Sphenoid sinus anatomical variants and pathologies: pictorial essay.

The sphenoid sinus (SS) is one of the four paired paranasal sinuses (PNSs) within the sphenoid bone body. Isolated pathologies of sphenoid sinus are uncommon. The patient may have various presentations like headache, nasal discharge, post nasal drip, or non-specific symptoms. Although rare, potential complications of sphenoidal sinusitis can range from mucocele to skull base or cavernous sinus involvement, or cranial neuropathy. Primary tumors are rare and adjoining tumors secondarily invading the sphenoid sinus is seen. Multidetector computed tomography (CT) scan and magnetic resonance imaging (MRI) are the primary imaging modalities used to diagnose various forms of sphenoid sinus lesions and complications. We have compiled anatomic variants and various pathologies affecting sphenoid sinus lesions in this article.

Can Volumetric and Morphological Variants of Sphenoid Sinuses Influence Sinuses Opacification?

Improvements in computed tomography and in functional endoscopic sinus surgery have recently increased interest toward paranasal sinus anatomy and anatomic variations that can be observed in patients affected by sinusitis. Isolated sphenoid sinusitis is a relatively rare pathology, often related to nonspecific symptoms, therefore making diagnosis difficult. The correlation between this type of sinusitis and anatomical variants remains unclear.The authors' aim was to retrospectively revise paranasal sinuses computed tomography scans of patients affected by sphenoid sinusitis, compared with a control group, analyzing the types of sphenoid sinus and the presence of aberrant pneumatization, and performing a segmentation of the sphenoid sinuses to calculate the volumes.Sphenoid sinuses of 60 patients affected by sinus opacification, compared with a control group, were segmented. Type of sinus (sellar, presellar, postsellar) and presence of aberrant pneumatization were assessed as well. Possible statistically significant differences in volumes according to sex and group were assessed through 2-way ANOVA test (P < 0.05). Post-hoc test was assessed through Student t test. χ test was applied in order to verify the statistically significance of differences in frequency of different types of sinus pneumatization variants (P < 0.05).Average volume of sphenoid sinuses in males was of 7.672 cm and of 7.751 cm in females within the group of patients; statistically significant differences in volume were found according to sex (P: 0.342), but not between the patients and control group (P: 0.0929). Post-hoc test verified that males affected by sinus opacification showed smaller volumes in comparison with the control males (P < 0.05). In addition, patients by affected sinus opacification showed more frequently the postsellar type and were less affected by pneumatization variants of the sphenoid bone than the control group (P < 0.05).This study first suggests the possible protective role of variants of pneumatization in the development of sphenoid sinus opacification.

Cavernous sinus thrombosis secondary to aspergillus granuloma: A case report and review of the literature.

Cavernous sinus thrombosis is a rare but serious complication of sphenoid aspergillosis. The rarity of this pathology makes its diagnostic very difficult on a clinical, biological and radiological sense. The authors present a case of cavernous sinus thrombosis with ipsilateral internal carotid artery thrombosis secondary to a non-invasive sphenoid aspergillosis in an immunocompetent host, responsible of a cavernous syndrome associated to a Claude Bernard Horner syndrome. One year after surgery, the patient is still asymptomatic without recurrence. Diagnostic modalities are detailed and several management of this pathology are compared. Surgery is essential in a diagnostic and therapeutic sense. There is no evidence of the interest of adjuvant therapies such as antibiotic and anticoagulation. Concerning the antifungal treatment, the attitude towards a non-invasive sphenoid aspergillosis in an immunocompetent host is unclear.

[A case of acute intracranial epidural hematoma caused by chronic nasal sinusitis].

Non-traumatic intracranial acute epidural hematoma(EDH)is rare. It is mostly caused by coagulation disorders, dural metastasis, or vascular malformations of the dura. We report a case of non-traumatic acute EDH caused by chronic nasal sinusitis and review the literature comprising 10 cases of acute EDH caused by chronic nasal sinusitis. A 16-year-old boy visited our outpatient clinic with a 2-day history of severe headache. He did not have fever or neurological abnormalities and showed no evidence of head trauma. Cranial computed tomography(CT)revealed sphenoid sinusitis and a small amount of epidural air in the middle fossa, but no other intracranial abnormalities. After eight days with no subsequent history of trauma, radiological exams showed a massive acute epidural hematoma in the left middle fossa and temporal convexity without any vascular lesion or skull fracture. The patient underwent a hematoma evacuation that revealed neither a skull fracture nor a vascular abnormality. In this adolescent, chronic nasal sinusitis caused fragility of the meningeal artery wall, an air collection in the epidural space, and the detachment of the dura mater from the inner surface of the skull, thereby resulting in a non-traumatic acute EDH.

