago, this was published in 1995, number one,
27:11
I've always looked for this disease entity
27:13
and eventually it does help you.
27:15
So this was a case I saw a few years ago,
27:18
it was Friday afternoon and I was on the, an neural rotation
27:22
and this was a sinus ET
27:23
and I was about to read it out as just disease involving
27:27
the ethmoid sinuses.
27:29
But then just as I was about to sign it,
27:32
something didn't seem right to me.
27:33
If I draw a line down the middle
27:34
and I compare the right side to the left side,
27:37
notice there's reticulation
27:38
to the fat on the left compared to the right.
27:41
And then lo and behold,
27:42
when I started taking a closer look at it,
27:44
there was dilatation of the superior ophthalmic vein.
27:46
So something just didn't seem right.
27:48
So I called up the ER
27:50
and I said, Hey, is there anything else in this patient?
27:52
And I got the famous response,
27:54
oh yeah, said, what do you mean?
27:55
Oh yeah, oh yeah, the patient has a six nerve palsy.
27:59
And I said, Hmm. So they have a six nerve palsy,
28:02
there's dilatation of the superior valve vein,
28:04
there's reticulation of the fat,
28:06
and the six nerve palsy was acute.
28:08
Well, all of a sudden I started thinking,
28:10
is it possible the patient has CRN sinus thrombosis?
28:13
So we ended up doing a CT angio, uh, CT angiogram
28:18
or should, should say a CT venogram.
28:20
And what we see here is opacification
28:22
of both internal carotid arteries and the basal artery.
28:25
But notice how there was no opacification of all
28:28
of the cavernous sinus.
28:29
So this in fact was a case of ca sinus thrombosis
28:32
that we were able to pick up earlier
28:35
and this patient actually did pretty well.
28:36
So the point is that when you get down to that area
28:39
of the cabinet, uh, the sphenoid sinus look real closely.
28:43
And this is just one of these cases
28:44
that still kind of haunts me.
28:46
This was about 15 years ago.
28:48
This was a, a child of an 11-year-old
28:50
that was imaged at night,
28:52
had a regular non-contrast head ct, a child that came in
28:56
with headaches and this was essentially read as normal.
28:59
Now when you be, look back on the retrospective scope,
29:02
there was probably a little bit of dilatation
29:04
of the anterior temporal horns
29:06
and there was opacification of the sphenoid sinus.
29:09
Well, it was read out by the res in the middle
29:11
of the night is essentially normal
29:12
because you know, that's the way it was read.
29:15
And unfortunately 11 hours later the patient died.
29:18
And when you go back
29:19
and look at it, yeah the temporal
29:21
horns were a little enlarged.
29:22
And when I, when we look at this
29:24
and we see this disease involving the sphenoid sinus,
29:27
you know, I have to wonder,
29:28
is it possible this patient had an acute sphenoid sinusitis
29:32
that ended up developing CRNs sinus thrombosis?
29:34
So I don't know about this for sure,
29:37
it's all con congest conjecture,
29:39
but you see these cases in your journey
29:42
and you put everything together
29:43
and you have different experiences.
29:45
But this was just one of those things you have to wonder,
29:48
you know, in the middle of the night you
29:49
see this and you see this.
29:51
Did we as radiologists have been more vigilant about more
29:54
aggressive and getting further imaging studies like an MR
29:57
or a contrast enhanced mr or contrast enhanced ct?
30:01
It's just hard to say, but again, my point is
30:03
that when you see this disease, you know,
30:05
please just don't dismiss it,
30:06
especially in symptomatic patients.
30:09
Well here's an example of a patient
30:11
that has complete opacification of the right sphenoid sinus.
30:14
Now are you gonna call this just sphenoid
30:17
disease mucosal thickening?
30:19
Are you gonna call it sphenoid sinusitis?
30:21
Well, don't call it sphenoid sinusitis
30:22
'cause it's a clinical diagnosis,
30:24
but what I do want you to appreciate is notice
30:27
how this lateral wall of the sphenoid sinus is thin
30:30
and dehiscence compared to the left side.
30:32
So look at the left side and look at the right side.
30:34
Now when you see this dehiscence
30:36
and you have to start thinking about other things,
30:38
and in fact in this case what this turned out to be
30:42
was actually A CSF leak.
30:44
So this patient has a CSF leak right here
30:46
with the S dehiscence
30:47
and this was all flu CSF fluid extending
30:51
into the sphenoid sinus.
30:52
And when we did our CT myelogram,
30:55
what we see here is this contrast material cti,
30:58
CT cisterna gram I should say.
31:00
What we see here is the intrathecal contrast extending into
31:03
the sphenoid sinus.
31:05
So not only do we have to consider infectious processes,
31:08
but when you see this dehiscence right here in the back
31:11
of your mind, you have to say,
31:13
is it possible it may not be just due to polyps?
31:16
Is it possible it could be due to a CSF leak?
31:19
Another example, here we have complete opacification
31:22
of the sphenoid sinus.
31:24
Are you just gonna call it sphenoid disease? No.
31:26
Now we're all experts. Take a real close look at that bone,
31:30
see that that bones dehiscence.
31:32
When you see something like that, you always have to wonder,
31:35
is it something inside going out
31:36
or is it something outside coming in?
31:39
And in this case, what this happens
31:41
to be is a lateral skull-based cephalic seal.
31:44
So we can have cephaloceles that can involve the floor,
31:47
the middle cranial fossa,
31:48
but these as you know, can also involve the sphenoid sinus.
31:53
And this is due to a little felt to be due
31:56
to a natural defect in the lateral wall
31:58
of the sphenoid sinus called sternberg's canal,
32:01
which is also known as a lateral cranial pharyngeal canal.
32:04
So this is it on a 3D imaging.
32:06
Again, it's important to point this out,
32:08
but what you don't wanna do as well is just call it polyps.
32:11
Because lo and behold, if the surgeon goes in there
32:14
and tries to do a, uh, does a sphenoid autotomy
32:17
and tries to resect this, all
32:18
of a sudden they're gonna be yanking on brain
32:20
tissue and you don't want that.
32:22
So the bottom line is when you are looking at sphenoid
32:24
sinus, take a really, really close look at the bone
32:27
because you don't wanna miss encephalocele.
32:31
So let's now move on
32:32
and talk about quote unquote maxillary sinusitis.
32:36
So as I said before, this is probably the most common thing
32:39
that you'll encounter in your practice.
32:41
And what we see here is an air fluid level
32:44
and frothy secretion.
32:45
So again, I wouldn't call this sinusitis.
32:48
What I would say is there's an air fluid level associated
32:51
with frothy secretions, which can be correlated
32:54
with clinical findings of acute maxillary sinusitis.
32:57
That's my dictation.
32:59
Now in this case, we have complete opacification
33:02
of the right maxillary sinus
33:04
and on the left one we'll say,
33:05
well there's trace mucosal thickening,
33:08
maybe a little air fluid level.
33:10
But again, as I mentioned
33:11
before, sometimes based on the windows that you're given
33:14
by the text, sometimes we can under call the degree
33:18
and involvement of the maxillary sinus.
