Pneumosinus dilatans of the spheno-ethmoidal complex associated with hypovitaminosis D causing bilateral optic canal stenosis.

INTRODUCTION: Pneumosinus dilatans (PSD) is a rare disorder of undetermined etiology characterized by expansion of the paranasal sinuses without bony erosion. Of the few cases of PSD described in indexed pediatric literature, there has been no reported case of this disorder presenting with optic canal stenosis in the setting of a vitamin deficiency. CASE MATERIAL: A 12-year-old girl presented with a 3-month history of progressive, painless, and asymmetric visual deterioration in her eyes. MRI showed prominent perioptic CSF spaces bilaterally and mild atrophy of both the optic nerves. CT head showed hyperpneumatization of the sphenoethmoidal air cells and both anterior clinoid processes with the optic nerves contained within narrowed intact bony canals. Blood investigations showed reduced vitamin D levels, and a subsequent skeletal survey showed diffuse osteopenia. She underwent endoscopic sphenoidotomy and bilateral decompression of the optic nerves. Following surgery, she reported improvement of vision in her left eye. She was started on vitamin D supplements for the endocrine abnormality. At a follow-up visit 6 months later, her visual acuity in both her eyes had improved. CONCLUSION: Pneumosinus dilatans is an unusual cause of progressive optic nerve dysfunction in the pediatric population. In the absence of any associated intracranial pathologies, conditions like hypovitamosis D should be ruled out.

Clinical Predictors of Diabetes Insipidus After Transcranial Surgery for Pituitary Adenoma.

OBJECTIVE: Diabetes insipidus (DI) is a well-known complication of transsphenoidal pituitary adenoma surgery. However, the risk factors for DI after transcranial surgery have not been clarified. In this study, the clinical parameters for predicting DI after transcranial surgery were investigated. METHODS: The perioperative records of 90 patients who underwent transcranial (TC) surgery at the authors' institution between November 2011 and March 2013 were chosen from 1657 patients with pituitary adenoma and retrospectively analyzed. The degree of deformation of the third ventricle and hypothalamus were assessed by preoperative magnetic resonance imaging. RESULTS: Immediate postoperative DI was found in 30 patients (33.3%). Persistent DI was noted in 11 patients (12.6%). Compared with patients in the nonpostoperative DI group, those with postoperative DI had a higher degree of deformation of the third ventricle and hypothalamus (P < 0.001). In a binary logistic regression analysis, the degree of deformation of the third ventricle and hypothalamus (odds ratio [OR], 3.079; 95% confidence interval [CI], 1.600-5.925; P = 0.001) had a significant positive correlation with immediate postoperative DI, as well as postoperative hemorrhage (OR, 6.235, 95% CI, 1.457-26.689; P = 0.014). Postoperative hemorrhage (OR, 4.363; 95% CI, 1.021-18.647; P = 0.047) showed a positive correlation with permanent DI, as well as the degree of deformation of the third ventricle and hypothalamus (OR, 2.336; 95% CI, 1.005-5.427; P = 0.049). CONCLUSIONS: The degree of deformation of the third ventricle and hypothalamus assessed by preoperative magnetic resonance imaging may help to predict postoperative DI. Postoperative hemorrhage might increase the incidence of postoperative DI, whether it is immediate postoperative DI or permanent DI.

Indication and limitations of endoscopic extended transsphenoidal surgery for craniopharyngioma.

