Subtotal darkening of the maxillary sinuses
As a rule, subtotal darkening of the maxillary sinuses is a consequence of chronic sinusitis in the acute stage.
Very often, a common cold can be fraught with a long-term persistent runny nose, which is difficult to get rid of.
Table of contents:
- Subtotal darkening of the maxillary sinuses
- X-ray: where to start
- X-ray of the maxillary sinus in normal and pathological conditions
- Symptom of "milk in a glass"
- How else are the sinuses examined?
- Subtotal darkening of the maxillary sinuses
- X-ray PPN - what is it?
- Why is a PPN x-ray prescribed?
- What can be seen on an x-ray?
- Interpretation of the radiograph
- What pathologies are detected using X-ray of PPN?
- Hypertrophic maxillitis
- Oncological diseases
- Cyst in the paranasal sinuses
- Exudative sinusitis
- Conclusion
- DARKENING IN THE MAXILLARY SINUS
- Causes of subtotal darkening of the maxillary sinuses on an x-ray
- Etiology and symptomatic picture of diseases
- Therapeutic measures
- Lor-RO
- Leading specialists in the field of otolaryngology:
- Volkov Alexander Grigorievich, Professor, Doctor of Medical Sciences, Head of the Department of Otorhinolaryngology, Rostov State Medical University, Honored Doctor of the Russian Federation, I Full Member of the Russian Academy of Natural Sciences, Member of the European Society of Rhinologists.
- Read more about the doctor...
- Boyko Natalya Vladimirovna, Professor, Doctor of Medical Sciences.
- Read more about the doctor...
- Zolotova Tatyana Viktorovna - Professor of the Department of Otorhinolaryngology of the Rostov State Medical University, Doctor of Medical Sciences, Corresponding Member of the Russian Academy of Economics, Best Inventor of the Don (2003), Awarded: V. Vernadsky Medal (2006), A. Nobel Medal for merits in the development...
- Read more about the doctor...
- Karyuk Yuri Alekseevich - otolaryngologist (ENT) of the highest qualification category, candidate of medical sciences
- Read more about the doctor...
- Page editor: Kryuchkova Oksana Aleksandrovna.
- MALIGNANT TUMORS OF THE MAXILLARY SINUSES: DIFFERENTIAL X-RAY DIAGNOSIS
Over time, patients develop headaches, especially with a sharp turn of the head, impaired sense of smell and taste, weakness and swelling of the eyelids, and runny nose. With untimely or inadequate treatment, the latter symptom can develop into a very dangerous disease called sinusitis and subsequently lead to subtotal darkening of the maxillary sinuses.
X-ray: where to start
During the examination, the specialist will make a preliminary diagnosis of “sinusitis” and send you for an x-ray to clarify suspicions.
An x-ray is a collection of images of the anatomical structures of the body obtained by x-ray irradiation. An X-ray image, like any negative image, consists exclusively of black and white shades. This is due to the fact that each tissue in the human body has its own degree of absorption of gamma radiation. The more tissue absorbs, the brighter and more intense it is visible in the image.
To diagnose certain diseases, it is extremely necessary to perform fluoroscopy in the optimally correct position, since only in this projection the areas required for inspection become visible. For example, there are several sinuses in the skull:
- frontal (frontal) sinus;
- wedge-shaped (main);
- maxillary (maxillary);
- lattice labyrinth.
In order for the nasal sinuses to be as visible as possible in the image, it is necessary to shoot in the following projections:
- axial - mainly used to assess the condition of the base of the skull, the rocky part of the temporal bone and visualization of the main sinuses;
- lateral – important for examining the frontal, determining the size of the sphenoid and maxillary sinuses, the condition of the anterior parts of the facial bones and the base of the skull;
- nasofrontal – optimal for studying the frontal sinuses, cells of the ethmoidal labyrinth and orbits;
- The most clear way to trace the pneumatization of the maxillary sinus is to position the patient with the chin and nose resting on the X-ray machine stand (nasochin position).
For correct diagnosis, it is very important that the image has good contrast and sharpness and does not have any extraneous shadows or artifacts. All this together will make it much easier for the doctor to make the correct diagnosis.
As a rule, complete darkening of the maxillary sinuses indicates that a large amount of pus has accumulated inside them due to an extensive inflammatory process caused by harmful microorganisms.
X-ray of the maxillary sinus in normal and pathological conditions
Before moving on to diagnostic criteria, it is necessary to evaluate the quality of the image. To do this, you need to pay attention to the clarity of the ethmoid bone structure and the pneumatization of the nasal sinuses.
The sinuses are hollow structures that have the same pneumatization as the orbits of the eyes, due to which they have the same dark color on an X-ray image. Therefore, during the initial assessment of the condition of the maxillary sinuses, it is necessary to simply compare them with the orbits.
In the initial stage of sinusitis, X-rays can reveal thickening of the affected contours, which may indicate inflammation of the mucous membrane. Thickening of the maxillary sinus mucosa can be observed in several cases:
- catarrhal (acute) inflammation;
- chronic process (exacerbation);
- swelling after treated sinusitis or allergies.
Also, do not forget that the ethmoid labyrinth is the first structure in which inflammation develops during sinusitis. In the absence of timely treatment, the process spreads to other sinuses, including the maxillary sinus, which is determined by subtotal darkening on the radiograph. Therefore, if there are no changes in this sinus, it is worth taking a close look at the structure of the ethmoid bone.
Symptom of "milk in a glass"
As acute sinusitis progresses, liquid contents accumulate in the maxillary sinus - an infiltrate, which is detected on an x-ray as a level of liquid against a background of subtotal darkening - the “milk in a glass” symptom. Subtotal darkening can be unilateral or bilateral, with different levels of fluid. As a rule, the darkening is homogeneous, homogeneous, with signs of thickening of the mucous membrane.
With sinusitis, an x-ray may not reveal the “milk in a glass” symptom, but there may simply be a homogeneous darkening in the entire maxillary sinus - a total darkening. This indicates that the entire sinus is clogged with pus and requires immediate surgical intervention.
Puncture of the sinus for the purpose of pumping out the contents significantly improves the general condition of the patient - the temperature decreases, headaches decrease. Also, pumping out the liquid allows you to study its nature more closely, so the puncture can also be carried out for diagnostic purposes, among other things. Despite the fact that emptying the cavity brings great relief to the patient, the treatment is not considered complete and must be supplemented with a course of antibiotic and hormonal therapy, which can be combined with the use of vasoconstrictors and rinsing the sinuses with various antiseptic solutions.