33:20
And when we open up to the wide windows,
33:22
what we see here are frothy secretions completely replacing
33:26
the left maxillary sinus.
33:28
So when we first think that there's predominant involvement
33:30
of the right, we actually see there's a fair amount
33:33
of involvement in the left.
33:34
But again, this is due to a different type
33:37
of inflammatory process.
33:39
This is more frothy secretions as opposed
33:41
to the polypoid mucosal
33:43
thickening that we're used to seeing.
33:46
Now here's an example of a patient that comes in
33:49
and you look at the sinuses
33:50
and they actually look pretty good
33:53
and you're about to call it normal.
33:55
Now, one thing that I will always try to look at, I
33:59
I do my best, is that if the patient is immunocompromised,
34:04
so if they have diabetes, uncontrolled diabetes,
34:07
if they have some type of um, uh, I
34:11
frank immunocompromised,
34:13
so let's say they have had a renal transplant
34:15
or kidney transplant or even now I'm seeing more
34:18
and more of this, you have a lot of patients
34:21
that are on immunosuppressive therapies, sort
34:23
of a low level immunosuppression.
34:25
What I always try to do is look real closely here at the
34:29
retro antral fat.
34:31
So when I look at the right side here,
34:33
what I see is soft tissue thickening involving the retro
34:35
antral fat on the right compared to the left.
34:38
And if you see this, this is the early signs
34:41
of acute invasive fungal sinusitis.
34:43
And the most common areas
34:45
that you'll end up seeing this are right
34:46
behind the maxillary sinus and the retro antral fat.
34:50
Or sometimes we'll see it right here in the perianal fat in
34:54
what we sometimes call the canine fossa.
34:56
So if I see this fat obliterated here
34:59
or this fat obl fat obliterated here, especially in patients
35:03
that are immunocompromised, then I'll raise the possibility
35:06
of invasive fungal sinusitis.
35:08
And this really is the right time to do it
35:10
because if you can catch it here,
35:12
you can make a big difference
35:14
because if this is untreated, then these patients can go on
35:18
to develop complete erosion of the maxillary sinus.
35:21
So here's another example of invasive fungal sinusitis
35:24
and this case much more extensive.
35:26
Now it's completely eroded the anterior posterior
35:29
and medial wall of the maxillary sinus.
35:31
And look here, this was a different patient.
35:34
And what we have here is notice the fat right here in the
35:38
inferior portion of the tego palatine fossa is
35:41
completely involved right now.
35:43
So this is all invasive fungal sinusitis extending into the
35:47
tegal palatine fossa.
35:48
These patients now have frozen eyes
35:51
because there's orbital involvement.
35:52
And quite frankly, it's really hard to cure these patients
35:56
if the aggressive fungal therapy doesn't work.
35:59
I've seen several patients have
36:00
to undergo orbital exenteration.
36:03
So my point is that once it gets to this point, number two
36:06
and number three, it's relatively obvious
36:08
to make the diagnosis.
36:09
But where we wanna do it is this stage.
36:12
'cause if you can catch it earlier,
36:14
then you can really affect the outcome of these patients.
36:18
So one of the things I always want, uh,
36:22
that I always try to do and I want you to be aware of
36:26
and again always pointed out to your surgeons, is be aware
36:28
of unilateral mucosal thickening.
36:30
So this was a patient I saw about two
36:32
and a half years ago that was being followed
36:34
for unilateral mucosal thickening.
36:37
And the surgeon thought, well it's just got some polyps,
36:39
it's probably just, uh, maybe,
36:42
maybe it's turning into a polyp
36:43
that's going from the maxillary antrum
36:45
to the nasal cavity we would call an antrum nasal polyp.
36:49
But when, when I looked at the study,
36:50
what I actually saw here was erosion of the posterior wall,
36:53
the maxillary sinus.
36:55
So remember I called up the ENT surgeon said, you know,
36:57
this isn't just not polyposis,
36:59
this is something more aggressive
37:00
and I think it needs to be biopsied.
37:02
And when we looked at the soft tissue windows, we can see
37:05
that there is a soft tissue mass that's a sort
37:07
of an increased same attenuation as the muscles.
37:10
And when they biopsy this, this turned out
37:12
to be squamous cell carcinoma.
37:14
So the bottom line is, is when you see
37:17
opacification unilateral opacification of a sinus,
37:22
I think you should always specifically mention
37:24
that in your interpretation.
37:26
And also I always recommend correlation
37:29
with direct visualization
37:30
and endoscopy is clinically indicated,
37:33
otherwise you run the risk
37:34
of missing things like squamous cell carcinoma.
37:37
So these are just some common things
37:39
that I've seen in my practices
37:41
regarding uni unilateral thickening of the max sitis.
37:44
This was an example of a an odontogenic caris.
37:48
This is just not the regular mucosal thickening.
37:51
If you have complete opacification the sinus
37:54
and we see that there is a root tooth right here.
37:57
This is a peric coronal right here.
37:59
This is an example of a entra cyst.
38:02
This was an example of mucosal thickening involving the
38:05
left maxillary sinus.
38:07
But when you look real closely,
38:09
we see the air right here involved in the superior portion.
38:12
But take a closer look.
38:13
There's actually air above the floor of the left orbit.
38:17
Now you can have air below the floor of the orbit,
38:19
but you shouldn't have air above the floor of the orbit.
38:22
And then when you look at the contrast
38:24
and hand study, what we see here is
38:27
that this same fluid attenuation is now located in the floor
38:30
of the orbit and it's superiorly displacing the
38:34
inferior rectus muscle.
38:35
So this in fact was a muco PSE with a
38:39
subperiosteal abscess.
38:42
And this was an example again, unilateral opacification.
38:45
This one's a little bit more obvious,
38:47
we can see the bone erosion,
38:48
but this was just an example of an neoblastoma.
38:51
But the bottom line is, is
38:53
that when you see this unilateral ification,
38:55
please don't dismiss it.
38:57
They specifically call that out to your ENT surgeons.
39:02
Well what about the next area that you'll see in the sinuses
39:05
that we always have to be cautious about?
39:07
And that's the nasal cavity.
39:08
So when we look in the nasal cavity,
39:10
we have the normal anatomy here of the nasal septum,
39:14
and then you have the inferior middle
39:15
and superior terminate.
39:17
And then you'll have right here your nasal septum.
39:19
Here's our unsaid process
39:20
and here's the lateral wall of the nasal cavity.
39:23
So when I am looking at the nasal cavity, the first place
39:26
where I have to always start is look for the perforation.
39:29
Now I gotta tell you, when I trained years ago,
39:33
my attendings at the time would not make a big deal about
39:37
septal perforations but kill they.
39:38
They'll say, well you know what?
39:41
The NT surgeon can look in and they can see the perforation
39:45
and it's, and it's done.
39:46
They can see that. So we should,
39:47
we don't need to comment on it.
39:49
But over a time I've realized that's not incorrect.
39:52
In fact, this was a case right here
39:54
where I didn't mention it and the surgeon called me up
39:56
and kind of got on my case
39:58
and said, you should have mentioned it's obvious.
