Congenital Paradoxical Lower Eyelid Retraction With Upgaze due to an Anomalous Extraocular Muscle.

Congenital anomalous orbital structures are rare and associated with strabismus, globe retraction, and dystopia. The authors present a case of congenital paradoxical right lower eyelid retraction with upgaze due to an anomalous extraocular muscle in a 17-year-old, healthy, female patient. Orbital computed tomography showed an intraconal, inferolateral soft-tissue band extending from the orbital apex to the inferior oblique muscle and lower eyelid. There was resolution of lower eyelid retraction and exposure symptoms after resection of the anterior portion of the fibromuscular band from the lower eyelid retractors and eyelid elevation with ear cartilage. To the authors' knowledge, this case is the first to report anomalous orbital structure as a rare cause of congenital paradoxical lower eyelid retraction, which can be improved with resection.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Positron emission tomography in Warthin's tumor mimicking malignancy impacts the evaluation of head and neck patients.

PURPOSE: 1) To determine SUVs and PET/CT characteristics of Warthin's tumors in patients presenting to a head and neck cancer clinic. 2) To analyze the impact of PET/CT on the clinical course of these patients. MATERIALS AND METHODS: This is a single-institution retrospective analysis of patients with proven Warthin's tumors who underwent PET/CT done at or near the time of diagnosis and presented to a head and neck cancer practice. Data were obtained from the electronic medical records of these patients and the imaging and pathology databases. RESULTS: Six patients with Warthin's tumor met the criteria for and form the study cohort. Three patients had bilateral tumors. The SUVs for Warthin's varied from 3.4 to 16.1 in these patients, with an average of 7.8 and these SUVs were higher for Warthin's than for the cancers. These findings on PET/CT in this group required additional workup of all patients and required FNA, surgery or SPECT-CT to confirm the diagnosis. CONCLUSION: Although it is known that Warthin's tumor may be hypermetabolic on PET, this finding in the parotid or neck on PET/CT alters the evaluation and treatment of head and neck cancer patients and patients with cancers outside the head and neck by raising the concern about metastatic disease or multiple primary cancers. In other patients, PET/CT obtained for other reasons may prompt concern about incidental malignancy. This series specifically characterizes clinical features, SPECT-CT and FNA findings that can help reinforce the diagnosis of Warthin's and facilitate management.

Calculated computed tomography volumes of lacrimal glands and comparison to clinical findings in patients with thyroid eye disease.

PURPOSE: To describe the range of lacrimal gland volumes on CT in Caucasian patients with thyroid eye disease (TED) and to correlate with clinical findings. METHODS: With institutional review board approval, 125 orbital CT scans for TED were reviewed. OsiriX software was used to calculate the volume of the lacrimal gland. Comparison of the volumes was made with previously published results of the normal population. Patient race, gender, smoking status, diplopia, tearing, exophthalmometry, superficial punctate keratitis (SPK), lagophthalmos, restriction in motility, and VISA score were collected. RESULTS: The mean volume of the lacrimal gland in patients with TED was 0.890 cm in right orbits (standard deviation [SD] 0.348), 0.851 cm in left orbits (SD 0.350), with no significant difference between right and left (p = 0.311). The mean volume was 0.811 cm in right male orbits (SD 0.386) and 0.911 cm in right female orbits (SD 0.335), with no significant difference between men and women (p = 0.774). These findings were confirmed in an analysis of left orbits. The volume of right and left orbits correlated well (r = 0.777, p < 0.0001). The lacrimal gland volume in patients with TED was greater compared with the normal population using a 2-sample t test (p < 0.0001). Exophthalmometry (right: r = 0.225, p = 0.0115; left: r = 0.267, p = 0.0026) and subjective tearing (right: r = 0.226, p = 0.0138; left: r = 0.197, p = 0.0322) correlated with lacrimal gland volume. CONCLUSIONS: This study is the first to report the volume of the lacrimal gland calculated on CT scan for patients with TED. The lacrimal gland is larger in patients with TED and correlates with subjective tearing and exophthalmometry.

