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1805 Title Imaging of Medial Canthus of the Orbit An Unexplored Territory eEdE eEdE110 ID: 340208

orbit axial medial t1w axial orbit t1w medial t2w canthus post contrast left year lacrimal mri duct coronal nasolacrimal

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Slide1

Control

#:1805

Title:

Imaging of Medial Canthus of the Orbit: An Unexplored Territory

eEdE

#:

eEdE-110Slide2

Disclosure

The authors have nothing to discloseSlide3

Imaging of Medial Canthus of the Orbit: An Unexplored Territory

J Nair, C Torres, J Chankowsky, R del carpioSlide4

Learning Objectives

1)

To revisit detailed anatomy of the medial canthus of the orbit. 2) To list the common and uncommon pathologies.

3) Describe the CT and MRI findings of each of these pathologies.

4) To discuss the relevance of imaging as regards patient management. Slide5

Normal

Anatomy

Medial Canthal Ligament

Medial Orbital Septum

Lacrimal Sac Medial

Rectus

Muscle

Anterior

Lacrimal crest

Posterior

Lacrimal crest

S

M

S

MSlide6

Lacrimal

drainage

apparatusOrbitParanasal Sinuses and Nasal CavityMiscellaneous

Local Disease

Systemic

Medial

Canthus lesions

Our Approach

Lymphoma

Metastasis

Langerhans Cell

H

istiocytosis

Sarcoidosis

OthersSlide7

Lacrimal Drainage ApparatusSlide8

Anatomy of Lacrimal Drainage System Slide9

Formation of Congenital Mucocele of Nasolacrimal Duct/ Dacryocystocele

Obstruction at the valve of

Hasner

by imperforate

Hasner

membrane

Co-existing

obstruction

at entrance

to lacrimal sac

Formation of closed cystic space

with amniotic fluid-

Amniotocele

Filling of cyst with mucous and epithelial debris from nasolacrimal duct

Mucocele Slide10

Post-Contrast CT scan in 18-day-old infant : Rounded

,

well-defined, rim-enhancing lesion abutting the

medial preseptal right orbit extending down the lacrimal canal into the inferior meatus

, causing obstruction of the nasal cavity.

DacryocystoceleSlide11

T2W Axial and Coronal MRI images in 5 year old male: Enlargement

of the left lacrimal duct with

bilobed shaped hyper intensity at

the medial nasal aspect of the orbit; consistent with left

dacryocystocele.

T2W Axial

T2W Coronal

DacryocystoceleSlide12

Post-Contrast CT in a 18year old male:

Soft

tissue swelling

centered over the medial canthus of the left orbit associated with preseptal soft tissue

swelling and inflammatory

changes of the left nasolacrimal duct s

uggestive

of left

dacryocystitis with preseptal

cellulitis

.

Dacryocystitis with pre-septal cellulitis Slide13

Post- contrast CT scan: Axial and Coronal images of the orbit in 47 year old female with left

preseptal

and post septal extra-

conal cellulitis and

dacryocystitis.

Dacryocystitis with pre and post-septal cellulitis

Teaching points:

Dacryocysitis

is diagnosed clinically unless associated with periorbital

cellulitus

.

Imaging allows to distinguish between post-septal orbital inflammation

(treated surgically)

from dacryocystitis

( treated non-surgically)Slide14

Post- contrast CT scan of the orbit in 45 year old male : Left

dacryocystitis and abscess

formation

Dacryocystitis with abscessSlide15

Post-contrast CT in 75 year old male:

Heterogeneously

enhancing soft tissue

along the medial wall of the left  orbit

with destruction of the lamina

papyracea,

widening

of nasolacrimal

duct

and infiltration

of the left

globe

along

the

insertion of superior oblique and medial recti

muscles.

Lacrimal sac squamous cell caSlide16

Post-Contrast CT and MRI in 66 year old male :

Heterogeneously enhancing mass

in

the left medial

canthus

involving the lacrimal sac with solid and cystic

components. The lesion extends

through the left

naso

-lacrimal duct

to the level of the middle meatus

of the nasal

cavity with

enlarged nasolacrimal duct.

