Paranasal Sinus CT Report Template: Normal and Rhinosinusitis Examples

Routine noncontrast sinus CT report framework

This framework is for a routine adult CT of the paranasal sinuses without intravenous contrast, commonly obtained to assess sinonasal inflammatory change. Adapt the coverage and technique fields to the actual examination; a tumor, invasive infection, orbital or intracranial complication, or dedicated preoperative question may require a different protocol and a more focused assessment.

Examination: Noncontrast CT of the paranasal sinuses with [axial acquisition and coronal/sagittal reformations / specify actual technique].

Comparison: [Prior sinus CT dated DD Month YYYY / None available.]

Findings: The frontal, ethmoid, maxillary, and sphenoid sinuses are [clear / described individually]. [Mucosal thickening, fluid, or opacification: specify side, sinus, and extent.] The [right/left] ostiomeatal complex is [patent/obstructed]. The frontal recesses and sphenoethmoidal recesses are [patent/describe]. [Describe nasal cavity, septum, turbinates, relevant bony anatomy, and any included orbital or intracranial finding when adequately visualized.]

Impression:
1. [No significant sinonasal opacification / Describe the distribution and drainage pathway involvement.]
2. [Relevant anatomic variant, complication, or limitation, if present.]

Do not retain normal statements by default. Report only the structures that are included and adequately visualized. A routine noncontrast sinus CT describes anatomy and mucosal findings; it does not by itself establish a clinical diagnosis of acute or chronic rhinosinusitis.

Confirm the clinical and protocol scope

The clinical indication determines which imaging question the CT needs to answer. A routine sinus CT is not a substitute for the evaluation of suspected orbital or intracranial complications, invasive fungal disease, or a sinonasal mass. The ACR Appropriateness Criteria distinguish these scenarios: CT and MRI have complementary roles, with MRI providing better soft-tissue assessment for suspected orbital or intracranial extension and tumor extent. If the request concerns a mass, complication, cerebrospinal-fluid leak, or surgical planning, check that the acquisition and coverage answer that specific question.

Before interpreting, verify:

• Is this a routine noncontrast sinus examination, a navigation/preoperative study, or a contrast-enhanced assessment?
• Are the frontal sinuses, ethmoid air cells, maxillary sinuses, and sphenoid sinuses all included?
• Are axial images and useful coronal and sagittal reformations available?
• Do dental restorations, motion, or other artifacts limit evaluation?
• Is there prior imaging or prior sinonasal surgery?
• Is the question inflammatory disease, a suspected mass, a complication, or anatomy for a planned procedure?

Systematic review: sinuses and drainage pathways

1. Frontal sinuses and frontal recesses

Review each frontal sinus for mucosal thickening, fluid, partial or complete opacification, and asymmetry. Assess the frontal recess when visible. Do not describe a drainage pathway as patent if it cannot be followed on the available images.

2. Ethmoid air cells

Review anterior and posterior ethmoid groups separately. Note whether the change is focal or diffuse and whether the ethmoid labyrinth is partially or completely opacified. The thin bony partitions and adjacent skull base and orbital walls may matter when the examination is intended for operative planning.

3. Maxillary sinuses and ostiomeatal complexes

Describe unilateral or bilateral mucosal thickening, fluid levels, retention cysts, and the extent of opacification. Review the infundibula and ostiomeatal complexes on both sides. When relevant, inspect the maxillary floors and included dentition for a possible odontogenic relationship; do not infer a dental source without supporting findings.

4. Sphenoid sinuses and sphenoethmoidal recesses

Assess each sphenoid sinus for mucosal change, fluid, opacification, and asymmetry. Describe the sphenoethmoidal recesses when they are visible. If the clinical question involves a lesion or complication near the skull base, state when the routine study is insufficient to assess soft-tissue extension.

5. Nasal cavity and adjacent structures

Review the nasal septum, turbinates, nasal cavity, and included nasopharynx. Mention anatomic variants when they are relevant to the indication, especially when the study is intended for surgical planning. Describe bony remodeling, erosion, or dehiscence when present. A variant alone is not proof that it causes symptoms.

Complete normal example

Fictional teaching case: An adult has a routine noncontrast sinus CT for persistent nasal symptoms. The study is technically adequate and shows no significant sinus opacification.