40:00
And I said, yeah, it is obvious but you can see it.
40:02
But the bottom line is is that ever since then,
40:05
I always specifically look at that
40:07
because if you do see this,
40:09
then there is a differential diagnosis
40:11
that's associated with this.
40:13
And I can tell you, at least in the United States,
40:15
as our healthcare system evolves, a lot of these patients
40:19
that are seen right now are not necessarily seen by
40:22
rhinologists, but they're seen by general ENTs are seen
40:26
by family practitioners or seen by nurse practitioners
40:29
and they just may not have that domain expertise.
40:32
So in situations like this, if I do see something like this,
40:35
I'll mention it and realize
40:37
that septal perforations can be due to prior surgery,
40:41
but they can also be due to patients
40:42
that may be using cocaine.
40:44
They can be due to granula granulomatosis polyangiitis.
40:48
We used to call Wagner's, so on and so forth.
40:51
So if I see something like this,
40:52
I always specifically mention it.
40:54
And this was an example of a pace that we saw in clinic.
40:57
And I gotta admit, you know, when they walked in there,
41:00
I had no idea there that there was this degree of erosion,
41:04
but this was a chronic cocaine user
41:07
and they had complete erosion not only of the, of the septum
41:11
of the nasal cavity and it actually eroded the hard palate.
41:14
So if you see something like this, you know you have
41:16
to consider the possibility cocaine is cocaine
41:20
or potentially really severe GPA
41:22
or on rare occasions sarcoidosis.
41:25
But I think in my experience, sarcoid has been pretty rare
41:28
to give something like this.
41:30
So if you are reading out your sinus ct, we can see here,
41:33
uh, well aerated perinasal sinuses,
41:36
when we look at the nasal cavity,
41:38
what we see here is a normal right inferior terminate,
41:40
but look at the left inferior terminates diffusely enlarged
41:44
and it's actually bowing the lateral wall
41:47
of the nasal cavity, which is also the media wall
41:49
of the maxillary sinus
41:50
and just happened to be a melanoma
41:54
involving the nasal cavity.
41:56
So if you see something like this,
41:57
again specifically mentioned to correlate
42:00
with direct visualization,
42:02
and this is an example of a patient
42:04
that has dis no disease involving the sinuses.
42:07
Is there a little disease right here?
42:09
Now that's not disease that happens
42:12
to be squamous cell carcinoma.
42:13
So we know the most common tumor to involve the head
42:16
and neck is gonna be squamous cell carcinoma.
42:18
But remember the proximity of the sinuses to the skin.
42:22
Occasionally you can have skin cancers that extend deeply
42:25
and these skin cancers tend to be squamous cell carcinoma,
42:29
basal cell carcinoma
42:30
or Merkel cell carcinoma if especially if you're living in
42:35
an area with a lot of sun.
42:36
So when you are looking at your sinuses,
42:39
cts again take a close look at the bone
42:41
and also look at the adjacent cell tissues.
42:44
And this was an example of a patient again,
42:47
we saw in clinic when he came in, his nose was kind
42:50
of drooping and this is what's referred to
42:53
as a perpe deformity.
42:55
So what happens here is
42:56
that this was a large squamous cell carcinoma,
42:59
it actually eroded the nasal septum
43:01
so there's no nasal septum.
43:03
And instead what ends up happening, the nasal septum tends
43:06
to buttress the nasal cavity.
43:08
So it's going more straight.
43:10
But in this case, because the septum was gone, this nasal,
43:14
all this nose right here basically starts to droop
43:17
and this is what we call a parit peak deformity.
43:19
And on a bad day you can miss something like this.
43:22
It's possible you could miss this little soft tissue.
43:25
In fact, when the initial CT scan was read
43:27
of the sinuses, they never mentioned that.
43:29
So this actually was a squamous cell carcinoma
43:32
that was involving the maxilla
43:35
and the anterior soft tissues that wasn't developed
43:38
and that's why this patient came in with
43:39
that paired beat deformity.
43:41
So when you're looking at the nasal cavity like this,
43:44
sorry about that, lemme take some more water
43:48
or diet coke that is here we have complete opacification
43:52
of the right nasal cavity.
43:54
So you're gonna look at this,
43:55
you're say is there polyposis here?
43:57
But remember what lies at the superior aspect
44:00
of the nasal cavity?
44:01
Well, it's the anterior skull base.
44:03
So one thing I always try
44:05
to do is if I see something like this,
44:07
always extend my eye superiorly.
44:09
And when I do, I want to look at the anterior cranial fossa.
44:13
And the normal anatomy should be the fovea ethmoidal,
44:16
the lateral lamella and the cribriform plate.
44:19
Well in this case what we see here is complete erosion
44:22
of the cribriform plate
44:24
and enlargement of this half of the anterior skull base.
44:27
And this is in fact the classical
44:29
appearance of encephalocele.
44:31
So when you are looking at your nasal C
44:33
and you think you see a bunch of polyps,
44:35
make sure you take a close look at the anterior skull base
44:38
if, because if you don't, you run the risk
44:40
of missing celu seals.
44:42
And celu seals can have various appearances to it.
44:45
And this is an example of a cephas seal right here
44:48
we can see the fovea ethmoidal is gone.
44:51
In this case the cribriform plate is intact.
44:54
This is predominantly involving the fovea ethmoidal.
44:57
And we can see here the brain context extending inferiorly.
45:01
Another example here, this one, the fovea ethmoid is intact,
45:05
but this is extending right through the cribriform plate,
45:08
through the olfactory sulcus.
45:09
And when we look at the T two weighted images,
45:12
boy it sure looks like a polyp on mr.
45:14
But on the other hand, when we look at the CT scan,
45:17
we can see that bony defect.
45:18
And this was a cephas elic setting into the nasal cavity.
45:22
Now in kids just realized
45:24
before the age of two years old,
45:26
you're not gonna have ossification of the cribriform plate.
45:30
So if you are performing sinus cts, remember
45:32
that plate's not gonna be ossified.
45:35
So if you do see something like this
45:37
that's located the superior nasal cavity, again, you have
45:40
to have a very high suspicion of cephas seal
45:43
because you cannot count on the absence
45:46
of the normal bony anatomy.
45:48
So if you see something like this involving polypoid mucosal
45:51
thickening involving the roof of the nasal cavity,
45:54
even though the the the bone, you know it's not ossified,
45:58
consider the possibility of a cephas seal.
46:00
And this again, same patient
46:03
demonstrates a cephas seal extending
46:05
through the cribriform plate involving the nasal cavities.
46:08
So just realize you can have many faces
46:11
and many types of radiographic findings
46:15
for these cephaloceles.
46:17
Well, when you're looking at the nas, excuse me,
46:20
the perinasal sinuses, we always have
46:22
to look at the oral cavity
46:23
because one of the most under called abnormalities
46:27
that involve, that can result in
46:30
sinusitis is an odontogenic origin.
46:33
So in general, when we think
46:35
of disease involving the perinasal sinuses, we think
46:37
of these polyps that kind of arise
46:40
because there's lack of normal pulsations
46:44
or movement of the CLIA that kind
46:46
of push stuff into the primary osteo.
