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.
Sphenoid sinus mucocele; Third nerve palsy; Transnasal approach
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.
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.
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.
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.
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
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.
Cerebrospinal fluid; Endoscope-assisted procedures; Sternberg's canal
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.
To report a rare case of unilateral cavernous sinus thrombosis caused by contralateral sphenoid sinusitis.
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.
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.
Carvenous sinus thrombosis; Sphenoiditis; Contralaterally; Endoscopy sinus surgery
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.
Transnasal approach; multilayer repair; sphenoid sinus; CSF leak
Ganglioneuromas (GNs) are well-differentiated, slow-growing, benign tumors that are quite rare and usually found in the posterior mediastinum and retroperitoneum. They are composed of ganglion and Schwann cells and their origin remains in dispute. GNs have been reported as intraosseous lesions, such as in temporal and orbital bones. There are rare reports of intracranial lesions, mostly in the pituitary fossa. Most GN patients are children and are clinically asymptomatic. Diagnosis of GN requires histopathologic evaluation since no specific clinical or radiologic diagnostic features have been identified. We report the case of a 35-year-old man with recurrent sinusitis whose radiologic workup revealed a lytic right sphenoid wing lesion with microcalcifications. He underwent gross-total resection of the lesion and the pathologic findings were diagnostic of ganglioneuroma. To the best of our knowledge, this is the first reported case of sphenoid wing GN. The nature and origin of this tumor are discussed, and the GN literature is reviewed.
ganglioneuroma; neural crest derived tumor; sphenoid wing; neuroblastoma; calvarial tumor
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.
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.
Dermoid cysts are rare congenital tumors that occur primarily at the midline at a characteristic intradural location. However, dermoid cysts located at extradural and lateral regions have been rarely reported until now. In the present study, the authors demonstrate the unusual instance of an intracranial extradural dermoid cyst at the lateral sphenoid ridge. A 53-year-old woman admitted because of progressive headache and dizziness. The patient had no neurologic deficits, and magnetic resonance imaging with no contrast enhancement revealed a mass at the right sphenoid ridge. The mass was accompanied with sphenoid bone erosion visible on computed tomography. The patient underwent right pterional craniotomy, and the tumor including the capsule was totally resected. Presence of a dermoid cyst was confirmed with histopathological examination. The patient had no complications during the postoperative period. This study suggests that dermoid cyst should be considered for differential diagnosis of extradural and lateral intracranial masses.
Dermoid cyst; Extradura; Bone erosion; Brain mass
We present the case of a rare sinonasal tumour originating in a rare location in close proximity to vital structures. We describe how the patient was managed, including detailed description of how the mass was removed.
A 54-year-old man presented with a long history of nasal blockage, recently complicated by severe headaches and a left VIth nerve palsy. CT scan showed complete opacification of the left sphenoid sinus.
Symptoms improved following administration of steroids and nasal decongestants. Histology from endoscopic debulking of the mass confirmed the presence of inverted papilloma. Fine-cut CT showed the course of the carotid artery and optic nerve, closely related to the tumour, allowing for complete removal during a second endoscopic procedure. Five years following the procedure, the patient remains symptom free.
With appropriate imaging, isolated sphenoid sinus tumours can be removed endoscopically even when in close relation to vital structures.
Cholesterol granuloma (CG) is usually associated with chronic middle ear disease, and is not common in the paranasal sinuses. Additionally, it is very rare for cases of CG to be associated with a fungal infection. However, in this paper, we report a case of sphenoid sinus CG that is associated with aspergilloma in a 78-year-old male patient who presented with right hemifacial pain, headache and toothache. CT revealed the presence of an expansile cystic mass lesion in the sphenoid sinus that showed a high signal intensity on both the T1 and T2 weighted images. This mass was later determined to be CG. The suspected etiologic mechanisms of both CG and aspergilloma of the paranasal sinuses are similar, and impaired drainage and obstruction of the ventilation of the paranasal sinuses are considered to be the causative mechanism of both diseases. Overall, the results of this study indicate that the use of MRI findings could be helpful for differentiating CG from other paranasal sinus mass lesions.
Cholesterol granuloma; Aspergilloma; Sphenoid sinus
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.
Plasmacytoma; Sphenoid sinus; Endoscopic surgical resection
Lateral sphenoid encephalocele, especially within the lateral aspect of the sphenoid sinus, when the sphenoid sinus has pneumatized extensively into the pterygoid recess, are considered exceedingly rare. We report a rare case of lateral intrasphenoidal encephalocele with spontaneous cerebral spinal fluid (CSF) rhinorrhea. Computed tomography demonstrated bilateral arachnoid pit, extensive sphenoid sinus pneumatization, and a defect in the superior wall of the left lateral recess of the sphenoid sinus. Magnetic resonance imaging demonstrated anteromedial temporal lobe herniating through the bony defect.
Arachnoid pit; lateral recess; sphenoid sinus; spontaneous CSF-leaks; spontaneous encephalocele
Giant cell reparative granulomas (GCRGs) are rare lesions in the cranial bones. We present a case of this rare lesion emanating from the clivus and replacing the sphenoid sinus, a highly unusual location for this entity.