Examination: Noncontrast CT of the paranasal sinuses with axial acquisition and coronal and sagittal reformations.

Comparison: None available.

Findings: The frontal, ethmoid, maxillary, and sphenoid sinuses are aerated without significant mucosal thickening or fluid. The ostiomeatal complexes, frontal recesses, and sphenoethmoidal recesses are patent. The nasal septum is near midline. No focal sinonasal mass or destructive osseous change is identified. The included orbital contents are unremarkable.

Impression: No significant paranasal sinus opacification.

Use the last sentence about the orbits only if they are included and adequately assessed. This normal imaging example does not rule out a symptom-based clinical diagnosis.

Fictional inflammatory-pattern examples

Minimal maxillary mucosal thickening

Case: A fictional adult has thin mucosal thickening along the floor of the right maxillary sinus. The remaining sinuses are clear and the drainage pathways are patent.

Examination: Noncontrast CT of the paranasal sinuses with coronal reformations.

Comparison: None available.

Findings: Minimal mucosal thickening along the floor of the right maxillary sinus. The remaining paranasal sinuses are clear. The ostiomeatal complexes are patent.

Impression: Minimal right maxillary sinus mucosal thickening. No obstructive sinus opacification.

Minor mucosal thickening is a descriptive finding; on its own it should not be called bacterial sinusitis or chronic rhinosinusitis.

Multisinus inflammatory change with a fluid level

Case: A fictional adult has bilateral maxillary and anterior ethmoid mucosal thickening, bilateral ostiomeatal obstruction, and a fluid level in the left maxillary sinus.

Examination: Noncontrast CT of the paranasal sinuses with coronal reformations.

Comparison: None available.

Findings: Mucosal thickening involves both maxillary sinuses and anterior ethmoid air cells, with obstruction of both ostiomeatal complexes. A fluid level is present in the left maxillary sinus. The frontal and sphenoid sinuses are clear.

Impression: Bilateral maxillary and anterior ethmoid mucosal disease with bilateral ostiomeatal obstruction. Left maxillary sinus fluid level; correlate with symptom duration and clinical findings.

The distribution and fluid level can be seen with inflammatory disease in the appropriate context, but CT alone does not determine symptom duration or establish the clinical syndrome.

Optional Lund–Mackay score

If a numeric extent score is requested or used locally, the Lund–Mackay system scores each side separately: maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal sinuses are each scored 0 (clear), 1 (partial opacification), or 2 (complete opacification); the ostiomeatal complex is scored 0 (not obstructed) or 2 (obstructed). The maximum is 12 per side and 24 overall. State the score as a supplement to the anatomic description, not as a stand-alone diagnosis or a substitute for the report.

Reporting checklist and limitations

• Identify the examination, contrast status, coverage, and available reformations.
• Compare with prior imaging and mention surgery or artifacts that affect interpretation.
• Review all five paired sinus groups and the relevant drainage pathways.
• Describe the side and extent of mucosal thickening, fluid, or opacification.
• Assess the ostiomeatal complexes, frontal recesses, and sphenoethmoidal recesses when visible.
• Review the nasal cavity, bony walls, and included adjacent structures within the study's scope.
• Keep imaging findings separate from a clinical diagnosis of acute or chronic rhinosinusitis.
• If a mass, invasive infection, or orbital/intracranial complication is suspected, state whether routine noncontrast CT is adequate for that question.

Mucosal thickening, retention cysts, and partial opacification are not interchangeable with a clinical diagnosis. Do not equate a small amount of mucosal thickening with active infection, and do not label every anatomic variant as the cause of symptoms. Routine noncontrast CT has limited soft-tissue characterization; the ACR pathway may call for contrast-enhanced CT, MRI, or both for a suspected mass or complication. Do not make an unqualified statement about structures outside the field of view.

References

• American College of Radiology. ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update. Journal of the American College of Radiology. 2022. doi:10.1016/j.jacr.2022.02.011 (opens in a new tab).
• American College of Radiology. ACR Appropriateness Criteria® Sinonasal Disease, full narrative (opens in a new tab).
• Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology. 1993;31:183–184. PubMed record (opens in a new tab) · Original article PDF (opens in a new tab).

Clinical note: Educational examples only. Adapt the report to the actual acquisition, indication, images, and local protocol.