The Role of Imaging in The Role of Imaging in SinusitisSinusitis

Dr Mohamed El Safwany, MD.Dr Mohamed El Safwany, MD.

Intended learning outcomeIntended learning outcome

• The student should learn at the end The student should learn at the end of this lecture role of imaging in of this lecture role of imaging in sinusitis.sinusitis.

Pediatric PopulationPediatric Population

• The nasal sinuses are not The nasal sinuses are not developed at birthdeveloped at birth• The maxillary and ethmoid sinuses begin The maxillary and ethmoid sinuses begin

to develop first and the frontal sinuses to develop first and the frontal sinuses are the last to appear between 5-7 yrs of are the last to appear between 5-7 yrs of ageage

• They become progressively aerated and They become progressively aerated and may not be completely developed until may not be completely developed until up to 10 yrs of ageup to 10 yrs of age

• A normal radiograph in a young child can A normal radiograph in a young child can be confused with sinusitis or other sinus be confused with sinusitis or other sinus disease due to opacification disease due to opacification

• This sometimes occurs when radiographs This sometimes occurs when radiographs are ordered for other reasons such as are ordered for other reasons such as traumatrauma

• Therefore, routine sinus radiographs are Therefore, routine sinus radiographs are not very useful in young children to make not very useful in young children to make the diagnosis of sinusitisthe diagnosis of sinusitis

Older Children and AdultsOlder Children and Adults

• In general, sinusitis is a clinical diagnosis In general, sinusitis is a clinical diagnosis and imaging should be reserved for and imaging should be reserved for cases that are unresponsive to cases that are unresponsive to treatment, when complications are treatment, when complications are suspected, or when the diagnosis is suspected, or when the diagnosis is questionablequestionable

• The typical imaging used for detecting The typical imaging used for detecting sinus disease are plain films and axial sinus disease are plain films and axial and coronal CT scansand coronal CT scans

Plain FilmsPlain Films

• The typical sinus series consists of 4 viewsThe typical sinus series consists of 4 views• The Water’s view can be useful in The Water’s view can be useful in

detecting maxillary sinusitis detecting maxillary sinusitis • Caldwell’s view is used to evaluate the Caldwell’s view is used to evaluate the

frontal sinusfrontal sinus• The submentovertex view looks at the The submentovertex view looks at the

sphenoid sinus and also the anterior and sphenoid sinus and also the anterior and posterior walls of the frontal sinusposterior walls of the frontal sinus

• The lateral view shows the frontal, The lateral view shows the frontal, maxillary, and sphenoid sinusesmaxillary, and sphenoid sinuses

• Plain films are not very specific for Plain films are not very specific for sinusitis because opacity can be sinusitis because opacity can be difficult to distinguish from other difficult to distinguish from other pathology such as tumorspathology such as tumors

• Signs on a plain film that suggest Signs on a plain film that suggest sinusitis include opacification, air-sinusitis include opacification, air-fluid level, or 6mm or more of fluid level, or 6mm or more of mucosal thickeningmucosal thickening

CT ScanCT Scan

• CT scan is considered the gold standard for sinus CT scan is considered the gold standard for sinus imaging and the coronal view is typically the image imaging and the coronal view is typically the image of choice. Axial views are needed to complement of choice. Axial views are needed to complement the coronal views when severe disease is suspected the coronal views when severe disease is suspected in the ethmoid and sphenoid sinuses.in the ethmoid and sphenoid sinuses.

• Signs suggestive of sinusitis on CT include Signs suggestive of sinusitis on CT include opacification, air-fluid level, sinus wall displacement, opacification, air-fluid level, sinus wall displacement, and/or mucosal thickening of 4mm or moreand/or mucosal thickening of 4mm or more

• Since CT scans can show much more anatomical Since CT scans can show much more anatomical detail of the sinuses, they are especially useful when detail of the sinuses, they are especially useful when clinicians are concerned about complications or clinicians are concerned about complications or extension of disease from sinusitis extension of disease from sinusitis

• CT scans are often used to evaluate a patient CT scans are often used to evaluate a patient before surgical intervention for chronic sinus before surgical intervention for chronic sinus diseasedisease

• Surgeons use it mainly to document the Surgeons use it mainly to document the presence of disease and to look for any presence of disease and to look for any anatomical abnormalities that could increase anatomical abnormalities that could increase the risk of complications during surgerythe risk of complications during surgery

• For surgical evaluation, the CT scan should For surgical evaluation, the CT scan should be obtained after treatment with broad be obtained after treatment with broad spectrum antibiotics and at least 4 weeks of spectrum antibiotics and at least 4 weeks of topical nasal steroids otherwise it is difficult topical nasal steroids otherwise it is difficult to assess the meaning of a positive scanto assess the meaning of a positive scan

Text BookText Book

• David Sutton’s RadiologyDavid Sutton’s Radiology

• Clark’s Radiographic positioning and Clark’s Radiographic positioning and techniquestechniques

AssignmentAssignment

• Two students will be selected for Two students will be selected for assignment.assignment.

QuestionQuestion

• Define role of CT in sinusitis?Define role of CT in sinusitis?

• Thank YouThank You