Acute isolated sphenoid sinusitis

INTRODUCTION

Acute isolated sphenoid sinusitis is seen in fewer than 3% of all cases of sinusitis. It is frequently misdiagnosed because of its vague symptoms and the paucity of clinical findings. We report 2 cases of isolated acute isolated sphenoid sinusitis with unusual presentations.

CLINICAL PICTURE

Both patients presented with acute headache, eye pain and fever, and were provisionally diagnosed as meningitis. In 1 case, the symptoms were on the contralateral side of the sphenoid infection. Intracranial complications were also present.

TREATMENT

Treatment included intravenous antibiotics and endoscopic sphenoidotomy.

OUTCOME

Both patients recovered with no residual neurological disability.

CONCLUSION

Acute sphenoiditis usually presents with subtle symptoms and elusive physical findings and hence a high index of suspicion is necessary. Complications may arise due to the close proximity of important structures to the sphenoid sinus. Uncomplicated cases can resolve with optimal antibiotic therapy if diagnosed and treated early. Persistence or progression of disease with development of intracranial complications are indications for immediate surgical drainage.

[The interesting case--case no. 59]

Complications after endoscopic sinus surgery are rare and occur in about 0.5 % of all cases. However postoperative symptoms such as severe cephalgia and nasal discharge of clear fluids indicate a cerebrospinal fluid leakage.

CASE

A 64 year-old-patient presented to our clinic four months after an endoscopic sinus surgery complaining of the two above mentioned symptoms for about 4 weeks. In a computed tomography study of the frontobasis there was no evidence of an osseous defect. An MRI of the head revealed a bilateral temporal fluid collection as seen in bilateral chronic subdural hematoma. Therefore the present illness was no consequence of the preceding surgery.

CONCLUSION

Significant symptoms of severe postoperative complications after endoscopic sinus surgery can still be misleading. Therefore accurate diagnostic and imaging procedures are always crucial to support the initial diagnosis.

Endoscopic treatment of the isolated sphenoid sinus lesions

Presenting symptoms of the isolated sphenoid sinus lesion are often vague and non-specific. Diagnostic nasal endoscopy procedures and imaging techniques are of great value for an early and precise diagnosis. Moreover, endoscopic sinus surgery is a safe and effective technique that allows a direct route to the sphenoid sinus. Because of its close vicinity to important and vulnerable structures of the skull base, delay in diagnosis and treatment can be potentially lethal. Endoscopically controlled procedures for the sphenoid sinus provide the surgeon with an obvious alternative to the traditional approaches. From November 1994 to May 2001 the authors operated on 41 patients with isolated sphenoid lesions. The pathology spectrum was rather wide and included 11 cases of isolated fungal sinusitis, 10 mucoceles, 7 bacterial sinusitis, 7 cerebrospinal fluid leaks, 3 inverted papillomas, 1 chondrosarcoma, 1 ossifying fibroma and 1 foreign body. The sphenoid sinus was the only sinus involved, and lesions arising from adjacent tissues were excluded. In this paper, the authors present clinical symptoms, endoscopic findings and imaging data as well as endoscopic surgical techniques for the treatment of sphenoid sinus disease.

Isolated sphenoid sinusitis presenting with unilateral VIth nerve palsy

Isolated sphenoid sinusitis is a rare disorder. There are some difficulties in its diagnosis and the first presentation of this disorder might be with complications. These complications are essentially due to the anatomical location of the sinus and its proximity to the intra-cranial and orbital contents, to which infection may easily spread. In this paper, we report a case of isolated sphenoid sinusitis in a 12-year-old girl who was presented with unilateral VIth nerve palsy. She was initially treated with parenteral antibiotherapy, the abducens nerve palsy recovered but as sphenoiditis persisted she underwent an endoscopic sphenoidotomy. We discuss the clinical features, the diagnostic tools, and the treatment options for this entity.

