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We discuss an unusual presentation of non-thrombotic cavernous sinus involvement in a patient who was treated for odontogenic fascial space infection arising from a maxillary molar.
References1.Ebright JR, Pace MT, Niazi AF (2001) Septic thrombosis of the cavernous sinuses. JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. February 25, 2009This article is based on a presentation given by Laurie Loevner and adapted for the Radiology Assistant by Jennifer Bradshaw. In addition, we need it to identify erosive processes and acquired developmental deficiencies of the bone.
When pathology approaches the orbital apex, an MRI study is necessary to assess spread to the cavernous sinus and intracranial compartment. The real value of unenhanced CT is the following: if you see an opacified sinus with hyperdense contents, it is usually a sign of benign disease. There is hyperdense material in the posterior right ethmoid, the bilateral spheno-ethmoidal recesses, the sphenoid sinus and there is involvement of the clivus. There is bilateral opacification of the nasal cavities, usually a sign of an inflammatory process or polyps.
When you understand the signal characteristics, you are readily able to distinguish soft tissues masses from inspissated secretions. The signal intensity of secretions can vary and mainly depends on the ratio of water to protein and the viscosity. Different protein contents result in different signal intensities on T1 and T2W-images (figure). Fungus usually has a high protein content of more than 28% and can mimic an aerated sinus because it is low on T1- and T2WI.
Involvement of the skull base is seen as replacement of the high signal of the fatty marrow on T1WI by hypointense signal of the tumor. Also look for foraminal extension, whether by perineural spread or direct invasion of the tumor. Notice the low signal intensity of the left sphenoid sinus, which also had a low signal intensity on the T1W-image (not shown). The signal characteristics on MRI and the attentuation on CT are a result of the high protein content of fungus. So, when invasive fungal infection is suspected, start with a CT, then move on to MRI to rule out spread to the eye, cavernous sinus and intracranial compartment! In general bright signal on T2 is a sign of benign disease, since fluid and mucosal disease usually have a high water content. On the pre-contrast scan you see relatively high signal content of the maxillary sinusses due to proteineous material.
In complicated cases both CT and MR are needed to demonstrate the extention of the disease. On the left CT-images of a patient post-lung transplant with fever and multiple rapidly progressing cranial nerve palsies. There is opacification of the sphenoid sinus with destruction of and osteopenia of the sphenoid bone.
Normal aspect of the right Meckel's cave, tissue in the left Meckel's cave extending into the cavernous sinus (blue arrow). The red arrow points to the dural margin of the cavernous sinus: there is enhancement on both sides of the dura. The disease wraps around the temporal lobe (green arrow) and extents downward in the foramen ovale (yellow arrow) and into the masticator space. Nine out of ten times an immunocompromised patient will have a fungal infection, in one out of ten it will be a lymphoma.
CT and MR have a complimentary role in this case, but finally a biopsy is called for to differentiate between these two diagnoses, because of different treatment. On the left images of a 64-yrs-old, immuno-competent patient, who had a follow-up scan for left-sided vestibular neuroma. On the image on the left hypointense tissue is seen in the pterygo-palatine fossa and videan canal (yellow arrow). On the image on the right, which is more cranial, there is hypointense tissue in the pterygo-maxillary fissure and pterygo-palatine fossa.
The differential diagnosis again consists of 2 catagories: neoplasm and chronic invasive fungal infection. This is the corresponding CT, performed not to make the diagnosis, but to assess the condition of the adjacent bony structures, especially the sphenoid sinus. The coronal image illustrates a normal foramen rotundum on the left (yellow arrow), which on the right has been obliterated by soft tissue. There is extensive bone destruction, and a possible area for biopsy is indicated by the blue arrow. MRI is necessary for assessing intracranial complications, such as brain or epidural abscesses, subdural empyema or sinus thrombosis.