Supplemental ERAS application for radiology residency match: A primer.

The supplemental ERAS application that includes three components: past experiences, geographic preferences, and program signals was introduced in 2022 to complement the standard ERAS CV material. The goal was to help programs identify optimal candidates to interview and to improve the chances of applicants being invited for interviews at programs that align with their goals and interests. Based on limited data, Program signal is the most emphasized component by the programs. Applicants should realize that programs have used signals to determine who to interview (aligned with AAMC guidance), and to determine the program's candidate rank list (contrary to AAMC guidance). We have herein suggested options for leveraging benefits from the ERAS supplemental application which has now been incorporated into the full ERAS application.

Progressive multifocal leukoencephalopathy in patients with multiple sclerosis.

PURPOSE OF REVIEW: Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system. It has been recently associated with selective immunosuppression in patients with multiple sclerosis. This review describes the pathogenesis, clinical presentation, diagnosis, and treatment of natalizumab-associated PML. RECENT FINDINGS: Treatment of multiple sclerosis with natalizumab first involves risk stratifying patients. Clinicians can employ new tools for risk stratification including JC-virus antibody status, prior immunosuppression, and length of natalizumab treatment. These tools can help minimize the risk of developing PML. Identifying patients with natalizumab-associated PML poses a diagnostic challenge for clinicians. Unique clinical features, sensitive laboratory analyses, and advanced MRI techniques have been identified that aid in the diagnosis of natalizumab-associated PML. SUMMARY: There continues to be significant gaps in our understanding of PML pathogenesis and its relationship with therapeutic immunosuppression. There have been advances made in our ability to treat multiple sclerosis, although these have come with the unintended risk of PML. Fortunately, natalizumab-associated PML remains a rare entity compared to multiple sclerosis-associated disability, and the risk may be mitigated with appropriate patient selection, accurate and rapid diagnosis, and aggressive treatment strategies.

Rapid decline in lung function in coal miners: evidence of disease in small airways.

BACKGROUND: Coal mine dust exposure can cause both pneumoconiosis and chronic airflow limitation. The contributions of various pathophysiologic mechanisms to dust-related lung function decrements remain unclear. METHODS: Clinical and physiological findings were assessed for 15 underground coal miners who had demonstrated accelerated FEV1 losses (decliners) over 6-18 years. Decliners' findings were evaluated in comparison to a group of 11 miners who had shown relatively stable lung function (referents) during the same period. RESULTS: At follow-up examination, the decliners showed significantly greater mean airway resistance (10.47 vs. 6.78 cmH2 O/L/s; P = 0.05) and more air trapping (RV/TLC = 37.5 vs. 29.1%; P < 0.01) compared to the referents. Decliners also demonstrated more evidence of small airways dysfunction and tended to have more bronchospasm than the referent group. Total lung capacity, lung compliance, diffusing capacity, and chest radiography did not differ significantly between the two groups. After cessation of mine dust exposures, the decliners' mean rate of FEV1 loss normalized. CONCLUSION: In a series of working coal miners, accelerated lung function declines were associated with air trapping and evidence of small airways dysfunction. A preventive benefit from controlling dust exposures was suggested.

Calculated CT volumes of lacrimal glands in normal Caucasian orbits.

