Endoscopic transsphenoidal approach to a sphenoid sinus inverted papilloma combined with pituitary adenoma: a case report

Sphenoid sinus inverted papilloma (IP) is a very infrequent tumor, and the combination of sphenoidal IP with pituitary tumor is extremely rare. In this report, the authors describe the case of a 63-year-old male with oculomotor nerve palsy in the left eye due to sellar region tumor. After endoscopic transsphenoidal surgery, the postoperative pathological examination confirmed the co-occurrence of an sphenoidal IP and pituitary adenoma. To our knowledge, the present case is the second reported case of an IP with a pituitary adenoma.

Chronic Sphenoiditis With Deep Neck Space Extension: Case Report With Review of the Literature and Postulated Mechanisms for Extracranial Extension

Isolated primary sphenoid sinusitis is a rare occurrence, estimated to make up less than 3% of sinus infections. The posterior anatomic location of the sphenoid makes treatment challenging when it becomes infected. Complications involving intracranial extension to surrounding structures often result in cranial nerve deficits due to their proximity. A single case of chronic sphenoiditis with direct extracranial extension into the prevertebral space is reported with a discussion on clinical presentation, diagnosis, and management. A 46-year-old female patient with diffuse headaches radiating into the neck and throat was evaluated in the office. Computed tomography demonstrated sphenoiditis with direct extension into the prevertebral space. Imaging revealed a purported route of direct extension through the clinoid and directly into the clivus to form an abscess in the longus colli muscle. The patient underwent endoscopic surgical management including drainage of the prevertebral abscess and has since made a full recovery. This is the first reported case of direct extension of sphenoiditis into the prevertebral space. The findings highlight the importance of aggressive treatment of chronic sphenoid infections to prevent detrimental complications. Computed tomography imaging proved an advantageous imaging modality to demonstrate bony erosion and sinus tracts from the skull base to the deep neck space.

Type IV optic nerve and Onodi cell: is there a risk of injury during sphenoid sinus surgery?

Objective

This study aims to determine the prevalence and types of Onodi cells through computed tomography and investigate the relationship between Onodi cell and the surrounding structures, paying particular attention to the risky proximity to the optic nerve canal.

Methods

In this study, 430 computed tomography scans of paranasal sinuses were analysed to establish the prevalence and different types of Onodi cells. Furthermore, the relationship between Onodi cell and different patterns of sphenoid sinus pneumatisation and surrounding structures were investigated. Special attention was paid to the relationship between Onodi cell and the optic nerve canal, particularly in cases when the optic nerve canal was bulging by more than 50% into the Onodi cell (Type IV).

Results

The Onodi cell was detected in 21.6% of cases, with the most common being Type I (48.5% right, 54.3% left). Type IV bulging of the optic nerve canal into the Onodi cell was observed in 47.1% of cases on the right side, 41.2% on the left side and bilateral in 11.7% of cases.

Conclusions

In our series, we observed a high prevalence of Type IV optic nerve bulging into the Onodi cell. For this reason, we suggest that clinicians should always try to identify it in a pre-operative setting with computed tomography to avoid catastrophic consequences during endoscopic sinus surgery approaching the sphenoid area.

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.

Endoscopic endonasal repair of temporal lobe meningoencephalocele in the lateral recess of the sphenoid sinus, complicated by intracerebral hematoma: illustrative case

BACKGROUND

Anomalies in the anatomical structure of the nasal cavity and paranasal sinuses often serve as a potential cause of spontaneous cerebrospinal fluid (CSF) leakage and may result in the development of a meningoencephalocele. In this report, the authors present a case of surgically treated intrasphenoidal meningoencephalocele attributed to the persistence of the lateral craniopharyngeal canal, which was further complicated by the occurrence of an intracerebral hematoma.

OBSERVATIONS

A temporal lobe meningoencephalocele located in the lateral recess of the sphenoid sinus was successfully managed using endoscopic endonasal transpterygoid repair (EETR). However, an intracerebral hematoma developed after resection of the meningoencephalocele, necessitating additional surgical interventions. Despite this complication, the patient exhibited a favorable clinical outcome after the surgical interventions.

LESSONS

This case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. A thorough examination of magnetic resonance imaging scans, especially identifying vascular structures, is crucial during surgical planning. This knowledge can help to prevent the occurrence of complications, including intracerebral hematoma.

Bilateral Orbital Apex Syndrome Related to Sphenoid Fungal Sinusitis

Orbital apex syndrome (OAS) is a rare condition that usually occurs due to damage to surrounding inner and surrounding bone tissue. Orbital apex syndrome may result from a variety of conditions that cause damage to the superior orbital fissure and to the optic canal leading to optic nerve (II) dysfunction. We recently experienced a rare case of sphenoidal Aspergillosis, which damaged the adjacent cavernous sinus structures and led to the definite symptom of bilateral OAS in a 77-year-old male. We present this rare case with a brief review of these disease's entities.

An artificial intelligence algorithm for the classification of sphenoid sinus pneumatisation on sinus computed tomography scans

BACKGROUND

Classifying sphenoid pneumatisation is an important but often overlooked task in reporting sinus CT scans. Artificial intelligence (AI) and one of its key methods, convolutional neural networks (CNNs), can create algorithms that can learn from data without being programmed with explicit rules and have shown utility in radiological image classification.

OBJECTIVE

To determine if a trained CNN can accurately classify sphenoid sinus pneumatisation on CT sinus imaging.

METHODS

Sagittal slices through the natural ostium of the sphenoid sinus were extracted from retrospectively collected bone-window CT scans of the paranasal sinuses for consecutive patients over 6 years. Two blinded Otolaryngology residents reviewed each image and classified the sphenoid sinus pneumatisation as either conchal, presellar or sellar. An AI algorithm was developed using the Microsoft Azure Custom Vision deep learning platform to classify the pattern of pneumatisation.

RESULTS

Seven hundred eighty images from 400 patients were used to train the algorithm, which was then tested on a further 118 images from 62 patients. The algorithm achieved an accuracy of 93.2% (95% confidence interval [CI] 87.1-97.0), 87.3% (95% CI 79.9-92.7) and 85.6% (95% CI 78.0-91.4) in correctly identifying conchal, presellar and sellar sphenoid pneumatisation, respectively. The overall weighted accuracy of the CNN was 85.9%.

CONCLUSION

The CNN described demonstrated a moderately accurate classification of sphenoid pneumatisation subtypes on CT scans. The use of CNN-based assistive tools may enable surgeons to achieve safer operative planning through routine automated reporting allowing greater resources to be directed towards the identification of pathology.

Successful Endoscopic Transsphenoidal Approach Treatment of Sphenoid Sinus Organized Hematoma Causing Visual Deficit: A Case Report

Background: Organized hematoma in the sphenoid sinus is rare, but serious complications, such as visual deficits, can occur. Three such case reports have been published previously in the literature; however, none have achieved complete recovery of the vision. Case presentation: A 69-year-old male patient was referred to the ear, nose, and throat department with an expansile soft tissue mass filling the right sphenoid sinus and blurry vision in his right eye. Complete mass removal was achieved by a wide opening of the sphenoid sinus via an endoscopic transsphenoidal approach, followed by cauterization of the feeding artery and coverage by a nasoseptal flap. The patient's vision was restored after the operation, and he declared no visual symptoms until the latest follow-up (one year after the surgery). Conclusions: Complete excision with an endoscopic endonasal transsphenoidal approach can restore visual deterioration caused by a sphenoid sinus organized hematoma.

