Sphenoid sinus barotrauma in diving: case series and review of the literature.

About 50% of scuba divers have suffered from barotrauma of the ears and about one-third from barotrauma of paranasal sinuses. The sphenoid sinuses are rarely involved. Vital structures, as internal carotid artery and optic nerve, adjoin the sphenoid sinus. Thus, barotrauma could lead to serious neurologic disorders, including blindness. After searching the literature (Medline) and other sources (Internet), we present some cases of sphenoid sinus barotrauma, because these injuries may be underreported and misdiagnosed due to the lack of awareness and knowledge. Therefore, information is provided, e.g. on anatomical and pathophysiological features. Divers and physicians should have in mind that occasional headache during or after diving sometimes signals serious neurological disorders like vision loss. We show that injuries can develop from both negative and positive pressures in the sinuses. Because visual recovery depends on prompt diagnosis and proper therapy, physicians like otolaryngologists, ophthalmologists and neurologists need to closely collaborate.

Spontaneous CSF rhinorrhea from the trigeminal canal in an adolescent.

We report a case of a seventeen-year old, healthy, non-obese young woman who presented with retro-orbital headaches and metallictasting, left-sided rhinorrhea. Computed tomography revealed a defect along the medial wall of the canal of V2 within a well-pneumatized lateral recess of the left sphenoid sinus. Prior imaging obtained 4 years earlier in the context of nasal trauma showed no such defect - thus lending support for the arachnoid granulation hypothesis of spontaneous CSF leaks from the sphenoid sinus. We perform a literature review and describe a successful repair through an endoscopic transpterygoid approach, which allowed for resolution of symptoms with minimal postoperative morbidity.

Trans-nasal-trans-sphenoidal brain injury by a fencing foil: an unusual case report and brief literature review.

In this report, the authors present an unusual case of a 10-year-old child who suffered a severe headache and rhinorrhea that occurred as a result of fencing foil sports injury via trans-nasal-trans-sphenoidal (TNTS) pathway. Following trauma, the child had shown neurological symptoms such a pupil dilatation, change in consciousness and mild hemiparesia. Imaging demonstrated destruction of bone structures including posterior wall of sphenoid sinus and antero-superior part of sella turcica, and also a contusion at right thalamic region. For treatment of rhinorrhea lumbar drainage system (LDS) had planted in order to relieve cerebrospinal fluid (CSF) leakage. After the treatment, the patient had fully recovered without any need of further surgical intervention. CSF leakage had prevented and neurological symptoms were completely treated. This case represents the first report of brain injury via TNTS pathway in a sports practice. Diagnosis, clinic follow-up and treatment options of this rare accidental sports injury are discussed.

Traumatic intra-sphenoidal pseudoaneurysm lodged inside the fractured sphenoidal sinus.

We describe a case of traumatic intra-sphenoidal right internal carotid artery pseudoaneurysm lodged inside the fractured sphenoidal sinus that developed in a patient with a previous history of frontal and skull base fractures involving the sphenoid sinus and walls of the carotid canal, but with normal intracranial findings at early CT angiography. The patient presented two episodes of massive life-threatening delayed epistaxis before successful endovascular treatment combining the use of coils and an uncovered stent was instituted. This case report highlights that patients with head trauma who present sphenoid sinus fractures with or without massive epistaxis should be evaluated for the development of traumatic internal carotid artery pseudoaneurysm as soon as possible. If the first angiographic evaluation reveals normal findings, repeated epistaxis should prompt a second angiographic evaluation because psudoaneurysm takes time to develop. Early treatment with uncovered stent of the aneurysm can be a life-saving therapeutic approach.

Endoscopic endonasal multilayer repair of traumatic CSF rhinorrhea.

The incidence of traumatic CSF has increased in recent years due to increased incidence of road traffic accidents (RTA) as well the increasing number of endoscopic sinus surgeries (ESS). The objective of this study is to present our experience in management of traumatic CSF leaks using the endoscopic multilayer repair technique. Forty-two patients (aged 10-75 years, 30 males and 12 females) presenting with confirmed post-traumatic CSF rhinorrhea were operated upon between January 2007 and December 2013. The endoscopic multilayer technique was used in all cases. Electromagnetic navigation was used in some cases. All cases presented with intermittent watery rhinorrhea. The duration of the rhinorrhea ranged from 3 days to 1 year before repair. One case presented after 10 years from the causative trauma. Ten cases had a history of meningitis. Nine cases had more than one defect. Iatrogenic defects were larger than defects following accidental trauma. Two cases, following RTA, developed pseudo-aneurysm of internal carotid artery. Ten cases had associated pneumocephalus. The mean duration of postoperative hospitalization was 6 days (range 4-8 days). The mean follow-up duration was 31.2 +/- 11.4 months (range 16-48 months). None of our patient developed serious intra- or postoperative complications. Only one case required another surgery to repair a missed second defect. Post-traumatic CSF leaks can be successfully managed via the endonasal endoscopic route using the multilayer repair technique. It is important to look for multiple defects in these cases. CT angiography is recommended for traumatic leaks involving the lateral wall of the sphenoid sinus to diagnose or exclude the development of pseudo-aneurysm of the internal carotid artery.