Subtotal and total darkening of the maxillary sinuses may also indicate the presence of dense neoplasms in the nose - sarcoma, osteoma, chondroma, etc. The formation can be homogeneous or have a dense membrane with liquid contents.
If the neoplasm is small in size and does not contribute to the accumulation of infiltrate, then the patient is not characterized by intoxication and the presence of pain. If the cyst is large, secondary sinusitis develops, the treatment of which may not give the desired result. Therefore, you must first differentiate the nature of the formation and take measures to remove it.
How else are the sinuses examined?
In addition to radiography, the most complete and voluminous picture of all pathological processes will be provided by studies such as magnetic resonance and computed tomography. They will provide more accurate information about the pathological process in the affected sinus, inside and outside the process. The method is expensive, but informative. There is also a method of ultrasound scanning of the maxillary sinuses, which does not provide much information, but is able to distinguish swelling from infiltration.
In any case, the attending physician must select a diagnostic method and study the conclusions, since it is he who is able to select adequate therapy depending on the type of pathological process in the affected sinus.
Source: http://gaimorit-sl.ru/diagnostika/subtotalnoe-zatemnenie-gaimorovyh-pazuh.html
Subtotal darkening of the maxillary sinuses
What is subtotal darkening of the maxillary sinuses? If an x-ray shows a decrease in transparency in the lower and middle parts of the maxillary sinus, this may indicate the presence of infectious inflammation or a benign tumor - a cyst, a polyp. X-rays are prescribed to patients if sinusitis, polypous sinusitis, cancer, etc. are suspected.
X-ray examination of the paranasal sinuses (SNS) allows us to assess the level of pneumatization (presence of air) in the mentioned anatomical structures. The image assesses the degree of inflammation of the maxillary sinuses, i.e. maxillary sinuses, and prescribe adequate treatment. The article discusses the interpretation of radiographs, as well as pathologies that are detected during subtotal and parietal eclipse of bone cavities.
X-ray PPN - what is it?
X-ray PPN is an instrumental method for examining the paranasal sinuses, which makes it possible to identify pathologies in the early stages of development. An X-ray image gives a clear idea of what pathological processes occur in the paranasal sinuses. Transillumination of intranasal structures allows you to determine:
- degree of inflammation of the mucous membranes;
- the presence of serous or purulent exudate in the nasal cavity;
- formation of benign or malignant tumors.
During the examination of the patient, the radiologist takes two pictures - in a supine and standing position. The absence of any pathologies in the maxillary sinuses looks like this on x-ray:
- the bone walls of the paranasal sinuses have a clear outline;
- the contours of the ethmoid cells located at the level of the nasal septum are not blurred;
- Pneumatization of the PPN is no different from the reference one, which is located at the level of the eye orbits.
If, after an instrumental examination, darkened areas are detected in the image, the patient is referred for a computed tomography scan. After an accurate diagnosis, he prepares a suitable drug treatment aimed at eliminating the inflammatory reactions in the maxillary sinuses.
Why is a PPN x-ray prescribed?
In the bones of the skull there are several pairs of air cavities, which are called paranasal or paranasal sinuses (sinuses). Their inner surface is covered with soft tissues, in particular ciliated epithelium. Its inflammation often leads to the development of sinusitis.
Sinusitis is a collective term for a group of respiratory diseases characterized by inflammation of the pelvic floor. Radiologists pay attention to the fact that not every sinusitis is sinusitis. Only when the maxillary (maxillary) sinuses are affected is a diagnosis of “maxillitis” or “sinusitis” made.
X-ray visualization of the maxillary sinus allows us to identify several forms of sinusitis:
An otolaryngologist cannot diagnose “sinusitis” only on the basis of the patient’s medical history and complaints.
When receiving an unclear image, it is impossible to say with certainty that the patient suffers from one or another type of pathology. In this case, the diagnostic examination is supplemented by computed tomography.
What can be seen on an x-ray?
The radiological term “opacification” actually refers to light spots in the sinus cavity. In the absence of pathological processes in the respiratory tract, the maxillary sinuses are quite dark. It is possible to understand that fluid or pus has accumulated in the paranasal cavities only by comparing the shade of the spots inside the bone structures with the spots in the eye orbits. If the shade in the right or left maxillary sinus is lighter than in the orbit, the development of bacterial sinusitis or a cyst is suspected.
As a rule, treatment is prescribed after a specialist makes a puncture in the maxillary sinus if there is pathological content in it. After this, the biomaterial is sent for microbiological examination, based on the results of which the causative agent of the infection is determined. And only after this, the otolaryngologist develops a suitable treatment strategy, prescribes antibiotics, corticosteroids and other drugs.
Interpretation of the radiograph
Even with an X-ray examination of the maxillary sinuses, it is not always possible to say that the cause of pathological symptoms is sinusitis. Deciphering the image requires analysis of a number of anatomical structures:
Deciphering one x-ray takes an experienced specialist no more than 10 minutes of time. If there are obvious dark spots in the bone cavity, the doctor may accidentally diagnose cancer. What does the specialist’s medical report indicate and how is the image interpreted?
- exudative maxillitis - light spots with a clear horizontal border in the upper part of the maxillary sinuses;
- parietal-hyperplastic maxillitis - parietal darkening in the area of the bone walls, associated with swelling of the mucous membrane; the wavy contour of the bone cavity faces the inside of the sinus;
- exudative maxillitis - total darkening of the maxillary sinuses associated with the accumulation of fluid in the anatomical structures;
- polypous sinusitis - protrusion of the parietal part of the sinus into the bone cavity;
- purulent sinusitis - subtotal (almost complete) darkening of one or both maxillary sinuses.
The above transcripts are provided for informational purposes only and therefore cannot be used for independent diagnosis and drawing up a treatment regimen.
Only a doctor can assess the degree of impairment of pneumatization of the maxillary sinus using an x-ray. When making a diagnosis, they take into account structural changes in the ethmoidal labyrinth, as well as the clarity of the contours of a single cell.
What pathologies are detected using X-ray of PPN?
