IMAGING IN

OTORHINOLARYNGOLOGY

Sianny Suryawati, dr., Sp.Rad

Radiology Department
Faculty of Medicine, Wijaya Kusuma University, Surabaya
COMPUTED TOMOGRAPHY
 Presently the mainstay of imaging in ENT
 Fine bone details a inner & middle ears
 Sinuses a provides a necessary roadmap of variable
anatomy before FESS
 Hunt for the ‘unknown primary’ in patients with enlarged
lymph node in the neck
MRI
 Unsatifactory for demostrating the middle ear
 Imaging investigation of choice for inner ear lesion and their
central connection
 Superior soft tissue contrast resolution
ULTRASOUND
 Now is underuses in this age of CT and MRI
 Soft tissues of the head and neck
 Investigatin of choice for thyroid nodules, salivary glands,
and most neck lumps
 Greater detail within lymphnodes
 Familiarity with the benefits and potential pitfalls of each
modality allows referring physicians and radiologists to tailor
imaging regimens to the needs of individual patients
 PARANASAL SINUSES
 CT is the optimal radiographic study to assess the paranasal
sinuses for evidence of disease.
 the use of plain radiographs has mostly fallen by the wayside
because of its relatively low sensitivity and specificity for most
conditions.
 plain radiography is still used at times in the setting of trauma or to
assess for sinus opacification (or air-fluid levels) in the setting of
suspected sinusitis.
 CT may demonstrate mucosal thickening, sclerosis, clouding, or
air-fluid levels.
 Imaging must be performed in the coronal plane to adequately
demonstrate the ethmoid complex. It can reveal the extent of
mucosal disease in the ostiomeatal complex.
( A–D) Coronal, sagittal, and axial CT images with bone windows demonstrate
the anatomy of the paranasal sinuses, including outflow tracts.
 Anatomic Variants

Coronal CT image demonstrates a right agger Coronal CT image demonstrates bilateral

nasi cell ( black arrow) resulting in narrowing Haller cells ( arrows) narrowing the maxillary
of the right frontoethmoidal recess ( white ostia. Also noted is mucosal thickening
arrow). Left frontal sinus disease is incidentally involving the frontal sinuses and left nasal
noted. cavity.
Coronal CT image demonstrates a right
concha bullosa ( asterisk) narrowing the Coronal image with arrows pointing
right maxillary ostium /infundibulum to enlarged ethmoid bulla
encroaching on the OMU
(arrowhead). Incidentally noted is a left
maxillary sinus retention cyst or polyp
(arrow).
( A, B) Coronal and sagittal CT images demonstrate posterior ethmoid air cells that extend into
the sphenoid bone superior to the sinus; these are known as Onodi cells ( asterisks); they are in
close proximity to the optic nerve.
 Acute Sinusitis

Axial CT image demonstrates near complete Axial CT image demonstrates mucosal

opacification of the right sphenoid and bilateral
ethmoid sinuses, as well as left sphenoid sinus thickening of the anterior wall of the left
mucosal thickening. This patient presented with
complaints of headache for 1 week and fever maxillary sinus ( arrowheads) with an
associated air-fluid level, indicating acute
sinusitis.
Coronal CT image demonstrates
soft tissue density material filling
the nasal cavities and paranasal
sinuses with dehiscence of the
cribriform plates bilaterally (
arrows), consistent with an
aggressive process. This patient
was diagnosed with invasive
fungal sinusitis.
Chronic Sinusitis

Axial CT image demonstrates

opacification of the right maxillary
sinus with sclerosis and thickening
of its wall, typical of chronic
sinusitis. The left maxillary sinus
has normal wall thickness.
 Mucocele

( A) Coronal CT image demonstrates complete opacification and expansion of the right frontal sinus
(asterisk), typical of a mucocele, with dehiscence of the inferior wall of the frontal sinus and mass effect
on the orbital contents. The globe is displaced anterior to the plane of this image. ( B) Sagittal MR image
in the same patient again demonstrates a frontal sinus mucocele ( asterisk) with mass effect on the
globe. The secretions within the sinus demonstrate high signal intensity on this T1-weighted image,
typical of desiccated secretions with high protein concentration.
 Retention Cyst

Coronal image with arrow pointing Axial T2WI shows hyperintens

to right maxillary sinus mucus retention cyst at right maxillary sinus.
retention cyst (MRC)
Polyps