Twelve-year-old girl with intracranial epidural abscess and sphenoiditis.

We report the case of a 12-year-old girl with an intracranial epidural abscess and sphenoiditis. Although she had no history of sinusitis, she developed acute severe headache, fever, and vomiting. Emergent CT and MRI showed a spherical space-occupying lesion of diameter 3 cm in the right cranial fossa with rim enhancement. The lesion was thought to be an epidural abscess adjacent to the right sphenoiditis. On the basis of the MRI findings, we performed emergent surgery to drain the abscess and sinusitis because of severe and rapidly worsening headaches. The patient showed great improvement the day after the operation. Intravenous antibiotics were administered for 8 days. She has completely recovered, with neither sequelae nor recurrence at 7 months after the operation. We believe that this report will be a useful reference for cases of acute onset headache and may be helpful in diagnosis and treatment decisions for severe sinusitis-related intracranial abscess in childhood.

[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.

[The diagnosis and management of isolated sphenoiditis in children].

OBJECTIVE: Analyzing the clinical manifestation, diagnosis and management of isolated sphenoiditis in children, retrospectively, was to get more information of the disease and to supply correct treatment early. METHOD: The symptoms, signs and imaging data of seventeen cases with isolated sphenoiditis hospitalized in our department from June 2001 to January 2010 were analyzed retrospectively. RESULT: Nine out of seventeen patients had the chief complaint of headache, three patients had blood in nasal discharge and had a fever, and five patients had postnasal drip with headache and a slight fever. The disease lasted for three months to one year. Five patients showed nasal discharge in rhinologic examination, one patient had solitary polyps in sphenoethmoid recess, eight patients had adenoid hypertrophy and the last three patients showed no positive signs. CT scan or MRI revealed opacification in sphenoid sinus. Eight patients received normative antibiotic therapy and were cured. The rest nine patients received endoscopic sinus surgery. The complaints relieved after the surgery and there was no signs of recurrence in 1 to 5 years of follow-up. CONCLUSION: Headache can be the chief and unique symptom of isolated sphenoiditis in children, which was easy to misdiagnose and miss diagnosis. CT or MRI was the evidence of diagnosis. Antibiotic therapy could be used for acute sphenoiditis. Patients with chronic sphenoiditis should receive endoscopic sinus surgery as early as better. From supraturbinal to sphenoid sinus natural ostia is the best way in sphenoidotomy.

[Sphenoid sinusitis with intracranial extension produced by an emergent fungus]. / Sinupatia esfenoidal con extensión intracraneal causada por un hongo emergente.

This is a case of fungal sphenoid sinusitis in a diabetic patient with non-specific symptoms and bone erosion radiological findings in the superior and posterior sphenoid walls. Surgical treatment was performed by transnasal endoscopic approach and voriconazole orally thereafter. The histopathological study found fungus hyphal without mucosa invasion and the molecular study determined DNA to be Phialemonium curvatum, an unusual pathogen.

Clinical features and outcomes of four patients with invasive fungal sinusitis.