X-ray of the PPN reveals characteristic changes in the intranasal structures. In a healthy person, the paranasal sinuses look like semi-oval dark formations. To identify pathology, you need to compare the degree of their staining with the shade of the eye orbits. Parietal darkening of bone cavities indicates the development of a whole range of respiratory diseases.
Hypertrophic maxillitis
Hypertrophic maxillitis is a chronic inflammation of the maxillary sinus, accompanied by thickening of the mucous membrane. In the image, the pathology does not appear as darkening, but as a wall layer with a ragged, curved edge. The interpretation of the radiographic image is described as follows: parietal darkening of the maxillary sinus due to hypertrophy (thickening) of the mucosa.
If the diagnosis contains the phrase “total darkening,” this indicates a complete violation of the pneumatization of the bone cavity. In other words, the patient is found to have complete obstruction (airlessness) of the maxillary sinus. Treatment of the disease involves the use of antibiotics and nasal corticosteroids. If the pathology has developed against the background of allergic rhinitis, antihistamines are included in the treatment regimen.
Oncological diseases
Transillumination of the maxillary sinuses allows us to determine the presence of benign or malignant tumors in the intranasal structures. By analyzing the x-ray, a specialist can identify:
- osteoma is a benign neoplasm that occurs in bone tissue; the tumor grows very slowly and almost never becomes malignant, so its course is considered favorable;
- sarcoma is an actively growing malignant tumor, which consists mainly of connective tissue; the rapid development of pathology leads to the destruction of bone structures in the paranasal sinuses;
- chondroma - a cartilaginous tumor prone to malignancy (malignancy); It is diagnosed mainly in young children and adolescents.
Benign and malignant tumors are subject to surgical removal and subsequent drug treatment.
Cyst in the paranasal sinuses
As a rule, a cyst on an x-ray is a surprise to a specialist. The process of tumor formation does not cause any discomfort to the patient, so in most cases it is diagnosed accidentally during an endoscopic or radiographic examination.
Spontaneous opening and evacuation of purulent secretion from the cyst into the surrounding tissues can lead to complications. A cyst is a hollow neoplasm containing fluid inside. In the picture, the cyst looks like a rounded small shadow located in the middle or lower part of the maxillary sinus. Treatment of cystic tumors requires surgery.
Exudative sinusitis
If the maxillary sinuses are filled with serous effusions, a horizontal level of fluid will be visible on the x-ray. In most cases, this indicates the development of exudative sinusitis - a respiratory disease in which a lot of fluid accumulates in the maxillary sinuses.
When carrying out differential diagnosis, a puncture is taken from the affected sinus to accurately determine the type of pathology. In otolaryngology, the following forms of sinusitis are distinguished:
- catarrhal - filling of the paranasal sinuses with serous effusions, accompanied by redness (hyperemia) and swelling of the mucous membrane;
- hemorrhagic - a dangerous and quite rare form of the disease in which blood accumulates in the maxillary sinuses;
- purulent - bacterial inflammation of the accessory sinuses, characterized by the accumulation of purulent exudate in the bone cavities.
Hemorrhagic sinusitis is dangerous due to increased vascular permeability, in which infection can easily penetrate the systemic bloodstream.
To treat the catarrhal form of the disease, vasoconstrictor drops (decongestants), mucolytics, antiallergic and antiviral agents are used. Purulent inflammation can be eliminated only by taking systemic antibiotics and local antimicrobial agents.
Conclusion
X-ray of the PPN is one of the most informative methods for examining patients suffering from respiratory diseases. Photographing intranasal structures is not accompanied by excessive radiation load on the body. An X-ray can be considered one of the most reliable methods for early diagnosis of pathologies of the paranasal sinuses.
Subtotal darkening on an x-ray looks like a large bright spot that fills almost the entire cavity of the maxillary sinus. This picture often indicates the presence of fluid or tumor in the maxillary sinuses. In turn, parietal darkening may indicate inflammation of the mucous membrane or the formation of a nasal polyp on its surface.
Author: Irada Huseynova
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DARKENING IN THE MAXILLARY SINUS
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Hello! I kindly ask you to help me make the correct diagnosis and preferably prescribe treatment, since I live in a village and there are no specialists to read the picture. The radiologist wrote in his conclusion “left-sided sinusitis” - darkening of the left maxillary sinus. At first I was just sick, with a runny nose and cough, and after a few days the runny nose started again, the headache in the frontal part, the back of the head and the bridge of the nose itself hurt, and I also felt very dizzy. I'm interested in the question: is there pus in the sinuses? Is it worth going to the city to see specialists or can you be treated with antibiotics?
c9ddc6b169531good afternoon! Help me figure out what’s wrong with my photo, I’m enlisting in the Ministry of Internal Affairs, so I still have a medical-military commission, will they let me through or reject me? That's what worries me about my photo. The doctor's conclusion is as follows: “prestal darkening in the sinus cavity.” Is treatment required or is this normal? Oh yes, I’m generally allergic and it just got worse in August, but you can’t tell from year to year when there is and when there is no allergy. In general, I feel good now, I haven’t been sick, my nose is breathing perfectly, I don’t have a runny nose and never had one.
blood. Nosebleeds are a common occurrence. I’ll send you a picture from the x-ray and what they wrote on the chart. I can’t make it out myself. They prescribed sinupret, loratadine, ascorutin
The ENT diagnosed: acute bilateral maxillary sinusitis (exudative on the right). He suggested doing a puncture of the maxillary sinus and treatment based on the results. I have a question - is there really no way without a puncture? After all, no nasal discharge is observed.
Source: http://www.consmed.ru/otorinolaringolog/view/486801/
Causes of subtotal darkening of the maxillary sinuses on an x-ray
With the onset of cold weather, a person becomes more susceptible to a variety of viral, infectious and colds. Their course is accompanied by a whole list of symptoms, including darkening of the maxillary sinuses, revealed on an x-ray.
The appearance of any inflammatory processes in the area of the maxillary sinuses is often indicated by subtotal darkening, clearly visible on an x-ray image. As a rule, it appears in the lower parts, indicating inflammation of the mucous epithelium lining the sinuses. In addition, it is a sign of excessive accumulation of purulent discharge in the cavity.
Darkening is easily established as a result of radiography and is detected by a radiologist. The examination also determines the presence of pus in the cavity, the degree of swelling of the sinuses and the location of the source of inflammation. The most likely causes of such changes are all kinds of sinusitis and other diseases of a similar nature.
