ABSTRACT ID - IRIA-1230 Imaging differentials in granulomatous diseases of head and neck: a retrospective study

Aims and objective 1. To analyse the varied etiology and recognise radiologic patterns of granulomatous diseases in the head and neck. 2. Formulate an appropriate imaging differential diagnosis for granulomatous disease manifestations in the head and neck Materials and methods Retrospective analysis of cross-sectional imaging done for granulomatous diseases of head and neck, using specific key word search from our PACS database Imaging features of various cases were analysed and categorised based on the etiologies as proved by histopathological /microbiological / serological examination Objectives & Methodology

Granulomatous diseases- Etiology Autoimmune Granulomatosis with polyangitis (Wegener’s granulomatosis) Churg Strauss IgG4 disease Behcet’s disease Infection TB Fungal Leprosy Actinomycosis Rhinoscleroma Syphilis Cat scratch Others Langerhans Cell histiocytosis Erdheim Chester disease Systemic lupus nephritis Sinus Histiocytosis Relapsing polychondritis Rheumatoid arthritis Hereditary Chronic GD Idiopathic Sarcoidosis

Analyzed cases 1784 cases

Biopsy proven granulomatous diseases

Granulomatosis with polyangitis ( W egener’s granulomatosis ) - SINONASAL INVOLVEMENT Soft tissue opacification of all sinuses[ ] ORBITAL INVOLVEMENT Enhancement along the orbital apex bilaterally [ ]

Granulomatosis with polyangitis SINONASAL & BONE INVOLVEMENT Erosion of inferior nasal septum, nasal turbinates and hard palate [ ] Associated soft tissue thickening in the maxillary and ethmoid sinuses

Sarcoidosis SINONASAL INVOLVEMENT Soft tissue opacification [ ] of left maxillary & ethmoid sinuses SALIVARY GLAND INVOLVEMENT Enlarged parotid glands bilaterally, right more than left [ ]

Sarcoidosis ORBITAL INVOLVEMENT Diffusely enlarged homogenously enhancing lacrimal glands Thickening of the extra ocular muscles bilaterally [ ] AERODIGESTIVE INVOLVEMENT Asymmetric thickening [ ] of the tracheal wall in its upper 2/3 rd

Fungal ORBITAL INVOLVEMENT Homogenously enhancing retrobulbar soft tissue mainly involving the extraconal fat and part of intraconal fat, causing bony erosion and intracranial extension[ ]

Fungal SINONASAL & INTRACRANIAL INVOLVEMENT Involvement of sinuses extending into the orbit & causes extra dural thickening [ ] Culture –invasive aspergillosis Sinusitis with T2 hypointense contents, intracranial extension, resultant infarcts [ ] Culture –angioinvasive mucormyosis

Langerhans cell histiocytosis ORBITAL & SINONASAL INVOLVEMENT Erosion of bony walls of sinuses, nasal septum, pterygoid bones Enhancing soft tissue encasing the optic nerve in intraconal fat region bilaterally [ ]

Langerhans cell histiocytosis ORBITAL, SKULL BASE, INTRACRANIAL INVOLVEMENT Enhancing soft tissue density in the sella [ ] and right temporal lobe [ ] Lytic destruction [ ]of the lateral wall of left orbit, adjacent zygomatic bone and greater wing of sphenoid

TB NODAL INVOLVEMENT Multiple rim-enhancing low- attenuation lymph nodes[ ] AERODIGESTIVE TRACT INVOLVEMENT Heterogenous thickening and enhancement [ ] of vocal cords, valeculla, enlarged neck nodes

TB SKULL BASE INVOLVEMENT Multiple ring enhancing lesions[ ] in the basal cistern with leptomeningeal enhancement [ ] along the basal meninges

IgG4 disease Erdheim Chester disease Involvement of the orbit [ ] & infra temporal region [ ] Involvement of the [ ]orbit and the tentorium cerebelli [ ]

Lepromatous leprosy Rhinoscleroma SINONASAL ORBITAL INVOLVEMENT Sinusitis, soft tissue thickeing at the right medial cantuhus. Synechia between the sinus inferior turbinate & septum [ ] ORBITAL INVOLVEMENT Soft tissue in both nasal cavities, paranasal sinuses, uniformly hyperintense, large extraconal component [ ]

Relapsing polychondritis AERODIGESTIVE TRACT INVOLVEMENT Airway laryngeal stenosis from supra to subglottis, soft tissue density[ ] around trachea, ossified laryngeal cartilage[ ], tracheostomy tube in situ [ ]

Imaging differentials based on radiological manifestations seen in our study ORBIT Wegener’s Fungal Sarcoidosis IgG4 Leprosy Erdheim Chester Disease Rhinoscleroma SINONASAL Wegener’s Fungal Tuberculosis Sarcoidosis IgG4 disease VASCULAR Wegener’s Fungal TB CRANIAL NERVES Sarcoidosis TB Leprosy SKULL BASE Tuberculosis Fungal LCH Wegener’s AERODIGESTIVE TRACT Wegener’s Tuberculosis Relapsing Polychondritis Sarcoidosis

Conclusion & References Conclusion Knowledge of the clinical and radiologic patterns of granulomatous diseases in the head and neck will allow interpreting radiologists to provide a useful differential diagnosis, thus facilitating appropriate clinical management References 1. Granulomatous Disease in the Head and Neck: Developing a Differential Diagnosis. O.K Nwawka, R Nadgir, A Fujita. Radiographics volume 34, issue 5 September-October Radiology Review Manual. Wolfgang Dahnert, 6 th edition 3. CT and MR imaging of the whole body. John Haaga. 4 th edition