The Relationship between Sphenoid Sinus, Carotid Canal, and Optical Canal in Paranasal Sinus Computed Tomography in Children

Objectives  The authors examined the structural differences in the paranasal sinus region at sphenoid sinus in the pediatric population. Methods  Paranasal sinus computed tomography (PNSCT) images of 86 pediatric subjects (30 males, 56 females) were included. In 13 to 15 years of age group ( n =34) and ≥16 years of age group ( n =52), sphenoid sinus pneumatization (SSP), optic canal and carotid canal classifications and dehiscence evaluation were performed. Results  In both sexes, type 1 and type 2 SS pneumatization were observed more frequently on both the right and left sides. On the right side, type 2> type 1; on the left side type 1> type 2 optic canals were detected in both gender. Type 3 optic canals were detected in 8.8 to 14.7% of the 13 to 15 years of age group; and 11.5 to 17.3% of ≥16 years of age group. Type 4 optic canals were detected in 2.9% of the 13 to 15 years of age group and 1.9% of the ≥16 years of age group bilaterally. Optic canal dehiscence was detected in 26.5% of the 13 to 15 years of age group and 17.3% of the ≥16 years of age group. Type 1 and type 2 carotid canals are most common in children, the percentages for type 3 carotid canals were 1.8 to 3.6% in children. Conclusion  In pneumatized SS, optic canal classifications got increased values which showed protrusion into the sphenoid sinus wall. Therefore, in children, the surgeons must be very careful for optic canal being nearer to the sphenoid sinus walls.

Cerebrospinal Fluid Rhinorrhea as the First Symptom of Metastatic Prostate Adenocarcinoma

The most common cause of cerebrospinal fluid (CSF) rhinorrhoea is damage to the skull base with a dura mater's rupture due to an accident or an iatrogenic injury. This applies to over 96% of cases. Other possibilities that can lead to CSF leakage are neoplasms of the nasal cavity, paranasal sinuses, and nasopharynx. Although prostate cancer spreads to bones, cranial metastases to paranasal sinuses are extremely rare. We present a case of an 83-year-old patient with CSF leakage due to infiltrating metastatic prostate cancer. Cerebrospinal fluid rhinorrhea turned out to be the first symptom of prostate cancer metastasis. Diagnostic and treatment strategies are presented in the discussion.

Metastatic Prostate Cancer Involving the Sphenoid Sinus and Mandible

Prostate cancer is the third most leading cause of cancer in men in the United States. Although expected metastatic spread to bone, liver, and lymph nodes are often monitored, there are other rare presentations that can occur. This case report demonstrates a rare presentation of prostate cancer spreading to the paranasal sinuses and orbit. Not only did this case have an atypical presentation mimicking infection, the diagnosis was also only achieved through pathological evaluation after an endoscopic examination and biopsy. This case demonstrates the importance of a low threshold for endoscopic examinations in uncertain sinonasal presentations, and consistent biopsies when performing endoscopic examinations.

Sphenoid Sinus Volumes of Patients with Unilateral Cleft Lip and Palate

OBJECTIVE

There is only one study in the literature in which 3D evaluation of sphenoid sinus volume in patients with cleft lip and palate was used. This shows that this issue has not been adequately evaluated. The present study aimed to compare the volume of the sphenoid sinuses in patients with cleft lip and palate on cone-beam computed tomography images, and to compare them with healthy controls. The high variability of sphenoid sinus volumes poses a risk for iatrogenic lesions during surgical procedures. Because the degree of pneumatization due to increased volume increases the likelihood of exposure of vital neurovascular structures such as the internal carotid artery, maxillary nerves, and optic nerves.

DESIGN

Retrospective cohort study.

SETTING

University Hospital.

PATIENTS

A total of 64 patients (32 cleft palate, 32 controls) over 18 years of age who had sphenoid sinuses in the image area were included in our study.

OUTCOMES

Sphenoid Sinus Volume.

RESULTS

When the groups were compared in terms of total sinus volume, there was a statistically significant difference between them. Total sinus volume was significantly mean 2.806,87 mm lower in patients with cleft lip and palate compared to the healthy group (P = .015).

CONCLUSION

To be aware this lower volume of the sphenoid sinus in cleft lip and palate patients will be useful for the surgical approach to sphenoid sinus. However, the literature on the subject is insufficient, more comprehensive clinical and radiological studies are needed on a larger sample.

Surgical reconstruction for spheno-orbital meningioma extending into the sphenoid sinus with hyperostosis

Spheno-orbital meningiomas (SOMs) are complex tumors that grow and extend into nearby structures. SOM tumor growth is often associated with hyperostosis caused by tumor cell infiltration and bone alteration. We describe the case of a 64-year-old man with SOM that extended into the sphenoid sinus without a direct connection between the intracranial and extracranial lesions. This report emphasizes the importance of identifying the growth patterns of SOMs and assessing the paranasal sinuses adjacent to the hyperostotic orbit walls from preoperative images.

Morphometry and Intracranial Relations of the Sphenoid Sinus in Context to Endoscopic Transnasal Transsphenoidal Surgery

Introduction Due to the variable degree of pneumatization, the shape and size of the sphenoid sinus are irregular. An endoscopic intranasal transsphenoidal approach is made in sphenoid sinus pathologies, sphenoid sinusitis, and sellar and parasellar diseases. A diagnostic approach to the sphenoid sinus is also done to get a better MRI scan of the pituitary. The present study aims to describe the variant types of sphenoid sinus, morphometry, anatomy, and relations of sphenoid sinus, which will be helpful to surgeons during an endoscopic approach to the sphenoid sinus. Materials and methods We studied 76 cadaveric sphenoid sinuses that were exposed by taking a sagittal section of 38 formalin-fixed cadaveric heads. After examining the inter-sphenoidal septum, it was removed to observe the inside aspect of the sphenoid sinus. Different dimensions of the sinus were noted down. The bulges inside the sinus due to neurovascular structures in relation to the sinus were observed. Results  The most prominent type found was the sellar in 68.4% of cases preceded by the postsellar in 23.7% of cases. Presellar type of pneumatization was seen only in 7.9% of cases and the conchal type was absent. Intersphenoid septum was seen in 92,1% of cases, out of which 11.4% of septums were deficient on the posterior aspect. An internal carotid artery bulge in the sphenoid sinus was seen in 46% of cases. In 27.6% and 19.7% of sphenoid sinuses, bulging of the optic and vidian nerves, respectively, were seen. Some of these structures were dehiscent in the sphenoid sinus. Conclusions To get more space in the sphenoid sinus, the septa in the sinus are removed by surgeons, which may damage the walls of the sphenoid sinus. Knowledge of the relations of neurovascular structures with the sphenoid sinus will be helpful to surgeons during the transsphenoidal endoscopic approach to avoid any injury to these structures.

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.

Analysis of the prechiasmatic sulcus in Chiari Malformation Type I

OBJECTIVE

This study aimed to assess morphological features of the prechiasmatic sulcus (PS) in Chiari Malformation Type I (CM-I).

METHODS

The study population consisted of computed tomography images of 42 CM-I patients (average age: 21.26±16.46 years; sex: 25 females and 17 males) and 58 normal subjects (average age: 28.12±22.60 years; sex: 29 females and 29 males). The measured parameters to determine the anatomy of PS were as follows: the planum length (PL), sulcal length (SL), sulcal angle (SA), and interoptic distance (IOD). Considering SL and SA measurements, PS was identified as four types: the narrow-steep-groove (NSG), narrow-flat-groove (NFG), wide-steep-groove (WSG), and wide-flat-groove (WFG).

