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1.  Value of anatomical landmarks in single-nostril endonasal transnasal-sphenoidal surgery 
The sphenoid sinus occupies a central location in transsphenoidal surgery (TSS). It is important to identify relevant anatomical landmarks to enter the sphenoid sinus and sellar region properly. The aim of this study was to identify anatomical landmarks and their value in single-nostril endonasal TSS. A retrospective study was performed to review 148 cases of single-nostril endonasal TSS for pituitary lesions. The structure of the nasal cavities and sphenoid sinus, the position of apertures of the sphenoid sinus and relevant arteries and the morphological characteristics of the anterior wall of the sphenoid sinus and sellar floor were observed and recorded. The important anatomical landmarks included the mucosal aperture of the sphenoid sinus, a blunt longitudinal prominence on the posterior nasal septum, the osseocartilaginous junction of the nasal septum, the ‘bow sign’ of the anterior wall of the sphenoid sinus, the osseous aperture and its relationship with the nutrient arteries, the bulge of the sellar floor and the carotid protuberance. These landmarks outlined a clear route to the sella turcica with an optimal view and lesser tissue damage. Although morphological variation may exist, the position of these landmarks was generally consistent. Locating the sphenoid sinus aperture is the gold standard to direct the surgical route of TSS. The ‘bow sign’ and the sellar bulge are critical landmarks for accurate entry into the sphenoid sinus and sella fossa, respectively.
PMCID: PMC3628397  PMID: 23596471
transsphenoidal approach; nasal cavity; sphenoid sinus; anatomical; landmark; pituitary
2.  Isolated sphenoid sinus disease — a retrospective analysis 
To evaluate the etiology, symptoms, signs, imaging, surgical findings and outcomes of isolated sphenoid sinus disease (ISSD).
Retrospective study.
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.
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.
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.
PMCID: PMC3450151  PMID: 23120685
Sphenoid sinus; Sphenochoanal polyp; Sinusitis; Headache; Sphenoidotomy
3.  The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery 
Journal of neurosurgery  2011;114(5):1319-1330.
A considerable degree of variability exists in the anatomy of the sphenoid sinus, sella turcica, and surrounding skull base structures. The authors aimed to characterize neuroimaging and intraoperative variations in the sagittal and coronal surgical anatomy of healthy controls and patients with sellar lesions.
Magnetic resonance imaging studies obtained in 100 healthy adults and 78 patients with sellar lesions were reviewed. The following measurements were made on midline sagittal images: sellar face, sellar prominence, sellar angle, tuberculum sellae angle, sellar-clival angle, length of planum sphenoidale, and length of clivus. The septal configuration of the sphenoid sinus was classified as either simple or complex, according to the number of septa, their symmetry, and their morphological features. The following measurements were made on coronal images: maximum width of the sphenoid sinus and sellar face, and the distance between the parasellar and midclivus internal carotid arteries. Neuroimaging results were correlated with intraoperative findings during endoscopic transsphenoidal surgery.
Three sellar floor morphologies were defined in normal adults: prominent (sellar angle of < 90°) in 25%, curved (sellar angle 90–150°) in 63%, flat (sellar angle > 150°) in 11%, and no floor (conchal sphenoid) in 1%. In healthy adults, the following mean measurements were obtained: sellar face, 13.4 mm; sellar prominence, 3.0 mm; sellar angle, 112°; angle of tuberculum sellae, 112°; and sellar-clival angle, 117°. Compared with healthy adults, patients with sellar lesions were more likely to have prominent sellar types (43% vs 25%, p = 0.01), a more acute sellar angle (102° vs 112°, p = 0.03), a more prominent sellar floor (3.8 vs 3.0 mm, p < 0.005), and more acute tuberculum (105° vs 112°, p < 0.01) and sellar-clival (105° vs 117°, p < 0.003) angles. A flat sellar floor was more difficult to identify intraoperatively and more likely to require the use of a chisel or drill to expose (75% vs 25%, p = 0.01). A simple sphenoid sinus configuration (no septa, 1 vertical septum, or 2 symmetric vertical septa) was noted in 71% of studies, and the other 29% showed a complex configuration (2 or more asymmetrical septa, 3 or more septa of any kind, or the presence of a horizontal septum). Intraoperative correlation was more challenging in cases with complex sinus anatomy; the most reliable intraoperative midline markers were the vomer, superior sphenoid rostrum, and bilateral parasellar and clival carotid protuberances.
Preoperative assessment of neuroimaging studies is critical for characterizing the morphological characteristics of the sphenoid sinus, sellar floor, tuberculum sellae, and clivus. The flat sellar type identified in 11% of people) or a complex sphenoid sinus configuration (in 29% of people) may make intraoperative correlation substantially more challenging. An understanding of the regional anatomy and its variability can improve the safety and accuracy of transsphenoidal and extended endoscopic skull base approaches.