Invasive fungal sinusitis due to Bipolaris hawaiiensis. Fallbericht. Invasive Pilzsinusitis verursacht durch Bipolaris hawaiiensis

A phaeohyphomycotic sinusitis due to Bipolaris hawaiiensis, observed in an immunologically competent patient, is reported and a review of data from the literature is given. The patient was successfully treated by surgical drainage and amphotericin B.

Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis

Postoperative meningitis is a well known complication of transsphenoidal surgery (TSS). The objective of this study was to evaluate whether postoperative external cerobrospinal fluid (CSF) drainage in case of intraoperative CSF-leakage, reduces the risk of postoperative meningitis. We retrospectively reviewed a series of 278 consecutive transsphenoidal operations. In all operations with intraoperative CSF leakage, an external lumbar drain (ELD) was inserted directly postoperatively, and removed after at least 5 days. The incidence of postoperative meningitis was compared with that in a previously studied series of 228 consecutive transsphenoidal operations, without insertion of an ELD in cases with intraoperative CSF leakage. In the present series, postoperative meningitis occurred in 2/278 (0.7%) operations, compared to 7/228 (3.1%) operations in the previous study period (P < 0.05). Intraoperative CSF leakage was noted in 70/278 (25.2%) operations. All these patients received an ELD immediately after surgery for at least 5 days. There were no reported complications of ELD insertion. In the present series, 1 of 70 (1.4%) patients with intraoperative CSF leakage developed meningitis, compared to 3 of 22 (13.6%) patients in the previous study (P < 0.05). The present report on 278 consecutive transsphenoidal operations shows that the routine insertion of an ELD in patients in whom intraoperative CSF leakage is observed significantly reduces the incidence of postoperative meningitis. Possibly, diversion of CSF prevents the formation of a CSF fistula and thereby the risk of infection. The role of prophylactic antibiotic treatment in patients with CSF rhinorrhea after TSS remains to be established.

Isolated inflammatory sphenoid sinus disease in children

Isolated inflammatory disease of the sphenoid sinus is very uncommon in the pediatric population. A 10-year review of all patients at our institution 16 years of age or younger with inflammatory sphenoid sinus disease found 8 patients with isolated sphenoid sinusitis and 3 with sphenoid mucoceles. The most common symptoms were headache and visual disturbance. Five patients with uncomplicated sinusitis were successfully managed medically, while 3 with either complicated sinusitis or sinusitis not responding to antibiotics were treated by endoscopic sphenoidotomy. All patients with a mucocele were treated surgically. Isolated inflammatory sphenoid sinusitis should be considered in children age 7 years or older who present with headache that does not respond to simple analgesia. Delayed diagnosis and advanced disease may lead to life-threatening complications.

Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature

OBJECTIVE AND IMPORTANCE

Isolated fungal granulomas originating within the sphenoid sinus are extremely rare in immunocompetent patients. In their symptoms and morphological appearance, these lesions may be mistaken for pituitary tumors. We report such a case and review the literature.

CLINICAL PRESENTATION

A 74-year-old man presented with a 3-week history of Cranial Nerve III paresis. The patient had a long-term history of snuff abuse. Computed tomography demonstrated a space-occupying lesion of the sellar and sphenoid sinus region with displacement of the cavernous sinus.

INTERVENTION

The lesion was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, mucus extruded spontaneously, and a brownish, crumbly mass was found and removed. The lesion had completely eroded the sella and clivus. Histological analysis revealed numerous Aspergillus hyphae. Postoperatively, the IIIrd cranial nerve paresis resolved completely within a few days. No systemic fungal infection was found in extensive serological studies. There was no evidence of immunosuppression.

CONCLUSION

Fungal granuloma must be included in the differential diagnosis of lesions in the sellar region, even in nonimmunosuppressed patients. Early diagnosis and transsphenoidal extirpation is crucial with this potentially life-threatening disease.

