 Okay, imaging of paranesial sinuses basically CT scan is one of the most frequently performed examination and the common pathologies that one look at or image for is sinusitis and polyps comparative to the sinusitis and polyphosis in paranesial sinus or compared to head neck tumors. Paranesial sinus or sinus tumors are not common, they're relatively uncommon. Many of these tumors have nonspecific presenting symptoms and imaging features, however some can help to narrow the differential diagnosis. Now, an important thing is that paranesial sinus has got a diverse histology, it has got ectoderm, mesoderm that is all the cells, dermal cells, glandular cells, vessels, cartilage bone, so a large variety of neoplasm can occur in this region. So let's see some cases, some tumor-like cases mimics their characteristics and some less common regions. Now, histological classification being like everywhere else is benign and malignant, so epithel tumors like papillomas, soft tissue tumors like hemangiomas, angiofibromas, bone and cartilaginous tumors like fibrous dysplasias and astromas, hematolymphoid tumors, neuroectodermal tumors, germ cell tumors. Then malignant counterparts are spoma cell CAs, adenu CAs, undifferentiated CAs, the soft tissue and bone malignant tumors be the muscle, the ractomyosarcoma, the bone, the osteosarcoma, lymphoma, plasmocytoma, etc. So again, there are certain mimics which can come as tumors. Now, just a slide on WHO classification of tumors of nasal cavity and perinatal sinusin and skull base, the fourth edition in 2017. Several new entities and provisional entities were added to the chapter of nasal cavity, PNS and skull base, which includes HPV-related multi-phenotypic synonasal carcinoma, the SMARCB1-deficient synonasal carcinoma, the renal cell-like adenosia, seromucinous hematomas, the nut carcinoma, bio-phenotypic synonasal sarcoma. So, this has been the newer edition which is the fourth edition in 2017. Now, let's go on to how my talk is going to be. It's going to relate to what kind of symptoms the patient comes with. So, it is a very practical approach to what you get in terms of patients. Most of the patient comes with nasal block, epistexis, pain and swelling. Let's start with nasal block. An 18-year-old male nasal block, breathing difficulty and on examination. This is what the ENT surgeon can see. There was a legion in the anterior necks. Beyond that, the ENT surgeon could not see. Mind you, 18-year-old male. I'll just take two laser pointer. Okay. So, these are all plain images, axial and coronal. You have a soft tissue density legion occupying the entire nasal cavity, peeping via the posterior pointer into, that is what it is seen, and into the nasal pharynx. And if you go in the axial, you'll appreciate that this area is very important. This is the spenopalatine foramen, pterigopalatine, ptosa, and lateral is the pterigopnexilary fissure. So, a large tumor or a legion, soft tissue density, occupying the nasal cavity, displacing the nasal septum to the opposite side, that is to the right. And as you go behind, you will see the posterior pointer, disposing, kind of abutting the hard palate. We'll see bone window, what happens. And this is the area of the pterigopalatine, ptosa. The bone window will show that the pterigoid plate is partially eroded. Let's see what happens on the coronal and sagittal image. We'll appreciate that there is widening of the superior and inferior orbital fissure. You can actually see the widening of the pterigopalatine ptosa very well. On post-contrast study, you'll see avidly or intensely enhancement, intense enhancement of the legion, which was seen in the nasal cavity. And so, the epicenter of this legion is in the spenopalatine porumine and pterigopalatine ptosa. Now, as an ideologist, your job is to identify where it has extended. Like in here, it is nasopharynx. It has gone into the reaching up to the anterior nares where it was seen. Here, unfortunately, this patient has an intracranial extension in the paracellar or medial temporal region, extra axial mind here. So, the moment the legion reaches this area that is intracranial, things get little complicated. They call it as a red flag because this patient may require before treatment radiation. Coronal image not only shows you the legion, it shows you how it has extended its extension into the spinoid sinus and intracranially. And this is the infratemporal extension. And on sagittal image, it shows you that the legion from the anterior nares to the posterior koina and into the nasopharynx not extending into the oropharynx in this and it is involving the entire itmoid air cells and the spinoid sinus. By now, you must, you already know what this legion is. It's a juvenile nasopharyngeal angiopitoma. And delayed images just done. If you want to go inferiorly here, you don't expect any internal