T2W Axial

T1W Axial

Post-Contrast CT

T2W Axial

T1W Axial +C

T1W Coronal +C

Oncocytic Papillary CystadenomaSlide17

CT and MRI of orbit in 52 year old female:

Heterogeneously enhancing mass along the

length of the left nasolacrimal duct

with

enlarged nasolacrimal duct.

Post-Contrast Coronal CT

Post-Contrast Axial CT

T2W Axial

T1W Axial

T2W Coronal

T1W Axial +C

Lacrimal duct invasive squamous cell carcinomaSlide18

OrbitSlide19

Post- contrast CT scan of the orbit in 28 year old female:

Oval-shaped fat density lesion

in the medial canthus of the left

orbit with no enhancement or bony erosion consistent with dermoid tumor

Dermoid

Teaching Points:

Dermoids are the most common congenital orbital masses.

Presence of fat, rim calcification , scalloping of bone

are the common imaging findings. Slide20

T1W Axial

T2W Axial

T1W Fat sat Axial

DWI

T2W Fat sat Coronal

CT and MRI

of the orbit in 14 year old male: W

ell circumscribed lesion

in the region of the right medial canthus

with

no

underlying bony changes. It shows

high signal on

T1 and T2 images

and

suppressed on fat

sat images

with

no restricted diffusion

or

post-contrast enhancement

Dermoid

Slide21

Sclerosing

orbital

pseudo tumor

T1W Axial

T2W Axial

T2W Coronal

T1W Axial +C

T1W Coronal + C

MRI of the orbit in 37 year old female :

H

omogenously enhancing soft

tissue mass lesion

in

the medial canthus of the right orbit

with expansion

of the

nasolacrimal duct, extending

into

the nasal

cavity with

obliterating of the right osteomeatal

complex.

Extension also noted into

the

intra

conal

compartment

of the orbit

with

thickening

of the medial

and inferior rectus muscle.

Teaching Points:

Orbital Pseudo tumor is an

autoimmune disorder

usually restricted to one or more

extraocular

muscles.

Restricted eye movements

due to pain,

diplopia and proptosis

are the common clinical manifestation.

Pseudotumors

are

iso

to

hypointense

on T2 weighted images

with loss of fat between involved muscle and periosteum of involved orbital wall.

Differential Diagnosis:

Grave’s disease, Lymphoma, Rhabdomyosarcoma and MetastasisSlide22

Paranasal Sinuses and Nasal CavitySlide23

E

thmoid mucocele

Contrast enhanced CT scan of the paranasal sinuses:

Mucocele

of the right anterior ethmoid air cells,

protruding through the right lamina

papyracea into the medial canthus in a 48 year old male with known

sinonasal

polyposis

  Slide24

Post-Contrast Axial CT

T1W Axial

T2W Axial

Post-Contrast Coronal

CT

T1W Coronal+C

Invasive Aspergillus of right ethmoid sinus

CT and MRI of the orbit in 43 year

old male: Left sided

naso

-ethmoidal

tumoral

mass

with irregular contours and low signal on the T1 and T2W images with

post contrast enhancement

extending in to the region of the right medial canthus with signs of

invasion of nasolacrimal duct. Slide25

T1W Coronal

T1W Axial

T2W Axial

T1W Axial +C

Malignant transformation of inverted papilloma

MRI of the orbits with contrast in 67 year old female:

Heterogeneously enhancing soft tissue mass lesion

representing malignant transformation

 

of

  a long standing inverted papilloma,

centered in  the right osteomeatal 

complex,

invading

the right orbit with

infiltration of the globe and the soft

tissues extending to the medial canthus Slide26

T1W Axial

T1W Axial +C

DWI

T1W Axial +C

T2W Axial

Nasal lymphoma to medial canthus

MRI of the orbit in 56 year old male :

S

oft

tissue mass lesion

appearing

predominantly

isointense on T1,

hypo intense

on T2

weighted images with

significant restricted diffusion

and

homogeneous post-contrast

enhancement

centered in the nasal cavity extending to the

medial canthus

of right orbit

with widened nasolacrimal duct Slide27

T1W Axial

T1W Axial

T2W Axial

T1W Axial +C

Squamous cell carcinoma of the nose

MRI of the orbit in 52 year old female:

L

arge

, irregular, ulcerative mass 

arising from the left nasal ala and

dorsum, extends

over the

medial canthus

of the left orbit,

with

abnormal

enhancement inside the nasolacrimal duct,

indicating invasion of the left lacrimal apparatus. Slide28

T2W Axial

T2W Axial

T1W Axial

Wegner’s

Granulomatosis

MRI of the orbit in 26 year old female:

Soft

tissue thickening

at the left medial canthus with

e

xtensive

changes in the nasal cavity and paranasal sinuses

resulting from

combination

of post surgical changes and inflammatory disease Slide29

MiscellaneousSlide30

Basal Cell Carcinoma

T1W Axial

T1W Axial +C

Post-Contrast CT

CT and

MRI of the orbit in 58 year old male :

Well-defined homogenously enhancing soft tissue mass

limited to

the medial canthus of the left

orbit.Slide31

T1W Axial

T1W Axial

T2W Axial

T2W Axial

T1W Axial +C

Capillary hemangioma

MRI

of the orbit in 54 year old male :

L

arge

right orbital mass

lesion predominantly involving extra conal compartment with

avid post-contrast enhancement

and

superiorly crossing

the midline to involve

the lacrimal sac and lacrimal duct medially. Slide32

Systemic DiseaseSlide33

Post-Contrast Axial CT

T2W Axial

T2W Coronal

T1W Axial +C

DW1

CT and

MRI of the orbit in 68 year old male :

Well-defined homogenously enhancing soft tissue mass

with

low signal on T2W image

and

restricted diffusion on DWI images

in

the medial canthus of the left

orbit.

LymphomaSlide34

T2W Axial

T2W Axial

T1W Axial +C

T1W Axial +C

T2W Coronal

T1W Axial

T1W Axial

MRI of the orbit in 65 year old female :

Hypo intense

lobulated

 

enhancing soft

tissue

in the

medial canthus and paranasal

sinuses 

with

 

diffusion restriction.

Diffuse

leptomeningeal enhancement

also noted.

Leukemic

depositsSlide35

Ultrasound with Doppler of the right orbit in 12 year old child:

H

eterogeneous lesion

in the medial canthus at

the inferomedial aspect of

the orbit

.

Color Doppler

evaluation shows

flow within.

the

lesion

Langheran’s

histiocytosisSlide36

T1W Axial

T2W Coronal

T1W Axial +C

T2W FS Axial

MRI orbit of the same child demonstrates focus of

T1

iso

- and T2 hyper-intensity

with

homogeneous post - gadolinium enhancement

. inferior to the right medial canthus, in the right infraorbital/nasal subcutaneous tissues.

Langheran’s

histiocytosisSlide37

Metastasis from squamous cell ca of tonsil

Metastasis

from poorly differentiated ca of

submandibular gland

MetastasisSlide38

Conclusion

Medial

Canthus of the orbit can be involved by a wide range of pathologies. Careful examination and systematic imaging approach with knowledge of the pathologies is the key to successful patient management.

This pictorial review from our institution will familiarize the radiologists with imaging features of common and uncommon lesions involving the medial canthus

.Slide39

References

Russell EJ,

Czervionke L, Huckman M, Daniels D, McLachlan D. CT of the infenomedial

orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. AJNR 1985;6:759-766 

Rand P, Ball WS, Kulwin DR. Congenital nasolacrimal

mucoceles

: CT evaluation.

Radiology

1989; 173:691-694

Cibis

GW,

Spurney

RO,

Waeltermann

J . Radiographic visualization of congenital lacrimal sac

mucoceles

.

Ann

Ophthalmol

I 986; 18:68-69

Escott

 EJ. A variety of appearances of malignant melanoma in the head: a review. 

RadioGraphics 2001;21(3):625–639.

 

Isiklar

I, Leeds NE, Fuller GN, Kumar AJ. Intracranial metastatic melanoma: correlation between MR imaging characteristics and melanin content. AJR Am J

Roentgenol

1995;165(6):1503–1512. Slide40

Imaging of Medial Canthus of the Orbit: An Unexplored Territory

J Nair, C Torres, J Chankowsky, R del carpio