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Clinical Observations |
1 Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins
Dr., Iowa City, IA 52242.
2 Department of Otolaryngology, Asan Medical Center, Seoul, Korea.
3 Department of Radiology, Asan Medical Center, Seoul, Korea.
4 Department of Pathology, Asan Medical Center, Seoul, Korea.
Received August 22, 2005;
accepted after revision January 23, 2006.
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Abstract
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CONCLUSIONS. Organized hematoma should be included in the differential diagnosis when patients have recurrent epistaxis and an expansile mass in the maxillary sinus.
Keywords: CT • head and neck imaging • maxillary sinus
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Seven patients underwent CT with a soft-tissue algorithm in both the direct axial and direct coronal planes in 3- or 5-mm contiguous sections. For these patients, images were obtained both before and after IV administration of a total dose of 100-150 mL of iodinated contrast medium. For five other patients, contiguous 5-mm direct axial and 3-mm direct coronal scans were obtained with a bone algorithm and without administration of contrast medium. One patient underwent only 5-mm contiguous axial CT with a soft-tissue algorithm and without contrast administration. Because only one of our patients underwent MRI, MRI information was not included in our review.
CT scans were reviewed by two radiologists in consensus. The scans were evaluated to assess the presence of maxillary sinus expansion, to determine which skeletal sinus walls were involved, to determine the presence of mucoperiosteal thickening of the antral wall, and to assess the density of the organized hematoma compared with the masticator muscles before and after contrast administration.
Preoperative endonasal endoscopic biopsy was performed on all patients. All patients underwent surgical removal of the organized hematoma, and pathologic examination was performed on all specimens.
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The masses involved the maxillary sinus in all patients and extended into the ipsilateral ethmoid sinus in eight patients. In four patients, the mass extended into the anterior ethmoid sinus, including the ethmoid bullae, and in the other four patients, the mass extended into the posterior ethmoid sinus. The right side was involved in seven patients and the left side in six.
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Preoperative endoscopic nasal examination in all patients revealed friable reddish masses extending from the maxillary sinus into the nasal cavity. In nine patients, the nasal cavity on the involved side was obliterated by the expanding medial maxillary sinus wall. The surfaces of the organized hematomas were a mix of yellow, brown, and dark red nodules. Because the lesions were so friable, it was not possible to remove them en bloc. Bleeding was not serious during or after surgery, and the only postoperative complication was temporary swelling of the cheek.
Histologic examination revealed the excised lesions were composed of fibrin clots mixed with blood cells in most locations. There were no neoplastic components. Areas of focal inflammation, neovascularization, fibrosis, and hemosiderin deposition were frequently detected (Fig. 3). The histologic features were most compatible with organized hematoma.
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It is believed that the histopathologic mechanism by which both cholesterol granuloma and organized hematoma develop is the result of sinus obstruction that leads to repetitive cycles of hemorrhage and subsequent granulation tissue formation. Graham and Michaels [5] concluded that hemorrhage was the primary event causing cholesterol granuloma. Those authors suggested that organized hematoma arises from sinus or nasal cavity hemorrhage. Obstruction of the sinus ostium leads to negative intraluminal pressure, which causes rupture of the fragile vessels that line the sinus mucosa.
Although both organized hematoma and cholesterol granuloma begin with initial hemorrhage into a closed cavity, organized hematoma contains areas of neovascularization, whereas cholesterol granuloma has deposits of cholesterol crystals. Why the initial hemorrhage develops into these two pathologic conditions along different lines is not known. We hypothesize the difference may be related to the degree of negative pressure within the sinus. Organized hematoma and cholesterol granuloma appear to represent extremes of hemorrhagic mucocele. In our patients, organized hematoma usually developed 3 months after epistaxis. In comparison, cholesterol granuloma appears to take longer to evolve [6]. One experimental study [7] showed that in monkeys, cholesterol granuloma of the ear develops when the eustachian tube is obstructed for 6-12 months.
