Introduction

The 4th edition of the 2017 World Health Organization (WHO) classification of head and neck tumors has been
pub- lished and tumors of the nasal cavity and paranasal sinuses were reorganized. This classification includes
three new, relatively well-defined entities: seromucinous hamartoma, NUT carcinoma, and biphenotypic sinonasal
sarcoma, while the total number of entities has been reduced by exclud- ing tumor types if they did not occur
exclusively or pre- dominantly at these sites or if they are discussed in detail in other sections [1]. However, a
significant diversity of enti- ties is still listed at the sinonasal region, and updating the knowledge of various
disease entities and classifications is clinically crucial for radiologists.

Among tumors of the nasal cavity and paranasal sinuses, this article especially focused on the benign
mass lesions including benign tumors and inflammatory diseases. This article also included
nasopharyngeal lesions because the nasopharyngeal lesions often extend into the nasal cavity and
paranasal sinuses and sometimes occur in such regions. Although most benign lesions are curative by
total resection or medical treatment, some benign lesions should be given attention in the follow-up
period and before surgery. For example, sinonasal papillomas sometimes recur because of incomplete
resection and have potential for malignant trans- formation, inflammatory diseases often present as
tumor- like lesions and could be misdiagnosed as malignant tumors before surgical resection, and
hypervascular tumors includ- ing hemangioma or nasopharyngeal angiofibroma may cause massive
bleeding. Therefore, understanding the computed tomography (CT) and magnetic resonance (MR)
imaging features of various types of nasal and paranasal benign mass lesions is clinically important for
appropriate therapy. Table 1 Benign tumors in the 2017 WHO classification of tumors of the nasal cavity, paranasal sinuses,
and skull base

Sinonasal papillomas

Inverted type, oncocytic type, and exophytic type Respiratory epithelial lesions

Respiratory epithelial adenomatoid hamartoma Seromucinous hamartoma

Salivary gland tumors Pleomorphic adenoma

Benign soft tissue tumors Leiomyoma Hemangioma Schwannoma Neurofibroma

Other tumors Meningioma

Sinonasal ameloblastoma Chondromesenchymal hamartoma

Table 2 Benign tumors in the 2017 WHO classification of tumors of the nasopharynx
Benign lesions Hairy polyp

Ectopic pituitary adenoma Craniopharyngioma

Soft tissue tumors Nasopharyngeal angiofibroma

Sinonasal papillomas

Inverted type, oncocytic type, and exophytic type

Pathologic and clinical features

Sinonasal papillomas are benign epithelial neoplasms aris- ing from Schneiderian mucosa and are
histopathologically divided into three subtypes (inverted [62%], oncocytic [6%], and exophytic [32%]) [2].
Inverted papilloma (IP) is the most frequent papilloma of the sinonasal region, showing inverted growth with a
mul- tilayered epithelium [3]. Multiple inversions of the surface epithelium into the underlying stroma, which are
composed of squamous and/or respiratory cells and lined by a distinct and intact continuous basement membrane,
are a typical morphology. A non-keratinizing squamous or transitional epithelium frequently predominates and is
covered by a layer of ciliated columnar cells. IPs are most frequent in the fifth and sixth decades of life and are 2.5–
3 times more com- mon in males than in females [3–5]. Patients present with non-specific symptoms such as nasal
obstruction, polyps, epistaxis, rhinorrhea, hyposmia, and headache. The lateral wall of the nasal cavity and the
median wall of the maxillary sinus are the most common locations. Although benign, IPs have a high propensity for
recurrence, local aggressiveness, multicentricity, and malignant transformation (1.9–27% of IPs become squamous
cell carcinoma [SCC]) [6, 7]. IPs are suspected to associate with human papillomatous virus (HPV) [3].
Oncocytic papilloma (OP) is derived from the sinonasal epithelium, which is composed of both exophytic fronds
and endophytic invaginations lined by multiple layers of columnar cell with oncocytic features. Intraepithelial
microcysts containing mucin and neutrophils are characteristic of OPs. Most patients are older than the sixth decade
of life with no sex predilection [5]. The main symptoms are nasal obstruction and intermittent epistaxis. OPs almost
always occur unilaterally on the lateral nasal wall or in the paranasal sinuses. Malignant transformation is identified
in about 10% of OPs. Unlike in inverted and exophytic papillomas, HPV has not been identified in OPs [8].
Exophytic papilloma (EP) derived from sinunasal mucosa composed of papillary fronds with delicate fibro-
vascular cores covered by a multilayered epithelium, which varies from squamous to ciliated pseudostratified
columnar cells or may be transitional between the two [9]. EPs occur in the third to sixth decades of life and are 2–
10 times more common in males than in females. Symptoms are unilateral nasal obstruction and epistaxis. EPs
usually arise on the lower anterior nasal septum. Malignant transformation is extremely rare. As in IPs, EPs are
also suspected to associ- ate with HPV [9]. Imaging findings (Fig. 1)

