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1.  Combined Lateral Orbitotomy and Endoscopic Transnasal Orbital Decompression in a Case of Orbital Aspergillosis with Impending Intracranial Invasion 
Case Reports in Ophthalmology  2012;3(3):418-423.
A 64-year-old man with a known history of diabetes and hypertension presented to the Accident and Emergency Department with a 2-day history of sudden decreased vision in the right eye. Temporal arteritis was suspected with an elevated erythrocyte sedimentation rate (71 mm/h), and oral prednisolone was started immediately. Four days later, the patient's right eye vision deteriorated from 0.6 to 0.05, with a grade-4 relative afferent pupillary defect and ophthalmoplegia. Computed tomography showed a contrast-enhancing orbital apex mass in the right orbit abutting the medial and lateral portions of the optic nerve with extension to the posterior ethmoid and sphenoid sinuses. A transethmoidal biopsy was performed which yielded septate hyphae suggestive of Aspergillus infection. Ten days later, the patient's right eye vision further deteriorated to hand movement with total ophthalmoplegia. MRI of the orbit showed suspicion of cavernous sinus thrombosis. A combined lateral orbitotomy and transethmoidal orbital apex drainage and decompression were performed to eradicate the orbital apex abscess. Drained pus cultured Aspergillus. The patient was prescribed systemic voriconazole for a total of 22 weeks. The latest MRI scan, performed 8 months after surgery, showed residual inflammatory changes with no signs of recurrence of the disease. To our knowledge, this is the first case report which describes the use of a combined open and endoscopic approach for orbital decompression and drainage in a case of orbital aspergillosis. We believe the combined approach gives good exposure to the orbital apex, and allows the abscess in this region to be adequately drained.
doi:10.1159/000346043
PMCID: PMC3551432  PMID: 23341818
Orbital aspergillosis; Lateral orbitotomy; Transethmoidal orbital apex drainage
2.  Isolated sphenoid sinus disease — a retrospective analysis 
Objective
To evaluate the etiology, symptoms, signs, imaging, surgical findings and outcomes of isolated sphenoid sinus disease (ISSD).
Design
Retrospective study.
Settings
Tertiary university based referral center.
Materials and methods
All 8 patients aged 17–63, managed surgically in the department of ENT and Head and Neck Surgery at St. John’s Medical College and Hospital, Bangalore from 2006 to 2008 for ISSD. Demographic data, presenting signs and symptoms endoscopic and imaging findings, surgical management, surgical pathology and clinical outcomes were investigated in the above patients.
Results
Of the 8 cases of ISSD, 5 were male; 3 were female, with an age range of 17–63 years. The most common presenting symptom was headache (7 patients [87.5%]), followed by nasal obstruction and recurrent URTI (5 cases [62.5%]). Imaging included CT and/or MRI studies in all cases. Sphenoid sinus pathology was varied and included 5 (62.5%) inflammatory cases, 1 (11.1%) cerebrospinal fluid fistula and 2 (22.2%) cases of sphenoid sinus neop;asms. Of the inflammatory cases 2 (40%) had isolated polyps in the sphenoid sinus [sphenochoanal polyps] and 3 (60%) had fungal sinusitis. Treatment was surgical, endoscopic transnasal sphenoidotomy under general anesthesia in all 5 patients with inflammatory ISSD Two patients with sphenoid sinus tumors underwent endoscopic biopsy.
Conclusion
ISSD is rare. A high index of suspicion is required for diagnosis, which should be an active process and not one of exclusion. Both diagnostic nasal endoscopy and CT imaging are essential for diagnosis. The direct approach to the sphenoid sinus, transnasal endoscopic sphenoidotomy without ethmoidectomy is safe and effective. With early and adequate surgery we were able to avoid the morbidity associated with ISSD.
doi:10.1007/s12070-010-0016-6
PMCID: PMC3450151  PMID: 23120685
Sphenoid sinus; Sphenochoanal polyp; Sinusitis; Headache; Sphenoidotomy
3.  Non-Hodgkin's lymphoma of the sphenoid sinus presenting as isolated oculomotor nerve palsy 
Background
Solitary involvement of the sphenoid sinus has rarely been reported in non-Hodgkin's lymphoma. Isolated oculomotor nerve palsy is uncommon as an initial presentation of malignant tumors of the sphenoid sinus.