Two cases of Aspergillus sinusitis with bone destruction

We experienced the clinical courses of two cases of destructive Aspergillus in paranasal sinuses in which an Aspergillus fungus ball was formed, and which caused bony destruction are described. The case in which a nidus could not be completely surgically removed and with intervening diabetes had an unfavorable prognosis. It is recommend to perform an early expanded operation as well as to administer a sufficient amount of antifungal drugs for the treatment of destructive Aspergillus in paranasal sinuses.

Powered endoscopic marsupialization for recurrent sphenoid sinus mucocele: a case report

We report a case of recurrent sphenoid mucocele successfully treated by using a powered instrument under endoscopic control. A 59-year-old male came to our clinic complaining of severe headache, right-side facial numbness (in the areas of the first and second branches of the trigeminal nerve), diplopia, and right blepharoptosis. Computed tomography (CT) imaging revealed opacification and expansion of the sphenoid sinus lesion. The lesion was diagnosed as right-side sphenoid mucocele affecting the functions of the trigeminal (first and second branches), oculomotor, and abducent nerves. Endoscopic drainage of the right-side sphenoid mucocele leads to gradual improvement of these symptoms. Approximately 1 year after the drainage procedure, the size of the enlarged sphenoid sinus ostium had decreased. The patient underwent endoscopic right-side total marsupialization of the sphenoid sinus using a powered instrument. Subsequently, the patient has presented no evidence of recurrent disease after 1 year of follow-up.

Evaluation and surgical management of isolated sphenoid sinus disease

OBJECTIVES

To evaluate the pathologic conditions, preoperative evaluation, treatment, and clinical outcomes associated with sphenoid sinus disease.

DESIGN

Retrospective study.

SETTING

Tertiary university-based referral center.

PATIENTS

All patients with isolated sphenoid sinus disease managed surgically or in which surgery was considered a primary treatment option.

MAIN OUTCOME MEASURES

Demographic data, presenting signs and symptoms, endoscopic and imaging findings, surgical management, surgical pathology, and clinical outcomes were investigated in patients presenting with sphenoid sinus disease to the Medical College of Wisconsin, Milwaukee, between January 1, 1991, and December 31, 2001.

RESULTS

The study population included 17 women and 12 men with a mean age of 52.3 years (range, 15-82 years). The most common presenting symptom was headache (20 patients [69%]). Imaging evaluation included computed tomography and/or magnetic resonance imaging studies in all cases. Sphenoid sinus abnormality was variable and included sinusitis (11 patients [38%]), tumor (7 [24%]), mucocele (5 [17%]), fungal process (3 [10%]), and cerebrospinal fluid fistula (3 [10%]). Twenty-one cases (72%) were managed endoscopically and 4 (14%) were managed with a transseptal approach. One patient (3%) underwent combined extracranial-endoscopic transnasal approach, while another (3%) underwent a midface degloving approach. The remaining 2 patients (7%) did not undergo surgical intervention.

CONCLUSIONS

Given the high prevalence of noninflammatory lesions within the sphenoid sinus, thorough preoperative evaluation is imperative. Initially, this should include nasal endoscopy and computed tomography to help define the location, extent, and character of the lesion. In some cases, magnetic resonance imaging may help further define the nature and extent of a lesion. Angiography should be considered if a vascular lesion is suspected. The clinical and imaging findings should all be taken into consideration when the surgical approach is planned.

Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures

The endoscopic endonasal transsphenoidal approach has been proposed in the past decade as a minimally invasive surgical technique for the removal of pituitary tumors. From January 1997 to November 1999, 100 consecutive patients with pituitary tumors underwent endoscopic endonasal surgery, according to Jho's technique. We employed 0 degrees, 30 degrees, 45 degrees, and 70 degrees rigid endoscopes, 18 - 30 cm in length, 4 mm in diameter with an outer sleeve for irrigation and secured to a holder. Among the 87 pituitary adenomas, tumor removal was total in 51, subtotal (> 80 %) in 20 and partial in 16 cases. Four craniopharyngiomas were totally removed and an intra-suprasellar arachnoid cyst was emptied; a biopsy was performed in the two patients with a clivus chordoma. The two cases of sphenoid sinusitis were cured by surgery, the three patients with spontaneous CSF rhinorrhea were successfully treated and the residual nasal meningocele was removed. The endoscopic endonasal transsphenoidal approach appeared to be less traumatic than the traditional microsurgical approach, was very effective, and was characterized by a reduced number of complications. However, the relatively small series together with the short follow-up do not allow us to draw definitive conclusions. The post-operative reduction in hospital stay (two days in 40 of 100), significantly reduced the cost of patient's management.

Smoke exposure and outcome of endoscopic sinus surgery in children

OBJECTIVE

The study goal was to determine whether cigarette smoke exposure in children who are undergoing endoscopic sinus surgery (ESS) for chronic sinusitis will have an impact on the outcome.

DESIGN

We conducted a cohort study in a tertiary care children's hospital setting.

PATIENTS AND METHODS

The study population consisted of 118 patients who underwent ESS between January 1994 and June 1999. The mean age was 6.5 (range, 2 to 13 years). The outcome of ESS was measured > or =1 year after the operation. A questionnaire was mailed to the caretakers to measure success. Those who required revision subsequently were considered as failures.

RESULTS

Multivariate logistic regression analysis was performed with smoke exposure as an independent variable and outcome measured as success of procedure. The overall success rate was 83%. Univariate analysis of smoke exposure and outcome of surgery revealed that children exposed to smoke in household had a 70% success rate compared with children not exposed to smoke, who had a 90% success rate (P = 0.007). Multivariate analysis revealed smoke exposure continued to be an independent predictor of success.

CONCLUSION

ESS in children with cigarette smoke exposure predisposes to a poorer outcome. This needs to be taken into consideration when recommending ESS for those children.

Treatment of isolated sphenoid sinus inflammatory disease by endoscopic sphenoidotomy without ethmoidectomy

OBJECTIVES/HYPOTHESIS

Isolated chronic sphenoid sinusitis is a rare entity. The study was conducted to determine the efficacy of endoscopic sinus surgery with partial middle turbinectomy and without ethmoidectomy in treating isolated sphenoid opacification from inflammatory and infectious disease.

STUDY DESIGN

Case series of 20 patients generated by retrospective review of 307 consecutive patients who underwent surgical treatment for chronic rhinosinusitis.

METHODS

The medical records were reviewed for pertinent demographic, symptom, radiographic, and endoscopic data preoperatively, interoperatively, and postoperatively. All patients in the series underwent computed tomographic image-guided endoscopic sphenoid sinus surgery with partial middle turbinectomy.

RESULTS

The study population consisted of 12 male and 8 female patients between 28 and 75 years of age. Headache (15 patients) and/or postnasal drip (14 patients) were the presenting symptoms in 17 of the patients. Three patients were asymptomatic. Surgical findings included inspissated secretions (15 patients), fungal debris (2 patients), and mucopyoceles (3 patients). The 17 patients with preoperative symptoms were symptom free by 12 weeks postoperatively and have remained so with follow-up ranging from 12 months to 3.25 years (mean follow-up, 23.1 mo). There were no operative complications in the series.

CONCLUSIONS

Endoscopic sphenoid sinus surgery without ethmoidectomy is effective for treating isolated sphenoid sinus opacification associated with inflammatory or infectious sinus disease. Partial middle turbinectomy at the time of surgery facilitates the approach, as well as postoperative cleaning and surveillance.