Notice however the abnormal tissue in the frontal sinus (yellow arrow), subperiosteal abscess (red arrow) and the fluid-fluid level (green arrow) in the large intracranial lesion which has ring enhancement.
This is a subperiosteal abscess and osteomyelitis of the frontal bone, usually with a soft tender swelling of the forehead. This is also called Pott's puffy tumor after Sir Pott, an English surgeon who first described this entity.
On the left images of another patient, who had recently been treated for sinusitis and now presented with a seizure. The CT shows an abnormality in the left temporal lobe with shaggy thick rim enhancement, and a large amount of vasogenic edema.
This is also a brain abscess, most probably due to reflux of bacteria into cranial veins and the venous plexus around the cavernous sinus. The T1WI shows loss of normal fat compared with the right side, and extension into the orbital apex (red arrow).
On the coronal image there is bilateral high signal at the junction of the nasolacrimal duct and sac, indicative of a fluid collection. Lateral to the naso-lacrimal ducts on both sides, there are the fluid collections which now show peripheral enhancement. The additional images (T2WI) show mucosal disease of the right maxillary sinus and a fluid level in the left maxillary sinus, in addition to extensive ethmoidal and sphenoidal sinus disease.


This patient had acute sinusitis which was complicated by orbital cellulitis and dacrocystitis with abscesses.
Developmental or inflammatory narrowing of the naso-lacrimal duct is a risk factor for developing dacrocystitis. The Hounsfields Units of the tiny abnormalities that the asterisk points to were around -120. With this complication, usually the patient goes home feeling fine, and then shows up approximately two weeks later with CSF leak and meningitis, due to the defect in the bone and dura. Tension pneumocephalus occurs when air in the head acts like a mass: there is a bony defect which lets air in but not out (valve-like function). Every time the patient sneezes, air is forced through the defect into the intra-cranial space, and remains trapped there. At a certain moment the amount of air is sufficient to cause mass effect on the surrounding intra-cranial structures. When it comes to imaging of neoplasms of the paranasal sinuses, CT and MRI play complementary roles. It is not about the histology but about answering the question 'is it tumor or not?' and then determining the extent of the disease, for example intracranial or orbital extension. Coronal T2WI of the patient on the left show an abnormal structure in the right nasal cavity.
When you've decided what it is, then stop to think about whether the abnormality is developmental or acquired. The second clue is the cortical dysplasia (yellow arrow) as part of a migrational abnormality.
Acquired encephaloceles (ie after surgery) tend to lead to dead gliotic brain, which would have a high signal intensity on T2WI. The strange looking structure in the left image (red arrow) is surgical packing, placed there after the involuntary encounter with brain tissue. The blue arrow points to the sphenoid sinus which is hyperintense, due to mucoid impaction as a result of obstruction by the encephalocele.
Mucoceles are benign, locally expansile paranasal sinus masses most commonly found in the frontal sinus. Secondary to obstruction of the sinus ostia, there is accumulation of fluid within a mucoperiosteal lined cavity, resulting in erosion and remodelling of the surrounding bone.
The most common causes of mucoceles are chronic infection, allergic sinonasal disease, trauma and previous surgery.
The most common location of a mucocele is the fronto-ethmoidal sinus, followed by the sphenoid sinus. Looking at the CT scan on the far left you will notice a convex soft tissue mass in the frontal sinus. Did you notice the bony defect on the left side, at the lateral border of the ethmoid air space (yellow arrow)? The two most common causes of mucoceles are trauma and chronic inflammation due to blockage of the ostia.
This patient has chronic sinusitis with sino-nasal opacification, mucoid impaction in the maxillary sinusses and huge bilateral mucoceles. The CT shows hyperdensity and the MRI shows hyperintensity on T2WI, both of which you will remember are benign signs in sino-nasal disease, indicating a proteinaceous substance. There is smooth bone remodelling and elevation of the frontal sinusses, and although it looks as if there is bony destruction at the orbital boundary of the frontal sinus, usually the surgeon will still see a fine line of bone in place.
