TESTING – CT Imaging the Sinuses (Sinus CT Scan)

Everyone who has ever had ANY medical test deserves to have at least some understanding of what the test is for and how the results are used. That holds true for sinus x-rays and CT scans. Be sure to read my article on Development of the Sinuses, and also this one about What to Expect When Taking Your Child for Their Sinus CT Scan. Here is a short course in “reading” CT scans of your child’s sinuses.

How To “Read” A Sinus CT Scan

CT Imaging of the Sinuses

Today I will focus on imaging the sinuses. Computed Tomography (CT) Scans.

(I will cover imaging of the neck, and imaging of the ears – along with imaging of the temporal bones, separately at another time).

Important consideration: All test results must be interpreted along with the medical history. A CT scan alone does not determine whether a patient has acute sinusitis, chronic sinusitis, or whether they may need surgery. The whole patient must be considered when reviewing the test results.

How to “Read” a CT Scan: Orientation

The beauty of CT scans is that they can be artificially “rotated” inside the computer. This gives docs the ability to change the angle of the “slices” through the head – the “plane”.

In practical terms, there are only 2 planes that are common for imaging the sinuses: the coronal plane, and the axial plane:

Images of Coronal and Axial Planes

 

Drawing of Coronal Plane for Sinus Imaging

Drawing of Coronal Plane for Sinus Imaging

Above is a drawing of the CORONAL PLANE.

Our view is from the front (ARROW).

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Drawing of Axial Plane for Sinus CT Imaging

Drawing of Axial Plane for Sinus CT Imaging

Above is a drawing of the AXIAL PLANE.

Our view will be looking up at the slice (ARROW).

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First, some ground rules for “reading” Sinus CT Scans

  • white stuff is bone (or teeth)
  • black stuff is air
  • gray stuff is something else – cheek, brain, eyeball, snot, blood – something else, can’t tell what

Let’s take a look at a few Sinus CT Scans From Patients

 

Here is a reminder of where the sinuses are:

Image of Face with Sinuses

 

pediatric sinusitis pediatric allergies allergic rhinitis children toddlers infants

Sinuses in the Facial Skeleton: Maxillary (M), Ethmoid (E), Frontal

On the drawing above, E denotes Ethmoid Sinuses, and M denotes Maxillary Sinuses.

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CT Scan of Sinuses in the Coronal Plane

 

CT Scan of Pediatric Sinuses Coronal Plane

CT Scan of Pediatric Sinuses, Coronal Plane

 

The drawing on the left shows us about where the slice was taken for the CT Scan Image on the right. It goes through the mid or front part of the eye sockets (orbits), ethmoid sinuses, and maxillary sinuses. Compare the CT scan on the right with the drawing of the sinuses and the child’s face just above.

Let’s “Read” The Coronal Sinus CT Scan Above

On the right, the patient is facing us, their right side is on our left and vice versa. Look toward the right side (the patient’s left sinuses): all of the sinuses are black – full of air. That’s a good thing. Now look over at the left side (the patient’s right sinuses): there is some gray stuff in the Maxillary Sinus. Can’t tell exactly what that is, but we can speculate, based on years of experience. Some of it is probably secretions – snot. Some of it is probably swelling. That swelling that goes all the way around the sinus suggests chronic inflammation – chronic sinusitis.

CT Scan of the Sinuses in the Axial Plane

CT Scan of Sinuses in Axial Plane

CT Scan of Sinuses in Axial Plane

Let’s “Read” The Axial Sinus CT Scan Above

The drawing at the left shows the level of the slice, below the eye sockets, through the level of the maxillary sinuses. The CT Scan on the right shows the maxillary sinuses full of black – air (arrows). These are relatively healthy sinuses. We are looking up at the slice, so the patient’s right is on our left of the image, and vice versa.

CT Scan of the Sinuses in the Axial Plane


Let’s “Read” The Axial Sinus CT Scan Above

The drawing at the left shows the level of the slice, through the middle of the eye sockets, higher up than the previous scan. The CT Scan on the right shows the ethmoid sinuses, full of black – air (arrows). Again, these are relatively healthy sinuses.

CT Scan of Sinuses in the Coronal Plane

 

Pediatric Sinusitis CT Scanning

Pediatric Sinusitis – CT Scan, Coronal Plane

Let’s “Read” The Coronal Sinus CT Scan Above

The drawing on the left shows the level of the coronal slice, through the back part of the eye socket. The corresponding CT Scan image on the right shows the ethmoid sinuses, and the maxillary sinuses, nearly full of gray stuff.

