Variable anatomical features of acromegaly in the nasal cavity and paranasal sinuses: implications for endoscopic endonasal transsphenoidal surgery.

PURPOSE: Growth hormone (GH)-secreting pituitary neuroendocrine tumors (PitNETs) are the most common cause of acromegaly. The endoscopic endonasal transsphenoidal approach (EEA) is commonly employed to remove them. Although morphological differences in the nasal cavity exist between acromegaly patients and those with other types of PitNET, few quantitative studies have been performed. This study aimed to evaluate the anatomical features of the nasal cavity and paranasal sinuses in patients with acromegaly. METHODS: Preoperative computed tomography images of the nasal cavity and paranasal sinuses were compared between 20 patients with a GH-secreting PitNET (acromegaly group) and 22 with a non-functioning PitNET (control group). In the acromegaly group, the relationships between preoperative GH and/or insulin-like growth factor 1 (IGF-1) levels and anatomical characteristics were assessed. RESULTS: In the acromegaly group, the distance between the nostril and dorsum sellae was significantly longer and the distance between the parasellar internal carotid arteries was significantly shorter (p = 0.0022 and 0.0092, respectively). Pneumatization volume in the nasal cavity did not differ between the groups. Nasal mucosa and bony hypertrophy were observed in the acromegaly group. Preoperative GH level was correlated with the width of the piriform aperture (p = 0.0171). CONCLUSION: The nasal and paranasal changes associated with acromegaly can make EEA challenging to perform. Widening the surgical corridor anterior to the sphenoid sinus is important in these patients.

Mullan's triangle or anteromedial triangle of the middle cranial fossa: a cadaveric study with its surgical importance.

BACKGROUND: Surgical approaches to the cavernous sinus (CS) and middle cranial fossa (MCF) can be challenging, particularly for young neurosurgeons. The anteromedial (Mullan's) triangle is a triangle by the side of the CS and constitutes part of the floor of the MCF. The contents include the sphenoid sinus, superior ophthalmic vein, and sixth cranial nerve. The literature contains very little research that has precisely defined and measured the anteromedial triangle while considering anatomical variances minimally. METHODOLOGY: The present study was conducted on the skulls of 25 adult human cadavers which were dissected to expose the anteromedial (Mullan's) triangle on both sides. After precisely defining the triangle on each side, measurements of the three borders were taken, and using Heron's formula, the area of each triangle was calculated. RESULTS: On average, the length of the medial border was 12.5 (+ 3.1 mm); the length of the lateral border was 9.9 (+ 3.1 mm); the length of the base was 10.75 (+ 2.4 mm) and the area of the anteromedial triangle was 43.9 (+ 15.06 mm2). CONCLUSION: Precise anatomical knowledge of the Mullan's triangle enables the treatment of disorders in often deformed anatomy or difficult-to-access structures. That is the reason it is important to gain a thorough understanding of the surgical anatomy and to adopt a safe procedure.

Langerhans cell histiocytosis in sphenoid sinus with vision impairment: Case report and literature review.

Langerhans cell histiocytosis (LCH) is a neoplastic disease characterized by aberrant proliferation of the mononuclear phagocyte system, predominantly affecting children under the age of 3 years. Although LCH can affect almost all organs, sinus involvement is rare. This case report documents a 9-year-old boy presented with vision impairment and intermittent headache on the right side. The CT scan and MRI examination revealed the presence of a soft mass in the right atrium of sphenoid sinus, which impacted the right optic canal. Biopsy results confirmed the presence of LCH. Considering the involvement of optic canal and vision impairment, meticulous debridement was performed followed by a 12-month standard chemotherapy. After 2 years of follow-up, the patient showed significant improvement, despite the presence of an encapsulated cyst in the right sphenoid sinus. This case highlights the importance of considering LCH when encountering an isolated soft mass accompanied by decreased vision in the sphenoid sinus. A thorough physical examination, laboratory tests, and imaging methods should be performed, with a biopsy being necessary to confirm the type of lesion and guide the appropriate treatment.