RESULTS

SA was greater in CM-I (32.80±18.21°) compared to the control group (23.05±14.53°) (p=0.004), but the others were similar in both groups. Distribution ranking of PS types was found as NFG (31%) > NSG (26.20%) > WSG (23.80%) > WFG (19%) in CM-I group, while as WFG (37.90%) > WSG (20.70%) = NFG (20.70%) = NSG (20.70%) in the control group. Distribution rate of PS types relative to both groups showed that the classification system was not affected by CM-I (p=0.226).

CONCLUSIONS

SA value is approximately 25% greater in CM-I than the control; thus, CM-I subjects have more vertical groove. The percentage of narrow-type (NSG + NFG) in CM-I was higher than in the control group.

Olfactory neuroblastoma limited to sphenoid sinus

Olfactory neuroblastoma (ONB) is a rare tumour of the skull base, typically originating from the nasal cavity and around the cribriform plate. We present the rare case of ONB originating from and limited to the sphenoid sinus in a 42-year old lady. Pre-operatively the lesion was thought to be a sinonasal polyp and underwent functional endoscopic sinus surgery (FESS) and total excision of the polypoid lesion. Review of histology unexpectedly revealed ONB. She underwent further surgery to ensure wide local excision was achieved with negative margins on histology, followed by radiotherapy. This is only the third reported case of ONB limited to the sphenoid sinus and the ninth reported case of primary sphenoid ONB in the literature. We review the literature pertaining with primary sphenoidal ONB here and suggest complete resection is indicated in ectopic ONB, not unlike classical ONB. There may be a role for adjuvant oncological treatments and lifelong follow up in a multidisciplinary approach is recommended.

Prevalence of the Onodi cell in the Polish adult population: an anatomical computed tomography study

BACKGROUND

Onodi cell is a posterior ethmoid air cell with the optic canal bulging into it; the common position of the bulge is into the sphenoid sinus, usually immediately posterior to the posterior ethmoid air cells. Variable pneumatisation patterns lead to various structures of lamellae and sinuses occasionally exposing important nerves and vessels, such as the optic and vidian nerves, internal carotid artery and cavernous sinus. In clinical practice, special imaging techniques are used to navigate through the paranasal sinuses and hence avoid injury to these structures. This study is aimed to determine the prevalence of the Onodi cell in the Polish population and compare it with other reported occurrences.

MATERIALS AND METHODS

A retrospective analysis of 296 computed tomography (CT) scans of patients treated in Krakow, Poland, using a Siemens Somatom Sensation 16 spiral CT scanner. No contrast medium was administered.

RESULTS

The Onodi cell was found in 31 out of the 296 patients, or approximately 10.5%, consistent with the majority of research reporting on Onodi variants. Additionally, there was one presentation of a bilateral Onodi cell in a male patient. No statistically significant difference was found between the male and female populations with a positive identification of the variant (p = 0.095, Chi2 test).

CONCLUSIONS

This study helped approximate the Onodi variant prevalence of 10.47%, falling within a commonly reported range 8-14%. This gives clinicians and surgeons a better understanding of this variant's structure and significance, and therefore an opportunity to improve treatment outcomes and research.

Volumetric evaluation of the sphenoid sinus among different races in the Southeast Asian (SEA) population: a computerized tomography study

Introduction: The fundament of forensic science lies in identifying a body. The morphological complexity of the paranasal sinus (PNS), which varies greatly amongst individual, possess a discriminatory value that potentially contributes to the radiological identification. The sphenoid bone represents the keystone of the skull and forms part of the cranial vault. It is intimately associated with vital neurovascular structures. The sphenoid sinus, located within the body of the sphenoid bone, has variable morphology. The sphenoid septum's inconsistent position and the degree, as well as the direction disparities of sinus pneumatization, have indeed accorded it a unique structure in providing invaluable information in forensic personnel identification. Additionally, the sphenoid sinus is situated deep within the sphenoid bone. Therefore, it is well protected from traumatic degradation from external causes and can be potentially utilized in forensic studies. The authors aim to study the possibility of variation among the race, and gender in the Southeast Asian (SEA) population, using volumetric measurements of the sphenoid sinus. Materials and methods: This is a retrospective cross-sectional analysis of computerized tomographic (CT) imaging of the PNS of 304 patients (167 males, 137 females) in a single centre. The volume of the sphenoid sinus was reconstructed and measured using commercial real-time segmentation software. Result: The total volume of sphenoid sinus of male gender had shown to be larger, 12.22 (4.93 - 21.09) cm³ compared to the counterpart of 10.19 (3.75 - 18.72) cm³ (p = .0090). The Chinese possessed a larger total sphenoid sinus volume, 12.96 (4.62 - 22.21) cm³) than the Malays, 10.68 (4.13 - 19.25) cm³ (p = .0057). No correlation was identified between the age and volume of the sinus (cc= -.026, p = .6559). Conclusion: The sphenoid sinus volume in males was found to be larger than those of females. It was also shown that race influences sinus volume. Volumetric analysis of the sphenoid sinus can potentially be utilized in gender and race determination. The current study provided normative data on the sphenoid sinus volume in the SEA region, which can be helpful for future studies.

[Features characteristics of the sphenoid sinus disease in elderly patients.]

The aim of the study was to identify the features of diagnosis and treatment of sphenoid sinus diseases in patients over 60 years old. Clinical manifestations, results of endoscopic and radiological examination methods, and surgical intervention tactics were compared between elderly patients and younger patients (aged 18-59 years) who sought treatment for sphenoiditis in I.P.Pavlov Saint-Petersburg First State Medical University. The study analyzed 51 patients with isolated sphenoid sinus pathology, of which 9,8% were over 60 years old. The most common symptom in elderly patients was headache. Surgical treatment was required in 80% of patients over 60 years old. Endoscopic endonasal surgery of the sphenoid sinus can be safely performed by a specialized surgical team in patients over 60 years old with low anesthesiological risk. The results of our study showed that there were no statistically significant differences in the length of hospital stay between patients in both groups. This indicates that caring for elderly patients with sphenoid sinus pathology does not necessarily lead to prolonged hospitalization or increased economic burden on healthcare systems. Further research is needed to better understand the causes of the disease and to develop more effective approaches to the diagnosis, therapy, and prevention of sphenoid sinus pathology in elderly people.

Sphenoid sinus is a rare site for tumor-induced osteomalacia: A case report and literature review

BACKGROUND

In this paper, we present a rare case of tumor-induced osteomalacia (TIO) and a literature review of this rare disease.

METHODS

A case of TIO of the isolated sphenoid sinus was reported. Furthermore, the clinical features of TIO in the sphenoid sinus and other sinonasal sinuses were also reviewed and summarized.

RESULTS

A 35-year-old man with muscle weakness and lower back pain came to the Department of Neurology. No obvious neurological disease was found; however, magnetic resonance imaging of the extremities accidentally showed a tumor in the axilla. Bone scintigraphy showed suspicious bone metastasis. Hypophosphatemia was neglected. Interestingly, 2-deoxy-2-[fluorine-18]fluoro-d-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) detected a tumor in the axilla and another in the sphenoid sinus, but only the tumor in the sphenoid sinus had somatostatin receptor (SSTR) expression in 68-gallium 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid octreotate (Ga-68 DOTATATE) PET/CT. The sphenoid sinus tumor was proven to be a phosphaturic mesenchymal tumor (PMT), and the phosphate levels returned to normal after surgery. The literature review showed only 17 cases of TIOs that occurred in the sphenoid sinus, with an average age of 43.3 ± 13.7 years. Only three cases of TIOs in the sphenoid sinus did not invade the nasal cavity or other paranasal sinuses, which could be identified as isolated sphenoid sinus diseases. We compared the clinical features of sphenoid TIOs with those of non-sphenoid sinonasal TIOs, and it was found that the concentration of 1,25-dihydroxy vitamin D in the group with sphenoid TIOs was much higher than that in the group with non-sphenoid sinonasal TIOs. A total of 153 cases of TIOs in the sinonasal sinus were reviewed. The ethmoid sinus was found to be the major site (64.7%), followed by the nasal cavity (50.3%), maxillary sinus (19.0%), frontal sinus (16.4%), and sphenoid sinus (11.8%). There were 66 patients (43.1%) who showed tumors invading more than one sinus. Most of the tumors (69.3%) were diagnosed as PMTs by pathology, followed by hemangiopericytoma (14.3%). Immunostaining was beneficial in the differential diagnosis of these tumors; however, larger sample sizes are needed for better accuracy.