PMCID: PMC4131853  PMID: 21235317
sphenoid sinus; sella turcica; tuberculum sellae; clivus; transsphenoidal approach; pituitary gland
4.  A Cross-Sectional Study of Sphenoid Sinus through Gross and Endoscopic Dissection in North Karnataka, India 
Introduction: Sphenoid sinus has got importance due to trans-sphenoid approach to the pituitary gland. This study is an attempt to know the variations in North Karnataka population, through cadaveric dissection and CT scan study.
Objective: We want to study variations in sphenoid sinus and its percentage in North Karnataka population.
Material and Methods: Endoscopic examination and dissection of sphenoid sinus was carried out in 30 cadavers (three female and 27 male) using 0°, 30°, 70° rigid nasal endoscopes. Sections were then made in the sagittal plane to confirm the anatomical findings and to take the necessary measurements with millimeter strips.
Results: In six of cadavers pre-sellar, in four it was sellar and in 20 it was post-sellar while conchal type of sphenoid sinus was absent. The septa terminated on bone covering internal carotid artery (ICA) in seven cadavers while in two cadavers they terminated on the bone covering Optic nerve (ON). Findings of CT scan study were pre-sellar-8, sellar-14 and post-sellar-37 and in case of one subject left side sinus was conchal. Pneumatization of greater wing of sphenoid was observed in two sinuses, of pterygoid process in four sinuses and of anterior clinoid process in two sinuses. We also found onodi cell in one sinus.
Conclusion: Sphenoid sinus shows various types of pneumatisation, and this place the sinus in close proximity to important neurovascular structures that are present around the sinus. Newer techniques are used to confirm surgical landmarks making these techniques very safe.
PMCID: PMC4064884  PMID: 24959426
Sphenoid sinus; Endoscopy, Pneumatization; Optic nerve; Internal carotid artery; Trans-sphenoid hypophysectomy
5.  Anatomic Variations of the Sphenoid Sinus and Their Impact on Trans-sphenoid Pituitary Surgery 
Skull Base  2008;18(1):9-15.
Introduction: The trans-sphenoid access to the pituitary gland is becoming the most common approach for pituitary adenomas. Preoperative evaluation of the anatomy of the sphenoid sinus by computed tomography (CT) scan and magnetic resonance imaging (MRI) is a routine procedure and can direct the surgical decision. Purpose: This work determines the incidence of the different anatomical variations of the sphenoid sinus as detected by MRI and CT scan and their impact on the approach. Methods: The CT scan and MRI of 296 patients operated for pituitary adenomas via a trans-sphenoid approach were retrospectively reviewed regarding the different anatomical variations of the sphenoid sinus: degree of pneumatization, sellar configuration, septation pattern, and the intercarotid distance. Results: There were 6 cases with conchal pneumatization, 62 patients with presellar, 162 patients with sellar, and 66 patients with postsellar pneumatization. There was sellar bulge in 232 patients, whereas this bulge was absent in 64 patients. There was no intersphenoid sinus septum in 32 patients, a single intersphenoid septum in 212 patients, and an accessory septum in 32 patients. Intraoperatively, the sellar bulge was marked in 189 cases and was mild in 43 cases. Discussion: The pattern of pneumatization of the sphenoid sinus significantly affects the safe access to the sella. A highly pneumatized sphenoid sinus may distort the anatomic configuration, so in these cases it is extremely important to be aware of the midline when opening the sella to avoid accidental injury to the carotid and optic nerves. The sellar bulge is considered one of the most important surgical landmarks, facilitating the access to the sella. The surgical position of the patient is also a crucial point to avoid superior or posterior misdirection with resultant complications. It is wise to use extreme caution while removing the terminal septum. Conclusion: Different anatomical configurations of the sphenoid sinus can seriously affect the access to the sella via the nose. The surgeon should be aware of these findings preoperatively to reach the sella safely and effectively.
PMCID: PMC2435468  PMID: 18592020
Sphenoid sinus; pneumatization; pituitary adenoma; trans-sphenoid approach
6.  Ectopic acromegaly due to a GH-secreting pituitary adenoma in the sphenoid sinus: a case report and review of the literature 
BMC Research Notes  2013;6:411.
In more than 98% of cases, acromegaly is due to a GH-secreting pituitary adenoma. The term “ectopic acromegaly” includes neuroendocrine tumors secreting GH releasing hormone (GHRH), usually located in the lungs, thymus and endocrine pancreas. Considerably less frequent are cases of ectopic acromegaly due to GH-secreting tumors located out of the pituitary fossa; except for one isolated case of a well-documented GH-secreting lymphoma, the majority of these lesions are located in the sphenoid sinus.