Anteriorly tilted CT to visualize the anterior wall of the sphenoid sinus.

OBJECTIVE: To elucidate the effectiveness of a 30-degree anteriorly tilted coronal CT in visualizing the anterior wall of the sphenoid sinus. METHODS: Medical records and CTs of patients who underwent septoplasty, inferior turbinectomy, or endoscopic sinus surgery were reviewed. We evaluated the visibility of the anterior wall of the sphenoid sinus on conventional coronal CT scans and categorized its orientation. We then created anteriorly tilted coronal CT images to evaluate its improved visibility. RESULTS: A total of 129 patients were evaluated. While conventional coronal CT scans fully visualized the anterior wall of the sphenoid sinus in cases with an Onodi cell, 17.7% remained unidentified when the Onodi cell was absent. However, anteriorly tilted coronal CT scans consistently identified the anterior wall regardless of the presence of an Onodi cell. CONCLUSION: Our study highlights the effectiveness of anteriorly tilted coronal CT scans in consistently visualizing the anterior wall of the sphenoid sinus, regardless of the presence of an Onodi cell. It is possible that some other structures may become less identifiable on anteriorly tilted coronal CT.

Endoscopic Transpterygoid Repair of Sphenoid Sinus Meningocele: A Comprehensive Case Report and Literature Review.

We report a challenging and uncommon case involving a 53-year-old Japanese man with cerebrospinal fluid (CSF) leakage caused by a meningocele in the lateral recess of the sphenoid sinus. Our innovative treatment approach involved a combination of transpterygoid and endoscopic modified medial maxillectomy techniques, with special emphasis on the preservation of the sphenopalatine artery. This strategic preservation was pivotal to the successful use of the ipsilateral nasoseptal flap for reconstruction, which played a crucial role in the prevention of postoperative CSF leakage. Otolaryngologists and neurosurgeons collaborated to perform the bath-plugging technique; effective collaboration was instrumental to the success of the procedure. This report highlights significant advancement from conventional frontal craniotomy to a more sophisticated endoscopic technique, shows the importance of meticulous surgical planning and execution, emphasizes careful preservation of critical anatomical structures during complex neurosurgical and otolaryngological procedures, and underscores the evolving landscape of surgical approaches for managing complex medical conditions.

Vidian Canal in Chiari Type I Malformation: A Computed Tomography Study.

OBJECTIVE: To evaluate the position and dimension of the Vidian canal (VC) in Chiari type I malformation (CIM). MATERIALS AND METHODS: Radiologic views of 49 CIM (mean age: 23.58±15.62 y, sex: 23 males/26 females) and 51 healthy subjects (mean age: 42.50±20.12 y, sex: 21 males/30 females) were included in this computed tomography study. RESULTS: In comparison with controls, the VC angle and the distance of the round foramen to VC were greater in CIM, but VC length and the distances of the superior wall of the bony sphenoidal sinus, midsagittal plane, and vomerine crest to VC were smaller in CIM. Relative to the sphenoid bone, the position of VC in CIM was determined as type 1 (59.2%) >type 2 (28.6%) >type 3 (12.2%), whereas in controls as type 1 (54.9%) >type 3 (25.5%) >type 2 (19.6%). Relative to the medial pterygoid plate, the position of VC in CIM was determined as type A (63.3%) >type B (20.4%) >type C (16.3%), while in controls as type B (43.1%) >type A (40.2%) >type C (16.7%). CONCLUSION: VC size and position correlated with CIM. Compared with controls, CIM patients had more partially protruded VC into the bony sphenoidal sinus and more medially located VC according to the medial pterygoid plate.

Silent threat of isolated sphenoid sinus tuberculosis resulting in blindness and ophthalmoplegia.

