Presentation
Asymptomatic patient with elevated alkaline phosphatase. Bone scintigraphy performed due to concern for malignancy.
Patient Data
Complete obstruction of the right frontal, ethmoidal, sphenoidal, and maxillary sinuses with heterogeneous hyperdense contents. Partial obstruction of the right nasal airways. Diffuse osseous remodeling of the right sinus walls. Moderate to intense uptake in the right superior and medial sphenoid sinus wall and right superior maxillary sinus wall, with mild uptake in the other sinus walls. Bowing of the nasal septum, medial maxillary sinus wall, and medial orbital wall, with possible areas of dehiscence or erosion.
Right greater than left mandibular uptake likely from recent dental procedure.
Complete opacification of the right maxillary sinus, with near complete opacification of the right ethmoid, sphenoid, and frontal sinuses. Osseous remodeling throughout the right paranasal sinuses. Ill-defined hyperdensity in the right nasal cavity, with obliteration of the right middle turbinate.
Case Discussion
Bone scintigraphy should always be evaluated for non-standard soft tissue or osseous regions, because incidental findings are common. In this case, the patient was referred for abnormal lab values, but no evidence of osteoblastic metastatic disease was identified. The scan did demonstrate intense uptake in the right nasal and paranasal osseous structures. SPECT-CT helped to further elucidate the anatomic localization of the uptake. The SPECT-CT and CT revealed significant right-sided chronic nasal and paranasal sinus disease. Classic signs of chronic non-invasive fungal sinusitis are noted in the imaging of this case, including the hyperdense, partially calcified fungal ball in the right middle meatus, hyperdense opacifying material through the right sinuses, and chronic remodeling of the osseous structures.
Endoscopy revealed a mycetoma and polyp in the right middle meatus with extensive mucosal inflammation. Purulence was streaming over the middle turbinate, but no acute bacterial infection was identified.