INTRODUCTION: The objective was to describe the range of normal volumes for the lacrimal gland calculated from CT. METHODS: A retrospective review with institutional review board approval of 293 CT scans of 586 orbits was performed. Patients were included if they were Caucasian and aged 18 years or older. Orbits were excluded if there was a disease or trauma. OsiriX software was used to outline the lacrimal gland in consecutive axial slices and to calculate the volume. Inter-rater agreement was assessed in a subset of 30 randomly selected orbits by observers of different levels of training using the intraclass correlation coefficient (ICC). RESULTS: Two hundred sixty orbits of 187 patients were included. The mean volume of the lacrimal gland was 0.696 cm2 in right orbits (SD = 0.261) and 0.649 cm2 in left orbits (SD = 0.231), with no significant difference between right and left (p= 0.125). The mean volume was 0.680 cm2 in men (SD = 0.241) and 0.662 cm2 in women (SD = 0.260), with no significant difference between men and women (p = 0.564). There was an inverse relationship between gland volume and age (Pearson r= -0.428 right orbits and -0.469 left orbits). Of the 73 bilateral patients, right and left orbits correlated well (Pearson r = 0.712). Agreement was good among the observers (ICC = 0.727). CONCLUSIONS: This is the first study to report the range of normal volume for Caucasian lacrimal glands measured on CT scans. The volume of the lacrimal gland decreases with age, and there is no gender or laterality difference.

Facial nerve schwannoma: Case report and brief review of the literature.

Schwannomas are rare nerve sheath tumors that can occur throughout the body, and are symptomatic based on location, size, and impingement on adjacent structures. These tumors are often benign lesions and occur sporadically or from genetic conditions such as neurofibromatosis. Schwannomas may arise from peripheral nerves, gastrointestinal nerves, spinal nerve roots and cranial nerves. Facial nerve schwannomas arise from cranial nerve VII, commonly involving the geniculate ganglion, labyrinthine segment, and internal auditory canal. While small lesions are asymptomatic, larger lesions can cause facial nerve paralysis, and facial spasms. Lesions in the internal auditory canal can cause hearing loss, tinnitus, vertigo, and otalgia. High-resolution CT imaging and MRI imaging are useful for distinguishing between other pathologies that arise from the same region. High-resolution CT scans can show bony degeneration of nearby structures such as the labyrinth or ossicles. MRI imaging shows hypo intensity on T1 imaging, and hyperintensity on T2 imaging. On T1 postcontrast, enhancement can be homogenous or heterogeneous with cystic degeneration if the lesion is large. Nodular enhancement is commonly seen on facial nerve schwannomas within the internal auditory canal. Vestibular schwannomas involving CN VIII are more common, and appear similar to facial nerve schwannomas, but can be distinguished apart due to growth in the geniculate ganglion and/or the labyrinthine segment. Management of asymptomatic or mild lesions is typically conservative with follow up imaging, and surgery for larger lesions. Here, we present a case of a facial nerve schwannoma in a 57-year-old woman.

Spinocerebellar ataxia-type 34: A case report and brief review of the literature.

Neurodegenerative disorders are classified as a group of diseases with progressive loss of neurons secondary to aggregation of misfolded proteins. A few of these neurodegenerative diseases have been associated with degeneration of the transverse pontocerebellar tracts and median pontine raphe nuclei. This specific neuron degeneration results in the radiologic hot cross bun sign (HCBS) on MRI T2 imaging and helps narrow down the differential diagnosis. While multiple system atrophy has a higher prevalence of the HCBS than other neurodegenerative diseases, the sign has also been described with other neurodegenerative disorders such as spinocerebellar ataxia (SCA), and variant Creutzfeldt-Jakob disease. Here, we present a case of spinocerebellar ataxia type 34 with a characteristic hot-cross bun sign and provide a brief review of the literature.

Online interactive medical neuroimaging exercise to identify human brain structures.