CONCLUSION

TIO in the sinonasal sinus, especially in the sphenoid sinus, is rare. Moreover, isolated sphenoid sinus disease can be easily misdiagnosed. When the clinical manifestation of osteomalacia is atypical, associating it with sphenoid sinus disease is even more difficult. Thus, TIO in the sphenoid sinus needs further exploration.

[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.

A Case of Sphenoid Mucocele Causing Hypopituitarism

Mucocele is rarely seen in the sphenoid sinus. It may cause compression of neighboring structures due to significant destruction of the bony structure and its expansile nature. Although headache is the main symptom, it may present with different symptoms. Imaging methods play an important role in the diagnosis and differential diagnosis.

Development of the Sphenoid Sinus in Japanese Children: A Retrospective Longitudinal Study Using Three-Dimensional Computed Tomography

Background: The sphenoid sinus (SS) is located close to vital structures, such as the pituitary gland, and it has significant clinical relevance. This study aimed to clarify the growth pattern of the SS in Japanese children using three-dimensional computed tomography (CT). Methods: Seventy-eight participants with congenital, acquired, or external auditory canal cholesteatoma were recruited and underwent CT more than twice during their treatment. Using the volume-rendered images, the size and volume of the SS were measured. Furthermore, on the scout image, the morphological measurements of the cranial base were determined. Results: The size and volume of the SS increased with age, and peaked at the mean age of 15 years. For males, the volume of the SS was smaller than that of females aged <5 years. The growth rate of the SS was significantly higher in males than in females. The maximum growth rate was detected at the age of 12 years for males and 10 years for females. For females, the increase in the length of the anterior cranial base ceased at approximately 10 years of age and remained constant thereafter. In contrast, for males, the length of the anterior cranial base increased gradually until 15 years of age. Conclusions: Considering the similarity of the periods between the adolescent growth spurt and the maximum growth rate of the SS, changes in the size of the SS may be used as an indicator of the physical growth spurt.

Surgical and Radiological Differences in Intersphenoid Sinus Septation and the Prevalence of Onodi Cells with the Endoscopic Endonasal Transsphenoidal Approach

Background and Objectives: Understanding the anatomical variation in the sphenoid sinus is important to fully expose the sellar floor and clivus. Materials and Methods: The Onodi cell and intersphenoid sinus septation based on preoperative paranasal sinus computed tomography (PNS CT) and the surgical records of 877 patients who underwent the endoscopic endonasal transsphenoidal approach (EETSA) were retrospectively reviewed. Results: An intersphenoid sinus septum (ISS) blocking the clivus was defined as a pseudoclivus. Complete and incomplete pseudoclivuses were found in 2.97% and 10.5% of patients, respectively. Intraoperative and PNS CT ISS findings differed in 17.1% of patients. Misconceptions regarding a ridge or vertical ISS and confusion between an incomplete pseudoclivus and a vertical ISS were common. Conclusions: Because intraoperative and PNS CT findings may differ, anatomical variation in the paraclival area should be evaluated carefully. A pseudoclivus mimicking the clivus is important to attain a fully exposed EETSA surgical view.

Typical and Atypical Symptoms of Petrous Apex Cholesterol Granuloma: Association with Radiological Findings

Objective: Petrous apex cholesterol granuloma (PACG) is a lesion that can give rise to different symptoms, and correlations with etiopathology are ambiguous. The aim of this study is to analyze the association between PACG symptoms and radiological findings at presentation, in order to establish a reproduceable pre-operative radiological evaluation and guide the surgical indication. Methods: PACG patients were collected in two tertiary care hospitals. All cases underwent CT/MRI to evaluate the cyst localization and erosion of surrounding structures. Typical and atypical symptoms were then analyzed and compared to radiologic findings established in accordance with the literature. Results: Twenty-nine patients were recruited; the most common symptoms were headache (69%), diplopia (20.7%) and fainting (24.1%), an atypical clinical manifestation related to jugular tubercle involvement. Significant associations between symptoms and radiologic findings were noted in terms of headache and temporal lobe compression (p = 0.04), fainting and jugular tubercle erosion (p < 0.001), vestibular symptoms and internal auditory canal erosion (p = 0.02), facial paresthesia and Meckel’s cave compression (p = 0.03), diplopia and Dorello canal involvement (p = 0.001), and tinnitus and cochlear basal turn erosion (p < 0.001). All patients were treated via an endoscopic−endonasal approach, in which extension was tailored to each case. At a median follow-up of 46 months, 93.1% of patients experienced resolution of symptoms. Conclusions: This clinico-radiological series demonstrates associations between symptoms and anatomical subsites involved with PACG. Hence, it may guide the surgeon at the time of surgical decision, since it asserts that typical and atypical symptoms are actually related to PACG.

Anatomical identification of supraseptal posterior ethmoid cells and its significance for endoscopic sinus surgery

BACKGROUND

To investigate the anatomical imaging characteristics of supraseptal posterior ethmoid cells (SPEC).

MATERIALS AND METHODS

Paranasal sinus computed tomography scans of 153 inpatients from February 2019 to September 2021 were reviewed, and the anatomical characteristics of SPEC in the scans were collected.

RESULTS

Supraseptal posterior ethmoid cells are posterior ethmoid (PE) cells extending medially and superiorly to the posterior superior of the nasal septum and into the sphenoid body but not close to the optic canal. The SPEC, Onodi cell, and sphenoidal sinus (SS) may appear in the posterior superior of the nasal septum, but the occurrence rate of the SPEC (5.88%; 9/153 cases) was significantly lower than that of the SS (22.88%) and Onodi cell (21.57%). The anterior SPEC is adjacent to the cribriform plate, the perpendicular plate of the ethmoid bone and the posterior ethmoidal artery (PEA). The posterior SPEC is adjacent to the SS and PE (6/9 cases), the SS and Onodi cell (2/9 cases) or the PE only (1/9 cases).

CONCLUSIONS

The SPEC is a rare pneumatization that occurs in the posterior superior area of the nasal septum. Care should be taken to protect the skull base, cribriform plate and PEA when opening the SPEC during endoscopic sinus surgery.

Isolated Sphenoid Sinusitis: Anatomical Features for Choosing a Method of Treatment, a Case-Control Study

Isolated sphenoid sinusitis (ISS) is a group of pathologies characterized by inflammation in one or both sphenoid sinuses. The gold standard for analyzing and diagnosing ISS is computer tomography. Many researchers have discussed the treatment of patients with ISS variants such as fully opacified sinus, mostly with surgery. A retrospective analysis of clinical data of 59 patients (21 male (35%), 38 female (65%)) with ISS, who were treated in the Otorhinolaryngological Department of Pavlov First Saint Petersburg State Medical University between January 2017 and January 2020, was conducted. All patients were in the first stage of the same medical therapy. In cases where there was no recovery, these patients were referred to surgery. For the control group, we analyzed patients without any disorders according to CT-scan examination. After analyzing the obtained clinical and radiological data, we found indicators that were common in patients who did not recover after medical therapy. According to the reverse regression method statistical model, in male patients with a diffuse headache and nasal discharge it was shown that medical therapy was highly effective (more than 78%). The presence of nasal septum deviation and adenoids in male and female patients leads to the highest risk of surgical treatment (83% probability of the logistic model). The detailed analysis of CT-scans and the complaints of patients with ISS can be the key to determining the preferred therapy choice. Not all cases need to have an endoscopic opening of the sphenoid sinus, according to our research.