46:49
So part of it is due to some type of malfunction
46:51
of the clia, such as in patients
46:53
with cystic fibrosis, et cetera.
46:55
But realize a certain percentage of this disease is going
46:59
to be odontogenic in origin.
47:02
So the reason why that's important is
47:04
because if you have run
47:06
of the mill disease involving the sinuses,
47:08
this can be treated with IV antibiotics.
47:11
But if you have sinus disease that's due
47:13
to odontogenic origin,
47:15
all the antibiotics in the world is not gonna cure it.
47:19
What's gonna cure it is removing the rotten tooth.
47:22
And what we see here is a peri apical cyst.
47:25
And if you look real closely, this is the alveolar recess
47:28
of the maxillary sinus.
47:30
And here we see a bony defect right here.
47:33
So this is due to a peri apical abscess
47:36
that has eroded the uh, apex of the alveo recess
47:40
and extend into the sinus.
47:41
So the best way to treat this is to actually remove
47:44
that tooth and if you remove the tooth
47:47
and that sinus disease is gonna go away,
47:49
and again, you may be missing this, so you have
47:51
to be real careful to point that out.
47:54
In this case, this is the next level.
47:56
What we have here is erosion of the left alveo recess,
48:00
but notice how it's contiguous
48:02
and eroded all the way
48:04
through the alveo ridge of the maxilla.
48:07
So this is what we refer to as an oral antral fistula.
48:11
So in this case they can do all the antibiotics in the world
48:14
they want to, but what they have to do is repair
48:17
that direct communication between the oral cavity
48:20
and the sinuses because if they don't repair that,
48:23
this is still gonna be pathway
48:26
of oral germs or bacteria to extend into the sinus.
48:30
So this is an oral antral fistula
48:32
and again, you specifically have to look for this,
48:35
otherwise you run the risk of missing it.
48:37
And in this case, this was an example of a patient
48:39
that presented with multiple skin infections.
48:42
And what we see here is that the reason
48:44
for the skin infections
48:46
and also the disease here involving the left alveo recess is
48:50
again due to a peri apical infection.
48:52
So here we see the little peri apical abscess,
48:55
the skin disease and we see the disease involving
48:59
the alveo recess of the maxillary sinus.
49:01
So when you do have these little sinus disease, please,
49:04
please, please take a close look
49:06
to determine whether it's odontogenic in origin.
49:10
These are some other things that you can see.
49:14
I was in ENT clinic yesterday.
49:16
We had a patient come in with these bilateral exostosis.
49:19
So these are like exostosis, they sort
49:21
of look like the little rams horns almost.
49:23
They look like devil's ears if you will.
49:25
This is an example of a patient that has bilateral osteos
49:29
and this was a patient with Gartner syndrome
49:31
and this looks completely normal, right?
49:33
But when you look real closely,
49:34
we see erosion right here involving the floor
49:37
of the nasal cavity, which also doubles as the hard palate.
49:42
So if I see something like this, I always mention it
49:45
and suggest they correlate clinically
49:47
because this patient actually had a squamous cell
49:49
carcinoma of the heart palate.
49:51
And this is another example.
49:53
This disease was not necessarily due
49:55
to polypoid mucosal thickening,
49:57
but this was due to adenoid cystic carcinoma
49:59
of the hard palate.
50:01
So when you look at this, your eye is gonna go to here,
50:03
but remember to look at all the components
50:05
of the oral cavity
50:07
and this happened to be an adenoid cystic carcinoma.
50:11
Well, we always wanna look intracranial as well.
50:13
It's a common pathology.
50:15
I remember when I was a fellow, one
50:17
of our techs ended up having a CT at night
50:20
and they ended up having a meningioma in their brain picked
50:23
up on a sinus ct.
50:25
Again, it's one of these things that I always remember.
50:27
So I always wanna look at the brain specifically.
50:30
This was a patient with ventricular magaly.
50:33
This was another patient I saw about two years ago.
50:36
It's kind of hard to see,
50:37
but you can actually look at these low attenuation little
50:41
subdural collections.
50:42
And when we did an MR on this,
50:44
turns out this patient had bilateral chronic subdural
50:47
hematomas and this was a patient that had trauma.
50:50
If you look real closely,
50:51
we can see a little defect right here.
50:53
And this was acute sub subdural, uh, hemorrhages
50:56
that were due from the trauma.
50:59
This was a patient that had diffuse enlargement of the cell.
51:02
You probably see this and more aware of it on a brain mr,
51:06
but you'll also see it on a CT
51:08
because this patient has diffuse enlargement of the cell.
51:11
And this was due to idiopathic
51:13
intracranial hyper protection.
51:15
And as I mentioned before, I pointed out
51:17
to look at the carotid artery.
51:19
Well, if you look at that carotid artery
51:21
and you see diffuse enlargement right here of
51:24
that bony covering of the carotid artery
51:26
and extends into the sphenoid sinus,
51:29
I think it's definitely worth following this up
51:31
and getting a CT angiogram.
51:33
And in this case, this was due to a large intercranial, uh,
51:36
yeah, I should say a carotid artery aneurysm
51:39
that extended into the sphenoid sinus.
51:43
We can have other disease that's involving the orbits.
51:46
Remember to look at the orbits.
51:47
This was a case of thyroid pathy.
51:50
This was a patient that had sinus disease involving the
51:53
superior portion of the nasal cavity.
51:55
But if you look real closely, this disease extends laterally
51:58
to involve the globe.
51:59
And this was an example of a mucus seal.
52:02
This patient has disease right here involving the
52:05
right ethmoid air cell.
52:07
But remember right here is the lamina capricia
52:09
and these vessels can traverse the lamina caption extend
52:13
into the medial aspect of the orbit.
52:15
And this patient ended up having a subperiosteal abscess.
52:19
So when you are looking here at the sinuses,
52:21
take a really close look at the orbit
52:23
because this was a case I saw years ago when I was at UNC.
52:28
Friday afternoon. I'm looking at the sinus CT
52:31
and I see this air right here.
52:32
And I said, well, I can see air in the spleen, weight sinus,
52:35
but I shouldn't see in the orbit.
52:36
And when we look at the Corona, lo
52:38
and behold, this patient had sinus disease,
52:41
had a prior orbital blowout fracture
52:44
and actually presented with an intra orbital abscess.
52:47
So when you are looking at these things, again, look
52:49
for these unusual collections of air,
52:52
air wear and should be.
52:53
And in this case it turned out
52:54
to be an intra orbital abscess.
52:57
Now one thing I will point out is that I do see a lot
53:00
of people doing cone beam cts.
53:02
I wanna make you aware that cone beam cts,
53:04
they're getting better and better,
53:06
but please use them in the proper clinical indications.
53:09
This was a patient that initially underwent a cone beam CT
53:13
that was read as disease involving the left maxillary sinus.
53:17
And but when you look at this,
53:18
when you look at the soft tissues,
53:20
there's too much soft tissue thickening right here.
53:22
And then when we look a little bit more anteriorly, notice
53:25
how V two is enlarged compared to the right.
