Isolated sphenoid sinus disease: an analysis of 122 cases

Cranial nerve VI palsy in chronic sphenoid sinusitis

Sphenoid sinusitis is a rare disease associated with life-threatening complications that can be avoided with early recognition and timely treatment. Here, we present a case of a woman in her 80s admitted for symptomatic anaemia likely secondary to a gastrointestinal bleed with left cranial nerve (CN) VI palsy incidentally discovered on physical examination. CT and MRI were suggestive of chronic left sphenoid sinusitis with possible involvement of the left cavernous sinus. Surgical treatment was deferred due to high cardiac risk for perioperative mortality and recent ischaemic stroke. Despite antibiotic treatment, the patient's CN VI palsy remained unchanged. This report contributes to the current understanding of sphenoid sinusitis by presenting a complex case of chronic sphenoid sinusitis in which urgent surgical intervention was deferred due to the patient's multiple comorbidities. Furthermore, it highlighted the importance of the CN examination and imaging modalities in diagnosing sphenoid sinusitis.

Sphenochoanal polyps

Nasal polyps are a common aetiology for persistent nasal obstruction. While antrochoanal polyps predominate the literature, the lesser known sphenochoanal polyp is equally as bothersome. To our knowledge, no prior dedicated review exists that characterises the patient population affected by this disease. We present a case and associated literature review over the past 30 years on the patient demographics and treatment of sphenochoanal polyps. A total of 88 cases were identified. Of the published cases, 77 were included in our search as patient characteristics were available. The age ranged from 2 to 80 years old. There were 35 female and 42 male patients. Only 58 studies established laterality, with the polyps originating from the left in 32 cases, right in 25 and bilateral in 1 case. Sphenochoanal polyps occur in all ages, nearly even distribution across sex. Endoscopic removal is safe with favourable outcomes.

Cavernous sinus and jugular thromboses, base of skull osteomyelitis and cranial nerve palsies: catastrophic complications of sphenoid sinusitis

Sphenoid sinusitis is a clinically important entity as it may be associated with catastrophic complications including cavernous sinus thrombosis (CST), cerebral abscess or infarction, meningitis, base of skull osteomyelitis and cranial nerve palsies. We report a case of occult sphenoid sinusitis presenting as Streptococcus intermedius bacteraemia, bilateral jugular vein and CST, cranial nerve palsy and base of skull osteomyelitis.

Isolated Sphenoid Sinus Disease in Children

The rarity of isolated sphenoid sinus disease (ISSD) and the specificity of pediatric populations meant that a separate analysis was required in this study. This study aimed to present and discuss the results of an analysis of clinical manifestations, radiological findings and surgical methods based on a large series of exclusively pediatric patients. The study group covered 28 surgically treated children (aged 5.5-17.5 years). The medical data were retrospectively analyzed and meticulously discussed with regards to presenting signs and symptoms, radiographic findings, surgical approaches, complications, post-op care, histopathological results and follow-ups. The dominant symptom was a persistent headache (78%). Four children presented visual symptoms, diplopia in two cases, visual acuity disturbances in one case and both of these symptoms in one patient. Sixteen children presented chronic isolated rhinosinusitis without nasal polyps, six suffered from mucocele and one presented chronic sphenoiditis with sphenochoanal polyp. Four patients turned out to exhibit neoplastic lesions and developmental bony abnormality was diagnosed in one case. No fungal etiology was revealed. The transnasal approach was used in 86% of patients. A transseptal approach with concurrent septoplasty was used in four patients. The patient with visual acuity disturbances completely recovered after the surgery. All children with visual symptoms reported improvement in the vision immediately after surgery. No postoperative complications were observed. Fungal etiology was extremely rare in the pediatric population with ISSD. The surgical treatment should be a minimally invasive procedure regarding a limited range of the pathology in ISSD. Emergency surgery should be performed if ISSD produces any visual loss.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

A rare case of sphenoid sinus lymphoma

Malignancy of the sphenoid sinus is rare. Tumors may extend to adjacent anatomic structures before detection and may be easily missed. Outcomes are typically poor and vary by tumor type. Clinicians should maintain vigilance for neoplastic disease in patients presenting with headache and ocular/neurological complaints of the face/sinuses.

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.

Case Report: Oncocytic Schneiderian Papilloma Originating From the Sphenoid Sinus

A rare case of oncocytic Schneiderian papilloma originating from the sphenoid sinus characterised, for 3 years, by non-specific symptoms of severe headache, a block of nasal breathing, and deprecating sense of smell was presented by an elderly female patient. Sphenoid sinus functional endoscopic sinus surgery (FESS), with a one-block tumour excision, through an endonasal approach, with a histological study of removed tumour masses, were performed on the patient. Long observation in the post-operative period was necessary, considering the risk of recurrence and malignancy of oncocytic Schneiderian papilloma (OSP). Although the oncocytic papilloma of the sphenoid sinus is rare, non-specific symptoms make this pathology easily misdiagnosed. Thus, any isolated unilateral process in the paranasal sinuses with long-existing symptoms must be given careful attention due to the chance of this process being an inverted papilloma with malignization. CT scan indicating a unilateral opacification of paranasal sinuses with local calcifications is a typical manifestation, and endoscopic sphenoidotomy can be recommended as a treatment of choice.

Sphenochoanal polyps in children - a systematic review (1995‒2021)

OBJECTIVES

Nasal polyps that originate from the sphenoid sinus and reach the nasopharynx are called sphenochoanal polyps. Reports on sphenochoanal polyps in children have thus far been limited only to case reports. This review aims to describe and summarize clinical presentation, diagnosis, management, surgical approaches to the sphenochoanal polyps with recurrence rate after surgery in pediatric patients reported in the literature.

METHODS

A systematic literature review was performed using PubMed, MEDLINE and Cochrane Library Databases for articles published prior to December 2021 to identify all studies reporting on pediatric patients with sphenochoanal polyps. Clinical presentation, management options, surgical approaches and outcomes of applied management were extracted from included studies.

RESULTS

9 articles provided data on 11 eligible patients with an age range 3 years and 8 months-16 years. The commonest symptoms included: nasal obstruction, nasal discharge, and headache respectively. All patients were subjected to surgical treatment. No recurrences after the endoscopic sphenoidotomy were reported.

