Control 1805 Title Imaging of Medial Canthus of

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Control#: 1805 Title: Imaging of Medial Canthus of the Orbit: An Unexplore Territory e.

Control#: 1805 Title: Imaging of Medial Canthus of the Orbit: An Unexplore Territory e. Ed. E#: e. Ed. E-110

 Disclosure The authors have nothing to disclose

Disclosure The authors have nothing to disclose

Imaging of Medial Canthus of the Orbit: An Unexplored Territory J Nair, C Torres,

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.

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 Medial Canthal Ligament Medial Orbital Septum M Lacrimal Sac

Normal Anatomy S S M Medial Canthal Ligament Medial Orbital Septum M Lacrimal Sac Medial Rectus Muscle Anterior Lacrimal crest Posterior Lacrimal crest

 Our Approach Medial Canthus lesions Local Disease Lacrimal drainage apparatus Orbit Paranasal Sinuses

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

Lacrimal Drainage Apparatus

Anatomy of Lacrimal Drainage System

Anatomy of Lacrimal Drainage System

Formation of Congenital Mucocele of Nasolacrimal Duct/ Dacryocystocele Obstruction at the valve of Hasner

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

Dacryocystocele Post-Contrast CT scan in 18 -day-old infant : Rounded, well-defined, rim-enhancing lesion abutting

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 T 2 W Axial T 2 W Coronal T 2 W Axial and

Dacryocystocele T 2 W Axial T 2 W Coronal T 2 W 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 18 year old male: Soft tissue

Dacryocystitis with pre-septal cellulitis Post-Contrast CT in a 18 year 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

Dacryocystitis with pre and post-septal cellulitis Teaching points: Post- contrast CT scan: Axial and Coronal 1) Dacryocysitis is diagnosed clinically unless associated with periorbital cellulitus. images of the orbit in 47 year old female with left preseptal and post septal extra 1) Imaging allows to distinguish between post-septal orbital inflammation (treated conal cellulitis and dacryocystitis. surgically) from dacryocystitis ( treated non-surgically)

Dacryocystitis with abscess Post- contrast CT scan of the orbit in 45 year old

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

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 T 2 W Axial T 1 W Axial +C

Oncocytic Papillary Cystadenoma Post-Contrast CT T 2 W Axial T 1 W Axial +C T 2 W Axial T 1 W 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 T 1 W Axial Post-Contrast

Lacrimal duct invasive squamous cell carcinoma Post-Contrast Coronal CT T 1 W Axial Post-Contrast Axial CT T 2 W Coronal T 2 W Axial T 1 W 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

Orbit

Dermoid Teaching Points: Post- contrast CT scan of the orbit in 28 year old

Dermoid Teaching Points: Post- contrast CT scan of the orbit in 28 year old female: Oval-shaped fat density lesion 1) Dermoids are the most common congenital orbital masses. in the medial canthus of the left orbit with no enhancement or bony erosion consistent 2) Presence of fat, rim calcification , scalloping of bone are the common imaging with dermoid tumor findings.

Dermoid T 1 W Axial DWI T 2 W Axial CT and MRI of

Dermoid T 1 W Axial DWI T 2 W 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 T 1 and T 2 images and suppressed on fat sat images with no restricted diffusion or postcontrast enhancement T 2 W Fat sat Coronal T 1 W Fat sat Axial

Sclerosing orbital pseudo tumor T 1 W Axial Teaching Points: T 2 W Axial

Sclerosing orbital pseudo tumor T 1 W Axial Teaching Points: T 2 W Axial T 2 W 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 T 2 weighted images with loss of cavity with obliterating of the fat between involved muscle and periosteum of involved orbital wall. right osteomeatal complex. 4) Differential Diagnosis: Grave’s disease, Lymphoma, Rhabdomyosarcoma Extension also noted into the intra and Metastasis conal compartment of the orbit T 1 W Axial +C T 1 W Coronal + C with thickening of the medial and inferior rectus muscle.

Paranasal Sinuses and Nasal Cavity

Paranasal Sinuses and Nasal Cavity

 Ethmoid mucocele Contrast enhanced CT scan of the paranasal sinuses: Mucocele of the

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 T 1 W Coronal+C CT

Invasive Aspergillus of right ethmoid sinus Post-Contrast Axial CT T 1 W 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 T 1 and T 2 W 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. T 1 W Axial T 2 W Axial

Malignant transformation of inverted papilloma T 1 W Axial T 1 W Coronal T

Malignant transformation of inverted papilloma T 1 W Axial T 1 W Coronal T 2 W 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 T 1 W Axial +C

Nasal lymphoma to medial canthus T 2 W Axial T 1 W Axial +C

Nasal lymphoma to medial canthus T 2 W Axial T 1 W Axial +C DWI MRI of the orbit in 56 year old male : Soft tissue mass lesion appearing predominantly isointense on T 1, hypo intense on T 2 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 T 1 W Axial MRI of the orbit

Squamous cell carcinoma of the nose T 1 W 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. T 2 W Axial T 1 W Axial +C

Wegner’s Granulomatosis T 1 W Axial T 2 W Axial MRI of the orbit

Wegner’s Granulomatosis T 1 W Axial T 2 W 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

Miscellaneous

Basal Cell Carcinoma Post-Contrast CT T 1 W Axial CT and MRI of the

Basal Cell Carcinoma Post-Contrast CT T 1 W 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. T 1 W Axial +C

Capillary hemangioma T 1 W Axial T 2 W Axial T 1 W Axial

Capillary hemangioma T 1 W Axial T 2 W Axial T 1 W 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

Systemic Disease

Lymphoma Post-Contrast Axial CT DW 1 T 2 W Axial T 2 W Coronal

Lymphoma Post-Contrast Axial CT DW 1 T 2 W Axial T 2 W Coronal T 1 W Axial +C CT and MRI of the orbit in 68 year old male : Well-defined homogenously enhancing soft tissue mass with low signal on T 2 W image and restricted diffusion on DWI images in the medial canthus of the left orbit.

Leukemic deposits T 2 W Axial T 1 W Axial +C T 2 W

Leukemic deposits T 2 W Axial T 1 W Axial +C T 2 W Coronal T 1 W Axial T 2 W Axial T 1 W 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:

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 T 1 W Axial T 2 W FS Axial T 2 W

Langheran’s histiocytosis T 1 W Axial T 2 W FS Axial T 2 W Coronal MRI orbit of the same child demonstrates focus of T 1 iso - and T 2 hyper-intensity with homogeneous post - gadolinium enhancement. inferior to the right medial canthus, in the right infraorbital/nasal subcutaneous tissues. T 1 W Axial +C

Metastasis from squamous cell ca of tonsil Metastasis from poorly differentiated ca of submandibular

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

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 Russell EJ, Czervionke L, Huckman M, Daniels D, Mc. Lachlan D. CT of

References Russell EJ, Czervionke L, Huckman M, Daniels D, Mc. Lachlan D. CT of the infenomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. AJNR 1985; 6: 759766 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. Radio. Graphics 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.

Imaging of Medial Canthus of the Orbit: An Unexplored Territory J Nair, C Torres,

Imaging of Medial Canthus of the Orbit: An Unexplored Territory J Nair, C Torres, J Chankowsky, R del carpio