A persisting need remains for developing methods for inspiring and teaching undergraduate medical students to quickly learn to identify the hundreds of human brain structures, tracts and spaces that are clinically relevant (viewed as three-dimensional volumes or two-dimensional neuroimages), and to accomplish this with the option of virtual on-line methods. This notably includes teaching the essentials of recommended diagnostic radiology to allow students to be familiar with patient neuroimages routinely acquired using magnetic resonance imaging (MRI) and computed tomography (CT). The present article includes a brief example video plus details a clinically oriented interactive neuroimaging exercise for first year medical students (MS1s) in small groups, conducted with instructors either in-person or as an entirely online virtual event. This "find-the-brain-structure" (FBS) event included teaching students to identify brain structures and other regions of interest in the central nervous system (and potentially in head and neck gross anatomy), which are traditionally taught using brain anatomy atlases and anatomical specimens. The interactive, small group exercise can be conducted in person or virtually on-line in as little as 30 min depending on the scope of objectives being covered. The learning exercise involves coordinated interaction between MS1s with one or several non-clinical faculty and may include one or several physicians (clinical faculty and/or qualified residents). It further allows for varying degrees of instructor interaction online and is easy to convey to instructors who do not have expertise in neuroimaging. Anonymous pre-event survey (n = 113, 100% response rate) versus post-event surveys (n = 92, 81% response rate) were attained from a cohort of MS1s in a neurobiology course. Results showed multiple statistically significant group-level shifts in response to several of the questions, showing an increase in MS1 confidence with reading MRI images (12% increase shift in mean, p < 0.001), confidence in their approaching physicians for medical training (9%, p < 0.01), and comfort levels in working online with virtual team-based peers and with team-based faculty (6%, p < 0.05). Qualitative student feedback revealed highly positive comments regarding the experience overall, encouraging this virtual medium as a desirable educational approach.

"Resident Managed Peer-Mentoring Program": A Novel Way to Engage Medical Students and Radiology Residents in Collaborative Research.

RATIONALE AND OBJECTIVES: Engaging medical students and radiology residents in research during clinically focused training in residency can be challenging. We investigated extending a substantial degree of supervised autonomy to qualified residents to engage, mentor, and manage teams of medical students and other residents in research projects, fostering a system of laddered mentoring, referred to as "Resident Managed Peer Mentoring Program." The structure is as follows: a resident with research experience (preceptor) first identifies small-scale hypothesis driven projects which different novice learner-researchers at different levels of research background and training can undertake. The learner and preceptor then outline the learner's deliverables and set deadlines for outcomes, with regular faculty check-ins and oversight. MATERIALS AND METHODS: This observational study assessed the outcomes of our "Resident Managed Peer Mentoring Program" beginning November 2019. Primary outcomes were numbers of peer-reviewed publications credited to individual radiology physicians. Secondary outcomes were: numbers of radiology physicians who participated in publication and academic rank-based analysis of publication numbers for attending radiologists before and after the intervention. RESULTS: Number of peer-reviewed PubMed publications increased after our intervention (47.8%, in year-1; 167.4% in year-2). Increases also occurred in the number of radiology physicians who authored publications. The effect was largest for early career physicians. CONCLUSION: The "Resident managed peer-mentoring program" was a productive method that proved especially beneficial for students, residents, and early career physicians in our clinically focused training program. This approach may be transferable to other programs where an increase in research participation and productivity are valued.

Google Trends Data of Radiologists Who Accept Medicare: A Potential Tool for Predicting State Demand.