CONCLUSION

Sphenochoanal polyps should be kept in mind in the differential diagnosis of unilateral nasal cavity or paranasal sinuses masses. Misdiagnosis can result in recurrences in patients with sphenochoanal polyp, who can be mistakenly diagnosed with antrochoanal polyp and underwent inadequate treatment not involving sphenoidotomy and exact identification of the site of implantation. The symptoms of sphenochoanal polyps are nonspecific.

Surgical treatment of isolated sphenoid sinusitis - A case series and review of literature

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Isolated sphenoid opacification is a rare pathology that is increasingly being described and it represents 1–2% of sinus infections.

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The most frequent symptom associated with isolated sphenoid sinusitis is intractable headache.

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Isolated sphenoid sinusitis is usually treated surgically and endoscopic transnasal sphenoidectomy is the preferred surgical technique.

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Highly inflammatory diseases such as fungal infections may be associated with an increased risk of re-ossification of the sphenoid ostium following sphenoidectomy.

Introduction

Isolated sphenoid opacification is a rare pathology. Unlike other sinusitis, the treatment is most often surgical. Only few studies reporting the recurrence rates with long-term follow-ups are available in the literature. In our experience, isolated sphenoid sinusitis tends to have a significant recurrence rate after a first surgical intervention. This study aims to describe our experience with patients operated for isolated sphenoid sinusitis and to compare our reoperation and complication rates with those reported in the literature.

Methods

We conducted an electronic chart review of patients operated at the CHU de Québec between 2007 and 2018 for isolated sphenoid sinusitis.

Results

29 patients were analyzed. All patients had a sphenoidectomy with a transnasal approach. The reoperation rate was 103% (3/29) and the mean recurrence time was 15 (9–26) months. Among the patients reoperated, 2 patients had a fungus ball and one had a mucocele. Both patients with fungal balls had reossification of their sphenoidal ostium whereas the patient with the mucocele rather had a mucosal closure. No patient encountered any serious post-operative complication. Median duration of follow-up was 44 months (IQR: 25–68) for the 29 patients analyzed in our study.

Conclusion

Reoperation rates reported in the literature are probably underestimated. Our series emphasizes the importance of long-term follow-up for these pathologies. Highly inflammatory and chronic conditions such as fungal diseases could be linked to an increase in the occurrence of relapses.

Headache and rhinosinusitis: A review

PURPOSE OF REVIEW

To explain our current understanding of headache attributed to rhinosinusitis, an often inappropriately diagnosed secondary headache.

RECENT FINDINGS

Recent studies have shown that headache attributed to rhinosinusitis is often over-diagnosed in patients who actually have primary headache disorders, most commonly migraine. Failure to recognize and treat rhinosinusitis, however, can have devastating consequences. Abnormalities of the sinuses may also be treatable by surgical means, which may provide headache relief in appropriately selected patients.

SUMMARY

It is important for the practicing physician to understand how rhinosinusitis fits into the differential diagnosis of headache, both to avoid overdiagnosis in patients with primary headache, and to avoid underdiagnosis in patients with serious sinus disease.

Isolated Sphenoid Sinusitis

Isolated disease of sphenoid sinus is rare, representing 2-3% of all paranasal sinus lesions. Usually it is inflammatory in origin; very rarely it is due to neoplasm. Isolated sphenoid sinus diseases are difficult to diagnose and to treat because either the symptoms are very vague or they present to us very late as a result of disease complications. Here we are presenting a case of isolated sphenoid fungal sinusitis. A 40 year female came to our ENT outpatient department with complaints of intermittent headache for past 3 months. She was treated for similar complaints by a general practitioner with antibiotics and analgesics before three months. She was referred to an ophthalmologist and neurologist as the headache did not subside. Since there was no abnormality in ophthalmological examination, the neurologist suggested a MRI which showed opacification of the sphenoid sinus. Hence she was referred to an ENT specialist. ENT Clinical examination was normal. Urgent CT scan along with MRI was ordered which revealed complete opacification of the sphenoid sinus. There was no air fluid level, no hyper dense foci suggestive of fungal elements. There was no bony erosion. A provisional diagnosis of Chronic Sphenoid sinusitis was made and planned for endoscopic sphenoidotomy under general anesthesia. Sphenoid sinus was opened and fungal debri was seen inside, which was sent for culture. Sphenoid ostium was widened. Post operatively patient was completely relieved of headache. Patient was started on Tab.Itraconazole 200mg/day for 6 weeks, since the culture was suggestive of aspergillosis. Owing to the non specific presentation and the vague symptomology of the disease there may be considerable delay in diagnosing and treating the patient. Hence imaging studies like CT and MRI is necessary when the disease is suspected for prompt diagnosis.

Complications of Isolated Fungal Sphenoiditis: Patient Clinical Characteristics

OBJECTIVE

To evaluate the clinical characteristics of patients with complications of isolated fungal sphenoiditis.

MATERIALS AND METHODS

The records of patients diagnosed with isolated fungal sphenoiditis at Songklanagarind Hospital from January 2004 to December 2017 were retrospectively reviewed. Data related to demographics, clinical presentation, underlying disease, type of complication, surgical procedure, and clinical outcome were collected.

RESULTS

Among the 35 participating patients, complications were found at a rate of 40%. The most common complication was visual loss (71.43%). We also compared the clinical characteristics between patients with and without complications via univariate analysis. The enrolled patients consisted of 12 men and 23 women (1:2). The mean age was older in the complications group 64 (41-84) vs. 57.43 (36-81) years, respectively. Underlying diabetes mellitus and complete opacity of the sphenoid sinus were factors that related significantly to the occurrence of complications. After treatment, 35.72% of the participants made a complete recovery; underlying diabetes mellitus was associated with a poor prognosis.

CONCLUSION

This report indicates that practitioners must be careful of complications arising in elderly and female patients with isolated fungal sphenoiditis, who have a complete opacity of the sphenoid sinus and underlying diabetes mellitus.

Isolated Sphenoid Sinus Lesions: Experience with a Few Rare Pathologies

INTRODUCTION

The sphenoid sinus is often neglected because of its difficult access. The deep position of the sphenoid sinus hinders early diagnosis of pathologies in that location. Delayed diagnosis can cause serious complications due to proximity to many important structures.

OBJECTIVES

The aim of this study is to demonstrate different pathologies which can affect the sphenoid sinus and elucidate the findings.

METHODS

Cases of isolated sphenoid sinus lesions encountered in the neurosurgical setting which had rare pathologies are discussed. Pathologies such as Langerhans cell histiocytosis, solitary plasmacytoma, chordoma, pituitary adenoma, leiomyosarcoma, fungal infection, and mucocele which appeared primarily in sphenoid sinus are discussed along with their imaging features and pathological findings.