( A, B) Axial and coronal CT images (in soft tissue windows) demonstrate an

antrochoanal polyp filling the left maxillary sinus and extending through the
accessory maxillary ostium into the nasal cavity.
Silent Sinus Syndrome

Coronal CT image (in soft tissue windows) demonstrates an opacified left

maxillary sinus ( asterisk) with inferior retraction of the roof of the sinus (orbital
floor) and medial retraction of the lateral sinus wall ( arrowheads), typical of
silent sinus syndrome
Benign Neoplasms

Coronal CT image demonstrates a lobular Axial CT image demonstrates a large

inverted papilloma arising from the right
nasal cavity, which has extended through ossific mass ( arrow) arising from the right
and enlarged the middle meatus and ethmoid sinus and extending into the orbit,
infundibulum and has filled the maxillary
sinus. with mass effect on the intraorbital
contents. This appearance is typical of an
ethmoid osteoma.
Fibrous Dysplasia

( A , B ) Axial and coronal CT images demonstrate bony expansion

of the right maxilla with a ground-glass appearance typical of
fibrous dysplasia. The right maxillary sinus is obliterated.
Malignant Neoplasms

Axial contrast-enhanced T1-weighted Axial contrast-enhanced T1-weighted MR image

MR image (with fat suppression) (with fat suppression) demonstrates a destructive
demonstrates an enhancing enhancing mass filling the left maxillary sinus and
squamous cell carcinoma arising from invading the nasal cavity in this patient with
the left ethmoid sinus and extending adenocarcinoma. The solid enhancement pattern
through the lamina papyracea into the aids in distinction of this neoplasm from
left orbit, causing significant proptosis. inflammatory disease.
 Mandibular invasion in oral cancer

Mandibular invasion. T2-weighted axial

Mandibular invasion. Axial CT shows frank bone
MR image shows increased signal in and
around the right mandibular ramus erosion ( arrows ) from an alveolar squamous cell
(arrows ), indicating tumor invasion, in carcinoma.
comparison with low signal of the normal
left side ( arrowhead ).
 Cartilage invasion in laryngeal cancer

False-positive MR image. Axial T2- Laryngeal cartilage invasion. Contrast-

weighted MR image shows a primary enhanced axial CT shows a right anterior
squamous cell carcinoma of the left true true vocal cord carcinoma extending into the
vocal cord ( arrowhead ) with high T2 overlying thyroid cartilage. Note the abrupt
signal in the underlying thyroid cartilage ( cutoff ( arrow) of densely ossified cartilage.
arrow ), suggesting cartilage invasion. No
cartilage invasion was present on the
surgical specimen.
Normal laryngeal ossification. The ossification patterns of the laryngeal
cartilages can be irregular and easily mistaken for tumor invasion. This
patient was imaged for distant pathology and had no evidence of laryngeal
cancer.
Hearing loss
 Hearing loss presents in one of three forms: sensorineural (SNHL),
conductive (CHL), and mixed (MHL).
 The best imaging study in the work-up of hearing loss is dictated by
a combination of patient age and type of hearing loss.
 Isolated SNHL a contrast-enhanced MRI of the internal auditory
canals
 CHL a noncontrast CT of the temporal bones
 MHL a loss of hearing sensitivity by bone conduction accompanied
by an even greater loss of sensitivity by air conduction
 No specific guidelines for imaging MHL
 Decision to use MRI versus CT a should be based on the
etiology of the MHL.
 Noncontrast CT of the temporal bones in children
 Contrast-enhanced CT of the temporal bones in adults.
 In certain clinical scenarios, a combined approach to analyze
the middle ear with CT and the inner ear with MRI might be
needed.
 Otosclerosis. The MR findings of otosclerosis
Otosclerosis. The early CT findings of are seen only when it has progressed to the
otosclerosis can be subtle, consisting of only cochlear form and consist of a halo ( arrows )
an ill-defined focus of decreased density in of enhancement and abnormal signal around
the region of the fissula ante fenestrum ( the cochlea, as seen on this enhanced T1-
arrow) in the otic capsule. weighted axial MR image. The finding is
bilateral.
Sinonasal tumors