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.

A Large Cavernous Sinus Giant Cell Tumor Invading Clivus and Sphenoid Sinus Masquerading as Meningioma: A Case Report and Literature Review

Giant cell tumor (GCT) of the bone is a rare benign, locally aggressive tumor that occurs in the epiphysis of long bones, especially the lower femur and the upper tibia. GCT of the bone of cranial origin is very rare, accounting for 1% of all GCT of the bone. We report the diagnosis, treatment, and immunohistochemistry of a rare case of intracranial GCT of the bone. We also review and summarize the imaging features, diagnostic markers, and current major treatment options for GCT of the bone. Our case and literature review emphasizes the importance of considering the full picture when making a diagnosis, rather than relying on imaging alone to make the diagnosis.

Vision loss caused by immunoglobulin G4-related disease of the skull base complicated by a mucocele of the sphenoid sinus

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a fibro-inflammatory disorder and manifestation in de paranasal and sphenoid sinus is well recognized. In this patient, IgG4-RD presented in an unusual manner with vision loss due to mucocele formation in the sphenoid sinus.

CASE DESCRIPTION

A 19-year-old man, with an unremarkable medical history, was referred with decreased vision in the left eye, headaches, and a sharp pain in the left orbit and ear. Compression of the left optic nerve due to a large mucocele caused papillary edema and emergency endoscopic marsupialization of the mucocele was performed. When the vision decreased again, a more extensive decompressing sphenoidotomy was performed. Histopathology showed IgG4-RD. Despite dexamethasone, the lesion expanded to the anterior skull base and the patient required repeat endoscopic surgery. After 3 months, a decrease in smell and vision warranted for a fourth extensive endoscopic decompressing surgery, complicated by a cerebrospinal fluid leak. Prednisone and later rituximab were commenced. Unfortunately, the patient reported a complete loss of vision after 4 months of rituximab due to increased mass effect on the optic nerve. An extensive combined craniofacial-endoscopic surgery was performed to remove the entire mucocele and to prevent further contralateral and intracranial progression. Methylprednisolone monthly was commenced to prevent further complications.

DISCUSSION

This case illustrates that in therapy-resistant sino-orbital IgG4-RD, extensive surgery might be necessary at an earlier stage. It may even be the only option to prevent irreversible damage to the surrounding tissues. A multidisciplinary approach in the management of sino-orbital IgG4-RD is therefore warranted.

Sphenomaxillary Plate: Landmine or Landmark?

OBJECTIVES

Sphenomaxillary plate (SMP) is an inconstant bony septum separating the maxillary and sphenoid sinuses. Neglecting the SMP during endoscopic sinus surgery may lead to mistaking the sphenoid sinus for the posterior ethmoid cell with potentially dangerous consequences. However, its proper identification may allow planned sphenoidotomy through the posterior wall of the maxillary sinus or to enlarge transnasal or transethmoidal sphenoidotomy. The aim of this study was to evaluate (1) the incidence and morphology of the SMP and (2) possibility and safety of trans-SMP sphenoidotomy.

METHODS

In the radioanatomical part of the study multiplanar reconstruction analysis of 117 consecutive paranasal sinus CT scans was conducted. In the clinical part of the research, trans-SMP sphenoidotomy was performed in consecutive patients operated on for chronic rhinosinusitis.

RESULTS

The SMP was found in 25% of sides (34% of patients). It was constantly located superolateral to the posterior insertion of the middle turbinate. The SMP formed the prominence on the posterior wall of the maxillary sinus that could be identified using volume rendering in 11% of sides (19% of patients). 30 trans-SMP sphenoidotomies were performed in 18 patients. The SMP prominence was identified in 15 sides. In absence of SMP prominence, identification of the SMP was still possible using other anatomical landmarks.

CONCLUSIONS

The SMP is present in over 30% Caucasian subjects at least on one side. Sphenoidotomy through the SMP is feasible and safe.

Detection of traumatic internal carotid artery pseudoaneurysm by postmortem imaging: A case report

RATIONALE

Postmortem imaging (PMI), including computed tomography (PMCT), postmortem computed tomography angiography (PMCTA), and postmortem magnetic resonance imaging (PMMRI), is rapidly becoming effective and a practical method in forensic medicine. This study aimed to present a specific forensic case in which the PMI approach and its applications were used.

PATIENT CONCERNS

A 40-year-old male patient had moderate unilateral nose bleeding constantly 10 times after suffering from a head injury induced by a car accident. After a bilateral massive nose bleeding for the last time, he died from hemorrhagic shock. Traumatic internal carotid artery pseudoaneurysm (TICAP) was suspected in this patient.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

A whole-body scanning was performed using PMCT and PMMRI. Then, PMCTA using left ventricular cardiac puncture was also implemented. A water-soluble contrast agent was injected into the left ventricle and pumped toward the intracranial, followed by a repeated whole-body PMCT scan. The PMCT/PMMRI detected a high-density/signal mass inside the left sphenoid sinus. The PMCTA detected a distinct leakage of the contrast agent into the left sphenoid sinus from an adjacent aneurysm of the C3 section of the left internal carotid artery. Autopsy and histology confirmed a TICAP inside the sphenoid sinus.

LESSONS

This case showed that the PMI was of great value for identifying the cause of death in special cases. When vascular lesions are suspected in the body, PMI and especially the PMCTA approach may be an effective detection method.

[The method of instrumental dilatation of the anastomosis of the sphenoid sinus in the surgical treatment of chronic sphenoiditis]

Features of the location of the sphenoid sinus determine the possibility of developing severe intraoperative complications in the surgical treatment of patients with chronic sphenoiditis. Technical difficulties during sphenoidotomy may arise at the initial stage of expansion of the natural anastomosis with its anatomical narrowness and the impossibility of inserting biting forceps.

PURPOSE OF THE STUDY

To study the clinical efficacy and safety of the proposed original method of dilatation of the sphenoid sinus fistula in the surgical treatment of various forms of chronic sphenoiditis.

MATERIAL AND METHODS

The study included 68 patients of both sexes older than 18 years with chronic sphenoiditis, who are indicated for surgery on the sphenoid sinus. Patients of the 1st group (n=36) underwent expansion of the fistula of the sphenoid sinus using the traditional method. Patients of the 2nd group (n=32) underwent dilatation of the anastomosis of the sphenoid sinus using the tool developed by us. Intraoperatively, the quality of visualization of the surgical field, the time of the operation, and the presence of complications were assessed. In the postoperative period, the number of complications, relapses of the disease and the condition of the sinus were recorded according to the results of computed tomography 3-4 months after the operation.

RESULTS

The use of the method of dilated expansion of the anastomosis of the sphenoid sinus using special forceps developed by us helps to reduce the duration of the operation, improve intraoperative visualization of the sphenoid sinus and improve the results of treatment according to endoscopy and control computed tomography. When using the developed tool, the number of episodes of intraoperative bleeding that hindered visualization and necessitated coagulation was lower than when using an alternative technique.

CONCLUSION

The technique of endoscopic dilatation of the anastomosis of the sphenoid sinus using the developed tool can be used both independently and as a preliminary step for expanding the anastomosis of the sphenoid sinus, followed by the use of a shaver or Kerrison forceps.