CONCLUSION

Multitude of different pathologies can occur in sphenoid sinus. Detailed preoperative imaging is very helpful, but transnasal biopsy and histological study are required often for definitive diagnosis. The possible advantages of early diagnosis before spread of pathology for prognosis cannot be overemphasized.

Isolated Inflammatory Sphenoid Sinus Disease: A Revisitation of Computed Tomography Indications based on Presenting Findings

Background

Isolated inflammatory sphenoid sinus disease (IISSD) can be difficult to diagnose. Frequently, history and physical are inadequate in establishing a diagnosis. Computed tomography (CT) is an excellent screening tool; however, it often is obtained late in the disease process because of vague symptoms at presentation. Identifying the most common presenting symptoms of IISSD may allow earlier detection and avoidance of more severe sequelae by determining earlier indications for CT. Presently, headache is not an indication for sinus CT.

Methods

A retrospective chart review of IISSD presentation was performed at our institution. A literature review was performed also to quantitatively document trends in presentation of IISSD, including characterization of headache symptoms by location. Cumulative findings were then compared with current CT indications to determine if presentation patterns warrant a change in indications for CT.

Results

A total of 361 cases were evaluated by our inclusion criteria. Headache was the most common finding (81.7%), particularly peri/retro-orbital, vertex, and frontal headache. Ocular changes (17.5%) and cranial nerve involvement (16.1%) were common also, but headache frequently was a solitary finding (42.6%). Twenty-six IISSD cases were reviewed at our institution over 7 years, with similar results. Under current guidelines, the only IISSD findings that are indications for CT scan are the ophthalmologic and neurological complications.

Conclusion

Not every headache necessitates a CT scan. However, the deep-seated vertex, frontal, and, particularly, peri/ retro-orbital headaches, especially when aggravated by head movement and refractory to analgesics, as is often seen in IISSD, should be an indication for CT evaluation. (American Journal of Rhinology 19, 627–632, 2005)

Challenges in the Management of Sphenoid Inverted Papilloma

Background

Inverted papilloma (IP) arising in the sphenoid sinus is extremely rare. Management of sphenoid sinus IP is especially challenging because of the paucity of sinonasal symptoms on presentation and the inherent surgical risks associated with the anatomic location of the sphenoid sinus.

Methods

We performed a retrospective review of medical records of all patients with IP arising within the sphenoid sinus.

Results

A total of five patients were identified. All patients were managed with endoscopic resection. The most common presenting symptom was headache (three patients). The mean follow-up period was 37.6 months (range, 10–79 months). Two patients with erosive skull base lesions adjacent to the internal carotid artery were managed with a staged endoscopic resection. Only one patient developed a recurrence after 38 months and underwent revision endoscopic resection.

Conclusions

Endoscopic management of sphenoid IP allows maximal resection with minimal morbidity and facilitates endoscopic postoperative surveillance. Complete preoperative radiological assessment of tumor extent is essential. Preoperative medical therapy can help normalize inflamed mucosa and minimize intraoperative bleeding. For large erosive IP, surgical risks may be minimized by considering a staged resection and using computer-aided surgery.

Clinical features of visual disturbances secondary to isolated sphenoid sinus inflammatory diseases

Background

Visual disturbances associated with isolated sphenoid sinus inflammatory diseases (ISSIDs) are easily misdiagnosed due to the nonspecific symptoms and undetectable anatomical location. The main objective of this retrospective case series is to investigate the clinical features of visual disturbances secondary to ISSIDs.

Methods

Clinical data of 23 patients with unilateral or bilateral visual disturbances secondary to ISSIDs from 2004 to 2014 with new symptoms were collected. Collected data including symptoms, signs, neuroimaging and pathologic diagnosis were analyzed.

Results

There were 14 males and 9 females, and their ages ranged from 31 to 83 years. Fifteen patients suffered blurred vision and 11 patients suffered binocular double vision, including 3 patients who had unilateral visual changes and diplopia simultaneously. Headache was observed in 18 patients, and orbit pain/ocular pain in 8 patients. Other presenting symptoms included ptosis (4 patients) and proptosis (1 patient). Only 5 patients had nasal complaints. The corrected visual acuities were between NLP to 20/20. Patients with diplopia included 5 with unilateral oculomotor nerve palsy and 6 with unilateral abducens nerve palsy. All patients performed orbital/sinus/brain radiologic examination and found responsible lesions in sphenoid sinus. All patients underwent endoscopic sinus surgery, and 9 patients were found to suffer sphenoid mucocele, 9 with fungal sinusitis, and 5 with sphenoid sinusitis. Visual disturbances improved in 6 patients, and all the patients with diplopia had a postoperative recovery.

Conclusion

Visual disturbances resulting from ISSIDs are relatively uncommon, but it is crucial that the patient with new vision loss or diplopia and persistent headache or orbit pain be evaluated for the possibility of ISSIDs especially before corticosteroid administration.

Isolated sphenoid sinus opacifications: a systematic review and meta-analysis

BACKGROUND

Isolated sphenoid sinus opacifications (ISSOs) represent a relatively uncommon disease with the potential for serious complications. To better understand this disease, we performed a systematic review to further characterize the underlying pathologies, associated symptoms, and treatment outcomes of patients with ISSOs.

METHODS

A systematic review of ISSO case series was performed utilizing the Medline, Embase, Web of Science, and Cochrane databases in accordance with guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data of interest included disease pathology, associated symptoms, and treatment outcomes.

RESULTS

Of the initial 1051 hits from the 4 databases, 17 articles, with a combined 1133 ISSO patients, were ultimately included in the review. On a weighted analysis, the underlying pathologies were classified as chronic rhinosinusitis without nasal polyps (CRSsNP) (28.3%), mucoceles (20.3%), fungal sinusitis (12.5%), malignant neoplasms (7.7%), intracranial lesions (7.0%), benign neoplasms (5.7%), chronic rhinosinusitis with nasal polyps (CRSwNP) (3.4%), and other lesions (4.7%). Cranial neuropathies were present in 16.3% (95% confidence interval [CI], 10.1-22.5%) of ISSO patients. A favorable surgical complication rate of 1.5% (95% CI, -0.1% to 3.2%) was found in patients undergoing surgery for an ISSO.

CONCLUSION

ISSOs are caused by diverse pathologies. Given the considerable rates of neoplastic disease and cranial neuropathies, patients affected by an ISSO should be monitored closely and treated aggressively. Prompt surgical intervention, with either diagnostic or therapeutic intent, is often indicated.