53:29
So what this was is that this patient actually had a history
53:32
of adenoid cystic uh, carcinoma
53:36
and had recurrent sinus disease.
53:38
And the disease was not necessarily due
53:40
to the sinus disease,
53:42
but rather the pain was due to perineural spread
53:45
and recurrent disease extending along V two.
53:48
So the point is that if you are doing cone beam cts,
53:51
that's fine, but I do wanna make you aware that,
53:54
make sure you're doing the proper indication.
53:56
I personally don't think that you should be doing cone beam
53:59
cts in patients that have been treated with a prior history
54:03
of either squamous cell carcinoma
54:05
or a malignant minus sal salivary gland tumor,
54:08
because you do run the risk of,
54:10
of missing soft tissue abnormalities involving in the orbit
54:13
and also possibly perineural spread.
54:17
Well, we can also have other pathology involved in the
54:19
temporal bone and the skull base.
54:23
So when you're looking at something like this, remember
54:25
to look at the mastoid air cell
54:27
because in this case,
54:28
this unilateral mucosal thickening was caused
54:31
by nasopharyngeal carcinoma.
54:33
Remember, the eustachian tube runs from the nasal
54:35
pharynx in the mastoid air cell.
54:37
So this was caused in that unilateral mucosal thickening.
54:40
So if it is included on those images,
54:42
you need to look at it.
54:43
Another example here, this is a case that I saw.
54:46
I almost blew past this.
54:48
I'm looking here involving the maxillary sinus,
54:50
and I saw this stuff right here.
54:52
So I'm sort of doing my assessment.
54:54
I'm like, what the heck's going on here?
54:56
Well, it turns out this was all mucosal thickening involved
54:58
in the mastoid air cell.
55:00
And then I thought, that's kind of weird.
55:02
And then here's a normal petro clival fissure on the left.
55:05
And lo and behold, there's erosion here.
55:08
And it turns out when I called up the referring physician,
55:11
the patient had pain, they were diabetic.
55:14
And it turns out that this was all skull base osteomyelitis
55:17
that presented as bone erosion.
55:19
And the initial study that was performed was
55:22
actually a sinus ct.
55:23
So we always have to look for that type of deep infection.
55:27
Sometimes patients will end up getting
55:30
sinus cts for otalgia.
55:31
Very, very common. So look at the temporal bone
55:34
to make sure they don't have arthropathy.
55:36
This was a patient that ended up having a meningioma
55:39
involving the skull base.
55:41
This was an unusual case.
55:42
This was a cholesteatoma that was seen in the temporal bone.
55:45
And this was a case I completely missed.
55:48
I read this case as basically normal on a sinus ct.
55:52
And then one of my colleagues called me back
55:53
and said, Hey, you may wanna look at the temporal bone
55:55
because the patient has an EAC atresia.
55:58
So I totally miss this.
55:59
So ever since then, that's why I have so much vigilance
56:03
to try to look at the temporal bone.
56:05
'cause these things, it may not make a difference
56:07
clinically, they can see it,
56:09
but on the other hand, if you do mention it, it does
56:11
increase your credulity.
56:13
And then we also have to look at everything else.
56:16
Remember, when you're looking at your sinus studies,
56:18
make sure you look at the visceral space.
56:20
This was a patient that had an incidental
56:22
nasopharyngeal carcinoma.
56:24
This was a patient. When we look at the maxillary sinus
56:26
right here, we can see diffuse, uh, enlargement
56:29
of the right, uh, ramus of the mandible.
56:32
This was in the masticator space.
56:34
And this was an incidental neoblastoma.
56:36
This was a patient that had a mass involving the
56:39
para pharyngeal space.
56:40
This patient had a sinus ct.
56:42
And when we looked at this, you can see with a leap
56:45
of faith, there's loss
56:46
of the normal tiger stripes on the
56:48
right compared to the left.
56:49
And this happened to be a buccal space lesion.
56:52
This turned out to be a minor salivary gland lesion.
56:54
And in this case, you can look at the sinuses here,
56:57
but on the other hand, look at the parid gland.
56:59
We see all of these little calcifications.
57:02
And this patient had, uh, sjogren's disease
57:04
with multiple inter parotid salis.
57:08
So the challenge that we run into in sinus cts is, look,
57:12
this is it's low hanging fruit.
57:14
But I do want to emphasize is
57:16
that we do sinus cts all the time
57:20
and they're relatively straightforward to read.
57:22
But I do wanna at least mention to you some of the things
57:25
that we could overlook
57:26
because medical legally, we are responsible
57:29
for interpreting all the images on the studies.
57:32
So at the very least, I wanted to give you some type
57:35
approach when you're looking at the sinuses.
57:37
So yes, this is low hanging fruit.
57:40
I I also want to make you aware
57:41
of the potential al uh, alligators.
57:44
And finally, I want to thank you for attending.
57:46
I'm sorry about my voice. I'm a I'm about to lose,
57:48
it's becoming hoarse.
57:50
But I do wanna point out our, um,
57:53
head and neck remote fellowship.
57:54
In fact, it's starting, we had our, uh, our call today
57:58
for the introduction, but we did extend the deadline
58:00
'cause we knew that we were giving this talk today.
58:03
So if you are willing
58:04
or interested in to participate in our 10 week head
58:07
and neck radiology fellowship, we'd love to have you.
58:10
We have a few more slots open.
58:11
You know, please go ahead and scan this in or talk to Ashley
58:14
or the medal team and would love to have you.
58:17
So again, thank you very much for your attention.
58:19
Sorry about my voice. I'm doing the best I can.
58:22
Um, I'm happy to answer any questions.
58:24
That'll gimme a chance to drink some folk or whatever.
58:27
And uh, Ashley, I'll turn over to you.
58:29
So thank you very much for your attention.
58:31
For sure. Yeah. Thank you so much for
58:33
that awesome lecture, Dr.
58:34
McCury. Um, at this time we will open
58:36
the floor for questions.
58:38
If you've got them, please go ahead
58:39
and put them in that q and a box.
58:43
It helps us sort through them a little quicker. Uh, Dr.
58:47
McCury, I'm not sure if you could open it.
58:49
I can get us started by reading the first one
58:51
and then if you wanna Sure.
58:53
Are are we doing the chat
58:54
or see, I just drank something feels better.
58:56
Are we doing the chat or are we doing the q and a?
58:58
Where's the QI don't see the
58:59
QAQ and a. Yeah, right now.
59:00
It might be at the top
59:01
of your screen since you're sharing.
59:03
It's a Q and a bubble.
59:06
Okay. Let you want me to escape then?
59:08
Sure. Um, you tell me what you want me to do.
59:13
Uh, you, you wanna read it out to me
59:16
and I'll try to find my little box here?
59:17
Yeah, yeah. I'll read the first one. I Okay. First one is
59:20
When I got it.
59:22
I got it. Okay. You got it. All right.
59:23
I found it was on the right side. Yeah. Okay.
59:28
Um, go ahead. You want me
59:31
to start from the top or, uh, at the bottom?
59:33
That works. Yep. Okay, great. Okay.
