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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.
PMCID: PMC3551432  PMID: 23341818
Orbital aspergillosis; Lateral orbitotomy; Transethmoidal orbital apex drainage
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.  Adenocarcinoma of the sphenoid sinus 
Adenocarcinomas of the sphenoid sinus are exceptional. In this paper, we report a new case with a review of the literature. Our patient was a 45-year-old man who presented with isolated retro orbital headache. CT and MRI suspected a malignat tumor of the sphenoid sinus. The patient underwent a debulking surgery. The final pathology carried out the diagnosis of primary adenocarcinoma. The patient died several months later from radiotherapy complications. Even if adenocarcinomas of the sphenoid sinus are exceptional, they should be considered in the differential diagnosis of sphenoid sinus masses. The prognosis is poor.
PMCID: PMC4247863  PMID: 25469178
Sphenoid sinus; adenocarcinoma; endonasal surgery; radiotherapy
4.  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
5.  Sphenoid Sinus and Sphenoid Bone Fractures in Patients with Craniomaxillofacial Trauma 
Background and Purpose Sphenoid bone fractures and sphenoid sinus fractures have a high morbidity due to its association with high-energy trauma. The purpose of this study is to describe individuals with traumatic injuries from different mechanisms and attempt to determine if there is any relationship between various isolated or combined fractures of facial skeleton and sphenoid bone and sphenoid sinus fractures.
Methods We retrospectively studied hospital charts of all patients who reported to the trauma center at Hospital de San José with facial fractures from December 2009 to August 2011. All patients were evaluated by computed tomography scan and classified into low-, medium-, and high-energy trauma fractures, according to the classification described by Manson.
Design This is a retrospective descriptive study.
Results The study data were collected as part of retrospective analysis. A total of 250 patients reported to the trauma center of the study hospital with facial trauma. Thirty-eight patients were excluded. A total of 212 patients had facial fractures; 33 had a combination of sphenoid sinus and sphenoid bone fractures, and facial fractures were identified within this group (15.5%). Gender predilection was seen to favor males (77.3%) more than females (22.7%). The mean age of the patients was 37 years. Orbital fractures (78.8%) and maxillary fractures (57.5%) were found more commonly associated with sphenoid sinus and sphenoid bone fractures.
Conclusions High-energy trauma is more frequently associated with sphenoid fractures when compared with medium- and low-energy trauma. There is a correlation between facial fractures and sphenoid sinus and sphenoid bone fractures. A more exhaustive multicentric case-control study with a larger sample and additional parameters will be essential to reach definite conclusions regarding the spectrum of fractures of the sphenoid bone associated with facial fractures.
PMCID: PMC3773063  PMID: 24436756
craniofacial trauma; sphenoid sinus; fracture; sphenoid bone; facial trauma; CT
6.  Pediatric Masked Mastoiditis Associated with Multiple Intracranial Complications 
Case Reports in Otolaryngology  2015;2015:897239.
Masked mastoiditis is a distinct form of mastoiditis with little or no symptomatology, characterized by its potential to generate severe otogenic complications. Therefore, suspected masked mastoiditis should be diagnosed and treated without delay. This study reports a rare case of masked mastoiditis, manifested by multiple intracranial complications in an immunocompetent girl. The child exhibited headache and neurological symptomatology. Imaging studies revealed an epidural and a large cerebellar abscess and the patient was immediately treated with a triple antibiotic therapy. Mastoid surgery and drainage of the epidural abscess took place after the stabilization of the patient's neurologic status, on the 3rd hospitalization day. The cerebellar abscess was treated by craniectomy and ultrasound-guided needle aspiration in the 3rd week of hospitalization. The girl was finally discharged in excellent condition. Two years later, she is still in good health, without otological or neurological sequelae. Masked mastoiditis is an insidious disease which requires increased clinical awareness and adequate imaging. Should clinical and/or radiological findings be positive, mastoidectomy must follow in order to prevent severe otogenic complications that can be triggered by masked mastoiditis.
PMCID: PMC4499394  PMID: 26221557
7.  Non-Hodgkin's lymphoma of the sphenoid sinus presenting as isolated oculomotor nerve palsy 
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.
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.
PMCID: PMC1950883  PMID: 17683562
8.  A rare presentation of tuberculous prostatic abscess in young patient 
•Prostate tuberculosis is much less common than renal, vesico-seminal and epididymal TB.•We report a case of unusual presentation of tuberculous prostatic abscess in young, healthy, immunocompetent patient.•MRI revealed extra prostatic collection on either side.•Tuberculous prostatic abscess in a young healthy male presenting as rectal sinus is extremely uncommon.
Genitourinary tuberculosis contributes 15–20% of extra pulmonary tuberculosis. Prostatic tuberculosis is much less common than renal, vesico-seminal and epididymal TB. Predisposing factor include prior tubercular infection, immunocompromised status, previous BCG therapy. Nevertheless, isolated tuberculous prostatic abscess are uncommon especially in immunocompetent patient.