Patterns and sequelae of sphenoid sinus fractures.

BACKGROUND: The sphenoid sinus is one of the most commonly fractured regions of the skull base after blunt head trauma. These fractures may be associated with complications such as blunt carotid artery injury (BCAI) and cerebrospinal fluid (CSF) leak. Association of these sequelae with sphenoid sinus fractures has yet to be analyzed thoroughly in the literature. OBJECTIVE: Analyze patterns of traumatic sphenoid sinus fractures and assess relationships between fracture patterns and incidence of BCAI and traumatic nasal CSF leaks. METHODS: A retrospective review of 123 patients sustaining sphenoid sinus fractures was performed. Patient medical records and radiographic images were reviewed. Fractures were classified based on the sinus walls involved. Logistic and linear regressions were used to analyze associations between injury mechanisms, fracture subsites, and sequelae. RESULTS: The most commonly fractured sphenoid sinus subsites included the carotid canal, sphenoid roof, and lateral wall (60%, 49% and 48%, respectively). CSF leaks occurred in 9% of sphenoid sinus fractures, whereas BCAI occurred in 1.6%. On logistic regression, sphenoid roof fractures were significantly associated with CSF leaks (odds ratio [OR] = 12.4, p = 0.002). No fracture subsite was associated with BCAI. The positive predictive value (PPV) of sphenoid roof fractures for the presence of CSF leaks was 17%, whereas the negative predictive value (NPV) was 98%. The PPV of carotid canal fractures for BCAI was 3%, whereas the NPV was 100%. There was no association between the number of fractured sinus walls and the incidence of BCAI or CSF leak. Penetrating injuries were significantly associated with CSF leak (OR = 24.7, p = 0.01), but no other injury mechanisms were associated with BCAI or CSF leak. CONCLUSION: Nasal CSF leak was the most common sequela of sphenoid sinus fractures, whereas BCAI was extremely uncommon. Analysis of fracture patterns can be useful in determining the need for additional evaluation.

Frontobasilar fractures: proposal for image reviewing algorithm.

OBJECTIVE: The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface. MATERIAL AND METHODS: The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports. RESULTS: The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed. CONCLUSIONS: Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.

Classification and characteristics of pterygoid process fracture associated with maxillary transverse fracture.

OBJECTIVE: This study aimed to classify pterygoid process fractures associated with maxillary transverse fractures. STUDY DESIGN: Pterygoid process fractures in 100 patients with maxillary transverse fractures were observed 2- and 3-dimensionally using image processing software. Fracture line course and height and sphenoid sinus involvement were recorded. RESULTS: Pterygoid process fractures were classified as follows: class I, vertical (simple separation between medial and lateral plates); or class II, transverse (3 subcategories according to location of fracture line: II-1, within pterygoid fossa; II-2, above pterygoid fossa, not extending to sphenoid sinus floor; II-3, above pterygoid fossa, involving sphenoid sinus floor). Class I fracture was observed on 5 sides (2.7%); II-1, on 125 (66.5%); II-2, on 36 (19.1%); and II-3, on 22 (1.7%). CONCLUSIONS: Pterygoid process fractures were predominantly near the upper edge of the pterygoid fossa. Pneumatization of the pterygoid process is a risk in fractures involving the sphenoid sinus floor.

Lateral orbital wall fracture as a mechanism of blow-out fracture in a patient with extensive pneumatization of the sphenoid bone.

We report a patient with a lateral orbital wall fracture that occurred as a result of a blow-out fracture. The patient has extensive pneumatization of the sphenoid sinus, and the air extends into the lateral orbital wall. It makes the lateral orbital wall much thinner unusually, being more vulnerable to a sudden increase in intraorbital pressure. Pure blow-out fracture of the lateral orbital wall has not been reported in the medical literature. Therefore, this is the first case report of a lateral orbital wall fracture occurring as a blow-out mechanism.

Unilateral optic neuropathy from possible sphenoidal sinus barotrauma after recreational scuba diving: a case report.

A case report is presented of a 35-year-old woman who developed a progressive right optic neuropathy while surfacing from a series of four recreational dives on the Great Barrier Reef, Queensland, Australia. The patient reported severe sudden onset blurred vision in the right eye associated with a mild headache and epistaxis on surfacing from diving. The patient had her first medical review the day after returning from her trip. At this time visual acuity in the right eye was 20/80, with left eye 20/20. There was a relative afferent pupillary defect in the right eye. A high-resolution computed tomography scan showed fluid in the right sphenoid sinus. Computed perimetry revealed patchy visual field loss in the right eye. The provisional diagnosis of sphenoidal sinus barotrauma-induced optic neuropathy was made. Over 10 days of observation, the visual acuity returned to 20/20 in the right eye and visual field changes resolved. This case highlights a very unusual cause of visual loss associated with diving.

