The Different Causes and Management of
Chronic Sphenoid Rhinosinusitis
Ali Almomen1*, Abdullah A AlShakhs2, Ali AlTuraifi2, Njood Alaboud2 and Mousa Alshehri2
1Consultant Rhinology & Skull base surgery, King Fahad Specialist Hospital, Saudi Arabia
2Medical intern, Saudi Program, Saudi Arabia
Submission: March 03, 2020; Published: March 30, 2020
*Corresponding author:Ali Almomen, Consultant Rhinology & skull base surgery, King Fahad Specialist Hospital Dammam, Kingdom of Saudi Arabia
How to cite this article: Ali A, Abdullah A A, Ali A, Njood A, Mousa A. The Different Causes and Management of Chronic Sphenoid Rhinosinusitis. Glob J
Oto, 2020; 22(1): 556076. DOI: 10.19080/GJO.2020.22.556076
Background: Chronic sphenoid rhinosinusitis (CSRS) is a rare clinical condition reported only in 1-3% cases of paranasal sinus disease. The most common symptoms of CSRS were headache, ophthalmological and nasal symptoms. Even though CSRS is rare, it’s very significant clinically due to its undetectable anatomical location, ambiguous symptoms and the complications associated with it.
Objective: WTo present the different clinical manifestations, diagnostic, and management strategies of chronic sphenoid rhinosinusitis in order to prevent delayed diagnosis and providing early management.
Method: This is a retrospective clinical study, which was conducted between January 2008 to November 2019. This study was conducted in the ENT department of King Fahad specialist Hospital in Saudi Arabia. It included only the patients with sole involvement of chronic rhinosinusitis.
Conclusion: CSRS is difficult to diagnose and treat due to ambiguous and vague clinical features. CSRS most common symptoms are headache, visual loss, and nasal obstruction. The cornerstone of radiological diagnosis of CSRS is CT scan. Endoscopic sinus surgery is the gold standard of the surgical treatment for CSRS.
Chronic sphenoid rhinosinusitis (CSRS) is defined as a spectrum of either inflammatory or infective diseases occurring exclusively in sphenoid sinus which last for at least 12 weeks without complete resolution . This may include fungal rhinosinusitis, bacterial rhinosinusitis, and mucocele. The pneumatization of sphenoid sinuses usually start at the age of 6 years and is completed by the 9th to 12 years . Up to date, the youngest known patient who diagnosed with sphenoiditis was 10 years old . There are several important structures adjacent to sphenoid sinus which vulnerable to injury through any sphenoid sinus lesion, including the pituitary gland, optic nerve and chiasm, middle cranial fossa, internal carotid artery, cavernous sinus, the dura, pterygoid canal and nerve and cranial nerve III, IV, V1, V2, and VI [4,5]. Even though isolated sphenoid sinus lesion is rare, it’s very significant clinically due to its undetectable anatomical location, ambiguous symptoms and the complications associated
with injury to the above structures . The main focus of this study is to present the different clinical manifestations and diagnostic strategies of CSRS, in order to prevent delayed diagnosis and providing early management. It was conducted at King Fahad Specialist Hospital (KFSHD), Eastern region, Saudi Arabia.
This is a retrospective clinical study which was conducted in the otolaryngology department of King Fahad specialist Hospital, Dammam, Saudi Arabia, from January 2008 to November 2019. The clinical features, radiological images, operative findings, and clinical outcomes were retrospectively reviewed and analysed with full description of some selected cases are presented in this report. Patients included were: 1- isolated sphenoid chronic rhinosinusitis which were confirmed by computed tomography (CT) and/or magnetic resonance imaging (MRI); 2- intraoperative evidence of chronic rhinosinusitis within the sphenoid sinus. This
study was reviewed and approved by the institutional review
board (IRB) at our institution.
A diagnosis of isolated sphenoid bacterial sinusitis (40%),
fungal ball (23.3%), allergic fungal rhinosinusitis (23.3%),
Mucocele and mucopyocele (13.3%), had been made in 30
patients with the age ranging between 14-50 years old. The
most common symptoms were headache followed by nasal and
ophthalmological symptoms. Even though CT scan was the most
important tool in the diagnosis, the conformation of the diagnosis
was made either intraoperatively or by cultures. Endoscopic sinus
surgery was the standard care of management [Table 1].
In this study, bacterial sphenoid rhinosinusitis (BSRS) was
the most common sphenoid inflammatory disease, occurring in
12 out of 30 patients. The commonest isolated pathogens were
Staphylococcus aureus, anaerobes and aerobic gram-negative
Bacilli [7-10]. The majority of patients presented with headache,
which was not specific in site, quality, as well as intensity. Other
important features were blurred vision, nasal obstruction, and
rhinorrhea . Physical examination and endoscopic finding of
cases may show polypoid tissue in the sphenoethmoidal recess,
Edema of the sphenoethmoidal recess mucosa and mucopurulent
secretion at the sphenoethmoidal area. In most cases CT imaging
was the key to proper diagnosis. In BSRS CT scan may demonstrate
abnormal findings of partial or complete opacification, changes in
air–fluid level and mucosal thickening (Figure 1). Management
of patients with BSRS is mainly medical with antibiotic based on
culture and sensitivity in addition to corticosteroid and topical
decongestant. The only patients who failed to respond to medical
treatment or presented with complications, were managed
surgically with endoscopic sphenoidotomy (Figure 2).