Sphenoid Sinus Diseases: A Review of 1,442 Patients

Objective

To review and report diseases of the sphenoid sinus from the literature and from a university hospital.

Methods

Inpatients' data were retrospectively gathered and reviewed from January 2006 to June 2016. Clinical data, imaging, organisms, and pathological reports were collected. Pathology was divided into infection/inflammation, tumor, and miscellaneous. A literature review was performed with the search term “isolated sphenoid disease” in PubMed. Original primary studies with 20 patients or more were reviewed.

Results and Discussion

One hundred and twenty-two patients were enrolled. Seventy-two subjects were female (59%). The average age was 54.3 years (±18.0). Imaging abnormalities were found incidentally in 27 patients (22.1%). The most common symptom was headache (63.9%). Visual loss, the second most common symptom, was more frequent in the tumor group (30.6% versus 54.2%). From the literature review, 21 primary studies with 1,320 total patients were included. From all studies and the present study, infection/inflammation was the most common pathology (75%) [95% confidence interval (CI): 0.696, 0.804]. Overall, tumors were found in 18.9% and malignant tumors in 7.0% [95% CI: 0.045, 0.095].

Conclusion

A specific diagnosis of a sphenoid lesion is needed during active investigation. Infection/inflammation was the most common pathology and malignancy was found in 7%.

Ocular cranial nerve palsies secondary to sphenoid sinusitis

Objective

The clinical presentation of sphenoid sinusitis can be highly variable. Rarely, sphenoid sinusitis may present with cranial nerve complications due to the proximity of these structures to the sphenoid sinus.

Method

A case series from Rabin Medical Center and all cases of cranial nerves palsies secondary to sphenoid sinusitis that have been reported in the literature were reviewed.

Results

Seventeen patients were identified. The abducent nerve was the most common cranial nerve affected (76%), followed by the oculomotor nerve (18%). One patient had combined oculomotor, trochlear and abducent palsies. The most common pathology was isolated purulent sphenoid sinusitis in 64% followed by allergic fungal sinusitis (AFS) in 18%, and fungal infection in 18%. 94% had an acute presentation. The majority (85%) received a combined intravenous antibiotics and surgical treatment. The remainder received conservative treatment alone. Complete recovery of cranial nerve palsy was noted in 82% during follow up.

Conclusion

Sphenoid sinusitis presenting as diplopia and headaches is rare. A neoplastic process must be ruled out and early surgical intervention with intravenous antimicrobial therapy carry an excellent outcome with complete resolution of symptoms.

Isolated sphenoid sinus opacification: A systematic review

OBJECTIVE

Unilateral sphenoid sinus opacification (SSO) on imaging is a common incidental radiologic finding. Inflammatory sinus disease is rarely isolated to one sinus cavity therefore SSO raises the potential for neoplastic etiology. The clinical significance of SSO was evaluated and compared to maxillary sinus opacification (MSO).

METHODS

A systematic review of unilateral sinus opacification was performed via Medline (1966-January 12th, 2015) and Embase (1980-January 12th, 2015), limited to English literature and human subjects. Case series of patients treated with radiologic evidence of unilateral sinus opacification either from maxillary or sphenoid sinuses and with pathology results were included. Individual cases were classified as neoplastic, malignant, or a condition requiring surgical intervention (i.e. fungal ball). Exclusion criteria were single case reports, lack of primary data, series of complications, or single pathology series. Case-by-case analysis was performed for both SSO and MSO.

RESULTS

Search strategy revealed 3264 studies. A total of 31 studies including 1581 patients met the inclusion criteria. In these studies, SSO was described in n=1215 (76.9%) and MSO in n=366 (23.1%). For SSO, the final diagnosis was neoplasia 18%, (malignancy in 10.9%). 58.3% of cases required surgical intervention and 13% were inflammatory. For MSO, neoplasia represented 18.3% (malignancy 7.1%), surgical intervention required in 47% of cases and 27.6%. were inflammatory.

CONCLUSION

Isolated MSO and SSO is a marker of neoplasia in 18% and malignancy in 7-10% of patients presenting with these radiologic findings. Clinicians should be wary of conservative management given the high incidence of neoplasia and consider a lower threshold for early surgical intervention.

Evaluation and treatment of isolated sphenoid sinus diseases

PURPOSE OF REVIEW

To review cause, clinical evaluation, medical and surgical management of isolated sphenoid sinus diseases.

RECENT FINDINGS

Early diagnosis of isolated sphenoid sinus diseases requires a high index of clinical suspicion and appropriate radiological imaging. Sphenoid sinus can be approached endoscopically via a few different surgical techniques.

SUMMARY

Isolated sphenoid sinus diseases are uncommon, with nonspecific clinical presentation. Early diagnosis requires a high index of clinical suspicion, proper endoscopic nasal examination, and appropriate radiological imaging. Surgical intervention is the primary treatment modality for most of the isolated sphenoid sinus diseases. Endoscopic endonasal approach to sphenoid sinus is the technique of choice. The location of sphenoid sinus disease, the extent of the surgery, and anatomic configuration of the sphenoid sinus are the main factors that help to decide the most suitable surgical approach to the sphenoid sinus.

How Often Does Isolated Sphenoid Sinus Disease Turn Out to be a Neoplasm?

Isolated sphenoid sinus disease (ISSD) describes a wide spectrum of pathologies including inflammatory, vascular, bony dysplastic, and neoplastic diseases. The aim of this study was to assess the frequency with which a neoplastic process was diagnosed in patients of ISSD and patient management strategies. A retrospective analysis was conducted for all ISSD patients who underwent surgery between January 2005 and January 2014 at a tertiary center. The clinical characteristics, radiologic studies, operative findings, endoscopic surgical techniques, pathology results, and treatment outcomes of the patients were analyzed. In all, 42 patients (31 women and 11 men) were included in the study. Histopathologic examinations revealed that 10 patients (23.4%) had neoplasms (8 benign and 2 malignant), 19 (45.2%) had mucocele, 7 (16.7%) had fungal disease, and 6 (14.3%) had meningoencephalocele and cerebrospinal fluid leakage. With the exception of 2 patients with plasmacytoma, complete removal of the lesions was achieved in all patients using transnasal or transethmoidal endoscopic approaches, and no local recurrences were observed during the mean follow-up period of 42 months. More than one fifth of the patients with ISSD were diagnosed with neoplasms. The results indicated that endonasal endoscopic approaches could effectively help manage patients with ISSD lesions, including those that were neoplastic. It is clear that precaution during preoperative planning is imperative to avoid unexpected situations and complications that may put surgeons in a difficult position during surgery.

