[Acute bilateral amaurosis in sphenoid empyema caused by Streptococcus pneumoniae]

PATIENT

A 14-year-old boy suffered from an acute bilateral blindness which occurred in 24-h time, accompanied by headache and raised temperature, with inconspicuous optic nerve head and fundus. After diagnosis of empyema with magnet resonance tomography (MRT) the sphenoid sinus was fenestrated and streptococcus pneumoniae isolated. Liquor and serology being inconspicuous, there was no evidence of leucaemic or autoimmune disease, intoxication or intracranial tumor.

CLINICAL COURSE

The condition of the patient improved under systemic antibiotic therapy. The bilateral amaurosis remained and opticus atrophy developed.

CONCLUSION

A bilateral amaurosis with descending opticus atrophy as a consequence of a sphenoiditis and spreading inflammation to the meninges and the optic nerve in the area of the chiasm is a rare event. The imaging technique of the MRT offers new opportunities for an early and more pointed diagnosis and therapy.

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.

MR features of pachymeningitis presenting with sixth-nerve palsy secondary to sphenoid sinusitis

Pachymeningitis manifested by localized enhancing dural thickening adjacent to the clivus on MR images of two patients with sphenoid sinusitis and sixth-nerve palsy is presented. This is an unusual complication of sphenoid sinusitis. Prompt diagnosis and therapy may avoid significant intracranial complications.

Aspergillosis of the paranasal sinuses

Aspergillosis of the paranasal sinuses is a well-established clinical entity which has recently been classified into non-invasive and invasive forms with distinct sub-divisions of both types. Two cases are described, both highlighting potential serious complications of the disease as well as the importance of adequate medical and surgical treatment in effecting a favourable outcome. The disease is reviewed and the question as to whether cases necessarily fall into previously-defined clinical and pathological categories is also discussed.

[Chronic sphenoid sinusitis]

Sphenoid sinusitis is often ignored by doctors, for the sphenoid sinuses are the most neglected paranasal sinuses and sphenoid sinusitis lacks specific symptoms. 58 cases of sphenoid sinusitis were reported in this article. The specific clinical symptoms remain to be deficient. At present, computerized tomography, MRI and telescope help to make accurate evaluation of sphenoid sinus diseases. The endoscopic intranasal surgery for sphenoid sinusitis enables the complicated surgical procedures simple. In our series, most cases (53) are sphenoethmoid sinusitis. The isolated sphenoid sinusitis is rare in clinical practice.

Functional endoscopic sinus surgery for isolated sphenoid sinus disease

BACKGROUND

This article reviews 12 cases of isolated sphenoid sinus disease: chronic inflammatory sinusitis (7), mucoceles (2), aspergillus lesions (2), and isolated polyp (1).

METHODS

Criteria for diagnosis were based on clinical symptoms, nasal endoscopic evaluation, and computed tomography (CT). Magnetic resonance imaging was used only in cases of bone erosion and when patients presented with vision problems. All patients were treated by functional endoscopic sphenoidotomy. Any postoperative complications were noted.

CONCLUSION

The reported good results, on the basis of regression of functional symptoms and with nasal endoscopic and CT evaluation, suggest that intranasal sphenoidotomy under endoscopic control is a safe and effective method of treatment of nonmalignant isolated sphenoid disease. The mean follow-up is 26 months.

Isolated palsy of the superior branch of the oculomotor nerve due to chronic erosive sphenoid sinusitis

We report one case with isolated unilateral superior branch oculomotor nerve palsy due to an erosive sphenoid sinusitis. Within 8 weeks after surgical drainage of the sphenoid sinusitis, the patient recovered fully from the superior branch oculomotor palsy. In view of the dramatic clinical improvement that followed surgery, we hypothesized a compression of the superior branch of the oculomotor nerve by the sphenoidal abscess. To our knowledge, this is the first reported case of a superior branch oculomotor nerve palsy related to an erosive sinusitis and cured by sinusotomy, a safe and simple surgical procedure. Thus, we believe that our observation bears some practical implications of clinical importance in the management of patients who present partial oculomotor nerve palsy.