Inverted papilloma is characterized by inversion of the neoplastic epithelium into the underlying stroma.
It presents as a unilateral nasal polyp arising from the lateral nasal wall, usually in the region of the middle meatus and middle turbinate. Biopsy is necessary to make the diagnosis and because more than 10% of inverted papillomas harbor a squamous cell carcinoma. When you want to differentiate inspissated secretions from neoplasms it is important to have pre- and post-contrast images.
If you were to just look at the post-contrast study on the right, you might be tempted to think that there was solid enhancement of the mass in the nasal cavity (asterisk) as well as in the ethmoidal and maxillary sinus on the right.
Looking at the pre-contrast study, however, you will notice that the contents of the ethmoidal and maxillary sinuses are hyperintense as opposed to the mass in the nasal cavity (the middle meatal region), because the sinuses are filled with inspissated secretions. The imaging findings are non-specific and the differential diagnosis includes a polyp or a carcinoma. Decide for yourself whether you are looking at a solid mass, inspissated secretions, a combination of both or something entirely different. The pre-contrast T1WI shows a hyperintense area within the maxillary sinus, corresponding to a proteinaceous substance.
Medial to it is an area with hypointense signal similar to the signal in the orbital globes (so probably cystic).
If the patient is a surgical candidate, frontal endoscopic sino-nasal surgery won't be enough and a cranio-facial take-down will also be required. On the left is a patient with a meningioma, which spreads along the anterior clinoid (arrow).
On this contrast-enhanced MRI we see a non-enhancing expansile lesion in the right maxillary sinus. It is tempting to call this a retention cyst and move on to the next case, but a CT is called for to make the correct diagnosis.
This is called the silent sinus syndrome, which consists of painless facial asymmetry and enophthalmos caused by chronic maxillary sinus atelectasis. The most characteristic imaging feature of the silent sinus syndrome is the inward retraction of the sinus walls into the sinus lumen with associated decrease in sinus volume and enlargement of the middle meatus (2). In many cases the infundibulum is occluded due to lateral retraction of the uncinate process. Fibro-osseous lesions are very common incidental findings and often misinterpreted as tumor. CT is usually diagnostic, so when you see a bizarre lesion at the skull-base, think of a fibro-osseous lesion and get an unenhanced CT.
On the T2W-images there is a hypointense lesion (yellow arrow) with a cystic component (red arrow).
On the pre- and post-contrast T1W-images there is solid enhancement of a mass with peripheral enhancement of the cystic portion.


On CT this is classic fibrous dysplasia (FD) with cortical sparing and ground-glass appearance. Many of the fibrous dysplasia lesions in the clivus, skull base or sino-nasal cavity and in children may have large cystic components, so don't let that dissuade you from the diagnosis! On the left another patient read as having a soft tissue tumor (yellow arrow) anterior to the temporal bone. These are the corresponding axial CT images showing classic fibrous dysplasia of the sphenoid wing.
On the left images of a different patient with soft tissue in the sphenoid sinus on the left, and an abnormality of the left sphenoid wing, which is about 3 times its normal size whilst maintaining its normal shape.
Mind you, I first read this while lying on my back doing leg lifts at Fitness Firm, the gym I belong to. I am a passionate sinus blogger, published author, public speaker, triple board certified MD, President of Sinus Solutions LLC. At Allcare Pharmacy & Healthcare Services, our personalized approach we take to customized medications and medical supplies truly sets us apart from other pharmacies. If you manage this site and have a question about why the site is not available, please contact us directly. MRA are the preferred techniques because they are not adversely affected by intraluminal clot.
Intermediate signal intensity may be seen in the basal cisterns on T1-weighted images in these cases. The highlights were ipsilateral abducens sparing, contralateral abducens involvement and lack of significant orbital congestion. Note the concentric lamellated appearance of alternating hyper- and hypodensity in the maxillary sinusses.