Paranasal Sinus Pathologies in Patients Presenting with Headache as the Primary Symptom

Headache is a frequent symptom of lesions in the paranasal sinuses. Although some inflammatory symptoms are suggestive of pathologies of the paranasal sinuses, occasional headache is sometimes the major presenting symptom. In a retrospective study, we examined the chart histories of 36 patients presenting for treatment at our hospital from 1 January 1992 to 30 June 2001 who were diagnosed as having pathologies of the paranasal sinuses with the primary symptom being headache. All patients had been evaluated with complete otolaryngological and neurological examinations, diagnostic nasal endoscopy, and sinus computed tomographic (CT) scans. Sinus surgery was arranged after failure in performing appropriate medical treatment. Among the 36 patients, 33 showed significant improvement after sinus operation (92%). A paranasal sinus aetiology of headache is an important factor in the differential diagnosis of chronic headache. Those patients who are clinically suspected of having headaches arising from paranasal sinus pathology should receive comprehensive otorhinolaryngological examination and evaluation. Nasal endoscopy and sinus CT scans are good diagnostic tools. Surgical management may be beneficial in those for whom medical treatment fails to resolve the problem.

The clinical behavior of isolated sphenoid sinusitis

Objective

We sought to study the clinical behavior and treatment outcome of isolated sphenoid sinusitis (ISS).

Study Design and Setting

We conducted a retrospective study of patients diagnosed with ISS in a tertiary medical center over 20 years.

Results

Of 72 patients with ISS, 79 percent had acute symptoms, 15 percent had chronic symptoms, and 6 percent had incidental radiological findings. Fifteen percent were children. Most patients were diagnosed between January and April ( P < 0.01), and increasing incidence was noted over the years ( P < 0.001). Headache was the most common presenting symptom (85%). Chronic patients complained also of nasal symptoms (82%). Six patients had a major complication of sinusitis (none of them were children), and two patients died. Immunocompromised patients had more major complications ( P ≤ 0.001) and increased mortality ( P ≤ 0.01).

Conclusion

Most patients need conservative treatment alone. However, life-threatening complications are not infrequent. Close observation and early surgical intervention, if needed, provide the mainstay of treatment.

Significance

This is the first large series that focuses on the clinical behavior, complications, and treatment of ISS.

Results of transnasal transostial sphenoidotomy in 79 cases of chronic sphenoid sinusitis

OBJECTIVE

This study was designed to retrospectively review the postoperative results of transnasal transostial sphenoidotomy in 79 patients with isolated chronic sphenoid sinusitis operated between 1995 and 2013 and evaluate the recurrence rate due to postoperative closure of the sphenoidotomy.

PATIENTS AND METHODS

Seventy-nine patients, 44 women and 35 men (M:F sex ratio: 0.79) aged 10 to 84 years (mean age: 48), were included. The most common presenting symptom was headache in 61% of cases. Visual disturbances were present in three cases. The diagnostic work-up comprised nasal endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) of the sinuses. The surgical indication was based on failure of antibiotic therapy and/or the nature and severity of sphenoid sinusitis. All patients were operated by endoscopic transnasal transostial sphenoidotomy. Samples were taken for histological, bacteriological and mycological examination.

RESULTS

No intraoperative or immediate postoperative complications were observed. Nature of the lesion: forty-seven patients (59.5%) presented nonspecific inflammatory lesions with negative bacterial or fungal culture and inflammatory mucosal changes, 19 patients (24%) had fungal sinusitis presenting as a fungus ball and 13 patients (16.4%) had documented bacterial sinusitis. Mean postoperative follow-up was 7.4 months (range: 6-48). No recurrence of the sinusitis or symptoms was observed in 71 cases (89.8%). Recurrence: eight cases (10.2%) of postoperative closure of the sphenoidotomy were observed, requiring one (6 cases) or several (2 cases) reoperations with a mean of 16.4 months after the initial procedure. Symptoms of recurrence consisted of varying degrees of headache, with similar symptoms to those of the first episode in 7 cases, and retro-orbital headache in 1 case. Reoperation was performed via a transnasal transostial approach in 6 cases and a transethmoidal approach in 2 cases.

CONCLUSION

The transnasal transostial surgical approach is a safe and effective procedure for the treatment of isolated sphenoid sinusitis. However, the recurrence rate due to postoperative closure of the sphenoidotomy observed in our series raises the question of postoperative maintenance of a patent and functional sphenoidotomy.

Free Air in the Cavernous Sinus Secondary to Acute Isolated Sphenoid Sinusitis

Pneumocephalus is a rare but important complication of acute isolated sphenoid sinusitis (ISS). If not adequately treated, it may cause serious neurological and life-threatening complications. We report the presence of free air in the cavernous sinus arising from intracranial extension of acute ISS. A 41-year-old healthy man presented to our department with a 7-day history of headache. Neurological examination revealed no meningitis, and cerebrospinal fluid culture was negative. A head computed tomography (CT) and magnetic resonance imaging on admission revealed sinusitis in the sphenoid sinus and presence of air in the cavernous sinus. We started an antibiotic treatment and the patient’s fever immediately decreased and the inflammatory response improved. In addition, the bilateral retro-orbital headache diminished. A repeated head CT scan revealed that fluid retention in the sphenoid sinus and air in the cavernous sinus had disappeared. To our knowledge, this is the fifth case of pneumocephalus accompanied by acute ISS reported in the literature and the first case report of intracranial air located only in the cavernous sinus. Meningitis accompanied by pneumocephalus can be a warning sign for poor outcome in patients with ISS.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Unilateral isolated sphenoid sinusitis with contralateral abducens nerve palsy - A rare complication treated in a low-resource setting

Background

Unilateral isolated sphenoid sinus disease (ISSD) is a rare diagnosis of the paranasal sinuses that can be associated with complications involving vascular, neurologic, and optic structures in close proximity.

Case presentation

A 62 year old female presented to a hospital in Georgetown, Guyana with right lateral rectus palsy, diplopia, and a severe progressively worsening headache. CT scan revealed an opaque left sphenoid sinus consistent with unilateral ISSD. A transnasal sphenoidotomy was performed without complication under local anesthetic in the absence of endoscopic guidance. The patient's headache resolved immediately after surgery while the diplopia and lateral rectus palsy resolved completely after 6 weeks.