PURPOSE: To identify and analyze the demand for radiologists who accept Medicare per state from 2004 to 2009, as reflected by volume of Google searches, and to place such demand in context with other available data by state. METHODS: The number of radiologists who accept Medicare by state was divided by each state's population to achieve the radiologist density per 10,000 residents. Relative search volume (RSV) for the term "radiologist" was collected from Google Trends from 2004 to 2009. The Radiologist Demand Index (RDI) for each state was then calculated by dividing each state's RSV by the radiologist density for that state. To standardize values, each state's RDI was divided by the largest RDI to generate the Relative Radiologist Demand Index (RRDI). Utilization of medical imaging per 1000 Medicare beneficiaries in each state, overall health of a population in each state, and percentage of the population enrolled in Medicare in each state were used to compare trends with the RRDI. RESULTS: West Virginia had the greatest curiosity about radiologists who accept Medicare (as represented by proportion of Google searches) (RSV=100), followed by Mississippi (RSV=95), and Arkansas (RSV=87). Oregon demonstrated the lowest level of curiosity about radiologists who accept Medicare, by having the lowest proportion of google searches (RSV=43), followed by Vermont (RSV=49), California (RSV=50), and Colorado (RSV=50). The highest radiologist densities per population were found in Montana, D.C., and Wyoming (3.25, 1.56, 1.11, respectively). The lowest radiologist densities were found in Oklahoma, Texas, and Utah (0.4, 0.4, 0.41, 0.41, respectively). The RRDI was greatest in Louisiana (100), Arkansas (94.8), and Texas (86.3), and smallest in Montana (10.6), D.C. (17.7) and Wyoming (28.4). Positive trends between utilization of medical imaging per 1000 Medicare beneficiaries and state overall health and the RRDI were recognized. No trend between each state's RRDI and percentage of population enrolled in Medicare was noted. CONCLUSION: Imaging studies performed, an indirect measure of demand, showed trends with RRDI. Higher RRDI and imaging per 1000 Medicare beneficiaries trended with lower health scores for a state's general population. RRDI may be a useful tool reflecting each state's demand for radiologist who accepts Medicare.

Acute ischemic optic neuropathy in a case of heroin overdose.

Presence of acute optic disc and optic nerve infarction in a young man is uncommon finding. This is most commonly seen in the setting of vasculitis and infection. Ischemic optic neuropathy has been reported with cocaine use, amlodipine and alcohol use. To our knowledge there is no reported case of ischemic optic neuropathy in the setting of heroin / opioid use. MR imaging findings in the setting of substance use are similar to other etiologies of ischemic optic neuropathy, with high T2/FLAIR signal, diffusion restriction and abnormal gadolinium enhancement. Here we report a case of 23-year-old man with heroin use disorder presenting with optic nerve infarct resulting in acute painless monocular vision loss.

Primary nodular chest amyloidoma: A case report and review of literature.

Primary nodular chest wall amyloidoma, in which a solitary mass of amyloid is deposited in and around the lungs with no evidence of systemic amyloidosis, is extremely rare, most often asymptomatic, and may resemble primary bronchogenic carcinoma. As a result, there are fewer than 100 cases published in the literature and no controlled clinical trials. Primary nodular chest wall amyloidoma is typically diagnosed either as an incidental radiological finding or after very serious and destructive mass growth at which point late-stage respiratory and pain symptoms finally develop, most often in elderly patients. We present imaging studies of a 61-year-old male patient with an unusually massive and destructive chest wall mass, originating in the chest wall, diagnosed as chest wall amyloidoma by histopathology analysis. Our CT, MRI, and PET scan findings are consistent with and contribute to the developing pattern of imaging characteristics seen in other case studies, which can be used to identify amyloidoma before it becomes destructive using non-invasive imaging analyses.

Computed tomography dimensions of the lacrimal gland in normal Caucasian orbits.

INTRODUCTION: CT is frequently used to assess the lacrimal gland, yet no published reports exist of normal dimensions using this modality. We retrospectively evaluated CT data from normal orbits and measured the lacrimal gland dimensions. METHODS: Two-hundred ninety-three consecutive orbital CT scans (586 orbits) of 282 patients were identified. Caucasian patients aged 18 years and older without known orbital disease were included. Traumatized orbits were excluded. All repeated scans were excluded. Length and width of the lacrimal gland were measured in axial and coronal sections with GE Centricity Software. The primary outcome was a descriptive analysis of the distribution of dimensions in normal orbits. A random subset of patient scans was measured independently by observers at different levels of training, and intraclass correlation coefficients (ICCs) were established. RESULTS: Three hundred orbits (150 right orbits and 150 left orbits) of 282 patients were included. Normal distributions occurred with axial and coronal length measurements. Mean (10th and 90th percentiles) lacrimal gland axial length in right orbits was 14.7 mm (10.9 mm and 18.3 mm) and 14.5 mm in left orbits (10.3 mm and 18.3 mm). Coronal length averaged 17.7 mm in right eyes (13.9 mm and 21.8 mm) and 16.9 mm in left eyes (12.8 mm and 20.8 mm). Axial and coronal width showed non-normal distributions. No statistically significant difference in dimensions was found between genders, and a significant inverse linear relation occurred between gland size and age. Agreement was significant among the observers (ICC >0.7). CONCLUSION: This study presents a normal range of Caucasian lacrimal gland dimensions seen on CT. Lacrimal gland size decreases with age, and no gender difference exists. This range can aid in differentiating diseased and nondiseased lacrimal glands, especially when correlated with physical examination. This may be useful in clinical trials that involve lacrimal gland size.