Bacteriology of acute and chronic sphenoid sinusitis

Aspirates of 16 acutely infected and 7 chronically infected sphenoid sinuses were processed for aerobic and anaerobic bacteria. A total of 29 isolates were recovered from the 16 cases of acute sphenoid sinusitis (1.8 per specimen): 22 aerobic and facultative (1.4 per specimen), and 7 anaerobic (0.4 per specimen). Aerobic and facultative organisms alone were recovered in 10 specimens (62%), anaerobes alone were isolated in 3 (19%), and mixed aerobic and anaerobic bacteria were recovered in 3 (19%). The predominant aerobic and facultative species were Staphylococcus aureus (9 isolates), Streptococcus spp (9), and Haemophilus influenzae (2). A total of 28 isolates were recovered from the 7 cases of chronic sphenoid sinusitis (4.0 per specimen): 11 aerobic and facultative (1.6 per specimen) and 17 anaerobic (2.4 per specimen). Aerobic and facultative organisms alone were recovered in I instance (14%), anaerobes alone in 3 instances (43%), and mixed aerobes and anaerobes in 3 instances (43%). The predominant aerobic bacteria were gram-negative bacilli (Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa; 1 each). The predominant anaerobes included Peptostreptococcus spp (4 isolates), Prevotella spp (5), and Fusobacterium spp (4). These findings illustrate the unique microbiology of acute and chronic sphenoid sinusitis.

Minimally invasive approaches to the sphenoid sinus

OBJECTIVE

We sought to develop an algorithm for surgical approaches to the sphenoid sinus.

STUDY DESIGN AND SETTING

Retrospective review was conducted of all patients who underwent a sphenoid sinusotomy by the senior author between July 1994 and August 2001.

RESULTS

The study population consisted of 141 patients, in whom 5 different surgical approaches were used: transseptal (47 [33.3%]), transnasal (19 [13.5%]), transethmoid (72 [51.1%]), transmaxillary (2 [1.42%]), and external (1 [0.7%]). Of the 47 transseptal approaches, 43 (91.5%) were for extirpation of a neoplasm. In contrast, 60 of 72 (83.3%) transethmoid procedures were for infectious/inflammatory disorders. An endoscopic approach was used for 7 of 8 (87.5%) skull base repairs. Four transsphenoid optic nerve decompressions were performed. The minor and major complication rates were 2.1% and 0.71%, respectively.

CONCLUSIONS

The anatomic location of the pathologic process can guide the surgeon in selecting the most appropriate technique.

SIGNIFICANCE

Surgical treatment of sphenoid pathology can be safely and successfully performed through a variety of approaches.

Skull base erosion by sphenoid fungus balls: diagnosis and endoscopic treatment

BACKGROUND

Fungus balls typically are innocuous lesions found in immunocompetent hosts. They are located most commonly in the maxillary sinus but may be life-threatening when found in the sphenoid sinus.

METHODS

We review our series offour sphenoid fungus balls with skull base erosion.

RESULTS

Our average patient age was 68.7 years old (56-86 years) with three women and one man. One patient was insulin-dependent diabetic, the other three patients were otherwise healthy. The most common presenting symptoms were headache and dizziness with relatively few sinus-specific complaints. Endoscopy revealed polyps in two of the four patients. Computerized tomography scans revealed thickened osteitic bone in three cases and two of the four computed tomography scans showed microcalcification. All patients had bony erosion over the internal carotid arteries. Additionally, one patient internal carotid artery thrombosis, one patient had erosion of the planum sphenoidale, and a third patient had erosion to the brainstem inferior to the sella turcica. Three patients had magnetic resonance imaging that revealed heterogeneous lesions. Two magnetic resonance images showed hypointense T1 and T2 imaging. The third was isointense on T1 and hypointense on T2. All patients were treated with endoscopic marsupialization and removal of all gross fungal debris without complications. All pathological specimens were diagnostic for fungus balls. One offour cultures was positive for fungus. All patients are asymptomatic at time of lastfollow-up.

CONCLUSIONS

Sphenoid fungus balls present with vague, non-rhinological symptoms, but may have significant local expansion and destruction. These potentially lethal lesions usually can be suspected on preoperative imaging and are best treated with endoscopic removal.

