38i

Paranasal Sinuses on MR Images

of the Brain: Significance of Mucosal
Thickening

Kevin M. Rak1 One hundred twenty-eight patients were examined prospectively to determine the
John D. Newell 112 significance of mucosal thickening seen in the paranasal sinuses during routine MR
Wayne F. Yakes1 imaging of the brain. On the basis of responses to a questionnaire, each patient was
categorized as symptomatic (n = 60) or asymptomatic (n = 68) for paranasal sinus
Melissa A. Darnian&
disease. Patients were categorized further on the basis of the maximal mucosal thick-
American Journal of Roentgenology 1991.156:381-384.

James M. Luethk&
ening seen by MR in any paranasal sinus. A modified t test was used to compare the
prevalence of various degrees of mucosal thickening between symptomatic and asymp-
tomatic groups. Statistically significant differences between the groups were seen only
in those patients with normal sinuses and in those with 4 mm or more of mucosab
thickening.
We conclude that mucosab thickening of up to 3 mm is common and backs clinical
significance in asymptomatic patients. An ancillary finding is that I- to 2-mm areas of
mucosal thickening in the ethmoidal sinuses occur in 63% of asymptomatic patients.
This minimal mucosal thickening in the ethmoidal sinuses is thought to be a normal
variant, possibly a function of the physiologic nasal cycle.

AJNR i1:1211-i214, November/December 1990; AJR 156:381-384, February 1991

MR imaging is sensitive for detecting inflammation of the mucosa that occurs

with sinusitis. In a prospective study of i 28 patients, we attempted to determine
the clinical significance of mucosal abnormalities seen in the pananasal sinuses
during routine MR imaging of the brain.

Subjects and Methods

We prospectively examined 1 28 random patients (age range, 1 5-85 years) who had MR
imaging for intracranial disease. All patients were scanned on a 1 .5-T (Signa, General
unit
Electric; Milwaukee, WI). Spin-echo axial MR images, 2800/45,90 (TR/TE), were obtained
through the paranasal sinuses in all patients. Ti -weighted sagittal images (600/20) also were
obtained in all patients.
With the assistance of an otolaryngologist, we developed a questionnaire to delineate
common presentations of paranasal sinus disease. Before the MR examination, each patient
Received March 12, 1 990: revision requested completed this questionnaire,
commenting on the presence or absence of (1 ) facial or
May 20, 1 990: revision received June 1 1 , 1990: retroorbital pain, (2) rhinorrhea, (3) current symptoms of allergy/hay fever or of the common
accepted July 13, 1990.
cold, and (4) current use of medications such as antihistamines. Patients with one or more
The opinions or assertions contained herein are positive responses to these questions were categorized as symptomatic for sinus disease,
the private views of the authors and are not to be
whereas patients with all negative responses were classified as asymptomatic. The MR
construed as official or as reflecting the views
of the Department of the Army or Department of examinations were blindly reviewed without knowledge of the questionnaires’ results. Each
Defense. paranasal sinus was evaluated for mucosal thickness, presence or absence of air/fluid level,
1 Department of Radiology, Fitzsimons Army and evidence of retention cyst/polyp. High signal intensity on the T2-weighted images was
Medical Center, Aurora, CO 80045-5001 . Address used to distinguish inflamed mucosa from the lower signal of bone in the sinus wall. Retention
reprint requests to K. M. Aak. cysts and polyps could not be consistently distinguished from each other, but were reported
2 Radiology Imaging Associates, Porter Memo- as lobular intrasinus lesions of high signal intensity on T2-weighted images.
rial Hospital, Denver, CO 80210. Each patient was categorized according to the maximal mucosal thickening present in any
0361-803X/91/1562-0381 paranasal sinus. Thus, categories included normal, 1 mm of thickening, 2 mm, 3 mm, and 4
 382 RAK ET AL. AJA:156, February 1991

mm or more of mucosal thickening. Data from the asymptomatic and population precludes performance of statistical tests on this
symptomatic groups were compared by using a modified t test. variable.
Significant differences were indicated by a two-tailed probability of
.05 or less.
Discussion
MR imaging is highly sensitive for detecting mucosal thick-
Results
ening of the paranasal sinuses [i ]. It has previously been
In our initial analysis (Table i), only two MR categories reported with CT that abnormalities in one or more pananasal
showed statistically significant differences between asymp- sinuses are seen in 42% of asymptomatic adults [2]. Similarly,
tomatic and symptomatic patients. Normal pananasal sinuses various degrees of mucosal thickening in the paranasal si-
were more prevalent in the asymptomatic population, and 4 nuses are commonly seen during routine MR of the brain.
mm or greaten mucosab thickening in any sinus was more Our goal was to delineate the significance of these abnon-
common in the symptomatic group (Figs. i and 2). An inter- malities and to determine if there is a degree of mucosab
esting finding was that 63% of the asymptornatic patients (43 thickening that helps distinguish a symptomatic from an
of 68) and 69% of all patients (88 of i 28) had minimal, i- to asymptornatic population. Such a finding would be of obvious
2-mm, mucosal thickening in the ethmoidal sinuses. A second clinical importance regarding further medical workup and
analysis was performed with this minimal ethmoidab thickening therapy.
considered as normal. Ethmoidal abnormality was then cate- An understanding of the normal nasal cycle is essential for
gonized only if 3 mm on more of mucosal thickening was interpreting our data. Zinneich et al. [3] report that, in a normal
present. The results again showed statistical significance only adult, changes in the nasal mucosal volume occur cyclically,
in those patients with normal sinuses and in those with 4 mm alternating from side to side. The time course of each cycle
American Journal of Roentgenology 1991.156:381-384.