Case presentation
We present the case of a 45 year old woman with acromegaly whose MRI showed an empty sella without evidence of a pituitary adenoma but revealed a large mass within the sphenoid sinus. She underwent transsphenoidal surgery and the excised sphenoid sinus mass, proved to be a GH-secreting adenoma; the sellar floor was intact and no other lesions were found in the pituitary fossa. She required postoperative treatment with somatostatin analogs and cabergoline for clinical and biochemical control.
This case highlights the importance of carefully evaluating the structures surrounding the sellar area when a pituitary adenoma is not found with currently available imaging techniques. The finding of an intact sellar floor and duramater lead us to conclude that the patient’s tumor originated de novo from embryological pituitary remnants. Upon a careful review of the literature and a critical evaluation of our case we found neither clinical nor biochemical features that would distinguish an ectopic from the more common eutopically located somatotrophinoma.
PMCID: PMC3874769  PMID: 24119925
Ectopic acromegaly; Sphenoid sinus; GH-secreting adenoma
7.  Temporary Unilateral Amaurosis with Pneumosinus Dilatans of the Sphenoid Sinus 
Skull base surgery  1994;4(3):169-175.
Pneumosinus dilatans (PSD), first described by Meyes in 1898, is an abnormal dilatation of one or more of the paranasal sinuses without bony erosion. The term sinus pneumocele indicates the presence of bony erosion. Review of the literature from 1968 to 1992 revealed 24 cases of idiopathic PSD and 17 cases of pneumocele of various paranasal sinuses. PSD occurred most commonly in the frontal sinus. Males were more often affected than females. The average age for males ranged from 16.5 for the maxillary sinus to 35.5 years for the sphenoid sinus. Pneumoceles occurred most commonly in the maxillary sinus. The average age for males ranged from 29 years for the frontal sinus and 47 years for the ethmoid sinus. Two patients (1 pneumocele and 1 PSD) had a temporary loss of vision. We report the case of a 37-year-old mountain climber who experienced temporary loss of vision in his left eye above 3000 m. Vision returned below 2000 m. High resolution computed tomography scan revealed pneumosinus dilatans of the sphenoid sinus with dehiscence of the optic canal on the left side. Endonasal microendoscopic resection of the anterior wall of the left sphenoid sinus was performed. The patient has remained symptom-free after 2 years of follow-up. Pneumosinus dilatans should always be considered in the differential diagnosis of sudden visual loss associated with atmospheric pressure changes.
PMCID: PMC1661801  PMID: 17171168
8.  Pituitary infiltration by non-Hodgkin's lymphoma: a case report 
Pituitary adenomas represent the most frequently observed type of sellar masses; however, the presence of a rapidly growing sellar tumor, diabetes insipidus, ophthalmoplegia and headaches in an older patient strongly suggests metastasis to the pituitary. Since the anterior pituitary has a great reserve capacity, metastasis to the pituitary and pituitary involvement in lymphoma are usually asymptomatic. Whereas diabetes insipidus is the most frequent symptom, patients can present with headaches, ophthalmoplegia and bilateral hemianopsia.
Case presentation
A 70-year-old woman with no previous history of malignancy presented with headaches, right oculomotor nerve palsy and diabetes insipidus. As magnetic resonance imaging revealed a sellar mass involving the pituitary gland and infundibular stalk, which also extended into the right cavernous sinus and sphenoid sinus, the patient underwent an immediate transsphenoidal decompression surgery. Her prolactin was 102.4 ng/ml, whereas her gonadotropic hormone levels were low. A low level of urine osmolality after overnight water deprivation, along with normal plasma osmolality suggested diabetes insipidus. Histological examination revealed that the mass had been the infiltration of a high grade B-cell non-Hodgkin's lymphoma involving respiratory system epithelial cells. Paranasal sinus computed tomography scanning and magnetic resonance imaging of the thorax and abdomen were performed. Since magnetic resonance imaging did not reveal any abnormality, after paranasal sinus computed tomography was performed, we concluded that the primary lymphoma originated from the sphenoid sinus and infiltrated the pituitary. Chemotherapy and radiotherapy to the sellar area were planned, but the patient died and her family did not permit an autopsy.
Lymphoma infiltration to the pituitary is difficult to differentiate from pituitary adenoma, meningioma and other sellar lesions. To plan the treatment of lymphoma infiltration of the pituitary gland, it must be differentiated from other sellar lesions.
PMCID: PMC2803816  PMID: 20062782
9.  Cavernous sinus thrombosis caused by contralateral sphenoid sinusitis: a case report 
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.
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.
PMCID: PMC3605125  PMID: 23497466
Carvenous sinus thrombosis; Sphenoiditis; Contralaterally; Endoscopy sinus surgery
10.  Anatomic Variation of Sphenoid Sinus and Related Structures in Libyan Population: CT Scan Study 
The Libyan Journal of Medicine  2008;3(3):128-133.
Sphenoid sinus is the most inaccessible paranasal sinus, enclosed within the sphenoid bone and intimately related to numerous vital neural and vascular structures. Anatomic variation of the sphenoid sinus is well documented and may complicate surgery in such a place.