The transsphenoidal approach has been utilized in intrasellar craniopharyngioma surgeries. However, the advent of endoscopic extended transsphenoidal approach (EETSA) has expanded its indication to suprasellar craniopharyngiomas. We compared the indication and limitations of EETSA to those of unilateral basal interhemispheric approach (UBIHA), which presents similar indications for surgery. We analyzed 30 patients with tumors located below the foramen of Monro and the lateral boundary extending slightly beyond the internal carotid artery (UBIHA: N = 18; EETSA: N = 12). Postoperative magnetic resonance imaging (MRI) revealed gross total resection in 10 patients in the EETSA group (83.3%) and 12 in the UBIHA group (66.7%). Postoperative MRI in the EETSA group revealed residual tumor at the cavernous sinus in one patient, at the prepontine in one; in the UBIHA group, residual tumors were located in the retrochiasmatic area in two patients, infundibulum-hypothalamus in one, on the stalk in one, and in the intrasellar region in two. No intergroup differences were observed in the preservation of pituitary function and postoperative improvement of visual function. The extent of resection was better with EETSA than with UBIHA. EETSA is considered the first-line therapy because the distance between the optic chiasm and the superior border of the pituitary is large; the lateral extension does not go beyond the internal carotid artery; and the tumor does not extend inferiorly beyond the posterior clinoid process. However, in patients showing poorly developed sphenoid sinuses or pituitary stalks anterior to the tumor, surgery is difficult regardless of the selection criteria.

Análisis y seguimiento en 50 cirugías trans-esfenoidales de la región sellar / Analysis and monitoring in 50 consecutive transsphenoidal surgeries

El tratamiento de las lesiones de la región selar requiere un equipo multidisciplinario. La evaluación y seguimiento endocrinológico, neurooftalmológico y neuroradiológico, así como el desarrollo de la técnica quirúrgica, el diagnóstico histopatológico y a decisión sobre el tratamiento complementario apuntan a un manejo más integral de esta patología con el objetivo de lograr mejores resultados. Debido a la baja morbi-mortalidad del acceso transesfenoidal, la gran mayoría de las cirugías de la región selar se realizan con este acceso. Este estudio analiza retrospectivamente 50 cirugías transesfenoidales consecutivas realizadas por el autor, incluyendo la clínica, evaluación preoperatoria, algunos aspectos técnicos quirúrgicos, diagnóstico anátomopatológico, así como resultado y seguimiento postoperatorio en las diferentes patologías, con especial énfasis en aspectos como residuo tumoral, resultados endocrinológicos, neurooftalmológicos y complicaciones quirúrgicas. Los resultados fueron analizados estadísticamente y se compararon con los de la literatura.

The treatment of sellar region lesions requires a multidisciplinary approach. The endocrinologic, neuro-ophthalmologic and neuroradiologic evaluation and follow-up, as well as the development of the surgical technique, the histopathologic findings and the decision about complementary therapy aim to a more comprehensive treatment of these pathologies in order to achieve better outcome. Due to the low morbimortality risk of transsphenoidal approach, most of the surgeries of the sellar region are performed by way of this route. This study analyses retrospectively 50 consecutive transsphenoidal surgeries performed by the author, including clinical picture, preoperative evaluation, some issues regarding surgical technique, histopathological diagnosis, as well as results and follow-up in different diseases with special emphasis in residual tumor, endocrinologic and neuro-ophthalmologic outcome, and surgical complications. Results were statistically analyzed and compared to the literature.

Propionibacterium skull osteomyelitis treated with daptomycin.

Propionibacterium acnes (P. acnes) is emerging as a pathogen in postneurosurgical infections. A case of cranial bone flap infection due to P. acnes successfully treated with daptomycin is presented. This case demonstrates the potential of daptomycin as an option in the treatment of P. acnes.

Asystole due to trigemino-cardiac reflex: a rare complication of trans-sphenoidal surgery for pituitary adenoma.

The trigemino-cardiac reflex (TCR) is a well-known reflexive response in which bradycardia, hypotension, and gastric hypermotility are induced by stimulation of a peripheral or central portion of the trigeminal nerve. This reflex occurs during craniofacial surgery and other operations on or near the cerebellopontine angle, petrosal sinus, orbit and trigeminal ganglion. TCR is a well-known, although not well documented, phenomenon commonly observed during trans-sphenoidal surgery for resection of pituitary adenomas. We report a case in which asystole occurred during trans-sphenoidal surgery on a pituitary adenoma that was infiltrating the right cavernous sinus. When the anesthesiologist reported asystole, the team stopped manipulation and administered intravenous atropine. Intra-operative MRI showed a small tumour remnant in the right cavernous sinus. The operation was terminated but subsequent radiosurgery was planned for the residual tumor. Although TCR is rare and usually self-limiting, this case led us to change our treatment strategy. Surgeons who perform trans-sphenoidal surgery should be aware of this potential problem. Invasive pituitary adenomas should be removed gently and the risk of triggering TCR should be kept in mind.