Case presentation
A 53-year-old woman presented with a three-month history of headache and diplopia. Neurological examination revealed complete left oculomotor nerve palsy. Magnetic Resonance Imaging (MRI) demonstrated a homogenous soft-tissue lesion occupying the left sphenoid sinus and invading the left cavernous sinus. The patient underwent transsphenoidal biopsy and the lesion was histologically diagnosed as non-Hodgkin's lymphoma, diffuse large B-cell type. Tumor cells were positive for CD20 and negative for CD3. Following six cycles of chemotherapy, the left oculomotor nerve palsy that had been previously observed was completely resolved. There was no enhancing lesion noted on follow-up MRI.
Conclusion
It is important to recognize that non-Hodgkin's lymphoma of the sphenoid sinus can present with isolated oculomotor nerve palsy, although it is extremely rare. The cranial nerve deficits can resolve dramatically after chemotherapy.
doi:10.1186/1477-7819-5-86
PMCID: PMC1950883  PMID: 17683562
4.  Endoscopic Craniofacial Approach for Intracranial Polyposis: The “Blue–Sky Technique” 
Skull Base  2003;13(4):235-239.
ABSTRACT
Massive sinonasal polyposis associated with skull base dehiscence and intracranial extension is a difficult disease to treat. Conventional transnasal or transfacial techniques can result in dural injury, cerebrospinal fluid (CSF) leak and infection. We describe our experience with a combined neurosurgical–endoscopic technique that protects the meninges. Five patients with massive sinonasal polyposis extending intracranially through skull base dehiscence were reviewed retrospectively. The minimum follow–up was 2 years. A frontal craniotomy was performed through a bicoronal approach. The dura was carefully separated from all infectious material at the floor of the anterior cranial fossa. The frontal lobe with the intact meninges was elevated off the anterior cranial floor. A sheet of blue plastic material was inserted under the frontal lobe from the craniotomy site to the planum sphenoidale. Next, a transnasal endoscopic ethmoidectomy, sphenoidectomy, and frontal sinusotomy were performed to remove the inflammatory processes. The blue plastic material was visible through any existing or potential skull base dehiscence, thus providing visual protection for the dura and brain. All gross disease was removed from the frontal, ethmoid, and sphenoid skull base regions in the 5 patients without dural injury. None of the patients developed a CSF leak or meningitis. Two patients developed recurrent polyposis limited to the sinuses without intracranial extension. The endoscopic craniofacial approach with the “Blue–Sky” protective technique offers a safe method for completely removing massive sinonasal polyposis associated with an intracranial extension.
doi:10.1055/s-2004-817700
PMCID: PMC1131857  PMID: 15912183
Sinonasal polyposis; craniofacial resection
5.  Isolated Sphenoid Sinus Mucocele Presenting as Third Nerve Palsy 
A sphenoid mucocele often presents late due to its deep seated anatomical site. And it has varied presentation due to its loose relationship to the cavernous sinus and the base of the skull. We describe a case of large sphenoid sinus mucocele. A middle aged old man suddenly developed third cranial nerve palsy. Brain imaging study revealed an isolated sphenoid sinus mucocele, compressing right cavernous sinus. Endoscopic marsupialization of the mucocele via transnasal approach led to complete resolution of the third cranial nerve palsy. Involvement of the third cranial nerve in isolated mucocele is rare but important neurosurgical implications which must be excluded. In addition, proper and timely treatment must be performed to avoid permanent neurologic deficit.
doi:10.3340/jkns.2010.48.4.360
PMCID: PMC2982917  PMID: 21113366
Sphenoid sinus mucocele; Third nerve palsy; Transnasal approach
6.  Isolated sphenoid sinus pathologies – the problem of delayed diagnosis 
Summary
Background
Isolated sphenoid sinus pathologies are relatively rare. In the majority of cases, symptoms do not arise in the early stages of the disease or are non-specific, therefore making diagnosis difficult. The aim of this study was to investigate the diagnostic process and the reasons for development of complications in patients with isolated sphenoid sinus pathology.
Material/Methods
The clinical data and observation charts of 32 patients were investigated to determine how long the main symptoms of sphenoid pathology had been present before the patients were referred for medical treatment, and the time that elapsed from the first ambulatory medical assessment to the initial diagnosis.
Results
Complaints and symptoms of sphenoid sinus pathology had been present for 10.2 months before the diagnosis was established. Although the duration of complaints in “ORL” (diagnosed by otorhinolaryngologist) and “non-ORL” (diagnosed by other specialists) group of patients was similar (10.8 and 9.5 months on average, respectively), unexpectedly, in the “non-ORL” group of patients, the time necessary for making the initial diagnosis was actually shorter than in the “ORL” group (1.8 vs 4.1 months). At the time of hospital admission, endoscopic examination revealed no abnormalities in 31.2% of patients. In 28.1% of patients the pathological process in the sphenoid sinus was diagnosed only after the onset of complications.