[Treatment of sphenoethmoidal sinus disease with optic nerve compression by way of nasal endoscopy: report of a case]

Esphenoetmoidal diseases when complicated may present serious diagnostic and therapeutic difficulties. A case of esphenoetmoidal mucocele compressing the optic nerve, treated with marsupialization by endoscopic intranasal way, is reported. The literature concerning the subject is commented.

[Functional endoscopic sinus surgery. Evaluation methods and results]

Functional Endoscopic Sinus Surgery (FESS) is now undoubtedly the choice procedure for the surgical treatment of chronic sinusitis and nasal polyposis after failure of medical treatment. Between January 1990 and December 1992, 51 patients with chronic sinusitis and 44 with nasal polyposis who underwent FESS were evaluated (170 ethmoidectomies). Preoperative evaluation is obtained through personal scaling combined with a CT of the sinuses, whereas postoperative assessment is based on the same scoring together with an endoscopic evaluation. Good functional results and no significant differences between the two types of pathology are obtained after a 1 year follow-up.

[Diagnostic aspects of isolated sphenoid sinusitis]

The clinical occurrence of isolated sphenoid sinusitis is rare. Due to a long history and few initial symptoms, diagnosis of this potentially fatal infections can be difficult. Radiological aspects in 10 patients are presented (e.g. type and design of examination and whether inflammatory or destructive changes could be shown), as well as clinical aspects (cranial nerve palsy, concurrent inflammation, duration of disease and therapy). CT proved to be superior in diagnosing the extent of any bony changes, while MRI was more useful in detecting inflammation.

[A rare case of isolated aspergilloma of the sphenoid sinus]

The authors report an interesting case of an isolated pathology of the sphenoid sinus (more precisely, in this case a mycotic infection of this paranasal sinus), up to a few years ago an extremely rare disease and still today an exceptional entity in the clinical practice of an otolaryngologist. The investigations carried out indicated that the infection was caused by Aspergillus candidus, a fungus which only rarely becomes pathogenic in man. The paper reports the main anamnestic data as well as the clinical and instrumental assessment of the disease. It furthermore describes the surgical procedure employed, the relative reports obtained and supplies data concerning the microbiological tests carried out on the material removed and the histological pattern observed. The surgery had an excellent outcome: the patient was cured and showed no sign of recurrence of the disease. The discussion briefly presents the clinical picture created in man by Aspergillus and stresses the rarity of the disease, noting that, including the case in question, only 23 reports, documented with histological and microscopic data, have been made in literature. The AA affirm that to their knowledge this particular case of sphenoid sinusitis caused by Aspergillus candidus [correction of Candida] is the first ever to be reported and in conclusion underline the extreme care necessary in dealing with this pathology and in making a "quoad vitam" prognosis.

[Computerized tomography as routine examination procedure in the diagnosis of paranasal sinus diseases from the otorhinolaryngologist's viewpoint. Results]

The renaissance of endonasal microsurgery is not only based on a deeper knowledge of the mucociliar clearance and better operation instruments but depends as well as on the improved radiological diagnosis provided by computed tomography. Since 1986, high-resolution computed tomography in two plains has been part of the authors' preoperative routine diagnostic program for paranasal sinus diseases at their clinic. One hundred and fifty-eight computed tomograms of patients with chronic rhinosinusitis, complicated acute rhinosinusitis, and polyposis nasi were reexamined. The involvement of the paranasal sinuses and abnormalities of the lateral nasal wall were analyzed. The anterior ethmoid is the most frequently affected area in all of the diseases. The computed tomogram is most important for the rhinosurgeon. The ethmoid cell system can be visualized without superimposing structures. Therefore even circumscript pathologic mucosa alterations and the extent of the disease can be defined. All this enables the surgeon to put forward an exact diagnosis and to plan a safe operation as regards important physiological structures of the nose and paranasal sinuses.