A diabetic woman in her fifties presented with a sudden onset of failing vision and diplopia involving the right eye for two days, along with fever and headache. Radiological investigations revealed right sphenoid sinusitis along with inflammation around the right orbital apex and optic nerve. Functional endoscopic sinus surgery, with orbital and optic nerve decompression improved the ocular movements, but not the visual acuity. Histopathology was suggestive of a granulomatous inflammatory lesion, and high-resolution computed tommography (HRCT) of the thorax revealed lung lesions suggestive of an old tubercular infection, and antitubercular treatment (ATT) was then initiated.At the end of two months of ATT, there was complete resolution of ophthalmoplegia, relative afferent pupillary defect, direct and consensual light reflex however, failure of improvement in her visual acuity, indicated damage to the optic nerve.Extrapulmonary tuberculosis involving an isolated sphenoid sinus is rare and elusive. Prompt radiological investigations, followed by orbital decompression and ATT, provide the best possible outcomes.

Computed tomography based evaluation of the association between sphenoid sinus pneumatization patterns and variations of adjacent bony structures in relation to age and gender.

Many studies revealed that the sphenoid sinus pneumatization (SSP) affects the protrusion/dehiscence of adjacent structures including optic canal (OC), foramen rotundum (FR), vidian canal (VC), and carotid canal (CC). Knowledge of this relationship bears vital importance to identify the safest surgical route during transsphenoidal procedures. Therefore, we aimed to determine the individualized prevalence of the protrusion/dehiscence of adjacent structures based on sagittal and coronal SSP (SSSP and CSSP) patterns. Computed tomography images of 300 patients were analysed to identify the SSSP and CSSP types, and the protrusion/dehiscence of adjacent structures was determined. The relationship between the variables was examined using statistical analysis in terms of age, gender, and laterality. The most prevalent SSSP type was postsellar (62.7%), followed by sellar (30%), presellar (6.6%), and conchal (0.7%). In 71.3% of patients, five types of CSSP were observed, with 23.6% and 21.7% exhibiting Type IV and V, respectively. Our results indicated that postsellar type, Type IV and V CSSP associated with the highest likelihood of protrusion/dehiscence of OC, FR, VC, and CC. Furthermore, no significant correlation was observed between these qualitative variables and gender, with the exception of the VC dehiscence, the protrusion of OC and CC. No notable differences were identified with respect to laterality. Also, the probability of having postsellar type, Type IV and V CSSP, as well as the protrusion of OC, VC, and CC, decreased with increasing age. Further detailed analysis of this association is required to predict the size of the surgical window and to prevent neurovascular injury.

Anatomical variations of sphenoid sinus in terms of volume and protrusions of optic nerve/internal carotid artery in a subgroup of Pakistani population.

Objective: To compare the volume of sphenoid sinus with protrusions of optic nerve and internal carotid artery in both males and females. METHODS: The cross-sectional study was conducted from October 2020 to February 2021 at the Radiology Department of Dow University of Health Sciences, Karachi, and comprised males and females aged 20-60 years having no sphenoid sinus bony abnormality. Sphenoid volume and optic nerve and internal carotid artery protrusions were examined in the computed tomography scans of the paranasal sinus. Based on the protrusions, the scan findings were split into four groups: Group 1 had no protrusion, Group 2 had optic nerve protrusion, Group 3 had internal carotid artery protrusion, and Group 4 had protrusions of both the optic nerve and the internal carotid artery. Data was analysed using GraphPad Prism 9. RESULTS: Of the 300 subjects, 171(57%) were males and 129(43%) were females. The overall mean age was 39.27±10.9 years. There were 147(49%) subjects in group 4, followed by 72(24%) in group 3, 42(14%) in group 2 and 39(13%) in group 1. Statistically significant difference was observed between sphenoid volume across the study groups for both male and female subjects (p<0.001). Conclusion: There was significant relationship between internal carotid artery and optic nerve protrusions and sphenoid volume.

[Ectopic pituitary tumor of sphenoid sinus: a case report].

