Chronic sphenoid rhinosinusitis: management challenge

Identifying the Risk Factors for Orbital Complications in Isolated Sphenoid Rhinosinusitis

Background and Objectives: Isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures. This study aimed to identify patients with isolated sphenoid inflammatory diseases at high risk for developing orbital complications and requiring aggressive management through investigation of the clinical and computed tomography (CT) characteristics of patients with isolated sphenoid rhinosinusitis. Materials and Methods: The medical records of patients who underwent endoscopic sinus surgery between 2005 and 2022 were retrospectively reviewed. Patients with isolated sphenoid rhinosinusitis were identified based on a manual review of the clinical and histopathological findings. Participants' clinical and CT features were reviewed. Results: Among the 118 patients with isolated sphenoid rhinosinusitis, 15 (12.7%) developed orbital complications, including diplopia, extraocular motility limitation, ptosis, and visual impairment. Headaches and facial pain occurred significantly more frequently in patients with orbital complications than in those without orbital complications (p < 0.001). Patients with diabetes mellitus or malignant neoplasms were more likely to develop orbital complications than those without these comorbidities (p < 0.05). Bony dehiscence on CT images was significantly more common in patients with orbital complications than in those without. In the regression analysis, diabetes mellitus (OR, 4.62), malignant neoplasm (OR, 4.32), and bony dehiscence (OR, 4.87) were significant predictors of orbital complications (p < 0.05). Conclusions: Headaches and facial pain are the most common symptoms of isolated sphenoid rhinosinusitis. Orbital complications of isolated sphenoid rhinosinusitis are more common in patients with comorbidities such as diabetes mellitus or malignancy or in those with bony dehiscence on CT images.

3D Printing as a Planning Tool to Optimize Sinonasal Irrigation

BACKGROUND

Topical sinus irrigation plays a critical role in the management of sinonasal diseases. Yet, the penetration of irrigant to targeted sinuses may be highly variable and difficult to predict. Here, we investigate the use of 3D printing as a planning tool to optimize outcomes.

METHODS

Eight post-operative models were 3D printed with a FormLabs Form3 printer based on individual CT scans. Irrigations were performed and video recorded with a squeeze bottle attached via silicon water-tight seal, in 4 head positions: 45° to-the-side, 90° to-the-side, 45° forward and 45° to-the-side, and 90° forward, with irrigation fluid entering the upper (conventional) or lower (backfill) nostrils.

RESULTS

Significant individual variations were observed in sinus penetration as a function of head position. In general, the maxillary sinus was the easiest to irrigate in most head positions (P < .05), followed by frontal and ethmoid, with sphenoid being the most difficult. Both the 90°-to-the-side and the 90°-forward positions were significantly more effective than the others (P < .05), with 90°-forward better for frontal sinuses and 90°-to-the-side superior for all other sinuses. The backfill was significantly superior to conventional technique in head positions involving a side tilt (P < .05).

CONCLUSION

Variations in technique and position significantly impacted irrigation outcome. Backfill irrigation that pushes fluid against gravity to pool around the ostium, seems to provide overall better outcomes. This study demonstrates the advantage of 3D printing as a rapid planning tool to guide irrigation strategies.

Sphenoid Lymphoma: A Diagnostic Challenge

Sphenoid sinus lesions grasp the attention of Otorhinolaryngologists due to their prime location and vital surrounding structures. Once detected, these lesions require prompt investigation to identify the underlying cause, usually attributed to a tumor, fungal infection, sinusitis, or polyps, thus allowing tailored treatment. We report a case of an elderly lady whose neurological presentation lead to the diagnosis of sphenoid sinus lymphoma. We discuss the diagnostic challenge in view of its interesting presenting symptoms as well as the surgical approach risk and limitations.

[Possibilities of differential diagnosis of chronic diseases of the nasal cavity after surgical treatment and topical antibiotic therapy]

OBJECTIVE

The study was performed to assess the endoscopic state of the nasal mucosa after the use of local anti-inflammatory and antibacterial therapy, in particular, Polydexa nasal spray with phenylephrine containing Dexamethasone sodium metasulfobenzoate + Neomycin + Polymyxin B + Phenylephrine, and for the treatment of granulomatosis with polyangiitis.