Conclusion

We present a rare complication of ISSD and highlight challenges associated with diagnosis and management of ISSD in a resource-limited setting. This is the second reported case of unilateral ISSD with contralateral lateral rectus palsy in the literature.

The complications of sinusitis in a tertiary care hospital: types, patient characteristics, and outcomes

Objective. To study the complications of sinusitis in a referral hospital and the outcome of the treatment according to the type of complication. Methods. A retrospective study was performed on patients with sinusitis who were admitted to a referral hospital from 2003 to 2012. The data for the sinusitis patients who had complications were reviewed. Results and Discussion. Eighty-five patients were included in the study, of whom 50 were male (58.8%). Fourteen of the cases were less than 15 years old, and 27 of the patients (31.7%) had more than one type of complication. The most common complication was of the orbital type (100% in the children, 38% in the adults). After the treatment, all of the children and 45 of the adults (63.4%) recovered, eight of the adult patients died (11.3%), and 18 of the adults were cured with morbidity (25.3%). The patients with more numerous complications had poorer outcomes. When the types of complications were compared (adjusted for age, gender, and comorbidities), the intracranial complication was the only one that was statistically significant for mortality. Conclusion. The outcomes of the treatment depended on the number and type of complications, with the poorest results achieved in cases of intracranial complications.

Intracranial complication of rhinosinusitis from actinomycosis of the paranasal sinuses: a rare case of abducens nerve palsy

Sinonasal actinomycosis should be suspected when a patient with chronic sinusitis does not respond to medical therapy or has a history of facial trauma, dental disease, cancer, immunodeficiency, long-term steroid therapy, diabetes, or malnutrition. Radiological evaluation with computed tomography and magnetic resonance imaging are important in differential diagnosis, evaluating the extent of disease, and understanding clinical symptoms. Endoscopic sinus surgery associated with long-term intravenous antibiotic therapy is the gold standard for treatment of sinonasal actinomycosis. We report an unusual case of abducens nerve palsy resulting from invasive sinonasal actinomycosis in a patient with an abnormally enlarged sphenoid sinus. A review of the current literature highlighting clinical presentation, radiological findings, and treatment of this uncommon complication is also presented.

Isolated sphenoid sinus lesion: A diagnostic dilemma

Isolated sphenoid sinus lesions are an uncommon entity and present with non-specific symptoms. In this case report, the patient presented with a history of headaches for a duration of one month without sinonasal symptoms. A computed tomography scan showed a soft tissue mass occupying the sphenoid sinus. An endoscopic biopsy revealed fungal infection. Endoscopic wide sphenoidotomy with excision of the sphenoid sinus lesion was then performed however, the microbiological examination post-surgery did not show any fungal elements. Instead, Citrobacter species was implicated to be the cause of infection.

Unilateral pathological lesions of paranasal sinuses removed by endoscopic surgery

INTRODUCTION

The aim of this study was to analyze the incidence and nature of unilateral pathological lesions of paranasal sinuses in patients who had endoscopic sinus surgery performed in ENT.

MATERIALS AND METHODS

In the years 2006-2011 endoscopic sinus surgery for unilateral pathological lesions of paranasal sinuses was performed in 1847 patients (838 women and 1009 men). The enrollment of patients was based on the findings of otolaryngological clinical and subjective examinations, assessment of the paranasal sinuses on three-dimensional CT scans, and laboratory examinations. Based on the analysis of medical history data, including gender, age, the type of surgical procedure performed, and histopathological findings the cases were finally analyzed.

RESULTS

Pathological lesions of the paranasal sinuses were localized on the left side in 132 (57%) patients, and on the right side in 100 (43%) patients. Of the 232 patients with unilateral pathological changes, 41.8% subjects underwent endoscopic sinus surgery for polypotic changes in the ethmoid and maxillary sinuses; 28.4% for the maxillary sinus; 10.8% for the ethmoid, maxillary and frontal sinuses; and 8.6% patients for all paranasal sinuses on one side. The number of operations of only one sinus was considerably lower: sphenoid sinus, 4.7%; ethmoid sinus, 2.2%; and frontal sinus, 1.7% patients. The histopathological analysis of unilateral pathological lesions removed by endoscopic surgery showed chronic paranasal sinusitis with polyps in 56.5% patients; chronic paranasal sinusitis in 22.8% patients; and maxillary sinus cyst was confirmed in 11.6% patients. In 5.1% patients inverted papilloma was diagnosed and in 2.2% patients the presence of osteoma was found.

CONCLUSIONS

Unilateral paranasal pathological lesions, leaving aside rather typical maxillary sinus cysts, require a particularly thorough pre-operative diagnosis and a precise histopathological assessment.

Skull base inverted papilloma: a comprehensive review

Skull base inverted papilloma (IP) is an unusual entity for many neurosurgeons. IP is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This paper is a comprehensive review of the reports, studies, and reviews published in the current biomedical literature from 1947 to September 2010 and synthesize this information to focus on its potential invasion to the base of the skull and possible intradural extension. The objective is to familiarize the clinician with the different aspects of this unusual disease. The role of modern diagnostic tools in medical imaging in order to assess clearly the limits of the tumors and to enhance the efficiency and the safety in the choice of a surgical approach is pointed out. The treatment guidelines for IP have undergone a complex evolution that continues today. Radical excision of the tumour is technically difficult and often incomplete. Successful management of IP requires resection of the affected mucosa which could be achieved with open surgery, endoscopic, or combined approach. Radio and chemotherapy were used for certain indications. More optimally research would be a multicenter randomized trials with large size cohorts.

Acute isolated sphenoid sinusitis in children

BACKGROUND

Isolated pediatric sphenoidal sinusitis is an uncommon disorder with sphenoiditis more commonly found as part of pansinusitis. Recognizing the condition on history and examination alone is difficult and delayed diagnosis many occur in many cases. Nasal endoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) are essential adjuncts to confirm diagnosis. This study was designed to confirm the clinical features and diagnostic difficulties associated with isolated sphenoidal sinusitis in children.

METHODS

A 16-year review was performed of cases diagnosed and treated in a tertiary teaching hospital.

RESULTS

Two different groups of patients were identified. One group presented with fever and headache, frequently associated with neurological complications. Swimming and/or diving could be identified as possible causative agents. The second group presented with headache alone and a less severe clinical presentation.