Blindness resulting from orbital complications of sinusitis

Loss of vision remains a potential complication of orbital infection. Appropriate evaluation and management of the patient with signs and symptoms of orbital inflammation may prevent progression to blindness. Evaluation of patients with orbital inflammation from sinusitis includes a comprehensive clinical examination and radiographic studies. Clinical examination should test for changes in visual acuity, pupillary reactivity, and extraocular motion. Computerized tomography (CT) has facilitated the diagnosis of orbital infections and aids in diagnosis. However, CT can be misleading in patients with acute orbital infections and should not be relied on to determine the need for surgical intervention. We reviewed the records of all patients admitted to Parkland Memorial Hospital from 1978 to 1988 with orbital complications resulting from sinusitis. Four of 159 patients in this group had permanent blindness. The presence of an abscess, which was ultimately found at surgical exploration, was not diagnosed by CT in any of these four patients. Clinical examination remains the most important indicator for surgical intervention in patients with orbital complications of sinusitis. We present our findings and give guidelines for surgical intervention in patients with orbital infections resulting from sinusitis.

Isolated sphenoid sinus disease

Isolated sphenoid sinus disease is an unusual entity that is encountered infrequently. With advances in antibiotic therapy and imaging techniques, the nature of isolated sphenoid sinus disease has significantly changed. More tumors and less inflammatory disorders are being encountered. We have retrospectively reviewed the medical records of patients who had undergone sublabial transseptal sphenoidotomy for isolated sphenoid sinus disease at Allegheny General Hospital for Pittsburgh between January 1985 and July 1989. Thirteen patients were identified with isolated sphenoid sinus disease who were successfully managed with sublabial transseptal sphenoidotomy. This approach allows maximal visualization and safety with minimal morbidity.

Transantral sphenoethmoidectomy: a procedure for the 1990s?

Currently, among otolaryngologists, much attention is focused on the surgical management of paranasal sinus disease. However, transantral sphenoethmoidectomy is rarely mentioned in the literature of the past several decades. We reviewed a consecutive series of 98 patients over a 12-year period who underwent transantral sphenoethmoidectomy in the treatment of severe chronic hyperplastic pansinusitis. The major and minor complications encountered are tabulated, as are the clinical outcomes. A description of the operative technique is followed by a discussion of the indications for this approach. We believe transantral sphenoethmoidectomy has a useful place in modern paranasal sinus surgery.

The role of computed tomography in revision sinus surgery

In this retrospective study, 34 patients with recurrent hyperplastic rhinosinusitis who subsequently underwent further surgical intervention were evaluated with computed tomography scans in order to assess the role of computed tomography in revision sinus surgery. Fourteen of these patients had originally undergone sphenoethmoidectomies, 8 had endoscopic sinus surgeries, 6 had Caldwell-Luc operations, and 6 had intranasal antrostomies. Computed tomography scan was instrumental in correctly identifying the site and reasons for failure and assisted in localizing further surgical intervention to the appropriate sites in 30 patients. The indications for computed tomography and revision surgery are discussed and defined.

Intranasal and transantral ethmoidectomy: a 20-year experience

Ethmoidectomy is an operation that has engendered controversy concerning the best route of surgical access. The purpose of this study was to present the results of the authors' experience in more than 1300 intranasal sphenoethmoidectomies and transantral sphenoethmoidectomies performed over a 20-year period. The authors contend that the most effective ethmoidectomy is the most complete ethmoidectomy and have previously presented a case for ethmoid marsupialization. Polyp recurrence rates of less than 20% and a major complication rate of less than 1% were reported in this study.

[Cochleovestibular syndrome caused by sphenoiditis]

Due to sphenoiditis, the patient developed a cochleovestibular syndrome at the labyrinthine level which was eliminated only by surgical treatment of sphenoiditis. This observation suggests that sphenoiditis can be referred to the factors responsible for hearing and vestibular disorders. Another interesting observation was that in the presence of pus in the sphenoidal sinus contrast X-ray did not reveal a filling defect. Such a finding was not the first of this type seen by the author.