59:35
Um, the first question we had was, when's it gonna start?
59:39
So it's started, it's done. So thank you very much.
59:43
Um, the next thing is,
59:44
will AI replace sinus CT for interpretation?
59:50
And, um, no, I, let me put it this way.
59:53
And, you know, I spend a lot of time in ai.
59:55
I consult with a few AI companies.
59:57
That's one of my areas of interest.
59:59
Um, I don't believe AI will ever replace
60:02
sinus CT interpretation.
60:04
Um, it may get to the point
60:05
where it can help us identify normal versus abnormal
60:08
or may help us screen,
60:10
but I don't think it's ever gonna replace sinus ct.
60:13
Like a lot of ai.
60:15
Um, like I, I give five or six AI talks every year.
60:18
Um, like a lot of artificial intelligence.
60:21
I think it's gonna make us more efficient.
60:23
So it may be helpful for a triage approach,
60:26
but I don't think it's ever going to, um, replace, um, AI,
60:31
or excuse me, I don't think ever AI is ever gonna, uh,
60:34
replace us for CT interpretations.
60:37
Um, so the next one is, uh,
60:40
thank you for your kind comments.
60:42
Um, do you have any experience using zero TEMR
60:45
as a replacement for evaluating the sinuses?
60:48
So, that's a great question.
60:49
Um, I know zero T has, um,
60:53
zero T has been used in several places
60:55
because it's a pretty good surrogate for the bone.
60:59
Um, I personally don't have any experience,
61:01
but what I will say, um,
61:03
and this is from Murray, um,
61:05
what I will say is sometimes what's new, what's,
61:09
what's old is new and what's new is old.
61:11
So back in the late 1990s, we,
61:15
there was a lot of people including myself,
61:18
that were starting to do screening help,
61:22
T two weighted mrs, to look for the sinuses.
61:25
And I think that was beneficial to some extent.
61:29
And, uh, but it never really caught on for various reasons.
61:32
First of all, the surgeons like to look at the bone
61:34
when they actually do their, um, endoscopic sinus surgeries.
61:38
And then also the cost is more, it costs a lot more
61:41
to get an MR than a ct.
61:43
So now when I saw the zero te mrs coming back,
61:46
and I've heard this question several times lately, um,
61:49
I think the bone is really helpful.
61:52
But yes, we may be able to use as a screening school,
61:55
but realize a lot of times that we do our sinus ct, it's,
61:58
it's being part of some type of image guidance.
62:02
So I think there could be a potential role in selective
62:06
areas, but I don't think it's ever gonna replace,
62:08
um, sinus cts.
62:10
And also, again, if we're gonna use it as a screening tool,
62:13
at least in the United States
62:14
or we have to pay for our healthcare, it is much cheaper
62:17
to get a sinus ct, then it will be to get, uh, an mr.
62:22
Um, so the next one is, uh, great question.
62:26
What imaging would you recommend if you see
62:29
concerning sphenoid sinus disease on a non-contrast ct?
62:33
Um, I would, um, um, fair enough.
62:37
He said, I would call it soft tissue density
62:39
rather than opacification.
62:40
I think that's fair. I use the term
62:42
polypoid, mucosal thickening.
62:43
That's what I always, that's what I always use.
62:45
That's my terminology. Um, if I saw something there,
62:48
then if I saw something on a, on a non-contrast sinus ct
62:52
and I was, especially with an air fluid level, I always
62:57
recommend consideration of a dedicated pre
63:00
and post contrast skull base, Mr.
63:03
So I don't think a brain MR is necessarily
63:05
completely sufficient.
63:07
Um, at our shop we have, uh, dedicated protocols
63:11
to specifically look at the region around the sphenoid sinus
63:15
and specifically look for that meningeal enhancement.
63:18
'cause sometimes you could miss that on a regular brain. Mr.
63:23
Um, can I make a book available for us?
63:26
Um, I don't have a book
63:29
that I've written on the sphenoid sinus.
63:31
Uh, my suggestion to that,
63:32
and granted I'm biased, is to, uh, come join our fellowship
63:37
and use modality and, and go to modality.
63:40
'cause I know, uh, Dave Uson did a fabulous job on the,
63:44
um, sinuses.
63:46
I think he wrote the module, I think he did the, um,
63:48
individual, uh, um, uh, uh, the, the courses on the modules,
63:53
uh, for sinus ct.
63:54
So that's what I would recommend.
63:57
Um, the next one is I would like
63:59
to ask about silent sinus syndrome.
64:01
Do the orbit apathy
64:02
and sinus volume decreasing
64:04
to report the suspicion in cor correlate clinically fes it's
64:08
obligatory to visualize a sinus opacification.
64:10
Um, alright, so I'll give you my
64:14
2 cents on si silent sinus syndrome.
64:17
So the way, what silent sinus syndrome is, is
64:23
hypoplasia of the maxillary sinus
64:27
that's associated
64:28
because a sinus is small, there's less volume.
64:32
So what ends up happening is that the orbit becomes bigger
64:36
and the sinus is smaller.
64:39
So what I end up doing is that if there is a patient
64:43
that has polypoid mucosal thickening involving a a,
64:48
a maxillary sinus, the
64:53
reaction is typically gonna be I need
64:56
to treat this patient with antibiotics.
64:58
And if it gets worse
64:59
or doesn't go away, then I need
65:01
to perform functional endoscopic sinus surgery.
65:03
In general, that's a thought process of the rhinologist.
65:07
So if I see something there's opacification,
65:11
I specifically mention if the sinus is small,
65:15
and I would say that this could be due
65:17
to silent sinus syndrome
65:18
because the importance is, is that the ciliary function
65:23
of the silent sinus is abnormal.
65:26
You don't have the normal motility.
65:28
So the surgeons can perform the functional endoscopic sinus
65:32
surgery on the involved sinuses, but
65:34
because of the dysfunction of the cilia,
65:37
that sinus in general is never gonna get cleared up.
65:40
I mean, they may be able to remove a co couple polyps,
65:43
but in general that sinus is always gonna be diseased.
65:47
So once I mention it that it's silent sinus,
65:50
at least the surgeons are, is aware of it, then it's up
65:53
to them to determine whether they wanna proceed with this.
65:59
Um, let's see.
66:03
Yeah, the next one is really interesting.
66:05
Um, the thanks for the wonderful talk. Thank you.
66:09
Whoever the honest person was, I appreciate that.
66:12
Should we mention normal variance in our report?
66:15
That's a great question.
66:17
So when, and I'll just give you my approach.
66:21
So when, when I first started doing this,
66:26
we would sort of do sinus cts in a sort
66:29
of a haphazard manner.
66:30
And then what ended up happening is that
66:33
functional endoscopic sinus surgery was introduced
66:36
and then all of a sudden we started
66:38
to standardize our approach for sinus cts.
66:42
And once we did this,
66:43
we started talking about the osteomeatal unit,
66:46
the osteomeatal complex, so on and so forth.
66:48
And then we started to realize there are a tremendous number
66:52
of variants that we can see in the sinuses.