Conclusions
The occult character of the disease and the lack of severe and specific symptoms, rather than the delay in getting extensive diagnostic tests, are responsible for the delayed diagnosis and treatment.
doi:10.12659/MSM.881454
PMCID: PMC3524726
sphenoiditis; isolated lesion; complications
7.  An Unusual Case of Cerebral Penetrating Injury by a Driven Bone Fragment Secondary to Blunt Head Trauma 
Temple trauma that appears initially localized to the skin might possess intracranial complications. Early diagnosis and management of such complications are important, to avoid neurologic sequelae. Non-penetrating head injuries with intracranial hemorrhage caused by a driven bone fragment are extremely rare. A 53-year-old male was referred to our hospital because of intracerebral hemorrhage. He was a mechanic and one day before admission to a local clinic, tip of metallic rod hit his right temple while cutting the rod. Initial brain computed tomography (CT) and magnetic resonance imaging demonstrated scanty subdural hematoma at right temporal lobe and left falx and intracerebral hematoma at both frontal lobes. Facial CT with 3-D reconstruction images showed a small bony defect at the right sphenoid bone's greater wing and a small bone fragment at the left frontal lobe, crossing the falx. We present the unusual case of a temple trauma patient in whom a sphenoid bone fragment migrated from its origin upward, to the contralateral frontal lobe, producing hematoma along its trajectory.
doi:10.3340/jkns.2011.50.6.532
PMCID: PMC3272517  PMID: 22323943
Head injury; Penetrating; Bone fragment
8.  Brain abscess and generalized seizure caused by halo pin intracranial penetration: case report and review of the literature 
European Spine Journal  2008;18(Suppl 2):172-175.
The objective of our study is to report a rare complication of halo pin insertion associated with an epileptic seizure and brain abscess, and to discuss the diagnostic and therapeutic approach to its management. The treatment of unstable cervical spine injuries with a halo vest is an established procedure. Complications of pin penetration such as brain abscess and seizure are rare, and need to be urgently treated. Intracranial abscess and seizure associated with the use of the halo device is an unusual complication, and only a few cases have been reported in the literature. A 21-year-old male had a halo vest placed for the management of an odontoid type II fracture, which he sustained from a motor vehicle accident. Ten weeks after halo ring placement he complained of headaches which relieved by analgesics. After 2 weeks he was admitted at the emergency unit in an unconscious condition after a generalized tonic-clonic seizure. The halo pins were displaced during the seizure and were removed at his admission. No drainage was noted from the pin sites, and a Philadelphia cervical collar was applied. A brain CT and MRI revealed intracranial penetration of both posterior pins and a brain abscess in the right parietal lobe. Computed tomography of the cervical spine revealed stable fusion of the odontoid fracture. Cultures from the pin sites were negative; however, intravenous wide spectrum antibiotic treatment was administered to the patient immediately for 4 weeks followed by oral antibiotics for additional 2 weeks. Anti-epileptic medication was also started at his admission. The patient was discharged from the hospital in 6 weeks without symptoms, continuing anti-epileptic medication. On the follow-up visits he had fully recovered without any neurologic sequelae. In conclusion, complications of halo pin penetration are rare which need immediate intervention. Any neurologic or infectious, local or generalized, symptom need to be investigated urgently with available imaging techniques and treated promptly. Pin over-tightening may cause bone penetration and possible deep cranial infection with serious complications.
doi:10.1007/s00586-008-0759-x
PMCID: PMC2899570  PMID: 18751739
Odontoid fractures; Halo pin penetration; Brain abscess; Seizure
9.  Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis 
Skull Base  2007;17(2):125-132.
ABSTRACT
Cerebrospinal fluid (CSF) leaks result from a communication between the subarachnoid space and the upper aerodigestive tract. Because of the risk of complications such as meningitis, brain abscess, and pneumocephalus, all persistent CSF leaks should be repaired. Surgical repair may be achieved transcranially or extracranially using a wide variety of autogenous, allogenic, and synthetic patching materials. We report our results with a transnasal transsphenoidal endoscopic approach for the repair of CSF leaks coupled with a multilayer closure using acellular dermis (Alloderm™). We conducted a retrospective review of all patients presenting to our institution over the past 5 years with isolated sphenoid sinus CSF fistulas. Results: Twenty-one patients were included in the study. Nineteen patients (90.5%) had their sphenoid sinus CSF fistula repaired during the first attempt; 2 patients (9.5%) needed a second attempt. The multilayer repair of the CSF leak using acellular dermis via a transsphenoidal endoscopic approach is an effective and successful method of surgical repair of the fistula site. Neither the number, size, nor cause of the CSF fistula affected surgical outcomes. However, the presence of hydrocephalus was a significant negative variable, altering the surgical outcomes of our patients. The acellular dermis offers the advantage of not requiring autogenous tissue for the effective repair of CSF leaks in the sphenoid sinus.
