Development of Chronic Sphenoid Sinusitis After Sellar Reconstruction with Medpor Porous Polyethylene Implant.

OBJECTIVE: The Medpor porous polyethylene implant is reported to be safe and effective for sellar reconstruction after transsphenoidal surgery (TSS). However, we have observed several cases of delayed chronic sphenoid sinusitis related to the implant. The purpose of this study is to describe the presentation and management of implant-related sphenoid sinusitis after sellar reconstruction. METHODS: This is a retrospective study of patients who underwent endonasal TSS with Medpor sellar reconstruction between December 2008 and January 2013 at a tertiary care institution. Patient demographics, initial surgical management, sinonasal symptoms, postoperative imaging, sinusitis management, and resulting outcomes were analyzed. RESULTS: From 2008-2013, 139 patients underwent sellar reconstruction using Medpor. Five patients (3.6%) presented between 8 and 60 months after surgery with chronic sphenoid sinusitis that required surgical management. All 5 patients presented as outpatients for management of headaches and nasal drainage, 4 patients experienced chronic nasal congestion, and 3 patients noted recurrent sinusitis. At the time of revision surgery, all 5 patients were found to have mucosal inflammation and edema surrounding the implant, and 4 of the 5 had an exposed or partially extruded implant that was removed. CONCLUSIONS: Reconstruction of the sellar floor may be performed after TSS to prevent postoperative complications. Although porous polyethylene implants have previously been described as safe and effective for this purpose, surgeons should be aware of the risk of subsequent implant extrusion and chronic sphenoid sinusitis that can occur in a delayed manner.

Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms.

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Sellar reconstruction without intrasellar packing after endoscopic surgery of pituitary macroadenomas is better than its reputation.

OBJECTIVES: Sellar reconstruction with intrasellar packing following endoscopic resection of pituitary macroadenomas remains a subject of clinical and radiological discussion particularly, when an intraoperative cerebrospinal fluid (CSF) leakage is absent. This study was conducted to contribute our experience with sellar reconstruction after a standard endoscopic surgery of pituitary macroadenomas without intraoperative CSF leakage to the ongoing discussion between techniques with and without intrasellar packing. METHODS: A consecutive series of 47 pituitary macroadenomas undergoing excision via a standard endoscopic endonasal transsphenoidal surgery (EETS) without evident intraoperative CSF leakage were retrospectively evaluated over a 10-months mean follow-up period. According to the sellar reconstruction technique, three groups could be identified: Group A - with no intrasellar packing, Group B - with haemostatic materials packing, and Group C - with abdominal fat packing. Postoperative clinical and radiological assessments of the three groups were documented and analyzed for differences in outcome. RESULTS: Postoperative clinical assessment did not differ significantly between the three groups. In group A, postoperative CSF leakage, sphenoid sinusitis and empty sella syndrome were not observed. However, a significant difference in radiological assessment could be identified; the interpretation of sellar contents in postoperative MRI of group A succeeded earlier and more reliably than in other groups with intrasellar packing. CONCLUSIONS: There is no difference in the incidence of postoperative CSF leakage and empty sella syndrome among the various reconstructive techniques with and without intrasellar packing, irrespective of size and extension of the pituitary adenoma. Sellar reconstruction without intrasellar packing following a standard EETS is not inferior to other techniques with packing and even shows more radiological advantages, which made it our preferred technique, at least if no intraoperative CSF leakage is evident.

[Clinical analysis of sphenoid sinusitis after transsphenoidal sellar surgery].

OBJECTIVE: To analyze the possible influence factors of sphenoid sinusitis after endoscopic transsphenoidal sellar surgery. METHODS: A retrospective analysis of 177 patients who underwent transsphenoidal sellar surgery, from January 2009 to January 2014 in Tianjin Huanhu Hospital was performed. All patients were followed up with nasal endoscope. The risk factors of sphenoid sinusitis after surgery were analyzed statistically, such as sex, age, categories of disease, surgical produres, tumor size, using artificial or self material repair, with or without EC glue intraoperatively, etc. SPSS 17.0 software was used to analyze the data. RESULTS: After surgery, there were 34 (19.2%) patients developed postoperative sinusitis. EC glue was the sole risk factor for postoperative sinusitis (34.57% vs 6.25%, χ(2)=22.701, P<0.01), but the sex, age, categories of disease, surgical produres, tumor size and patching material had no significant difference (all P>0.05). CONCLUSIONS: In patients with endoscopic transsphenoidal sellar surgery, regular postoperative nasal endoscopic follow-up found that the use of EC glue was the risk factor for the development of postoperative sphenoid sinusitis.