AFRS is an immunological reaction to fungal antigen rather
than a fungal infection. This commonly results in mucosal
thickening and marked bone resorption as a result of the
secretion of enzymes. Additionally, a thick mucin may cause bony
decalcification. Interestingly, it is common in immunocompetent
younger patient with atopic background. Sphenoid allergic fungal
rhinosinusitis (SAFRS) was reported in 7 out of 30 patients in our
study. The clinical presentation of (SAFRS) is often nonspecific
and vague; thus, diagnosis may be delayed in many cases .
Up to date, headache refractory to the medical management is
the most common symptom of isolated sphenoid sinus lesion; it
presents in 70 to 90% of patients [13,14]. In this series, the most
presenting feature was headache followed by nasal discharge.
History and physical examination have little benefit in establishing
the correct diagnosis. Imaging studies (CT scanning and/or MRI)
and Nasal endoscopy are essential for a thorough evaluation and
All patient did CT scan which provided valuable information
regarding the diagnosis of SAFRS and its relation to bony
erosion. CT findings of SAFRS may present with heterogeneous
hyperdensities that are often unilateral and asymmetric as shown
in one of our cases (Figure 3). SAFRS can easily compress the
cranial nerves. It had been documented that cranial neuropathies
occur in 10% of cases of SAFRS with bone erosion . Endoscopic
surgery has become the fundamental approach for SAFRS. It’s
includes surgical debridement of fungal material in order to open
and ventilate the sinuses (Figure 4), and post-operative steroid to
control the recurrence. There are few reports about complication
of ISAFRS. Actually, the main complication of allergic comes after
sphenoid sinus involvement. The main complications are visual
disturbances, diplopia and cavernous sinus thrombosis [18,19].
We have reported one case in our series with cavernous sinus
thrombosis as a complication of isolated sphenoid allergic fungal
sinusitis. Left sphenoidotomy was done and she was treated with
Meropenem, Vancomycin, Amphotericin B and Enoxaparin and
Fungal ball (FB) is an accumulation of dense fungal hyphae,
most commonly in the maxillary sinus, with only 10% of the cases
in sphenoid sinus . Isolated sphenoid fungal ball (ISFB) was
reported in 7 out of 30 patients in our study. The exact mechanism
of spread of fungal infection only to sphenoid sinus is unknown.
It has been hypothesized that ostial closure creates an anaerobic
environment favourable for growth of Aspergillus, or that chronic
sinusitis predisposes to the development of FB . Headache
refractory to the medical management is the most common
symptom of ISFB [13,14]. In our study, the most presenting
feature was post-nasal discharge followed by headache and rarely
cough. History and physical examination have little benefit in
establishing the correct diagnosis. Imaging studies (CT scanning
and/or MRI) and Nasal endoscopy are essential for a thorough
evaluation and management [15,16]. Figure 5 shows, fungal ball
appears as hyper-attenuating in CT due to dense hyphae with
evidence of thickening of the wall of the paranasal sinuses and
chronic inflammation with sclerosis. MRI should only provide for
patient with suspicion of invasion to surrounding structures .
On Nasal endoscopy the most common findings are bone
thickening or sclerosis of sinus walls (Figure 6). This can be
secondary to the inflammatory process associated with the fungal
ball and is often reversible after removing it [5,12]. Microbiology
confirms fungal infection and eventually identifies fungal species.
The microscopic appearance of Aspergillus on direct smear is that
of a conidiophore . On culture, the most frequently isolated
fungus is Aspergillus fumigates. One of our fungal ball cases showed Aspergillus but the remaining 6 cases had -ve culture. The
surgical management of sphenoid sinus include both endoscopic
and open techniques. However, endoscopic surgery has become
the fundamental approach for sphenoid sinus lesions. It can be
proceeded in a trans-ethmoidal fashion or through the anterior
sphenoid sinus wall directly at the site of the natural ostium
. No post-operative medical treatment was necessary for all
patients. Post-operative follows up was done for all patient with
no complication and recurrence.
Mucoceles are benign, encapsulated lesions filled with mucus
and lined by epithelium. They are expansile and locally destructive
with the ability to resorb bone, causing erosions of the bony walls
of the sinus .
Thinning, distension and erosion of the sinus bony walls
happens because of the retained mucoid secretion within
the sinus. Our study has identified 4 out of 30 patients with
mucocele. The clinical features of sphenoid sinuses mucocele
includes headache, diplopia, external ophthalmologist and visual
disturbances due to involvement of optic or oculomotor, trochlear
and abducent nerves.
CT scan is the main tool for diagnosis of sphenoid sinus
mucocele . Figure 7 shows CT scan findings of one of our
cases. MRI scan of one of our cases (Figure 8) shows a low
signal on T1 and a high signal on T2. Regarding treatment,
asymptomatic mucocele, could be left without any surgical
intervention. However, surgical intervention is recommended
in symptomatic, or complicated cases. Endoscopic trans-nasal
image-guided sphenoidotomy has become the fundamental
treatment approach, as illustrated in Figure 9. The purpose of
surgery is to allow adequate drainage and to avoid recurrences of
the condition (Figure 10). Marsupialization is another option in
the management of mucocele.
Even though chronic sphenoid rhinosinusitis is rare, it’s
clinically important because untreated CSRS can cause significant
orbital and intracranial complications due to the vital structures
near the sphenoid sinuses. The clinical features of CSRS are
ambiguous which make its diagnosis more difficult. Headache
refractory to the medical management and post-nasal discharge
is the most common symptom of CSRS. CT scan is still the
cornerstone of radiological diagnosis of CSRS. Endoscopic sinus
surgery is the standard care of management. Post-operatively, the
majority of patient had good results with no complication and
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