Transcript Imaging of Medial Canthus of the Orbit: An

Control #:1805
Title: Imaging of Medial Canthus of the Orbit: An
Unexplored Territory
eEdE#: eEdE-110
Disclosure
The authors have nothing to disclose
Imaging of Medial Canthus of the Orbit:
An Unexplored Territory
J Nair, C Torres, J Chankowsky, R del carpio
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.
Normal Anatomy
S
S
M
M
Medial Canthal Ligament
Lacrimal Sac
Medial Orbital Septum
Medial Rectus Muscle
Anterior Lacrimal crest
Posterior Lacrimal crest
Our Approach
Medial Canthus lesions
Local Disease
Lacrimal drainage
apparatus
Orbit
Paranasal Sinuses and
Nasal Cavity
Miscellaneous
Systemic
Lymphoma
Metastasis
Langerhans Cell
Histiocytosis
Sarcoidosis
Others
Lacrimal Drainage Apparatus
Anatomy of Lacrimal Drainage System
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 fluidAmniotocele
Filling of cyst with
mucous and epithelial
debris from nasolacrimal
duct – Mucocele
Dacryocystocele
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.
Dacryocystocele
T2W Axial
T2W Coronal
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.
Dacryocystitis with pre-septal cellulitis
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 suggestive of left dacryocystitis
with preseptal cellulitis
Dacryocystitis with pre and post-septal cellulitis
Teaching points:
Post- contrast CT scan: Axial and Coronal
1) Dacryocysitis
diagnosed
clinically
unless associated with periorbital cellulitus.
images of theisorbit
in 47 year
old female
with left preseptal and post septal extra1) Imaging
allows and
to distinguish
between post-septal orbital inflammation (treated
conal cellulitis
dacryocystitis.
surgically) from dacryocystitis ( treated non-surgically)
Dacryocystitis with abscess
Post- contrast CT scan of the orbit in 45 year old
male : Left dacryocystitis and abscess formation
Lacrimal sac squamous cell ca
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.
Oncocytic Papillary Cystadenoma
Post-Contrast CT
T2W Axial
T1W Axial
T1W Axial +C
T2W Axial
T1W Coronal +C
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.
Lacrimal duct invasive squamous cell carcinoma
Post-Contrast Coronal CT
T1W Axial
Post-Contrast Axial CT
T2W Coronal
T2W Axial
T1W Axial +C
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.
Orbit
Dermoid
Teaching Points:
Post- contrast CT scan of the orbit in 28 year old female: Oval-shaped fat density lesion
1)
Dermoids
the most
orbital masses.
in the
medial are
canthus
of thecommon
left orbitcongenital
with no enhancement
or bony erosion consistent
2)
fat, rim calcification , scalloping of bone are the common imaging
withPresence
dermoidof
tumor
findings.
Dermoid
T1W Axial
DWI
T2W Axial
CT and MRI of the orbit in
14 year old male: Well
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 postcontrast enhancement
T2W Fat sat Coronal
T1W Fat sat Axial
Sclerosing orbital pseudo tumor
T1W Axial
Teaching Points:
T2W Axial
T2W Coronal
MRI of the orbit in 37 year old
female
Homogenously
enhancing
1) Orbital Pseudo tumor
is an :autoimmune
disorder
usually restricted to one
soft tissue mass lesion in the
or more extraocular muscles.
medial canthus of the right orbit
2) Restricted eye movements due to pain, diplopia and proptosis are the
with expansion of the nasolacrimal
common clinical manifestation.
duct, extending into the nasal
3) Pseudotumors are iso
to hypointense
on T2ofweighted
images with loss of
cavity
with obliterating
the
fat between involvedright
muscle
and periosteum
osteomeatal
complex.of involved orbital wall.
4) Differential Diagnosis:
Grave’salso
disease,
Extension
notedLymphoma,
into the intraRhabdomyosarcoma
and Metastasis
conal compartment of the orbit
T1W Axial +C
T1W Coronal + C
with thickening of the medial and
inferior rectus muscle.
Paranasal Sinuses and Nasal Cavity
Ethmoid 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
Invasive Aspergillus of right ethmoid sinus
Post-Contrast Axial CT
T1W Coronal+C
CT and MRI of the orbit in 43 year
old male: Left sided nasoethmoidal 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
Post-Contrast Coronal right medial canthus with signs of
CT
invasion of nasolacrimal duct.
T1W Axial
T2W Axial
Malignant transformation of inverted papilloma
T1W Axial
T1W Coronal
T2W Axial
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
T1W Axial +C
Nasal lymphoma to medial canthus
T2W Axial
T1W Axial +C
T1W Axial
T1W Axial +C
DWI
MRI of the orbit in 56 year old male : Soft 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
Squamous cell carcinoma of the nose
T1W Axial
T1W Axial
MRI of the orbit in 52 year old female: Large,
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.
T2W Axial
T1W Axial +C
Wegner’s Granulomatosis
T1W Axial
T2W Axial
T2W Axial
MRI of the orbit in 26 year old female: Soft tissue thickening at the left medial
canthus with extensive changes in the nasal cavity and paranasal sinuses resulting
from combination of post surgical changes and inflammatory disease
Miscellaneous
Basal Cell Carcinoma
Post-Contrast CT
T1W Axial
CT and MRI of the orbit in
58 year old male : Welldefined homogenously
enhancing soft tissue
mass limited to the medial
canthus of the left orbit.
T1W Axial +C
Capillary hemangioma
T1W Axial
T1W Axial
T2W Axial
T2W Axial
T1W Axial +C
MRI of the orbit in 54 year old male : Large 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.
Systemic Disease
Lymphoma
Post-Contrast Axial CT
DW1
T2W Axial
T2W Coronal
T1W Axial +C
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.
Leukemic deposits
T2W Axial
T1W Axial
T1W Axial +C
T2W Coronal
T1W Axial
T2W Axial
T1W Axial +C
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.
Langheran’s histiocytosis
Ultrasound with Doppler of the right orbit in 12 year old child: Heterogeneous lesion in
the medial canthus at the inferomedial aspect of the orbit. Color Doppler evaluation
shows flow within.
Langheran’s histiocytosis
T1W Axial
T2W FS Axial
T2W Coronal
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.
T1W Axial +C
Metastasis from squamous cell ca of tonsil
Metastasis from poorly differentiated ca of
submandibular gland
Metastasis
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.
References
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CT of the infenomedial orbit and the lacrimal drainage
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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
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Imaging of Medial Canthus of the Orbit:
An Unexplored Territory
J Nair, C Torres, J Chankowsky, R del carpio