Reconstructed bone chip detachment is a risk factor for sinusitis after transsphenoidal surgery.

OBJECTIVES/HYPOTHESIS: Sphenoid sinusitis is a complication associated with endoscopic transsphenoidal pituitary surgery. Studies that address the relationship between methods of sellar defect reconstruction and postoperative sinusitis are rare. The purpose of this study was to investigate the incidence, the possible risk factors, and the causative pathogens of sphenoid sinusitis after endoscopic transsphenoidal pituitary surgery. STUDY DESIGN: Prospective cohort study. METHODS: We performed a prospective analysis of 182 patients with benign pituitary tumor who underwent endoscopic transsphenoidal pituitary surgery and sellar defect reconstruction with bone chip, from July 2008 through July 2011. All patients were followed up with nasal endoscopy for at least 6 weeks. RESULTS: Fifty-seven (31.3%) patients developed postoperative sphenoid sinusitis. Comparing the sinusitis and nonsinusitis groups, we found that bone chip detachment was a significant risk factor for postoperative sinusitis, with a relative risk of 2.86 (64.1% vs. 22.4%). The most common pathogens present in cases of postoperative sinusitis were methicillin-sensitive Staphylococcus aureus, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Regular follow-up with nasal endoscopy can prevent delayed diagnosis of postoperative sphenoid sinusitis. Culture-directed antibiotics with aggressive endoscopic debridement are an effective treatment for these patients. An optimal reconstruction strategy should be further developed to reduce bone chip detachment and secondary sinusitis.

[A case of cavernous sinus aspergillosis].

We reported a case of cavernous sinus aspergillosis. A 62-year-old man complained of trigeminal neuralgia in the right V1 region. Neurological examination on admission showed ptosis, loss of light reflex and ophthalmoplegia externa in the right side. MRI enhanced with gadolinium demonstrated sphenoid sinusitis and mass lesion in the right cavernous sinus. MRA revealed right internal carotid artery occlusion. An open biopsy using the extradural temporopolar approach was performed. Pus discharge was observed from the cavernous sinus and histological examination showed hypha of Aspergillus. With early voriconazole treatment, the patient had improvement in headache, ptosis and ophthalmoplegia externa. Cavernous sinus aspergillosis is often found after sphenoiditis. It results in invasion to an internal carotid artery and worsens the patient's prognosis by cerebral infarction, so early diagnosis and treatment are important. We should consider aspergillosis as one of the differential diagnoses of a mass in the cavernous sinus. The epidural approach to this lesion was available to obviate aspergillus dissemination into the medullary cavity.

Mini-nasoseptal flap for recalcitrant sphenoid sinusitis.

BACKGROUND: Recalcitrant sphenoid sinusitis occurs in 27% of patients undergoing revision functional endoscopic sinus surgery. One of the main causes of disease recurrence in the sphenoid is cicatricial scarring of the ostium. Highly inflammatory lesions such as fungal balls or chronic mucoceles can predispose patients to restenosis. We present a novel use of a modified nasoseptal flap to cover exposed bone after sphenoid wide sinusotomy to prevent restenosis and expedite healing. METHODS: A case series was performed. RESULTS: The mini-nasoseptal flap was successful in preventing sphenoid ostium restenosis in nine patients undergoing endoscopic sinus surgery for highly inflammatory sphenoid sinus pathology with a mean postoperative follow-up of 8.4 months (range, 2-21 months). Patients had a mean of 2.3 prior sinus surgeries (range, 0-7 surgeries). Most common indications for the flap in this series included long-standing fungal sinusitis or fungal balls (n = 6) with or without significant sphenoid wall osteoneogenesis (n = 6). There were no significant side effects related to flap harvest or inset. CONCLUSION: The mini-nasoseptal flap decreases the risk of restenosis after sphenoid sinusotomy by preventing circumferential cicatricial scarring and offers an effective surgical option on the spectrum of sphenoid surgical interventions in select patients.

Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature.

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Isolated sphenoid sinusitis or mucocele: a potential complication of endonasal transsphenoidal surgery.

Rhinosinusitis/mucocele are rare complications of transsphenoidal surgery. We present a retrospective analysis of 323 patients who received transsphenoidal surgery for pituitary adenoma. Twenty of the 323 patients (6.2%) developed rhinosinusitis/mucocele after transsphenoidal surgery as shown by MRI. All 20 patients with rhinosinusitis/mucocele occurred in the group who received the small sphenoidotomy approach and simple postoperative nasal care. Medical management was successful in 13 of 20 cases (65%). The remaining seven patients received endoscopic sphenoidotomy. On re-operation, purulent pus was discovered in two, a necrotic fat graft in one, mucocele in one, a dropped tumor in two, and a bone chip in one. Sphenoid sinusitis resolved in all seven cases. The formation of sphenoid sinusitis/mucocele is related to the size of the sphenoidotomy, frequency of postoperative nasal care, and foreign body accumulation. Early surgical drainage is necessary in patients with rhinosinusitis/mucocele refractory to medical management to prevent ascending meningitis.

Current management of isolated sphenoiditis.

Isolated sphenoiditis (IS) is a relatively rare clinical entity which might present with serious complications. The clinical records of ten patients with IS were reviewed. The presenting symptoms, the findings, and the treatments given were noted. Eight patients were female and two were male, and their age varied between 9 and 65 years (mean 31 years). The main presenting symptom was headache in five patients, diplopia in four patients, and postnasal drainage in one patient. The duration of the symptoms ranged between 48 h and 1 year. The diagnosis was accomplished by history, nasal endoscopy and radiological examination (computed tomography and/or magnetic resonance imaging). Two patients had fungus ball. One patient was a scuba diver as a possible predisposing factor. All of the patients underwent medical treatment consisting of intravenous antibiotics or oral antibiotics, and endoscopic sinusotomy was performed in nine patients additionally. Complete resolution was obtained for all patients except one who had diplopia for one year. IS may present with headache and orbital symptoms. Timely diagnosis and treatment are substantial in order to avoid serious complications, and to obtain a complete recovery. Medical treatment does not avoid surgery in majority of cases. Surgery is indicated from the very beginning specifically for the cases starting with diplopia which might be suggestive of a progression of the infection. Currently the most frequently used approach is endoscopic transnasal sphenoidotomy. This technique seems to be effective and less traumatic compared to other approaches.

MRSA with progression from otitis media and sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an immunocompetent 10-year-old patient.

A previously healthy 10-year-old patient with headache, otalgia, and hearing loss was diagnosed with pachymeningitis and methicillin-resistant Staphylococcus aureus otitis media and bacteremia. Despite antimicrobial therapy, intracranial extension progressed, including clival osteomyelitis, sphenoid sinusitis, cavernous sinus inflammation and cranial nerve palsies, until the sphenoid sinus was drained. This case exemplifies an aggressive MRSA intracranial infection that advanced despite antibiotic therapy.

Acute visual loss in a head and neck cancer patient with ocular metastasis and sphenoid pyocele.

We report an extremely rare case of head and neck cancer patient with right acute visual loss by ocular metastasis after excluding compressive optic neuropathy by endoscopic decompression of the sphenoid pyocele. The ocular metastasis from head and neck cancer had been reported only once in English literatures. Besides, the patient combined with sphenoid pyocele increases the difficulty in differentiating the etiologies. In this article, we describe the history of this patient and discuss the possible cause of acute visual loss and the treatment strategy. Although to differentiate the etiology of acute visual loss between metastatic malignancy and compressive optic neuropathy remain difficult, treatment strategy should focus on rescuing visual acuity. Ocular metastases should always keep in mind when acute visual loss is encountered in patients with previously treated head and neck squamous cell carcinoma.