Organized hematoma grows slowly and finally compresses against a skeletal wall of the maxillary sinus, causing pain and discomfort. In most patients, the expansile maxillary sinus mass causes nasal obstruction. Protrusion through the anterior wall of the maxillary sinus causes an anterior cheek mass, and neovascularization produces recurrent bleeding. The maxillary sinus reportedly is the one antrum in which organized hematoma occurs because it is the largest paranasal sinus that allows conditions of negative pressure and decreased ventilation. The occurrence of organized hematoma in other sinuses has not been reported [1-3].
Common CT findings of organized hematoma are expansion of one maxillary sinus; occasional extension into the ipsilateral ethmoid sinus; frequent bone erosion of the medial sinus wall, including the uncinate process; heterogeneous high density on unenhanced CT scans; and mucoperiosteal thickening. The other important finding is heterogeneous enhancement in a patchy distribution after administration of contrast medium. We suggest that neovascularization causes patchy contrast enhancement. Therefore, for CT evaluation of an expansile maxillary sinus lesion, administration of contrast medium is highly recommended.
In addition to organized hematoma, the main lesions to be included in the differential diagnosis of expanded maxillary sinus encountered on CT include mucocele [8], cholesterol granuloma [9], antrochoanal polyp [10], hemangioma [11], and maxillary sinus carcinoma [12]. The clinical history may contain a significant clue because recurrent epistaxis is most frequently encountered in patients with hemangioma, cholesterol granuloma, or organized hematoma. In patients with a history of trauma, cholesterol granuloma and organized hematoma should be the primary considerations.
Lesion location and pattern of extension should be examined. Whereas mucocele, cholesterol granuloma, organized hematoma, and early carcinoma may fill and expand the sinus, only antrochoanal polyp actually protrudes through a maxillary sinus ostium, doing so in a dumbbell configuration with a substantial component in the posterior nasal cavity. Extension into the ipsilateral ethmoid sinus should lead first to consideration of maxillary sinus carcinoma and then to consideration of organized hematoma and cholesterol granuloma. Frank osseous destruction, rather than thinning and expansion and erosion of the sinus walls, associated with extension to the orbit or pterygopalatine fossa or onto the cheek is a hallmark of carcinoma [12].
Density on unenhanced CT scans often can be used to differentiate lesions. Antrochoanal polyp has low density and is well circumscribed and fluid containing. Most types of carcinoma, mucocele, cholesterol granuloma, and hemangioma have soft-tissue isodensity. Organized hematoma, some types of carcinoma, and mucocele, especially those associated with fungal infections, have high density. Administration of contrast medium in the evaluation of these lesions is extremely useful because antrochoanal polyp, mucocele, and cholesterol granuloma do not become enhanced (although occasional peripheral enhancement of mucocele may be encountered). In rare instances, hemangioma becomes dramatically enhanced, often in a lobulated pattern. Carcinoma has a rather solid pattern of nodular enhancement [12]; organized hematoma has a patchy heterogeneous overall pattern, typically less than that of carcinoma and of other types of hemangioma.
Recommended management of organized hematoma is the Caldwell-Luc operation or endoscopic sinus surgery [2]. Regardless of the approach, complete resection of the lesion is curative.
In conclusion, organized maxillary sinus hematoma is caused by and produces frequent epistaxis and expansion of the sinus, which lead to nasal obstruction. CT scans show an expansile lesion of the maxillary sinus with heterogeneous high density on unenhanced CT and patchy heterogeneous enhancement on contrast-enhanced CT. If CT reveals an expansile maxillary mass in a patient with a history of frequent epistaxis, organized maxillary sinus hematoma should be included in the differential diagnosis.
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  E.Y. Kim, H.-J. Kim, S.-K. Chung, H.-J. Dhong, H.Y. Kim, Y.J. Yim, S.T. Kim, P. Jeon, and Y.-H. Ko Sinonasal Organized Hematoma: CT and MR Imaging Findings AJNR Am. J. Neuroradiol., June 1, 2008; 29(6): 1204 - 1208. [Abstract] [Full Text] [PDF]
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