[Endoscopic endonasal reconstruction of skull base defects in the lateral recess of the sphenoid sinus: evaluation of computed tomograms for planning operations]

OBJECTIVE

Determine the influence of the anatomical features and sizes of the lateral pocket with a defect on the choice of surgical access and the quality of the performed plastics.

MATERIAL AND METHODS

A retrospective analysis of computed tomograms of 38 patients who underwent surgical treatment at the Burdenko National Medical Research Center for Neurosurgery of the Ministry of Health of Russia about defects of the skull base in the area of the lateral pocket of the sphenoid sinus. The patients were divided into three groups depending on the approach used (the 1st group), the recurrence rate (the 2nd group), and the characteristics of intraoperative visualization of the defect (the 3rd group).

RESULTS

There were no statistically significant differences in anatomical features in patients who underwent trans-pterygoid and transsphenoidal approaches, as well as in patients of the 2nd group. Patients of the 3rd group (with visualization features) showed statistically significant differences between the distance from the defect to the VR line (p=0.007). In patients with good visualization of the defect using direct optics, this distance was shorter than in patients in whom the defect was visualized with an angled endoscope. No other anatomical differences were noted.

CONCLUSIONS

The anatomical features of the lateral pocket structure (type of pneumatization, size and volume) did not affect the choice of access to the defect and the frequency of recurrence. When comparing the approaches, it was noted that the trans-pterygoid access, providing direct visualization of defects, minimizes the risk of recurrence in the postoperative period. An objective anatomical indicator for choosing an access to the defects of the lateral pocket can be the distance from the defect to the VR line: at a distance of more than 0.7 cm, it is advisable to perform a trans-pterygoid approach; at a distance of less than 0.7 cm, it is possible to achieve direct visualization of the defect and perform high-quality plastic surgery with a transsphenoidal access.

Pneumatization Patterns of the Sphenoid Sinus in Adult Nigerians and Their Clinical Implications

BACKGROUND

The variant pneumatization patterns of the sphenoid sinus have significant surgical implications due to their associated inconsistent neurovascular relations. This study aimed at evaluating the pneumatization patterns of the sphenoid sinus in adult Nigerians.

METHODS

This was a retrospective study conducted at the Radiology Department of a Tertiary Hospital in Nigeria after obtaining institutional ethical approval. Brain Computed Tomography images of 336 patients (137 females, 199 males) aged ≥20 years were studied for the variant pneumatization patterns of the sphenoid sinus. Statistical Package for Social Sciences version 23 was used for data analysis. Chi-square test was used to assess for the association of the variants with gender and side. Pvalue was considered significant at <0.05.

RESULTS

The predominant pneumatization pattern in relation to the seller turcica was the sellar type (181;53.9%) followed by the presellar type (65;19.3%), post-sellar (62;18.5%), and lastly the conchal type (28;8.3%). The most prevalent clival recess was the subdorsal type (25;7.4%) followed by the dorsal (18;5.4%), combined (7;2.1%), and lastly occipital (3;0.9%). The frequency of pneumatized anterior clinoid process, greater wing of sphenoid and pterygoid process was 76;22.6%, 60;17.9% and 141;42% respectively and these showed significant side difference (P=0.001 each). None of the pneumatization patterns showed a significant gender difference. Sphenoid sinus agenesis was not observed.

CONCLUSION

The pneumatization patterns in our study varied from the findings in previous Nigerian studies and other populations. There is therefore the need for preoperative evaluation before endoscopic transsphenoidal surgical procedures.

Agenesis of the sphenoid sinus and a single sphenoid sinus: a computed tomography anatomical evaluation

BACKGROUND

Sphenoid sinuses are pneumatic spaces within the body of the sphenoid bone. Their development begins in the prenatal life and continues until the adulthood. Agenesis of the sphenoid sinuses is a situation in which they are undeveloped. On the other hand, asingle sphenoid sinus lacks the presence of the main septum, leading to the formation of a single antrum. Contemporary use of transnasal transsphenoidal approaches for the pituitary surgery, as well as functional endoscopic sinus surgery urges medical professionals to be well acquainted with the aforementioned variant.

MATERIALS AND METHODS

Paranasal sinuses of 300 patients (150 females, 150 males) were evaluated using computed tomography, without the use of contrast medium. Inclusion criteria involved absence of any identifiable pathology within the sphenoid sinuses and age over 18 years. Subgroup analysis involved probing for potential sources of heterogeneity, namely gender.

RESULTS

In the whole research material of 300 patients, agenesis of the sphenoid sinuses was noted in 1% of the patients. No statistically significant differences were noted between the absence of the sphenoid sinuses and gender (p = 0.999). A single sphenoid sinus was found in 0.33% of the patients. There were no statistically significant differences found between the presence of fully developed sphenoid sinuses and gender (p = 0.498).

CONCLUSIONS

Both agenesis of the sphenoid sinuses, as well as a single sphenoid sinus are rare anatomical variants. Adequate planning for transsphenoidal surgeries with preoperative medical imaging is of essence in order to perform a safe and quality procedure.

Variant neurovascular relations of the sphenoid sinus in adult Nigerians

Background

With the advent of endoscopic sinus surgery, the variant neurovascular relations of the sphenoid sinus are important to surgeons to minimise the iatrogenic complications. This study elucidates the variant neurovascular relations of the sphenoid sinus in adult Nigerians.

Materials and Methods

This study was conducted at the Radiology Department of Delta State University Teaching Hospital after institutional approval. Brain computed tomography images of 336 patients, aged ≥20 years and spanning over 5 years' duration were utilised. We evaluated the sphenoid sinus for protrusion and dehiscence of neurovascular structures bilaterally. The position of the optic nerve in relation to the sinus was classified from Type 0-4. The Statistical Package for the Social Sciences software version 23 was used for the data analysis. The Chi-square test was used to probe for the association between the variants with regard to side and gender. P < 0.05 was considered statistically significant.

Results

Dehiscence and protrusion of the internal carotid artery (ICA) occurred in 34, 10.1% and 83, 24.7% patients correspondingly. The dehiscence of optic, maxillary and Vidian nerves was (26, 7.7%), (60, 17.9%), and (53, 15.8%), whereas the frequency of their protrusion was (50, 14.9%), (76, 22.6%) and (87, 25.9%), respectively. All these variants except the ICA and maxillary nerve dehiscence showed a significant association with the side of occurrence (P = 0.001). Out of the 672 optic canals evaluated bilaterally, a preponderance of Type I (534, 79.5%) was observed followed by II (96, 14.3%), IV (35,5.2%), III (7, 1.0%) and Type 0 (0, 0%).

Conclusion

Our study has shown that the neurovascular relations of the sphenoid sinus vary from previously documented reports, thus confirming the need for pre-operative evaluation.

