Eur. Radiol.

6, 553-556 (1996) Springer-Verlag 1996

European Radiology

Original article
Another CT sign of sinonasal polyposis: truncation of the bony middle turbinate
E. Y. Liang 1, W. W. M. Lam 1, J. K. S. Woo 2, C. A. Van Hasselt 2, C. Metreweli 2
1Department of Diagnostic Radiologyand Organ Imaging,the ChineseUniversityof Hong Kong,Prince of Wales Hospital, Shatin, Hong Kong 2Division of Otorhinolaryngology,Department of Surgery,the ChineseUniversityof Hong Kong,Prince of WalesHospital, Shatin, Hong Kong. Received 9 May 1995; Revisedversion received 31 July 1995; Accepted 12 September 1995 ment plan [2-4]. Maximum medical treatment should be given before opting for surgery. Computed tomography is required to properly evaluate deeper pathology within the sinuses and behind the obstructing polyp which is not visualized with endoscopy [1]. Sinus CT is therefore important to confidently diagnose SNP and assess its extent and severity. Our aim was to study the features of SNP on coronal sinus CT, and to report a new sign: truncation of the bony middle turbinate.

Materials and methods

We reviewed retrospectively coronal sinus CT of 100 consecutive patients. All patients had significant symptoms suggesting recurrent inflammatory sinonasal disease and, FESS was being considered when CT was requested. They all had a period of medical treatment prior to CT scanning in order to demonstrate medically nonreversible disease on CT. There were 52 males and 48 females; all were Hong Kong Chinese; age ranged from 7 to 74 years. Sinonasal polyposis was the commonest pattern found in 34 patients. Seven patients did not have complete documentation and were rejected for further analysis. A total of 21 patients had final FESS diagnosis of SNR Six patients had endoscopic examination but no surgery: 5 patients had polyposis and 1 did not have nasal polyposis on endoscopy, but clearly had extensive bilateral polypoidal lesions in the sinuses on CT. The 27 SNPs with complete documentation were analysed. The incidence of our new sign "truncation of bony middle turbinate" were noted. Previously reported CT features [6], namely polypoidal mass, widened infundibulum, bony trabecular attenuation and lateral bulging of lamina papyracea, were also evaluated.

Introduction
The development of functional endoscopic sinus surgery (FESS) provides a tool by which surgeons can accurately diagnose, and meticulously and atraumatically perform, surgery for nasal polyp disease [1]. However, sinonasal polyposis (SNP) remains a significant challenge to the treating physician. Endoscopic surgery for sinonasal polyposis (SNP) is more extensive, more risky and the results are not as good as other patterns of sinusitis. Medical treatment is the mainstay of the treat-

Correspondence to: E.Y. Liang

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E.Y. Liang et al.: Another CT sign of sinonasal polyposis

E.Y. Liang et al.: Another CT sign of sinonasal polyposis

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Table 1. Frequencies of various features of sinonasal polyposis on coronal sinus CT in the current series and compared to the series of Drutman et al. [6] Drutman et al. Features Liang & Lam et al. Bilateral involvement (%) Percentage Percentage Incidence Polypoidal mass Widened infundibulum Bony trabecular attenuation Lateral bulging of lamina papyracea Truncation of bony middle turbinate 22 of 27 26 of 27 23 of 27 3 of 27 15 of 26a 81 96 85 11 58

8~ (~8 of ~) 88 (23 of 26) 100 (23 of 23) 66 (2 of 3) 80 (12 of 15)

9~ 89 63 51 -

a One patient who had previous bilateral middle turbinectomies was excluded from calculation; all 15 patients included had no history of previous turbinectomy

Table 2. Pattern of inflammatory sinus disease in the current series and compared to the series of Harnsberger et al. [5]
Disease-patterns SNP OMU Infundibulum SER Sporadic Normal Liang & Lam et al.

(%)

Harnsberger et al.

(%)

34 37 18 1 20 3

10 25 26 6 24 27

NOTE: In some patients there is simultaneous occurrence of more than one pattern resulting in the total of all percentages greater than 100

We n o t e d the p r e s e n c e of a previously u n d e s c r i b e d sign: t r u n c a t i o n of the b o n y m i d d l e turbinate. The bulbous part of the b o n y middle turbinate was missing, leaving b e h i n d a variable length of the vertical lamellar part of the b o n y middle turbinate. The sign was p r e s e n t in 16 of the 27 S N P patients. O n e of these patients had previous bilateral m i d d l e turbinectomies. Thus, the incidence of this feature was 15 of 26 (58 %); 13 of 15 (87 %) were bilateral. This sign was n o t f o u n d in o t h e r patterns of i n f l a m m a t o r y sinus disease.