Ectopic pituitary adenoma is rare in clinical practice. This article reports a case of ectopic pituitary adenoma of sphenoid sinus, and summarizes the clinical characteristics, diagnosis and management. A 54-year-old female patient complaining with occasional head distension without dizziness and headache for more than 1 month was admitted due to sinus mass on conventional physical examination. Imaging examination revealed a mass in the occipital slope and bilateral sphenoid sinus. The patient underwent endoscopic resection of the mass under general anesthesia. Postoperative histopathological examination showed "pituitary neuroendocrine tumor". Postoperative recovery was good and no complications occurred. She was followed up for 2 months without relapse.

Visual Acuity Impairment from Inflammatory Isolated Sphenoid Sinus Disease.

BACKGROUND/AIM: To investigate the treatment outcomes and determinants of prognosis in patients experiencing visual acuity (VA) deterioration due to inflammatory isolated sphenoid sinus disease (ISSD) who underwent endonasal endoscopic surgery (EES). PATIENTS AND METHODS: Thirteen patients with 14 lesions treated with EES between March 2010 and April 2022 were included. Evaluation included improvements in VA using the logarithm of the minimum angle of resolution (LogMAR) scale, resolution rates of associated symptoms, and identification of factors predicting VA recovery. A literature review was conducted to assess the outcomes for ISSD-related VA impairments. RESULTS: The most common etiology is mycetoma (n=5), followed by an equal representation of mucocele and sphenoiditis (n=4). The mean interval from symptom onset to intervention was 4.7 months, with an average follow-up duration of 14.4 months. Seven eyes exhibited preoperative VA of 2.1 LogMAR or worse, with diplopia/ptosis (n=8) and headache (n=5) being the predominant co-occurring symptoms. After surgery, all ancillary symptoms improved, with an overall VA recovery rate of 87.5% (improvement more than 0.2 logMAR units). Mucocele exhibited the best improvements, whereas sphenoiditis showed the least progress (p=0.021). Poor baseline VA (p=0.026) and combined diplopia/ptosis (p=0.029) were identified as negative prognostic factors for VA recovery. CONCLUSION: Our findings suggest a favorable prognosis for VA recovery following EES in patients with inflammatory ISSDs, with response variations based on disease entity. However, further research is needed to personalize therapeutic strategies for enhanced outcomes.

The relationship between sphenoidal sinus and sella turcica morphometry in the Turkish population: a retrospective study.

PURPOSE: The anatomical position of the sphenoidal sinus (SS) is very important for neurosurgeons because of the transsphenoidal approach to the pituitary gland. Therefore, the aim of this study was to determine the volume and shape of the SS and its relationship with the morphometry of the sella turcica. METHODS: This study included CT images of 282 males and 258 females with a mean age of 50.52 years (range 18-75) who underwent head CT. The morphometric values of the sella turcica and the volume of the SS were measured on the included radiologic images. Measurements were made on the sagittal slice closest to the midline in T1 sequence. Morphometric measurements were made with Micro Dicom Viewers software program and volume measurements were made with ITK SNAP software program. RESULTS: In this study, 4 types of SS shapes were obtained in the whole population: amorphous, pentagonal, triangular and quadrilateral. The mean SS volume was 7055.88 mm3 in males and 5694.48 mm3 in females and a statistically significant difference was observed (p < 0.001). In addition, a statistically significant difference was found between the sexes in the width and surface area parameters of the sella turcica (p < 0.05). CONCLUSION: In this study, the morphometric relationship between the shape of the sinus sphenoidale and sella turcica was demonstrated between men and women. In particular, the shape of the sinus sphenoidale was found to be anthropometrically different between men and women in the Turkish population. It is hypothesised that the data obtained in our study will guide surgeons performing transsphenoidal approach.

Radiologic evaluation of the Vidian canal in the pediatric population.