doi:10.1055/s-2007-970556
PMCID: PMC1876155  PMID: 17768442
Transnasal approach; multilayer repair; sphenoid sinus; CSF leak
10.  Retained transorbital foreign body with intracranial extension after pipe bomb explosion 
Background
Penetrating brain injuries caused by explosions are survived in extremely rare cases only. However, potential casualties of such cases may be encountered by regular physicians even outside a war zone, e.g., due to an assault or terror blast. There is very limited literature to this end; therefore, we report the successful neurosurgical management of a penetrating head injury due to a pipe bomb explosion.
Case Description
A 19-year-old man was brought to the ER with a swollen, bleeding right orbit, and a severely injured left hand after having sustained an unwitnessed explosion from a self-made pipe bomb. He presented with a GCS (Glasgow Coma Scale) of 15 at time of admission, work-up revealed an intracranial retained metal fragment measuring 5 × 1 × 0.2 cm lodged retro-orbitally and in the skull base. The patient underwent emergent right temporal craniotomy and temporal lobectomy and simultaneous right enucleation before the petrous bone and sphenoid wing lodged metal fragment was successfully removed.
Conclusion
This case underscores the importance of having a high suspicion for the presence of an intracranial injury and a retained foreign body in the setting of a penetrating head injury. Aggressive and timely workup as well as expeditious surgical management are crucial in these settings and can generate exceptionally good outcomes despite a major trauma.
doi:10.4103/2152-7806.74241
PMCID: PMC3019363  PMID: 21246061
Brain injury; explosion; intracranial foreign body; pipe bomb; transorbital
11.  Sphenoid Sinus Expansion: A Radiographic Sign of Intracranial Hypotension and The Sunken Eyes, Sagging Brain Syndrome (An American Ophthalmological Society Thesis) 
Purpose:
To test the hypothesis that in patient with sunken eyes, sagging brain syndrome, bone remodeling is not limited to the orbits. Volumetric analysis of the sphenoid sinus is performed in this study.
Methods:
In this university-based retrospective case-control study, the dimensions of the sphenoid sinus were measured in four patients (2 males, 2 females; mean age 26.3 years, range 16–38 years) out of five individuals identified with sunken eyes, sagging brain syndrome. Three measurements were taken: the distance between the orbital apices, the posterior extension of the sphenoid sinus posterior to the orbital apices, and the maximal horizontal width. The mean of each was determined and compared to that of the control group (5 males, 5 females; mean age 35.6 years, range 23–45 years).
Results:
Posterior extension and width of the sphenoid sinus were markedly larger in the enophthalmic patients than in the control group: posterior extension (26.3±4.1 mm vs 13.4±6.3 mm, P=.0015, Student’s t test), width (39.2±8.7 mm vs 25.1±6.9 mm, P=.0035, Student’s t test). Mean distance between the orbital apices was slightly greater (36.3±1.7 mm vs 34.1±2.1 mm, P=.047, Student’s t test).
Conclusions:
Skull remodeling occurring in association with intracranial hypotension after ventriculoperitoneal shunting is not limited to the orbits. In this study we have demonstrated expansion of the sphenoid sinus. This finding adds to our knowledge and understanding of the scope of the sunken eyes, sagging brain syndrome and elucidates a clinically useful radiographic sign.
PMCID: PMC3797832  PMID: 24167328
12.  A Modified Surgical Procedure for Endoscopic Optic Nerve Decompression for the Treatment of Traumatic Optic Neuropathy 
Background:
Although the endoscopic anterior-to-posterior technique offers many advantages, the long-term effects of the iatrogenic trauma (removal of the uncinate process and anterior ethmoidal sinus) resulting from the complete ethmoidectomy procedure used to gain full access to the optic nerve canal is unknown, and sequelae such as nasal synechia and sinusitis should not be ignored.
Aims:
The aim of our study is to develop a less invasive procedure for endoscopic optic nerve decompression.
Materials and Methods:
We proposed a modified trans-sphenoidal surgical procedure for endoscopic optic nerve decompression in five patients with traumatic optic neuropathy (TON), all with high sphenoidal pneumatisation and without Onodi cellulae.