jugular vein thrombosis. Now, the usual supply to this is internal magillary artery. Now, what next? What is the role of the radiologist? Now, in comes the role of a interventional radiologist is the embolization. And the embolizing material is PVA particles and it is 250 to 300 microns. And when is the embolization done? Basically, whenever they plan the surgery, the surgery has to be done 48 to 72 hours. So, not before 48 hours and not after 72 hours of embolization. And in our institute, we do per week, one embolization for JNA. It's a very high JNA institute. So, this is one case where we are seeing that there is a pre embolization. You can see the blush. This is selective catheterization of internal magillary artery. And the catheter is gone beyond that. And you can see that there is a blush. And after PVA particle, you will see that it is completely embolized. Mind you, before embolization, one has to see where that hopefully that there are no feeders from internal carotid artery, especially in tumors, which have an intracranial extension. Now, one should also know how a postoperative CT in a postoperated for JNA looks like in this, they have removed the nasal septum. They have made a large kind of a window in the region of synonazole cavity. You cannot identify the normal anatomy of the magillary sinus, nasal septum or the tourbillon. So, whenever you see this kind of appearance, go and ask what, even if the patient is older, go and ask the history whether the patient was operated for JNA because the kind of resection done for JNA is quite extensive. Now, all of you already know that it's an exclusively lesion occurring or tumor occurring in males, usually adolescence, but I have seen cases as young as eight years and as late as 28 years. It's one of the benign tumor. Its location, as I've already told you, spinoparitain foramen, terigoparitain posa, and its extension is very important. That is what as a diagnostic radiologist is, where exactly it is extending. Basically, once it enters the infratemporal posa, its extension into the other areas and also extension if there is extension of orbit and intracranial cavity. Now, there are certain signs that one is, one should be aware when you are there is JNA. One is boiling of the posterior wall of the magillary sinus called as Perlman-Miller sign. Then extension of the lesion into the pterygoid wedge. So, if you see, this is the pterygoid bone and the lesion extends into the pterygoid wedge. Like here, the lesion is extending into the pterygoid wedge. This is the medial pterygoid plate, this is the lateral pterygoid plate and the lesion is extending into the wedge of the pterygoid. That is a Ram-Haran sign. And what is the Hondosa sign? Hondosa sign is the widening of the gap between the ramus of the mandible. This is the ramus of the mandible and magillary body. So, this gap is widened as compared to this. So, in this patient, there is the Ram-Haran sign and in this patient, apart from Ram-Haran sign, there is also Hondosa sign. Another similar case, but not that extensively involving spreading of same 15-year-old. So, adolescent male with epistaxis, you have a soft tissue density lesion in the spinoparatan pterygoparatan fossa in the nasopharynx posterior koina, as you can see in the coroner. And here on the bone minder, you can see the lesion extending into the wedge of the pterygoid plate. This is a nicely corticated normal pterygoid wedge and see there is cortical defect. So, again the Ram-Haran sign. Post-contrast study, you will see that there is moderate enhancement and the lesion is partially extending to wedge of the pterygoid plate. So, this is a smaller tumor as compared to the first one and what this societal image shows that the lesion is involving the extending and causing widening of the pterygoid maxillary fissure. So, this is another case of JNE. Another case, another pathology patient presented now with epistaxis. Actual image, plane, coronal, anterior most part where you are not seeing the turbinate. So, there is an oval soft tissue density lesion in the left side of the nasal cavity abutting the nasal septum as well as the lateral cartilaginous portion of the nasal wall. What next? Stop here or do CCT? Yes, you are going to do CCT. Our example, this thing is tumors and mimics we are going to do contrast and CCT scans. So, what do you find here? You have a heterogeneously enhancing oval lesion which was what I showed you on plane. It is heterogeneously and partially avidly enhancing lesion. I don't know whether you can see but this is 112 and this was 32. So, avidly enhancing but heterogeneously enhancing and this radical image shows that a lesion is not abutting the inferior turbinate. It is just abutting the nasal septum immediately and anteriorly the under surface of the lateral wall of the nasal cartilaginous portion of the