Etiology and symptomatic picture of diseases
Most often in such cases, sinusitis is detected. It can develop in one or both cavities of the maxillary sinuses. It is characterized by the formation of purulent discharge, which, when accumulated, leads to difficulty breathing. As a result, the sense of smell sharply deteriorates, severe headaches occur, and vision often deteriorates.
Important! Often, sinusitis is preceded by inflammatory processes in the mucous membrane of the epithelial tissue lining the ethmoid bone.
If the darkening of the maxillary sinuses is diagnosed too late, they can spread to neighboring cavities.
In addition, other signs indicate the disease:
- high body temperature;
- severe nasal congestion;
- general state of weakness;
- hypersomnia (excessive sleepiness);
- copious mucus secretion;
- swelling of the eyes.
Sinusitis can also cause subtotal darkening. This is an inflammation of the mucous membrane of the epithelium covering the paranasal sinuses. It is caused by viruses or pathogenic bacteria. It develops in case of untimely treatment of acute respiratory viral infections, acute runny nose, and various injuries in the facial area. In some situations, the source of infection is teeth affected by caries.
The clinical picture includes:
- purulent nasal discharge;
- photophobia (painful perception of bright light by the eye);
- temperature increase;
- impaired lacrimation;
- constant headaches.
Finally, one of the most severe forms of sinusitis – frontal sinusitis – can lead to darkening of the maxillary sinuses in the image. It is an inflammation of the mucous membrane of the frontal sinus. As a rule, it is accompanied by profuse purulent discharge from the nose. At first they have a yellow-green tint, but over time they begin to lighten. The cause of frontal sinusitis is all kinds of injuries to the frontal bone, rhinitis, and acute runny nose.
Depending on the speed and severity, acute and chronic forms of the disease are distinguished. The clinical picture of these two types is different.
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Important! If the disease is not detected and treated in a timely manner, frontal sinusitis is highly likely to turn from an acute form into a chronic one.
In the acute form, the following symptoms are observed:
- breathing problems;
- pain in the frontal lobe, intensifying when pressed;
- temperature increase.
- copious nasal discharge with a specific odor;
- increased pain in case of drinking alcohol, smoking and fatigue;
- severe pain in the frontal region, pressing or aching in nature;
- Mostly in the morning, expectoration of sputum occurs.
If you have one or more of the symptoms described above, you should immediately consult a doctor.
Therapeutic measures
First of all, the specialist carries out a number of diagnostic measures to determine the type, stage and severity of the disease. For this purpose, the patient is sent for an X-ray examination. The resulting image fully reflects the picture of the development of the disease. In addition, if necessary, the composition and type of fluid filling the sinuses is determined.
Next, the treatment method is selected. In most cases, a puncture of the maxillary sinuses is prescribed. During this procedure, the doctor pierces the inflamed cavity with a specialized needle, then thoroughly rinses it and removes the accumulated purulent discharge. Such an operation can be carried out from one to several times.
However, more and more often today they resort only to medication, avoiding surgical intervention. The basis of such therapy is a variety of broad-spectrum antibacterial drugs. They quite effectively destroy the source of inflammatory processes.
Important! When diagnosing a particular pathology, you should never self-medicate.
Since this will not only not lead to recovery, but will also cause severe complications, including death.
Subtotal darkening of the maxillary sinuses quite naturally raises the patient’s question – what is it and what is causing it. Such changes can indicate a whole range of different diseases. But do not despair, because modern medicine allows us to reduce all negative manifestations of the disease to a minimum, and also makes it possible to avoid serious consequences. Specialists have precise diagnostic methods at their disposal, the main one being radiography. When treating, the doctor can rely on both drug therapy and surgical intervention.
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Source: http://opnevmonii.ru/nos/zabolevaniya/gajmorit/subtotalnoe-zatemnenie-gajmorovyx-pazux.html
Lor-RO
Leading specialists in the field of otolaryngology:
Volkov Alexander Grigorievich, Professor, Doctor of Medical Sciences, Head of the Department of Otorhinolaryngology, Rostov State Medical University, Honored Doctor of the Russian Federation, I Full Member of the Russian Academy of Natural Sciences, Member of the European Society of Rhinologists.
Read more about the doctor...
Boyko Natalya Vladimirovna, Professor, Doctor of Medical Sciences.
Read more about the doctor...
Zolotova Tatyana Viktorovna - Professor of the Department of Otorhinolaryngology of the Rostov State Medical University, Doctor of Medical Sciences, Corresponding Member of the Russian Academy of Economics, Best Inventor of the Don (2003), Awarded: V. Vernadsky Medal (2006), A. Nobel Medal for Merit in the Development of Invention (2007) .).
Read more about the doctor...
Karyuk Yuri Alekseevich - otolaryngologist (ENT) of the highest qualification category, candidate of medical sciences
Read more about the doctor...
Page editor: Kryuchkova Oksana Aleksandrovna.
MALIGNANT TUMORS OF THE MAXILLARY SINUSES: DIFFERENTIAL X-RAY DIAGNOSIS
Recognition of primary malignant tumors of the nose, nasopharynx and maxillary sinuses in many cases is based on either simpler or more complex differential diagnosis with other lesions. It does not require explanation that distinctive recognition is carried out based on the sum of all clinical symptoms, among which X-ray signs play a significant role. The range of diseases that need to be differentially diagnosed is quite significant. Moreover, the more difficult it is, the more clear is the logical sequence in resolving two questions that are usually intertwined and merge with each other: 1) is the lesion malignant?
2) in which organ the detected malignant tumor originated.
To answer the first question, it is necessary to differentiate cancer and sarcoma with a large number of inflammatory dystrophic, dysplastic and benign tumor processes that occur inside the maxillary sinus, in the cavities of the nose and nasopharynx, in the bones of the facial skull, soft tissues of the face, etc.
For. To answer the second question, it is necessary to differentiate primary tumors of the nasal cavity, maxillary sinuses and nasopharynx with secondary ones that spread to these organs per continuitatem.
Practical differential diagnosis by a number of researchers and our own experience show that for some patients it is not possible to determine the nature or important features of the lesion, despite the use of all clinical and radiological research methods. In such cases, it is necessary to resort to one or another form of pathological examination.