OBJECTIVE: The frequency of invasive fungal sinusitis (IFS) has increased in recent years with the use of steroids, onset of diabetes mellitus, and the administration of antibacterial agents. We report on the clinical features and outcomes of four patients with IFS involving the cavernous sinus and orbit. Prognostic factors facilitating an early diagnosis are described, and the usefulness of combination therapy involving systemic administration of antifungal agents and surgical intervention is discussed. METHODS: We treated four patients with IFS between March 2003 and November 2007 at Ehime University Hospital. Patients were two males and two females, aged from 61 to 74 years (mean 67.8 years). RESULTS: With regard to clinical symptoms, headache was observed in all patients, and cranial nerve paralysis (visual disturbance, blindness, cheek paresthesia) was seen in 3 patients. ß-D-Glucan levels in four patients were high compared with normal values. Aspergillus was histopathologically identified from biopsy specimens in all patients. One patient was complicated with Candida in addition to the Aspergillus infection. Orbital exenteration and ESS were performed in 2 patients as surgical debridement. In all patients, systemic administration of antifungal agents was initiated after surgery. CONCLUSIONS: All patients received strategic treatment with surgery and systemic administration of anti-fungal agents. The single fatality was due to brain infarction caused by the spread of Aspergillus, and the remaining three patients are still alive. Our observations in these patients suggest that early diagnosis and strategic treatment may improve the prognosis of IFS.

Sphenoid sinus aspergillosis simulating pituitary tumor in immunocompetent patient.

Aspergillosis of the sphenoid sinus is rare in immunocompetent patients. It may be mistaken for a sellar region tumor. A 65-year-old, human immunodeficiency virus-negative man presented with a 3-week history of cranial nerve III paresis and visual deterioration. The patient had a long-term history of tobacco snuff abuse. CT scans and MRI demonstrated a space-occupying lesion of the sellar and sphenoid sinus region. Presumptive diagnosis of pituitary macroadenoma was made and the patient was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, a yellow-brownish gluey material with crumbly debris extruded and was aspirated. The dura was intact. Histopathology revealed numerous Aspergillus hyphae without tissue invasion. Postoperatively, the cranial nerve III paresis resolved in a few days and visual acuity improved. Sphenoid sinus aspergillosis should be included in the differential diagnosis of sellar region processes, even in immunocompetent patients. Early diagnosis and transsphenoidal removal provides good results without the need for systemic antifungal therapy in non-invasive aspergillosis.

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.

Medial sphenoid ridge meningiomas: classification, microsurgical anatomy, operative nuances, and long-term surgical outcome in 35 consecutive patients.

OBJECTIVE: On the basis of contemporary multiplanar imaging, microsurgical observations, and long-term follow-up in 60 consecutive patients with sphenoid ridge meningiomas, we propose a modification to Cushing's classification of these tumors. This article will concentrate on patients from this series with global medial sphenoid ridge tumors. METHODS: Data were collected prospectively for 35 patients with global meningiomas arising from the medial portion of the sphenoid ridge that were surgically treated between 1982 and 2002. RESULTS: All patients were followed for the entire length of this study (mean, 12.8 yr). The tumor size ranged from 2 to 8 cm (mean, 4.5 cm). Of the 24 patients with purely intradural tumors, four (17%) had Simpson Grade I and 19 had Simpson Grade II resections; 23 (96%) had gross total resections. Of the 11 patients with tumors extending extradurally (i.e., cavernous sinus), one (9%) patient had a Simpson Grade II resection, whereas nine (82%) had Simpson Grade III resections, with the latter being all visible tumor removed except that in the cavernous sinus. One (9%) of these 11 patients had a gross total resection, and 9 (82%) had radical resections, with the latter defined as total removal of all intradural tumor. The overall morbidity rate was 18%. There was no surgical mortality or symptomatic cerebral infarction. CONCLUSION: An accurate classification of global medial sphenoid meningiomas is mandatory to gain insight into their clinical behavior and for understanding the long-term efficacy and safety of available treatment options. Primary medial sphenoid ridge tumors consistently involve the unilateral arteries of the anterior cerebral circulation, and therefore, the resection of tumor from around these arteries is the most important operative nuance for their safe excision.

Invasive Aspergillus terreus sinusitis with orbitocranial extension: case report.

BACKGROUND: Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient. CASE DESCRIPTION: This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month. CONCLUSION: A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.

Chronic sphenoid sinusitis revisited: comparison of multidetector axial sections, multiplanar reconstructions, and virtual sinoscopy with endoscopic sinus surgery.

