A case of pituitary adenoma with infiltration into the sphenoid sinus accompanied by melanocyte proliferation.

A 71-year-old woman presenting with headache and nausea was admitted to hospital. Magnetic resonance imaging revealed a tumorous lesion that surrounded the sella turcica and infiltrated the sphenoid sinus with bone destruction. The tumor was removed by nasal endoscopy. The histology was consistent with pituitary adenoma; immunohistochemistry indicated silent corticotroph adenoma with melanocyte proliferation. The possibility that melanocytes were incorporated into the tumor mass in the sphenoid sinus and underwent proliferation was evaluated by investigating the mechanisms of melanocyte proliferation associated with basic fibroblast growth factor (bFGF) and α melanocyte-stimulating hormone (αMSH). In the normal tissue, the pars intermedia and adrenocorticotropic hormone (ACTH)-producing cells were positive for αMSH. None of the control adenoma tissues were positive for bFGF or αMSH by immunostaining. In the present case, bFGF-positive cells and αMSHpositive cells were observed, suggesting that both may have been involved in melanocyte proliferation. The expression of bFGF has been linked to aggressive disease. Pituitary adenoma with melanocyte proliferation has not been previously reported. Careful follow-up is deemed necessary in the future.

Spontaneous cerebrospinal fluid leak via foramen rotundum in a non-obese male presented as pseudo-Chiari malformation type I: a case report and literature review.

Spontaneous cerebrospinal fluid (sCSF) leak from the skull base has been previously reported, but there are few reports of sCSF leak from the foramen rotundum due to its rare occurrence. This case report describes a 15-year-old male patient that presented with left side watery rhinorrhoea that had been present since he was 4 years of age and a history of repeated bouts of meningitis of unknown cause. A discharge sample from the nose tested positive for beta-2 transferrin. Preoperative computed tomography (CT) revealed a fistula between the cerebellopontine angle and the left sphenoid sinus. There was also a pseudo-Chiari malformation type I with ectopia of the cerebellar tonsil. Endoscopic transnasal surgery identified a leak from the foramen rotundum that was repaired using autologous material and a contralateral pedicle nasoseptal flap. At 6 months after surgery, the patient reported no recurrence of the CSF leakage. Postoperative CT imaging revealed that the cerebellar tonsil was back in the normal position, indicating that the preoperative Chiari malformation was possibly due to decreased CSF volume. This current case shows that a rare case of sCSF leak from the foramen rotundum can be effectively repaired using the endoscopic transnasal approach.

Ectopic pituitary adenoma of the TSH-secreting sphenoidal sinus with excellent response to somatostatin analogs. Theory of the embryogenesis and literature review from a clinical case.

Ectopic thyrotropin-secreting pituitary adenomas are rare, with only 10 published cases. We report the case of a 52-year-old woman who was referred for primary hypothyroidism, who showed clinical signs of hyperthyroidism and had been under treatment with levothyroxine. Her exams revealed high levels of thyroid stimulating hormone (TSH), at odds with free thyroxin (FT4) and raised triiodothyronine (T3), which remained elevated after medication suspension, suggesting possible central hyperthyroidism. Sellar MRI showed normal pituitary gland, with a mass in the sphenoid sinus of 24 mm. A possible ectopic TSH secreting pituitary tumor of sphenoid sinus was hypothesized. After a intramuscularly (IM) single dose of a sustained-relase of a somatostatin analog (octreotide) 20 mg, plasma levels of thyroid hormones were normalized and a significant tumor reduction was demonstrated in MRI control at 7-weeks' follow-up. The tumor was removed by transsphenoidal endoscopy, and the biopsy confirmed an adenoma with positive immunostaining for TSH and GH. Hyperthyroidism recurrence was observed in hormonal controls 4 weeks after surgery. Treatment with sustained-release octreotide was reinitiated, every 60-days for two years, with normalization of the thyroid hormone profile, but with a residual lesion with the appearance of a tumor in the MRI. A second tumor resection was performed, achieving sustained hormonal cure and no residual tumor lesion at 2-years' follow-up. To our knowledge, this is the first report of an ectopic thyrotropin-secreting pituitary adenoma of the sphenoid sinus. Clinical and laboratory aspects relevant to this entity are reviewed, emphasizing the usefulness of octreotide in the management of the reported case.

Mucin gene expression in nasal polyps.