Apparently, the views of different authors are unanimous regarding both the benefits and indications for biopsy. V. S. Brezhnev, for example, believes that the indications for excisional biopsy of bone tumors established at one time (E. A. Lichtenstein, 1952) are quite applicable for malignant lesions of a number of organs of the upper respiratory tract. Our own experience in studying primary malignant tumors of the nasal cavity, maxillary sinuses and nasopharynx also shows that such indications really are:
1) suspicion of a malignant neoplasm and the inability to quickly and reliably establish a diagnosis using clinical methods;
2) the need for complete and absolute confidence in the diagnosis before very serious treatment measures (massive radiation therapy, jaw resection, etc.);
3) the need to find out tumor features that are inaccessible to clinical and radiological methods;
4) study of tumors, in particular comparative assessment of various types of therapy.
In recent years, along with the so-called exfoliative cytology, a new direction in the diagnosis of tumors has emerged and widely developed in our country - diagnostic puncture followed by cytological examination of the resulting cell suspension. The experience already collected in puncture determination of the nature of various lesions of the paranasal sinuses and bones makes it possible to highly appreciate the diagnostic puncture as an additional method of recognition to the clinical one. A puncture, of course, cannot yet completely replace a biopsy either in the evidence of conclusions or in the detail of determining the nature of the neoplasm, its histogenetic affiliation, etc. Therefore, the biopsy retains its indications. However, one should persistently emphasize the main advantage of a diagnostic puncture - the low burden on patients.
Both biopsy and diagnostic puncture should be considered as the last diagnostic measure when all other methods of distinctive recognition have been completely exhausted.
Benign lesions arising inside the sinus
The variety of benign lesions of the maxillary sinuses is well known. Some of these lesions arise in the mucous membrane of the sinus itself or originate from its bone walls, while some invade the sinus for the second time, starting in the surrounding organs and tissues.
According to their nature, benign diseases of the maxillary sinus can be divided into inflammatory, traumatic, tumor, dystrophic, dysplastic, etc. It should, however, be noted that regarding a number of diseases there is no single point of view and any classification inevitably raises persistent objections. Here they are discussed only from one, narrowly practical point of view - the need to distinguish them from malignant tumors.
Naturally, only those diseases supposedly occurring inside the sinus that cause darkening of the maxillary sinus require X-ray differential diagnosis with blastemas. Indeed, with primary tumor lesions, the air content of the sinus sharply decreases, its darkening is an obligatory symptom. Therefore, X-ray detection of sinus transparency allows us to immediately reject the assumption of a neoplasm and, in general, of any intrasinus process. At the same time, negative X-ray data proving the intactness of the maxillary sinus always turns out to be the most easily achievable and convincing.
The differential diagnostic value of X-ray data is also great in cases of partial darkening of the maxillary sinus, in which distinctive recognition is relatively easy.
In fact, all the data known to date (section 6) show that before surgery, a malignant neoplasm invariably causes a total darkening of the sinus, at least by the time the patient notices his illness and consults a doctor. The darkening becomes inhomogeneous, partial, marginal, i.e., the same as in a number of benign processes, only after opening the sinus; in such patients, surgical findings and subsequent histological examination of the extracted material provide a confident diagnosis even before x-ray examination. If partial darkening is detected in non-operated patients, this directly means that the sinus lesion is benign in nature, which resolves the most important issue of differential diagnosis. Therefore, we can limit ourselves here to only a brief description of a number of nosological forms, the main x-ray symptom of which is partial darkening of the maxillary sinus.
Partial darkening is characteristic primarily of benign tumors developing in the bone walls of the sinus. Some of them (osteochondroma) are found in all parts of the skeleton, while others (cancellous osteoma, odontoma, adamantinoma) are characteristic of the jaws, including the upper one.
Intra-axillary osteochondroma appears to be very rare. One case of osteochondroma of the maxillary sinus is briefly described in the second edition of their book by Pendergrass, Schaeffer, and Houde. In our only observation, the tumor was located on the medial wall of the sinus and protruded into the lumen of the latter in the form of a very clearly defined semicircular rather dense shadow, against which spotted shadows of calcifications and tree-like branching, intertwined bone beams were projected, thinning and disappearing towards the periphery of the tumor. This X-ray pattern, well studied in other parts of the skeleton, allowed for preoperative recognition, which was subsequently confirmed histologically.
The X-ray picture turned out to be similar for a rare tumor for this location - glioma, which we also observed only once. The shadow of the glioma lying on the medial wall of the sinus had a semi-oval shape and a clear, smooth, arcuate contour. The overall density of the tumor shadow was significant, which depended on the inclusion of many small and minute spot-like calcifications (psammoma). No bone destruction was detected. X-ray symptoms made it possible to reject the assumption of a malignant tumor, with which the patient was sent, but it was not possible to establish the true nature of the neoplasm, since osteochondroma was assumed. The diagnosis of glioma was made based on histological findings after surgical removal of the tumor.
In the vast majority of cases, differential recognition of malignant tumors from osteomas and maxillary sinuses is simple.
The X-ray picture of osteomas of the paranasal sinuses has been well and repeatedly described. We had to observe only 3 osteomas of the maxillary sinuses, i.e., fewer than osteomas of the other paranasal sinuses (18 observations), which corresponds to the literature descriptions, the vast majority of which relate to osteomas of the ethmoid and frontal sinuses.
Osteomas of the maxillary sinuses raise suspicion of a malignant lesion either when they are large in size (when a bulge appears in the area of the canine fossa, exophthalmos and other signs of an increase in the volume of the sinus, sometimes accompanied by a feeling of fullness and even slight pain), or when the X-ray symptoms are incorrectly interpreted from a survey image of the sinuses , made due to persistent rhinitis. The detection of a dense shadow inside the sinus is regarded as a sign of a malignant tumor, as a result of which the patient is sent to specialized institutions or even subjected to radiation therapy.
Meanwhile, it is osteoma of the paranasal sinus that gives a very characteristic, one might say pathognomonic, X-ray picture. The additional shadow located in the maxillary sinus is dense, clearly caused by tissue containing lime. With a small osteoma or in the marginal parts of large osteomas, a cancellous bone structure can be detected. The contours of the osteoma are always very clear, in the vast majority of cases clearly polycyclic, which reflects the usually well-defined lobulation of this neoplasm - a specific and distinctive feature of almost all osteomas that have reached a sufficient size. Multiaxial radiography or tomography usually reveals that the shadow of the osteoma partially merges with one of the walls of the sinus, from which the stalk of the tumor or its wide base extends (Fig. 62).