To outline the surgically risky anatomic variants of the sphenoid sinus as well as the variable relationships between the sinus and related neurovascular structures, for the safe removal of intrasphenoid and pituitary lesions.
Materials and Methods
We undertook a prospective review of 300 paranasal sinus CT scans of Libyan patients; coronal CT scans were obtained by special parameter techniques. We assessed pneumatization of pterygoid process (PP), anterior clinoid process (ACP), and greater wing of sphenoid (GWS); we also examined protrusion and dehiscence of internal carotid artery (ICA), optic nerve (ON), maxillary nerve (MN), and vidian nerve (VN) into the sphenoid sinus cavity.
Pneumatization of PP, ACP, and GWS were seen in 87 (29%), 46 (15.3%), and 60 patients (20%), respectively. Protrusion of ICA, ON, MN, and VN were noticed in 123 (41%), 107 (35.6%), 73 (24.3%), and 81 patients (27%), respectively; dehiscence of these structures was encountered in 90 (30%), 92 (30.6%), 39 (13%), and 111 patients (37%), respectively. Statistically, there was a highly significant association between ACP pneumatization and ICA protrusion, ACP pneumatization and ON protrusion, PP pneumatization and VN protrusion; and GWS pneumatization and MN protrusion (p-value < 0.001).
The sphenoid sinus is highly variable; this variability necessitates a comprehensive understanding of the regional sphenoid sinus anatomy by a detailed CT scan sinus examination before surgery in and around the sinus. This study indicates the possibility of a racial anatomical variation of the sphenoid sinus in the Libyan population.
PMCID: PMC3074265  PMID: 21499453
Sphenoid sinus; variation; internal carotid artery; optic nerve; maxillary nerve; vidian nerve; CT scan; Libyan
11.  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.
PMCID: PMC3436399  PMID: 22966310
sphenoid bone; osteoblastoma
12.  Isolated Sphenoid Pyocele with Thornwaldt’s Cyst of Nasopharynx 
Isolated sphenoid sinusitis (ISS) is a rare entity. ISS accounts for about 1–2% of all sinus infections. Isolated sphenoid sinus involvement may include mucoceles, pyoceles and isolated mycotic infections. We report a case of isolated sphenoid pyocele in a 35 year-old female who presented in August 2007 with frontal and occipital headache, post nasal discharge and bilateral nasal obstruction for 6 years. CT scan showed isolated right sphenoid sinusitis. Diagnostic nasal endoscopy showed a streak of post nasal discharge on right side above the torus tubaris confirming right sphenoiditis. A cyst in the nasopharynx was incidentally detected which was confirmed by fluid aspiration to be Thornwaldt’s cyst (TC). TCs have reported prevalence of 0.2–5% and though most are asymptomatic their location renders them vulnerable to infection. Sphenoidotomy was done and the cyst in the nasopharynx was removed and marsupialised. Postoperative course was uneventful.
PMCID: PMC3146695  PMID: 22754866
Sphenoid pyocele; Thornwaldt’s cyst; Nasopharyngeal bursa
13.  Sphenoid Sinus Myxoma: Case Report and Literature Review 
The Ochsner Journal  2008;8(4):166-171.
Objectives: We present the first known case in the English-language literature of a myxoma arising in the sphenoid sinus. By describing the patient's clinical course and the salient features of this rare neoplasm, we seek to increase the awareness of the presentation, histological features, and treatment considerations for myxomas of the head and neck. In the process, we intend to describe the work-up of isolated sphenoid sinus lesions and focus on the varying and evolving techniques for surgical access to the sphenoid sinus.
Study Design and Methods: Case report and literature review.
Results: We describe the clinical course of a patient with a myxoma of the sphenoid sinus. The patient underwent an external sphenoethmoidectomy through a lateral rhinotomy approach with medial maxillectomy under MRI-guidance. He remains without evidence of recurrent disease after 8 months.
Conclusions: Myxomas of the head and neck are rare neoplasms. Their infiltrative nature and tendency to recur demand an aggressive surgical approach that may be accomplished with minimal morbidity using currently available image-guided techniques.
PMCID: PMC3096368  PMID: 21603497
Myxoma; neoplasms; sphenoid sinus
14.  Sphenoid Sinus Basaloid Squamous Cell Carcinoma Presenting as a Sellar Mass: Report a Case with Review of the Literature 
Head and Neck Pathology  2010;5(1):81-85.