Therapeutic potential of intranasal photobiomodulation therapy for neurological and neuropsychiatric disorders: a narrative review

The application of photobiomodulation therapy (PBMT) for neuronal stimulation is studied in different animal models and in humans, and has shown to improve cerebral metabolic activity and blood flow, and provide neuroprotection via anti-inflammatory and antioxidant pathways. Recently, intranasal PBMT (i-PBMT) has become an attractive and potential method for the treatment of brain conditions. Herein, we provide a summary of different intranasal light delivery approaches including a nostril-based portable method and implanted deep-nasal methods for the effective systemic or direct irradiation of the brain. Nostril-based i-PBMT devices are available, using either lasers or light emitting diodes (LEDs), and can be applied either alone or in combination to transcranial devices (the latter applied directly to the scalp) to treat a wide range of brain conditions such as mild cognitive impairment, Alzheimer's disease, Parkinson's disease, cerebrovascular diseases, depression and anxiety as well as insomnia. Evidence shows that nostril-based i-PBMT improves blood rheology and cerebral blood flow, so that, without needing to puncture blood vessels, i-PBMT may have equivalent results to a peripheral intravenous laser irradiation procedure. Up to now, no studies were conducted to implant PBMT light sources deep within the nose in a clinical setting, but simulation studies suggest that deep-nasal PBMT via cribriform plate and sphenoid sinus might be an effective method to deliver light to the ventromedial part of the prefrontal and orbitofrontal cortex. Home-based i-PBMT, using inexpensive LED applicators, has potential as a novel approach for neurorehabilitation; comparative studies also testing sham, and transcranial PBMT are warranted.

Value of Hounsfield Units in the Evaluation of Isolated Sphenoid Sinus Lesions

Radiologic findings of fungal sinus disease are generally opacification in paranasal computed tomography (CT) images. The Hounsfield unit (HU) is a standardized objective unit that is also suitable for measuring remodeling and opacifications on CT scans of bone sections of patients with chronic rhinosinusitis. We hypothesized that HU values could provide valuable information in isolated sphenoid sinus lesions before surgery. Between 2012 and 2019, 35 patients underwent functional endoscopic sinus surgery for sphenoid sinus lesions. Tissues obtained from the sphenoid sinus were divided into two groups, fungal and nonfungal, according to the findings of histopathologic examinations. HU values were measured in sphenoid sinus sections on paranasal CT scans of these two groups. Differences in mean and maximum HU values between the two groups were statistically significant (p < .05). The maximum HU values calculated from the sphenoid sinus were 435.08 and 196.23 (p ≤ .05) in the fungal group and nonfungal group, respectively. The mean HU values calculated from the sphenoid sinus were 64.31 and 29 (p ≤ .05) in the fungal and nonfungal groups, respectively. At the maximum cutoff value of 241, the sensitivity and specificity of the HU maximum were 84.6% and 77.3%, respectively. At the mean cutoff value of 41.5, the sensitivity and specificity of the HU mean were 76.9% and 86.4%, respectively. HU is an objective value used in radiographic density measurement. The HU values were higher in fungal lesions than in nonfungal inflammations, and they are useful in preoperative measurement.

How important is the Sphenoseptal cell in identifying the skull base? Recent incidence and demonstration of endoscopic surgical steps

Background/aim

Because of close relations to important anatomical structures such as cavernous sinus and optic nerve, sphenoid sinus variations must be well trained by the otolaryngologist who has an interest in endoscopic sinus surgery. Newly defined sphenoseptal cell (SSC) is one of those variations that may lead to insufficient endoscopic sinus surgery outcomes if not defined preoperatively with imaging studies. The present study aimed to present the main characteristics of this special type of nasal cell.

Materials and methods

In this study, 610 paranasal sinus CT scans were analyzed and reviewed retrospectively between May 2018 and December 2019. Also, endoscopic findings of SSC that cause a surgical catastrophe in identifying skull base and sella are presented during transnasal transsphenoidal pituitary surgery.

Results

According to its definition and relation to the sphenoid sinus and the skull base, an SSC was seen in 21 scans of 610 patients (3.4%), 11 were women (55%) and 10 were men (45%).

Conclusion

Although an SSC is a rare variation of nasal air cells, preoperative diagnosis of this cell is of paramount importance in some patients during endoscopic transnasal surgery for the identification of skull base.

Assessment of variations in sphenoid sinus pneumatization in Indian population: A multidetector computed tomography study

Background and Purpose:

The purpose of our study was to assess the prevalence of variations in the extent of sphenoid pneumatization in the Indian population and compare with existing literature.

Materials and Methods:

This retrospective study included 500 patients who underwent CT of the paranasal sinuses. The multiplanar reformations of paranasal sinus were assessed for the type of pneumatization of the sphenoid sinus and type of clival, lateral recess, lesser wing, and anterior recess extensions.

Results:

The conchal, presellar, incomplete sellar, and complete sellar types comprised 0%, 1.2%, 22.2%, and 76.6% of patients. The extensions of pneumatization subtypes in the study population were clival in 76.6% subjects; lateral recess, lesser wing, and anterior recess in 59.7%, 20.4%, and 20.4% of sinuses, respectively. The pure forms were seen in 25.4% and combined forms in 61% of sinuses. The presellar type (1.2%) was less common and sellar type (98.8%) being common in our population compared to the Caucasian and East Asian population. The sphenoid sinuses were extensively pneumatized in our population compared to the Chinese and Caucasian population, the prevalence being 76.6%, 68%, and 44.5% for clival; 59.7%, 46%, and 28.3% for lateral recess; 20.4%, 32%, and 12% for lesser wing extension, respectively. The pure forms were relatively less common and combined forms being more common compared to the Chinese and Caucasian population in our study.

Conclusion:

The extent of pneumatization of the sphenoid sinus has clinical and surgical implications in sellar and central skull base lesions, and variability in different populations confirms that ethnicity influences the differences in prevalence.

A computed tomography comprehensive evaluation of the ostium of the sphenoid sinus and its clinical significance

BACKGROUND

The purpose of this research was to evaluate the size of the sphenoid sinuses' ostia, the distance between them and the distance between the medial margin of the ostia and the median line in the Polish adult population.

MATERIALS AND METHODS

The analysis was undertaken as a retrospective study of 296 computed tomography (CT) scans of patients (147 females, 149 males) with no comorbidities in their sphenoid sinuses. The paranasal sinuses were investigated by using Spiral CT Scanner (Siemens Somatom Sensation 16), in the option Siemens CARE Dose 4D, without administering any contrast medium. Having obtained transverse planes, multiplans reconstruction tool was used in order to glean sagittal and frontal planes.

RESULTS

The average size of both sphenoid sinuses ostia was 0.31 cm for both genders (for females ranging from 0.1 to 0.5 cm and from 0.1 to 0.6 cm for males). The mean distance between both sphenoid sinuses ostia was 0.6 cm for both genders (the range for females was 0.1-1.4 cm, whereas 0.1-1.8 cm for males). The average distance between the medial margin of the ostium and the median line was 0.32 cm for both genders (0.31 cm for females in the range of 0-0.9 cm and 0.32 cm for males in the range of 0-1 cm).

CONCLUSIONS

Intraoperative identification of the sphenoid sinus ostia might prove difficult and their inadequate excision could lead to potential iatrogenic complications, hence detailed anatomical descriptions are still warranted in specific populations in order to perform safe and effective procedures.

Trigeminal Numbness After Intracranial Repair of a Spontaneous Meningoencephalocele of the Lateral Wall of the Sphenoid Sinus

A 58-year-old female with an eight-year history of rhinorrhea and a two-day history of subjective fever, chills, and vomiting presented to the emergency department for neurosurgical evaluation. Brain MRI demonstrated herniation of the meninges and portions of the inferomedial right temporal lobe through a defect of the lateral wall of the right sphenoid sinus, extending to the sphenoethmoidal recess and posterior right ethmoid air cells. A right pterional craniotomy was performed where the herniated part of the right temporal lobe, and its associated meninges, were excised. After surgery, she had hypoesthesia at the right maxillary division of the trigeminal nerve. This finding was caused by the proximity of the trigeminal nerve to the dural dissection that we performed at the bone defect. This rare complication has never been described after intracranial surgery. Only eight literature reports have described hypoesthesia or paresthesia of the trigeminal nerve after endoscopic resection of a sphenoid sinus meningoencephalocele. The patient has not had any recurrence of rhinorrhea after a six-month follow-up period.