nose. So, diagnosis, adenomatous nasal polyp versus angioma. It turned out to be hemangioma. What are the types of hemangiomas? Capillary and cavernous. Capillary are lobulated or composed of capillary size vessels lined by flatten epithelium. Basically, these hemangiomas can occur in all ages. They peak in children and adolescent males. They are commoner in females in their reproductive age and beyond the fifth decade, male and female are equally affected. The cavernous hemangiomas are usually large inhomogeneous mass with heterogeneous enhancement of either centripetal or multifocal nodular pattern. You can do an MRI with biophasic contrast injection. Another case, intermittent episodes of epistaxis in three months and on examination, of course, ENT surgeon could see a anterior nasal cavity lesion on the left side again. So, here the lesion is not exactly in the anteriorness but minimally, mildly posteriorly again attached to the nasal septum. This lesion has lower density than the first one is 12.8 and post contrast. It is really avidly enhancing to 160. More intensely enhancing than the previous lesion. So, as you can see, there is heterogeneous avid enhancement seen in the lesion located in the left nasal cavity, abutting here the inferior terminate and also the nasal cavity and it is not abutting the floor of the nasal cavity. The sagittal images shows that the lesion is arising from the inferior terminate, sorry from the middle terminate and abutting the inferior terminate. So, actually you are not able to see the middle and inferior terminate anatomy very well on the anterior aspect of the terminate or nasal cavity and on sagittal images you will see the lesion rising from the middle terminate under surface and this is the inferior terminate. So, point here I am trying to tell you is always look at the sagittal image. You tend to look only at the coronal and at the most axial but definitely look at the sagittal image which will give you an idea where the lesion is arising from. Just the delayed images. So, this turned out to be a LCH not Langer and Celistocytosis but Lobular Capillary Hemangioma. So, what do you look at? Now, if you look for presence of bone destruction if the lesion is rapidly growing. So, usually these lesions do not cause bony destruction but if they are rapidly growing definitely they cause bony destruction and if the lesion is from at the roof of the nasal cavity like this lesion what at the middle terminate. So, the mid and inferior part of the nasal cavity but a similar lesion at the roof of the nasal cavity then look for any intracranial extension. Another patient of 43 year old male presented with swelling over the cheeks. So, from nasal blockage to epistaxis we have come to another symptomatology where swelling and is a non-diabetic. I purposely said non-diabetic because we saw a lot of mucor non-diabetic non-covid a 43 year old patient with cheeks swelling. Now, these are MRI images. What do you have in MRI? The T2 weighted images shows a kind of I am using a specific term called gyre form or cerebriform pattern of lesion which is T2 hyper intense but not as hyper intense as sinusitis but it with areas of linear areas of hypo intensity on T2. On T1 it is definitely iso intense to the muscle. Now, apart from that you have to look about the location. So, this lesion is located in the nasal cavity on the left side extending into the maxillary sinus beyond the maxillary sinus in the posterior retro maxillary area and on the coronal image you can say a large infratemporal extension and you can see a large intra orbital extension. It is not restricted on DWI and not low on ADC. Actually the stack images of the shown same patient shows the intranasal lesion in the left side middle turbinate anatomy not seen intra orbital extension so on and so forth. Maxillary sinus here is normal you can't appreciate the maxillary sinus and a large pre maxillary infra orbital component which is what the patient presented with. Post contrast images shows the proptosis intra orbital extra as well as intra coronal extension and just to show you that the lesion abuts the inferior turbinate middle turbinate normal of normal side is not seen. The bone window the CT scan basically I want to show you the bone window there is erosion of the medial wall of the maxillary sinus anterior wall posterior wall and this is a heterogeneously enhancing lesion with a large pre maxillary component. So, exactly image shows you the intra orbital now here this is more extra extra conical partner because you can see the inferior rectus elevated this is the optic nerve and here you cannot identify the inferior rectus muscle and you can see erosions of the lateral wall as well. So, this turned out to be inverted papilloma called as ipad they are mostly most frequently encountered behind epithelial neoplasm and ipad is the most