Isolated sphenoid sinus disease: an analysis of 122 cases

Isolated sphenoid sinus disease (ISSD) is a relatively uncommon disease. The present study is a retrospective review of 122 patients with ISSD who were treated at the Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital at Shanghai Medical University over a 25-year period. The diagnosis of ISSD was made on the basis of history and physical examination, signs and symptoms, nasal endoscopy, and computed tomography (CT) and magnetic resonance imaging (MRI). The final diagnosis of ISSD was confirmed by histopathologic and microbiological examinations of the surgical specimens. The pathological findings in this study included sphenoid cyst (47 cases), sphenoid sinusitis (31 cases), fungal disease (19 cases), inverted papilloma (4 cases), sphenochoanal polyp (1 case), foreign body (8 cases), malignant tumors (8 cases), and others (4 cases). The most common initial symptom was headache, followed in decreasing order by visual changes, cranial nerve palsies, and nasal symptoms. The more frequent use of routine CT and MRI scanning, as well as endoscopy, in the diagnosis of sinus disease has led to an increase in the early diagnosis of ISSD. The recent advances in endoscopic sphenoidotomy has allowed for relatively safe and immediate treatment of ISSD, preventing late extension into adjacent vital structures, which is commonly fatal. Endoscopic surgery also enables the surgeon to make a precise pathological diagnosis.

[Treatment of the sphenoid sinusitis with neuro-ophthalmologic syndromes]

OBJECTIVE

To analyze the diagnosis and the treatment of neuro-ophthalmologic syndromes caused by sphenoid sinusitis.

METHOD

5 cases with neuro-ophthalmologic syndromes caused by acute or chronic sphenoid sinusitis were reviewed, 3 of them were performed a sphenoidostomy and other two were treated by injecting antibiotics and steroid.

RESULT

The surgery and antibiotics can relieve the headache. However, recovery of the neuro-ophthalmologic syndromes was inconstant.

CONCLUSION

CT scan can provide an early diagnosis and differential diagnosis. The delayed surgery may be response for the unsatisfied treatment results.

The intracranial complication of acute isolated sphenoid sinusitis

Acute isolated sphenoid sinusitis is a rare, potentially destructive entity, which has indistinct clinical findings and non-specific symptoms. Hence, it can be easily be misdiagnosed. We present and discuss a case of an isolated sphenoiditis with intracranial complication.

[The diagnosis and treatment of isolated sphenoid sinus disease]

OBJECTIVE

To detail the underlying symptoms and signs of patients with isolated sphenoid sinus inflammatory disease and enhance the initial diagnostic accuracy.

METHOD

49 patients with isolated sphenoid sinus inflammatory disease were reviewed, and the outcomes of the endoscopic surgery were compared with the non-endoscopic surgery.

RESULT

In patients who underwent endoscopic sphenoidotomy, 31 were virtually free from symptoms and 5 still experienced mild headache and hyposmia but their radiographic finding had become normalized. None of them need re-operation within 6-48 months follow-up. However, in patients with non-endoscopic sinus irrigation, only one was free from the symptoms and 5 patients underwent re-operation because of recurrence.

CONCLUSION

Nasal endoscopy and CT/MRI scan could provide a precise diagnosis for isolated sphenoid sinus disease and endoscopic surgery is valuable in its treatment.

[Prognostication and treatment of fronto-spheno-ethmoiditis in patients with post-traumatic deformities of the upper and middle parts of the face]

Different types of frontosphenoethmoiditis in patients with posttraumatic deformities of the upper and middle facial regions including deformation of the naso-orbito-ethmoidal, naso-fronto-orbito-ethmoidal and sphenoidal complexes are described. Mechanisms of development of posttraumatic sinusitis are considered regarding type of the trauma. Clinical symptoms and diagnosis, problems of reconstructive interventions, variants of treatment policy are discussed.