Results:
After performing a direct sphenoidotomy through the natural ostium of the sphenoid sinus rather than a complete ethmo-sphnoidectomy, we found that the modified approach provided adequate access to the optic nerve canal and the apex using a 45° angled endoscope. Successful decompression of the canal optic nerve was performed trans-sphenoidally in all five TON patients using an angled endoscope. No surgical complications occurred, and none of the patients suffered from anterior ethmoidal sinus or skull base damage.
Conclusions:
The modified trans-sphenoidal approach is a feasible, safe, effective, and minimally invasive approach for TON patients with high sphenoidal pneumatisation and without supersphenoid-ethmoid cellulae.
doi:10.4103/1947-2714.134372
PMCID: PMC4083528  PMID: 25006562
Endoscopic technique; Optic nerve decompression; Traumatic optic neuropathy
13.  Monophasic Epithelial Synovial Sarcoma Accompanied by an Inverted Papilloma in the Sphenoid Sinus 
Case Reports in Medicine  2012;2012:379720.
A 58-year-old man presented with a six-month history of intermittent blood-stained posterior nasal discharge. Five years ago, he had a three-week episode of fitful light headaches. Nasal ventilation, olfactory sensation, and facial sensation were normal; there were no ophthalmological complaints. Coronal computed tomography (CT) scans revealed soft masses in the bilateral sphenoid sinuses with bone absorption. The patient underwent bilateral functional endoscopic sinus surgery and resection of right nasal papillary masses. Papillary masses and mucosa in both sphenoid sinuses were also removed. The mass in the left sphenoid sinus was diagnosed as two separate entities, one being a primary monophasic epithelial synovial sarcoma and the other an inverted papilloma, while the mass in the right sphenoid sinus was an inverted papilloma. After surgery, the patient underwent radiotherapy and chemotherapy. At the 50-month follow-up visit, there were no signs of recurrence.
doi:10.1155/2012/379720
PMCID: PMC3522498  PMID: 23251173
14.  Inflammatory Pseudotumor of the Head Presenting with Hemiparesis and Aphasia 
Inflammatory pseudotumor most commonly occurs in the orbit and produces orbital pseudotumor, but extension into brain parenchyma is uncommon. We report a case of inflammatory pseudotumor involving sphenoid sinus, cavernous sinus, superior orbital fissure, orbital muscle, and intracranial extension into left temporal lobe producing right hemiparesis and wernicke's aphasia. The patient improved clinically and radiologically with steroid administration. This paper provides an insight into the spectrum of involvement of inflammatory pseudotumor and the importance of early diagnosis of the benign condition.
doi:10.1155/2011/176546
PMCID: PMC3420747  PMID: 22937331
15.  Endoscope-Assisted Trans-Sphenoidal Approach for Treatment of Sternberg's Canal 
We report an uncommon case of a 45-year-old woman who presented with spontaneous rhinorrhea. A computed tomography (CT) scan of the head revealed an abnormally large sphenoid sinus associated with a parasellar bony defect (Sternberg's canal) through which magnetic resonance imaging could detect an encephalocele of the right temporal lobe. An endoscope-assisted trans-sphenoidal approach was performed and, with the aid of image guided surgery, reduction of the encephalocele was obtained and followed by surgical repair of the dural and bony defects. The postoperative course was uneventful and the cerebrospinal fluid fistula was closed as confirmed by the postoperative CT scan and by the absence of rhinorrhea. After three years of monitoring the patient remained asymptomatic.
doi:10.3340/jkns.2012.52.6.555
PMCID: PMC3550425  PMID: 23346329
Cerebrospinal fluid; Endoscope-assisted procedures; Sternberg's canal
16.  An unusual case of a pituitary fossa aspergilloma in an immunocompetent patient mimicking infiltrative tumour 
Journal of Surgical Case Reports  2013;2013(4):rjt018.
Sellar aspergillosis is a rare infection commonly mistaken for a pituitary tumour. We present a rare case of pituitary fossa Aspergillus fumigatus mycetoma in an immunocompetent 90-year-old female, who presented with headaches. Magnetic resonance imaging scans demonstrated an enhancing pituitary fossa mass that appeared to infiltrate the sphenoid sinus, suggestive of an invasive tumour. Stereotactic trans-sphenoidal resection confirmed localized A. fumigatus infection. The abscess was debrided and the dura was left intact. Her headaches resolved post-operatively and she was treated with voriconazole. This indicates that aspergilloma should be considered as a differential for an unexplained pituitary lesion even in elderly immunocompetent patients.