on more of mucosal thickening (Table 2). varies from 50 mm to 6 hr. Mucosal volume changes are
The prevalence of retention cysts/polyps was not signifi- observed in the mucosa of the turbinates, the nasal septum,
cantly different between the symptomatic and asymptomatic lateral wall and cavity floor, nasobacnimal ducts, and ethmoidal
patient groups. Four instances of air/fluid level on complete sinuses. The frontal, maxillary, and sphenoidal sinuses are
sinus opacification were seen in the symptomatic population; not affected [3].
however, the absence of any cases in the asymptomatic Although our patients were scanned at only one time rather

TABLE 1: Comparison of Asymptomatic and Symptomatic Groups with All Mucosal Disease
Reported

Air/Fluid Maxi mal Muco sal Thickening

Retention Level or
Normal
ysts ompiete mm 2 mm 3 mm 4 mm
Opacification

Asymptomatic (n = 68) 21 8 0 i1 30 4 2
Symptomatic (n = 60) 6 10 4 13 23 9 9
T value 2.95 0.80 - 0.73 0.69 i .66 2.37
Two-tailed probability 0.004 0.425 - 0.469 0.49i 0.iOO 0.019

Note-Absence of air/fluid level or complete opacification in asymptomatic group precluded statistical comparison
of that factor.

Fig. 1.-MR image, SE 2800/90, shows typical

appearance of diffuse 2-mm rim of mucosal
thickening bilaterally in maxillary sinuses in an
asymptomatic patient.

Fig. 2.-MR image, SE 2800/90, shows max-

imum of 5 mm mucosal thickening in right max-
illary sinus in a clinically symptomatic patient.
 AJR:156, February 1991 MR OF PARANASAL SINUSES 383

than cyclically, we think that our findings corroborate those [5]. Our study is limited in that we have relied strictly upon
of Zinneich et al. We have found that in the asymptomatic clinical history to categorize patients as symptomatic or
group, 63% of patients had minimal ethmoidal “abnormality,” asymptomatic. Although such a categorization is not definitive
with i -2 mm of mucosal thickening. That this finding was of a pathologic diagnosis, it is certainly clinically relevant
limited to the ethmoidal sinuses and that the ethmoidal si- because only such symptomatic patients would seek medical
nuses are the only pananasal sinuses to undergo cyclical attention.
mucosal volume changes suggests a direct relationship be- In comparing abnormalities between the asymptomatic and
tween these points. Furthermore, Zinreich et al, [3] reported symptomatic groups, statistically significant results were ob-
that on T2-weighted images, the hypenintensity of the nasal tamed only in those patients with normal sinuses and in those
cycle was similar to that shown by inflammatory mucosa. with 4 mm or more of mucosal thickening. We are not
Given these facts and the prevalence of this mucosal thick- suggesting that mucosal disease of 3 mm on less is not
ening in the asymptomatic population, we postulate that clinically significant; however, our results show that up to 3
minimal, 1 - to 2-mm areas of high T2 signal in the ethmoidab mm of mucosal thickening may commonly be seen in asymp-
sinuses are a physiologically normal variant, a function of tomatic patients. As such, findings on nadiographs and MR
mucosal volume changes occurring in the nasal cycle. Con- images may not match clinical Symptoms. Thus, clinical con-
vensely, only two (3%) of 68 asymptomatic patients had areas relation is required rather than blanket medical therapy.
of ethmoidab mucosal thickening greater than 2 mm. Thus, The absence of any cases of air/fluid bevels or complete
this degree of thickening is not thought to be a function of sinus opacification in the asymptomatic group precludes sta-
normal physiologic responses. The physiologic ethmoidal mu- tistical comparison with the symptomatic group. However, on
cosal edema may be diffuse on focal (Figs. 3A and 3B). It is the basis of the four cases in the symptomatic group, we
commonly bilateral, suggesting that in the nasal cycle, the suspect that extrapolation to a larger study population would
American Journal of Roentgenology 1991.156:381-384.

resolution of mucosal edema may be somewhat delayed, show this factor to be significant.
such that edema may persist on one side while the contralat- Retention cysts are due to obstruction and dilatation of a
eral mucosa has already become edematous. duct of a minor seromucinous gland. They are typically asymp-
Sinusitis is a nebulous disease, with subjective symptoms tomatic [4], and their comparable prevalence in our two
that are commonly vague on nonspecific. Clinical history is populations was expected.
essential in the assessment of sinus disease [4], but symp- In conclusion, i - to 2-mm areas of mucosal edema/thick-
toms may not reflect the true state of the pananasal sinuses ening in the ethmoidal sinuses are thought to be a normal

TABLE 2: Comparison of Asymptomatic and Symptomatic Groups with 1-2 mm of Mucosal

Thickening in Ethmoidab Sinuses Classified as Normal

Maximal Muco sal Thickening

Normal
imma 2mm8 3mm 4mm

Asymptomatic (n = 68) 44 11 7 4 2
Symptomatic (n = 60) 24 5 13 9 9
Tvalue 2.92 1.41 1.85 1.66 2.37
Two-tailed probability 0.004 0.1 60 0.066 0.1 00 0.019

“ Exclusive of ethmoidal sinuses.

Fig. 3.-A and B, MR images, SE 2800/90,

show diffuse (A) and focal (B) mucosal edema
in ethmoidal sinuses. Findings of this degree are
thought to be physiologic. Both patients were
asymptomatic.
A B
 384 RAK ET AL. AJA:156, February 1991

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