Discussion Results
The C T features of these 27 SNPs are s u m m a r i z e d and c o m p a r e d with the findings of D r u t m a n et al. [6] in Table 1. All o u r SNPs w e r e bilateral. T h e r e was a strong t e n d e n c y for extensive i n v o l v e m e n t including the posterior e t h m o i d and sphenoid, which were m u c h less c o m m o n l y involved in o t h e r patterns of sinusitis. Sinonasal polyposis is relatively c o m m o n in our locality. T h e relative incidence of S N P d i a g n o s e d on c o r o n a l sinus C T in o u r series is m o r e t h a n three times that of H a r n s b e r g e r et al.'s series (Table 2), a l t h o u g h the same C T diagnostic criteria were used [5]. The difference could be due to a variety of reasons. T h e r e m a y be a difference in genetic allergic predisposition and m u c o s a l hyperreactivity; different e n v i r o n m e n t a l factors m a y also be important. R e f e r r a l patterns w e r e p r o b a b l y different. B e c a u s e we had m u c h lower incidence of n o r m a l sinus CT, o u r patients were m o r e likely to b e l o n g to a selected g r o u p with severe and r e c u r r e n t symptoms. These patients were m o r e likely to have S N P t h a n o t h e r patterns of i n f l a m m a t o r y sinus disease. I n c i d e n c e of various a l r e a d y - r e c o g n i z e d C T features of S N P in our series was similar to that r e p o r t e d by D r u t m a n et al. (Table 1), except that lateral bulging of lamina p a p y r a c e a was less c o m m o n in our series. Polypoidal masses in nasal vault and within sinuses w e r e very c o m m o n in b o t h series. W h e n the nasal vault or sinus was c o m p l e t e l y o p a q u e , the p r e s e n c e o f polyps was n o t a p p r e c i a t e d [7]. W i d e n i n g of i n f u n d i b u l u m was also c o m m o n in b o t h series. This sign can occur in diseases such as a n t r o c h o a n a l polyp, inverted p a p i l l o m a or any o t h e r conditions w h e r e there is a slow-growing mass within the i n f u n d i b u l u m e x p a n d i n g it. H o w e v e r , w h e n there is bilateral widening t o g e t h e r with o t h e r signs of extensive sinusitis, S N P w o u l d be the m o s t likely diagnosis. All o u r S N P patients have bilateral sinus involvement. Pansinusitis with extensive and bilateral inv o l v e m e n t is a strong suggestion o f S N R r a t h e r t h a n neoplastic condition, which tends to be focal and unilateral.

Fig.1. Normal appearance of the bony middle turbinates (short thin arrows) despite adjacent inflammatory changes. Osteomeatal unit pattern on the left side, with mucosal thickening in the left ethmoid and maxillary sinus (thick arrows), narrow left infundibulum occluded by thickened mucosa (long thin arrow) leading towards the hiatus semilunaris and the middle meatus, both with thickened mucosa. On the right there is a mucus retention cyst in the antrum Fig. 2. Sinonasal polyposis without truncation of bony middle turbinates. There is bilateral symmetrical extensive involvement of maxillary sinuses, ethmoidal sinuses and the middle meati. The following are noted: polypoidal masses (asterisks), the grossly widened infundibula (stars), the remains of the eroded uncinate process (arrow), lateral bulging of lamina papyracea (large arrowheads), and attenuation of ethmoid bony trabeculae. The bony middle turbinates are not yet truncated, but are eroded on the right side (small arrowheads) Fig.3. Sinonasal polyposis with bilateral truncation of middle turbinates (arrowheads). Note the bilateral symmetrical involvement: polypoidal masses (stars) and the widened infundibula (asterisks). Also note the deossification of the nasal septum Fig.4. Sinonasal polyposis with unilateral truncation of bony middle turbinate. Note the bilateral, but asymmetrical, involvement that on the left side is more severe than on the right side. The left bony middle turbinate is truncated (black arrow) whilst the right one (white arrow) is intact. Note also the widened infundibulum on the left (asterisk)

556 E t h m o i d bony trabecular attenuation was more comm o n in our series. It is our empirical observation that the degree of deossification is related to chronicity of symptomatic SNR Truncation of the bony middle turbinate was characteristic and easily recognizable. It is likely to be due to deossification caused by mechanical pressure erosion from polyposis as well as hyperaemia from mucosal inflammation. As with ethmoid bony trabecular attenuation, the presence of this sign might be related to chronicity of the disease. Usually, it is the bulbous part of the bony middle turbinate that is missing and the vertical part remains intact. In patients with previous middle turbinectomy, the resection is high at the root of the middle turbinate and the vertical part is also missing. I n the absence of previous middle turbinectomy, we found this sign to be specific for SNP and not observed in other patterns of inflammatory sinus disease.

E.Y. Liang et al.: Another CT sign of sinonasal polyposis maximized before opting for surgery. Truncation of the bony middle turbinate is a characteristic and easily recognizable sign. This new sign is not a cardinal sign, but is instead an ancillary sign. It appears to be specific to SNR and it does add confidence in the diagnosis. References 1. Josephson JS (1989) The role of endoscopic sinus surgery for the treatment of nasal polyposis. Otolaryngol Clin North Am 22:831-840 2. Friedman WH, Slavin RG (1984) Diagnosis and medical and surgical treatment of sinusitis in adults. Clin Rev Allergy 2: 409-412 3. Lildholt T, Fogstrup J, Gammelgaard Net al. (1988) Surgical versus medical treatment of nasal polyps. Acta Otolaryngol (Stockh) 105:140-143 4. Settipane GA (1987) Nasal polyps: epidemiology, pathology, immunology, and treatment. Am J Rhinol 1:129-126 5. Harnsberger HR, Babbel RW, Davis WL (1991) The major obstructive inflammatory patterns of the sinonasal region seen on screening sinus computed tomography. Semin Ultrasound CT MR 12:541-560 6. Drutman J, Harnsberger HR, Babbel RW, Sonkens JW, Braby D (1994) Sinonasal polyposis: investigation by direct coronal CT. Neuroradiology 36:469-472 7. Small R Frenkiel S, Black M (1981) Multifactorial etiology of nasal polyps. Ann Allergy 46:317-320

Conclusion C o m p u t e d tomography is an important adjunct to endoscopy in preoperative assessment of patients with chronic sinus disease. It is important to diagnose sinonasal polyposis preoperatively so that medical treatment is