PURPOSE: This examination aimed to display the size and topographic position of the Vidian canal (VC) in normal children. METHODS: 180 pediatric subjects aged 1-18 years were included this computed tomography examination. The distances of VC to certain landmarks, and VC length were measured. The locations of VC according to the sphenoid sinus, and the medial plate of pterygoid process were classified as three types, separately. RESULTS: The distances of VC to the vomerine crest, midsagittal plane, round foramen, and the superior wall of sphenoid sinus were measured as 12.68 ± 3.17 mm, 10.76 ± 2.52 mm, 8.62 ± 2.35 mm, and 14.16 ± 5.00 mm, respectively. The length and angle of VC were measured as 12.00 ± 2.52 mm, and 16.60 ± 9.76°, respectively. According to the sphenoid bone, VC location was identified as Type 1 in 113 sides (47.5%), as Type 2 in 70 sides (29.4%), and as Type 3 in 55 sides (23.1%). According to the medial plate of pterygoid process, VC location was identified as Type A in 274 sides (76.1%), as Type B in 55 sides (15.3%), and as Type C in 31 sides (8.6%). VC location types correlated with pediatric ages, but not sex or side. CONCLUSION: With advancing pediatric age, the protrusion of VC into the sphenoid sinus increases, and VC shifts from medial to lateral side of the medial plate of pterygoid process.

Persistent Severe Headache After Removal of Fungus Ball From the Sphenoid Sinus: A Case Report.

OBJECTIVE: Granulomatous invasive fungal sinusitis (GIFS) is a rare and life-threatening disease, whereas fungus ball (FB) is the most common form of noninvasive fungal sinusitis. Both GIFS and FB primarily develop in immunocompetent patients, with the former associated with higher mortality and morbidity. METHODS: A chart review and review of the literature. RESULTS: We present the case of a 77-year-old woman with mixed fungal sinusitis who was successfully treated with voriconazole. CONCLUSIONS: GIFS and FB can coexist in extremely rare cases, known as mixed fungal sinusitis; however, the diagnosis and subsequent treatment of mixed fungal sinusitis can be delayed because of a lack of awareness of the underlying concept. Therefore, it is crucial for clinicians to recognize the concept of mixed fungal sinusitis.

Magnetic Resonance Imaging Features of the Sphenoid Sinus in Patients with Non-Functioning Pituitary Adenoma.

Background and Objectives: A magnetic resonance imaging (MRI) scan is part of the diagnostic protocol in pituitary adenoma patients. The goal of the present study is to present and analyse the MRI appearances of the sphenoid sinus (SS) in patients with non-functioning pituitary adenoma (NFPA). Materials and Methods: This is a retrospective case-control study conducted between January 2015 and December 2023 in a tertiary referral hospital. Forty NFPA patients were included in the study group, while the control group consisted of 30 age- and gender-matched cases. Results: The sellar type of SS pneumatization was the most frequently encountered pattern among both groups. The presence of the lateral recess of the SS, mucosal cysts, and sphenoethmoidal cells was similar in both patient groups. The proportion of patients with SS mucosal thickness greater than 3 mm was 42.5% in NFPA group and 3% in the control group, and this difference was statistically significant (p < 0.001). The space between the two optic nerves was significantly larger in the NFPA group as compared to the control group (p < 0.001). Conclusions: Our study was able to establish a statistically significant association between the presence of NFPA and both the thickening of the SS mucosa and increased space between optic nerves.

Determination of safety margin of nasal septum osteotomy for sphenoid sinus in cleft lip and palate patients.

BACKGROUND: Nasal septum osteotomy is used for separating the nasal septum and maxilla during a Le Fort I osteotomy. If this osteotomy is applied too high or is tilted into the nasal cavity, the sphenoid sinus and various adjacent vital structures may be damaged, and serious bleeding, neurological complications, blindness or even death may occur. The aim of this study is to determine the safety margin of the nasal septum osteotomy for sphenoid sinus during the Le Fort I surgery in cleft lip and palate (CLP) patients. METHODS: Twenty cleft lip and palate (the CLP group) and 20 healthy individuals (the control group) were included in this study. Three values (two lines and an angle) were measured by cone beam computed tomography (CBCT). The first line is the line passing through the junction of the spina nasalis anterior point and the lower point of the perpendicular lamina of the palatine bone. The undersired line is the line passing through the junction of the spina nasalis anterior point and the lower anterior border of the base of the sphenoid sinus. The osteotomy angle is the angle between these two lines. RESULTS: In the control group; a surgical line of 44.11-61.14 mm (mean 51.91 ± 4.32), an undesired line of 52.48-69.58 mm (mean 59.14 ± 5.08) and an angle of 18.22-27.270 (mean 22.66 ± 2.55) were found, while in the CLP group, a surgical line of 34.53-51.16 mm (mean 43.38 ± 4.79), an undesired line of 46.86-61.35 mm (mean 55.02 ± 3.24) and an angle of 17.60-28.810 (mean 22.60 ± 2.81) were found. CONCLUSIONS: Although the angle to the sphenoid sinus was not significantly affected by CLP, careful planning and consideration of these anatomical differences are crucial to prevent complications and ensure the safety of Le Fort I surgery in CLP patients. Further research with larger sample sizes and subgroup analysis of unilateral and bilateral CLP cases is needed to improve our understanding of these anatomical variations and improve surgical approaches to individuals with CLP undergoing orthognathic procedures.