doi:10.1093/jscr/rjt018
PMCID: PMC3635217  PMID: 24964429
17.  Endoscopic Endonasal Transsphenoidal Resection of Solitary Extramedullary Plasmacytoma in the Sphenoid Sinus with Destruction of Skull Base 
Solitary extramedullary plasmacytomas are isolated plasma cell tumors of soft tissue that typically do not metastasize. They are rare and account for 4% of all plasma cell tumors. To our knowledge, only 14 cases of solitary extramedullary plasmacytomas in the sphenoid sinus have been reported. A 32-year-old man presented to our department with complaint of ocular pain in the right eyeball and diplopia. Physical and neurological examinations revealed intact and prompt direct and indirect light reflexes in both pupils and limitation of extraocular muscle movement seen with the lateral gaze of the right eyeball. Magnetic resonance imaging suggested the presence of mucocele or mycetoma, therefore surgical resection was performed with endoscopic endonasal transsphenoidal approach. Histopathology was consistent with plasmacytoma. Systemic work-up did not show any evidence of metastasis and the sphenoid sinus was the sole tumor site, and therefore the diagnosis of solitary extramedullary plasmacytoma was confirmed. We report a rare case of solitary extramedullary plasmacytoma in the sphenoid sinus with successful treatment using the endoscopic endonasal transsphenoidal resection and adjuvant radiotherapy.
doi:10.3340/jkns.2009.46.2.156
PMCID: PMC2744026  PMID: 19763219
Plasmacytoma; Sphenoid sinus; Endoscopic surgical resection
18.  Locally destructive skull base lesion: IgG4-related sclerosing disease 
Allergy & Rhinology  2012;3(1):e41-e45.
A unique case of IgG4+ sclerosing disease was diagnosed in the sphenoid sinus, a previously unreported location, and was treated in a novel manner. This study describes the clinical presentation and management of IgG4 sclerosing disease in the paranasal sinuses. A retrospective case review and review of the medical literature were performed. A 38-year-old woman with a 2-year history of constant frontal headaches presented to our clinic. Imaging showed bony destruction of the sphenoid sinus and sellar floor. The patient underwent a right-sided sphenoidotomy with debridement and biopsy. Pathological evaluation showed a dense plasmacytic infiltrate with >150 IgG4+ cells/high-power field. She was subsequently started on a nasal corticosteroid with improved patency of the sphenoid antrostomy. We report an unusual case of a middle-aged woman who presented with IgG4-sclerosing disease (IGSD) isolated to the sphenoid sinus. Although our knowledge concerning treatment in extrapancreatic organs is lacking, there is evidence that glucocorticoid treatment improves nasal sinus opacification on CT findings (Sato Y, Ohshima K, Ichimura K, et al., Ocular adnexal IgG4-related disease has uniform clinicopathology, Pathol Int 58:465–470, 2008). This case study and literature review adds to the growing literature describing IGSD in the head and neck and more specifically isolated to the sphenoid sinus with preliminary data concerning local control with topical steroids.
doi:10.2500/ar.2012.3.0026
PMCID: PMC3404477  PMID: 22852129
Corticosteroid; IgG4; IGSD; sclerosing disease; skull base; sphenoid; sphenoidectomy
19.  Rapid Development of Bilateral Internal Carotid Artery Aneurysm from Sphenoid Sinus Aspergillosis 
Skull base surgery  1998;8(4):211-214.
The purpose of this case report is to familiarize the sinus surgeon with the possibility of the rapid development of internal carotid artery aneuryams from fungal infections of the sphenoid sinuses. A renal dialysis patient with progressive loss of vision was treated with high doses of steroids for the presumed diagnosis of temporal arteritis. Subsequent work-up included a magnetic resonance arteriogram (MRA) and computed tomography (CT) with contrast that failed to demonstrate aneurysmal changes of the carotid arteries but suggested the presence of a mycotic infection of the sphenoid sinuses. During a sphenoidotomy two days later, in addition to the anticipated aspergillus infection of the sinuses, an aneurysm extending from the left internal carotid artery into the sphenoid sinus was encountered. An emergency arteriogram immediately following the surgery revealed a second newly developed large mycotic aneurysm of the right internal carotid artery filling the right sphenoid sinus as well. This case report documents the rapidity with which mycotic aneurysms can develop from a sphenoid sinus infection secondary to aspergillosis in an immunocompromised host.
Images
PMCID: PMC1656709  PMID: 17171068
20.  Cavernous sinus thrombosis caused by contralateral sphenoid sinusitis: a case report 
Objective
To report a rare case of unilateral cavernous sinus thrombosis caused by contralateral sphenoid sinusitis.