common subtype why is it called why is it called inverted papilloma because it's got an endophatic growth pattern usually presents between 5th through 7th decade ipad is more common in men than women. I already told you it has got the MRI showed the cribriform pattern or columnar pattern characteristic for ipad CT delineates bony remodeling focal erosion and may show bone strut or focal hyperostasis at the point of attachment of the legion. Now, if the destruction of the bone is too much you can say it is ipad with suspicion of malignant transformation. Now, it is important to report the site of attachment as complete resection is required to prevent resection. Osiref necrosis of disruption of the architecture or as I showed you severe destruction of bone you should raise suspicion of coexistence tumor. So, the final diagnosis in this case was ipad with malignant transformation with coexistence swamper cell carcinoma. Now, this patient a 72 year old next patient mass in the buccal cavity night nasal cavity and had a histological proven papilloma. What is snyderian papilloma also called as sino nasal papilloma considered as benign sino nasal tumor arising from snyderian epithelium. Now, ipad is most common subtype of this snyderian epithelium epithelium malignancy or papilloma. This the other one being exophytic papilloma and the third one being oncocyte. Now, this is a 72 year old patient. You will see this plane CT scan shows a large component in the nasal cavity from the anterior nail to the posterior nail with erosion at of the hard palate and extension of the lesion or on the plane CT we don't know whether this is extension of a lesion or sinusitis because you can see the density of this is different from the medial and enterometal component of the macular sinus. This is sinusitis and this probably is the invasion of the mass also anteriorly it is extend involving causing erosion of the maxillary alveolus bone window shows extensive destruction of the maxillary alveolus also of the hard palate so on and so forth. This is post contrast image showing you heterogeneous moderate post contrast enhancement of the lesion and its extension. The coronal images also shows that there is an intraoral component of the lesion and you can measure the intraoral component from anterior to the posterior aspect and receive your erosion of the hard palate. So, maxillary sinus nasal cavity intraoral component. The previous CT showed the lesion but remember there was no nasal component and of course the previous CT was from outside and they have not done open mouth view. Now if you see the difference this is the previous CT this is the current CT you will see that the open mouth view showed the intraoral component very well the closed mouth was cannot really appreciate the intraoral component also if you compare there is severe there is growth of the lesion so there is involvement of the anterior nares and complete obstruction of the anterior nares as well as the nasal cavity. So, if you have always in cases of tumors try to understand or ask the patient if there is a previous CT in this patient it is definite increase in the size of the lesion and increase extension. Coming to another pathology where there is an exoticia density lesion with erosion of the walls of the maxillary sinus you can't really see medial wall, inferior wall, the hard palate it looked like the previous case this is nothing but malignancy. Now commercial carcinoma what are the CT features is prominent bone destruction and MRI what are the MRI findings it is intermediate T1 signal intensity, hyper intense on T2 as compared to fluid because remember the fluid which is non-fungal of course non-fungal infection just sinusitis is very bright on T2 so these lesions are less than that of the fluid most commercial carcinoma have a non-specific imaging appearance. So, let's go on to see some cases again if you if I if you remember the first case I showed you the nasopharyngeal angiopibroma it had a nasal component but look at this this is not widened that is a spinopalatine foramen and tericopalatine posa is not widened the lesion looks the same but the key factor is here the lesion is extending into the maxillary sinus and in the JNA there was not much lesion that we saw of course you can get but not very common so this is anterior parenteral extension of the lesion of course there is intra-orbital extension also post-contrast shows heterogeneous moderate enhancing lesion involving not only of the nasal cavity like here maxillary sinus, itmoid air cell and intra-orbital extension and causing retention sinusitis you can see the intra-orbital extension extensive bone erosions I will just quickly show you I've finished my 25 minutes at captain alarm so you can see that extension of the lesion into in the nasal cavity as well as the maxillary sinus the itmoid sinus