Langerhans Cell Histiocytosis in Sphenoid Sinus: Uncommon Bone Involvement.

BACKGROUND Langerhans cell histiocytosis (LCH) is a rare and uncontrolled proliferation of dendritic cells of myeloid origin. The incidence of LHC was estimated at 5 cases per million children ages 0-15 years old. The most common places for this tumor are the jaw, vertebra, pelvis, and the extremities. The disease with multisystem involvement can present a mortality rate of 20% and one-third of children have multisystem involvement. We present a case with unusual bone involvement of the anterior cranial base with a challenging diagnosis and a complex surgical approach. CASE REPORT We report the case of a 6-year-old boy who manifested the disease with daily holocranial headache, worse in the frontal region and refractory to analgesia for 10 days, strabismus homonymous, diplopia, and right palpebral ptosis. The tumor affected the sphenoid sinus, internal carotid artery, and sella turcica, and made contact with the pituitary gland. A joint surgery with Otorhinolaryngology and Neurosurgery was performed by nasal endoscopic access to the skull base by means of the right medial turbinectomy (for the access) and right sphenoid opening, septectomy and opening of the left sphenoid to work with 4 hands and, after resection of lesion, inside the sphenoid. CONCLUSIONS This patient had rare bone involvement from LCH and atypical clinical presentation next to the important and delicate structures of the anterior skull base, but had a satisfactory outcome.

[Diagnosis and treatment of spontaneous meningoencephalocele in lateral recess of sphenoid sinus and analysis of its influencing factors].

Objective:To explore the influencing factors of adult spontaneous meningoencephalocele, which occurs in the lateral recess of sphenoid sinus, in order to improve the level of clinical diagnosis and treatment. Methods:The clinical data of 27 adults with spontaneous meningoencephalocele in lateral recess of sphenoid sinus in Department of the Otorhinolaryngology, the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2022 were retrospectively analyzed. Preoperative sinus CT and MRI were performed to confirm the diagnosis and location of meningoencephalocele. Results:①There were 0 cases of lateral recess of sphenoid sinus type Ⅰ, 8 cases of lateral recess of sphenoid sinus type Ⅱ and 19 cases of lateral recess of sphenoid sinus type Ⅲ. ②Among the 27 adult patients with spontaneous meningoencephalocele, 9 were male and 18 were female, and the onset age was 19-72 years old, with an average age of（50.7±12.4） years old. 18 cases were complicated with cerebrospinal fluid leakage, 11 cases with headache and dizziness, 3 cases with recurrent meningitis（complicated with cerebrospinal fluid leakage）, and 2 cases with epilepsy. ③There were 20 patients with intracranial hypertension, 17 patients with body mass index（BMI） ≥25 kg/m², and 8 patients with empty sella. Conclusion:Type Ⅲ of lateral recess of sphenoid sinus is the most common type in adult spontaneous meningoencephalocele, and intracranial hypertension and obesity are the influencing factors of this disease. Puncture, biopsy or operation should not be performed for patients suspected of spontaneous meningoencephalocele, and imaging examination should be performed to identify the source of the tumor.