Case report
A 33-year-old female visited our hospital for severe, right-sided, temporal headache, chemosis, periorbital edema, and proptosis. These signs were associated with congested erythematous nasal mucosa with purulent discharge from the right superior nasal meatus. Contrast enhanced CT showed dilated left superior ophthalmic vein, suggestive of thrombosis, contrast enhancement of the left cavernous sinuses, and dilation of cavernous sinus, indicating cavernous sinus inflammation. The right maxillary, ethmoid and sphenoid sinuses showed mucosal thickening and retention of purulent material. She was diagnosed with cavernous sinus thrombosis caused by contralateral sphenoid sinusitis. All clinical symptoms and signs improved after endoscopic sphenoidotomy and appropriate medical treatment.
Conclusions
Sphenoiditis can cause contralateral cavernous sinus thrombosis. Early surgical sphenoidotomy and aggressive medical treatment are the cornerstones of successful management of this life-threatening complication.
doi:10.1186/1746-160X-9-9
PMCID: PMC3605125  PMID: 23497466
Carvenous sinus thrombosis; Sphenoiditis; Contralaterally; Endoscopy sinus surgery
21.  Brain abscess in the computed tomography era: A 10-year experience from Auckland, New Zealand 
Notes were reviewed for 68 patients with brain abscess diagnosed at Auckland Hospital, Auckland, New Zealand between 1978 and 1988. Mean age was 30 years (range one week to 74 years). There were 48 men and 40% were Maori or Pacific Island Polynesians. Seventy-two per cent of patients had headache, 54% had fever and 72% had lateralizing neurological signs. Thirty-one per cent of abscesses were associated with contiguous infection (otic, sinus, dental). Forty-four per cent were in the frontal lobe. Two abscesses were sterile; 197 bacterial isolates were cultured from the remainder. Fifty-four per cent contained obligate anaerobes, which were the only isolates in 22%. Streptococcus anginosus was the single most common isolate present in 22% of the abscesses. Amoxycillin plus metronidazole provided cover for approximately 95% of the total isolates on the basis of sensitivity testing. Treatment was with surgery and antibiotics in all but three patients, who were cured with antibiotics alone. Sixty per cent had a definitive regimen of penicillin (or ampicillin/amoxycillin) and/or metronidazole, always intravenous initially but subsequently often orally. Median duration of antibiotic treatment was 57 days (range 28 to 206). Seventy-five per cent had initial aspiration, 9% open drainage and 7% were excised initially. Seventy-one per cent had a good functional outcome. Mortality was 8.8%. Factors associated with a poor outcome were trauma as a cause, and delays after admission of more than seven days to diagnosis and/or operation.
PMCID: PMC3250801  PMID: 22346451
Antibiotics; Brain abscess; Outcome; Surgical management
22.  Brain Abscesses of Ear, Nose, and Throat Origin 
Skull base surgery  1998;8(4):163-168.
This retrospective study analyzed 29 cerebral abscesses of ear, nose, and throat (ENT) origin. The mean follow-up of patients was 37 months. ENT etiologies included 45% otitis media (n = 13), 48% sinusitis (n = 14), and 7% ethmoidal sinus tumors (n = 2). Thirty-eight percent (n = 5) of otogenic abscesses occurred within 15 days after a mastoidectomy. Sinogenic abscesses were never due to surgery but were associated in 31% of cases (n = 5) with anterior skull base defects. The main locations of otogenic abscesses were the temporal lobe (54%; n = 7) and the cerebellum (23%; n = 3), whereas sinogenic abscesses were located in the frontal lobe in 75% of cases (n = 12). Because of this location, sinogenic abscesses were less symptomatic than otogenic ones and had greater size and encapsulation at the time of diagnosis. Thus, they required longer antibiotic treatment (p = 0.05) and more numerous surgical drainages (p = 0.02). Bacteriologic abscesses samples were positive in 90% of cases. Bacteria found in brain abscesses were different from the ones found in ENT samples in 62% of cases. Thus, the results of ENT bacteriologic samples were not helpful for choosing adequate antibiotic agents in case of negative brain abscess samples. Although mortality was not significantly higher in otogenic abscesses (31%; n = 4) than in sinogenic ones (6%; n = 1, p = 0.08), otogenic abscesses appeared more threatening. Indeed, they represented 80% (n = 4) of lethal cases and encompassed more clinical or radiological prognosis pejorative factors than sinogenic ones (p = 0.006). In conclusion, higher danger of otogenic abscesses mainly resulted both from their temporal or cerebellous locations and from the bacteria that were more frequently resistant to antibiotics.