MATERIAL AND METHODS

The study included 940 patients who underwent examination and treatment for chronic rhinosinusitis in the clinic of otorhinolaryngology of I.P. Pavlov SPbSMU surgical treatment of the paranasal sinuses underwent 907 patients. In the postoperative period, the first group (211 patients) underwent toileting of the nasal cavity. The second group (307 patients) received irrigation therapy. The third group (389 patients) received a topical treatment combined of Polydexa with phenylephrine. The dynamics of the condition was assessed on the 1st, 3rd and 7th days of treatment, the evaluation of the effectiveness of the treatment was carried out on the 3rd and 7th days. Differential diagnosis with granulomatosis with polyangiitis was carried out in 33 patients. All patients with granulomatosis with polyangiitis showed signs of chronic rhinosinusitis. Patients were prescribed local anti-inflammatory and antibacterial therapy with Polydexa with phenylephrine for 7 days with endoscopic control of the nasal cavity.

CONCLUSION

The use of the combined topical drug Polydexa with phenylephrine in patients with chronic rhinosinusitis and in patients with granulomatosis with polyangiitis has a positive effect, which reduces the clinical manifestations of chronic rhinosinusitis.

[Methods of surgical treatment for isolated lesions of the sphenoid sinus]

This article presents an analytical review of scientific publications on the topic of surgical treatment of isolated lesions of the sphenoid sinus. The publications, research data presented in the RSCI database, PubMed in the period 1985-2021 are analyzed. The selection of the material was carried out according to the keywords: sphenoid sinus, isolated sphenoiditis, phenotypes of sphenoiditis, endoscopic sphenotomy, relapses of sphenoiditis, sphenoid sinus, isolated sphenoiditis, phenotypes of sphenoiditis.

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.

Sphenoid sinusitis: a rare cause of ischaemic stroke

We present the case of a 61-year-old woman who presented to the accident and emergency department with an ischaemic stroke, on a background of receiving intravenous and oral antibiotics to treat chronic left sphenoid sinusitis. Initially presenting with right-sided weakness and aphasia, a diagnosis of acute ischaemic stroke was made. Antibiotics had been commenced 1 month prior to the ischaemic stroke. Imaging at that time showed changes in keeping with chronic sphenoid sinusitis along with a small dehiscence in the lateral wall of the left sphenoid sinus and thrombosis of the left superior ophthalmic vein. During that admission blood cultures grew Streptococcus constellatus, a member of the Streptococcus milleri group. We discuss the unusual aetiology of this stroke, the emerging evidence associating chronic rhinosinusitis with stroke and the complex multidisciplinary approach required for management in this case.

Unusual case presentation of fungal ball infection causing diabetes insipidus and seizure disorder

Sphenoid sinus fungal ball (FB) is a noninvasive fungal infection affecting predominantly immunocompetent middle-aged female patients. Common clinical manifestations include headaches, postnasal drip, and nasal discharge. In this case report, we present a 56-year-old female with a 10-year history of occasional dizziness, vertigo, nystagmus, feeling disoriented and feeling her eyes moving rapidly. Complaints of restlessness, insomnia, anxiety, stress and anger were also present. Due to the nonspecific nature of her symptoms, a diagnosis of sphenoid sinus FB was overlooked. Definitive diagnosis was established after performing a nasal endoscopy and subsequent histopathological examination of the collected sinus tissues. The histopathology report disclosed Aspergillosis FB with chronic sinusitis. Due to the decade long delay in diagnosis and proper treatment, septal wall collapse occurred, with the patient developing diabetes insipidus with hyponatremia that led to a massive seizure and fall, resulting in multiple disc herniations. Surgical removal of the FA elicited a complete resolution of her symptoms and a full recovery.

Although fungal rhinosinusitis is a well recognized spectrum of diseases by ENT specialists, through this case report we hope to draw attention to this particular pathological entity within fungal infections, while simultaneously underlining the broad spectrum of symptoms with which it may manifest and the importance of including FA infections when considering the differential diagnosis in patients with long-standing chronic sinusitis.

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.

Intraoperative Sphenoid Sinus Volume Measurement as an Alternative Technique to Intraoperative Computer Tomography

Isolated sphenoid sinus disease (ISSD) is where there is a group of pathologies characterized by inflammation in one or both sphenoid sinuses. Although computer tomography (CT)-based 3D reconstruction remains the gold standard among noninvasive approaches to ISSD diagnostics, no standardized techniques for direct intraoperative measurements of the sphenoid sinus volume in ISSD patients have been documented. We suggest a novel technique for the intraoperative measurement of the sphenoid sinus volume. Our technique is based on filling the sinus with 0.01% methylene blue solution after an endoscopic endonasal sphenoidotomy. The proposed technique was applied to 40 ISSD patients during surgery. Obtained intraoperative measurements were compared to noninvasive measurements from 3D reconstructions based on preoperative CT scans. Our results demonstrated that the obtained measurements did not exhibit significant differences exceeding 0.4 cm³, with CT-scan-based measurements in 39 out of 40 cases (p < 10⁻⁶, Wilcoxon sign-rank nonparametric test), thus confirming the accuracy of the proposed technique. Disagreements between direct intraoperative and CT-based measurements in a single case have been attributed to the presence of remaining pathological masses in the sinus, which was further confirmed during the secondary check of the operated sinus. Accordingly, we suggest that the agreement between the CT-based and intraoperative volume measurements can be used as an indicator of the successful elimination of all pathological masses from the sinus without having to perform an adequate exposure of the entire sphenoid sinus to reduce intraoperative bleeding. The proposed technique is accurate and does not require the involvement of specialized intraoperative CT scanners and avoids additional radiation exposure for the patient during an additional postoperation CT scan to confirm the success of the surgery.