In this case, these are nasal and sinus polyps. Only the patient’s right maxillary sinus (on the left of the CT scan) shows a small area of air (black).

This is severe, advanced polyp disease. This can be seen in children with Cystic Fibrosis.

Summary

That should provide the basics to help understand your little boogorhead’s Sinus CT scans. At least, when your ENT doc discusses the findings you can keep up now. For the curious, check out some of the previous articles on this blog about Sinus CT scans, listed below in Resources. Please leave a reply or email me with questions or comments! Thanks for visiting!

More imaging later: I will cover imaging of the neck, and imaging of the ears (and temporal bones) separately at another time.

Over the coming months there will be experts from various areas of medicine here to review the how-and-why of testing. Stay tuned.

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Resources From This Blog:

  1. Role of the Beattles in the Invention of the CT Scanner: http://www.whittington.nhs.uk/default.asp?c=2804&t=1
  2. 8 Dangerous Complications of Sinusitis, 3 That Can Kill: http://wp.me/pR4iB-57
  3. Nasal and Sinus Anatomy, Histology, & Physiology: http://wp.me/pR4iB-1g
  4. 3-Year-Old Boy Hospitalized for Severe Chronic Sinusitis: http://wp.me/pR4iB-2k

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Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

Comments

  1. excellent post on reading images of a sinus CT scan. looking forward to more of your posts on imaging.

    I’m curious though, why is the sagittal plane not really used when looking at sinus CT scans?

    • Russell A. Faust, PhD, MD says:

      Hi Wisdom,
      To answer your question: the sagittal orientation simply does not provide an optimal view of the most important areas of sinus drainage – the “osteo-meatal complex”, whereas the axial and coronal planes provide this and more.
      Thanks for visiting. RF

  2. Eve Heshler says:

    Thank you for your article. My son recently had a CT scan of his sinuses after being diagnosed with chronic sinusitis. He previously had been diagnosed with moderate sleep apnea. He has been continuously sick with sinus infections, eye infections, etc. We are waiting to meet with the ENT tomorrow and I was curious to see what he may say. I can see that his maxillary sinuses are completely gray. Hopefully this will help clarify why he has been so sick and help with a resolution.

    • Russell A. Faust, PhD, MD says:

      Hi Eve,
      Best success! Let us know how it goes.
      RF

      • Eve Heshler says:

        Update: The CT scan showed the sinuses had cleared. Unfortunately he had been on antibiotics for a few days before we could get an appointment. He was ok for about a month before he started having recurrent strep infections. He ended up with 2 visits to the ER and a diagnosis of PANDAS before having his tonsils and adenoids removed. We are now dealing with some depression and neurological tics as a result. It’s been a long road.

        • Russell A. Faust, PhD, MD says:

          Eve,
          So sorry to hear about your son’s PANDAS. No idea why, but I had a group of patients (all children, of course) with PANDAS when I was faculty at the University of Virginia. Some of them had great relief from tonsillectomy/adenoidectomy.
          The good news about the clear CT scan is that his sinuses cleared while on antibiotics. That tells me that the issue with his sinuses is not anatomic. That is, the openings are clear. He either has “mucosal disease” (allergic swelling or other chronic inflammatory changes), or perhaps biofilm. Biofilm bacterial infections typically “clear” while on antibiotics, but return full force within a couple weeks after completing the course of antibiotics. Take a look at this site for articles on ridding him of “biofilm”.
          Please let us know how things go for your boy.
          RF

  3. Eve Heshler says:

    I actually did follow your advice on biofilm. We did nasal rinses regularly for awhile and the sinus infections stopped for awhile. Unfortunately the strep started. Is it possible to have strep in your sinuses? After the last bout of strep was over, he got another sinus infection. He was also diagnosed with blepharitis, which I was wondering if that could also be related to strep. Anyway, he is healing well from the T&A and we’re hoping the tics he has disappear after he returns to his former healthy self. They seem to have started as a result of the discomfort from strep as well a the constant post nasal drip.

