Endoscopic Treatment of Isolated Sphenoid Sinus Disease in Children

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Treatment outcomes of neuroendoscopic and microscopic trans-sphenoidal pituitary adenomectomies and the effects on hormone levels

BACKGROUND

We aimed to compare the treatment outcomes of neuroendoscopic and microscopic trans-sphenoidal pituitary adenomectomies, as well as the effects on hormone levels and clinical symptoms.

METHODS

A total of 82 patients with pituitary adenomas that were surgically resected from June 2018 to March 2021 were selected and divided into a group receiving neuroendoscopic trans-sphenoidal pituitary adenomectomy (group A, N.=40), and the other group receiving microscopic surgery (group B, N.=42). Surgery-related indices, hormone levels before discharge and alleviation of symptoms 24 weeks after surgery were compared.

RESULTS

Both groups had significantly different degrees of tumor resection (P<0.05). The proportion of cases receiving total adenomectomy in group A significantly exceeded that of group B (P<0.05). The surgical time of group A was significantly longer than that of group B (P<0.05). Group A had significantly shorter mean hospitalization stay than that of group B (P<0.05). The postoperative hormone levels of both groups decreased significantly differently (P<0.05). Before discharge, the hormone recovery rate of group A significantly surpassed that of group B (P<0.05). The hormone levels of cases with prolactinoma, adrenocorticotropic hormone adenoma and growth hormone adenoma in group A dropped more significantly than those of group B did (P<0.05).

CONCLUSIONS

Compared with microscopic surgery, neuroendoscopic trans-sphenoidal pituitary adenomectomy worked more effectively, induced fewer postoperative complications and better promoted the postoperative recovery of hormone levels.

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.

Isolated sphenoid sinus opacification is often asymptomatic and is not referred for otolaryngology consultation

Isolated sphenoid sinus opacifications (ISSOs) are clinically important because they can lead to serious complications. However, some patients with ISSOs are asymptomatic, and not all patients are properly referred to the otolaryngology department. Because past studies of ISSOs focused only on patients who received treatment, in this study we selected ISSO cases based on radiology reports, then determined whether these patients had symptoms and were appropriately referred for specialty care. We conducted a retrospective analysis of data collected from patients who underwent computed tomography or magnetic resonance imaging from January 2007 to March 2017 at Osaka General Medical Center. We searched for the terms “sphenoid” or “sphenoidal” using F-REPORT to identify patients who had a sphenoid disease. We checked all selected images and diagnosed ISSOs. Examination of 1115 cases revealed 223 cases of ISSOs, of whom 167 (74.9%) were asymptomatic. We categorized patients with ISSOs into four groups: inflammation, mucocele, fungal diseases, and unclassifiable; the final category was used when edges were irregular or complete opacity was encountered. In the unclassifiable group, the majority of cases required otolaryngology consultation, but 37 of 47 unclassifiable patients did not have an otolaryngology visit. ISSOs are often identified by chance on imaging tests performed by non-otolaryngologists. However, our study revealed that many patients with ISSOs who should be treated by otolaryngologists were not referred to the otolaryngology department. Accordingly, it is important to promote awareness of the disease among other types of clinicians.

Acute isolated sphenoid sinusitis in children: A case series and systematic review of the literature

OBJECTIVE

This study aims to present a case series and systematic review of acute isolated sphenoid sinusitis (AISS) in children in order to better characterize clinical presentation, diagnosis, treatment, and outcomes of this condition.

DATA SOURCES

Ovid MEDLINE, Pubmed, Embase, Cochrane Library, and Google Scholar.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text, peer-reviewed journal publications from 1994 to 2020 in English; focus on acute sphenoid sinusitis; pediatric patients (<18 years of age); series with two or more children. Studies were assessed for data including demographics, presenting symptoms and signs, radiological investigations, treatment, outcomes and complications.

RESULTS

Ten studies identifying 71 patients were included. Average age at presentation was 12.0 years (range 5-17 years). M:F ratio 1:1. The most common presenting symptoms were headache (98.6%), fever (50.7%), nasal symptoms (22.5%) ocular symptoms (19.7%) and decreased level of consciousness (12.7%). Twenty patients (28.1%) had neurological signs. Twenty-three patients (32.4%) presented with headache in isolation. Unsuspected diagnosis at presentation was noted in 54.0%. Average time to initial presentation was 14.0 days (median = 5.5 days, range 1-90 days). The majority of children were treated with antibiotics (98.6%) with 31.0%, 2.8% and 2.8% also undergoing sinus surgery, revision sinus surgery and neurosurgery, respectively. Intracranial complications occurred in 16.9% of patients. Significant long term sequelae occurred in 2 children (2.8%) and one death (1.4%) was also reported.

LIMITATIONS

All studies were retrospective case note reviews.

CONCLUSIONS

Acute sphenoid sinusitis is a rare and difficult condition to diagnose in children. The majority of patients make a full recovery with appropriate treatment. If treatment is delayed however consequences can be life-threatening.

Two Cases of Acute Isolated Sphenoid Sinusitis in Children

Acute isolated sphenoid sinusitis is a rare disease, and accounts for less than 3% of all sinusitis, especially in young children. Delayed diagnosis or misdiagnosis can occur frequently due to atypical clinical presentations. This can lead to serious complications because of the involvement of anatomically related intracranial structures. Therefore, nasal endoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) are important diagnostic tools to confirm the diagnosis. We report two cases of a previously healthy 6-year-old girl and a 13-year-old boy, whose chief complaints were uncontrolled headache and high fever over 38°C. Physical examination and initial laboratory test results of blood, urine, and cerebrospinal fluid were normal. The diagnosis was made after a brain MRI revealed isolated sphenoid sinusitis. The girl was treated with third generation cephalosporins intravenously. The boy, however, had to undergo an emergent endoscopic sinus surgery as his headache and eyeball-pain symptoms did not resolve by medical treatment alone. Both cases had good outcomes, without neurological sequelae.

Prevalence of accessory septations of sphenoid sinus in pediatric population: Applications to endoscopic sinus surgery

Sphenoid sinus accessory septations and their possible insertion on internal carotid artery (ICA) may represent a risk for endoscopic sinus surgical procedures. However, scarce data on this variant for children are available so far. This retrospective study included 220 maxillofacial CT-scans equally divided among males (13.4 ± 2.1 years) and females (13.9 ± 2.2 years). On each CT-scan, prevalence of accessory septations, number of septations in sphenoid sinuses, and their possible insertion onto ICA bone walls were recorded. Significant differences in protrusion and insertion of septations onto the ICA bone walls according to sex were assessed through Chi-square test (p < .05). Possible correlations between the prevalence of accessory septations, ICA insertion, and number of accessory septations and age were assessed by means of Pearson's regression (p < .05). On average, 66% of males and 71% of females had at least one accessory septation, without significant differences according to sex or age (p > .05): septal insertion on ICA was found in 13% of subjects, without any significant difference for sex or age (p > .05). The number of septations was significantly increased with age (p < .05). The present study showed that the prevalence of accessory septations and insertion onto the ICA are independent of age and these results are similar to those reported in adults. Results will be useful for the management of endoscopic sinus surgery.