Presentation of case
We report a case of tuberculous prostatic abscess in young, healthy immunocompetent patient, from India, who has initial presentation of pyrexia of unknown origin. All his investigation and treatment were done in India. He was diagnosed with prostatic abscess, treated with TRUS guided aspiration and antituberculous drugs. But he did not respond to the treatment and later on presented as extraprostatic extension of abscess and rectal sinus, a rare complication. MRI revealed this finding. Sigmoidoscopy was done and in same sitting we drained the abscess through perineal route. ATT was continued and he responded to treatment.
Urogenital tuberculosis most frequently affects the kidneys. Ureter and bladder tuberculosis is secondary to descending infection. Prostate tuberculosis is usually asymptomatic and as an incidental prostatectomy finding. Prostatic abscess is rare but occur in AIDS patients with urogenital TB.
Prostatic tuberculous cavities or abscesses may discharge into the surrounding tissues, forming sinuses or fistulae to the perineum or rectum and are demonstrated best on MRI scans.
Tuberculous prostatic abscess although very uncommon in immunocompetent patient, we should have high index of suspicion in patients of PUO. Once diagnosed it should be treated with complete drainage of abscess and ATT with close follow up.
PMCID: PMC4429845  PMID: 25805615
Genitourinary tuberculosis; Tuberculous prostatic abscess; Rectal sinus; TRUS
9.  Endoscopic Craniofacial Approach for Intracranial Polyposis: The “Blue–Sky Technique” 
Skull Base  2003;13(4):235-239.
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.
PMCID: PMC1131857  PMID: 15912183
Sinonasal polyposis; craniofacial resection
10.  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
11.  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.
PMCID: PMC2982917  PMID: 21113366
Sphenoid sinus mucocele; Third nerve palsy; Transnasal approach
12.  Cerebrospinal Fluid Rhinorrhea and Seizure Caused by Temporo-Sphenoidal Encephalocele 
This case report describes the symptoms and clinical course of a 35-year-old female patient who was diagnosed with a temporo-sphenoidal encephalocele. It is characterized by herniation of cerebral tissue of the temporal lobe through a defect of the skull base localized in the middle fossa. At the time of first presentation the patient complained about recurrent nasal discharge of clear fluid which had begun some weeks earlier. She also reported that three months earlier she had for the first time suffered from a generalized seizure. In a first therapeutic attempt an endoscopic endonasal approach to the sphenoid sinus was performed. An attempt to randomly seal the suspicious area failed. After frontotemporal craniotomy, it was possible to localize the encephalocele and the underlying bone defect. The herniated brain tissue was resected and the dural defect was closed with fascia of the temporalis muscle. In summary, the combination of recurrent rhinorrhea and a first-time seizure should alert specialists of otolaryngology, neurology and neurosurgery of a temporo-sphenoidal encephalocele as a possible cause. Treatment is likely to require a neurosurgical approach.
PMCID: PMC4414777  PMID: 25932300
Encephalocele; Cerebrospinal fluid rhinorrhea; Skull base; Encephalitis; Epilepsia
13.  Unilateral isolated sphenoid sinusitis with contralateral abducens nerve palsy - A rare complication treated in a low-resource setting 
Unilateral isolated sphenoid sinus disease (ISSD) is a rare diagnosis of the paranasal sinuses that can be associated with complications involving vascular, neurologic, and optic structures in close proximity.
Case presentation
A 62 year old female presented to a hospital in Georgetown, Guyana with right lateral rectus palsy, diplopia, and a severe progressively worsening headache. CT scan revealed an opaque left sphenoid sinus consistent with unilateral ISSD. A transnasal sphenoidotomy was performed without complication under local anesthetic in the absence of endoscopic guidance. The patient's headache resolved immediately after surgery while the diplopia and lateral rectus palsy resolved completely after 6 weeks.
We present a rare complication of ISSD and highlight challenges associated with diagnosis and management of ISSD in a resource-limited setting. This is the second reported case of unilateral ISSD with contralateral lateral rectus palsy in the literature.
PMCID: PMC4359434  PMID: 25889683
ISSD (Isolated Sphenoid Sinus Disease); Abducens nerve palsy; Transnasal sphenoidotomy; Paranasal sinuses
14.  Isolated sphenoid sinus pathologies – the problem of delayed diagnosis 
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.
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.
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.
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.
PMCID: PMC3524726
sphenoiditis; isolated lesion; complications
15.  Isolated sphenoid sinus lesion: A diagnostic dilemma 
Qatar Medical Journal  2014;2014(1):57-60.
Isolated sphenoid sinus lesions are an uncommon entity and present with non-specific symptoms. In this case report, the patient presented with a history of headaches for a duration of one month without sinonasal symptoms. A computed tomography scan showed a soft tissue mass occupying the sphenoid sinus. An endoscopic biopsy revealed fungal infection. Endoscopic wide sphenoidotomy with excision of the sphenoid sinus lesion was then performed however, the microbiological examination post-surgery did not show any fungal elements. Instead, Citrobacter species was implicated to be the cause of infection.