Basaloid squamous cell carcinoma (BSCC) is a distinctive variant of squamous cell carcinoma (SCC) with more aggressive behavior. It occurs preferentially in the upper aerodigestive tract. Sinonasal tract BSCC is uncommon, and only limited studies have been reported in literature. In these studies, most BSCCs arose from the nasal mucosa with or without extension to the paranasal sinuses. Rare reported cases of BSCC involved only the paranasal sinus. In this report, we present a case of a female patient with a sphenoid sinus mass. Clinically, the patient had progressively decreasing vision and headache. Magnetic resonance imaging (MRI) and computerized tomographic (CT) scan showed an infiltrating tumor mass involving the sphenoid sinus and the sella with compression of the optic nerve. Pathologic examination revealed an invasive basaloid epithelial neoplasm that was arranged in lobules, nests and cords. The tumor also showed palisading of peripheral cells, focal abrupt squamous differentiation and in situ carcinoma in the surface mucosa. In the immunohistochemical studies, this tumor revealed a strongly positive nuclear staining for p63. The morphologic and ancillary studies indicated a BSCC. To the best of our knowledge, this is the first report of sinonasal tract BSCC that mainly involved the sphenoid bone and sella. In this region, BSCC should be distinguished from benign and malignant neoplasms that more often affect sella and base of skull, such as pituitary adenoma with extensive necrosis, small cell neuroendocrine carcinoma (SCNC), olfactory neuroblastoma, malignant germ cell tumor, paranasal adenoid cystic carcinoma (ACC), and a variety of metastatic malignancies.
PMCID: PMC3037465  PMID: 20972844
Basaloid squamous cell carcinoma; Sphenoid sinus; Sellar mass
15.  Pseudomeningoceles of the sphenoid sinus masquerading as sinus pathology 
The Laryngoscope  2011;121(12):2507-2513.
To describe the clinical presentation, pathophysiology and treatment of spontaneous cerebrospinal fluid (CSF) leaks of the sphenoid bone, with an emphasis on a previously undescribed form in this location, in which CSF is trapped under the mucosa of the sinonasal cavity or in the soft tissue of the skull base.
Study design
Case series and literature review. Level of evidence 4.
Analysis of cases through medical records and literature review.
Four examples of unusual spontaneous CSF leaks of the skull base are presented. In each case, a CSF collection was contained behind the sinonasal mucosa of the sphenoid sinus, resembling a nasal polyp or mucocele on exam or imaging. In one case, the fluid collection was also associated with significant bone resorption and extravasation into the soft tissue of the infratemporal fossa. In each case, small defects of the ventral skull base (sphenoid bone) were the source of the CSF leaks. Successful treatment was achieved after transnasal endoscopic repair of the skull base defects using a combination of free abdominal fat grafts, free fascial grafts and pedicled nasoseptal flaps. Postoperatively, a ventriculoperitoneal shunt was placed if the intracranial pressure was elevated.
Spontaneous CSF leaks arising in the sphenoid sinus may not always present with overt CSF rhinorrhea but with a submucosal fluid collection (pseudomeningocele) that may mimic a mucocoele or nasal polyp. These bona fide pseudomeningoceles of the skull base may be associated with elevated intracranial pressure and can be managed using endoscopic endonasal surgery.
PMCID: PMC3223265  PMID: 22052361
CSF leak; mucocele; meningocele; skull base; sinus
16.  Topical Drug Delivery in Chronic Rhinosinusitis Patients before and after Sinus Surgery Using Pulsating Aerosols 
PLoS ONE  2013;8(9):e74991.
Chronic rhinosinusitis (CRS) is a common chronic disease of the upper airways and has considerable impact on quality of life. Topical delivery of drugs to the paranasal sinuses is challenging, therefore the rate of surgery is high. This study investigates the delivery efficiency of a pulsating aerosol in comparison to a nasal pump spray to the sinuses and the nose in healthy volunteers and in CRS patients before and after sinus surgery.
99mTc-DTPA pulsating aerosols were applied in eleven CRSsNP patients without nasal polyps before and after sinus surgery. In addition, pulsating aerosols were studied in comparison to nasal pump sprays in eleven healthy volunteers. Total nasal and frontal, maxillary and sphenoidal sinus aerosol deposition and lung penetration were assessed by anterior and lateral planar gamma camera imaging.
In healthy volunteers nasal pump sprays resulted in 100% nasal, non-significant sinus and lung deposition, while pulsating aerosols resulted 61.3+/-8.6% nasal deposition and 38.7% exit the other nostril. 9.7+/-2.0 % of the nasal dose penetrated into maxillary and sphenoidal sinuses. In CRS patients, total nasal deposition was 56.7+/-13.3% and 46.7+/-12.7% before and after sinus surgery, respectively (p<0.01). Accordingly, maxillary and sphenoidal sinus deposition was 4.8+/-2.2% and 8.2+/-3.8% of the nasal dose (p<0.01). Neither in healthy volunteers nor in CRS patients there was significant dose in the frontal sinuses.
In contrast to nasal pump sprays, pulsating aerosols can deliver significant doses into posterior nasal spaces and paranasal sinuses, providing alternative therapy options before and after sinus surgery. Patients with chronic lung diseases based on clearance dysfunction may also benefit from pulsating aerosols, since these diseases also manifest in the upper airways.