this is the medial rectus so extraconal extension so on and so forth so higher age group extensive involvement of the structure adjacent to the nasal cavity and parenteral sinus with bony destruction like you're like you're going to see here lamina paparicia the roof of the maxillary sinus medial wall the itmoid trabeculae and as you go posteriorly the lesion is also causing partial extension and erosion of the lateral recess of the spinoid sinus so keep in mind the age of the patient and erosion of the bone this was a sinonazole carcinoma so enteral or maxillary carcinoma are uncommon head fist neck tumor average age being 45 more common in males than females almost five to one despite pro large lesion but it is confined to the maxillary sinus hence the symptoms are quite late another patient female your proptosis left eye with diminution of vision associated pain and left nasal discharge again the findings are similar expansile lesion in the nasal cavity with intra orbital extension moderate heterogeneous enhancing lesion severe bony destruction but the age is higher also the fovea itmoidalis is eroded so is the anterior part and where your kerosos classification remember the cribiform plate is eroded it presents of a soft tissue in the nasal cavity as of now there is not any intracranial extension again a sinonazole carcinoma we went ahead and did the MRI T1 it is iso intense on T2 it is hyper intense but not as much as the maxillary sinus sinusitis so this is retention sinusitis and this is extension of the lesion into the maxillary sinus this is extraconal extension of the lesion T2 it is hyper intense on diffusion it is restricted with low ADC value post contrast it shows heterogeneous enhancement so both are CT and MRR cross sectional imaging showing you the extension and here it is also extending to the supra orbital air cell but there is no intracranial extension a sinonazole carcinoma was given and the histopathology came as adenoid cystic carcinomas they are very rare tumor sarajevi grants are more affect involved in sinonazole region and the problem is you cannot really differentiate a adenoid cystic carcinoma from a suomacil carcinoma another patient with epistasis headache nasal obstruction you have the lesion which is now has an intracranial extension along the base of the antiraclinin kosha with erosion of the cribriform plate fovia ithmoidalis this turned out to be a esthesia neuroblastoma so yes there is a confusion when it comes to ithmoidal cell tumor and esthesia of rastoma i'm not going to read all this because i'm falling short of time now this is 11 month old so our age is changing 11th old 11 month old male mother knows this just swelling so again a soft tissue density lesion in the nasal cavity extending into the orbit lamina paparice has eroded and it is abutting the medial rectus muscle on post-contrast study it shows heterogeneous now the age is different so when you have a child now this was less than two years and you have a large lesion which is causing erosion like you're in lamina paparice are normal and abnormal think of abdomia sarcoma common in males Caucasian children below the age of 15 types you all know and i'm a differential diagnosis of lymphoma treatment is usually a radiotherapy now this is an interesting case i will quickly go through it a 65 year old histopathologically rhinoscleroma a debulking surgery was done we did a CT scan on 13 december 2021 you see again a soft tissue density lesion with ithmoid invasion medullary sinus this is plain let's see what happens on post-contrast and this on bone window shows rarifaction it is not complete erosion but rarifaction of the medial wall of the medullary sinus posterior lateral wall of the medullary sinus and also the interior wall so there is a rarifaction of the lesion and the current CT also shows that the second CT that is that was for us the current CT shows that this is an enhancing lesion which is has got a large preseptile component and it is abutting the eyeball and has got has got an anterior nasal cavity component and pre-ental component and to our surprise look at the lesion in the neck multiple lymph nodes on the left side right side a large lobulated mass causing all the mass effects on the internal carotid artery the common carotid artery and this lesion has an intraoral component so extensive lymph adenopathy so we told them that kindly revisit and repeat a biopsy because on on imaging it looks like a lymphoma though it has a rhinoscleroma diagnosis from before and the repeat biopsy suggested the lymphoma so lymphoma can occur in synonasal cavity remember necrosis is uncommon compared to other malignancies in lymphoma on MRI it is iso intense to other soft tissues on T1 with homogenous enhancement a characteristic feature of NHL is hyper intense signal on long that is T2 aided images or stir sequences