The case and clinical course of a 29-year-old female who presented with a large sphenoid mass are described here. The patient presented with symptoms of severe headache and diplopia; imaging demonstrated a large sphenoid mass which was completely resected via an endoscopic endonasal approach. It was based on the clivus and was shown to be a GCRG.
GCRGs are benign granulomatous lesions which should be considered in the differential in the setting of a sphenoid mass.
Clivus; diplopia; giant cell reparative granuloma; giant cell tumor; neurofibromatosis-1
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.
Antibiotics; Brain abscess; Outcome; Surgical management
Ophthalmoplegia due to 3rd nerve palsy is a common occurrence, and is usually a sign of diabetes mellitus or a serious intracranial disease. We report a rare case of pupil sparing 3rd nerve palsy caused by mucocele of the sphenoid sinus. The patient regained 3rd nerve functions after successful decompression of the mucocele. Early and correct diagnosis of this relatively benign condition is important to prevent permanent neurological deficits, including visual loss by optic nerve atrophy. Etiology, clinical manifestations and treatment of the sphenoid mucoceles is discussed and available literature is reviewed.
Mucocele; ophthalmoplegia; sphenoid sinus; 3rd nerve palsy
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.
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.
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.
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.
Endoscopic technique; Optic nerve decompression; Traumatic optic neuropathy
A basal encephalocele often shows an insidious clinical course. Only two cases of temporal lobe encephalocele accompanied with tension pneumocephalus have previously been reported. In this paper, we describe a case of lateral sphenoid sinus encephalocele presenting with intraventricular tension pneumocephalus. A 54-year-old man was referred to our institution presenting with intraventricular tension pneumocephalus. He had undergone ventriculoperitoneal shunt placement for postmeningitis hydrocephalus 3 months before this admission. Precise imaging examinations detected evidence suggestive of a lateral sphenoidal sinus recess encephalocele. Endoscopic transnasal approach was performed for surgical repair of the encephalocele. The encephalocele was removed with subsequent repair of the bony defect. Histological examination showed that the encephalocele includes a part of the ventricular system. This indicates that air might enter directly into the ventricular system after rupture of the temporal lobe encephalocele. A lateral sphenoid sinus encephalocele would potentially cause intraventricular tension pneumocephalus, although pneumocephalus is an extremely unusual complication of this type of basal encephaloceles.
Encephalocele; endoscopic surgery; pneumocephalus; sphenoid sinus
Trans-sphenoid anterobasal temporal lobe meningoceles are rare and can be associated with temporal lobe epilepsy or recurrent meningitis. Surgical treatment is described via complicated infratemporal or intracranial approaches with high morbidity. A 32-year-old man presented with an 18-year history of two types of seizures and confirmed epileptic activity in electroencephalogram. A trans-sphenoid meningocele in the left pterygopalatine fossa was found on computed tomography and magnetic resonance imaging. A midfacial degloving was chosen instead of a large neurosurgical approach to remove it and to repair the dura defect with lyophilized dura, collagen, and abdominal fat. The postoperative course was uneventful without visible scars and the patient remains free of seizures without antiepileptic medication 3 years after surgery. Although midfacial degloving is not described yet as a treatment of trans-sphenoid meningoceles, this approach proved to be fast, safe, effective, and reliable and should be considered as the only alternative to large external approaches.
Midfacial degloving; trans-sphenoid meningocele; pterygopalatine fossa
A case of painful ophthalmoplegia associated with an extensive lesion involving the sella turcica, superior orbital fissure, and sphenoid sinus in a 57-year-old man is reported. Even though nasal and ocular symptoms and signs represent the usual features of sphenoidal mucoceles, extension to the intracranial cavity as seen in this lesion is rare. Surgical exploration via a sublabial, transseptal approach revealed a mucocele of the sphenoid sinus. This case exhibited extensive and aggressive behavior simulating a malignant neoplasm.
We present a case (55-year-old) with a metastasis to the sphenoid sinus from an occult prostatic adenocarcinoma as the first evidence of disease. The patient’s symptoms were progressive left-sided headache of a few months duration and a 2-week history of blurred vision with diplopia. Clinical examination revealed a left cranial nerve III palsy and ptosis. A computed tomography scan showed a 2 cm large, well delineated soft tissue lesion involving the left sphenoid sinus and extending to the left cavernous sinus with sclerosis of the adjacent sphenoid bone. Histological and immunohistochemical examinations revealed a poorly differentiated adenocarcinoma that was positive for prostate specific antigen (PSA) and broad-spectrum cytokeratins (Cam 5.2). Subsequent urological examination confirmed a locally advanced prostatic carcinoma with significantly increased serum-PSA (4,561 μg/l) and bone scintigraphy showed widespread metastasis.
Metastasis; Sphenoid sinus; Sinonasal; Prostatic carcinoma; Carcinoma; Occult
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.
Head injury; Penetrating; Bone fragment