Transient vision loss at depth due to presumed barotraumatic optic neuropathy.

Pressure-related vision loss has been reported during ascent to altitude. We report the case of an otherwise healthy diver who suffered painless, sudden-onset binocular vision loss at depth, followed by complete recovery immediately upon surfacing. We examine the dive and briefly discuss the differential diagnosis of transient vision loss in the setting of ambient pressure changes. We conclude that the diver likely suffered from sphenoid sinus barotrauma, possibly in association with dehiscence of the bony canals of the optic nerves as they travel in close proximity to the walls of the sphenoid sinus.

Accident entry of titanium screw into the sphenoid sinus during paranasal augmentation with porous polyethylene implant.

We report a rare case of accident entry of titanium screw into the sphenoid sinus during paranasal augmentation with porous polyethylene implant. The screw was finally retrieved from the sphenoid sinus by a nasal endoscope. We emphasize that, on this surgery region, the simple fixation skill must be performed delicately. Otherwise, an adverse event may still happen.

Removal of a low-velocity projectile from the base of the sphenoid sinus using navigation-guided endoscopy.

PURPOSE: A patient surviving after a metal projectile penetrates the sphenoid sinus is unusual. Removing a foreign object from this region is challenging because of the difficult access and proximity to delicate structures. The use of navigation-guided endoscopy makes the manipulation of the surgical instruments near delicate structures safer, and the procedure is minimally invasive. RESULTS: A computed tomographic scan of brain showed the projectile located at the base of the left sphenoid sinus. To prevent infection and irritation and avoid secondary surgical damage, navigation-guided endoscopy was used to remove the bullet. Using the BRAINLAB navigation system, the movement of the endoscope could be followed on the screen, and the tip could be navigated into close contact with the projectile. The bullet could be located, without being visible through the endoscope, making the incision and removal of the bony wall of the sinus minimal; it was removed without complications. Intraoperative navigation of endoscopes is very useful because it enables the surgeon to correlate the visual information through the endoscope with the localization of the instruments seen on the navigation screen. Patient safety and reinforced self-confidence of surgeons are advantages of this procedure. Reduced operative time may not always occur because of a lack of experience with the navigation system. CONCLUSIONS: When there are no vascular or neurologic complications, a minimally invasive treatment using nasal navigation-guided endoscopic removal can limit the potential surgical damage.

Sphenoid sinus barotrauma after scuba diving.

We report the case of an 18-year-old male patient operated on for sphenoid sinus barotrauma after scuba diving. The patient attended our emergency department because of intractable headache but did not improve with conservative treatment. After computed tomography and magnetic resonance imaging examination, he was diagnosed with sphenoid sinusitis that extended to the nasal septum. He therefore underwent surgery for sinus ventilation and abscess drainage.

A transnasal intracranial stab wound by a plastic-covered umbrella tip.

A 48-year-old man died from a transnasal intracranial stab wound caused by an umbrella. The track of the stab passed from the right nostril, through the sphenoid sinus, the left side of the sella turcica and anterior clinoid process, and finally reached the surface of the brain. The stab wound crossed the left internal carotid artery, causing an exsanguination and aspiration of blood into the airway, resulting in death. It is extremely rare that an umbrella tip used during a struggle would stab the nostril of the victim. Transnasal intracranial stab wounds can be overlooked and require sensitive handling.

[An unusual case of gunshot wounds caused with an air gun]. / Niezwykly przypadek postrzalu z broni pneumatycznej.

A 28-year-old woman was shot in the face with an air gun while driving a car. The patient was examined in the Department of Forensic Medicine in Katowice. An inconspicuous scar was found near the medial angle of the right eye. Further ophthalmological and radiological examinations revealed the presence of small foreign bodies in the vitreous body of the right eye, the sphenoid sinus and the ethmoid cells. The authors issued an expert opinion, in which they stated that the sustained injuries had not caused any significant organ dysfunction.

Endoscopic treatment of transnasal intracranial penetrating foreign body.

Transnasal intracranial penetrating injury is rare. We report a case of transnasal intracranial penetrating metallic chopstick, which was removed successfully by endoscopic approach, and management of transnasal intracranial penetrating injuries.

Treatment outcomes of endoscopic repairs of sinonasal cerebrospinal fluid leaks.

OBJECTIVE: The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base. MATERIALS AND METHODS: A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009. RESULTS: The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted. CONCLUSIONS: Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

Sphenoid sinus barotrauma after free diving.

We report 2 cases of a 29- and a 37-year-old male patient both having sphenoid sinus barotrauma associated with free diving at about 12-m depth. A unilateral occupation of the sphenoid sinus was revealed in both cases by computed tomography and magnetic resonance imaging examination of the paranasal sinuses.