now just quickly going to quickly go into the different spectrum that is increased bone density this is ground glass opacity involving the zygoma as well as the maxilla basically encroaching the magrary sinus this is nothing but fibrous dysplasia once quick example of a three-year-old child with nasal blockage due to a a lesion which they could see in the nasal cavity the child had a nasal be nasal breathing so actual coronal sagittals or plane images shows a hypodense lesion in the nasal cavity which is expanded with displacement of the nasal septum on contrast study there is no enhancement and maybe there is a kind of a defect seen in the level of the cribriform plate it went ahead and that did MRI MRI shows that it's a hypo intense lesion in the nasal cavity with few septum on T2 sagittal and coronal image you can see hyper intensity hyper intense signal within the lesion which is involving the anterior nerve of the posterior koina and there is this stock like area with a defect which I showed you on the CT scan we usually don't do flare below the age of two years but in this patient we did flare to show that this is nothing but CSF because the signals have got suppressed post contrast also did not show any enhancement of the lesion per se but peripherally there was enhancement and patient was operated for this encephalosil frontal it model encephalosil so basically there are three types of frontal encephalosil nasal it model being the most common which was the case I showed you nasal frontal being second and the least common being nasal orbital few quick examples of mucosils there is complete opacification of the involved peronazole sinus like in this the ethmoid peronazole sinus pressure erosion of the adjacent mode like in this patient here is the lamina papyrusia erosion and there is extension of the lesion into adjacent compartments like in this this is the extra corner extra corner compartment of orbit causing mass effect on the medial rectus stretching the optic nerve and also causing proptosis so basically it is complete opacification of the peronazole sinus whichever it is involved like here it is involving the part of the frontal sinus supraorbital air cell complete opacification non-enhancing pressure erosion and it is abutting the eyeball so mucosil just showing you the bone window that it is pressure erosion so I have already told you complete opacification expansion thinning out or bony resorption and extension into the adjacent structure now hyper dense lesion like here this is a bony lesion seen in the ethmoid air cell this is nothing but an ostoma what is the importance smaller as ostomas or the size is important because it can hamper the drainage side this was a large cartilaginous tumor which is seen in the lesion or you can say a hyper dense a lesion expansile lesion seen in the nasal cavity with conduit max conduit max matrix and expansion of the nasal cavity it is not extended into the orbit neither has he extended into the maxillary sinus except the ostomy at the unit is compromised so there is maxillary sinusitis so this was a conduit tumor some other hyper dense lesion areas in the nasal cavity or in the max or in the peronazole sinuses like in this this is a rhinolith or it could be a foreign body with if there is no history of foreign body insertion and this if you can see you can safely call it a rhinolith if something similar is there in the sinus it can be a sinus like in this patient where there is sinusitis with high density area within the opacified maxillary sinus this is nothing but a sinus so before you before the end I would like to summarize by saying sinus and neoplasms are rare accounting for 3 percent of head and neck malignancies and 3.6 percent of upper aerodigestive tracts malignancies in the national institute of health surveillance epitomology and end result studies CTR and MRI are complementary modalities CT diagnosis common pathologies as regards to neoplasm location and overall size of such masses and then potential extension into the adjacent lesion thus there is what is our role is to help them plan their therapy either surgical resection or at least debulking if not complete resection basically to prognosticate and tell the patient what are the chances of there losing the eyesight or losing the they have to open up the cranium because it to open up a cranium or the skull and to tell the patient is a very important part of the ENT surgeon and you should tell yes there is a extension into the intracranial that finishes my lecture thank you so much for having me here thank you so much for sharing your knowledge ma'am there are no questions in the box yet let me stop sharing thank you Abhishek thank you so much ma'am before we move on to the next session we have Dr. Parker stepping in for a quick word thank you Naga I think you go back to the match right Naga