Sinonasal undifferentiated carcinoma. ( A ) Axial CT demonstrates the effect of the aggressive

tumor on bone, particularly erosion of the septa ( arrowheads ). ( B ) MR image better delineates
soft tissue spread ( arrowhead ) and distinguishes tumor (T) from entrapped secretions (S), which
was difficult on the CT. A combined approach with MRI and CT is sometimes needed in the
evaluation of sinonasal malignancies.
Perineural spread. A patient with squamous cell carcinoma of the nasal cavity was imaged for
progressive facial numbness. ( A ) Axial CT shows widening of the foramen rotundum ( arrow ), a
relatively late sign of perineural spread. ( B ) Axial enhanced T1-weighted image in the same patient
better delineates the spread along V2 ( arrowheads ) and shows extension into the cavernous sinus
and Meckel's cave ( arrow ). MRI is superior to CT for the evaluation of perineural spread.
Intracranial tumor spread. Coronal enhanced
T1-weighted MR image shows spread of
malignancy from the infratemporal fossa across
the dura and into the brain parenchyma ( arrow
). MRI is superior to CT for this analysis.
Recurrent cholesteatoma versus
postoperative granulation tissue

Recurrent cholesteatoma. ( A ) Axial CT shows a soft tissue mass (∗ ) filling the

mastoidectomy bed and epitympanum. This finding is suggestive of recurrent cholesteatoma
but not diagnostic. ( B ) Axial diffusion-weighted MR image in the same patient shows
restricted diffusion ( arrow ) in the mastoidectomy bed, confirming recurrence
Congenital neck masses

Patent thyroglossal duct. Sagittal reformatted

contrast-enhanced CT shows a completely patent Thyroglossal duct cyst. Axial T2-weighted
thyroglossal duct ( arrowheads ) and demonstrates
the complex relationship between the duct and the MR image shows a well-defined, high-
hyoid bone (∗ ). CT is usually adequate for the signal cystic mass in the midline tongue
evaluation of infrahyoid thyroglossal duct anomalies base. MRI is preferred over CT for
and may be superior to MRI for the evaluation of
perihyoid thyroglossal duct anomalies. evaluation of lesions in this location.
First branchial cleft cyst. Contrast-enhanced
CT shows a low-density mass ( arrow) near
the left external auditory canal. Although
MRI provides greater soft tissue detail for
most congenital neck masses, CT may
have an advantage in this particular
diagnosis because of the improved analysis
of the relationship to the external auditory
canal.
Thymic cyst. ( A) Contrast-enhanced CT shows a fluid-attenuation mass (
arrowheads) between the common carotid artery and internal jugular vein. (
B) T2-weighted MR image more clearly delineates the extent of the thymic
cyst ( arrowheads), including a small focus of extension into the
retropharyngeal space ( arrow) that was not evident on the CT.
 Metastatic cervical lymph nodes from
squamous cell carcinoma

Necrotic lymph node. Coronal contrast- Lymph node with normal fatty hilum. Axial
enhanced MR image shows an enlarged contrast-enhanced CT shows a lymph
lymph node ( arrow) with a rim of
enhancement. The lack of central node ( arrow) of normal size with a central
enhancement indicates necrosis and is a area of lower density. This normal fatty
strong indicator of malignancy. hilum should not be mistaken for central
necrosis.
Petrous apex

Asymmetric petrous apex pneumatization. ( A ) Unenhanced T1-weighted MR image

shows asymmetry of the petrous apices, with greater signal on the right ( arrow ) that
might be mistaken for a mass. ( B ) CT in the same patient shows the high signal to be
from marrow fat in a normal petrous apex. The contralateral side contains an air cell.
Petrous apex chondrosarcoma. Axial CT
shows a large mass ( arrowheads) at the
medial right petrous apex. Although MRI
might provide better delineation of tumor
extent, CT can provide a precise
histopathologic diagnosis because of the
characteristic central calcifications.
SUMMARY
 CT and MRI are complementary examinations providing
different information about the tissues they interrogate.
 Unfortunately, it is not cost-effective to image every patient with
both techniques.
 There is continued controversy in the literature about which
modality is superior for imaging different areas of the head and
neck.
 Often, the decision rests on institutional or physician
preferences.
 Familiarity with the benefits and potential pitfalls of each
modality allows referring physicians and radiologists to tailor
imaging regimens to the needs of individual patients.
Thank you