PMCID: PMC4197375  PMID: 25320694
sphenoid sinusitis; Citrobacter; sphenoid lesion; sinuses
16.  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.
PMCID: PMC3272517  PMID: 22323943
Head injury; Penetrating; Bone fragment
17.  Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis 
Skull Base  2007;17(2):125-132.
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.
PMCID: PMC1876155  PMID: 17768442
Transnasal approach; multilayer repair; sphenoid sinus; CSF leak
18.  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.
PMCID: PMC2899570  PMID: 18751739
Odontoid fractures; Halo pin penetration; Brain abscess; Seizure
19.  Retained transorbital foreign body with intracranial extension after pipe bomb explosion 
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.
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.
PMCID: PMC3019363  PMID: 21246061
Brain injury; explosion; intracranial foreign body; pipe bomb; transorbital
20.  Sphenoid Sinus Expansion: A Radiographic Sign of Intracranial Hypotension and The Sunken Eyes, Sagging Brain Syndrome (An American Ophthalmological Society Thesis) 
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.
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).
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).
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
21.  A Modified Surgical Procedure for Endoscopic Optic Nerve Decompression for the Treatment of Traumatic Optic Neuropathy 
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.
PMCID: PMC4083528  PMID: 25006562
Endoscopic technique; Optic nerve decompression; Traumatic optic neuropathy
22.  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.
PMCID: PMC3522498  PMID: 23251173
23.  Primary Ewing's sarcoma of the sinonasal tract, eroding the ethmoid and sphenoid sinus with intracranial extension: A rare case report 
Molecular and Clinical Oncology  2015;3(4):807-810.
Ewing's sarcoma (ES) is an aggressive tumour that may present with skeletal and extraskeletal forms. The extraskeletal form is rarely encountered in the head and neck region and is extremely rare in the sinonasal tract. This is the case report of a ES of the ethmoid sinus with intracranial and orbital extension in a 33-year-old male patient who presented with anosmia, epistaxis, reduction of visual acuity in the left eye and headache. On otorhinolaryngological clinical examination and biopsy via flexible endoscope, the lesion was misdiagnosed as ethmoid sinus carcinoma. The subsequent magnetic resonance imaging (MRI) of the brain revealed a large mass (6×7 cm) eroding the ethmoid and sphenoid sinuses, extending beyond the orbits and occupying the anterior cranial fossa with a maximum extension of ~5 cm. The patient underwent surgical resection and the microscopic examination of the specimen established the diagnosis of ES (immunohistochemically positive for CD99, neuron-specific enolase, CD56, synaptophysin, pancytokeratin, low-molecular weight cytokeratins and vimentin. The periodic acid Schiff stain exhibited strong intracytoplasmic block positivity and fluorescence in situ hybridization revealed a t(22;11) translocation. First-line chemotherapy was administered for 3 cycles; however, on restaging MRI, local disease progression was diagnosed. The patient received radiotherapy and second-line chemotherapy for 6 cycles. At 15 months after the diagnosis, the patient remains recurrence-free and maintains a good functional status and quality of life.
PMCID: PMC4487037  PMID: 26171185
Ewing's sarcoma; sinonasal tract; intracranial extension; magnetic resonance imaging; chemotherapy
24.  Sphenoid Sinus Inverted Papilloma: A Case Report and Literature Review 
Introduction Inverted papilloma is a rare benign tumor of the nasal fossa, which usually originates from its lateral wall. Only 5% of cases demonstrate exclusive sinus involvement. Primary sphenoid sinus involvement is even rarer. Although considered a benign lesion, the tumor has a potentially invasive nature and has also been found to have an associated malignancy rate of 7 to 15%.
Objectives To report a case of inverted nasal papilloma originating in a rare location: the sphenoid sinus.
Resumed Report a 56-year-old woman, presented to our outpatient clinic complaining of frontal headache, occasional otalgia and recent forgetfulness. She was initially evaluated by a neurologist and then submitted to a head magnetic resonance imaging. A lesion was found to be filling both sphenoid sinuses. Sinus computed tomography showed an opacified sphenoid sinus with apparent bony integrity. The patient underwent sphenoidotomy through a transnasal endoscopic approach. A bleeding papillomatous lesion was identified. A biopsy was performed and histopathologic study suggested inverted papilloma. The lesion was then completely resected. The patient has been followed for 60 days after surgery; no signs of recurrence were found upon flexible nasofibroscope examination.
Conclusion Inverted Papilloma exclusively involving the sphenoid sinus is a rare entity. Non specific symptomatology and Clinical presentation make this kind of tumor a diagnostic and therapeutic challenge. The Endoscopic Sphenoidotomy has been the treatment of choice. Close follow-up is required in order to detect possible recurrences and malignant transformation.
PMCID: PMC4297015  PMID: 25992117
inverted papilloma; nasal cavity; sphenoid sinus
25.  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.
PMCID: PMC3550425  PMID: 23346329
Cerebrospinal fluid; Endoscope-assisted procedures; Sternberg's canal

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