Partial darkening of the maxillary sinus is caused by a frequently occurring cyst of the mucous membrane lining the sinuses.
Since there is no reason to think that the presence of a malignant neoplasm in one sinus causes the appearance of a cyst in another sinus, the cyst should be considered a common disease. As the above figures show, it occurred in 8.7% of all transparent sinuses, or in 5.6% of those observations in which there was no total darkening of the sinuses. In most patients, the discovery of a cyst was essentially an accidental finding; it did not cause subjective symptoms, and only a few patients presented minor complaints upon special questioning. This is consistent with everyday clinical experience - often very large retention cysts of the maxillary sinus mucosa are found in patients who began to complain just a few days before the examination; therefore, such cysts developed asymptomatically for a long time.
Distinctive recognition in cases where an enlarging cyst already occupies the entire maxillary sinus, and the pressure caused by the cyst on the walls of the sinus leads to their atrophy, is discussed below.
An X-ray picture similar to retention cysts of the maxillary sinus mucosa is given by periodontal cysts that have grown into the maxillary sinus, as J. Bardakh thoroughly demonstrated and our isolated observations confirmed. The distinction between the two named processes, possible on the basis of analysis of radiographs, stereograms and tomograms, is facilitated by the presence of a bone septum between the lumens of the periodontal cyst and the sinus. Here we should again mention the benefits of replacing or supplementing intraoral photographs of the alveolar process with extraoral ones. The latter make it possible to trace the upper sections of the cyst, the impossibility of which is persistently complained by Ya-Bardakh, who did not use such photographs. Confusion of X-ray signs of a periodontal cyst and a malignant tumor of the maxillary sinus occurs rarely.
The analysis of benign lesions that give partial darkening of the maxillary sinus should end with the most common of them - inflammatory thickening of the mucous membrane. A characteristic feature of the latter is the variability of the X-ray picture, which has long been described, especially under the influence of treatment: the wall shadows either become thinner and more delicate, then thicken again; exacerbations lead to the appearance of diffuse darkening of the sinus due to effusion, which can also quickly disappear, etc.
Differential X-ray diagnosis with primary malignant tumors becomes much more difficult in cases where a benign painful process developing inside the maxillary sinus leads to its total darkening. In this direction, one should consider cystic sinus distensions, cholesteatoma, fibromyxoma, angiofibroma and, almost most importantly, inflammatory diseases, which should be given first place.
Inflammation of the mucous membrane of the maxillary sinus is undoubtedly the most common lesion of the latter. The consequence of both acute and chronic sinusitis, as well as polyposis or polypous sinusitis, is often the filling of the entire maxillary sinus with pathological contents, which leads to its homogeneous darkening - the first and obligatory symptom also in primary malignant neoplasms of the sinus. Such similarity inevitably causes diagnostic errors: a significant proportion of patients suffering from cancer or sarcoma at the onset of their disease are treated for “sinusitis”.
As already indicated, despite all the practical importance of differential X-ray diagnostics between inflammatory and tumor lesions, it is, by all accounts, impracticable while the neoplasm is in the intracavitary phase of its development. It is well known that the intensity and homogeneity of sinus darkening, as well as the one-sidedness of the lesion, characteristic of tumors, also occur with sinusitis.
In some cases, if the contents of the inflammatory altered maxillary sinus are quite liquid and do not fill its entire lumen, when taking survey photographs in a vertical position of the patient’s head, it is possible to detect a horizontal level between air and pus, which indicates the inflammatory nature of the lesion.
Dynamic X-ray monitoring of patients brings well-known benefits. However, it must be used for differential diagnosis with great caution. General oncological considerations do not allow the period of such observation to be long, and in a short time (10-15 days) the development of a malignant tumor changes the X-ray picture little. In practice, usually only an attempt can be made to detect a decrease or disappearance of X-ray symptoms under the influence of conservative treatment, which is characteristic of inflammatory lesions. Therefore, dynamic x-ray observation should be used in those cases where the majority of data speaks in favor of the inflammatory process and repeated examinations of the patient should only confirm this assumption.
When treating sinusitis, the X-ray symptoms caused by it, as is known, are usually changeable - there is a decrease in the intensity of darkening of the sinus, often its partial clearing, etc. The absence of changes in darkening of the sinus, especially in combination with the patient’s continued poor health, casts doubt on the diagnosis of sinusitis and speed up recognition through pathological examination.
Differential X-ray diagnosis between malignant tumors and polyposis is very difficult, since polyposis usually causes darkening of both the nasal cavity and other paranasal sinuses. There remains only one indirect sign that distinguishes polyposis from a tumor: with polyposis, more often, there is a bilateral spread. In all cases of doubt, it is necessary to resort to pathomorphological examination of the contents of the sinus. However, even biopsy data do not always allow one to reject the assumption that the lesion is malignant.
In our own experience, polypous growths repeatedly accompanied the development of cancer, and the pieces taken for histological examination did not at all reflect the actual lesion.
Thus, the problem of using X-ray data for differential diagnosis between the early stages of primary malignant tumors of the maxillary sinus and inflammatory lesions of the latter remains unresolved.
In this regard, it is worth recalling that from an oncological point of view, we have to abandon the insufficiently strict assessment of the symptom of darkening of the sinus, which is often considered the basis for the radiological conclusion: “sinusitis”. Meanwhile, such darkening may be the first symptom of a malignant tumor. Consequently, if this symptom is the only one, then, apparently, one should deviate from the rule accepted in clinical radiology to complete the research protocol with a pathological interpretation of the detected symptoms and a conclusion about the nature of the lesion. Without these or those additional signs, without reliable clinical symptoms, one should not make a conclusion about sinusitis. The otolaryngologist, having received in the protocol only an indication of the filling of the maxillary sinus with pathological contents, is forced to use this sign in conjunction with all clinical data and decide for himself what the nature of the disease is. The absence of a conclusion will alert the attending physician and force him to conduct further research.