PMCID: PMC3770586  PMID: 24040372
17.  Visual loss secondary to eosinophilic mucin rhinosinusitis in a woman: a case report 
Eosinophilic mucin rhinosinusitis is an inflammatory pathological condition of the nose and paranasal sinuses. It is rare, occurs in immunocompetent patients and is characterised by peripheral eosinophilia and extensive bilateral sinus disease. To the best of our knowledge, visual loss with this condition has not been previously reported.
Case presentation
We present the case of a 26-year-old Asian woman with a background history of chronic sinusitis who presented with acute left-sided visual loss. Imaging showed significant opacification in the frontal, ethmoidal and sphenoidal sinuses as well as evidence of a unilateral optic neuritis. Histological analysis of sinus mucin revealed dense eosinophilic infiltrate and, despite medical and surgical intervention, vision was not restored in her left eye.
We introduce visual loss as a complication of eosinophilic mucin rhinosinusitis. This adds further evidence to previous reports in the literature that optic neuropathy in sinusitis can occur secondary to non-compressive mechanisms. We also describe a rare finding: the vision in this patient did not improve following steroid therapy, antifungal therapy or surgical intervention. There are very few such cases described in the literature. We conclude that chronic sinusitis is an indolent inflammatory process which can cause visual loss and we reiterate the importance of recognizing and considering sinusitis as a cause of visual loss in patients in order that prompt medical and surgical treatment of the underlying disease can be initiated.
PMCID: PMC2978232  PMID: 21034471
18.  Nasopharyngeal carcinoma with paranasal sinus invasion: the prognostic significance and the evidence-based study basis of its T-staging category according to the AJCC staging system 
BMC Cancer  2014;14(1):832.
To evaluate the prognostic significance of paranasal sinus invasion for patients with NPC and to provide empirical proofs for the T-staging category of paranasal sinus invasion according to the AJCC staging system for nasopharyngeal carcinoma.
The clinical records and imaging studies of 770 consecutive patients with newly diagnosed, untreated, and nondisseminated NPC were reviewed retrospectively. The overall survival, distant metastasis-free survival, and local relapse-free survival of these patients were analyzed using the Kaplan-Meier method, and the differences were compared using the log-rank test.
The incidence of paranasal sinus invasion was 23.6%, with the rate of incidence of sphenoid sinus invasion being the highest. By multivariate analysis, paranasal sinus invasion was shown to be an independent prognostic factor for overall survival, distant metastasis-free survival, and local relapse-free survival (p < 0.05 for all). No significant differences in overall survival, distant metastasis-free survival, and local relapse-free survival were observed between patients with sphenoid sinus invasion alone and those with maxillary sinus and ethmoid sinus invasion (p = 0.87, p = 0.80, and p = 0.37, respectively). The overall survival, distant metastasis-free survival, and local relapse-free survival for patients with stage T3 disease with paranasal sinus invasion were similar to the survival rates for patients with stage T3 disease without paranasal sinus invasion (p = 0.22, p = 0.15, and p = 0.93, respectively). However, the rates of overall survival and local relapse-free survival were better for patients with stage T3 disease with paranasal sinus invasion than for patients with stage T4 disease (p < 0.01, and p = 0.03, respectively).
Paranasal sinus invasion is an independent negative prognostic factor for NPC, regardless of which sinus is involved. Our results confirm that it is scientific and reasonable for the AJCC staging system for nasopharyngeal carcinoma to define paranasal sinus invasion as stage T3 disease.
PMCID: PMC4247012  PMID: 25403714
Nasopharyngeal carcinoma; Paranasal sinus; Invasion; Prognosis; Staging
19.  Invasive Fungal Sinusitis of the Sphenoid Sinus 
This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival.
A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted.
Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P=0.027).
The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus.
PMCID: PMC4135153  PMID: 25177433
Invasive; Fungus; Sinusitis; Sphenoid sinus
20.  Nasal mass mimicking antrochoanal polyp 
BMJ Case Reports  2010;2010:bcr12.2009.2578.
Sphenochoanal polyp is a rare form of choanal polyp. As the name suggests, it originates from the sphenoid sinus and extends down the choana and nasopharynx. If wrongly diagnosed as an antrochoanal polyp, it can lead to unnecessary exploration of the maxillary sinus and incomplete removal of the sphenoid component of polyp. Here we report a case of 40-year-old woman who presented with history of progressive left nasal obstruction and mass in the oropharynx. A diagnosis of sphenochoanal polyp was made on the basis of nasal endoscopy and computed tomography scan. The polyp was removed endoscopically. We discuss the clinical presentation, management and review of the literature of this clinically mistaken entity.
