ABSTRACT ID - IRIA-1230

Imaging differentials in granulomatous diseases of

head and neck: a retrospective study

Aims and objective 1. To analyse the varied etiology and recognise radiologic

patterns of granulomatous diseases in the head and neck. 2. Formulate an appropriate imaging differential diagnosis for

granulomatous disease manifestations in the head and neck

Materials and methods Retrospective analysis of cross-sectional imaging done for

granulomatous diseases of head and neck, using specific key word search from our PACS database

Imaging features of various cases were analysed and categorised based on the etiologies as proved by histopathological /microbiological / serological examination

Objectives & Methodology

Granulomatous diseases- Etiology

Autoimmune

Granulomatosis with polyangitis (Wegener’s granulomatosis)Churg StraussIgG4 diseaseBehcet’s disease

Infection

TBFungalLeprosyActinomycosisRhinoscleromaSyphilisCat scratch

OthersLangerhans Cell histiocytosisErdheim Chester disease Systemic lupus nephritisSinus HistiocytosisRelapsing polychondritisRheumatoid arthritis

HereditaryChronic GD

IdiopathicSarcoidosis

Analyzed cases

1784 cases

847

407

265

8383 18

17 51810 121063

FungalTBSarcoidosisChurg straussActinomycosisWegener'sIgG4 diseaseLeprosyWegener'sLCHErdheim chesterLCHRelaps polychSyphilis

Biopsy proven granulomatous diseases

33

1713

10

6

6 5

3 1 1 1 FungalTuberculosisSarcoidosisLCHRelapsing polychonActinomycosisWegenersChurg straussSyphilisLeprosyRhinosceroma

Granulomatosis with polyangitis(Wegener’s granulomatosis)

-

SINONASAL INVOLVEMENTSoft tissue opacification of all sinuses[ ]

ORBITAL INVOLVEMENT Enhancement along the orbital apex bilaterally [ ]

Granulomatosis with polyangitis

SINONASAL & BONE INVOLVEMENTErosion of inferior nasal septum, nasal turbinates and hard palate [ ] Associated soft tissue thickening in the maxillary and ethmoid sinuses

Sarcoidosis

SINONASAL INVOLVEMENTSoft tissue opacification [ ] of left maxillary & ethmoid sinuses

SALIVARY GLAND INVOLVEMENTEnlarged parotid glands bilaterally, right more than left [ ]

Sarcoidosis

ORBITAL INVOLVEMENTDiffusely enlarged homogenously enhancing lacrimal glandsThickening of the extra ocular muscles bilaterally [ ]

AERODIGESTIVE INVOLVEMENTAsymmetric thickening [ ] of the tracheal wall in its upper 2/3 rd

Fungal

ORBITAL INVOLVEMENTHomogenously enhancing retrobulbar soft tissue mainly involving the extraconal fat and part of intraconal fat, causing bony erosion and intracranial extension[ ]

Fungal

• SINONASAL & INTRACRANIAL INVOLVEMENT Involvement of sinuses extending into the orbit & causes extra dural thickening [ ]

• Culture –invasive aspergillosis• Sinusitis with T2 hypointense contents,

intracranial extension , resultant infarcts [ ] • Culture –angioinvasive mucormyosis

Langerhans cell histiocytosis

ORBITAL & SINONASAL INVOLVEMENT Erosion of bony walls of sinuses, nasal septum, pterygoid bones Enhancing soft tissue encasing the optic nerve in intraconal fat region bilaterally [ ]

Langerhans cell histiocytosis

ORBITAL , SKULL BASE, INTRACRANIAL INVOLVEMENT Enhancing soft tissue density in the sella [ ] and right temporal lobe [ ]Lytic destruction [ ]of the lateral wall of left orbit, adjacent zygomatic bone and greater wing of sphenoid

TB

NODAL INVOLVEMENT Multiple rim-enhancing low-attenuation lymph nodes[ ]

AERODIGESTIVE TRACT INVOLVEMENT Heterogenous thickening and enhancement [ ] of vocal cords, valeculla, enlarged neck nodes

TB

SKULL BASE INVOLVEMENT Multiple ring enhancing lesions[ ] in the basal cistern with leptomeningeal enhancement [ ] along the basal meninges

IgG4 disease Erdheim Chester disease

Involvement of the orbit [ ] & infra temporal region [ ]

Involvement of the [ ]orbit and the tentorium cerebelli [ ]

Lepromatous leprosy

Rhinoscleroma

SINONASAL ORBITAL INVOLVEMENT Sinusitis, soft tissue thickeing at the right medial cantuhus. Synechia between the sinus inferior turbinate & septum [ ]

ORBITAL INVOLVEMENT Soft tissue in both nasal cavities, paranasal sinuses, uniformly hyperintense, large extraconal component [ ]

Relapsing polychondritis

AERODIGESTIVE TRACT INVOLVEMENT Airway laryngeal stenosis from supra to subglottis, soft tissue density[ ] around trachea, ossified laryngeal cartilage[ ], tracheostomy tube in situ [ ]

Imaging differentials based on radiological manifestations seen in our study

ORBITWegener’s

FungalSarcoidosis

IgG4Leprosy

Erdheim Chester Disease

Rhinoscleroma

SINONASAL Wegener’s

Fungal TuberculosisSarcoidosis

IgG4 disease

VASCULARWegener’s

Fungal TB

CRANIAL NERVES

SarcoidosisTB

Leprosy

SKULL BASETuberculosis

FungalLCH

Wegener’s

AERODIGESTIVE TRACT

Wegener’sTuberculosis

Relapsing Polychondritis

Sarcoidosis

Conclusion & References

Conclusion Knowledge of the clinical and radiologic patterns of

granulomatous diseases in the head and neck will allow interpreting radiologists to provide a useful differential diagnosis, thus facilitating appropriate clinical management

References

1. Granulomatous Disease in the Head and Neck: Developing a Differential Diagnosis. O.K Nwawka, R Nadgir, A Fujita. Radiographics volume 34, issue 5 September-October 2014

2. Radiology Review Manual. Wolfgang Dahnert, 6th edition

3. CT and MR imaging of the whole body. John Haaga. 4th edition