CONCLUSIONS: A large set of mucin genes is expressed in nasal polyps. The expression pattern is complex and may reflect the wide spectrum of variables involved in polyp formation and progression. Prospective studies including subgroups of nasal polyps and involving substantial numbers of cases in each subgroup will be required to elucidate these variables and to understand how they affect mucus secretion. OBJECTIVE: At present, 15 of the 19 known mucin genes are expressed in the human airways. Nasal polyps might be expected to have a mucin expression pattern comparable to that of the airways. The aim of this study was to investigate mucin expression in nasal polyps. MATERIAL AND METHODS: Nasal polyp samples were obtained from 20 patients during functional endoscopic sinus surgery. Normal (control) sphenoid sinus mucosa was obtained from patients undergoing trans-sphenoid hypophysectomy. The expression of eight mucin genes (MUC1-4, -5AC, -5B, -6 and -7) was studied by in situ hybridization utilizing digoxigenin-labelled oligonucleotide probes. RESULTS: MUC6 and -7 were not expressed in sphenoid sinus mucosa, while all the studied mucin genes were expressed in nasal polyps. Expression patterns varied widely between individual polyps. The predominant epithelial mucin genes were MUC4, -5AC and -3, while MUC5B and -7 were mainly of glandular origin. MUC1, -2 and -6 were weakly expressed. The major alteration in gene expression in nasal polyps was found in the submucosal glands. MUC4 and -5AC represent a major component of both submucosal glands and epithelial cells in nasal polyps.

Nitric oxide production in the sphenoidal sinus by the inducible and constitutive isozymes of nitric oxide synthase.

OBJECTIVE: To study the production of nitric oxide (NO), and the presence of different isoforms of the NO-synthesising enzyme, NO-synthase (NOS), in the paranasal sinus. MATERIALS AND METHODS: Ten patients, undergoing surgery for pituitary adenoma, were examined for the presence of NO gas in the sphenoidal and maxillary sinus. The distribution of different NOS isozymes in mucosal biopsies from sphenoid and maxillary sinus and ethmoidal cells was studied. RESULTS: The mean concentration of NO was 2575 ppb in the sphenoidal sinus and 6792 ppb in the maxillary sinus. Morphological analyses revealed intense NADPH-diaphorase staining throughout the epithelium. Immunoreactivity against NOS2 (inducible NOS) was observed in the apical cell layer but not of the basal layer. NOS1 (neuronal NOS)-immunoreactivity was mainly seen in the subapical part of the epithelium and NOS3 (endothelial NOS)-immunoreactivity was observed only in the most apical part of the epithelium. CONCLUSION: NO concentration in the sphenoidal sinus is about the same as in the nasal cavity and approximately half of the concentration found in the maxillary sinus. All of the three main different isozymes of NOS can be demonstrated in the mucosa of the sphenoidal and maxillary sinus and ethmoidal cells, NOS2 being the most abundant isoform.

Blood-brain barrier opened by stimulation of the parasympathetic sphenopalatine ganglion: a new method for macromolecule delivery to the brain.

OBJECT: Drug delivery across the blood-brain barrier remains a significant challenge. Based on earlier findings, the authors hypothesized that parasympathetic innervation of the brain vasculature could be used to augment drug delivery to the brain. METHODS: Using a craniotomy-cerebrospinal fluid superfusate paradigm in rats with an intravenous injection of tracer the authors demonstrated that stimulation of the postganglionic parasympathetic fibers of the sphenopalatine ganglion (SPG) increased the concentration of fluorescein isothiocyanate-dextran (4-250 kD) in the superfusate by two- to sixfold. A histological examination indicated the presence of dextran in the parenchyma. In another experiment the amount of Evans blue dye in the brain following SPG activation was similarly significantly elevated. The chemotherapeutic agents anti-HER2 monoclonal antibody and etoposide were also delivered to the brain and reached therapeutic concentrations. Brain homeostasis was not disturbed by this procedure; a measurement of nicotinamide adenine dinucleotide reduction did not show a decrease in the tissue metabolic state and brain water content did not increase significantly. CONCLUSIONS: Sphenopalatine ganglion activation demonstrates a promising potential for clinical use in the delivery of small and large molecules to the brain.

Growth hormone-secreting pituitary adenoma confined to the sphenoid sinus associated with a normal-sized empty sella.

We present a case of growth hormone (GH)-secreting ectopic pituitary adenoma confined to the sphenoid sinus associated with a normal-sized empty sella. It has been well known that acromegaly is sometimes associated with an empty sella. However, such a case usually has a macroadenoma and an empty sella that is large. The authors considered the possible mechanisms of the association between a normal-sized empty sella and an ectopic pituitary adenoma in the sphenoid sinus as the following. Primary empty sella existed originally, and the pituitary adenoma developed later. The adenoma extended into the sphenoid sinus because of the pulsatile intracranial cerebrospinal fluid pressure.