PMCID: PMC3047578  PMID: 22736058
21.  Sphenoid Sinus Mucocele Caused by a Completely Thrombosed Intracavernous Carotid Artery Aneurysm: An Unusual Association 
Background Mucocele is an inflammatory disease caused by the retention of mucoid secretions within a paranasal sinus. Although rare, the presence of a vascular lesion inside the sphenoid sinus could determine ostium obstruction, thus causing mucocele development.
Clinical Presentation An 84-year-old woman was referred to our institution due to a lesion abutting into the sphenoid sinus; she was complaining of constrictive frontal headache, progressive worsening of visual acuity in the left eye; later, sudden homolateral ptosis and diplopia occurred. The radiologic evidence was consistent with the diagnosis of thrombosed aneurysm of the right intracavernous carotid artery, surrounded by sphenoidal mucocele. The patient underwent an endoscopic endonasal transsphenoidal approach exclusively for sphenoid mucocele drainage.
Conclusion Although rare, the presence of a vascular lesion inside the sphenoid sinus has to be considered among the possible diagnostic hypotheses of masses abutting in this cavity; the association with mucocele is even more rare and, to date, has not been described.
PMCID: PMC4110156  PMID: 25083367
sphenoidal mucocele; aneurysm; endoscopic endonasal surgery; skull base surgery; sinus surgery
22.  Fungus Balls of the Bilateral Paranasal Sinuses 
We describe the clinical and radiographic characteristics of fungus balls in the bilateral paranasal sinuses. The medical records of 8 of 245 patients with fungus balls of the bilateral paranasal sinuses between 2000 and 2010 were retrospectively reviewed. The incidence of bilateral paranasal sinus fungus balls was 3.3%. Fungus balls were located in the maxillary sinuses bilaterally in 4 cases (50%), followed by the maxillary sinus and contralateral sphenoid sinus in 3 cases (37.5%), and the sphenoid sinuses bilaterally in 1 case (12.5%). There were no predisposing anatomic variations for the occurrence of bilateral paranasal fungus balls. Although the presenting symptoms and signs were non-specific, CT findings were helpful in the diagnosis of bilateral fungus balls. Endonasal removal by an endoscopic approach was performed in all patients. No peri-operative complications or recurrences were noted. Fungus balls in the bilateral paranasal sinuses are most frequently found in the maxillary sinuses bilaterally. Because symptoms of bilateral paranasal fungus balls and findings on nasal endoscopic examination are frequently non-specific, a high index of suspicion is needed and imaging studies, such as CT, are essential to establish the correct pre-operative diagnosis.
PMCID: PMC3738784  PMID: 24427669
Fungus disease; Sinusitis; Bilateral; Paranasal sinuses; Endoscopic surgical procedure
23.  Ectopic Sphenoid Sinus Pituitary Adenoma (ESSPA) with Normal Anterior Pituitary Gland: A Clinicopathologic and Immunophenotypic Study of 32 Cases with a Comprehensive Review of the English Literature 
Head and Neck Pathology  2012;6(1):75-100.
Ectopic sphenoid sinus pituitary adenoma (ESSPA) may arise from a remnant of Rathke’s pouch. These tumors are frequently misdiagnosed as other neuroendocrine or epithelial neoplasms which may develop in this site (olfactory neuroblastoma, neuroendocrine carcinoma, sinonasal undifferentiated carcinoma, paraganglioma, melanoma). Thirty-two patients with ESSPA identified in patients with normal pituitary glands (intact sella turcica) were retrospectively retrieved from the consultation files of the authors’ institutions. Clinical records were reviewed with follow-up obtained. An immunohistochemical panel was performed on available material. Sixteen males and 16 females, aged 2–84 years (mean, 57.1 years), presented with chronic sinusitis, headache, obstructive symptoms, and visual field defects, although several were asymptomatic (n = 6). By definition, the tumors were centered within the sphenoid sinus and demonstrated, by imaging studies or intraoperative examination, a normal sella turcica without a concurrent pituitary adenoma. A subset of tumors showed extension into the nasal cavity (n = 5) or nasopharynx (n = 9). Mean tumor size was 3.4 cm. The majority of tumors were beneath an intact respiratory epithelium (n = 22), arranged in many different patterns (solid, packets, organoid, pseudorosette-rosette, pseudopapillary, single file, glandular, trabecular, insular). Bone involvement was frequently seen (n = 21). Secretions were present (n = 16). Necrosis was noted in 8 tumors. The tumors showed a variable cellularity, with polygonal, plasmacytoid, granular, and oncocytic tumor cells. Severe pleomorphism was uncommon (n = 5). A delicate, salt-and-pepper chromatin distribution was seen. In addition, there were intranuclear cytoplasmic inclusions (n = 25) and multinucleated tumor cells (n = 18). Mitotic figures were infrequent, with a mean of 1 per 10 HPFs and a <1% proliferation index (Ki-67). There was a vascularized to sclerotic or calcified stroma. Immunohistochemistry highlighted the endocrine nature of the tumors, with synaptophysin (97%), CD56 (91%), NSE (76%) and chromogranin (71%); while pan-cytokeratin was positive in 79%, frequently with a dot-like Golgi accentuation (50%). Reactivity with pituitary hormones included 48% reactive for 2 or more hormones (plurihormonal), and 33% reactive for a single hormone, with prolactin seen most frequently (59%); 19% of cases were non-reactive. The principle differential diagnosis includes olfactory neuroblastoma, neuroendocrine carcinoma, melanoma, and meningioma. All patients were treated with surgery. No patients died from disease, although one patient died with persistent disease (0.8 months). Surgery is curative in the majority of cases, although recurrence/persistence was seen in 4 patients (13.8%). In conclusion, ESSPAs are rare, affecting middle aged patients with non-specific symptoms, showing characteristic light microscopy and immunohistochemical features of their intrasellar counterparts. When encountering a tumor within the sphenoid sinus, ectopic pituitary adenoma must be considered, and pertinent imaging, clinical, and immunohistochemical evaluation undertaken to exclude tumors within the differential diagnosis. This will result in accurate classification, helping to prevent the potentially untoward side effects or complications of incorrect therapy.