    • Russell A. Faust, PhD, MD says:

      Eve,
      Nasal saline rinses ARE the treatment for biofilm, but eradication of the biofilm requires adding things to the saline. Manuka honey is the most effective, and also easiest when dealing with children – nice to make the rinses sweet-tasting. The other thing to consider is adding a couple drops of baby shampoo. Research has shown that baby shampoo (or other detergents, but baby shampoo is the mildest) can help break up the biofilm. A word of caution: ONLY a couple drops! More than that burns! Speaking from personal experience :))
      Best success with your son! Please do keep us updated on his progress.
      RF

  4. Eve Heshler says:

    How long after a T&A can we resume nasal rinses, specifically those with baby shampoo?

    • Russell A. Faust, PhD, MD says:

      Hi Eve,
      You COULD begin them immediately. But if you are including the baby shampoo to the rinse (remember to be cautious with how much you add – only a couple drops!) to help eliminate chronic biofilm, I would wait one week after T&A. Just to minimize the misery. After all, even a little of that shampoo in the rinse may burn a bit, and life is miserable enough after a T&A.
      Let me know how things go.
      RF

  5. Eve Heshler says:

    Just got back from the doctor and my son has another sinus infection just a few weeks after the last. We will definitely be adding the baby shampoo to the nasal rinses to try to rid him of that biofilm.

    • Russell A. Faust, PhD, MD says:

      Eve,
      That’s frustrating!!

      A word of warning: Go EASY with the baby shampoo! Just a couple drops per rinse bottle. I have made the mistake of putting ounces in at a time – wow, that burned!!!

      Also: if you have not done so already, consider adding a daily probiotic to his regimen – the Probiotic Pearls for Children, by Ingtegrative Therapeutics, is BY FAR the best on the market, and the one that I give to my own little boogorheads. I take their Probiotic Pearls for adults, the Advantage one, I think. (transparency: I have no financial arrangements with Integrative Therapeutics. I buy mine on Amazon, like everyone else).

      Wishing you success, and do keep me updated!
      RF

      • 2 days off of antibiotics and my son is complaining of of the same symptoms already. We are doing the nasal rinses and probiotics, as well as Nasonex. Is there anything I should request from my ENT ? This doesn’t seem normal to me.

        • Russell A. Faust, PhD, MD says:

          I’m sorry to hear that, Eve.
          Depending on your son’s age, and depending on what his symptoms are, it may be that his symptoms are not necessarily from his sinuses. My best advice is to find a worthy physician that you trust, and work with them to figure things out.
          Please keep us updated on what is going on.
          Best success,
          RF

          • Just an update…the pediatrician referred us to an immunologist after finding low IGg in bloodwork. It turns out my son has very low pneumococcal titers which can cause sinusitis. He gave him a booster shot and in 3-4 wks he will recheck his titers.

          • Russell A. Faust, PhD, MD says:

            Hi Eve,
            Yes, those subtle immune anomalies can cause chronic troubles. And for the chronic troubles where we aren’t able to find the immune anomalies, I suspect that we are merely looking in the wrong place, or can’t yet detect the anomaly.
            Thanks for the update, and for sharing this. I hope that parents with children struggling with chronic inflammatory issues ask their pediatricians about possible subtle immune deficiencies.
            RF

  6. Very nice post. I simply stumbled upon your blog and wanted to say that I have really loved browsing your blog posts.

Trackbacks

  1. […] Year Old Boy Hospitalized for Severe Sinusitis”:  http://wp.me/pR4iB-2k Also see article on How to Read Your CT Scan: […]

  2. […] Some instructions on reading sinus CT scans: black is air; white is bone; gray is “soft tissue,” or everything else – brain, eyeball, cheek tissue, thickened sinus lining, or snot.  The two orange arrows point to the maxillary sinuses.  Instead of being full of air (black) like normal, they are full of gray – something else: snot, thickened lining, polyp, it is uncertain. […]

  3. […] Please take a look at my review of nasal and sinus anatomy and histology for the basic anatomy. Also take a look at my article on How to “Read” A Sinus CT Scan. […]

  4. […] couple weeks back I reviewed How to “Read” a CT Scan. That article grew out of the fact that I see many families show up in my clinic with a pack of CT […]

  5. […] A computed tomographic (CT) scan can reveal the condition of the sinuses, and whether there is obstructing adenoid growth in the nasopharynx or obstruction of the sinus openings. Check this link for How To Read Your Child’s Sinus CT Scan. […]

  6. […] How to “Read” a Sinus CT Scan […]

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