Radioiodine uptake in the head and neck.

OBJECTIVE: To report two cases of sinusitis-associated radioiodine uptake in patients with thyroid cancer and to review the reported causes of false-positive radioiodine uptake in the head and neck area. METHODS: We present the radiologic findings in two patients who had undergone treatment for papillary thyroid cancer and discuss other settings in which radioiodine uptake suggested the presence of metastatic disease. RESULTS: Radioiodine whole-body scans of two patients who had had thyroid cancer demonstrated uptake in the sphenoid and maxillary sinuses, respectively, mimicking bone or brain metastatic involvement. The thyroglobulin levels were low. Computed tomographic (CT) scanning disclosed mucosal swelling in the sinuses, consistent with sinusitis. The radioiodine uptake cleared on a follow-up scan in one case and was more localized than the CT findings in the other. Eighteen causes of false-positive radioiodine uptake in the head and neck area have been reported. On the basis of the mechanism of uptake, they can be classified into four categories: (1) physiologic uptake (ectopic thyroid tissue), (2) nonthyroidal pathologic conditions (dacryocystitis, sinusitis, sinus mucocele, sialadenitis, folliculitis, Warthin's tumor, parotid cyst, porencephaly, posttraumatic cerebromalacia, and inflammation due to dental disease or a nose ring), (3) internal retention (ectasia of the carotid artery and an artificial eye), and (4) external contamination by body secretions (sweat and nasal, tracheobronchial, lacrimal, and salivary secretions). The estimated prevalence of external contamination in the head and neck area on whole-body radioiodine scans is 0.3%. CONCLUSION: Physicians should rule out the presence of radioiodine uptake by inflamed mucosa of the paranasal sinuses, as well as various other causes of false-positive radioiodine uptake, before metastatic thyroid cancer in the head and neck area is diagnosed.

Comparison of CT and MRI features in sinusitis.

OBJECTIVE: To correlate the features of inflammatory changes in the paranasal sinuses on magnetic resonance imaging (MRI) with computed tomography (CT). METHODS AND PATIENTS: One hundred and fourteen patients with histologically proven nasopharyngeal carcinoma (NPC) were staged with both CT and MRI. All CT and MRI images of patients with mucosal thickening but no tumour involvement of the sinuses were retrospectively analysed. RESULTS: There were inflammatory changes in 36 maxillary, 21 sphenoid and 16 ethmoid sinuses. These changes include mucosal thickening, retention cysts, retained secretions, inspissated secretions and dystrophic calcification. MRI is superior to CT in separating thickened mucosa, retained secretions and retentions cysts. CONCLUSION: It is important to appreciate CT changes of sinusitis and the corresponding spectrum of MRI features.

[Alcohol concentration in the paranasal sinus fluid in drowning]. / Alkoholkonzentration in der Nebenhöhlenflüssigkeit beim Ertrinken.

In 20 of 31 drowned persons we found 0.3 to 3.5 ml fluid in the maxillary and sphenoid sinus. In 18 cases the fluid could be recognised roentgenologically. In 9 cases blood and fluid in the paranasal sinus were free of ethanol. In 6 of 11 cases the concentration of ethanol in blood and fluid of the paranasal sinus corresponded very well, in the other cases the variation ranged from -51.8 to 147%. Ethanol in both blood and fluid of the paranasal sinus seems to confirm the diagnosis "drowning".

Quantitative histology of the normal sphenoidal sinus.

From 32 normal sphenoidal sinuses in 16 patients the mucosa was removal at autopsy, stained by the PAS-alcian blue whole mount method, and the density of goblet cells as well as of mucous glands was determined. The median density of goblet cells was 6200 cells per mm2, without statistically significant differences between the walls. The median density of glands was very low, 0.06 gland/mm2, highest in the anterior wall which has 0.1 gland/mm2 and lowest in the posterior wall which has 0.05 gland/mm2. The total gland count was less than 50 in 94% of the sinuses, 51--80 in 4%. The glands were small, tubulo-acinous. Hence, the production of mucus by the glands is entirely negligible in relation to that of the goblet cells.

Air-fluid levels in the sphenoid sinus in epistaxis and nasal packing.

Air-fluid levels in the sphenoid sinus have been described in association with skull fracture, cerebrospinal fluid rhinorrhea, and sinusitis. The authors have observed this sign in the absence of significant trauma in patients with epistaxis and nasal packing. The fluid is probably normal sinus secretion retained due to prolonged recumbency, although other explanations for its accumulation are discussed.