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