Can Volumetric and Morphological Variants of Sphenoid Sinuses Influence Sinuses Opacification?

Improvements in computed tomography and in functional endoscopic sinus surgery have recently increased interest toward paranasal sinus anatomy and anatomic variations that can be observed in patients affected by sinusitis. Isolated sphenoid sinusitis is a relatively rare pathology, often related to nonspecific symptoms, therefore making diagnosis difficult. The correlation between this type of sinusitis and anatomical variants remains unclear.The authors' aim was to retrospectively revise paranasal sinuses computed tomography scans of patients affected by sphenoid sinusitis, compared with a control group, analyzing the types of sphenoid sinus and the presence of aberrant pneumatization, and performing a segmentation of the sphenoid sinuses to calculate the volumes.Sphenoid sinuses of 60 patients affected by sinus opacification, compared with a control group, were segmented. Type of sinus (sellar, presellar, postsellar) and presence of aberrant pneumatization were assessed as well. Possible statistically significant differences in volumes according to sex and group were assessed through 2-way ANOVA test (P < 0.05). Post-hoc test was assessed through Student t test. χ test was applied in order to verify the statistically significance of differences in frequency of different types of sinus pneumatization variants (P < 0.05).Average volume of sphenoid sinuses in males was of 7.672 cm and of 7.751 cm in females within the group of patients; statistically significant differences in volume were found according to sex (P: 0.342), but not between the patients and control group (P: 0.0929). Post-hoc test verified that males affected by sinus opacification showed smaller volumes in comparison with the control males (P < 0.05). In addition, patients by affected sinus opacification showed more frequently the postsellar type and were less affected by pneumatization variants of the sphenoid bone than the control group (P < 0.05).This study first suggests the possible protective role of variants of pneumatization in the development of sphenoid sinus opacification.

Headache Secondary to Isolated Sphenoid Sinus Fungus Ball: Retrospective Analysis of 6 Cases First Diagnosed in the Neurology Department

Fungal sphenoid sinusitis is easily misdiagnosed in clinic, particularly for patients with normal immunological status. Due to the anatomic characteristics of sphenoid sinus, patients presented with various nonspecific symptoms and complications. Headache is the most common presentation, but location of headache is not fixed. We intended to analyze 6 cases of headache secondary to the isolated sphenoid sinus fungus ball (SSFB) which were first diagnosed in the Neurology Department. There was significant female predominance with mean ages of 55 years. They had repeatedly headache history from months to years. The headache was unilateral and usually on the side of lesions. Medication of pain relievers worked well in the beginning of SSFB, but not in the late stage of disease. Notably, all patients did not present positive nervous systemic signs. A preoperative computed tomography (CT) scan or magnetic resonance imaging (MRI) demonstrated the inflammation in sphenoid sinus. Some cases showed calcification in soft tissue or bone lesions of sinus wall. All of 6 patients undertook transnasal endoscopic sphenoidotomy without antifungal therapy after operation. Characteristic fungus ball (FB) was detected after histopathological examination. No headache recurrence was found after average 15.5 months follow-up. Our results suggested that transnasal endoscopic sphenoidotomy is the treatment of choice to remove the FB in sphenoid sinus with a low rate of morbidity and recurrence.

Isolated fungus ball in sphenoid sinus: tips and pitfalls of T 1 hyperintense lesions

Isolated sphenoid sinus fungus ball is a very rare condition. CT is the most used imaging investigation for diagnosis. In some cases, MRI may provide further information to evaluate the extracompartmental invasion. We report the case of an elderly female patient who presented with headache and a soft tissue mass filling the right sphenoid sinus on CT, misdiagnosed as simple sinusitis. After 1 year, with recrudescence of symptoms, brain MRI showed a hyperintense soft tissue mass on T₁ weighted images within the right sphenoidal sinus; a new CT examination revealed calcifications within the mass. Surgical histological examination showed fungus ball. Fungal ball should be included in the differential diagnosis of T₁ hyperintense lesions in the sphenoid sinus.