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Differential Diagnosis

Inverted papilloma arising from the maxillary sinus has to be distinguished from antrochoanal polyp, fungus ball, and from malignant neoplasms (Savy et al. 2000).

The antrochoanal polyp, though exhibiting a similar pathway of extent, is usually diagnosed in adolescents, rather than in adults, and shows a homogeneous cystic content. Nevertheless, its variant - i.e., the angiomatous polyp - may be more difficult to differentiate. In fact, a strangled antrochoanal polyp passing through a constrictive ostium generally shows a more complex signal pattern. Its constricted mucosal folds and vessels resemble linear and parallel/fan-shaped structures exiting the ostium (Fig. 8.20). Moreover, the intranasal portion of the sinochoanal polyp exhibits bright enhancement, probably due to stasis. If a mainly cystic intra-sinusal component is present, an angiomatous polyp is more probable.

On CT, fungus balls may show findings comparable to those of inverted papilloma, namely remodeling and destruction of the medial antral wall and discrete densities within the lesion. They are easily differentiated on MR because almost totally hypoin-tense on T2 sequences.

Generally, squamous cell carcinomas - being the most frequent antral malignant lesion - are characterized by a more extensive destruction of the bony walls, and do not show the striated pattern on MR.

The differential diagnosis is more complex for inverted papilloma presenting as a unilateral nasal mass. Of course, sinonasal polyposis typically involves both nasal cavities; therefore the detection of a unilateral polypoid lesion in the adult raises the suspicion of inverted papilloma among other benign and malignant neoplasms.

Scan Inverted Turbinate

Fig. 8.19a,b. Enhanced SE T1 on axial (a) and sagittal (b) planes. a Squamous cell carcinoma of the left ethmoid (1) with erosion of left nasal bone (2), displacement and remodeling of left lamina papyracea/periorbita (3). The posterior part of the lesion (black arrows), located in the sphenoid sinus, shows more intense enhancement. Thin hypointense and parallel linear densities, arranged in a roughly septation pattern, can be detected within the tumor (short black arrows). Pathologic examination of the specimen demonstrated foci of IP in this area. On sagittal plane (b), two different sites of anterior cranial fossa floor abnormalities are demonstrated. Anteriorly, extradural intracranial neoplastic invasion (1) is suggested by the presence of enhancing tissue extending through the bone/periosteum, covered by thickened enhancing dura. A few millimeters posteriorly, the fluid signal intensity of a mucocele secondary to the more lobulated component (black arrows) remodels both the planum sphenoidalis (2) and the roof/posterior wall of the sphenoid sinus (3)

Fig. 8.19a,b. Enhanced SE T1 on axial (a) and sagittal (b) planes. a Squamous cell carcinoma of the left ethmoid (1) with erosion of left nasal bone (2), displacement and remodeling of left lamina papyracea/periorbita (3). The posterior part of the lesion (black arrows), located in the sphenoid sinus, shows more intense enhancement. Thin hypointense and parallel linear densities, arranged in a roughly septation pattern, can be detected within the tumor (short black arrows). Pathologic examination of the specimen demonstrated foci of IP in this area. On sagittal plane (b), two different sites of anterior cranial fossa floor abnormalities are demonstrated. Anteriorly, extradural intracranial neoplastic invasion (1) is suggested by the presence of enhancing tissue extending through the bone/periosteum, covered by thickened enhancing dura. A few millimeters posteriorly, the fluid signal intensity of a mucocele secondary to the more lobulated component (black arrows) remodels both the planum sphenoidalis (2) and the roof/posterior wall of the sphenoid sinus (3)

Angiomatous Polyp
Fig. 8.20a,b. Angiomatous polyp of the right maxillary sinus, TSE T2 and enhanced VIBE on the axial plane

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