Sphenoid Bone Pneumatisation on Lateral Cephalograms of Patients With Neurofibromatosis Type 1

BACKGROUND/AIM

Neurofibromatosis type 1 (NF1) is an autosomal dominant hereditary disease that causes tumors and many developmental disorders, e.g., cranial dysplasia. The purpose of this retrospective study was to analyse the pneumatisation of the sphenoid bone in NF1.

PATIENTS AND METHODS

The anonymised lateral cephalograms of 166 NF1 patients and 166 age- and sex-matched controls were examined for anterior-posterior sphenoid pneumatisation. The patient group analysis considered whether the patients had been affected by a facial plexiform neurofibroma (FPNF).

RESULTS

Sphenoid pneumatisation was significantly lower in NF1 patients than in controls [odds ratio (OR)=0.184; 95%CI=0.11-0.32; p<0.001]. A FPNF statistically significantly reduced sinus formation in patients (OR=0.38; p=0.002).

CONCLUSION

The condition 'NF1' has an effect on sphenoid pneumatisation. The findings are relevant for planning surgical procedures in this region and confirm current concepts to evaluate NF1 as a histogenesis control gene. The examination technique and basis of calculation presented here are easy-to-use and low-irradiation exposure instruments for screening for differences in sphenoid bone pneumatisation in defined populations.

A Study of the Developing Paediatric Skullbase Anatomy and its Application to Endoscopic Endonasal Approaches in Children

Objective

The sinonasal anatomy in growing children undergoes change in size along with progressive pneumatization, this is of particular significance in endoscopic endonasal surgery. We aim to measure and quantify the sinonasal dimensions in the Indian paediatric population, which are relevant to skull base surgeons.

Material and Methods

This is a retrospective radio anatomical study of sinonasal measurements and volumetric analysis of the sphenoid sinus performed on archived CT images of children less than 18 years of age.

Results

CT scan images of 110 patients (male, 68; female, 42) were included for the study. The number of patients in each age groups was as follows [0-6 years, 17; 7-9 years, 20; 10-12 years, 27; 13-15 years, 29; 16-18 years, 17]. The distance from the nares to the sphenoid and from the sphenoid to the sella was significantly greater in children of 13-15 years (69.4 ± 5.2 mm) as compared to children less than six years (62.6 ± 6.7 mm) (P < 0.003). The volume of the sphenoid in children between 0 and 6 years was 4641.4 ± 1924.7 mm³. The pneumatized sphenoid volume in the same age group was 1655 ± 1631.1 mm³. In older children between 13 and 15 years, the total volume of sphenoid sinus was 11732.8 ± 2614.4 mm³. The volume of pneumatization in the sphenoid sinus in this group was 6287.5 ± 2157.9 mm³. The total volume of the sphenoid sinus (Pearson coefficient (r) = 0.704, P < 0.001) and the volume of pneumatization of the sphenoid sinus was also seen to have a positive correlation to the age of the child (r = 0.62, P < 0.0001). The narrowest distance between both the internal carotid arteries was seen at the level of the proximal dural ring. In children less than six years of age it was 13.4 ± 2.0 mm, a significant change was seen by the age of 10-12 years where this distance was 15.6 ± 2.2 mm (P = 0.036).

Conclusion

The sinonasal anatomy shows progressive development between the age of 6 to 15 years after which it plateaus. The pneumatization in young children may be incomplete, which necessitates drilling in the sphenoid sinus. The intercarotid distance was not seen to be a hindrance for endoscopic endonasal surgery. None of the measurements of the skull-base, made in this study appear to restrict endoscopic endonasal surgery in children. However, a meticulous preoperative assessment of the CT scan may be needed for optimal surgical outcome.

Bacterial Flora in the Sphenoid Sinus Changes with Perioperative Prophylactic Antibiotic Administration

The complications of endonasal transsphenoidal surgery (ETSS) include meningitis and sinusitis, and these complications are troublesome. Some reports have investigated the type of bacteria and the susceptibility of sphenoid sinus mucosal flora to drugs. However, most specimens can be collected after perioperative antibiotic administration. In this study, 95 and 103 sphenoid sinus mucosal samples collected during ETSS from September 2013 to February 2015 and from June 2017 to January 2019, respectively, were examined for bacterial culture. Sphenoid sinus mucosal samples were collected after antibiotic administration in the first period, whereas samples were collected before antibiotic administration in the second period. Hence, the specimens in the second period were not affected by antibiotics. Moreover, drug susceptibility tests for the detected bacteria were performed. Overall, 52 and 51 bacterial isolates were collected during both periods. Gram-positive cocci (GPCs), including Staphylococcus aureus and Staphylococcus epidermidis, were more common in the non-antibiotic group than in the antibiotic group (p <0.01). However, the proportion of gram-negative rods (GNRs) did not significantly differ between the two groups (p = 0.54). The antibiotic group had a significantly higher proportion of bacteria resistant to ampicillin (p <0.01) and first-generation cephalosporin (p = 0.01) than the non-antibiotic group. In conclusion, there was a difference in bacterial flora in the sphenoid sinus mucosal samples collected before and after intraoperative antibiotic administration.

Unusual Presentation of a Sphenoidal Sinus Neuroendocrine Tumor: A Case Report and Review of Literature

Neuroendocrine tumors (NETs) have a heterogeneous pathology and indolent behavior, with the most common location being the gastrointestinal tract and then the lungs. The head and neck are rare sites of NET presentation with varied clinical signs and symptoms, which occasionally delay the diagnosis, thereby leading to an advanced stage at presentation. We present a rare case of paranasal sinus small cell neuroendocrine tumor and perform a review of the literature. A 71-year-old man presented with continuous bleeding from the left nostril and nasal congestion without any prior medical history. Clinical examination revealed nasal congestion, rhinorrhea, postnasal drip, and active bleeding. The laboratory data were within normal limits. Imaging studies showed a left sphenoid sinus mass extending to the left ethmoid sinus with a break in the cribriform plate encephalocele. An enlarged lymph node measuring 2.2 cm was noted in the left neck and supraclavicular region. The evaluation through stereotactic endoscopic sinus surgery and biopsy revealed left nasopharyngeal, sphenoid sinus, and ethmoid sinus masses. Pathologic biopsy findings were consistent with high-grade, malignant, small, round blue cell tumors. Immunohistochemical analysis confirmed high-grade small cell neuroendocrine carcinoma. The patient was diagnosed with stage IV (TXN2bM0, T: tumor size, N: lymph node, M: metastasis) high-grade neuroendocrine tumor of the left paranasal sinus. He was treated with concurrent chemoradiation therapy with two cycles of etoposide and cisplatin and radiation therapy with proton beam radiation therapy followed by two cycles of adjuvant etoposide cisplatin chemotherapy. The patient showed a good response to the treatment, as confirmed using imaging. He is currently being regularly followed up with serial imaging.

Dopamine Agonist-Induced Cerebrospinal Fluid Rhinorrhoea: A Case Report

Introduction

Prolactinomas are the most common pituitary adenomas. Medical therapy with dopamine agonists (DAs) is the mainstay of treatment and rarely requires surgical manipulation. Patients may rarely present with cerebrospinal fluid (CSF) rhinorrhoea after starting therapy with DA in case of massive or invasive prolactinomas.

Case Description

We present a case of a 29-year-old lady with invasive prolactinoma who presented with CSF rhinorrhoea after a month of starting bromocriptine therapy with the development of meningitis and warranting early surgical repair.

Practical Implications

Patients with macroprolactinoma should be closely monitored initially after starting on DA to avoid life-threatening complications.