CONCLUSION

Isolated pediatric sphenoidal sinusitis may be more prevalent than was previously thought with CT/MRI helping establish the diagnosis in many cases. Pediatricians should be aware of this unusual but still potentially devastating condition. A nasal endoscopy is a useful diagnostic tool in this patient group, being noninvasive and well tolerated in children and adolescents.

Sensitivity and specificity of computed tomography and magnetic resonance imaging in the diagnosis of isolated sphenoid sinus diseases

OBJECTIVES/HYPOTHESIS

The sphenoid sinus is uncommonly affected by inflammatory or neoplastic lesions. Initial onset of isolated sphenoid sinus diseases (ISSD) is generally asymptomatic. The objectives of this study were to estimate the sensitivity and specificity of computed tomography (CT) and magnetic resonance imaging (MRI) in diagnosing ISSD and establish guidelines to declare hidden ISSD through correlation of radiological diagnosis to final pathological diagnosis.

STUDY DESIGN

A prospective cohort study.

METHODS

There were 66 patients with isolated sphenoid sinus lesions presenting to Ain-Shams University Hospitals, Cairo, Egypt. Provisional diagnosis of ISSD was done by CT and MRI, followed by histopathologic and immunohistochemical staining, and if needed microbiological examination of resected specimens to establish the final diagnosis.

RESULTS

Patients were classified into four groups according to the type of lesion: inflammatory, neoplastic, bony dysplastic disorders, and sphenoid sinus roof defect-related lesions. Radiological imaging provided the greatest diagnostic information and guided management. The sensitivity of CT and MRI in diagnosing inflammatory lesions was 95% versus 61%, whereas those of the neoplastic group were 72% and 100%, respectively. In the osseous group the sensitivity was 100% for both CT and MRI, whereas in sphenoid sinus roof defect the sensitivity was 50% and 100% for CT and MRI, respectively.

CONCLUSIONS

Because of CT's superiority in defining the bony margins and MRI's superior soft tissue resolution, CT and MRI should be used in a complementary manner in the evaluation of isolated sphenoid sinus disease in addition to mapping the lesion better and identifying intracranial and intraorbital extension. The use of one modality only should be restricted to straightforward lesions.

Isolated sphenoid sinus pathologies – the problem of delayed diagnosis

Background

Isolated sphenoid sinus pathologies are relatively rare. In the majority of cases, symptoms do not arise in the early stages of the disease or are non-specific, therefore making diagnosis difficult. The aim of this study was to investigate the diagnostic process and the reasons for development of complications in patients with isolated sphenoid sinus pathology.

Material/Methods

The clinical data and observation charts of 32 patients were investigated to determine how long the main symptoms of sphenoid pathology had been present before the patients were referred for medical treatment, and the time that elapsed from the first ambulatory medical assessment to the initial diagnosis.

Results

Complaints and symptoms of sphenoid sinus pathology had been present for 10.2 months before the diagnosis was established. Although the duration of complaints in “ORL” (diagnosed by otorhinolaryngologist) and “non-ORL” (diagnosed by other specialists) group of patients was similar (10.8 and 9.5 months on average, respectively), unexpectedly, in the “non-ORL” group of patients, the time necessary for making the initial diagnosis was actually shorter than in the “ORL” group (1.8 vs 4.1 months). At the time of hospital admission, endoscopic examination revealed no abnormalities in 31.2% of patients. In 28.1% of patients the pathological process in the sphenoid sinus was diagnosed only after the onset of complications.

Conclusions

The occult character of the disease and the lack of severe and specific symptoms, rather than the delay in getting extensive diagnostic tests, are responsible for the delayed diagnosis and treatment.

Isolated sphenoid sinus mucocele presenting as third nerve palsy

A sphenoid mucocele often presents late due to its deep seated anatomical site. And it has varied presentation due to its loose relationship to the cavernous sinus and the base of the skull. We describe a case of large sphenoid sinus mucocele. A middle aged old man suddenly developed third cranial nerve palsy. Brain imaging study revealed an isolated sphenoid sinus mucocele, compressing right cavernous sinus. Endoscopic marsupialization of the mucocele via transnasal approach led to complete resolution of the third cranial nerve palsy. Involvement of the third cranial nerve in isolated mucocele is rare but important neurosurgical implications which must be excluded. In addition, proper and timely treatment must be performed to avoid permanent neurologic deficit.

Recurrent contralateral abducens nerve palsy in acute unilateral sphenoiditis

OBJECTIVE

We describe a patient who presented with recurrent, contralateral abducens nerve palsy resulting from acute sphenoiditis.

METHODS

Patient medical record and imaging studies were reviewed. A literature review of complications of sphenoiditis was performed.

RESULTS

Our patient presented with symptoms consistent with an upper respiratory tract infection, as well as severe headache, disequilibrium, and diplopia. Physical examination demonstrated left-sided sixth cranial nerve palsy. Imaging studies were consistent with right sphenoid sinus inflammatory disease. Her medical history was significant for a similar episode 9 years previously, which was managed medically. The current episode was treated acutely with antibiotics and prednisone. Upon resolution of her symptoms, she underwent an endoscopic sphenoidotomy.

CONCLUSIONS

Although cranial nerve palsies associated with isolated sphenoiditis have been reported, we describe a unique case of recurrent isolated sphenoiditis causing contralateral abducens nerve palsy. Acute management can be medical, with surgical therapy reserved for refractory cases or to prevent future episodes.

Isolated inverted papilloma of the sphenoid sinus

Primary inverted papilloma of the sphenoid sinus is rare. Such a case, of a 42-year-old female, is reported here, discussing the clinical presentation, diagnostic clues, radiographic features, histological findings and management. In contrast to the vast majority of cases that present with nasal complaints because of lateral nasal wall involvement, the clinical presentation of inverted papillomas confined to the sphenoid sinus is often nonspecific and insidious. Nasal endoscopy and radiologic imaging are key to an accurate diagnosis. Preoperative imaging with computed tomography and the surgeon's experience will dictate the appropriate surgical approach. In our opinion, transnasal endoscopic large sphenoidotomy remains an effective modality for management of patients with this lesion when the sphenoid sinus is the only sinus requiring investigation. A more anatomically directed approach to the sphenoid sinus with less violation of other sinuses can be achieved.

Isolated sphenoid sinus disease - a retrospective analysis

OBJECTIVE

To evaluate the etiology, symptoms, signs, imaging, surgical findings and outcomes of isolated sphenoid sinus disease (ISSD).

DESIGN

Retrospective study.

SETTINGS

Tertiary university based referral center.

