Isolated sphenoid sinus abscess: clinical and radiological failure in preoperative diagnosis. Case report and review of the literature

Lateral rectus muscle palsy secondary to sphenoid sinusitis

Isolated sphenoid sinus disease is a rare, often misdiagnosed condition of the paranasal sinus. If left untreated, it can lead to complications involving pituitary gland, cavernous sinus, neurological and vascular structures nearby. Early recognition and treatment are critical to prevent the progression of the disease. We present a case of a 60-year-old woman with a history of severe left-sided headache, facial pain, diplopia and left lateral rectus palsy. She was initially referred to ophthalmology and rheumatology for possible giant cell arteritis. Magnetic resonance imaging revealed opacification in left sphenoid sinus with cavernous sinus/superior orbital fissure involvement consistent with left sphenoid sinusitis. She was then referred to the ear, nose and throat department and had endoscopic transnasal sphenoidotomy in theatre. Culture results showed Haemophilus influenza and fungal pseudohyphae. She recovered three months later after a course of antibiotics and antifungals. The onset of isolated sphenoid sinus disease is often insidious and the diagnosis of this condition remains a challenge. Magnetic resonance imaging and computed tomography remain the best diagnostic tools to recognise and manage this condition.

Spontaneous Unilateral Intrasphenoidal Meningocele

The sphenoid sinus is an uncommon location for protrusion of a meningocele. When this does occur, it nearly always presents with leakage of cerebrospinal fluid through the nasal cavity. We present a case of a 38-year-old female found to have a meningocele protruding into the left sphenoid sinus, who presented with intractable headache but no CSF rhinorrhea. The lesion was discovered on computed tomography angiography, which was performed in order to rule out intracranial pathology as the etiology of her headache. Prior imaging, including pre- and post-contrast MRI, demonstrated the fluid within the sphenoid sinus, but did not reveal the communication through a defect in the base of the skull. Thus, it was assumed to be strictly related to sinus disease in the past. Our case represents a phenomenon whereby meningoceles protruding through the basilar skull into the sphenoid sinus or any other location are potentially misdiagnosed due to poor visualization of the osseous defect and lack of awareness of this entity.

Clival inflammation with cavernous sinus thrombophlebitis and orbital subperiosteal abscess--case report

A 64-year-old woman presented with a very rare case of three infectious lesions, cavernous sinus thrombophlebitis, clival inflammation, and orbital subperiosteal abscess (SPA), manifesting as abducens palsy. An isolated non-specific mass in upper clivus was initially suspected to be derived from paranasal sinusitis. The clival lesion was approached by an endonasal transsphenoidal route and diagnosed as inflammation. However, progressive enlargement of an orbital mass was recognized, with eyelid erythema and swelling. Magnetic resonance imaging showed massive paranasal sinusitis and an intra-orbital mass, which was proved to be an orbital SPA by open surgery. Cavernous sinus thrombophlebitis might have been caused by primary paranasal sinusitis, and the origin of orbital cellulitis was suspected to be cavernous sinusitis based on the preoperative radiological findings. These unusual lesions should be kept in mind as one of the differential diagnoses.

Current management of isolated sphenoiditis

Isolated sphenoiditis (IS) is a relatively rare clinical entity which might present with serious complications. The clinical records of ten patients with IS were reviewed. The presenting symptoms, the findings, and the treatments given were noted. Eight patients were female and two were male, and their age varied between 9 and 65 years (mean 31 years). The main presenting symptom was headache in five patients, diplopia in four patients, and postnasal drainage in one patient. The duration of the symptoms ranged between 48 h and 1 year. The diagnosis was accomplished by history, nasal endoscopy and radiological examination (computed tomography and/or magnetic resonance imaging). Two patients had fungus ball. One patient was a scuba diver as a possible predisposing factor. All of the patients underwent medical treatment consisting of intravenous antibiotics or oral antibiotics, and endoscopic sinusotomy was performed in nine patients additionally. Complete resolution was obtained for all patients except one who had diplopia for one year. IS may present with headache and orbital symptoms. Timely diagnosis and treatment are substantial in order to avoid serious complications, and to obtain a complete recovery. Medical treatment does not avoid surgery in majority of cases. Surgery is indicated from the very beginning specifically for the cases starting with diplopia which might be suggestive of a progression of the infection. Currently the most frequently used approach is endoscopic transnasal sphenoidotomy. This technique seems to be effective and less traumatic compared to other approaches.