Because imaging differences among the three subtypes of sinonasal papillomas have not been revealed [10, 11],
we mainly describe the imaging features of IPs. CT could pro- vide information about the site of origin of IPs,
where focal hyperostosis on the sinus wall is often identified [12]. In con- trast, bone sclerosis is usually more
diffuse in other inflam- matory sinonasal diseases. On MR imaging, IPs frequently show a lobulated shape with
hyperintensity on T2-weighted image and iso- to hypointensity on T1-weighted image. A convoluted cerebriform
pattern (CCP) is characteristic of IPs, showing alternating hypointense and hyperintense bands on T2-weighted
image and contrast enhanced T1-weighted image, which resemble the cerebral gyri [13]. A focal loss of CCP, a necrotic
lesion, or invasion to the surrounding tissue may be additional signs that indicate the presence of coexistent SCC
(Fig. 2) [14].

Clinical and diagnostic tips

Because recurrences and malignant transformation are fre- quent in inadequate excision, identifying the hyperostotic
region in adjacent bone is crucial before surgery. CCP is a characteristic sign of IPs, and a focal loss of CCP or a
 necrotic lesion may indicate the presence of coexistent SCC. A sum- mary of the differentiation between IPs and other
benign mass lesions is shown in Table 3.

Respiratory epithelial lesions

Respiratory epithelial adenomatoid hamartoma

Pathologic and clinical features

Respiratory epithelial adenomatoid hamartoma (REAH) is a benign neoplasm occurring in the nasal cavity and
para- nasal sinuses. The histopathologic feature is dominated by the presence of a submucosal glandular
proliferation, which is lined by a ciliated respiratory epithelium with a polypoid appearance [15].
Median patient age is in the sixth decade of life, ranging from the third to ninth decades, and the male to female
ratio is 7:1. The most common symptoms are nasal obstruction, rhinorrhea, and loss of smell [15–18]. Most REAHs
are found on the anterior half of the olfac- tory clefts (OC) or the posterior nasal septum [15, 19]. Involvement of
other sites occurs less common [15].

Imaging features (Fig. 3)

CT shows a homogeneous mass with clear enlargement of the OC without bone destruction [19]. MR imaging shows
well-delineated tissue filling on T2-weighted image and homogeneous contrast enhancement. Although REAHs
have been classically recognized as an isolated lesion, it also occurs coincident with diffuse sinonasal polyposis
and other paranasal diseases. This coincident type of REAH also shows wide OC, as in the isolated type [19].

Clinical and diagnostic tips

Significant widening of the OC with the characteristic location (in the anterior half of the OC) is a specific trait of
REAHs. The main differential diagnosis is IPs, which require more
extensive surgical excision to avoid recurrence or malignant transformation. In contrast, complete excision is
curative in REAHs with no reports of malignant transformation [20].

Meningioma

Pathologic and clinical features

Sinonasal meningioma, often blended with the surface squa- mous or respiratory epithelium, is arranged in lobules
of whorled syncytial meningothelial cells [41, 42]. Of the 15 histological types of meningioma, the meningothelial,
tran- sitional, metaplastic, and psammomatous types are common in sinonasal meningiomas. Most of these
meningiomas are grade 1 tumors, whereas grade 2 and 3 meningiomas are rare [41]. Sinonasal meningiomas account
for fewer than 2% of all meningiomas, including both primary and secondary types, which are based on the absence
or presence of intrac- ranial attachments, respectively [43]. Primary extracranial
 meningiomas of the sinonasal tract with no direct cranial attachment are extremely rare, whereas secondary
sinonasal meningiomas, which show direct extension, are much more common [41].
Adults (mean age: in the fifth decade) are mainly affected with a female predilection (male to female = 1:1.7–
2.1). Symptoms are generally non-specific, including a mass or polyp and nasal obstruction. Sinonasal
meningiomas most commonly involve the nasal cavity, followed by the frontal sinus [41].