OBJECTIVES: To assess the role of multidetector computed tomography (CT) and CT virtual sinoscopy in the evaluation of chronic sphenoid sinusitis and to compare the imaging findings with functional endoscopic sinus surgery. DESIGN: Prospective study. SETTING: Tertiary care teaching hospital. PATIENTS: Thirty patients with chronic sphenoid sinusitis referred for preoperative CT. INTERVENTIONS: Thin-section helical axial CT was performed using a multidetector CT scanner with multiplanar reformation (MPR) and volume-rendered or virtual sinoscopy images. Sixty sinuses were divided into quadrants for analysis. Extrasinus extension was labeled as the "fifth quadrant." MAIN OUTCOME MEASURES: Imaging findings were compared with those of functional endoscopic sinus surgery, and accuracy of the imaging modality was determined. RESULTS: Multidetector CT (axial CT and MPR) was found to be 100% sensitive, specific, and accurate in the evaluation of extent of sinusitis, status of the sinus septum, integrity of the optic nerve canal in relation to the sinus, and type of sinus pneumatization. Axial CT and MPR images showed sensitivity of 98% and specificity of 92% compared with functional endoscopic sinus surgery in evaluating the ostia. Regarding carotid canal integrity, axial CT and MPRs were 100% sensitive and 98% specific. Virtual sinoscopy showed sensitivity and specificity of 67% and 92%, respectively, for the 22 ostia that could be visualized and evaluated using this modality. CONCLUSIONS: Axial multidetector CT with secondary MPRs provide the necessary preoperative information regarding extent of disease and sphenoid sinus anatomy. Virtual sinoscopy is a navigational aid, an adjunct to endoscopy, and an educational tool for surgeons-in-training.

Endoscopic transnasal sphenoidotomy with or without ethmoidectomy.

OBJECTIVES: We evaluated endoscopic transnasal sphenoidotomy (ETNS) with or without ethmoidectomy in patients with inflammatory sphenoid sinus disease (ISSD). PATIENTS AND METHODS: A retrospective review was conducted in 42 patients (17 males, 25 females; mean age 41 years; range 17 to 67 years) who underwent ETNS with (n=37) or without (n=5) ethmoidectomy for ISSD. The disase was staged according to our staging system based on computed tomography findings. RESULTS: Postnasal drainage was the most common symptom (n=37, 88.1%). Chronic rhinosinusitis was accompanied by sinonasal polyps in 25 patients (59.5%). Five patients (11.9%) had isolated sphenoid disease and 16 patients (38.1%) had unilateral disease. Five patients (11.9%) had stage 1, 15 patients (35.7%) had stage 2, and 22 patients (52.4%) had stage 3 disease. Surgery involved 68 sides. Ethmoidectomy was used in 63 sides of 37 patients, eight of whom required a supplementary procedure. At least one complication was seen in eight patients (19%), including severe perioperative hemorrhage (n=2), early postoperative hemorrhage (n=2), minor injuries to the lamina papyracea (n=4), and synechiae (n=5). CONCLUSION: In patients with isolated ISSD, the direct approach to the sphenoid sinus by ETNS without ethmoidectomy is a favorable technique, whereas ETNS with ethmoidectomy is necessary for patients with concurrent disease in other paranasal sinuses.

[Clinical analysis of isolated sphenoid disease first manifesting headache and/or ophthalmic symptoms].

OBJECTIVE: To improve the diagnosis and treatment of isolated sphenoid disease first manifesting headache and/or eye symptoms. METHOD: The clinical data of 25 cases suffering from isolated sphenoid disease first manifesting headache and/or eye symptoms from 1996 to 2005 were analyzed retrospectively, and the correlated documents were reviewed. RESULT: In this group of the 25 patients, 21 failed to be diagnosed at the first time of medical consultation. The diagnosis confirmed by CT or MRI and pathology included 7 cases with isolated sphenoiditis, 4 with mycosis, 3 with sphenoid cysts, 6 with purulent sphenoid cysts, 2 with polyps and sphenoiditis, 1 with foreign body, 1 with craniopharyngioma, and 1 with oncocytoma. All of the patients underwent endoscopic sphenoid surgery. The symptoms of 24 cases of the patients were improved or disappeared after the operations. CONCLUSION: This isolated sphenoid diseases were easily misdiagnosed. The diagnosis depends on CT or MRI and nasal endoscopy. CT by three-dimensional reconstruction can provide more special and precise information. Endoscopic sinus surgery is effective and safe technique for the treatment of the disease.

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.