Sellar lymphoma mimicking sphenoid infection presenting with cavernous sinus syndrome

Lymphomas can occur throughout the body, but are relatively rare in the sphenoid region. The clinical presentations are atypical, ranging from nasal symptoms, pituitary hormone dysfunction and neurological impairment. We report a 63-year-old female patient who suffered nasal discharge, retro-ocular pain and left lateral gaze palsy for 3 months. Cranial MRI revealed sellar and suprasellar lesions involving the clivus, cavernous sinus and sphenoid sinus. The patient was treated for chronic sphenoid sinusitis. Histopathological review for possible misdiagnosis was arranged owing to treatment failure 1 month later. The final diagnosis was primary large B-cell lymphoma, which was confirmed by immunohistochemical study and systemic survey. The symptoms of sellar lymphoma resemble those of chronic sphenoid sinusitis. MRI and hematoxylin and eosin histological examination can accurately diagnose most cases. Immunohistochemistry assay is recommended in equivocal cases and provides a more detailed tumor classification.

Diffusion-weighted MR imaging findings in an isolated abscess of the clivus

We report the finding of restricted diffusion in an isolated abscess of the clivus and discuss the imaging differential diagnosis, with an emphasis on the usefulness of diffusion-weighted imaging.

Mucoceles of the sphenoid sinus

PURPOSE

Mucoceles of the sphenoid sinus represent 1-2% of all paranasal sinus mucoceles. The aim of this paper is to report our experiences in patients with mucoceles of the sphenoid sinus.

PATIENTS AND METHOD

In a period of 4 years, we observed six patients in whom a mucocele of the sphenoid sinus was suggested pre- or intraoperatively. Symptoms and signs included headache, visual loss and palsies of the III and VI cranial nerve. All patients were investigated by MRI and/or CT. Imaging findings were compared with operative and/or histological findings.

RESULTS

In three cases there were simple mucoceles, in one case we found a tumour (nasopharyngeal carcinoma) associated mucocele and in two cases, malignant tumours (carcinoma, chordoma) imitated a mucocele. The diagnosis of simple mucoceles was no problem at all by imaging. Difficulties made the two malignant tumours and the tumour associated mucocele. In the first two cases, repeated histological samples were necessary to make the final diagnosis.

CONCLUSION

Mucoceles of the sphenoid sinus should be investigated and handled very carefully with regard to differential diagnoses and tumour associated cases.

Sphenoid sinusitis disguised by precocious puberty

Isolated sphenoid sinusitis in childhood is a rare clinical entity which is often very difficult to diagnose, hence, it can easily be misdiagnosed. The rarity of this entity is related to the absence at the sinus in children and the lack of development in patients with sinopathology. The first presentation of this disorder might be disguised by another disease. We present a case sphenoid sinusitis in ten years old girl where precocious puberty and slight headache were the main symptoms. Surgical drainage and antimicrobial treatment were administered. Clinical features, diagnostic tools and treatment options for this entity are discussed.

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.

Ocular manifestations of sphenoid mucoceles: clinical features and neurosurgical management of three cases and review of the literature

BACKGROUND

Sphenoid mucoceles (SMCs) are unusual lesions, with about 130 cases reported in the literature. Although benign, they may involve the orbit and cause acute restrictive ophthalmoplegia, proptosis, and reduced visual acuity.

METHODS AND RESULTS

We present three cases (1 male, 2 females, aged 35, 36, and 46 years) of orbital involvement with acute decreased visual acuity by SMC. The lesions were promptly excised via a transnasal approach to decompress the optic nerve. After the decompression, the patients recovered completely.

CONCLUSION

We believe that immediate surgical drainage of the SMC and prolonged antibiotic therapy are necessary and resulted in recovery of visual acuity. Prompt microsurgical transsphenoidal decompression is simple, effective, safe, and is necessary for avoiding persistent visual loss. Antibiotic therapy alone usually results in a poor outcome. We discuss the etiology, clinical manifestations, and management of this rare condition in the light of 130 other cases in the literature.