Imaging findings (Fig. 9)

CT shows a mass with adjacent bone erosion or hyperosto- sis. In most cases, direct extension by permeative
growth from the intracranial primary lesion can be documented. MR imaging shows various signal intensities on
T2-weighted image, and hypointensity on T1-weighted image with homogenous contrast enhancement [44].

Clinical and diagnostic tips

Identification of hyperostosis may be useful for diagnosis of meningiomas. In the diagnosis of secondary extracranial
meningioma, a characteristic feature that displays a different signal intensity and enhancement patterns between intra
and extracranial components may be identified [45].
Nasopharyngeal angiofibroma Pathologic and clinical features

Nasopharyngeal angiofibroma (NA), which is also called juvenile nasopharyngeal angiofibroma, is a rare, benign,
highly vascular, and locally aggressive neoplasm, composed
 of two components: vascular and stromal tissues. The blood vessels are of various sizes, shapes, and thicknesses,
ranging from slit-like capillaries to irregularly dilated and branching vessels. The stroma consists of bipolar or stellate
fibroblastic cells, which appear to be arranged around the blood vessels [53].
NAs develop almost exclusively in adolescent and young males (mean age; 17 years), showing a puberty-
associated growth because of their frequent expression of an andro- gen receptor. Patients present with the classic
triad of nasal obstruction, epistaxis, and nasopharyngeal mass. Most NAs arise from the pterygopalatine fossa and
nasopharynx of the posterolateral nasal cavity wall [53].

Imaging findings (Fig. 11)

CT shows a remarkably enhanced mass that is centered within the sphenopalatine foramen [54]. Anterior bowing
of the posterior wall of the maxillary antrum and widening of the pterygopalatine fossa are typical. As the tumor
grows, extension to surrounding tissue and destruction of adjacent bone are sometimes identified. MR imaging is
superior to CT for detecting the intracranial extension, which is seen in 10–30% of cases. MR imaging shows iso-
to hyperintensity on T2-weighted image, and hypointensity on T1-weighted image with avid contrast enhancement.
A flow void may be seen because of the hypervascularity [54].

Clinical and diagnostic tips

Patient’s age and sex, specific location with a bowing poste- rior wall of the maxillary antrum, and hypervascularity
can be characteristic features, which allow diagnosis and accu- rate estimation of the extent without recourse to the
dangers of biopsy. Because of the hypervascularity, angiography is also diagnostic and useful for identifying the
feeding artery (usually the internal maxillary artery) and preoperative embolization [53].
Inflammatory polyp Pathologic and clinical features

Sinonasal inflammatory polyp often originates from the maxillary sinus. Inflammatory polyp is caused by allergy,
vasomotor rhinitis, infections, cystic fibrosis, aspirin intoler- ance, or nickel exposure. Fluid accumulation in the
lamina propria results in polyp formation. Furthermore, inflam- matory polyp may be associated with mucocele
or antral cyst formation in the maxillary sinus because of increased pressure in the antrum, resulting in expansion
through an accessory or secondary ostium below the middle meatus. Antrochoanal polyp is a relatively rare type of
inflammatory polyp, which often arises from the ostium of the maxillary sinus, extends through the ostium, across
the choana, and into the nasopharynx, and usually occurs unilaterally [35].
Patient age at presentation varies widely with no sex predilection. Symptoms are non-specific, most commonly
including nasal obstruction and rhinorrhea.

Imaging findings (Fig. 12)

CT shows inflammatory polyp, including antrochoanal polyp, as an oval hypodense mass but may be hyperdense
because of increased protein content or fungal infection.
 MR imaging shows inflammatory polyp, including antro- choanal polyp, as hypo- to hyperintensity on T2-weighted
image associated with the components, and isointensity on T1-weighted image with peripheral contrast
enhancement. In particular, an antrochoanal polyp tends to be a single, unilateral expansile process, revealing
nearly total maxillary sinus opacification, mucosal thickening, and extension into the nasopharynx [35].

Clinical and diagnostic tips

Although a large inflammatory polyp, especially antrochoa- nal polyp, may be misdiagnosed as other tumors, such
as IPs, because of overlapping imaging features, peripheral enhancement may be useful for differentiation [55].
Sinona- sal inflammatory polyps, including antrochoanal polyps, can coexist with a wide variety of pathologic
entities ranging from infective granuloma diseases to malignant tumors [56].