66:56
And the next thing I knew,
66:57
the reports were getting really large
66:59
because we were mentioning every single variant
67:01
and every person had at least one
67:03
or two variants that we would mention this.
67:05
And then Peter Som wrote an article in 2009
67:09
and basically said, no, you don't need
67:11
to mention the variants.
67:13
And that made me really happy.
67:15
So from my standpoint, I tend not to mention every variant
67:20
what I do, what what I do mention is the following is
67:24
that I will mention if there's an enlarged con,
67:29
especially if there's unilateral
67:32
mucosal thickening involving the perinasal sinuses.
67:35
So if you have a large conal on the left
67:39
and it's pushing up against the osteo natal unit
67:42
and the left maxillary sinus
67:44
and the left frontal sinus are involved with disease,
67:47
then I will mention that
67:48
because then the surgeon has to take off the conal.
67:52
I always mention septal deviations and septal perforations
67:57
and nasal spurs.
67:58
I always mention those, um, specific things
68:01
because sometimes patients will present with headaches
68:04
and sometimes the headaches are gonna be due to a nasal spur
68:08
that abuts the lateral wall of the sinus.
68:11
And you can get something called looter's neuralgia.
68:14
And some people believe in
68:16
that if they remove the nasal spur
68:18
or some of those patients will get treated
68:19
with a nerve block that kind of pushes the otologist to, um,
68:24
excuse me, that kind of pushes the pain doctor
68:26
to to, to do those.
68:28
People always ask about the carros classification.
68:30
Do I include carros classifications?
68:33
I include cla caro's classifications.
68:36
Now if I feel that there's a lot of mucosal thickening
68:40
and the patients are undergoing to go fest, if
68:43
otherwise it's basically a normal study, I tend not
68:45
to mention caro's classification,
68:47
but I do mention if I think the patient
68:49
has substantial disease.
68:50
So that's sort of my approach.
68:53
Um, so that's my sort of my approach to, um,
68:58
um, uh, the normal variance.
69:03
Okay. So the next case is, is there any way
69:05
to differentiate infective and allergic sinusitis?
69:08
So the question I would say here is, um,
69:14
I have to know more information about what you mean
69:16
by allergic sinusitis.
69:18
So when I think of sinusitis,
69:20
in fact I have a completely separate talk on this
69:22
and that's why I didn't talk about in this, this was more
69:25
of, you know, how
69:26
to case stay outta keep stay away from the alligators.
69:28
But I have a completely 45 minute talk on,
69:31
on sinus infectious and inflammatory processes.
69:34
So the bottom line is the following is that when I look at
69:39
sinusitis disease, you can have, um, diseases
69:43
that are due to bacterial infections,
69:45
but you also have a variety of fungal infections.
69:49
And one of the types
69:50
of fungal infections is allergic sinusitis,
69:53
and it's that sort of hay fever.
69:56
So if the question is referring to allergic sinusitis due
69:59
to some type of hay fever
70:02
that's just a regular mucosal thickening
70:04
or the air fluid levels, we see,
70:05
there's no way to separate that.
70:08
But on the other hand, if you're talking about allergic
70:11
fungal sinusitis, yes there is a way
70:14
because allergic fungal sinusitis involves typical
70:18
multiple perinasal sinuses.
70:20
They oftentimes expand the sinuses
70:23
and they're associated with increased attenuation on the
70:25
non-contrast ct.
70:27
So if you have expansion of the sinuses,
70:30
some bone demineralization
70:32
and there's diffuse increased attenuation on the
70:35
non-contrast study, then that's allergic fungal sinusitis.
70:38
And if you, Ashley, if you guys ever want to have a talk on
70:41
that, I'm happy to to to talk on
70:43
that in the future as well too.
70:46
Um, can nasal decongestion cause erosions like cocaine?
70:51
You know, um, that's a good question.
70:53
I think they can, but you have to use it a lot
70:57
because the nasal de decongestion,
70:59
I believe have epinephrine.
71:01
And so like anything else,
71:02
I think if you use too many nasal decongestion
71:05
and you use too much epinephrine
71:07
and you probably overuse steroids, I think the combination
71:11
of steroids over excessive use of steroids
71:14
and over use of decongestion that contain epinephrine
71:19
directly applied, I believe that can give you, um, erosions
71:23
and eventually lead to a perforation.
71:25
It's a really good question. Um,
71:29
how can I interpret fluid intensity signals at the maxillary
71:32
sinus when I can see it at coronal T two brain?
71:38
So I'm not sure what you're asking about.
71:41
Um, I think where you're going is
71:44
that if I am doing a brain mr,
71:47
because we always go down basically to the mid portion
71:49
of the maxillary sinuses.
71:52
If I do see increased T two signal in the sinuses,
71:56
I'll go ahead and say there's scattered polypoid,
71:59
mucosal thickening involving multiple perinasal sinuses,
72:02
and I'll just leave it like that
72:03
because oftentimes you're looking
72:05
for other intracranial pathology.
72:07
But if, if I do see involvement of the sinuses,
72:10
then I'll mention at the report, um,
72:13
what I don't wanna do is recommend
72:15
or suggest a sinus CT out of the blue
72:18
because, you know, then again, I al I'm very concerned about
72:21
how much patients are gonna pay for their healthcare
72:24
and I just assume in many cases if they haven't met their
72:27
deductible, they may have to pay
72:28
for the whole darn thing in the United States.
72:30
So I'm always a little bit reluctant about being too
72:34
dogmatic about referring stuff,
72:36
so I would probably just mention it and leave it like that.
72:40
Um, do I recommend direct visualization every time I see
72:45
unilateral ification?
72:46
The answer is yes. If I see unilateral ification, um,
72:49
I will say this should be correlated
72:50
with direct visualization.
72:51
So yes, I do because just realized the earliest form
72:55
of a cy nasal malignancy is gonna be
72:57
that unilateral ification.
73:00
Um, great. Okay. We have an ENT surgeon. Oh, great.
73:04
Um, yeah, that's perfect. This is such a great question.
73:07
So thank you Attila. Um, I didn't talk about in this,
73:11
but I talk about in another talk I have on normal
73:13
anatomy and variants.
73:15
So the question is, hello, thank you
73:17
for the excellent PA presentation.
73:18
Thank you very much. As an ENT surgeon,
73:21
I also welcome comment on the f mortal artery
73:26
as potential exposure.
73:27
So Ashley, do I have enough time to bring up
73:30
a different presentation or do you guys have to go?
73:34
Sure, yeah, and we can, we can, um, do that
73:37
and then maybe take one
73:39
or two more questions and we'll wrap. Okay.
73:41
Okay, sounds good. No,
73:42
I think it's a really good question.
73:43
Um, let me just bring this up
73:45
because this is the discussion that I have with, um,
73:49
this is the discussion that I have with our sinus surgeons,
73:53
um, as opposed to what I should
73:55
and shouldn't me mention during, um, orbits, uh, uh, what I,
74:00
what I should and shouldn't mention in the routine reports.
74:03
And I'm glad this question was asked.
74:05
Um, so when I go
74:08
through this is a talk on anatomy preoperative checklist.