As has been repeatedly emphasized, in the opinion of all competent researchers, the ability to radiologically distinguish malignant neoplasms from inflammatory lesions of the sinus and thereby achieve at least partial overcoming of the existing recognition delay appears only in the phase of tumor spread, which occurs soon after the onset of the disease. It is necessary to once again list the most important signs of malignancy that appear in this phase, the failure of which leads to further neglect of the disease: regional darkening, deformation of the soft tissue shadow accompanying the lower orbital edge, signs of bone destruction, darkening of the lumens of surrounding organs. The presence of these signs allows one to identify blastomatous lesions of the maxillary sinus.
Total darkening of the maxillary sinus is also characterized by its cyst-like distensions - hydrops, mucocele or pyocele, depending on the contents of the sinus.
As the name of the disease suggests, cystic sprain is characterized by an increase in the volume of the sinus. However, this does not happen immediately. Thus, a retention cyst or accumulation of mucus can occupy the entire lumen of the maxillary sinus, without yet leading to changes in the walls of the latter. Intense and homogeneous darkening of the sinus does not provide any reference points for distinguishing between the cyst and the intracavitary phase of a malignant tumor, sinusitis, etc. X-ray examination in such cases only forces one to begin differential diagnosis using other clinical or pathomorphological methods. When an increase in the volume of sinus contents causes changes in its walls, this can be detected by x-ray examination much earlier than by all other methods of examining the patient.
Identical or very similar X-ray symptoms are characteristic of both an increasing accumulation of a particular fluid (true cystic sinus distension) and dense soft tissue benign tumors that arise inside the maxillary sinus.
Due to increased intra-sinus pressure, the walls of the sinus become thinner, and then bulge outwards to a greater or lesser extent, which leads to an increase in volume and deformation of the sinus and the entire upper jaw.
X-ray symptoms for expansively growing intracavitary tumors have already been partially outlined by V. G. Ginzburg: “1) upward movement of the line of the lower wall of the orbit on the chin-nasal photograph; 2) raising the infraorbital foramen to the level of the lower edge of the orbit; 3) deformation of the lower orbital foramen with pronounced changes; 4) posterior movement of the posterolateral wall of the sinus—violation of the symmetry of the “crossing of lines” on a semi-axial image.
To this we must add the symptoms of bulging of the other two walls of the maxillary sinus - medial and anterior. These walls sharply become thinner, acquire a shell-like character and, in the form of more or less steep arcs, protrude into the lumen of the nasal cavity and anteriorly, into the soft tissues of the cheek. The cross of the anterior wall becomes deformed or disappears altogether. An important symptom of cystic or benign tumor distension of the sinus is characteristic changes in the anterior outer edge of the upper jaw. The density and width of its shadow sharply decrease, concavity towards the sinus is replaced by straightness or even convexity.
These symptoms are visible both on the naso-chin image and on oblique images of the upper jaw and are perfectly reflected on stereograms and tomograms, which once again emphasizes the importance of using additional methods.
In most patients, the X-ray symptoms of cystic distension of the maxillary sinus are so clear and distinct that differential diagnosis with malignant tumors is not difficult.
However, in some cases, the thinning of the walls of the sinus can reach such a degree that it leads to partial and sometimes complete disappearance of one or another wall, which simulates a malignant lesion. Most mistakes, including our own, are made in such cases. An insufficiently in-depth x-ray examination may not only fail to resolve the diagnostic doubts of otolaryngologists, but even direct recognition along the wrong path.
In some patients, changes caused by a retention cyst - total intense darkening of the maxillary sinus, destruction of many of its walls, darkening of the ethmoid sinus, etc. - create a syndrome extremely similar to the syndrome of a primary malignant tumor.
At the same time, even in cases difficult to recognize, the reference
Rice. 62. Direct tomogram (at a height of 4 cm) of patient 3, 40 years old. Osteoma on the medial wall of the left maxillary sinus.
MALIGNANT TUMORS OF THE MAXILLARY SINUSES: DIFFERENTIAL X-RAY DIAGNOSIS
Rice. 63. Nasomental radiograph of patient M-va. On the right is a symptom of a significant expansion of the accompanying shadow. Homogeneous intense darkening of the right maxillary and ethmoid sinuses. Impacted tooth in the maxillary sinus. The outer anterior edge of the upper jaw is destroyed.
Points for distinguishing between cystic distension and tumor are still available.
The purely x-ray difference lies in the fact that with a cyst, on x-rays and stereo x-rays it is usually possible to trace the remains of the bulging walls of the sinus, mainly at the place where they depart from other walls. If it is possible to identify even a small remnant of a displaced, pushed back, protruding wall, the assumption of primary cancer or sarcoma should be abandoned. For our own experience of studying various lesions of the maxillary sinus forces us to fully agree with the position that was first formulated on the basis of his data by V. S. Brezhnev: in the presence of two x-ray signs at once - destruction of the walls of the sinus (characteristic of a malignant neoplasm) and protrusion of the walls (characteristic of benign processes) - the greatest importance should be given to the latter. Indeed, only benign lesions are capable of changing the position and shape of the thin bone plate that makes up the wall of the maxillary sinus and causing “swelling” of the latter. The mechanism of such “bloating” is well traced in other bones. It occurs when, along with slow atrophy from the pressure of the internal layers of the bone wall facing the lumen of the sinus, an even slower formation of new outer layers of bone occurs due to irritation of the periosteum. If the second of these processes lags behind the first, then a defect occurs in the walls of the sinus, reminiscent of bone destruction in malignant tumors.
Underestimation of the possibility of bone destruction occurring in an essentially benign process leads to diagnostic errors.
No less important for differential diagnosis is the discrepancy between the assessment of the severity of suffering from X-ray and clinical pictures, which is revealed in cases of advanced cystic distension of the maxillary sinus, which has caused significant bone destruction. If bone destruction were caused by a malignant tumor, then the latter would already have a widespread distribution and would cause a severe clinical picture and significant suffering for the patient. Meanwhile in. In such cases, pain is usually absent or mild and the entire manifestation of the disease is much milder than with a common malignant neoplasm.
The example below shows that the difficulties encountered in clinical differential diagnosis can be very great, but can be overcome with the help of x-ray examination.
Patient M-ov, 20 years old. 8 months before contacting the State Oncology Institute, short-term exophthalmos appeared, lasting several days, accompanied by moderate pain in the right cheek. After 2 months, lacrimation appeared from the right eye, and after another 3 months, difficulty breathing through the right half of the nose and exophthalmos again, now significant. A diagnosis of sarcoma of the right upper jaw was made, confirmed during the initial clinical examination at the institute.