Atypical imaging presentation of a massive intracavitary cardiac thrombus: A case report and brief review of the literature.

Intracavitary cardiac thrombi, uncommonly found in the right chambers, have been shown to form secondary to endocardial and myocardial diseases. The differential diagnosis for an intracavitary cardiac mass is broad, including primary cardiac tumors, cardiac metastases, anatomic variants, vegetations, and thrombi. Here we present a unique case with a large calcified intracavitary cardiac thrombus in a 26-year-old woman with obesity, immune thrombocytopenic purpura, and a new diagnosis of systemic lupus erythematosus. Initial imaging presentation in this case masqueraded as a tumor, delaying the true diagnosis. A combination of cardiac imaging techniques, including transthoracic and transesophageal echocardiograms, cardiac CT, and cardiac MRI were required to correctly diagnose this calcified bland thrombus.

Tracheobronchial amyloidosis: A case report and review of literature.

Tracheobronchial amyloidosis, manifested by amyloid deposits limited specifically to tracheal and bronchial tissue, is a rare manifestation with only a few hundred published cases. Patients classically present with symptoms related to fixed upper airway obstruction caused by tracheal stenosis. Clinical symptoms are non-specific and include hoarseness, dyspnea, cough, stridor, hemoptysis, and dysphagia, which are similar to those caused by more common airway disorders, often leading to incorrect, missed, and delayed diagnosis. The wide-spread use of computerized tomography (CT) imaging has the potential of dramatically advancing the early diagnosis of tracheobronchial amyloidosis. We present a case of a patient with chronic and progressive hoarseness, diagnosed with tracheobronchial amyloidosis, with a focus on unusually clear and precise CT soft tissue neck imaging. CT imaging demonstrated nodular circumferential raised mass-like thickening involving the long-segment posterior wall of the distal trachea. The wall thickening also extended into the proximal left main stem bronchi, but spared the distal bronchial tree. This resulted in moderate (approximately 50%) narrowing of the tracheal lumen, which explained the patient's hoarseness. Routine CT imaging of patients with chronic and progressive respiratory symptoms, including cough, hoarseness, and dyspnea, is recommended. Tracheobronchial amyloidosis is an uncommon disease, but it may become more commonly recognized with broader use of more effective CT imaging protocols.

Nasal congestion and nasal obstruction: An unusual presentation of renal cell carcinoma.

Renal cell cancer (RCC) is among the 10 most common cancers affecting both genders in the United States. Advanced RCC often remains clinically silent for much of its natural history. This can make the diagnosis challenging, especially when presenting symptoms arise from a metastasis. Sinonasal malignancies are rare, accounting for <1% of all malignant tumors and 3% of malignant tumors of the upper aerodigestive tract. RCC is the most common infraclavicular malignant primary tumor that metastasizes to the nasal cavity and paranasal sinus, followed by breast and lung. We describe a case of a 59 year-old male presenting with nasal congestion and allergy-like symptoms for 6 months duration. CT examination revealed a large hyper-vascular mass within the right maxillary and ethmoid sinuses and nasal cavity. Primary RCC was recognized only after surgical removal of sinonasal mass. We discuss the epidemiology, clinical presentation, differential diagnosis, imaging, pathology, and treatment for sinonasal RCC.