PMCID: PMC1656703  PMID: 17171060
23.  Traumatic Carotid Cavernous Fistula Concomitant with Pseudoaneurysm in the Sphenoid Sinus 
Interventional Neuroradiology  2008;14(1):59-68.
Summary
This study was designed to elucidate the generating mechanism, diagnosis and treatment of traumatic carotid cavernous fistula (tCCF) concomitant with pseudoaneurysm in the sphenoid sinus. Six cases of tCCF concomitant with pseudoaneurysm in the sphenoid sinus were analyzed in this study. Clinical history, neurological examination, CT and MRI scans, pre- and postembolization cerebral angiograms and follow-up data were included.
All patients presented with massive epistaxis and symptoms of tCCF. The pseudoaneurysms and fistulas were occluded with detachable balloons, and preservation of the parent artery in two cases. One patient also had indirect carotid cavernous fistula (CCF) on the contralateral side embolized by transfacial vein approach with microcoils. Complete symptom resolution was achieved in all cases, without procedure related complications. During the follow-up period all patients returned to work.
Falling from a high speed motorcycle without wearing a helmet may be one of the main causes of this disease. The site of impact during the accident mostly localizes in the frontal and lateral of the orbit. Intracavernous sinus hypertension of tCCF combining with fracture of the lateral wall of the sphenoid may lead to the formation of a pseudoaneurysm in the sphenoid sinus. MRI scan is very helpful in the diagnosis of this disease before the patient receives angiography. Detachable balloon occlusion of the pseudoaneurysm and fistula is a safe and efficient treatment.
PMCID: PMC3313707  PMID: 20557787
pseudoaneurysm, head injury, epistaxis, interventional therapy
24.  Aggressive osteoblastoma of the sphenoid bone 
Oncology Letters  2010;1(2):367-371.
For osteoblastoma, with its predilection for the spinal column and appendicular skeleton, the skull is an unusual site, and paranasal sinus involvement is very rare. Herein, we report on a case in which the disease was located within the sphenoid bone. To the best of our knowledge, this is the 4th reported case of osteoblastoma with a sphenoid origin (1). We report an osteoblastoma of the sphenoid sinus in a 12-year-old girl who presented with exophthalmos. Computed tomography (CT) demonstrated an expansile lesion of the sphenoid which caused the orbital contents to be compressed and deviated to the right. In the magnetic resonance imaging scan, the lesion was found to invade the cranial base in the frontal and temporal region, approximating to the cavernous sinus and internal carotid artery on the right. Bilateral fronto-orbital craniotomy was performed. Histologically, the lesion was composed of proliferating osteoblasts along with vascular stroma. The tumor was described as an aggressive osteoblastoma. In the follow-up CT four months later, a pathological mass was observed in the area of the nasal septum, and a signal void was present on all sequences in the densely sclerotic areas. A second resection was performed. The patient has been disease-free for 61 months. Herein, we present the diagnosis and management of this unusual lesion. The histopathology and the imaging characteristics are shown.
doi:10.3892/ol_00000065
PMCID: PMC3436399  PMID: 22966310
sphenoid bone; osteoblastoma
25.  Extramedullary plasmacytoma masquerading as Tolosa–Hunt syndrome: a case report 
BMJ Case Reports  2009;2009:bcr08.2008.0804.
Painful ophthalmoplegia due to extramedullary plasmacytoma is a rare initial manifestation of multiple myeloma. The present report describes a 48-year-old man who suffered an acute onset of retro-orbital pain, left abducens palsy and left facial hypoesthesia. In addition, he exhibited an elevated erythrocyte sedimentation rate and partial responsiveness to corticosteroid treatment, all of which resemble the features of Tolosa–Hunt syndrome. Imaging studies revealed a multilobulated tumour invading the left sphenoid bone and sphenoid sinus, later confirmed as a plasmacytoma at pathology. Multiple myeloma was also diagnosed by bone marrow examination. After completion of chemotherapy and radiotherapy, the patient has been free of symptoms for 10 months. Although cranial neuropathies with any combination of oculomotor, abducens, trochlear, ophthalmic and maxillary nerves may indicate a cavernous sinus lesion, neuropathies exclusive to the abducens and maxillary nerves may raise the possibility of extracavernous sinus origin. Cranial imaging is crucial in diagnosing painful ophthalmoplegia with additional minimal cranial nerve signs.
doi:10.1136/bcr.08.2008.0804
PMCID: PMC3029032  PMID: 21686622

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