[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.

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.

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.

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.

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.

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.

Acute isolated sphenoid sinusitis in children.

OBJECTIVE: Acute infection of the sphenoid sinus usually affects both pre-adolescent and adolescent subjects and is associated with infections of the other paranasal sinuses. Acute isolated sphenoiditis, though uncommon, is frequently misdiagnosed as symptoms are vague and there are few clinical findings. Indeed, it is not usually diagnosed until the patient develops neurological complications. The aim of this report is to discuss our cases of acute isolated sphenoiditis and compare them with those reported in the International literature. METHODS: We reviewed our 10-year records of paediatric patients affected by acute isolated sphenoid sinusitis, as confirmed by nasal endoscopy and/or CT scan, and compared them with paediatric cases of sphenoid sinusitis reported in literature. In particular, we focused on clinical findings, associated risk factors, diagnostic approach, and treatment. RESULTS: As previously stated at the Brussels Consensus Meeting, patients can be separated into two groups on the basis of clinical findings: the first including patients affected by severe acute sphenoiditis presenting fever and headache, and frequently associated with neurological symptoms, with swimming and diving as possible predisposing factors. The second group includes patients with non-severe acute sphenoiditis, mainly associated with headache, allergic rhinitis being a possible predisposing factor. CONCLUSIONS: Acute isolated sphenoid sinusitis appears to be difficult to diagnose, and there are few reports in peer-reviewed paediatric journals. We wish to alert paediatricians and ENT specialists of the importance of this rare but still potentially devastating disorder.

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.

Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals.

We report the computed tomographic appearance of invasive fungal disease of the paranasal sinuses in 13 patients. Coronal and axial computed tomographic images were obtained in each patient and data were analysed. Eight patients had Aspergillus flavus infection, four had Mucormycosis, and one had mixed Candida and Mucor. Our experience was different from that of other workers in many respects. All of our patients were immunocompetent. On radiological imaging by computed tomography, ethmoid sinuses were involved in 85% of our patients. In previously reported series maxillary sinuses were most frequently affected. Calcification in the inflammatory mass was not encountered in any of our patients, whereas this feature was present in many reported cases. Features in our patients that were similar to other studies were contrast enhancement, extension of the disease into the orbit and cranial cavity and a high mortality. The clinical course and radiological features of invasive mycosis simulate malignancy. Certain features that may help to differentiate invasive fungal infection from malignancy are discussed. We conclude that invasive fungal infection can affect immunocompetent individuals and should be considered in the differential diagnosis in appropriate clinical settings.

Nasal septum after sublabial transseptal transsphenoidal pituitary surgery.

Transseptal transsphenoidal approach to the pituitary fossa is a well-described and effective procedure. This article relates our experience with this procedure with specific emphasis on the nasal septum, both before and after surgery. It has been our experience that this surgery has minimal local complications in the nose and it would appear to improve septal alignment with subjective improvement in nasal function as reported by the patient. A total of 55 patients undergoing a sublabial transseptal transsphenoidal approach to the pituitary fossa were included in this study. All other approaches to the pituitary gland were excluded. Visual changes and headaches were the most common presenting symptoms, occurring alone or in combination in 28 (51%) patients. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated septum was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients after the surgery. Sinusitis developed in two patients, and one patient subsequently required surgery. No synechiae or septal perforations were noted.

Isolated sphenoid sinus disease.

Disease of the sphenoid sinus is often vague and nonspecific in its clinical presentation. Therefore, the otolaryngologist must maintain a high index of suspicion when evaluating patients who present with such nonspecific symptoms. A thorough understanding of the radiologic characteristics of sphenoid sinus disease is essential in the proper evaluation and management of these patients.

Pediatric sphenoidotomy.

The posterior ethmoid air cells and the sphenoid sinuses have a complex anatomy that is surrounded by vital structures. To more easily protect these structures, three approaches are presented that make pediatric sphenoidotomy a safer procedure. The approaches include measuring the distance from the anterior nasal spine to the anterior and surgical posterior faces of the sphenoid sinus intraoperatively and comparing these to the patient's height and age, the use of the "ridge" to ensure a safe entry into the sphenoid, and, in patients where isolated sphenoid disease is present, the use of a powered instrument to enlarge the sphenoid ostium. The availability of measurements relating the height of the patient to the location of the sphenoid sinus, the use of the "ridge," and the use of powered instrumentation, should help the surgeon enter the sphenoid with greater confidence and achieve a more effective result.

Isolated sphenoid sinusitis.

Isolated sphenoid sinusitis is a relatively rare clinical entity and can cause severe complications. Diagnostic nasal endoscopy using Hopkins telescopes and coronal and axial paranasal-sinus CT made the diagnosis of the sphenoid sinus disease easier. Eight out of 221 patients with paranasal sinus infection refractory to medical treatment--and treated surgically at the 2nd ENT Clinic of Ankara Numune Hospital between 1990-1995--had isolated sphenoid sinus infection. The most common symptom was headache felt in the retro-orbital region. Surgical procedure was intranasal endoscopic approach to the sphenoid sinus. The symptoms of the patients with isolated sphenoid sinusitis were completely resolved after surgery. As the literature is reviewed, it is concluded that endoscopic approach to the sphenoid sinus disease is the most appropriate method of surgery in order to reduce intra-operative morbidity and mortality.