Office-based procedures in rhinosinusitis.

The availability of nasal endoscopes enables the rhinologist to visualize pathology in the posterior nasal cavity and middle meatus. With limited surgical equipment, the surgeon skilled in local anesthesia can perform biopsies, debridements, polypectomies, and turbinate reductions successfully in the office. With more specialized equipment and powered instrumentation,endoscopic maxillary antrostomies and other limited sinus surgeries become possible. On occasion, the surgeon might perform a limited ethmoidectomy,revise a sphenoidotomy, or remove polyps from within the maxillary sinus. For the properly selected patient, office surgery provides convenience and cost savings by eliminating hospital fees, anesthesia charges and preanesthesia testing. For the busy surgeon, office surgery allows improved efficiency by eliminating travel and anesthesia time.

[Choice of anesthetic method and prevention of ophthalmic complication in sphenoid sinus endoscopic surgery].

OBJECTIVE: To evaluate the anesthetic method and the prevention of the ophthalmic complication in endoscopic surgery for sphenoid sinus disease. METHOD: All 65 patients underwent local anesthesia with improved surface anesthesia. Arrest blood completely in the surgical operation. The position of sphenoid sinus, the assimilation and destruction of sinus wall, the location and the appearance of lesion were determined carefully. To avoid damaging the optic nerve, the behavior of eyes was observed intently. RESULT: The follow up period ranged from 6 months to 2 years. Five patients were lost to follow up. 53 of 60 patients recovered. 7 patients had recurrence among them with 2 cases of inverted papilloma and 5 cases of spheniod sinusitis with nose polyp, but they were successfully resected by endoscopic endonasal sinus surgery. Ophthalmic complication occurred in 5 patients. CONCLUSION: Endoscopic sphenoid sinus surgery can be performed successfully under local anesthesia with improved surface anesthesia. Familiarity with the anatomic marker and variable anatomy, and meticulous surgical technique are essential for reducing ophthalmic complication.

[Endonasal transsphenoidal surgery under local anesthesia for elderly patient with pituitary tumor: case report].

We present a surgical case under local anesthesia of an 88-year-old woman suffering from visual disturbance caused by pituitary adenoma. Magnetic resonance (MR) imaging showed a large pituitary tumor with suprasellar extension compressing the chiasmatic nerve. Neither she nor her family would agree to surgical therapy. However, when we proposed surgery under local anesthesia, they accepted it. Partial removal of the tumor via the endonasal transsphenoidal approach was carried out, uneventfully. The nasal surface was infiltrated with 4%-Xylocaine prior to the ordinary xylocaine injection to the nasal mucosa. The patient did not complain of any pain associated with the surgical procedure, including saline injection to the subarachnoid space through spinal drainage. The postoperative course was fine except for the temporarily appearance of diabetes insipidus. Postoperative MR imaging showed complete relief of compression to the chiasmatic nerve. Her visual field was improved dramatically. Endonasal transsphenoidal surgery under local anesthesia is thought to be one of the most useful methods of choice, especially in cases of elderly patient with pituitary tumor.

Trans-superior meatal approach to the sphenoid sinus.

We have recently operated on patients with isolated lesions of the sphenoid sinus using the trans-superior meatal approach that we developed. This may be one of the least traumatic methods for treating the isolated lesions of the sphenoid sinus. Though it has a few limitations, this approach provides a direct and safe short-cut to the sphenoid sinus and is well tolerated by the patient under local anesthesia. We present our experience with transnasal trans-superior meatal approach to the sphenoid sinus and introduce the technique with case reports.