The X-ray pattern of the detected changes is shown in Fig. 63, 64 and 65. Based on the totality of all data, we assumed a cystic distension of the right maxillary sinus with extension into the ethmoid labyrinth. To confirm this recognition, it was decided to perform maxillary sinusography.
Upon insertion of the needle into the maxillary sinus (through its medial wall), about 15 ml of yellowish purulent liquid with many small shiny crystalline inclusions was sucked out. Then 7 ml of iodolipol was injected into the sinus. The subsequent radiographs and stereograms (Figs. 66 and 67) showed an exceptionally large spread of the cyst, the size of which exceeded initial assumptions.
A cytological examination of the resulting fluid showed the following: neutrophils in a state of necrobiosis cover all fields of vision; a significant number of squamous epithelial cells without signs of atypia; a large number of cholesterol crystals; flora is missing. Conclusion: a festering cyst.
The diagnosis of the cyst was confirmed during radical surgery.
As already mentioned, benign tumors arising inside the maxillary sinus give almost the same x-ray picture as cystic sinus distension. This applies to rare fibromyxomas (Fig. 68), angiofibromas, etc.
Benign lesions extending into the sinus
X-ray examination is highly responsible and difficult, but in most cases very useful in the differential diagnosis between primary malignant tumors of the maxillary sinus and benign lesions extending into the lumen of the latter, arising in the bony walls of the sinus. These include adamantinoma, odontoma, osteoblastoclastoma, fibrous dysplasia of the maxilla and some other lesions.
Adamantinoma, which is characteristic of the lower jaw, relatively less often affects the upper jaw. Here it does not have the usual appearance of a multilocular cyst with clear septa separating different sizes of clearing. Adamantinoma, which arises in the alveolar process of the upper jaw, apparently spreads along the line of least resistance into the maxillary sinus, fulfills it and, continuing to develop, leads to an increase in the volume of the sinus.
Differential X-ray diagnosis with malignant tumors, which are suspected in patients due to facial deformation, is based on signs of expansive spreading of the walls of the sinus. Radiologically, with adamantinoma, a total darkening of the “swollen” sinus is determined, the walls of which are thinned, bulging, but usually preserved and can be traced on a series of radiographs or stereo radiographs.
Distinctive radiological recognition is essential for various types of dental odontics characteristic of the dentoalveolar system.
Differential X-ray diagnosis in rare cases of hard odontoma is practically uncomplicated. A dense, well-defined, polycyclic contour shadow of the odontoma itself, consisting of hard dental tissues, as well as a strip-like enlightenment surrounding such a shadow (corresponding to the connective tissue membrane or, more precisely, the tumor matrix) ensure correct recognition.
Differential diagnosis with soft odontoma turns out to be more difficult. We observed 3 patients with the named tumor, and in each observation it was possible to determine only the very likely benign nature of the lesion, but not the histogenetic affiliation of the neoplasm, which was established by pathomorphological examination after surgery. Soft odontoma gives (Fig. 69) almost the same x-ray symptoms as intra-axillary benign tumors or adamantinoma (according to T.P. Vinogradova, the histological difference between the two named tumors often presents technical, and, according to a number of researchers, fundamental difficulties) .
It seems to us that worthy of attention is an attempt to look for differential diagnostic x-ray symptoms of a rare type of odontomas - the so-called cementum, which has (T.P. Vinogradova) a unique structure. The basis of the tumor is cellular-fibrous tissue, which is a matrix for the formation of structures such as cementicles. Such cementicles lie isolated from each other, separated by layers of soft tissue. The quantitative relationships between the cell-fibrous basis of the tumor and its solid structures are different. In some cases there are a large number of cementicles, in others they are few in number and the bulk of the tumor consists of cellular elements and bundles of collagen fibers.
Such structural features of cementoma predetermine the x-ray picture of the lesion. Judging by the isolated observations that we have (3 patients), cementoma, arising inside one or another part of the upper jaw, soon leads to its destruction, as well as to the filling of the maxillary sinus. Due to the calm course of the disease, which is of little concern to patients, they seek help already at a time when the clinical and x-ray picture resembles a primary malignant tumor of the maxillary sinus: increasing facial deformation, often exophthalmos, pain, symptoms of regional darkening and deformation of the accompanying shadow, total and intense darkening of the sinus itself, accompanied by destruction of its walls, etc.
In our first observation, we mistook cementoma for cancer. Only upon retrospective examination of the radiographs was it noticed that the shadow of the tumor itself was uneven: against the background of the soft tissue compaction, very delicate, but still distinguishable compactions ranging in size from a pin to a match head were identified.
In the second observation, such dense inclusions were so clearly expressed that we overestimated their significance and suspected osteogenic sarcoma of the upper jaw. Again, subsequent histological analysis of the radiographs showed that the incorrect preoperative diagnosis was caused by incorrect interpretation of the radiological data. Due importance was not given to the low severity of symptoms from the soft tissues of the face, the inhomogeneity of the sinus darkening, etc.; in addition, if the existing symptoms could be interpreted in favor of osteogenic sarcoma, then a very advanced lesion should be assumed, which was not consistent with the mild clinical picture.
Only in the third observation were we able to correctly recognize the cementoma, using the reflection on the radiographs of the cementicles mentioned above.
Relatively often it is necessary to carry out a differential diagnosis between a clinically suspected primary malignant tumor of the maxillary sinus and fibrous dysplasia of the facial bones, primarily the upper jaw and zygomatic bone.
Patients seek help with very different severity of this still little studied disease, as noted by a number of authors [Fries et al. I and as confirmed in our experience. In some patients, only minor destruction of the lower orbital margin or the wall of the sinus is detected, while maintaining its transparency; in others, fibrous dysplasia of the jaw leads to extremely pronounced, severe changes (Fig. 70).
Frieze, not without reason, divides fibrous dysplasia of the jaws into three types: pagetoid, sclerotic and cyst-like. The greatest difficulties for differential diagnosis
is a cyst-like type, in which the maxillary sinus is filled with soft tissue contents, and its walls are swollen, deformed and partially destroyed. The basis for discrimination in such cases is the identification of at least small signs of expansive spreading of the walls of the sinus, as well as a comparison of significant, pronounced changes in the upper jaw and the inappropriate mildness of the clinical course of the disease.