74:12
So what I do is I kind of take this, uh,
74:15
I take the closed approach,
74:17
but I wanted to mention, so to answer
74:20
that question in particular, it's an excellent question is
74:24
that I'll just go over the anatomy.
74:27
So here's the fovea ethmoidal, here's the lateral lamella,
74:30
and this is the groove for the anterior ethmoidal artery.
74:34
And this right here is gonna be the, uh, Krista galley
74:38
and the, and the um, cribriform plate is gonna be here.
74:42
This little groove for the ethmoid uh,
74:44
artery typically traverses the, um,
74:49
the lateral lamella, which is the wall right here,
74:53
what my surgeons have told me to include.
74:55
And I will defer to the, the, you know, the laryn,
74:58
the rhinologist for the definitive answer.
75:00
But what I do now is that if there is bone
75:04
above the canal right here for the anterior ethmoid artery,
75:08
I will say that the anterior ethmoid artery is covered,
75:12
which means that the roof
75:13
of the anterior ethmoid artery is covered by bone.
75:17
Now this on the other hand is that what we see here is
75:20
that this anterior ethmoid artery,
75:23
which extends from the medial portion of the anterior of
75:28
that extends from the orbit, it extends laterally into
75:32
the intracranial fossa.
75:33
We can see right here is that
75:35
above it there's actually pneumatized
75:39
supraorbital ethmoid air cells.
75:41
And the reason it's important to mention this
75:43
that I was told is
75:44
that if the surgeons are doing their endoscopic sinus
75:46
surgery and they,
75:48
they somehow injure the anterior ethmoid artery,
75:51
they can go ahead and clip it very easily.
75:53
But in this particular case, if they happen
75:56
to injure the anterior ethmoid artery,
75:59
that ethmoid artery can retract into the orbit
76:02
and then all of a sudden they can have an an
76:05
interorbital hemorrhage.
76:06
So from my standpoint, one of the things
76:08
that the normal variants that I do mention is
76:11
that if I am doing a sinus ct, I always specifically look
76:15
for whether that anterior ethmoid artery is covered.
76:17
And I will say in this case it's covered
76:19
and in this case it's uncovered
76:22
because there is pneumatization
76:24
of the supraorbital ethmoid air cells.
76:26
So I hope that answered your question.
76:28
Um, I think it's a terrific question.
76:32
Uh, and thanks for, thanks for bringing it up.
76:35
Boy, there's so many good questions here.
76:36
Um, you know, um, I'll just go by what the top it says, uh,
76:40
well this will be easy.
76:41
Mucus seal is mucoid. Um, can we know on ct?
76:45
So I think what they're asking for in this question,
76:48
it's a great question by Georgetta, is I think
76:52
what they're saying is the mucus seal oid,
76:54
meaning when you look at a mucus seal, the
76:58
mucus seal is almost like a balloon.
77:01
So if you have a, a sinus
77:04
and you continue to have fluid that in the sinus
77:08
and it can't drain, it gets bigger and bigger and bigger.
77:10
In fact, in my other talk it looks like a water balloon.
77:13
So a mucus seal in the acute stage is like a water balloon
77:17
because the sinus can't drain
77:19
and it just gets bigger and bigger and bigger.
77:21
If that is chronic, what ends up happening is
77:24
that the fluid tends to dry up, it becomes desiccated
77:28
and as a result the attenuation changes from fluid to more
77:33
dense to more protein.
77:36
So on CT sometimes it can be hard
77:38
to separate the fluid from the desiccated secretions.
77:41
And the only way, or I should say the best way
77:43
that I can tell is in those situations where we're not sure,
77:47
I end up getting an MR
77:49
and I look for high T one signal on mr
77:52
and on T two, sometimes the protein can give you decreased
77:56
signal, but for me the most reliable sign is the
77:58
high T one signals.
78:00
So the bottom line is acute mucus seals when they're
78:02
relatively new, will be fluid.
78:04
If it's been there for a while, it tends to desiccate
78:07
and that can be hard to pick up on a CT scan.
78:11
So what I end up doing is doing a, an MR
78:13
and specifically the non-contrast T one
78:16
'cause I find that really, really helpful
78:18
and, um, you wanna do one more real quick?
78:21
Um, let's do it. Um, let's see.
78:26
Um, you know, I think, uh, I do, uh,
78:30
let's see, let's see.
78:32
I'm trying to do a short one, uh, nasal septum overgrowth.
78:36
Bony area can be removed with surgery
78:38
and it is dangerous if overgrown.
78:40
Um, this is from Amni, I think I would really defer
78:45
to the surgeon, but I don't necessarily know it's dangerous.
78:48
But what can happen is that if you have a septal deviation
78:53
and the spur overgrows, um,
78:56
what ends up happening are a couple things.
78:58
So as you know, I see patients every Wednesday afternoon
79:01
in our tumor clinic.
79:02
So I see a lot of these clinical septal
79:04
deviations and perforations.
79:06
The challenge that you run into is that, um, number one,
79:10
the the patients can have difficulty breathing,
79:13
it could potentially lead to some type of sleep apnea.
79:16
So that needs to be removed to improve the airway flow.
79:20
The second thing is, I mentioned if the bony overgrowth is
79:23
really, really big, it can abut the lateral nasal wall.
79:26
And some people think that it could result in a headache
79:29
that we call slutter neuralgia.
79:32
And um, occasionally what can happen is
79:35
that if you really have bad sinus disease,
79:37
that nasal septum can predispose patients to polyps
79:41
because sometimes the normal secretions behind that, um,
79:46
bony overgrowth may not be able to come outta your nose.
79:50
So those are all, um, reasons why, uh, uh, it's always good
79:54
to mention, um, the little, um, uh, uh,
79:58
nasal spurs in the bony overgrowth.
80:01
Do you want me to keep going or? Um, we done?
80:04
I think we wrap. Yeah. Thank you so much Dr. McCorey.
80:08
Hmm, thank you very much. So always a pleasure.
80:12
Um, always a pleasure being here
80:13
and, um, appreciate the invitations and the support.
80:17
Also the enthusiasm.
80:18
We had over 200 people still around for the q and a.
80:21
So I, I, I appreciate, um, everyone hanging in there
80:24
and the, and the enthusiasm and interest in um, sinus cts.
80:29
Yeah, and I appreciate you sticking around
80:31
for taking extra questions.
80:33
Really appreciate it
80:34
and for everyone else, for asking such great questions,
80:38
you can access the recording in today's conference in all
80:40
of our previous noon conferences by creating a free account.
80:42
And we will also email out a link to the replay later today.
80:47
Be sure to join us on Monday,
80:48
May 19th at 12:00 PM Eastern, where Dr.
80:51
Ashwin Perra will le deliver a lecture entitled Optimizing
80:55
Cancer Care with Non F DG pet,
80:58
A focus on FDA Approved radiopharmaceuticals.
81:01
You can register for that@mriline.com
81:03
and follow us on social media for updates.
81:05
Thanks again for learning with us and have a great day.
Suresh K Mukherji, MD, FACR, MBA
Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging
© 2026 Medality. All Rights Reserved.