PMCID: PMC3311955  PMID: 22430769
Sphenoid sinus; Ectopic pituitary adenoma; Neuroectodermal tumor; Neuroendocrine tumor; Adenoma; Pituitary neoplasm; Nasal cavity; Pituitary hormones; Sphenoid sinus pathology; Immunohistochemistry; Prognosis; Survival; Imaging; Differential diagnosis
24.  Multiparametric statistical correlations between paranasal sinus anatomic variations and chronic rhinosinusitis 
Improvements in functional endoscopic sinus surgery (FESS) and computed tomography (CT) have concurrently increased interest in the anatomy of the paranasal region. Common anatomical variations are not rare in patients with chronic paranasal sinusitis. The aim of this retrospective study was to analyze the incidence of anatomic variations of the lateral nasal wall in a series of 200 patients with persistent symptoms of rhinosinusitis, after failure of medical therapies, and their correlation with paranasal sinus disease. A detailed analysis of CT scans showed that 140 of 200 (70%) patients had anatomic variations. In particular, 122 patients (87%) were affected by common anatomic variations, and 18 patients (13%) with uncommon variations. There were 85 (60.7%) male and 55 (39.3%) females with ages ranging from 13 to 77 years (mean 45.5 years). The maxillary sinus was most commonly involved, followed by the anterior ethmoid, frontal sinus, posterior ethmoid and sphenoid sinus. Statistically significant association was found between the presence of common anatomic variations – septal deviation, bilateral concha bullosa, medial deviation of uncinate process, Haller cell, ethmoidal bulla hypertrophic, agger nasi cell – and the presence of sinus mucosal disease (p < 0.05). There was no significant correlation between other common and uncommon anatomic variations and mucosal pathologies. The associations were evaluated using the Fisher's exact test, and compared with those reported in the literature. Considering the results obtained, we believe that some anatomic variations may increase the risk of sinus mucosal disease. We therefore emphasize the importance of a careful evaluation of CT study in patients with persistent symptoms and recurrent chronic rhinosinusitis in order to identify those with anatomical variations that may have an increased risk of developing rhinosinusitis.
PMCID: PMC3468938  PMID: 23093814
Anatomic variations; Chronic rhinosinusitis; Paranasal sinuses; Computed tomography; Endoscopic sinus surgery
25.  New Landmark for the Endoscopic Endonasal Transsphenoidal Approach of Pituitary Surgery 
To clarify the anatomical correlations of the sphenoid sinus with surrounding structures in the normal Korean population, and to identify surgical landmarks for safe sellar floor dissection in the anterior skull base by endoscopy and microscopy.
We reviewed the 196 brain magnetic resonance imaging findings showing a normal appearance, and measured the distances between anatomical landmarks.
The mean distances from the base of the columella to the anterior wall of the sphenoid sinus and the sellar floor were 69.71±4.25 mm and 86.26±4.57 mm, respectively in the over 15 age group, and showed the smallest degree of variation among the measurements. The mean angles between the floor of the nasal cavity and the straight line connecting the base of the columella and the sellar floor were 29.45±3.25° and 24.75±4.00° in the over 15 and under 15 age groups, respectively. The mean values of both distances and angles increased with age until 15 years after which no further increases were evident. There were no significant differences in the measurements between males and females or among subjects with different degrees of pneumatization in the over 15 age group.
The distances from the base of the columella to the sellar floor and the anterior wall of the sphenoid sinus, which were consistent among individuals, could be used as a surgical indicator to investigate the sellar floor in endoscopic or microscopic transsphenoidal approaches.
PMCID: PMC3698231  PMID: 23826477
Pituitary gland; Neuroendoscopy; Sphenoid sinus; Skull base neoplasm

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