In the ethmoidal region some of the hyper-density reflects periostitis and neo-osteogenesis along the septae. When I asked Randy Nicholson, the owner, where he got the quote, he shrugged and said his wife had told him. In 400 BC, Hippocrates believed that the safest way to good health was a combination of good nutrition and exercise, not too little and too much.
We should be reserving medicines for those that truly need it, and start teaching prevention.
Several studies have shown that certain nationalities such as the French and Italians have a lower rate of obesity when compared to us here in the United States because they spend more time in the kitchen. Unfortunately, when you mention the Mediterranean diet to most people, they envision spaghetti with meatballs, garlic bread, a bottle of Chianti and a side order of pizza. For me and my wife, a modified Paleo diet (fish, chicken mostly with some red meat and a lot of vegetables) along with 3-4 hours of vigorous exercise weekly works well.
I will be dedicating a whole section on healthy eating and exercise because I believe that this is an integral part of being healthy in the 21st century. Some patients may experience a case of AFS again in their lifetime this experience, however is not uncommon. Next, I tried to Google it, but still I couldn’t find the originator of this quote, so whoever came up with it, thank you.
Meanwhile, in that same time period, Chinese physicians realized that preventive medicine was superior to treating preventable disease and this could be achieved through diet and exercise.
There are more people, technology created labor saving devices allowing for more free time to allow us to do important things like watch TV, play video games and participate in social media – just to name a few. Compound this mindset with: don’t worry about how you are poisoning yourself, we have the antidote for you in the form a pill.
In contrast, people of the UK have the same obesity rate as we do because they spend approximately the same amount of time in the kitchen as we do. National Geographic this month has done an excellent focus called The Evolution of Diet on the benefits of eating like our ancestors.
The reality is that the Mediterranean diet consists of a daily consumption of fruits and vegetables, legumes and nuts with a base of whole grain products such as whole grain breads and pasta along with rice, polenta, potatoes and quinoa. Unfortunately for many, though they may want to exercise that way, but there just aren’t enough hours in a day when you factor in commute times, dual careers and obligations with children between school and extra-curricular activities.
I write informative Sinus Blogs discussing case studies, various sinusitis infections and treatments, and sinus related situations.
As we enter the 21st century, it has become increasingly apparent that disease management has become more complex, as more and more people are able to not only survive, but thrive, with several chronic diseases simultaneously.
This is becoming very evident as we begin to understand the complexity of biofilm and how recalcitrant chronic wounds are to heal through conventional therapies.
There is more, however, and this is what I believe is the unholy alliance among Madison Avenue (advertising), the food industry and the pharmaceutical industry.
The latest example of this is the Nexium commercial where grandma is filling some guy’s plate with a ton of food but he’s worry about his reflux.
Meats such as chicken and fish are consumed on a weekly basis and red meat maybe once or twice a month. Accessed 13 Jul 20113.Yassur I, Hirschbein MJ, Karesh JW (2002) Ophthalmic considerations in oral and maxillofacial infections. The concern with those that oppose the Paleo diet is that the consumption of red meat leads to high cholesterol levels, running a higher risk of cardiovascular disease. Translation: the energy requirements of our Paleo ancestors were much greater than that of ours today.
In: Topazian RG, Goldberg MH, Hupp JR (eds) Textbook of oral and maxillofacial infections, 4th edn. Not to be out-done, Maggiano’s has gotten on the health kick also, offering “lighter” versions of certain meals so that you don’t have to go to Pilates class or eat a quinoa salad. Proponents of the Paleo diet believe that the risk for high cholesterol is due to the high consumption of carbohydrates in the Western diet today.   I cannot argue this last point, as it is my belief that the American diet has become carbohydrate centered between flour-based products and other starches. The concern, though, is the amount of grains and starches that they may consume on a daily basis.



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