MATERIALS AND METHODS

All 8 patients aged 17-63, managed surgically in the department of ENT and Head and Neck Surgery at St. John's Medical College and Hospital, Bangalore from 2006 to 2008 for ISSD. Demographic data, presenting signs and symptoms endoscopic and imaging findings, surgical management, surgical pathology and clinical outcomes were investigated in the above patients.

RESULTS

Of the 8 cases of ISSD, 5 were male; 3 were female, with an age range of 17-63 years. The most common presenting symptom was headache (7 patients [87.5%]), followed by nasal obstruction and recurrent URTI (5 cases [62.5%]). Imaging included CT and/or MRI studies in all cases. Sphenoid sinus pathology was varied and included 5 (62.5%) inflammatory cases, 1 (11.1%) cerebrospinal fluid fistula and 2 (22.2%) cases of sphenoid sinus neop;asms. Of the inflammatory cases 2 (40%) had isolated polyps in the sphenoid sinus [sphenochoanal polyps] and 3 (60%) had fungal sinusitis. Treatment was surgical, endoscopic transnasal sphenoidotomy under general anesthesia in all 5 patients with inflammatory ISSD Two patients with sphenoid sinus tumors underwent endoscopic biopsy.

CONCLUSION

ISSD is rare. A high index of suspicion is required for diagnosis, which should be an active process and not one of exclusion. Both diagnostic nasal endoscopy and CT imaging are essential for diagnosis. The direct approach to the sphenoid sinus, transnasal endoscopic sphenoidotomy without ethmoidectomy is safe and effective. With early and adequate surgery we were able to avoid the morbidity associated with ISSD.

Inverted papilloma of the sphenoid sinus: clinical presentation, management, and systematic review of the literature

OBJECTIVES

Inverted papilloma (IP) of the sphenoid sinus is a rare neoplasm with a nonspecific and insidious presentation that is further complicated by difficult access for assessment and follow-up. In conjunction with a systematic review of the English literature, we review our experience with IP of the sphenoid sinus to better delineate the clinical presentation, prevalence, management, and recurrence of this challenging lesion.

METHODS

A systematic search strategy was developed to assess and summarize the best available evidence on sphenoid IP. A retrospective chart review of the 5-year database of one tertiary care Otolaryngology-Head and Neck Surgery practice was performed; all patients with histologically confirmed IP of the nasal cavity or paranasal sinuses were included.

RESULTS

Seventy-one patients (49 males, 22 females; mean age, 57.2 years) treated between June 2003 and January 2009 were included. Nine patients were diagnosed with IP originating in the sphenoid sinus. Two of these patients were asymptomatic, and in the remaining seven patients the most common presentation was headache (42.9%), followed by visual disturbances, hearing loss, and nasal obstruction (28.6% each). Review of the literature confirms our finding that the most common presenting symptom is headache (45.0%), followed by nasal obstruction (30.0%) and epistaxis (22.5%).

CONCLUSIONS

This is the largest reported series of sphenoid sinus IP in the English literature. We have demonstrated a predominance of neurological and visual symptoms in symptomatic patients with sphenoid IP, and suggest that these may be early manifestations of sphenoid IP, before the more common sinonasal symptoms develop secondary to extension into the nasal cavity and paranasal sinuses.

Primary cancer of the sphenoid sinus--a GETTEC study

BACKGROUND

Primary involvement of the sphenoid sinus occurs in 2% of all paranasal sinus tumors and is associated with dismal prognosis. Optimal management remains debatable.

METHODS

A total of 23 patients were treated for a primary cancer of the sphenoid sinus from 1988 to 2004. Charts were reviewed for patient-, tumor-, and treatment-related parameters. Univariate and multivariate analyses were conducted to identify prognostic factors for locoregional control and survival.

RESULTS

Cranial neuropathies were present in 12 patients. Pathologic findings included adenoid cystic carcinoma, adenocarcinoma, lymphoma, squamous cell carcinoma, sarcoma, neuroendocrine carcinoma, melanoma, and malignant hemangiopericytoma. All but 2 patients had stages III to IV cancer. Radiotherapy was performed in 18 patients and chemotherapy in 12. Of 10 patients undergoing surgery, total excision with grossly negative margins was achieved in 4 patients and subtotal resection in 6. Median locoregional control and overall survival were 12 and 41 months, respectively. On multivariate analysis, cranial neuropathy was associated with worse locoregional control and survival. Surgery was rarely complete because of advanced stages at presentation, but it yielded better outcomes than other treatments without surgery in non lymphoma-cases.

CONCLUSION

Early CT and MRI should be performed when facing aspecific, rhinological, or neuro-ophtalmological symptoms. Cranial neuropathies indicate a worse prognosis. Surgery, including debulking surgery, may be preferred to combined modality treatments without surgery. Its apparently favorable impact on prognosis would need to be tested in homogenous histological groups of patients, which is impossible because of the rarity of the disease. Highly conformal radiotherapy (adjuvant or definitive) should be encouraged and optimized with concurrent chemotherapy in advanced stages. Aggressive multidisciplinary management including surgery, chemotherapy, and radiotherapy should be encouraged and adapted on histology and tumor extensions. Progress is still warranted to improve outcomes.

Unusual clivus lesion demonstrating extramedullary haematopoiesis: case report

INTRODUCTION

An unusual clivus mass is reported, following investigation of memory disturbance and headaches in a patient with beta thalassaemia and sickle cell disease. This lesion proved to be a site of extramedullary haematopoiesis. RADIOLOGICAL FINDINGS: Computed tomography demonstrated a 2 cm mass at the base of the sphenoid. However, magnetic resonance imaging showed little bony expansion, and the differential diagnosis included chordoma, dermoid cyst and fibrodysplasia. HISTOLOGICAL FINDINGS: Examination of the biopsy showed the presence of bone marrow demonstrating erythroid hyperplasia and small aggregates of B-cell lymphocytes. The features were considered compatible with erythroid hyperplasia associated with haemolytic anaemia.

MANAGEMENT

The patient was reassured that she did not have a neoplastic lesion, and was referred back to the haematologists for further management of her sickling beta thalassaemia.

CONCLUSIONS

Extramedullary haematopoiesis occurs outside the reticuloendothelial system in response to haemolytic anaemia. Extramedullary haematopoiesis causing a clivus mass is an unusual ENT presentation. Such haematopoiesis is occasionally seen in the calvarial skull, but this is the first report of this process occurring in the anterior skull base, to our knowledge.